Unit IV Patient populations

Chapter 8 Health care for special populations By Jahangir Moini, M.D., M.P.H. and Morvarid Moini, D.M.D., M.P.H.

Overview Some special populations have less access to health care services: Higher risk of poor health Underprivileged people’s situations due to: Economic conditions Geographic conditions Social conditions

Overview Special populations include: Children Women Minorities Elderly HIV/AIDS patients Chronically ill Homeless Uninsured

Children More than 53% covered by private insurance More than 38% covered by Medicaid If below poverty level: They receive less health care Schooling is often impacted

Children Unique factors: Adults must assist with: Illnesses Dependency Developmental vulnerability New morbidities Adults must assist with: Illnesses Social circumstances Emotional disorders Alcohol or drug abuse Injuries Disrupted family units Learning difficulties Violence

Children Demographics and socioeconomic factors impact their oral health care Family income is closely related Poor oral health often results in: Missed school Emergency department visits Lowered quality of life

Divisions of child health programs Personal medical and preventive services Primary, specialty; Mostly private insurance, out-of-pocket, or Medicaid Population-based community health services Disease prevention/health promotion, immunization, screening, abuse/neglect Mostly federally funded Health-related support services Nutrition education, family support, early intervention, rehabilitation

Women Usually live 4.8 years longer than men Have increased morbidity and poorer health Though men have higher occurrence, more women die from heart disease or stroke Higher annual charges for all types of care Receive more intensive services More likely to delay care than men

Figure 8-1: A waiting room with more female patients than male patients

Women Death related to alcohol abuse is higher than in men Older women = much higher degrees of Alzheimer’s Many programs focus on women’s health issues Women are more often dependents under their husbands’ plans

Ethnic minorities Minorities make up more than 36% of population White Black American Indian, Alaska native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiians, other Pacific Islanders Some other race Minorities make up more than 36% of population

Percentages of larger minority groups in the USA Hispanics or Latinos 16.3% Blacks (African Americans) 12.3% Asians 4.7% Two or more races 1.9% American Indians, Alaska Natives 0.7% Native Hawaiians, other Pacific Islanders 0.2%

Culturally competent care Provision of care that is sensitive to patient values Ethnic or religious backgrounds Specificity in cross-cultural clinical interactions between patients and providers Culturally competent care can be more successful

Hispanics or Latinos Fastest-growing minority in U.S. About 57 million people in the country 1 in 4 live below the federal poverty level Barriers to care include language Generally less educated or job-skilled More likely to be uninsured or underinsured

Blacks (African Americans) Usually less economically advantaged Poorer health Shorter life expectancies Increased age-adjusted death rates Increased mortality rates for: Pregnant women Infants Young children Much higher percentages of low-birth-weight babies

Asians About 16.5 million Asians in the U.S. Generally higher education levels, higher wages Poor preventive care for Asian women, due to cultural beliefs Overall lowest smoking rates Except for Korean Americans Asian Indians more than twice as likely to have diabetes than white Americans

American Indians and Alaska Natives Among lowest socioeconomic classes in U.S. 3 of 4 live outside of reservations or trust lands High rates of: Diabetes mellitus Hypertension Chemical dependency AIDS/HIV mortality Death from alcoholism Tuberculosis Homicides Injuries Infant mortality and morbidity Suicides

American Indians and Alaska Natives Health is improving Life expectancy 4.6 years less than overall population Government is expanding their health services However, less access to treatment Partially because of geography

Native Hawaiians and other Pacific Islanders Government funds health centers for Native Hawaiians Barriers to care = cultural, financial, geographic, social More than 1.4 million people in this group 21.5% more likely to live in poverty than total population They have more: Cancer deaths Infant mortality Diabetes mellitus Obesity Smoking Alcohol use

Elderly Chronic diseases mean future disabilities, related care May require increasing amounts of assistance for: Hypertension Arthritis Heart disease Cancer Diabetes Hearing impairment Visual impairment Dementia Stroke Hip fractures

Figure 8-2: An elderly woman

Elderly For the oldest-old Americans Hospital and nursing home stays are common After age 65, about 1.6 million in institutional settings Medicare and Medicaid cover many elderly people Need for long-term care is increasing Costs are rising Not enough caregivers

Elderly Program of All-Inclusive Care for the Elderly (PACE) helps them remain in their communities: Day care Physical therapy Occupational therapy Recreational therapy Nutrition counseling Personal care Social services Medical care Meals Home care Hospital care Nursing home care

Elder abuse Intentional harmful or negligent acts: Causing harm to vulnerable elderly: Bruises, broken bones, abrasions, burns, pressure marks Withdrawal, changes in alertness, unusual depression Sudden financial changes Bedsores, unattended needs, poor hygiene, weight loss Spousal threats or uses of power, control Strained relationships, arguments (patient / caregiver)

People with disabilities 15% of worldwide population Lack of access = higher vulnerability to conditions Barriers: Excessive costs (especially transportation) Physical barriers Limited availability of services Inadequate skills of providers

Levels of disability Level Description I (affects 2% of adults) Can’t perform basic activities of daily living (ADLs) without help (walking, eating, etc) II (affects 3% of adults) Can’t perform instrumental activities of daily living (IADLs) without help (mobility, preparing meals) III (affects 4% of adults) Can’t perform 1+ activities, or difficulty with 2 ADLs, but not needing help IV (affects 5% of adults) Can perform, but with difficulty, 2 or more activities V (affects 8% of adults) Can perform, but with difficulty, only 1 activity VI (affects 78% of adults) No functional limitations Childhood (4% of children) Long-lasting conditions limiting physical abilities, or mental/emotional conditions affecting regular schoolwork

People with disabilities Most are under 65, and still work Elderly more likely to be disabled, often severely Five common work-limiting conditions: Mental retardation Lung or bronchial cancer Multiple sclerosis Absence of a leg or legs Blindness in both eyes

People with disabilities Many health care options available Level I through V disabled = 2 of every 3 people have private insurance 1 in 5 have public coverage About 17% have no insurance

HIV/AIDS Human immunodeficiency virus (HIV) Development of acquired immune deficiency syndrome (AIDS) Deaths decreasing due to better treatments Number of AIDS patients increasing Black males have highest rates

Reported AIDS cases in various groups, in the U.S. (as of 2010) Reported Number of Cases Males, 13 and older 810,676 Females, 13 and older 198,544 Children under 13 9,209 Ethnic groups Black 473,229 White 429,804 Hispanic 197,449 Asian 8,759 American Indian/Alaska Native 3,721 Native Hawaiian or other Pacific Islander 870

HIV/AIDS Antiretroviral therapy Women Top 2 methods of exposure: Reduces mother-to-fetus transmission Women Quickly growing population for HIV/AIDS Top 2 methods of exposure: Heterosexual contact Injected drug use

HIV/AIDS Highest risk groups: Homosexual men Inner-city young adults Poorer women Substance abusers that have left treatment

HIV/AIDS Slow overall response to the HIV epidemic No cure Due to homophobia No cure Transmission is not affected by current treatments Patients require increased care as AIDS progresses Often involving government coverage

Chronically ill 7 of 10 deaths are from chronic diseases They are now a leading cause of death Heart disease, cancer, and stroke Cause more than 50% of annual deaths More than 1 in 4 adults has 1 or more chronic illness

Modifiable risk factors for chronic disease Physical activity Only 1 in 5 Americans get enough Nutrition Less than 1 in 4 eat enough fruits and vegetables daily Smoking 1 in 5 smoke tobacco cigarettes Alcohol – #1 drug problem in the country 3 of 4 Americans consume alcohol Only 6% are actually alcoholics

Homeless About 3.5 million homeless, of all ages Most are men 1.35 million are children Most are men Second most are families with children Significant cause: Domestic violence Linked to 18% of families

Homeless Poor access to health care, often uninsured Leads to additional health problems More likely to: Be hospitalized Receive outpatient care Often provided without compensation

Uninsured Adult Americans usually have less insurance Minorities more likely to be uninsured Most uninsured are: Younger workers Lacking a college degree Uninsured people are usually in poorer health

Uninsured percentages of various Americans Hispanics or Latinos 30.4% Blacks (African Americans) 17.8% Asians 16.2% Whites 14.9%

Illegal immigrants Often poor, seeking better opportunities here Such as farmworkers Estimated 12 million illegal immigrants 75% of migrant workers born in Mexico or Central America

Illegal immigrants Migrant workers not considered “legal” Work in jobs of which the government is aware More than half receive public assistance Significant health problems: Obesity Tuberculosis HIV/AIDS