Disability-related inequalities in the prevalence of loneliness across the lifespan: trends from Australia, 2003 to 2020

BACKGROUND

Experiencing loneliness can be distressing and increasing evidence indicates that being lonely is associated with poor physical and mental health outcomes. Cross-sectional studies have demonstrated that people with disability have increased risk of experiencing loneliness compared to people without disability. However, we do not know if these inequalities have changed over time. This study investigated the prevalence of loneliness for people with disability in Australia annually from 2003 to 2020 to examine whether disability-related inequalities in loneliness have changed over time, and disaggregated results for subgroups of people with disability by age group, sex, and disability group.

METHODS

We used annual data (2003-2020) from the Household, Income and Labour Dynamics in Australia Survey. Loneliness was measured by a single question assessing the subjective experience of loneliness. For each wave, we calculated population-weighted age-standardised estimates of the proportion of people experiencing loneliness for people with and without disability. We then calculated the absolute and relative inequalities in loneliness between people with and without disability for each wave. Analyses were stratified by 10-year age groups, sex, and disability group (sensory or speech, physical, intellectual or learning, psychological, brain injury or stroke, other).

RESULTS

From 2003 to 2020, the prevalence of loneliness was greater for people with disability, such that people with disability were 1.5 to 1.9 times more likely to experience loneliness than people without disability. While the prevalence of loneliness decreased for people without disability between 2003 and 2020, the prevalence of loneliness did not decrease for people with disability during this period. Inequalities in loneliness were more substantial for people with intellectual or learning disabilities, psychological disability, and brain injury or stroke.

CONCLUSION

This study confirms that people with disability have increased risk of loneliness compared to people without disability. We add to the existing evidence by demonstrating that disability-related inequalities in loneliness have persisted for two decades in Australia without improvement. Our findings indicate that addressing inequalities in loneliness for people with disability is a critical public health concern given that loneliness is associated with a wide range of poor health outcomes.

Disability and loneliness in the United Kingdom: cross-sectional and longitudinal analyses of trends and transitions

BACKGROUND

Loneliness can have a detrimental impact on health, yet little is known about the association between disability and loneliness.

METHODS

Secondary analysis of three waves of data collected between 2017 and 2020 by the UK's annual household panel study, Understanding Society. Direct age-standardisation was used to compare the prevalence of loneliness at each wave and the persistence of loneliness across all three waves for participants with/without disabilities aged 16-65 years. Transitional probabilities for the stability of loneliness, the stability of non-loneliness, the onset of loneliness and the offset of loneliness between consecutive waves were also estimated.

RESULTS

At each wave, the prevalence of loneliness was significantly higher among respondents with disabilities than respondents without disabilities; these inequalities persisted with no evidence of change over time. The prevalence of persistent loneliness was 46% for respondents with disabilities compared with 22% for respondents without disabilities. Risk factors for the likelihood of persistent loneliness included disability, financial stress, not living as a couple, living in rented accommodation, being female and not being employed. The probability of the onset and stability of loneliness between successive waves were markedly higher for people with disabilities compared with people without disabilities.

CONCLUSION

Adults with disabilities were more likely to experience loneliness, become lonely and remain lonely over time than their peers. Policies and interventions aimed at reducing loneliness should ensure that they are accessible and effective for people with disabilities. Further research is needed to explore the health outcomes of persistent loneliness among people with/without disabilities.

Trends in mental health inequalities for people with disability, Australia 2003 to 2020

OBJECTIVE

Cross-sectional studies have demonstrated that people with disability have substantial inequalities in mental health compared to people without disability. However, it is not known if these inequalities have changed over time. This study compared the mental health of people with and without disability annually from 2003 to 2020 to investigate time trends in disability-related mental health inequalities.

METHODS

We use annual data (2003-2020) of the Household, Income and Labour Dynamics in Australia Survey. Mental health was measured using the five-item Mental Health Inventory. For each wave, we calculated population-weighted age-standardised estimates of mean Mental Health Inventory scores for people with and without disability and calculated the mean difference in Mental Health Inventory score to determine inequalities. Analyses were stratified by age, sex and disability group (sensory or speech, physical, intellectual or learning, psychological, brain injury or stroke, other).

RESULTS

From 2003 to 2020, people with disability had worse mental health than people without disability, with average Mental Health Inventory scores 9.8 to 12.1 points lower than for people without disability. For both people with and without disability, Mental Health Inventory scores decreased, indicating worsening mental health, reaching the lowest point for both groups in 2020. For some subpopulations, including young females and people with intellectual disability, brain injury or stroke, mental health inequalities worsened.

CONCLUSION

This paper confirms that people with disability experience worse mental health than people without disability. We add to previous findings by demonstrating that disability-related inequalities in mental health have been sustained for a long period and are worsening in some subpopulations.

Health and wellbeing outcomes associated with loneliness for people with disability: a scoping review

BACKGROUND

Loneliness is a significant public health concern due to its detrimental impact on health and wellbeing. Despite people with disability reporting higher levels of loneliness than the general population, there has been little research into how this is affecting their health and wellbeing. In light of this, the aim of our study was to scope both the existing evidence about the health and wellbeing outcomes associated with loneliness for people with disability, as well as the conceptual frameworks and measures utilised in this field of research.

METHODS

To conduct this scoping review, we followed the methodology outlined by JBI and searched MEDLINE, Scopus, Informit, Embase, and Web of Science for peer-reviewed, English-language articles published between 1 January 2000 and 8 February 2023. Two independent reviewers completed screening, full-text review and data extraction, with consensus sought at each stage. Data were analysed using content analysis and presented both numerically and narratively.

RESULTS

Out of the initial 1602 publications identified in the scoping review, only nine were included after duplicate removal, title and abstract screening, and full-text review. This limited number of studies, with the earliest study one published in 2015, represents a key finding. Eight of the nine studies were quantitative, and all were conducted in high income countries. Most of these studies utilised a version of the University of Los Angles Loneliness Scale to measure loneliness and addressed specific impairment groups. Notably, most of the studies identified associations between loneliness and health and wellbeing outcomes for people with disability.

CONCLUSIONS

This scoping review highlights the current scarcity of studies examining the effect that loneliness has on the health and wellbeing outcomes of people with disability. As most of the reviewed studies relied on loneliness measures designed for individuals without disability, they potentially overlook the unique life experiences of people with disability. Given that loneliness is an international public health concern, it is imperative that people with disability are not left behind or overlooked in efforts to address the impact of loneliness on health and wellbeing.

The impact of employment on mental healthcare use among people with disability: distinguishing between part- and full-time employment

OBJECTIVE

Employment can improve mental health among people with disability (PWD), however, little is known about how different levels of workforce participation influence mental healthcare use. The aim of this study was to estimate the extent to which different levels of working hours are associated with changes in mental healthcare use among PWD.

METHODS

Data on working hours and healthcare use among working age PWD who were receiving government benefits (N=260 825) was obtained from Australian Census-linked administrative records between 2011 and 2019. Individual fixed effects panel models were used to estimate the impact of increased working hours on mental healthcare (services and prescriptions). Heterogeneity analyses by job security and key sociodemographic characteristics were conducted.

RESULTS

Compared to not working, we found that working 1-14, 15-29, and ≥30 hours per week was respectively associated with a 3.3%, 18.0%, and 9.9% reduction in the use of mental healthcare prescriptions as well as a 6.8%, 18.4%, and 22.3% reduction in the use of mental healthcare services by PWD. The effects were larger for PWD in more secure work and those living in rural and disadvantaged areas.

CONCLUSIONS

Working more hours was associated with reduced mental healthcare use among PWD. Policy interventions should consider the broader benefits of enabling part-time and secure work placements for PWD, particularly for those living in rural and disadvantaged regions.

COVID-19 vaccination coverage and vaccine hesitancy among Australians with disability and long-term health conditions

ISSUE ADDRESSED

COVID-19 vaccination is the cornerstone of managing Australia's COVID-19 pandemic and the success of the vaccination program depends on high vaccination coverage. This paper examined differences in COVID-19 vaccination coverage and vaccine hesitancy for people with disability, long-term health conditions, and carers - subgroups that were prioritised in Australia's vaccination program.

METHODS

Using data from 2400 Australians who participated in two waves of the Taking the Pulse of the Nation survey in April and May 2021, we described vaccination coverage and hesitancy among people with disability, severe mental health conditions, severe long-term health conditions, frequent need for assistance with everyday activities, and carers.

RESULTS

Vaccination coverage was estimated to be 8.2% in the population overall and was similar for people with disability, those with frequent need for assistance, and carers. It was higher for people with severe long-term health conditions (13.4%) and lower for people with severe mental health conditions (4.3%). Vaccine hesitancy was high overall (35.6%) and was similarly high across the priority groups, with only small differences for people with disability, severe long-term health conditions and frequent need for assistance.

CONCLUSIONS

This study highlights a lack of difference in vaccination coverage for people with disability, long-term health conditions, and carers compared to the general population. So what? Sub-optimal vaccination coverage for people in the priority groups leaves many people at significant risk of serious disease or death if exposed to COVID-19, particularly in light of easing of disease-control restrictions across Australia and the emergence of new variants.

Part-time versus full-time employment and mental health for people with and without disability

Objectives

This paper investigates the relationship between part-time and full-time employment and mental health for people with and without disability, as well as differences in the relationship by age and sex.

Methods

Using data from 13,219 working-aged people (15-64 years) in the labour force who participated in five annual waves of a longitudinal cohort study in Australia, the analysis used fixed effect regression models to examine within-person changes in mental health associated with changes in employment status (full-time; part-time; unemployed). Differences in the relationship between employment status and mental health by disability, sex, and age were assessed.

Results

Among people with disability, there was evidence that working part-time and full-time were associated with a 4.2-point (95% CI 2.6, 5.7) and 6.0-point (95% CI 4.4, 7.6) increase in mental health scores compared with when they were unemployed. For people without disability, there were much smaller differences in mental health associated with working part-time (β = 1.0, 95% CI 0.2, 1.9) and full-time (β = 1.4, 95% CI 0.5, 2.2) compared with when they were unemployed. The positive effects of both part-time and full-time employment were of greater magnitude for people with disability aged younger than 45 years compared to those aged 45 years and older.

Conclusions

The results of this study suggest that both part-time and full-time employment may have beneficial effects on the mental health of people with disability, particularly for younger people. The findings underscore the value of employment for people with disability, given we found much larger beneficial mental health effects in comparison to people without disability.

Does employment status mediate the association between disability status and mental health among young adults? Evidence from the Household, Income and Labour Dynamics in Australia (HILDA) survey

OBJECTIVE

Young adults with disabilities are less likely to be employed and more likely to have poor mental health than peers without disabilities. Growing evidence shows that social determinants of health may be causally related to mental health outcomes of people with disabilities. We aimed to assess if the disability to mental health association was mediated by employment status among young adults aged 20-35 years.

METHODS

Four consecutive years (2016-2019) of data from the Household, Income and Labour Dynamics in Australia survey were used to conduct a causal mediation analysis. We decomposed the total causal effect of disability status on mental health (Short Form-36 Mental Health Inventory-5) into the natural direct effect from disability to mental health and the natural indirect effect representing the pathway through the employment mediator (being employed; being unemployed or wanting to work).

RESULTS

3435 participants (3058 with no disabilities, 377 with disabilities) were included in the analysis. The total causal effect of disability status on mental health was an estimated mean decrease in mental health of 4.84 points (95% CI -7.44 to -2.23). The indirect effect, through employment status, was estimated to be a 0.91-point decline in mental health (95% CI -1.50 to -0.31).

CONCLUSIONS

Results suggest disability has an effect on the mental health of young adults; a proportion of this effect appears to operate through employment. The mental health of young adults with disabilities could potentially be improved with interventions to improve employment outcomes among this group, and by supporting individuals with disabilities into suitable employment.

A systematic review of the impact of the COVID-19 pandemic on the mental health of adolescents and young people with disabilities aged 15-29 years

BACKGROUND

The COVID-19 pandemic has exacerbated the psychological burden on young people around the world and may have disproportionately large impacts for young people with disabilities. This review aims to systematically review the quantitative evidence on the impact of the COVID-19 pandemic on the mental health of young people with disabilities and evaluate the quality of included studies.

METHODS

A systematic search was conducted using 5 electronic databases. The quality of the studies was assessed using the SIGN risk of bias assessment tool. A narrative synthesis was performed to synthesize the results of included studies.

RESULTS

The initial search yielded 1935 studies, of which two met the eligibility criteria, one longitudinal study and one cross-sectional study, both assessed to be of low quality. In the cross-sectional study, young people with intellectual and developmental disabilities self-reported an increase in mental health symptoms. The longitudinal study found no evidence of a change in mental health symptoms from pre-pandemic to during the pandemic among young people with autism spectrum disorder, although these individuals reported negative impacts of the COVID-19 pandemic on their emotional or mental health.

CONCLUSIONS

The findings of this review provide some weak evidence of a negative impact of the COVID-19 pandemic on the mental health of young people with disabilities. Importantly, the findings highlight the lack of research in this area. More research is needed to investigate the impact of the pandemic on the mental health of young disabled people, in order for governments to develop emergency preparedness plans to safeguard the well-being of this population.

Smoking Inequality Trends by Disability and Income in Australia, 2001 to 2020

BACKGROUND

While policies to reduce smoking in many countries have been successful, disadvantaged groups (such as low-income groups) have only seen minor gains. People with disability are one such disadvantaged group and are more likely to smoke. However, evidence is limited on trends and inequalities in smoking for disabled people and on whether those also on low incomes are more likely to smoke.

METHODS

We use annual data from 2001 to 2020 of the Household Income and Labour Dynamics in Australia survey. We use a Bayesian model to estimate smoking prevalence trends and inequalities for people with disability (2020, n = 1,370) and without disability (2020, n = 6,229) across the whole population and within income tertiles. To avoid reverse causation (smoking causing disability), we focus on younger people (15-44 years).

RESULTS

Absolute reductions (per 100 people, [95% credible intervals]) in smoking were similar for people with (-13 [-16, -11]) and without disability (-15 [-16, -14]), with stable absolute but increasing relative inequalities. In the low-income group, absolute reductions in smoking prevalence for people with disability (-10 [-14, -6]) were smaller than in people without disability (-14 [-15, -12]), resulting in moderate evidence for increasing absolute inequalities (4 [0, 8]) and strong evidence for increasing relative inequalities. In high-income groups, disability-related absolute inequalities narrowed (-6 [-10, -3]), and relative inequalities were stable.

CONCLUSIONS

Disabled people in Australia, especially those on low incomes, show signs of being left behind in efforts to reduce smoking.

Disability-related inequalities in health and well-being are mediated by barriers to participation faced by people with disability. A causal mediation analysis

Large inequalities in health and well-being exist between people with and without disability, in part due to poor socio-economic circumstances, and potentially also related to societal factors including issues associated with accessibility and participation. To better understand the contribution of societal factors, we used a unique longitudinal survey of disability in Great Britain to quantify the extent to which barriers to participation contribute to poorer health and well-being. We used data from 2354 individuals who participated in three waves of the Life Opportunities Survey between 2009 and 2014 and compared five health and well-being outcomes (self-rated health, anxiousness, life satisfaction, life worth, happiness) between adults who acquired an impairment and those who remained disability-free. Causal mediation analysis was conducted to quantify how much of the effect of disability acquisition on each outcome was explained by barriers to participation in employment, economic life, transport, community, leisure and civic activities, social contact, and accessibility. People who recently acquired a disability had poorer health and well-being compared to people with no disability. Barriers to participation explained 15% of inequalities in self-rated health, 28% for anxiousness, 32% for life satisfaction, 37% for life worth, and 70% for happiness. A substantial proportion of the inequalities in health and well-being experienced by people with recently acquired disability were socially produced, driven by barriers to participation in different life domains. Furthermore, there was evidence that barriers to participation mediated the effect of well-being measured to a greater extent than the more clinically aligned measures, self-reported health and anxiousness. These findings highlight modifiable factors amenable to public health interventions that could lead to substantial improvements in health and well-being for people with disability.

The impact of the COVID pandemic on working age adults with disability: Meta-analysis of evidence from four national surveys

Concern has been expressed about the extent to which people with disabilities may be particularly vulnerable to negative impacts of the 2020 COVID-19 pandemic. However, to date little published research has attempted to characterise or quantify the risks faced by people with/without disabilities in relation to COVID-19. We sought to compare the impact of the early stages of the COVID-19 pandemic and associated government responses among working age adults with and without disabilities in the UK on; COVID-19 outcomes, health and wellbeing, employment and financial security, health behaviours, and conflict and trust. We undertook secondary analysis of data collected in four UK longitudinal surveys; the Millennium Cohort Study, Next Steps, the British Cohort Study and the National Child Development Study. Combining analyses across surveys with random effects meta-analysis, there was evidence that people with disabilities were significantly more likely to report having had COVID-19 and had significantly increased levels of stress, less exercise, poorer sleep patterns, more conflict with their partner and others in their local area, and to have less trust in the government. While most outcomes did not differ significantly between participants with and without disability, the findings suggest that in the early days of COVID-19 a detrimental impact emerges for those with disabilities which is more pronounced among older people with disabilities. Future research is needed to determine the longer-term impact of the pandemic.

How much of the effect of disability acquisition on mental health is mediated through employment and income? A causal mediation analysis quantifying interventional indirect effects using data from four waves of an Australian cohort study

OBJECTIVES

There is evidence that disability acquisition causes a decline in mental health, but few studies have examined the causal mechanisms through which the effect operates. This study used a novel approach to mediation analysis to quantify interventional indirect effects (IIEs) through employment and income.

DESIGN AND SETTING

We used four waves of longitudinal data (2011-2014) from the Household, Income and Labour Dynamics in Australia Survey, a nationally representative survey of Australian households.

PARTICIPANTS

Working aged individuals who acquired a disability (n=233) were compared with those who remained disability-free in all four waves (n=5419).

PRIMARY OUTCOME MEASURE

Self-reported mental health was measured using the Mental Health Inventory subscale of the Short Form 36 general health questionnaire, which measures symptoms of depression, anxiety and psychological well-being.

STATISTICAL ANALYSIS

We conducted a causal mediation analysis quantifying IIEs of disability acquisition on mental health operating through two distinct mediators: employment status and income. We used multiple imputation with 50 imputed datasets to account for missing data.

RESULTS

The total causal effect of disability acquisition on mental health was estimated to be a 4.8-point decline in mental health score (estimated mean difference: -4.8, 95% CI -7.0 to -2.7). The IIE through employment was estimated to be a 0.5-point difference (-0.5, 95% CI -1.0 to 0.0), accounting for 10.6% of the total effect, whereas there was no evidence that income explained any of the effects.

CONCLUSIONS

This study estimated that disability-related mental health inequalities could be reduced by 10.6% if employment rates were the same for people with disability as those without disability. The results suggest that employment is implicated in the relationship between disability acquisition and mental health and that more research is needed to understand the influence of other aspects of employment and other socioeconomic characteristics.

The impact of disability on employment and financial security following the outbreak of the 2020 COVID-19 pandemic in the UK

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic may have a greater impact on people with disabilities than non-disabled people. Our aim was to compare the short-term impact of the 2020 COVID-19 pandemic and first lockdown on the employment and financial security of working age adults with and without disabilities in the UK.

METHODS

Secondary analysis of data collected in Wave 9 and the special April, May and June COVID-19 monthly surveys of 'Understanding Society', the UK's main annual household panel study.

RESULTS

During the first 3 months of the introduction of the COVID-19 lockdown in the UK, respondents with disability were more likely than their peers to be working reduced hours and experience higher levels of financial stress. These differences were attenuated, but not eliminated, when estimates were adjusted to take account of pre-lockdown financial status.

CONCLUSIONS

Working age adults with disability were particularly disadvantaged by the financial impact of the COVID-19 lockdown in the UK. The UN Secretary-General António Guterres has stated the need for a disability-inclusive COVID-19 government response. The results of our analysis suggest that these pleas have either not been heeded, or if measures have been implemented, they have so far been ineffectual in the UK.

1443A causal mediation analysis of the effect of disability on mental health mediated by employment

Background

There is evidence that disability acquisition causes a decline in mental health, but few studies have examined the causal mechanisms through which the effect operates. This study used a novel approach to mediation analysis to quantify interventional indirect effects through employment and income.

Methods

We used four waves of longitudinal data to compare self-reported mental health between working aged individuals who acquired a disability (n = 233) and those who remained disability-free (n = 5419). We conducted a causal mediation analysis quantifying interventional indirect effects of disability acquisition on mental health operating through two distinct mediators: employment status and income. We used multiple imputation with 50 imputed datasets to account for missing data.

Results

The total causal effect of disability acquisition on mental health was estimated to be a 4.8-point decline in mental health score (estimated mean difference: -4.8, 95% CI -7.0, -2.7). The interventional indirect effect through employment was estimated to be a 0.5-point difference (-0.5, 95% CI -1.0, 0.0), accounting for 10.6% of the total effect, whereas there was no evidence that income explained any of the effect.

Conclusion

This study estimated that disability-related mental health inequalities could be reduced by 10.6% if employment rates were the same for people with disabilities as those without. The results highlight the need to implement measures to enable people with disabilities to remain in employment and improve employment and vocational training opportunities for people who acquire a disability.

1074The role of epidemiology in improving the health of people with disability

Focus and outcomes for participants

The symposium will focus on the role of epidemiologists in building an evidence base to improve the health of the 15% of the world’s population with disability who currently experience vast health inequalities. Participants will be introduced to new ways of conceptualising disability in epidemiology; state of the art approaches to monitoring disability-related socio-economic and health inequalities; methodological challenges and solutions to address the biases due to misclassification, confounding and reverse causation; and the application of causal mediation analysis and natural experiments in identifying potential policy solutions. Participants will gain a greater understanding of how epidemiological methods can be applied to improve the health of people with disability, as well as insights and ideas for their research. A network of epidemiologists interested in this topic will be generated to foster ongoing communication and collaborative opportunities.

Rationale for the symposium, including for its inclusion in the Congress

The health of disabled people has largely been ignored by epidemiologists. This is despite emerging evidence that people with disability experience poorer health because of factors unrelated to their impairment, including socio-economic disadvantage, discrimination, and violence. However, turning epidemiologists’ efforts to the health of people with disability presents conceptual and methodological challenges, some of which are unique to the content area. Participants will be shown a suite of approaches that can be deployed to address these problems. Participatory methods and innovative graphical and statistical methods for analysing disability-related health inequalities, approaches rarely used in epidemiology, will be covered. The symposium will also concentrate on the application of methods to optimise causal inference in the presence of multiple potential biases, and methods that simulate randomised controlled trial conditions to model policy interventions.

Presentation program

The presentations are from researchers from the CRE-DH, funded through Australia’s National Health and Medical Research Council organised four themes.

Theme 1: Conceptualisation of disability

We will present findings from a scoping review of original articles in epidemiology journals and will argue that, while, disability is usually conceptualised in epidemiology as an outcome, reconceiving of disability as an exposure, mediator and/or effect modifier can provide important insights on the determinants of health of people with disability.

Theme 2: Monitoring disability-related inequalities

We will demonstrate how the CRE-DH has used participatory methods, where people with disability are ‘experts through lived experience’, to develop indicators to monitor disability-related inequalities and design a National Community Attitudes survey. We will demonstrate innovative ways to graphically illustrate prevalence, absolute and relative inequalities simultaneously, and discuss how hierarchical Bayesian methods can be used to overcome inadequate power due to disaggregation and assess inequalities under uncertainty.

Theme 3: Approaches to minimising bias

We will talk about how biases can affect estimates of disability prevalence and disability-outcome associations, including reverse causation, confounding and misclassification. We will discuss a range of approaches we have used to address these challenges including modelling incident (rather than prevalent) disability, using fixed effects models and propensity score approaches, and approaches to addressing misclassification bias drawing on examples from our program of research.

Theme 4: Identification of policy interventions

We will discuss methods that can be used to model the impact of policies on the health of people with disability using examples from our research. We will present the results of a causal mediation analysis modelling the impact of different employment policy interventions on mental health outcomes. We will illustrate the value of natural policy experiments for estimating effects of policy changes on employment and health of people with disability using two examples – the 2014 reassessment of Disability Support Pensioners under stricter impairment tables and the introduction of Australia’s National Disability Insurance Scheme.

The symposium will conclude with a facilitated discussion focussed on how epidemiologists can come together internationally to grasp the opportunities and address the challenges in research focussed on the health of people with disabilities.

Names of presenters

Professor Anne Kavanagh, PhD

Dr Nicola Fortune, PhD

Dr George Disney, PhD

Dr Zoe Aitken

Dr Samia Badji, PhD

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

Background

While emerging evidence shows increased mortality from COVID-19 among people with disability, evidence regarding whether there are disability-related inequalities in health during the pandemic is lacking.

Objective

This study compares access to COVID-19 and non-COVID-19 related health care and mental health of people with and without disability.

Methods

Longitudinal analysis of 12,703 adults (16–64 years) who participated in W9 (2017–2019) and the April and/or May COVID-19 special surveys of the UK Understanding Society study. Descriptive analyses and Poisson regression (adjusted for age, gender, ethnicity and financial stress) were conducted to estimate associations between disability (measured at Wave 9) and a number of different COVID-19-related health and health care outcomes (COVID-19 symptoms, testing and hospitalisation), mental health and loneliness, and non-COVID-19 related health care (e.g. outpatient and inpatient hospital care, prescription medications).

Results

Results from the fully-adjusted regression models found that people with disability were more likely: to be hospitalised if symptomatic (adjusted PRR 3.0 95% 1.07–8.43); to experience current symptoms of psychological distress (PRR 1.15, 95% CI 1.05–1.26) and to report being lonely (PRR 1.75, 95% CI 1.46–2.09) compared to non-disabled people. People with disability reported much higher levels of comorbidities than people without disability. However, inability to access health care and treatment were similar.

Conclusions

As the UK opens up, it is important that health care services and social policy address the poor mental health and social isolation of people with disability so that the inequalities occurring early in the pandemic do not become further entrenched.

The association between disability and risk of exposure to peer cyber victimisation is moderated by gender: Cross-sectional survey

BACKGROUND

Little is known about the exposure of youth with disability to cyber victimisation.

OBJECTIVE

/Hypothesis: To estimate the prevalence of peer cyber and non-cyber victimisation in a nationally representative sample of 14-year-old adolescents with and without disability and to determine whether gender moderates the relationship between disability and exposure to victimisation.

METHODS

Secondary analysis of data collected in Wave 6 of the UK's Millennium Cohort Survey on 11,726 14-year-old adolescents living in the UK.

RESULTS

Adolescents with disability had higher prevalence of cyber and non-cyber victimisation than those with no disability. For cyber victimisation there was a statistically significant interaction between gender and disability, with evidence of increased cyber victimisation for adolescents with disability compared to those with no disability among girls, but not boys. For non-cyber victimisation there was no evidence of an interaction between gender and disability.

CONCLUSIONS

The prevalence of both cyber and non-cyber victimisation was higher among adolescents with disability than those with no disability. The association between disability and risk of exposure to peer cyber victimisation appears to be moderated by gender.

Overt acts of perceived discrimination reported by British working-age adults with and without disability

BACKGROUND

Exposure to discrimination can have a negative impact on health. There is little robust evidence on the prevalence of exposure of people with disabilities to discrimination, the sources and nature of discrimination they face, and the personal and contextual factors associated with increased risk of exposure.

METHODS

Secondary analysis of de-identified cross-sectional data from the three waves of the UK's 'Life Opportunities Survey'.

RESULTS

In the UK (i) adults with disabilities were over three times more likely than their peers to be exposed to discrimination, (ii) the two most common sources of discrimination were strangers in the street and health staff and (iii) discrimination was more likely to be reported by participants who were younger, more highly educated, who were unemployed or economically inactive, who reported financial stress or material hardship and who had impairments associated with hearing, memory/speaking, dexterity, behavioural/mental health, intellectual/learning difficulties and breathing.

CONCLUSIONS

Discrimination faced by people with disabilities is an under-recognised public health problem that is likely to contribute to disability-based health inequities. Public health policy, research and practice needs to concentrate efforts on developing programs that reduce discrimination experienced by people with disabilities.

The effect of gender on mental health service use: an examination of mediation through material, social and health-related pathways

PURPOSE

We aimed to understand how much of the gender difference in mental health service use could be due to the joint mediation of employment, behavioural and material factors, social support and mental health need.

METHODS

We used data from employed individuals aged 18-65 years who participated in the 2015-2017 waves of the Household, Income and Labour Dynamics in Australia survey. The exposure (male, female) and confounders were measured in 2015, mediators in 2016 and the outcome-whether a person had seen a mental health professional in the previous year-was measured in 2017. We estimated natural mediation effects using weighted counterfactual predictions from a logistic regression model.

RESULTS

Men were less likely to see a mental health care provider than women. The total causal effect on the risk difference scale was  - 0.045 (95% CI  - 0.056,  - 0,034). The counterfactual of men taking the mediator values of women explained 28% (95% CI 1.7%, 54%) of the total effect, with the natural direct effect estimated to represent an absolute risk difference of  - 0.033 (95% CI  - 0.048,  - 0.018) and the natural indirect effect  - 0.012 (95% CI  - 0.022,  - 0.0027).

CONCLUSION

Gendered differences in the use of mental health services could be reduced by addressing inequalities in health, employment, material and behavioural factors, and social support.

The impact of the disability support pension on mental health: evidence from 14 years of an Australian cohort

OBJECTIVE

To assess the effect of the Australian Disability Support Pension (DSP) on the symptomology of depression and anxiety over and above the effects of reporting a disability itself.

METHODS

We used the Household Income Labour Dynamics in Australia (HILDA) survey from 2004 to 2017. We used fixed effects regression to understand mental health differences (using the Mental Health Inventory-5 [MHI-5]) when a person reported: i) a disability; or ii) a disability and receiving the DSP) compared to when they reported no disability. The models controlled for time-varying changes in the severity of the disability and other time-related confounders.

RESULTS

There was a 2.97-point decline (95%CI -3.26 to -2.68) in the MHI-5 when a person reported a disability compared to waves in which they reported no disability and 4.48-point decline (95%CI -5.75 to -3.22) when a person reported both a disability and being on the DSP compared to waves in which they reported neither.

CONCLUSIONS

Results suggest that accessing and being in receipt of the DSP can impact the mental health of people with disabilities. Implications for public health: Government income support policies should address the unintended adverse consequences in already vulnerable populations.

Exposure to discrimination and subsequent changes in self-rated health: prospective evidence from the UK's Life Opportunities Survey

OBJECTIVES

We sought to estimate risk of poor self-rated health (SRH) following exposure to disability-related and other forms of overt discrimination in a cohort of working age adults.

STUDY DESIGN

The study design is a population-based cohort survey.

METHODS

Secondary analysis of data collected in Waves 1 and 2 of the UK's Life Opportunities Survey which at Wave 2 involved the participation of 12,789 working age adults. Adjusted prevalence rate ratios were used to estimate the impact of exposure to disability and non-disability discrimination on two measures of SRH at Wave 2, controlling for SRH status at Wave 1.

RESULTS

Exposure to disability discrimination in the previous year was reported by 3.9% of working age British adults. Other forms of discrimination were reported less frequently (age: 3.7%, ethnicity: 2.5%, gender: 1.6%, religion: 0.8%, sexual orientation: 0.4%). In all analyses, there were stronger associations between exposure to disability discrimination and poor SRH at Wave 2 when compared with exposure to other forms of discrimination.

CONCLUSIONS

Disability discrimination represents a violation of human rights. It is also likely to be a major contributor to the health inequities experienced by working age adults with disability.

Do financial hardship and social support mediate the effect of unaffordable housing on mental health?

PURPOSE

Unaffordable housing has a negative impact on mental health; however, little is known about the causal pathways through which it transmits this effect. We examine the role of financial hardship and social support as mediators of this relationship.

METHODS

We identified households where housing costs changed from affordable to unaffordable across two waves of the Household, Income and Labour Dynamics in Australia (HILDA) Survey (2014-2015). The sequential causal mediation analysis was used to decompose the total effect of unaffordable housing on mental health into the portion attributable to financial hardship and social support [natural indirect effect (NIE)] and the portion not occurring through measured pathways [natural direct effect (NDE)]. Mental health was measured using the Mental Health Inventory (MHI) and Kessler psychological distress (KPD) scale. Baseline covariates included age, sex, household income, financial hardship, social support, marital status and employment status. Bootstrapping with 1000 replications was used to calculate 95% confidence intervals (CIs). Multiple imputations using chained equations were applied to account for missing data.

RESULTS

Unaffordable housing led to a change in mean mental health score on the MHI scale (- 1.3, 95% CI: - 2.1, - 0.6) and KPDS scale (0.9, 95% CI: 0.4, 1.4). Financial hardship accounted for 54% of the total effect on MHI scale and 53% on KPD scale. Collectively, financial hardship and social support explained 68% of the total effect on MHI scale and 67% on KPD scale, respectively.

CONCLUSIONS

In conclusion, the negative mental health effect of unaffordable housing is largely mediated through increased financial hardship.

Do gender and psychosocial job stressors modify the relationship between disability and sickness absence: An investigation using 12 waves of a longitudinal cohort

Objectives A considerable proportion of the working population reports a disability. These workers may be at risk of adverse outcomes, including longer periods of sickness absence. This study examined the causal effect of disability on sickness absence and the role of psychosocial job stressors and gender as effect modifiers. Methods Data on paid and unpaid sick leave, disability (yes/no) and psychosocial job stressors were available from 2005 to 2017 from the Household, Income and Labour Dynamics in Australia (HILDA) survey. Negative binomial models were used to model the rate of sickness absence in a year. Results In the random effects model, workers with disability had 1.20 greater rate of sickness absence in a year [95% confidence interval (CI) 1.17-1.23, P<0.001] after adjustment for confounders. The rate was slightly lower in the fixed effects model. There was evidence of multiplicative interaction of the effect by gender and job control. The effect of disability on sickness absence was greater among men than women, and higher for people with low job control compared to those with high job control. Conclusions There is a need for more research about the factors that can reduce sickness leave among workers with disabilities.

Predictors of Change in Employment Status and Associations with Quality of Life: A Prospective International Study of People with Multiple Sclerosis

Purpose This prospective international study aimed to assess the changes in employment, and predictors thereof, and associated change in mental health quality of life in people with multiple sclerosis (MS). Methods People with MS were recruited online through social media, forums and newsletters to complete an online English-language survey in 2012 and again in 2015, to assess changes in employment and clinical characteristics. Results 1276 people with MS of working age were included of whom 35.9% were employed full time, 25.6% part-time, 3.1% were unemployed and seeking employment, 19.7% were retired due to disability and 15.7% were not in the labour force. Part/full time employment decreased from 61.4 to 57.1% of the sample 2.5 years later, and 25.5% experienced some change in employment status. Lower level of education and higher level of disability at baseline predicted loss of employment at follow-up. 62.0% of the sample indicated that MS impacted on employment over their lifetime, associated with a lower level of education and progressive MS at time of diagnosis. Retiring due to disability was predictive of a decreased mental health related QOL score. Conclusion Employment status was negatively impacted by MS for most participants. We showed for the first time that employment loss was prospectively associated with poorer mental health related quality of life. Employment support including vocational services, reasonable flexibility in the workplace, and legal protection against discrimination should be widely available to assist people with MS, especially for those with progressive onset MS, higher disability and lower levels of education who are at higher risk of employment loss.

The cumulative effect of living with disability on mental health in working-age adults: an analysis using marginal structural models

PURPOSE

Previous studies have shown that acquiring a disability is associated with a reduction in mental health, but they have not considered the cumulative impact of having a disability on mental health. We used acquisition of a non-psychological disability to estimate the association of each additional year lived with disability on mental health (measured using the Mental Component Summary score of the Short Form Health Survey).

METHODS

We used the first 13 waves of data (years 2001-2013) from the Household, Income and Labour Dynamics in Australia Survey. The sample included 4113 working-age (18-65 years) adults who were disability-free at waves 1 and 2. We fitted marginal structural models with inverse probability weights to estimate the association of each additional year of living with disability on mental health, employing multiple imputation to handle the missing data.

RESULTS

Of the 4113 participants, 7.7 percent acquired a disability. On average, each additional year lived with disability was associated with a decrease in the mean Mental Component Summary score (β = - 0.42; 95% CI - 0.71, - 0.14).

CONCLUSIONS

This study provides evidence that each additional year lived with non-psychological disability is associated with a decline in mental health among working-age Australians.

The wellbeing of working-age adults with and without disability in the UK: Associations with age, gender, ethnicity, partnership status, educational attainment and employment status

BACKGROUND

Few population-based studies have examined the association between disability and personal wellbeing (PWB) among working-age adults.

OBJECTIVE/HYPOTHESIS

To determine: (1) the magnitude of differences in wellbeing between working-age adults with and without disability in contemporary samples representative of the UK population; and (2) whether the size of any observed differences between people with and without disability is moderated by age, gender, ethnicity, partnership status, educational attainment or employment status.

METHODS

Secondary analysis of data from three national cross-sectional surveys.

RESULTS

In each survey, people with disability scored lower than people without disability on all four indicators of PWB. Adjusting for the main effects of potentially moderating variables reduced the effect size of disability on PWB by an average of 24%. Subsequently adjusting for the two-way interaction terms between disability and potentially moderating variables reduced the effect size of disability (main effect) on PWB by an additional average of 73%. PWB among people with disability was significantly lower for: (1) men; (2) younger people; (3) those who belong to the majority ethnic group (white British); (4) those without a partner; and (5) people with lower socio-economic position.

CONCLUSIONS

Our findings indicate that demographic characteristics and exposure to specific social determinants of poor health play a major role in the negative association between disability and personal wellbeing. A more sophisticated understanding of how social determinants interact to produce inequities associated with identities such as disability, gender, race, sexuality, and class (intersectionality) can inform effective policy interventions.

Does the effect of disability acquisition on mental health differ by employment characteristics? A longitudinal fixed-effects analysis

PURPOSE

Longitudinal studies have suggested a causal relationship between disability acquisition and mental health, but there is substantial heterogeneity in the magnitude of the effect. Previous studies have provided evidence that socioeconomic characteristics can buffer the effect but have not examined the role of employment characteristics.

METHODS

We used data from 17 annual waves of the Household, Income and Labour Dynamics in Australia Survey to compare the mental health of working age individuals before and after disability acquisition, using the Mental Health Inventory, a subscale of the SF-36 health questionnaire. Linear fixed-effects regression models were used to estimate the effect of disability acquisition on mental health. We tested for effect modification by two characteristics of people's employment prior to disability acquisition: occupational skill level and contract type. Multiple imputation using chained equations was used to handle missing data.

RESULTS

Disability acquisition was associated with a substantial decline in mental health score (estimated mean difference: - 4.3, 95% CI - 5.0, - 3.5). There was evidence of effect modification by occupational skill level, with the largest effects seen for those in low-skilled jobs (- 6.1, 95% CI - 7.6, - 4.5), but not for contract type.

CONCLUSIONS

The findings highlight the need for social and health policies that focus on increasing employment rates, improving the sustainability of employment, and providing employment services and education and training opportunities for people who acquire a disability, particularly for people in low-skilled occupations, to reduce the mental health inequalities experienced by people with disabilities.

Does a modifiable risk factor score predict disability worsening in people with multiple sclerosis?

Background

Risk factors for chronic disease include smoking, hazardous alcohol consumption, physical inactivity, unhealthy body mass index and poor diet (SNAP factors). In multiple sclerosis (MS) SNAP factors are associated with health outcomes such as disability in cross-sectional studies, but longitudinal data are lacking.

Objective

The objective of this study was to assess whether a combined SNAP risk score predicts disability worsening.

Methods

Longitudinal self-reported data from two time-points 2.5 years apart from an international survey of 1225 people with MS were used in linear regression models adjusted for potential confounding. Disability worsening was measured using the patient-derived Multiple Sclerosis Severity Score.

Results

The majority (62%) had two or more risk factors, with insufficient fruit and vegetable intake (83%), unhealthy body mass index (42%) and physical inactivity (33%) most common. Some SNAP factors at follow-up were associated with disability at follow-up (cross-sectionally), and in addition there was some evidence that increasing risk factors was associated with disability worsening over the 2.5 year study period. Baseline SNAP score was not predictive of disability worsening at follow-up, however.

Conclusion

Known risk factors for morbidity and mortality were common and associated with disability cross-sectionally, but not prospectively. Further studies using longer time frames, objective measures and interventions may elucidate potential benefits from changes in risk factors on MS outcomes.

Disabling working environments and mental health: A commentary

Employment is a fundamental Social Determinant of Health known to have large impacts on mental health and other health outcomes. Across many countries of the world, people with disabilities are much more likely to be unemployed and looking for work than those without disabilities. The deprivation of employment opportunities is likely to have notable impacts on the health of people with disabilities. In this commentary, we outline the concept of "disabling working environments," which are defined as the range of experiences that affect the likelihood of people with disabilities in obtaining and maintaining quality employment which may then affect a disabled person's health. Disabling working environments are comprised of the following three mutually reinforcing components: 1) Differential selection into work; 2) Selection into certain types of jobs and exposure to poor psychosocial working environments when in employment, and; 3) Differential selection out of work (e.g., leaving employment at an earlier age than those who do not have a disability). We argue that policy and intervention design should consider the life course effects of employment on the mental health of people with disabilities.

To what extent is the association between disability and mental health in adolescents mediated by bullying? A causal mediation analysis

Background

Disability among adolescents is associated with both poorer mental health (MH) and higher levels of bullying-victimization. Bullying, therefore, conceivably mediates the association between disability and MH. Quantifying this pathway is challenging as the exposure (disability), mediator (bullying) and outcome (MH) are subjective, and subject to dependent measurement error if the same respondent reports on two or more variables.

Methods

Utilizing the counterfactual and potential outcomes approaches to causal mediation, we decomposed the total effect of disability on MH into natural indirect effects (through bullying) and natural direct effects (not through bullying) using a sample of 3409 adolescents. As the study included data from multiple informants (teacher, parent, adolescent) on the outcome (MH, as measured on the Strengths and Difficulties Questionnaire) and two informants (adolescent, parent) on the mediator (bullying), we assessed the influence of dependent measurement error.

Results

For preferred analysis (using parent-reported bullying and adolescent-reported MH), the total effect was a 2.18 [95% confidence interval (CI): 0.66-3.40] lower MH score for adolescents with a disability, compared with those with no disability (strength of association equivalent to 37% of the standard deviation for MH). Bullying explained 46% of the total effect. Use of adolescent-reported bullying with adolescent-reported MH produced similar results (37% mediation, 95% CI: 12-74%).

Conclusions

Disability exerts a detrimental effect on adolescent MH, and a large proportion of this appears to operate through bullying. This finding does not appear to be spurious due to dependent measurement error.

The relationship between an electronic mental health stigma campaign and suicidal thoughts and behaviours: a two-arm randomized controlled trial in the Australian construction industry

Males employed in the construction industry are at greater risk of suicide than other employed males. It is plausible that a high level of stigma against mental health problems explains the elevated rates of suicide among this group. This study sought to test the effectiveness of an electronic mental health stigma intervention on suicide ideation, communication about suicide and attempts. Participants were randomly assigned to receive either a series of brief contact interventions over a 6-week period or a wait list control. Suicidal ideation, communication about suicide and suicide attempts were assessed using the Suicidal Behaviors Questionnaire-Revised at post-intervention. We used linear regression to assess effectiveness at post-intervention, adjusting for relevant covariates using both conventional methods and a propensity score approach. Results indicate that the intervention had no significant impact on suicidal thoughts, communication or suicide attempts. There was some indication that individuals in the intervention group reported a slight increase in attempts and communication about suicide. These observations underscore an urgent need for more research to understand the complex and nuanced relationship between stigma and suicide in non-clinical populations.

Emotional difficulties and self-harm among British adolescents with and without disabilities: Cross sectional study

BACKGROUND

Little is known about the prevalence of emotional difficulties and self-harm among adolescents with a disability.

OBJECTIVE

Our aims were: (1) to estimate the prevalence of emotional difficulties and self-harm among British adolescents with and without disability; (2) to determine whether prevalence varies by gender, severity of disability and type of functional limitation associated with disability.

METHODS

Secondary analysis of age 14 data from the UK's Millennium Cohort Study.

RESULTS

Adolescents with disability reported significantly higher rates of emotional difficulties and self-harm than their non-disabled peers. Among participants with and without disability, prevalence rates were notably higher among girls for most outcomes. The strength of the association between disability and emotional difficulties and self-harm was greater for: maternal report of adolescent emotional difficulties; disabled adolescents with moderate/severe activity limitations; and adolescents with psychosocial impairments.

CONCLUSIONS

There is a clear need for providers of all mental health services to ensure that reasonable accommodations are made to services to ensure that they are responsive to the specific needs of adolescents with disabilities. Further research is needed to determine the extent to which our results can be generalised to adolescents in other settings, to specific subgroups of adolescents with disabilities, to other measures of emotional difficulties and to other informants. Future research is also needed to further explore the consistency and determinants of the intersection between gender by disability regarding adolescent mental health.

Health Outcomes and Lifestyle in a Sample of People With Multiple Sclerosis (HOLISM): Longitudinal and Validation Cohorts

Objective: To report the methodology and summary data of the Health Outcomes and Lifestyle In a Sample of people with Multiple sclerosis (HOLISM) longitudinal and validation cohorts. We report (1) data on participation, socio-demographics, disease characteristics, medication use, modifiable lifestyle risk factor exposures, and health outcomes of the HOLISM longitudinal cohort 2.5-years post enrolment; (2) attrition at this 2.5-year wave; and (3) baseline characteristics of the associated HOLISM validation cohort. Methods: The HOLISM longitudinal study recruited people internationally with self-reported diagnosed multiple sclerosis (MS) through web 2.0 platforms and MS society newsletters. Participants, first recruited in 2012, were invited 2.5-years later to participate in a follow-up survey. At both time points, participants completed a comprehensive online questionnaire of socio-demographics, modifiable lifestyle exposures, and health outcomes using validated and researcher-designed tools. The same methodology was used to recruit a new sample: the HOLISM validation cohort. Characteristics were explored using summary measures. Results: Of 2,466 people with MS at baseline, 1,401 (56.8%) provided data at 2.5-year follow-up. Attrition was high, likely due to limited amount of contact information collected at baseline. Completion of the 2.5-year wave was associated with healthier lifestyle, and better health outcomes. Participants completing follow-up had diverse geographical location, were predominantly female, married, unemployed or retired. At 2.5-year follow-up, nearly 40% were overweight or obese, most were physically active, non-smokers, consumed little alcohol, used vitamin D/omega-3 supplements, and 42% reported current disease-modifying drug use. Thirty percentage of reported cane or gait disability, while 13% relied on major mobility supports (Patient Determined Disease Steps). Approximately half the respondents reported a comorbidity, 63% screened positive for clinically significant fatigue (Fatigue Severity Scale), and 22% screened positive for depression (Patient Health Questionnaire-9). The validation cohort's characteristics were mostly consistent with previously reported HOLISM baseline data. Conclusions: Exploring prospective associations of modifiable environmental/behavioral risk factors with health outcomes in this international longitudinal sample of people with MS will be beneficial to MS research. Impacts of attrition and selection bias will require consideration. The validation cohort provides opportunity for replication of previous findings, and also for temporal validation of predictive models derived from the HOLISM cohort.

Effectiveness of Exercise Interventions for Pain Reduction in People With Multiple Sclerosis: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To systematically review the evidence of the effect of exercise compared with passive control on pain in people with multiple sclerosis.

DATA SOURCE AND STUDY SELECTION

Five electronic databases were searched for randomized controlled trials published up to March 2017 that recruited people with multiple sclerosis where exercise was the intervention and pain was an outcome (PROSPERO registration number CRD42017060489).

STATISTICAL ANALYSIS

A random-effects meta-analysis was conducted to estimate the standardized mean difference of the effect of exercise on pain between treatment and control groups. We assessed risk of bias, fitted meta-regression models to explore heterogeneity between studies, and assessed small study effects.

DATA SYNTHESIS

Ten studies met the inclusion criteria (total sample size=389), and all studies were at high risk of bias. We found that exercise interventions were associated with less pain compared with passive control groups (standardized mean difference=-.46; 95% CI, -.92 to .00). There was high between-study heterogeneity (I²=77.0%), which was not explained by the prespecified study characteristics. There was also some evidence of small study effects.

CONCLUSION

This is the first systematic review of the effect of exercise interventions on pain in people with multiple sclerosis, a chronic neurological disorder that affects 2.5 million people. We found some evidence that exercise compared with passive control alleviates pain in this population, but there were limitations in reporting and study quality with high risk of bias of individual studies and heterogeneity between studies.

A Longitudinal Study Examining Changes in Street Connectivity, Land Use, and Density of Dwellings and Walking for Transport in Brisbane, Australia

BACKGROUND

Societies face the challenge of keeping people active as they age. Walkable neighborhoods have been associated with physical activity, but more rigorous analytical approaches are needed.

OBJECTIVES

We used longitudinal data from adult residents of Brisbane, Australia (40-65 years of age at baseline) to estimate effects of changes in neighborhood characteristics over a 6-y period on the likelihood of walking for transport.

METHODS

Analyses included 2,789-9,747 How Areas Influence Health and Activity (HABITAT) cohort participants from 200 neighborhoods at baseline (2007) who completed up to three follow-up questionnaires (through 2013). Principal components analysis was used to derive a proxy measure of walkability preference. Environmental predictors were changes in street connectivity, residential density, and land use mix within a one-kilometer network buffer. Associations with any walking and minutes of walking were estimated using logistic and linear regression, including random effects models adjusted for time-varying confounders and a measure of walkability preference, and fixed effects models of changes in individuals to eliminate confounding by time-invariant characteristics.

RESULTS

Any walking for transport (vs. none) was increased in association with an increase in street connectivity (+10 intersections, fixed effects OR=1.19; 95% confidence interval (CI): 1.07, 1.32), residential density (+5 dwellings/hectare, OR=1.10; 95% CI: 1.05, 1.15), and land-use mix (10% increase, OR=1.12; 95% CI: 1.00, 1.26). Associations with minutes of walking were positive based on random effects models, but null for fixed effects models. The association between land-use mix and any walking appeared to be limited to participants in the highest tertile of increased street connectivity (fixed effects OR=1.17; 95% CI: 0.99, 1.35 for a 1-unit increase in land-use mix; interaction p-value=0.05).

CONCLUSIONS

Increases in street connectivity, residential density, and land-use heterogeneity were associated with walking for transport among middle-age residents of Brisbane, Australia. https://doi.org/10.1289/EHP2080.

Underemployment and its impacts on mental health among those with disabilities: evidence from the HILDA cohort

BACKGROUND

Underemployment (defined as when a person in paid employment works for fewer hours than their desired full working capacity) is increasingly recognised as a component of employment precarity. This paper sought to investigate the effects of underemployment on the mental health of people with disabilities.

METHODS

Using 14 waves of the Household, Income and Labour Dynamics in Australia survey, we used fixed-effects models to assess whether the presence of a disability modified the association between underemployment and mental health. Both disability and underemployment were assessed as time-varying factors. Measures of effect measure modification were presented on the additive scale.

RESULTS

The experience of underemployment was associated with a significantly greater decline in mental health when a person reported a disability (mean difference -1.38, 95% CI -2.20 to -0.57) compared with when they did not report a disability (mean difference -0.49, 95% CI -0.84 to -0.14). The combined effect of being underemployed and having a disability was nearly one point greater than the summed independent risks of having a disability and being underemployed (-0.89, 95% CI -1.75 to -0.03).

CONCLUSION

People with disabilities are more likely to experience underemployment and more likely to have their mental health adversely affected by it. There is a need for more research and policy attention on how to ameliorate the effects of underemployment on the mental health of persons with disabilities.

Disability acquisition and mental health: effect modification by demographic and socioeconomic characteristics using data from an Australian longitudinal study

OBJECTIVES

There is evidence of a causal relationship between disability acquisition and poor mental health, but the substantial heterogeneity in the magnitude of the effect is poorly understood and may be aetiologically informative. This study aimed to identify demographic and socioeconomic factors that modify the effect of disability acquisition on mental health.

DESIGN AND SETTING

The Household, Income and Labour Dynamics in Australia Survey is a nationally representative longitudinal survey of Australian households that has been conducted annually since 2001. Four waves of data were included in this analysis, from 2011 to 2014.

PARTICIPANTS

Individuals who acquired a disability (n=387) were compared with those who remained disability-free in all four waves (n=7936).

PRIMARY OUTCOME MEASURE

Mental health was measured using the mental health subscale of the Short Form 36 (SF-36) general health questionnaire, which measures symptoms of depression, anxiety and psychological well-being.

METHODS

Linear regression models were fitted to estimate the effect of disability acquisition on mental health, testing for effect modification by key demographic and socioeconomic characteristics. To maximise causal inference, we used a propensity score approach with inverse probability of treatment weighting to control for confounding and multiple imputation using chained equations to assess the impact of missing data.

RESULTS

On average, disability acquisition was associated with a 5-point decline in mental health score (estimated mean difference: -5.1, 95% CI -7.2 to -3.0). There was strong evidence that income and relationship status modified the effect, with more detrimental effects in the lowest (-12.5, 95% CI -18.5 to -6.5) compared with highest income quintile (-1.1, 95% CI -4.9 to 2.7) and for people not in a relationship (-8.8, 95% CI -12.9 to -4.8) compared with those who were (-3.7, 95% CI -6.1 to -1.4).

CONCLUSIONS

Our results suggest that the detrimental effect of disability acquisition on mental health is substantially greater for socioeconomic disadvantaged individuals.

Status inconsistency and mental health: A random effects and instrumental variables analysis using 14 annual waves of cohort data

Status inconsistency refers to a discrepancy between the position a person holds in one domain of their social environment comparative to their position in another domain. For example, the experience of being overeducated for a job, or not using your skills in your job. We sought to assess the relationship between status inconsistency and mental health using 14 annual waves of cohort data. We used two approaches to measuring status inconsistency: 1) being overeducated for your job (objective measure); and b) not using your skills in your job (subjective measure). We implemented a number of methodological approaches to assess the robustness of our findings, including instrumental variable, random effects, and fixed effects analysis. Mental health was assessed using the Mental Health Inventory-5. The random effects analysis indicates that only the subjective measure of status inconsistency was associated with a slight decrease in mental health (β-1.57, 95% -1.78 to -1.36, p < 0.001). This size of these coefficients was maintained in the instrumental variable analysis. We suggest that status inconsistency might explain some of the relationship between social determinants (such as work and education) and health outcomes.

Inequalities in socio-economic characteristics and health and wellbeing of men with and without disabilities: a cross-sectional analysis of the baseline wave of the Australian Longitudinal Study on Male Health

BACKGROUND

Internationally, men with disabilities have higher rates of social and economic disadvantage and poorer health and wellbeing than men without disabilities. No single study has provided comprehensive, population-level information about the magnitude of such differences among adult men using a well-validated instrument to measure disability.

METHODS

We analysed baseline data from Ten to Men - an Australian longitudinal study of male health. Ten to Men used a stratified multi-stage cluster random sample design to recruit a national sample of males aged 10 to 55 years residing in private dwellings. Data were collected between October 2013 and July 2014 from 15,988 males. This analysis was restricted to 18-55 year old participants with data available on age and disability (n = 13,569). We compared the demographic, socio-economic characteristics and health and wellbeing of men with and without disabilities using chi squared tests for proportions and t tests for continuous variables. Linear regression adjusted for age was used to assess the association between disability status and health and wellbeing, which were measured using the SF-12 mental and physical health component scores and the Personal Wellbeing Index.

RESULTS

Men with disabilities were older and more likely to be born in Australia, speak English at home, be Aboriginal and Torres Strait Islander and were less likely to be married or de facto, or to live in urban areas. They were less likely to have completed secondary school, be employed and live in affordable housing, and were more likely to live on low incomes, in more socio-economically disadvantaged areas, and in rental accommodation and to experience shortages of money. Among employed men, those with disabilities were less likely to be in high skilled jobs, worked less hours on average, and were more likely to report that they would prefer to work more. Men with disabilities had lower levels of social support and community participation and poorer mental and physical health and overall wellbeing.

CONCLUSION

Adult men with disabilities experience marked social and economic disadvantage and poorer health and wellbeing. Improving the health and wellbeing of disabled men should be a priority for public health researchers and policy-makers.