key: cord-0809371-qyweobd3
authors: Assi, Lama; Deal, Jennifer A.; Samuel, Laura; Reed, Nicholas S.; Ehrlich, Joshua R.; Swenor, Bonnielin
title: Access to food and health care during the COVID-19 pandemic by disability status in the United States
date: 2022-01-19
journal: Disabil Health J
DOI: 10.1016/j.dhjo.2022.101271
sha: 93f0d5e0d817c932afca628920ad691f6119ebb0
doc_id: 809371
cord_uid: qyweobd3

Background The COVID-19 pandemic has impacted people’s access to food and health care. People with disabilities may be disproportionately affected by these outcomes due to structural and social barriers. Objective/Hypothesis To examine the relative prevalence of food insufficiency and unmet health care needs among U.S. residents by vision, hearing, cognition, and mobility disability. Methods We used data from the Household Pulse Survey wave conducted from April 14, to April 26, 2021, when questions about functional disability were first included. Participants were asked about difficulty seeing, hearing, remembering or concentrating, and walking or climbing stairs. The outcomes of interest were food insufficiency, delaying needed medical care and not getting needed medical care. Poisson regression models with robust variance adjusted for potential confounders were used to examine the prevalence ratio of each of these outcomes by disability status in separate models for each type of disability. Results During April 14-26, 2021, 39.5% adults in the U.S. reported cognitive disability, 30.8% reported vision disability, 23.2% reported mobility disability, and 14.9% reported hearing disability. Adults with any type of disability were more likely than those without to experience food insufficiency (range of prevalence rate ratios [PRR]: 1.67-1.96), and delay (range of PRR: 1.48-1.87) or not get (range of PRR: 1.60-2.07) needed medical care. Conclusions These disparities suggest there is an urgent need to address the negative impact of the COVID-19 pandemic on people with disabilities. The prioritization of disability data collection is key in achieving that goal.

During the Coronavirus Disease 2019 pandemic, more Americans are reporting 29 food insecurity, 1 and unmet health care needs 2 than before the pandemic, especially among 30 people from ethnic, and racial minorities, 1,2 and low socioeconomic backgrounds. 2 People 31 with disabilities may also be disproportionately affected by the COVID-19 pandemic's 32 impact on health and socioeconomic outcomes, 3-6 but data are scarce. 7 33 34 Even before the COVID-19 pandemic, people with disabilities were more likely than those 35 without to report decreased access to food and health care; around a third of food insecure 36 households included a young adult with disability, 8 The Household Pulse Survey (HPS), which examines the experience of American households 44 during the pandemic, began collecting data on vision, hearing, cognitive, and mobility 45 disability during the April 14 to 26, 2021 wave. The association between these disability 46 types with food insufficiency and unmet health care needs was examined. 47

Participants were asked about four disability categories: vision ("Do you have difficulty 74 seeing, even when wearing glasses?"), hearing ("Do you have difficulty hearing, even when 75 using a hearing aid?"), cognition ("Do you have difficulty remembering or concentrating?"), 76 and mobility ("Do you have difficulty walking or climbing stairs?"). In primary analyses, 77 each disability category was considered independently. Having vision, hearing, cognitive or 78 mobility disability was defined as answering "yes-some difficulty", "yes-a lot of difficulty", 79 or "cannot do at all" to the respective question. Those with a specific disability were 80 compared to those who did not report having that disability ("no difficulty"). To be inclusive 81 of the diverse population of people with disabilities, this broad definition of disability was 82 used for the primary analyses since limiting analyses to people with the most severe forms of 83 disability may restrict the population to those with congenital or long-term impairments. In 84 secondary analyses, first, a stricter definition was used to categorize severe disability. Having 85 severe vision, hearing, cognitive, or mobility disability was defined as reporting "yes-a lot of 86 difficulty" or "cannot do at all" (compared with "yes-some difficulty" or "no difficulty"). 87

Second, a general disability variable combining disability types was constructed (no 88 disability, vision disability only, hearing disability only, cognitive disability only, mobility 89 disability only, multiple disabilities). 90 91 Population characteristics stratified by each disability type were presented. Weighted 92 percentages of outcomes by disability status were stratified by age due to differential 93 probability of experiencing disability and accessing resources based on age. Poisson 94 regression models with robust variance adjusted for self-reported age, gender, ethnicity, race, ratios of each of these outcomes by disability status in the overall population, and stratified 99 by age. Prevalence ratios were used as they can be more easily interpreted than odds ratios 100 from logistic regression models. In primary analyses, each disability type was evaluated in a 26.7% reported one type of disability, and 30.7% reported more than one disability. The most 115 common disability reported was cognitive (39.5%), followed by vision (30.8%), mobility 116 (23.2%), and hearing disability (14.9%). The majority of participants categorized as having a 117 disability reported having "some difficulty (rather than "a lot of difficulty" or "cannot do at 118 all") ( Table S1 ). Having any type of disability was associated with increased prevalence of 119 food insufficiency and unmet healthcare needs, as compared to not having a disability, and 120 the unadjusted prevalence of outcomes was highest among those in the younger age groups 121 ( Figure 1 ). 122

In adjusted models ( In secondary analyses using the severe disability definition, observed associations were 150 similar to or larger in magnitude than results from the primary analyses that defined disability 151 inclusively (Table S2 ). In analyses examining single and multiple disabilities, people with a 152 one disability and people with more than one disabilities had significantly higher relative 153 prevalence of food insufficiency, delaying care, and not receiving medical care compared 154 with those with no disability (Table S3) These data indicate that during the COVID-19 pandemic, adults with disabilities had a higher 165 prevalence of food insufficiency and unmet health care needs than adults without disability. 166

Notably, disability-based disparities were found for vision, hearing, cognitive, and mobility 167 disability, and were greatest among those with more than one disability, suggesting that 168 multi-component interventions are needed to address the disparities. Disability status was 169 associated with higher rates of food insufficiency and food insecurity and delayed or forgone 170 medical care even before the pandemic. 8,15-17 171 172 Disability may be linked to food insufficiency via several mechanisms, including work and 173 functional limitations. 8 A study conducted in Australia showed that having a disability during 174 the pandemic was associated with food insecurity, 3 and in the U.S., working-age adults with 175 disabilities were more likely to experience food insufficiency than those without disability 176 before the pandemic (in March 2020) and during the pandemic (in September 2020). 13 In this 177 study, we adjust for employment status to examine the impact of having functional disability 178 on food insecurity independent of work limitations. Mobility disability has been previously 179 linked to food insecurity via transportation barriers that may limit access to food stores. 8 This 180 may be even more significant during the pandemic with the limitations in public 181 transportation options. Moreover, self-service check-out options which have become 182 increasingly popular during the pandemic may not always be accessible to people using 183 wheelchairs. Cognitive disability may be associated with food insufficiency by affecting 184 people's ability to appropriately budget for food and prepare meals, 8 which may be 185 exacerbated by the pandemic's increased toll on mental health. 18 Vision disability may also 186 be having a greater impact on food insecurity during the pandemic with the increased 187 dependence on potentially inaccessible technology for food delivery and self-service check-out. Similar to our results, in a national study conducted before the COVID-19 pandemic, 189 when accounting for other functional limitations, hearing disability was associated with food 190 insecurity only among younger adults. 8 Having hearing loss has been shown to be associated 191 with social isolation, 19 and this may be contributing to food insufficiency among this group. 8 192 This may be more significant among young adults as hearing loss is not as prevalent among 193 this group, thus potentially making the experience more isolating. healthcare were most evident among older adults with disabilities whereas disparities for 208 food insufficiency were most pronounced among younger adults, except for those with 209 vision-related disabilities. These results suggest that the COVID-19 pandemic may be 210 exacerbating existing disparities. We hypothesize that quarantining and physical distancing, 211 commonly employed during the pandemic to limit the spread of COVID-19, may lead to a 212 loss of social network and support for some, and this could prevent them from accessing food 213 or health care services. 11,21 Interruptions to public transportation and increased reliance on 214 technology that may be inaccessible could also impact people's access to food and health 215 care. 21,22 216 217 Addressing these disparities will require improvements to underlying structural factors like 218 accessibility and provision of free or affordable social services for people with disabilities. 219

Additionally, changes that aim to mitigate the spread of COVID-19 should be implemented 220 with a focus on accessibility and inclusivity. For example, technology platforms for food 221 delivery and self-check-out options in grocery stores should be accessible to people 222 disabilities. Moreover, alternative safe options for those who rely on public transportation 223 should be provided. In health care settings, policies such as banning hospital visitors or 224 support persons, as well as universal use of non-clear masks should be evaluated for their 225 potential negative impact on people with disabilities. 226 227 In our study, the prevalence of disability was higher than previous estimates using self-report 228 data such as the American Community Survey 23 or the Behavioral Risk Factor Surveillance 229

System. 17 In both surveys, participants were asked about "serious difficulty" with vision, 230 hearing, cognition, and mobility. In our study, having any degree of difficulty performing an 231 activity was considered as having a disability. Using this broad definition of disability 232 captures even mild disability. While this approach may include more people with disabilities, 233 the associations were sometimes attenuated due to the inclusion of those with mild 234 limitations, as was shown with the models using the stricter disability definition. Moreover, 235 the high prevalence of cognitive disability may partly reflect the increased prevalence of J o u r n a l P r e -p r o o f 

Association Between Receipt of Unemployment 257

Insurance and Food Insecurity Among People Who Lost Employment During the 258

COVID-19 Pandemic in the United States

Care Among US Adults During the Initial Phase of the COVID-19 Pandemic

Food Insecurity in Australia during the COVID-19 Pandemic