two

Part 1: This week’s first discussion forum will focus on the population of abused individuals. Abuse is a pervasive problem in our society. Although the forms of abuse, as well as the intensity and duration can vary from case to case, each abused person is tasked with dealing with the scars left from the abuse.  As you can imagine, this task can be very challenging to say the least. Using research to help you form an opinion, which form of capital (social or human capital) do you feel will have a greater influence over resources accessible to the abused?  Discuss which form of capital you would rely on for emotional support and help through difficult times if abused.  Explain your rationale. Chapter 3 of the course text defines these terms in more detail. 

Post should be 250 to 300 words in length. Your research and claims must be supported by your ATTACHMENTS and at least one other scholarly source.  

Part 2: Review attached video “Reinventing Healthcare Video” .

You may be familiar with the common quote “An ounce of prevention is worth a pound of cure.” In reality, however, you may know of a person, family, or group who is not receiving adequate preventive or medical care due to a lack of resources and funds. 

1)  Choose one specific chronic illness or disability of your choice.

2)  Select two resources in your community that address issues related to the chronic illness/disability and describe the services offered.

3)  Select two national resources that address issues related to the chronic illness/disability and describe the services offered.

4)  Analyze whether or not the continuum of care services are adequate for the population with the chosen chronic illness/disability.  Explain why or why not.

Post should be 250 to 300 words in length. Your research and claims must be supported by ATTACHMENTS and Reinventing Healthcare Video, and at least one other scholarly source.  

Due Jan 29,20 @10am Eastern w/ plag report.

dueon time

3

Why Are Some More Vulnerable
Than Others?

Learning Objectives

After reading this chapter, you should be able to:

• Explain social, political, and economic conditions and trends that contribute to the cre-
ation of food deserts.

• Evaluate how the population of the United States is changing, and consider how this
affects vulnerable populations.

• Analyze how changes in social, political, and economic factors contribute to the vulner-
ability that represents the haves and have-nots.

• Define social capital and how it is related to health.

• Identify political factors that affect health.

• Recognize economic factors that affect health.

Courtesy of JurgaR/iStockphoto

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CHAPTER 3

Introduction

Introduction

Towns and cities have planning and zoning departments within their local govern-ment structures. The Planning and Zoning Department is responsible for ensuring that the city infrastructure, including telephone lines, roads, electricity, and water,
reaches all necessary areas. It is also responsible for the local codes that keep large retailers
like Walmart from moving into residential neighborhoods. Town planning helps mini-
mize traffic on residential streets by creating shopping districts that are near but not in
neighborhoods where people live.

Think about how far the nearest grocery store is from your home. Is it within walking
distance? If so, how do you transport the groceries home? For many Americans, locat-
ing shopping districts outside of neighborhoods creates a need for vehicle transportation
from home to the grocer. Many people living in low-income urban housing lack access to
cars, and public transportation leaves much to be desired in many cities and is completely
absent in many towns. Large retailers need a lot of customers to support the store and a
lot of people to staff it. For this reason, many large grocers avoid urban areas and many
rural areas where there are not a lot of potential customers nearby, opting instead to set up
shop in densely populated suburban areas.

This phenomenon has created a serious problem in many urban areas in cities and small
town centers alike. Food deserts are residential areas with no readily available access to
grocers who carry fresh fruits, vegetables, and meats. Many residents in food deserts sub-
sist mainly on cheap processed foods that they can purchase at mini-marts and gas sta-
tions. A diet lacking in fresh healthy foods creates long-lasting health problems. As many
food deserts also lack accessible health care, the health of the vulnerable populations in
these areas is doubly impacted.

The food desert issue is one of social, political, and economic factors. Socially, these
areas have needs, such as access to affordable food, shelter, and clean water, that must be
addressed. Politically, it is up to the government to change zoning codes and offer incen-
tives to encourage grocers and health care providers to move into areas in need of access.
Economically, it is difficult for retailers and service providers to grow in economically
depressed areas. This chapter investigates ways in which social, political, and economic
factors increase vulnerability for at-risk populations.

Critical Thinking

Do you live in a food desert? If so, what options do you have for accessing areas with fresh fruits, veg-
etables, and meats?

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CHAPTER 3Section

3.1 Portrait of the Nation

Self-Check

Answer the following questions to the best of your ability.

1. Which of the following best describes a food desert?
a. a physical desert that lacks food
b. residential areas with no readily available access to grocers who carry fresh

fruits, vegetables, and meats
c. residential areas with no readily available access to water
d. an economically depressed region

2. Why is it bad to locate shopping districts outside of neighborhoods?
a. Not everyone has access to transportation.
b. Locally grown food is more beneficial.
c. People do not connect as closely with grocers.
d. People become reliant on junk food.

3. Besides food, what do many food deserts also lack?
a. gas stations
b. sanitation
c. water
d. health care

Answer Key

1. b 2. a 3. d

3.1 Portrait of the Nation

The population’s needs change as the makeup of the population itself changes. The country is evolving as both the country and the populace age. America has long been known as “the melting pot,” where many people from different cultures live
side by side. Never in the country’s history has this been truer than it is today. A more
diverse populace has more diverse needs, and it is not surprising that some groups have
their needs met more effectively than others.

The U.S. population increased at a rate of 5.3% from 2000 to 2005 (U.S. Census Bureau,
2007). This population growth is attributable to many factors, including more births than
deaths, as well as immigration. It is also compounded by the fact that people live longer
now than ever before. The baby boomer generation, which includes those individuals born
between the years 1946 and 1964, is the largest current generation in the United States. As
the baby boomers enter their senior years, America’s population portrait is aging along
with them. America experienced its highest median age ever at 36.2 on July 1, 2005, and it
is expected to increase as the baby boomer generation ages. Average life expectancy is also
increasing as medical and health science improves. The average American life expectancy
in 1996 was 76 years; it is expected to rise to 82.6 in 2050. The fertility rate is not expected
to change much from the current 2.1 births per adult female; therefore, America’s popula-
tion might see a slight decline when the baby boomer generation dwindles with age (U.S.
Census Bureau, 2007).

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CHAPTER 3Section 3.1 Portrait of the Nation

The ethnic makeup of the United States is changing as well. While America’s largest race
population has historically been Caucasian, census data shows that this population’s
growth rate slowed to just 1% from 2000 to 2005. In contrast, the African American popu-
lation experienced a 6% growth rate during this time, which is higher than the national
average. The Native American and Alaska Native population grew at 7%. America’s
Asian population boomed at 20% growth, and the Hispanic population had the highest
increase at a rate of 21% (U.S. Census Bureau, 2007). In 2000, Caucasians made up 75.1%
of the American population, and African Americans represented 12.3% of the nation’s
population. By 2010, the percentage of the population identified as Caucasian declined
to 72.4%, while African Americans increased to 12.6% of the population. The percentage
of the population identified as Asian rose from 3.6% in 2000 to 4.8% in 2010 (U.S. Census
Bureau, 2011a). As the population growth rates for minority populations race to catch up
with the Caucasian population total, the growth for Caucasians has slowed. This means
that Caucasians will not be the majority population in the United States for much longer,
and the face of America is becoming increasingly multicultural.

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

1. What is America’s largest race population?
a. Caucasian
b. African American
c. Asian
d. Hispanic

2. The average American life expectancy is expected to be _______ by 2050.
a. 76.4
b. 82.6
c. 91.3
d. 88.7

3. In 2010, what percentage of the U.S. population was African American?
a. 2%
b. 10%
c. 10.3%
d. 12.6%

Answer Key
1. a 2. b 3. d

Critical Thinking

The makeup and size of the U.S. population is changing rapidly. What challenges do you predict for the
U.S. health care system in the year 2050, assuming that the current trends continue?

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CHAPTER 3Section

3.2 How We Live

3.2 How We Live

The makeup of the average American family has changed drastically over the last 40 years. In 1970, 40.3% of the population was married couples with children under age 18. By 2005, this group made up only 23.1% of the population. By 2010, the num-
ber of married couples with children under age 18 further declined to 21% (U.S. Census
Bureau, 2010). The percentage of married couples without children increased from 53%
in 2005 to 58% in 2010 (U.S. Census Bureau, 2012d). The percent of “other family house-
holds,” composed of single parents, unmarried parents, or extended family households,
rose from 10.6% of the population in 1970 to 16.7% in 2005. Populations of men and women
living alone have also increased slightly, from 5.6% and 11.6%, respectively, to 11.2% and
15.2%, respectively (U.S. Census Bureau, 2007). Increases were seen in every “other fam-
ily households” category in the 2010 census, including those with men or women living
alone (U.S. Census Bureau, 2012e).

Children under age 18 composed 24% of the 2010 American population (U.S. Census
Bureau, 2011b). Although the majority (69%) of children in the United States continue to
live with both parents, there has been a significant decline from 85.2% in 1970. The num-
ber of children living with one parent continues to favor the mother, at 10.8% of all chil-
dren in 1970 and 24% in 2009 (U.S. Census Bureau, 2011c). In 1970, 1.1% of children lived
with their fathers only. That number rose to 4.8% in 2005 (U.S. Census Bureau, 2007). In
2011, there were 1.7 million single fathers in the United States, representing 15% of all
single parents (U.S. Census Bureau, 2012f).

America’s changing family structures both contribute to and are affected by the changes
in housing, education, and income trends throughout the population. As we will see, the
ties between people have significant effects on vulnerability, as social support can help us
reach our goals and keep us safe. Where we live and our financial situations also affect
vulnerability in terms of resource allocation. Statistically, snapshots of how we live offer
insight into the ways in which per-
sonal resources—housing, educa-
tion, and income—limit or increase
vulnerability. This understanding
allows us to seek ways to address
the needs of those most vulnerable.

Housing

Of the 124.4 million housing units in
the United States in 2005, 77.7 mil-
lion were single-family detached
units. Single-family attached units
accounted for 7 million housing
units. In that year, there were 31
million multifamily units. Owner-
occupied homes were the majority,
at 62% of all housing units. Renter-
occupied units made up 28% of all

Courtesy of Dan Barnes/iStockphoto

Almost two thirds of the housing units in the United States
in 2005 were separate, single-family units.

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CHAPTER 3Section 3.2 How We Live

housing units. The American Housing Survey (AHS) found that owner-occupied units
were significantly more likely to be appropriately equipped with housing elements such
as safe drinking water, functional plumbing, and cooking appliances.

African Americans are more likely than other ethnic groups to live in housing with severe
deficiencies, such as vermin, continuing water leaks, and exposed wiring (10.4%). Hispan-
ics are a close second at 9.2%. Asians and Caucasians live in dwellings with severe defi-
ciencies at rates of 4.6% and 4.4%, respectively (U.S. Department of Housing and Urban
Development, 2012).

The U.S. Department of Housing and Urban Development (HUD) works with local hous-
ing agencies to provide public housing for low-income individuals and families. HUD
estimates that there are around 1.2 million families and individuals living alone that rely
on public housing (2012).

Education

Statistics from 2005 show that Caucasians were most likely to graduate from high school,
and Asians were a close second (90.1% and 87.6%, respectively). African Americans had a
high school graduation rate of 81.1%, while Hispanics were at 58.5% (U.S. Bureau of Labor
Statistics, 2012).

The United States experienced a record number of individuals with bachelor’s degrees and
higher in 2004 and 2005. The Asian population led in postsecondary education completion
with 50.2%. Caucasians were a distant second at 30.6%. The gap is smaller between Cau-
casians and African Americans, who had a 2005 postsecondary education rate of 17.6%.
Hispanics had the lowest rate at 12% (U.S. Bureau of Labor Statistics, 2012).

Income and Poverty

It is important to consider inflation and the rise in the cost of living when comparing
income across decades. Real median income is middle average income level for the
United States, adjusted for inflation. America’s real median income increased slowly from
$35,379 in 1967 to $46,326 in 2005 (U.S. Census Bureau, 2007). Figure 3.1 shows the real
median income disparity across America’s most prominent ethnic groups.

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CHAPTER 3Section 3.2 How We Live

Figure 3.1: Real median income disparity across ethnic groups

There is a significant disparity between the real median incomes of Asian households and African
American households.

U.S. Census. (2010). Retrieved from http://www.census.gov/population/www/pop-profile/files/dynamic/MoneyIncome

African American households had the lowest median income ($30,900). Asian households
had the highest ($61,100). The median for non-Hispanic white households was $50,800.
The median for Hispanic households was $36,000 (U.S. Census Bureau, 2007).

Since 1970, the poverty rate in the United States has vacillated around the 12% mark. The
number of people living in poverty is significantly higher than the poverty rate and expe-
riences greater variances. The number of Americans living in poverty was lowest during
the 1970s, staying around 25 million. By the early 1990s, that number had risen to nearly
40 million people. In 2005, an estimated 37 million Americans were living in poverty (U.S.
Census Bureau, 2007).

Critical Thinking

College graduation rates have increased steadily since the 1970s but so, too, have poverty rates. What
do these trends tell us about access to education and poverty? Based on what you read, do you see a
relationship between income and education?

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http://www.census.gov/population/www/pop-profile/files/dynamic/MoneyIncome

CHAPTER 3Section

3.3 Social Conditions: Social Capital

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

1. In 2005, owner-occupied homes were what percentage of all housing units?
a. 32%
b. 45%
c. 62%
d. 78%

2. In 2005, ____ of the college-aged Asian population in the United States had com-
pleted postsecondary education.

a. 50.2%
b. 64.3%
c. 78.9%
d. 98.6%

3. Since 1970, the poverty rate in the United States has vacillated around what
percentage?

a. 2%
b. 12%
c. 23%
d. 30%

Answer Key

1. c 2. a 3. b

3.3 Social Conditions: Social Capital

Lucinda and Brad are nurses at a large, urban children’s hospital. One of their cancer patients, a 9-year-old named Josh, took a turn for the worse and was rushed into surgery to stop internal bleeding. At the end of Lucinda and Brad’s work shift, Josh
still had not awoken after surgery, and doctors were concerned that he would not make a
good recovery. Both nurses left work exhausted and with heavy hearts for a patient they
were fond of. Lucinda went home to her toddler and husband. Brad went home to an
empty apartment.

Recall from Chapter 1 that social capital is the measure of interpersonal relationships that
people have with others; to phrase it differently, social capital is the support network of
family and friends who take care of us when we are ill and hug us at the end of a bad
day. In the example, Lucinda has more social capital than Brad because Lucinda is able to
escape the trials of a bad day at work by enjoying the company of her child and husband
through family activities like eating dinner together or playing a game.

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CHAPTER 3Section 3.3 Social Conditions: Social Capital

Having people to call on to lend a hand when we need assistance is important to every per-
son’s physical and emotional well-being. Patients with strong support networks are more
likely to recuperate faster and have shorter hospital stays. Parents with family nearby are
more likely to enjoy an occasional night out knowing that their children are well cared for
in their absence. Caring friends and family can offer shelter or financial help when times
are tough. Studies have found that people in at-risk populations generally have less social
capital than those who are not generally part of vulnerable populations.

Vulnerable Mothers and Children

Many American children have parents who work outside the home. For working parents,
child care is a necessity and can be difficult to maintain. Think back to your childhood.
What did you do during the day before beginning primary school? Who did you stay
with? Did your parents or guardians pay for that care, or were you cared for by a family
member who did not charge for the service? When you fell ill, was a parent able to take
off work to stay home with you?

Many people in vulnerable populations lack the type of job stability that allows them to
take off work whenever they might be needed at home. This is particularly problematic
for single parents. It is difficult to maintain a healthy work-life balance without a strong,
supportive social network to fill the gaps left by an absent parenting partner. Single par-
ents who can call on friends and relatives to keep their sick children so they can go to work
are more likely to maintain long-term employment.

A look at employment rates of unmarried mothers by race supports the theory that Cauca-
sians are more likely to have more social capital than their peers (Ciabattari, n.d.). Figure
3.2 shows that Caucasian single mothers are more likely to be employed than those of
other ethnic groups.

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CHAPTER 3Section 3.3 Social Conditions: Social Capital

Figure 3.2: Employment rates and ethnicity among single mothers

Black and Hispanic single mothers are less likely than their white counterparts to be employed.

U.S. Department of Labor Statistics. (2004). Retrieved from http://www.upjohninst.org/publications/wp/05-118

Social capital can also affect a person’s health care choices. Married mothers are over
three times more likely than unmarried mothers to receive prenatal care early and often.
Caucasian adults are the group most likely to seek prenatal care during the first trimester.
Studies show that Caucasian women are also the ethnic group that rates highest in social
capital. A strong, supportive network of friends and family is more likely to encourage a
healthy pregnancy and positive attitude than a weak, unsupportive group. In this way, a
person’s social capital can have a negative effect by discouraging early prenatal care and
having negative opinions about the pregnancy. For example, a pregnant 17-year-old in
her senior year of high school may feel that her friends no longer want her around, and
perhaps that her parents don’t want to talk about the pregnancy. This isolating situation
may lead the young mother to make unhealthy choices in diet, medical care, and perhaps
even in drug use as she strives to act as if she is not pregnant in order to fit in with her
peers and pacify or rebel against her parents.

Abused Individuals

One of the earmarks of abuse is withdrawal from friends and family. Abusers often alien-
ate their victims by harassing, bullying, or physically abusing them when they attempt to

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http://www.upjohninst.org/publications/wp/05-118

CHAPTER 3Section 3.3 Social Conditions: Social Capital

build or maintain personal relationships. Abuse victims often allow themselves to become
isolated out of shame and a reluctance to be found out. Child abuse victims often have a
tendency to isolate themselves from adults such as teachers as well as from their peers. Iso-
lation is also a significant factor in the difficulty of reporting elder abuse, as many abused
elders have been removed from their homes and away from friends due to physical needs.

Chronically Ill and Disabled Persons

People with strong relationships with others are more likely to maintain healthy lifestyle
habits. For example, married men are more likely to eat healthier and get more exercise than

their unmarried peers. Women
with strong friendships often
encourage each other to take
time for themselves, keep their
bodies healthy, and stay physi-
cally fit. The physical rewards
of quality relationships mitigate
the risk for chronic illness.

Chronic illness and disability
can diminish a person’s social
capital by making it difficult
to maintain relationships. A
marriage or domestic partner-
ship may suffer if one member
is unable to fully participate in
the relationship due to chronic
illness. Chronic diseases and
disabilities can make it diffi-
cult for a person to leave home
to engage in civic groups and

activities or to travel with friends. This can be particularly true with degenerative diseases
like multiple sclerosis (MS). MS causes dysfunction of the nervous system, and symptoms
can range from shaking to paralysis of the limbs. A 47-year-old woman with MS may once
have enjoyed dinners out with friends and romantic weekends away with her partner, but
find it increasingly difficult to leave the house as the disease progresses. Missing the fun
may add to her feelings of isolation, which contribute to her loss of social capital when she
feels disconnected from her friends and partner. When a chronically ill or disabled person
is no longer able to engage in activities with friends and family, that person loses social
capital as those relationships weaken.

Persons Living With HIV/AIDS

During the 1980s, HIV was stigmatized as a “gay men’s” illness. Many families aban-
doned members upon learning of their HIV positive status, leaving them to rely solely
on friends and themselves for help and support as they combated the disease. Though
society now knows that HIV affects people of all races, ages, genders, and behaviors, the
stigma attached to HIV has only slightly dissipated, in part because men who have sex

Courtesy of Silvia Jansen/iStockphoto

It can be difficult to preserve social relationships when one
suffers from a chronic illness or disability.

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CHAPTER 3Section 3.3 Social Conditions: Social Capital

with men (MSM) are still the demographic with the highest HIV infection rate. Education
programs within the lesbian, gay, bisexual, and transgender (LGBT) community focus
on lowering the rate of infection, while specialized community health programs work to
provide emotional support and help obtain appropriate care for people living with HIV/
AIDS.

Though treatments are available to lengthen the life expectancy of HIV/AIDS patients,
the disease is fatal. Death usually follows a prolonged period of serious illness, during
which the patient’s medical care is both costly and time consuming. Many HIV positive
children are born to low-income mothers who lack both the financial and social support
resources to care for the children. HIV positive adults often lose much of their social sup-
port due to both the stigma attached to HIV and the intensity of the illness as their health
fails. These factors contribute to a loss of social capital for people diagnosed with HIV/
AIDS, which makes dealing with the disease significantly more difficult.

Persons Diagnosed With Mental Conditions

Our relationships with other people help define us. People who lack social capital report
higher stress levels and more symptoms of depression and other mental illness than peers
with fulfilling social networks. The disruption of the family unit is associated with mental
conditions that can last an entire lifetime. Many mental conditions, such as depression,
have the negative effect of causing sufferers to withdraw from family and friends. Often,
the more a person withdraws, the worse the illness becomes. Maintaining close personal
ties is closely associated with mental health. Consider the earlier example of the pregnant
17-year-old. In addition to the stress of being pregnant and a teenager, she also now has
the stress of feeling alienated from her friends at a time when her friends should be boost-
ing her self-esteem. All the added stress combined with the loss of close friendships puts
her more at risk for developing depression.

Suicide- and Homicide-Liable Persons

Suicide was the 10th leading cause of death in the United States in 2007 at a rate of 11.3 per
100,000 people (National Institute of Mental Health [NIMH], 2007). Risk factors for both
suicide and homicide include abusive families, firearms in the home, substance abuse,
and mental disorders. The risk of suicide is significantly increased for those who have a
family history of suicide.

Bullying increases a young person’s suicide risk. This is particularly true for adolescents
who identify as LGBT. However, a strong support network of family, friends, and teach-
ers lessens a young person’s suicide risk by providing the victim of bullying with the
emotional support necessary to maintain his or her positive self-esteem. This is true for
people of all ages and in all situations, not only adolescent bullying victims. Feeling val-
ued by others and having somebody to turn to protects against suicide risk factors. More
important, a person who is suicidal may have friends who can advise him or her to seek
professional help. They may encourage him or her, for example, to contact the National
Suicide Prevention Lifeline (1-800-273-TALK), which is available toll free, 24 hours a day.

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CHAPTER 3Section 3.3 Social Conditions: Social Capital

Loss of close relationships and loved ones, in addi-
tion to loss of independence, can cause depression
leading to suicide in the elderly.

Homicide rates are similarly associated with a lack
of social capital. Disconnection from other people,
combined with the trials of economic depression,
creates a deficit of social trust that leads to violent
crime. Gangs prey on members’ needs for social
ties and acceptance and encourage violent behav-
ior as a means to earn respect. Low-income areas
have a higher rate of familial dysfunction, creat-
ing a social situation wherein gangs can thrive
and increasing the homicide rates in these areas.

Persons Affected by Alcohol and
Substance Abuse

Social capital is closely linked to alcoholism and
substance abuse. Evidence exists that a predis-
position to alcoholism may be at least partially
passed genetically from parent to child. Children
who grow up in households where adults abuse
alcohol, smoke cigarettes, or use illicit drugs are
significantly more likely to do the same in their
adulthoods.

Social capital is also linked to substance abuse in terms of emotional and physical support
gained from close personal relationships. Many people turn to alcohol and illicit drugs as
a coping mechanism to deal with adversity when their needs are not otherwise met. The
people who contribute social capital can also be a strong force in overcoming alcohol and
drug addictions.

Indigent and Homeless Persons

Social isolation and lack of social capital are earmark characteristics of indigent people.
The lack of close social ties contributes directly to the condition of homelessness, as well
as to the many risk factors, such as alcoholism and poverty, that can create homelessness.
Many teenagers who report homelessness cite abusive living situations as the reason for
leaving home. Some of these teens stay for short periods of time with various friends
and relatives but never stay in one place for very long. Many others end up in the streets
because they lack the social capital to find places to stay, meaning nobody is willing to
take them in, care for them, and keep them safe.

Surveys of sheltered homeless report that many adults experiencing homelessness also
experienced homelessness or transient homelessness in childhood. Transient homeless-
ness is a state of being homeless but staying with friends or family for short periods of

Courtesy of Mehmet Dislsiz/Fotolia

In 2007, suicide was the 10th leading cause
of death in the United States. Risk factors
and a disconnect from social interactions
and support can increase a person’s
likelihood of committing suicide.

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CHAPTER 3Section 3.3 Social Conditions: Social Capital

time before moving on. The social isolation of indigent people also contributes to diffi-
culty in counting and tracking homelessness in America. Much of the information gath-
ered on the homeless in America comes from surveys of sheltered homeless individuals.

Immigrants and Refugees

Immigrants often leave behind friends and family to come to America. Once here, they
must establish new social networks in order to rebuild social capital. Though many infor-
mal groups exist to help immigrants connect with others from their home countries,
America’s immigration policies are a roadblock to building such social networks. As we
will discuss in later chapters, many immigrants and refugees live in low-income hous-
ing because once they are on American soil, they find a dearth of government resources
to help them establish new lives. Additionally, America’s social attitudes toward foreign
nationals are often isolating.

The mental distress that many refugees experience from having lived through events
such as guerrilla warfare that caused them to seek refuge outside their home countries
also makes it difficult for them to establish new, meaningful relationships. Many legal
immigrants move to the United States to find that they cannot practice their professions
in the United States due to licensing regulations (as is often the case for physicians and
attorneys). Illegal immigrants face similar challenges, as they attempt to stay under law
enforcement’s radar. The mental stress of losing income can lead to loss of self-respect and
the perceived loss of the respect of one’s peers. In addition to legal barriers and barriers
to resources, immigrants to America must also overcome language barriers and differing
customs to build social capital and the benefits that come with it.

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

1. Which ethnic group is most likely to seek prenatal care during the first trimester?
a. African American
b. Asian
c. Pacific Islander
d. Caucasian

2. What activity increases a young person’s suicide risk?
a. bullying
b. Facebooking
c. dating
d. drug use

Critical Thinking

How would you rate your social capital? Think about who you would turn to if you found yourself in a
predicament. Who could you talk to? Who would you go to for emotional—or even monetary—support?

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CHAPTER 3Section

3.4 Political Conditions: Social Status

3. Surveys of sheltered homeless report that many adults experiencing homeless-
ness also experienced homelessness at what stage of life?

a. childhood
b. early adolescence
c. early adulthood
d. infancy

Answer Key

1. d 2. a 3. a

3.4 Political Conditions: Social Status

Social status can improve with higher amounts of social capital and human capital. It can also decline if the same factors decline. A person with a high level of education, reasonable wealth, steady employment, and strong family and friend connections
has more social status than a low-income individual with little education and no wealth.

Social status is also tied to age. The very young and the very old hold less social status
in our society because they are dependent on others for help with daily living. Race also
affects social status, for both socioeconomic reasons and the history of discrimination as
well as discriminatory attitudes that still exist in American culture. Gender is tied to social
status in much the same way that race is. African Americans were formally given the right
to vote by the 15th Amendment in 1870, whereas women did not receive that right until
the passing of the 19th Amendment in 1920. This fact alone shows that gender and politics
are strongly intertwined.

Vulnerable Mothers and Children

Social status plays a fundamental role in the lives of high-risk mothers and infants. Afri-
can Americans had the highest rate of teen pregnancy until 2005, when the teen birthrate
among the Hispanic population bypassed that of African Americans. Figure 3.3 illustrates
recorded teen birthrates by race.

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CHAPTER 3Section 3.4 Political Conditions: Social Status

Figure 3.3: Teen births by ethnicity

While white, black, and Hispanic teens have similarly high rates of teen pregnancy, American Indian/
Alaska Native and Asian/Pacific Islander teens each give birth to less than 10,000 children each year.

Center for Disease Control and Prevention. (2011). Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_01 #table15

African Americans have the highest rate of gestational hypertension, or high blood pres-
sure during pregnancy (Centers for Disease Control and Prevention [CDC], 2012a). This
might be due to a genetic predisposition, but lifestyle choices linked to area of residence
cannot be ignored. Many food deserts are in urban areas populated by low-income Afri-
can Americans, many of whom are high-risk mothers. Unemployment; unsafe housing
and neighborhoods; lack of access to fresh fruits, fresh vegetables, and lean meats; and
lack of health care access are also all likely contributors to the high fetal mortality rate
among African American women. Lack of social status and lack of human capital are
closely linked in the lives of high-risk mothers and babies.

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http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_01 #table15

CHAPTER 3Section 3.4 Political Conditions: Social Status
Abused Individuals

Abuse is about power and the roles people play within relationships. As discussed,
the very young and very old lack social status partly because they depend on others for
their daily care. This puts them
at a distinct disadvantage within
the social structure of any rela-
tionship, most especially those
with caregivers.

Social workers and clinicians
report a significant trend in
intimate partner abuse wherein
the victim is somehow of lesser
social status than the offender.
The difference in status may
result from financial inequal-
ity (for example, the victim is
financially dependent upon the
abuser) or even from a differ-
ence in education levels. Many
reports indicate that social ide-
ology about the woman’s role in
the household (tend the home
and children, obey the man), the
“right” way for men to act (strong, in control, and domineering), and the way children
should behave (seen-not-heard, obedient) contributes to the power disparity that allows
for abusive situations to occur.

Chronically Ill and Disabled Persons

The most severely disabled children rely heavily on help from adults to achieve basic
activities of daily living, and many continue to do so into adulthood. Chronically ill and
disabled adults may find it difficult to maintain employment. The U.S. Census Bureau
reports that 9.9% of people ages 16 to 64 in the noninstitutionalized population reported
disabilities in 2009 (U.S. Census Bureau, 2007). Of the population reporting disabilities,
17.8% were employed in 2011, compared with 63.6% of the population with no reported
disabilities in the same year (U.S. Bureau of Labor Statistics, 2012).

Vulnerable populations are at increased risk for negative outcomes regarding chronic ill-
ness and disability. Lack of health care access and the living conditions associated with
poverty put vulnerable groups at increased risk for developing chronic illnesses and dis-
abilities. Lack of social and human capital makes it more difficult for them to cope with
long-term ailments. In this way, the very young and very old who suffer chronic condi-
tions are particularly vulnerable.

Courtesy of Goodshoot/Thinkstock

Society’s endorsement of strict gender roles and the way
children should behave may contribute to the unbalanced
power dynamic that make abusive situations possible.

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CHAPTER 3Section 3.4 Political Conditions: Social Status

Persons Diagnosed With HIV/AIDS

HIV is more prevalent in low socioeconomic
urban areas than in neighborhoods with higher
levels of education and income. Injection drug
users have the second highest HIV/AIDS inci-
dence, and injection drug use is rampant in
America’s economically depressed areas. The
number of minorities living with HIV/AIDS is
due to the prevalence of minorities in economi-
cally depressed urban areas, as well as the higher
rate of injectable drug use among many young
minorities. As low-income urban neighborhoods
have higher numbers of minority residents, lack
of access to preventive education programs and
health care increases the HIV/AIDS transmit-
tal rate among the socially and economically
disadvantaged.

Persons Diagnosed With Mental
Conditions

Childhood events help shape mental health later
in life. Children dealing with poverty, family dis-
ruption, abuse, chronic illness, or minority group
status are more likely to exhibit symptoms of
mental illness. Many symptoms of mental con-
ditions first appear in adolescence, a time when

young people’s bodies and minds are rapidly changing. The Administration for Children,
Youth, and Families reports that single mothers raising children in poverty have a particu-
larly high incidence of mental illness due to the stressors associated with their situations.

While situational stressors resulting from social status can induce mental illness, so too
can mental illness reduce a person’s social status. Withdrawal from friends and family can
cause a loss of social capital that contributes to a loss of social status. Maintaining employ-
ment can be impossible in cases of severe mental illness. Loss of income and dependency
on others for financial support reduces a person’s social status.

Suicide- and Homicide-Liable Persons

Social status based on race, gender, education and income levels, and power directly influ-
ences violence. Intimate partner abuse is based on the power differences between those in
the relationship. Children and the elderly have less social status than people ages 20 to 65,
who are more likely to be abusers. Disadvantaged minority groups have higher suicide
and homicide rates than members of higher social standing.

Courtesy of Peeter Viisimaa/iStockphoto

A large number of the people living
with HIV/AIDS are minorities. This may
be due to the fact that injectable drug
use, prevalent in low-income, minority-
populated areas, is the second leading
cause of HIV/AIDS infection.

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CHAPTER 3Section 3.4 Political Conditions: Social Status

Hispanics’ moderate suicide rates are attributed to a communal respect for family. His-
panics with risk factors, including substance abuse, mental conditions, low human cap-
ital, and broken families, have higher suicide and homicide rates than those with few
risk factors.

Suicide and homicide in Alaska Native and Native American communities are associated
with broken communities and the disintegration of their traditional cultures and family
structures. These communities are plagued with the effects of systemic economic depres-
sion. Suicide and homicide risks for this ethnic group include mental illness, family vio-
lence, and substance abuse.

Persons Affected by Alcohol and Substance Abuse

Adolescents experience increased risk for experimenting with alcohol and other sub-
stances because, at this developmental stage of life, they are testing boundaries and are
eager to fit in with their peer group. Adolescents with risk factors, including family vio-
lence, poor educational opportunities, and pov-
erty, are significantly more likely to try and to
continue use of alcohol, cigarettes, and illicit
drugs. The effects of these substances on devel-
oping brains add to the likelihood of continued
use and considerably negative outcomes.

The elderly occupy a similar rung on the social
status ladder as adolescents. Though alcohol-
ism and substance abuse rates are lowest among
the elderly, access to habit-forming prescription
drugs increases their risk of substance abuse.
Separation from family and friends, loss of
intimate partners and independence, and the
depression associated with leaving a lifelong
home contribute to alcoholism and substance
abuse by the elderly.

Social status associated with gender and eth-
nicity also contributes to alcohol and substance
abuse. Individuals may be influenced by cul-
tural norms to use certain drugs or alcohol,
such as Native Americans who use peyote for religious purposes. Similarly, expected
gender roles and idealized concepts of self contribute to a person’s likelihood to use
drugs and alcohol.

Indigent and Homeless Persons

The global economic recession of the early 2000s saw many middle-class Americans lose
their jobs and slip into poverty. As people struggled to stay in their homes, a mortgage
crisis erupted, fueled by illegal and unethical lending and foreclosure practices. The strain
on America’s low-income housing programs increased, while government spending on

Courtesy of Digital Vision/Thinkstock

The pressure of adhering to societal gender
roles and entertaining an embellished sense
of self contributes to a person’s likelihood to
use alcohol and drugs.

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CHAPTER 3Section 3.4 Political Conditions: Social Status

social welfare programs decreased. Becoming unemployed and losing a home creates a
loss of social status that affects most aspects of one’s life.

Homeless children are particularly vulnerable to deficiencies in health care and poor nutri-
tion. They are also more likely to experience mental distress and have many unexcused
school absences. These factors hinder a child’s ability to gain a meaningful and complete
education, contributing to low human capital later in life.

Like the number of homeless family units, the number of unaccompanied youth is also
growing. Counting both those who are part of homeless family units and unaccompa-
nied homeless youth, estimates put the annual number of children experiencing home-
lessness for at least one night around 1.6 million (Paquette, 2010). Many unaccompanied
homeless youth are runaways, but a great many have been expelled from their homes
or family units by adults. A majority of these young homeless are fleeing severe mental,
physical, and sexual abuse. Abuse is also a driving factor in the homelessness of women
and minorities. Once homeless, women become particularly vulnerable to drug abuse,
assault, unwanted pregnancies, adverse pregnancy outcomes, and negative health out-
comes. Homeless women and children’s particular vulnerability creates an even greater
social status deficit for these individuals, which greatly increases their risk of disease.

Immigrants and Refugees

Even well-educated immigrants to America experience a loss of social status due to lan-
guage barriers, cultural differences, and negative social attitudes regarding immigration
and particular ethnicities. The loss of social capital caused by leaving one’s home coun-
try also contributes to a loss of social status. Many refugees find it difficult to subsist
in a country where very few people grow their own food and build their own shelter,
especially when they come from regions where the ability to do so was the foundation of
social status and life. Refugees fleeing wars in Somalia and Liberia often find it difficult
to transition to a lifestyle where food comes wrapped in plastic and everybody wants an
enormous house.

Female refugees are particularly vulnerable, as many are uneducated and do not speak
English at all. Refugee women and children often suffer severe emotional distress caused
by the brutality from which they are fleeing. Depression as well as language and education
barriers make it difficult to build new relationships and access programs and resources
that ease the strain of building a life in a foreign place. As many refugees come from
impoverished regions, they often arrive with serious health care needs. The American
health care system is particularly difficult to navigate if you do not speak its language.

Critical Thinking

Mental illness, family violence, and substance abuse are contributing risk factors of suicide in Alaska
Natives and Native Americans. Based on what you have read, why do you think these are higher factors
for Alaska Natives and Native Americans than for other ethnic groups?

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CHAPTER 3Section

3.5 Economic Conditions: Human Capital

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

1. Because they depend on others for their daily care, the very young and the very
old lack what kind of status?

a. economic
b. political
c. social
d. familial

2. Injection drug users have the second highest rate of ____________
a. HIV/AIDS.
b. suicide.
c. infant mortality.
d. homelessness.

3. Even well-educated immigrants to America experience a loss of social status due
to what type of barriers?

a. political
b. economic
c. physical
d. language

Answer Key

1. c 2. a 3. d

3.5 Economic Conditions: Human Capital

An individual’s human capital is measured by level of completed education, employ-ment status and position, and living conditions. These factors are tied together because a person’s ability to maintain a high-paying job increases relative to how
much he or she has invested in his or her education. For example, consider the fact that
a child’s ability to learn during the school day is directly tied to both the condition of
the school and the education offered, which are both tied to society’s investment in the
school by way of government funding. For both children and adults, public and private
investment in the living conditions of neighborhoods and housing units deeply affects all
aspects of life, from the ability to focus during the school day to the ability to maintain
viable employment. Economic conditions directly affect human capital, and vice versa.

Vulnerable Mothers and Children

Human capital is directly linked to the timing and quality of prenatal care, the ability of
the mother to recuperate after the birth, and the ability of the mother to care for the infant.
Low-income regions have a lower rate of early and sufficient prenatal care than wealthier
areas. Mothers living at or below the poverty line are significantly less likely to receive

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CHAPTER 3Section 3.5 Economic Conditions: Human Capital

any prenatal care at all. A 1988 study found that only 53% of expectant mothers with less
than a high school diploma sought early prenatal care, compared with 92% of expectant
mothers with at least some college education (CDC, 2012c).

Abused Individuals

Though abused individuals exist at all socioeconomic levels, there is a direct causal rela-
tionship between poverty and lack of education and reported abuse. This is thought to be
due to the additional stresses associated with inadequate housing and food, the perils of
dangerous neighborhoods, and increased violence and drug abuse rates in low-income
neighborhoods. The risk of abuse increases when the offender has more education and
income than the victim, as the disparity in human capital causes a disparity in social status.

Chronically Ill and Disabled Persons

America’s public school systems are intended to provide education for all children,
regardless of aptitude. Most public schools offer specialized programs for children with
disabilities. The focus of these programs is basic knowledge and daily living skills
rather than the dissemination of advanced theories and thought processes. In this way,
America invests in the education of disabled children. America also invests in disabled
individuals through the Social Security system. The Supplemental Security Income
program (SSI) provides financial support for disabled citizens. However, that program
pays very little. Most people who depend on SSI also rely on government aid for hous-
ing and food. As poverty puts people more at risk for developing chronic illness and
disabilities, conditions which in turn contribute to personal poverty, health vulnerabil-
ity poses a particularly distressing situation for at-risk populations. More investment in
human capital by way of neighborhood improvements and education funding for low-
income neighborhoods is necessary to stop this cycle.

Persons Diagnosed With
HIV/AIDS

The financial cost of HIV/AIDS
treatments is unmanageable for
many patients, even those with
health insurance coverage. How-
ever, treatments are more effec-
tive and less costly the earlier
they are begun (U.S. Department
of Health and Human Services,
Agency for Health Care Research
and Quality, 2011). Though the
civil rights bill specifically for-
bids termination from a job
based on HIV status, the effects
of the disease can make it diffi-
cult to maintain employment. As

Courtesy of Thomas Norcut/Thinkstock

Federal funds and resources are available to help people living
with HIV/AIDS.

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CHAPTER 3Section 3.5 Economic Conditions: Human Capital

many HIV/AIDS patients belong to low-income vulnerable groups, education and income
levels were likely low before the onset of the disease. Low-paying jobs and loss of employ-
ment put people at risk for losing health insurance coverage and health care access.

The United States offers several federally funded resources to help those living with
HIV/AIDS. Low-income HIV/AIDS patients are eligible for both housing assistance
and disability-based income assistance through the federal government. The Ryan
White HIV/AIDS Program, administered by the Health Resources and Services Admin-
istration, provides funding to states and community-based organizations to improve
health care access and provide life-saving medications for HIV/AIDS patients in low-
income areas.

Persons Diagnosed With Mental Conditions

Mental illness is more prevalent among low-income groups, but the causal relationship
between poverty and mental illness is uncertain. The social stress theory posits that the
stressors experienced by low socioeconomic groups—inadequate housing, drug abuse,
neighborhood crime, lack of education, and unemployment and underemployment—
cause mental health disorders. The opposing argument is the social selection theory,
which argues that mental illness causes people to fall into low socioeconomic status.

Generally speaking, both theories are correct. The problems caused by poverty cause high
stress levels, which can lead to adverse mental health outcomes. At the same time, the
onset of mental illness can cause a person to withdraw from society and have difficulty
maintaining gainful employment, causing the individual to lose socioeconomic status.

Suicide- and Homicide-Liable Persons

Low income and education levels can create competition for resources, including afford-
able housing and jobs. Many low-income neighborhoods lack the human capital neces-
sary for improvement and, as such, experience a faster rate of deterioration than higher
socioeconomic areas. As businesses vacate economically depressed regions, they take
employment opportunities with them, further limiting investment in the community. This
trend correlates to urban ghettoization, which in turn correlates to increased violence.

Suicide among males is nearly four times the rate of suicide among females (CDC, 2010).
Native American and Alaska Native males have the highest suicide rate, which is attrib-
uted to social beliefs and low socioeconomic status within those cultures (CDC, 2012b).
Caucasian males have the second highest suicide rate, which is attributed to internalized
frustration and a perceived loss of power in response to changing social expectations.

A Closer Look: National HIV/AIDS Strategy

President Barack Obama implemented the National HIV/AIDS Strategy (NHAS) on July 13, 2010. NHAS
was implemented to reduce the amount of new HIV infections annually, restrict the HIV transmittal
rate, and improve health care access for those living with HIV/AIDS. For information on ways NHAS is
addressing the HIV/AIDS epidemic, visit the White House Office of National AIDS Policy NHAS website
at http://www.aids.gov.

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http://www.aids.gov

CHAPTER 3Section 3.5 Economic Conditions: Human Capital

In contrast, African American males of the same age group are more likely to externalize
frustrations with the social deficits in education and employment opportunities plaguing
this group. This externalization contributes to increased homicide rates among African
American males. Rates of violent crime types differ between ethnic groups, partially due
to the internalizing versus externalizing responses to social constraints and the issues fac-
ing different ethnic groups (see Figure 3.4).

Figure 3.4: Violent crime by ethnic group

Aggravated assault is the most commonly committed violent crime across all ethnic groups.

U.S. Census. (2012). Retrieved from http://www.census.gov/compendia/statab/2012/tables/12s0325

Persons Affected by Alcohol and Substance Abuse

Varying levels of human capital contribute to differences in alcohol and drug abuse. Ciga-
rette use is inversely related to education and income levels. The opposite is true with alco-
hol use, which increases with education and income levels (CDC, 2012c). Different illicit
drugs are favored by members of different socioeconomic groups. In the 1980s, cocaine
was associated with wealth, whereas crack continues to be more accessible to those of low
socioeconomic standing. Methamphetamine is thought of as “a poor man’s drug” because
it is inexpensive to make. However, it is so highly addictive that methamphetamine use is
growing among all socioeconomic groups.

Substance abuse is higher in economically depressed areas where underemployment and
unemployment are rampant. The causal relationship between employment status and
drug abuse is multidirectional. Substance abuse can create an environment where gainful

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http://www.census.gov/compendia/statab/2012/tables/12s0325

CHAPTER 3Section 3.5 Economic Conditions: Human Capital

employment cannot be maintained. It is also used by many as a coping mechanism for
dealing with economic disparity and the loss of self-esteem associated with underemploy-
ment and unemployment.

Figure 3.5: Methamphetamine prevalence of abuse among 8th to 12th graders

10th graders have a higher incidence of methamphetamine use than 8th or 12th graders across all three
measured time periods.

National Institute on Drug Abuse [NIDA]. (2010). Retrieved from http://www.drugabuse.gov/publications/infofacts/methamphetamine

A Closer Look: Monitoring Methamphetamine

The National Survey on Drug Use and Health began monitoring school-age children for methamphet-
amine use in 1999. As Figure 3.5 shows, reported methamphetamine use is declining among American
children. This positive trend is attributable in part to preventive education programs that aim to keep
children from trying methamphetamine even once. These programs are important because metham-
phetamine is highly addictive, and many addicted users claim to have become addicted after just one
use (National Institute on Drug Abuse [NIDA], 2010).

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CHAPTER 3Section 3.5 Economic Conditions: Human Capital
Indigent and Homeless Persons

A trend has been established that differentiates the current condition of homelessness
from the homeless experience between 1950 and 1970. During that time, a majority of
homeless people did have shelter, however inadequate it might have been. As the home-
less rate increases and government spending on social welfare programs struggles to keep
up, the current homelessness experience is significantly more likely to involve actually
sleeping outdoors.

America’s subsidized low-income housing has aged, and little has been done to remedy
the inadequacies of faulty wiring, disintegrating roofs, and rusted plumbing. Instead
of renovating crumbling structures, much of America’s low-income housing has been
demolished to make way for trendy, new urban homes for the upper-middle class. This
is directly responsible for the diminished availability of affordable housing in socioeco-
nomically depressed neighborhoods.

At the same time that America’s low-income housing began being replaced by more
expensive options, federal funding for social welfare programs and housing subsidies
began a steady decline. Housing subsidies were cut 80% from 1980 to 1989. State and fed-
eral governments have continued to struggle with paying for housing subsidies and other
social welfare programs, while tax income has decreased due to rampant unemployment
and corporate tax incentives.

Immigrants and Refugees

There are essentially three immigrant statuses in America. Overdocumented immigrants
have official refugee status. This term reflects the large amount of screening and paper-
work required of this group to prove the health status and the ability to support them-
selves. Undocumented immigrants are often referred to as “illegal aliens” and have not
completed the official immigra-
tion process. Documented immi-
grants have come to the United
States through legal channels but
have not had to undergo the rigor-
ous level of screening experienced
by refugees or overdocumented
immigrants.

Of these three types, undocumented
immigrants have the least amount
of human capital. Many cross the
border from Mexico to escape that
country’s violent drug war and
seek employment. In response, the
U.S. federal government seeks to
control illegal immigration through
the 1986 Immigration Reform and
Control Act.

Courtesy of Richard Thronton/Shutterstock

Undocumented immigrants lack much of the human capital
necessary to feel productive and included in society.

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CHAPTER 3Section 3.5 Economic Conditions: Human Capital

The flow of illegal immigration into the United States and frustration over current fed-
eral immigration laws have resulted in many states, including Arizona, enacting laws
to address the increasing number of illegal immigrants in their states. In 2010, the Ari-
zona legislature enacted stringent immigration laws. The Arizona law does not allow law
enforcement officers to stop someone just to check on documentation papers, but officers
may ask for documentation papers if someone is stopped for some other violation of the
law. Suspected illegal immigrants are turned over to the Federal Immigration Services. In
response to Arizona legislation, President Obama called on Congress to overhaul federal
immigration laws that would clearly restrict state powers regarding illegal immigration.

Even as Americans argue over immigration law, undocumented immigrants continue to
hold the country’s lowest paying, least desirable jobs. Many work in hot, dusty fields as
agricultural day laborers. They are paid in cash and are not provided with any stability,
security, or benefits. Still, many seek the shelter of America’s slums over the bloodshed
and economic instability of their home countries.

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

1. Among young people aged 15–24, almost six times more males than females
commit what act?

a. murder
b. rape
c. suicide
d. abandonment

2. What directly affects human capital?
a. economic conditions
b. political conditions
c. weather conditions
d. stock market conditions

3. Which group of immigrants has the least amount of human capital?
a. overdocumented immigrants
b. undocumented immigrants
c. married immigrants
d. female immigrants

Answer Key
1. c 2. a 3. b
Critical Thinking

Arizona’s 2010 immigration law has become a hotly debated topic. Do you think states or the federal
government should have authority over enforcing immigration violations?

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CHAPTER 3Section 3.5 Economic Conditions: Human Capital

Case Study: Food Deserts Put Children at Risk for Lifelong Health Problems

It’s 8:00 on a humid Saturday morning in August, and a group of volun-
teers is gathering with spades, shovels, buckets, and gardening gloves.
Their mission: Build a community garden that will both provide a source
of fresh produce in a low-income neighborhood and teach local residents
how they can improve their health with a little effort and a lot of sun-
light. As they work, children walk over to stare and wonder. The volun-
teers invite the kids over and begin explaining how to grow tomatoes. The
children’s mothers arrive, checking on their little ones, and the gardeners
take advantage of the opportunity to engage the resident adults in the
community garden. The volunteers explain that not only will the garden
provide fresh, healthy food, but those who contribute to the work will also
be engaging in pleasant exercise as they till and weed.

These volunteers are part of a nationwide movement to improve eating
and exercise habits across the nation, and especially in underserved areas.
Teaching healthy eating habits is fundamental to progress as America
works to do away with food deserts and combat childhood obesity. Com-
munity programs, such as Food is Elementary, and urban gardens work to
encourage children to make healthy eating choices and to help their fami-

lies do the same. Simply building grocery stores in low-income neighborhoods is not enough. Healthy
eating habits are much like the old adage, “You can lead a horse to water, but you can’t make him drink.”
That is why First Lady Michelle Obama’s Let’s Move! campaign worked not only to encourage children
and adults to adopt healthier lifestyles, but also funded public programs that gave people the skills to
make healthy lifestyle choices and positively affected public policy that increased access to fresh fruits
and vegetables to residents in low-income areas.

Most of America’s food deserts are located in low-income areas. A study published in Rural Sociology in
2009 studied the body mass index (BMI) of students living in identified food deserts in rural Pennsylva-
nia. Researchers found students who reside in identified food deserts have a higher rate of obesity than
their peers who live in non food desert areas (Schafft, Jensen, & Hinrichs, 2009).

This research drives home the fact that food deserts do not completely lack access to food of any sort.
Rather, food deserts are marked by a lack of fresh, healthy foods. Convenience stores that stock pro-
cessed foods with long shelf lives do exist in food deserts. So, too, do fast-food restaurants that serve
processed meals, which are high in fat, sugar, and cholesterol.

A diet that relies on high-fat, processed food is more likely to create obesity than a diet rich in fresh
fruits, fresh vegetables, and lean meats. Obesity contributes to a range of health problems, including
heart disease, diabetes, and arthritis. Childhood obesity predisposes America’s youth to chronic dis-
eases early in life. As eating habits are difficult to change, it is likely that the overweight children of today
will grow into obese adults. Obesity, and the health risks associated with it, puts an increasing strain on
America’s health care delivery system.

Courtesy of cheitt/fotolia

Neighborhoods without
access to fresh fruits,
vegetables, meat, and
other healthy foods are
known as food deserts.

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CHAPTER 3Self-Check

Chapter Summary

Negative health outcomes are caused by factors on both micro and macro levels of society. Social capital refers to the social factors and resources that people rely on for emotional support and help through hard times. Close family ties can alleviate
stress, lessening the risk of developing mental conditions. Strong social networks provide
help with everything from child care to finding gainful employment. The political factors
that affect health are based on the social status of the individual and the groups they are
associated with. Women, children, and the elderly are particularly vulnerable regarding
social status factors. Human capital is greatly enhanced by high levels of social status, as
higher social-status groups generally have more education and income to invest in them-
selves and others. There is a defined spectrum of social, political, and economic factors
and vulnerability that represents the haves and have-nots.

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

1. The average American life expectancy is expected to rise to 82.6 in 2050. True or
false?

a. True
b. False

2. During the 1980s, HIV was stigmatized as what type of illness?
a. “single man’s” illness
b. “old man’s” illness
c. “gay man’s” illness
d. “married man’s” illness

3. Which two communities are associated with high suicide risk due to broken com-
munities and the disintegration of their traditional cultures and family struc-
tures? (Select two.)

a. Hispanic
b. Alaska Native
c. Native American
d. Caucasian

Critical Thinking

Community gardens have been one response to the food desert issue, but in most locations, gardens
are not a year-round solution. Water availability can also be a major obstacle. If you had the power to
make real and substantial changes to increase access to fresher and healthier foods in a food desert
community, what would you do and why?

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CHAPTER 3

Additional Resources

4. Which social ideologies contribute to the power disparity that allows for abusive
situations to occur? (Select three.)

a. gun ownership as an exercise of the right to bear arms
b. the woman’s role in the household (tend the home and children, obedience

to the man)
c. the “right” way for men to act (strong, in control, and domineering)
d. political beliefs (Republican or Democrat)

5. Tax income for housing subsidies and welfare programs has decreased due to
what factor(s)?

a. rampant unemployment
b. corporate tax incentives
c. understaffed government housing offices
d. A and B only

6. First Lady Michelle Obama started the ____________ campaign to encourage
healthier lifestyles.

a. Let’s Move!
b. Walk Your Dog!
c. Smart Choices
d. Chefs in Schools

Answer Key

1. a 2. c 3. b and c 4. a, b, and c 5. d 6. a

Additional Resources

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

Food is Elementary program

http://www.foodstudies.org/images/stories/hopkins%20article

First Lady Michelle Obama’s Let’s Move campaign

http://www.letsmove.gov/

USDA’s interactive food desert map

http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx

bur25613_03_c03_079-110.indd 108 11/26/12 10:31 AM

http://www.foodstudies.org/images/stories/hopkins%20article

http://www.letsmove.gov/

http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx

CHAPTER 3Key Terms

Web Exercise

Using the three websites listed in this section, discuss the following in a two-page paper:

• Define and identify a food desert and what criteria the USDA uses to determine
where food deserts are located. (http://www.ers.usda.gov/data/fooddesert/
documentation.html)

• What progress has been made regarding whether food deserts are problematic in the
United States? (http://www.npc.umich.edu/news/events/food-access/final_bitler
_haider )

• Discuss alternative solutions. (http://www.economist.com/node/18929190)

Key Terms

documented immigrant An immigrant
who has come to the United States through
legal channels but has not had to undergo
the rigorous level of screening experi-
enced by refugees or overdocumented
immigrants.

food deserts Residential areas without
readily available access to grocers who
carry fresh fruits, vegetables, and meats.

gestational hypertension High blood
pressure during pregnancy.

overdocumented immigrant A legal
immigrant to the United States that has
official refugee status.

real median income The middle aver-
age income level for the United States,
adjusted for inflation.

Ryan White HIV/AIDS Program A fed-
eral program administered by the Health
Resources and Services Administration
that provides funding to states and com-
munity-based organizations to improve
health care access and provide life-saving
medications for HIV/AIDS patients in
low-income areas.

social selection theory The argument that
mental illness causes people to fall into
low socioeconomic status.

social stress theory The argument that
the stressors experienced by low socio-
economic groups cause mental health
conditions.

Supplemental Security Income program
(SSI) A federal program administered
by the Social Security administration that
provides financial support for disabled
citizens.

transient homelessness A state of home-
lessness wherein the affected individuals
move from home to home, often staying
with various family or friends for short
periods of time before moving on.

undocumented immigrant Often referred
to as “illegal aliens,” immigrants from
countries outside the United States or its
territories who have not completed the
official immigration process.

bur25613_03_c03_079-110.indd 109 11/26/12 10:31 AM

http://www.ers.usda.gov/data/fooddesert/documentation.html

http://www.ers.usda.gov/data/fooddesert/documentation.html

http://www.npc.umich.edu/news/events/food-access/final_bitler_haider

http://www.npc.umich.edu/news/events/food-access/final_bitler_haider

http://www.economist.com/node/18929190

bur25613_03_c03_079-110.indd 110 11/26/12 10:31 AM

4

Seeking an Effective Care Continuum

Learning Objectives

After reading this chapter, you should be able to:

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

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

• Identify the preventive care services available to vulnerable populations.

• Examine the treatment services available to vulnerable populations.

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

Courtesy of Kurhan/Fotolia

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CHAPTER 4

Critical Thinking

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

Introduction

Introduction

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

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

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

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CHAPTER 4Section

4.1 The Need for an Effective Continuum of Care

Self-Check

Answer the following questions to the best of your ability.

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

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

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

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

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

Answer Key

1. b 2. c 3. a

4.1 The Need for an Effective Continuum of Care

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

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

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

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

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

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

Courtesy of WavebreakMediaMicro/Fotolia

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

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

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

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

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

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

Answer Key

1. d 2. c 3. a

A Closer Look: Community Health Departments

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

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

Critical Thinking

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

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CHAPTER 4Section

4.2 Health Maintenance Through Preventive Care Services

4.2 Health Maintenance Through Preventive Care Services

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

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

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

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

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

Courtesy of soupstock/Fotolia

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

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

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

Vulnerable Mothers and
Children

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

Courtesy of nyul/Fotolia

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

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

Program Pros Cons

Maternal and Child Health (MCH)

The Program for Children with
Special Health Care Needs

Title X of the Public Health
Service Act

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

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

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

Food Stamp Program

Provide nutrition support
services for qualifying families.

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

Maternity and Infant Care
Projects

Community and Migrant Health
Centers

National Health Services Corp

Planned Parenthood

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

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

School-based behavioral risk
education programs

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

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

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

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

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

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

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

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

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Abused Individuals

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

Table 4.2: Preventive services available to abused individuals

Program Pros Cons

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

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

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

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

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

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

Chronically Ill and Disabled Persons

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

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

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

Program Pros Cons

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

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

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

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

Health and injury prevention
programs for the elderly

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

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

Persons Diagnosed With
HIV/AIDS

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

Courtesy of Mariano Ruiz/Fotolia

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

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

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

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

Program Pros Cons

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

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

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

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

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

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

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

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Persons Diagnosed With Mental Conditions

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

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

Type of Program Pros Cons

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

These programs face funding
challenges that restrict
availability and accessibility.

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

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

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

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Courtesy of Loren Rodgers/Fotolia

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

Suicide- and Homicide-
Liable Persons

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

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

Program Pros Cons

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

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

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

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

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

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Persons Affected by Alcohol and Substance Abuse

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

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

Program Pros Cons

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

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

Screening and counseling
programs

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

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

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

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

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CHAPTER 4Section 4.2 Health Maintenance Through Preventive Care Services

Indigent and Homeless Persons

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

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

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

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

Table 4.8: Preventive services available to indigent persons

Program Pros Cons

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

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

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

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

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

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

Courtesy of wjarek/Fotolia

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

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

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

Immigrants and Refugees

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

Table 4.9: Preventive services available to immigrants and refugees

Program Pros Cons

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

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

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

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

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

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

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

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CHAPTER 4Section

4.3 Reclaiming Health Through Treatment Services

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

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

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

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

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

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

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

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Vulnerable Mothers and
Children

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

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

Program Pros Cons

Substance abuse cessation
programs

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

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

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

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

Abused Individuals

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

Courtesy of iStockphoto/Thinkstock

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Courtesy of reflektastudios/Fotolia

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

Table 4.11: Treatment services available to abused individuals

Program Pros Cons

Emergency and outpatient
medical services

Treat injuries caused by abuse
and screen for abusive situations.

Many abuse victims avoid
medical services for fear of
intervention.

Crisis response services and
hotlines

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

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

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

Victims and offenders must be
active, willing participants.

Chronically Ill and
Disabled Persons

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

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

Program Pros Cons

Care management services
(managed care organizations
[MCOs])

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

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

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

Emergency rooms are expensive
and are short-term care.

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

These programs can be
expensive, which limits access.

Persons Diagnosed With HIV/AIDS

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

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

Program Pros Cons

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

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

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

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

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

Program Pros Cons

Outpatient mental health
services

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

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

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

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

Substance abuse cessation
programs

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

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

Persons Diagnosed With Mental
Conditions

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

Courtesy of WavebreakmediaMicro /Fotolia

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Suicide- and Homicide-Liable Persons

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

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

Program Pros Cons

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

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

Crisis intervention centers and
hotlines

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

Lack of coordination between
agencies complicates quality
assurance.

Persons Affected by Alcohol and Substance Abuse

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

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

Program Pros Cons

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

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

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

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services

Table 4.17: Treatment services available to indigent persons

Program Pros Cons

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

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

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

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

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

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

Indigent and Homeless Persons

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

Courtesy of Oleg Kozlov/Fotolia

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

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CHAPTER 4Section 4.3 Reclaiming Health Through Treatment Services
Critical Thinking

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

Immigrants and Refugees

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

Table 4.18: Treatment services available to immigrants and refugees

Program Pros Cons

Emergency and inpatient medical
services

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

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

Outpatient medical and mental
health services

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

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

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

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

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CHAPTER 4Section

4.4 Maintaining Quality of Life Through Long-Term Care

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

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

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

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

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

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

Answer Key

1. a 2. c 3. a

4.4 Maintaining Quality of Life Through Long-Term Care

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

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

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

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

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

Vulnerable Mothers and
Children

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

Courtesy of Dalia Drulia/Fotolia

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

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

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

Program Pros Cons

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

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

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

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

Abused Individuals

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

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

Program Pros Cons

Counseling services and peer
support self-help groups

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

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

Protective services and welfare
agency programming

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

Funding and staffing are uneven
and inadequate.

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

Most are privately funded and
have small operating budgets.

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

Domestic disputes are handled
differently by different
responders and departments.

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

Chronically Ill and Disabled
Persons

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

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

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

Program Pros Cons

Nursing homes and independent
living communities

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

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

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

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

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

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

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

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

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

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

The Basic Vocational
Rehabilitation Service Program

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

Federal funding is always in
danger.

Courtesy of Lisa F. Young/Fotolia

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

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

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

Courtesy of mangostock/Fotolia

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

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

Program Pros Cons

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

AIDS hospices depend largely on
volunteers and private donors.

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

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

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

These services depend on
private donors and volunteers to
function.

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

Persons Diagnosed With Mental Conditions

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

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

Program Pros Cons

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

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

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

The caregivers need a lot of
resources and support.

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

Affordability can be a barrier to
access.

Community-based care including:

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

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

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

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

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

Program Pros Cons

Criminal justice system Removes violent offenders from
society.

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

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

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

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

Persons Affected by Alcohol and Substance Abuse

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

Suicide- and Homicide-Liable
Persons

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

Courtesy of Alexander Edmonds/Fotolia

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

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

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

Program Pros Cons

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

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

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

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

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

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

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

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

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

Patients must be compliant with
session attendance.

Indigent and Homeless Persons

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

Courtesy of elavuk81/Fotolia

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

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

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

Program Pros Cons

Inpatient mental health
programs

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

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

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

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

Immigrants and Refugees

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

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

Program Pros Cons

English as a Second Language
(ESL) courses

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

Program funding can be difficult
to maintain.

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

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

Voluntary refugee assistance
programs

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

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

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

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

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

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

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

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

Answer Key

1. a 2. c 3. a

Critical Thinking

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

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CHAPTER 4

Chapter Summary

Chapter Summary

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

Case Study: Health Insurers Support Preventive Services

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

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

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

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

Critical Thinking

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

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CHAPTER 4Self-Check

Self-Check

Answer the following questions to the best of your ability.

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

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

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

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

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

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

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

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

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

Answer Key

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

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CHAPTER 4

Web Exercise

Additional Resources

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

Patient Centered Medical Home

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

The American Health Care Association

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

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

http://www.nachc.com/

Web Exercise

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

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

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

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

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

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

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

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

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

http://www.nachc.com/

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

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

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

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

CHAPTER 4Key Terms

Key Terms

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

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

inflation Loss of currency value.

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

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

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

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

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

treatment services Services intended to
restore health to ailing individuals.

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

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