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					        POPULATION-BASED, SELF-REPORTED DISABILITY
              ASSESSMENT IN SOUTH CAROLINA

   Results of the Behavioral Risk Factor Surveillance System for 2004

           SECTION I.     2004 RESULTS FOR DEMOGRAPHICS AND HEALTHY
                          PEOPLE 2010 LEADING HEALTH INDICATORS

           SECTION II.    2004 RESULTS FOR ADDITIONAL HP 2010 OBJECTIVES
                          AND OTHER VARIABLES


                                                April 2006


                                    South Carolina BRFSS
                                    Disability Report, 2004



                                                                    Adults with
                                                                    Disabilities
                                                                      20.1%




                        From the Department of Family and Preventive Medicine,
                 University of South Carolina School of Medicine, in collaboration with the
                     South Carolina Department of Health and Environmental Control


The information provided in this report was supported by Cooperative Agreement Number U59/CCU421834-
04 from the Centers for Disease Control and Prevention (CDC). The contents are solely the responsibility of
                  the authors and do not necessarily represent the official views of CDC.
                                      Acknowledgments


This report is a collaborative effort of the SC Disability and Health Project in the Department of
    Family and Preventive Medicine, University of South Carolina School of Medicine, with
     participation of the South Carolina Department of Health and Environmental Control.


This study and report were supported by Cooperative Agreement Number U59/CCU421834-04
  from the Centers for Disease Control and Prevention (CDC). The contents are solely the
   responsibility of the authors and do not necessarily represent the official views of CDC.




                                    For Additional Information
                            Please direct requests for additional information to:

                                        Suzanne McDermott, Ph.D.
                              Department of Family and Preventive Medicine
                                         USC School of Medicine
                                           Columbia, SC 29203




                                                  i
                  Executive Summary: Objectives, Study Design, and Results
1. Objectives

    Obtain a population-based estimate of the prevalence of adults with disability for the state of South
      Carolina using responses to a random-sample telephone survey (Behavioral Risk Factor Survey or
      BRFSS, coordinated nationwide by the Centers for Disease Control and Prevention).
    Examine disparities in health status, risk factors and receipt of preventive health services between
      South Carolina respondents with disability and those with no disability.
    Relate the results to the objectives of Healthy People 2010, understanding that many BRFSS
      variables may not relate directly to HP 2010.

2. Study Design

    The source of data for this report is the South Carolina Behavioral Risk Factor Surveillance System
      (SC BRFSS), part of an ongoing national effort, funded in all 50 states and five territories by the
      Centers for Disease Control and Prevention (CDC), to conduct a telephone interview of a
      representative sample of non-institutionalized South Carolina adults aged 18 years and older.
    Sampling and interviewing were performed by a professional survey organization under contract to
      the SC Department of Health and Environmental Control, and followed a standardized protocol
      specified by the CDC.
    The questionnaire is composed of multiple modules, with a relatively stable core asked annually, and
      additional questions in CDC and state-added modules. The core and modules typically cover a
      variety of topics related to health and safety, considering both knowledge and practices regarding
      health status, health care access and utilization, use of preventive services (e.g. immunization),
      chronic conditions such as hypertension, diabetes, and overweight, behaviors such as exercise,
      tobacco use, and fruit and vegetable consumption, injury control, HIV and AIDS, women's health,
      and demographic information.
    This report describes the results for a subset of variables selected for their relevance to expanding
      our understanding of disability in South Carolina.


3. Section I. Results for Prevalence of Self-Reported Disability in Adult Residents of South
              Carolina

   IA. Disability Definition and Prevalence

   IA1. SC BRFSS 2004 Definition of Disability
       For 2004, disability status was based on positive responses to either of the following two questions:
       Q 1. Are you limited in any way in any activities because of physical, mental, or emotional
             problems?
       Q 2. Do you now have any health problem that requires you to use special equipment, such as a
             cane, a wheelchair, a special bed, or a special telephone?



                                                      ii
IA2. Disability Prevalence

       For 6,881 South Carolinians ages 18 and over who responded to the telephone survey, the set
        of two questions defining disability for 2004 resulted in an estimated prevalence of 20.1 percent,
        or approximately 1 in 5 respondents.
       The overall 2004 weighted results for South Carolina were in the same range as in surveys from
        1998-2001 (when using a one-to-four question definition of disability), generally similar to those
        reported for Rhode Island (1998) and the 2000 census, but above the 2003 estimate for North
        Carolina of 17.9% and Georgia of 18.3% (as reported at the CDC web site for the BRFSS).


IA3. Demographic Attributes
       As observed in previous years, prevalence of disability for 2004 increased markedly with age
        and was associated with education less than high school and low income. Individuals with a
        disability were much less likely to be currently employed. Conversely, they were more likely to
        report each of the following: being retired, a student/homemaker, unemployed, and unable to
        work.
       There was not a significant difference in the prevalence of disability between men and women.
        Results for racial/ethnic groups also showed no significant difference in disability prevalence
        between white and non-white categories (a finding consistent with previous years).


IB.    Healthy People 2010 Leading Health Indicators (LHI) for Adults by Disability Status
                Healthy People is the health plan for the United States, summarizing a vision for the health
of the nation, with updates conducted every 10 years. The current cycle is HP 2010, with a total of 467
objectives. HP 2010 identified ten issues with 22 objectives as Leading Health Indicators that reflect
                                                             st
the major health concerns in the United States for the 21 century. This report begins with the BRFSS
results as they relate to the HP 2010 LHI by disability status and then summarizes the results for other
objectives and for additional important variables not directly related to HP objectives.


IBA. Summary of Results for Disparities in Healthy People 2010 Leading Health Indicators.

      a. Significant Disparity or Risk Status Unfavorable for People with Disability: 6 Indicator
         Variables.

          (1-2). Access to health care: Coverage/insurance and cost limitation, age <65
                For 2004, the proportion of people with disability under age 65 without health coverage
      was 21.8% vs. 19.2% for adults with no disability (HP Objective 1-1, target 100%). The proportions
      for „unable to visit a doctor in the past 12 months because of cost‟ were 24.7% for respondents with
      disability (People With Disability, PWD) and 12.8% for those with no disability (People WithOut
      Disability, PWOD) (no specific HP Objective). This reported difference may represent a real




                                                     iii
disparity in the ability of PWD to afford health care, or may instead be reflective of increased need
for health care among PWD that brings to light the sometimes prohibitive costs of health care.
    (3). Physical activity: Moderate exercise.
         The proportion of individuals with disability who reported no leisure time physical activity
was over double the level for those with no disability, 42.6% and 19.2% respectively (HP
Objectives 22-2 and 22-3, target 30%). Only 25.3% of those with disability reported moderate
levels of exercise compared with a 34.2% proportion for those with no disability. In addition, only
4.8% of adults with disability were exercising vigorously for at least 30 minutes a day at least five
days of the week, compared to 10.5% of those with no disability, with both levels well below HP
2010 targets.
    (4). Tobacco use: Daily cigarette smoking.
          Smoking practices differed between groups, with people PWD being more likely to smoke
everyday than PWOD (21.0% vs. 17.3%) (HP Objective 27-1a, target 12%).
    (5). Overweight and Obesity (BMI =>30).
        The SC BRFSS 2004 data for obesity were similar to those widely reported for the nation
and even more significant for PWD, as 34.5% of adults with disabilities met the obesity criterion of
Body Mass Index equal to or exceeding 30, compared to 23.0% for adults without disabilities (HP
Objective 19.2, target 15%).
    (6). Mental health
        The HP 2010 LHI for mental health is to increase the proportion of adults with recognized
depression who receive treatment (HP18-9b); a related objective though not an LHI is to reduce the
proportion of adults with disabilities who report sad feelings that interfere with activities (HP6-3,
target 7%). The SC BRFSS 2004 content did not address depression treatment directly, but a core
question on mental health status is closely related and indicated a significant disparity for people
with disability. The question related to the number of days during the past 30 days mental health
was not good, with response choices of 0 days, 1 - 14 days, and 15-30 days. For those with
disability, 23.9% reported mental health was not good for 15-30 of the past 30 days compared to
only 7.1% of those with no disability. Other measures related to quality of life and life satisfaction
were also less satisfactory in those with disability (details in Section II).



b. No significant disparity or disparity favorable for PWD: 5 Indicator Variables
    (1). Health care source available.
        Although health care coverage for individuals with disability was lower than for those with
no disability, the proportion of those with one or more personal health care providers was favorable
for PWD, 88.5% compared to 80.6% for PWOD (HP Objective 1-4c, target 96%). Nevertheless,
results were well below the target values for both groups with and without disability.
    (2-3). Immunization for influenza (all adults) and pneumonia (age 65 and over).




                                                iv
              Influenza immunization in the past 12 months was higher for those with disability, 46.5% to
   31.9%. Pneumonia immunization is recommended for those over 65 years of age, and the
   percentages for this group were 72.2% for PWD and 59.7% for PWOD. The proportions receiving
   influenza and pneumonia immunization remain well below the 90% goal of HP 2010 (Objective 14-
   29).
          (4). Substance abuse: Binge drinking.
              Excessive intake of alcohol is detrimental, and binge drinking exceeds the HP 2010 target
   of 6% by the same amount in both groups (HP Objective 26-11c). For adults with and without
   disability in 2004, 6.5% were binge drinkers, consuming five or more drinks on an occasion more
   than five times in the past 30 days.
          (5). Responsible sexual behavior
              HP 2010 objectives for this LHI are not addressed specifically in BRFSS (eg. HP
   Objectives 13-7 and 25-11). The most closely aligned question included in the BRFSS was in the
   HIV/AIDS section and asked those under age 65 if they had ever been tested for HIV. The
   differences between the two groups were not significant, with yes responses 49.6% for PWD and
   46.0% for PWOD.

IC. Summary of Results for Disparities in Additional Healthy People 2010 Objectives.

   a. Significant Disparity or Risk Status Unfavorable for People with Disability (PWD):
      4 Variables

          (1). Activities limited by arthritis.
              For 2004, people with disabilities were highly likely to have the unfavorable status of
   limitations in activities due to arthritis and chronic joint symptoms (69.1% vs. 13.7%) (HP Objective
   2-2, target 21%).
          (2). Diabetes.
   The proportion of PWD exceeded PWOD for clinically diagnosed diabetes (19.7% vs. 5.6%) (HP 5-
   3, target 2.5%).
          (3-4). Dental health.
              In addition, adults with disabilities were more likely to have had all of their natural teeth
   extracted (25.6% vs. 17.1%) (HP 21-4, target 20%) and were less likely to have no permanent
   teeth extracted (31.2% vs. 56.4%).


   b. No Significant Disparity or Disparity Favorable for PWD: 4 Variables
          (1-2). Preventive screenings and interventions
              PWD were more likely to receive a sigmoidoscopy/colonoscopy screening (61.8% vs.
   53.6%) (HP Objective 3-12b, target 50%) than PWOD. There was no significant difference
   between PWD and PWOD for fecal occult blood tests (45.4% vs. 44.2%) (HP Objective 3-12a,
   target 50%).



                                                     v
             (3-4). Counseling: Preventive Medicine Counseling (Diet and Condom Use)
                 The 48.5% of PWD receiving dietary counseling significantly exceeded the 32.4%
        proportion for PWOD. The amount of counseling offered on condom use was minimal in both
        groups (13.4% for PWD vs. 15.1% for PWOD) and not statistically significantly different.
4. Section II. SC BRFSS 2004. Results for Selected Additional Variables
        a. Significant Disparity or Risk Status Unfavorable for People with Disability (PWD):
           4 Variables

             (1-3). General health, physical health, usual activities.
                 Using a scale of five choices ranging from excellent to poor, adults with disabilities reported
        a much higher proportion of days that were fair/poor for general health (51.8% vs. 9.2%). For the
        number of days physical health was not good during the past 30 days, 39.9% vs. 4.2% responded
        in the 15-30 day range (and also for mental health, 23.9% vs. 7.1%; included in IB). People with
        disability were also more likely to report being kept from usual activities by poor physical or mental
        health 15-30 of the previous 30 days (38.5% vs.4.5%).


             (4). Asthma.
                 PWD were more likely to have a history of asthma (18.5% vs. 10.2%).

        b. No Significant Disparity or Disparity and Risk Status Favorable for PWD: 1 Variable
             (1). Prostate Specific Antigen (PSA) Test, ever
                 The 69.6% of PWD receiving the PSA test was significantly higher than the 65.2%
    proportion for PWOD.


5. Comments and Conclusions
    These estimates from BRFSS population-based surveys indicate that although a number of services
are favorable for those with disability, there are more instances of substantial disparities unfavorable for
those with disability. For the total of 24 BRFSS variables assessed in this study, 14 were unfavorable, 6
were favorable, and 4 were neutral. Although these self-reported, cross-sectional data do not indicate
causation, internal consistencies and comparability to data from other sources lend credence to the results
and provide important indications of intervention needs. The relationship between disability and preventive
and curative health care can be complex, complicating development of corrective interventions (Diab and
Johnston, 2004). As noted by Kinne et al (2004), addressing and reducing these disparities is a clear
health promotion challenge, requiring interventions that are specific for the relationship between individual
risk factors and environmental determinants of health and quality of life affecting people with disability. For
South Carolina, these BRFSS data indicate that improving overall health status, especially mental health,
should be a priority. In addition to enhancing overall quality of life, risk factors and diseases needing
special attention for people with disability are arthritis and obesity.




                                                         vi
                                                                TABLE OF CONTENTS
                                                                                                                                                              Page
Acknowledgments ......................................................................................................................................... i
Executive Summary: Objectives, Study Design, and Results ....................................................................... ii
Table of Contents………………………………………………………………………………………………….....viii
List of Data Tables………...…………………………………………………………………………………….…...x
List of Figures……………………………………………………………………………………….……………..….xi
Introduction            ............................................................................................................................................ .1
Section I. Prevalence of Disability and Healthy People 2010 Leading Health Indicators
                       IA. Disability Definition and Prevalence
                              IA1. 2004 SC BRFSS Definition of Disability ……………………………..................2
                              IA2. Disability Prevalence........................................................................................ 2
                              IA3. Demographic Attributes of Responders… …..…. ............. …………………..…3

                       IB. Healthy People 2010 Leading Health Indicators for Adults
                           by Disability Status (Univariate Analysis) ...................................................................... 7
                            IB A. Leading Health Indicators, Part 1, IB A1-IB A3 ................................................. 8
                              IB A1. Access to Healthcare.................................................................................. 9
                              IB A2. Physical Activity . ...................................................................................... 11
                              IB A3. Immunization ............................................................................................ 13
                            IB B. Leading Health Indicators, Part 2, IB B4-IB B8 ............................................... 13
                              IB B4. Substance Abuse: Binge Drinking ........................................................... 14
                              IB B5. Tobacco Use: Cigarette Smoking ............................................................. 15
                              IB B6. Overweight and Obesity .................................................................. …….16
                              IB B7. Mental Health ........................................................................................... 16
                              IB B8. Responsible Sexual Behavior .................................................................. 17
                            IB C. Leading Health Indicator with No BRFSS Data .............................................. 17
                              IB C10. Environmental Quality .............................................................................. 17

                       IC. Additional Healthy People 2010 Objectives by Disability Status ................................ 18
                             IC1. Joint Symptoms (Arthritis) ........................................................................... 19
                             IC2. Diabetes, Clinically Diagnosed .................................................................... 20
                             IC3. Dental Health a and b. Permanent Teeth Extracted ................................... 20
                             IC4. Stool Blood Testing (ever) ........................................................................... 21
                             IC5. Sigmoidoscopy/Colonoscopy ...................................................................... 22
                             IC6. Received Counseling ................................................................................... 22

Section II. SC BRFSS 2004. Results for Selected Additional Variables: Summary
                of Additional Variables ...................................................................................................... 24
                IIA. Health Assessment Indicators by Disability Status ................................................... 25
                IIB. Other High Prevalence Risk Factors ........................................................................ 26
                      IIB1. Asthma .......................................................................................................... 26
                      IIB2. Prostate Specific Antigen (PSA) test ............................................................ 26
                      IIB3. Summary of Unfavorable Risk Factors ......................................................... 27
                IIC. Additional Variables, cont. Summary of Preventive Measures
                     by Disability Status ................................................................................................... 28

                       IID. Relationship of Demographic Attributes and Health Care Coverage
                            to Selected Variables (Univariate and Multivariate Analysis)................................... 29

Section III. Methods
                IIIA. The Behavioral Risk Factor Surveillance System and Its
                      Application in South Carolina (SC BRFSS) .............................................................. 31


                                                                                 vii
                       IIIB. Strengths and Limitations of the Estimation Process ............................................... 32
                       IIIC. Sampling Techniques and Sampling Frame............................................................. 32
                       IIID. Data Processing and Analyses ................................................................................. 33

Section IV. Comments and Conclusions .................................................................................................. 33

Section V. References ................................................................................................................................ 36
           Other Documents and Data Sources ....................................................................................... 37




                                                                           viii
                                                   LIST OF DATA TABLES


Table 1.       SC BRFSS 2004 Demographic Data by Disability Status ................................................... 4
Table 2a-g.    Demographic Attributes by Category and Disability Status .............................................4-6
Table 3.       Summary of HP 2010 Leading Health Indicators and SC BRFSS 2004 ............................. 8
Table 4a.      Access: Health Care Coverage/Insurance ...................................................................... 10
Table 4b.      Access: Could Not See Doctor Because of Cost ............................................................. 10
Table 4c.      Access: Number of Personal Health Care Providers ........................................................ 11
Table 5a.      Any Exercise...................................................................................................................... 12
Table 5b.      Moderate or Vigorous Exercise ......................................................................................... 12
Table 6.       Immunization (Influenza and Pneumonia) ......................................................................... 13
Table 7.       Substance Abuse: Alcohol Consumption and Binge Drinking ......................................... 15
Table 8.       Tobacco Use: Cigarette Smoking ..................................................................................... 15
Table 9.       Obesity: Body Mass Index................................................................................................ 16
Table 10.      Mental Health .................................................................................................................... 16
Table 11.      Responsible Sexual Behavior: Ever Tested for HIV.......................................................... 17
Table 12.      Summary of Healthy People 2010 Additional Objectives and BRFSS 2004 .................... 19
Table 13a-h.   Data for Additional Objectives and BRFSS 2004 ........................................................21-23
Table 14.      Summary of Additional Variables ...................................................................................... 24
Table 15.      Health Assessment Indicators ........................................................................................... 25
Table 16.      Asthma Data ...................................................................................................................... 26
Table 17.      Results of PSA Test .......................................................................................................... 26
Table 18.      Summary of Preventive Measures .................................................................................... 28
Table 19a.     Risk Factors Uncontrolled for Age, Race, Income, and
               Health Care Coverage/Insurance ...................................................................................... 29

Table 19b.     Odds Ratios for Risk Factors and Limitations in Preventive Measures
               and Counseling by Disability Status After Controlling for Age, Race,
               Income, and Health Care Coverage/Insurance ................................................................. 30




                                                                     ix
                                                         LIST OF FIGURES


Figure 1. SC BRFSS 2004. Comparison of Yes Responses to HP 2010 Target Values
          for Selected Leading Health Indicators by Disability Status ......................................................... 9

Figure 2. SC BRFSS 2004. Comparison of Yes Responses with HP 2010 Target Values
          for Selected Variables by Disability Status ................................................................................. 14

Figure 3. SC BRFSS 2004. Summary of Risk Factors with Significant Disparity or
          Unfavorable Status for People with Disability ............................................................................ 26




                                                                     x
                                               INTRODUCTION

    The objectives of this study were (1) to obtain a population-based estimate of the prevalence of adults
with disability for the state of South Carolina using a carefully designed and validated random-sample
telephone survey (Behavioral Risk Factor Survey [BRFSS], coordinated nationwide by the Centers for
Disease Control and Prevention), (2) to examine disparities in health status, risk factors and preventive
health services between South Carolina respondents with disability (People With Disability, PWD) and
those with no disability (People Without Disability, PWOD), and (3) to relate the results to the objectives of
Healthy People 2010 as much as possible. Making this connection requires appreciating that some
variables of BRFSS interest may not relate directly to HP 2010, and the BRFSS questionnaire design can
relate to only a few of the many HP 2010 objectives.
    The information in this report evaluates the health status of individuals with disability and no disability
as assessed in the questions asked in the telephone survey of the BRFSS. This report deals with the
BRFSS administered to a representative sample of adults ages 18 and above in South Carolina for the
year 2004. Since data from prior years have been reported previously (8,9), this report focuses exclusively
on 2004 data.
    As a demographic descriptor rather than a health outcome, disability is an essential indicator for
measuring and tracking disparities in health status (HP 2010, Disability and Secondary Conditions, Chap.6,
2001) and the BRFSS format is a proven strategy for disparity assessment (1,4,8,13). Healthy People
2010 objectives and the BRFSS have a strong preventive orientation emphasizing the assessment of risk
factors, so there is considerable overlap. However, capability for comparison is constrained by differences
in wording and BRFSS concerns different from those of HP 2010. Healthy People is the nation‟s health
plan, designed to highlight public health issues, motivate action, and measure progress. Updated every 10
years, we are currently in the HP 2010 plan. HP 2010 includes a group of objectives, the Leading Health
                                                                                                           st
Indicators (LHI), selected to reflect the major health concerns in the nation at the beginning of the 21
century.
    The first section of this report describes the results for BRFSS variables that relate to the LHI followed
by sections for additional HP 2010 objectives and data on other variables. Section I evaluates the Healthy
People 2010 Leading Health Indicators for adults with disability and those with no disability. This section
begins with an overview of the demographic attributes of the respondents and extends to issues such as
exposure to health risks and availability and utilization of preventive services. Section II includes a
subsection with additional variables that are part of HP 2010 but not leading indicators, and a second
subsection on other important BRFSS items such as those describing general health status that are not
part of HP 2010. The validation and application of BRFSS methodology are described in more detail in
Section III of this report. Section IV, Comments and Conclusions, amplifies observations on the results,
and Section V contains references and lists other data sources.
    The 2004 response rate, defined as the ratio of complete interviews to complete plus refused
interviews, was 43.8%, below the rate of 44.2% in 2000. Both levels are markedly lower than the value of
68.8% in 1998, continuing the trend of reduced participation in telephone interviews. The interviewers met


                                                        1
the sample size goals with total interviews of 6881 and an overall disability sample size of 1557. The
demographic data were weighted for the 2004 distributions of age, gender, and race distributions for the
state and adjusted for the multistage, stratified random sampling strategy using SUDAAN. After weighting,
the disability prevalence was 20.1%. The frequency data used to calculate proportions were not adjusted.

Section I. Prevalence of Disability and Healthy People 2010 Leading Health Indicators

IA. Disability Definition and Prevalence

    IA1. 2004 SC BRFSS Definition of Disability
         Those responding yes to either of two questions in the BRFSS core set of questions were
    classified as disabled.
        1. Are you limited in any way in any activities because of physical, mental, or emotional
    problems?
        2. Do you now have any health problem that requires you to use special equipment, such as a
    cane, a wheelchair, a special bed, or a special telephone?


    IA2. Disability Prevalence
        The resulting disability prevalence estimate after weighting was 20.1% of all respondents in the 18
years of age and older sampling frame, about one in five residents. (The classification process is
discussed in the Methods section). Results from multiple sources affirm the magnitude of the problem. US
Census data for 2000, using two questions different from, but related to, the SC BRFSS questions,
indicated a disability rate of 19.7% for South Carolina. National data available from CDC and the US
Census for 2000 estimated that 19.8% of US non-institutionalized adults 21 years of age or older had a
disability (3,8). The corresponding value for the 1990 Census was 19.4 percent. Estimates from
neighboring states for 2003 are in a similar range (North Carolina 17.9%; Georgia 18.3%) (6), as are those
for other years from other states (3,7, 9). The 2004 US Census estimate for the size of the civilian
population of South Carolinians ages 18 and over was about 3,173,368, resulting in a disability estimate of
637,847 people.




                                                      2
        IA3.     Demographic Attributes of Responders
    The demographic data are summarized in Tables 1 and 2. In Table 1, column 1 lists the categories or
variables and column 2 is the proportion (percent) and number (n) of respondents in that category who met
the definition of disability (disability). Column 3 lists the same data for those not meeting the disability
definition (no disability), so the percentages for each row will sum to 100% (or very close depending on
rounding effects). Column 4 is the p-value for the difference between two proportions; p-values were
computed using the chi-square statistic with SUDAAN. For Table 1, the p value was <0.0001 for the
differences in age, education, income and employment categories. The differences were not significant for
gender or race/ethnic group.
    Table 2 is a group of sub-tables that expand the data of Table 1 by adding the 95% Confidence Interval
(95%CI, the range within which the true value will be found with repeated samples 95% of the time).
Tables 2a-2g are divided into four columns. The first column lists the variable for which the data are
provided. The second column (Measure) has 3 parts: the first part is the proportion or percentage of the
respondents who meet the variable definition (%), second is the 95% CI, and third is the actual number of
individuals (not weighted) meeting the definition (n). (Note that for many variables, the sample size is
relatively large with correspondingly narrow CIs). The third column contains the Measure values for those
who met the disability definition (Disability), and the fourth column contains the Measure values for those
who did not meet the disability definition (No Disability). The top row is the proportion of those with
disability or with no disability for that variable so that the percentages will sum to 100% (or very close
depending on rounding effects).
    As shown in Tables 1 and 2, the prevalence of disability increased markedly with age and was
associated with education less than high school and low income. Employment status also differed for
people with and without disability, with individuals with disability being markedly less likely to be employed
(p<0.0001). The data for gender indicated no difference in the prevalence of disability between men and
women (p=0.1136), and the data for racial/ethnic groups showed no difference between white and non-
white categories (p=0.7678).




                                                        3
      Table 1: SC BRFSS 2004. Demographic Data by Disability Status

          SOCIODEMOGRAPHIC           DISABILITY         NO DISABILITY         P-value
          CATEGORY
                                  Percent     n         Percent     n
          All Respondents
                                    20.1     1557         79.9     5324
                (ages >18)
          AGE
              18-64                 71.6     1031         86.5     4265
                                                                              0.0000
               65+                  28.4      510         13.5     1014
          GENDER
              Male                  45.3     580          48.1     2046
                                                                              0.1136
              Female                54.7     977          51.9     3278
          RACE/ETHNICITY
              White                 69.4     1219         69.9     4109
                                                                              0.7678
              Non-white             30.6      331         30.1     1182
          EDUCATION
              Less than H.S.        18.6      283         10.2     497
                                                                              0.0000
              H.S. or higher        81.4     1269         89.8     4819
          INCOME
              <$25,000              51.8     726          26.9     1218
                                                                              0.0000
              $25,000 +             48.2     607          73.1     3441
          EMPLOYMENT
              Employed              29.1     419          67.0     3406
              Not employed
                Retired             25.4     455          13.5     1003
                Student/                                                      0.0000
                                     8.7     132          12.4     594
                Homemaker
                Unemployed           9.0     109           5.6     225
                Unable to Work      27.8     436           1.5     77



Table 2. Demographic Attributes by Category and Disability Status.

      Table 2a. Disability and No Disability Proportions for the Total Statewide Sample



                     TOTAL n      MEASURE             DISABILITY     NO DISABILITY

                                      %                  20.1               79.9
                                    95% CI             19.0-21.2          78.8-81.0
                       6,881
                                      n                  1557               5324




                                                  4
       Table 2b. Disability and No Disability Proportions by Age*


         AGE      MEASURE         DISABILITY      NO DISABILITY

                                     17.2                82.8
                      %
        18-64       95% CI         16.0-18.4           81.6-84.0
                      n              1031                4265

                      %              34.5                65.5
         65+        95% CI         31.8-37.3           62.7-68.2
                      n
                                      510                1014

            *p<0.0001



   Table 2c. Disability and No Disability Proportions by Gender


    GENDER        MEASURE          DISABILITY          NO DISABILITY


                      %                19.1                  80.9
     MALE           95% CI           17.4-20.9             79.1-82.7
                       n                580                  2046

                      %                21.0                  79.0
    FEMALE          95% CI           19.6-22.4             77.7-80.4
                      n                 977                  3278

       p=0.1136




Table 2d. Disability and No Disability Proportions by Race/Ethnicity


RACE/ETHNICITY          MEASURE           DISABILITY          NO DISABILITY


                           %                 20.0                    80.0
                         95% CI            18.8-21.2               78.8-81.2
    WHITE                  n                 1219                    4109

                           %                 20.4                    79.6
  NON-WHITE              95% CI            17.9-23.0               77.0-82.2
                           n                  331                    1182

   p=0.7678




                                    5
Table 2e. Disability and No Disability Proportions by Education*

         EDUCATION            MEASURE             DISABILITY         NO DISABILITY


                                 %                    31.5                68.5
       <HIGH SCHOOL            95% CI               27.4-35.6           64.4-72.7
                                 n                     283                 497

                                 %                    18.5                81.5
       =>HIGH SCHOOL           95% CI               17.4-19.7           80.3-82.6
                                 n                    1269                4819

       *p<0.0001

Table 2f. Disability and No Disability Proportions by Income*

          INCOME          MEASURE            DISABILITY            NO DISABILITY


                             %                     32.3                67.7
                           95% CI                29.6-34.9           65.1-70.4
          <$25,000           n                      726                1218

                             %                     14.0                86.0
          $25,000+         95% CI                12.8-15.2           84.8-87.2
                             n                      607                3441

           *p<0.0001

 Table 2g. Disability and No Disability Proportions by Employment Status*


        EMPLOYMENT               MEASURE              DISABILITY        NO DISABILITY

                                      %                    9.9               90.2
          EMPLOYED                  95% CI              8.7-11.0           89.0-91.3
                                      n                   419                3406
                                      %                  32.1                67.9
           RETIRED                  95% CI             29.3-34.9           65.1-70.7
                                      n                   455                1003
                                      %                  15.0                85.0
    STUDENT/HOMEMAKER               95% CI             12.0-18.0           82.0-88.0
                                      n                   132                 594
                                      %                  28.6                71.5
        UNEMPLOYED                  95% CI             22.4-34.7           65.3-77.6
                                      n                   109                 225
                                      %                  82.7                17.3
      UNABLE TO WORK                95% CI             78.6-86.9           13.1-21.4
                                      n                   436                 77
       *p<0.0001




                                             6
IB. Healthy People 2010 Leading Health Indicators for Adults by Disability Status

    The HP 2010 Leading Health Indicators and other objectives have a strong preventive orientation
emphasizing the assessment and reduction of risk factors and disparities in health status, with a special
section on people with disabilities. In this section of the report we evaluate the status of the Healthy
People 2010 Leading Health Indicators for individuals with disability and those with no disability. The HP
2010 Leading Health Indicators are listed in Table 3 in the order in which they are considered in this
report and are indexed as Part 1, IB A1-IB A3 and Part 2, IB B4-IB B8.
    For Table 3, the objectives and the Healthy People 2010 number for the objective are listed in column
1. The HP 2010 target proportion for people with disability is listed in column 2. The percentages
responding yes for the SC BRFSS 2004 disability and no disability categories are shown in columns 3
and 4. Table 3 includes p-values; Tables 4-11 add the 95% Confidence Interval (95% CI, indicating the
range within which the true value will be found with repeated samples 95% of the time). Prevalence
estimates, standard errors, confidence intervals, and p-values from the chi-square statistic were
calculated with SUDAAN (Research Triangle Institute, Research Triangle Park, NC). The key that locates
the question in the BRFSS questionnaire is shown in column 5 of Table 3. The three components of the
BRFSS are core, optional modules, and additional questions added by states. In Table 3, all of the
variables except one come from questions in the BRFSS core and are coded as CQ; the one additional
question added by a state is coded State Add. More information on the composition of the BRFSS
questionnaire and methods is provided in Section III of this report.
    For Part 1, three disparities unfavorable for people with disability were inability to see a doctor
because of cost (30.9% vs. 14.2%), physical activity, as a smaller percentage of PWD were active for 30
minutes five days per week (26.1% vs. 36.4%), and lack of health insurance coverage (21.8% vs. 19.2%),
with both PWD and PWOD falling both the HP 2010 target of 100% coverage. Results that were
favorable for PWD were having multiple sources of health care (88.5% vs. 80.6%) and immunization for
flu and pneumonia (46.5% vs. 31.9% and 72.2% vs. 59.7% respectively).
    Part 2 contains three unfavorable disparities for PWD, for tobacco use (21.0% vs. 17.3%), for
overweight and obesity (34.5% vs. 23.0%), and for mental health not good 15-30 of past 30 days (23.9%
vs. 7.1%). A neutral result was indicated in the substance abuse category for binge drinking (6.50% vs.
6.51%), with both levels exceeding HP 2010 targets. A question related to the responsible sexual
behavior category (asked of those under age 65), was ever having an HIV test (49.6% vs.46.0%); the
result was also neutral for PWD.




                                                      7
Table 3. Summary of HP 2010 Leading Health Indicators and SC BRFSS 2004 by Disability
         Status



                                                     HP 2010          SC BRFSS 2004 % Yes
      HP 2010 Objectives That Are Leading                                                           BRFSS
                                                      Target
          Health Indicators for Adults                                                              Source
                                                        %          Disability      No Disability
    IB A1a. Access to Health Care (HP1.1):                                  **
                                                       100           78.2               80.8        CQ3.1
    % under age 65 with health coverage.

    IB A1b. Access to Health Care (HP1-4A):
                                                        96           88.5 *             80.6        CQ3.2
    % with disabilities have care source.

    IB AIc. Access to Health Care: % under age
    65 who could not see doctor in past 12             NA            30.9 *             14.2        CQ3.3
    months because of cost.
    IB A2. Physical Activity (HP22-1): % of
                                                                                                   State Add
    adults age 18+ with disability who are active       30           26.1*              36.4
                                                                                                   Q1.3/4/6/7
    30 min 5 days/wk.

    IB A3a. Immunization (HP14-29a,c) Adults
                                                        90           46.5 *             31.9        CQ12.1
    w/disabilities who annually received flu shot.

    IB A3b. Immunization (HP14-29b,d) Adults
    w/disabilities ages 65+ who ever received           90           72.2 *             59.7        CQ12.3
    pneumonia immunization.

    IB B4. Substance Abuse: Alcohol                                        NS
                                                       6.0           6.5                 6.5        CQ8.3
    Consumption, Binge drinking (HP26-11c).

    IB B5. Tobacco Use (HP27-1a): Adults
                                                        12           21.0*              17.3        CQ7.2
    w/disabilities who smoke cigarettes daily.

    IB B6. Overweight and Obesity (19-2a):
                                                                                                   CQ13.10
    Women and men w/disabilities who are                15           34.5*              23.0
                                                                                                   CQ13.11
    obese.
    IB B7. Mental Health: Increase % of adults
    with recognized depression who receive
    treatment (HP18-9b). BRFSS data                     17           23.9 *              7.1        CQ2.2
    available for “Mental health not good 15-30
    of past 30 days”.

    IB B8. Responsible Sexual Behavior; Ever                               NS
                                                       NA           49.6                46.0        CQ20.3
    tested for HIV (HP13-7), age <65.


        Disability vs. no disability, *p<0.0001, **p<0.01, NS=Not significant, NA=Not Available




IB A. Leading Health Indicators Part 1, IB A1-IB A3.

    Figure 1 summarizes the results for a subset of the indicators, items IB A1-IB A3. Individuals under
age 65 with disability were significantly less likely to have health care insurance than those with no
disability (p<.01). For having at least one personal health care provider, levels for disability were
significantly favorable in comparison with the no disability group, suggesting the potential for more health
care encounters for those with disability despite less coverage. Encounter frequency may relate to the



                                                         8
result that immunization rates for influenza and pneumonia were significantly higher for individuals with
disability. Moderate Exercise was the only variable of the five that was close to or exceeded the HP 2010
targets, with the other four variables in the figure well below desired levels.



           Figure 1. SC BRFSS 2004. Comparison of Yes Responses to HP 2010 Target Values
                     for Selected Leading Health Indicators by Disability Status.


                              SC BR           om
                                   FSS 2004. C par i son of Yes R              P
                                                                 esponses t o H 2010 Tar get Val ues f or Sel ect ed Leadi ng
                                                                             H   e   a   l   t   h     I   n   d   i   c   a   t   o   r   s




                                            100
                                                                       96
                1   0   0




                                                          88. 5                                                                                                90                     90
                              78. 2 80. 8                      80. 6                  I
                                                                                     D SABI LI TY
                    8   0
                                                                                                                                                                         72. 2
                                                                                      O I
                                                                                     N D SABI LI TY
                                                                                      P        G
                                                                                     H 2010 TAR ET
  PERCENT YES




                    6   0
                                                                                                                                                                              59. 7

                                                                                                                                                 46. 5

                                                                                                                                                      31. 9
                    4   0


                                                                                                                       34. 2

                                                                                                 25. 3                                     30
                    2   0




                        0
                                       eal
                                      H th                         ar
                                                       Per sonal C e Pr ovi der                      Moder at e Exer ci se                      Fl u Shot ( Tabl e 6)        oni
                                                                                                                                                                        Pneum a Shot >=65
                            cover age/ I nsur ance <65        ( Tabl e 4c)                               ( Tabl e 5b)                                                        ( Tabl e 6)
                                    ( Tabl e4a)
                                                                                I G EALTH I N I C R
                                                                            LEAD N H         D ATO



IB A1a. Access to Health Care, Below Age 65 (result unfavorable for PWD).

The Healthy People 2010 Objectives:
    Increase the proportion of people with disabilities under age 65 who have health care
     coverage/insurance to 100% (HP1-1).
    Increase the proportion of people with disabilities ages 18+ who have a specific source of ongoing
     care to 96% (HP 1-4a).
    Increase the proportion of pregnant women who begin prenatal care in the first trimester of
     pregnancy to 90% (HP 16-6a).


The 2004 SC BRFSS asked the following question related to health care coverage:
    “Do you have any kind of health care coverage, including health insurance, prepaid plans such as
     HMOs, or government plans such as Medicare?”




                                                                                                           9
    Table 4a.    SC BRFSS 2004. Access: Health Care Coverage/Insurance During the Past
                 12 Months by Age Group <65 and Disability Status.*

                                                       Disability                 No Disability
                     SC BRFSS 2004                %     (95% CI)     n        %     (95% CI)       n

             Health care coverage/insurance
             for age <65
                      Yes                   78.2 (74.6-81.8) 831             80.8 (79.2-82.4)     3567
                      No                    21.8 (18.2-25.4) 199             19.2 (17.6-20.8)      681

                 *p<0.01

    Although a large percentage of adults in both disability and no disability groups under age 65 reported
coverage such as insurance or other plans to meet health care costs, there were still 21.8% and 19.2%
respectively without coverage. (The BRFSS does not distinguish the type of coverage). The percentage
unfavorable for disability reached statistical significance. Both South Carolina proportions without
coverage were above the results for the 2002 National Health Interview Survey of 16.6% for the US. The
proportion without coverage for PWOD was below the survey‟s result of 20.2% for the South, but the
proportion of PWD without coverage was still higher than this percentage. All measures were well below
the HP 2010 target of 100% coverage, presumably for those under age 65, as those age 65 and above
are covered by Medicare.

IB A1b. Unable to See Doctor Because of Cost (result unfavorable for PWD).

The Healthy People 2010 Objective:
    No specific objective for this topic; included here because of its relationship to health care access.

The 2004 SC BRFSS asked the question:
    “Was there a time in the past 12 months when you needed to see a doctor but could not because
     of the cost?”

    Table 4b.    SC BRFSS 2004. Access: Unable to See Doctor Because of Cost
                 by Disability Status.*

                                                 Disability                  No Disability
                     SC BRFSS 2004         %      (95% CI)     n         %     (95% CI)      n

                  Unable to see doctor
                  because of cost
                          Yes          24.7 (21.9-27.5)  356             12.8 (11.6-14.0)  616
                          No           75.3 (72.5-78.1) 1193             87.2 (86.0-88.4) 4702

                     *p<0.0001

    These results, coupled with those from Table 4a, are consistent with the conclusion that the disability
group is associated with significantly reduced access to health care when compared to the no disability
group, especially for those less than 65 years of age. Note that the greater disparity identified in Table 4b
is potentially a function of two factors: (1) the level of health care coverage or the ability to pay out of



                                                       10
pocket for health care and (2) the propensity to seek health services. If PWD are more likely to perceive a
need for health care, difficulties in paying for such services would likely be made more readily apparent.



IB A1c. Specific Source of Ongoing Care (result favorable for PWD).

The Healthy People 2010 Objective:
    Increase the proportion of people with disabilities ages 18+ who have a specific source of ongoing
     care to 96% (HP1-4c).

The 2004 SC BRFSS asked the question:
    “Do you have one person you think of as your personal doctor or health care provider?”

        Table 4c. SC BRFSS 2004. Access: Number of Personal Health Care Providers
                  by Disability Status.*

                                                   Disability                   No Disability

                   SC BRFSS 2004             %      (95% CI)       n      %      (95% CI)       n


            One health provider
               Yes, only one                72.8   (70.0-75.6)    1142   73.0   (71.4-74.6)   4106
               More than one                15.8   (13.6-18.0)    264    7.6    ( 6.7- 8.5)   422
               No                           11.5    ( 9.2-13.8)   147    19.4   (17.9-20.9)   777


            One or more health providers
               Yes                          88.5   (86.2-90.8)    1406   80.6   (79.1-82.1)   4528
               No                           11.5   ( 9.2-13.8)    147    19.4   (17.9-20.9)    777

                *p<0.0001

    For the category of health provider, the percentage of people with disability who had more than one
health care provider was significantly higher than for people with no disability, 15.8% vs. 7.6%
respectively. For the percentages having no provider, the disability proportion was significantly less than
no disability (11.5% and 19.4%), suggesting those with disability have more opportunity or greater need
for more than one provider. When the health provider categories were combined (one or more health
providers), the percentage in the disability group (88.5%) was also significantly higher than the no
disability group (80.6%).

IB A2. Physical Activity (result unfavorable for PWD).

The Healthy People 2010 Objectives:
    Reduce the proportion of adults with disabilities who engage in no leisure-time physical activity to
     20% (HP22-1).
    Increase the proportion of adults with disability who are physically active for at least 30 minutes per
     day 5 days per week to 30% (HP22-2).
    Increase the proportion of adults who engage in vigorous physical activity that promotes
     cardiorespiratory fitness three or more days per week for 20 or more minutes per occasion (HP22-
     7).




                                                     11
The 2004 SC BRFSS asked the question:
    “During the past month, other than your regular job, did you participate in any physical activities
       or exercises such as running, calisthenics, golf, gardening, or walking for exercise?”

            Table 5a. SC BRFSS 2004. Any Exercise Past 30 Days by Disability Status.*

                                             Disability                  No Disability
                   SC BRFSS 2004
                                       %      (95% CI)     N       %      (95% CI)        n

                   Exercise
                     Yes              57.4   (54.4-60.4)   863    80.8   (79.5-82.1)     4,317
                     No               42.6   (39.6-45.6)   689    19.2   (17.9-20.5)     1002

                     *p<0.0001

    More than half of those with disability reported participating in some physical activity in the past
month. However, as might be expected, people with disability were definitely less active than people with
no disability. The proportion reporting no exercise was 42.6% and 19.2% respectively. This result is
unfavorable and far from the HP 2010 target of no more than 20% non-participation or at least 80%
participation by PWD.

The 2004 SC BRFSS also asked other exercise-related questions that are more specific:
    “Now, thinking about the moderate activities you do in a usual week, do you do moderate activities
      for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or
      anything else that causes some increase in breathing or heart rate?” (HP18.2)
    “How many days per week do you do these moderate activities for at least 10 minutes?” (HP18.3)
    “On days when you do moderate activities for at least 10 minutes at a time, how much total time
      per day do you spend doing these activities?” (HP18.4)
    “Now, thinking about the vigorous activities you do in a usual week, do you do vigorous activities
      for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that
      causes large increases in breathing or heart rate?” (HP18.5)
    “How many days per week do you do these vigorous activities for at least 10 minutes at a time?”
      (HP18.6)
    “On days when you do vigorous activities for at least 10 minutes at a time, how much total time per
      day do you spend doing these activities?” (HP18.7)

        Table 5b. SC BRFSS 2004. At Least 30 Minutes of Moderate or Vigorous Exercise at
                  Least Five Days a Week by Disability Status*

                                             Disability                  No Disability
                    SC BRFSS 2004
                                       %      (95% CI)      n      %      (95% CI)        n

                    Moderate
                      Yes
                                      25.3 (22.5-28.1) 337        34.2 (32.6-35.8) 1694
                      No
                                      74.7 (71.9-77.5) 1060       65.8 (64.2-67.4) 3171

                    Vigorous
                       Yes            4.8  (3.4-6.2)   58         10.5 (9.3-11.7)        453
                       No             95.2 (93.8-96.6) 1387       89.5 (88.2-90.7)       4474

                     *p<0.0001



    For moderate exercise, people with disability were significantly below those without limitations, and


                                                      12
were also below the HP 2010 target of 30%. Interestingly, PWOD exceeded the HP goal. The current
level of moderate exercise in the two groups suggests resetting the target proportion above 30% would
be desirable. For the highest exercise level, only 4.8% of adults with disability reported exercising
vigorously for at least 30 minutes a day at least five days of the week.

IB A3a and b. Immunization (results favorable for PWD).
The Healthy People 2010 Objective:
    Increase the proportion of non-institutionalized adults with disabilities who are vaccinated annually
     against influenza and ever vaccinated against pneumococcal disease to 90% (HP14-29 a,b).
The SC BRFSS 2004 asked the questions:
    “During the past 12 months have you had a flu shot (BRFSS Core 10.1)?”
    “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person‟s
     lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”

        Table 6. SC BRFSS 2004. Immunizations by Disability Status.*

                                               Disability                    No Disability
                    SC BRFSS 2004
                                         %        (95% CI)    n        %       (95% CI)       n

                     Flu Shot (All)
                          Yes
                                        46.5   (43.4-49.6)    762     31.9   (30.4-33.4)     1859
                          No
                                        53.5    (50.4-56.6)   789     68.1   (66.6-69.6)     3456
                    Pneumonia (All)
                         Yes
                                        43.3   (40.2-46.4)    676     21.8   (20.3-23.3)     1117
                         No
                                        56.7    (53.6-59.8)   785     78.2   (76.7-79.7)     3791
                   Pneumonia (>=65)
                        Yes
                                        72.2   (67.3-77.1)    358     59.7   (56.2-63.2)     591
                        No
                                        27.8    (22.9-32.7)   131     40.3   (36.8-43.8)     398

                 *p<0.0001


    For the categories including all adults, those with disability were significantly more likely to report
receiving influenza or pneumonia immunization. For influenza, it was 46.5% vs. 31.9%; for pneumonia,
43.3% vs. 21.8%. When the groups of those 65 years of age and above were examined for pneumonia
vaccination, the difference between PWD and PWOD was 72.2% and 59.7% respectively, remaining
higher in the disability group. However, in all groupings, the level of immunization was unfavorable, and
well below the Healthy People 2010 target of 90% coverage. The South Carolina rates are higher than
the rates of vaccination in US adults 65 years of age and over: for 2004, US coverage for this age group
was 64.7% for pneumonia (CDC BRFSS Data).

IB B. Leading Health Indicators, Part 2, IB B4-IB B8.
    Of the following five variables (Figure 2), three were decidedly unfavorable for people with disabilities,
indicating greater risk of illness, missing the desired HP 2010 targets by a wide margin, and providing
clear targets for intervention. The disparity was significantly higher in individuals with disability for daily



                                                       13
cigarette smoking, obesity, and mental health problems. The variables binge drinking and HIV testing
were not significantly different between PWD and PWOD. Binge drinking tended to be above target for
both groups, a level regarded as unfavorable.


Figure 2. SC BRFSS 2004. Comparison of Yes Responses to HP 2010 Target
   Values for Selected Leading Health Indicators by Disability Status.


                       SC BRFSS 2004. Comparison of Yes Responses to HP 2010 Target Values for Selected Leading
                                                  Health Indicators (Bars are 95% CI)

                 60
                                                                                                                                                     49.6

                                                                                           DISA B ILITY
                 50                                                                        NO DISA B ILITY
                                                                                                                                                               46
                                                                                                 0
                                                                                           HP 201 TA RGET


                 40                                                               34.5
   PERCENT YES




                 30                                                                                                 23.9
                                                    21                                     23
                                                         17.3
                 20
                                                                                                   15
                                                                     12
                       6.51                                                                                                  7.1
                 10            6.5                                                                                                    7
                                        6


                 0
                      Subst ance abuse: Binge   Tobacco use: Smoking daily     Obesit y: BMI >29.9 (Table 9)   Ment al healt h not good (15-30 of   Responsible sex behavior:
                         drinking (Table 7)              (Table 8)                                                 past 30 days) (Table 10)         Test ed f or HIV (Table 11)*
                                                                          LEADING HEALTH INDICATOR
                                                                            (*=No target set for PWD)


IB B4. Substance Abuse: Alcohol Consumption, Binge Drinking (result neutral for PWD)

The Healthy People 2010 Objectives:
    Reduce the proportion of adults engaging in binge drinking of alcoholic beverages during the past
     month below 6% (HP26-11c).
    Reduce the proportion of adults using any illicit drug during the past 30 days (HP26-10c).

The 2004 SC BRFSS asked the following questions:
    “A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1
     cocktail, or 1 shot of liquor. During the past 30 days, how many days per week or per month did
     you have at least one drink of any alcoholic beverage?” (HP12.1)
    “Considering all types of alcoholic beverages, how many times during the past 30 days did you
     have five or more drinks on an occasion?” (HP12.3)




                                                                                      14
        Table 7.     SC BRFSS 2004. Alcohol Consumption and Binge Drinking in the Past Month
                     by Disability Status

                                          Disability                           No Disability
          SC BRFSS 2004          %        (95% CI)           N          %       (95% CI)         n

        Alcoholic beverage
        past month*
           Yes                 36.6     (33.5-39.7)     526            50.5    (48.8-52.2)     2648
           No                  63.4     (60.3-66.5)     1027           49.5    (47.8-51.2)     2644

                         NS
        Binge Drinking
           0                   72.5     (67.2-77.8)     402            71.7    (69.4-74.0)     2043
           1                   8.6      (4.8-12.4)      36             7.9     (6.6-9.2)       188
           2-5                 12.4     (8.5-16.3)      53             13.9    (12.1-15.7)     289
           >5                  6.5      (3.6-9.4)       32             6.5     (5.1-7.9)       119

        *p<0.0001, NS=Not significant

    Overall, in 2004, 36.6% of those with disability and 50.5% of the no disability group reported alcohol
consumption. Although the difference between the two groups was significant for alcohol consumption in
general, it was not significant for binge drinking.

IB B5. Tobacco Use (result unfavorable for PWD).
The Healthy People 2010 Objective:
    Reduce cigarette smoking by adults to 12% (HP27.1a).

The 2004 SC BRFSS asked the following questions:
    “Have you smoked at least 100 cigarettes in your entire life?”
    If so, “Do you now smoke cigarettes every day, some days or not at all?”


Table 8. SC BRFSS 2004. Tobacco Use: Cigarette Smoking by Disability Status.*

                                               Disability                      No Disability
                   SC BRFSS 2004
                                         %      (95% CI)         n       %       (95% CI)       n
                   Currently smoke
                     Every day         21.0    (18.4-23.6)       290    17.3    (16.0-18.6)    839
                     Some days         7.9     (6.0-9.8)         110    5.88    (5.0-6.8)      272
                     Former smoker     29.7    (26.9-32.5)       489    20.3    (19.1-21.5)    1258
                     Never smoked      41.4    (38.4-44.4)       661    56.5    (54.9-58.1)    2934
                 *p<0.0001

    In 2004, 21% of adults with disability and a lower proportion of 17.3% of adults without disability
currently smoked daily. The rate for US adults in 2004 was 20.9% (CDC BRFSS Data). A significantly
greater percentage of those with no disability reported not smoking at all compared to those with
disability, 56.5% vs. 41.4%.

IB B6. Overweight and Obesity (result unfavorable for PWD).

The Healthy People 2010 Objectives:
    Reduce the proportion of adults who are obese to 15% (HP19-2).
    Increase the number of men and women who are at a healthy weight to 60% (HP19-1a).


                                                       15
The 2004 SC BRFSS collected data on height and weight for calculation of Body Mass Index, the ratio of
weight to height for each individual. A BMI less than 25 is considered normal weight, 25-30 is overweight,
and obese is over 30.

Table 9. SC BRFSS 2004. Obesity: Body Mass Index Categories by Disability Status.*


                  SC BRFSS 2004             Disability                    No Disability

                                      %      (95% CI)        n      %       (95% CI)       n
                  BMI
                    < 25             33.0   (29.9-36.1)      469   40.0   (38.3-41.7)     2115
                    25-29.9          32.5   (29.6-35.4)      501   37.0   (35.4-38.6)     1913
                    > 29.9           34.5   (31.6-37.4)      529   23.0    (21.6-24.4)    1125
                    *p<0.0001

    In 2004, a significantly greater percentage of adults with disability (34.5%) were obese compared to
adults with no disability (23.0%). Although more adults with disability are obese, many people in both
categories must lose weight if SC is to reach the Healthy People 2010 goal of a 15% level of obesity in
adults.

IB B7. Mental Health (result unfavorable for PWD).

The Healthy People 2010 Objective:
    Increase the proportion of adults with recognized depression who receive treatment (HP18-9b).
    Although not ranked as a Leading Health Indicator, a related objective is adults with disabilities who
     report sad feelings that interfere with activities (HP6-3).

The 2004 SC BRFSS has content that relates to these objectives, as indicated by the following question:
    “Now thinking about your mental health, which includes stress, depression, and problems with
      emotions, for how many days during the past 30 days was your mental health not good?” Results
      were grouped into three categories.

          Table 10. SC BRFSS 2004. Number of Days in Past 30 Days Mental Health Not Good by
          Disability Status.*

                                            Disability                    No Disability
                  SC BRFSS 2004
                                      %      (95% CI)         n      %     (95% CI)        n

                  0 days             50.0   (46.8-53.2)      779   68.3   (66.7-69.9)     3662
                  1 - 14 days        26.1   (23.1-29.1)      347   24.6   (23.1-26.1)     1200
                  15-30 days         23.9   (21.2-26.6)      358    7.1    (6.3-7.9)      380

                    *p<0.0001

    As shown in Section II below for three other variables that assess overall quality of life and health
status, the proportion of those with disability who reported difficulty was much higher in PWD than in
PWOD. For the mental health variable as an example, 23.9% of PWD reported mental health not good
for 15-30 of the last 30 days, compared to 7.1% for PWOD.




                                                        16
IB B8. Responsible Sexual Behavior (result neutral for PWD).
The Healthy People 2010 Objective:
    Increase the number of HIV-positive persons who know their serostatus (HP 13-7; developmental;
     target not established)
The 2004 SC BRFSS asked a related question under the HIV/AIDS section of those under age 65:
    “Have you ever been tested for HIV? Do not count tests you may have had as part of a blood
     donation.”

Table 11. SC BRFSS 2004. Responsible Sexual Behavior: Ever Tested for HIV by
                                            NS
           Disability Status (Adults 18-64).

                                   Disability                 No Disability
        SC BRFSS 2004
                             %      (95% CI)     n      %      (95% CI)        N

        Had HIV test
          Yes               49.6   (45.7-53.5)   453   46.0   (44.1-47.9)     1750
          No                50.4   (46.5-54.3)   530   54.0   (52.1-55.9)     2325
       NS=Not Significant

This result was neutral, with no significant differences in HIV testing between PWD and PWOD.


IB C. Leading Health Indicator with No BRFSS Data
IB C10. Environmental Quality
The Healthy People 2010 Objectives:
    Reduce the proportion of persons exposed to air that does not meet the U.S. Environmental
     Protection Agency‟s health-based standards for ozone (HP8-1a).
    Reduce the proportion of nonsmokers exposed to environmental tobacco smoke (HP27-10).

The SC BRFSS 2004 asked questions about a person‟s smoking status (IB5 above) but not about
exposure to secondhand smoke.




                                                       17
IC. Additional Healthy People 2010 Objectives by Disability Status

     Table 12 summarizes selected SC BRFSS 2004 questions that relate to HP 2010 objectives in
addition to the Leading Health Indicators presented in Section IB. The variables are indexed as IC1-IC6.
The objectives and the Healthy People 2010 number for the objective are listed in column 1. The HP
2010 target percentage for the US population is listed in column 2. The percentages responding yes for
the SC BRFSS 2004 disability and no disability categories are shown in columns 3 and 4. An asterisk
denotes a statistically significant difference as determined by the chi-square statistic. The key locating
the question in the BRFSS questionnaire is shown in column 5, where Core Q identifies a question in the
BRFSS Core section, and Module identifies a question located in a BRFSS Module. Section III of this
report provides more information on the composition of the BRFSS questionnaire and methods.
    Of the six variables, three (50%) were significantly unfavorable disparities for People With Disabilities
(PWD). PWD appeared much more likely than People WithOut Disability (PWOD) to have limited activity
because of arthritis or joint symptoms (IC1, 69.1% vs. 13.7%), clinically diagnosed diabetes (IC2, 19.7%
vs. 5.6%), and poorer dental health (more extractions of all natural teeth, IC3a, 25.6% vs. 17.1%, and
fewer proportions with no permanent tooth extractions, IC3b, 31.9% vs. 56.4%). The two variables on the
favorable side indicated that PWD were more likely than PWOD to have received a sigmoidoscopy/
colonoscopy (IC5, 61.8% vs. 53.6%) and to receive counseling on diet (IC6a, 48.5% vs. 32.4%). There
was no significant difference between PWD and PWOD in receipt of a fecal occult blood test (45.4% vs.
44.2%), and counseling on condom use was also similar in both groups, 13.4% vs. 15.1%. The
proportions receiving a sigmoidoscopy/colonoscopy exceeded the HP 2010 target in a favorable direction.
    Table 12 provides expanded data on the additional objectives.




                                                     18
    Table 12: Summary of HP 2010 Additional Objectives and SC BRFSS 2004 by
              Disability Status


             HP 2010 Objectives                  HP 2010         % Yes SC BRFSS 2004             BRFSS
                                                 Target %                                        Source
                                                               Disability      No Disability
    IC1. Limitation in activities due to
    arthritis (HP2-2): Adults limited by joint     21.0            69.1*             13.7      Module Q17.5
    symptoms.

    IC2. Diabetes clinically diagnosed
                                                    2.5           19.7 *              5.6         CQ10.1
    (HP5-3).

    IC3a. Dental health: All natural teeth
                                                   20.0           25.6 *             17.1         CQ11.2
    extracted, ages 65-74 (HP21-4)
    IC3b. Dental Health: Adults with
    disabilities who have no or some
                                                   42.0           31.2 *             56.4         CQ11.2
    permanent teeth extracted due to
    dental caries (HP21-3).

    IC4. Stool blood test (ever) (fecal                                  NS
                                                   50.0           45.4               44.2         CQ17.1
    occult blood test), ages 50+ (HP3-12a)


    IC5. Sigmoidoscopy (ever), ages 50+
                                                   50.0           61.8 *             53.6         CQ17.3
    (HP3-12b)


    IC6a. Counseling: Patient education
                                                    75            48.5 *             32.4      Module Q12.2a
    related to diet and nutrition (HP19-17a)

     IC6b. Counseling: Received
                                                                         NS
     counseling for condom use (HP13-6a),               50          13.4              15.1       CQ20.11
     age < 65
    *Disability significantly different from No disability, p<0.0001 NS=Not Significant
    NA= Not Available

Table 13. Expanded Data for HP 2010 Additional Objectives and SC BRFSS 2004
          by Disability Status

IC1. Activity Limited by Joint Symptoms (result unfavorable for PWD).
The Healthy People 2010 Objective
       Reduce the proportion of adults with chronic joint symptoms ages 18+ who have a limitation in
         activity to 21% (HP2-2).

The SC BRFSS 2004 asked the question:
        “Are you now limited in any way in any of your usual activities because of arthritis or joint
         symptoms?”




                                                          19
    Table 13a. IC1. SC BRFSS 2004. Limited in Usual Activities due to Arthritis (HP2-2). *

                                          Disability                     No Disability
          SC BRFSS 2004             %      (95% CI)      n         %         (95% CI)     n


     Limited by joint symptoms
          Yes                      69.1   (66.1-72.1)   836       13.7    (12.0-15.4)    293
          No                       30.9   (27.9-33.9)   381       86.3    (84.6-88.0)    1821


        *p<0.0001

    The 69.1% of PWD reporting difficulty with joint symptoms was highly unfavorable, much higher than
the case for PWOD, and well above the desired HP 2010 target of 21%.


IC2. Diabetes (result unfavorable for PWD).

The Healthy People 2010 Objective:
    Reduce people with disabilities who are new and previously diagnosed with diabetes to 25/1000 or
     2.5% (HP5-3).

The SC BRFSS 2004 asked the question:
    “Have you ever been told by a doctor that you have diabetes?”

    Table 13b. IC2. SC BRFSS 2004. Diabetes Clinically Diagnosed by Disability Status (HP5-3).*

                                           Disability                             No Disability
           SC BRFSS 2004          %         (95% CI)          n          %         (95% CI)          n

         Diabetes (ever)
             Yes                 19.7     (17.4-22.0)    318           5.6      (5.0-6.2)         360
             No                  80.3     (78.0-82.6)    1237          94.4     (93.8-95.0)       4963

            *p<0.0001

    The proportion of PWD reporting diabetes has the highly unfavorable value of 19.7%, a level well
above the 5.6% of PWOD and far above the HP 2010 target. The 2004 US rate of physician-diagnosed
diabetes was 7.0% (CDC BRFSS Data).


IC3. Dental Health. Extraction of Teeth Due to Disease (result unfavorable for PWD).
The Healthy People 2010 Objective:
    Reduce the proportion of adults with disabilities ages 65-74 who have all teeth extracted below
     20% (HP21-4).

The SC BRFSS 2004 asked the question:
    “How many of your permanent teeth have been removed because of tooth decay or gum disease?
      Do not include teeth lost for other reasons, such as injury or orthodontics. If wisdom teeth are
      removed because of tooth decay or gum disease, they should be included in the count for lost
      teeth. Include teeth lost due to infection.” (BRFSS Mod2 Q3) Response choices included All or
      None, the source for the data in Tables 14e (IC5a) and 14f (IC5b).
IC3a. Dental Health a. Extraction of All Natural Teeth (result unfavorable for PWD).


                                                        20
             Decrease the proportion of adults with disabilities who have all of their teeth extracted from
              dental caries to 20% (HP21-4).

        Table 13c. IC3a. SC BRFSS 2004. Extraction of All Natural Teeth Ages 65-74
        by Disability Status (HP21-4).*

                                                  Disability                  No Disability
                    SC BRFSS 2004          %       (95% CI)       n     %       (95% CI)       n


                   All teeth extracted
                         Yes              25.6    (19.7-31.5)   69     17.1    (14.0-20.2)    118
                         No               74.4    (68.5-80.3)   199    82.9    (79.8-86.0)    530

                     *p<0.0001

    People with disability in the 65-74 age group have a significantly higher proportion with extraction of
all teeth, a percentage which is above the target value of 20%, an unfavorable disparity for PWD. Those
with no disability are in the desirable region below the target value.

IC3b. Dental Health b. Extraction of Teeth Due to Disease (result unfavorable for PWD).

The Healthy People 2010 Objective:
    Increase the proportion of adults with disabilities who have never had a permanent tooth extracted
     from dental caries to 42% (HP21-3).

        Table 13d. IC3b.      SC BRFSS 2004. No Permanent Teeth Extracted Due to Dental Caries
                              or Periodontal Disease, All Adults, by Disability Status (HP21-3).*

                                                 Disability                   No Disability
                   SC BRFSS 2004
                                          %       (95% CI)       n       %      (95% CI)       n

                 No teeth extracted
                        Yes              31.2    (28.1-34.3)    413    56.4    (54.8-58.0)    2700
                        No               68.8    (65.7-71.9)    1107   43.6    (42.0-45.2)    2547

                         *p<0.0001

    The proportion of PWD with no tooth extraction is unfavorable, significantly lower than for PWOD and
below the HP 2010 target of 42%. The rate for PWOD is favorable, and well above the target of 42%.

IC4. Stool Blood Test (result favorable for PWD).
The Healthy People 2010 Objective:
    Increase the proportion of adults with disabilities age 50+ who have received a fecal occult blood
     test in the preceding two years to 50% (HP3-12a).

The SC BRFSS 2004 asked the question of those 50+ years of age:
    “A blood stool test is a test that may use a special kit at home to determine whether the stool
      contains blood. Have you ever had this test using a home kit?”
                                                                                                     NS
Table 13e. IC4. SC BRFSS 2004. Stool Blood Test (ever) (Fecal Occult Blood Test) (HP3-12a).




                                                         21
                                   Disability                          No Disability
         SC BRFSS 2004
                             %      (95% CI)        n          %         (95% CI)       n

         Stool blood test
              Yes           45.4   (41.9-48.9)     503        44.2     (42.0-46.4)     1140
              No            54.6   (51.1-58.1)     568        55.8     (53.6-58.0)     1323

            NS=Not Significant

    The proportion of PWD reporting a stool blood test was not significantly different than the value for
PWOD, but both were in a similar range and unfavorable, far below the HP 2010 target value of 50%.

IC5. Sigmoidoscopy/Colonoscopy (result favorable for PWD).

The Healthy People 2010 Objective:
    Increase the proportion of adults with disabilities age 50+ who have ever received a sigmoidoscopy
     to 50% (HP3-12b).

The SC BRFSS 2004 asked the question of respondents who were 50+:
    “Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the
     bowel for signs of cancer or other health problems. Have you ever had either of these exams?”

        Table 13f. IC5. SC BRFSS 2004. Sigmoidoscopy/colonoscopy (ever), Ages 50+ (HP3-12b)*

                                            Disability                                  No Disability
            SC BRFSS 2004
                                     %           (95% CI)          n           %            (95% CI)      n

         Sigmoidoscopy (ever)
             Yes                   61.8    (58.3-65.3)         663           53.6      (51.3-55.9)      1366
             No                    38.2    (34.7-41.7)         394           46.4      (44.1-48.7)      1091

            *p<0.0001

    The 61.8% of PWD age 50 and above who reported receipt of sigmoidoscopy/colonoscopy is higher
than the 53.6% for PWOD; both values are in a favorable range that exceeds the desirable HP 2010
target of 50%.


IC6.   Counseling
IC6a. Counseling Regarding Diet (result favorable for PWD).

The Healthy People 2010 Objective:
    Increase the proportion of people with disabilities with hyperlipidemia, cardiovascular disease or
     diabetes who receive office visits that include education related to diet and nutrition to 75% (HP19-
     17a).
The SC BRFSS 2004 asked the question:
    “Within the past 12 months, has a doctor, nurse, or other health professional told you to eat fewer
     high fat or high cholesterol foods?”




                                                         22
    Table 13g. IC6a. SC BRFSS 2004. Dietary Counseling by Disability Status (HP19-17a).*

                                                Disability                       No Disability
                  SC BRFSS 2004             %       (95% CI)     n         %         (95% CI)     n

                Received counseling
                on diet
                      Yes                48.5   (45.4-51.6)     736       32.4     (30.9-33.9)   1725
                      No                 51.5   (48.4-54.6)     770       67.6     (66.1-69.1)   3415

                    *p<0.0001

    The 48.5% of PWD receiving dietary counseling is significantly higher than the 32.4% proportion for
PWOD. However, more than half of each group did not report receiving this important information.


IC6b. Counseling Regarding Condom Use (result neutral for PWD).
The Healthy People 2010 Objective:
    No specific objective exists for counseling, but there is an objective to increase the proportion of
sexually active persons who report condom use (HP 13-6, target 50%), and also to one for having health
and wellness programs and facilities that provide full access for people with disabilities (HP 6-10).

The SC BRFSS 2004 asked the question:
    “In the past 12 months has a doctor, nurse, or other health professional talked to you about
     preventing sexually transmitted diseases through condom use?”

    Table 13h. SC BRFSS 2004. Responsible Sexual Behavior: Received Counseling Regarding
                                                            NS
               Condom Use by Disability Status (Adults <65).

                                       Disability                      No Disability
          SC BRFSS 2004
                                 %      (95% CI)       n         %      (95% CI)        n

        Received counseling
        on condom use
             Yes                13.4   (10.2-16.6)    99        15.1   (13.6-16.6)     489
             No                 86.6   (83.4-89.8)    924       84.9   (83.4-86.4)     3703

            NS=Not Significant (p=0.3444)


    The amount of counseling offered on condom use was minimal in both groups (13.4% for PWD vs.
15.1% for PWOD) and not different for either receiving or not receiving the service. (Note that HP 13-6a
is directed to women aged 18-44 with reported condom use by partners).




                                                           23
  SECTION II. SC BRFSS 2004. RESULTS FOR SELECTED ADDITIONAL VARIABLES
  This category of BRFSS questions does not have closely related HP 2010 objectives, but the results are
important for assessing disparities in the quality of life and other factors affecting the disability group to no
disability group comparison. These results indicate the quality of life may be significantly lower for PWD
than for PWOD; the data are summarized in Table 14.
  Disparities were unfavorable for six of the seven variables in this section, as follows: general health fair to
poor (IIA 1, 51.8% vs. 9.2%), physical health not good for 15-30 of the last 30 days (IIA 2, 39.9% vs. 4.2%),
mental health not good for 15-30 of last 30 days (IIA 3, 23.9% vs. 7.1%), kept from usual activities by poor
physical or mental health 15-30 of last 30 days (IIA 4, 38.5% vs. 4.5%), limited in usual activities by arthritis
or joint symptoms (IIA 5, 69.1% vs. 13.7%), and asthma (ever told by health professional)(IIB 1, 18.5% vs.
10.2%). A favorable status was present for prostate specific antigen (PSA) testing (IIB 3, 69.6% vs. 65.2%).

           Table 14. SC BRFSS 2004. Summary of Additional Variables by Disability Status


                               Variable                    % Yes SC BRFSS 2004              BRFSS
                                                                                            Source
                                                          Disability    No Disability
               IIA 1. General health fair to poor           51.8 *           9.2          Core Q1.1

               IIA 2. Physical health not good for 15-
                                                            39.9 *           4.2          Core Q2.1
               30 of the last 30 days

               IIA 3. Mental health not good for 15-30
                                                            23.9 *           7.1          Core Q2.2
               of last 30 days

               IIA 4. Keep from usual activities by
               poor physical or mental health 15-30 of      38.5 *           4.5          Core Q2.3
               last 30 days

               IIA 5. limited in usual activities by
                                                            69.1*           13.7          Mod Q17.5
               arthritis or joint symptoms

               IIB 1. Asthma (ever told by health
                                                            18.5 *          10.2          Core Q9.1
               professional)

               IIB 3. Prostate specific antigen (PSA)
                                                           69.6**           65.2          Core Q16.1
               testing
               *Disability significantly different from No disability, p<0.0001 **p=.01
               NS=Not Significant




                                                          24
 Section II A. Health Assessment Indicators by Disability Status (results unfavorable for PWD).

 The SC BRFSS 2004 asked the following questions related to this topic:
      “Would you say that in general your health is Excellent, Very Good, Good, Fair, or Poor?”
      “Now thinking about your physical health, which includes physical illness and injury, for how many
       days during the past 30 days was your physical health not good?”
      “Now thinking about your mental health, which includes stress, depression, and problems with
       emotions, for how many days during the past 30 days was your mental health not good?”
      “During the past 30 days, for about how many days did poor physical or mental health keep you
       from doing your usual activities, such as self-care, work, or recreation?”
      “Are you now limited in any way in any of your usual activities because of arthritis or joint
       symptoms?”

 Table 15 provides detailed data for the health assessment questions.

     Table 15. SC BRFSS 2004. Health Assessment Indicators by Disability Status (results
               unfavorable for PWD).*

                                                            Disability                 No Disability
       2004 BRFSS Variables
                                                 %          (95% CI)       n     %       (95% CI)        n

      (CQ1.1)..in general health is:
                Excellent                       5.7      (4.3-7.1)       79    24.2   (22.8-25.6)      1272
               Very Good                       13.0      (11.0-15.0)     198   35.8   (34.2-37.4)      1919
                  Good                         29.5      (26.6-32.4)     451   30.9   (29.4-32.4)      1626
                   Fair                        27.4      (24.6-30.2)     426   7.8    (7.0-8.7)        426
                  Poor                         24.4      (21.8-27.0)     399   1.4    (0.9-1.8)        77

(CQ1.2)..how many days in past 30 days
       physical health not good:
                0 days                         31.8      (28.8-34.8)     467   72.6   (71.1-74.1)      3811
              1-14 days                        28.3      (25.4-31.2)     401   23.3   (21.8-24.8)      1186
            15-30 days++                       39.9      (36.8-43.0)     605    4.2   (3.5-4.8)        228

(CQ1.3)..how many days in past 30 days
        mental health not good:
                0 days                         50.0      (46.9-53.2)     779   68.3   (66.7-69.9)      3662
              1-14 days                        26.1      (23.1-29.1)     347   24.6   (23.1-26.1)      1200
            15-30 days++                       23.9      (21.2-26.6)     358   7.11   (6.29-7.93)      380

(CQ1.4)..how many days poor physical or
   health kept form usual activities:
                0 days
               1-14 days                       35.2      (32.0-38.4)     428   69.1   (66.8-71.4)      1702
             15-30 days++                      26.3      (23.2-29.4)     301   26.4   (24.2-28.6)      617
                                               38.5      (35.1-41.9)     443   4.5    (3.5-5.5)        114

  (CQ15.5)…limited by joint symptoms
                 Yes                           69.1      (66.1-72.1)     836   13.7   (12.0-15.4)      293
                 No                            31.0      (27.9-33.9)     381   86.3   (84.6-88.0)      1821

 *Disability significantly different from no disability, p<0.0001




                                                              25
Section II B. SC BRFSS 2004. Other High Prevalence Risk Factors


 IIB 1. Table 16. SC BRFSS 2004. Asthma Data by Disability Status (result unfavorable for PWD).*


    The SC BRFSS 2004 asked the question: “Have you ever been told by a doctor, nurse or other
health professional that you had asthma?”


                                           Disability                   No Disability
                 SC BRFSS 2004      %       (95% CI)      n      %        (95% CI)        n

                 Ever had asthma
                       Yes         18.5    (16.2-20.8)   313    10.2    (9.1-11.3)      516
                       No          81.5    (79.2-83.8)   1239   89.9    (88.8-90.9)     4800

                   *p<0.0001

        The 18.5% of PWD with a history of asthma significantly exceeds the 10.2% level for PWOD.


IIB 2. Table 17. SC BRFSS 2004. PSA Test by Disability Status (result favorable for PWD).*

The SC BRFSS 2004 asked the question: “A Prostate-Specific Antigen test, also called a PSA test, is a
blood test used to check men for prostate cancer. Have you ever had a PSA test?”


                                           Disability                  No Disability
                  SC BRFSS 2004      %       (95% CI)     n      %       (95% CI)        n

                  Ever had PSA
                        Yes         69.6   (64.5-74.7)   355    65.2    (62.2-68.2)     908
                        No          30.4   (25.3-35.5)   124    34.8    (31.8-37.8)     431

                   *p=.01

   The 69.6% of PWD receiving the PSA test was significantly higher than the 65.2% proportion for
PWOD.




                                                    26
 IIC. Additional Variables, cont. Summary of Preventive Measures by Disability Status.


 Table 18. SC BRFSS 2004. Additional Variables, cont. Summary of Preventive Measures
           by Disability Status.

       PREVENTIVE CARE                               PERCENTAGE OBTAINING PREVENTIVE MEASURES
                                                       Disability                     No Disability
                                           %          (95% CI)            n     %      (95% CI)             n
Colon examination (ever)                 61.8*      (58.3-65.3)          663   53.6   (51.3-55.9)         1366
Immunization
        Flu (18 and older)               46.5*      (43.4-49.6)          762   31.9   (30.4-33.4)         1859
        Pneumonia (>64)                  72.2*      (67.3-77.1)          358   59.7   (56.3-63.1)          591
Told by MD to eat less fat               33.4*      (30.5-36.3)          516   20.3   (19.0-21.6)         1125
Occult blood test                        45.4*      (41.9-48.9)          503   44.2   (42.0-46.4)         1140
                                               **
PSA (Ever)                               69.6       (64.5-74.7)          355   65.2   (62.2-68.2)          908
 * Disability significantly different from no disability, p<0.0001, **p=0.01

     All six of the variables in Table 18 were favorable for PWD (immunization includes two variables).
 Accordingly, PWD are receiving a meaningful number of screenings.
     The next two tables analyze selected risk factors and limitations in preventive care when uncontrolled
 (Table 19a) and after controlling for age, race, income, and health care coverage (Table 19b). (Note that
 one model in Table 19b was analyzed predicting lack of health care coverage controlling for only age,
 race, and income.) For Table 19a, significance was assessed with the chi square p-value (and the 95%
 Confidence Interval) determined with SUDAAN. Variables for which a deficiency increases risk are
 labeled with the “no” designation.
     Before controlling for key demographic variables and health care coverage/insurance (Table 19a),
 PWD were significantly more likely then PWOD to report greater risk or unfavorable disparities for being
 diagnosed with diabetes. Results were favorable, or risks were lower, for (1) having health care coverage
 (2) having a personal health care provider, (3-4) influenza and pneumonia immunization, (5) colon
 examination, (6) mammogram, (7) PSA test, and (8-9) counseling about diet and exercise. The outcomes
 (1) breast exam, (2) PAP test, and (3) counseling for sexual practices were items not different between
 the two groups and can be rated as neutral.




                                                              27
IID. Relationship of Demographic Attributes and Health Care Coverage to Selected Variables

    Table 19a. SC BRFSS 2004. Risk Factors and Limitations in Preventive Care and
               Counseling by Disability Status Uncontrolled for Age, Race, Income, and
               Health Care Coverage/Insurance.


  SC BRFSS 2004. Risk
  Factors and Limitations in
                                                  Disability                             No Disability
  Preventive Care by Disability
  Status

                                    %              (95% CI)         n               %      (95% CI)            n
  No health coverage (<65)        21.8**          (18.2-25.4)       199         19.2      (17.6-20.8)      681

  No Personal health care          11.5*           (9.2-13.8)       147         19.4      (17.9-20.9)      777
  provider

  No flu shot                      53.5*          (50.4-56.6)       789         68.1      (66.6-69.6)      3456

  No pneumonia shot (>64)          27.8*          (22.9-32.7)       131         40.3      (36.8-43.8)      398
                                          **
  No PSA test                     30.4            (25.3-35.5)       124         34.8      (31.8-37.8)      431

  No Colon examination             38.2*          (34.7-41.7)       394         46.4      (44.1-48.7)      1091

  Never had a mammogram            18.4*          (15.3-21.5)       149         36.9      (34.9-38.9)      1002
                                         NS
  Never had breast physical        8.5             (6.2-10.7)           77      8.9       (7.5-10.3)       213
  exam by doctor
                                         NS
  Never had a PAP test            3.98              (2.3-5.7)           31      4.4        (3.3-5.5)           96

  Diagnosed with Diabetes          19.7*          (17.3-22.0)       318         5.6        (4.9-6.2)       360

  No health professional counseling about:

   Diet or eating habits           51.5*       (48.4-54.6)        770        67.6       (66.1-69.1)     3415

   Exercise                        55.6*           (52.5-58.7)     823          67.5      (66.0-69.0)      3347
                                         NS
   Sexual practices               86.6             (83.4-89.8)     924          84.9      (83.4-86.4)      3703

        *Disability significantly from no disability, p<0.0001, **p≤0.01, NS: not significant




                                                             28
    Table 19b. SC BRFSS 2004. Odds Ratios for Risk Factors and Limitations in Preventive
                  Measures and Counseling by Disability Status After Controlling for Age, Race,
                  Income, and Health Care Coverage/Insurance.

            For calculation of the Odds Ratio, the No Disability value was set at 1.0 for each variable.

                 BRFSS 2004. Risk Factors and Limitations in
                                                                          Disability
                 Preventive Care by Disability Status

                                                                    OR          (95% CI)

                 No health coverage/Insurance**                    0.88         (0.68-1.15)

                 No Personal health care provider                  0.52         (0.40-0.68)

                 No flu shot                                       0.65         (0.55-0.78)

                 No pneumonia shot                                 0.47         (0.38-0.57)

                 No PSA test                                       0.96         (0.70-1.32)

                 No colon examination                              0.68         (0.55-0.83)

                 Never had a mammogram                             0.43         (0.34-0.56)

                 Never had breast physical exam by doctor          0.70         (0.47-1.02)

                 Never had a PAP test                              0.69         (0.40-1.18)

                 Diagnosed with Diabetes                           3.36         (2.69-4.19)

                 No health professional counseling about:

                     Diet or eating habits                         0.55         (0.47-0.65)

                     Exercise                                      0.63         (0.54-0.74)

                     Sexual practices                              1.42         (1.03-1.95)

                    **Controlled for age, race and income
    After controlling for demographics and health care coverage, reported results for PWD were
significantly less likely than PWOD to have unfavorable ORs and disparities for the following variables: (1)
personal health care provider, (2-3) influenza and pneumonia immunizations, (4) colon examination, (5)
mammogram, and (6-7) counseling about diet and exercise. Viewed from the direction of a significant
favorable or protective Odds Ratio (OR), PWD were more likely to have a favorable disparity for the same
variables. The breast exam was marginally significant for favorable status. Significantly unfavorable ORs
were present for (1) diabetes and (2) counseling about sexual practices. Compared to the univariate
results for the variables of Table 19a, controlling the health care coverage/insurance variable for age,
race and income changed the result from an unfavorable status for PWD to neutral with no significant
difference between the two groups. Controlling for age, race, income, and health care coverage, having a
personal health care provider, influenza and pneumonia immunizations, colon examination, mammogram,
dietary counseling, and exercise counseling remained favorable. Clinical breast exams by a physician
became marginally favorable. Counseling for sexual practices and PSA tests became unfavorable.



                                                      29
SECTION III. METHODS

III A. The Behavioral Risk Factor Surveillance System and Its Application in South Carolina (SC
        BRFSS)

    The source of data for this report is the South Carolina Behavioral Risk Factor Surveillance System
(SC BRFSS). SC BRFSS is part of an ongoing national effort, funded in all 50 states and five territories
by the Centers for Disease Control and Prevention (CDC), to monitor the prevalence of behavioral risk
factors for chronic diseases and other leading causes of death and disability among adults in the United
States (2).
    Over half of the two million US deaths each year are related to personal health behaviors. In the
early 1980‟s, CDC and the states started to assess and track these behaviors and health measures using
a telephone survey. CDC coordinates and provides technical assistance and the states conduct the
surveys. South Carolina has participated since 1984.
    BRFSS was designed to collect uniform data, with priority given to behaviors and conditions that
place adults at risk for the chronic diseases, injuries, and preventable infectious diseases that are the
leading causes of morbidity and mortality in the United States and its territories. The results are essential
to planning and evaluating health promotion efforts to reduce the prevalence of these health risk
behaviors, to identify trends and to measure progress toward achieving state-specific and national
Healthy People 2010 Objectives. A comparison of matching questions on the BRFSS and the National
Health Interview Survey (NHIS) found satisfactory agreement for 13 of 14 items (15). The principal
difference was a lower estimate of fair or poor health status for NHIS than BRFSS despite identical
wording.
    The 2004 SC BRFSS consisted of a telephone interview of a representative sample of non-
institutionalized South Carolina adults aged 18 years and older. This survey excluded: (1) individuals in
penal, mental, or other institutions; (2) individuals living in other congregate care arrangements such as
dormitories, barracks, convents, or boardinghouses, and (3) individuals living in a household without a
telephone or requiring electronic telephone devices (i.e. TDD or TTY). Interviews were conducted in
English or Spanish depending on the respondent's preference. Sampling and interviewing were
performed by a professional survey organization under contract to the SC Department of Health and
Environmental Control, and followed the overall protocol from the CDC (details below; additional
information is available on the CDC.gov website).
    The SC BRFSS questionnaire contains multiple modules, with a relatively stable core asked annually,
and additional questions in CDC and state-added modules. The core and modules typically cover a
variety of topics related to health and safety, considering both knowledge and practices regarding health
status, health care access and utilization, use of preventive services (e.g. immunization), chronic
conditions such as hypertension, diabetes, and overweight, behaviors such as exercise, tobacco use, and
fruit and vegetable consumption, injury control, HIV and AIDS, women's health, and demographic
information. For the 1998-2000 period, the SC Disability and Health Program expanded the SC BRFSS



                                                     30
to include CDC's validated Quality of Life module and an additional set of sixteen Quality of Life/Disability
questions. The added questions were not asked in South Carolina after 2000.


III B. Strengths and Limitations of the Estimation Process
    Strengths include (1) breadth of content (multiple sources of health risks); (2) flexible, ongoing data
collection; (3) addresses emerging health issues; (4) less expensive than in-person interviews; (5) relative
standardization of survey content and procedures allows comparisons; (6) random sampling
representative of the population allows generalization of results; and (7) widespread participation (all 50
states + territories)(2). Examples of limitations are (1) lack of depth on many health risk issues; (2) self-
report respondents may have selective recall and also may modify their report to conform to socially
acceptable criteria or legal standards; (3) reliance on telephone survey methodology is cost-effective, but
has greater vulnerability to incomplete sample coverage, non-response, and other sources of error; (4)
the disability question set is relatively new and not widely used previously, and (5) as in all such surveys,
question wording may be a problem for some responders.
    The population from which the SC BRFSS samples were drawn was the total non-institutionalized
South Carolina population living in the state most of the year and residing in telephone-equipped
households. Since the design necessarily excludes people without telephones, and those who live in
institutional facilities, such as nursing homes or residential facilities for people with developmental
disabilities and people with mental illness, and the homeless, the estimated proportion of people with
disabilities is almost certainly lower than the actual value.


III C. Sampling Techniques and Sampling Frame
    Disproportionate Stratified Random Digit Dialing (RDD), a population-based sampling procedure, was
conducted for selected South Carolina households. This sophisticated random sampling methodology
was approved by CDC and provided independent monthly samples using trained and experienced
interviewers. In addition, special call verification and refusal protocols were used, including a
Nonresponse Conversion staff. At least 95 percent of refusals were called back to attempt conversion to
interview completion. Typical Computer-Aided Telephone Interview (CATI) quality control logic such as
valid ranges and error checks were also included. Interviews were conducted continuously and data
forwarded monthly. Interviews were conducted from 5:30 a.m. to 9:30 p.m. on weekdays and on one
Saturday morning each month and at other times if required to obtain a sufficient number of responses.
The response rate was defined by the criteria of the Council of American Survey Research Organizations
[CASRO]. The continuing decline in response rate is cause for concern, with the expanding use of cell
phones likely to cause even more difficulty in locating potential responders. Of note is the report of
Biener et al (1), who compared estimates from two state surveys to census data and concluded that
declining response rates have not resulted in less accurate or biased estimates of smoking behavior.




                                                       31
III D. Data Processing and Analyses
    All data processing and analyses were performed using the SUDAAN package from the Research
Triangle Institute, Research Triangle Park, NC. Unless otherwise specified, individuals who answered
that they did not know or refused to answer a question were excluded from the denominators when
calculating the percentages. The exclusion of "don't know” and “refused" categories from denominators
might slightly elevate the percentages in other categories. Any subgroup analyses containing small
sample sizes were presented using whole numbers. Weighting of results presented in this report was
performed using SUDAAN to reflect the age, gender, and race distribution of the 2004 South Carolina
population estimates, allowing generalization of the survey results to the entire state. The frequency
data used to calculate proportions were not adjusted.

    Some of the variables in this report are interrelated. For example, age is an important determinant for
many health-related conditions and health behaviors, and people with disabilities tend to be older than
people without disabilities. Therefore comparisons between people with and without disabilities on any
behavior/condition that is not adjusted for age will be biased. For some variables, those below and above
age 65 were separated to reduce the effects of age differences. Associations among variables can be
managed by identifying the independent effect of each variable and is the most complete approach for
handling such relationships. However, the scope of this report does not extend to analysis of confounding
variables. Therefore, the reader needs to be aware of potential interactions between variables when
interpreting the results.




                                                    32
                                   IV. COMMENTS AND CONCLUSIONS


    A notable attribute of Healthy People 2010 is the first inclusion of objectives specifically addressing
the health of Americans with disabilities (Chap. 6, Dec. 2001). In Dr. Satcher‟s Foreword to the Healthy
People 2010 chapter on Disability and Secondary Conditions, he cites the importance of the new
recognition by the Healthy People series that people with a disability can have healthy lives and
participate equally in society (14). The goal of the Healthy People 2010 unit on Disability and Secondary
Conditions is to “promote the health of people with disabilities, prevent secondary conditions, and
eliminate disparities between people with and without disabilities in the U. S. population.”
    For this report from the South Carolina BRFSS, the results were related to the objectives of Healthy
People 2010 as much as possible. However, a number of BRFSS variables important for all people were
not included in the Healthy People 2010 objectives. Particularly noticeable is the limited information on
Women‟s Health in the current questionnaire.

    The overall 20.1 percent disability estimate for South Carolina reinforces the significance of disability
as a public health problem in the state and is generally consistent with (1) previous South Carolina
BRFSS results for the years 1998-2003, (2) national grouped data, and (3) the results from other state
BRFSS reports. The 20.1 percent rate for 2004 was similar to the previous five-year range of 18-22%.
Differences in these estimates of disability rates are most likely the result of changes in the definition of
disability. The four-question set in the 1998-2000 surveys was more comprehensive (higher sensitivity)
than the two-question definition. Application of the two-question definition to the 1998-2000 data reduced
the rate below 22 percent. However, Diab and Johnston (4) state that, although previous reports use an
additive strategy for dichotomizing disability, their analysis did not support the reliability of adding
disability items together. They constructed an ordinal scale of disability severity that does not assume an
equal separation between levels. Their strategy was to discard the 4.05% of cases from 1998 and 2.3%
from 2000 that stated they needed help with routine needs but had no activity limitations. Comparison of
our data with the results on the CDC website showed that the CDC computation was based on the
answer to only one question; the result estimate of 18.6% (95%CI 17.4-19.8 n=1173) was lower than our
two-question definition of 20.1%.

    Objective 6.1 of Healthy People 2010 is “Include in the core of all relevant Healthy People 2010
surveillance instruments a standardized set of questions that identify people with disabilities.” The pair of
questions used for the 2004 BRFSS disability definition was chosen to match those used in the National
Health Interview Survey (NCHS-NHIS) and the National Health and Nutrition Examination Survey
(NHANES). While these two questions are accepted by Healthy People 2010 and the CDC BRFSS as
an adequate first step, a more extensive set of surveillance questions is needed to improve
understanding of health status, prevalence of secondary conditions, availability and utilization of
preventive services and related factors for people with disabilities (4,5,9).




                                                       33
    The sample profile in this telephone survey makes it likely that the estimate falls below the true value
for adults because of exclusions such as those in nursing homes and other congregate care facilities, the
deaf, the homeless and those without telephones. The planned large sample size was met despite the
increasing reluctance of people to participate in such telephone surveys. The similarity to previous years
supports the generalization of the results for the state‟s population, but one important effect of the
reduced response rate is a significant increase in costs.

    As observed in previous years, the data indicate a strong tendency for disability prevalence to
increase with age and to be associated with less education, unemployment and lower income. Results by
gender differences and racial/ethnic classification showed no significant differences between men and
women or white and non-white groups.
    An aim of Healthy People 2010 regarding disability is to modify the traditional view that equates
disability status with health status. Past practices that addressed the health and well-being of people with
disability primarily as a problem of medical care, rehabilitation and long-term financing have contributed to
misconceptions such as all people with disabilities automatically have poor health and the effect of
environment is negligible. On the other hand, there are connections between disability and health status
that blur the distinctions. One strategy for managing these connections is to consider disability primarily
as another demographic marker such as age and gender. Healthy People 2010 materials note that
disability is to be regarded as a demographic descriptor rather than a health outcome, useful as a monitor
of disparities in health status and social participation without imputing disability as the cause of poor
quality of life and/or poor health. For example, age or disability and certain diseases can be associated,
but age or disability are not the cause of the disease. Similarly, the self-reported descriptive data of
BRFSS cannot establish causative links between disability and a specific variable, but meaningful
associations can be identified that are important guides to needs and interventions.
    The HP 2010 summaries state as generalities that compared to people without disabilities, people
with disabilities are more likely to have an ongoing source of care and two vaccinations. However,
compared to people without disabilities, people with disabilities are less likely to have health insurance
and engage in physical activity 3 days a week, and are more likely to be obese and smoke cigarettes.
The SC BRFSS results are similar to those of the HP 2010 report, with a preponderance of unfavorable
disparities suggesting that overall health status for people with disability is likely to be reduced when
compared to people not identified as disabled, but the causative agent is not identified.
    The significance of age for disability needs more detailed assessment. For instance, should an
equivalent level of disability severity be interpreted differently for those of working age compared to those
who are retired? Diab and Johnston (5) stress the importance of assessing type and severity of disability
to get a more useful description of services needed and received. Additional analysis of these BRFSS
data from a severity perspective is likely to be informative and could be addressed in a follow-up analysis.
Also of potential value is the suggestion that time since receipt of a regular checkup could be a key
variable (5) and should be considered for addition to the SC BRFSS.




                                                      34
    A principal concern for people with disability is the relationship of health disparities to physical
accessibility/environmental barriers and societal attitudes that impact access to care, issues not
addressed in depth by the BRFSS question set. The breadth of the BRFSS and the diversity of the
disability cohort are inherent restrictions that limit the capacity to reach a higher level of conformity with
the Healthy People 2010 objectives by assessing such problems, but additional resources would permit a
meaningful increase in the depth of assessment.

    Efforts to deal with the problem are complicated by the great diversity of causes and degrees of
impairment, factors that relate to the difficulties in developing a clear case-definition of disability. More
work is needed to identify a question or question set that is suitable for diverse respondents with varying
interpretations of the effects of a limitation on their lives. Assessment is also affected by the variation in
disability severity over time, producing variation in the reliability of any measure of limitation.

    In conclusion, BRFSS data for South Carolina demonstrate less than optimal preventive services and
health status for both disabled and non-disabled groups. In this initial data review for 2004, 24 variables
were examined and rated for disparity as favorable, neutral or unfavorable for people with disability.
Fourteen of the variables were unfavorable, 6 were favorable, and 4 were neutral. Clearly, much more
attention and effort must be directed toward reducing the unfavorable measures and enhancing those that
are favorable. Rather than the similarity of access to health care observed in previous years, more adults
with disability than with no disability reported a problem with health coverage. Nevertheless, adults with a
disability again reported higher levels of a number of preventive interventions. A possible contributing
factor is a higher number of health contacts for people with a disability (4), increasing the likelihood of
receiving certain services. A contribution of the BRFSS is to assist in identifying areas needing more
detailed exploration. One such area is the interplay of health care coverage/insurance with service
provision for people with disability. For example, how Medicaid and Medicare may interact and contribute
is not clear. A general deficiency is the usually large gap between HP 2010 objective targets and current
service levels.
    From the standpoint of preventing secondary conditions, risk factors that stand out as extremely
important concerns in people with disability are obesity and diabetes, associated with a level of physical
activity well below that found in people with no disability. The daily smoking rates of people with disability
also exceeded the level for those with no disability, while the proportion with the risky behavior of high
alcohol use was similar in those with and without a disability.
    Since it is likely that the number of people with disability will increase as the population ages and
more people survive life-threatening events, the issues surrounding adequate health care and health
promotion for people with disability will become increasingly urgent.




                                                       35
                                         V. REFERENCES
1.    Biener L, Garrett CA, Gilpin EA, et al. Consequences of declining survey response rates for
      smoking prevalence estimates. Am J Prev Med 2004;27(3).

2.    CDC. Behavioral Risk Factor Surveillance, 1986-1990. MMWR 1991;40 (SS-4).

3.    CDC. Prevalence of disabilities and associated conditions among adults-United States. MMWR
      2001;50(07);120-125.

4.    Chan L, Doctor JN, MacLehose RF, Lawson II, Rosenblatt RA, Baldwin LM, and
      Jha A. Do Medicare patients with disabilities receive preventive services? A population-
      based study. Arch Phys Med Rehabil 1999;80(6);642-6.

5.    Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive
      health services. Arch Phys Med Rehabil 2004;85;749-57.

6.    Havercamp S, Roth MS, Scandlin D, Herrick H, and Gizlice Z. Health and disability in
      North Carolina 2003. A Joint Report from the NC Office on Disability and Health and The
      State Center for Health Statistics. March 2004.
      http://www.schs.state.nc.us/SCHS/brfss

7.    Kim H, Panarace J, Speare M et al. Rhode Island Disability Chartbook. Disability
      and Health Program, Rhode Island Department of Health. June, 2000

8.    Kinne S. Comparing state-level data on disability prevalence. Office of Disability
      and Health, CDC; Washington State Department of Health; Center for Disability
      Policy and Research, Univ. of Washington. DOH/prevalence Web address is
      "ocs/nchs0803,doc. 1999.

9.    Kinne S, Patrick DL, Doyle DL. Prevalence of secondary conditions among people with
      disabilities. Am J Public Health 2004:94(3);443-445.

10.   McCutcheon E, Daguise V, McDermott S, Thomas-Koger M. Population-based, self-reported
      disability assessment in South Carolina; Results of statewide surveys, 1998-2000. A report to
      CDC summarizing data obtained with the behavioral risk factor surveillance system. March 2002.

11.   McCutcheon E., Daguise V., McDermott S., Thomas-Koger M. Population-based, self-reported
      disability assessment in South Carolina; Results of the BRFSS for 2001. A report to CDC
      summarizing data obtained with the behavioral risk factor surveillance system. Dec. 2002.

12.   McNeil, JM. Disability. U.S. Census Bureau, Population Division and Housing and Household
      Economic Statistics Division, 2001.

13.   Mitra M, Chung M-C, Wilber N, Walker, DK. Smoking status and quality of life. A longitudinal
      study among adults with disabilities. Am J Prev Med 2004;27(3).

14.   National Center on Birth Defects and Developmental Disabilities. Healthy People 2010.
      Chapter 6, Disability and Secondary Conditions. Vision for the Decade: Proceedings and
      Recommendations of a Symposium. Atlanta, GA: Centers for Disease Control and
      Prevention, Dec. 2001. http://www.cdc.gov/ncbddd/dh.

15.   Nelson DE, Powell-Griner E, Town M, Kovar MG. A comparison of national estimates
      from the National Health Interview Survey and the Behavioral Risk Factor Surveillance
      System. Am J Public Health 2003;93:1335-1341.




                                                  36
16.     Wang H, McCutcheon E, McDermott S, Selassie A, Thomas-Koger M. Factors associated with
        self-rated fair and poor health among South Carolinians in 1996. Presented at the annual BRFSS
        meeting, Atlanta GA. May 1998.




                           VI. OTHER DOCUMENTS AND DATA SOURCES

1. CDC BRFSS Data. http://apps.nccd.cdc.gov/gisbrfss/

2. Freid VM, Prager K, MacKay AP, Xia H. Chartbook on Trends in the Health of Americans. Health,
   United States, 2003. Hyattsville MD: National Center for Health Statistics. 2003. 468 pp. DHHS
   Pub. No. 2003-1232.

3. Institute of Medicine (U.S.). Disability in America: Toward a National Agenda for Prevention,
   Washington, DC: National Academy Press, 1990.

4. Institute of Medicine (U.S.). The Second 50 Years: Promoting Health and Preventing Disability.
   Washington, DC: National Academy Press, 1990.

5. National Center for Health Statistics. Health, United States, 2004. With Chartbook on Trends in the
   Health of Americans. Hyattsville MD: 2004. 498 pp. DHHS Pub. No. 2004-1232.

6. National Institute on Disability and Rehabilitation Research. Chartbook on Disability in the United
   States. Washington D.C. 1989.

7. NIH. National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation,
   and Treatment of Overweight and Obesity in Adults. The Evidence Report. Reprint, 1998.

8. U.S. Department of Health and Human Services, National Center on Birth Defects and
   Developmental Disabilities. Healthy People 2010, Chapter 6, Disability and Secondary Conditions,
   Vision for the Decade. Atlanta, GA: Centers for Disease Control and Prevention, Dec. 2001.

9. Web Sites
       http://www,cdc.gov/ncbddd/dh and http://www.health.gov/healthy people
       http://www.census.gov/hhes/www.disability.html




                                                    37

				
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