34 unit one Foundations in Maternal, Family, and Child Care
trends in perinatal health. For example, women are start- ing their prenatal care earlier. In the latest CDC Behav- ioral Risk data (2004), 83.9% of women initiated prenatal care during the fi rst trimester. Smoking during pregnancy decreased from 20% in 1989 to less than 11% in 2003.
Also, today, there is more published information about proper nutrition, folic acid, and healthy lifestyles than ever before.
There is evidence that contemporary health care systems are more cognizant of women’s needs. Children maneuver- ing giant balloons as they eagerly bounce down the post- partum hall en route to visit their mothers and newborn siblings is a welcome and familiar sight. There is more understanding in research circles about the differences in the health care needs of women and men. Women are being empowered more in health care settings, enabling them, in turn, to make better health care decisions for their families.
Now Can You— Discuss elements of the current health status of American families and women?
1. Discuss how recent national trends have affected families’
access to health insurance?
2. Identify the three leading causes of death in women in the United States?
3. Describe a state-wide model developed by nurses to improve pregnancy outcomes and reduce maternal mortality?
chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 35
SOCIOECONOMIC INFLUENCES AND TRENDS The most egregious effects of inequality in the United States are seen on the streets of the inner cities among persons with little hope for the future. The more subtle but far-reaching effects are seen in workers with insecure jobs. These are persons who rightly fear that major illness would result in personal catastrophe. Many single moth- ers report that they are merely one sick child away from losing their jobs and entire paychecks (Edin & Lein, 1997; Redfern-Vance, 2000).
In addition, there are the elderly who must expend nearly all of their resources before they can accept pub- lic funding for needed long-term care. For the elderly, the cost of medications can add up at the same rapid rate as do the chronic health conditions associated with the aging process. There are also those who may be clas- sifi ed in a low- or a high-income group, may be young or may be elderly, may be living in a busy metropolis, in suburbia, or in a lonesome rural area, and yet maintain- ing lives that offer little opportunity for control or meaningful social participation. Certainly these inequal- ities are, in part, inequalities in income. However, more than an inequality of income is at issue. In a fundamen- tal sense, these inequalities are refl ective of a society that works well for those at the top, and far less well for everyone else.
The Increasing Rate of Poverty
Most persons consider items like adequate food, housing, clothing, heat, electricity, telephone service, and essential health care as necessities rather than luxuries. This is not true for everyone. Overall, 12.7% of Americans were liv- ing in poverty in the United States in 2004. The number has risen each year since 2000 (U.S. Census Bureau, 2006). Economic changes, racial inequality, suburban movement, manmade and natural disasters, and industri- alization all contribute to poverty circumstances.
The Feminization of Poverty
Women are the most impoverished demographic group in American society (Edin & Lean, 1997). In 2005, 56% of persons older than age 18 living in poverty were women.
Single mothers with their children constitute 82% of the poverty population. More than 60% of U.S. women with children younger than the age of 2 now work outside the home (U.S. Census Bureau, 2000).
In 2000, one-fi fth of all U.S. children were living in poverty. Between 2000 and 2003, the number and per- centage of single mothers living in poverty increased while the percentage of single mothers with jobs fell. At the same time, poverty among children rose, and the number of children living below half of the poverty line (about $620 a month in 2003 for a single mother with two children) increased by nearly 1 million. These structural features of U.S. society have contributed to what has been coined as the “feminization of poverty.”
Single mothers face oppressive barriers to achieve the
“economic self-suffi ciency,” now legislatively prescribed for them, commonly referred to as “welfare to work.” The es sence of the new legislation, entitled Temporary Assis- tance for Needy Families (TANF), is that work now becomes compulsory and lifetime limits are imposed.
TANF replaces the former public assistance program that was known as Aid to Families with Dependent Children (AFDC). There is a maximum period that a person is allowed to receive public assistance at one time, and a lifetime limit. The mandates apply to pregnant women as well as those with infants older than the age of 3 months.
The Wage Gap
Gender inequity persists and the ratio of full-time work- ing women’s weekly earnings to those of men was 77 cents to the men’s dollar in 2004. Proportionately, more fami- lies are being supported by women today than ever before.
Three out of fi ve U.S. families were headed by women and 22% of all children in the United States lived in mother- only families in 1990, an increase of 11% since 1970 (U.S.
Census Bureau, 2006).
Now Can You— Discuss aspects of political and socioeconomic infl uences that impact the nation’s health?
1. Identify and discuss three socioeconomic trends that have a negative impact on the health of persons living in the United States?
2. Describe two public programs intended to improve the health of American women, children, and families?
3. Describe what is meant by the phrase “the feminization of poverty”?
Communications and the Digital Divide
One of the factors promoting patient empowerment is the ready access to health care information over the Internet. Fox (2006), reporting on the Internet and health, found that “looking specifi cally at online discus- sion groups devoted to health and well-being, the audi- ence is also stable – about half of internet users helped someone else through an illness in the past two years;
one in fi ve internet users dealt with their own illness during that time” (p. 5).
In modern society, however, there exists what has been termed the “digital divide” (Wagner, Bundorf, Singer,
& Baker, 2005). Families with discretionary income and with some formal education are more likely to access health information and educational resources from the World Wide Web. Those with less income, in particular those from racial and ethnic minority backgrounds, are less likely to have access to electronic materials. In addi- tion, there is what is called the “gray gap,” referring to seniors who do not use Internet technology. Approxi- mately 68% of Americans reported ready access to the Internet in 2005. In families with incomes of $75,000, 95% of children have a computer at home. One out of fi ve Americans claims they have never used the Internet or e-mail. Again, the “digital divide” separates and discrimi- nates against the poor or elderly who do not have access to computers or who have not learned computer skills (U.S. Census Bureau, 2007).
Vulnerable Populations
Bellah, Madsen, Sullivan, Swiler, and Tipton (1991), who conducted a landmark study of mainstream American culture, articulated a problem described as “excessive
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36 unit one Foundations in Maternal, Family, and Child Care
individualism.” The cultural norm of individualism focuses attention away from critical societal issues such as the ever-increasing gap between the “haves” and the “have- nots,” as evidenced by the alarming rise in homelessness, hunger, and violence. The dark side of individualistic thinking advocates a policy of “choosing and creating your own reality” which then leads to “blaming the victim” and ignoring the social context, where “choices” are not, and have never, been equal. As a society, it behooves Ameri- cans to focus on a shared vision and goals, such as those afforded to us by the Healthy People 2010 initiative. To do so, it is important to consider the vulnerable populations in the United States. As Aday (2001) notes, “as members of human families and communities, we are all potentially vulnerable” (p. 53). Vulnerability encompasses threats to physical and psychological health, as well as vulnerable social circumstances and stages within the life course.
HOMELESSNESS. Homelessness is rising among all popu- lations, but most noticeably for families. There is an increase in families at the extreme poverty level (about
$17,000 for a family of three in 2007). Income levels such as this are woefully inadequate to maintain a household.
The increase in homelessness has resulted in more and more entire families who regularly visit homeless shelters and soup kitchens across the country. In New York City, 73% of the shelter population comprises children and their parents. The random collection of community shel- ters and free food kitchens that have proliferated through- out the United States during the past several years have had a diffi cult time keeping up with the needs. It has not helped that recent policy changes have resulted in the elimination of several programs that previously served as safety nets for health care and housing subsidies. Persons displaced as a result of wars and disasters have also added to the number of those desperately seeking assistance.
For homeless persons and families, health is a momen- tous challenge. The poverty, stigma, poor nutrition, and increased susceptibility to violence and mental illness all take their toll. Access to health care is a problem due to lack of transportation and fi nances, so that hospital emer- gency rooms are often the only option for medical atten- tion. It is diffi cult to obtain accurate numbers on the homeless population but the Partnership for the Homeless estimates that currently there are about 2 million home- less persons in the United States, with 8105 homeless families in New York City alone.
Nursing Insight—
Putting Homelessness into Proper PerspectiveTo enhance understanding of the magnitude of the problem of homelessness in the United States, it is useful to consider the following statistics. These fi gures relate to families who were sleeping in Department of Homeless Services (DHS) city shelters in New York City during 1 month in 2005:
• 8105 families
• 13,062 children
• 11,854 adults
• Average family size: 3.18
• Average length of stay: 361 days
• 32.3% remain in shelters more than 1 year Source: http://www.partnershipforthehomeless.org/
UNDOCUMENTED IMMIGRANTS AND REFUGEES. Undocu- mented persons who enter the United States illegally in order to work constitute another highly vulnerable popu- lation. Many persons are from Mexico or Central America and are drawn to the United States for economic reasons or to escape political confl icts. Undocumented persons are willing to work in what are considered the lowest paid and least desirable occupations in the United States.
They generally have no job security, health care access, or decent housing. Most face language barriers as well.
Without fi nancial resources, hospital and health clinic doors are generally closed to them. In addition, this pop- ulation is experiencing mounting resentment from a public that is leaning more and more toward isolationism since the World Trade Center attack (Goldman, Smith, &
Sood, 2006).
PERSONS RESIDING IN RURAL AREAS. Persons living in rural neighborhoods are less likely to have access to quality health care. Primary care providers are increasingly reluc- tant to locate in rural areas. Many small, rural hospitals have been forced to close because of centrali zation of intensive care services.
ABUSED AND NEGLECTED CHILDREN. The National Child Abuse and Neglect Data System (NCANDS)is the federal reporting system that analyzes data on child abuse that are collected on an annual basis. In 2006, NCANDS reported that the information obtained in the 2004 count included 3 million cases of reported child abuse. Child abuse can take many forms. The most common is child neglect, which can mean withholding food, clothing, shelter, love, supervi- sion, or medical attention. Physical and child sexual abuse are other types and it is not uncommon for all three forms of abuse and neglect to overlap. According to the American Academy of Pediatrics, study estimates predict that one out of four girls and one out of eight boys will be inappropri- ately touched sexually by the time they turn 18 (Kellogg and the Committee on Child Abuse and Neglect, 2005).
NCANDS reports that three children die of child abuse in the home each day (U.S. DHHS, 2007). Fewer than 1%
of children are abused by strangers. Children are most commonly abused by someone they know. In 79% of cases, the perpetrator is a parent. Child abuse can set up a perpetuating cycle of suffering and more violence later in life, potentially reaching into future generations.
Nurses have a legal obligation to report any observed known or suspected child abuse to child protective ser- vices. Thus, it is critical for nurses to learn to assess the signs and symptoms of child abuse (see Chapter 23).
VICTIMS OF SEXUAL VIOLENCE. Historical beliefs and atti- tudes toward women continue to infl uence women’s lives and health. In the past, women were viewed as physically and psychologically inferior to men. They were denied rights and privileges routinely granted to men, such as owning property and voting.
Sexual violence haunts the lives of all women, both with its frequency and its impact. In a U.S. Department of Justice, Offi ce of Justice Programs, National Violence Against Women Survey (NVAWS), nearly one out of fi ve to six women report having been raped (Tjaden &
Thoennes, 2000). Some have called the United States a
“rape-prone” society (Buchwald, Fletcher, & Roth, 1995).
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chapter 2 Contemporary Issues in Women’s, Families’, and Children’s Health Care 37
Sexual violence is linked with deleterious long-term psychological, social, and physical effects such as sub- stance abuse, major depression, gynecological disorders, and others (Koss & Harvey, 1991; Wolfe, 1996). Unwanted sexual attention also devalues women and takes a toll on their health. Lewd sexual comments, cat calls, whistling, and intrusive looks are demeaning actions that negatively affect women’s health (Esacove, 1998).
VICTIMS OF INTIMATE PARTNER VIOLENCE. It is diffi cult to obtain accurate numbers about intimate partner violence (IPV) because of varying defi nitions and widespread under- reporting. The National Violence Against Women Survey (National Institute of Justice and the Centers for Disease Control and Prevention) revealed that nearly 5.3 million incidents of IPV occur each year among U.S. women ages 18 and older, and 3.2 million IPV incidents occur among men. The majority of reported assaults did not result in serious injury and consisted of pushing, grabbing, shoving, slapping, and hitting (Tjaden & Thoennes, 2000a).
Research suggests that nurses in clinical settings are still reluctant to question patients about intimate partner violence. Nurses need to routinely ask the violence screen- ing questions and offer to help abused patients develop a safety plan. It is important for nurses to know that the most dangerous times for abused women are during preg- nancy and when a woman tries to leave her partner.
GAY/LESBIAN/TRANSGENDERED INDIVIDUALS. Studies repeat- edly demonstrate that access to sensitive health care for gay, lesbian, and gender transitioning patients is extremely limited. Stigma and prejudice continue to prevail in atti- tudes toward those living an “other than heterosexual”
lifestyle (see Chapter 6 for further discussion about specifi c health issues among this population).
INCARCERATED WOMEN. An invisible population of mar- ginalized women exists within the hidden pockets of the richest country in the world. One hears very little about incarcerated women, yet they currently inhabit U.S. jails and prisons in ever increasing numbers, with a sixfold increase during the past 20 years (Braithwaite, Arriola,
& Newkirk, 2006). The growth rate of women prisoners has now bypassed the growth rate of male prisoners, and at present, women constitute 10% of the total inmate popu- lation (Hufft, 2004). In this country, which has the highest incarceration rate in the world, there are approximately 1 million women behind bars.
As a population, incarcerated women are not healthy.
They tend to have a myriad of health problems, particularly illnesses that stem from the stresses of poverty, physical and sexual abuse, addiction, and motherhood. Imprisoned women frequently do not have access to the benefi ts of health education. Mental health issues abound in this vul- nerable population as well.
More than 70% of incarcerated women are mothers.
This is an issue that greatly impacts the health of families.
Approximately 1.3 million minor children have no mother to care for them on a daily basis. Inevitably, children are affected by the abrupt changes commonly associated with incarceration of a parent. They may experience a sudden change in caretaking arrangements, social stigma, the potential for abandonment, and the loss of family support and fi nancial resources.
The Girl Scouts of America organization has developed a unique program for girls who are separated from their mothers because of incarceration (Hufft, 2004). Called
“Girl Scouts Behind Bars,” this program is similar to regu- lar scouting programs and has the same goals of self- esteem building and incremental accomplishments. It includes prison visitation between mothers and daugh- ters, and especially targets social risks for which these young women are more vulnerable. The program also attempts to help incarcerated women hone their parenting skills. Forensic psychiatric nurses play an important con- sulting role in this national program, now operational in 13 states.
A nurse who is able to deliver culturally competent care to incarcerated populations quickly becomes cogni- zant of the challenges as well as the importance of raising standards and improving the present system. Work per- formed with this vulnerable population is signifi cant far beyond the prison walls. Nearly 95% of prisoners will eventually be released into communities where they will likely face poverty, stigma, unemployment, and defi cien- cies in health care.
PERSONS WHO ARE SUBSTANCE ABUSERS. Substance abuse is a major health issue for families. Unfortunately, chil- dren are often the ones who suffer the most. Children in families with substance use problems are likely to be abused and neglected. These same children are also more likely to become substance users themselves. See Chapters 11 and 23 for further information.
Now Can You— Identify vulnerable populations of women, children, and families that exist in the United States today?
1. Identify and describe four vulnerable populations in the U.S.?
2. Describe the population group at present experiencing the largest rise in homelessness?
3. Explain why undocumented immigrants are considered a vulnerable population?
PERSONAL AND CULTURAL INFLUENCES AND TRENDS
The world of today has dramatically changed from the era when telephones, televisions, and airplanes were giant novelties. Now nursing students “text message”
friends on their cell phones in real time. The popula- tion relies on mass media for news and entertainment and the electronic gaming industry is thriving. Even dating relationships have changed. According to the U.S. Census Bureau, of the 44% of American adults who are single, 40% have tried online dating (Madden
& Lenhart, 2006). The global education businesses that use e-learning are estimated to climb to a worth of
$212 billion by the year 2010.
Other cultural changes include an increase in lan- guage barriers and cultural differences within the U.S.
population. There is also a cultural component to many health issues. For example, the dramatic rise in eating disorders demonstrates how present-day popular culture can strongly infl uence health. Media images of so-called
“perfection” fl ood the media, yet these images rarely represent healthy role models.
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