What does health and wellbeing mean in the context of disability?

In this article, Dr. Sarah Wallace (LSHTM) introduces the World Health Organisation’s definition of health and wellbeing, and describes what this means in the context of disability.

Defining Health

The World Health Organisation’s founding constitution in 1948 defined health as

“A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.”¹

At the time this was ground-breaking because of the inclusion of mental and social components of health in the definition. Secondly, the positive description of health as wellbeing, rather than as an absence of disease, was well received.²

It is all too easy to think of poor health in relation to specific diseases, and to forget that disease is only one aspect of wellbeing. Considering health as wellbeing requires a more holistic view of medicine and health services than simply the science of treating disease.

The definition provides a useful framework for thinking about health and wellbeing in these three domains, but it is important to remember that they are also inter-related, as shown below. For example, think of ways in which social factors such as loss of employment or bereavement can impact negatively on a person’s physical and mental wellbeing.

Figure 1: Pictoral representation of WHO’s definition of health

However there have also been criticisms of this definition.² Can anyone ever be said to be in complete health? Does using this definition effectively mean that it is impossible to achieve complete health if you have an impairment for which there is no treatment? It is also a difficult concept to measure, particularly across different cultures.

While this provides much food for thought, the WHO definition of health is the most widely used and we will use this when we consider health and wellbeing in the context of disability.

Health, Wellbeing and Disability

It is important to consider what “complete physical, mental and social wellbeing” means for people with disabilities, and potential challenges that people with disabilities may face in achieving this.

The 2016 National Survey of Disability in Guatemala, led by ICED, showed that people with disabilities reported lower quality of life outcomes compared to people without disabilities, including in physical and psychological health domains, and in terms of social relationships.³

A number of studies have also found that people with disabilities are often at increased risk of physical health problems. In the Guatemala study for example, 47% of people with disabilities reported having experienced a serious health problem in the past year, compared to 23% of those without disabilities.³

People with disabilities may be at greater risk of poor general health and wellbeing, and may face greater barriers to accessing health services than people without disabilities. They may also have additional health or wellbeing needs specific to their impairment or underlying health condition.

It is important to remember however, that there are a very wide range of causes of disability: some individuals may have high physical health and healthcare needs, and others may experience a very high standard of physical health.⁴ Disability may also be primarily mental health related e.g. related to severe depression and intellectual disabilities, or in relation to a physical impairment or health condition that impacts adversely on the mental wellbeing of an individual.⁶

In the foreword to the World Report on Disability, Professor Stephen Hawking reflects on social wellbeing in terms of how his experience of disability has been very different from “the majority of people with disabilities in the world [who] have an extremely difficult time with everyday survival, let alone productive employment and personal fulfilment”.⁴

Disability may impact on social wellbeing, including family life, access to employment and education, and on socioeconomic status. In North West Cameroon for example, adults with disabilities were 3.6 times less likely to have been married and children 20 times less likely to attend school.⁷ In India adults with disabilities were much less likely to work (44% vs 80%).⁸ There is evidence of a significant association between disability and economic poverty, which is apparent across ages, regions and disability types.⁹

Conclusion: Putting it into practice

A holistic approach to health should lead to improved provision of health services and care for people with disabilities, as professionals consider each person’s physical, mental and social needs.

However it also is important when considering health services and health systems more broadly. For example ensuring that mental health, physical health and wellbeing are all treated and measured as important health outcomes.

Questions to consider or reflect on in the comments

• Do you think that health services appropriately identify the social wellbeing needs of people with disabilities?

• Do health service providers work closely enough with other institutions or organisations within society to ensure that people are able to reach health as defined by the WHO (physical, mental and social wellbeing)?