The association between disability and all-cause mortality in low and middle-income countries: a systematic review and meta-analysis

Abstract

AbstractBackgroundThere are at least one billion people with disabilities globally. On average they have poorer health, yet worse healthcare access. We aimed to systematically review the association between disability and mortality in low- and middle-income countries (LMICs).MethodsWe searched MEDLINE, Global Health, PsycINFO and EMBASE from 1st January 1990 to 14th November 2022. We included any longitudinal epidemiological study in any language with a comparator group that measured the association between disability and all-cause mortality in people of any age. Two reviewers independently assessed study eligibility, extracted data, and assessed risk of bias. We used a random-effects meta-analysis to calculate the pooled hazard ratio (HR) for all- cause mortality by disability status. We then conducted meta-analyses separately for different impairment and age groups.FindingsWe identified 6146 unique articles, of which 70 studies (81 cohorts) were included in the systematic review, from 22 countries. There was variability in the methods used to assess and report disability, as well as mortality. The meta-analysis included 53 studies, representing 62 cohorts (comprising 267,415people with disabilities). Pooled HRs for all-cause mortality were 2.06 (95%CI 1.80 - 2.34) for people with disabilities versus those without disabilities, with high heterogeneity between studies (τ²=0·24, I²=98%). This association varied by impairment type; from 1.32 (95%CI 1.13 – 1.55) for visual impairment to 3.39 (95%CI 0.90 – 12.76) for multiple impairments. The association was highest for children under 18 (4.46, 95%CI 3.01–6.59); and lower in people aged 15 – 49 (3·53, 95%CI 1·29–9·66); and older people over 60 years (1·97, 95%CI 1·63–2.38).ConclusionDisability increases the risk of all-cause mortality in LMICs, particularly in childhood. Interventions are needed to improve health of people with disabilities and reduce their risk of death.Key messagesWhat is already known on this topicGlobally, people with different impairments have a higher risk of death than those without disabilities and many deaths will be avoidable.What this study addsPeople with disabilities in LMIC have two-fold higher mortality rates that those without disabilities. Disability is associated with a higher hazard of age-adjusted all-cause mortality across diverse LMIC settings and populations as well as impairment types. The risk of dying early is highest for children with disabilities.How this study might affect research, practice or policyImproved understanding of the association between disability and mortality will help to inform public health planning and policy, and the allocation of limited health-care resources to optimise healthy longevity for all populations worldwide. Without a focus on disability it may be difficult to reach SDG3 and other key global health targets.