Ethical
Chapter 9 attached, three research methods are available (descriptive, analytic, and evaluative). Discuss these methods and give one example of how each would be used when conducting research using homeless individuals as subjects. Analyze regulatory, accreditation, ethical, and legal issues and challenges related to each research method.
Your initial contribution should be 250 to 300 words in length.
Due 2/15/20 @10m Eastern w/plag report
9
Studying Vulnerable Populations
Learning Objectives
After reading this chapter, you should be able to:
• Recognize the three types of research needed to identify, understand, and address the
needs of vulnerable populations.
• Identify vulnerable populations using descriptive research.
• Identify vulnerability using analytic research.
• Assess program efficacy using evaluative research.
Courtesy of Zack Blanton/iStockphoto
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CHAPTER 9
Critical Thinking
The three types of research all have advantages in certain situations and disadvantages in others. Do
you think there would there be a benefit in using only one type of research in all situations to ensure
consistency and accuracy?
Introduction
Introduction
To understand how to best address the needs of vulnerable populations, research must be conducted. The type of research used to study special populations in America’s health care system falls into three broad categories. Descriptive research
focuses on identifying those most at risk and the methods of identifying these groups and
their needs—for example, identifying which youth are most at risk for violent behavior.
Analytic research focuses on iden-
tifying the reasons for vulnerability
and ways to prevent and remediate
vulnerability, so it is used to iden-
tify why certain youth have higher
risks of violent behavior than others.
Evaluative research helps determine
the success of existing programs that
aim to provide services to vulner-
able groups—meaning that evalu-
ative research asks such questions
as, “What programs are effective at
addressing the needs of youth iden-
tified as being at risk for violent
behavior?”
Each research category serves an
important purpose; However, more
integration between research types
and studies would help improve
the understanding of vulnerability
as well as the programs that serve
America’s most vulnerable. The research associated with vulnerable populations is often
fragmented, in that studies often look at one particular issue or group but do not always
consider the connections that exist across issues and populations.
Courtesy of Gina Sanders/Fotolia
Descriptive, analytic, and evaluative research are
all essential types of research used to study special
populations in America’s health care system.
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CHAPTER 9Section
9.1 Descriptive Research: Identifying the Vulnerable
Self-Check
Answer the following questions to the best of your ability.
1. Which type of research focuses on identifying those most at risk and the methods
of identifying these groups and their needs?
a. descriptive research
b. analytic research
c. evaluative research
d. collaborative research
2. Which type of research focuses on identifying the reasons for vulnerability and
the ways to prevent and remediate vulnerability?
a. descriptive research
b. evaluative research
c. analytic research
d. electronic research
3. Which type of research works to determine the success of existing programs that
aim to provide services to vulnerable groups?
a. evaluative research
b. descriptive research
c. analytic research
d. qualitative research
Answer Key
1. a 2. c 3. a
9.1 Descriptive Research: Identifying the Vulnerable
Studies that work toward identifying vulnerable groups fall into the descriptive research category, which means that they seek to describe which groups are most vulnerable. Unfortunately, efforts to identify and count America’s vulnerable popu-
lations are disjointed, with the result that there is little uniformity in terms of the defini-
tions being used. Furthermore, lack of consistency when defining the characteristics of
vulnerable groups causes data to become skewed—such as in some studies where specific
groups are over- or underrepresented—and difficult to compare across studies. Issues of
data collection necessary to study high-risk populations further complicate this problem.
For example, one study may ask care providers to define patients by race while another
study asks patients to define themselves by ethnicity. It would be much easier and more
accurate if the two studies used the same terminology and definitions. Though using the
same source for data is not always needed (for example, if the studies want to see the
difference in how providers and patients define patients’ races), using standardized data
sources and data collecting methods (paper survey vs. computerized data mining) helps
in performing cross-comparisons of the studies. Even as definitions begin to form, the
length of time taken to interpret and report data leads much of it to be obsolete before a
report is written.
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
Research into the descriptive characteristics of vulnerable populations should pay atten-
tion to the definitions used in prior research studies and use them where they can or
address the changes in the reporting so that terminology is consistent across the various
studies. In general, best practices that establish common terminology and provide for
uniformity in data collection and reporting are necessary.
Vulnerable Mothers and Children
Traditionally, birth and death records were the main source of data available to those
working on descriptive research of vulnerable mothers and children. The National Vital
Statistics System (NVSS) is maintained by the Centers for Disease Control and Pre-
vention’s National Center for
Health Statistics (NCHS). NVSS
is a reporting system that tracks
birth, death, and health data to
provide a picture of what the
American population looked
like in the past and what it looks
like now; NVSS uses that data to
estimate future birth, death, and
health trends.
NCHS frequently reviews data
reporting methods. Lack of reg-
istered births and incomplete
registrations continue to be
problematic for NVSS and the
researchers who rely on its data.
Previous efforts to remedy this
problem have included updat-
ing classifications and survey-
ing households (Hetzel, 1997).
NCHS also provides standardized reporting forms, training, and an instruction manual to
help those charged with reporting to ensure complete and accurate information.
Abused Individuals
Two issues plague data regarding child abuse, intimate partner abuse, and elder abuse.
The definitions of abuse are somewhat subjective, and it is suspected that a considerable
number of incidents go undetected and unreported. Data for descriptive research into
abused individuals usually comes from clinical studies, household surveys, interviews
with victims and perpetrators of abuse, and protective service agency reports.
The Administration for Children and Families conducts the National Incidence Study
(NIS) on Child Abuse and Neglect about once per decade. The study was created as a
requirement of the Child Abuse Prevention and Treatment Act. NIS contributes to the
field of descriptive research not only by compiling data but also by creating standard-
ized terminology and a framework for classifying and reporting child abuse by severity,
Courtesy of Alena Kovalenko/Fotolia
Future birth, death, and health trends can be estimated based
on current data from the National Vital Statistics System.
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
maltreatment type, and demographics (Administration for Children and Families, n.d.b).
Researchers conducting clinical studies and interpreting official reports should consider
using the standards set forth by the NIS. Doing so would help create a network of research
on the subject that would improve research accuracy.
Chronically Ill and Disabled Persons
Descriptive research on the chronically ill and disabled is relied on when determining
health care program eligibility. The primary problem with this research is that much of it is
subjective. For example, two patients with similar
arthritis symptoms may report different amounts
of pain on a scale of 1 to 10. What one patient finds
uncomfortable, say bending over to tie shoelaces,
may be impossibly painful for another patient
with a similar amount of inflammation. Should
the second patient receive more physical therapy
paid for by insurance or have his or her medica-
tion costs subsidized while the patient reporting
less pain is deemed ineligible for such programs?
The broadest information set available cover-
ing the chronically ill and disabled in the United
States is the National Health Interview Survey
(NHIS) conducted annually by the U.S. Census
Bureau. The bureau selects households to par-
ticipate in the survey and asks the participants to
meet with interviewers to answer questions about
race, living situation, diagnosed health issues, and
perceived health issues and wellness. Survey par-
ticipation is about 90% of selected households; of
those that refuse the survey, replacements are not
selected (Centers for Disease Control and Preven-
tion, 2012f). By conducting the survey through
live interviews, participants are encouraged to
provide complete and accurate information.
However, much of a person’s perceived health is
subjective, and accuracy cannot be guaranteed.
Persons Diagnosed With HIV/AIDS
Descriptive research helps to identify those groups that are most at risk for contracting
the HIV virus so that preventive programming can be directed in appropriate ways. In
the 1980s, HIV was thought of as a “gay man’s” disease. However, HIV is also prevalent
among intravenous drug users and can be transmitted through bodily secretions regard-
less of sexual preference. It is therefore important to determine who in the population has
HIV, who in the population is most likely to contract HIV, and through what means the
disease is most often contracted among different groups. Socioeconomic characteristics
are also important in determining which groups are most at risk.
Courtesy of muro/Fotolia
Health care program eligibility for the
disabled and chronically ill is determined
by descriptive research, which is largely
subjective.
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
In the early stages of the epi-
demic, studies lacked unifor-
mity in the way they defined
HIV/AIDS cases. Some looked
at HIV in the early stages, while
others did not define HIV/AIDS
until the point when AIDS actu-
ally set in. In 1985, the CDC and
the World Health Organization
(WHO) published a case defini-
tion for AIDS with the intention
of improving testing and diag-
noses procedures and creating
a standardized definition to be
used in research. In 1987, the
official definition changed to
make it easier to diagnose AIDS
in Africa and other underdevel-
oped countries where medical
technology is lacking. The last
CDC/WHO definition of HIV/AIDS was published in 1993 and led to earlier diagnosis of
HIV in women and children (Center for Disease Control, 1993).
Many local health departments and physicians’ offices participate in the CDC seropreva-
lence surveys. Seroprevalence is the incidence of infection, based on blood serum testing
and the presence of antibodies for a specific disease in a given population. Though these
surveys track new HIV diagnoses, they usually do not include much demographic infor-
mation. Changes have been made in the last decade, however, to the CDC’s reporting pro-
gram to help reporters include nonpersonal socioeconomic and demographic information,
such as race, gender, and insurance type. Some states and cities have mandatory reporting
laws that compel physicians at specified locations and clinic types to report HIV/AIDS
cases and provide counseling for diagnosed patients. The New York City Department of
Health and Mental Hygiene has one such program under a New York state law (New York
City Department of Health and Mental Hygiene, 2012).
Persons Diagnosed With Mental Conditions
Research that attempts to identify populations with mental conditions and those at risk of
developing mental conditions faces obstacles from questions regarding what constitutes
a mental illness and what methods are used to classify mental illness. Furthermore, the
issue of primacy—whether the mental condition is the primary health factor or whether
it is a secondary symptom of something else—is particularly important. Counting the
number of people treated for mental conditions is also complicated by the wide variety of
physicians who treat a wide variety of problems. For example, a person with severe men-
tal illness may see a psychiatrist, but someone who is feeling blue might be more likely to
see his or her general practitioner, who is less likely to participate in reporting programs
that seek to study the population diagnosed with mental conditions.
Courtesy of franckreporter/iStockphoto
Contrary to early popular thought, HIV is not a specifically
“gay man’s” disease, but can be transmitted through bodily
secretions regardless of sexual preference.
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
The Substance Abuse and Mental Health Services Administration (SAMHSA) publishes
reports on the state of mental health in the American population and on mental health ser-
vices in the country. Beginning with the 2008 report, “Mental Health, United States, 2008,”
SAMHSA began including data from a variety of sources instead of just information from
the administration. The inclusion of various sources provides for a broader look at mental
health in the United States (Substance Abuse and Mental Health Services Administration
[SAMHSA], 2010b).
Suicide- and Homicide-Liable Persons
The vital statistics system reports data on suicides and homicides. However, many
attempted suicides go unreported, and medical examiners report that many achieved sui-
cides are not reported as such due to the stigma associated with suicide (Bureau of Justice
Statistics, 2011). Official records and coroner reports are the main sources of data on sui-
cide numbers.
The main sources of data on homicide numbers come from police reports, the Federal
Bureau of Investigation (FBI), and other areas of the criminal justice system. The FBI pub-
lishes multiple reports that include information on homicide, including Uniform Crime
Reports and the Homicide Reports supplement and the National Crime Victimization
Survey (formerly the National Crime Survey). The National Crime Victimization Survey
is taken on an ongoing basis from a sampling of U.S. households and asks about experi-
enced crime events such as rape and burglary (Bureau of Justice Statistics, 2011). As such,
underreporting of personally traumatic events (like rape) and underrepresentation of the
groups most affected by crime due to nonparticipation skew the numbers. In addition to
sources from the FBI, the CDC offers access to the National Violent Death Reporting Sys-
tem (NVDRS). The NVDRS gathers data from multiple sources for each reported incident.
By doing so, the NVDRS helps create a more accurate picture of suicide and homicide in
the United States.
Persons Affected by Alcohol and Substance Abuse
The network of data available on the prevalence of alcohol and substance abuse is inco-
hesive because different reports focus on different aspects of the problem and on different
populations. Social surveys, like the National Household Survey on Drug Abuse and the
Monitoring the Future survey, are subject to the same underreporting issues that nearly
all social surveys are subject to. SAMHSA works through the Center for Mental Health
Services (CMHS) to develop and publish standards for reporting on mental health and
substance abuse services. The CMHS Uniform Reporting System (URS) provides stan-
dardized data that is easily compared. Even with the URS in place, there remains a need
for research into the prevalence and nature of alcohol and substance abuse that uses
reporting standards that make using the data for program implementation faster, easier,
and more universal.
The CDC’s Behavioral Risk Factor Surveillance System is an ongoing survey that tracks
behaviors associated with poor health outcomes, including the prevalence of alcohol,
tobacco, and drug use. The survey is conducted by phone and is used to measure the
current health status and the current risk behaviors in the country, as well as monitor the
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
ties between risk behaviors like
alcohol abuse and health (Cen-
ters for Disease Control and Pre-
vention, 2012g). The CDC tracks
similar information on risk-
associated behaviors, including
alcohol use, drug use, tobacco
use, seat belt use, and eating
habits among America’s youth
using the ongoing Youth Risk
Behavior Surveillance System
(YRBSS). YRBSS is conducted
utilizing many resources to
reach youth, including schools;
state, local, and tribal agencies;
and health organizations (Cen-
ters for Disease Control and
Prevention, 2012h). The CDC’s
efforts to collect data on risk-
associated behavior on an ongo-
ing basis are essential to study-
ing and predicting America’s health, identifying vulnerable populations, and recognizing
risk factors that contribute to vulnerability.
Indigent and Homeless Persons
As discussed in earlier chapters, studying the prevalence of and risk factors for homeless-
ness is challenging because the homeless population is transient and therefore difficult to
quantify. Also, homelessness does
not necessarily mean that a per-
son is sleeping on the street. Shel-
ters and other temporary housing
programs are able to provide some
information, such as a nightly count
of the number of people staying
there. Some places offer additional
services, such as counseling and
medical services, and are therefore
able to offer some amount of infor-
mation regarding the reasons for
homelessness and common medi-
cal issues.
Another method used to gather
data on the incidence rate of home-
lessness in a given area is the
point-in-time count. A point-in-
time count seeks to determine the
total number of homeless people
Courtesy of delkoo/fotolia
Collecting comprehensive data on alcohol and substance
abuse can prove difficult due to issues of underreporting and
variations of focus among data collection services.
Courtesy of Aaron Kohr/shutterstock
Due to the transient nature of the homeless population, it
is difficult to analyze the rate of occurrence and risk factors
for homelessness.
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CHAPTER 9Section 9.1 Descriptive Research: Identifying the Vulnerable
Critical Thinking
The very nature of many populations, like homeless and commuters, make them inherently difficult to
accurately measure. How do you think this lack of knowledge impacts public funding for health care
and services? Consider a descriptive research study that can examine the needs of these populations
without measuring the populations directly. What variables could this study measure? What knowledge
could be obtained from the data gathered?
sleeping outdoors in a specific area during a specific period. Counters walk the streets
looking for homeless individuals and count the number found and note where they were
located. Point-in-time counts, however, do not provide a thorough assessment of a city’s
homeless needs because the scope is so small.
Immigrants and Refugees
Though the U.S. Census Bureau, Program for Research on Immigration Policy, U.S. Immi-
gration and Customs Enforcement, and other independent organizations have tried, no
exact count of the number of undocumented workers in the United States currently exists.
Reports on current estimates categorize undocumented workers into three groups: those
making a permanent move to the country (settlers), those making a temporary trip to the
country (sojourners), and those who enter the United States to work but who return home
after the growing season or other work season is done (commuters). However, there are
no strongly supported counts for any category.
The Immigration and Naturalization Service (INS), Current Population Survey, and cen-
sus do supply some data on the number of documented immigrants and refugees seeking
asylum in the United States. The Office of Refugee Resettlement conducts surveys of the
demographics, socioeconomics, and use of public services by refugees. Other than the
data from these surveys, little cross-disciplinary, cohesive research exists on the subject.
Self-Check
Answer the following questions to the best of your ability.
1. What reporting system tracks birth, death, and health data to provide a picture of
what the American population looks like?
a.
National Vital Statistics System
b. United States Census
c. electronic health records
d. Center for Health and Human Services
2. Descriptive research on the chronically ill and disabled is relied on when deter-
mining health care program eligibility. What is the primary problem with this
research?
a. it is informal
b. it is anecdotal
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CHAPTER 9Section
9.2 Analytic Research: Understanding Vulnerability
c. it is subjective
d. it is objective
3. Which of the following is one of the problems with research into identifying
populations with mental conditions?
a. identifying what constitutes a mental illness
b. privacy regulations such as HIPAA
c. lack of overall data
d. poor record keeping
Answer Key
1. a 2. c 3. a
9.2 Analytic Research: Understanding Vulnerability
Analytic research of vulnerable populations attempts to explain why vulnerability occurs and to identify programs that address the problem of vulnerability and the needs of existent high-risk populations. Much analytic research fails to consider
how issues from other academic fields affect the points and people being studied. For
example, analytic research on health care quality may not necessarily consider research on
poverty. Examining cross-disciplinary research concerns, like the way poverty affects the
quality of health care received, broadens the scope of the research and sheds light on the
interconnectedness of the macro- and microlevel characteristics that cause vulnerability.
The characteristics that create vulnerability and the consequences of vulnerability to indi-
viduals and society at large are best measured and reported in longitudinal studies. Lon-
gitudinal studies consider the data in terms of large spans of time, such as a high-risk
individual’s lifetime or years of policy results. Take, for example, a longitudinal study of
children in foster care. Interviews were conducted of both the children and their caregiv-
ers regarding the children’s risk behaviors during a period termed “Time 1.” Those same
children and caregivers were interviewed again six years later during a period termed
“Time 2.” The study results indicate that the risk behaviors identified in Time 1 were
directly tied to the risk behavior outcomes found in Time 2 (Taussig, 2002).
Comparative studies that consider the characteristics of one group with those of other
groups are useful in identifying the causes of vulnerability. An example is a study that
identifies work disability outcomes between health care workers in urban areas and
health care workers in rural areas. The study found that rural health care workers are
more susceptible to poor work disability outcomes and identified factors including heavy
workloads and increased overtime as contributing to the problem (Franche et al., 2010).
Researchers conducting comparative studies often find that it is difficult to collect similar
data across many populations, especially those identified as vulnerable. This is because
many of America’s vulnerable people are transient both in where they live and in the ser-
vices they use. A cross-disciplinary approach can help with data collection. By including
data available from studies outside a given discipline, researchers are given more to work
with to present a broader understanding of the issues surrounding vulnerability.
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CHAPTER 9Section 9.2 Analytic Research: Understanding Vulnerability
Vulnerable Mothers and Children
Analytic research on the vulnerability of mothers and children tends to either rely on
outdated data or to be outdated itself. The National Maternal and Infant Health Survey
(NMIHS) and the corresponding longitudinal follow-up surveys are among the most fre-
quently cited data sets on mater-
nity outcomes; unfortunately, the
NMIHS was conducted in 1988.
As such, the oft-cited NMIHS is
an insufficient source for research-
ers who want to know the current
state of health care for vulnerable
mothers and children, though it
is useful for longitudinal study
comparison purposes.
Expanded birth records offer
more updated information. In
addition to the standard birth cer-
tificates that are available, which
list parents’ names, birth dates,
and birth location, expanded birth
records collect data on behavioral
risk factors of the mother as well
as information on the medical
handling of births and postnatal
care. Similarly, revised death cer-
tificates are useful resources for collecting data on causes of death, including causes of
infant mortality. Linked birth and death records are also available, which provide a more
complete picture of the risk factors that contribute to vulnerability.
Abused Individuals
A 2005 study by the World Health Organization (WHO) found a link between intimate
partner violence and physical and mental health. Victims surveyed reported health prob-
lems, including suicidal thoughts, dizziness, and vaginal discharge. Many reported hav-
ing such symptoms years after the abuse had ended (World Health Organization [WHO],
2005). The WHO study relied on survey participant answers and included longitudinal
questions regarding when and for how long participants were in abusive situations.
However, while the WHO study sheds light on the effects of abuse, the data does not seek
explanations for the abuse. Researchers attempting to identify causal factors would do bet-
ter to take a multidisciplinary view of the problem and make sure to always avoid forcing
the data to match a theory. Although household factors, such as economic struggles within
the family, are important to consider, the macrolevel factors—like the social ideology that
informs relationship dynamics—that can contribute to abuse must not be overlooked when
determining who is most at risk for abuse. Data can be mined from police and protective
services reports; however, incidence rates are believed to be lower than the reality because
many incidents of abuse go unreported.
Courtesy of Sabryna Washington/Fotolia
Expanded birth records provide a more comprehensive
picture of a person by including detailed data on the mother,
such as her behavioral risk factors and history of pre- and
postnatal care.
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CHAPTER 9Section 9.2 Analytic Research: Understanding Vulnerability
Chronically Ill and Disabled Persons
Analytic models are useful in identifying the needs of chronically ill people, how those
needs are met, and the utilization rates of programs for the chronically ill and disabled.
Standards for analytic research on topics associated with this particular vulnerable group
have been published by the National Center for Health Statistics and the National Insti-
tute on Aging. These standards outline the basic data sets needed and analysis necessary
to guide policy and program decisions.
Analytic research also helps identify the population-based factors associated with the
development of chronic diseases. One such study found a link between consuming sug-
ary beverages and type 2 diabetes diagnoses (Malik et al., 2010). With analytic research,
descriptive research is pooled to create a macrolevel view of the chronic illnesses and
programs for such in a given population or geographic area. This research is useful for
measuring risk factors’ contributions to the problem of chronic illness and for analyzing
programs on both a microlevel and a macrolevel, which indicates how well a given com-
munity is responding to the needs of the chronically ill and disabled.
Persons Diagnosed With HIV/AIDS
Analytic research into the epidemiology of HIV/AIDS necessitates a cross-disciplinary
approach with the social sciences. HIV presents a particularly interesting epidemic because
the majority of HIV transmission is caused directly by human behavior, as opposed to
diseases like cholera that can transmit through the water supply. The National Institute
of Allergy and Infectious Diseases
(NIAID) supports research into
HIV/AIDS epidemiology, includ-
ing the search for a vaccine against
HIV, efficacy of HIV/AIDS treat-
ment and prognosis improve-
ment, and behavioral risk factors
and social issues that contribute
to the epidemic. NIAID makes
much of the research available to
policy makers, other researchers,
and the public through its website
and publications (NIAID, 2012).
The U.S. military also has an HIV
research program, with a focus on
preventing U.S. troops from con-
tracting the disease while travel-
ing on assignment. The military’s
HIV research program studies
the HIV/AIDS epidemic across
the globe and translates those find-
ings into data to help create pro-
grams to decrease the incidence of HIV within the military (U.S. Military HIV Research
Program, 2012). Both of these organizations use multidisciplinary approaches to learn
more about treating and preventing HIV.
Courtesy of emin kuliyev/shutterstock
In addition to supporting the search for a vaccine against
HIV, the National Institute of Allergy and Infectious Diseases
(NIAID) supports research into behavioral risk factors and
social issues that contribute to the epidemic.
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CHAPTER 9Section 9.2 Analytic Research: Understanding Vulnerability
Persons Diagnosed With Mental Conditions
Analytic research into the mind focuses on both the physical brain and the emotional
psyche. For example, pharmaceutical companies need to know not only whether a drug
works but also how it works on the brain. After all, a drug must accomplish what it is
designed to do without causing irreparable physical or psychological damage. Different
organizations conduct and fund analytic research for different reasons.
The National Institutes of Health (NIH) supports research into the human brain through a
program called the Human Connectome Project. The goal of the project is to map the brain
and neurons that affect human behavior and emotion. Two projects funded through the
Human Connectome Project are the WU-Minn Consortium and the Harvard/MGH-UCLA
Project. Altogether, the Human Connectome Project is working to create a better under-
standing of neurological and psychiatric disorders. However, the Connectome Project is
mostly focused on physical mapping of the brain. More research is needed into the social
factors that contribute to mental conditions (National Institutes of Health [NIH], 2012).
Suicide- and Homicide-Liable Persons
Attempts at researching the reasons for death in suicide cases are often conducted post-
mortem through psychological autopsies, wherein researchers attempt to find a cause for
the suicide through interviewing people who knew the victim. This approach provides
useful information on the risk factors of suicide, and research on the topic has helped to
inform policy makers and program administrators on the best methods to try to prevent
suicide in high-risk groups.
Analytic research into homicide rates and the social and emotional factors that contrib-
ute to homicide is sparse, and research projects are disconnected. A cross-disciplinary
approach that considers both the micro- and macrolevel contributing factors of homi-
cide is needed. Data resources for analytic research into homicides come mainly from
the same sources where descriptive researchers find their information. Additionally, ana-
lytic researchers seeking information on homicides can turn to criminal records and court
records for extended information that might shed more light on the problem.
Persons Affected by Alcohol and Substance Abuse
Analytic research into the causes of alcohol and substance abuse is often theory-driven.
This is one field of research wherein the subjects are generally available for interviews and
can be studied longitudinally. Additionally, new research mapping the physical attributes
of the brain may be considered in tandem with research into other risk factors, thereby
providing a better understanding of why some people are more prone to alcohol and
substance abuse than others. For example, the National Institute on Drug Abuse (NIDA)
(2011b) confirms that a combination of factors ranging from biology to socioeconomic
situations cause drug addiction.
Research into alcohol and substance abuse must overcome the obstacle of lack of pro-
gram data. Lack of standardization for measurements of program and patient success,
unclear outcome expectations, and personal biases are contributing factors to the gap in
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CHAPTER 9Section 9.2 Analytic Research: Understanding Vulnerability
information regarding the efficacy of programs addressing the needs of people affected by
alcohol and substance abuse.
Indigent and Homeless Persons
Longitudinal research into the outcomes of home-
lessness and indigence is lacking due mostly to
the transience of this group and the fact that many
indigent and homeless people move in and out of
homelessness. Of particular importance is research
into the effects of homelessness on children and
how that experience will shape their adult lives.
Shelters have reported increased numbers of
homeless families, but many lack programs for
continued tracking of homeless children. Schools
could be of use in gathering information about
the effects of homelessness on children, but there
is no standardized reporting system for collecting
this type of information.
Analytic research into the economic factors that
contribute to homelessness does exist through
organizations such as the National Institute of
Mental Health (NIMH) and the National Alli-
ance to End Homelessness (NAEH) (n.d.). There
have been studies that attempt to recognize the
micro- and macrolevel risk factors that lead to
homelessness, including mental illness (micro)
and economic recessions (macro). However,
research projects that focus on one issue pertain-
ing to indigence and homelessness, such as the
prevalence of substance abuse, would do well
to consider their own research in relation to work done on other topics and in other
disciplines.
Immigrants and Refugees
Studies on the lives of immigrants and refugees in the United States need to be designed
with cultural sensitivity. For example, when analyzing the lack of service usage by cer-
tain immigrant or refugee populations, it is not enough to simply say “they don’t use this
service”; rather, the socioeconomic and cultural reasons that services are not used need
to be found.
More longitudinal research is also needed that follows immigrant children in the United
States as they develop into adults. Some of this work is done in educational settings, as
schools work to better serve the needs of immigrant children as they grow. Schools can be
instrumental in helping outside researchers gather data and contact immigrant families.
The Longitudinal Immigrant Student Adaptation (LISA) study conducted by researchers
Courtesy of Tubol Evgeniya/shutterstock
A standardized reporting system for
collecting information on homelessness
would enable researchers to utilize schools
to glean insight about the effects of
homelessness on children.
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CHAPTER 9Section 9.2 Analytic Research: Understanding Vulnerability
Critical Thinking
Assume that you want to do a cross-disciplinary study on abused individuals. How would you take a
cross-disciplinary approach to investigate this population? At what other fields would you look?
at NYU Stienhardt School of Culture, Education, and Human Development (2012) fol-
lowed the social and educational development of immigrant children and their families
for five years and identified risks and needs associated with educating immigrant chil-
dren. (For more information on this study, read Learning in a New Land by Carola Suarez-
Orozco, Marcelo Suarez-Orozco, and Irina Todorova.) Many of the community services
available to immigrants and refugees are independently operated, and many rely on vol-
unteers. These outreach programs could provide useful information on the ways in which
these families integrate and develop once in the United States, but a standardized, central-
ized reporting system is needed for the data to be comparable.
Self-Check
Answer the following questions to the best of your ability.
1. A 2005 WHO study sheds light on the effects of abuse, but what does it not seek
to find?
a. the causal factors of abuse
b. how long abuse lasted
c. the household factors involved
d. a link between intimate partner abuse and mental health
2. What are the causes of the majority of HIV transmissions?
a. mental illness
b. domestic violence
c. human behavior
d. violent crime
3. When researchers interview people who knew a suicide victim in an attempt to
find a cause for the suicide, they are performing ______________.
a. psychological autopsies
b. forensics
c. crime scene investigation
d. analytical research
Answer Key
1. a 2. c 3. a
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CHAPTER 9Section
9.3 Evaluative Research: Studying Program Efficacy
9.3 Evaluative Research: Studying Program Efficacy
Evaluative research seeks to determine the value of existing programs that address the needs of vulnerable groups and offer guidance on ways to improve services to these groups. Evaluative research often relies on service providers for data. This
means that much of the data collected is ambiguous and, in some cases, skewed.
Evaluative researchers studying the needs of vulnerable populations frequently find
themselves dealing with funding cuts. In addition to limiting the size and scope of these
studies, funding shortages can prolong the amount of time taken to collect information
and report findings. As with all other types of research into vulnerability, evaluative
research is often outdated before results are even made available. Combining research
efforts across disciplines and organizations pools resources and improves the likelihood
that an evaluative study will be completed in a timely manner.
Vulnerable Mothers and Children
Biases sometimes skew research results on the efficacy of programs aimed at reducing risks
for vulnerable mothers and children. Many studies exist that focus on specific children’s
health issues associated with prematurity and low birth weight. For example, a study done
by the University of Rhode Island
found that children born prema-
ture experience poorer health as
they grow, experience more social
struggles than their full-term peers,
and have an increased risk of heart
health as adults (University of
Rhode Island, 2011). However, not
as much research has been con-
ducted into the health and social
outcomes for vulnerable mothers.
Research into the barriers of access
to prenatal and preventive care for
mothers is scarce. As such, it is dif-
ficult to define which programs
are most effective, though research
indicates that early and regularly
scheduled prenatal care is linked to
lowered health risks for infants.
Abused Individuals
Evaluative research into programs for addressing the needs of abused individuals and
for preventing abuse indicates that preventive programs are more cost effective than
responsive programs. Still, research into these programs would be improved by conduct-
ing studies that involve both control and test groups in a given program. Then, the results
could be compared against clearly outlined program objectives. Barriers to this research
include an uncoordinated system of programs aimed at this vulnerable population.
Courtesy of lilly 3/iStockphoto
The scarcity of research into the barriers of access to
prenatal care for mothers makes it difficult to gauge the
efficacy of various programs.
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CHAPTER 9Section 9.3 Evaluative Research: Studying Program Efficacy
The Administration for Children and Families (n.d.a) provides some guidance on appro-
priate responses to child abuse and treating child victims of abuse. This information can
be used to help standardize research into program viability.
Chronically Ill and Disabled Persons
Chronic illnesses and disabilities are costly to patients, the nation, and insurance com-
panies. Because of this, much research has been conducted into program outcomes for
treating this vulnerable group, like the many ongoing research programs conducted by
the Agency for Healthcare Research and Quality (2012). These programs seek to improve
health care outcomes while minimizing health care costs. Whereas too much reliance on
theories often plagues research into other fields, research into programs for the chroni-
cally ill and disabled often has a problematic lack of theory behind it. More research is
needed into the ways in which public policy affects this vulnerable group, as public policy
decisions trickle down through the health care delivery system. More emphasis on the
health outcomes for individuals is also important for creating programs that respond to
the needs of chronically ill and disabled people instead of just the need to reduce costs.
Persons Diagnosed With HIV/AIDS
Research intended to evaluate programs for people diagnosed with HIV/AIDS should
also include research into the behaviors of this group of patients. Research results should
be compared with clearly stated program outcome goals and then consideration given
as to why some patients exhibit behaviors that lead to negative health outcomes after an
HIV diagnosis. This research should not be conducted in a bubble; treatment programs
should be compared with data on other treatment programs to find the best possible ways
in which to influence positive patient behavior and treatment compliance, as well as to
establish the efficacy of programs in relation to each other.
Persons Diagnosed With Mental Conditions
Just as the network of programs to address the needs of people diagnosed with mental
conditions, including private practitioners and mental health wards in short- and long-
term inpatient settings, is disjointed and nonstandardized, so too is the research into said
programs. Program objectives need to be clearly defined to create programs that work and
encourage patients to continue treatments. As with HIV/AIDS, patient behavior affects
compliance and program outcomes. Clearly defined test groups and control groups may
offer insight into the ways in which patient behavior can be altered to encourage improved
outcomes. Other problems exist with the reporting of mental health data due to the stig-
matization of mental illness and the protections put into place through the Health Insur-
ance Portability and Accountability Act (HIPAA) and other privacy laws.
Studies of existing program evaluations offer insight into how research in this field should
be conducted and understood. Research comparing programs via existing evaluations has
found that prevention programs for children, like those focusing on preventing physical
abuse and drug abuse, do have a positive impact on the recipients’ risk of developing
mental disorders. Yet cost is always a factor in health care, and more research is needed
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CHAPTER 9Section 9.3 Evaluative Research: Studying Program Efficacy
to establish which existing programs are most cost effective and how mental health pro-
grams can improve to become more cost efficient and to better patients’ health outcomes.
Suicide- and Homicide-Liable Persons
Research is needed to improve existing programs that respond to the needs of people who
are prone to violence against themselves or others. Not every program is most effective for
every vulnerable subgroup. Studies need to consider the subgroups addressed by preven-
tion programs and match the programs with the right subgroups. For example, suicide
prevention hotlines may be more effective at reducing suicide attempts among adolescents
than among the elderly. The Center for Elderly Suicide Prevention & Grief Counseling
(CESP) (n.d.) offers a suicide pre-
vention program aimed specifi-
cally at the elderly, and portions
of the program may not translate
well for use with adolescents.
External evaluation of existing
programs is needed because
internal program evaluation is
not always unbiased. Research
is under way that is currently
investigating the efficacy of exist-
ing programs, how public policy
affects such programs, and ways
in which providers can improve
mental health treatment and
respond to the needs of suicide-
liable individuals. The Services
Effectiveness Research Program
(SERP) at Duke University stud-
ies mental health prevention and
treatment services and works to
improve standardization of the
health care field and create new
prevention and treatment methods to reach more people (Duke University, Department of
Psychiatry and Behavioral Sciences, 2011).
Persons Affected by Alcohol and Substance Abuse
In the 1980s, federal and state governments responded to drug abuse rates by funding
research and prevention programs, but funding dwindled into the 1990s and on into the
2000s. However, that is not to say that research has ceased entirely. The National Institute
on Drug Abuse (NIDA) continues to support research into the causes of alcohol and drug
dependence and the best ways to treat patients and mitigate the problem in the country.
Prevention programs are thought to be most cost effective in the field of substance abuse.
Many school systems continue to utilize the Drug Abuse Resistance Education (DARE)
(2012) program to teach elementary- and middle-school students ways and reasons to
avoid drug use.
Courtesy of Diego Cervo/Shutterstock
Additional research, specific to each vulnerable subgroup,
is necessary in order to more effectively meet the needs of
people with a predisposition for violent behavior.
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CHAPTER 9Section 9.3 Evaluative Research: Studying Program Efficacy
Though DARE and other preventive programs have been around for decades, research
into the overall outcomes of these programs is problematic. Many such programs lack
clearly stated measurable goals, a problem that complicates measuring outcomes and pro-
gram integrity. In fact, it has been alleged that DARE is not as effective at preventing drug
abuse as was once believed (Fitzgerald, 2006; Hanson, n.d.; Perri, 2010). More research is
needed into the influencing factors associated with alcohol and drug abuse and into ways
in which prevention and treatment programs can respond to them.
Indigent and Homeless Persons
Problems with standardization
of information and an overall
lack of program evaluation make
it difficult to compare services
and programs that address the
needs of indigent and homeless
people. This is because many
services are community based,
located in churches and pri-
vate organizations. Resources,
including funds and manpower,
are at a premium in these orga-
nizations. As such, little is left
for research and documentation.
The U.S. Department of Hous-
ing and Urban Development
(HUD) (n.d.) is a resource for
information on public policy
affecting programs for low-
income and homeless individu-
als. As discussed earlier, the
Homelessness Resource Center,
a program administered by SAMHSA, has used research to provide recommendations for
standardization and best practices for programs that address the needs of the homeless.
Researchers can use these resources as a basis for comparison when evaluating programs.
Immigrants and Refugees
Research into the unintended consequences of public policy regarding immigration, such
as increased racism against certain immigrant groups, is needed to inform future policy
decisions. Research is also needed that assesses the ramifications of policy decisions on
the physical and mental health of both documented and undocumented immigrants. Fur-
thermore, research into direct correlations between public policy and immigration rates
would be useful in determining what future goals should be.
Courtesy of sonne07/Fotolia
Researchers can utilize resources such as the U.S. Department
of Housing and Urban Development (HUD) and the
Homelessness Resource Center to gather information on and
compare programs for low-income individuals.
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CHAPTER 9Section 9.3 Evaluative Research: Studying Program Efficacy
Critical Thinking
Much of the evaluative data on services for special populations comes from service providers and is
usually skewed and inaccurate. Why would this be the case? Why wouldn’t a service provider provide
complete and accurate information?
Organizations like the Pew Research Center (2012) and the National League of Cities
(2010) perform and support research into the effects of public policy on the lives of immi-
grants and into the efficacy of existing programs. Information from third-party research
sources may also offer interesting insights and a knowledge foundation that can inform
future research efforts.
Self-Check
Answer the following questions to the best of your ability.
1. What do many programs such as DARE lack?
a. clearly stated measurable goals
b. participation
c. corporate sponsors
d. administrative staff
2. What factor contributes to the lack of information standardization and program
evaluation of indigent and homeless populations?
a. the transient nature of the population
b. the unwillingness of researchers to be exposed to unclean environments
c. the lack of funding for documentation and record keeping
d. the unwillingness of the indigent population to communicate due to
embarrassment
3. Identify one unintended consequence of public policy regarding immigration
mentioned in the text.
a. increased racism against certain immigrant groups
b. reduction of funding by states to immigrant groups
c. harsher anti-immigration laws
d. reduction in admissions of immigrants to higher education
Answer Key
1. a 2. c 3. a
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CHAPTER 9Section 9.3 Evaluative Research: Studying Program Efficacy
Case Study: Health Surveys Are Subjective
Much of the research that seeks to define and project numbers of vulnerable populations is subjective.
Survey respondents may decide not to participate, which creates a situation wherein some social groups
are over- or underrepresented in the surveys. Of those who do choose to participate, absolute honesty
is not guaranteed. Face-to-face surveys often have better participation rates, but respondents may feel
uncomfortable disclosing private health and financial information to surveyors.
An example of one such health survey was recently conducted by the health department in the city of
Louisville, Kentucky. The survey sought information on the way residents used health care providers
throughout the city, with the intention of learning how citizens perceive the current health system in
Louisville. All Louisville residents were invited to participate. However, one limiting factor of the survey
was that it was available online and not mailed or otherwise made available. The online nature of the
survey meant that certain groups, particularly immigrants and low-income individuals who did not have
Internet access at home, were likely to be underrepresented in the survey results. The multiple-choice
answer selection also limited the survey by forcing participants into a set response, not allowing for
answers outside the multiple-choice selection or for further information regarding a particular incident.
Some of the survey questions were objective, such as the participant’s zip code, gender, and age range.
Some questions were purposefully subjective, and answers were likely to be skewed by respondents’
understanding of the questions and possible answers. Examples of subjective questions from the survey
include the following:
The last time you had to use the emergency room, what was the reason?
a. nonemergency issue (rash, prescription refill, etc.)
b. urgent issue (cut, injury to joint, fever, etc.)
c. emergency (difficulty breathing, chest pain, seizures)
d. not applicable
This question relies on the respondent and the questioner having the same idea of what constitutes an
emergency. Suggestions are included in parentheses, but not every possibility is listed. Another example
of subjective survey questioning is the rating scale:
Using the scale below, please check the box for each issue that you think is a big barrier to health care
in Louisville Metro/Jefferson County.
Strongly
agree
Agree Neither
agree nor
disagree
Disagree Strongly
disagree
No opinion
1. Doctor’s
office hours
2. Trans-
portation
3. Knowing
where to go
in a health
care facility
4. Cost or
expenses (continued)
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CHAPTER 9
Chapter Summary
Strongly
agree
Agree Neither
agree nor
disagree
Disagree Strongly
disagree
No opinion
5. Discrim-
ination/bias
6. Health
knowledge
7. Health
beliefs
8. Insurance
issues
9. Stigma
10. Culture and
language
11. Medi-
caid rules
12. Fear of
depor-
tation
Source: LouisvilleKY.gov. (2012). 2012 Community Health Needs Assessment Survey. http://www.surveymonkey.com/s/HealthNeeds
Survey
Researchers are often aware that sliding scale questions like this are subjective, and in this case patient
perception (which is subjective by nature) was exactly what researchers wanted to know. Subjectivity
in survey questions is not always a barrier to quality research, but readers should be aware of it when
reading research results.
Chapter Summary
Though descriptive, analytic, and evaluative research does exist that seeks to improve the ways in which vulnerability is mitigated and managed in the United States, much of that research needs improvement. Improving research outcomes involves
improving reporting systems in order to gather information from an unconnected sys-
tem of providers and programs that serve vulnerable populations. Much more research is
needed into the causes of vulnerability and how to best limit negative outcomes that come
from high-risk situations and behaviors. Public policy has a large effect on program viabil-
ity and overall outcomes for many groups within the country. Research into the causes of
vulnerability and the needs of the vulnerable can work to better inform policy makers.
Similarly, research into the effects of public policy on programs can help shape the future
of vulnerability in America.
Case Study: Health Surveys Are Subjective (continued)
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http://www.surveymonkey.com/s/HealthNeedsSurvey
http://www.surveymonkey.com/s/HealthNeedsSurvey
CHAPTER 9Self-Check
Critical Thinking
Previous chapters in this text have discussed many of the vulnerable groups and the issues associated
with them. You have also performed some basic research on your own to expand your knowledge.
Based on what you have read and done thus far, do you perceive a research method or technique that
will consider the connections that exist across issues and populations?
Self-Check
Answer the following questions to the best of your ability.
1. The definitions of abuse are somewhat objective.
a. True
b. False
2. The last CDC/WHO definition of HIV/AIDS was published in what year?
a. 1982
b. 1987
c. 1993
d. 2001
3. Studies on the lives of immigrants and refugees in the United States need to be
designed with what consideration?
a. older generations
b. cultural sensitivity
c. major political funding
d. future employment eligibility
4. What type of research also helps identify the population-based factors associated
with the development of chronic diseases?
a. qualitative
b. evaluative
c. analytical
d. quantitative
5. It is possible that suicide prevention hotlines may be more effective at reducing
suicide attempts among __________ than among the _______.
a. adolescents, elderly
b. elderly, homeless
c. low-income, high-income
d. new mothers, elderly
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CHAPTER 9
Web Exercise
6. Reports on current estimates categorize undocumented workers into which three
groups?
a. settlers, sojourners, commuters
b. students, residents, migrants
c. hostile, friendly, neutral
d. employable, nonemployable, disabled
Answer Key
1. b 2. c 3. b 4. c 5. a 6. a
Additional Resources
Visit the following websites to learn more about the topics covered in this chapter:
National Vital Statistics System
http://www.cdc.gov/nchs/nvss.htm
The Services Effectiveness Research Program
http://serp.mc.duke.edu/
Office of Refugee Resettlement
http://www.acf.hhs.gov/programs/orr/
Centers for Disease Control
http://www.cdc.gov/minorityhealth/populations.html
Web Exercise
Create a fictional character that falls into at least one of the special populations covered in
this chapter. For example:
An immigrant to the United States, who has a job but does not have health benefits,
discovers on a visit to a local health clinic that he has type 2 diabetes.
Be reasonable and make sure it is a logical scenario.
Create a presentation that identifies the following:
• who your subject is
• what special population your subject falls into
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http://www.cdc.gov/nchs/nvss.htm
http://serp.mc.duke.edu/
http://www.acf.hhs.gov/programs/orr/
http://www.cdc.gov/minorityhealth/populations.html
CHAPTER 9
Key Terms
• two to three pieces of existing research that have been done regarding the special
population
• two to three examples of what cross-disciplinary research could be done with this
information
Be sure that your sources of information are reliable and professional. Remember that you
cannot use or cite publicly editable sites/articles such as Wikipedia, YouTube, or blogs. All
content and sources must be in APA format.
Key Terms
analytic research Studies that focus on
identifying the reasons for vulnerability
and the ways to prevent and remediate
vulnerability.
comparative studies Research that com-
pares the characteristics of one group with
those of other groups.
cross-disciplinary research Collecting and
examining data from multiple academic
fields.
descriptive research Studies that focus
on identifying those most at risk and the
methods of identifying these groups and
their needs.
evaluative research Studies that work to
determine the success of existing programs
that aim to provide services to vulnerable
groups.
longitudinal studies Research that con-
siders the data in terms of large spans of
time.
National Vital Statistics System
(NVSS) A reporting system that tracks
birth, death, and health data to provide a
picture of what the American population
looked like in the past and what it looks
like now; NVSS uses that data to estimate
future birth, death, and health trends.
point-in-time count A method used to
determine the total number of homeless
people sleeping outdoors in a specific area
during a specific period of time.
primacy Whether the condition is the
primary health factor or whether it is a
secondary symptom of something else.
seroprevalence The incidence of infection,
based on blood serum testing, in a given
population.
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