Social Determinants of Health for Older Adults with an Intellectual Disability
People with disabilities experience poorer health than people without disabilities often due to secondary risks associated with some health conditions or impairments they experience (Emerson et al., 2015). However, people with disabilities as a group with generally low incomes and who experience discrimination also experience higher rates ot common health conditions; poorer health outcomes; and restricted access to timely effective health care (Emerson et ah, 2011; Emerson et ah, 2015). In a life course perspective, there are also cumulative effects of health inequalities that compound over time (Raphael, 2006). For people with intellectual disabilities such health inequalities begin early in their lives, and their cumulative effect and adverse health outcomes inevitably impact most heavily as they get older (Emerson, Baines, Allerton, & Welch, 2012).
Ireland: A Case Study
To illustrate the value ot social determinants ot health as a framework to better understand the contributors to the health inequalities experienced by people ageing with an intellectual disability, we will focus on Ireland as a case study, using data from the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-T1LDA). Poorer health outcomes have been identified for older people with intellectual disabilities. For example 71% people with intellectual disabilities aged 40 years and above were found to be multimorbid (i.e. having two or more chronic conditions), and this increased to 86% for those aged 65 plus. This compares with a rate ot 73% for the general Irish population of older adults (Hernandez, Reilly, & Kenny, 2019) and reports from a systematic review of prevalence studies of older adult community samples which found a median prevalence of 63% and a mode of 67% (Salive, 2013). Such data have limitations, as studies did not use the same list of chronic conditions. Nevertheless, rates are higher for people with intellectual disabilities and often at earlier ages (McCallion, Burke, et al., 2013; McCallion, Swinburne, et al., 2013; McCarron et al., 2013). For people with intellectual disabilities there is the additional challenge that as a group their relationships (unlikely to have spouses and or children), financial resources (unlikely to have jobs and savings), educational levels (most have not completed elementary education), health behaviours (physical activity and healthy eating), and access to healthcare are more likely to be impoverished (McCarron, Haigh, & McCallion, 2017). Using this model, these outcomes can be traced to structural and intermediary social determinants (within the WHO model).
At a structural level, the socio-economic positions of this population demonstrate a societal disadvantage compared to the general population. For example one-third (33%) ot older people with intellectual disabilities had no formal education at all, almost three-quarters (74%>) had not completed primary level schooling, and less than 2%> had achieve a second-level qualification (McCarron et al., 2011; McCausland, 2016). In terms of employment, just 6.6% of older adults with intellectual disabilities were in employment and 70% had never done paid work in their lives (McCausland, Carroll, McCallion, & McCarron, 2020; McCausland, McCallion, Brennan, & McCarron, 2020). And with regard to housing, just 16% were living independently or with family (McCarron, Haigh, & McCallion, 2017), while 75% had no choice in where they lived and 86% had no choice in who they lived with (McCarron et al., 2011). For people with intellectual disabilities, socio-economic positions such as these stem from social, economic, and political processes and the prevailing cultural and societal values ot Irish society over many years. This has, for example resulted in an older generation living with the historical legacy of institutional living (Health Service Executive, 2011).
With regard to the intermediary determinants of the WHO model, findings from IDS-TILDA illustrate the context in which particular health outcomes are shaped for individuals ageing with an intellectual disability including living circumstances, relationships, and social support that comprise
‘psychosocial factors’ within the framework. Statistical analysis (hierarchical ordinary least squares regression) examining the contribution ot environmental, enabling, predisposing, need and all combinations of the sets of variables conducted using the IDS-TILDA data confirmed the importance ot family contact, transportation and health care access to personal health choices for older people with intellectual disabilities (McCallion, Burke, et al., 2013; McCallion, Swinburne, et ah, 2013).