# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 6 {#section-1 .Chapter-#}

# Disability and Secondary Conditions

Co-Lead Agencies: Centers for Disease Control and Prevention\
National Institute on Disability and Rehabilitation\
Research, U.S. Department of Education

### Contents {#contents .Heading-Special}

[Goal Page 6-3](#__RefHeading___Toc486927297)

[Overview Page 6-3](#overview)

[Issues Page 6-3](#issues)

[Trends Page 6-4](#trends)

[Disparities Page 6-5](#disparities)

[Opportunities Page 6-6](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
6-7](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
6-8](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
6-9](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
6-22](#related-objectives-from-other-focus-areas)

[Terminology Page 6-25](#terminology)

[References Page 6-26](#references)

[]{#__RefHeading___Toc486927297 .anchor}

## Goal

Promote the health of people with disabilities, prevent\
secondary conditions, and eliminate disparities between\
people with and without disabilities in the U.S. population.

## Overview

Because disability status has been traditionally equated with health
status, the health and well-being of people with disabilities has been
addressed primarily in a medical care, rehabilitation, and long-term
care financing context. Four main misconceptions emerge from this
contextual approach: (1) all people with disabilities automatically have
poor health, (2) public health should focus only on preventing disabling
conditions, (3) a standard definition of "disability" or "people with
disabilities" is not needed for public health purposes, and (4) the
environment plays no role in the disabling process. These misconceptions
have led to an underemphasis of health promotion and disease prevention
activities targeting people with disabilities and an increase in the
occurrence of secondary conditions (medical, social, emotional, family,
or community problems that a person with a primary disabling condition
likely experiences).

### Issues

Challenging these misconceptions will help to clarify the health status
of people with disabilities and address the environmental barriers that
undermine their health, well-being, and participation in life
activities. A broad array of health promotion activities are relevant to
all people experiencing a disability, whether they are categorized by
racial or ethnic group, gender, and primary conditions or diagnoses,
such as major depression, cerebral palsy, diabetes, spinal cord injury,
or fetal alcohol syndrome. The similarities among people with
disabilities are as important as or more important than the differences
among clinical diagnostic groups. Caregiver issues also have been
considered, as well as environmental barriers. Environmental factors
affect the health and well-being of people with disabilities in many
ways. For example, weather can hamper wheelchair mobility, medical
offices and equipment may not be accessible, and shelters or fitness
centers may not be staffed or equipped for people with disabilities.
Compliance with the Americans with Disabilities Act (ADA) would help
overcome some of these barriers. A crosscutting goal is to eliminate
disparities with the nondisabled population.

The *International Classification of Functioning and Disability*
(ICIDH-2), developed by the World Health Organization (WHO) with the
input of numerous nations---including the United States---provides
uniform language and a framework for describing functioning, health, and
disability status among all people.[^1] This framework clarifies
definitional issues and includes environmental factors.

### Trends

An estimated 54 million persons in the United States, or nearly 20
percent of the population, currently live with disabilities.[^2] Data
for the period 1970 to 1994 suggest that the proportion is
increasing.[^3] The increase in disability among all age groups
indicates a growing need for public health programs serving people with
disabilities.

From 1990 to 1994, disability rates increased among youth under age 18
years.Error: Reference source not found There was a 33 percent increase
in activity limitations among girls, from 4.2 percent to 5.6 percent,
and a 40 percent increase in activity limitations among boys, from 5.6
percent to 7.9 percent.

Among adults aged 18 to 44 years, there was a 16 percent increase in
activity limitations, from 8.8 percent in 1990 to 10.3 percent in
1994.Error: Reference source not found This increase suggests that 3.1
million more people aged 18 to 44 years were limited in 1994 than in
1990.

The absolute number of adults aged 65 years and older with disabilities
increased from 26.9 million in 1982 to 34.1 million in 1996. Because the
total number of adults aged 65 years and older increased even faster,
the proportion of those with disabilities declined from 24.9 percent in
1982 to 21.3 percent in 1994.Error: Reference source not found However,
the rise in numbers indicates a growing need for programs and services
to serve this older population.

The direct medical and indirect annual costs associated with disability
are more than \$300 billion, or 4 percent of the gross domestic
product.[^4] This total cost includes \$160 billion in medical care
expenditures (1994 dollars) and lost productivity costs approaching
\$155 billion.

The health promotion and disease prevention needs of people with
disabilities are not nullified because they are born with an impairing
condition or have experienced a disease or injury that has long-term
consequences.[^5] People with disabilities have increased health
concerns and susceptibility to secondary conditions. Having a long-term
condition increases the need for health promotion that can be medical,
physical, social, emotional, or societal.

People who have activity limitations report having had more days of
pain, depression, anxiety, and sleeplessness and fewer days of vitality
during the previous month than people not reporting activity
limitations.[^6] Increased emotional distress, however, does not arise
directly from the person's limitations. The distress is likely to stem
from encounters with environmental barriers that reduce the individual's
ability to participate in life activities and that undermine physical
and emotional health. In view of the increased rates of disability among
youth, it is particularly important to target activities and services
that address all aspects of health and well-being, including promoting
health, preventing secondary conditions, and removing environmental
barriers, as well as providing access to medical care. For an older
person with a disability, it is important to target worsening coexisting
conditions that may intensify and thus threaten general well-being. For
example, declining vision combined with declining hearing can greatly
impair mobility, nutrition, and fitness.[^7]

### Disparities

Disability can be viewed as a universal phenomenon everyone experiences
at some time.[^8] Disability also can be viewed as representing a
minority of the population, in that people with disabilities may be less
visible, undercounted, and underserved.[^9] As a potentially underserved
group, people with disabilities would be expected to experience
disadvantages in health and well-being compared with the general
population. People with disabilities may experience lack of access to
health services and medical care and may be considered at increased risk
for various conditions.

Few data systems identify people with disabilities as a subpopulation.
Disparities need to be identified to plan appropriate public health
programs. Despite the paucity of data, some disparities between people
with and without disabilities have been noted. These disparities include
excess weight, reduced physical activity, increased stress, and less
frequent mammograms for women over age 55 years with
disabilities.[^10]![](media/image2.wmf){width="4.647222222222222in"
height="4.394444444444445in"}

### Opportunities

Health promotion programs that focus on improving functioning across a
spectrum of diagnoses and a range of age groups are effective in
reducing secondary conditions and outpatient physician visits among
people with disabilities.[^11]**^,^** [^12]**^,^** [^13] For example, a
focus on improving muscle tone, flexibility, and strength can accrue
benefits for mobility-impaired people in wheelchairs and
mobility-impaired people with arthritis.[^14] For people with
communication disabilities and disorders, interventions can improve
access to health-enhancement programs. People with sight impairments can
have access to readable job applications, food labels, and medications.
People with hearing impairments can have access to televised or
videotaped exercise programs that are captioned or signed by
interpreters depicted within an inset of a video screen. Often, the most
effective interventions may be environmental rather than medical.

Many health promotion interventions already in place for the population
at large may be easily adapted to the needs of people with disabilities.
New strategies can be influenced by results from studies that describe
risk factors for secondary conditions or protective factors against
additional impairments. For example, the number of cases of secondary
osteoporosis among able-bodied women and their range of bone mineral
density deficits can be estimated by using existing Federal data sets.
The degree to which women exercise and ingest calcium or estrogen
supplements also can be estimated, leading to measurements of the
influence of both risk and protective factors associated with
osteoporosis in the able-bodied population. Because women with mobility
impairments experience an elevated risk for secondary osteoporosis at
earlier ages, their risk factors, including diminished bone mineral
density, and their potential protective factors, including optimal
calcium or estrogen supplementation and types of exercise, become
critically important epidemiologic parameters.[^15]**^,^** [^16] The
results of investigations of secondary osteoporosis already influence
health promotion strategies among able-bodied women. Similar
investigations can augment the development of health promotion
strategies among women with disabilities.

Current guidelines provide opportunity to design health promotion
interventions targeting people with disabilities that accommodate
ongoing evidence-based evaluation[^17] and demonstrate
cost-effectiveness.[^18]**^,^** [^19] For example, clinical
interventions that focus on appropriate and timely medical care can be
equally accessible for people with and without disabilities. Mammography
screening is recommended every 1 to 2 years, with or without an annual
clinical breast examination, for able-bodied women aged 50 to 69
years.[^20] This recommendation also can be adapted for women with
disabilities. Clinical providers, however, must first recognize the
reasons women with disabilities often refrain from seeking mammography
services, such as the lack of adaptive equipment on

mammography screening machines or unfamiliarity with the needs of people
with disabilities expressed by clinicians. Counseling to prevent
injuries among all adults also is recommended. For example, men and
women with disabilities, especially those with skeletal insufficiencies
or calcium deficits, are at increased risk for fractures. Adding bone
mineral screening and fitness counseling during clinical encounters may
be beneficial in preventing injuries. In these ways, evidence-based
health promotion and disease prevention programs can be developed,
implemented, and evaluated to target the health and injury disparities
between people with and without disabilities.

Health promotion interventions for people with disabilities---in the
community, clinical settings, or elsewhere---should include culturally
and linguistically appropriate elements.

## Interim Progress Toward Year 2000 Objectives

Healthy People 2000 did not have a chapter specifically establishing
health objectives for people with disabilities. However, some objectives
targeted people with disabilities, including leisure-time physical
activity, use of community support programs by people with severe mental
disorders, treatment for depression, activity limitations associated
with chronic conditions and back conditions, and receipt of recommended
clinical preventive services. A progress review held in January 1997
showed that none of these specific objectives relevant to people with
disabilities had been met,Error: Reference source not found and parity
with the nondisabled population will continue to be monitored.

People with disabilities reporting no leisure-time physical activity
declined from the 1985 baseline of 35 percent to 29 percent in 1995,
short of the target of 20 percent for 2000. In addition, the review
noted several disparities: 40 percent of people with disabilities aged
20 years and older reported being overweight compared with 35 percent of
the general population and short of the goal of 25 percent; 49 percent
of people aged 18 years and older with disabilities reported adverse
health effects from stress compared with 34 percent of the general
population; and clinical preventive services showed disparities for data
on tetanus boosters (56 percent versus 59 percent for the general
population), Pap tests (69 percent versus 77 percent of women aged 18
years and over in 1994), and breast exams and mammograms (50 percent
versus 56 percent for women aged 50 years and over).

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Disability and Secondary Conditions {#disability-and-secondary-conditions-1 .Heading-Special-Sub}

**Goal:** Promote the health of people with disabilities, prevent
secondary conditions, and eliminate disparities between people with and
without\
disabilities in the U.S. population.

  ------------ -------------------------------------------------------------
  **Number**   **Objective Short Title**

  6-1          Standard definition of people with disabilities in data sets

  6-2          Feelings and depression among children with disabilities

  6-3          Feelings and depression interfering with activities among
               adults with disabilities

  6-4          Social participation among adults with disabilities

  6-5          Sufficient emotional support among adults with disabilities

  6-6          Satisfaction with life among adults with disabilities

  6-7          Congregate care of children and adults with disabilities

  6-8          Employment parity

  6-9          Inclusion of children and youth with disabilities in regular
               education\
               programs

  6-10         Accessibility of health and wellness programs

  6-11         Assistive devices and technology

  6-12         Environmental barriers affecting participation in activities

  6-13         Surveillance and health promotion programs
  ------------ -------------------------------------------------------------

## Healthy People 2010 Objectives

6-1. Include in the core of all relevant Healthy People 2010\
surveillance instruments a standardized set of questions that identify
"people with disabilities."

**Target:** 100 percent.

**Baseline:** No Healthy People 2010 surveillance instruments include a
standard set of questions that identify people with disabilities in
1999.

**Target setting method:** Total coverage.

**Data source:** CDC, NCEH.

The call for statistics on people with disabilities is longstanding and
increasing. Various Federal agencies have attempted to collect these
data in several research areas.[^21] Two separate issues exist regarding
data collection: (1) using different operational definitions of
disability and (2) not collecting information from people with
disabilities during surveys. None of the federally funded surveys
attempting to collect data on people with disabilities is using the same
definition of disability. This lack of standardization has made it
difficult to (1) identify and include individuals with a disability, (2)
measure the nature and extent of disability in the United States, (3)
assess the impact of various disabilities on the person's ability to
participate in society, (4) assess the extent of secondary conditions
among people with disabilities, and (5) identify environmental barriers
to participation and risk factors for poor health in this population.

The issue of not including people with disabilities is reflected in the
initial survey design. Most studies are not designed to include, target,
and analyze data on people with disabilities. People with disabilities
could be included as a select population if, for example, the data
collection method ensured appropriate access and outreach.

To remedy these gaps, a set of survey questions has been developed and
is being tested to identify individuals with varying degrees of
disability in terms of activity limitations.[^22] This short set of
questions may be placed in the core of all Healthy People surveillance
instruments that collect demographic data to include and standardize
information on people with disabilities. On the basis of standardization
and inclusion in the Nation's disability data collection activities, the
call for disability statistics may be satisfied. Once collected, these
data will help government policymakers, consumers and advocates,
researchers, and clinicians make better informed choices to promote the
health status and well-being of people with disabilities.

6-2. Reduce the proportion of children and adolescents with disabilities
who are reported to be sad, unhappy, or\
depressed.

**Target:** 17 percent.

**Baseline:** 31 percent of children and adolescents aged 4 to 11 years
with disabilities were reported to be sad, unhappy, or depressed in
1997.

**Target setting method:** 45 percent improvement (parity with children
and\
adolescents without disabilities in 1997).

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------+------------+-------------+
| **Children and Adolescents Aged 4 to 11  | **Reported |             |
| Years, 1997**                            | To Be      |             |
|                                          | Sad,\      |             |
|                                          | Unhappy,   |             |
|                                          | or         |             |
|                                          | D          |             |
|                                          | epressed** |             |
+==========================================+============+=============+
|                                          | **With\    | **Without\  |
|                                          | Disa       | Disab       |
|                                          | bilities** | ilities\*** |
+------------------------------------------+------------+-------------+
|                                          | Percent    |             |
+------------------------------------------+------------+-------------+
| > **TOTAL**                              | 31         | 17          |
+------------------------------------------+------------+-------------+
| **Race and ethnicity**                   |            |             |
+------------------------------------------+------------+-------------+
| > American Indian or Alaska Native       | DSU        | DSU         |
+------------------------------------------+------------+-------------+
| > Asian or Pacific Islander              | DSU        | 13          |
+------------------------------------------+------------+-------------+
| > Asian                                  | DSU        | 16          |
+------------------------------------------+------------+-------------+
| > Native Hawaiian and other Pacific      | DSU        | DSU         |
| > Islander                               |            |             |
+------------------------------------------+------------+-------------+
| > Black or African American              | DSU        | 16          |
+------------------------------------------+------------+-------------+
| > White                                  | 31         | 17          |
+------------------------------------------+------------+-------------+
|                                          |            |             |
+------------------------------------------+------------+-------------+
| > Hispanic or Latino                     | 32         | 16          |
+------------------------------------------+------------+-------------+
| > Not Hispanic or Latino                 | 30         | 17          |
+------------------------------------------+------------+-------------+
| > Black or African American              | DSU        | 17          |
+------------------------------------------+------------+-------------+
| > White                                  | 31         | 18          |
+------------------------------------------+------------+-------------+
| **Gender**                               |            |             |
+------------------------------------------+------------+-------------+
| > Female                                 | 32         | 16          |
+------------------------------------------+------------+-------------+
| > Male                                   | 30         | 18          |
+------------------------------------------+------------+-------------+
| **Family income level**                  |            |             |
+------------------------------------------+------------+-------------+
| > Poor                                   | 37         | 20          |
+------------------------------------------+------------+-------------+
| > Near poor                              | 31         | 17          |
+------------------------------------------+------------+-------------+
| > Middle/high income                     | 27         | 17          |
+------------------------------------------+------------+-------------+
| **Geographic location**                  |            |             |
+------------------------------------------+------------+-------------+
| > Urban                                  | 27         | 17          |
+------------------------------------------+------------+-------------+
| > Rural                                  | 39         | 16          |
+------------------------------------------+------------+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*The total represents the target. Data for population groups by race,
ethnicity, gender, socioeconomic status, and geographic location are
displayed to further characterize the issue.

Note: The table above may have continued from the previous page.

6-3. Reduce the proportion of adults with disabilities who\
report feelings such as sadness, unhappiness, or\
depression that prevent them from being active.

**Target:** 7 percent.

**Baseline:** 28 percent of adults aged 18 years and older with
disabilities reported feelings that prevented them from being active in
1997 (age adjusted to the year 2000 standard population).

**Target setting method:** 75 percent improvement (parity with adults
aged 18 years and older without disabilities in 1997).

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+------------------------------------------+--------------+---+-----------+
| **Adults Aged 18 Years and Older, 1997** | **Reported   |   |           |
|                                          | Feelings     |   |           |
|                                          | That\        |   |           |
|                                          | Prevent      |   |           |
|                                          | Activity**   |   |           |
+==========================================+==============+===+===========+
|                                          | **With\      |   | *         |
|                                          | Di           |   | *Without\ |
|                                          | sabilities** |   | Disabil   |
|                                          |              |   | ities\*** |
+------------------------------------------+--------------+---+-----------+
|                                          | Percent      |   |           |
+------------------------------------------+--------------+---+-----------+
| > **TOTAL**                              | 28           | 7 |           |
+------------------------------------------+--------------+---+-----------+
| **Race and ethnicity**                   |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > American Indian or Alaska Native       | 22           | 1 |           |
|                                          |              | 5 |           |
+------------------------------------------+--------------+---+-----------+
| > Asian or Pacific Islander              | 30           | 7 |           |
+------------------------------------------+--------------+---+-----------+
| > Asian                                  | DSU          | 6 |           |
+------------------------------------------+--------------+---+-----------+
| > Native Hawaiian and other Pacific      | DSU          | 1 |           |
| > Islander                               |              | 4 |           |
+------------------------------------------+--------------+---+-----------+
| > Black or African American              | 31           | 8 |           |
+------------------------------------------+--------------+---+-----------+
| > White                                  | 28           | 7 |           |
+------------------------------------------+--------------+---+-----------+
|                                          |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > Hispanic or Latino                     | 40           | 9 |           |
+------------------------------------------+--------------+---+-----------+
| > Not Hispanic or Latino                 | 27           | 7 |           |
+------------------------------------------+--------------+---+-----------+
| > Black or African American              | 31           | 8 |           |
+------------------------------------------+--------------+---+-----------+
| > White                                  | 27           | 6 |           |
+------------------------------------------+--------------+---+-----------+
| **Gender**                               |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > Female                                 | 30           | 8 |           |
+------------------------------------------+--------------+---+-----------+
| > Male                                   | 26           | 6 |           |
+------------------------------------------+--------------+---+-----------+
| **Family income level**                  |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > Poor                                   | 38           | 1 |           |
|                                          |              | 3 |           |
+------------------------------------------+--------------+---+-----------+
| > Near poor                              | 30           | 1 |           |
|                                          |              | 0 |           |
+------------------------------------------+--------------+---+-----------+
| > Middle/high income                     | 21           | 6 |           |
+------------------------------------------+--------------+---+-----------+
| **Education level** (aged 25 years and   |              |   |           |
| older)                                   |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > Less than high school                  | 34           | 1 |           |
|                                          |              | 0 |           |
+------------------------------------------+--------------+---+-----------+
| > High school graduate                   | 29           | 7 |           |
+------------------------------------------+--------------+---+-----------+
| > At least some college                  | 25           | 5 |           |
+------------------------------------------+--------------+---+-----------+
| **Geographical location**                |              |   |           |
+------------------------------------------+--------------+---+-----------+
| > Urban                                  | 29           | 7 |           |
+------------------------------------------+--------------+---+-----------+
| > Rural                                  | 26           | 6 |           |
+------------------------------------------+--------------+---+-----------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*The total represents the target. Data for population groups by race,
ethnicity, gender, socioeconomic status, and geographic location are
displayed to further characterize the issue.

Note: The table above may have continued from the previous page.

Children and adults with disabilities and their families face issues of
coping, adapting, adjusting, and learning to live well with the
disability---a dynamic, ongoing process. Good mental health, including
refusing to internalize the social stigma of disability and developing a
positive attitude and strong self-esteem, is a key ingredient to
overcoming these issues.[^23] Improving mental health status among
people with disabilities and their families will help address
psychological barriers and enhance their ability to participate fully in
society.[^24]

6-4. Increase the proportion of adults with disabilities who\
participate in social activities.

**Target:** 100 percent.

**Baseline:** 95.4 percent of adults aged 18 years and older with
disabilities participated in social activities in 1997 (age adjusted to
the year 2000 standard population).

**Target setting method:** Total participation (parity with adults aged
18 years and older without disabilities in 1997).

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+-----------------------------+-------------------+-------------------+
| **Adults Aged 18 Years and  | **Participation   |                   |
| Older, 1997**               | in Social         |                   |
|                             | Activity**        |                   |
+=============================+===================+===================+
|                             | **With\           | **Without\        |
|                             | Disabilities**    | Disabilities\***  |
+-----------------------------+-------------------+-------------------+
|                             | Percent           |                   |
+-----------------------------+-------------------+-------------------+
| > **TOTAL**                 | 95.4              | 100.0             |
+-----------------------------+-------------------+-------------------+
| **Race and ethnicity**      |                   |                   |
+-----------------------------+-------------------+-------------------+
| > American Indian or        | 87.4              | 100.0             |
| > Alaska\                   |                   |                   |
| > Native                    |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Asian or Pacific Islander | 99.6              | 100.0             |
+-----------------------------+-------------------+-------------------+
| > Asian                     | 99.5              | 100.0             |
+-----------------------------+-------------------+-------------------+
| > Native Hawaiian and other | 100.0             | 100.0             |
| > Pacific Islander          |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Black or African American | 95.0              | 99.8              |
+-----------------------------+-------------------+-------------------+
| > White                     | 95.6              | 100.0             |
+-----------------------------+-------------------+-------------------+
|                             |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Hispanic or Latino        | 93.9              | 100.0             |
+-----------------------------+-------------------+-------------------+
| > Not Hispanic or Latino    | 95.5              | 100.0             |
+-----------------------------+-------------------+-------------------+
| > Black or African American | 95.0              | 99.8              |
+-----------------------------+-------------------+-------------------+
| > White                     | 95.7              | 100.0             |
+-----------------------------+-------------------+-------------------+
| **Gender**                  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Female                    | 95.2              | 99.9              |
+-----------------------------+-------------------+-------------------+
| > Male                      | 95.7              | 100.0             |
+-----------------------------+-------------------+-------------------+
| **Family income level**     |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Poor                      | 93.1              | 99.9              |
+-----------------------------+-------------------+-------------------+
| > Near poor                 | 95.8              | 99.9              |
+-----------------------------+-------------------+-------------------+
| > Middle/high income        | 96.5              | 100.0             |
+-----------------------------+-------------------+-------------------+
| **Education level** (aged   |                   |                   |
| 25 years and older)         |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Less than high school     | 94.1              | 99.9              |
+-----------------------------+-------------------+-------------------+
| > High school graduate      | 94.8              | 99.9              |
+-----------------------------+-------------------+-------------------+
| > At least some college     | 96.0              | 100.0             |
+-----------------------------+-------------------+-------------------+
| ###### Geographic location  |                   |                   |
+-----------------------------+-------------------+-------------------+
| > Urban                     | 95.3              | 100.0             |
+-----------------------------+-------------------+-------------------+
| > Rural                     | 95.6              | 99.9              |
+-----------------------------+-------------------+-------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*The total represents the target. Data for population groups by race,
ethnicity, gender, socioeconomic status, and geographic location are
displayed to further characterize the issue.

Note: The table above may have continued from the previous page.

People with disabilities report significantly lower levels of social
participation compared with people without disabilities.[^25]
Participating in social activities routinely requires personal
interaction with the environment, a component of life that is vital to
the well-being of all humanity. ICIDH-2, the *International
Classification of Functioning and Disability,* highlights the importance
of participating in social activities as a measurable outcome of living
well with a disability.Error: Reference source not found The ICIDH-2
framework indicates that the environment should be examined as a barrier
to participation.

Social participation can include activities such as volunteering,
shopping, going to the movies, or attending sporting events. Targeting
increased participation in regular social activities such as traveling,
socializing with friends and family, attending church or community
events, and voting can result in improved functional status and
well-being.

6-5. Increase the proportion of adults with disabilities reporting
sufficient emotional support.

**Target:** 79 percent.

**Baseline:** 71 percent of adults aged 18 years and older with
disabilities reported sufficient emotional support in 1998 (data from 11
States and the District of\
Columbia; age adjusted to the year 2000 standard population).

**Target setting method:** 11 percent improvement (parity with adults
aged 18 years and older without disabilities in 1998).

**Data source:** Behavioral Risk Factor Surveillance System (BRFSS),
CDC, NCCDPHP.

+------------------------------------------+------------+---+-------------+
| **Adults Aged 18 Years and Older, 1998** | **Reported |   |             |
|                                          | S          |   |             |
|                                          | ufficient\ |   |             |
|                                          | Emotional  |   |             |
|                                          | S          |   |             |
|                                          | upport\*** |   |             |
+==========================================+============+===+=============+
|                                          | **With\    |   | **Without\  |
|                                          | Disa       |   | Disa        |
|                                          | bilities** |   | bilities** |
+------------------------------------------+------------+---+-------------+
|                                          | Percent    |   |             |
+------------------------------------------+------------+---+-------------+
| > **TOTAL**                              | 71         | 7 |             |
|                                          |            | 9 |             |
+------------------------------------------+------------+---+-------------+
| **Race and ethnicity**                   |            |   |             |
+------------------------------------------+------------+---+-------------+
| > American Indian or Alaska Native       | 56         | 7 |             |
|                                          |            | 2 |             |
+------------------------------------------+------------+---+-------------+
| > Asian or Pacific Islander              | 49         | 6 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
| > Asian                                  | DSU        | D |             |
|                                          |            | S |             |
|                                          |            | U |             |
+------------------------------------------+------------+---+-------------+
| > Native Hawaiian and other Pacific      | DSU        | D |             |
| > Islander                               |            | S |             |
|                                          |            | U |             |
+------------------------------------------+------------+---+-------------+
| > Black or African American              | 53         | 6 |             |
|                                          |            | 8 |             |
+------------------------------------------+------------+---+-------------+
| > White                                  | 74         | 8 |             |
|                                          |            | 2 |             |
+------------------------------------------+------------+---+-------------+
|                                          |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Hispanic or Latino                     | 44         | 6 |             |
|                                          |            | 8 |             |
+------------------------------------------+------------+---+-------------+
| > Not Hispanic or Latino                 | 72         | 8 |             |
|                                          |            | 0 |             |
+------------------------------------------+------------+---+-------------+
| > Black or African American              | DNA        | D |             |
|                                          |            | N |             |
|                                          |            | A |             |
+------------------------------------------+------------+---+-------------+
| > White                                  | DNA        | D |             |
|                                          |            | N |             |
|                                          |            | A |             |
+------------------------------------------+------------+---+-------------+
| **Gender**                               |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Female                                 | 70         | 7 |             |
|                                          |            | 9 |             |
+------------------------------------------+------------+---+-------------+
| > Male                                   | 70         | 7 |             |
|                                          |            | 8 |             |
+------------------------------------------+------------+---+-------------+
| **Education level** (aged 25 years and   |            |   |             |
| older)                                   |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Less than high school                  | 58         | 7 |             |
|                                          |            | 0 |             |
+------------------------------------------+------------+---+-------------+
| > High school graduate                   | 74         | 7 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
| > At least some college                  | 74         | 8 |             |
|                                          |            | 3 |             |
+------------------------------------------+------------+---+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data are from 11 States and the District of Columbia.

**^^**The total represents the target. Data for population groups by
race, ethnicity, gender, socioeconomic status, and geographic location
are displayed to further characterize the issue.

Emotional support often is derived from a person's social support
systems. Two hypotheses suggest that social support helps a person cope
with stress and that supportive relationships are a protective factor in
various life situations.[^26] With the information gained by monitoring
the personal perspective, the United States may better meet the needs of
people with disabilities.

6-6. Increase the proportion of adults with disabilities reporting\
satisfaction with life.

**Target:** 96 percent.

**Baseline:** 87 percent of adults aged 18 years and older with
disabilities reported satisfaction with life in 1998 (data from 11
States and the District of Columbia; age adjusted to the year 2000
standard population).

**Target setting method:** 10 percent improvement (parity with adults
without\
disabilities in 1998).

**Data source:** Behavioral Risk Factor Surveillance System (BRFSS),
CDC, NCCDPHP.

Note: The table below may continue to the following page.

+------------------------------------------+------------+---+-------------+
| **Adults Aged 18 Years and Older, 1998** | **Reported |   |             |
|                                          | Sat        |   |             |
|                                          | isfaction\ |   |             |
|                                          | With       |   |             |
|                                          | Life\***   |   |             |
+==========================================+============+===+=============+
|                                          | **With\    |   | **Without\  |
|                                          | Disa       |   | Disa        |
|                                          | bilities** |   | bilities** |
+------------------------------------------+------------+---+-------------+
|                                          | Percent    |   |             |
+------------------------------------------+------------+---+-------------+
| > **TOTAL**                              | 87         | 9 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
| **Race and ethnicity**                   |            |   |             |
+------------------------------------------+------------+---+-------------+
| > American Indian or Alaska Native       | 78         | 9 |             |
|                                          |            | 2 |             |
+------------------------------------------+------------+---+-------------+
| > Asian or Pacific Islander              | 78         | 9 |             |
|                                          |            | 8 |             |
+------------------------------------------+------------+---+-------------+
| > Asian                                  | DSU        | D |             |
|                                          |            | S |             |
|                                          |            | U |             |
+------------------------------------------+------------+---+-------------+
| > Native Hawaiian and other Pacific      | DSU        | D |             |
| > Islander                               |            | S |             |
|                                          |            | U |             |
+------------------------------------------+------------+---+-------------+
| > Black or African American              | 83         | 9 |             |
|                                          |            | 2 |             |
+------------------------------------------+------------+---+-------------+
| > White                                  | 88         | 9 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
|                                          |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Hispanic or Latino                     | 80         | 9 |             |
|                                          |            | 3 |             |
+------------------------------------------+------------+---+-------------+
| > Not Hispanic or Latino                 | 87         | 9 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
| > Black or African American              | DNA        | D |             |
|                                          |            | N |             |
|                                          |            | A |             |
+------------------------------------------+------------+---+-------------+
| > White                                  | DNA        | D |             |
|                                          |            | N |             |
|                                          |            | A |             |
+------------------------------------------+------------+---+-------------+
| **Gender**                               |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Female                                 | 87         | 9 |             |
|                                          |            | 5 |             |
+------------------------------------------+------------+---+-------------+
| > Male                                   | 86         | 9 |             |
|                                          |            | 6 |             |
+------------------------------------------+------------+---+-------------+
| **Education level** (aged 25 years and   |            |   |             |
| older)                                   |            |   |             |
+------------------------------------------+------------+---+-------------+
| > Less than high school                  | 84         | 9 |             |
|                                          |            | 4 |             |
+------------------------------------------+------------+---+-------------+
| > High school graduate                   | 87         | 9 |             |
|                                          |            | 5 |             |
+------------------------------------------+------------+---+-------------+
| > At least some college                  | 89         | 9 |             |
|                                          |            | 7 |             |
+------------------------------------------+------------+---+-------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

\*Data are from 11 States and the District of Columbia.

**^^**The total represents the target. Data for population groups by
race, ethnicity, gender, socioeconomic status, and geographic location
are displayed to further characterize the issue.

Note: The table above may have continued from the previous page.

Satisfaction with life is associated with the more general term "quality
of life," which is a personal evaluation of one's own position in
numerous dimensions of life, including physical, emotional, social,
spiritual, environmental support, and level of independence.[^27]
Monitoring the life satisfaction of people with disabilities, as well as
that of the broader population, allows an opportunity to evaluate
society's progress in accommodating the needs of people with
disabilities.

7.  Reduce the number of people with disabilities in\
    congregate care facilities, consistent with permanency planning
    principles.

Target and baseline:

+-----------+-------------------------------+------------+------------+
| Objective | Reduction in People With\     | 1997\      | 2010\      |
|           | Disabilities in Congregate\   | Baseline   | Target     |
|           | Care Facilities               |            |            |
+-----------+-------------------------------+------------+------------+
|           |                               | #####      |            |
|           |                               | ## Number  |            |
|           |                               | of Persons |            |
+-----------+-------------------------------+------------+------------+
| **6-7a.** | Persons aged 22 years and     | 93,362     | 46,681     |
|           | older\                        |            |            |
|           | in 16 or more bed congregate\ |            |            |
|           | facilities                    |            |            |
+-----------+-------------------------------+------------+------------+
| **6-7b.** | Persons aged 21 years and     | 24,300     | 0          |
|           | under in congregate care      |            |            |
|           | facilities                    |            |            |
+-----------+-------------------------------+------------+------------+

**Target setting method:** 50 percent improvement for 6-7a; total
elimination for\
6-7b.

**Data source:** Survey of State Developmental Disabilities Directors,
University of Minnesota.

Many people with activity limitations or cognitive impairments need
ongoing and long-term assistance, yet some do not require institutional
care.[^28] From the 1970s through the 1990s, States began reducing the
size of and closing State institutions that served people with mental
retardation or developmental disabilities. This social, political, and
economic movement resulted in a dramatic growth in the total number of
individuals served in community residential settings---from 5,000 in
1960 to 255,117 in 1996.[^29]**^,^** [^30] This movement, coupled with
increases in life expectancy and an expanding elderly population,
resulted in the development of several community-based and in-home
assistance programs, such as home-delivered meals, hospice care, and
homemaker and home-health services. The goal to increase home and
community-based care will broaden health and lifestyle choices for
people with disabilities and their families.[^31]

Much of this expansion in community services is funded through the
Medicaid Home and Community-Based Services (HCBS) Waiver Program, a
Federal-State partnership authorized in 1981 under Title XIX of the
Social Security Act. Between 1990 and 1997, the HCBS Program
demonstrated a 25.8 percent increase in benefits per person.Error:
Reference source not found Despite this dramatic growth to support home
and community-based care, in 1993, only 11 percent of long-term Medicaid
expenditures and 5.3 percent of total Medicaid expenditures went toward
community-based care.[^32] The other sources of support for
community-based long-term care are Medicare, Title III of the Older
Americans Act, and the Social Services Block Grant.Error: Reference
source not found

6-8. Eliminate disparities in employment rates between\
working-aged adults with and without disabilities.

**Target:** 82 percent.

**Baseline:** 52 percent of adults aged 21 through 64 years with
disabilities were employed in 1994--95.

**Target setting method:** 58 percent improvement (parity with adults
without\
disabilities in 1994--95).

**Data source:** Survey of Income and Program Participation (SIPP),
U.S.\
Department of Commerce, Bureau of the Census.

+-----------------------------------+-----------------+----------------+
| **Adults Aged 21 through 64       | **Employment of | **Employment   |
| Years, 1994--95**                 | People With\    | of People      |
|                                   | Disabilities**  | Without        |
|                                   |                 | Di             |
|                                   |                 | sabilities\*** |
+===================================+=================+================+
|                                   | Percent         |                |
+-----------------------------------+-----------------+----------------+
| > **TOTAL**                       | 52              | 82             |
+-----------------------------------+-----------------+----------------+
| **Race and ethnicity**            |                 |                |
+-----------------------------------+-----------------+----------------+
| > American Indian or Alaska       | 41              | 77             |
| > Native                          |                 |                |
+-----------------------------------+-----------------+----------------+
| > Asian or Pacific Islander       | 48              | 78             |
+-----------------------------------+-----------------+----------------+
| > Asian                           | DNC             | DNC            |
+-----------------------------------+-----------------+----------------+
| > Native Hawaiian and other       | DNC             | DNC            |
| > Pacific Islander                |                 |                |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | 37              | 77             |
+-----------------------------------+-----------------+----------------+
| > White                           | DNA             | DNA            |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| > Hispanic or Latino              | 45              | 76             |
+-----------------------------------+-----------------+----------------+
| > Not Hispanic or Latino          | DNA             | DNA            |
+-----------------------------------+-----------------+----------------+
| > Black or African American       | DNA             | DNA            |
+-----------------------------------+-----------------+----------------+
| > White                           | 57              | 84             |
+-----------------------------------+-----------------+----------------+
| ###### Gender                     |                 |                |
+-----------------------------------+-----------------+----------------+
| > Female                          | 46              | 75             |
+-----------------------------------+-----------------+----------------+
| > Male                            | 60              | 90             |
+-----------------------------------+-----------------+----------------+
| **Education level**               |                 |                |
+-----------------------------------+-----------------+----------------+
| > Less than high school           | 34              | 69             |
+-----------------------------------+-----------------+----------------+
| > High school graduate            | 54              | 81             |
+-----------------------------------+-----------------+----------------+
| > At least some college           | 63              | 83             |
+-----------------------------------+-----------------+----------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*The total represents the target. Data for population groups by race,
ethnicity, gender, and socioeconomic status are displayed to further
characterize the issue.

The ability to work has implications for economic and social
self-sufficiency, for full inclusion and integration into society, and
for personal self-esteem. Work and disability are understood best within
the context of a person's abilities and the role of accommodation,
accessibility, and legal mandates. The Presidential Task Force on
Employment of Adults with Disabilities emphasized the need for a
coordinated and aggressive national policy to address the many
components of work and disability.[^33] Changes in economic policies and
benefits underscore the need to continue to examine and address the
structural, social, and psychological deterrents to work for some
persons with disabilities.

In 1994--95, employment rates varied depending on degree of disability.
For persons aged 21 through 64 years with no disability, the rate was 82
percent, whereas those with a nonsevere disability had a rate of 77
percent, and those with a severe disability had a rate of 26 percent.
Analyses of rates by gender indicate similar patterns.Error: Reference
source not found Moreover, employment patterns for persons with
disabilities mirror general social patterns of employment rates for age,
race, and ethnicity.[^34] Education has a positive association with
employment for all people, although the association is strongest for
adolescents and adults with a "work disability."

6-9. Increase the proportion of children and youth with\
disabilities who spend at least 80 percent of their time\
in regular education programs.

**Target:** 60 percent.

**Baseline:** 45 percent of children and youth aged 6 to 21 years with
disabilities spent at least 80 percent of their time in regular
education programs in the\
1995--96 school year.

**Target setting method:** 33 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** Data Analysis System (DANS), U.S. Department of
Education,\
Office of Special Education.

> **Data for population groups currently are not analyzed.**

This objective aims to improve the well-being of students with
disabilities by encouraging academic and learning opportunities and
nonacademic social and emotional experiences that can facilitate normal
growth and development, postsecondary educational attainment,
independent living skills, and economic participation as adults. Serving
students with disabilities in regular nonspecial education classrooms is
a concern that cuts across the goals of many Federal agencies. The
current target of the Office of Special Education and Rehabilitative
Services is that 60 percent of children and youth with disabilities aged
6 through 21 years will be reported by the States as being served in the
regular education classroom at least 80 percent of the time. In support
of the target, the 1997 Amendments to the Individuals with Disabilities
Education Act states that "to the maximum extent appropriate, children
and youth with disabilities, including children in public or private
institutions or other care facilities, are educated with children who
are not disabled."[^35]

6-10. (Developmental) Increase the proportion of health and wellness and
treatment programs and facilities that\
provide full access for people with disabilities.

**Potential data source:** National Independent Living Centers Network.

For people with disabilities to have the opportunity for healthy lives,
both physically and emotionally, programs and facilities that offer
wellness and treatment services must be fully accessible. Effective
enforcement of the Americans with Disabilities Act can improve services
for people with disabilities and help prevent secondary disabilities.

6-11. (Developmental) Reduce the proportion of people with\
disabilities who report not having the assistive devices and technology
needed.

**Potential data source:** National Health Interview Survey (NHIS), CDC,
NCHS.

In 1990, a one-time survey showed that 2.5 million people said they
needed assistive technology that they did not have.[^36] The inability
to pay for such technology was the main reason given for the unmet need.
Assistive technology can be critical in the lives of people with
disabilities; thus, technology need, availability, and use must be
studied.[^37] Technology can aid the independence and self-sufficiency
of people with disabilities and can enable people to work, attend
school, and participate in community life. Without assistive technology,
people with disabilities may become dependent and isolated.

6-12. (Developmental) Reduce the proportion of people with\
disabilities reporting environmental barriers to participation in home,
school, work, or community activities.

**Potential data source:** Behavioral Risk Factor Surveillance System
(BRFSS), CDC, NCCDPHP.

The focus on measuring the environmental impact on people with
disabilities\
echoes the underlying theme of the disability rights movement and the
ADA.[^38] Both argue that the most important outcome for persons with
disabilities---in fact, for all persons in the United States---is their
full participation as active, involved, and productive members of
society. Indeed, this participation is the implicit outcome for the
overarching Healthy People goals to achieve a healthier life and
eliminate disparities.

A special 1999 Colorado Behavioral Risk Factor Surveillance System
(BRFSS) survey showed that compared to 43 percent of people without
disabilities, 55 percent of adults aged 18 years and older with
disabilities reported encountering environmental barriers daily or
weekly and/or barriers that were very problematic.[^39] Similar data
will be collected from several other States.

Full participation cannot be achieved without eliminating environmental
barriers found within architectural structures, technology,
organizational policies and practices, and social attitudes and without
moving toward universal design and nondiscriminatory elements. Thus
public health agencies need to measure not only the nature and extent of
disability in the United States but also the extent to which
environmental barriers and universal design elements impede or
facilitate social participation.

6-13. Increase the number of Tribes, States, and the District of
Columbia that have public health surveillance and health promotion
programs for people with disabilities and\
caregivers.

Target and baseline:

+----------+-----------------------------+--------------+-------------+
| O        | Increase in Public Health\  | 1999\        | 2010\       |
| bjective | Surveillance and Health     | Baseline     | Target      |
|          | Promotion Programs for      |              |             |
|          | People With\                |              |             |
|          | Disabilities and Caregivers |              |             |
+----------+-----------------------------+--------------+-------------+
|          |                             | ##           |             |
|          |                             | ##### Number |             |
+----------+-----------------------------+--------------+-------------+
| **       | States and the District of  | 14           | 51          |
| 6-13a.** | Columbia                    |              |             |
+----------+-----------------------------+--------------+-------------+
| **       | Tribes                      | D            |             |
| 6-13b.** |                             | evelopmental |             |
+----------+-----------------------------+--------------+-------------+

**Target setting method:** Total coverage.

**Data sources:** Tribal, State, and District of Columbia reports;
Office on Disability and Health, CDC.

The needs of people with disabilities and caregivers should be addressed
by public health activities. In a telephone survey, 23 percent of all
U.S. households included at least one caregiver.[^40] While not all
people with disabilities are dependent on the services of an unpaid
(usually a family member) or paid caregiver, meeting the needs of those
who benefit from personal assistance cannot be easily separated from the
needs of people who provide assistance.[^41] Whether caring for infants,
children, or adults with disabilities or for the increasing number of
people who become activity-limited as they grow older, the caregiver is
an important health component.[^42]

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-1. Persons with health insurance

1-4. Source of ongoing care

1-5. Usual primary care provider

1-6. Difficulties or delays in obtaining needed health care

1-16. Pressure ulcers among nursing home residents

2\. Arthritis, Osteoporosis, and Chronic Back Conditions

2-3. Personal care limitations

2-5. Employment rate

2-8. Arthritis education

2-11. Activity limitations due to chronic back conditions

3\. Cancer

3-9. Sun exposure and skin cancer

3-11. Pap tests

3-12. Colorectal cancer screening

3-13. Mammograms

4\. Chronic Kidney Disease

4-2. Cardiovascular disease deaths in persons with chronic kidney
disease

4-7. Kidney failure due to diabetes

5\. Diabetes

5-1. Diabetes education

5-2. New cases of diabetes

5-3. Overall cases of diagnosed diabetes

5-4. Diagnosis of diabetes

5-9. Foot ulcers

5-10. Lower extremity amputations

7\. Educational and Community-Based Programs

7-1. High school completion

7-3. Health-risk behavior information for college and university
students

7-6. Participation in employer-sponsored health promotion activities

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

9\. Family Planning

9-2. Birth spacing

9-4. Contraceptive failure

9-7. Adolescent pregnancy

12\. Heart Disease and Stroke

12-1. Coronary heart disease (CHD) deaths

12-7. Stroke deaths

12-9. High blood pressure

12-10. High blood pressure control

12-11. Action to help control blood pressure

12-12. Blood pressure monitoring

12-13. Mean total blood cholesterol levels

12-14. High blood cholesterol levels

12-15. Blood cholesterol screening

14\. Immunization and Infectious Diseases

14-22. Universally recommended vaccination of children aged 19 to 35
months

14-24. Fully immunized young children and adolescents

14-26. Children participating in population-based immunization
registries

14-29. Influenza and pneumococcal vaccination of high-risk adults

16\. Maternal, Infant, and Child Health

16-1. Fetal and infant deaths

16-2. Child deaths

16-3. Adolescent and young adult deaths

16-4. Maternal deaths

16-6. Prenatal care

16-9. Cesarean births

16-10. Low birth weight and very low birth weight

16-11. Preterm births

16-13. Infants put to sleep on their backs

16-16. Optimum folic acid levels

16-17. Prenatal substance exposure

16-19. Breastfeeding

16-21. Sepsis among children with sickle cell disease

16-22. Medical homes for children with special health care needs

16-23. Service systems for children with special health care needs

17\. Medical Product Safety

17-3. Provider review of medications taken by patients

18\. Mental Health and Mental Disorders

18-4. Employment of persons with serious mental illness

18-9. Treatment for adults with mental disorders

19\. Nutrition and Overweight

19-1. Healthy weight in adults

19-2. Obesity in adults

19-3. Overweight or obesity in children and adolescents

19-4. Growth retardation in children

19-5. Fruit intake

19-6. Vegetable intake

19-7. Grain product intake

19-8. Saturated fat intake

19-9. Total fat intake

19-10. Sodium intake

19-11. Calcium intake

19-12. Iron deficiency in young children and in females of childbearing
age

19-13. Anemia in low-income pregnant females

19-17. Nutrition counseling for medical conditions

19-18. Food security

20\. Occupational Safety and Health

20-1. Work-related injury deaths

21\. Oral Health

21-1. Dental caries experience

21-2. Untreated dental decay

21-3. No permanent tooth loss

21-4. Complete tooth loss

21-5. Periodontal disease

21-6. Early detection of oral and pharyngeal cancers

21-8. Dental sealants

21-10. Use of oral health care system

15. Referral for cleft lip or palate

16. Oral and craniofacial State-based surveillance system

22\. Physical Activity and Fitness

22-1. No leisure-time physical activity

22-2. Moderate physical activity

22-3. Vigorous physical activity

22-4. Muscular strength and endurance

22-5. Flexibility

23\. Public Health Infrastructure

23-4. Data for all population groups

23-5. Data for Leading Health Indicators, Health Status Indicators, and
Priority Data Needs at Tribal, State, and local levels

23-6. National tracking of Healthy People 2010 objectives

24\. Respiratory Diseases

24-1. Deaths from asthma

2.  Hospitalizations for asthma

3.  Hospital emergency department visits for asthma

4.  Activity limitations

24-5. School or work days lost

24-6. Patient education

7.  Appropriate asthma care

8.  Surveillance systems

9.  Activity limitations due to chronic lung and breathing problems

10. Deaths from COPD

27\. Tobacco Use

27-1. Adult tobacco use

27-5. Smoking cessation by adults

27-6. Smoking cessation during pregnancy

28\. Vision and Hearing

28-4. Impairment in children and adolescents

28-10. Vision rehabilitation services and devices

28-12. Otitis media

28-13. Rehabilitation for hearing impairment

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Activity limitations:** Problems in a person's performance of everyday
functions such as communication, self-care, mobility, learning, and
behavior.

**Assistive devices and technology:** Under the Assistive Technology Act
of 1998 (Public Law 105-394), "any item, piece of equipment, or product
system, whether acquired commercially, modified, or customized, that is
used to increase, maintain, or improve the functional capabilities of
individuals with disabilities."

**Congregate care facilities:** An out-of-home facility that provides
housing for people with disabilities in which rotating staff members
provide care---16 or more beds when referring to adults and any number
of beds when referring to children and youth under age 21 years.
Congregate care excludes foster care, adoptive homes, residential
schools, correctional facilities, and nursing facilities.Error:
Reference source not found

**Disability:** The general term used to represent the interactions
between individuals with a health condition and barriers in their
environment.

**Environmental factors:** The policies, systems, social contexts, and
physical barriers or facilitators that affect a person's participation
in activities, including work, school, leisure, and community events.

**Health promotion:** Efforts to create healthy lifestyles and a healthy
environment to prevent medical and other secondary conditions, such as
teaching people how to address their health care needs and increasing
opportunities to participate in usual life activities.

**ICIDH-2:** *International Classification of Functioning and
Disability*, the World Health Organization's conceptual and coding
framework for describing a person's functioning and disability
associated with his or her health condition.

**People with disabilities:** People identified as having an activity
limitation or who use assistance or who perceive themselves as having a
disability.

**Permanency planning**: A planning process undertaken by public and
private agencies on behalf of a child with developmental disabilities
and their families with the explicit goal of securing a permanent living
arrangement that enhances the child's growth and development.Error:
Reference source not found

**Secondary conditions:** Medical, social, emotional, mental, family, or
community problems that a person with a primary disabling condition
likely experiences.

## References 

[^1]: World Health Organization (WHO). *International Classification of
    Functioning and Disability (ICIDH-2): Beta-1 Draft for Field
    Trials*. Geneva, Switzerland: WHO, 1997, 11-21, 206-215, 221-225.

[^2]: McNeil, J.M. Americans with disabilities 1994--95. *Current
    Populations Report* P7061:3-6, August 1997.

[^3]: National Institute on Disability and Rehabilitation Research.
    *Trends in Disability Prevalence and Their Causes: Proceedings of
    the Fourth National Disability Statistics and Policy Forum, May 16,
    1997, Washington, DC*. San Francisco, CA: The Disability Statistics
    Rehabilitation Research and Training Center, 1998.

[^4]: Institute of Medicine. *Enabling America: Assessing the Role of
    Rehabilitation Science and Engineering*. Washington, DC: National
    Academy Press, 1997, 2.

[^5]: U.S. Department of Health and Human Services (HHS). *Healthy
    People 2000: National Health Promotion and Disease Prevention
    Objectives*. Pub. No. (PHS) 91-50213. Washington, DC: HHS, Public
    Health Service (PHS), Office of Disease Prevention and Health
    Promotion (ODPHP), 1991, 39-42.

[^6]: Centers for Disease Control and Prevention (CDC). Health-related
    quality of life and activity limitation---Eight states, 1995.
    *Morbidity and Mortality Weekly Report* (47):134-140, 1998.

[^7]: Manton, K.; Corder, L.; and Stallard, E. *Chronic Disability
    Trends in Elderly in United States Populations 1982--1994*.
    Washington, DC: National Academy of Sciences, 1997, 2593-2598.

[^8]: Zola, I. Disability statistics, what we count and what it tells
    us, a personal and political analysis. *Journal of Disability Policy
    Studies* 4(2):10-39, 1993.

[^9]: Hahn, H. The political implications of disability definitions and
    data. *Journal of Disability Policy Studies* 4(2):42-52, 1993.

[^10]: HHS. *Healthy People 2000 Progress Review, People With
    Disabilities.* Washington, DC: HHS, PHS, ODPHP, 1997, 1-3.

[^11]: Seekins, T.; White, G.; Ravesloot, C.; et al. Developing and
    evaluating community-based health promotion programs for people with
    disabilities. In: *Secondary Conditions Among People With
    Disabilities: Current Research and Trends*. Pacific Grove, CA:
    Brookes-Cole Publisher, in press.

[^12]: Lorig, K. A workplace health education program that reduces
    outpatient visits. *Medical Care* 9:1044-1054, 1995.

[^13]: Research and Training Center on Rural Rehabilitation. *Cost
    Containment Through Disability Prevention: Preliminary Results of a
    Health Promotion Workshop for People With Physical Disabilities*.
    Missoula, MT: University of Montana, the Center, 1996.

[^14]: Lorig, K.; Lubeck, D.; Kraines, R.; et al. Outcomes of self-help
    education for patients with arthritis. *Arthritis Rheumatism*
    28(6):680-685, 1985.

[^15]: National Osteoporosis Foundation. *Physician Guide to Prevention
    and Treatment of Osteoporosis*. Washington, DC: the Foundation,
    1998.

[^16]: Melnikova, N; Hough, J.; and Lollar, D. Osteoporosis among women
    with physical disabilities: Risk factors and protective factors.
    Paper presented at 126th Annual Meeting of the American Public
    Health Association, Disability Forum Special Interest Group in
    Washington, DC, November 17, 1998.

[^17]: HHS. *Healthy People in Healthy Communities: A Guide for
    Community Leaders*. Washington, DC: HHS, PHS, Office of Public
    Health and Science (OPHS), ODPHP, 1998.

[^18]: HHS. *U.S. Preventive Services Task Force: Guide to Clinical
    Preventive Services.* 2nd ed. Washington, DC: HHS, OPHS, ODPHP,
    1995, Chapter V.

[^19]: HHS. *Task Force on Community Preventive Services: Guide to
    Community Preventive Services*. Washington, DC: HHS, in press.

[^20]: U.S. Public Health Service. *Putting Prevention Into Practice:
    Clinicians Handbook of Preventive Services*. 2nd ed. McLean, VA:
    International Medical Publishing, Inc., 1998, Chapter 36.

[^21]: National Council on Disability. *Reorienting Disability Research:
    Letter to the United States President.* Washington, DC: the Council,
    1998, 1-17.

[^22]: Office on Disability and Health. *1999 Behavioral Risk Factor
    Surveillance System Disability Module*. Atlanta, GA: CDC, 1999.

[^23]: Tuttle, D. *Self Esteem and Adjusting With Blindness: The Process
    of Responding to Life Demands*. Springfield, IL: Charles C. Thomas
    Publisher, 1984, 61, 145-158.

[^24]: Sowers, J., and Powers, L. Enhancing the participation and
    independence of students with severe and multiple disabilities in
    performing community activities. *Mental Retardation* 33(4):209-220,
    1995.

[^25]: Kaye, S. Is the status of people with disabilities improving?
    *Disability Status Abstract* (21):3-4, May 1998.

[^26]: Novack, T., and Gage, R. Assessment of family functioning and
    social support. In: Cushman, L., and Scherer, M., eds.
    *Psychological Assessment in Medical Rehabilitation.* Washington,
    DC: American Psychological Association, 1995, 286-297.

[^27]: Patrick, D. Rethinking prevention for people with disabilities
    part 1: A conceptual model for promoting health. *American Journal
    of Health Promotion* 11(4):25-260, 1997.

[^28]: Swain, P. Helping disabled people: The users view. *British
    Medical Journal* 306(6883):990-992, 1993.

[^29]: Braddock, D.; Hemp, R.; Parish, S.; et al. *The State of the
    States in Developmental Disabilities.* 5th ed. Washington, DC:
    American Association on Mental Retardation, 1998, 9-10.

[^30]: Prouty, R., and Lakin, K. *Residential Services for Persons With
    Developmental Disabilities: Status and Trends Through 1997*.
    Minneapolis, MN: University of Minnesota, Research Training Center
    on Community Living, Institute on Community Integration, 1998, xii,
    47, 53, 58, 60, 65-67, 76, 88, 101.

[^31]: Kane, R. Expanding the home care concept: Blurring distinctions
    among home care, institutional care and other long-term care
    facilities. *Milbank Quarterly* 73(2):161-186, 1995.

[^32]: Hardwick, S.; Pack, J.; Donohoe, E.; et al. *Across the States
    1994: Profiles of Long-Term Care Systems*. Washington, DC: American
    Association of Retired Persons, Center on Elderly People Living
    Alone, Public Policy Institute, 1994, 5-7.

[^33]: Presidential Task Force on Employment of Adults with
    Disabilities. *Recharting the Course: First Report.* Washington, DC:
    the Task Force, 1998.

[^34]: Stoddard, S.; Jans, L.; Ripple, J.; et al. *Chartbook on Work and
    Disabilities in the United States, 1998.* Washington, DC: U.S.
    Department of Education (DoE), National Institute on Disability and
    Rehabilitation, 1998.

[^35]: DoE. *To Assure the Free Appropriate Public Education of All
    Children with Disabilities: Nineteenth Annual Report to Congress on
    the Implementation of the Individuals with Disabilities Education
    Act, Section 618*. Washington, DC: DoE, 1997.

[^36]: Laplante, M.; Hendershot, G.; and Moss, A. Assistive technology
    devices and home accessibility features: Prevalence, payment, need,
    and trends. In: *Advance Data from Vital and Health Statistics: No.
    217.* Hyattsville, MD: National Center for Health Statistics, 1992.

[^37]: National Council on Disability. *Study on Financing of Assistive
    Technology Devices and Services for Individuals With Disabilities*.
    Washington, DC: the Council, 1993.

[^38]: National Council on Disability. *Equality of Opportunity: The
    Making of the Americans with Disabilities Act*. Washington, DC: the
    Council, 1997, 9-21.

[^39]: Craig Hospital and the Colorado Department of Public Health and
    Environment. Craig Hospital Inventory of Environmental Factors.
    Short form (CHIEF SF). *Colorado 1999 Behavioral Risk Surveillance
    System Disability Study*. Englewood, CO: Craig Hospital, Denver, CO,
    and Colorado Department of Public Health and Environment, Survey
    Research Unit.

[^40]: National Alliance for Caregiving and the American Association of
    Retired Persons. *Family Caregiving in the U.S.: Findings From a
    National Survey*. Bethesda, MD: American Association of Retired
    Persons, Washington, DC, 1997, 8.

[^41]: Singer, G., and Irvin, L. *Support for Caregiving Families:
    Enabling Positive Adaptation to Disability*. Baltimore, MD: Paul H.
    Brooks Publishing Company, 1989, 44.

[^42]: Pugliese, J.M.; Ingram, T.O.; and Edwards, G. *Stability of
    Employment Status of Caregivers Who Have a Child With a Disability*.
    Birmingham, AL: United Cerebral Palsy of Greater Birmingham, Inc.,
    1998.