Events Across the Life Course Contribute to Higher Mobility Impairment Rates in Rural U.S.

Purpose: This paper investigates how life events such as injuries, health insurance coverage, geography, and occupation contribute to mobility disability rates over time. Findings can inform policies and practices to address factors that may contribute to disability in rural and urban areas. Methods: We utilized 27 waves of the National Longitudinal Survey of Youth (NLSY) data from 1979 to 2016 to explore how past injury, occupation, health insurance coverage, and rurality predicted mobility impairment at ages 40 and 50 using regression analysis. Findings: Rural respondents reported significantly higher rates of mobility impairment at age 40 and age 50 relative to people living in urban areas, and were more likely to report injury, work in high exertion occupations, and experience several pain-related health conditions. Using logistic regression and controlling for race and education, we found that people had higher odds of experiencing mobility impairment at age 40 if they reported a broken bone in the last 10 years, reported ever being knocked unconscious, had any workplace injury from 1988 to 2000, or lived in a rural area. People reported lower odds of mobility impairment if they had more consistent health insurance coverage over time. Further analysis showed that people consistently uninsured over time were 91% more likely to report mobility impairment at age 40 than those consistently insured. Conclusion: A better understanding of environmental factors associated with disability such as access to insurance, risk exposures, resources, and other place-based behaviors can inform additional strategies for reducing the severity and duration of mobility disability.

Effects of an exercise intervention on participation reported by people with disabilities: A mixed methods randomized trial.

BACKGROUND: Despite a long history of research on the benefits of exercise for people with mobility impairments, little is known about how exercise affects participation in their daily activities. OBJECTIVE: This randomized mixed-methods study examined the effects of participating in a structured community-based exercise program on pain, depression, fatigue, exertion and participation in daily activities. METHOD: Study participants were recruited from a population-based sample of people who returned a survey (n = 800) and indicated they would be willing to participate in another study. The intervention group was randomly assigned to participate in a physical therapy evaluation and 30 exercise sessions within four months and the control group completed measures only. Ecological momentary assessment and a daily diary was used to evaluate treatment outcomes for the intervention relative to the control group on pain, depression, fatigue, exertion and participation in high exertion activities. We also interviewed a subset of intervention participants to solicit their lived experience from engaging in the exercise intervention. RESULTS: Exercise intervention participants reported 28% less pain and 19% less fatigue than control participants. They also reported engaging in 11% more bathing and grooming, 22% more household chores, and left their homes 13% more than control participants. These results were mirrored in qualitative interview results. CONCLUSIONS: Participating in an exercise program leads to less pain and fatigue and more participation in activities that require relatively high levels of exertion like bathing and leaving home.

Is the presence of home entrance steps associated with community participation of people with mobility impairments?

BACKGROUND: Little is known about how home entrances are related to community participation for people with mobility impairments. OBJECTIVE: This investigation explored how the need to navigate steps at the entrance of a home affects the community participation levels of people with mobility impairments. METHODS: This survey study used pre-measure data collected from three different samples. Participants were adults living independently in the community aged 18-94 years old who self-reported having a mobility impairment. Measures included the Brief Community Engagement Questionnaire to examine potential differential effects on the number of non-discretionary trips people make into the community (e.g., getting groceries, medications) versus the number of discretionary activities (e.g., socializing outside the home) people reported over seven days. RESULTS: People with mobility impairments were less likely to report a stepped entrance than people without MI, but when the entrance they use the most had steps they reported significantly higher exertion to use the entrance. The presence of steps had no effect on non-discretionary trips (p = .74), but was associated with 49% (p < .01) fewer discretionary activities reported by people with mobility impairment relative to those without MI. CONCLUSION: Steps at the home entrance of people with mobility impairment may be an important mediating factor in their level of participation. When researchers and practitioners evaluate interventions that aim to increase community participation of people with mobility impairment, they should control for the presence of steps at their home entrance.

Effects of a consumer driven home modification intervention on community participation for people with mobility disabilities.

BACKGROUND: Community participation has become a key outcome measure for people with disabilities. This has resulted in a shift in researchers focus from the individual to the environment. However, research has focused primarily on participation barriers in the community with limited research examining the role of the home environment. For people with mobility disabilities the home environment is the starting place for community participation and research is needed to understand the relationship between the home and participation outcomes. OBJECTIVE: This study explores the effects of a consumer-driven home modification intervention on community participation for people with mobility disabilities. METHODS: We conducted a randomized control trial (from June 2017-April 2019) of the effects of a consumer-directed home modification intervention on community participation. The intervention, the Home Usability Program, was implemented with consumers at two different Centers for Independent Living (N = 195) and included a self-assessment of their home environment and implementation of a home usability change. RESULTS: The Home Usability program positively affected the community participation of people with mobility disabilities. Overall, intervention participants reported a 39.5% (p < .05) increase in social and recreational activities immediately following the intervention relative to the control group after controlling for health status and month when outcome data were collected. Six months after the intervention, this effect returned to baseline. CONCLUSIONS: Community-based, consumer-driven home modification programs show promise for improving community participation outcomes among people with disabilities, however, more research is needed to understand why results did not persist.

Health status changes with transitory disability over time.

RATIONALE: The six-question disability set from the American Community Survey serves as the national standard for measuring disability across all surveys conducted by the U.S. Department of Health and Human Services. These questions are intended to identify people who experience a long-term disability, and data from these questions are frequently interpreted as capturing discrete groups of individuals. Recent research has shown that a significant proportion of individuals respond to these questions inconsistently over time, possibly indicating that the six-question set also identifies transitory disability. However, it is unclear if these inconsistent responses are associated with changes in health status. We begin to test the validity of these observations by exploring how changes in health related quality of life correspond to changes in disability status. METHODS: We recruited 525 participants to complete a longitudinal paper and pencil survey four times over 18 months that included the six disability questions, measures of health related quality of life, and mobility equipment use. We computed within person changes in health related quality of life variables to investigate how changes in disability status are associated with changes in health status. RESULTS: Among respondents who reported disability, half or less consistently reported the same disability. Additionally, respondents who changed disability responses also reported changes in health related quality of life. For example, when individuals transition into walking disability, their health-related quality of life index decreases by, on average, 0.18 s.d. (p<0.05), and when individuals transition out of walking disability their health-related quality of life index increases by, on average, 0.27 s.d. (p<0.001). CONCLUSION: The six-question set identifies people who experience both enduring and transitory disability. Changes in health related characteristics correlate with changes in disability status. This suggests that observed transitions in disability reflect real changes in perceived health and impairment.

Transitory and Enduring Disability Among Urban and Rural People.

BACKGROUND: Disabilities are not evenly distributed across geography or age, yet few studies on disability have considered these factors. The purpose of this study was to explore rural-urban differences in disability rates, particularly related to gender and race, and what other rural-urban disparities help explain these differences. METHODS: Utilizing the 2008-2016 Current Population Survey (CPS), we first examined rural and urban disability trends by gender and race, estimating means and rural-urban percentage differences for men and women by race and conducting t test analysis to test group differences by age cohort (eg, comparing white, non-Hispanic, rural 15- to 24-year-old women to white, non-Hispanic, urban 15- to 24-year-old women). We then conducted a logistic regression to explore whether or not the effects of rurality on disability rates could be explained by rural-urban differences in demographic and socioeconomic characteristics. RESULTS: Descriptively, rural people report disability at higher rates than urban people across nearly all age category, gender, and racial combinations. These differences are more pronounced for nonwhite respondents in middle to older age categories. Additionally, while some of the rural disability disparity can be explained by adding demographic and socioeconomic variables to the logistic regression model, the effect of rurality remains significant. CONCLUSIONS: Our findings suggest that when researchers, policy makers, and service providers are addressing rural and urban differences in health and well-being, self-reported disability is another factor to consider. Future work should be mindful of how disability and space intersect with gender and race, creating significant disparities for people of color in rural places.

Life Starts at Home: Bathing, Exertion and Participation for People With Mobility Impairment.

OBJECTIVE: To investigate the relationship between perceived exertion while bathing/dressing/grooming and associations with social-recreational activities outside the home for individuals with mobility impairment (MI). DESIGN: A 2-study approach was used to examine data from the American Time Use Survey (ATUS) and primary data from the Health and Home Survey (HHS). The relationship between bathing/dressing/grooming and engagement in social-recreational activities was explored, as well as the role that exertion in the bathroom may play in participation in these activities. SETTING: General community setting. PARTICIPANTS: For the ATUS survey, participants (n=6002) included individuals who reported an MI. For the HHS, 2 mail-based recruitment methods were used to recruit a sample of individuals with MI (n=170) across 3 geographically diverse U.S. communities. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Participation in social and recreational activities. RESULTS: People with MI (relative to those without MI) were less likely to report spending any time bathing/dressing/grooming on a given day, but spent more time when they did. People with MI reported higher exertion while bathing/dressing/grooming than people without. People with MI were less likely to leave the house or engage in social-recreational activities on days where they did not engage in bathing activities. People who reported greater exertion in the bathroom engaged in fewer social-recreational activities. CONCLUSIONS: Exertion in the bathroom may present a barrier to participation, indicating a relationship between exertion in the bathroom and social-recreational participation. Research that examines the impact of home modifications on exertion and participation is needed.

Disability Items From the Current Population Survey (2008-2015) and Permanent Versus Temporary Disability Status.

OBJECTIVES: To examine longitudinal responses to the disability indicator questions that have been adopted as the standard across national surveys sponsored by the US Department of Health and Human Services. METHODS: Data from the Current Population Survey between 2008 and 2015 were linked to create a longitudinal sample of 721 178 individual respondents. RESULTS: Responses to the disability questions fluctuated significantly. Although 17% of all respondents reported a disability at some point, only 3% consistently reported the same set of disabilities. Demographic differences were found between people who always reported a consistent set of disabilities and those whose responses fluctuated. CONCLUSIONS: The disability questions capture 2 discrete groups: people who experience a permanent disability and those who experience a temporary disability. Demographic differences between these groups suggest that this is not simply due to measurement error.

Why stay home? Temporal association of pain, fatigue and depression with being at home.

BACKGROUND: Community participation is important to most people with disabilities despite the fact that common secondary conditions like pain, fatigue and depression may increase the difficulty of leaving home. Despite decades of research on these secondary conditions, little is known about how they are associated with being at home. OBJECTIVE: We used Ecological Momentary Assessment data to examine within subject fluctuation in these secondary conditions to examine their effect on the likelihood that participants remain at or return home. METHODS: Participants (n = 139) were recruited from a population based sampling frame to complete an Ecological Momentary Assessment that queried their location and experience with secondary conditions six times a day for two weeks. RESULTS: Between subjects secondary condition ratings averaged across time periods indicated that pain and depression were associated with the share of measurement periods that respondents reported being at home. Within subject results indicated that a standard unit increase in pain, fatigue and depression was associated with being home one to two days later. Within day results indicated that increases in pain and fatigue were associated with increased likelihood of being home later, but increases in depression were associated with lower likelihood of being home later. CONCLUSION: These results suggest there may be a complicated relationship among these secondary conditions and community participation with effects observed both across and within days. One interpretation suggests that secondary condition severity is tempered by adjusting participation. These results may have implications for intervening on these secondary conditions.