Review the descriptions of the ten special populations addressed in Chapter 1 of your course textbook.  Identify the three groups you feel are most vulnerable. Explain your reasoning for selecting the groups based on:

  • An analysis of the statistical data/trends related to the populations. How did you use data to determine the three most vulnerable populations? Explain your thought process.
  • The World Health Organization’s formal definition of “health.”  How are the physical, mental, and social aspects of health compromised in these three vulnerable populations in comparison to the others?
  • The statistical data and the health compromises identified above. Create a list of at least three health service needs for each vulnerable group you identified.

Your initial contribution should be 250 to 300 words in length. Your research and claims must be supported by your course text and at least one other scholarly source.  Use proper APA formatting for in-text citations and references as outlined in the Ashford Writing Center.

Can someone do my discussion 1 for Wk. 1? SP
1 Identifying the Vulnerable Learning Objectives After reading this chapter, you should be able to: •Explain the concept of vulnerable populations. •Discuss how the theories of common good and individual rights contribute to the cre- ation of public policy in health care. •Determine how the concept of resource availability relates to one’s health. •Examine the aggregate statistical data on the number and growth of identified vulnerable populations. •Identify the vulnerable populations in the United States. Courtesy of Chris Bett/fotolia bur25613_01_c01_001-038.indd 1 11/26/12 10:32 AM Introduction Introduction T wo women enter the hospital with pneumonia. They are similar in age, but of dif- ferent races. One patient has private health insurance; the other is on Medicaid. One patient recovers quickly while the other languishes. What can be surmised from the differences in the two patients? Thinking on this and asking the right questio ns allows health care providers to create patient care plans that better meet each patient’s needs. Providing better health care to all patients requires awareness of environmental factors that may prohibit timely recovery and put the patient at risk for secondary and repeat infections. Environmental factors such as finances, family, and education all affect a person’s vulner- ability, or risk level. Understanding statistical data on vulnerable populations will help you interpret patient information. This allows easier identification of those who a re at risk, so that providers may plan care accordingly. Addressing the needs of at-risk popula – tions leads to faster patient recovery, thereby lowering the cost of patient care. Lowering health care costs is important for the patient, the care provider, and the whole country. Nonprofit organizations and government agencies work to identify and help at-risk groups. This activity affects both government and organizational policy among health care providers. This text investigates the statistical data and indicators of vulnerable populations in American health care. It also covers the causes of vulnerability and the prevailing ideolo – gies on dealing with at-risk populations. We will also discuss what is currently being done through policymaking and program implementation to address the needs of vulnerable populations and what the future looks like for at-risk groups. This chapter focuses on identifying vulnerable populations. The relationship between resource availability and health is an important part of recognizing at-risk groups. Finally, we will look at statistical data concerning the at-risk groups identified in the book. Critical Thinking The text states, “Addressing the needs of at-risk populations leads to faster patient recovery, thereby lowering the cost of patient care.” How does addressing the needs of at-risk populations lead to faster patient recovery? bur25613_01_c01_001-038.indd 2 11/26/12 10:32 AM CHAPTER 1 Section 1.1 Social Theory and Public Policy in Health Care Self-Check Answer the following questions to the best of your ability. 1. Asking the right questions allows health care providers to create ______________ that better meet each patient’s needs. a. patient care plans b. outpatient clinics c. health insurance plans d. genetically modified medicines 2. Environmental factors such as finances, family, and education all affect a person’s vulnerability, or __________. a. mortality b. life span c. risk level d. quality of life 3. Nonprofit organizations and which agencies work to identify and help at-risk groups? a. cultural entities b. labor unions c. local businesses d. government agencies Answer Key 1. a 2. c 3. d 1.1 Social Theory and Public Policy in Health Care H ealth is both an individual consideration and a community concern. In ot her words, an individual makes decisions that directly affect him or herself, and a society makes decisions that affect and manage the society itself. For example, a person may choose to smoke cigarettes, thereby damaging his or her own lungs. However, this action also has an impact on those around the smoker because secondhand smoke has been shown to be a valid health concern. Thus, society may create public policy, or laws, that outlaw smoking in public places with the intent of ensuring that on e person’s deci – sion to smoke does not harm others. A law that bans smoking in public places is based on the social theory of the common good, meaning it is intended to help everybody. The concept of the common good focuses on creating a benefit for the most members of a community. Sometimes the common good is juxtaposed with the social theory of individual rights, which is based on protecting personal freedoms. Public controversy often ensues when the common good is perceived to infringe on such individual rights. For example, social theory center ed on the common good led to the creation of public policy in the form of a law banning smoking in public places, which results in heated debate among lawmakers and citizens. One side argues bur25613_01_c01_001-038.indd 3 11/26/12 10:32 AM CHAPTER 1 Section 1.1 Social Theory and Public Policy in Health Care that such laws are necessary to protect society; the opposition argues that personal freedom should not be inhibited by the collective citizenry. The United States Bill of Rights is the pri- mary protector of individual lib- erties in the United States. The argument that personal freedom should not be inhibited by the collective citizenry is primarily based on three amendments: • The Ninth Amendment states, “The enumera- tion in the Constitu- tion, of certain rights, shall not be construed to deny or disparage others retained by the people.” • The Tenth Amendment further protects individual liberties by stating, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” • The Fourteenth Amendment states, “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdic- tion the equal protection of the laws.” However, the argument in favor of passing legislation to pro- mote the common good is based directly on the preamble to the Constitution: • “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tran- quility, provide for the com- mon defence, promote the general Welfare, and secure the Blessings of Liberty to Courtesy of bbbar/Fotolia Pareto’s principle explains why the common good and individual fairness often conflict. In many cases, a small group of people do most of the work, which the majority then benefits from. Courtesy of iStockphoto/Thinkstock Prohibiting smoking in public places exemplifies the social theory of the common good, because the mandate is meant to benefit everyone. bur25613_01_c01_001-038.indd 4 11/26/12 12:47 PM CHAPTER 1 Section 1.1 Social Theory and Public Policy in Health Care ourselves and our Posterity, do ordain and establish this Constitution for the United States of America” (Constitution of the United States of America and the Bill of Rights, 1787). The Constitution and amendments then go on to describe Congress’s power to legislate. Which option is the fair choice? That question plagues American health policy. America dogmatically strives for justice and fairness for all citizens. Social theorists and policy – makers alike refer to the Pareto principle when the common good and individual rights are directly at odds. The Pareto principle is the theory that 80% of the outcome is caused by 20% of the effort (Juran, 1994). This is often seen in community involvement situat ions wherein a handful of people do most of the work while the majority does very little. In social theory, the Pareto principle is often translated to mean that fairness for all does not necessarily create fairness for every individual and that some instances occur wherein fairness for all has negative effects on the common good (Kaplow & Shavell, 2000). Take the case of a communist society wherein all resources are combined then doled out equally among people, regardless of how much each person contributed. Ensuring food for all citizens benefits the common good, but a farmer who worked hard all year to fill the pan- try may end up without enough to feed his family for the winter because others were less industrious, so his equal share becomes less than what he worked for. Social Attitudes Versus Individual Choice The smoking ban example illustrates how social attitudes—which are positive or nega- tive evaluations of people, places, things, events, and the like, and ar e shared by a majority of the community as a whole—and individual choice are not always in agreement. Social attitudes are the result of generalized, shared ethics in a society. They help shape our over – all health environment. For example, positive social attitudes toward cigarettes viewed smoking in public spaces to be perfectly acceptable and even doctor recommended in the early 1900s. The current social attitude toward cigarette smoking has caused the number of cigarette users in the United States to drop below 20% (see Figure 1.1). This in turn has created a drop in tobacco-related illness and death. Negative social attitudes about cigarette use, caused by a collective realization regarding the negative effects of smoke, secondhand smoke, and related illnesses, have positively affected the nation’s health. bur25613_01_c01_001-038.indd 5 11/26/12 12:47 PM CHAPTER 1 Section 1.1 Social Theory and Public Policy in Health Care Figure 1.1: Percentage of adults in the U.S. who use cigarettes Social attitudes toward cigarette smoking have changed drastically in the last 50 years, causing cigarette use to decline. Centers for Disease Control and Prevention (CDC). (2011). Trends in current cigarette smoking among high school students and adults , United States, 1965–2010. Retrieved January 9, 2012, from http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/ index.htm Social attitudes are part of the collective, or macro, influences on our health. Other macro – level influences include messages from the media, such as commercials for fast food. Health policy is often created in response to macro influences on our society’s health environment, or the combined collective knowledge created through rigorous study, comprehensive eval – uation, and peer-reviewed publication of facts related to the collective public good. Considering only the macro view does not consider the individual, or micro, influences or decisions that we each make about our health. Micro influences on health include whether we choose to walk, bike, or drive to work or school, and which foods we select at the gro – cery. A debate lingers over whether the micro or macro perspective is more useful when considering health decisions and policy. Critical Thinking Can you think of other examples where social attitudes conflict with individual choice? Would abortion (a woman’s right to choose) fall into this category? What about medical marijuana? bur25613_01_c01_001-038.indd 6 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Self-Check Answer the following questions to the best of your ability. 1. During which time period did the media and medical professionals promote smoking as “good for your health?” a. early 1900s b. late 1950s c. middle 1970s d. early 2000s 2. The common good refers to principles and laws intended to help which of the fol- lowing groups? a. a few people b. a specific group of people c. everybody d. no one 3. The Pareto principle refers to which of the following principles? a. 90% of the outcome is caused by 5% of the effort b. 10% of the outcome is caused by 80% of the effort c. 100% of the outcome is caused by 100% of the effort d. 80% of the outcome is caused by 20% of the effort Answer Key 1. a 2. c 3. d 1.2 Considerations for Studying Vulnerable Populations H ow do we apply social theory to the study of vulnerable populations? Fir st, we must begin by categorizing the influences that affect the health of these groups. The influences are used to determine which social groups in our society are defined as vulnerable populations. Community and Personal Values Americans largely associate good health with good personal habits and decisions. This means that culturally, Americans expect each person to take responsibility for his or her health-related habits and actions. Daily exercise, dietary choices, and other behaviors are not heavily regulated by public policy or community values. Each person’s own valu es determine his or her health outcomes. Of course, we cannot entirely disregard community health values. After all, they do shape public health policy. Community values also affect the community’s investment in resources and opportunities that impact health, from regulating pollution levels to ensur – ing the availability of fresh produce. Community-based health policies help bridge the bur25613_01_c01_001-038.indd 7 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations gap between microlevel personal choices and macrolevel governmental thinking. Most public policy decisions grow, not from massive governmental thinking, but from grass- roots efforts, like the previously discussed smoking ban(s). These grassroots efforts are evidence of the power of individuals to affect public policy. The Louisville, Kentucky, Farm to Table program offers a good example. Two movements were simultaneously growing in the Louisville community. One movement, led by local farmers and entrepreneurs, focused on expanding access to locally farmed foods within the community; the other movement, led by parents and school cafeteria employees, focused on improving the nutrition of school lunches. When these two groups combined efforts, the Farm to Table program was altered, and creating avenues to getting locally farmed foods into school cafeterias became an important goal throughout the commu- nity. As the community at large increased program participation, the local city govern – ment became involved with programs and grants to increase the scope of the Farm to Table program. Access to Resources From a macro perspective, we see that the distribution of resources within a community has a direct impact on health risk. Resource distribution often correlates with social status, social capital, and human capital. Though American society tries to equalize the distribu – tion of resources through social welfare programs, it is no secret that individuals gain or lose access to opportunities and resources depending on their social status, social ties, and ability to invest in their own potential. Social Status An individual’s place in society, called social status, is attributable to personal charac – teristics, opportunities, and rewards. Personal characteristics such as age, gender, ethnic – ity, geographic location, educa- tion level, and income result in social rewards like social power, or a lack thereof. Age affects a person’s wellness (e.g., elderly people are usually more sus – ceptible to chronic illness than young adults) as well as a per – son’s need to depend on others for his or her well-being (e.g., children depend on adults for medical care). Gender is also an important fac – tor in health and level of health risk. Women are more suscepti- ble to certain cancers, for exam – ple, but are more likely to seek medical care. Men are more sus- ceptible to work-related health Courtesy of 123RF Limited/123RF Opportunities, rewards, and personal characteristics can be attributed to an individual’s social status. bur25613_01_c01_001-038.indd 8 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations risks, as they traditionally hold more physically demanding jobs. The emotional differences between men and woman also affect vulnerability. Statistically, women are more likely to suffer the ill consequences of eating disorders, whereas it can be said that men are socially trained to eat more red meat and maintain a more robust physique, deci- sions which come with their own sets of health risks. Ethnicity and race are two of the most studied factors in social status and health risk because minorities historically have less access to the social rewards that limit risk levels. Lower-class urban neighborhoods with a high number of minority residents often lack representation in social politics and suffer for it with higher levels of air and water pollution, which increase the level of health risk for all residents. Furthermore, poverty can breed crime, and the stress of living in a high-crime area also negatively affects a person’s health. Stress can manifest physically by presenting as com – plaints such as headaches. Stress can also increase the likelihood of negative health behaviors, such as cigarette and alcohol use. Limited access to resources, including fresh vegetables and medical care, increases the burden. Low-income areas are commonly populated with fast-food restaurants that serve high-fat foods, whereas more affluent areas often have more grocery stores and farmers’ markets. Additional factors such as migrant sta- tus further increase a person’s vulnerability. Risk factors do not stand alone. An elderly minority female has different risk factors than an elderly Caucasian male. Social Capital Social capital is the measurement of personal relationships in an individual’s life. The number, type, and reliability of interpersonal relationships greatly influence a person’s vulnerability and health risk. For example, a single mother is less likely to spend a day in bed, resting and recov – ering from an illness, than a mother who has a Courtesy of Hemera/Thinkstock Health risk depends on several factors, including the quantity and quality of a person’s interpersonal relationships. Courtesy of Brand X Pictures/Thinkstock Minorities are less able to take advantage of the social rewards that diminish risk levels; thus, ethnicity and race are oft-studied factors in social status and health risk. bur25613_01_c01_001-038.indd 9 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Critical Thinking Do you have a support network? Can they help with family needs such as child care or transportation? Are they supportive of your education goals? partner or someone reliable who can care for the children. Working parents are better able to maintain viable employment if grandparents and other relations are available to help with child care. The ability to work creates opportunities and other social rewards. An upwardly mobile career path grants access to money and insurance to help pay for doctor vis its and medi- cine. The opportunity to meet people and grow friendships at work adds to a person’s support network. A strong, healthy support network directly influences psychological and physical well-being, lessening a person’s health risk. Hospitals and rehabilitation facilities have found that patients who have reliable support systems enjoy faster recovery times and spend less time recuperating in the medical center in favor of convalescing at home with the assistance of a robust, developed support system. Reducing the length and frequency of hospital stays reduces the risk of secondary and recurrent infections. Human Capital Human capital is the amount of investment in a person’s potential. Low-income indi – viduals often have low human capital, while higher-income individuals enjoy investment in their potential in the form of education, opportunities for advanceme nt, and even better access to higher-quality health care. The more investment made in a person’s potential, or future, the more that person will be able to contribute to society in a positive way. Data on various subjects including education, wage earnings, and health care access indi – cates gaps in human capital based on gender, age, and ethnicity. Poor-performing schools are more common in low-income neighborhoods, females are sometimes passed over for advanced training and managerial positions, and minorities often suffer a lack of social resource allocation. In all of these examples, failure to invest in people’s potential nega – tively influences their long-term outcomes. Poorly educated children are less likely to attend college, the disenfranchised female will lose work productivity, and the neighbor – hood that needs public resources to fix streetlights will see an increase in crime. Outside influences are not the only way to invest in human capital. Individuals invest in their own potential by working hard at school and work and by organizing communities to create the change they want. Conversely, investment in human capital can be negatively impacted by a collective lifestyle perspective. The collective lifestyle perspective dictates behavior based on social constructs, or ideas, about the way people “like me” should behave (Barnes, Hall, & Taylor, 2010). Middle-class mothers may perceive that smoking is unacceptable among their peers and so give up smoking. Conversely, adolescents in low- income areas may perceive that smoking makes them more accepted among their peers and so take up the unhealthy habit. bur25613_01_c01_001-038.indd 10 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Health Indicators The World Health Organization (WHO) is an international organization that coordinates health-related efforts around the globe. The WHO definition of health goes beyond the mere absence of illness, proposing that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization [WHO], 2012). From this definition of health, we can see where values and resources are directly linked to well-being. The WHO definition indicates that health exists in varyin g degrees, based on a number of recognized indicators. Indicators of physical health are considered the measurements of the body’s wellness, such as bodily illness and disability. Mental health indicators measure emotional issues such as stress and mental illness. The WHO defini- tion also includes social well-being, based on indicators such as relationships with others. Figure 1.2 illustrates the health continuum. Figure 1.2: The health continuum Health is not simply the absence of disease. A person’s degree of health exists on a spectrum, fluctuating throughout life. Health is measured along a continuum, with great health at one end and death on the opposite end. Minor ailments fall nearer the perfect health end of the continuum, with more severe needs nearer the death end. The WHO definition of health clearly includes physical, mental, and soci al components. Physical health deals with the body and bodily functions, mental health includes brain functions such as thought and emotions, and social health includes inter personal relation- ships with others. Physical health is measured by patient perception, doctor opinion, and clinical testing. Another way to measure health is based on a patient’s abilities to perform activities of daily living (ADLs). Basic ADLs include personal hygiene and being able to dress oneself, feed oneself, walk with or without assistance, and use the restroom (Weiner, Hanley, Clark, & Van Nostrand, 1990). Patient perception of well-being cannot be overlooked when measuring health. An impor – tant part of patient perception of well-being involves the concept that people alter their behavior when they perceive that they are unwell. Staying in bed and eating chicken soup are two common “sick role” behaviors. Perception is a key tool in measuring both mental health and social health, as people interpret stressors and relationships differently. Patient perception, doctor opinion, and clinical testing are standard ways of measuring individual health status but do not offer a larger picture of community health status. Community health status is measured with statistics of the rates of occurrence of illness, bur25613_01_c01_001-038.indd 11 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Critical Thinking Where does your current total health fall on the health continuum? Can you think of a time when your health measured nearer the negative end? Do you feel that patient perception is a reliable method of measurement for use in global decisions regarding heath issues? disease, and death within a recognized group. This data, such as that shown in Figure 1.3, is used to influence public policy and the distribution of public resources. Figure 1.3: U.S. infant mortality rates per 1,000 live births, by maternal education and race Mortality rates for children born to white mothers is much lower overall than for children born to black mothers; however, both races see a significant decrease in infant mortality as the mother’s number of years of completed education rises. Singh, G. K. & Yu, S. M. (1995). Infant mortality in the United States: Trends, differentials, and projections, 1950 through 2010. American Journal of Public Health, 85(7). Retrieved January 12, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615523/pdf/ amjph00445-0063.pdf bur25613_01_c01_001-038.indd 12 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Public Policy The World Health Organization works to affect public health policy and practices on a global scale. In the United States, public health policy is created by local, state, and federal politicians. Many organizations influence the policies as they are created. Some organiza- tions or groups that influence public health policy in this country include the fol lowing: • Health insurers • Lobbyists Risk Potential The data on infant mortality and maternal race and education in Figure 1.3 also illustrates the concept of relative risk, or risk potential. Relative risk is the potential of imperfect health in groups exposed to risk factors, such as drug use, in rela – tion to the potential of imperfect health in groups not exposed to the same risk factors. The concept of relative risk embodies the differential vulnerability hypothesis , which theorizes that some people have more adverse reactions than others to negative life events. Studies of the differential vulnerability hypoth- esis have found that members of low socioeco – nomic status groups experience higher levels of anxiety, stress, and emotional duress when faced with negative events and information than do persons of higher socioeconomic status. Con- sidering the factors that contribute to health and well-being (social status, social capital, and human capital), we can ascertain that a deficiency in these factors is a likely cause of the higher levels of mental duress in stressful situations experienced by members of low socioeconomic groups. For example, a wealthy person who receives a speeding ticket is less likely to be concerned about how he or she will pay the ticket than a person on a fixed income. For the latter, paying a ticket strains an already tight budget that must pay for food and shelter. Without reasonable levels of social status, social capital, and human capital, where is the extra money to come from? Courtesy of iStockphoto/Thinkstock In groups exposed to certain risk factors, negative life events can cause more adverse reactions than in groups not exposed to those same factors. Critical Thinking Why do you think members of low socioeconomic status groups experience higher levels of anxiety, stress, and emotional duress when faced with negative events and information than do persons of higher socioeconomic status? bur25613_01_c01_001-038.indd 13 11/26/12 10:32 AM CHAPTER 1 Section 1.2 Considerations for Studying Vulnerable Populations Critical Thinking With so many organizations having an influence on public health care policy, do you think it is possible for one person to make a difference? • Planned Parenthood of America • Health care providers • The American Public Health Association • The Centers for Disease Control and Prevention • The Public Health Initiative • National Association of Public Boards of Health • Public Health Foundation • The World Health Organization • American Medical Association The list of groups influencing public health policy in the United States goes on and o n, but one thing is important to note: There is a community of these organizations. Though Americans primarily take the micro perspective on good health, believing that individu- als should be personally responsible for healthy lifestyle choices, the macro perspective is ever present. Individuals belong to communities, from the neighborhood level to the international community, and every group in between. The community perspective of health care pol – icy emphasizes the creation of a social support system that cares for vulnerable people and populations. Government regulations control the distribution of resources that can strengthen a vulnerable community and positively affect the level of vulnerability to at- risk populations. Self-Check Answer the following questions to the best of your ability. 1. The distribution of ____________ has a direct impact on health risks. a. clinics b. money c. resources d. government 2. The WHO is which of the following? a. A rock band formed in the 1960s b. World Health Organization c. Woman’s Health Organization d. Workers Health Organization 3. Government regulations control the distribution of __________. a. personnel b. hospitals bur25613_01_c01_001-038.indd 14 11/26/12 10:32 AM CHAPTER 1 Section 1.3 Statistical Data on Identified Vulnerable Populations c. resources d. ambulances Answer Key 1. c 2. b 3. c 1.3 Statistical Data on the Population Totals and Growth Trends of Identified Vulnerable Populations P ublic policymakers and health care researchers rely on statistical data from gov- ernmental or academic studies to inform decision makers on necessary cha nges to resource allocation. Many organizations perform studies that provide statistics and other data, but the most influential American organization on the subject of public health is the National Center for Health Statistics (NCHS) (2012). The NCHS is part of the Cen – ters for Disease Control and Prevention (CDC). It collaborates with numerous organiza- tional members of the health community in every community across the nation to survey and identify health problems and vulnerable populations in the United States. The result of these studies is the national Healthy People objectives list, which specifies the nation’s most pressing health needs and indicates ways to address them and fund programs for doing so. The Healthy People health objectives list is updated every 10 years. Considerations in Studying Data It is difficult to get definitive data on any given population. Variations in how studies are conducted, the communities in which they are conducted, and the type of respondents all contribute to incomplete and inaccurate data compilation. Add to these hurdles the fact that vulnerable populations overlap, and it is nearly impossible to create a perfect picture of the total number of America’s vulnerable populations, their relative risk profiles, and their needs. Different data sources, including vital statistics counts of deaths and births, patient per – ception of illness, health agency records, and clinical diagnoses reports, provide differing estimates of individual needs within groups. It is difficult to compare needs across groups, and studies may be biased. Increases and decreases in some statistics are subjective due to influences of social, or in some cases medical, ethics. For example, a r ise in reports of child abuse may not indicate an increase in actual child abuse but instead may indicate a shift in social ethics that has made people more likely to report child abuse incidents. It is also difficult to compare data across groups because different indicators are used to measure statistics. Resource needs for the chronically ill are often based on clinical records measuring physical limitations. These measurements are based on clinical information, physician recommendations, and patient perceptions of pain and illness. Statistics on fam – ily abuse are based on case reports. It is understood that many abuse cases go unreported, but the number of unreported cases is unknown. Needs assessments of other vulnerable populations are based on varying evidence of poor health and functioning. The Public Health Data Standards Consortium promotes standardization of health and community statistical studies and data in an effort to make the data more accessible and meaningful. bur25613_01_c01_001-038.indd 15 11/26/12 10:32 AM CHAPTER 1 Section 1.3 Statistical Data on Identified Vulnerable Populations Connections Between Vulnerable Groups The last few decades have seen interesting changes in the population numbers of vulner- able groups. The number of Americans living with HIV and AIDS has risen drastically since the virus was first recognized by the CDC in the 1980s. In fact, the number of people with HIV/AIDS doubled in almost every measured area of residence from 2004 to 2008, as shown in Figure 1.4. Figure 1.4: Reported number of people living with HIV/AIDS by area of residence Reported AIDS cases rapidly increased nationwide from 2004 to 2008. Center for Disease Control and Prevention. (2008a). Reported AIDS cases and persons reported living with AIDS, by area of re sidence, 2004–2008 and as of December 2008—eligible metropolitan areas and transitional grant areas for the Ryan White HIV/AIDS Treatment Extension Act of 2009. Retrieved from http://www.cdc.gov/hiv/surveillance/resources/reports/2010supp_vol17no1/pdf/2010_hiv_aids_ ssr_vol17_n1.pdf#page=8 This data does not include unreported cases, which is a problematic inconsistency in the data measurement. An unknown number of unreported cases complicate resource alloca- tion for this vulnerable population. bur25613_01_c01_001-038.indd 16 11/26/12 10:32 AM CHAPTER 1 Section 1.3 Statistical Data on Identified Vulnerable Populations Self-Check Answer the following questions to the best of your ability. 1. The most influential American organization on the subject of public health is the a. National Center for Health Statistics (NCHS). b. AFL/CIO Labor Union. c. United States Congress. d. Pharmaceutical political lobbyists. Critical Thinking Title II of HIPAA (Health Insurance Portability and Accountability Act) has “administrative simplifica- tion” provisions and requires national standards for electronic health care transactions. It also sets forth stipulations ensuring privacy and security of health records. Considering how many populations fit in many areas of “at risk,” do you believe HIPAA will help or interfere with research involving these special populations? Courtesy of Tony Baggett/iStockphoto The homeless population is affected by HIV/AIDS at a rate three times greater than the general population. HIV/AIDS affects the homeless population at an estimated 3.4%, a higher rate than the gen- eral population at 1% (National Coalition for the Homeless [NCH], 2007). Homelessness is difficult to define and track because it is often a transitory situation. The homeless population is measured primarily based on shelter occupancy and street counts, which can vary depending on a range of factors, starting with weather. Migrants and migrant workers often make up a significant percentage of the homeless popula – tion. Statistics on migrants obtaining legal perma- nent resident status in the United States are easily tracked by the Department of Homeland Security (2010). Unauthorized immigrants are difficult to track because they avoid the immigration system. This selection of vulnerable populations illus- trates how intermingled the groups are. At-risk mothers and infants can be homeless, living with HIV/AIDS or other chronic illnesses, immi – grants, or all three. Alcohol and substance abuse is found in all populations, not only vulnerable ones. Chronic illnesses are prevalent among the homeless population and the elderly. Population- specific data better illustrates this point. bur25613_01_c01_001-038.indd 17 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care 2. Which group promotes standardization of health and community statistical stud – ies and data in an effort to make the data more accessible and meaningful? a. National Institute of Mental Health (NIMH) b. Centers for Disease Control and Prevention (CDC) c. Public Health Data Standards Consortium d. Department of Health and Human Services (HHS) 3. Statistics on migrants obtaining legal permanent resident status in the United States are tracked by which organization? a. Department of Homeland Security b. Department of Defense c. Department of Health and Human Services (HHS) d. Various state organizations Answer Key 1. a 2. c 3. a 1.4 Defining Vulnerable Populations in American Health Care A person’s vulnerability to negative health outcomes increases as the level of risk exposure increases. Everybody is vulnerable at some point in his life, though some people’s level of vulnerability is rarely very high. Vulnerable populations are those groups of people who are exposed to many risk factors, such as inadequate access to fruits and vegetables, alcohol use, tobacco use, and inadequate housing. The WH O defines risk factors as any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Some examples of the more important risk factors are underweight, unsafe sex, high blood pres – sure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene. (WHO, 2012) Individuals and communities that lack resources, social status, social capital, and human capital are referred to as “vulnerable populations.” The most prominent vulnerable popu – lations in America are as follows: • vulnerable mothers and children • abused individuals • chronically ill and disabled people • people diagnosed with HIV/AIDS • people diagnosed with mental conditions • suicide- and homicide-liable people • people affected by alcohol and substance abuse • indigent and homeless people • immigrants and refugees bur25613_01_c01_001-038.indd 18 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care This list represents vulnerable American groups with the highest population numbers and risk factors. These groups appear to be growing quickly and thus putting an increas- ing strain on America’s resources. The macro perspective social theory of public policy recognizes that mitigating risks for vulnerable populations must include reform at the community level. These interventions include programs that include access to housing, food, and health care by geographically locating such resources where there were previ – ously few. The micro perspective social theory of public policy focuses on reforming the resource delivery system on the individual level. These interventions include programs that educate schoolchildren on proper nutrition and pay for immunizations for Medicaid recipients. Public policy strategists struggle to keep up with increasing demands on both the community and individual levels. Allocating resources to at-risk groups is complicated by the fact that they do not exist in independent bubbles. The problems of these groups are intertwined. Alcohol and sub – stance abuse can be a factor with abusive individuals and high-risk mothers and infants; suicide is a problem among homeless people; and people living with HIV are chronically ill and so have many of the same resource needs as that group. As at-risk populations grow and their problems become more intertwined, the country struggles to find solu – tions for a lack of needed resources and resource delivery. Vulnerable Mothers and Children Many factors can contribute to a pregnancy being termed “high risk.” Maternal health in terms of preexisting medical conditions—unhealthy weight; medication use; nutri – tion; alcohol, tobacco, and substance use—and domestic security can a ll have negative effects on the unborn baby. Eth- nicity has also been shown to be a factor in fetal and maternal health and will be discussed specifically in a later chapter. Though high-risk maternity has a different meaning for differ – ent populations, the population of vulnerable mothers and chil- dren is marked by inadequate medical care; negative health- related behaviors on behalf of the mother; teenage pregnancy; and infant drug addiction, pre- maturity, and low birth weight. Inadequate medical care dur – ing pregnancy leads to higher rates of infant mortality, prema – ture birth, and low birth weight. Infant mortality is caused by many factors, including undeveloped and improperly developed organs, malnutrition (sometimes caused by poor maternal nutrition while in utero), and drug addiction. Pre – mature birth is marked by a gestational age of less than 37 weeks. Low birth weight Courtesy of Keith Brofsky/Thinkstock Maternal health, whether good or poor, has a significant bearing on the health of the unborn baby. bur25613_01_c01_001-038.indd 19 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Careis considered to be a nything under 5.5 pounds. Proper prenat al care can mitiga te the r isks of these ne gative outcomes b y helping the mother ensure proper hab its and nutri – tion throughout th e pregnanc y . The earlier the m other receives regu lar prenatal ca re, t he lower the risk of negative outcomes for both her and th e baby. But man y vulnerable women do not receiv e early prenatal care : The total percentage of mothers se ek ing health care during the first trimester of pregnancy was 83. 2% in 2006 (H enry J. Kaise r Family F oundation [KFF], 2012a). There i s a direct cor relation between a lack of prenatal care and infant mortality. The United States has the highest infant mortality rate among developed nations (Mac- Dorman & Mathews, 2008). The infant mortality rate in the United States has hovered around 6.5 deaths per 1,000 births for a decade. Although socioeconomic status plays a large role in infant and maternal mortality rates, the number leaves much to be explained. Non-Hispanic blacks had the highest 2005 infant mortality rate, at 13.63 per 1,000 live births, and Cubans living in the United States had the lowest 2005 infan t mortality rate, at 4.42 per 1,000 live births. The total infant mortality rate in the United States declined slightly from 2005 to 2007, with a total rate of 6.86 infant deaths per 1,000 live births in 2005, and 6.75 infant deaths per 1,000 live births in 2007 (Mathews & MacDorman, 2011). It is estimated that the rate will further decline to 5.98 infant deaths per 1,000 live births in 2012 (U. S. Central Intel – ligence Agency [CIA], 2012a). Maternal mortality rates are also linked to early, quality prenatal health care. Maternal mortality was high in the early 20th century, at a rate of 607.9 maternal deaths per 100,000 live births. The rate dropped to 12.1 maternal deaths per 100,000 live births in 2003 (U.S. Department of Health and Human Services [HHS], 2007). This is attributable to advances in medical science and better health care access. Teen mothers are among the most at risk for negative outcomes. The rate of live births in the United States declined 3% from 2008 to 2009 (Martin et al., 2011). The nation saw a peak in teen births in 1991. The decline in teen births to 39.1 per 1,000 tot al live births in 2009 is 37% below the 1991 peak of 61.8, and the lowest in seven decades. The teen birth – rate declined fairly steadily from 48 live births per 1,000 teen females ages 15 to 19 in 2000, to 34 live births per 1,000 teen females of the same age group in 2010 (Centers for Disease Control and Prevention [CDC], 2012a). The decline in teen births may be a contributing factor to the decline in preterm deliveries and low birth weight infants. Both 2008 and 2009 saw declines in preterm deliveries both before 34 weeks gestation and at 34–36 weeks gestation. The 2009 total preterm birthrate was 12.18% of all births in America. The preterm birthrate dropped only slightly to 11.99% in 2010 (Hamilton, Martin, & Ventura, 2011). The low birth weight rate in the United States has been steadily increasing since the 1980s. The low birth weight rate in 1989 was 7.05%. By 1999, the rate had increased to 7.62%. Final data for 2009 showed the low birth weight rate to be 8.16%. It is notable that African Americans have a disproportionately high inci – dence of low birth weight babies, though the incidence rate for this group has remained fairly steady, ranging from 13.61% in 1989, to 13.23% in 1999, to 13.61% in 2009. Hispanics also remained fairly consistent at 6.18% in 1989, to 6.38% in 1999, to 6.94% in 2009. Cauca – sians, however, have experienced a considerable increase in low birth weight infants. In bur25613_01_c01_001-038.indd 20 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care 1989, Caucasians had a low birth weight rate of 5.62%. That number rose to 6.64% in 1999 and rose again to 7.19% in 2009 (Martin et al., 2011). Abused Individuals Children, the elderly, and female partners and spouses are the individuals most vulner- able to abuse. Abuse comes in many forms, most prominently neglect, physical abuse, emotional abuse, and sexual abuse. Data on abuse is often unspecific regarding the type of abuse being discussed, mostly because different forms of abuse often occur simultaneously. Many public agencies exist to deal with the prob – lem of domestic abuse and to protect the vulner – able. The U.S. Administration for Children and Families tracks data on abuse within families. The number of reported abuse cases has increased over the last few decades. But the data is skewed by social norms. It is believed that a contributing factor to the increase in reported abuse cases is due to a social ethic that used to hide and ignore abuse, and now recognizes that it is not the vic – tim’s fault and that abuse must be investigated. Even so, the data indicates that child abuse and neglect are on the rise. Child abuse cases are counted in two ways. The number of incidents counted is known as the duplicate victim rate ; the number of victimized children counted is known as the unique victim rate. Two separate rates are tabulated to account for the fact that the same child may be reported multiple times in a year. The duplicate victim rate in 2010 was 10 in 1,000 total children in the U.S. population. The unique victim rate was 9.2 per 1,000 children in the United States. This shows that the data collection methods are working, as the difference between the unique count and the duplicate count is small. Of the unique victims from 2006 to 2010, 75% had not been previously reported. In 2010, 81.3% of reported abused children were victims of their parents. A significantly lower 13% were victimized by people who were not their parents (U.S. HHS, Administration for Children and Families, Admin – istration on Children, Youth and Families, Children’s Bureau, 2011). Courtesy of Hemera/Thinkstock Two methods are used to count child abuse incidents, taking into consideration the fact that the same child may be the victim of multiple incidents in a given year. Critical Thinking There is a difference of 9.21 per 1,000 infant mortality deaths between non-Hispanic blacks and Cubans. There is a roughly equal chance of low income and lack of medical access in both of these populations. What contributing factors might explain the difference? bur25613_01_c01_001-038.indd 21 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Child abuse statistics show a definite age factor, with abuse reports shrinking in number the older the victim. In 2010, 34% of child victims were infants to 3 years old, 23.4% were 4–7 years old, 18.7% were 8–11 years old, 17.3% were 12–15 years old, and 6.2% were 16–17 years old (see Figure 1.5). Figure 1.5: Child abuse by age Child abuse report rates decline as the age of the child increases. U.S. Department of Health and Human Services (HHS). (2010). Retrieved from http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf Just as the young are vulnerable because they cannot defend themselves, so are the elderly. It is estimated that only 1 in 14 elder abuse incidents is reported, and only 1 in 25 incidents of elder financial exploitation is reported each year. Self-neglect, when a person does not attend to physical needs such as nutrition and bathing, is also a factor in elder abuse. Data from 1996 shows 450,000 seniors were abused by others, and an estimated 100,000 seniors neglected their own care (U.S. Administration on Aging, National Center on Elder Abuse, 2005). bur25613_01_c01_001-038.indd 22 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Neglect is the most common form of elder abuse; 36.7% of the perpetrator s are adult children of their victims (U.S. Administration on Aging, National Center on Elder Abuse, 1997). Statistics show that females were significantly more likely to be the victims of elder abuse, at an incidence rate of 67.3%. Neglect can manifest as the intentional fail – ure to meet the health-related needs of an individual, but it can also involve failing to meet the household necessities of an individual. A survey of states’ Adult Protective Ser – vices departments shows a marked increase in the number of reports of elder abuse, investigated cases of elder abuse, and substantiated reports of elder abuse from 2000 to 2004 (U.S. Administration on Aging, National Center on Elder Abuse, 2006). Whether the increases are due to expanded public awareness of the problem of elder abuse, or due to an increased number of elderly in the community, or due to an actual increase in elder abuse incidents is uncertain. Financial exploitation is another form of mistreatment suffered by the elderly, and it can come in many forms, from the deliberate misuse of a legal relationship (power of attorney, guardianship, conservatorship, or trustee) to the embezzlement of funds under false pre – tenses (for example, the taking of government-issued checks or assistan ce). Next we turn to a discussion of partner or spousal abuse. Child and elde r abuse are more likely to be reported than spousal abuse, but family violence affects all members of a house – hold. An estimated 30% to 60% of people who abuse their domestic partners also abuse children in the household. Approximately 16,800 homicides occur in the United States A Closer Look: Elder Abuse Estimates The American Psychological Association (APA) (2012) estimates a stagger – ing number of elderly abuse cases, suggesting that 2.1 million older Ameri – cans experience some kind of abuse during their elder years. Consider this scenario: Shortly after her 87th birthday, Beth, suffering from the effects of degen – erative arthritis and chronic heart disease, moved in with her adult daugh- ter, Laura. This living arrangement caused stress between them. With her financial worries, her 25-year-old son also living at home, and her hus – band’s job always at risk, Laura has lost her temper numerous times. She has called Beth names and has even gone as far as blaming her mother for ruining her tranquility and home life with her family. This has made Beth feel like a prisoner in Laura’s home, isolated from the life she knew, as well as frightened and worthless. Or take the case of Diane, 78, who lives at home with assistance from a home health nurse and a certified nurses’ aide. They visit her daily to care for and assist her with activities of daily living. She also depends on home health care assistance with home-based routines and to give her someone from the outside world to talk with. In the beginning, her nursing assistant was extremely helpful and sweet, but recently the assistant has begun ignoring requests, snapping at Diane, and has even come close to knocking her over while cleaning or vacuuming. Diane believes the assistant is bumping her deliberately, but she is afraid to say anything for fear of losing her link with the outside world, so she doesn’t confront her nursing assistant. Courtesy of Simon Bourne/ iStockphoto An estimated 2.1 million older Americans experience some kind of abuse during their elder years. bur25613_01_c01_001-038.indd 23 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Critical Thinking This chapter is concerned with a discussion of the health care needs of special populations. We have already talked about high-risk mothers, infant mortality, and households affected by substance abuse; these populations are particularly vulnerable to negative health outcomes. Why do you think abused individuals would also be categorized as a “special population”? every year as a result of domestic violence. If these numbers seem low, there is reason for it because domestic partner abuse is one of the most underreported crimes in the nation (National Coalition Against Domestic Violence [NCADV], 2007). Even with a lack of consistent reporting, trends show that domestic violence is declining. Reporting might be on the rise, at an estimated 60% of incidents reported between 1998 and 2002. The National Crime Victimization Survey (1998–2002) attempted to remedy the reporting gap by surveying members of different populations in the United States. The survey had a limited scope but some interesting findings. In 1993, the estimated vic- tim rate was 5.4 domestic abuse victims per 1,000 U.S. residents. That number fell to 2.1 in 2002. Domestic abuse accounted for 11% of all violent crimes from 1998 to 2002. The majority of domestic abuse offenders are male, and the majority of victims are female. Domestic violence by intimate partners including current and past spouses, boyfriends, and girlfriends constituted over a quarter (26%) of all nonfatal viole nt crimes against women in 2009. In that same year, domestic violence constituted only 5% of all nonfatal violent crimes against men (National Center for Victims of Crime, 2011). Of the perpetra – tors in domestic violence cases in federal court, 67% are younger than age 40, and 72% are Caucasian (Durose et al., 2005). Although domestic abuse may be declining, many factors are unchanged. Chronically Ill and Disabled People Chronic illness refers to those illnesses that are usually not fully recovered from once a person has them. Diabetes, HIV/AIDS, and emphysema are all examples of life-altering chronic illness. Chronic illnesses can create disabilities, though disabilities also include physical impairments to bodily function that interfere with activities of daily living. Dis – abilities and chronic ailments have a negative effect on lifestyle, and cost the country millions of dollars per year in health care and other resources. The Centers for Disease Control and Prevention show that chronic disease is the cause of 70% of U.S. deaths every year. Although chronic disease affects our community on the macrolevel, many causes of chronic illness are directly related to individual lifestyle choices. Cigarette use is linked to cancer of the lungs, throat, and other organs; habitual binge drinking causes cirrhosis of the liver; and lack of aerobic exercise leads to diabetes, obesity, and heart disease. Heart disease was responsible for 26.6% of all registered deaths in 2005. Chronic lower respiratory diseases accounted for 53%, and diabetes was the cause of 3.1 % of deaths in 2005. There has been little change in causes of death for age-adjusted death rates in the last few decades. As Figure 1.6 shows, heart disease rates have declined only slightly each year, and hypertension rates are on the rise after a small decline in the 1980s (Kung, Hoy – ert, Xu, & Murphy, 2008). bur25613_01_c01_001-038.indd 24 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care The pie chart shows age-adjusted death rates for select leading causes of death over the last five decades. Center for Disease Control and Prevention. (2010). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf The prevalence of chronic disease is tracked by the CDC’s Behavioral Risk Factor Surveil- lance System. This ongoing telephone survey collects anonymous information directly from patients about their chronic illnesses and quality of life. Data collected in 2009 shows a correlation between respondents who answered that their general health is fair or poor and many chronic illness risk factors such as cigarette use. According to the U.S. Depart – ment of Health and Human Service’s Healthy People 2020 initiative, al most one-half of all American adults reported at least one chronic illness. Noninstitutionalized people over age 65 report the most limitations of activity due to chronic illnesses at a rate of 32.6%. Youth under age 18 had the next highest rate in 2006, at 7.3%, and adults ages 18 to 44 reported limited activity at a rate of 5.5% (U.S. Department of Health and Human Services, Healthy People 2020, 2012). The CDC reports that asthma is one of the most common chronic illnesses in school-age children, with 5.6 million chil – dren with asthma reported in 2007. Asthma prevalence puts a strain on schools, the health care system, and community resources. Figure 1.6: Leading causes of death by age-adjusted rates bur25613_01_c01_001-038.indd 25 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Critical Thinking Although many chronic diseases are related to personal lifestyle choices such as cigarette smoking, which can cause lung cancer and other serious respiratory diseases, asthma in school-age children does not seem to be related to lifestyle choice. What factors might be causing/influencing such a large popu- lation to be afflicted with a chronic disease at such a young age? People Diagnosed With HIV/AIDS Human immunodeficiency virus (HIV) prevalence has increased rapidly since the 1980s. Public education about HIV and other sexually transmitted diseases (STDs) has helped mitigate the number of HIV and AIDS patients in the United States. However, in 2011, the African continent was still strug – gling with rapidly increasing numbers, even as the rest of the world tried to send resources to combat the epidemic. Antiretroviral pharmaceuticals help people living with HIV/ AIDS maintain a higher quality of life and prolong their expected life span. These therapies are expensive, and Americans have struggled to let go of antihomo- sexual prejudice that blocks pub- lic policy that would help HIV/ AIDS patients receive needed medical treatment. The number of people living with HIV/AIDS has increased steadily since 1978 and is now estimated at 490,696 people in the United States in 2008. The number of new HIV/AIDS infections per year in the United States has remained under 200,000, with 2011 numbers estimated at 50,000 new infections each year (CDC, 2012a). Although HIV/AIDS has spread to all American populations, the most affected popula – tion is African American homosexual and bisexual men. In 2009, this group made up 61% of all new HIV infections. Statistics for 2008 show this group accounting for 49% of the total number of Americans living with HIV/AIDS. Heterosexuals represented 27% of new HIV infections in 2009 and 28% of the population living with HIV/AIDS in 2008. HIV infections are on the rise among Latinos, with the 2009 estimate of new infections sh owing that Latino men are two and a half times more likely than Caucasian men to contract the disease (CDC, 2012a). Courtesy of Dan Moore/iStockphoto The number of HIV and AIDS patients in the United States has decreased as a result of public education about HIV and other sexually transmitted diseases. bur25613_01_c01_001-038.indd 26 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care In 2001, black non-Hispanics represented the highest rate of AIDS-related deaths with an estimated 8,041. White non-Hispanics were second with 4,501 estimated AIDS-related deaths. Hispanics were third with 2,882 estimated AIDS-related deaths in 2001 (CDC, 2012a). In 2008, the total estimated number of HIV/AIDS-related deaths for the United States was 17,374. Numbers from 2009 indicate that people age 40 to 44 years old had the highest number of new HIV/AIDS diagnoses at an estimated 5,689. Adults age 35 to 39 years old had the highest total number of people living with HIV/AIDS at an estimated 234,575 (CDC, 2012a). From 1999 to 2007, the rate of HIV-related deaths declined for people 45 to 64 years of age and people 18 to 44 years of age (see Figure 1.7). HIV-related deaths for children under age 17 remained steady. HIV-related deaths for people age 65 and over increased slightly through 2006 before declining in 2007. Figure 1.7: Rate of HIV-related deaths by age group The number of HIV-related deaths for people between the ages of 45 and 64 fluctuated some between 1999 and 2007, but a significant, steady decrease in HIV-related deaths was seen in people 18–44 years of age. U.S. Department of Health and Human Services (HHS). (2010). Retrieved from http://www.ahrq.gov/qual/nhqr10/Chap2a.htm bur25613_01_c01_001-038.indd 27 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Critical Thinking HIV/AIDS is a disease commonly associated with behaviors deemed socially negative (for example, homosexuality, illicit drug use, sexual promiscuity). How do you think public policy regarding medical treatment for HIV/AIDS patients would change if the disease were not associated with such behaviors? Are there other circumstances in which an individual might contract the disease that carry no socially negative implications? People Diagnosed With Mental Conditions Diagnoses of mental illness include psychosis, neurosis, depression, obsessive-compulsive disorder, bipolar disorder, schizophrenia, and other ailments connected with mental facul- ties. Mental disabilities include cognitive disorders and mental retardation. Nearly 50% of Americans surveyed claim to have experienced a mental health problem at one time or another. Estimates indicate that one-quarter of the adult population experience s some form of mental health disruption within a given year, though only 5.8% of cases are severe or debilitating (National Institute of Mental Health [NIMH], n.d.). A portion of the National Survey on Drug Use and Health’s (NSDUH) definition of seri- ous mental illness includes the substantial interference with daily life. The 2010 study found that approximately 5% of American adults were diagnosed with serious mental illness. Women were 3.1% more likely to have this diagnosis than men (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Young adults age 18 to 25 years old had the highest incidence rate, as shown in Figure 1.8. bur25613_01_c01_001-038.indd 28 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Figure 1.8: Incidence rates of mental illness by age in America in 2010 Diagnosis of mental illness occurs most frequently in young people, age 18–25. National Institute of Mental Health (NIMH). (2010). Prevalence of serious mental illness among U.S. adults by age, sex, and race. Retrieved from http://www.nimh.nih.gov/statistics/SMI_AASR.shtml The use of mental health services by adults increased from 12.8% in 2004 to 13.4% in 2008. Among adults age 18 and over, 13.7% used mental health services in 2010 (National Insti – tute of Mental Health [NIMH], 2012). Increased use of mental health services indicates a positive trend in access to those services; however, the increased suicide rate indicates an increased prevalence of mental illness in the population. The positive trend in services might be due to the negative trend in illness rates and not actually indicative of better resource access. Suicide- and Homicide-Liable People Suicide and homicide can be driven by the same social factors. A sense of being stuck in a hopeless situation leads people to a wide range of negative outcome s. Community resource programs that mitigate needs for safety, food, shelter, and education have a large influence on homicide rates in the communities where they function. Suicide rates have increased, from 11.08 suicides per 100,000 people in 2004 to 11.26 suicides per 100,000 people in 2007 (NIMH, n.d.). In 2010, 1 million adults reported making plans to commit suicide, and 1.1 million adults actually attempte d suicide (SAMHSA, 2011). Homicide refers to both murder and manslaughter. Murder is the term given to the pur – poseful, malicious killing of another person. Manslaughter is the killin g of another person due to negligence. In other words, intentionally causing a death, even if in the heat of the moment, is murder, whereas causing a death by hitting another car because you were tex – ting while driving is considered manslaughter. bur25613_01_c01_001-038.indd 29 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care The prevalence of homicides in the United States increased during the early and mid- 1990s. The total number did not fall below 18,000 until 1998 when data s howed 16,974 homicides during that year. Homicide rates have hovered between 15,000 and 18,000 since then (U.S. Department of Justice, 2012). People Affected by Alcohol and Substance Abuse According to the 2010 National Health Survey, 51% of legal adults use alcohol regularly. Simple alcohol and substance use differs from both abuse and dependence. Substance abuse indicates a maladaptive pattern of substance use that leads to significant impair – ment or distress. Substance dependence, on the other hand, indicates addiction, where an individual can develop tolerance, withdrawal, or compulsive drug-taking behavior. Both use and abuse/dependence can have negative health effects and increase a person’s health risk potential. Overall rates of alcohol and substance use and abuse hav e been declining slowly over the last four decades, though rates of certain drug abuse have increased. The country has experienced a small decrease in nonmedical drug use among all surveyed groups from 2002 to 2008. This is a positive change, as the 1990s saw an increase in illicit drug use for children ages 12 to 17. Marijuana use among high school seniors was 33.7% in 1980 and then declined for a period through 1991. In 1995, marijuana use rose drasti – cally to 21.2% and has declined only slightly since, to 20.6% in 2009. C ocaine use among high school seniors followed a similar trajectory. In 1985, the rate of cocaine use among this vulnerable age group was 6.7%. Since then, it has hovered between 1% and 2%, with a 2009 rate of 1.3% (see Figure 1.9) (U.S. Department of Health and Human Services, 2011a). bur25613_01_c01_001-038.indd 30 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Illicit drug use has declined only slightly for the age groups between 12 and 25, but the rate has remained almost constant for the age groups 26 and over. Center for Disease Control and Prevention. (2010). Retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf#061 In 2010, 50.9% of legal adults reported regular alcohol use, and 13.6% of respondents reported occasional alcohol use. There were 14,406 alcoholic liver disease deaths in the United States in 2007, and 23,199 nonaccident and nonhomicide alcohol-related deaths (CDC, 2012a). Figure 1.10 shows that alcohol use declined overall among high school seniors, with 72% in 1980 and 43.5% in 2009. Hard data is not available as to the reason for this decline, but it is thought to be due to more strict enforcement of laws regulating access to alcohol and community-based prevention programs. Figure 1.9: Substance abuse in the past month among persons 12 years of age and over bur25613_01_c01_001-038.indd 31 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Critical Thinking The Drug Abuse Resistance Education (DARE) program was founded in 1982 as an effort by law enforce- ment to educate adolescents about the hazards (both health and lifestyles) of illicit drug use. As dis – cussed earlier, there has been a measurable decrease in illicit drug use by adolescents. Do you believe that programs like DARE have had an effect on this reduction? If not, what other factors do you believe may be responsible? Figure 1.10: Alcohol use among high school seniors Overall, alcohol use among high school seniors has declined over the last three decades. Centers for Disease Control and Prevention (CDC). (2012a). Retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf#062 Emergency room reports provide many statistics on alcohol and drug abuse in the United States. These reports are made via the Drug Abuse Warning Network (DAWN), through the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. There were 4.6 million drug-related emergency department vis – its across the nation in 2009. Of these, approximately 50% were related to side effects of medications that were taken correctly. The rest included 27.1% related to nonmedical use of prescription drugs; 21.2% of DAWN-reported cases involved illegal drugs; and 14.3% involved drugs and alcohol combined (National Institute on Drug Abuse [NIDA], 2011a). bur25613_01_c01_001-038.indd 32 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Indigent and Homeless People Homeless people have an extremely high risk for negative outcomes. Homicide, suicide, mental illness, chronic illness, and acute illness all plague the homeless population. Hun- ger and exposure to the elements are the immedi – ate concerns government and community groups work to alleviate in the homeless population. Cre – ating positive, permanent outcomes for America’s homeless takes resources and an understanding of the people in need of aid. In 2009, an estimated 643,067 homeless people were both in shelters and on the streets on a given night. The Department of Housing and Urban Development (HUD) estimates that homeless numbers held steady from 2009 to 2010, but that the number of homeless families has increased in relation to the number of homeless individu – als (U.S. Department of Housing and Urban Development [U.S. HUD], 2011). HUD’s 2010 Annual Homeless Assessment Report to Congress found a decline in long-term homelessness, cred – ited largely to the Homelessness Prevention and Rapid Re-Housing Program. Immigrants and Refugees Immigration to the United States has increased in fits and starts since the year 1820, with some years seeing less immigration than others. Migrants obtaining legal permanent resident status in 2010 totaled 1,042,625 (U.S. Department of Homeland Security, 2010). Both legal and illegal migrants and refugees present unique challenges to America’s social welfare system. Language barriers strain resource delivery to the migrant population. Educators have developed English as a Second Language (ESL) programs to address the educational needs of migrant and refugee children. Health care organizations purposefully seek bilin- gual employees who communicate well with patients. Differences in ethical and social norms sometimes prohibit migrants from seeking assistance for housing, health care, and other needs. The United States office of Citizenship and Immigration Services oversees all legal immi – gration to the country. Programs exist for the naturalization of foreign-born adopted children, work visas, marriage, citizenship through naturalization, and for those seek – ing asylum. Legal immigration through the appropriate channels better enables resource delivery to migrant populations. However, legal immigration does not automatically give the foreign-born person the same access to publicly funded health care programs. Special programs exist for aiding refugees. Refugees are different from immigrants because they Courtesy of Richard Thornton/Shutterstock Of the more than half a million people who are homeless on a given night, a growing percentage of that number are families. bur25613_01_c01_001-038.indd 33 11/26/12 10:32 AM CHAPTER 1 Section 1.4 Defining Vulnerable Populations in American Health Care Critical Thinking In the United States, people hold very different attitudes toward immigrants and refugees. These atti- tudes range from the belief that illegal immigrants drain our resources and bring those that prey on them, such as drug dealers and con artists, to peaceful neighborhoods to the belief that by providing the needed resources, the common good will improve. Do you perceive that there is a benefit to providing these resources? are forced to flee their home country, as opposed to immigrants who come and leave freely. The federal Office of Refugee Resettlement (ORR) provides critical resources for refugees seeking asylum in the United States. Self-Check Answer the following questions to the best of your ability. 1. The ongoing telephone survey that collects anonymous information directly from patients is known as a. Survey Says. b. CDC’s Behavioral Risk Factor Surveillance System. c. System Support Network. d. Satisfaction Survey. 2. There are an estimated _________ new HIV infections every year. a. 75,000 b. 20,000 c. 38,000 d. 50,000 3. Diagnoses of mental illness include a. hypertension. b. urinary tract infection. c. obsessive-compulsive disorder. d. diabetes. Answer Key 1. b 2. d 3. c bur25613_01_c01_001-038.indd 34 11/26/12 10:32 AM CHAPTER 1 Case Study: Macro Perspective Versus Micro Perspective: The Patient Protection and Affordable Care Act of 2010 We have seen all of these principles of social theory in the debate over the Patient Protection and Affordable Care Act of 2010 (PPACA) (One-Hundred Eleventh Congress, 2010). The PPACA was signed into law by President Barack Obama and was his signature legislative project. Both President and First Lady Obama dedicated themselves to improving the health and access to health care of all Americans. The primary focus of the PPACA is to limit the power of the private health insurance companies to deny claims and coverage, to improve affordability of health care, and to expand the qualifications for Medicaid. The Pareto principle that the common good actually has a negative effect on some is at the heart of the debate. One side argues that reforming America’s health care system is vital for the public good. The opposition argues that the reforms called for in the PPACA will cost the collective a great deal but will benefit only a few. A similar but slightly different argument given is that a few will be forced to pay for the collective. Both of these arguments are based on the concept that the common good (in this case, reform of the health care system) is not good for all. Wrapped up in the economic concerns over the PPACA is the issue of individual rights versus the com- mon good. Americans worry that a single-payer system would take away individuals’ rights to select their own doctors and dictate their own course of health care. This concern is based on the macro versus micro dichotomy, as public policy works on a macro scale but greatly alters our micro influences. Chapter Summary A ny society that wants to call itself modern must recognize the populations most at risk of negative outcomes and provide resources to help create positive outcomes for these vulnerable groups. Doing so adds to the health and economic viability of the community. But an “all for one, and one for all” model does not always work on a large scale. Resource allocation must be done thoughtfully to create the most positive outcomes for the most people. Statistical data on vulnerable populations helps inform public policy decisions that equalize fairness as much as possible while providing for those in need. At a pivotal point in America’s history, following a recession that saw many people lose health care access, recognizing who is vulnerable and how to help them is key for improving the chances of positive outcomes for individuals and the community as a whole. Critical Thinking Why is it important for society to help ensure that the health care needs of the special populations described in this chapter are met? Are the methods of data gathering that are described able to provide enough information to enable well-informed and intelligent decisions by policymakers? bur25613_01_c01_001-038.indd 35 11/26/12 10:32 AM CHAPTER 1 Chapter Summary Self-Check Answer the following questions to the best of your ability. 1. For over a decade the infant mortality rate in the United States was a. 7.3 deaths per 7,000 births. b. 6.5 deaths per 1,000 births. c. 1.8 deaths per 3,100 births. d. 4.2 deaths per 4,000 births. 2. Marijuana use among high school seniors was a. 15.3% in 2003. b. 21.8% in 1987. c. 100% in 1936. d. 20.6% in 2009. 3. An estimated _______ elderly neglected their own care in 1996. a. 100,000 b. 2,300 c. 42 d. 7 million 4. Statistical data on vulnerable populations helps inform public policy de cisions that equalize fairness as much as possible while providing for those in need. a. True b. False 5. The CDC show that chronic disease is the cause of what percentage of U.S. deaths? a. 30% b. 50% c. 70% d. 85% 6. Overall rates of alcohol and substance use and abuse have been declining slowly over what period of time? a. the last year b. the last four decades c. the last four years d. the last century Answer Key: 1. b 2. d 3. a 4. a 5. c 6. b bur25613_01_c01_001-038.indd 36 11/26/12 10:32 AM CHAPTER 1 Self-Check Additional Resources Visit the following websites to learn more about the topics covered in this chapter: Louisville, Kentucky, Farm to Table program http://www.louisvilleky.gov/healthyhometown/farmtotable/ World Health Organization http://www.who.int/en/ The Centers for Disease Control and Prevention http://www.cdc.gov/ Web Exercise Choose one of the special populations mentioned in this chapter and research the prob- lems and suggested solutions about how industry will meet the needs of t hese popula – tions. Write a two-page paper with the following information: • population selected and why you chose that group •the barriers they face in accessing health care •proposed solutions to help remove or to remove those barriers •your thoughts on whether or not the solutions suggested are valid and an explana – tion of your position Select at least three reputable websites that explain your group’s problems in accessing health care and the proposed solutions. These websites must be reputable and reliable (no public editing such as Wikipedia or blogs). Your paper must meet APA standards. The final product will be double-spaced, Times New Roman 12-point font, with appropriate grammar and correct spelling. Be sure to include the websites you visited. bur25613_01_c01_001-038.indd 37 11/26/12 10:32 AM CHAPTER 1 Web Exercise Key Terms common good Social theory based on reciprocity and doing good for all society members. differential vulnerability hypothesis The theory that some people have more adverse reactions than others to negative life events. duplicate victim rate The number of child abuse incidents counted. human capital The amount of investment in a person’s potential. individual rights Social theory based on individuals’ choices and freedoms. macro influences Larger social and envi- ronment influences on our lives. manslaughter Killing another person due to negligence. micro influences Personal decisions and influences on our lives. murder The purposeful, malicious killing of another person. Pareto principle The theory that 80% of the outcome is caused by 20% of the effort. public policy Laws, regulations, and other government activities that dictate how society should function. relative risk The potential of imperfect health in groups exposed to risk factors in relation to the potential of imperfect health in groups not exposed to the same risk factors. social attitudes Positive or negative evaluations of people, places, things, and events that are shared by a majority of the community as a whole. social capital The measurement of per – sonal relationships in an individual’s life. social status A person’s place in society as created by personal characteristics, oppor – tunities, and rewards. unique victim rate The number of victim- ized children counted in child abuse cases. vulnerability A person’s risk level, based on factors such as environment, education, resources, and finances. bur25613_01_c01_001-038.indd 38 11/26/12 10:32 AM CHAPTER 1 Key Terms