Health profile for Danish adults with activity limitation: a cross-sectional study

Health can be described as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity [1], and health is fundamental for all people’s well-being and essential for daily activity and (social) participation. The United Nations Convention on the Rights of Persons with Disabilities reinforces the rights of persons with disabilities to attain the highest standard of health care, without discrimination [1] and the WHO states that ‘Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential, and more pragmatically, that none should be disadvantaged from achieving this potential, if it can be avoided.’ [2]. According to the WHO and the International Classification of Functioning (ICF), ‘disability’ is an umbrella term, covering bodily impairments, activity limitations, and participation restrictions [3].

Unfortunately, the morbidity and mortality of people with disabilities are considerably higher than in the general population [4‐12]. A study from the UK indicated that people with intellectual disabilities die 13–20 years earlier than the general population [7], and although the literature is sparse and both mortality and health probably differ by type and extent of disability, this study highlights the need for further investigations. The early death of people with disabilities may result from a primary health condition, but some of the inequalities in longevity may also be caused by secondary health conditions, suboptimal use of health care and unhealthy lifestyle. Studies have shown that secondary health problems are very common among people with intellectual disability [13, 14].

In 2011, the World Report on Disability emphasized that there are systematic barriers to the health and longevity of people with disabilities, and more importantly, that many of these barriers are modifiable [1]. Examples of barriers to overcome are a physical inaccessible environment and infrastructure, unmet needs for assistance (persons or tools) and health care, higher economic expenses (medicine, transport, food etc.), and discrimination in the labour market.

Very few international, peer-reviewed studies on the over-all health of people with disabilities have been published; to our knowledge, no European studies have yet been published on this topic. However, three health profile studies from the US and Korea (where the study by Havercamp et al., 2015 represents five other studies on the US Behavior Risk Factor Surveillance study [13, 15‐19]) show that people with disabilities have a range of unhealthy behaviours like physical inactivity, smoking, obesity; they have inadequate emotional support, a range of chronic health conditions and inadequate medical care [16, 20, 21]. These studies have been supported by single-indicator studies showing that people with disability more often are physically inactive [22‐24], obese [25, 26], smokers [27, 28] and experience life dissatisfaction and inadequate social support [29] as compared to people without disability.

In addressing the Danish National Government’s focus on equality in health, the aim of this study was to investigate 31 factors related to health and well-being, health behaviour and social relations among Danes with activity limitation (AL) and to compare the occurrence of these factors to the occurrence among individuals with no AL.

This study illustrated that a large proportion of Danish adults with AL experienced a poorer health and well-being, had an unhealthier lifestyle and poorer social relations than adults without AL, and there seemed to be a trend towards higher risk of poor health with more pronounced AL.

The Danish Health and Morbidity Surveys have the strengths of National representativity with random selection of potential participants through National registers, the large number of participants and the large amount of data on participants’ health and well-being, health behaviour, social relations and use of the health care system. Furthermore, the surveys include information on over-the-counter medicine which is not available from the Registry of Medical Statistics. The specific strengths of this health profile are the large number of health indicators and participants (both participants with profound, some and no AL) and that the questionnaire was also sent to institutionalized individuals. Furthermore, central questions were international and validated standard measures (for example self-perceived health [33], Cohen’s Perceived Stress Scale [34], the Saltin-Grimsby Physical Activity Level Scale [35], diseases [36]), and for other indicators, standard cut-points were used (overweight and obesity, alcohol limits, physical activity).

One of the potential weaknesses of this study is that only 57% of the invited chose to participate and although this participation rate is relatively high compared to other and similar studies, there is still a risk of underestimating the prevalence of AL, if individuals with AL were less likely to answer the questionnaire. There is also a possibility of selection if some of the potential participants were not able to answer the questionnaire due to physical, cognitive, or psychological limitations. The weighting for non-participation has dealt with some of this underrepresentation, but it is not possible to control for absent groups. Last, since the question on AL referred to health problems or disease, the relative risks might have been smaller if the question referred to general AL. It is emphasized that the study design does not allow differentiation between AL caused by an unhealthy lifestyle (health behaviour), and unhealthy lifestyle caused by AL.

The results of the few studies on the health of people with disabilities are remarkably consistent; in particular, the results on overall self-rated health are very strong [16, 21]. This is very similar to our finding that individuals with profound AL are three times more likely to experience poor self-perceived health. In our study, only alcohol and fast food were inversely and not consistently associated with AL, respectively. A possible explanation for the result that only among individuals with some AL, a higher proportion of individuals had a weekly intake of fast food could be accessibility – that individuals with profound AL do not have the same access to fast food as individuals with some or no AL. Regarding alcohol, the explanation could also be accessibility, but it could also be possible interference with medication or mobility. This result is supported by both the US Behavioral Surveillance System Study and the Korean study by Ko et al. [19, 20] showing that AL or disability was associated with lower odds of binge drinking [19] and not associated with binge drinking, respectively [20].

We also found that individuals with AL have a less satisfying sexual life than individuals with no AL. This is consistent with results from the US Behavioral Surveillance System Study where Kinne et al. found a lack of romantic relationships among people with disabilities [13]. Kinne et al. also reported more fatigue, sleeping problems, periods of depression, problems seeing/making friends and feelings of being isolated among people with disabilities as compared to people with no disabilities [13]. These findings are very similar to our findings on the same indicators.

However, the most relevant comparisons are probably studies in neighbour countries. In Sweden and Norway, the health of people with disabilities has only been published in native language reports from 2008 and 2010, respectively [37, 38]. The studies used data very similar to the data in our study, and although the studies did not include as many health indicators as the present study, the results were very similar and showed that individuals with functional disability had markedly poorer health status, health behaviour, and social contact than the general population. The relative risks of poor health were very similar to the relative risk found in our study, and furthermore, the prevalence of a high alcohol intake was lower among individuals with disability as compared to the general population [37, 38]. For example, in the Norwegian report, the risk of feeling alone was 4.4 and 3.4 for women and men, respectively, and the risk of obesity was 1.6 in both women and men.

It should be noted that the studies used different measures of disability. However, since disability is an umbrella term, covering bodily impairments (functional limitations), activity limitations, and participation restrictions, these measures, and combinations of them, all measure aspects of disability.

Our study shows that even in a Nordic welfare system like the Danish, the relative health of people with disabilities is very similar to the relative health of people with disabilities in the US. Striking is also the fact that preventable aspects of health and health behaviour are worse among individuals with AL compared to individuals with no AL. According to the WHO ‘Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential, and more pragmatically, that none should be disadvantaged from achieving this potential, if it can be avoided’ [1]. A range of factors influence health status and the barriers persons with disabilities meet in their environment, including individual factors, living conditions, general socioeconomic, cultural and environmental conditions, and access to health care services [1]. Equality in health therefore inevitably involves the concept of accessibility in a wide perspective and can only be obtained by taking multiple approaches including social equality (inclusion), physical accessibility (physical environment and transport), an outreaching, pro-active and inclusive health care system, and education and awareness/acknowledgement among healthcare personnel. In relation to policy and legislation this specifically implies that discrimination is stopped and that people with activity limitation are included and prioritized in public health strategies. Furthermore, efforts should be done to secure the availability and flexibility of health care services and primary prevention programs; the environment (societies and communities) should be designed and arranged to facilitate the inclusion of people with activity limitation; and any intervention or service should be available close to the homes of people with activity limitation. Last, it should be ensured that people with activity limitation can afford the same standard of health care and health behaviour as other people.