Focus on two selected groups:

·  Vulnerable mothers and children

·  People affected by alcohol and substance abuse

Review: the video segments titled “Premature Babies: Risks and Costs” (Vulnerable Mothers and Children group) and “Social Cost of Alcohol Abuse”, People Affected by Alcohol and Substance Abuse group, and attached chapters.

Write: For each segment, select three specific factors from Chapter 2 attached (e.g., age, gender, culture, ethnicity, education, and income) that are present.

·  Reflecting on your experiences and knowledge gained in previous courses, discuss how these factors relate to the group’s vulnerability.

 

·  Based on the selected factors, assess the health care needs that can be inferred for each group. Discuss which approach(es) to care from Chapter 4, Section 4.1 (i.e., preventive, treatment, or long term), might help address them.

https://youtu.be/Bbn5pV_02bA

Burkholder, D. M., & Nash, N. B.  (2013). 

Special populations in health care

[Electronic version]. Retrieved from

https://content.ashford.edu/

Post  should be 250 to 300 words . Your research and claims must be supported by attachments  and at least one other scholarly source.  Use proper APA formatting

Due 1/23/20 @10am Eastern w/plag report

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.

Courtesy of Fuse/Thinkstock

bur25613_02_c02_039-078.indd 39 11/26/12 10:31 AM

CHAPTER 2

Critical Thinking

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

Introduction

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, pre-
ventive 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 pre-
vent 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 vulner-
ability. 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 con-
straints 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.

bur25613_02_c02_039-078.indd 40 11/26/12 10:31 AM

CHAPTER 2Section

2.1 Common Factors

Self-Check

Answer the following questions to the best of your ability.

1. Preventive medicine reduces illness and disease by
a. providing members of the community with vaccines.
b. educating the community on healthy lifestyle habits.
c. providing medicine to the community to cure specific diseases.
d. researching cures to diseases.

2. What is the focus of curative medicine?
a. educating the community on healthy lifestyle habits
b. providing healthy lunches at schools
c. distributing condoms and clean needles to the community
d. curing existing diseases and conditions

3. Comparisons are made between vulnerable groups in order to
a. provide the right access at the right time to the right group.
b. provide the right vaccine to the right person.
c. provide the best diet recommendations based on need.
d. find the correct cure.

Answer Key

1. b 2. d 3. a

2.1 Common Factors

At each stage in the life cycle, different populations experience vulnerability differ-ently. 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 dif-
fering levels and types of vulnerability. Many people who are at risk for poor health out-
comes 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

bur25613_02_c02_039-078.indd 41 11/26/12 10:31 AM

CHAPTER 2Section 2.1 Common Factors

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

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

Critical Thinking

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

bur25613_02_c02_039-078.indd 42 11/26/12 10:31 AM

http://www.cdc.gov/nchs/data/dvs/MortFinal2007_Worktable310

CHAPTER 2Section

2.2 Comparing Vulnerable Groups by Age

Self-Check
Answer the following questions to the best of your ability.

1. Studies frequently use four categories, or factors, to compare statistical trends
across populations. Which of the following categories is not used?

a. age
b. gender
c. education
d. citizenship

2. Different populations experience vulnerability differently.
a. true
b. false

3. What information is used to compare vulnerable populations?
a. Citizenship
b. Marital status
c. Statistical data
d. Occupation

Answer Key

1. d 2. a 3. c

2.2 Comparing Vulnerable Groups by Age

According to the U.S. Cen-sus Bureau, the median age in 2000 was 35.5.
As the baby boomer genera-
tion 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 genera-
tion passes away (U.S. Census
Bureau, 2012a).

Age is a crosscutting factor in all
vulnerable populations. People
experience vulnerability differ-
ently depending on age. Infants
and children are among the
most vulnerable of all popula-
tions because they rely entirely

Courtesy of Monkey Business/Fotolia

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

bur25613_02_c02_039-078.indd 43 11/26/12 10:31 AM

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

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 preva-
lence 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.

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 sig-
nificant 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 Preven-
tion [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.

Courtesy of Gert Vrey/Fotolia

Ethnicity, education, income levels, and maternal age all factor
into the risk of low birth weight risk.

bur25613_02_c02_039-078.indd 44 11/26/12 10:31 AM

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

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 chil-
dren 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. Ver-
bal 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 popu-
lation that encourages the reporting of abuse.

bur25613_02_c02_039-078.indd 45 11/26/12 10:31 AM

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

Figure 2.2: Rates of elder abuse by type

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 ill-
nesses 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.

bur25613_02_c02_039-078.indd 46 11/26/12 10:31 AM

http://205.207.175.93/HDI/TableViewer/chartView.aspx

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

Arthritis and osteoporosis are common in the 65 and over population, and both can seri-
ously 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 high-
est number of new HIV diagnoses in 2009 with an estimated total of 6,237 new diagno-
ses. 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 demen-
tia (HAD). Many elderly persons are affected by similar dementia conditions, including
Alzheimer’s disease. Serious mental illness (SMI) is any mental disorder that signifi-
cantly 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 high-
est 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 impor-
tant factor for all mental disorders: One-half of the total number of mental health condi-
tions begins under age 14 (NIMH, 2012b).

bur25613_02_c02_039-078.indd 47 11/26/12 10:31 AM

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

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 homi-
cide 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 com-
mon 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.

Eldercide is the killing of persons age 65 and older. It accounts for about 5% of all homi-
cides. The elderly are more likely than any other age group to be killed during the com-
mitting 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, mea-
sured as five or more drinks per
occurrence. Adults report fewer
binge drinking episodes per
month than underage drink-
ers. 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

Courtesy of Aaron Amat/Fotolia

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

bur25613_02_c02_039-078.indd 48 11/26/12 10:31 AM

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

Teenagers report more binge drinking episodes than adults.

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

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

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

bur25613_02_c02_039-078.indd 49 11/26/12 10:31 AM

http://www.udetc.org/documents/Drinking_in_America

CHAPTER 2Section 2.2 Comparing Vulnerable Groups by Age

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 popula-
tion. 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

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

bur25613_02_c02_039-078.indd 50 11/26/12 10:31 AM

http://www.dhs.gov/files/statistics/publications/LPR06.shtm

CHAPTER 2Section

2.3 Comparing Vulnerable Groups by Gender

Self-Check
Answer the following questions to the best of your ability.

1. Mothers in what age range have the smallest risk of having low birth weight
babies?

a. 10–14 years of age
b. 25–29 years of age
c. 31–36 years of age
d. 43–46 years of age

2. According to the U.S. National Center on Elder Abuse, approximately how many
people over age 60 are victimized annually?

a. 150,000
b. 350,000
c. 450,000
d. 1,000,000

3. Children in what age range have the lowest incidence of HIV diagnosis?
a. 1–4 years of age
b. 5–9 years of age
c. 10–12 years of age
d. 13–15 years of age

Answer Key

1. b 2. c 3. d

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.

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.

bur25613_02_c02_039-078.indd 51 11/26/12 10:31 AM

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

Vulnerable Mothers and Children

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 moth-
ers and babies based on gender
focuses on infants, as the moth-
ers are obviously women.

The total United States popu-
lation 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 particu-
larly 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 statisti-
cally 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 statisti-
cally more likely to become domestic violence offenders in their adulthood.

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.

bur25613_02_c02_039-078.indd 52 11/26/12 10:31 AM

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

Child Abuse
Although more men are domestic vio-
lence 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 overrepre-
sented 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 lon-
ger, there is more opportunity for abuse.

Although women represent a higher incidence rate of elder abuse in nearly all catego-
ries, 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 activi-
ties more difficult. Men had a slightly lower rate of 17.3%. Among the senior citizen popu-
lation, 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 hav-
ing had cancer at some point in their lives, compared with 7.9% of men (U.S. Department
of Health and Human Services, 2012).

Courtesy of Ia_64/Fotolia

Male children account for 48.5% of child abuse cases.

bur25613_02_c02_039-078.indd 53 11/26/12 10:31 AM

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender
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 dis-
orders, 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 pres-
sure 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 expe-
rience mental conditions that do not have a social component at equal rates. Bipolar dis-
order 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.

bur25613_02_c02_039-078.indd 54 11/26/12 10:31 AM

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

Figure 2.5: Suicide method by 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 vic-
tims. 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).

bur25613_02_c02_039-078.indd 55 11/26/12 10:31 AM

http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

Figure 2.6: Homicide offenders and victims by gender

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.

Because women are more likely
than men to have multiple,
simultaneous addictions to alco-
hol and different drugs (Office
of Substance Abuse Services
[OSAS], 2004) and experience

Courtesy of Ryan McVay/Thinkstock

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

bur25613_02_c02_039-078.indd 56 11/26/12 10:31 AM

http://bjs.ojp.usdoj.gov/content/homicide/teens.cfm

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

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 coun-
terparts 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 relation-
ships women build during group therapy programs than about the actual course of treat-
ment (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 over-
represented, 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 oppo-
site from those of unauthorized immigrants. Of the 1,042,625 people who gained per-
manent resident status in 2010 to the United States, 471,849 were male, compared with

bur25613_02_c02_039-078.indd 57 11/26/12 10:31 AM

CHAPTER 2Section 2.3 Comparing Vulnerable Groups by Gender

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 employ-
ment 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 home-
makers 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

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?

bur25613_02_c02_039-078.indd 58 11/26/12 10:31 AM

http://www.dhs.gov/files/statistics/publications/LPR06.shtm

CHAPTER 2Section

2.4 Comparing Vulnerable Groups by Culture and Ethnicity

Self-Check
Answer the following questions to the best of your ability.

1. The infant mortality rate for females is _____ deaths for every 1,000 females born.
a. 1.32
b. 2.53
c. 3.57
d. 4.97

2. The method men commonly use to deal with mental issues is known as
a. externalizing.
b. internalizing.
c. binge eating.
d. becoming depressed.

3. Women seem to respond better to what type of substance abuse resources?
a. mental health treatment centers
b. faith-based treatment centers
c. same-gender treatment centers
d. addiction-specific treatment centers

Answer Key

1. c 2. a 3. c

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 per-
son’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). Com-
munity 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 organi-
zations 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, prena-
tal care. Minority populations account for a large portion of Americans living in pov-
erty. 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,

bur25613_02_c02_039-078.indd 59 11/26/12 10:31 AM

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

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.

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 sig-
nificantly 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 mor-
tality 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 post-
natal 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

Courtesy of yurmary/Fotolia

Infants born underweight are especially
prevalent in teen pregnancies.

bur25613_02_c02_039-078.indd 60 11/26/12 10:31 AM

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

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.

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

bur25613_02_c02_039-078.indd 61 11/26/12 10:31 AM

http://www.cdc.gov/teenpregnancy/LongDescriptors.htm

http://www.cdc.gov/teenpregnancy/LongDescriptors.htm

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

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

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).

bur25613_02_c02_039-078.indd 62 11/26/12 10:31 AM

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

Figure 2.10: Child abuse offenders by race and ethnicity

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

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 Fami-
lies, Administration on Aging, 1998).

Chronically Ill and Disabled People

Hawaiians and Pacific Islanders have the highest prevalence of diabetes, at 23.7%. Afri-
can 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).

bur25613_02_c02_039-078.indd 63 11/26/12 10:31 AM

http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity
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 rela-
tionship between HIV and AIDS cases by affected ethnic groups (CDC, 2008).

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

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

bur25613_02_c02_039-078.indd 64 11/26/12 10:31 AM

http://www.cdc.gov/hiv/topics/surveillance/basic.htm#hivaidsrace

http://www.cdc.gov/hiv/topics/surveillance/basic.htm#hivaidsrace

http://www.cdc.gov/hiv/topics/surveillance/basic.htm#aidsrace

http://www.cdc.gov/hiv/topics/surveillance/basic.htm#aidsrace

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity
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).

bur25613_02_c02_039-078.indd 65 11/26/12 10:31 AM

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

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

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 illus-
trates the percentage that each ethnic group represents in the total number of counted
homeless persons.

bur25613_02_c02_039-078.indd 66 11/26/12 10:31 AM

http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#3.1.4

http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#3.1.4

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity

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 from http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet

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 com-
position 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.

Figure 2.13: Ethnic group representations in the homeless population

bur25613_02_c02_039-078.indd 67 11/26/12 10:32 AM

http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet

CHAPTER 2Section 2.4 Comparing Vulnerable Groups by Culture and Ethnicity
Self-Check
Answer the following questions to the best of your ability.

1. Cultural attitudes regarding the reporting of abuse may alter the statistics of
which ethnic group?

a. Pacific Islanders
b. Non-Hispanic blacks
c. Native Americans
d. Caucasians

2. According to the 2004 Survey of Adult Protective Services, what percentage of
reported elder abuse victims are white?

a. 63.9%
b. 77.1%
c. 83.2%
d. 94.7%

3. According to the Substance Abuse and Mental Health Services Administration
(SAMHSA), what percentage of persons who use shelters and other homeless
services are “other races”?

a. 4.5%
b. 15.6%
c. 27.9%
d. 49.8%

Answer Key

1. c 2. b 3. a

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?

bur25613_02_c02_039-078.indd 68 11/26/12 10:32 AM

CHAPTER 2Section

2.5 Comparing Vulnerable Groups by Education and Income Levels

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

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 com-pleted 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 educa-
tions. 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 educa-
tion 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

bur25613_02_c02_039-078.indd 69 11/26/12 10:32 AM

http://www.census.gov/compendia/statab/2012/tables/12s0692

http://www.census.gov/compendia/statab/2012/tables/12s0692

CHAPTER 2Section 2.5 Comparing Vulnerable Groups by Education and Income Levels

Vulnerable Mothers and
Children

The rate of Americans failing to
obtain needed health care, den-
tal care, and prescription drugs
because they are unable to afford
them is on the rise. This situa-
tion particularly affects moth-
ers and infants during one of the
most high-risk times of their lives.
There is a direct inverse relation-
ship 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 likeli-
hood 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 respon-
sible for the higher prevalence of child abuse and neglect. Common problems in impov-
erished 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

Courtesy of Engine Images/Fotolia

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

bur25613_02_c02_039-078.indd 70 11/26/12 10:32 AM

CHAPTER 2Section 2.5 Comparing Vulnerable Groups by Education and Income Levels

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 sta-
tus 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 Cauca-
sian population has the lowest overall HIV prevalence rate of 0.2%. There are more Afri-
can 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 debilitat-
ing 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).

bur25613_02_c02_039-078.indd 71 11/26/12 10:32 AM

CHAPTER 2Section 2.5 Comparing Vulnerable Groups by Education and Income Levels

Suicide- and Homicide-
Liable People

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 indi-
vidual’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 sub-
stance abuse rate of 7.3%. Those who finished high school but did not continue on to col-
lege 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; sub-
stance abuse rates increase as employment levels decrease. Adults with full-time employ-
ment 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 home-
less persons who were underemployed.

Courtesy of Mitarart/Fotolia

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

bur25613_02_c02_039-078.indd 72 11/26/12 10:32 AM

CHAPTER 2Section 2.5 Comparing Vulnerable Groups by Education and Income Levels

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 (Cama-
rota, 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

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.

bur25613_02_c02_039-078.indd 73 11/26/12 10:32 AM

CHAPTER 2Section 2.5 Comparing Vulnerable Groups by Education and Income Levels
Self-Check
Answer the following questions to the best of your ability.

1. What percentage of children in households of less than $15,000 annual income
experience abuse and neglect?

a. 22%
b. 37%
c. 43%
d. 79%

2. What percentage of people in France, the United States, the Netherlands, and
other first-world countries suffer depression at one time or another?

a. 3%
b. 5%
c. 11%
d. 15%

3. In 2002, the Center for Immigration Studies reported that the percentage of immi-
grants within the United States’ total population was

a. 1.7%.
b. 4.3%.
c. 9.4%.
d. 11.5%.

Answer Key

1. a 2. d 3. d

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?

bur25613_02_c02_039-078.indd 74 11/26/12 10:32 AM

CHAPTER 2

Chapter Summary

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.

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 Medi-
cal 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 hos-
pital. 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 wom-
en’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 popu-
lation 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 Con-
way’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.

Critical Thinking

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

bur25613_02_c02_039-078.indd 75 11/26/12 10:32 AM

CHAPTER 2

Additional Resources

Self-Check
Answer the following questions to the best of your ability.

1. What has a significant effect on immigration trends to the United States?
a. Political and economic strife in other parts of the world
b. Political and economic strife in the United States
c. The price of gas in other parts of the world
d. The price of gas in the United States

2. What is the average income for households with some high school education but
no diploma or GED?

a. $16,454
b. $25,604
c. $31,000
d. $45,650

3. Elder adults with what income level have the highest elder abuse prevalence in
all abuse categories?

a. Under $5,000
b. $5,000 to $9,999
c. $10,000 to $19,999
d. More than $20,000

Answer Key

1. a 2. b 3. b

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

bur25613_02_c02_039-078.indd 76 11/26/12 10:32 AM

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

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

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

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

CHAPTER 2Key Terms

alcoholism Overuse and dependence on
alcohol.

binge drinking Five or more drinks per
occurrence.

curative medicine Medical practices
focusing on curing existing diseases and
conditions.

eldercide The killing of persons age 65
and older.

episodic homelessness Recurring, fre-
quent, or ongoing homelessness.

externalizing disorders Mental conditions
that lead to outward activities of destruc-
tion such as drug abuse and violence.

infanticide The killing of children age 5
and under.

internalizing disorders Mental health
conditions that cause emotional responses,
such as anxiety disorders and depression.

preventive medicine Medical practice
focusing on education and lifestyle choices
with the intention of minimizing the risk
of illness.

serious mental illness (SMI) Any mental
disorder that significantly interferes with
daily life.

sudden infant death syndrome
(SIDS) The unexplainable death of an
infant any time before the first birthday.

transitional homelessness Short-term
homelessness.

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 popu-
lations. 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 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.

Key Terms

bur25613_02_c02_039-078.indd 77 11/26/12 10:32 AM

bur25613_02_c02_039-078.indd 78 11/26/12 10:32 AM

4

Seeking an Effective Care Continuum

Learning Objectives

After reading this chapter, you should be able to:

• Identify programs that address the health issues surrounding workplace accidents.

• Assess the need for a continuum of care that comprises a comprehensive approach to
health care for vulnerable populations.

• Identify the preventive care services available to vulnerable populations.

• Examine the treatment services available to vulnerable populations.

• Explain the options that vulnerable populations have for accessing long-term care.

Courtesy of Kurhan/Fotolia

bur25613_04_c04_111-148.indd 111 11/26/12 10:30 AM

CHAPTER 4

Critical Thinking

OSHA provides many programs to ensure workers’ health and safety. Is there a similar program for
health care elsewhere? If not, could OSHA be used as a model to create or redesign existing programs?

Introduction

Introduction

Workplace injuries, deaths, and work-related illnesses cost the United States approximately $693.5 billion a year (National Safety Council, 2009). The Occu-pational Safety and Health Administration (OSHA), established in 1970,
ensures safe and healthy working conditions for men and women by setting standards
and providing training, outreach, and education. In other words, OSHA focuses on the
prevention of injuries by regulating the workplace.

In contrast, workers’ compensation programs, which are administered through the
Department of Labor, help workers who have already sustained a work-related injury or
an occupational disease. These programs focus on wage replacement, medical treatment,
and rehabilitation services coverage. Employers pay into the workers’ compensation
programs through companies that work to mitigate costs to insurance companies, called
insurance underwriters, or government programs to help cover these expenses. Although
paying into the national workers’ compensation program represents a significant expense
for employers, lost employee productivity is more costly. To minimize workers’ compen-
sation and lost productivity expenses, many employers have preventive workplace safety
programs that include educational sessions on safety and even posters with images and
safety messages to remind workers of best practices for safety. These preventive programs
aim to minimize risks both to the workers and the employers. Some of these programs
are available through OSHA, the national programs for workers’ compensation, or their
company insurance or liability underwriter.

Workplace safety programs and workers’ compensation programs provide a continuum
to address the health issues surrounding workplace accidents. From prevention to treat-
ment to rehabilitation to return-to-work, workplace safety and workers’ compensation
programs address the specific health care needs of America’s working population. This is
one example of the way a continuum of care works and how programs can work together
to create a continuum of care. Every population group can benefit from a strong contin-
uum of care, but America’s most vulnerable populations often have particular needs that
are best met with a quality care continuum. This chapter discusses the need for an effec-
tive continuum of care and the existing programs that provide this type of continuum of
care for America’s vulnerable populations.

bur25613_04_c04_111-148.indd 112 11/26/12 10:30 AM

CHAPTER 4Section

4.1 The Need for an Effective Continuum of Care

Self-Check

Answer the following questions to the best of your ability.

1. According to the 2009 National Safety Council, what cost the United States
approximately $693.5 billion?

a. DWI prosecution
b. workplace injuries and illnesses
c. health care fraud
d. immigration services

2. Which types of programs help workers affected by workplace accidents?
a. substance abuse counseling
b. legal advice
c. workers’ compensation
d. financial planning

3. Employers pay into workers’ compensation programs through _____________,
which work to mitigate costs to insurance companies.

a. insurance underwriters
b. employees
c. federal agencies
d. undocumented immigrants

Answer Key

1. b 2. c 3. a

4.1 The Need for an Effective Continuum of Care

An effective continuum of care ensures access to preventive health services, treat-ment services, and long-term care services. These three types of health care do not function independently; rather, each is reinforced or weakened by the quality
of the others, with treatment services in the central position. A solid continuum of care
should be available throughout a person’s life.

There is a push in the American health care system to increase access and use of preven-
tive care services, which are medically related and medically based services that focus
on maintaining health. These services range from patient education on healthy lifestyle
choices, to medical and commonsense aids to help patients make healthy choices. For
example, smoking cessation programs offer preventive care in the form of education on
the risks of smoking while enabling patients to quit through support groups and pharma-
ceutical smoking cessation aids. Preventive care is vital for reducing the cost of health care
in the nation, as it is less expensive than treatment and long-term care services. Maintain-
ing physical health also improves quality of life and keeps people in the workforce.

bur25613_04_c04_111-148.indd 113 11/26/12 10:30 AM

CHAPTER 4Section 4.1 The Need for an Effective Continuum of Care

Although physicians play an
important role in prevention,
preventive services in the United
States more frequently come
from community-based health
services and resource develop-
ment. Treatment services are
delivered by physicians and
the health care delivery system,
which includes clinics, doctors’
offices, hospitals, and long-term
care facilities. The goal of treat-
ment services is to restore health
to ailing individuals. Long-term
care, on the other hand, focuses
on the constant, ongoing health
care needs of individuals. It is
delivered through both commu-
nity-based programs, such as
Hospice, and institutional set-
tings, such as nursing facilities
and assisted living facilities.

In an effective care continuum, each type of care works in tandem with the others to
maximize patient physical and psychological functions. Unfortunately, these programs
are often systemically divided in a sort of “left hand doesn’t know what the right hand is
doing” situation. For example, a woman might visit a gynecologist for annual preventive
care but see a family practitioner when she gets sick. Unless they are located in the same
office, the family practitioner does not have access to the patient’s records from the gyne-
cologist’s office. In this way, the patient’s preventive medicine and treatment services lack
communication between the two, so each is ignorant of what the other is doing. For the
care continuum to be truly effective, prevention, treatment, and long-term care must be
integrated and accessible.

Access to preventive services is subject to the limiting factors associated with most
community-based health resources, among which funding ranks highest. Many
community-based health resources are only partially funded by the legislature and rely
heavily on private donations. Both funding sources diminish during economic down-
turns, limiting what an agency is capable of providing. Similarly, financial constraints
keep people from seeking medical attention when it is needed, and certainly there are
many people with and without health insurance coverage who cannot afford to see a
physician for preventive care. When community health resources cannot fill the gap,
where are people to turn for health care?

Courtesy of WavebreakMediaMicro/Fotolia

An effective continuum of care consists of three elements:
access to preventive health services, treatment services, and
long-term care services.

bur25613_04_c04_111-148.indd 114 11/26/12 10:30 AM

CHAPTER 4Section 4.1 The Need for an Effective Continuum of Care
Self-Check
Answer the following questions to the best of your ability.

1. Where do preventive services in the United States frequently come from?
a. long-term care facilities
b. hospitals
c. physicians
d. community-based health services

2. Which of the following is a typical challenge for preventive services?
a. need
b. access to population
c. costs
d. effectiveness

3. Which of the following is a main advantage to building an effective care
continuum?

a. reducing medical costs
b. researching vaccination usefulness
c. providing surgeries to newborns
d. treating common illnesses

Answer Key

1. d 2. c 3. a

A Closer Look: Community Health Departments

Community Health Departments exist to help fill the need for accessible, affordable health care. Unfor-
tunately, many people are unaware of the wide array of services offered at public clinics. Still others
avoid them for fear of costly services; however, Community Health Departments provide services at
significantly lower rates than many other options.

An effective care continuum reduces medical costs, allowing community-based services
to serve more people. It also reduces the need for treatment and long-term care services
by maintaining health rather than treating illness. Building an effective, integrated care
continuum that will reduce vulnerability for those most at risk means considering the
strengths and shortcomings of existing programs.

Critical Thinking

There are many benefits associated with preventive care services. Can you think of a disadvantage?

bur25613_04_c04_111-148.indd 115 11/26/12 10:30 AM

CHAPTER 4Section

4.2 Health Maintenance Through Preventive Care Services

4.2 Health Maintenance Through Preventive Care Services

Vulnerability in the United States is rooted in poverty and social attitudes that deter-mine how resources are distributed among the population. These attitudes have changed dramatically in the last six decades, from being a top concern among
the people and government to being marginalized and defunding programs that address
vulnerability. America’s national poverty rate was 19% in 1964. President Lyndon B.

Johnson created the War on Pov-
erty in response to the nation’s
high poverty rate. The War on
Poverty brought about the Eco-
nomic Opportunity Act and the
U.S. Office of Economic Oppor-
tunity, which served to address
the reasons for poverty in the
country at that time.

Social attitudes about welfare
programs began to change in
the 1970s. America began a shift
to a smaller federal role and
decentralized government ser-
vices by giving the states more
power to administer social wel-
fare programs. America began
to rely more heavily on an econ-
omy based on open competition
among corporations with lim-

ited government regulation to address social needs. During the shift to an increasingly
free market economy, the country experienced inflation and recession throughout the
1970s and 1980s. In doing so, programs such as the early childhood education program
Head Start and Community/Migrant Health Centers, which provides health care access
for low-income individuals, continue to lose funding, and, thereby, are increasingly lim-
ited in the services they can offer.

The economy and unemployment rate improved during the 1990s. However, there was a
considerable increase in the number of low-wage jobs during that decade. During this time,
income-assistance programs continued to lose government funding and were increasingly
disadvantaged in the face of inflation, or the loss of currency value. The savings and loan,
economic housing, and technology bubbles widened the gap between groups of different
income levels, or socioeconomic classes, and the free market failed to provide adequately
for the vulnerable. When those economic bubbles burst under the presidency of George
W. Bush in the early 2000s, the American middle class slipped further down the socioeco-
nomic ladder. The Great Recession of 2008 caused millions of Americans to lose their jobs
and their homes—and increased the strain on underfunded social welfare programs.

Courtesy of soupstock/Fotolia

As America shifted to a smaller federal role and decentralized
government services in the 1970s, social attitudes about
welfare programs began to change.

bur25613_04_c04_111-148.indd 116 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Clear evidence exists that public health issues are rooted in politics and economics.
However, social attitudes about health care and the free market encourage a primary
focus on microlevel, or personal, behaviors and environments. Experts on health care
delivery have suggested that focusing on the microlevel is not enough to mitigate the
negative health outcomes that come from socioeconomic disadvantage, but that changes
must be made at the sociopolitical macrolevel, in all society, in order to address the lack
of organization, quality management, and funding that plagues public health organiza-
tions and initiatives.

Declining funding amounts for public prevention services and the sociopolitical attitudes
that ignore the need for such services create additional strain on the private health care sec-
tor. The private sector historically focuses on treatment and often leaves health education
and prevention to the public sector. In fact, a 2011 study published in the Archives of Internal
Medicine found that many primary care physicians are reluctant to broach the subject of
weight with patients, although patients are more likely to show motivation to lose weight
when their doctors bring it up (Post et al., 2011). Additional problems with private sector,
treatment-based health care include financial and organizational barriers that affect vulner-
able groups in particular, leaving an unfulfilled need for preventive health education and
services in the gap between the public and private sector access venues.

Vulnerable Mothers and
Children

Preventive services are fundamen-
tal for the healthy development
of children. Prenatal care focuses
on prevention services to sup-
port healthy pregnancy and birth
outcomes. Many government-
funded programs support high-
risk women and children through
pregnancy and the early years of
child-rearing (see Table 4.1).

Courtesy of nyul/Fotolia

Title X of the Public Health Service Act focuses on providing
health care and prevention services access to high-risk
women and children.

bur25613_04_c04_111-148.indd 117 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Table 4.1: Preventive services available to high-risk mothers and children

Program Pros Cons

Maternal and Child Health (MCH)

The Program for Children with
Special Health Care Needs

Title X of the Public Health
Service Act

Focus on providing health care
and prevention services access to
high-risk women and children.

Federal funding continues to
diminish by way of budget cuts
and inflation.

Special Supplemental Food
Program for Women, Infants, and
Children (WIC)

Food Stamp Program

Provide nutrition support
services for qualifying families.

Federal funding is channeled
through the states in block
grants, which do not guarantee
exact monies for specific
programs. The Great Recession
of 2008 increased dependence
on these programs while funding
from both the federal and state
levels diminished.

Maternity and Infant Care
Projects

Community and Migrant Health
Centers

National Health Services Corp

Planned Parenthood

Provide access to physicians and
nurse practitioner clinics for low-
income individuals and families.

Social attitudes about family
planning and abortion services
plague these groups, diminishing
political support and funding.

School-based behavioral risk
education programs

Encourage healthy lifestyle habits
and risk prevention regarding
smoking, sexual activity, and
healthy eating within the
structure of the educational
system.

Many of the teachers are not
qualified to teach some special
topics. Many parents opt their
children out of special topic
education programs such as sex
education.

Prenatal care Allows for prevention services,
screenings, and treatment
services simultaneously. Prenatal
care is provided in physicians’
offices, and the mother often
has control over her physician
selection.

Though many women have
health insurance to help
offset the costs of prenatal
care, it is expensive. Many
high-risk mothers lack health
care coverage and depend on
public programs for prenatal
care, which diminishes their
autonomy.

The Early and Periodic Screening,
Diagnosis, and Treatment
(EPSDT) program

Covers early childhood physician
services, including immunizations
and screening services for
Medicaid recipients.

Approximately half of eligible
children receive these services.
Program funding is endangered
by budget cuts, inflation, and
increased need.

Head Start Provides health programs,
preschool access, and social
services to low-income
preschool-age children.

Funding for this program is
diminishing. Low enrollment
numbers indicate a problem with
accessibility.

bur25613_04_c04_111-148.indd 118 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Abused Individuals

Aggression is rooted in the human social structure, where power is gained by removing
the competition and those with power are able to dominate those they view as inferior.
Preventive services for abused individuals lie mainly in the realm of social programming.
However, many health care providers work to prevent child abuse by providing support
and information to new families (see Table 4.2).

Table 4.2: Preventive services available to abused individuals

Program Pros Cons

Public media campaigns Use media, including television,
billboards, and radio, to reach
a great number of people with
reminders about available
support networks and warnings
such as “Never shake a baby.”

The programs they advertise
are often viewed as inaccessible
to low-income families. Social
stigma and fear of child welfare
services also compel parents to
avoid seeking help for abusive
habits.

Legal deterrence Seeks to protect abuse victims
and to punish and rehabilitate
offenders. Mandatory reporting
laws require teachers and other
public servants to immediately
report suspected abuse.
Legislation seeks to inhibit abuse
by restricting access to weapons
and decreasing response times to
abuse reports.

Legal deterrence is often a
reaction to abuse, rather than a
prevention.

Social services Provide education and
counseling on family planning,
resource access, and abuse
prevention. Home visits by social
service professionals have been
found to decrease the incidents
of child and elder abuse both by
being a deterrent and through
supporting families.

Many people may see social
services and home visits as an
invasion of privacy. Funding
continues to be an issue in the
face of a growing workload.

Chronically Ill and Disabled Persons

Prevention of chronic illness and disability focuses on healthy lifestyle choices and safety
(see Table 4.3). Educational programs like the Cooper Clayton method to stop smoking
that is offered by many health departments throughout the United States teach people
about the risks of smoking and provide support groups for those choosing to quit smok-
ing (Cooper & Clayton, 2010). Prevention during prenatal care works to prevent complica-
tions like gestational diabetes in pregnant women and fetal alcohol syndrome in babies.

bur25613_04_c04_111-148.indd 119 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Preventive care is also critical for those who are elderly and who already have chronic
illnesses. Educational preventive care for elderly patients often focuses on fall prevention
to address mobility limitations that come with age. Many chronic illnesses, like diabetes,
increase the risk of further problems. Preventive programs for people with chronic illness
often seek to educate patients on their individual care needs to make patients active partic-
ipants in their health. Teaching diabetes patients how to properly care for their feet and to
cut toenails straight across reduces the risk of losing a foot due to diabetes complications.

Table 4.3: Preventive services available to the chronically ill and disabled

Program Pros Cons

Education services Encourage healthy lifestyle habits
and workplace safety through
education and support services.

Because many education services
are provided through physicians’
offices and membership-based
health clubs, these services have
restricted access.

Prenatal care Can detect health concerns early
on. Prenatal care reduces the
likelihood of negative pregnancy
outcomes by helping to ensure
healthy habits during pregnancy,
thereby diminishing the chances
of fetal alcohol syndrome, drug
addiction, and physical disability.

Prenatal care educates the
pregnant mother but often falls
short of offering treatments for
substance abuse, alcoholism,
and cigarette use. Prenatal care
is also expensive, and those who
most need prenatal preventive
services in order to grow healthy
infants often do not receive early,
regular prenatal care.

Health and injury prevention
programs for the elderly

Focus on helping the elderly
understand their changing health
and safety needs.

Many elderly patients have little
control over their environments.
Unhealthy habits, such as
cigarette use, are more difficult
to change with age.

Persons Diagnosed With
HIV/AIDS

Lifestyle choice education pro-
grams that focus on sexual
behavior and drug abuse are
common HIV/AIDS prevention
programs (see Table 4.4). Some
of this preventive education is
done through public media cam-
paigns that include television
commercials, billboards, radio
messages, and print advertise-
ments that act as reminders to
be selective about sexual part-
ners and to use protection in the

Courtesy of Mariano Ruiz/Fotolia

Needle exchanges reduce needle sharing among intravenous
drug users, thereby reducing the transmission of HIV.

bur25613_04_c04_111-148.indd 120 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

form of condoms when engaging in a sexual relationship. Some HIV/AIDS prevention
programs are taught in schools in an attempt to provide HIV/AIDS prevention to entire
generations.

It is important to note that HIV is not only spread through sexual contact. Needle sharing
among intravenous drug users continues to spread HIV and other diseases throughout
vulnerable populations. Needle exchange programs, like Clean Needles Now (n.d.) in Los
Angeles, California, provide clean needles for drug users. Although such programs do
not necessarily work to prevent intravenous drug use, they do work to prevent the spread
of disease. Needle exchange programs were banned from receiving federal funds for 20
years because many in society worried that such programs contributed to drug abuse.
The ban was lifted by Congress in 2009 (Sharon, 2009). By allowing needle exchange pro-
grams to receive federal funding, such programs can expand services to include drug
abuse counseling and medical care.

Table 4.4: Preventive services available to people diagnosed with HIV/AIDS

Program Pros Cons

Public media campaigns Transmit prevention education
to a large audience through
television, radio, and billboard
advertising.

Public media campaigns are
expensive, and many of the
advertised programs are viewed
as inaccessible by low-income
individuals.

Community programs The Centers for Disease Control
and Prevention National
Partnerships Program supports
educational and HIV prevention
programming through
community-based organizations.

Community programs rely on
community-based organizations
such as schools and churches
to educate the public, thereby
creating issues of accessibility
and programming differences.

Street outreach programs Go directly to the communities
that most need HIV prevention
education and support.

Street outreach programs are
costly to run and often rely on
private donors and volunteers
through community-based
organizations. These programs
are rare in most regions.

Needle exchanges Reduce needle sharing among
intravenous drug users, thereby
reducing the transmission of HIV.

Social attitudes that view
needle exchanges as enabling
drug abuse restrict funding and
access.

bur25613_04_c04_111-148.indd 121 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Persons Diagnosed With Mental Conditions

Preventive mental health services increased in popularity after the deinstitutionalization
movement that began in the 1950s. The Community Mental Health Center Act of 1963
compelled states to fund community-based mental health programs. The act, combined
with the development of more effective antipsychotic drugs, enabled patients to receive
mental health care from early stages and to better manage symptoms like hallucinations
experienced by people with schizophrenia, thus preventing the need for prolonged insti-
tutionalization (see Table 4.5).

Table 4.5: Preventive services available to people diagnosed with mental conditions

Type of Program Pros Cons

Universal Targets the entire population.
Includes programs such as
prenatal and early childhood
intervention programs and injury
reduction programs.

These programs face funding
challenges that restrict
availability and accessibility.

Selective Targets groups identified as
having a higher risk of developing
mental health disorders. Includes
substance and alcohol abuse
prevention and intervention
programs.

Lack of funding for community-
based programs targeting specific
low-income, high-risk groups
restricts delivery.

Indicated Targets individuals identified as
having a higher risk of developing
mental health disorders. Includes
evaluation, education, and
therapeutic programming for
individuals.

For an individual to be
identified as having a higher
risk of developing mental
health disorders, that person
must come in contact with
the appropriate health care
workers and community program
organizers.

bur25613_04_c04_111-148.indd 122 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Courtesy of Loren Rodgers/Fotolia

Recent studies indicate low-income areas experience higher
rates of homicide, partly due to inadequate living conditions
and poor educational opportunities.

Suicide- and Homicide-
Liable Persons

Violence is linked to systemic
poverty. Low-income areas expe-
rience higher homicide rates
than middle- and upper-class
neighborhoods. The frustrations
of poverty, including a limited
ability to positively affect one’s
social status, poor educational
opportunities, hunger, and inad-
equate living conditions all con-
tribute to increased homicide
and suicide rates, particularly
among young adult males. Sui-
cide and homicide prevention
programs tend to focus on indi-
viduals rather than address the
social issues that create an envi-
ronment that exacerbates vio-
lence (see Table 4.6).

Table 4.6: Preventive services available to suicide- and homicide-liable persons

Program Pros Cons

Legal deterrence Punishes offenders and attempts
to limit violence with the threat
of punishment.

Legal deterrence is more
reactive than proactive; research
indicates that legal deterrence is
ineffective at limiting violence.

Family living education programs Focus on education to support
families, reduce unplanned
pregnancies, and teach problem-
solving skills.

Accessibility to these programs
is limited, and willingness to
participate is low.

Suicide prevention programs Identify high-risk individuals and
provide therapy and support for
both the individuals and their
families.

Functional screening tools and
training for those in a position to
recognize the warning signs (such
as teachers, social service workers,
and nursing home administrators)
is fundamental for suicide
prevention programs to work.

bur25613_04_c04_111-148.indd 123 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Persons Affected by Alcohol and Substance Abuse

Laws limiting access to drugs and alcohol often emerge from a moral stance that the use
of drugs and alcohol is morally objectionable. However, access-limiting laws may reduce
social risks by helping to limit the number of drug and alcohol users in the general popu-
lation. Preventive services that focus on risky behaviors educate people on the risks of
alcohol and drug abuse. Services that seek to reduce drug and alcohol use in individuals
assume a disease-oriented attitude, that addiction is a treatable medical condition (see
Table 4.7).

Table 4.7: Preventive services available to people affected by alcohol and substance abuse

Program Pros Cons

Legal deterrence Limits access to illicit drugs
and alcohol by intercepting
disbursement and punishing
offenders.

People who are addicted to
drugs will find a way to get them;
criminalizing drugs may cause
increased antisocial behaviors.
Studies have found that legal
deterrence is ineffective as a
means to stop drug and alcohol
abuse.

Screening and counseling
programs

Identify high-risk individuals
and provide counseling and
education of life skills and drug
and alcohol avoidance.

For individuals to be identified
for screening and counseling
services, they must come in
contact with workers who are
trained to recognize risk factors.

Public education programs Include media campaigns
educating the public on
substance abuse avoidance
and available programs. These
programs also include school-
based curriculum and special
programming to educate children
early on about the risks of
alcohol and drug use.

Funding can be difficult to
maintain; the programs
advertised by media campaigns
may be viewed as inaccessible by
some of the most at-risk groups.

bur25613_04_c04_111-148.indd 124 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Indigent and Homeless Persons

Preventing homelessness involves changing social attitudes about helping indigent peo-
ple and providing affordable housing and other social welfare programs (see Table 4.8).

Support for government-funded
housing has dwindled, leaving
community-based programs to
fill many needs. Although some
community-based programs do
provide housing, there are a great
many that provide what they can
in terms of food and clothing. Some
even provide access to health care.

Preventive health care for home-
less people focuses on providing
preventive primary care, such as
gynecological exams for women,
as well as on health-related risk
factors that homeless and indigent
people are particularly susceptible
to. Vaccination clinics for this vul-
nerable population work to pre-
vent illness and the spread of dis-

ease by providing preventive care in the form of vaccines against common ailments such
as flu and pneumonia.

Table 4.8: Preventive services available to indigent persons

Program Pros Cons

Government-funded housing Provides three types of housing
to fit individuals’ needs:
emergency housing, low-income
housing, and supportive housing.

Negative social attitudes
about welfare programs have
allowed funding to diminish for
government-supported housing
programs.

Health care programs Focus on health-related risk
factors that indigent people
are particularly vulnerable to,
including gynecological care and
family planning, substance abuse
and mental health counseling,
and HIV prevention.

These programs are more
reactive to the needs of the
homeless and only marginally
useful for improving an
individual’s living situation.

Community-based programs Provide meals and clothing for
indigent people, help individuals
find employment, and access
programs to help them reclaim a
reasonable standard of living.

There is little government
funding support for many
privately run community-based
programs, so these programs are
forced to rely on donors from
surrounding areas.

Courtesy of wjarek/Fotolia

Community-based programs provide meals and clothing for
indigent people.

bur25613_04_c04_111-148.indd 125 11/26/12 10:30 AM

CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services
Critical Thinking

“Social attitudes about health care and the free market encourage a primary focus on microlevel behav-
iors and environments.” How does this statement relate to the American belief in “freedom of choice”
and how it affects health care?

Immigrants and Refugees

Many refugees have little or no health care in their native countries; thus, they are drawn
to the United States for its robust health care system. Once here, many immigrants face the
hard reality that America’s health care system is inaccessible and unaffordable for many.
Government health services are available to help meet the needs of immigrants, but many
barriers exist to gaining access to such services, as we will see in later chapters. As a pro-
tective measure, the government does ensure that documented refugees undergo health
screening before being approved to come into the country. However, undocumented
migrants are not subject to these health screenings (see Table 4.9).

Table 4.9: Preventive services available to immigrants and refugees

Program Pros Cons

Public health services Provide basic health care and
health education services to low-
income populations.

A myriad of unconnected
agencies exist, including
government-funded public
health departments and private,
nonprofit agencies like Planned
Parenthood. This subset of the
health care system is disjointed
and can be difficult to navigate,
especially for those who are not
fluent in English. Undocumented
immigrants often avoid these
programs for fear of deportation.

Private health services Include traditional health
services from physicians,
hospitals, and other “traditional”
health care providers.

Private health services are
expensive and inaccessibly so for
people without health insurance.

Self-Check
Answer the following questions to the best of your ability.

1. Prenatal care, which supports healthy pregnancy and birth outcomes, can be
considered which type of service?

a. educational
b. preventive
c. child placement
d. nutritional

bur25613_04_c04_111-148.indd 126 11/26/12 10:30 AM

CHAPTER 4Section

4.3 Reclaiming Health Through Treatment Services

2. Suicide- and homicide-prevention programs tend to focus on individuals rather
than address which types of issues?

a. mental
b. hunger
c. social
d. medical

3. What reality concerning the United States health care system do many immi-
grants face?

a. Health care is expensive and inaccessible for many.
b. Immigrants do not receive health care.
c. Only immigrants from select areas receive health care.
d. Only natural-born U.S. citizens receive advanced health care.

Answer Key
1. b 2. c 3. a
4.3 Reclaiming Health Through Treatment Services

The U.S. health care system is one of the most technology-oriented health care sys-tems on the planet. This is partially driven by the free market mentality that rules America’s economy, which encourages innovations in new technology. As such, the
health care system is geared not toward preventive medicine but toward treating ailments.
In doing so, health care providers are able to show results that can be billed for. The same
advanced technologies that improve treatment also drive up the cost of care.

Problems arise when patients present with physical, social, and psychological symptoms
that their treating physicians are not versed in. The American health care system is not
well integrated between delivery channels and providers. A general practitioner might
miss signs of psychological trouble due to lack of knowledge of that particular type of
illness. Additionally, physicians often seek a quick fix (such as inexpensive antibiotics for
a sinus infection) and fail to recognize the psychosocial elements of a patient’s life that
contribute to risk factors for the illness that occurs (such as a child living in a home with
cigarette users). If that child is part of a vulnerable population, such as an abusive family,
it is likely that the child will suffer recurrence of the presented illness until the root cause
is addressed. If the physician only bothers writing a prescription and sends the family on
their way, the child’s health care needs are not appropriately met.

As such, a problem arises regarding patient wellness. For a low-income family, a child
with recurring pneumonia might lead to lost income, making it increasingly difficult
to afford the child’s medical care. Preventive services mitigate this type of situation by
reducing risky behaviors that contribute to illness. Much of America’s health care system
is based on the free market and run by privately held companies. These health care cor-
porations focus on treatment because treatment uses more advanced technology and is
therefore billed at higher rates than preventive care. The free market focus on treatment
makes health care and wellness increasingly inaccessible to vulnerable people.

bur25613_04_c04_111-148.indd 127 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Vulnerable Mothers and
Children

Treatment services for high-risk
mothers and babies focus on
prenatal care for the mother and
postnatal care for the infant (see
Table 4.10). Substance abuse
cessation programs that help
pregnant women to stop using
drugs, alcohol, and tobacco help
minimize risks to both mother
and baby and limit the need for
neonatal intensive care treat-
ments. For those infants who
are born with congenital heart
or lung disorders, fetal alcohol
syndrome, drug addiction, or
other life-threatening complica-
tions, expensive treatments are
available in neonatal intensive
care units.

Table 4.10: Treatment services available to high-risk mothers and children

Program Pros Cons

Substance abuse cessation
programs

Help get pregnant women to
stop using drugs, alcohol, and
tobacco.

Accessibility to these programs
is limited by access to prenatal
care.

Neonatal intensive care units Treat infants for a range of
problems, including fetal alcohol
syndrome and drug addiction.

Neonatal intensive care units
are expensive to provide, and do
not prevent poor outcomes, only
address them.

Abused Individuals

Treatment services for abused individuals focus on emergency response, counseling, and
legal ramifications for offenders (see Table 4.11). When injuries occur due to abuse, emer-
gency medical services (EMS) and police are often called to the scene. Other times, the
victims seek treatment at emergency rooms and outpatient medical clinics. It is common
for victims of abuse to avoid medical services altogether for fear of legal intervention.
When treatment is sought, it usually focuses on treating injuries and providing counseling
services for both victims and offenders.

Courtesy of iStockphoto/Thinkstock

Substance abuse cessation programs can help pregnant women
stop using harmful substances and also lessen the need for
intensive care treatments.

bur25613_04_c04_111-148.indd 128 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Courtesy of reflektastudios/Fotolia

Emergency rooms allow for fast medical intervention for
injuries and can limit the likelihood of an injury causing long-
term disability.

Table 4.11: Treatment services available to abused individuals

Program Pros Cons

Emergency and outpatient
medical services

Treat injuries caused by abuse
and screen for abusive situations.

Many abuse victims avoid
medical services for fear of
intervention.

Crisis response services and
hotlines

Provide emergency counseling
and physical protection in the
form of police, EMS, and social
service responders.

These services are nonexistent
in many areas; training and
maintaining personnel is costly.

Mental health services Treat both the victims and
offenders. These services focus
on changing behaviors.

Victims and offenders must be
active, willing participants.

Chronically Ill and
Disabled Persons

Treatment for chronic illness
focuses on symptom relief and
disease management. Disability
treatment involves rehabilita-
tion and educating patients on
relevant life skills so they can
live the fullest lives possible
while dealing with their disabil-
ities (see Table 4.12).

bur25613_04_c04_111-148.indd 129 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Table 4.12: Treatment services available to the chronically ill and disabled

Program Pros Cons

Care management services
(managed care organizations
[MCOs])

Coordinate medical care for
chronically ill and disabled
patients between the many
facets of their health care
needs, from pharmaceutical
management, to treatments, to
rehabilitation.

The absence of electronic
health records makes it difficult
for patients to manage and
coordinate their own care
between primary care physicians
and any specialists the patient
sees, so third-party care
management services are often
necessary.

Hospital care Emergency rooms allow for fast
medical intervention for injuries
and can limit the likelihood of
an injury causing long-term
disability.

Emergency rooms are expensive
and are short-term care.

Rehabilitation programs Help patients learn to live with
chronic illness and disability.

These programs can be
expensive, which limits access.

Persons Diagnosed With HIV/AIDS

HIV symptoms can be reasonably well managed with antiretroviral drugs that suppress
the human immunodeficiency virus (HIV). However, these life-prolonging therapies are
expensive, partly due to the fact that the therapy usually necessitates the simultaneous
use of multiple antiretroviral drugs taken multiple times per day. This makes these thera-
pies somewhat inaccessible to America’s most vulnerable populations (see Table 4.13).

Table 4.13: Treatment services available to people diagnosed with HIV/AIDS

Program Pros Cons

Counseling Addresses the negative mental
health effects of living with an
HIV diagnosis and teaches skills
for living with HIV/AIDS.

Accessibility is limited by
insurance coverage, ability to
pay, and geographical location
of counseling centers. Also,
the patient must be willing to
participate.

Medical treatment Life-prolonging antiretroviral
drugs keep patients healthier,
longer.

Medical treatment is
expensive and difficult to
access, especially for the most
vulnerable populations. Medical
intervention is most effective
when begun early. Many patients
do not take their medications
regularly (often for financial
reasons).

bur25613_04_c04_111-148.indd 130 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Table 4.14: Treatment services available to people diagnosed with mental conditions

Program Pros Cons

Outpatient mental health
services

Include counseling and drug
therapies; are available through
a wide range of providers; many
are relatively inexpensive; and
some health insurance plans
cover some outpatient mental
health services.

Patients with severe mental
health disorders may be
noncompliant with outpatient
programs. Can be financially
inaccessible for persons without
health insurance coverage.

Crisis response services Available on both an outpatient
and inpatient basis; provide
immediate help for patients
suffering severe emotional
traumas, such as psychotic
episodes and nervous
breakdowns.

Services can be expensive with
limited accessibility to low-
income individuals.

Substance abuse cessation
programs

Available on both an outpatient
and inpatient basis; focus on
changing lifestyle habits that
contribute to drug and alcohol
abuse that then contribute to
mental health disorders.

Inpatient programs are
expensive; outpatient programs
depend on the individual’s level
of compliance.

Persons Diagnosed With Mental
Conditions

Since the deinstitutionalization movement that
began in the 1950s, most treatment programs
for mental health conditions are delivered on an
outpatient basis (see Table 4.14). These services
include pharmacological therapies to manage
symptoms like feelings of sadness and confusion
in people suffering from depression and halluci-
nations in people with schizophrenia. Outpatient
therapy for people with mental illness also often
includes regular counseling sessions and sub-
stance abuse cessation programs when needed.
Crisis response services are available to fill in
where outpatient mental health services are
unavailable (such as after hours).

Courtesy of WavebreakmediaMicro /Fotolia

Outpatient mental health services
include counseling and drug therapies
and are available through a wide range of
providers; many are relatively inexpensive,
and some health insurance plans cover
some outpatient mental health services.

bur25613_04_c04_111-148.indd 131 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Suicide- and Homicide-Liable Persons

Homicide treatment is delivered via the criminal justice system, which both removes vio-
lent offenders from society and has programs in place to help rehabilitate offenders with
the intention of releasing them to be contributing members of society. Suicide treatment is
really suicide prevention, though often after failed suicide attempts (see Table 4.15).

Table 4.15: Treatment services available to suicide- and homicide-liable persons

Program Pros Cons

Mental health services Address the mental health
needs of suicide-prone patients;
educate both suicide- and
homicide-prone people about
how to invoke positive coping
mechanisms.

Patients must be compliant in
attending counseling sessions
and taking medications when
necessary. Mental health services
can be financially inaccessible.

Crisis intervention centers and
hotlines

Are provided by many separate
agencies, which increases
accessibility; are vital resources
for at-risk people and families.

Lack of coordination between
agencies complicates quality
assurance.

Persons Affected by Alcohol and Substance Abuse

Substance and alcohol abuse treatments vary from pharmacological therapies to counsel-
ing services. Many patients do best with a combination of therapies, but ongoing support
is vital for prolonged recovery (see Table 4.16). Programs like Alcoholics Anonymous (AA)
provide support groups and self-help methods to lead to recovery. Methadone clinics exist
that allow people who are addicted to opiates, like heroin, to gain access to methadone in
place of opiate drugs. Some such clinics also provide counseling and medical services to
support treatment and improve outcomes.

Table 4.16: Treatment services available to people affected by alcohol and
substance abuse

Program Pros Cons

Pharmacological therapies May be used to replace a
harmful, addictive drug; may be
used to block the effects of a
drug, which supports weaning
from drug use; or may be used to
relieve withdrawal symptoms.

Pharmacological therapies
must be tailored to the
individual patient and can be
expensive; patients must be
medication-compliant.

Behavioral therapies Are available on both inpatient
and prolonged outpatient
basis, can be tailored to meet
individual needs and evolve with
patient needs.

Patients must be compliant with
counseling session attendance,
and counseling can be expensive;
many patients lapse.

bur25613_04_c04_111-148.indd 132 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Table 4.17: Treatment services available to indigent persons

Program Pros Cons

The Robert Wood Johnson
Foundation Health Care for the
Homeless project (now The
Health Resources and Services
Administration Health Care for
the Homeless program)

Directly addresses the needs of
homeless people, including a
holistic approach that considers
social, economic, and health
care needs; recognizes the
relationship between wellness
and the need for resources,
including food and shelter. The
program includes outreach
programs to improve service
accessibility, case management,
and a multidisciplinary approach.

Funding is in danger; all involved
personnel must be well trained
on an ongoing basis.

Veterans Administration
Homeless Chronically Mentally
Ill and Health Care for Homeless
Veterans programs; The National
Institute of Mental Health
Community Mental Health
Services Demonstration Program;
the Access to Community Care
and Effective Services program

Address specific needs of specific
homeless populations; many use
the same holistic approach taken
by the Robert Wood Johnson
Foundation Health Care for the
Homeless project; receive federal
funding.

Social attitudes and constrained
budgets cause federal funding for
these programs to diminish.

Indigent and Homeless Persons

Treatment services for home-
less people focus on addressing
health care needs and providing
resources for preventive ser-
vices (see Table 4.17).

Courtesy of Oleg Kozlov/Fotolia

The Health Resources and Services Administration Health
Care for the Homeless program includes outreach programs
to improve service accessibility, case management, and a
multidisciplinary approach.

bur25613_04_c04_111-148.indd 133 11/26/12 10:30 AM

CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services
Critical Thinking

The example was given earlier of a child who is prescribed antibiotics for a sinus infection. This may
seem like a simple and obvious treatment for an infection, but one wonders if the doctor would have
modified the treatment in any way if the doctor had known about the contributing factors to the
child’s illness, such as the fact that the child was consistently exposed to secondhand smoke in the
home environment. Based on the information provided in this example, do you think that physicians
have an obligation to investigate the environmental and socioeconomic risk factors that may play a
part in their patients’ illnesses?

Immigrants and Refugees

Documented immigrants and refugees to the United States experience the same hurdles
attempting to access appropriate health care that the rest of the population faces. Undocu-
mented immigrants have less access to health care for financial and legal reasons (see
Table 4.18).

Table 4.18: Treatment services available to immigrants and refugees

Program Pros Cons

Emergency and inpatient medical
services

An increasing number of
hospitals and emergency clinics
employ workers who speak
languages other than English
to better serve the immigrant
population. Immigrants receive
the same level of care as U.S.
natives.

Accessibility is based on financial
ability, and language barriers do
still exist.

Outpatient medical and mental
health services

Patients with health insurance or
who can otherwise afford their
care have the ability to select
their health care providers. More
affordable options include public
health departments and privately
run, not-for-profit clinics.

Financial accessibility and
physical accessibility barriers
can be prohibitive. Many
undocumented immigrants avoid
routine health care for fear of
deportation.

Dental and vision services Many refugees have never
experienced specialized dental
and vision care and the health
benefits thereof.

Financial and physical
accessibility are barriers; many
immigrants do not use dental
and vision services because
they are not familiar with the
practices.

bur25613_04_c04_111-148.indd 134 11/26/12 10:30 AM

CHAPTER 4Section

4.4 Maintaining Quality of Life Through Long-Term Care

Self-Check
Answer the following questions to the best of your ability.

1. Disability treatment involves rehabilitation and teaching which of the following
skills to enable patients to live the fullest lives possible while dealing with their
disabilities?

a. life skills
b. vocational skills
c. social skills
d. coping skills

2. HIV symptoms can be reasonably well managed with what type of drugs?
a. antibiotics
b. opiates
c. antiretroviral drugs
d. amphetamines

3. What is considered to be the most vital aspect in alcohol and substance abuse
treatment?

a. ongoing support
b. pharmaceutical therapies
c. faith-based support
d. incarceration

Answer Key

1. a 2. c 3. a

4.4 Maintaining Quality of Life Through Long-Term Care

The Substance Abuse and Mental Health Services Administration (SAMHSA) esti-mates that one-quarter to one-half of all homeless people suffer from a mental dis-order (National Coalition for the Homeless, 2009). In many cases, the disorder is
the root cause of the homelessness, as some psychological illnesses can make it nearly
impossible to maintain employment and close social connections. For this vulnerable sub-
group, the long-lasting movement to deinstitutionalize people who need long-term care
increases the risk for negative outcomes.

Long-term care facilities that specialize in rehabilitation, behavioral health, and nurs-
ing facilities for the elderly and infirm were once fairly common in the United States.
Specialized facilities existed for patients with mental disorders and long-term illnesses.
However, the deinstitutionalization movement had certain detrimental effects on the
homeless population.

bur25613_04_c04_111-148.indd 135 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Although the move to deinstitutionalize patient care was born both out of concern about
the effectiveness of long-term facilities and the economic costs of running them, mass
deinstitutionalization did not see the majority of evicted patients placed into loving, capa-
ble homes. Even those who did return to family environments suffered from a lack of
community resources to support the families caring for them at home.

As the baby boomer generation matures to old age, the number of institutionalized patients
is increasing, and not just of the elderly. Skilled nursing facilities (SNFs), once associated
only with caring for the elderly and a few seriously handicapped or activities of daily living
(ADLs) aid-dependent patients, are now accepting an increasing number of vulnerable
patients from many at-risk populations, including those affected by drug dependence and
HIV. Nationwide programs through Leading Age and the American Health Care Associa-
tion (AHCA) have been undertaken to improve the education of all SNF staff to enhance
care and quality of life for those outside of the previous core constituency of long-term care
providers. This education includes caring for the at-risk populations specific to needs and is
focused on continuum of care and quality of life. Each new population introduced to the
long-term care community has a unique plan of care, has a specific needs set, and demands
their quality of life not diminish despite institutionalization. At the same time that more
individuals are being institutionalized, adult caregivers of their own elderly parents are
increasingly seeking support from community- or home-based resources. This is creating a
refreshed focus on community-based programs and services that provide long-term care
and support for patients and families across all populations.

Vulnerable Mothers and
Children

Long-term care for high-risk
mothers and babies is gener-
ally provided on an outpatient
basis and focuses on parenting
skills, social support, ongoing
medical care, and case man-
agement to help them access
the resources available to them
(see Table 4.19). Home-visit
programs through local health
departments and social services
provide long-term care for new
mothers and babies by sending
nurses or social workers to visit
families with new babies in their
own homes. A home visit allows the worker to build a relationship with the family while
providing information on parenting skills and available resources.

Courtesy of Dalia Drulia/Fotolia

Medical care addresses ongoing health and wellness of the
healing mother and new infant.

bur25613_04_c04_111-148.indd 136 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Table 4.19: Long-term care services available for high-risk mothers and children

Program Pros Cons

Medical care Addresses ongoing health and
wellness of the healing mother
and new infant. Medical care
also provides immunizations and
screenings for health issues and
abuse risk.

Many high-risk mothers are
unaware of the available
resources and are unfamiliar with
the fragmented delivery system.

Social services Include home visits that provide
social support, encouragement,
and resources for high-risk
mothers and babies.

Some mothers may decline help
from social service workers for
fear of unwanted intervention.

Abused Individuals

Long-term care for abused individuals includes counseling for victims and offenders, pro-
tection for victims, criminal punishment for offenders, and shelters for battered women
and children (see Table 4.20).

Table 4.20: Long-term care services available to abused individuals

Program Pros Cons

Counseling services and peer
support self-help groups

Support victims through the
emotional ramifications of abuse;
work with offenders to alter
abusive behaviors.

These services and groups can
have the negative effect of
enabling a victim to prolong the
relationship.

Protective services and welfare
agency programming

Identify and intervene with
abusive situations. Child
protective services have the
ability to immediately remove a
child from a home if they believe
the child is being harmed.

Funding and staffing are uneven
and inadequate.

Shelters and safe houses Provide safe housing for women
and children escaping from
abusive relationships. They
also connect victims with other
resources.

Most are privately funded and
have small operating budgets.

Criminal justice system Provides some protection of
abuse victims and punishes
repeat offenders.

Domestic disputes are handled
differently by different
responders and departments.

bur25613_04_c04_111-148.indd 137 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Chronically Ill and Disabled
Persons

Long-term care of both chronically
ill and disabled people involves
managing different types of care
and resources from many agen-
cies. Care managers can be vital in
helping both a patient and the fam-
ily coordinate care (see Table 4.21).
Long-term care facilities, including
assisted living and nursing care
facilities, are expensive. Many fam-
ilies choose to avoid that expense
and to keep their loved ones
nearby or care for them in their
own homes. In-home care can also
be very expensive and can put a lot
of stress on care providers. Services

exist to help with in-home nursing and to give caregivers breaks so they can run errands
or even have a night off without worrying about the loved one left at home.

Table 4.21: Long-term care services available to the chronically ill and disabled

Program Pros Cons

Nursing homes and independent
living communities

Provide varying levels of care
to meet the differing needs of
patients in different stages of life.

These communities are costly;
furthermore, much of the
expense of these homes is not
covered by Medicare.

Hospices and in-home care Allow terminally ill patients to
remain at home with support
from a medical team.

Hospice receives some
government funding but mostly
relies on insurance payments
and private donations. Other
in-home options are paid for by
insurance or out of pocket.

Social health maintenance
organizations (S/HMOs) and the
Program of All-Inclusive Care for
the Elderly (PACE)

These consolidated health
care models deliver long-term,
primary, and preventive services
through comprehensive delivery
systems. S/HMOs are designed
to keep people out of medical
institutions.

S/HMOs are a form of private
health insurance; PACE is
dependent on federal funding.

U.S. Department of Education,
Office of Special Education and
Rehabilitative Services

Funds state programs for special
education of disabled children to
age 21.

Resources stop at age 21; federal
funding is always in danger.

The Basic Vocational
Rehabilitation Service Program

Funds state programs to help
disabled individuals find gainful
employment. There is no age limit.

Federal funding is always in
danger.

Courtesy of Lisa F. Young/Fotolia

Hospices allow terminally ill patients to remain at home
with support from a medical team.

bur25613_04_c04_111-148.indd 138 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care
Persons Diagnosed With HIV/AIDS

Most nursing homes are not prepared to care for
dying HIV/AIDS patients. Therefore, specialized
AIDS hospices and community-based programs
exist to help ailing HIV/AIDS patients (see Table
4.22). Some palliative, or end-of-life, care facili-
ties do not accept HIV/AIDS patients because the
palliative period is difficult to predict. Specialized
hospices, like Project Transitions (n.d.) in cen-
tral Texas, go beyond palliative care and include
housing, counseling, and support groups for
HIV/AIDS patients nearing the end of their lives.

Courtesy of mangostock/Fotolia

Volunteers provide meals, transportation,
housekeeping, and other services free of
charge or at very low rates to HIV/AIDS
patients.

Table 4.22: Long-term care services available to people diagnosed with HIV/AIDS

Program Pros Cons

AIDS hospices Provide specialize palliative care
for people dying of AIDS.

AIDS hospices depend largely on
volunteers and private donors.

Home health care services Provide licensed home-based
health care for AIDS patients.

Home health care services are
very expensive; access depends
on private health insurance
coverage and the individual’s
ability to pay.

Volunteer services Include community-based
services that depend on
volunteers to provide meals,
transportation, housekeeping,
and other services free of charge
or at very low rates to HIV/AIDS
patients.

These services depend on
private donors and volunteers to
function.

bur25613_04_c04_111-148.indd 139 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Persons Diagnosed With Mental Conditions

Although private psychiatric hospitals still exist, many emotionally disturbed patients are
cared for at home with the help of outside resources (see Table 4.23). Partial-care centers
act as daytime care for adults with mental illnesses who cannot be left alone while family
members go to work. Unfortunately, partial-care centers are not available in all regions.
Community-based programs are available from a wide range of organizations, including
the National Institute of Mental Health (NIMH). Such programs provide access to ser-
vices, including education and counseling, for both the patient and the caregivers. Case
managers are useful in helping families find the right combination of resources to best
meet their needs.

Table 4.23: Long-term care services available to people diagnosed with mental conditions

Program Pros Cons

Institutionalization Few government-run psychiatric
institutions still exist, but
private institutions do still fill
the need for full-time care.
Nursing homes care for a large
number of elderly patients with
dementia and other mental
conditions. Jails and prisons
act as de facto institutions for
people with mental disturbance
when they are arrested for
breaking laws. Satellite housing,
halfway houses, and other board
and care homes also exist as
institutionalization options.

All these resources together
are not enough to provide safe,
secure housing for people with
severe mental conditions in this
country.

Home care A resource that provides for
mentally ill patients to remain
home with family.

The caregivers need a lot of
resources and support.

Partial-care centers A resource for families caring for
a mentally disturbed loved one
who cannot be left alone during
the day when the caregivers
must go to work.

Affordability can be a barrier to
access.

Community-based care including:

The National Institute of
Mental Health Community
Support Program, the Child
and Adolescent Service System
Program, and the Program of
Assertive Community Treatment

Various resources for educating,
housing, and supporting mentally
ill people. These resources focus
on coordinated, comprehensive
care continuums for those with
mental disorders.

A case manager is often needed
to help families and individuals
with mental conditions access
the many disjointed resources.

bur25613_04_c04_111-148.indd 140 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Table 4.24: Long-term care services available to suicide- and homicide-liable persons

Program Pros Cons

Criminal justice system Removes violent offenders from
society.

Prisons are violent environments,
and studies indicate that they
are not effective rehabilitation
centers.

Residential treatment centers Treat violent and suicidal youth. Treatment and funding are
uneven.

Community-based programs Include social services and
private and volunteer programs
that provide counseling and
support services for violent
offenders, suicide-prone
individuals, and their families.

Most community-based
programs do not interface with
other programs to create a
continuum of care.

Persons Affected by Alcohol and Substance Abuse

Long-term care and treatment services for alcoholism and substance abusers go hand in
hand (see Table 4.25). While detoxification helps remove substances from the body, ongo-
ing counseling and support is usually necessary for ongoing rehabilitation.

Suicide- and Homicide-Liable
Persons

Long-term “care” of violent offend-
ers focuses on removing them from
society rather than on rehabilita-
tion. Reports on the effectiveness of
programs designed to alter violent
behaviors indicate that the social
situations that propagate violence
must be addressed to reduce the
risk level for homicide-prone indi-
viduals. Inpatient mental health
services and vocational rehabilita-
tion programs exist to help suicide-
and homicide-liable persons (see
Table 4.24).

Courtesy of Alexander Edmonds/Fotolia

Prisons are violent environments, and studies indicate that
they are not effective rehabilitation centers.

bur25613_04_c04_111-148.indd 141 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Table 4.25: Long-term care services available to people affected by alcohol and
substance abuse

Program Pros Cons

Medical detoxification Uses pharmaceuticals given
in a hospital or other type of
inpatient medical facility to
remove the drug from the
patient’s body.

Medical detoxification needs
to be followed with long-term
counseling to be effective.

Social detoxification Allows the body to clean out the
drug naturally while the patient
is in a specialized facility under
the watch of trained personnel.

Social detoxification is not
covered by all insurance plans;
physicians may be called in but
are not always on the premises.

Rehabilitation and recovery Includes programs that enable
the patient to recover from
a drug addiction and restore
functioning needed for a healthy
lifestyle.

These programs are not covered
by all insurance plans; patient
must be compliant for the
program to work.

Custodial programs Provide shelter, food, and
support on an ongoing basis, but
the patients may come and go at
will (usually within set hours).

Many of these programs
are supported through
donor funding and nonprofit
organizations.

Nonresidential programs Include therapy sessions, both
in groups and on an individual
basis, that provide treatment and
recovery services to patients.

Patients must be compliant with
session attendance.

Indigent and Homeless Persons

Long-term care of homeless
people involves getting them
off the streets and treating the
factors that contributed to their
homelessness (see Table 4.26).

Courtesy of elavuk81/Fotolia

It is estimated that 50% of homeless people in the United
States have some type of significant mental condition.

bur25613_04_c04_111-148.indd 142 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care

Table 4.26: Long-term care services available to indigent persons

Program Pros Cons

Inpatient mental health
programs

It is estimated that 50% of
homeless people in the United
States have some type of
significant mental condition.
Inpatient mental health programs
offer a way to get these patients
off the streets and address the
mental disorders that may have
led to their homelessness.

Some inpatient institutions will
reject patients perceived to
be problematic; all inpatient
programs must be paid for
somehow.

Housing placement Outreach programs are key
components to placing homeless
people in long-term housing.
Some programs, like the Veterans
Administration, have developed
creative programs to place
individual patients in board
and care homes. Some private
agencies and local governments
support free and low-income
housing for which many
homeless people are eligible.

Case management services offer
a more effective method of
placing homeless families and
individuals in the right type of
home. Funding for all of these
programs is dependent on
government budget decisions
and individual donors.

Immigrants and Refugees

Long-term care for immigrants and refugees focuses on community-based support to help
them access resources (see Table 4.27).

Table 4.27: Long-term care services available to immigrants and refugees

Program Pros Cons

English as a Second Language
(ESL) courses

Help immigrants by teaching
them to speak, read, and write
English. The programs are often
available free of charge.

Program funding can be difficult
to maintain.

Social assistance programs Aid with housing, transportation,
securing employment, and
connecting refugees with
available resources.

Many of the programs are
disconnected from the others,
making the system difficult to
manage.

Voluntary refugee assistance
programs

Provide sponsorship and support
for refugee families through
networks of volunteers. Many
are supported by churches.

Some groups may engage in
illegal activity by acting as
an underground railroad for
undocumented immigrants.

bur25613_04_c04_111-148.indd 143 11/26/12 10:30 AM

CHAPTER 4Section 4.4 Maintaining Quality of Life Through Long-Term Care
Self-Check
Answer the following questions to the best of your ability.

1. Which of the following do shelters and safe houses provide to victims of abuse?
a. housing and connections to support
b. counseling
c. legal advice
d. a contact point for police investigations

2. It is estimated that ____ of homeless people in the United States have some type
of significant mental condition.

a. 30%
b. 42%
c. 50%
d. 67%

3. Which of the following groups provide sponsorship and support for refugee
families through networks of volunteers?

a. churches
b. state government
c. local businesses
d. professional organizations

Answer Key

1. a 2. c 3. a

Critical Thinking

Many discussions about the future of health care address the importance of long-term care. Given the
fact that the population of the United States is aging, why is this such an important issue?

bur25613_04_c04_111-148.indd 144 11/26/12 10:30 AM

CHAPTER 4

Chapter Summary

Chapter Summary

An effective continuum of care sees a patient through all phases of life. Prevention ser-
vices begun when young lessen a person’s risk of developing a need for treatment and
long-term care services later in life. Even when preventive services are accessed in later
life stages, programs that help people quit smoking, lose weight, and maintain a healthy
diet lower their risk of negative health outcomes. Even so, everybody gets sick at some
point, and treatment services are necessary to restore health and functioning. When health
cannot be fully restored, long-term care services must be accessible to help patients and
families with health and mental care needs. Accessibility to prevention, treatment, and
long-term care services is limited for America’s most vulnerable.

Case Study: Health Insurers Support Preventive Services

Humana, one of the nation’s largest health insurance companies, launched HumanaVitality© in 2012.
The program is available to Humana members at no additional charge. HumanaVitality rewards mem-
bers who log exercise, weight loss, and other healthy lifestyle habits with points that can be redeemed
for merchandise from various partner retailers. The program is similar to credit card rewards, but in
addition to points to spend, members gain a healthier lifestyle and Humana saves money on medical
treatments and long-term care (HumanaVitality, 2012).

Many athletic clubs and gyms offer similar rewards systems. Some YMCAs throughout the country have
instituted FitLinxx programs that allow members to log workouts and earn points. Rewards range from
YMCA water bottles and T-shirts to gift cards for local restaurants. The more workout points a member
earns, the better the rewards become. Using rewards systems to encourage healthier lifestyles is fairly
new because society’s focus on health care has changed from treating illness to preventing it.

Only in the last few decades have preventive services become popular in health care settings. Due to the
skyrocketing cost of health care in the United States, patients, the government, and health insurance
companies all have a vested interest in the propagation of preventive services. Insurers, including Medi-
care and Medicaid, are increasingly covering preventive health care services with no patient co-pays.
The Patient Protection and Affordable Care Act of 2010 mandates that insurers cover many preventive
services at no co-pay charge to the patients. This was a move by the federal government to mitigate the
costs of America’s obesity epidemic and other chronic diseases in the face of rising health care costs.

Many health insurance companies support the mandate as a way to encourage customers to use less
expensive preventive services instead of waiting and costing the insurers more money on treatments
and long-term care. In addition to dropping patient co-pays for preventive care services, many insurers
created programs that encourage their clients to make healthy lifestyle choices and use the covered
preventive services.

Critical Thinking

Discuss with supporting examples the need for a continuum of care that comprises a comprehensive
approach to health care for vulnerable populations.

bur25613_04_c04_111-148.indd 145 11/26/12 10:30 AM

CHAPTER 4Self-Check

Self-Check

Answer the following questions to the best of your ability.

1. A solid continuum of care should be available throughout a person’s life.
a. True
b. False

2. Which of the following caused millions of Americans to lose their jobs and their
homes—and increased the strain on underfunded social welfare programs?

a. the War on Terror
b. the Y2K Glitch
c. the Great Recession of 2008
d. the Swine Flu Epidemic

3. The American health care system is not well integrated between which of the fol-
lowing groups? (Select two.)

a. older generations
b. delivery channels
c. providers
d. corporations

4. Problems arise when patients present with which of the following symptoms that
their treating physicians are not versed in? (Select three.)

a. orthopedic
b. physical
c. social
d. oncological
e. psychological

5. Mass ______________________ did not see the majority of evicted patients placed
into loving, capable homes.

a. deinstitutionalization
b. decentralization
c. immigration
d. inflation

Answer Key

1. a 2. c 3. b and c 4. b, c, and e 5. a

bur25613_04_c04_111-148.indd 146 11/26/12 10:30 AM

CHAPTER 4

Web Exercise

Additional Resources

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

Patient Centered Medical Home

http://www.gilbertcenter.net/home.html

The American Health Care Association

http://www.ahcancal.org/Pages/Default.aspx

The website for the National Association of Community Health Centers and their mis-
sion to fill the gaps in health care services

http://www.nachc.com/

Web Exercise

Watch the following videos and script your own video (you do not have to produce the
video, just write a script) about preventive health care. You may use other video sources
but remember they must be reliable and valid (YouTube and Wikipedia do not count as
valid), and you must cite your source(s).

• Andrew Weil discusses preventive medicine in a short on Discovery.com:
http://dsc.discovery.com/videos/curiosity-is-preventative-medicine-becoming-

more-important-in-healthcare.html
• First Lady Michelle Obama and others discuss preventive health care in the

health care reform act:
http://www.whitehouse.gov/photos-and-video/video/preventive-health-care-

coverage-under-health-reform
• An example of how Medicare covers preventive health care:

http://www.dailymotion.com/video/xkebvp_medicare-made-clear-preventive-
health-care-services_people

bur25613_04_c04_111-148.indd 147 11/26/12 10:30 AM

http://www.gilbertcenter.net/home.html

http://www.ahcancal.org/Pages/Default.aspx

http://www.nachc.com/

http://dsc.discovery.com/videos/curiosity-is-preventative-medicine-becoming-more-important-in-healthcare.html

http://dsc.discovery.com/videos/curiosity-is-preventative-medicine-becoming-more-important-in-healthcare.html

http://www.whitehouse.gov/photos-and-video/video/preventive-health-care-coverage-under-health-reform

http://www.whitehouse.gov/photos-and-video/video/preventive-health-care-coverage-under-health-reform

CHAPTER 4Key Terms

Key Terms

continuum of care The combination of
preventive health services, treatment
services, and long-term care services that
spans a patient’s lifetime and provides for
the best health outcomes.

free market economy An economy based
on open competition among corporations
with a lack of government regulation.

inflation Loss of currency value.

insurance underwriters Companies that
evaluate the risk and exposure of potential
clients, decide how much coverage the
client should receive, and determine how
much the client should pay for it.

long-term care Care that focuses on con-
stant, ongoing health care needs.

Occupational Safety and Health Admin-
istration (OSHA) Established by the
Occupational Safety and Health Act of
1970, this group was created to ensure
safe and healthful working conditions for
working men and women by setting and
enforcing standards and providing train-
ing, outreach, education, and assistance.

preventive care services Medically related
and medically based services that focus on
maintaining health.

socioeconomic classes A combined eco-
nomic and social measure of a person’s
work experience and family economic
position in relation to others.

treatment services Services intended to
restore health to ailing individuals.

workers’ compensation A form of insur-
ance that provides wage replacement,
medical treatment, and rehabilitation
services to employees injured in the course
of employment.

bur25613_04_c04_111-148.indd 148 11/26/12 10:30 AM