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Racial/Ethnic Disparities in Self-Rated Health Status Among Adults With and Without Disabilities -- United States, 2004 -- 2006

Self-rated health status has been found to be an independent predictor of morbidity and mortality (1), and racial/ethnic disparities in self-rated health status persist among the U.S. adult population (2). Black and Hispanic adults are more likely to report their general health status as fair or poor compared with white adults (2). In addition, the prevalence of disability has been shown to be higher among blacks and American Indians/Alaska Natives (AI/ANs) (3). To estimate differences in self-rated health status by race/ethnicity and disability, CDC analyzed data from the 2004 -- 2006 Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which indicated that the prevalence of disability among U.S. adults ranged from 11.6% among Asians to 29.9% among AI/ANs. Within each racial/ethnic population, adults with a disability were more likely to report fair or poor health than adults without a disability, with differences ranging from 16.8 percentage points among Asians to 37.9 percentage points among AI/ANs. Efforts to reduce racial/ethnic health disparities should explicitly include strategies to improve the health and well being of persons with disabilities within each racial/ethnic population.

BRFSS is a state-based, random-digit -- dialed telephone survey of the noninstitutionalized, U.S. civilian population aged >18 years. In 2004, 2005, and 2006, approximately 1 million persons from all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands participated in the BRFSS survey.* Consistent with the definition of disability from Healthy People 2010 (4), respondents were asked, "Are you limited in any way in any activities because of physical, mental, or emotional problems?" and "Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?" Participants who responded "yes" to either question were classified as having a disability. To assess self-rated health status, participants were asked, "Would you say that in general your health is excellent, very good, good, fair, or poor?"

The following racial/ethnic categories were included in this analysis: white, black, Hispanic, Asian, Native Hawaiian or Other Pacific Islander, and AI/AN. Data from 2004, 2005, and 2006 were aggregated to provide sufficient power to analyze low-count racial/ethnic populations. Prevalence estimates were weighted and age adjusted to the 2000 U.S. standard population. Weighted population estimates were determined by taking the final weights for each year during 2004 -- 2006 and dividing by three. Data were weighted to compensate for unequal probabilities of selection, to adjust for nonresponse and telephone noncoverage, to ensure that results were consistent with population data, and to make population estimates.§ Prevalence estimates and standard errors were obtained using statistical software to account for the complex sampling design. Chi-square tests were used to compare self-rated health status between racial/ethnic populations and by disability status. Council of American Survey Research Organizations (CASRO) median response rates for the 2004 -- 2006 BRFSS surveys were 52.7% (2004), 51.1% (2005), and 51.4% (2006). The median cooperation rates** for each year were 74.3% (2004), 75.1% (2005), and 74.5% (2006).

During 2004 -- 2006, an estimated 19.9% of the total U.S. population aged >18 years (i.e., an average of 43 million persons) had a disability. The prevalence of disability was highest among AI/ANs (29.9%) and lowest among Asians (11.6%) (Table 1). Nearly 84% of the total U.S. adult population reported having good or better health, but substantial variation was observed in self-rated health status across racial/ethnic populations. Nearly 60% of white, Asian, and Native Hawaiian or Other Pacific Islander respondents (59.3%, 55.8%, and 55.4%, respectively) rated their health as very good or excellent, whereas 44.4% of black respondents reported their health to be very good or excellent. White and Asian adults had similar rates of self-rated fair or poor health (12.9% and 10.4%, respectively), whereas fair or poor health was reported more frequently among other minority populations: 21.1% among blacks, 14.8% among Native Hawaiian or Other Pacific Islanders, and 24.5% among AI/ANs. Hispanic adults rated their health status approximately equally across the three health status categories: very good or excellent (33.6%), good (35.4%), and fair or poor (31.1%).

Overall, adults with a disability were less likely to report excellent or very good health (27.2% versus 60.2%; p<0.01) and more likely to report fair or poor health (40.3% versus 9.9%; p<0.01), compared with adults without disability (Table 2). White adults without a disability had the highest proportion of respondents who rated their health as very good or excellent (66.9%), whereas 49.9% of black respondents without a disability reported very good or excellent health. Reports of fair or poor health among adults with a disability were most common among Hispanics and AI/ANs (55.2% and 50.5%, respectively) and least common among Asians (24.9%).

Reported by: LA Wolf, MPH, BS Armour, PhD, VA Campbell, PhD, Div of Human Development and Disability, National Center for Birth Defects and Developmental Disabilities, CDC.

Editorial Note:

The Surgeon General's Call to Action to Improve the Health and Wellness of People with Disabilities notes that good health is essential if persons with disabilities are to work, learn, and fully interact with their families and community (5). The concept of health should be the same for persons with and without disabilities (5). As in previous studies (2), the findings in this report indicated that, in 2004 -- 2006, self ratings of fair or poor health were generally higher among black, Hispanic, Native Hawaiian or Other Pacific Islander, and AI/AN adults than among their white and Asian counterparts. Also, as in previous studies (3), the findings in this report show that a higher proportion of persons with disabilities rated their health as fair or poor compared with persons without disabilities. This analysis also determined that the difference in self-rated fair or poor health between persons with and without disabilities varied by race/ethnicity. The absolute difference between persons with and without disabilities ranged from 16.8 percentage points for Asians to 37.9 percentage points for AI/ANs. These differences are attributed, in part, to health-care and wellness promotion services being inaccessible or unavailable for certain persons with disabilities (5). Health-care delivery has been slow to reduce disparities that would enable many persons with disabilities to achieve and maintain a good level of health (5).

The findings in this report are subject to at least five limitations. First, BRFSS does not include persons living in institutions or group homes. Therefore, because persons with disabilities are likely to reside in such facilities, the results likely underestimate the actual prevalence of adults with a disability. Second, the BRFSS questions used to define disability do not collect information on the type, severity, duration, or permanence of disability. Therefore, the definition of disability used in this analysis might have captured some persons with relatively minor or short-term disabilities (e.g., a sprained ankle). Third, because of the cross-sectional nature of the data, inferring any direction of causality between disability and fair or poor health is not possible. Fourth, BRFSS is conducted only in English and Spanish, which might preclude participation by persons who speak other languages. In addition, differences in the Spanish translation of the questionnaire might explain some of the health disparities observed in the Hispanic population (6). The Spanish language version of BRFSS uses the Spanish word "regular" for the category of "fair" health, an idiomatic difference that might alter the way the participant understands the question. Finally, racial/ethnic differences in self-rated health and disability might reflect differences in potentially confounding factors, such as education, income, and health insurance status, which are significantly associated with both race/ethnicity and disability and were not controlled for in this analysis (7,8). This is a direction for future work that CDC plans to undertake.

Despite efforts to identify and reduce health disparities among racial/ethnic populations in the United States, disproportionately high rates of disability and self-rated fair or poor health persist among certain racial/ethnic populations (9,10). Efforts to reduce health disparities among racial/ethnic populations should also address the needs of adults with disabilities. Such efforts must ensure that persons with disabilities have accessible, available, and appropriate health-care and wellness promotion services (5).

References

  1. Lee SJ, Moody-Ayers SY, Landefeld CS, et al. The relationship between self-rated health and mortality in older black and white Americans. J Am Geriatr Soc 2007;55:1624 -- 9.
  2. Mead H, Cartwright-Smith L, Jones K, Ramos C, Woods K, Siegel B. Racial and ethnic disparities in U.S. health care: a chartbook. New York, NY: The Commonwealth Fund; 2008. Available at http://www.commonwealthfund.org/usr_doc/mead_racialethnicdisparities_chartbook_1111.pdf.
  3. CDC. Disability and health state chartbook, 2006: profiles of health for adults with disabilities. Atlanta, GA: US Department of Health and Human Services, CDC; 2006. Available at http://www.cdc.gov/ncbddd/dh/chartbook/chartbook%20text.pdf.
  4. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov.
  5. US Department of Health and Human Services. The Surgeon General's call to action to improve the health and wellness of persons with disabilities. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General; 2005. Available at http://www.surgeongeneral.gov/library/disabilities/calltoaction/calltoaction.pdf.
  6. Berkanovic E. The effect of inadequate translation of Hispanics' responses to health surveys. Am J Public Health 1980;70:1273 -- 81.
  7. DeNavas-Walt C, Proctor BD, Lee CH. Income, poverty, and health insurance coverage in the United States: 2005. Current population reports (P60-231). Washington, DC: US Census Bureau; 2006. Available at http://www.census.gov/prod/2006pubs/p60-231.pdf.
  8. Altman B, Bernstein A. Disability and health in the United States, 2001 -- 2005. Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2008. Available at http://www.cdc.gov/nchs/data/misc/disability2001-2005.pdf.
  9. Field MJ, Jette AM, Martin L, eds. Workshop on disability in America: a new look. Washington, DC: National Academies Press; 2006. Available at http://www.nap.edu/catalog.php?record_id=11579#toc.
  10. Shi L, Green LH, Kazakova S. Primary care experience and racial disparities in self-reported health status. J Am Board Fam Pract 2004;17:443 -- 52.

* Hawaii did not collect data in 2004.

For this report, persons identified as white, black, Asian, Native Hawaiian or Other Pacific Islander, and AI/AN are all non-Hispanic. Persons identified as Hispanic might be of any race.

§ Additional information available at http://health.utah.gov/opha/ibishelp/brfss/issues.htm.

The percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted.

** The percentage of persons who completed interviews among all eligible persons who were contacted.

Table 1

TABLE
1. Disability and self-rated health status among U.S. adults aged >18 years, by race/ethnicity — Behavioral Risk Factor Surveillance System, United States,* 2004–2006
Race/Ethnicity†
Disability§
Excellent or very good health
Good health
Fair or poor health
Sample popu-
lation
Weighted U.S.
population¶
%**
SE††
Sample popu-
lation
Weighted U.S.
population
%
SE
Sample popu-
lation
Weighted U.S.
population
%
SE
Sample popu-
lation
Weighted U.S.
population
%
SE
White
195,804
32,437,544
20.3
0.1
429,877
89,109,657
59.3
0.1
225,743
42,965,935
27.8
0.1
130,116
21,053,344
12.9
0.1
Black
18,713
4,181,086
21.2
0.3
32,734
9,538,829
44.4
0.3
28,709
7,218,402
34.6
0.3
19,739
4,200,595
21.1
0.3
Hispanic
13,596
4,456,898
16.9
0.3
25,957
11,778,660
33.6
0.4
26,357
12,064,608
35.4
0.4
22,033
9,009,330
31.1
0.4
Asian
1,472
508,360
11.6
0.7
7,623
3,261,549
55.8
0.9
5,127
1,791,107
33.8
0.9
1,566
470,499
10.4
0.6
Native Hawaiian or
Other Pacific
Islander
351
106,044
16.6
2.1
1,043
439,397
55.4
2.7
692
231,004
29.7
2.3
300
81,042
14.8
2.2
American Indian/
Alaska Native
4,385
671,346
29.9
1.0
5,652
990,624
42.7
1.0
5,131
744,749
32.8
0.9
3,981
550,738
24.5
0.8
Total§§
241,863
43,786,716
19.9
0.1
512,996
117,631,008
53.4
0.1
298,772
66,518,557
30.2
0.1
183,253
36,412,487
16.4
0.1
* Includes the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Hawaii did not collect data in 2004.
† Persons identified as white, black, Asian, Native Hawaiian or Other Pacific Islander, and American Indian/Alaska Native are all non-Hispanic. Persons identified as Hispanic might be of any race.
§ Based on a “yes” response to either of the following questions: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”
¶ Weighted population estimates were determined by taking the final weights for each year during 2004–2006 and dividing by three. Data were weighted to compensate for unequal probabilities of selection, to adjust for nonresponse and telephone noncoverage, to ensure that results were consistent with population data, and to make population estimates. Additional information available at http://health.utah.gov/opha/ibishelp/brfss/issues.htm.
** Age adjusted to the 2000 U.S. standard population.
†† Standard error.
§§ Sample population and weighted estimates by race/ethnicity do not sum to column total because respondents who reported being multiracial or of other race were included in the total.
Return to top.
Table 2

TABLE 2. Disability among U.S. adults aged >18 years, by race/ethnicity and self-rated health status — Behavioral Risk Factor Surveillance System, United States,* 2004–2006
Disability§
No disability
Absolute
% point
difference
Race/Ethnicity† and
self-rated health status
Sample
population
Weighted U.S.
population¶
%**
SE††
Sample
population
Weighted U.S.
population
%
SE
White
Excellent or very good
45,799
8,461,103
29.7
0.3
380,061
79,708,577
66.9
0.1
37.2
Good
62,212
10,542,506
33.4
0.3
160,699
31,834,243
26.8
0.1
6.6
Fair or poor
86,670
13,289,406
36.9
0.3
41,643
7,423,348
6.3
0.1
30.6
Subtotal
194,681
32,293,015
100.0
582,403
118,966,168
100.0
Black
Excellent or very good
2,806
769,406
21.8
0.8
29,305
8,577,102
49.9
0.4
28.1
Good
5,229
1,244,095
31.6
0.8
22,858
5,805,151
36.4
0.4
4.8
Fair or poor
10,527
2,137,184
46.6
0.8
8,825
1,988,691
13.6
0.3
33.0
Subtotal
18,562
4,150,685
100.0
60,988
16,370,944
100.0
Hispanic
Excellent or very good
1,951
726,628
17.3
0.7
23,622
10,803,926
37.0
0.4
19.7
Good
3,220
1,174,570
27.5
0.9
22,670
10,525,422
37.1
0.4
9.6
Fair or poor
8,348
2,528,028
55.2
1.0
13,247
6,183,780
25.9
0.4
29.3
Subtotal
13,519
4,429,226
100.0
59,539
27,513,128
100.0
Asian
Excellent or very good
352
169,960
36.2
3.1
7,137
3,038,367
58.7
1.0
22.5
Good
546
197,675
38.9
3.3
4,465
1,544,372
33.3
1.0
5.6
Fair or poor
564
139,986
24.9
2.3
973
320,879
8.1
0.7
16.8
Subtotal
1,462
507,621
100.0
12,575
4,903,618
100.0
Native Hawaiian or
Other Pacific Islander
Excellent or very good
82
24,318
22.3
4.8
944
406,170
62.4
3.1
40.1
Good
113
43,046
41.3
6.5
565
181,304
26.8
2.3
14.5
Fair or poor
151
37,196
36.5
6.6
143
41,172
10.8
2.5
25.7
Subtotal
346
104,560
100.0
1,652
628,646
100.0
American Indian/Alaska Native
Excellent or very good
717
135,771
22.4
2.2
4,867
838,701
51.6
1.2
29.2
Good
1,236
177,565
27.1
1.7
3,805
552,187
35.8
1.2
8.7
Fair or poor
2,403
355,375
50.5
2.0
1,522
187,744
12.6
0.7
37.9
Subtotal
4,356
668,711
100.0
10,194
1,578,632
100.0
All racial/ethnic populations
Excellent or very good
53,166
10,610,265
27.2
0.3
454,452
105,528,004
60.2
0.1
33.0
Good
74,723
13,800,748
32.5
0.3
219,798
51,501,505
29.9
0.1
2.6
Fair or poor
112,511
19,159,470
40.3
0.3
67,947
16,493,297
9.9
0.1
30.4
Total§§
240,400
43,570,483
100.0
742,197
173,522,806
100.0
* Includes the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Hawaii did not collect data in 2004.
† Persons identified as white, black, Asian, Native Hawaiian or Other Pacific Islander, and American Indian/Alaska Native are all non-Hispanic. Persons identified as Hispanic might be of any race.
§ Based on a “yes” response to either of the following questions: “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”
¶ Weighted population estimates were determined by taking the final weights for each year during 2004–2006 and dividing by three. Data were weighted to compensate for unequal probabilities of selection, to adjust for nonresponse and telephone noncoverage, to ensure that results were consistent with population data, and to make population estimates. Additional information available at http://health.utah.gov/opha/ibishelp/brfss/issues.htm.
** Age adjusted to the 2000 U.S. standard population.
†† Standard error.
§§ Sample population and weighted estimates by race/ethnicity do not sum to column total because respondents who reported being multiracial or of other race were included in the total.
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Date last reviewed: 10/1/2008

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