Vulnerable Populations

See attached
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
• Identify the vulnerable populations in the United States.
Courtesy of Chris Bett/fotolia
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CHAPTER 1Introduction
Two 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 questions 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
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 are 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?
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CHAPTER 1Section 1.1 Social Theory and Public Policy in Health Care
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
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
Health is both an individual consideration and a community concern. In other 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 one 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 centered 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
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CHAPTER 1Section 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
• 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
However, the argument in favor
of passing legislation to pro-
mote the common good is based
directly on the preamble to the
• “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.
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CHAPTER 1Section 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 situations
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 are 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.
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CHAPTER 1Section 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
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?
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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations
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
How do we apply social theory to the study of vulnerable populations? First, 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 values
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
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CHAPTER 1Section 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
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Opportunities, rewards, and personal characteristics can be
attributed to an individual’s social status.
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CHAPTER 1Section 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.
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CHAPTER 1Section 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 visits 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 advancement, 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.
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CHAPTER 1Section 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 varying 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 social components.
Physical health deals with the body and bodily functions, mental health includes brain
functions such as thought and emotions, and social health includes interpersonal 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,
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CHAPTER 1Section 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
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CHAPTER 1Section 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 following:
• 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?
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CHAPTER 1Section 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 on,
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.
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
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CHAPTER 1Section 1.3 Statistical Data on Identified Vulnerable Populations
c. resources
d. ambulances
Answer Key
1. c 2. b 3. c
1.3Statistical Data on the Population Totals and Growth Trends
of Identified Vulnerable Populations
Public policymakers and health care researchers rely on statistical data from gov-ernmental or academic studies to inform decision makers on necessary changes 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 rise 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.
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CHAPTER 1Section 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 residence,
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
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.
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CHAPTER 1Section 1.3 Statistical Data on Identified Vulnerable Populations
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
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 1Section 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 WHO 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
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CHAPTER 1Section 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 all 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.
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CHAPTER 1Section 1.4 Defining Vulnerable Populations in American Health Care
is considered to be anything under 5.5 pounds. Proper prenatal care can mitigate the
risks of these negative outcomes by helping the mother ensure proper habits and nutri-
tion throughout the pregnancy. The earlier the mother receives regular prenatal care,
the lower the risk of negative outcomes for both her and the baby. But many vulnerable
women do not receive early prenatal care: The total percentage of mothers seeking health
care during the first trimester of pregnancy was 83.2% in 2006 (Henry J. Kaiser Family
Foundation [KFF], 2012a). There is a direct correlation 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 infant 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 total 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 1Section 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?
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CHAPTER 1Section 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
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,
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CHAPTER 1Section 1.4 Defining Vulnerable Populations in American Health Care
Neglect is the most common form of elder abuse; 36.7% of the perpetrators 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 assistance).
Next we turn to a discussion of partner or spousal abuse. Child and elder 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
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/
An estimated 2.1
million older Americans
experience some kind of
abuse during their elder
bur25613_01_c01_001-038.indd 23 11/26/12 10:32 AM
CHAPTER 1Section 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 violent 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 1Section 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
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, almost 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
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CHAPTER 1Section 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 showing
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.
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CHAPTER 1Section 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
bur25613_01_c01_001-038.indd 27 11/26/12 10:32 AM
CHAPTER 1Section 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 experiences 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 1Section 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
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 outcomes. 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 attempted 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 killing 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.
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CHAPTER 1Section 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 showed 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 have 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. Cocaine 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 1Section 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
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 1Section 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
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 1Section 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 1Section 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.
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 1Chapter Summary
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
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
Any 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
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 1Self-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 decisions
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.
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 1Web Exercise
Additional Resources
Visit the following websites to learn more about the topics covered in this chapter:
Louisville, Kentucky, Farm to Table program
World Health Organization
The Centers for Disease Control and Prevention
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 these 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 1Key Terms
Key Terms
common good Social theory based on
reciprocity and doing good for all society
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
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
Week 2 – Assignment
· DueJun 20by11:59pm
· Points17
Vulnerable Population Summary and Proposed Program
The first of your two written assignments for the course will provide a beginning framework that you will utilize in the development of your
Final Project: a proposal for a community-based program in your area. For this first written assignment, you will select one of the vulnerable groups identified in the text that will serve as your target population of interest throughout the duration of your next written assignment and Final Project.
Select one among the following groups from Chapter 1:
· 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
· Groups for special consideration (you may propose a different vulnerable population at the consent of the instructor)
Once you have selected a group of interest, write a three page paper that covers the following:
· Discuss the impact that at least two of the factors below have on the vulnerability of your chosen group:
· Age
· Gender
· Culture/Ethnicity
· Income
· Analyze the intersection of social, political, and economic factors affecting vulnerability (must address all three factors).
· Draft the design of a new model program, not currently existent within your community. Provide a two- to- three paragraph statement that introduces your proposed community program. This section is tentative and might change as you conduct more research. At a minimum, however, items to address should include:
· An explanation of the issues and risk factors experienced by the selected population.
· An evaluation of the health needs of the group and a proposed continuum of care level (preventive, treatment, or long-term care) based on the group’s issues, risk factors, and needs. Justify the proposed level with supportive research/evidence.
· A description of one to two proposed services your program will include.
Your assignment should be a minimum of three pages in length (excluding title and reference pages), and should include a minimum of three scholarly sources cited according to APA guidelines as outlined in the Writing Center.

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