Review the descriptions of the special populations addressed in Chapter 1 of your course textbook.? Identify the three groups yo

1

Identifying the Vulnerable

Learning Objectives

After reading this chapter, you should be able to:

• Explain the concept of vulnerable populations.

• Discuss how the theories of common good and individual rights contribute to the cre- ation of public policy in health care.

• Determine how the concept of resource availability relates to one’s health.

• Examine the aggregate statistical data on the number and growth of identified vulnerable populations.

• Identify the vulnerable populations in the United States.

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CHAPTER 1Introduction

Introduction

Two women enter the hospital with pneumonia. They are similar in age, but of dif-ferent races. One patient has private health insurance; the other is on Medicaid. One patient recovers quickly while the other languishes. What can be surmised from the differences in the two patients? Thinking on this and asking the right questions allows health care providers to create patient care plans that better meet each patient’s needs. Providing better health care to all patients requires awareness of environmental factors that may prohibit timely recovery and put the patient at risk for secondary and repeat infections.

Environmental factors such as finances, family, and education all affect a person’s vulner- ability, or risk level. Understanding statistical data on vulnerable populations will help you interpret patient information. This allows easier identification of those who are at risk, so that providers may plan care accordingly. Addressing the needs of at-risk popula- tions leads to faster patient recovery, thereby lowering the cost of patient care.

Lowering health care costs is important for the patient, the care provider, and the whole country. Nonprofit organizations and government agencies work to identify and help at-risk groups. This activity affects both government and organizational policy among health care providers.

This text investigates the statistical data and indicators of vulnerable populations in American health care. It also covers the causes of vulnerability and the prevailing ideolo- gies on dealing with at-risk populations. We will also discuss what is currently being done through policymaking and program implementation to address the needs of vulnerable populations and what the future looks like for at-risk groups. This chapter focuses on identifying vulnerable populations. The relationship between resource availability and health is an important part of recognizing at-risk groups. Finally, we will look at statistical data concerning the at-risk groups identified in the book.

Critical Thinking

The text states, “Addressing the needs of at-risk populations leads to faster patient recovery, thereby lowering the cost of patient care.” How does addressing the needs of at-risk populations lead to faster patient recovery?

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CHAPTER 1Section 1.1 Social Theory and Public Policy in Health Care

Self-Check

Answer the following questions to the best of your ability.

1. Asking the right questions allows health care providers to create ______________ that better meet each patient’s needs.

a. patient care plans b. outpatient clinics c. health insurance plans d. genetically modified medicines

2. Environmental factors such as finances, family, and education all affect a person’s vulnerability, or __________.

a. mortality b. life span c. risk level d. quality of life

3. Nonprofit organizations and which agencies work to identify and help at-risk groups?

a. cultural entities b. labor unions c. local businesses d. government agencies

Answer Key

1. a 2. c 3. d

1.1 Social Theory and Public Policy in Health Care

Health is both an individual consideration and a community concern. In other words, an individual makes decisions that directly affect him or herself, and a society makes decisions that affect and manage the society itself. For example, a person may choose to smoke cigarettes, thereby damaging his or her own lungs. However, this action also has an impact on those around the smoker because secondhand smoke has been shown to be a valid health concern. Thus, society may create public policy, or laws, that outlaw smoking in public places with the intent of ensuring that one person’s deci- sion to smoke does not harm others.

A law that bans smoking in public places is based on the social theory of the common good, meaning it is intended to help everybody. The concept of the common good focuses on creating a benefit for the most members of a community. Sometimes the common good is juxtaposed with the social theory of individual rights, which is based on protecting personal freedoms. Public controversy often ensues when the common good is perceived to infringe on such individual rights. For example, social theory centered on the common good led to the creation of public policy in the form of a law banning smoking in public places, which results in heated debate among lawmakers and citizens. One side argues

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CHAPTER 1Section 1.1 Social Theory and Public Policy in Health Care

that such laws are necessary to protect society; the opposition argues that personal freedom should not be inhibited by the collective citizenry. The United States Bill of Rights is the pri- mary protector of individual lib- erties in the United States. The argument that personal freedom should not be inhibited by the collective citizenry is primarily based on three amendments:

• The Ninth Amendment states, “The enumera- tion in the Constitu- tion, of certain rights, shall not be construed to deny or disparage others retained by the people.”

• The Tenth Amendment further protects individual liberties by stating, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.”

• The Fourteenth Amendment states, “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside. No State shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United

States; nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdic- tion the equal protection of the laws.”

However, the argument in favor of passing legislation to pro- mote the common good is based directly on the preamble to the Constitution:

• “We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tran- quility, provide for the com- mon defence, promote the general Welfare, and secure the Blessings of Liberty to

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Pareto’s principle explains why the common good and individual fairness often conflict. In many cases, a small group of people do most of the work, which the majority then benefits from.

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Prohibiting smoking in public places exemplifies the social theory of the common good, because the mandate is meant to benefit everyone.

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CHAPTER 1Section 1.1 Social Theory and Public Policy in Health Care

ourselves and our Posterity, do ordain and establish this Constitution for the United States of America” (Constitution of the United States of America and the Bill of Rights, 1787).

The Constitution and amendments then go on to describe Congress’s power to legislate.

Which option is the fair choice? That question plagues American health policy. America dogmatically strives for justice and fairness for all citizens. Social theorists and policy- makers alike refer to the Pareto principle when the common good and individual rights are directly at odds. The Pareto principle is the theory that 80% of the outcome is caused by 20% of the effort (Juran, 1994). This is often seen in community involvement situations wherein a handful of people do most of the work while the majority does very little. In social theory, the Pareto principle is often translated to mean that fairness for all does not necessarily create fairness for every individual and that some instances occur wherein fairness for all has negative effects on the common good (Kaplow & Shavell, 2000). Take the case of a communist society wherein all resources are combined then doled out equally among people, regardless of how much each person contributed. Ensuring food for all citizens benefits the common good, but a farmer who worked hard all year to fill the pan- try may end up without enough to feed his family for the winter because others were less industrious, so his equal share becomes less than what he worked for.

Social Attitudes Versus Individual Choice

The smoking ban example illustrates how social attitudes—which are positive or nega- tive evaluations of people, places, things, events, and the like, and are shared by a majority of the community as a whole—and individual choice are not always in agreement. Social attitudes are the result of generalized, shared ethics in a society. They help shape our over- all health environment. For example, positive social attitudes toward cigarettes viewed smoking in public spaces to be perfectly acceptable and even doctor recommended in the early 1900s. The current social attitude toward cigarette smoking has caused the number of cigarette users in the United States to drop below 20% (see Figure 1.1). This in turn has created a drop in tobacco-related illness and death. Negative social attitudes about cigarette use, caused by a collective realization regarding the negative effects of smoke, secondhand smoke, and related illnesses, have positively affected the nation’s health.

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CHAPTER 1Section 1.1 Social Theory and Public Policy in Health Care

Figure 1.1: Percentage of adults in the U.S. who use cigarettes

Social attitudes toward cigarette smoking have changed drastically in the last 50 years, causing cigarette use to decline.

Centers for Disease Control and Prevention (CDC). (2011). Trends in current cigarette smoking among high school students and adults, United States, 1965–2010. Retrieved January 9, 2012, from http://www.cdc.gov/tobacco/data_statistics/tables/trends/cig_smoking/

index.htm

Social attitudes are part of the collective, or macro, influences on our health. Other macro- level influences include messages from the media, such as commercials for fast food. Health policy is often created in response to macro influences on our society’s health environment, or the combined collective knowledge created through rigorous study, comprehensive eval- uation, and peer-reviewed publication of facts related to the collective public good.

Considering only the macro view does not consider the individual, or micro, influences or decisions that we each make about our health. Micro influences on health include whether we choose to walk, bike, or drive to work or school, and which foods we select at the gro- cery. A debate lingers over whether the micro or macro perspective is more useful when considering health decisions and policy.

Critical Thinking

Can you think of other examples where social attitudes conflict with individual choice? Would abortion (a woman’s right to choose) fall into this category? What about medical marijuana?

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Self-Check

Answer the following questions to the best of your ability.

1. During which time period did the media and medical professionals promote smoking as “good for your health?”

a. early 1900s b. late 1950s c. middle 1970s d. early 2000s

2. The common good refers to principles and laws intended to help which of the fol- lowing groups?

a. a few people b. a specific group of people c. everybody d. no one

3. The Pareto principle refers to which of the following principles? a. 90% of the outcome is caused by 5% of the effort b. 10% of the outcome is caused by 80% of the effort c. 100% of the outcome is caused by 100% of the effort d. 80% of the outcome is caused by 20% of the effort

Answer Key

1. a 2. c 3. d

1.2 Considerations for Studying Vulnerable Populations

How do we apply social theory to the study of vulnerable populations? First, we must begin by categorizing the influences that affect the health of these groups. The influences are used to determine which social groups in our society are defined as vulnerable populations.

Community and Personal Values

Americans largely associate good health with good personal habits and decisions. This means that culturally, Americans expect each person to take responsibility for his or her health-related habits and actions. Daily exercise, dietary choices, and other behaviors are not heavily regulated by public policy or community values. Each person’s own values determine his or her health outcomes.

Of course, we cannot entirely disregard community health values. After all, they do shape public health policy. Community values also affect the community’s investment in resources and opportunities that impact health, from regulating pollution levels to ensur- ing the availability of fresh produce. Community-based health policies help bridge the

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

gap between microlevel personal choices and macrolevel governmental thinking. Most public policy decisions grow, not from massive governmental thinking, but from grass- roots efforts, like the previously discussed smoking ban(s). These grassroots efforts are evidence of the power of individuals to affect public policy.

The Louisville, Kentucky, Farm to Table program offers a good example. Two movements were simultaneously growing in the Louisville community. One movement, led by local farmers and entrepreneurs, focused on expanding access to locally farmed foods within the community; the other movement, led by parents and school cafeteria employees, focused on improving the nutrition of school lunches. When these two groups combined efforts, the Farm to Table program was altered, and creating avenues to getting locally farmed foods into school cafeterias became an important goal throughout the commu- nity. As the community at large increased program participation, the local city govern- ment became involved with programs and grants to increase the scope of the Farm to Table program.

Access to Resources

From a macro perspective, we see that the distribution of resources within a community has a direct impact on health risk. Resource distribution often correlates with social status, social capital, and human capital. Though American society tries to equalize the distribu- tion of resources through social welfare programs, it is no secret that individuals gain or lose access to opportunities and resources depending on their social status, social ties, and ability to invest in their own potential.

Social Status An individual’s place in society, called social status, is attributable to personal charac- teristics, opportunities, and rewards. Personal characteristics such as age, gender, ethnic- ity, geographic location, educa- tion level, and income result in social rewards like social power, or a lack thereof. Age affects a person’s wellness (e.g., elderly people are usually more sus- ceptible to chronic illness than young adults) as well as a per- son’s need to depend on others for his or her well-being (e.g., children depend on adults for medical care).

Gender is also an important fac- tor in health and level of health risk. Women are more suscepti- ble to certain cancers, for exam- ple, but are more likely to seek medical care. Men are more sus- ceptible to work-related health

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Opportunities, rewards, and personal characteristics can be attributed to an individual’s social status.

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

risks, as they traditionally hold more physically demanding jobs. The emotional differences between men and woman also affect vulnerability. Statistically, women are more likely to suffer the ill consequences of eating disorders, whereas it can be said that men are socially trained to eat more red meat and maintain a more robust physique, deci- sions which come with their own sets of health risks.

Ethnicity and race are two of the most studied factors in social status and health risk because minorities historically have less access to the social rewards that limit risk levels. Lower-class urban neighborhoods with a

high number of minority residents often lack representation in social politics and suffer for it with higher levels of air and water pollution, which increase the level of health risk for all residents. Furthermore, poverty can breed crime, and the stress of living in a high-crime area also negatively affects a person’s health. Stress can manifest physically by presenting as com- plaints such as headaches. Stress can also increase the likelihood of negative health behaviors, such as cigarette and alcohol use. Limited access to resources, including fresh vegetables and medical care, increases the burden. Low-income areas are commonly populated with fast-food restaurants that serve high-fat foods, whereas more affluent areas often have more grocery stores and farmers’ markets. Additional factors such as migrant sta- tus further increase a person’s vulnerability. Risk factors do not stand alone. An elderly minority female has different risk factors than an elderly Caucasian male.

Social Capital Social capital is the measurement of personal relationships in an individual’s life. The number, type, and reliability of interpersonal relationships greatly influence a person’s vulnerability and health risk. For example, a single mother is less likely to spend a day in bed, resting and recov- ering from an illness, than a mother who has a

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Health risk depends on several factors, including the quantity and quality of a person’s interpersonal relationships.

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Minorities are less able to take advantage of the social rewards that diminish risk levels; thus, ethnicity and race are oft-studied factors in social status and health risk.

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Critical Thinking

Do you have a support network? Can they help with family needs such as child care or transportation? Are they supportive of your education goals?

partner or someone reliable who can care for the children. Working parents are better able to maintain viable employment if grandparents and other relations are available to help with child care.

The ability to work creates opportunities and other social rewards. An upwardly mobile career path grants access to money and insurance to help pay for doctor visits and medi- cine. The opportunity to meet people and grow friendships at work adds to a person’s support network. A strong, healthy support network directly influences psychological and physical well-being, lessening a person’s health risk. Hospitals and rehabilitation facilities have found that patients who have reliable support systems enjoy faster recovery times and spend less time recuperating in the medical center in favor of convalescing at home with the assistance of a robust, developed support system. Reducing the length and frequency of hospital stays reduces the risk of secondary and recurrent infections.

Human Capital Human capital is the amount of investment in a person’s potential. Low-income indi- viduals often have low human capital, while higher-income individuals enjoy investment in their potential in the form of education, opportunities for advancement, and even better access to higher-quality health care. The more investment made in a person’s potential, or future, the more that person will be able to contribute to society in a positive way.

Data on various subjects including education, wage earnings, and health care access indi- cates gaps in human capital based on gender, age, and ethnicity. Poor-performing schools are more common in low-income neighborhoods, females are sometimes passed over for advanced training and managerial positions, and minorities often suffer a lack of social resource allocation. In all of these examples, failure to invest in people’s potential nega- tively influences their long-term outcomes. Poorly educated children are less likely to attend college, the disenfranchised female will lose work productivity, and the neighbor- hood that needs public resources to fix streetlights will see an increase in crime.

Outside influences are not the only way to invest in human capital. Individuals invest in their own potential by working hard at school and work and by organizing communities to create the change they want. Conversely, investment in human capital can be negatively impacted by a collective lifestyle perspective. The collective lifestyle perspective dictates behavior based on social constructs, or ideas, about the way people “like me” should behave (Barnes, Hall, & Taylor, 2010). Middle-class mothers may perceive that smoking is unacceptable among their peers and so give up smoking. Conversely, adolescents in low- income areas may perceive that smoking makes them more accepted among their peers and so take up the unhealthy habit.

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Health Indicators

The World Health Organization (WHO) is an international organization that coordinates health-related efforts around the globe. The WHO definition of health goes beyond the mere absence of illness, proposing that “health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (World Health Organization [WHO], 2012).

From this definition of health, we can see where values and resources are directly linked to well-being. The WHO definition indicates that health exists in varying degrees, based on a number of recognized indicators. Indicators of physical health are considered the measurements of the body’s wellness, such as bodily illness and disability. Mental health indicators measure emotional issues such as stress and mental illness. The WHO defini- tion also includes social well-being, based on indicators such as relationships with others. Figure 1.2 illustrates the health continuum.

Figure 1.2: The health continuum

Health is not simply the absence of disease. A person’s degree of health exists on a spectrum, fluctuating throughout life.

Health is measured along a continuum, with great health at one end and death on the opposite end. Minor ailments fall nearer the perfect health end of the continuum, with more severe needs nearer the death end.

The WHO definition of health clearly includes physical, mental, and social components. Physical health deals with the body and bodily functions, mental health includes brain functions such as thought and emotions, and social health includes interpersonal relation- ships with others. Physical health is measured by patient perception, doctor opinion, and clinical testing. Another way to measure health is based on a patient’s abilities to perform activities of daily living (ADLs). Basic ADLs include personal hygiene and being able to dress oneself, feed oneself, walk with or without assistance, and use the restroom (Weiner, Hanley, Clark, & Van Nostrand, 1990).

Patient perception of well-being cannot be overlooked when measuring health. An impor- tant part of patient perception of well-being involves the concept that people alter their behavior when they perceive that they are unwell. Staying in bed and eating chicken soup are two common “sick role” behaviors. Perception is a key tool in measuring both mental health and social health, as people interpret stressors and relationships differently.

Patient perception, doctor opinion, and clinical testing are standard ways of measuring individual health status but do not offer a larger picture of community health status. Community health status is measured with statistics of the rates of occurrence of illness,

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Critical Thinking

Where does your current total health fall on the health continuum? Can you think of a time when your health measured nearer the negative end?

Do you feel that patient perception is a reliable method of measurement for use in global decisions regarding heath issues?

disease, and death within a recognized group. This data, such as that shown in Figure 1.3, is used to influence public policy and the distribution of public resources.

Figure 1.3: U.S. infant mortality rates per 1,000 live births, by maternal education and race

Mortality rates for children born to white mothers is much lower overall than for children born to black mothers; however, both races see a significant decrease in infant mortality as the mother’s number of years of completed education rises.

Singh, G. K. & Yu, S. M. (1995). Infant mortality in the United States: Trends, differentials, and projections, 1950 through 2010. American Journal of Public Health, 85(7). Retrieved January 12, 2012, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1615523/pdf/

amjph00445-0063.pdf

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Public Policy

The World Health Organization works to affect public health policy and practices on a global scale. In the United States, public health policy is created by local, state, and federal politicians. Many organizations influence the policies as they are created. Some organiza- tions or groups that influence public health policy in this country include the following:

• Health insurers • Lobbyists

Risk Potential

The data on infant mortality and maternal race and education in Figure 1.3 also illustrates the concept of relative risk, or risk potential. Relative risk is the potential of imperfect health in groups exposed to risk factors, such as drug use, in rela- tion to the potential of imperfect health in groups not exposed to the same risk factors.

The concept of relative risk embodies the differential vulnerability hypothesis, which theorizes that some people have more adverse reactions than others to negative life events. Studies of the differential vulnerability hypoth- esis have found that members of low socioeco- nomic status groups experience higher levels of anxiety, stress, and emotional duress when faced with negative events and information than do persons of higher socioeconomic status. Con- sidering the factors that contribute to health and well-being (social status, social capital, and human capital), we can ascertain that a deficiency in these factors is a likely cause of the higher levels of mental duress in stressful situations experienced by members of low socioeconomic groups. For example, a wealthy person who

receives a speeding ticket is less likely to be concerned about how he or she will pay the ticket than a person on a fixed income. For the latter, paying a ticket strains an already tight budget that must pay for food and shelter. Without reasonable levels of social status, social capital, and human capital, where is the extra money to come from?

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In groups exposed to certain risk factors, negative life events can cause more adverse reactions than in groups not exposed to those same factors.

Critical Thinking

Why do you think members of low socioeconomic status groups experience higher levels of anxiety, stress, and emotional duress when faced with negative events and information than do persons of higher socioeconomic status?

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CHAPTER 1Section 1.2 Considerations for Studying Vulnerable Populations

Critical Thinking

With so many organizations having an influence on public health care policy, do you think it is possible for one person to make a difference?

• Planned Parenthood of America • Health care providers • The American Public Health Association • The Centers for Disease Control and Prevention • The Public Health Initiative • National Association of Public Boards of Health • Public Health Foundation • The World Health Organization • American Medical Association

The list of groups influencing public health policy in the United States goes on and on, but one thing is important to note: There is a community of these organizations. Though Americans primarily take the micro perspective on good health, believing that individu- als should be personally responsible for healthy lifestyle choices, the macro perspective is ever present.

Individuals belong to communities, from the neighborhood level to the international community, and every group in between. The community perspective of health care pol- icy emphasizes the creation of a social support system that cares for vulnerable

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