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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.
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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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