HCA 430 Special Populations WK-1-D2

Ch. 2 Comparing Vulnerable Groups

Learning Objectives

After reading this chapter, you should be able to:

Explain the difference between curative and preventive approaches to health care.

Identify common factors among vulnerable populations.

Examine age as it relates to the concept of vulnerability.

Determine the ways in which gender contributes to vulnerability.

Discuss how culture and ethnicity affect vulnerability on both personal and population levels.

Explain the relationship between education and income levels, and vulnerability.

Introduction

The United States boasts one of the most robust health care systems in the world. It is statistically credited with the longer healthy lifetimes enjoyed by a majority of the American population. Advances in medical science and technology certainly improve medical interventions, but a recent change in the philosophy of medical care is credited with improving the population's health on a macro level. As the cost of health care in America soared during the 1990s and 2000s, the health care community's focus shifted from curative care to preventive medicine.

Curative medicine focuses on curing existing diseases and conditions. In contrast, preventive medicine works by educating the community on healthy lifestyle habits, such as regular exercise, nutritious food choices, and abstention from smoking. The idea is to prevent or forestall disease rather than wait until someone falls ill before providing treatment; however, living healthy lifestyles is still a personal choice. Studies indicate that preventive health care reduces morbidity, and that a preventive approach not only thwarts diseases that are associated with unhealthy choices, such as diabetes, heart disease, and cancer, but also creates strong immune systems to fight common illnesses like flu and cold viruses. Furthermore, people who do not get sick are more productive workers because they do not have as many sickness-related absences. This point is particularly important when considering vulnerable populations. For many people, especially those in the most at-risk groups, workdays lost to illness means days without pay. Financial instability detracts from a person's social status, which is a nonmaterial resource that contributes to vulnerability. Less social status means less access to community resources, such as health care and fresh foods. Lack of resource access leads to more illness, and so the cycle continues.

Many individuals have limited access to health care, which includes the inability to access medical clinics for reasons of proximity, the lack of insurance coverage, and financial constraints such as inability to pay for medical treatments. Preventive medicine focuses on educating people before they become ill, but resource accessibility restricts preventive medicine programs and responsive health care programs from reaching the most at-risk populations. Evidence of this is seen in data on topics like breast cancer diagnosis, where African American women have a higher mortality rate due in part to diagnosis at later stages. Just as determining who is vulnerable is vital to resource allocation, comparisons must be made between vulnerable groups in order to provide the right access at the right time to the right group. From this point, reactionary health care can lead to reinforcement of the principles of preventive health care, and sustainable lifestyle choices can be made to improve overall health.

Critical Thinking

Which methodology do you prefer, curative or preventive medicine? Why?

2.1 Common Factors

At each stage in the life cycle, different populations experience vulnerability differently. Infants, for example, who rely almost entirely on others for their physical and emotional needs, are more vulnerable than adolescents, who have achieved a certain measure of independence. Gender is also a factor when comparing vulnerability; because of the power differential between the two groups, men and women experience vulnerability in different ways. A person's cultural heritage or ethnicity is also a variable in terms of determining his or her level of vulnerability, as well as education and income level. It should be noted that subgroups within population groups also experience differing levels and types of vulnerability. Many people who are at risk for poor health outcomes fall into multiple categories: For example, a woman may also be homeless. In this sense, because she belongs to two vulnerable groups (she is a woman, and she is also a member of the homeless population), she is doubly vulnerable.

Vulnerable populations are often compared using statistical data. Studies frequently use four categories, or factors, to compare statistical trends across populations:

age

gender

culture and ethnicity

education and income levels

These factors allow researchers to compare groups within vulnerable populations as well as across vulnerable populations. Figure 2.1 illustrates cross-comparison data by race and age.

Figure 2.1: Cross-comparison of mortality by race and age

A bar graph illustrates youth mortality by race (White, Black, and American Indian) and age (each year from age 1 to 15).Youth mortality for Whites and Blacks peaks at age 1, generally decreases during childhood, and then increases as children become pre-teens and teenagers.Mortality for American Indians peaks at age 15, with a slightly lower mortality rate at age 1.

Mortality risk in juveniles is highest from ages 1 to 3, decreases during the elementary years, and then rises again at the start of adolescence.

Center for Disease Control and Prevention. (2010). Retrieved from http://www.cdc.gov/nchs/data/dvs/MortFinal2007_Worktable310.pdf

Critical Thinking

What vulnerable groups do you belong to? Describe the group and its vulnerability.

2.2 Comparing Vulnerable Groups by Age

Photograph of a grandmother and granddaughter smiling together.

Courtesy of Monkey Business/Fotolia

A person's age affects the type and extent of the vulnerability they face.

According to the U.S. Census Bureau, the median age in 2000 was 35.5. As the baby boomer generation reaches age 65, the median age in America will continue to rise. In fact, it is projected to be 39.1 in 2035 and then to decline very slowly in subsequent years as the baby boomer generation passes away (U.S. Census Bureau, 2012a).

Age is a crosscutting factor in all vulnerable populations. People experience vulnerability differently depending on age. Infants and children are among the most vulnerable of all populations because they rely entirely on others to provide for their physical and emotional needs. Adolescents and adults are less vulnerable because they are able to affect their circumstances and provide for some of their own needs. As older adults near the end of their lives, they once again become vulnerable as they rely on others for help with daily activities. Because they are more susceptible to chronic illnesses than people in other age groups, the elderly also have an increased need for medical care. Statistical data use appropriate, study-specific age ranges to help identify needs within vulnerable populations.

Vulnerable Mothers and Children

As discussed in Chapter 1, premature birth and low birth weight put infants at increased risk of health problems and death. Although factors such as ethnicity, education, and income levels do factor into the risk of low birth weight; maternal age is also closely linked to low birth weight risk. Mothers 10 to 14 years of age have the highest prevalence of low birth weight infants. Maternal age over 40 places second on the risk chart. Mothers between the ages of 25 to 29 years old show the least risk for having low birth weight babies.

Segregation and Teen Pregnancies

The prevalence of low birth weight occurrences in mothers under age 15 may partially be due to the reluctance of those mothers to seek appropriate prenatal care. Lack of a high school diploma is also tied to low birth weight, and mothers under age 15 have typically not completed high school. Mothers with unplanned pregnancies who negatively view their conditions also seek prenatal care later in the pregnancy. The urge to hide the pregnancy is common among mothers under age 15 (Kiely & Kogan, n.d.). Factors like education and attitude affect mothers in all age groups and are particularly prevalent in younger mothers.

It should be noted that the United States experienced a significant decline of nearly 30% in teen births from 1991 to 2005. In 2006 and 2007, the United States saw a small increase of 5% in teen births, but then the downward trend resumed in 2008 and 2009. These declines have occurred across all ethnic groups, signaling widespread positive attitudes about teen pregnancy prevention (Centers for Disease Control and Prevention [CDC], 2012a).

Over the same time period, more live births occurred to women of advanced maternal age, due in part to advances in reproductive technologies. The occurrence of multiple births increases with maternal age. While many reproductive technologies are known to carry a slightly increased risk of multiples, a woman's aging eggs also increase this risk.

Multiple births and complications (such as those resulting from an aging body that lacks as much elasticity as it did in youth) contribute to the increased rate of low and very low birth weight babies among mothers over age 40 (Martin et al., 2012).

Abused Individuals

Children and elderly people are more likely to suffer abuse than teens, young adults, and middle-aged adults. Children under the age of 3 years have the highest victimization rate (34%), with the rates decreasing as age increases. The reported abuse rate among children ages 4 to 7 is 23.4%. The rate for children ages 8 to 11 is 18.7%, followed by 17.3% for children ages 12 to 15. The abuse rate declines drastically from there to 6.2% for children ages 16 and 17. The rate of reported child abuse has declined steadily since 2006. This decline is due in part to states' alternative response programs and a decline in the number of Child Protection Services (CPS) investigations (U.S. Department of Health and Human Services, 2011b).

Elder Abuse

Adults over the age of 65 are particularly susceptible to abuse because the effects of aging often create a need for assistance with the activities of daily living. In fact, prevalence of abuse directly correlates with increased age.

Elder abuse takes many forms, including neglect, physical harm, and exploitation. As Figure 2.2 illustrates, neglect is the most commonly reported form of elder abuse. Verbal abuse and physical abuse follow in that order, with sexual abuse showing the lowest prevalence rate.

The U.S. National Center on Elder Abuse estimates that approximately 450,000 people over the age of 60 are victimized annually. Estimates are based on state numbers of reported and investigated incidents of abuse. It is unknown how many incidents actually occur each year because the majority of elder abuse takes place in private residences by victims' family members. Real rates of occurrence are suspected to be as high as five unreported incidents for each reported incident (U.S. National Center on Elder Abuse, 2005). Reports of elder abuse have increased significantly over the last few decades. This is likely due to America's aging population and a shift in the social attitudes of the current elderly population that encourages the reporting of abuse.

Figure 2.2: Rates of elder abuse by type

A pie graph illustrates the rates of elder abuse by type: neglect (61%), physical abuse (16%), exploitation (14%), emotional abuse (9%), and sexual abuse (0.3%).

Neglect accounts for the largest percentage of elder abuse.

Center for Disease Control and Prevention. (2010). Retrieved from http://205.207.175.93/HDI/TableViewer/chartView.aspx.

Domestic Violence

Women age 20 to 24 experience the highest prevalence of domestic abuse among adults; in fact, 85% of domestic abuse victims are women. Males under the age of 18 account for 10.7% of family violence assault victims. Approximately 62.4% of domestic violence offenders are over the age of 30. The percentage of spouse abuse offenders over age 30 is 73%. About 50% of abuse offenders who are in nonspousal relationships are in the 18 to 29 age range. This data signifies an age gap between domestic partner abuse victims and their offenders (Durose et al., 2005).

Chronically Ill and Disabled People

Chronic diseases are long-lasting and often incurable, as opposed to acute diseases, like the common flu, that are usually easily and quickly recovered from. Many chronic diseases are closely linked to disability and death. As the body ages, it deteriorates and chronic illnesses set in. Asthma is the most common chronic disease in children, and many children limited by asthma grow up to be only minimally affected by the disease. Other childhood diseases, such as diabetes, cystic fibrosis, congenital heart problems, and obesity, often have lingering effects that considerably impact health in adulthood. Disabilities that occur in childhood, such as losing the use of a limb, rarely change in adulthood.

Arthritis and osteoporosis are common in the 65 and over population, and both can seriously limit a person's mobility, quality of life, and activities of daily living. Obesity is classified as a chronic disease and is closely correlated with a propensity toward diabetes. Adults ages 65 to 79 had the highest incidence of diabetes diagnoses, but 2009 numbers show the population aged 45 to 64 years had the highest rate of new diabetes diagnoses (U.S. Department of Health and Human Services, CDC, and National Center for Health Statistics, 2012).

Cancer affects all age groups, but persons age 65 to 84 have the highest incidence rates overall. Children under age 20 have the highest rate of bone and joint cancers. Adults age 55 to 64 have the highest occurrence of cancers involving the eye and ocular orbit. Overall, cancer patients age 75 to 84 have the highest morbidity rate (U.S. Department of Health and Human Services, 2012).

People Diagnosed With HIV/AIDS

Children ages 13 to 14 have the lowest incidence of HIV diagnosis, with an estimated 21 total new HIV diagnoses for this age group in 2009. Adults ages 20 to 24 had the highest number of new HIV diagnoses in 2009 with an estimated total of 6,237 new diagnoses. People ages 13 to 29 years old comprised 39% of all new HIV diagnoses in 2009, the majority of which were ages 20 to 24 years old. The numbers are slightly different for new diagnoses of AIDS. In 2009, the Centers for Disease Control and Prevention (CDC) estimated 13 total new AIDS diagnoses for children under age 13 and 58 new diagnoses for teens age 13 to 14. Adults age 40 to 44 had the highest number of new AIDS diagnoses in 2009, at an estimated 5,689. In 2008, only seven children under age 13 diagnosed with HIV/AIDS died in the United States. Advances in antiretroviral drugs are prolonging the healthy life span enjoyed by HIV/AIDS patients. Public education programs on avoiding HIV are proving worthwhile as the rate of new HIV/AIDS diagnoses in the United States declines (CDC, 2012).

People Diagnosed With Mental Conditions

One common health problem that many HIV patients develop is HIV-associated dementia (HAD). Many elderly persons are affected by similar dementia conditions, including Alzheimer's disease. Serious mental illness (SMI) is any mental disorder that significantly interferes with daily life. Serious mental illnesses range in type, onset, and severity. The category includes mental illnesses such as bipolar disorder, major depression, and schizophrenia. Even including Alzheimer's disease in that category, the population age 50 and over has the lowest occurrence of SMI. Young adults ages 18 to 25 have the highest occurrence rate (National Institute of Mental Health [NIMH], 2012c). Even though a young adult may be diagnosed with a mental illness, this is a chronic condition and the person will still have the same diagnosis over the age of 50 and beyond. Symptoms may be controlled by medication but these patients are not "cured." Age of onset is an important factor for all mental disorders: One-half of the total number of mental health conditions begins under age 14 (NIMH, 2012b).

Suicide- and Homicide-Liable People

Suicide is linked to mental conditions. The National Institute of Mental Health (NIMH) found that people over age 65 are disproportionately liable to complete suicide. Of the general population, 11.3 people per 100,000 people committed suicide in 2007; persons 65 and older had a suicide rate of 14.3 suicides per 100,000 people. In contrast, suicide is the third leading cause of death for teenagers and young adults ages 15 to 24 (NIMH, 2012b).

Homicide offender and victimization rates by age are very similar, indicating that most homicides take place against the offenders' peers. Young homicide victims are more likely than those in other age groups to know their offenders. Young adults ages 18 to 24 have the highest homicide rate, a trend that has held steady for many decades, even as overall homicide rates have declined. The 1980s and 1990s saw a considerable increase in homicide rates in the 18 to 24 age group, while homicide rates in other age groups declined (U.S. Bureau of Justice Statistics, 2012).

Infanticide is the killing of children age 5 and under. Parents have the highest offender rate. Caucasians had the highest number of infanticide victims between 1976 and 2005, but African Americans had the highest per-capita incidence rate. Infanticide is most common in children under 1 year of age, and the risk of infanticide declines with age (NIMH, 2012c). Studies have found that most occurrences are by the mother. Domestic violence is often a contributing factor, as are poverty, mental illness, and substance abuse (Friedman & Resnick, 2007). Various factors contribute to the decrease in risk as a child ages. Stronger emotional bonds with parents may help decrease infanticide risk. Additionally, children become more social as they age, which may also increase safety.

Photograph of drugs (two lines of cocaine, two orange pills, a separate pile of cocaine, and another pile of a different drug) and a roll of cash in the background.

Courtesy of Aaron Amat/Fotolia

According to a 2009 survey, individuals as young as 12 sought treatment for drug and alcohol abuse.

Eldercide is the killing of persons age 65 and older. It accounts for about 5% of all homicides. The elderly are more likely than any other age group to be killed during the committing of a felony. Elder males are more likely than elder females to be eldercide victims. Eldercide rates have declined since 1976 from 5.4 eldercide victims per 100,000 people ages 65 and older, to 1.9 eldercide victims per 100,000 people ages 65 and older in 2005 (U.S. Bureau of Justice Statistics, 2012).

People Affected by Alcohol and Substance Abuse

Alcoholism is overuse of and dependence on alcohol. One of the earmarks of alcoholism is frequent binge drinking, measured as five or more drinks per occurrence. Adults report fewer binge drinking episodes per month than underage drinkers. College-age young adults between 18 and 20 report the highest level of binge drinking episodes in a month at a rate of 72%. Teenagers aged 15 to 17 are second, with a binge drinking reported rate of 65% (U.S. Department of Justice, 2002). Figure 2.3 shows the relationship between binge drinking episodes and age.

Figure 2.3: Binge drinking among youth and adult drinkers during last 30 days

A bar graph illustrates binge drinking among youth and adult drinkers during the last 30 days.The graph is divided into four age categories (ages 12-14, 15-17, 18-20, and adults), and those categories are subdivided to show the percent in each age group who engaged in binge drinking either at least one time or not at all.The adults engaged in binge drinking the least (57% did not binge drink at all in the last 30 days), while those 18-20 years old had the highest prevalence of binge drinking in the last month (72%).

Teenagers report more binge drinking episodes than adults.

U.S. Department of Justice. (2002). Retrieved from http://www.udetc.org/documents/Drinking_in_America.pdf

Substance abuse statistics in the United States indicate that children as young as 12 show a need for substance and alcohol abuse treatments. In 2009, 9.3% of the population age 12 and over sought treatment for substance and alcohol abuse (National Institute on Drug Abuse [NIDA], 2012). In 2003, people ages 18 to 25 had the highest incidence of illegal, or illicit, drug use. That rate dropped from 60.5% in 2003 to 56.6% in 2008. The age group of 26- to 34-year-olds had the highest illicit drug use rate of 58.2% in 2008, but 18- to 25-year-olds had the highest rates of current drug use of 19.6% in 2008 (NIDA, 2012).

Indigent and Homeless People

During the global recession caused by the collapse of the worldwide banking system in the early 2000s, the number of homeless families and children increased, though estimates are based on shelter reports and timed counts, and as such, it is difficult to estimate by exactly how much. From October 2009 to September 2010, children under the age of 18 accounted for 59.3% of the total number of counted homeless persons. Most homeless children enter shelters with their family units. Many homeless families are headed by mothers. This might be because 23.2% of homeless, indigent persons during the year were ages 18 to 30, a common age range for new maternity. People ages 31 to 50 who contribute significantly to the United States workforce accounted for 16.2% of the homeless population. Homelessness decreases with age, perhaps due to mortality rates.

Immigrants and Refugees

In 2006, the U.S. Department of Homeland Security (2006) listed adults age 30 to 34 as having the largest incoming immigration numbers, at 164,751 people. Adults ages 25 to 29 accounted for 146,551 immigrants to the United States. Teenagers 15 to 19 years of age made up 111,132 of total immigrants. Only 11,352 infants under 1 year of age immigrated during 2006. Figure 2.4 illustrates immigration to the United States by age group.

Figure 2.4: Immigration rate by age group in 2006

A bar graph illustrates the number of people who immigrated, broken into age groups.Those who were 30-34 years old immigrated in the highest numbers (more than 160,000), while people age 75 and over immigrated in the smallest numbers (less than 20,000).

Most people who immigrate to the United States do so between the ages of 25 and 40.

U.S. Department of Homeland Security. (2006). Retrieved from http://www.dhs.gov/files/statistics/publications/LPR06.shtm

Critical Thinking

Do the age groups in these categories surprise you? Did the fact that people over age 65 had a higher suicide rate than other groups surprise you? Or are you surprised that college-age young adults between 18 and 20 report the highest level of binge drinking episodes in a month at a rate of 72%? Explain your reaction.

2.3 Comparing Vulnerable Groups by Gender

Men and women experience vulnerability differently. Women are more likely to be the victims of domestic abuse and are more likely to head homeless family units. Men are more likely to experience violence. Men and women also experience health issues at differing levels. Even within an identified vulnerable population, men and women have different needs.

Vulnerable Mothers and Children

Photograph of a doctor taking a pregnant woman's blood pressure.

Courtesy of Comstock/Thinkstock

Pregnancy puts women at risk for developing health problems, but women already in at-risk groups have an even greater predisposition to experiencing problematic pregnancies.

The condition of pregnancy puts mothers at risk for negative health outcomes, though most pregnancies end with healthy mothers and infants. Mothers with other risk factors, such as poverty and ethnicity, experience more problems both during and after pregnancy. A discussion of high-risk mothers and babies based on gender focuses on infants, as the mothers are obviously women.

The total United States population in 1980 was 226,546,000 people. Out of that number, 110,053,000 were male, and 116,493,000 were female. In 2010, the total American population consisted of 151,781,000 males and 156,964,000 females. Thus, the trend of more females than males in the total population has continued. This is particularly interesting because slightly more males than females are born into the population each year. In fact, there were more male live births than female births in the United States for nearly three straight decades. In 2008, there were 105 males born for every 100 females. The data therefore indicates that males have a higher mortality rate overall than females (U.S. Census Bureau, 2012b).

Female babies have a longer life expectancy at birth of 80.6 years, in contrast to their male counterparts, who have an at-birth life expectancy of 75.7 years. The infant mortality rate for males is 6.72 deaths for every 1,000 males born. This is higher than the infant mortality rate for females, which is 5.37 deaths for every 1,000 females born (Central Intelligence Agency (CIA), 2012b).

Abused Individuals

According to the National Coalition Against Domestic Violence (n.d.), men are statistically more likely to be domestic violence offenders. In fact, females account for 85% of all intimate partner abuse victims. Male children who witness domestic violence are statistically more likely to become domestic violence offenders in their adulthood.

Child Abuse

Photograph of a young boy sitting in a corner with his legs curled up to his chest and using his hands to cover his face.

Courtesy of Ia_64/Fotolia

Male children account for 48.5% of child abuse cases.

Although more men are domestic violence offenders, more women abuse children. In 37.2% of child abuse cases, women were the sole, or independent offenders—compared with 19.1% of independent male offenders. Male children are statistically less likely to be victims of child abuse, at 48.5% of all child abuse cases, whereas female children accounted for 51.2% of child abuse cases (U.S. Department of Health and Human Services, 2011b).

Elder Abuse

As mentioned, there are slightly more women than men in the American population. This makes it difficult to determine the precise reason that women make up over half of the total number of elder abuse victims in the United States. It is possible that females may be slightly overrepresented in statistics on elder abuse by gender, partly because of the gap in age expectancy: The life expectancy is 75.7 years for males and 80.6 years for females. As women live longer, there is more opportunity for abuse.

Although women represent a higher incidence rate of elder abuse in nearly all categories, men have a higher rate of elder abuse by abandonment; overall, men have a higher offender rate of elder abuse. However, women represent a slight majority of elder abuse offenders by way of neglect. Similarly, women have a self-neglect rate of 65%, compared with the male self-neglect rate of 35% (U.S. National Center on Elder Abuse, n.d.).

Chronically Ill and Disabled People

According to the Centers for Disease Control and Prevention, in 2007, 20.3% of adult women had chronic illnesses, such as emphysema, and disabilities that make daily activities more difficult. Men had a slightly lower rate of 17.3%. Among the senior citizen population, 7.5% of women require help with activities of daily living, compared with 5.1% of men age 65 and over.

Specific chronic illnesses do not affect men and women at equal rates. Of adults over age 20, 11.8% of the total male population is diagnosed with diabetes, compared with 10.8% of the total female population. Heart disease is more common in the male population, at an occurrence rate of 12.7%. The rate of heart disease in the female population is lower, at 10.6%. Cancer is more prevalent among women, with 8.6% of the female population having had cancer at some point in their lives, compared with 7.9% of men (U.S. Department of Health and Human Services, 2012).

People Diagnosed With HIV/AIDS

Female heterosexuals account for 68% of new HIV diagnoses among heterosexuals. Of the total number of people living with HIV/AIDS in America, 75% are men. Men who have sex with men (MSM) have the highest group prevalence rate of 48% of all HIV/AIDS cases. At this time, there is insufficient data on the causal factors of HIV/AIDS among women who have sex with women (WSW).

In the total number of Americans living with HIV/AIDS, female injection drug users make up 26% and male injection drug users make up 16%. Overall, 72% of female HIV/AIDS patients contracted the disease through high-risk heterosexual activity. Just 13% of all males living with HIV/AIDS contracted it through heterosexual contact (Centers for Disease Control and Prevention, 2008b).

People Diagnosed With Mental Conditions

Overall, men and women report mental conditions at approximately the same rates. Women statistically suffer more serious mental disorders than men and have a higher incidence of internalizing disorders, or mental health conditions that cause emotional responses, such as anxiety and depression. Men have a higher rate of externalizing disorders, which lead to outward activities of destruction, such as drug abuse and antisocial behaviors (Thompson, 2008).

It is believed that social attitudes about gender roles and equality have much to do with the difference in mental disorders experienced by the genders. For example, social pressure about body image is proven to add to a woman's anxiety over her physique, which can lead to eating disorders. Likewise, social pressure over how a man "should" act encourages men to act out in response to anxiety instead of internalizing (NIMH, 2000).

The effects of social pressures on mental conditions explain the difference in condition types between the genders. This theory is furthered by the fact that men and women experience mental conditions that do not have a social component at equal rates. Bipolar disorder and schizophrenia each affect males and females at similar rates, and brain imaging tests have found that the brains of people with bipolar disorder are physically different from those with socially associated conditions such as depression (NIMH, 2012a).

Suicide- and Homicide-Liable People

Males have a higher suicide rate than females. In 2007, suicide was the seventh leading cause of death for men in the United States, and the 15th leading cause for women in the United States. In fact, although women have a higher rate of attempted suicides, men are nearly four times as likely as women to actually complete suicide. In addition, men and women choose markedly different methods when they commit suicide (NIMH, 2007). Figure 2.5 shows that men prefer firearms and women prefer poisoning.

Figure 2.5: Suicide method by gender

A bar graph illustrates three common methods of committing suicide (firearms, suffocation, and poisoning) and compares the rate at which each gender uses each method.Men use firearms much more than women to commit suicide (about 55% for men compared to 30% for women), while women use poisoning much more than men (40% for women versus about 12% for men).The rates at which men and women use suffocation to commit suicide are comparable and fairly even (near 20% for each gender).

Men and women commit suicide by suffocation at similar rates, but vastly differ in use of firearms and poisoning.

National Institute of Mental Health (NIMH). (2007). Retrieved from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

Men have significantly higher homicide offender and victim rates than women. Figure 2.6 shows the relationships between offenders and victims by gender. Numbers from 2005 indicated that men are four times more likely than women to be homicide victims. Men are more likely to kill other men, but women kill men at a higher rate than other women. This might be because women are more likely to be victims of other types of violent crimes, especially sex crimes and intimate partner abuse.

Male infants and elders are more likely than their female counterparts to be homicide victims. Females are significantly more likely to be victims of sex-related homicides. Social settings are a significant factor in homicide rates, as illustrated by the fact that 94.7% of gang-related homicides had male victims, compared with 5.3% female victims. Figure 2.6 shows the breakdown of homicide types by gender (U.S. Bureau of Justice Statistics, 2012).

Figure 2.6: Homicide offenders and victims by gender

A bar graph illustrates how homicide crimes are committed by gender, showing the number of male offenders with male victims (about 65%), male offenders with female victims (about 23%), female offenders with male victims (almost 10%), and female offenders with female victims (about 2%).

Most murders committed involve a male offender and male victim.

Bureau of Justice Statistics. (2005). Retrieved from http://bjs.ojp.usdoj.gov/content/homicide/teens.cfm

People Affected by Alcohol and Substance Abuse

Women report that they drink less alcohol and drink less often than men. In fact, women are almost twice as likely as men to be lifetime abstainers. Even so, alcohol abuse creates slightly different problems for men and women, and treatment methods thus differ for each gender.

Photograph of a long line of liquor bottles on a wooden shelf.

Courtesy of Ryan McV ay/Thinkstock

Women report that they drink alcohol less often than men and, when they do drink, tend to consume less than men.

Because women are more likely than men to have multiple, simultaneous addictions to alcohol and different drugs (Office of Substance Abuse Services [OSAS], 2004) and experience more barriers to addiction help via socioeconomics and health care access, they are more likely to seek treatment from general practitioners than from specialized treatment centers; they are therefore less likely to receive appropriate, addiction-specific treatment (Green, n.d.). Furthermore, because most women who seek substance abuse treatment are likely to have suffered physical or emotional abuse, and are more likely than their male counterparts to be of low socioeconomic backgrounds, treatments for women must address the specific issues that contribute to their substance abuse habits. Women seem to respond better to same-gender treatment centers and groups because the male influence affects the way women interact with each other and think about themselves. Therapists have found that all-female support groups often focus on emotional responses to events (such as childbirth), whereas all-male groups often focus on gaming, sports, or other activities. Men in mixed gender groups usually dominate the discussions, leaving the women with a lack of group support.

In general, women have better success and retention rates than men when they receive gender-specific treatments. However, researchers believe this is more about the relationships women build during group therapy programs than about the actual course of treatment (OSAS, 2004).

Indigent and Homeless People

Achieving an accurate count of the number of homeless persons in the United States is difficult. Statistics are based on reports from homeless shelters and counts taken by volunteers over specified periods. From October 2009 to September 2010, reported numbers of people in homeless shelters showed that males accounted for 62% of the total number of sheltered people, and females accounted for 38%. Males are also overrepresented, making up 80% of both transitional (or short-term) homelessness and episodic (or frequent) homelessness (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011b).

The number of family units experiencing homelessness rose in the early 2000s. Though males account for the majority of sheltered persons on a given night, females account for 77% of adults in sheltered families. Most families using shelters are made up of a mother, or other maternal figure, and two children, with no adult male. The number of homeless families is anticipated to decline to early 2000s levels as the global recession of the early 2000s to early 2010s abates (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011b).

Immigrants and Refugees

Males ages 18 to 34 represented 62% of the unauthorized immigrant population in 2010. In that same year, females dominated the 45 and over age group at 53%. Figure 2.7 shows the breakdown of unauthorized immigration to the United States in 2010 by age group and gender (Hoefer, Rytina, & Baker, 2011).

The gender trends for legal immigrants who gain permanent resident status are the opposite from those of unauthorized immigrants. Of the 1,042,625 people who gained permanent resident status in 2010 to the United States, 471,849 were male, compared with 570,771 females. The ratio of single to married persons in this group differs greatly by gender. Of the 471,849 men, 204,770 were single and 254,333 were married. Marriage was also more prevalent among females, though at a significantly higher incidence rate. Of the 570,771 women, 185,698 were single and 342,625 were married (U.S. Department of Homeland Security, 2011).

Many people immigrate to the United States to improve their lives through employment opportunities. As with most populations, legal immigrant males have a higher employment rate than their female counterparts. Less than half of the total number of new male permanent residents in 2010 were listed as not working, whereas more than half of the number of new permanent resident women were listed as not working. Female homemakers were more than 31 times more prevalent than male homemakers in this same population (U.S. Department of Homeland Security, 2011).

Figure 2.7: Total unauthorized immigration numbers by age and gender, 2010

A bar graph illustrates the total unauthorized immigrations by age and gender for 2010.Males and females ages 25-34 have the highest unauthorized immigration rates, while both males and females who are ages 55 and over have the lowest unauthorized immigration rates.

Unauthorized immigration is most prevalent in the 25–34 and 35–44 age groups. Of these unauthorized immigrants, slightly more are men.

U.S. Department of Homeland Security. (2006). Retrieved from http://www.dhs.gov/files/statistics/publications/LPR06.shtm

Critical Thinking

In 2010, the United States Census said that in the general population, there are 5,183 more women than men. Given the fact that 105 male children are born for every 100 female births, how would you explain the difference between more male births and fewer males in the adult general population?

2.4 Comparing Vulnerable Groups by Culture and Ethnicity

Minority groups in the United States are significantly more likely than members of the Caucasian majority to experience poverty due to insufficient health care, poor education, and an unmet need for social capital, human capital, and social status. Marriage/domestic partnership, for example, is just one factor that adds to a person's social capital. Marriage rates among 15- to 44-year-old female Hispanics and female non-Hispanic whites are around 50%, but non-Hispanic black females in this age range have a significantly lower marriage rate, at around 26%. It is interesting to note that across all ethnicities, individuals with bachelor's degrees or above have higher marriage rates than those with no postsecondary education (Goodwin, Mosher, & Chandra, 2010). Community programs often have difficulty meeting the needs of minority groups—an issue that cannot be solved simply by throwing more money at the problem. Nonprofit organizations within the United States might benefit more through cooperation and the sharing of resources, information, and the cessation of duplicate processes and systems.

Vulnerable Mothers and Children

Low income and a lack of health insurance contribute to a lack of early, quality, prenatal care. Minority populations account for a large portion of Americans living in poverty. This fact alone indicates that Hispanic, black, Native American, and other minority race mothers are statistically at a higher risk for poor maternity health outcomes (chronic health issues and low birth weight). During the prime childbearing age range of 15 to 44, marriage rates of female Hispanics and non-Hispanic white populations near 50%. Non-Hispanic blacks have a significantly lower rate. Mothers with paternal support are more likely to seek early and regular prenatal care, which increases their chances for positive outcomes for both mother and baby.

Infant Mortality

Poor prenatal health care increases the risks of infant and maternal mortality. There are approximately 2.5 infant deaths per 1,000 full-term live births in the United States. Out of that number, Asians and Pacific Islanders have the lowest infant mortality rates. Non-Hispanic whites experience infant mortality at 2.29 deaths per 1,000 live births. Non-Hispanic blacks' infant mortality rate is 67% higher than their white counterparts, with 3.82 deaths per 1,000 births (MacDorman & Mathews, 2011). Prenatal care levels and maternal lifestyle choices are cited as the main reasons for these differences.

Photograph of the profile of a young pregnant woman wearing a striped T-shirt and standing against a white background.

Courtesy of yurmar y/Fotolia

Infants born underweight are especially prevalent in teen pregnancies.

Sudden infant death syndrome (SIDS) is the unexplainable death of an infant any time before the first birthday. The 2006 SIDS rate in the United States was 0.53 occurrences per 1,000 live births. Out of that number, Native Americans and Alaska Natives had the highest prevalence, while the SIDS rate for non-Hispanic whites falls in the middle of the spectrum (Mathews, Menacker, & MacDorman, 2003).

Contributing factors to infant mortality include maternal health and low birth weight. Non-Hispanic blacks have the highest low birth weight prevalence at 13.6%. This is significantly higher than other ethnic groups. Hispanics have the smallest prevalence of low birth weight at 6.9%. Non-Hispanic whites fall in between blacks and Hispanics with a prevalence of 7.2% (MacDorman & Mathews, 2011).

Maternal Mortality

The 2007 maternal mortality rate in the United States was 12.7 deaths per 1,000 live births. Non-Hispanic blacks have the highest maternal mortality rate with 28.4 deaths per 1,000 births. This trend continues to plague health care researchers and the non-Hispanic black community as they search for ways to lower it. Non-Hispanic whites have the second highest maternal mortality rate at 10.5 deaths per 1,000 births, and Hispanics have the lowest at 8.9 deaths per 1,000 live births (Xu, Kochanek, Murphy, & Tejada-Vera, 2010).

Teenage Mothers

Teenage mothers have special prenatal and postnatal health needs. Teen mothers have a higher rate of low birth weight infants than most other age groups. The teen birthrate in the United States in 2009 was 38 births for every 1,000 teenagers 15 to 19 years old. Figure 2.8 shows the breakdown of teen births by ethnic group. Hispanic teens continue to have the highest teen birthrate, with non-Hispanic blacks having the second-highest prevalence rates (CDC, 2012).

Figure 2.8: U.S. birth rates for women aged 15–19 years by race/ethnicity

A line graph depicts the U.S. birth rates for women ages 15-19 for each year from 2005 to 2009 divided by race/ethnicity (White non-Hispanic; Black non-Hispanic; American Indian/Alaska Native; Asian/Pacific Islander; and Hispanic).Hispanic women had the highest birth rate for each of the five years (measured by live births per 1000 females in the age group), followed by Black non-Hispanic women, American Indian/Alaska Native women, White non-Hispanic women, and finally Asian/Pacific Islander women.

Hispanic and black women have the highest rate of teen pregnancy.

Centers for Disease Control and Prevention. (2010a). U.S. birth rates for women aged 15–19. Retrieved from http://www.cdc.gov/teenpregnancy/LongDescriptors.htm

Abused Individuals

Native Americans and Alaska Natives experience significantly higher domestic abuse rates than any other ethnic group in the United States. However, some researchers believe that factors such as personal interpretation of abuse and cultural attitudes regarding reporting abuse may alter the statistics. Asians and Pacific Islanders have the lowest incidence rate, while Caucasians and African Americans have similar rates in the middle of the spectrum (Tjaden & Thoennes, 2000). Figure 2.9 offers the rates of domestic abuse by ethnic group.

Figure 2.9: Domestic partner abuse rates by abuse type and ethnic group

A bar graph depicts domestic partner abuse rates by abuse type (rape, physical assault, and stalking) and ethnicity (White non-Hispanic, Black non-Hispanic, American Indian/Alaska Native, and Asian/Pacific Islander).American Indians/Alaska Natives had the highest percentage of persons victimized by an intimate partner in a lifetime in each of the three abuse categories (about 16% for rape, about 31% for physical assault, and 10% for stalking).Asian/Pacific Islanders had the lowest percentage in each of the three categories (about 4% for rape, about 13% for physical assault, and about 4% for stalking).

American Indians/Alaska natives have more victims of rape, physical assault, and stalking than any other ethnic group.

U.S. Department of Justice. (2010).

Child Abuse

Though Native Americans and Alaska Natives have the highest domestic partner abuse rates, they have very low child abuse rates. Caucasian children have a higher prevalence of child abuse, at 44.8%, than other ethnic groups in the United States. Child abuse rates for African Americans and Hispanics are close: 21.9% and 21.4%, respectively. Figure 2.10 shows that about half of child abuse offenders are Caucasians. Child abuse offender rates by ethnicity follow the same trends as the victim rates (U.S. Department of Health and Human Services, 2011b).

Figure 2.10: Child abuse offenders by race and ethnicity

A bar graph depicts the percentage of child abuse offenders by race and ethnicity (American Indian/Alaskan Native, about 2%; Asian, about 2%; Unknown, about 9%; Hispanic, about 19%; African American, 20%; and White, about 49%).

Conversely, American Indians/Alaska Natives make up less than 5% of all child abuse perpetrators, whereas whites make up nearly 50%.

U.S. Department of Health & Human Services. (2010). Retrieved from http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf

Elder Abuse

According to the 2004 Survey of Adult Protective Services, 77.1% of reported elder abuse victims are white and 21.2% are African American (U.S. National Center on Elder Abuse, 2006). Whites have the highest prevalence for abuse by neglect, emotional abuse, physical abuse, and financial abuse. Blacks are around 15% more likely to abuse by abandonment (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Aging, 1998).

Chronically Ill and Disabled People

Hawaiians and Pacific Islanders have the highest prevalence of diabetes, at 23.7%. African Americans have the highest rate of kidney disease, at 2.8%. Native Americans have the highest prevalence of multiple chronic diseases, including ulcers (9.9%), liver disease (2.6%), arthritis (25.5%), and chronic joint symptoms (33%). The difference in chronic disease prevalence among ethnic groups is partially due to genetics, but the effects of socioeconomic situations and lifestyle choices cannot be ignored (Schiller, Lucas, Ward, & Peregoy, 2012).

People Diagnosed With HIV/AIDS

African Americans are by far the ethnic group most affected by HIV in the United States. Caucasians represent a distant second in total number of HIV diagnoses. However, the gap is much smaller in the number of diagnosed AIDS cases. Figure 2.11 shows the relationship between HIV and AIDS cases by affected ethnic groups (CDC, 2008).

Figure 2.11: Estimated diagnosis of HIV and AIDS by ethnic group

A bar graph illustrates the estimated diagnosis of HIV and AIDS by ethnic group in 2009.Blacks/African Americans had the highest number of estimated HIV infections (about 21,000) and the highest number of estimated AIDS infections (about 17,000).Whites followed with about 12,000 HIV and about 9,000 AIDS infections.Hispanics/Latinos had about 8,000 HIV and 7,000 AIDS infections.Those who are multiple races, Asian, or American Indian/Alaska Native had very small infection rates, and Native Hawaiians/Other Pacific Islanders had no estimated infections of either HIV or AIDS.

Diagnosis of HIV and AIDS is extremely low in American Indian/Alaska Natives, Asians, Native Hawaiians, and those of multiple races.

U.S. Department of Health & Human Services. (2010). Diagnoses of HIV infection by race/ethnicity. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/basic.htm#hivaidsrace

U.S. Department of Health & Human Services. (2010). AIDS diagnoses by race/ethnicity. Retrieved from http://www.cdc.gov/hiv/topics/surveillance/basic.htm#aidsrace

People Diagnosed With Mental Conditions

Individuals listed as having family history from more than one race have the highest occurrence of serious mental illness (9.3% overall occurrence rate). Native Americans and Alaska Natives have the second highest serious mental illness rates at 8.5%. The serious mental illness rate for Caucasians is in the middle of the range (5.2% incidence rate), and African Americans are nearer the low end of the spectrum with an incidence rate of 4.4%. Native Hawaiians and other Pacific Islanders have the lowest occurrence of mental illness at a rate of 1.6% (SAMHSA, 2012).

Suicide- and Homicide-Liable People

Native American and Alaska Native males have the highest suicide rate of 27.61 per 100,000 in the population, followed by non-Hispanic white males with 25.96 suicides per 100,000 people of that population. Asian males have the lowest suicide rate among their gender with fewer than 10 suicides per 100,000 population, and non-Hispanic black females have the lowest suicide rate of their gender with approximately 2 suicides per 100,000 people (CDC, 2012b).

Most homicides have the same gender offenders and victims. African Americans have a higher incidence of felony murders, drug-related homicides, and homicides as a result of arguments. Caucasians have higher rates of infanticide and eldercide, and are more likely to involve multiple victims. For suicide, Caucasians use poison at a significantly higher rate than African Americans, though African Americans are only about 15% more likely than Caucasians to use guns (U.S. Bureau of Justice Statistics, 2012).

People Affected by Alcohol and Substance Abuse

According to the Substance Abuse and Mental Health Services Administration, alcohol use is most prevalent among Caucasians with over 50% reporting alcohol use in the past month. Hispanics have the highest rate of binge drinking at 25.1%, though Caucasians have the highest rate of heavy alcohol use. Figure 2.12 illustrates the prevalence of alcohol use by ethnicity and amount (2011b).

Figure 2.12: Alcohol use among persons aged 12 years or older by race/ethnicity, 2010

A bar graph illustrates alcohol use in 2010 by those age 12 or older by ethnicity (White, Black or African Americans, American Indian or Alaska Native, Asian, or Hispanic or Latino) and subdivides these categories by amount (current use, binge use, and heavy use).Whites have the highest overall use (about 57% total), followed by Blacks or African Americans (about 43%), Hispanics or Latinos (about 42%), Asians (about 39%), and American Indians or Alaskan Natives (about 37%).Whites also have the highest current alcohol use (32%) and heavy alcohol use (8%), but Hispanics have the highest binge use of alcohol (about 20%).

Total alcohol use is similar across non-white races; however, type of use varies greatly within that total.

U.S. Department of Health & Human Services. (2010). Retrieved from http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#3.1.4

African Americans have the second-lowest heavy alcohol use rate but the highest rate of illicit drug use with 10.7% reporting having used illegal drugs within the last month. Drug use went up for all groups except Asians during the period from 2002 to 2010 (SAMHSA, 2011b).

Indigent and Homeless People

Understanding the ethnic composition of the indigent population you are trying to serve informs decisions from staffing to programming. In general, the homeless population represents the ethnic makeup of the city in question. For example, Chicago, Illinois, is likely to have a higher percentage of African Americans in homeless shelters than Bowling Green, Kentucky.

The Substance Abuse and Mental Health Services Administration (SAMHSA) uses reports from shelters and temporary housing to count the number and demographics of homelessness in America. According to SAMHSA, a slight majority of all counted homeless persons are non-Hispanic whites, followed closely by blacks. Figure 2.13 illustrates the percentage that each ethnic group represents in the total number of counted homeless persons.

Figure 2.13: Ethnic group representations in the homeless population

A pie graph illustrates the percentage of the homeless population based on ethnicity.The homeless population is 47% White, 42% Black or African American, and 11% Hispanic or Latino.

A majority of the homeless population is either white or black, with Hispanics and Latinos making up little more than a tenth of the population.

U.S. Department of Health & Human Services. (2010). Retrieved fromhttp://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf

Immigrants and Refugees

Immigration to the United States is largely based on political and economic strife in other parts of the world. People move to the United States to flee war and poverty, to be with family, and to seek employment and upward mobility. In other words, the ethnic composition of new immigrants to the United States during a certain period largely reflects those areas of the world where political and economic strife is at its highest levels. For example, America experienced a considerable increase in the number of Asians seeking permanent residency after the Vietnam War ended in the 1970s. The 1980s saw an increase in immigrants from the Americas, seeking escape from the guerilla warfare plaguing both Central and South America at the time. In the 1990s, the ratio of immigration by country of origin changed again, this time to people fleeing civil wars in parts of Europe and Africa. Immigrants fleeing Mexico's drug war and Caribbean poverty accounted for the highest numbers of immigrants to the United States in the early 2000s.

Critical Thinking

In this section, you read about how the different cultures and ethnicities span a broad range of statistics and special health needs. African Americans are the most affected by AIDS/HIV but have the lowest alcohol use, whereas Asians/Pacific Islanders have the lowest infant mortality rates. Native Americans and Alaska Natives have the highest domestic abuse but the lowest child abuse rates. Do you believe that cultural values have an impact on these statistics?

2.5 Comparing Vulnerable Groups by Education and Income Levels

Education and income are part of the investment in people called "human capital." An evident income, resource, and health gap exists between people who have completed high school or the equivalent and people who have not. Another gap exists between people with high school diplomas and GEDs and people with college educations. The more education a person achieves, the higher that person's earning potential becomes. For example, the average income for households with some high school education but no diploma or GED is $25,604 per year. The number rises significantly to $39,647 with the completion of high school. Figure 2.14 shows the direct relationship between household income and completed level of education. In general, education leads to better, longer-lasting jobs and social relationships.

Figure 2.14: Relationship between education level and household income

A line graph illustrates that with each formal education milestone that a person completes (high school graduate, some college with no degree, associate's degree, bachelor's degree, etc.), their total household income generally increases.A person with less than a 9th grade education earns about $21,000 per year, while a person with a doctoral degree earns about $120,000 annually.

Household income increases as education level increases up to the professional degree level, then decreases slightly at the doctoral level.

U.S. Census. (2009). Educational attainment of householder. Retrieved from http://www.census.gov/compendia/statab/2012/tables/12s0692.pdf

Vulnerable Mothers and Children

Photograph of a doctor performing an ultrasound on a pregnant woman's abdomen.

Courtesy of Engine Images/Fotolia

Babies born to educated mothers have lower incidence of infant mortality compared to infants born to less-educated mothers.

The rate of Americans failing to obtain needed health care, dental care, and prescription drugs because they are unable to afford them is on the rise. This situation particularly affects mothers and infants during one of the most high-risk times of their lives. There is a direct inverse relationship between infant mortality and maternal education level. Infant mortality rates decline with each level of education gained. The low birth weight rate follows the same inverse relationship. The likelihood of breastfeeding increases with maternal education level (Mathews & MacDorman, 2007).

Abused Individuals

Much like education and income level, there is an inverse relationship between domestic abuse reports and income. Women in poverty are more likely to call upon the police to intervene in domestic disputes, or have the police called on their behalves. Women on government assistance programs are three times as likely to suffer domestic violence as women in middle income brackets. Women in households with an annual income under $7,500 are five times as likely to be involved in domestic abuse (Sampson, 2007).

Child abuse follows a similar pattern to that of partner abuse. Children in households of less than $15,000 annual income have a 22% higher likelihood of experiencing abuse and neglect than children in households with double the income. Poverty alone is not responsible for the higher prevalence of child abuse and neglect. Common problems in impoverished neighborhoods, such as substance abuse, low education levels, and inadequate housing, are also contributing factors (U.S. Department of Health and Human Services, Administration for Children and Families, 2003). Elder adults with an annual income of $5,000 to $9,999 have the highest elder abuse prevalence in all abuse categories (U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Aging, 1998).

Chronically Ill and Disabled People

Poor socioeconomic conditions include inadequate housing, lack of financial income, lack of a strong social support network, and poor access to fresh foods and social services like health care. Although chronic illnesses and disabilities do not necessarily strike people in low socioeconomic situations, the people in those situations are more adversely affected by chronic ailments.

Lack of affordable, accessible health care means that patients of low socioeconomic status are less likely to receive proper care for their ailments. Their quality of life is likely to be more adversely affected than those who have stronger familial ties and personal relationships. Add to these challenges the fact that many people in poverty-stricken areas have the types of jobs that are not flexible or kind about missed work, and the situation becomes even more dire. The American health care system relies on individuals to pay for treatment, and chronically ill and disabled people with low income and education levels are disproportionately affected.

People Diagnosed With HIV/AIDS

As with most health outcomes, HIV/AIDS prevalence increases as education and income decrease. Both African-American and Hispanic populations in low-income areas have an HIV prevalence rate of 2.1%. The HIV prevalence rate for Caucasians in low-income areas is below 2%. These numbers are significant when compared to the overall HIV prevalence rates of these populations. The overall HIV prevalence rate among African Americans is 1.7%. The Hispanic population has an overall HIV prevalence rate of 0.6%; and the Caucasian population has the lowest overall HIV prevalence rate of 0.2%. There are more African Americans and Hispanic people living in poverty than Caucasian people, which does account somewhat for the higher HIV prevalence rates in low-income areas. However, the numbers signify that HIV prevalence rates are higher overall and in each population among the poor (Denning & DiNenno, n.d.).

People Diagnosed With Mental Conditions

A study announced in the July 25, 2011, issue of BMC Medicine found that people in France, the United States, the Netherlands, and other first-world countries suffer depression at some point in their lives at a rate of 15% for the entire population, in contrast to people in less affluent countries, who suffer depression at a rate of 11% (U.S. Department of Health and Human Services, 2011b).

Within the United States, mental illness is more commonly associated with poverty than wealth. Poor living situations can induce depression and anxiety, making this type of mental condition more prevalent among low-income populations. People with debilitating mental illnesses often have difficulty maintaining gainful employment. As such, there is a high occurrence of individuals with severe mental illness seeking government aid (U.S. Public Health Service, 1999).

Suicide- and Homicide-Liable People

Photograph of a teenage girl sitting on the ground against a wall with her legs curled up to her chest, her arms resting on her knees, and looking sad.

Courtesy of Mitarart/Fotolia

Exposure to violence and substance abuse increase a person's risk of homicidal or suicidal behavior.

Both suicide and homicide are linked to exposure to violence and substance abuse. Even if a person does not personally have a history of exposure to violence and substance abuse, if those problems are persistent in the areas they live, then the individual's risk of homicide and suicide increase. Both studies and police report higher levels of suicide and homicide in areas of low socioeconomic standing (Macomber & Pergamit, 2009).

People Affected by Alcohol and Substance Abuse

Unlike so many of the topics covered here, where positive outcomes increase as education level rises, alcohol use increases as education level rises. College graduates have a regular alcohol use rate of 69.1%. The regular alcohol use rate for adults who did not finish high school is 36.8%. Young adults age 18 to 22 who are enrolled in college full-time have a binge drinking rate of 44.2%, whereas people in the same age group who are not enrolled in full-time college have a binge drinking rate of 35.6%. Average alcohol use is higher for adults with full-time jobs, but binge drinking and heavy alcohol consumption are higher among the unemployed/underemployed (SAMHSA, 2011b).

Substance abuse decreases with education level. Adults with college degrees have a substance abuse rate of 7.3%. Those who finished high school but did not continue on to college have a substance abuse rate of 8.3%. The rate jumps to 10.6% for those who do not finish high school. Employment level and substance abuse are also inversely related; substance abuse rates increase as employment levels decrease. Adults with full-time employment have a substance abuse rate of 8.9%. The rate for part-time employees is 10.9%. The rate of substance abuse by the unemployed is 15.7% (SAMHSA, 2011b).

Indigent and Homeless People

Homelessness is directly related to poverty. The global recession of the early 2000s caused a rise in unemployment, and the number of homeless persons who all too recently were relatively affluent increased significantly. The recession also created an increase in homeless persons who were underemployed.

Indigence and unemployment often create a cycle that can mire individuals. Without access to toileting and personal grooming facilities, it is difficult to present a clean appearance for job interviews. Organizations such as Dress for Success and government programs exist to help persons who are unemployed and homeless attain employment, through outreach to improve grooming and professional appearance.

Immigrants and Refugees

The Center for Immigration Studies reported in 2002 that 11.5% of the United States' total population was composed of immigrants. At that time, 30% of U.S. immigrants lacked a completed high school education. Immigrants are two-thirds more likely than U.S. natives to live in poverty. The poverty rate for natives in 2002 was 10.6%, whereas it was 17.6% for immigrants. At that time, 24.5% of immigrant families utilized government aid (Camarota, 2002). Figure 2.15 illustrates that the ratios haven't changed much in a decade and that naturalized U.S. citizens have a lower poverty rate than noncitizens (U.S. Census Bureau, 2012b).

Figure 2.15: Poverty rates by U.S. citizenship

A bar graph illustrates poverty rates by U.S. citizenship status (native, naturalized U.S. citizen, and not a U.S. citizen).Those who are not U.S. citizens have a higher poverty rate (about 28%) compared to native U.S. citizens (about 15%) or naturalized U.S. citizens (about 11%).

Poverty rates among native and naturalized citizens are similar; however, immigrants are almost three times as likely to live in poverty as American citizens.

U.S. Census Bureau. (2012). Poverty status of population by sex, age, nativity, and U.S. citizenship status: 2009.

Critical Thinking

This chapter discussed the direct relationship between levels of education, income, and health care. Many of the examples showed immediate relationships between these factors. Do you agree with the conclusion that low income is directly related to poor-quality health care?

Case Study: Health Care Access for Indigents and Women Blocks Hospital Merger

In 2011 a merger was proposed among health care providers operating in Kentucky that would combine Jewish Hospital Healthcare Services, Inc., CHI Kentucky, Inc., Catholic Health Initiatives, University Medical Center, Inc., Jewish Hospital & St. Mary's Healthcare, Inc., Flaget Healthcare, Inc., St. Joseph Health System, Inc., and JH Properties, Inc. The intention of the merger was to create a statewide united health care system (named Kentucky Statewide Network) and consolidate the finances of the organizations to rescue those within the group that were struggling.

Concerns about the merger were raised on the basis that the University of Louisville Hospital, managed by the nonprofit organization University Medical Center, Inc. (UMC), is a publicly owned teaching hospital. As such, the hospital is a public safety net resource, responsible for providing health care access to all persons, including indigents and others who are unable to pay for services. Though all hospitals are legally bound to provide medical care to all people, the merger brought up concerns that financial pressure would limit the hospital from continuing as a public health safety net.

Additional concerns about the merger involved the politically charged and belief-based topic of women's reproductive rights. With the exception of the hospital and UMC, Inc., all organizations involved in the proposed merger were already governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs). ERDs prohibit certain procedures, including tubal ligations, abortions, and fertility treatments. Under the merger agreement, the publicly funded hospital system and all of its affiliates would also be subject to these restrictions.

Merger proponents claimed that reproductive procedures would be moved off hospital property to other nonaffiliated health care offices. Opponents of the merger argued that the female indigent population would be particularly affected by the new restrictions; as they already lacked health care access, forcing them to go elsewhere for reproductive-related services was both physically and financially restrictive for this vulnerable group.

In the end, Kentucky Governor Steve Beshear refused to allow the merger on Attorney General Jack Conway's (2011) recommendation that the merger be blocked based on accessibility and other concerns regarding the hospital. The merger passed in 2012, without the inclusion of the University of Louisville Hospital and University Medical Center, Inc.

Chapter Summary

It is not enough to talk about vulnerable populations as separate groups with separate problems, risk factors, and needs. All vulnerable groups share many factors, including gender, age, ethnicity, and socioeconomic status. The data helps us to understand what makes these groups vulnerable and who the people we call vulnerable are. Poverty is a significant factor for all vulnerable groups because it limits access to resources that have the potential to improve the affected people's quality of life.

Critical Thinking

Vulnerable groups often share many common factors. Do you think there is one single predominant factor that makes groups vulnerable?

Additional Resources

Visit the following websites to learn more about the topics covered in this chapter:

Robert Wood Johnson Foundation

http://www.rwjf.org/vulnerablepopulations/

The World Health Organization

http://www.who.int/en/

Urban Institute: Health Policy Center on Vulnerable Populations

http://www.urban.org/health_policy/vulnerable_populations/index.cfm

Web Exercise

Choose one of the vulnerable populations mentioned in this chapter, and research the problems and suggested solutions about how industry will meet the needs of these populations. Write a two-page paper with the following information:

population selected and why you chose that group

a description of what makes them vulnerable

the barriers they face in accessing health care

proposed solutions to assist or remove barriers

your thoughts on whether or not the solutions suggested are valid and an explanation 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.

Key Terms

Click on each key term to see the definition.

alcoholism

binge drinking

curative medicine

eldercide

episodic homelessness

externalizing disorders

infanticide

internalizing disorders

preventive medicine

serious mental illness (SMI)