Recent prevalence estimates suggest that approximately 25% of American adults and 14% of American children and youth live with some type of disability.1–3 The prevalence of disability in the American population has increased over time and is expected to continue rising, due, in part, to an aging population and advances in medical care that extend life expectancy.4 People with disabilities experience profound health and social inequities that affect their health behaviors and outcomes. For example, people with disabilities are likely to report higher rates of diabetes and smoking, and lower rates of physical activity, than adults without disabilities5,6 and are 3 to 4 times more likely to have cardiovascular disease.5 They have higher rates of chronic diseases and mental health issues and are significantly less likely to receive preventive care and counseling.5
People with disabilities also experience substantial barriers to accessing health care. For instance, 1 in 3 adults does not have a primary care provider, 1 in 3 adults has an unmet health care need due to cost, and 1 in 4 adults did not have a routine checkup in the past year.6 Medical and health care facilities may not be fully accessible, and health care providers may not be adequately trained to work with people with disabilities. Social determinants of health, including socioeconomic level, education, and social disadvantages, have led people with disabilities to experience poverty and barriers to good health.5
Local health departments (LHDs) play an important role in addressing disability health disparities. However, LHDs may lack awareness of the prevalence of people with disabilities in the population they serve and lack knowledge of health disparities affecting people with disabilities.7 When LHDs are knowledgeable about people with disabilities in their jurisdictions, they are better equipped to reduce health inequities by engaging and including people with disabilities in their public health programs and activities.7
In 2014, the National Association of County and City Health Officials (NACCHO) conducted a baseline assessment to understand how LHDs include people with disabilities. More recently, NACCHO conducted a follow-up assessment with the purpose of comparing and evaluating progress over the past 4 years in LHDs' inclusion practices and awareness about people with disabilities living in the communities they serve.
NACCHO, in partnership with the Centers for Disease Control and Prevention (CDC), National Center on Birth Defects and Developmental Disabilities, developed the follow-up assessment questionnaire. The questionnaire comprised 22 items, including all of the items found on the baseline assessment questionnaire and additional items addressing LHD community engagement and staff training.
The follow-up assessment questionnaire was distributed online though Qualtrics Survey Software between February and March 2018 to a randomly selected and statistically representative sample of 795 LHDs. LHDs were stratified by census region and size of the population served (ie, small [<50 000 people served], medium [50 000-499 999 people served], and large [500 000 or more people served]). Because LHDs with large population sizes represent a relatively small portion of all LHDs, these LHDs were oversampled to ensure a sufficient number of responses for the analysis. Percentages were computed for each questionnaire item.
A total of 253 LHDs completed the follow-up assessment questionnaire, achieving a 32% response rate. The majority of respondents (60%) represented small LHDs, serving a population of fewer than 50 000 people. Respondents were most likely to represent the Midwest census region (43%). Most survey respondents (80%) served in agency leadership roles, such as a local health officer or LHD director.
LHD knowledge and awareness of disabilities
LHDs reported approximately the same level of awareness of the number of people with disabilities in their jurisdictions at both baseline and follow-up (46%; see Supplemental Digital Content Appendix A, available at http://links.lww.com/JPHMP/A620). LHDs also reported approximately the same level of staff knowledge regarding accommodations for people with disabilities (58%; see Supplemental Digital Content Appendix B, available at http://links.lww.com/JPHMP/A620) at baseline and follow-up.
In 2018, more LHDs (66%) reported awareness of the prevalence of chronic conditions among people with disabilities compared with 2014 (54%; see Supplemental Digital Content Appendix C, available at http://links.lww.com/JPHMP/A620). At follow-up, substantially more LHDs reported people with disabilities as a population that experiences health disparities in their jurisdictions (54%) compared with 2014 (11%; see Supplemental Digital Content Appendix D, available at http://links.lww.com/JPHMP/A620).
LHDs reported using several data sources to understand people with disabilities in their jurisdictions, including the Behavioral Risk Factor Surveillance System (BRFSS), the Census' American Community Survey, and CDC's Disability and Health Data System. LHDs were most likely to use BRFSS as a data source to learn about people with disabilities than other sources (see Supplemental Digital Content Appendix E, available at http://links.lww.com/JPHMP/A620).
The most commonly reported inclusive programmatic activities included community health improvement planning (CHIP; 92%), community health assessment (CHA; 90%), and clinical services (83%). Fewer respondents indicated that their maternal and child health services (72%) and accreditation planning/preparation (65%) were disability-inclusive programs.
Overall, LHD programs were more likely to be inclusive of people with disabilities in 2018 than in 2014. The proportion of LHDs implementing inclusive clinical services, such as preventive health services and sexual and reproductive health screening, increased to 89% and 84% in 2018 (from 26% and 20% in 2014), respectively. More LHDs also reported inclusive emergency preparedness activities, vaccination surveillance, obesity prevention, tobacco cessation, injury prevention, violence prevention, and maternal and child health services. The most prominent improvement was reported for education about mammograms and pap smears; only 20% of LHDs reported providing this inclusive education in 2014 compared with 78% of LHDs in 2018. LHDs also reported increased inclusion of people with disabilities for CHAs and accreditation planning or preparation.
LHDs included people with disabilities in their CHAs using a variety of methods. The most common way LHDs included people with disabilities in CHAs was through community health surveys, which was reported by 85% of LHDs implementing CHA processes.
Most LHDs (89%) engaged with community agencies that serve people with disabilities. Respondents reported the specific methods by which they engaged with community agencies that serve people with disabilities: as shown in Supplemental Digital Content Appendix F (available at http://links.lww.com/JPHMP/A620), most LHDs indicated engaging with these agencies through health promotion activities (90%), community health coalitions (77%), and emergency preparedness planning (70%).
Respondents reported the availability of training opportunities at their LHDs related to accommodating people with disabilities. More than half (59%) indicated their LHD did provide these training opportunities. E-learning opportunities (76%) were the most commonly selected type of available training. Many respondents indicated their LHDs offer in-person trainings facilitated by external trainers (45%) or internal subject matter experts (43%).
Health and disability resources
Most LHDs were not aware of NACCHO's health and disability program resources. Of those who were aware, most knew of NACCHO's publications (43%) and the Preparedness Brief (35%). Respondents that used NACCHO's health and disability program resources reported that these resources strongly impacted their work. The Preparedness Brief (93%) and Health and Disability 101 E-learning Module (93%) were 2 of the most popular resources LHDs reported using.
LHDs also indicated several ways NACCHO could better support them in developing and implementing programs to include people with disabilities. LHDs reported that Internet-based training (81%), fact sheets or issue briefs (69%), grant opportunities (66%), and outreach to people with disabilities (60%) would support their disability inclusion efforts (see Supplemental Digital Content Appendix G, available at http://links.lww.com/JPHMP/A620).
The purpose of the 2018 follow-up assessment was to explore disability-inclusive activities and services offered by LHDs and to compare the prevalence of these inclusive programs with the prevalence of LHDs' disability-inclusive programs reported in 2014.
Overall, LHDs were more aware of general disability issues in 2018 than in 2014, suggesting a shift in the way people with disabilities are perceived as a population experiencing health disparities and the provision of services to meet their needs. In 2018, the percentage of LHDs that considered people with disabilities as a population that experiences health disparities in their jurisdictions was more than 4 times higher than that reported in 2014. This finding may suggest that more LHDs are aware of health disparities that exist within their jurisdictions.
Most LHDs reported engaging with community agencies that serve people with disabilities and offering staff training to improve knowledge and awareness of disability as a public health issue. These findings suggest substantial shifts in LHD efforts to improve services for people with disabilities living in their jurisdictions since 2014.
Comparisons with data from the baseline assessment should be interpreted with caution. The sampling methodology, study population, and respondents were different for each assessment. In addition, comparisons were not tested for statistical significance. The 2014 assessment received a 29% response rate. Because of the 32% response rate in the 2018 assessment, the presented responses may not reflect all LHD programs and activities that are inclusive of people with disabilities.
Although many LHDs indicated they provided training opportunities for their staff on accommodating people with disabilities, locating appropriate and relevant training was also noted as a challenge. In 2017, NACCHO launched a free online training, Health and Disability 101: Training for Health Department Employees, to educate health department staff about the benefits of including people with disabilities in all public health programs, products, and services. LHD leadership is encouraged to offer this training to their staff to improve knowledge and awareness among staff members and improve inclusion among programs and services.
The majority of LHDs indicated that they were not aware of NACCHO's health and disability resources, which are available to support disability inclusion efforts at the local level. NACCHO's health and disability program will work with communications staff to increase promotion of the available resources through NACCHO's communication channels, including blog posts, newsletters, etc, as well as through direct outreach to stakeholders and partners. NACCHO staff will also increase promotion of the NACCHO Health and Disability Technical Assistance Program, through all communication channels and at NACCHO's annual conference.