RACIAL AND ETHNIC HEALTH DISPARITIES AMONG PEOPLE WITH

INTELLECTUAL AND DEVELOPMENTAL DISABILITIES

Sandra Magaña, Miguel A. Morales, Susan Parish, & Henan Li

American Association on Intellectual & Developmental Disabilities (AAIDD) Conference

June 2, 2015 |Louisville, KY

CONTENTS

• Introduction• Research question• Methods• Findings• Limitations• Implications

HEALTH DISPARITIES

Social determinants• Income (Adler & Stewart, 2010;

Lynch & Kaplan, 2000)• Education (Beckles & Truman,

2013; Egerter, Braveman, Sadegh-Nobarim Grossman-Kahn & Decker, 2011)

• Environmental factors, i.e., racial segregation (Pruitt et al. 2015; Rahman & Foster, 2015)

• Discrimination (Gee, 2002)

Micro and Macro levels of the social ecology (Smedley, Stith, & Nelson, 2002)

HEALTH DISPARITIES

Racial & ethnic disparities• Self-reported health status

(Subramanian, Acevedo-Garcia & Osypuk, 2004; Zack, 2013)

• Obesity (Baskin, Franklin & Allison, 2005; Dubay & Lebrun, 2012; Pan et al., 2009)

• Diabetes (McBean, Li, Gilbertson & Collins, 2004; Centers for Disease Control and Prevention [CDC], 2013)

• Breast cancer diagnosis and mortality (Markossian & Hines, 2012)

HEALTH DISPARITIES

IDD disparities• Poor/fair health (Emerson,

2005; Havercamp & Haleigh, 2015)• Obesity (Anderson et al., 2013;

Hsieh, Rimmer, & Heller, 2014; Stancliffe et al., 2011)

• Diabetes (Havercamp, Scandlin & Roth, 2004)

• Asthma (Reichard, Stolzle & Fox, 2011)

• Cardiovascular disease (Draheim, 2006)

Environment is an important determinant (Hsieh, Heller, Bershadsky & Taub, 2015)

http://www.thehealthyhoot.com/wp-content/uploads/2015/03/Healthy_Home.jpg

IDD, RACE & SES

• Is socio-economic status preeminent? (Link & Phelan, 2005; Phelan, Link, & Tehranifar, 2010)

• Racial & ethnic disparities persist after controlling for SES (Smedley et al., 2002)

• Multiple pathways to poor health: discrimination, institutional racism, cultural racism (Williams & Mohammed, 2013)

http://gettinderbox.com/wp-content/uploads/2013/11/Roads-merging-e1385420840822.jpg

INTERSECTION OF RACE & IDD

http://floridaphotomatt.com/wp-content/photos/2013/06/Intersection.jpg

RESEARCH QUESTION

• Are there racial and ethnic disparities in health status among adults with IDD?• Are there differences in health status among

Latinos and Blacks with IDD compared to Latinos & Blacks without IDD?• Outcomes: health status, mental health status,

obesity & diabetes

METHODS

• Sample- National Health Interview Survey (2000-2010)- Medical Expenditure Panel Survey (2002-2011)

• IDD identification- NHIS: Health Status and Limitation of Activity (1,094)- MEPS: ICD codes (181 individuals, 90 overlapping)- Final weighted sample of 972,099 (1,131 adults with

IDD)

METHODS

• Demographic variables- Age (continuous)- Race/ethnicity- Family income (<125% vs.

≥ 125% FPL)- Urban vs. rural (based on

Metropolitan Statistical Area)- Marital status (married vs.

not married)- Education (< HS vs.

graduated HS)- Insurance status (insured

all year vs. not insured all year)

• Outcome variables- Health status

(fair/poor vs. good/very good/excellent)

- Mental health status (fair/poor vs. good/very good/excellent)

- Obesity (BMI ≥ 30; yes vs. no)

- Diabetes (yes vs. no)

METHODS

• Data analysis: - Survey weight & variance adjustment - Software: Stata 13- Racial & ethnic differences: chi-square & t-tests- Demographic factors related to ethnic disparities in IDD:

Multivariate logistic regression - Disparities among Latinos & Blacks: Logistic regression.

TABLE 1: UNADJUSTED DISPARITIES IN OUTCOMES AMONG ADULTS WITH IDD

NL White (N = 615)

NL Black (N = 293)

Latino(N = 223)

F Test

Fair/poor health (%) 175 (23.2) 124 (40.6)

95 (44.9) 6.1***

Fair/poor mental health (%)

161 (24.4) 119 (37.8)

93 (42.3) 6.4 ***

BMI ≥ 30 (%) 216 (32.7) 121 (39.2)

91 (40.3) 1.4

Diabetes (%) 39 (5.3) 33 (8.6) 22 (10.9) 1.9+ p <.10, * p <0.05, **p <0.01, ***p<0.001. Weighted percentages appear in parentheses following unweighted counts unless otherwise specified.

TABLE 2: ADJUSTED ODDS OF HEALTH STATUS OUTCOMES AMONG ADULTS WITH IDD

Fair/poor health

(N=988)

Fair/poor mental health

(N=988)

Obesity(N=911)

Diabetes(N=908)

00.5

11.5

22.5

33.5

1.7 1.6 1.41.1

2.52.2

1.7

2.9

Black Latino

* * *+** **

Reference group = White; +< .10 *<.05 **<.01

TABLE 3: ADJUSTED ODDS OF HEALTH STATUS OUTCOMES WITHIN BLACK AND LATINO ADULTS (N= 137,857)

Black IDD Latino IDD0.01.02.03.04.05.06.07.08.09.0

10.0

2.0

5.3

3.6

9.0

2.0 1.70.7

2.3

Fair/poor HealthFair/poor Mental HealthObesityDiabetes

Reference group = Non IDD; +< .10 *<.05 **<.01 ***< .001

****** *** *** * *

SUMMARY OF FINDINGS

• Among adults with IDD- Latinos and Blacks were more likely to be in fair/poor

health and fair or poor mental health than Whites- Latino adults with IDD were more likely to be obese and

have diabetes compared to whites with IDD.

• Within Black and Latino adults:- Blacks and Latinos with IDD were more likely to report

fair/poor health and fair/poor mental health than Blacks and Latinos without IDD.

- Latino with IDD were more likely to have obesity and diabetes than non-IDD Latinos.

LIMITATIONS

Limitations

• Self-report• Different points in time• State variability in

health care access (Parish, Rose, Yoo, & Swaine, 2012; Parish, Thomas, Rose, Kilany, & Shattuck, 2012).

• Small sample for population estimates

Strengths

• Nationally representative sample• Robust measures

IMPLICATIONS

• Black and Latino adults with IDD have worse health than their white counterparts and the non-IDD adults within their racial/ethnic group. • Intersectionality of IDD status and racial/ethnic

identities contribute to compromised health outcomes• Existing initiatives have failed to address racial

and disability based health disparities• Need for more research on minority adults with

IDD living in the community

REFERENCES

• Adler, N. E., & Stewart, J. (2010). Health disparities across the lifespan: meaning, methods, and mechanisms. Annals of the New York Academy of Sciences, 1186(1), 5-23.

• Baskin, M. L., Ard, J., Franklin, F., & Allison, D. B. (2005). Prevalence of obesity in the United States. Obesity Reviews, 6(1), 5-7.

• Beckles, G. L., & Truman, B. I. (2013). Education and income—United States, 2009 and 2011. Morbidity and mortality weekly report surveillance summaries (Washington, DC: 2002), 62, 9-19.

• Centers for Disease Control and Prevention. (2013). Age-adjusted incidence of diagnosed diabetes per 1,000 population aged 18–79 years, by race/ethnicity, united states, 1997–2011. Retrieved April 5, 2015, from http://www.cdc.gov/diabetes/statistics/incidence/fig6.htm

• Draheim, C.C. (2006). Cardiovascular disease prevalence and risk factors of persons with mental retardation. Mental Retardation and Developmental Disabilities Research Reviews, 12, 3–12.

• Dubay, L.C. & Lebrun, L.A. (2012). Health, behavior, and health care disparities: disentangling the effects of income and race in the United States. International Journal of Health Services, 42(4), 607-625

• Egerter, S., Braveman, P., Sadegh-Nobari, T., Grossman-Kahn, R., & Decker, M. (2011). Education matters for health. Issue Brief Series: Exploring the Social Determinants of Education and Health. Robert Wood Johnson Foundation. Retrieved April 5, 2015, from http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf70447

• Gee, G. C. (2002). A multilevel analysis of the relationship between institutional and individual racial discrimination and health status. American Journal of Public Health, 92(4), 615-623

• Havercamp, S.M., Scandlin, D., Roth, M. (2004). Health disparities among adults with developmental disabilities, adults with other disabilities, and adults not reporting disability in North Carolina. Public Health Reports, 119(4), 418-26.

• Hsieh, K., Heller, T., Bershadsky, J., & Taub, S. (2015). Impact of adulthood stage and social-environmental context on body mass index and physical activity of individuals with intellectual disability. Intellectual and Developmental Disabilities, 53(2), 100-113.

REFERENCES

• Hsieh, K., Rimmer, J.H., Heller, T. (2014). Obesity and associated factors in adults with intellectual disability. Journal of Intellectual Disability Research, 58(9), 851-863.

• Lynch, J., & Kaplan, G. (2000). Socioeconomic position. In L.F. Berkman & I. Kawachi (Eds.), Social Epidemiology (pp. 13-35). New York, NY: Oxford University Press.

• Link, B., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior (Extra Issue), 80-94.

• Markossian, T.W., & Hines, R.B. (2012). Disparities in late stage diagnosis, treatment, and breast cancer-related death by race, age, and rural residence among women in Georgia. Women & Health, 52(4), 317-335.

• McBean, A.M., Li, S., Gilbertson, D.T., Collins, A.J. (2004). Differences in diabetes prevalence, incidence, and mortality among the elderly of four racial/ethnic groups: Whites, Blacks, Hispanics, and Asians. Diabetes Care, 27(10), 2317-2324.

• Parish, S.L., Rose, R.A., Yoo, J., & Swaine, J.G. (2012). State Medicaid policies and the health care access of low-income children with special health care needs living in the American South. North Carolina Medical Journal, 73, 15-23.

• Parish, S.L., Thomas, K., Rose, R.A., Kilany, M., & Shattuck, P.T. (2012). State Medicaid spending and financial burden of families raising children with autism. Intellectual & Developmental Disabilities, 50, 441-451.

• Phelan, J. C., Link, B. G., & Tehranifar, P. (2010). Social conditions as fundamental causes of health inequalities theory, evidence, and policy implications. Journal of Health and Social Behavior, 51 (1 suppl), S28-S40.

• Pruitt, S. L., Lee, S. J. C., Tiro, J. A., Xuan, L., Ruiz, J. M., & Inrig, S. (2015). Residential racial segregation and mortality among black, white, and Hispanic urban breast cancer patients in Texas, 1995 to 2009. Cancer, 121(11), 1845-1855.

REFERENCES

• Rahman, M., & Foster, A. D. (2015). Racial segregation and quality of care disparity in US nursing homes. Journal of Health Economics, 39, 1-16.

• Reichard, A., Stolzle, H., & Fox, M.H. (2011). Health disparities among adults with physical disabilities or cognitive limitations compared to individuals with no disabilities in the United States. Disability and Health Journal, 4, 59-67.

• Smedley, B.D., Stith, A.Y., & Nelson, A.R. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: Institute of Medicine, National Academies Press.

• Stancliffe, R.J., Lakin, K.C., Larson, S., Engler, J., Bershandsky, J., … & Ticha, R. (2011). Overweight and obesity among adults with intellectual disabilities who use intellectual disability/developmental disability services in 20 U.S. States. American Association on Intellectual and Developmental Disabilities, 116 (11), 401-418.

• Subramanian, S. V., Acevedo-Garcia, D., & Osypuk, T. L. (2005). Racial residential segregation and geographic heterogeneity in black/white disparity in poor self-rated health in the US: a multilevel statistical analysis. Social science & medicine, 60(8), 1667-1679.

• US Department of Health and Human Services. (2002). Closing the gap: A national blue-print for improving the health of individuals with mental retardation. Report of the Surgeon General's Conference on Health Disparities and Mental Retardation. Washington, D.C., Department of Health and Human Services, Office of the Surgeon General.

• Williams, D. R., & Mohammed, S. A. (2013). Racism and health I: Pathways and scientific evidence. American Behavioral Scientist, 57(8), 1152-1173.

• Yang, Q., Rasmussen, S.A., Friedman, J.M., (2002). Mortality associated with Down’s syndrome in the USA from 1983 to 1997: a population-based study. The Lancet, 359, 1019-1025.

• Zack, M. M. (2013). Health-related quality of life—United States, 2006 and 2010. CDC Health Disparities and Inequalities Report—United States, 2013, 62(3), 105.

CONTACT US

The contents of this presentation were developed under a grant from the United States Department of Health and Human Services, Administration for Community Living (ACL), National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Grant # 90RT5020-01-00. However, those contents do not necessarily represent the policy of the Department of Health and Human Services (DHHS), and you should not assume endorsement by the Federal Government.

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