International Encyclopedia of Rehabilitation

Improving Health and Wellness of People with Disabilities

Suzanne C. Smeltzer, RN, EdD, FAAN
Professor and Director, Center for Nursing Research
Villanova University College of Nursing
Suzanne.smeltzer@villanova.edu

Improving Health and Wellness of People with Disabilities

Need for Health Promotion

Over 650 million people across the globe have a disability, which represents 10 percent of the world's population (United Nations, 2008; World Health Organization [WHO], 2007). Disability is more common in developing countries than developed countries, increasing the pressure and strain on these countries' social structures and health services. The number of people with disabilities is growing rapidly. Factors contributing to growth of the population of people with disabilities include advances in health care and technology, survival of children and adults with acute and chronic illnesses and traumatic injuries including those associated with military, religious and ethnic conflicts around the world, and aging of the population (WHO, 2009a). Many individuals with disabilities including those with severe disabilities are living normal or near-normal life spans (Vandenakker & Glass, 2001); therefore, it is important to ensure that people with disabilities have the highest level of health and wellness possible.

June Kailes, a disability advocate, posed an intriguing question: can disability, chronic conditions, health and wellness coexist? Early models of health positioned health and disability at extreme ends of the health continuum, making them mutually exclusive. Newer models and definitions, however, view health as multidimensional with optimal health located within the context of a person's unique circumstances. Thus, the ability to practice healthy behaviors even in the presence of a disability has lead to a recent emphasis on the health and wellness of people with disabilities. Health and wellness must be recognized as important for those with a disability as for those without disability. Thus, efforts should focus on assisting people with disabilities to meet their individual potential for physical, social, emotional, and intellectual health (Kailes, 2005).

Important Definitions

Several definitions are key for a discussion of health and wellness in people with disabilities. The World Health Organization's definitions of health, disability, and health promotion are relevant to the topic of improving the health and wellness of people with disabilities.

Health

Since 1948, the World Health Organization has defined health as a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity. Health is defined by the individual; the individual's state of health is dependent on his or her resources and abilities to participate in healthy behaviors and on access to or ability to seek access to the health system (WHO, 2009a). Determinants of health identified by WHO include the social and economic environment, the physical environment and the person's individual characteristics and behaviors. Generally, the context in which an individual lives is of great importance to one's quality of life and health status. Thus, the social and economic environments are key factors in determining the health status of individuals. A determinant of health of particular relevance and importance to the health of people with disabilities is access to and use of health services that prevent, detect and treat disease (WHO, 2009a).

Disability

Disability is defined as an umbrella term that covers impairments, activity limitations, and participation restrictions. It is part of the WHO's international classification system (ICF) of functioning, disability and health. Impairments are problems in body function or structure; activity limitations are difficulties encountered by an individual in carrying out a task or function; participation restrictions are problems experienced by an individual in involvement in life situations. Disability is a complex phenomenon, reflecting an interaction between an individual and features of the society in which he or she lives. This definition of disability reflects the interactions between societal, community or institutional, interpersonal, and individual factors that have an impact on the lives of people with disabilities. These factors include those situations in which health care providers can influence the health status of people with disability by improving their functioning, promoting their health and wellness, and preventing disease and further disability (WHO, 2009a). Important features of the ICF definition are the following:

  1. it is universal without reference to particular impairment groups but is equally applicable to all, and
  2. it represents health as a basic human right (WHO, 2009a)

Health Promotion

Health promotion is defined as the process of enabling people to increase control over their health and its determinants, and thereby improve their health (WHO, 2009a). A goal of health promotion is equity in health and reduction of differences in health status to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills, and opportunities for making healthy choices. Control of factors that determine one's health is needed for individuals to achieve their fullest health potential (WHO, 2009a).

Rehabilitation Clinicians and Health Promotion

Most rehabilitation programs are short-term and typically focus on patients with acute illness or injury (Rimmer, 2002). As a result, rehabilitation clinicians often have as their primary focus the increased physical functioning of people with acute injury or illness and their return to the level of function they had prior to their illness or injury. Although rehabilitation specialists are the most appropriate health professionals to address these issues, all health care providers, including rehabilitation specialists, need a broad perspective that also focuses on strategies to enable people with long-term or pre-existing disabilities to achieve as high a level of health and wellness as possible through health promotion efforts. While health promotion has been identified as a core function of public health (WHO, 2009a) and relevant to social policy, it should also be embraced as a function of health care in general and health care professionals in rehabilitation in particular.

Many studies have demonstrated that people with disabilities do not receive health screening (e.g., gynecologic exam, mammography, digital rectal exam, colonoscopy, bone mineral density [BMD] screening) that is provided to people without disabilities. Further, many do not participate in other preventive behaviors that would enable them to maintain health and wellness within limitations imposed by their disability. These behaviors include exercise, smoking cessation, healthy eating, weight management, age-appropriate immunizations (Smith, 2008).

Barriers to Health Promotion for Persons with Disabilities

A variety of barriers make it difficult or impossible for many people with disabilities to achieve optimal health and wellness and to take advantage of health promotion services that are available to people without disabilities. These barriers may be environmental, structural, and attitudinal in nature. Although facilities that are used by individuals undergoing rehabilitative therapies are usually accessible, this is often not true of other clinical facilities, including some acute care hospitals, clinics, physicians' offices, and imaging centers. As a result, people with disabilities are often unable to access health care services and receive preventive health care aimed at maintaining or improving health as readily as people without disabilities. Across the globe, people with disabilities tend to be disproportionately undereducated, untrained, underemployed, unemployed and poor (United Nations, 2009). These factors individually and in combination serve as significant barriers to health and health promotion among people with disabilities.

Lack of accessible transportation to facilities that are physically accessible also contributes to the inability of many people with disabilities to participate in health-promoting activities. For example, women with mobility limitations, receive gynecological exams, mammograms, and bone mineral density testing significantly less often than women without disabilities and less often than recommended (Smeltzer, 2006). Although exercise is an important component of health promotion, many fitness centers are reported to be inaccessible for people with disabilities and lack trainers prepared to assist people with disabilities in using equipment (Rimmer et al., 2004, 2005). Further, staff of fitness centers or facilities may have negative attitudes about people with disabilities (Kailes, 2010) and are often ill equipped to address their needs or have fears about liability.

Lack of participation in health promoting behaviors may relate to

  1. lack of knowledge about the benefits of health promotion, including preventive screening,
  2. perceived inability to participate because of disability,
  3. lack of support related to health promotion and preventive screening from health care providers, and
  4. lack of information about health and wellness strategies

In addition, negative attitudes on the part of health care providers often serve as barriers that keep them from referring people with disabilities for preventive screening and from making recommendations for such screening and for other health promotion strategies. Negative attitudes may be subtle but may result in a climate that is unwelcoming and discouraging to people with disabilities.

In addition to the usual benefits of health promotion, an issue of particular important for people with disabilities is the prevention of secondary conditions. Secondary conditions that occur with disability (e.g., pain, fatigue, overweight and obesity, low physical function and fitness levels, pressure ulcers, osteoporosis, depression) are often related to poor health promotion in people with disabilities (Rimmer, 2002; Kinne, 2008). Although some of these issues may occur in people without disabilities, they are of particular importance and concern in people with disabilities who may have a smaller margin of safety. What might be a mild to moderate concern in people without disabilities, such as weight gain, could be a much greater issue for people with disabilities. Weight gain can affect one's ability to transfer or be transferred with another person's help. Inability to transfer or move may, in turn, increase the risk of other secondary conditions such as pressure ulcers and increase the burden of disease. Weight gain along with a sedentary lifestyle may also increase the likelihood of cardiovascular disease in people with disabilities. Another example is the need for BMD testing; the presence of a disabling condition, its treatment, the lack of weight bearing exercise, and lack of exposure to sunshine often increase the risk for bone loss and osteoporosis in people with disabilities. BMD screening or testing is often warranted at a younger age than usually recommended because of early bone loss and risk for osteoporosis and fractures.

People with disabilities often consider their specialist as their primary care provider; however, specialists often believe that people with disabilities have a primary care provider who is addressing and attending to preventive health issues and health promotion. As a result, it is incumbent on all health professionals, including rehabilitation specialists, to view promotion of health and wellness for people with disabilities as part of their professional role in their interactions with all people with disabilities, including those with chronic or preexisting disabilities. Health promotion for people with disabilities involves a combination of educational, organization, economic and environmental approaches that support their emotional, social, spiritual and intellectual health and wellness (American Association on Health and Disability, 2009). Health promotion strategies and programs may, however, require modification to be congruent with the social, cultural, and economic systems in which people with disabilities live.

Because people with disabilities may have to rely on family members or other caregivers for assistance and transportation, it is important that health promotion strategies and programs also include family members and caregivers.

Benefits of Health Promotion Efforts for People with Disabilities

An issue that is important to consider is the benefit of health promotion efforts on the health and wellness of disabilities. If health care professionals are asked to address these issues in their interactions with people with disabilities, it is important to be knowledgeable about the existing evidence on the effectiveness of health promotion efforts. A number of researchers have examined the effectiveness of health promotion programs for people with chronic and disabling conditions. In a recent study, Stuifbergen and her colleagues (2010) reviewed 190 studies that tested the benefits of such programs. They reported that almost 90% of the studies reviewed demonstrated positive effects of the programs on people with a wide variety of chronic and disabling conditions. Based on this review, one can conclude that health promotion programs result in positive immediate outcomes in people with disabilities.

The following table identifies selected health promotion issues, suggested strategies for health care professions, including rehabilitation specialists, to consider when caring for people with disabilities. It must be noted that cultural differences must be considered in assessing and planning health promotion efforts if they are to be of any benefit.

Health Promotion for People with Disabilities

Physical Activity

Selected Health Promotion Issues

  • increased risks associated with sedentary life-style (weight gain, obesity, bone loss, diabetes, cardiovascular disease)
  • lack of access to fitness facilities
  • lack of awareness of importance of physical activity
  • belief that participation in physical activity and fitness is not possible because of disability

Suggested Strategies

  • Physical activity guidelines apply to all people although those with disabilities may need to work with their health care providers to understand the types and amounts of physical activity appropriate for them.
  • Determine adaptations needed to ensure safe participation in activities and use of exercise equipment.
  • Consider risk for secondary conditions related to specific disabling disorders; monitor for development of secondary conditions.
  • If fitness centers, formal exercise programs, or formal physical activity programs for people with disabilities do not exist or are not available, alternative approaches can be used successfully

References/ Resources

Nutrition

Selected Health Promotion Issues

  • limited access to and ability to prepare healthy food
  • weight management issues (increased risk of overweight and disability due to unhealthy diet and limited physical activity/exercise)
  • potential risk of interaction of foods with medications
  • fluid requirements
  • need for adequate calcium and vitamin D due to risk for osteoporosis

Suggested Strategies

  • Determine ideal body weight for individual and current body weight as well as BMI to guide recommendations for changes in dietary intake.
  • Stress importance of healthy food intake and need for adequate fluid intake.
  • Stress importance of adequate fluid intake to avoid dehydration.
  • Encourage monitoring of weight, blood glucose and lipid levels.

References/ Resources

Health education

Selected Health Promotion Issues

  • need for information reinforcing that health and wellness are achievable
  • lack of information related to health and wellness of people with disabilities and their family members and other caregivers
  • lack of accessible formats of information due to language, literacy issues, and sensory impairments
  • lack of accessibility of many general health education programs to people with disabilities

Suggested Strategies

  • Assume that people with disabilities are interested in health and wellness rather than assume that they are not interested or will not benefit from it.
  • Provide health information in accessible formats preferred by the individual with a disability.
  • Provide health-related information that is empowering and promotes choice.
  • Use empowerment and self-determination models to build or restore self-efficacy.
  • Ask individuals with disability about what information they want.
  • Do not assume that health care providers are more knowledgeable about an individual's disability than he/she is.
  • Communicate with all people with disabilities as adults; do not assume lack of intelligence or ability of others to speak for people with disabilities.
  • Direct all communication to the person with a disability and not to accompanying person.
  • Identify and encourage use of accessible websites on health issues.

References/ Resources

Health screening

Selected Health Promotion Issues

  • lack of knowledge about health screening recommendations (BMD, gynecologic exam and Pap smear, mammography, digital rectal exam, colonoscopy, etc.)
  • failure of health care providers to recommend appropriate screening because of negative attitudes and belief that health screening is futile for people with disabilities
  • lack of access to accessible health care facilities and imaging centers
  • greater need for screening because of early age at onset of health problems because of disability

Suggested Strategies

  • Consider that people with disabilities may have had previous negative experiences and encounters with health care professionals.
  • Assist people with disabilities to identify, locate, and evaluate accessibility of screening sites or imaging centers.
  • Recognize increased risk for bone loss and osteoporosis at earlier age than people without disabilities.
  • Follow up to determine if recommended health screening has been obtained.

References/ Resources

  • AHRQ (2009) Guide to Clinical Preventive Services 2009
  • U.S. Department of Justice (2010): http://www.ada.gov/medcare_mobility_ta/medcare_ta.pdf

Immunizations

Selected Health Promotion Issues

  • lack of immunizations increases risks of diseases that compromise health status

Suggested Strategies

  • Encourage people with disabilities to adhere to age-appropriate recommendations for immunizations.
  • Follow up to determine if immunization recommendations were followed.

References/ Resources

  • Child & Adolescent Immunization Schedules 2010 (CDC)
  • Recommended adult immunization schedule 2010 (CDC)

Sexuality and reproductive health issues

Selected Health Promotion Issues

  • lack of information and support from health care providers
  • belief on part of health care providers and society at large that people with disabilities are asexual
  • stigma and prejudice about sexuality in people with disabilities

Suggested Strategies

  • Do not assume that people with disabilities are asexual and uninterested in sexual activity, intimate relationships and childbearing.
  • Consider that individuals with disability may have had previous negative experiences and encounters with health care professionals related to sexuality.
  • Provide same information and teaching that you would provide to anyone else (safer sex, contraception, etc.)

References/ Resources

Interpersonal violence and abuse

Selected Health Promotion Issues

  • failure of health care providers to assess people with disabilities for spectrum of abuse despite evidence that they are at greater risk than many other populations.

Suggested Strategies

  • Assess women, men, and children with disabilities for physical, emotional, and sexual abuse or neglect.
  • Use assessment protocols specifically designed for people with disabilities.
  • Assist those who are being abused to develop a safety plan.

References/ Resources

Smoking

Selected Health Promotion Issues

  • lack of health care providers' attention to smoking in people with disabilities
  • increases risks of cardiovascular and respiratory diseases, and certain forms of cancer
  • interferes with healing, increases risk for pressure ulcers, and accelerates bone loss

Suggested Strategies

  • Assess smoking history (past and current)
  • Encourage participation in smoking cessation programs that are accessible
  • Follow up to determine if recommendations were followed.
  • If smoking is used for stress relief, assist patient to identify healthy strategies to relieve stress.

References/ Resources

Alcohol and Substance Abuse

Selected Health Promotion Issues

  • may be associated with low self-esteem and depression in people with disabilities.
  • increase risks for secondary conditions, including falls and other injuries
  • can alter the effect of prescribed and over-the-counter drugs
  • can increase severity of disability due to neurological, cardiovascular, and gastrointestinal problems, including liver disease

Suggested Strategies

  • Assess history of use of alcohol and other drugs.
  • Identify accessible treatment programs and centers.
  • Follow up to determine if recommendations were followed.
  • If alcohol and drug use are used for stress relief, assist patient to identify healthy strategies to relieve stress.

References/ Resources

  • Alcohol and Public Health (2010)

Psychosocial health

Selected Health Promotion Issues

  • psychosocial issues are not uncommon with disability
  • depression is not an inevitable part of having a disability and should be treated

Suggested Strategies

  • Assess for depression and other psychosocial issues.
  • Identify accessible treatment programs and centers.
  • Encourage participation in activities and support groups.
  • Follow up to determine if recommendations were followed.
  • Assist patient to identify healthy strategies to cope with stress.

References/ Resources

This article has provided an overview of issues and strategies related to health and wellness of people with disabilities. Despite the presence of a disability, people with disabilities have the potential for health and wellness to the same extent as those without disability. The near-normal lifespan of many people with disabilities and their involvement in family and community activities provide strong rationale for addressing their long-term health and wellness. Strategies to ensure that people with disabilities have access to preventive health care and screening should be a high priority among all health care providers, including rehabilitation specialists, and should begin early in life rather than after additional health problems develop. These strategies have the potential to contribute to the wellbeing of people with disabilities, their families, and their communities.

References

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Centers for Disease Control and Prevention. 2010. Alcohol and Public Health. http://www.cdc.gov/alcohol. Accessed June 30, 2010.

Centers for Disease Control and Prevention. 2004. The health consequences of smoking: a report of the Surgeon General. Washington (DC): Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

Center for Research on Women with Disabilities (CROWD). 2005. Removing disability disparities in women's health. http://www.bcm.edu/crowd/. Accessed June 30, 2010.

Kailes JI. 2010. Using a fitness center does not have to be an exercise in frustration: Tips for people with mobility and visual disabilities. NCPAD Newsletter 9(6). http://www.ncpad.org/newsletter/. Accessed June 30, 2010.

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Kinne S. 2008. Distribution of secondary medical problems, impairments, and participation limitations among adults with disabilities and their relationship to health and other outcomes. Disability and Health Journal 1(1):42-50.

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Smeltzer SC, Zimmerman V, DeSilets LD, Frain ME, Duffin JM. 2003. Accessible Online Health Promotion Information for Persons with Disabilities. Online Journal of Issues in Nursing October 30. Available online: http://nursingworld.org/ojin/.

Smeltzer SC. 2006. Preventive health screening for breast and cervical cancer and osteoporosis in women with physical disabilities. Family Commun Health 29(1 Suppl):35S-43S.

Smith DL. 2008. Disparities in health care access for women with disabilities in the United States from the 2006 National Health Interview Survey. Disability and Health Journal 1(2):79-88.

Stuifbergen AK, Morris M, Jung JH, Pierini D, Morgan S. 2010. Benefits of wellness interventions for persons with chronic and disabling conditions. A review of the evidence. Disability and Health Journal 3(3):1333-1345.

United Nations. 2008. Rights and dignity of persons with disabilities. Factsheet on persons with disabilities. http://www.un.org/disabilities. Accessed June 30, 2010.

United Nations. 2009. Disability at a Glance 2009: a Profile of 36 Countries and Areas in Asia and the Pacific. New York: United Nations.

U.S. Department of Justice. 2010. Access to Medical Care for Individuals with Mobility Disabilities. U.S. Department of Justice, Civil Rights Division, Disability Rights Section.

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World Health Organization. 2004. Global Burden of Disease 2004, Part 3: Disease incidence, prevalence, and disability. Geneva: World Health Organization Press.

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Cite this article

Smeltzer SC. 2010. Improving Health and Wellness of People with Disabilities. In: JH Stone, M Blouin, editors. International Encyclopedia of Rehabilitation. Available online: http://cirrie.buffalo.edu/encyclopedia/en/article/300/

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