HCA430 Special Populations wk2-1
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HCA430-Chapter1.docx1.4 Defining Vulnerable Populations in American Health Care
A person's vulnerability to negative health outcomes increases as the level of risk exposure increases. Everybody is vulnerable at some point in his life, though some people's level of vulnerability is rarely very high. Vulnerable populations are those groups of people who are exposed to many risk factors, such as inadequate access to fruits and vegetables, alcohol use, tobacco use, and inadequate housing. The WHO defines risk factors as
any attribute, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury. Some examples of the more important risk factors are underweight, unsafe sex, high blood pressure, tobacco and alcohol consumption, and unsafe water, sanitation and hygiene. (WHO, 2012)
Individuals and communities that lack resources, social status, social capital, and human capital are referred to as "vulnerable populations." The most prominent vulnerable populations in America are as follows:
vulnerable mothers and children
abused individuals
chronically ill and disabled people
people diagnosed with HIV/AIDS
people diagnosed with mental conditions
suicide- and homicide-liable people
people affected by alcohol and substance abuse
indigent and homeless people
immigrants and refugees
This list represents vulnerable American groups with the highest population numbers and risk factors. These groups appear to be growing quickly and thus putting an increasing strain on America's resources. The macro perspective social theory of public policy recognizes that mitigating risks for vulnerable populations must include reform at the community level. These interventions include programs that include access to housing, food, and health care by geographically locating such resources where there were previously few. The micro perspective social theory of public policy focuses on reforming the resource delivery system on the individual level. These interventions include programs that educate schoolchildren on proper nutrition and pay for immunizations for Medicaid recipients. Public policy strategists struggle to keep up with increasing demands on both the community and individual levels.
Allocating resources to at-risk groups is complicated by the fact that they do not exist in independent bubbles. The problems of these groups are intertwined. Alcohol and substance abuse can be a factor with abusive individuals and high-risk mothers and infants; suicide is a problem among homeless people; and people living with HIV are chronically ill and so have many of the same resource needs as that group. As at-risk populations grow and their problems become more intertwined, the country struggles to find solutions for a lack of needed resources and resource delivery.
Vulnerable Mothers and Children
Many factors can contribute to a pregnancy being termed "high risk." Maternal health in terms of preexisting medical conditions—unhealthy weight; medication use; nutrition; alcohol, tobacco, and substance use—and domestic security can all have negative effects on the unborn baby. Ethnicity has also been shown to be a factor in fetal and maternal health and will be discussed specifically in a later chapter. Though high-risk maternity has a different meaning for different populations, the population of vulnerable mothers and children is marked by inadequate medical care; negative health-related behaviors on behalf of the mother; teenage pregnancy; and infant drug addiction, prematurity, and low birth weight.
A photo of a pregnant woman as she looks at her unborn baby's image on an ultrasound machine. A medical professional dressed in white holds the ultrasound wand on the woman's abdomen and points to the image of the unborn baby on a screen.
Courtesy of Keith Brofsky/Thinkstock
Maternal health, whether good or poor, has a significant bearing on the health of the unborn baby.
Inadequate medical care during pregnancy leads to higher rates of infant mortality, premature birth, and low birth weight. Infant mortality is caused by many factors, including undeveloped and improperly developed organs, malnutrition (sometimes caused by poor maternal nutrition while in utero), and drug addiction. Premature birth is marked by a gestational age of less than 37 weeks. Low birth weight is considered to be anything under 5.5 pounds. Proper prenatal care can mitigate the risks of these negative outcomes by helping the mother ensure proper habits and nutrition throughout the pregnancy. The earlier the mother receives regular prenatal care, the lower the risk of negative outcomes for both her and the baby. But many vulnerable women do not receive early prenatal care: The total percentage of mothers seeking health care during the first trimester of pregnancy was 83.2% in 2006 (Henry J. Kaiser Family Foundation [KFF], 2012a). There is a direct correlation between a lack of prenatal care and infant mortality.
The United States has the highest infant mortality rate among developed nations (MacDorman & Mathews, 2008). The infant mortality rate in the United States has hovered around 6.5 deaths per 1,000 births for a decade. Although socioeconomic status plays a large role in infant and maternal mortality rates, the number leaves much to be explained. Non-Hispanic blacks had the highest 2005 infant mortality rate, at 13.63 per 1,000 live births, and Cubans living in the United States had the lowest 2005 infant mortality rate, at 4.42 per 1,000 live births.
The total infant mortality rate in the United States declined slightly from 2005 to 2007, with a total rate of 6.86 infant deaths per 1,000 live births in 2005, and 6.75 infant deaths per 1,000 live births in 2007 (Mathews & MacDorman, 2011). It is estimated that the rate will further decline to 5.98 infant deaths per 1,000 live births in 2012 (U.S. Central Intelligence Agency [CIA], 2012a).
Maternal mortality rates are also linked to early, quality prenatal health care. Maternal mortality was high in the early 20th century, at a rate of 607.9 maternal deaths per 100,000 live births. The rate dropped to 12.1 maternal deaths per 100,000 live births in 2003 (U.S. Department of Health and Human Services [HHS], 2007). This is attributable to advances in medical science and better health care access.
Premature Babies: Risks and Costs
Teen mothers are among the most at risk for negative outcomes. The rate of live births in the United States declined 3% from 2008 to 2009 (Martin et al., 2011). The nation saw a peak in teen births in 1991. The decline in teen births to 39.1 per 1,000 total live births in 2009 is 37% below the 1991 peak of 61.8, and the lowest in seven decades. The teen birthrate declined fairly steadily from 48 live births per 1,000 teen females ages 15 to 19 in 2000, to 34 live births per 1,000 teen females of the same age group in 2010 (Centers for Disease Control and Prevention [CDC], 2012a).
The decline in teen births may be a contributing factor to the decline in preterm deliveries and low birth weight infants. Both 2008 and 2009 saw declines in preterm deliveries both before 34 weeks gestation and at 34–36 weeks gestation. The 2009 total preterm birthrate was 12.18% of all births in America. The preterm birthrate dropped only slightly to 11.99% in 2010 (Hamilton, Martin, & Ventura, 2011). The low birth weight rate in the United States has been steadily increasing since the 1980s. The low birth weight rate in 1989 was 7.05%. By 1999, the rate had increased to 7.62%. Final data for 2009 showed the low birth weight rate to be 8.16%. It is notable that African Americans have a disproportionately high incidence of low birth weight babies, though the incidence rate for this group has remained fairly steady, ranging from 13.61% in 1989, to 13.23% in 1999, to 13.61% in 2009. Hispanics also remained fairly consistent at 6.18% in 1989, to 6.38% in 1999, to 6.94% in 2009. Caucasians, however, have experienced a considerable increase in low birth weight infants. In 1989, Caucasians had a low birth weight rate of 5.62%. That number rose to 6.64% in 1999 and rose again to 7.19% in 2009 (Martin et al., 2011).
Critical Thinking
There is a difference of 9.21 per 1,000 infant mortality deaths between non-Hispanic blacks and Cubans. There is a roughly equal chance of low income and lack of medical access in both of these populations. What contributing factors might explain the difference?
Abused Individuals
A photo of a little boy sitting in a corner with a stuffed dog as he covers his face with his hands.
Courtesy of Hemera/Thinkstock
Two methods are used to count child abuse incidents, taking into consideration the fact that the same child may be the victim of multiple incidents in a given year.
Children, the elderly, and female partners and spouses are the individuals most vulnerable to abuse. Abuse comes in many forms, most prominently neglect, physical abuse, emotional abuse, and sexual abuse. Data on abuse is often unspecific regarding the type of abuse being discussed, mostly because different forms of abuse often occur simultaneously.
Many public agencies exist to deal with the problem of domestic abuse and to protect the vulnerable. The U.S. Administration for Children and Families tracks data on abuse within families. The number of reported abuse cases has increased over the last few decades. But the data is skewed by social norms. It is believed that a contributing factor to the increase in reported abuse cases is due to a social ethic that used to hide and ignore abuse, and now recognizes that it is not the victim's fault and that abuse must be investigated. Even so, the data indicates that child abuse and neglect are on the rise.
Child abuse cases are counted in two ways. The number of incidents counted is known as the duplicate victim rate; the number of victimized children counted is known as the unique victim rate. Two separate rates are tabulated to account for the fact that the same child may be reported multiple times in a year. The duplicate victim rate in 2010 was 10 in 1,000 total children in the U.S. population. The unique victim rate was 9.2 per 1,000 children in the United States. This shows that the data collection methods are working, as the difference between the unique count and the duplicate count is small. Of the unique victims from 2006 to 2010, 75% had not been previously reported. In 2010, 81.3% of reported abused children were victims of their parents. A significantly lower 13% were victimized by people who were not their parents (U.S. HHS, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, 2011).
Child abuse statistics show a definite age factor, with abuse reports shrinking in number the older the victim. In 2010, 34% of child victims were infants to 3 years old, 23.4% were 4–7 years old, 18.7% were 8–11 years old, 17.3% were 12–15 years old, and 6.2% were 16–17 years old (see Figure 1.5).
Figure 1.5: Child abuse by age
A line graph shows the percent of children abused divided into six age groups (ages 0-3, 4-7, 8-11, 12-15, 16-17, and unknown). The percent of children abused in each age group decreases as the children get older.
Child abuse report rates decline as the age of the child increases.
U.S. Department of Health and Human Services (HHS). (2010). Retrieved from http://www.acf.hhs.gov/programs/cb/pubs/cm10/cm10.pdf
Just as the young are vulnerable because they cannot defend themselves, so are the elderly. It is estimated that only 1 in 14 elder abuse incidents is reported, and only 1 in 25 incidents of elder financial exploitation is reported each year. Self-neglect, when a person does not attend to physical needs such as nutrition and bathing, is also a factor in elder abuse. Data from 1996 shows 450,000 seniors were abused by others, and an estimated 100,000 seniors neglected their own care (U.S. Administration on Aging, National Center on Elder Abuse, 2005).
A Closer Look: Elder Abuse Estimates
A photo of an elderly woman wearing a robe and looking distressed as she sits in an armchair in the corner of a room.
Courtesy of Simon Bourne/iStockphoto
An estimated 2.1 million older Americans experience some kind of abuse during their elder years.
The American Psychological Association (APA) (2012) estimates a staggering number of elderly abuse cases, suggesting that 2.1 million older Americans experience some kind of abuse during their elder years. Consider this scenario:
Shortly after her 87th birthday, Beth, suffering from the effects of degenerative arthritis and chronic heart disease, moved in with her adult daughter, Laura. This living arrangement caused stress between them. With her financial worries, her 25-year-old son also living at home, and her husband's job always at risk, Laura has lost her temper numerous times. She has called Beth names and has even gone as far as blaming her mother for ruining her tranquility and home life with her family. This has made Beth feel like a prisoner in Laura's home, isolated from the life she knew, as well as frightened and worthless.
Or take the case of Diane, 78, who lives at home with assistance from a home health nurse and a certified nurses' aide. They visit her daily to care for and assist her with activities of daily living. She also depends on home health care assistance with home-based routines and to give her someone from the outside world to talk with. In the beginning, her nursing assistant was extremely helpful and sweet, but recently the assistant has begun ignoring requests, snapping at Diane, and has even come close to knocking her over while cleaning or vacuuming. Diane believes the assistant is bumping her deliberately, but she is afraid to say anything for fear of losing her link with the outside world, so she doesn't confront her nursing assistant.
Neglect is the most common form of elder abuse; 36.7% of the perpetrators are adult children of their victims (U.S. Administration on Aging, National Center on Elder Abuse, 1997). Statistics show that females were significantly more likely to be the victims of elder abuse, at an incidence rate of 67.3%. Neglect can manifest as the intentional failure to meet the health-related needs of an individual, but it can also involve failing to meet the household necessities of an individual. A survey of states' Adult Protective Services departments shows a marked increase in the number of reports of elder abuse, investigated cases of elder abuse, and substantiated reports of elder abuse from 2000 to 2004 (U.S. Administration on Aging, National Center on Elder Abuse, 2006). Whether the increases are due to expanded public awareness of the problem of elder abuse, or due to an increased number of elderly in the community, or due to an actual increase in elder abuse incidents is uncertain.
Financial exploitation is another form of mistreatment suffered by the elderly, and it can come in many forms, from the deliberate misuse of a legal relationship (power of attorney, guardianship, conservatorship, or trustee) to the embezzlement of funds under false pretenses (for example, the taking of government-issued checks or assistance).
Next we turn to a discussion of partner or spousal abuse. Child and elder abuse are more likely to be reported than spousal abuse, but family violence affects all members of a household. An estimated 30% to 60% of people who abuse their domestic partners also abuse children in the household. Approximately 16,800 homicides occur in the United States every year as a result of domestic violence. If these numbers seem low, there is reason for it because domestic partner abuse is one of the most underreported crimes in the nation (National Coalition Against Domestic Violence [NCADV], 2007).
Even with a lack of consistent reporting, trends show that domestic violence is declining. Reporting might be on the rise, at an estimated 60% of incidents reported between 1998 and 2002. The National Crime Victimization Survey (1998–2002) attempted to remedy the reporting gap by surveying members of different populations in the United States. The survey had a limited scope but some interesting findings. In 1993, the estimated victim rate was 5.4 domestic abuse victims per 1,000 U.S. residents. That number fell to 2.1 in 2002. Domestic abuse accounted for 11% of all violent crimes from 1998 to 2002. The majority of domestic abuse offenders are male, and the majority of victims are female. Domestic violence by intimate partners including current and past spouses, boyfriends, and girlfriends constituted over a quarter (26%) of all nonfatal violent crimes against women in 2009. In that same year, domestic violence constituted only 5% of all nonfatal violent crimes against men (National Center for Victims of Crime, 2011). Of the perpetrators in domestic violence cases in federal court, 67% are younger than age 40, and 72% are Caucasian (Durose et al., 2005). Although domestic abuse may be declining, many factors are unchanged.
Critical Thinking
This chapter is concerned with a discussion of the health-care needs of special populations. We have already talked about high-risk mothers, infant mortality, and households affected by substance abuse; these populations are particularly vulnerable to negative health outcomes. Why do you think abused individualsabusive families would also be categorized as a "special population"?
Chronically Ill and Disabled People
Chronic illness refers to those illnesses that are usually not fully recovered from once a person has them. Diabetes, HIV/AIDS, and emphysema are all examples of life-altering chronic illness. Chronic illnesses can create disabilities, though disabilities also include physical impairments to bodily function that interfere with activities of daily living. Disabilities and chronic ailments have a negative effect on lifestyle, and cost the country millions of dollars per year in health care and other resources. The Centers for Disease Control and Prevention show that chronic disease is the cause of 70% of U.S. deaths every year. Although chronic disease affects our community on the macrolevel, many causes of chronic illness are directly related to individual lifestyle choices. Cigarette use is linked to cancer of the lungs, throat, and other organs; habitual binge drinking causes cirrhosis of the liver; and lack of aerobic exercise leads to diabetes, obesity, and heart disease.
Heart disease was responsible for 26.6% of all registered deaths in 2005. Chronic lower respiratory diseases accounted for 53%, and diabetes was the cause of 3.1% of deaths in 2005. There has been little change in causes of death for age-adjusted death rates in the last few decades. As Figure 1.6 shows, heart disease rates have declined only slightly each year, and hypertension rates are on the rise after a small decline in the 1980s (Kung, Hoyert, Xu, & Murphy, 2008).
Figure 1.6: Leading causes of death by age-adjusted rates
A pie chart depicts the four leading causes of death by age-adjusted rates: heart diseases (44%), malignant neoplasms (37%), cerebrovascular diseases (10%), and chronic lower respiratory diseases (9%).
The pie chart shows age-adjusted death rates for select leading causes of death over the last five decades.
Center for Disease Control and Prevention. (2010). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf
The prevalence of chronic disease is tracked by the CDC's Behavioral Risk Factor Surveillance System. This ongoing telephone survey collects anonymous information directly from patients about their chronic illnesses and quality of life. Data collected in 2009 shows a correlation between respondents who answered that their general health is fair or poor and many chronic illness risk factors such as cigarette use. According to the U.S. Department of Health and Human Service's Healthy People 2020 initiative, almost one-half of all American adults reported at least one chronic illness.
Noninstitutionalized people over age 65 report the most limitations of activity due to chronic illnesses at a rate of 32.6%. Youth under age 18 had the next highest rate in 2006, at 7.3%, and adults ages 18 to 44 reported limited activity at a rate of 5.5% (U.S. Department of Health and Human Services, Healthy People 2020, 2012). The CDC reports that asthma is one of the most common chronic illnesses in school-age children, with 5.6 million children with asthma reported in 2007. Asthma prevalence puts a strain on schools, the health care system, and community resources.
Critical Thinking
Although many chronic diseases are related to personal lifestyle choices such as cigarette smoking, which can cause lung cancer and other serious respiratory diseases, asthma in school-age children does not seem to be related to lifestyle choice. What factors might be causing/influencing such a large population to be afflicted with a chronic disease at such a young age?
People Diagnosed With HIV/AIDS
A photo of people at a rally holding a sign with an image of Uncle Sam that says, "I want you to test for HIV, find the nearest testing station."
Courtesy of Dan Moore/iStockphoto
The number of HIV and AIDS patients in the United States has decreased as a result of public education about HIV and other sexually transmitted diseases.
Human immunodeficiency virus (HIV) prevalence has increased rapidly since the 1980s. Public education about HIV and other sexually transmitted diseases (STDs) has helped mitigate the number of HIV and AIDS patients in the United States. However, in 2011, the African continent was still struggling with rapidly increasing numbers, even as the rest of the world tried to send resources to combat the epidemic.
Antiretroviral pharmaceuticals help people living with HIV/AIDS maintain a higher quality of life and prolong their expected life span. These therapies are expensive, and Americans have struggled to let go of antihomosexual prejudice that blocks public policy that would help HIV/AIDS patients receive needed medical treatment. The number of people living with HIV/AIDS has increased steadily since 1978 and is now estimated at 490,696 people in the United States in 2008. The number of new HIV/AIDS infections per year in the United States has remained under 200,000, with 2011 numbers estimated at 50,000 new infections each year (CDC, 2012a).
Although HIV/AIDS has spread to all American populations, the most affected population is African American homosexual and bisexual men. In 2009, this group made up 61% of all new HIV infections. Statistics for 2008 show this group accounting for 49% of the total number of Americans living with HIV/AIDS. Heterosexuals represented 27% of new HIV infections in 2009 and 28% of the population living with HIV/AIDS in 2008. HIV infections are on the rise among Latinos, with the 2009 estimate of new infections showing that Latino men are two and a half times more likely than Caucasian men to contract the disease (CDC, 2012a).
In 2001, black non-Hispanics represented the highest rate of AIDS-related deaths with an estimated 8,041. White non-Hispanics were second with 4,501 estimated AIDS-related deaths. Hispanics were third with 2,882 estimated AIDS-related deaths in 2001 (CDC, 2012a). In 2008, the total estimated number of HIV/AIDS-related deaths for the United States was 17,374. Numbers from 2009 indicate that people age 40 to 44 years old had the highest number of new HIV/AIDS diagnoses at an estimated 5,689. Adults age 35 to 39 years old had the highest total number of people living with HIV/AIDS at an estimated 234,575 (CDC, 2012a).
From 1999 to 2007, the rate of HIV-related deaths declined for people 45 to 64 years of age and people 18 to 44 years of age (see Figure 1.7). HIV-related deaths for children under age 17 remained steady. HIV-related deaths for people age 65 and over increased slightly through 2006 before declining in 2007.
Figure 1.7: Rate of HIV-related deaths by age group
A line graph depicts the rate of HIV-related deaths by three age groups (0-17 years, 18-44 years, and 45-64 years) from 1999-2007. The HIV-related death rate for people 0-17 years remained flat for the entire nine-year period. The rate for those 18-44 years old was cut in half between 1999 and 2007. The rate for those 45-64 years fluctuated slightly but remained stable from 1999 to 2007.
The number of HIV-related deaths for people between the ages of 45 and 64 fluctuated some between 1999 and 2007, but a significant, steady decrease in HIV-related deaths was seen in people 18–44 years of age.
U.S. Department of Health and Human Services (HHS). (2010). Retrieved from http://www.ahrq.gov/qual/nhqr10/Chap2a.htm
Critical Thinking
HIV/AIDS is a disease commonly associated with behaviors deemed socially negative (for example, homosexuality, illicit drug use, sexual promiscuity). How do you think public policy regarding medical treatment for HIV/AIDS patients would change if the disease were not associated with such behaviors?
Are there other circumstances in which an individual might contract the disease that carry no socially negative implications?
People Diagnosed With Mental Conditions
Diagnoses of mental illness include psychosis, neurosis, depression, obsessive-compulsive disorder, bipolar disorder, schizophrenia, and other ailments connected with mental faculties. Mental disabilities include cognitive disorders and mental retardation. Nearly 50% of Americans surveyed claim to have experienced a mental health problem at one time or another. Estimates indicate that one-quarter of the adult population experiences some form of mental health disruption within a given year, though only 5.8% of cases are severe or debilitating (National Institute of Mental Health [NIMH], n.d.).
A portion of the National Survey on Drug Use and Health's (NSDUH) definition of serious mental illness includes the substantial interference with daily life. The 2010 study found that approximately 5% of American adults were diagnosed with serious mental illness. Women were 3.1% more likely to have this diagnosis than men (Substance Abuse and Mental Health Services Administration [SAMHSA], 2011). Young adults age 18 to 25 years old had the highest incidence rate, as shown in Figure 1.8.
Figure 1.8: Incidence rates of mental illness by age in America in 2010
A line graph depicts the rate of HIV-related deaths by three age groups (0-17 years, 18-44 years, and 45-64 years) from 1999-2007. The HIV-related death rate for people 0-17 years remained flat for the entire nine-year period. The rate for those 18-44 years old was cut in half between 1999 and 2007. The rate for those 45-64 years fluctuated slightly but remained stable from 1999 to 2007.
Diagnosis of mental illness occurs most frequently in young people, age 18–25.
National Institute of Mental Health (NIMH). (2010). Prevalence of serious mental illness among U.S. adults by age, sex, and race. Retrieved from http://www.nimh.nih.gov/statistics/SMI_AASR.shtml
The use of mental health services by adults increased from 12.8% in 2004 to 13.4% in 2008. Among adults age 18 and over, 13.7% used mental health services in 2010 (National Institute of Mental Health [NIMH], 2012). Increased use of mental health services indicates a positive trend in access to those services; however, the increased suicide rate indicates an increased prevalence of mental illness in the population. The positive trend in services might be due to the negative trend in illness rates and not actually indicative of better resource access.
Suicide- and Homicide-Liable People
Suicide and homicide can be driven by the same social factors. A sense of being stuck in a hopeless situation leads people to a wide range of negative outcomes. Community resource programs that mitigate needs for safety, food, shelter, and education have a large influence on homicide rates in the communities where they function.
Suicide rates have increased, from 11.08 suicides per 100,000 people in 2004 to 11.26 suicides per 100,000 people in 2007 (NIMH, n.d.). In 2010, 1 million adults reported making plans to commit suicide, and 1.1 million adults actually attempted suicide (SAMHSA, 2011).
Homicide refers to both murder and manslaughter. Murder is the term given to the purposeful, malicious killing of another person. Manslaughter is the killing of another person due to negligence. In other words, intentionally causing a death, even if in the heat of the moment, is murder, whereas causing a death by hitting another car because you were texting while driving is considered manslaughter.
The prevalence of homicides in the United States increased during the early and mid-1990s. The total number did not fall below 18,000 until 1998 when data showed 16,974 homicides during that year. Homicide rates have hovered between 15,000 and 18,000 since then (U.S. Department of Justice, 2012).
People Affected by Alcohol and Substance Abuse
According to the 2010 National Health Survey, 51% of legal adults use alcohol regularly. Simple alcohol and substance use differs from both abuse and dependence. Substance abuse indicates a maladaptive pattern of substance use that leads to significant impairment or distress. Substance dependence, on the other hand, indicates addiction, where an individual can develop tolerance, withdrawal, or compulsive drug-taking behavior. Both use and abuse/dependence can have negative health effects and increase a person's health risk potential. Overall rates of alcohol and substance use and abuse have been declining slowly over the last four decades, though rates of certain drug abuse have increased.
The country has experienced a small decrease in nonmedical drug use among all surveyed groups from 2002 to 2008. This is a positive change, as the 1990s saw an increase in illicit drug use for children ages 12 to 17. Marijuana use among high school seniors was 33.7% in 1980 and then declined for a period through 1991. In 1995, marijuana use rose drastically to 21.2% and has declined only slightly since, to 20.6% in 2009. Cocaine use among high school seniors followed a similar trajectory. In 1985, the rate of cocaine use among this vulnerable age group was 6.7%. Since then, it has hovered between 1% and 2%, with a 2009 rate of 1.3% (see Figure 1.9) (U.S. Department of Health and Human Services, 2011a).
Figure 1.9: Substance abuse in the past month among persons 12 years of age and over
A bar graph depicts the incidence rates of mental illness in Americans in three age groups (18-25 years, 26-49 years, and 50+ years) in 2010. Americans 18-25 years old suffered the most mental illness proportionately compared to older age groups. Those 26-49 years old suffered mental illness proportionately more than older individuals; and those 50+ years old suffered less mental illness in 2010 than all younger age groups.
Illicit drug use has declined only slightly for the age groups between 12 and 25, but the rate has remained almost constant for the age groups 26 and over.
Center for Disease Control and Prevention. (2010). Retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf#061
In 2010, 50.9% of legal adults reported regular alcohol use, and 13.6% of respondents reported occasional alcohol use. There were 14,406 alcoholic liver disease deaths in the United States in 2007, and 23,199 nonaccident and nonhomicide alcohol-related deaths (CDC, 2012a). Figure 1.10 shows that alcohol use declined overall among high school seniors, with 72% in 1980 and 43.5% in 2009. Hard data is not available as to the reason for this decline, but it is thought to be due to more strict enforcement of laws regulating access to alcohol and community-based prevention programs.
Figure 1.10: Alcohol use among high school seniors
A line graph depicts the percentage of persons age 12 or older who engaged in substance abuse in the period of a month during 2002, 2007, and 2008. The persons are divided into six age groups (ages 12-13; 14-15; 16-17; 18-25; 26-34; and age 35 and over). In all three years studied, substance abuse was lowest in ages 12-13; peaked at ages 18-25; and gradually declined for those ages 35 and over.
Overall, alcohol use among high school seniors has declined over the last three decades.
Centers for Disease Control and Prevention (CDC). (2012a). Retrieved from http://www.cdc.gov/nchs/data/hus/hus10.pdf#062
Emergency room reports provide many statistics on alcohol and drug abuse in the United States. These reports are made via the Drug Abuse Warning Network (DAWN), through the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. There were 4.6 million drug-related emergency department visits across the nation in 2009. Of these, approximately 50% were related to side effects of medications that were taken correctly. The rest included 27.1% related to nonmedical use of prescription drugs; 21.2% of DAWN-reported cases involved illegal drugs; and 14.3% involved drugs and alcohol combined (National Institute on Drug Abuse [NIDA], 2011a).
Critical Thinking
The Drug Abuse Resistance Education (DARE) program was founded in 1982 as an effort by law enforcement to educate adolescents about the hazards (both health and lifestyles) of illicit drug use. As discussed earlier, there has been a measurable decrease in illicit drug use by adolescents. Do you believe that programs like DARE have had an effect on this reduction? If not, what other factors do you believe may be responsible?
Indigent and Homeless People
Photo of a homeless teenager sitting on the sidewalk with his head down and arms folded.
Courtesy of Richard Thornton/Shutterstock
Of the more than half a million people who are homeless on a given night, a growing percentage of that number are families.
Homeless people have an extremely high risk for negative outcomes. Homicide, suicide, mental illness, chronic illness, and acute illness all plague the homeless population. Hunger and exposure to the elements are the immediate concerns government and community groups work to alleviate in the homeless population. Creating positive, permanent outcomes for America's homeless takes resources and an understanding of the people in need of aid.
In 2009, an estimated 643,067 homeless people were both in shelters and on the streets on a given night. The Department of Housing and Urban Development (HUD) estimates that homeless numbers held steady from 2009 to 2010, but that the number of homeless families has increased in relation to the number of homeless individuals (U.S. Department of Housing and Urban Development [U.S. HUD], 2011). HUD's 2010 Annual Homeless Assessment Report to Congress found a decline in long-term homelessness, credited largely to the Homelessness Prevention and Rapid Re-Housing Program.
Immigrants and Refugees
Immigration to the United States has increased in fits and starts since the year 1820, with some years seeing less immigration than others. Migrants obtaining legal permanent resident status in 2010 totaled 1,042,625 (U.S. Department of Homeland Security, 2010). Both legal and illegal migrants and refugees present unique challenges to America's social welfare system.
Language barriers strain resource delivery to the migrant population. Educators have developed English as a Second Language (ESL) programs to address the educational needs of migrant and refugee children. Health care organizations purposefully seek bilingual employees who communicate well with patients. Differences in ethical and social norms sometimes prohibit migrants from seeking assistance for housing, health care, and other needs.
The United States office of Citizenship and Immigration Services oversees all legal immigration to the country. Programs exist for the naturalization of foreign-born adopted children, work visas, marriage, citizenship through naturalization, and for those seeking asylum. Legal immigration through the appropriate channels better enables resource delivery to migrant populations. However, legal immigration does not automatically give the foreign-born person the same access to publicly funded health care programs. Special programs exist for aiding refugees. Refugees are different from immigrants because they are forced to flee their home country, as opposed to immigrants who come and leave freely. The federal Office of Refugee Resettlement (ORR) provides critical resources for refugees seeking asylum in the United States.
Critical Thinking
In the United States, people hold very different attitudes toward immigrants and refugees. These attitudes range from the belief that illegal immigrants drain our resources and bring those that prey on them, such as drug dealers and con artists, to peaceful neighborhoods to the belief that by providing the needed resources, the common good will improve. Do you perceive that there is a benefit to providing these resources?
Case Study: Macro Perspective Versus Micro Perspective: The Patient Protection and Affordable Care Act of 2010
We have seen all of these principles of social theory in the debate over the Patient Protection and Affordable Care Act of 2010 (PPACA) (One-Hundred Eleventh Congress, 2010). The PPACA was signed into law by President Barack Obama and was his signature legislative project. Both President and First Lady Obama dedicated themselves to improving the health and access to health care of all Americans. The primary focus of the PPACA is to limit the power of the private health insurance companies to deny claims and coverage, to improve affordability of health care, and to expand the qualifications for Medicaid.
The Pareto principle that the common good actually has a negative effect on some is at the heart of the debate. One side argues that reforming America's health care system is vital for the public good. The opposition argues that the reforms called for in the PPACA will cost the collective a great deal but will benefit only a few. A similar but slightly different argument given is that a few will be forced to pay for the collective. Both of these arguments are based on the concept that the common good (in this case, reform of the health care system) is not good for all.
