key: cord-0805795-0fpmcmp8
authors: Pendergrast, Claire B.; Monnat, Shannon M.
title: Perceived Impacts of COVID-19 on Wellbeing among U.S. Working-Age Adults with ADL Difficulty
date: 2022-05-02
journal: Disabil Health J
DOI: 10.1016/j.dhjo.2022.101337
sha: c2558090f1cb76acc597483efd283cdddd11c6c3
doc_id: 805795
cord_uid: 0fpmcmp8

BACKGROUND: The COVID-19 pandemic has disproportionately impacted people with disabilities. Working-age adults with ADL difficulty may face unique challenges and heightened health risks because of the pandemic. It is critical to better understand COVID-19’s impacts on social, financial, physical, and mental wellbeing among people with disabilities to inform more inclusive pandemic response policies. OBJECTIVE: This study compares perceived COVID-19 physical and mental health, social, and financial impacts for U.S. working-age adults with and without ADL difficulty. METHODS: We analyzed data from a national survey of U.S. working-age adults (ages 18-64) conducted in February and March 2021 (N=3,697). We used logistic regression to compare perceived COVID-19-related impacts on physical and mental health, health care access, social relationships, and financial wellbeing among those with and without ADL difficulty. RESULTS: Adults with ADL difficulty were more likely to report negative COVID-19 impacts for many but not all outcomes. Net of covariates, adults with ADL difficulty had significantly greater odds of reporting COVID-19 infection (OR=2.1) and hospitalization (OR=6.7), negative physical health impacts (OR=2.0), and negative impacts to family relationships (OR=1.6). However, they had significantly lower odds of losing a friend or family member to COVID-19 (OR=0.7). There were no significant differences in perceived impacts on mental health, ability to see a doctor, relationships with friends, or financial wellbeing. CONCLUSIONS: Working-age adults with ADL difficulty experienced disproportionate health and social harms due to the COVID-19 pandemic. To address these disparities, public health response efforts and social policies supporting pandemic recovery must include disability perspectives.

to compare perceived COVID-19-related impacts on physical and mental health, health 14 care access, social relationships, and financial wellbeing among those with and without 15 ADL difficulty. 16

Results: Adults with ADL difficulty were more likely to report negative COVID-19 17

impacts for many but not all outcomes. Net of covariates, adults with ADL difficulty had 18 significantly greater odds of reporting COVID-19 infection (OR=2.1) and hospitalization 19

(OR=6.7), negative physical health impacts (OR=2.0), and negative impacts to family 20 relationships (OR=1.6). However, they had significantly lower odds of losing a friend or 21 family member to COVID-19 (OR=0.7). There were no significant differences in 22

perceived impacts on mental health, ability to see a doctor, relationships with friends, or 23 financial wellbeing. 24

Conclusions: Working-age adults with ADL difficulty experienced disproportionate health 25 and social harms due to the COVID-19 pandemic. To address these disparities, public 26 health response efforts and social policies supporting pandemic recovery must include 27 disability perspectives. The COVID-19 pandemic uniquely impacted adults with disabilities, both exacerbating 44 existing inequalities 1 and creating new obstacles. 2,3 In addition to the direct health risks 45

of COVID-19 to people with disabilities, the prolonged pandemic period has impacted 46 social, financial, and mental wellbeing due to disruptions in service access, social 47 support, employment opportunities, and more. 4 Yet, U.S. COVID-19 response 48

measures have not been disability inclusive. 5, 6 Research that considers the broad range 49

of COVID-19 impacts on wellbeing is essential for informing policies to mitigate adverse 50 outcomes among people with disabilities. 7 51

Recent studies document how COVID-19 has exacerbated common barriers faced by 52 adults with disabilities, including limited access to direct support, health care, and social 53 connections. 7 However, empirical studies assessing the social, financial, and health 54

impacts of COVID-19 on working-age adults with limitations in activities of daily living 55

(ADLs) are lacking. 8 Moreover, while significant research and policy attention has been 56 paid to the needs of older adults given their heightened vulnerability to severe illness 57

and death from COVID-19, the same attention and policy action has not been directed 58 towards working-age adults with activity limitations. More research is needed to assess 59 the pandemic's toll on working-age adults given this age group's contributions to the 60 labor force and family caregiving, and because adverse COVID-19 impacts may 61

influence care needs or personal resources in later life. 62

Accordingly, this study examines how perceived COVID-19 health, social, and financial 63 impacts differ between working-age adults with and without ADL difficulty. We use 64 nationally representative survey data to assess perceived impacts approximately one 65

year into COVID-19, providing a timely and comprehensive description of how U.S. 66

working-age adults with ADL difficulty are faring after a prolonged period of pandemic-67 related risks and disruptions. Given historical and ongoing structural barriers to 68 achieving equitable financial, social, and health-related outcomes for adults with 69 disabilities, including during the COVID-19 response, 1,6 we expect that negative impacts 70 will be more common among adults with ADL difficulty. Existing research shows that older adults reporting ADL limitations have higher rates of 81 adverse health outcomes, including mortality, chronic conditions, and poor mental 82 health. 11,12 Although ADL difficulty is often viewed as primarily a concern for older 83 adults, and especially the "oldest old," a growing body of research suggests that 84 difficulty with ADLs is common in younger ages. 10,13,14 85

The COVID-19 pandemic increased risks of serious illness and death, reduced access 86

to health care and community-based services, increased unemployment rates and 87 financial strain, and adversely impacted social relationships. 4 Working-age adults with 88 ADL difficulty may be especially susceptible to these negative impacts due to higher 89 prevalence of chronic conditions, less financial resources, and reduced access to health 90 care and community-based services for people with disabilities, 15 with ADL difficulties may also face heightened risk of losing friends, family members, or 131 colleagues during the pandemic given the heightened health risks COVID-19 presents 132

for members of the disability community. 28 133

Pre-pandemic, adults with disabilities were more than twice as likely to live in poverty as 135 those without disabilities, reflecting both labor market inequalities and social and health 136

policies. 29 People with disabilities have historically been disproportionately impacted 137 during economic downturns. For example, during the Great Recession, already high 138 unemployment rates were even higher among adults with disabilities, 29,30 suggesting 139 that negative financial impacts due to pandemic-related economic disruption may be 140 more common among working-age adults with ADL difficulties. In September 2020, 141

Brucker, Stott, and Phillips (2021) We addressed missing data using listwise deletion. We dropped 7.9% (N= 317) of 174 respondents with missing responses on any of the variables included in our analysis, 175

leaving us with an analytic sample of 3,697. 2 Respondents dropped from the sample did 176 not differ significantly from the remaining sample on any COVID-19 impact variables. 177

However, dropped respondents were significantly more likely than the remaining sample 178

to be female, non-White, unmarried, have less than a 4-year college degree, and report 179 one or more ADL difficulties. They also reported smaller average household sizes.

Independent variable 182

We assessed ADL difficulty using a series of questions that began with the prompt: 183

"Please tell us whether you have any difficulty doing each of the activities listed below. 184

Exclude any difficulties that you believe are temporary (e.g., that you expect to last less 185 than three months)." Respondents were asked to select 'no difficulty,' 'some difficulty,' 186

or 'a lot of difficulty' for five activities: (1) Eating, such as cutting up your food;

(2) Using 187 the toilet, including getting up and down; (3) Bathing or showering; (4) Getting out of 188 bed or up from a chair; and (5) Dressing, including putting on shoes and socks. We 189 categorized respondents as having ADL difficulty if they selected 'a lot of difficulty' for 190

one or more activities. We dichotomized responses so that those with ADL difficulty 191

were coded as '1' and those with no ADL difficulty were coded as '0'. We chose the 192 stricter definition of "a lot of difficulty" because we felt "some difficulty" was a less 193 meaningful indicator of respondents' functional status. However, we conducted 194 sensitivity analyses using a broader ADL definition that included both "some" or "a lot of" (married versus unmarried), and number of people in the household. We selected these 238 covariates because they could plausibly affect both the independent variable (ADL 239 difficulty) and dependent variables (COVID-19 impacts) and are therefore potential 240

confounders. 34- 36 We did not control for income or employment status because, rather 241 than confounders, they may be potential pathways (mediators) through which ADL 242 difficulties influence COVID-19 impacts. As a sensitivity check, we ran models that 243 included income and employment status, and the results did not meaningfully change 244 (see Appendix 1).

We first present descriptive statistics for the sample overall and by ADL difficulty status. 248

We used adjusted Wald tests to identify statistically significant differences in the 249 prevalence of negative COVID-19 impacts between respondents with versus without 250 ADL difficulty. We then conducted logistic regression to predict the odds of reporting 251

negative COVID-19 social, financial, and health impacts based on ADL difficulty. We 252 first present coefficients from unadjusted logistic regression models. We then show the 253 results from adjusted models. All models are weighted and include clustered standard 254 errors at the state level. Statistical analyses were conducted using STATA 16.1.

Just over 10% of the sample reported difficulty with one or more activities of daily living. 258 Table 1 present demographic characteristics for those with and without ADL difficulty. 259 Table 2 presents prevalence rates of self-reported COVID-19 impacts for those with and 260 without ADL difficulty. There are several significant differences. Respondents with ADL 261 difficulty were more likely to report negative physical health and mental health impacts. 262

They also had much higher rates of COVID-19 infection and hospitalization. Those with 263

ADL difficulty were significantly more likely than those without to report negative impacts 264 on relationships with family and friends. However, respondents with ADL difficulty were 265

significantly less likely to report losing a friend or family member to COVID-19. There 266

were no significant differences in reported financial impacts or ability to see a doctor. 267 268

[insert Table 1 In sensitivity models that included income and employment (Appendix Table S2 , the 294 direction, magnitude, and significance of the associations were similar to those in the 295 adjusted model reported in Table 3 . Alternative operationalization for age (age category, 296

age-squared) did not alter the findings. Results were also similar in sensitivity models 297 that controlled for COVID-19 infection (Appendix Table S3 ). In sensitivity models that 298

used the expanded definition of ADL difficulty as those reporting "some" or "a lot of" 299 difficulty with one or more ADLs (Appendix Table S4 ), the findings were similar to those 300 shown in Table 3 people with disabilities and may reflect a combination of greater prevalence of 325 comorbidities and delayed or restricted access to public health information for adults 326

with ADLs. Worse physical health impacts may be explained by reduced access to 327 home care, delays in seeking medical care, and heightened risk from COVID-19 itself. 328

We also found slightly greater odds of negative mental health impacts for adults with 329 ADL difficulty. This finding is in line with Okoro et al. (2021) , who found higher rates of 330 depressive symptoms, mental distress, suicidal ideation, and substance use for adults 331 with self-care disability compared to those without in the early months of the pandemic. 332

Our finding affirms Mitra and Turk (2021)'s call for policy action to support inclusive, 333

accessible, and affordable behavioral health services for adults with disabilities, 334

including those with ADL difficulty. 335

Second, unlike Czeisler et al.'s (2021) study that showed disruptions to health care 336 access among people with disabilities, we did not find significant differences in reported 337

ability to see a doctor because of COVID-19 between adults with versus without ADL 338 difficulties. Differences in question wording likely explain the difference in findings. 339

Czeisler et al.'s study asked about avoiding or delaying medical care, while the NWS 340 asked about inability to see a doctor due to COVID-19. 341

Third, despite worse reported health impacts, we did not find worse financial impacts 342 among people with ADL difficulty. It is possible that COVID-19 did not have a differential 343 effect on financial wellbeing because people with disabilities were already financially 344 disadvantaged, 29 and there were fewer financial/employment losses to be had. 37 More 345 generous safety net programs during the pandemic response, such as stimulus checks, 346 extended unemployment, and expanded SNAP benefits may also have reduced 347

financial stress for adults with ADL difficulties. 348

Finally, differences in reported impacts on social relationships were mixed. Working-age 349 adults with ADL difficulties were more likely to report that COVID-19 had a negative 350

impact on their relationship with family, but there was not a significant difference in 351

impacts to relationships with friends. Okoro et al. (2021) found that adults with disability 352

were more likely to report conflict or stress within the household in the early months of 353 the pandemic. Negative impacts on family relationships may reflect increasing reliance 354 on informal care due to disrupted access to home care or community-based services. 355

Social distancing measures reduced in-person social connection outside the household, 356

especially for those at risk of severe illness from COVID-19, potentially straining 357 relationships with family outside of the household and increasing the demands for 358 support from family within the household. Interestingly, we found that adults with ADL 359 difficulty had significantly lower odds of reporting losing a friend or family member to 360

COVID-19. This may suggest that adults with ADL difficulty adopted more stringent 361

precautions with their social networks to reduce risks. This finding may also reflect 362 fewer social ties for those with ADL difficulty. Finally, while our sample of 3,697 is large enough to provide ample power for analyses, 398

we dropped 6% of the sample who were missing on variables of interest. 399

Despite these limitations, this is the first study to consider differences in health, social, 400

and financial impacts from COVID-19 for people with versus without ADL difficulty using 401 a national sample of working-age adults-a population hit especially hard by COVID-402

19's economic and social consequences. 42 403

Our findings present a nuanced picture of the experiences of working-age adults with 405 ADL difficulty one year into the COVID-19 pandemic and point to an urgent need to 406 develop disability-inclusive public health and social policy approaches to reduce 407 disparities that were exacerbated by the pandemic. Adults with ADL difficulty reported 408 greater odds of experiencing COVID-19 infection and hospitalization and negative 409

impacts on their physical and mental health and relationships with family. These 410 findings reflect the importance for researchers and policymakers to consider both direct 411

COVID-19 health outcomes as well as secondary impacts associated with broader 412

pandemic-related disruptions. The needs of people with disabilities, including those with 413 ADL difficulty, must be included in policy decisions now and in future public health 414 emergencies to reduce adverse outcomes. 415 J o u r n a l P r e -p r o o f ^p<0.10; *p<0.05; **p<0.01; ***p<0.001 NOTES: N=3,679 §respondents could select as many employment status categories as applied to them (e.g., employment and a student), so percentages do not add to 100.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

Eliminating health and health care disparities among the growing 417 population of people with disabilities

Health Risks and 420 Consequences of a COVID-19 Infection for People with Disabilities: Scoping 421 Review and Descriptive Thematic Analysis

COVID-19 case-fatality disparities among people 424 with intellectual and developmental disabilities: Evidence from 12 US jurisdictions

Implications of COVID-19 for Social Determinants of Health

The public health response to the 430 COVID-19 pandemic for people with disabilities

People With Disabilities in COVID-19: 433 Fixing Our Priorities

New 436 obstacles and widening gaps: A qualitative study of the effects of the COVID-19 437 pandemic on U.S. adults with disabilities

A Call For Improved Data Collection On The Long-Term Services 440

And Supports Needs Of Working-Age Adults With Disabilities

Functional 447 impairment and decline in middle age a cohort study

Disability Stage is an Independent Risk 450 Factor for Mortality in Medicare Beneficiaries Aged 65 Years and Older

Psychosocial Well-Being Associated With Activity of Daily Living 453 Stages Among Community-Dwelling Older Adults

Prevalence 457 of Activity Limitations and Association with Multimorbidity Among US Adults 50 to 458 64 Years Old

Trends in disability and related chronic conditions among 461 the forty-and-over population: 1997-2010

The COVID-19 pandemic and people with disability

The COVID-19 response must be disability inclusive

Health and healthcare for people with 468 disabilities in the UK during the COVID-19 pandemic

Home Health and Home Care Agency Managers, Clients, and Aides: A Cross-476 Sectional Survey

COVID-19 Intensifies Home Care 480 Workforce Challenges.; 2021. Accessed

The invisible workforce during the COVID-19 483 pandemic: Family carers at the frontline

Unmet Need for Personal 486

Estimating the Shortfall in Hours of Help and Adverse 487 Consequences

Indicators of 490 poor mental health and stressors during the COVID-19 pandemic, by disability 491 status: A cross-sectional analysis

Stressors associated with the 494 COVID-19 pandemic, disability, and mental health: Considerations from the 495

The effects of the COVID-19 497 pandemic on the psychosocial well-being of people with disabilities. Disabil Health 498 J

Mental health impacts of COVID-19 on people with disabilities: 500 A call to action

Lockdown-Related Disparities 503 Experienced by People with Disabilities during the First Wave of the COVID-19 504 Pandemic: Scoping Review with Thematic Analysis

The COVID-19 pandemic, stress, and 507 trauma in the disability community: A call to action

Drew JAR. Disability, Poverty, and Material Hardship since the Passage of the 510 ADA

The impact of the Great Recession upon 512 the unemployment of Americans with disabilities

Food sufficiency and the utilization of free food 515 resources for working-age Americans with disabilities during the COVID-19 516 pandemic

Social policy responses to COVID-19 in 519

Explaining policy variations between two liberal 520 welfare state regimes

Use of Internet panels to conduct surveys

Covid-19 pandemic and the social 525 determinants of health

Preventing disability: The influence of 527 modifiable risk factors on state and national disability prevalence

Risk Factors for Six Types of 532 Disability among the Older People in Thailand in 2002

The impact of disability on employment 535 and financial security following the outbreak of the 2020 COVID-19 pandemic in 536 the UK. J Public Health (Oxf)

The Better Care Better Jobs Act and Home-and Community-Based 539 Services

US Census Bureau. How Disability Data are Collected from The American 544 Community Survey

COVID-19 outcomes among people with 547 intellectual and developmental disability in California: The importance of type of 548 residence and skilled nursing care needs

The COVID-19 Pandemic's Long-Term 551 Financial Impact.; 2021. Accessed