The racial/ethnic demography of disability.

In response to the growing awareness that racial/ethnic status and disability are linked, the U.S. Congress recently adopted legislation which began to address some of the issues which minorities with disabilities face. Section 21 of the 1992 Amendments to the Rehabilitation Act of 1973 called for the establishment of the Rehabilitation Cultural Diversity Initiative (RCDI). The wording of Section 21 specifically acknowledged "a changing racial profile in which one of every three Americans will be either African American, Latino, or Asian American by the year 2000" (Sec. 21. (a) (1)). In addition, "inequitable treatment of minorities" and the fact that "ethnic and racial minorities tend to have disabling conditions at a disproportionately high rate" were also acknowledged (Sec. 21 (a) (2) and (3)).

Margaret Heckler, former U.S. Secretary of Health and Human Services, succinctly caught the scope of America's disproportionate health and disability problems with the following introduction to the Report of the Secretary's Task Force on Blacks and Minority Health (1985):

There is a continuing disparity in the burden of death

and illness experienced by Blacks and other

minority Americans as compared with our nation's

population as a whole. This disparity has existed

ever since accurate federal record keeping began--more

than a generation ago. (p. ix)

The Secretary's Report (Heckler, 1985) was a landmark among government health documents because it focused on all four major minority groups (African Americans, Hispanics, Asians and Pacific Islanders, and Native Americans), was prepared under the direction of the National Institutes of Health, and led to the creation of the Office of Minority Health.

The disparity in disability rates between nonminorities and racial/ethnic minorities will place greater demands upon rehabilitation service providers to respond to the needs of underserved minority persons with disabilities (Alston & Mngadi, 1992; Asbury, Walker, Maholmes, Rackley, & White, 1991; Bowe, 1981, 1984, 1985; Hayes-Bautista, 1992; LaPlante, 1991, 1993; Thornhill & HoSang, 1988; U.S. Bureau of the Census, 1992; U.S. Department of Commerce, 1993a, 1993b, 1993c, 1993d, 1993e, 1993f; U.S. Department of Health and Human Services, 1985, 1991; Walker, Asbury, Maholmes, & Rackley, 1991). Rehabilitation has long been concerned with both disability prevention and disability management of individuals and the groups to which they belong.

This article discusses the link between the disproportionately higher disability rates of racial/ethnic minorities and five societal conditions: (a) low income and poverty; (b) employment in dangerous jobs; (c) lack of health insurance; (d) low educational attainment; and (e) faulty testing and diagnostic procedures. Evidence that documents these conditions is presented and the ramifications of these conditions for rehabilitation workers are discussed. Recommendations that address the challenges of these racial/ethnic demographics of disability are provided.

Data Sources on Disability Rates

One must be cautious in making generalizations about America's racial/ethnic populations because of the great differences within and among these minority groups. In a general sense, however, the assertion that disability rates for racial/ethnic minorities are disproportionately higher than those of white Americans is an accurate statement (Bowe, 1984; Hayes-Bautista, 1992; Thornhill & HoSang, 1988; U.S. Department of Education NIDRR, 1992; U.S. Department of Health and Human Services, 1985a, 1985b, 1991), except for most Asian and Pacific Islander groups (U.S. Bureau of the Census, 1992). As noted by Ficke (1992), however, clear linkages of causal attribution with these broad conditions are impossible to make at this time.

One factor which makes it difficult to draw conclusions about disability rates is the differences in the definition of disability. There is no uniform definition of disability since government agencies define disability differently (Zola, 1993). Further clouding the picture, some health demographers do not define disability as completely as do rehabilitation demographers. For example, while rehabilitation demographers define alcohol abuse and learning disabilities as disabilities, health demographers do not. Finally, rehabilitation demographers are also concerned about health conditions such as obesity, diabetes, and hypertension, which, if not defined as disabilities, are disposing factors that lead to disability. It is safe to assume that these narrow definitions and lack of consistency among agencies and different demographic methods results in underestimations and underreporting of the prevalence of disability.

As Thompson-Hoffman and Storck (1991) have pointed out, gathering accurate data about disability rates is an expensive undertaking and is never totally accurate. While notable gaps in the data exist, the most reliable sources of information are the large federally sponsored surveys conducted by the Census Bureau: the Current Population Survey, Survey of Income and Program Participation, and the National Health Interview Survey.

It should be noted that statistics may not accurately reflect the total disability reality due to the fact that disability rates increase with age. As a general rule, American minorities tend to be young (due to immigration and high birth rates) while white Americans tend to be aging. Simply thinking in terms of age categories, we would expect to find fewer disabilities among minorities because of their youthfulness. The opposite is the case, however, and this further underscores the disproportionate disability rates of minorities.

In spite of occasional higher rates of health and mental health problems, most Asians and Pacific Islanders do not fit the disability or socioeconomic profile of other minorities (U.S. Department of Commerce, 1993). Indeed, as a group, Asians and Pacific Islanders have fewer disabilities and report higher educational and socioeconomic attainment than do other minorities. An exception to the general success of Asians and Pacific Islanders is that of the recent immigrants (Hmongs, Laotians, Vietnamese, and Cambodians) who have not yet attained as favorable a position in society as have others of Asian background (U.S. Bureau of the Census, 1992).

Societal Conditions Related to Disability

Reviewing the survey data gathered since the mid-1960s on the prevalence of work disability, Thompson-Hoffman and Storck (1991) concluded that there are "four [sic] correlates of work disability: age, race, income, education, labor-force participation, and marital status has [sic] been highly consistent over time and across surveys" (p. 234).

Ficke (1992) is in general agreement with the two foregoing authors as evidenced by his statement:

According to the Bureau of the Census, those

factors having the strongest association with

disability are (1) age, (2) education, (3) income,

(4) race and ethnicity, (5) living arrangements,

and (6) gender. It is important to note that the issue

of causality between those demographic factors and

disability often cannot be determined at all from the

data. (p. 13)

Pope and Tarlov (1991) add support to those who see a link between minority status and disability. In their "executive summary" of a study sponsored by the Centers for Disease Control and the Institute of Medicine and approved by the National Research Council, they highlighted six general statements, one of which was "Disabilities are disproportionately represented among minorities, the elderly, and lower socioeconomic populations" (p. 1).

I. Low Income and Poverty

"For centuries, a vast body of evidence has shown that those in lower socioeconomic classes have higher rates of morbidity, disability, and mortality" (Syme & Berkman, 1981, p. 35). Ethnic minorities are overrepresented in lower socioeconomic statuses. Persons with low income are at a disadvantage in preventing the onset of disability and in ameliorating its effects after acquiring the disability (Alston & Mngadi, 1992; Thornhill & HoSang, 1988). They have less wealth at their disposal and are less able to secure either health care or job retraining. Persons with disabilities thus enter a cycle of low income, lack of financial resources for further education, poor health, and unemployment. This cycle is more pernicious for persons of racial/ethnic minority status (del Pinal, 1993).

Upon reviewing median family income statistics, wide variation within racial/ethnic groups is evident. Within the Asian group, for example, median family income varied from the highest group (Japanese) with an income of $51,550 to the lowest (Hmong) with an income of $14,327. Great differences were also shown in the range of median family income among Hispanic subgroups which varied from a high of $36,680 for Spaniards to a low of $21,941 for Puerto Ricans. An astounding 51% of the 437,431 American Indians living on reservations and tract lands were living below the poverty level in 1989! Aleuts, as a group, fared better, with 13.2% of the persons in that group below the poverty level.

McNeil (1993) reported that "persons with low incomes are more likely to have disabilities than persons with high incomes" (p. 11). He calculated a ratio of family income to a threshold of poverty for a family of specified size and composition and found a consistent relationship between low income status and severe disability across a range of income levels among persons 15 to 64 years of age as well as for persons 65 years old and older.

Bowe (1985) commented about African American disabilities in the following manner:

Why does disability occur so much more often

among blacks than among whites in the working-age

population? The more likely reasons are

occupation and poverty status. Blacks are more

likely than whites to perform physically demanding

work that may lead to disability; similarly conditions

that in whites may be corrected by medical means

may among blacks persist until they become

permanent disabilities. (p. 4)

II. Employment in Physically Dangerous Jobs

This nation has a history of discrimination in the work place (including the practice of slavery) which dates back three centuries. Even after the abolition of slavery, minorities and immigrants were more likely to find that menial and more dangerous jobs were the ones open to them. Olsen (1982) chronicled the more recent working conditions of migrant Mexican American workers, who experienced the effects of poor housing, poor nutrition, and limited availability or accessibility of medical care that accompanied the migrant lifestyle. Consistent with Olsen's observations is the fact that the accidental death rates of migrant farm workers is four times the national average (Olsen, 1982).

It should not be surprising, then, that minorities continue to experience higher unemployment rates and lower job status. U.S. Census Bureau reports indicate that job status and participation in the U.S. labor force are generally less favorable for persons of minority status. Persons of minority background tend to be over-represented in the job category "operators, fabricators, and laborers." This category includes such occupations as machine operators, assembly line workers, truck drivers, laborers, and material handlers. Minority persons are also more likely to work in "service occupations" including such jobs as food service work, building maintenance and cleaning, protective service, and security work. They are less likely to work in occupations which are categorized by the Census Bureau as "managerial and professional specialties occupations." These categories include work as executives, administrators, engineers, health specialists, and teachers (U.S. Department of Health and Human Services, 1991). The more physically demanding and higher-risk jobs which minority persons tend to hold make them more vulnerable to higher disability rates.

III. Lack of Health Insurance Coverage

A variety of sources indicates that non-white groups are less likely to have health insurance than whites (Ginzberg, 1992; Himmelstein, Woolhandler, & Wolfe, 1992). George Lundberg (cited in Zaldivar, 1991), editor-in-chief of the Journal of the American Medical Association, editorialized that

It is not a coincidence that the United States of

America and the Republic of South Africa--the only

two developed, industrialized countries that do not

have a national health policy--have substantial

numbers of underserved people who are different

ethnically from the controlling group. (p. 1)

Lundberg blamed "long-standing, systematic, institutionalized racial discrimination" (p. 1) against Blacks and Hispanics for this inequitable distribution of private or public health insurance. Only 58% of Blacks, 54% of Mexican Americans, and 51% of Puerto Ricans are covered, whereas 81% of whites have health insurance (Zaldivar, 1991). Among the reasons most often given for the racial disparity are higher unemployment among minorities and the fact that minorities are also clustered in low-paying service jobs and in jobs such as farm workers where insurance coverage is less common (Trevino, Moyer, Valdez, & Stroup-Benham, 1992).

LaPlante (1993) reported that "some 4.1 million Americans with disabilities have no health insurance, public or private, out of a total uninsured population of 35.3 million adults and children" (p. 48). By means of a regression analysis, he identified the characteristics that are associated with being uninsured. These sociodemographic characteristics are being male, being Black or races other than white, being Hispanic, reporting low education, being unmarried, and reporting good to poor health, poverty, and unemployment. LaPlante (1993) also examined the trends in insurance coverage from 1984 to 1989 and concluded that the rate of uninsurance,among children and adults increased by some 5-6% over this time period. Himmelstein et al. (1992) also reported a trend toward lower rates of insurance coverage in recent years.

Persons who have no health insurance contact physicians less often than those who have insurance (Council on Scientific Affairs, 1991). This is true for those who have no disabilities as well as those who have disabilities. LaPlante (1993) cautioned that

The lower utilization of the uninsured with severe

disabilities may mean they forego physician services

that may be necessary for the maintenance of

their health, potentially increasing the chance of

their condition worsening or developing secondary

conditions and increasing their disability. (p. 39)

IV. Low Educational Attainment

Upward social mobility and success in American society have been closely associated with educational attainment. Education serves as a buffer against disability because it plays both a preventive and rehabilitative role (Yelin, 1992). It is a preventive measure because those who are well educated are less likely to work in physically demanding and dangerous jobs, thus reducing the risk of disabling injuries (Bowe,1981). McNeil (1993) reported a very strong association" between years of school completed and the likelihood of having a disability. In a sample of 30,000 interviewees contacted in the 1990 and 1991 Federal Survey of Income and Program Participation, he found that the proportion of those aged 25 to 64 with a severe disability was 22.8% among persons who have not completed high school, but only 3.2% among college graduates.

African Americans, Hispanics, and Native Americans are consistently found to lag behind the general U.S. population in the number of years of school completed (Hodgkinson, 1985, 1992; Kominski & Adams, 1994a, 1994b; Levine, 1993; Montgomery, 1994; U.S. Department of Commerce, 1993a, 1993b, 1993c, 1993d, 1993f). This is also true of some subgroups of Asians and Pacific Islanders (U.S. Bureau of the Census, 1992).

Racial/ethnic groups are by no means monolithic, homogeneous groups. To the contrary, within each racial/ethnic category there is a wide variation in characteristics. This is particularly true of the Hispanic, Asian and Pacific Islander, and Native American, Eskimo, and Aleut groups (U.S. Department of Commerce, 1993c, 1993e, 1993f). Thus, while Asians as a group show high rates of high school graduation (77.5%) (U.S. Department of Commerce, 1993b), this does not hold true for the Asian sub-groups of Hmongs, Laotians, and Cambodians. Their 1990 high school completion rates were about 35% for men and about 25% for women, some 40-50% lower than the Asian group as a whole. Similarly, the percentage of Native Americans who completed high school varied across reservations by some 30%. Persons of Hispanic origin showed similar variation in educational attainment, with those of Mexican and Central American origin attaining a 30% lower high school graduation rate than those of South American origin (del Pinal, 1993; Paisano, 1993a, 1993b). The condition of the less educated person is illustrated by Bowe's (1981) statement that "fully 31% of those with less than an 8th grade education have work disabilities compared to 9% of those who have completed high school and 4.5% of those who have completed college" (p. 5).

V. Faulty and Inaccurate Testing and Assessment

Shapiro, Loeb, and Bowermeister (1993), in the lead article of a recent edition of U.S. News and World Report magazine, reported inequities within the education system which create barriers for minority children with disabilities. While citations from the popular press are rarely relied upon in professional journals, the article referred to here merits inclusion because it is based on a careful and complete analysis. Its authors examined records of 23,106 discrimination cases filed with the U.S. Department of Education Office of Civil Rights and traveled to eight states where they conducted more than 250 interviews with students, parents, teachers, administrators, researchers, and academics. At the conclusion of a 5-month review of current policies and practices, they reported "troubling anomalies" in the different rates of classification of students in special education programs. Based on an analysis of records in the U.S. Department of Education, they found that more than twice as many blacks as whites were classified as mentally retarded. Table 1 shows the percentages of four selected disabilities among African Americans, whites, and Hispanics as diagnosed by public school officials across the United States.

Table 1

Percentages of Disabilities by Racial/Ethnic Group (Children in Special Education Programs)

                           Racial/Ethnic Group
Disability              African    White   Hispanic
                        American

Mental retardation        26%       11%      18%
Learning disability       43%       51%      55%
Emotional disturbance      8%        8%       4%
Speech impairment         23%       30%      23%

The authors found that "in 39 states...black students were overrepresented in special education programs, compared with their percentage of the overall population" (p.48). In Alaska, only 3% of all special education students were classified as retarded; yet, in Alabama, 23% were considered retarded. The authors concluded that the differential rates of diagnosis were due to inexact and subjective testing and classification procedures, varying funding policies which reimburse school districts at a higher level for children enrolled in special education than for those enrolled in regular education classrooms, and lack of oversight by federal program administrators.

Some of the inequity that minorities with disabilities face in the American educational system can be attributed to faulty diagnostic testing and assessment procedures (Hamayan & Damico, 1991; Harry, 1992). Use of tests in English as a means of defining a disability must be undertaken with caution, particularly when the person being tested is not fluent in English. Many persons with minority background were not raised with English as their first language and, hence, are at a disadvantage in such testing procedures. Lack of English ability can be mistaken for mental retardation or learning disabilities. Figueroa (1989) was particularly outspoken in his concern about the use of psychological tests with persons of minority status, listing 47 different problem areas in the use of such tests. Included in these knowledge gaps were issues related to language, culture, and the emotional impact of such tests. Others (Anastasi, 1988; Arnold & Orozco, 1989; Butcher & Garcia, 1978; Goldstein & Hersen, 1990; Keller, Deneen, & Magallan, 1991; Smart & Smart, 1993) have also listed numerous cautions in the use of tests in the diagnosis of disability with various racial and ethnic groups. Thus, disability is not caused by disease and injury alone, but is also related to the way in which institutions define and diagnose disability.

Recommendations

A greater emphasis on research related to treatment and prevention of disabilities in minority populations is recommended. Unraveling the complex relationship between social conditions and minority status is an immense task. Nevertheless, research techniques which can accommodate multiple variables that are sensitive to racial/ethnic status should be identified and used to study the relationship between disability rates, racial/ethnic status, and the societal conditions discussed in this article. The research methodologies that were discussed by Adler et al. (1994) in their analysis of socioeconomic status and health hold promise as techniques that may help in understanding the link between racial/ethnic status and disability. Included in these methodologies are the use of tree-structured regression and "grade of membership" analyses. Tree-structured regression techniques partition populations into subgroups and then identify different paths to given outcomes. Their strength lies in their ability to analyze numerous, complex, interrelated variables.

Likewise, "grade of membership" analysis is able to accommodate large numbers of variables by developing "ideal descriptions," either theoretically or empirically, of various classes of individuals. This technique becomes more precise with the addition of more and more variables and may be suited to an empirical analysis of the complex variables listed in this article. An example of this technique is the study done by Berkman, Singer, and Manton (1989), who compared how Blacks and whites fit different profiles of health status. As Adler et al. (1994) stated,1

Ideally, we would assess variables that characterize

various aspects of SES, including education, income,

and occupational status; individual-level variables,

such, as depression, hostility, sense of control, and

health behaviors; and social-level variables, such as

characteristics of one's residential neighborhood

(e.g., percentage of poverty, air quality), communities

(health access, community norms regarding

health-relevant behaviors), and work environments.

(p. 22)

Fawcett (1990) identified ten "emerging standards" for community research and action which are recommended as values for guiding research into issues surrounding the etiology and treatment of minority disabilities. His standards include such principles as collaboration, empowerment, advocacy, and respect for the values of those who are being studied. These guidelines are endorsed because they express an attitude of respect for racial/ethnic minorities with disabilities.

Conclusion

The evidence is clear that rehabilitation workers will face an increased demand for culturally sensitive rehabilitation services. Indeed, there is a danger that the need for such services far outstrips the available resources. The data presented in this article clearly indicate a higher rate of disability among ethnic/racial minorities in the United States. The combination of (a) higher disability rates, (b) a growing absolute number of people of racial/ethnic minority origins, and (c) the younger average age of minorities who are thus of working age and hence eligible for rehabilitation services are likely to result in increasing demands on rehabilitation agencies. Root social causes of higher minority disability rates must be more clearly identified and studied so that prevention and treatment programs can be accelerated. Rehabilitation service workers, educators, and administrators need to become more informed about these socioeconomic conditions and their impact on the disability rates of minority clients. Social conditions linked to disability must be more fully understood if culturally sensitive and effective services are to be provided.

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