Disability and Population Health Discussion Paper

Issued on September 1 2005

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September 2005

Foreword

People with disabilities, their families, carers and advocateshave traditionally focused on striving to develop adequate andresponsive specialist support services to meet their needs. Thiswork continues today. However, the mechanisms and channels throughwhich this can happen are changing. Changes are occurring in thehealth services and other state agencies that have a responsibilityto provide services that meet the needs of people withdisabilities. The voluntary disability sector has continuouslyresponded to this change in a timely and professional manner. ThisDiscussion Paper on Disability and Population Health is anotherexample of how the disability sector is responding to thatchange.

Health policy was once thought to be about little more than theprovision and funding of direct medical care and intervention. Withthe emergence and development of the social model of health this isnow changing. The concept of Population Health is taking centrestage, internationally and nationally, in the strategic developmentof health and social care services. The Irish health care system isexperiencing a time of change, not only in terms of service designand delivery, but, perhaps more fundamentally, in relation tounderlying values, core principles and strategic thinking. Theestablishment of a designated Population Health Directorate withinthe Health Service Executive and the primacy of the approach withinthe Department of Health and Children should further energise andpromote the concept at national level. It is envisaged that theapproach will be central to the developing structures andconsequently service design at national, regional and localdelivery level.

People with disabilities are living longer. Many are survivinginto old age who in the past would not have survived. The generalpopulation is also living longer. What can our society do to reducethe incidence of disability, and to ameliorate its impact? Increased capacity in thediagnostic, genetic and information provision areas will meet upwith the moral, ethical, behavioural and social issues thatmainstreaming will throw up. We must not simply content ourselveswith only sorting out the current levels of unmet specialist needsand presume that disability as an issue has been dealt with onceand for all. We must develop a disability plan looking forward tothe next fifty years. The Population Health approach is key to anysuch plan.

This Discussion Paper is therefore very timely and relevant. Itprovides the cornerstone to our National Conference,''Disability and Population Health'', (Portlaoise, 5thand 6th October, 2005). It outlines DFI''s current positionregarding disability and the Population Health approach to healthpolicy. It sets out to define the concept, particularly within anIrish context, proceeds to develop key determinants for thedisability sector and finally makes recommendations for policydevelopment.

I wish to thank all those who contributed to the development ofthe Paper, in particular those individuals and organisations whocommented on and submitted responses to earlier drafts.

I am particularly grateful to Maria Fox, author of the Paper andto all the staff of DFI for their input. I would expect that theproposals contained in the Paper will contribute to the developmentand expansion of public health initiatives which will benefit notonly the disability sector, but all groups in the population.

John Dolan Chief Executive September 2005

SUMMARY OF RECOMMENDATIONS

Income and Social Status

Social Policy interventions should provide not only safety nets and basic entitlements, but also spring- boards to tackle early and recurrent disadvantage, (e.g. housing, income, education etc.).
Public health policies should remove barriers to health care, social services and social and affordable housing.
Introduce and pay a Cost of Disability Allowance at a base rate of €40 per week.
Disability Allowance to be increased by €17 to €165.80 in Budget 2006 in line with the commitment in the NAPS Review.

Social Exclusion

Increased support and legal enforcement of existing Equality Legislation to protect people with disabilities from discrimination and social exclusion.
There should be a statutory duty on all Government Departments, public bodies and publicly funded bodies and services to ''disability proof'' their activities from policy to operational matters. This is to ensure the inclusion of people with disabilities in all public policies and services.
Government should continue to develop its policy of Mainstreaming of Disability Services as committed to in the 1997 Programme for Government and the National Disability Strategy.
Improved supports for a Community Development approach within the voluntary disability sector to enhance the social inclusion of people with disabilities in mainstream society.
Support voluntary disability organisations to further engage in social inclusion initiatives for people with disabilities.

Early Child Development

Increased and earlier screening, detection and intervention programmes contribute to prevention of conditions and positive health and financial outcomes for all.
Develop improved preventative health care (including health education, care facilities) before the first pregnancy.
Continued promotion of folic acid intake among all women of child-bearing age.
Examination and development of other methods of folic acid intake promotion, particularly for hard to reach groups, eg disadvantaged young women, ethnic minorities and young women with disabilities.
Provide improved pre and post-natal care for mothers and babies.
Increase Child Allowance as a direct universal financial intervention for mothers and children.
Increase the general level of, and access to, education to improve the health of mothers and babies in the long run.
Strategic Task Force on Alcohol to address the issue of alcohol related harm to the foetus and developing child.

Unemployment, Employment and Working Conditions

Employment Policy should have as its goals:
- (i) to prevent unemployment and job insecurity,
- (ii) to reduce the hardship associated with unemployment and
- (iii) to restore people to secure jobs.
There is a need to further develop training and employment opportunities, in both the public and private sector, for people with disabilities.
Tax relief, employment grants and other financial incentives to be provided to employers to increase the participation of people with a disability in the workforce.
The 3% target (of employment of people with disabilities) within the public sector needs greater monitoring and adherence.
All workers should be protected by minimum income guarantees, minimum wages legislation and access to work related services, (e.g. employee assistance programmes).
To reduce musculoskeletal disorders workplaces must be ergonomically designed.
There is an ongoing need to protect people from exposure to toxic materials at work, by increased adherence and enforcement of health and safety and other worker protection legislation, including the workplace smoking ban.
Workplace health protection should encompass legal aspects, including health and safety legislation and powers of inspection, and workplace health initiatives such as employee assistance programmes and work/ life balance programmes.
Limitations on working hours must be enforced as a matter of priority.
Appropriate involvement in decision-making benefits employees at all levels in an organisation.
Good management involves ensuring appropriate rewards - financial, status and self-esteem - with a subsequent positive health impact for all employees.

Stress

Social policy needs to address both psychosocial and material needs, as both are major causes of stress.
In association with the medical response to treating stress, more attention should be focused upstream on reducing the major causes of chronic stress (insecurity, low self-esteem, working environment, poverty etc.).
Increased financial and other support systems for carers as an acknowledgement of the vital role this group provides in responding to the care needs of people with disabilities

Health Services

The Health Service Executive in partnership with the Department of Health and Children, the voluntary disability sector and other stakeholders should develop as a priority a comprehensive, targeted, National Population Health Strategy.
A National Assessment of the Health Needs of People with Disabilities should be undertaken to compile baseline data. This data will determine needs, priorities and targets for the planning and development of all health services for people with disabilities.
All health screening and protection initiatives (e.g. cancer screening programmes) be made available and accessible to people with disabilities including those in all residential settings.
Population Health programmes and interventions need to be specifically targeted and delivered in partnership with disability organisations if take-up is to increase past its current unacceptably low levels.

Physical Environment

The Departments of Health and Children and Environment, Heritage and Local Government to develop a joint national accommodation and support strategy for people with disabilities.
The principle of Universal Design is the target in relation to the built environment.
Local Authorities should encourage and require, by legal means if necessary, that all building developments, as a minimum, comply with Part M of the Building Regulations.
Local Authorities should employ an Access Officer to inspect planning applications and building developments.
All Local Authorities to implement and deliver on the commitments of the Barcelona Declaration.
The Department of the Environment, Heritage and Local Government should ''design in'' the issues and needs of people with disabilities in line with the Government''s commitments in the National Disability Strategy and to Mainstreaming, particularly with regard to the housing and accommodation needs of people with disabilities.
The six Government Departments mandated to implement the National Disability Strategy through the development of Sectoral Plans to develop a partnership approach to the development, implementation and monitoring of these initiatives.
Government Agencies and Partner Groups to continue the promotion and enforcement of the Workplace Tobacco Ban.
There should be continued improvement and development of an accessible public transport network, to include rural and other hard to reach communities.
Increased implementation and enforcement of the penalty points system as a proven road safety measure.
Reduction of the blood alcohol concentration level to zero in line with that of most other EU countries.
Continued promotion of designated driver schemes, such as free soft drinks, through licensed premises.

INTRODUCTION

This Paper outlines DFI''s current position regarding thePopulation Health approach to health policy. It first defines andoutlines the concept, particularly within the Irish context, thenproceeds to develop some key determinants for the disability sectorand subsequently make recommendations for policy development. DFImember organisations and the broader voluntary disability sectorhave traditionally been active in health promotion, education andearly intervention. This work emphasis draws parallels with thePopulation Health concept and its relevance to the sector will bedeveloped in the course of the Paper. Throughout the text the WHOdefinition of health, which states that,

''health is a state of complete physical, mental and social wellbeing, not merely the absence of disease or infirmity'', is adopted. In 1986 this was redefined to include health as ''a resource for everyday life, not the objective of living.''

It is important to note at the outset that the purpose of thisPaper is to develop and set out priorities for the disabilitysector within the parameters of a Population Health approach tohealth and social services. Prevention is the cornerstone of anyrational health policy. As a result issues of health promotion,disease and disability prevention are discussed. This is by nomeans contrary to the social and rights based model of disabilityto which DFI is committed. Rights and responsibilities are notsubstituted or diluted through the exploration and promotion ofimproved health status, reduced inequalities and greater socialparticipation for all, including people with disabilities.

The Concept of Population Health

Health policy was once thought to be about little more than theprovision and funding of direct medical care and intervention. Withthe emergence and development of the social model of health this isnow changing. The concept of Population Health is taking centre stage, internationally andnationally, in the strategic development of health and social careservices. Population Health is an approach to health that aims toimprove the health and wellbeing of the entire population and toreduce inequities in health status among particular populationgroups. In order to do this it works at, and acts on, the broadrange of factors and conditions that have a strong influence on ourhealth, known as the determinants of health. Multiple factors andconditions contribute to our health. These range from biologicaland hereditary factors to lifestyle and community factors throughto general socio-economic, cultural and environmentalconditions.

Subsequent action is directed at the health of the entirepopulation, or sub groups of the population, rather than theindividual. A healthier population makes more productivecontributions to overall societal development, requires lesssupport in the form of health care and social benefits, and isbetter able to support and sustain itself over the long term. Anunderlying assumption of the approach is that reductions in healthinequities require a reduction in material and social inequities.There is broad agreement in the research that the best approachesto tackling health inequalities focus on addressing the underlyingstructural determinants of social and economic inequalities insociety, (in Burke, S et al 2004). The outcomes or benefits of aPopulation Health approach therefore extend beyond improvedPopulation Health outcomes to include a sustainable and integratedhealth care system, increased net growth and productivity,strengthened social cohesion and improved quality of life, (HealthCanada 2001).

The concept of Population Health builds on a long tradition ofpublic health, community health and health promotion policy andpractice. It has its foundations in Canadian health policydating from the early 1970s. The theoretical framework for healthpromotion and Population Health are similar, both are concernedwith improving health and reducing health inequities. They bothregard health as

''a capacity or resource for everyday living, that enables us to pursue our goals, acquire skills, satisfy personal aspirations and cope with life''s challenges'', (WHO 1986).

However certain sectors in society are at a disadvantage in this regard, these include homeless persons, ethnic minorities and people with disabilities.

An underlying principle is that all people should have an equalopportunity to develop and maintain their health, and itacknowledges that certain population groups have uniquerequirements for health, e.g. people with disabilities. Theapproach assesses needs and develops strategies that accommodatethe distinctive characteristics of particular population groups,thus optimising health outcomes for all is its main objective.

The Irish Health Care System

The Irish Health Care System is experiencing a time of change,not only in terms of service design and delivery, but, perhaps morefundamentally, in relation to underlying values, core principlesand strategic thinking. There is a move from a focus on curativemedical intervention towards a healthcare system which incorporatesdisease prevention and health protection initiatives. The currentHealth Strategy, ''Quality and Fairness: A Health System for You'' contains many references to Population Health andaddressing health inequalities, particularly among certainpopulation groups. Allied to this are its four guiding principles;equity, people-centeredness, quality and accountability, all ofwhich hold resonance with a Population Health agenda. It states;

'' Achieving full health potential does not depend solely on the provision of health services. Many other factors and therefore many other individuals, groups, institutions and public and private bodies have a part to play in the effort to improve health status and achieve the health potential of the nation'', (p60).

The National Primary Care Strategy. ''Primary Care -A New Direction'' also defines its remit broadly to includehealth promotion, screening and assessment, rehabilitation andpersonal social services along with traditional diagnosis andtreatment services. It states;

''Population Health services will be strengthened and expanded to ensure widespread uptake of initiatives such as screening, immunisation and early intervention'', (p26).

The establishment of a designated Population Health Directoratewithin the Health Service Executive and the primacy of the approachwithin the Department of Health and Children will further energiseand promote the concept at national level. It is envisaged that theapproach will be central to the developing structures andsubsequent service design at national, regional and local deliverylevel. Its prominence within the developing policy and deliverymechanisms should influence strategic planning and ultimatelyservice initiatives.

The Disability Sector

The Population Health approach holds particular benefits for thedisability sector. People with disabilities are not immune to otherhealth concerns. They are not immune to illness and diseaseunrelated to their particular disabling condition. People withdisabilities experience cancers and cardiovascular disease and allother illnesses that effect the general population. In fact forsome people with disabilities co-morbidity (being affected withmore than one health condition) is a particular reality resultingin additional pressure for the person concerned.

Having a disability can to a certain degree compromiseone''s ''health expectancy''. There are particularlinks between Down''s Syndrome and the onset ofAlzheimer''s, and between Muscular Dystrophy and Diabetes. Onereview of the research carried out by Carvill in 2001 concludedthat people with learning disabilities are between 8.5 and 200times more likely to have a vision impairment compared to thegeneral population and around 40% are reported to have a hearingimpairment, with people with Down''s Syndrome at particularlyhigh risk of developing vision and hearing loss. There is a growing awareness ofincreased incidences of depression and other mental health issuesamong those with spinal and head injury and other late onsetconditions. Also given our ageing population we should expect tosee a corresponding increase in these realities in the decadesahead with subsequent demands on the healthcare system. Developinga Population Health response to these concerns should increaseaccess to health promotion, screening and other public healthprogrammes for people with disabilities. Such services need to bespecifically targeted and delivered in partnership with disabilityorganisations if take-up is to increase past its currentunacceptably low levels.

DFI Members

A focus on prevention and targeted interventions is wellestablished in the voluntary disability sector. Our members havebeen active in this area for decades, with many organisationsoriginally set up in response to particular needs among theirclient/membership base. Voluntary disability organisations provideservices such as information, advice, therapeutic interventions,training and employment, advocacy and specialist support, to name afew. In real terms we are about the business of not only keepingpeople well, but also actively improving health and social gain forpeople with disabilities and their families. The sector is a majorsource of information and influence concerning cross-sectoralissues, having developed and maintained successful partnershiparrangements over time. Our members consistently respond to new andchanging demands from their clients and from funding providers, ina coherent and professional manner. This management of change issomething our sector is experienced and skilled in. We alsopositively acknowledge and welcome change, particularly if it is tothe benefit of people with disabilities and their families.

THE DETERMINANTS OF HEALTH FOR THE DISABILITY SECTOR

A range of factors influence people''s health. These areknown as the determinants of health. Some of these are fixed,including age, sex and genetic make-up. Individual behaviour andlifestyle choices, including smoking, physical activity levels anddiet also impact on health. There is also a growing understandingand acceptance that a wide range of social, environmental, economicand cultural factors also have a significant impact. Each of thesefactors is important in its own right, while also beinginterrelated. The key determinants, as argued by DFI, for thedisability sector are outlined below.

Income and Social Status

''The one thing that all people with disabilities in Ireland have in common is the considerable risk that they will experience a high level of poverty'', (DFI 2003).

There is strong and growing evidence that higher social andeconomic status is associated with better health. Health statusimproves at each step up the income and social hierarchy. As earlyas 1980 the evidence of this was overwhelming. The Black Report inthe UK detailed the growing class gradient in mortality andmorbidity from all the major diseases commenting that;

''There are marked inequalities in health between the social classes in Britain… Mortality tends to rise inversely with falling occupational rank or status, for both sexes and at all ages,'' (Jones et al, 2002).

The healthiest populations are those in societies which are notonly prosperous but which also have an equitable distribution ofwealth. It is not the poorest societies that experience thegreatest health inequalities, but societies in which the gapbetween rich and poor is widest, (Combat Poverty Agency 2004). InIreland poorer people in the population experience poorer healthand have less access to health services. Research from around theworld, including Ireland, has recognised socio-economic and geographicgradients in indicators of disease and health. In general we knowthat as socio-economic status improves so too does health, (inBurke, S et al 2004).

This is a key determinant for people with disabilities, giventhe well established fact that poverty and disability areinextricably linked. People with disabilities as a group are poorerthan the general population, and people living in poverty are morelikely than others to have a disability. People with disabilitieshave lower education and income levels than the rest of thepopulation. They are more likely to have incomes below povertylevel, and less likely to have savings and other assets than othergroups financial circumstances of adults with disabilities found that;

''whether measured in terms of income, consumer goods, diet or basic social needs, as a population group they were especially vulnerable to poverty'' (Jones et al, 2002).

To further compound this reality, certain groups within the disabled population are more vulnerable to the risk of poverty, including the elderly, those with mental and intellectual disabilities and women, (Elwan, 1999).

On a practical level, income to a large extent determines livingconditions and the ability to buy sufficient good food. This is aparticular reality and an additional complication for people withdisabilities. People with disabilities face extra costs in dailyliving associated with travel, heating, diet and medication. Peoplewith disabilities and their families, are meeting these extracosts. It is clear that people with disabilities and their familiesare more likely than the rest of the population to live in poverty,and that this is a two-way relationship - disability adds tothe risk of poverty, and conditions of poverty increase the risk ofdisability, (Elwan, 1999).

The Evidence:

The rate of hospitalisation for mental illness is more than six times higher for people in the lower socio- economic groups as compared with those in higher groups, (Burke, S et al 2004).
The incidence of chronic physical illness has been found to be two and a half times higher for poor people than for the wealthy, (Burke, S et al 2004).
Men in unskilled jobs are four times more likely to be admitted to hospital for schizophrenia than higher professional workers, (Burke, S et al 2004).
Research has shown that poverty directly harms the health of those on low incomes, (in Burke, s et al 2004).
Low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes, regardless of age, sex, race and place of birth, (Health Canada 1999).
A major British study of civil servants found that, for most major categories of disease (cancer, cardiovascular etc.), health increased with job rank, even when other risk factors such as smoking were taken into account, (Canadian Institute of Health Information 2004)
Two thirds of households headed by an ill/disabled person fall below the 60% median income line, (Combat Poverty Agency 2004).
Research has consistently shown a strong association between poor health and low income on the one hand and higher income and better health on the other, (Barrington 2004).
People further down the social ladder usually run twice the risk of serious illness and death as those near the top, (WHO 2003).
The mortality rate for all causes of death between 1989 and 1998 was almost two and a half times greater for the lowest socio-group than the highest, (Balandaand Wilde, 2001).
Ireland has the highestlevel of income inequality in Europe, and the second highest levelof income inequality in OECD countries after the US, (in Burke, Set al 2004).

Policy Recommendations:

Social Policy interventions should provide not only safety nets and basic entitlements, but also spring- boards to tackle early and recurrent disadvantage, (eg; housing, income, education etc.)
Public health policies should remove barriers to health care, social services and social and affordable housing
Introduce and pay a Cost of Disability Allowance at a base rate of €40 per week.
Disability Allowance to be increased by €17 to €165.80 in Budget 2006 in line with the commitment in the NAPS review.

Social Exclusion

Social exclusion, which is linked to poverty and relativedeprivation, has a major impact on the health of some populationgroups, including people with disabilities. This exclusion from theeveryday activities of living and contributing to society hasrepercussions for people''s self esteem, mental health andoverall general wellbeing. Social exclusion can result fromdiscrimination, stigmatisation and hostility. People withdisabilities experience many barriers to participation in educationor training, and gaining access to other general activities. Thisis a particular concern for those living in residentialenvironments. They are excluded from participating in societythrough low incomes, physical exclusion and lack of access toindependent advocacy. This is socially and psychologicallydamaging, materially costly and harmful to health, (WHO 2003).

The Evidence:

People who live in, or have left institutions may be particularly susceptible to social exclusion.
Poverty and social exclusion increase the risk of disability, illness and social isolation and vice-versa, forming vicious circles that deepen the predicament people face, (WHO 2003).
Some experts have concluded that the health effect of social relationships may be as important as established risk factors such as smoking, physical activity, obesity and high blood pressure, (Canadian Institute of Health Information 2004).

Policy Recommendations:

Increased support and legal enforcement of existing Equality Legislation can help protect people with disabilities from discrimination and social exclusion.
There should be a statutory duty on all Government Departments, public bodies and publicly funded bodies and services to ''disability proof'' their activities from policy to operational matters. This is to ensure the inclusion of people with disabilities in all public policies and services.
Government should continue to develop its policy of Mainstreaming of Disability Services as committed to in the 1997 Programme for Government and the National Disability Strategy.
Improved supports for a Community Development approach within the voluntary disability sector to enhance the social inclusion of people with disabilities in mainstream society.
Support voluntary disability organisations to further engage in social inclusion initiatives for people with disabilities.

Early Child Development

New evidence on the effects of early experiences on braindevelopment, school readiness and health in later life has sparkeda growing consensus about early childhood development as a powerfuldeterminant of health in its own right (Public Health Agency ofCanada 2005). Observational research and intervention studies haveshown that the foundations for adult health are laid before birthand in early childhood. Poor foetal development and low birthweight is a risk for health in later life. Slow physical growth ininfancy is associated with reduced cardiovascular, respiratory,pancreatic and kidney development and function, which increase therisk of illness and disability in adulthood, (WHO 2003). Earlyidentification, diagnosis and treatment of conditions such as inaudiology services can result in more positive outcomes in themedium and longer term.

Many of the causes of morbidity and mortality in children relateto preventable causes such as infectious diseases, certaincongenital abnormalities (e.g. neural tube defects) and injuriesand poisonings. Immunisation uptake is considered to be a goodmorbidity proxy - yet immunisation uptake in Ireland is wellbelow target rates and a social class gradient is clear, (in Burke,S et al 2004).

In Ireland approximately half of all pregnancies are unplanned,(Kiely 2004). This raises particular challenges in relation toeducation and other prevention campaigns aimed at women of childbearing age. For example, while there is general awareness of thebenefits of folic acid supplementation, the majority of women arenot taking it at the time of conception. Providing children with agood start in life means supporting mothers and care givers and thepositive health impact of early development and education lasts alifetime.

The Evidence:

Experiences from conception to age 6 have the most important influence of any time in the life cycle on the connecting and sculpting of the brain''s neurons. Positive stimulation early in life improves learning, behaviour and health into adult life, (Health Canada 1999).
Investment in the health of mothers and children has a double advantage in improving early life status and influencing life trajectory opportunities, (in Burke, S et al 2004).
There is a well documented and established relationship between increased folic acid intake and a decreased risk of neural tube defects (NTD) in infancy, (Kiely 2004).
While we have seen a reduction of the incidence of NTD in Ireland in recent years, compared to other European countries we still have a high incidence of occurrence, (Kiely 2004)
Tobacco, alcohol and other drug use during pregnancy can lead to poor foetal development and poor birth outcomes, including low birth weight and foetal alcohol syndrome, (Health Canada 1999).
Smoking during pregnancy can impact on foetal growth and is associated with adverse pregnancy outcomes, including low birth weight, (Kiely 2004).
The incidence of asthma is higher among children whose parents smoke and research has shown that parental smoking increases the risk of sudden infant death, (Kiely 2004).
Infants and children who suffer from abuse are at a higher risk for injuries, a number of behavioural social and cognitive problems later in life, and death, (Health Canada 1999).
Research shows a strong relationship between income level of the mother and the baby''s birth weight, (Health Canada 2004).
Low birth weight has links with problems during child- hood and into adulthood, (HealthCanada 2004).
Low birth weight not only increases the risk of ill health or death in the first year oflife, but is also associated with the development of heart disease,diabetes and high blood pressure later in life, (Burke, S et al2004).
Parental deprivation (characterised by poverty, poor diet, smoking, substance abuse) canlead to poor foetal growth and impaired cardiovascular, respiratoryand kidney development.

Policy Recommendations:

Increased and earlier screening, detection and intervention programmes contribute to prevention of conditions and positive health and financial outcomes for all.
Develop improved preventative health care (including health education and care facilities) before the first pregnancy.
Continued promotion of folic acid intake among all women of child-bearing age.
Examination and development of other methods of folic acid intake promotion, particularly for hard to reach groups, e.g. disadvantaged young women, ethnic minorities and young women with disabilities.
Provide improved pre and post-natal care for mothers and babies.
Increase Child Allowance as a direct universal financial intervention for mothers and children.
Increase the general level of and access to education, to improve the health of mothers and babies in the long run.
Strategic Task Force on Alcohol to address the issue of alcohol related harm to the foetus and developing child.

Unemployment, Employment and Working Conditions

In general, having a job is better for your health than nothaving a job. Unemployment puts health at risk, and the risk ishigher in areas and among groups where rates of unemployment arehigh. Even after allowing for other factors, unemployed people andtheir families suffer a substantially higher risk of illness andpremature death. The health effects of unemployment are linked toboth its psychological consequences and the financial problems itbrings, especially debt. This is of particular relevance to thedisability sector. We know that at 70%, people with disabilitiesendure substantially higher rates of unemployment compared to thegeneral population. Such employment exclusion, combined withexperiences of poverty and discrimination, has significantimplications for the health and wellbeing of people withdisabilities, (Burke, S et al 2004).

The situation is, however, a little more complicated than that.Job insecurity, along with underemployment, low decision makingauthority, stressful and dangerous working environments areassociated with poorer health. Merely having a job will not alwaysprotect physical and mental health; job design and quality is alsoimportant.

The Institute of Public Health in Ireland published a Review ofthe Health Impacts of Employment in March 2005 which outlined thevaried and intrinsic ways in which employment can affect health. Itconcluded that;

''The material wellbeing and sense of purpose that a job provides are beneficial to health… .however some types of work are healthier than others. Stressful working conditions, bullying, harassment and low pay are all detrimental to health… .and the disruption of work/life balance through long or irregular working hours and stressful commuting is also unhealthy'', (p16).

The Evidence:

High levels of unemployment and economic instability in a society can cause significant mental health
problems and adverse effects on unemployed people, their families and their communities, (Canadian Institute of Health Information 2004).
Lack of control over one''s work is particularly related to an increased risk of low back pain, sickness absence and cardiovascular disease, (WHO 2003).
Between 70% and 80% of people with disabilities are unemployed compared to around 5% of the general population.
Conditions at work, both physical and psychosocial can have a profound effect on people''s health and wellbeing, (Health Canada 1999).
In Ireland work related accidents and diseases are the main reasons for impairments and disabilities for people aged 45 to 54, (in Doyle et al 2005).
Having too much work, having responsibility for others at work and the physical working environment are important causes of stress in Ireland, (in Doyle et al 2005).
Many people have negative preconceptions about the ability of people with disabilities to be productive in the workplace and this can lower advancement opportunities and self-esteem, (Doyle et al 2005).
The greater the level of control over the work environment, the better someone''s health is likely to be, (Doyle et al 2005).

Policy Recommendations

Employment Policy should have as its goals:
- to prevent unemployment and job insecurity,
- to reduce the hardship associated with unemployment and
- to restore people to secure jobs.
There is a need to further develop training and employment opportunities in both the public and private sector for people with disabilities.
Tax relief, employment grants and other financial incentives to be provided to employers to increase the participation of people with a disability in the workforce.
The 3% target (of employment of people with disabilities) within the public sector needs greater monitoring and adherence.
All workers should be protected by minimum income guarantees, minimum wages legislation and access to services.
To reduce musculoskeletal disorders workplaces must be ergonomically designed.
There is an ongoing need to protect people from exposure to toxic materials at work, by increased adherence and enforcement of Health and Safety and other worker protection legislation, including the workplace smoking ban.
Workplace health protection should encompass legal aspects, including health and safety legislation and powers of inspection, and workplace health initiatives such as employee assistance programmes and work/ life balance programmes.
Limitations on working hours must be enforced as a matter of priority.
Appropriate involvement in decision-making benefits employees at all levels in an organisation.
Good management involves ensuring appropriate rewards - financial, status and self-esteem - with a subsequent positive health impact for all employees.

Stress

The relationship between physical and emotional health is welldocumented and this link is generally accepted by all exponents ofan holistic understanding and definition of health. Positive mentaland emotional health contributes to physical health and wellbeing. Stressful circumstances,leading to feelings of worry, anxiousness and inability to cope,are damaging to health and may lead to illness and prematuredeath.

The reality of dealing with a disability, either from birth oracquired, can be a particular cause of stress. This additionalstress affects not only the person with the disability but alsotheir partner, parents, wider family members and friends. Carers,in particular family carers, play a vital role in providingessential personal support services to people with disabilities.This is often carried out under extremely time consuming,physically demanding and stressful circumstances. There is theanxiety and worry caused by the financial, social and practicaldifficulties experienced due to disability. As a result increasedstress is a particular outcome and cause of ill health for somepeople with disabilities and their families.

The Evidence:

Long-term anxiety, insecurity, low self-esteem, social isolation and lack of control over home and work life, have powerful effects on health. Such psychosocial risks accumulate over the lifetime and increase the chances of poor mental health and premature death.
Long-term effects of stress contribute to a wide range of conditions including infections, diabetes, high blood pressure, cardiovascular disease, depression and aggression, (WHO 2003).
People experiencing poverty, including people with disabilities, report higher levels of mental illness and stress, and lower levels of satisfaction with life than the better off, (Combat Poverty Agency, 2004).

Policy Recommendations:

Social policy needs to address both psychosocial and material needs, as both are major causes of stress.
In association with the medical response to treating stress, more attention should be focused upstream on reducing the major causes of chronic stress (insecurity, low self-esteem, working environment, poverty etc.).
Increased financial and other support systems for carers as an acknowledgement of the vital role this group provides in responding to the care needs of people with disabilities.

Health Services

While we know that health services are not the only, or indeed,the main cause of health inequalities, we also know that healthservices are very important for people who are sick. This oftenincludes children, women of child-bearing age, those with chronicillnesses and disabilities and older people, (Public HealthAlliance Ireland 2004).

The underlying principles, design and delivery of healthservices contribute positively or negatively to people''sgeneral health and wellbeing. When centred on disease prevention,the promotion and maintenance of health and the restoration ofhealth functioning, health and social service systems cancontribute immensely to health. This concept permeates currentinternational and national health policy. The establishment anddevelopment of a Population Health approach underlies the currentNational Health Strategy and the ongoing Health Service ReformProgramme.

The Evidence:

Disease and injury prevention activities in areas such as immunisation and the use of mammography are showing positive results, (Health Canada 1999).
There is traditionally no planning for, or inclusion of, people with disabilities in programmes and subsequently very low take up rates of screening and other health protection initiatives.
Only 19% of women with learning disabilities are likely to undergo cervical smear test compared to 77% of the general population, (Djuretic et al 1999).
At 33%, women with learning disabilities are much less likely to engage in breast cancer examinations or receive invitations to mammography than the general population, (Davies & Duff 2001).
Within Ireland poorer people in the population experience poorer health and have less access to health services, (Burke, S et al 2004).

Policy Recommendations:

The Health Service Executive in partnership with the Department of Health and Children, the voluntary disability sector and other stakeholders should develop as a priority a comprehensive, targeted, National Population Health Strategy.
A National Assessment of the Health Needs of People with Disabilities should be undertaken to compile baseline data. This data will determine needs, priorities and targets for the planning and development of all health services for people with disabilities.
All health screening and protection initiatives (e.g. cancer screening programmes) be made available and accessible to people with disabilities including those in all residential settings.
Population Health programmes and interventions need to be specifically targeted and delivered in partnership with disability organisations if take-up is to increase past its current unacceptably low levels.

Physical Environment

The physical environment is an important determinant of health.At certain levels of exposure contaminants in our air, water, foodand soil can cause a variety of adverse health effects, includingcancer, birth defects, respiratory and gastrointestinal ailments. In the built environment housing,air quality and design of communities and transport systems cansignificantly influence our health and wellbeing, (Public HealthAgency of Canada, 2005).

The physical environment includes where people live and areaccommodated. While housing for people with disabilities is not thefocus of this Paper, as a determinant in its own right it requiresmentioning. There is clear evidence that poor housing andaccommodation, such as cold, damp or poorly designed homes hasadverse effects on the health of people living in them. Coldambient temperature, with inadequate heating and insulation,dampness with condensation, and mould all contribute to illness anddeaths from hypothermia, respiratory illness and ischaemic heartdisease, (in Burke, S et al 2004). These living conditions are areality for some people with disabilities in Ireland. For furtherdiscussion and particular recommendations see DFI''s Programmefor Local Government 2004 entitled; ''Housing - TheVital Element''.

The physical environment is also of particular relevance topeople with disabilities, especially in the areas of accessibilityand safety. Physical access remains a major obstacle to the abilityof people with physical and sensory disabilities to live in, andcontribute, to their own communities. Lack of accessible publictransport continues to be a major impediment to both the social andeconomic advancement, and subsequently the health of people withdisabilities. It is therefore vital to ensure that everyone canmake full use of the buildings and environments they live in, workin and visit. Availability and accessibility of communication andinformation systems for people with disabilities is vital,particularly given the non-stop technical advances in this field.It holds boundless opportunities for people with disabilities, ifharnessed and developed, for the further inclusion not exclusion ofthis population group.

In terms of the prevention of disabling conditions the physicalenvironment, socio-cultural influences and individual behaviour choices combine to result in increasedincidences of accidents and injuries. Nowhere is this more evidentthan in the annual toll of road traffic accidents in Ireland andthe subsequent acquired brain and spinal injuries experienced bymany of the survivors. This holds particular resonance for thoseaged under twenty-five years of age. Cardiovascular disease andcancer are by far the most important causes of morbidity andmortality in the population as a whole. However, for those agedunder twenty-five years, accidents and unintentional injuries arethe commonest cause of death and illness in this group, (Kiely2004). Much of this is preventable. According to the NationalSafety Council, the main causes of death and injury on Irish roadsremain excessive or inappropriate speed, drink driving, non wearingof seat belts, driver fatigue or a combination of these factors.Given that deaths are only part of the problem, since acute andchronic injuries leave a legacy of disability and personal andfamily disruption, accident prevention has the potential tosignificantly impact on public health, (Kiely 2004). It is obviousfrom this analysis that many acquired disabilities, especiallythose caused by road traffic accidents, are preventable.

The Evidence:

The prevalence of childhood asthma (which is highly sensitive to airborne contaminants) has increased sharply over the last 20 years among the 0 to 5 year age group, (Health Canada 1999).
Exposure to Environmental Tobacco Smoke (ETS) has a well accepted negative impact on health, most notably cardiovascular and cancer rates.
Research indicates that lung cancer risks from ETS are greater than the risks from the hazardous air pollutants from all regulated industrial emissions combined, (Canadian Institute of Health Information 2004)
In Ireland approximately 1 2,000 people are injured in road crashes annually, 1,500 of whom are seriously injured, (National Safety Council 2004)
Of 55 drivers, pedestrians and passengers killed in the North East between 2001 and 2002, 22 or 40% had alcohol detected in blood samples, (Bedford 2004).
It is estimated that alcohol is associated with at least 30% of all Irish road accidents, (Kiely 2004).
In the built environment, factors associated with housing, indoor air quality and the design of communities and transportation can significantly influence our physical and psychological wellbeing, (Public Health Agency of Canada 2005).

Policy Recommendations:

The Departments of Health and Children and Environment, Heritage and Local Government to develop a joint national accommodation and support strategy for people with disabilities.
The principle of Universal Design is the target in relation to the built environment.
Local Authorities should encourage and require, by legal means if necessary, that all building developments, as a minimum, comply with Part M of the Building Regulations.
Local Authorities should employ an Access Officer to inspect planning applications and building developments.
All Local Authorities to implement and deliver on the commitments of the Barcelona Declaration.
The Department of the Environment, Heritage and Local Government should ''design in'' the issues and needs of people with disabilities in line with the Government''s commitments in the National Disability Strategy and to Mainstreaming, particularly with regard to the housing and accommodation needs of people with disabilities.
The six Government Departments mandated to implement the National Disability Strategy through the development of Sectoral Plans to develop a partnership approach to the development, implementation and monitoring of these initiatives.
Government agencies and partner groups to continue the promotion and enforcement of the Workplace Tobacco Ban.
There should be continued improvement and development of an accessible public transport network, to include rural and other hard to reach communities
Increased implementation and enforcement of the penalty points system as a proven road safety measure.
Reduction of the blood alcohol concentration level to zero in line with that of most other EU countries
Continued promotion of designated driver schemes such as free soft drinks, through licensed premises.

CONCLUSION

Some of the factors which influence health are fixed and areoutside our direct control, such as age and genetics. However, itis now widely accepted that many other factors, includingsocio-economic and environmental conditions are also key indetermining levels of health and wellbeing. These determinants havea direct impact of the health and social gain of people withdisabilities, who as a population group are not immune, but indeedmore susceptible to conditions such as poverty and socialexclusion, resulting in negative impacts on their health andwellbeing.

As social beings, we need not only good material conditions, butfrom early childhood onwards we need to feel valued andappreciated. We need friends, we need more sociable societies, weneed to feel useful and we need to exercise a significant degree ofcontrol over meaningful work. Without these we become more prone todepression, drug use, anxiety, hostility and feelings ofhopelessness, which all rebound on health. However importantindividual genetic susceptibilities to disease may be, the commoncauses of the ill health that affect populations are environmental,(WHO, 2004).

This Paper has set out DFI''s current position in relationto the Population Health concept, with particular reference to itsimportance to people with disabilities. It makes very specificrecommendations for action, which if adopted would not only improvethe lives of people with disabilities, but should also havepositive outcomes in relation to many preventable conditions. Theconcept represents a shift in thinking from the purely curative,medical approach to health policy and practice to a more holistic,preventative view encompassing the many varying factors whichinfluence why some people experience good health and others donot.

As a result the challenge is set.Planning and working towards good health for all is not merely theresponsibility of the health sector, rather it falls within theremit of all offices of State and Government. It demandsmainstreaming in action and cross-departmental workingpartnerships. It requires that all public policy is health anddisability proofed to ensure a positive impact on health and socialinclusion is experienced by the whole population, and not merelythe advantaged few.

We know that good societal planning, design and practice is ofbenefit to all members of that society. In this regard we note therecent commitment of the Taoiseach * to the amendment of cabinetprocedures to ensure that all policy and legislation coming tocabinet is disability proofed in the future. This positive actionmeasure will target a well recognised disadvantaged group, peoplewith disabilities. The current National Health Strategy,''Quality and Fairness - A Health System for You'', has as its vision,

'' A health system that supports and empowers you, your family and your community to achieve your full health potential.''

It also goes on to include as an action,

''Initiatives to eliminate barriers for disadvantaged groups to achieve healthier lifestyles will be developed and expanded,'' (Action 19).

These assertions depend upon the development of a more strategic approach to health service design and delivery, an approach strong on tackling the current inequalities, which exist not only in the health care system but also within society as a whole.

Policy makers need to plan and work towards systems wherebyhousing, employment, social cohesion, child development and thephysical environment are conducive to the health of the wholepopulation. To achieve these demands, there is a need for aparticular focus on certain groups andsectors that are starting from a position of disadvantage. Amongthese are people with disabilities. It is only through investing inprogrammes and initiatives which impact upon the key determinantsfor our sector will we witness any reduction in the current levelsof health inequities and subsequent ill health which are aneveryday reality for people with disabilities.

REFERENCES

Balanda, K & Wilde, J2001. ''Inequalities in Mortality 1989 - 1998, AReport on All-Ireland Mortality Data.'' The Institute ofPublic Health, Dublin.

Doyle, C et al 2005.Health Impacts of Employment - A Review. Institute of PublicHealth in Ireland. Ireland.

Barrington, R 2004.''Poverty is Bad for Y our Health.'' Combat PovertyDiscussion Paper No 5, Dublin.

Elwan, A 1999.''Poverty and Disability - A Survey of theLiterature.'' The World Bank Social Protection Unit Paper No9932, Washington.

Bedford, D 2004.''Blood-alcohol levels in persons who died as a result of roadtraffic crashes, in Cavan, Monaghan and Louth in 2001 &2002''. North Eastern Health Board.

Health Canada 1999.''Toward a Healthy Future: Second Report on the Health ofCanadians. Federal, Provincial and Territorial Committee onPopulation Health,'' Canada.

Burke, S., Keenaghan, C.,O''Donovan, D., Quirke, B. 2004. Health in Ireland - An unequalState.Public Health AllianceIreland, Dublin.

Health Canada 2001 .''The Population Health Template: Key Elements & Actionsthat Define a Population Health Approach'', Canada.

Canadian Institute of HealthInformation 2004. ''Strategies for Population Health- Investing in the Health of Canadians,'' Canada.

Jones, L, Sidell, M, &Douglas, J 2002. ''The Challenge of Promoting Health- Exploration and Action,'' 2nd Edition. The OpenUniversity/Palgrave, Oxford.

Carvill, S 2001. Review:Sensory impairments, intellectual disability and psychiatry.Journal of Intellectual Disability Research, 45, 467-483.

Kiely, J 2004."Better Health Through Prevention", Fourth AnnualReport of the Chief Medical Officer. Department of Health andChildren, Dublin.

Davies, N., & Duff, M2001. Breast cancer screening for older women withintellectual disability living in community group homes. Journal ofIntellectual Disability Research, 45, 253-257.

National Safety Council, www.nsc.ie 2004.

O''Shea, E & Kelleher, C. ''Health Inequalities in Ireland'' in CombatPoverty Agency, Poverty Briefing Spring 2004, Dublin.

Department of Health and Children1999. The National Health Strategy, ''Quality andFairness - A Health System for You'', Dublin.

Public Health Agency of Canada, 2005.Websitewww.phac-aspc.gc.ca

Department of Health and Children 2001.''Primary Care. A NewDirection'', Dublin.

Public Health Alliance Ireland,2004. Health in Ireland - An Unequal State -Summary, Dublin.

Disability Federation of Ireland(DFI), 2004. Programme for Local Government, Housing -The Vital Element, Dublin.

WHO 1986.

''Ottawa Charter on Health Promotion. WHO Regional Officefor Europe'', Copenhagen.

WHO 2003.

Disability Federation of Ireland (DFI),2003. Pre-Budget Submission, NoSlowdown. Dublin.

''Social Determinants of Health - The SolidFacts,'' 2nd Edition. Edited by Wilkinson, R & Marmot, M.WHO Regional Office for Europe, Copenhagen.

Djuretic, T et al 1999.Concerted effort is needed to ensure these women use preventativeservices. British Medical Journal, 318, 536.

DFI - NATIONAL COUNCIL AND ASSOCIATE MEMBERSHIP 2005

Action for Mobility
AHEAD
Alzheimer Society of Ireland
Anne Sullivan Centre*
APT
Arklow Disability Action Group*
Arthritis Ireland
ASPIRE
Asthma Society of Ireland
AWARE
BIH
Housing Association
Bodywhys*
Brainwave
BRÍ
Caring and Sharing Association
Center for Independent Living
Central Remedial Clinic
Centre for Independent Living Blanchardstown*
Centre for Independent Living Carlow*
Centre for Independent Living Dublin 7*
Centre for Independent Living Galway*
Centre for Independent Living Mayo
Centre for Independent Living Offaly*
Centre for Independent Living Sligo*
Centre for Independent Living Tipperary
Centre for Independent Living Waterford*
Centre for Independent Living Wexford*
Cheeverstown House Cheshire Ireland*
Children in Hospital Ireland*
COPE Foundation
Co. Roscommon Support Group of People with Disabilities

* Associate Members.

Cystic Fibrosis Association of Ireland
DEBRA Ireland
Diabetes Federation of Ireland
Southern Regional Office*
Disabled Drivers Association
Disabled People of Clare
Doorway to Life
Down Syndrome Ireland
Dyslexia Association of Ireland
Dyspraxia Association of Ireland*
Enable Ireland
Féach *
Fibromyalgia Support Group (Midlands)*
Fighting Blindness
Focus Ireland
Freidreich''s Ataxia Society of Ireland
Galway County Association for Mentally Handicapped Children*
Genetic & Inherited Disorders Organisation
HAIL
Housing Headway Ireland
Heart Children Ireland*
Huntington''s Disease
Association of Ireland
Irish Association for Spina Bifida and Hydrocephalus
Irish Deaf Society
Irish Guide Dogs for the Blind
Irish Haemophilia Society
Irish Kidney Association
Irish Motor Neurone Disease Association
Irish Raynaud''s & Scleroderma Society
Irish Society for Autism
Irish Wheelchair Association
Jack and Jill Children''s Foundation
KARE
Leitrim Association of People with Disabilities
Lucan Disability Action Group*
Migraine Association of Ireland*
Multiple Sclerosis Society of Ireland
Muscular Dystrophy Ireland
National Association for Deaf People
National Council for the Blind of Ireland
National Federation of Arch Clubs
Neurofibromatosis Association of Ireland
Noinin Support for Autism*
North West MS Therapy Centre
Out and About Association*
Parkinsons Association of Ireland
Peacehaven Trust*
Peter Bradley Foundation*
Post Polio Support Group
Reach Ireland
Rehab Group
Royal Hospital Donnybrook
Schizophrenia Ireland
Shannon Community Workshops
Sophia Housing Association
Special Olympics Ireland
Spinal Injuries Ireland
St. Catherine''s Association
St. Gabriel''s School and Centre
St. Mary''s Hospital & Residential School
St. Michael''s House
Vantastic
Vergemount Housing Fellowship
Walkinstown Association
West Limerick Community Workshop
Western Care Association

Supporting Organisations to Enable People withDisabilities An Advocate for the Voluntary DisabilitySector

Disability Federation of Ireland (DFI)is the national support organisation and advocate for voluntarydisability organisations in Ireland who provide services to peoplewith disabilities and disabling conditions.

Hidden
Intellectual
Mental Health
Physical
Sensory
Emotional

Disability Federation of Ireland (DFI)works to ensure that Irish society is fully inclusive of peoplewith disabilities and disabling conditions so that they canexercise fully their civil, social and human rights. In pursuit ofthis vision:

DFI acts as an advocate for the voluntary disability sector
Supports organistions to further enable people with disabilities

DFI represents and supports over 150voluntary disability organisations and groups of which 72 compriseits National Council, and 25 of which are Associate Members. Alliedto this, it works with and supports over 200 organisations andgroups around the country that have a significant and growingdisability interest, mainly coming from the statutory and voluntarysectors. DFI provides:

Information
Training and Support
Organisation and Management Development
Research and Policy Development Networking
Advocacy and Representation

DFI also supports the broader voluntaryand disability sector through its representation of the disabilitystrand within the Community and Voluntary Pillar of the SocialPartnership process, as a social partner at the National Economicand Social Forum, Health Board Co-ordinating Committees and otherfora at regional, national and European level.

Disability Federation of IrelandFumbally Court, Fumbally Lane, Dublin 8 Telephone: 01 4547978 Fax:01 4547981 Email: info@disability-federation.ie Website: www.disability-federation.ie