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Identifying Vulnerable Populations

Contact Hours: 4

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Contact Hours: 4

This online independent study activity is credited for 4 contact hours at completion.

Course Purpose

To provide healthcare professionals with knowledge of identifying common and not-so-common members of the vulnerable population that may seek assistance in the healthcare system and review the process of nurse advocacy.

Overview

The nurse’s role as a patient advocate for the vulnerable was first instituted in the early 1850’s by Florence Nightingale. Vulnerability is a general term that identifies susceptibility and one who is at risk for health problems. A vulnerable person is one who is at risk for poor social, psychological, or physical health. Patients within vulnerable populations include (but are not limited to) high-risk mothers and infants, the chronically ill, those afflicted with mental illness, persons who abuse alcohol and other substances, the homeless, those living with HIV and AIDS, those at risk for suicide or homicide, are immigrants, terminally ill, and are illiterate. To be an effective nurse advocate, the nurse must use the 4 stages of advocacy, which include the assessment of needs, identifying the patient’s specific goals, implementation the advocacy plan, and evaluate the outcome of advocacy behaviors.

Objectives

Upon completion of this activity, the learner will be able to:

  • Describe the circumstances that would cause one to be considered part of a vulnerable population.
  • Review the various vulnerable populations within various communities.
  • Understand the healthcare professionals‚Äô role as a patient advocate for vulnerable persons.

Policy Statement 

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Fast Facts: Identifying Vulnerable Populations

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Case Study

Please review the following case study. After reading the case study, list the identifiable factors for vulnerability and actions that the nurse can take to advocate for the patient.

Jim Simpson is a 45-year-old male who recently lost his job. As a result, he also lost his health insurance. Mr. Simpson was diagnosed with type II diabetes in his 30’s, and 1 year ago he was diagnosed with a melanoma on his scalp. He had the melanoma removed, however 1 week ago he started experiencing extreme headaches. He was able to get the next available appointment to see a physician through the county services, but the date of the appointment is 2 months away. Mr. Simpson has not had his medications for diabetes in over a month, and his headaches have become debilitating. He is unable to seek work because of his symptoms and has refused to seek care in the emergency room due to the cost of treatment. He has exhausted all his financial resources and is unable to pay this month’s rent. What identifiable factors include Mr. Simpson in the vulnerable population? As a healthcare provider, what can you do to advocate for Mr. Simpson? The identifiable factors and advocacy solutions to assist Mr. Simpson will be discussed at the end of the lesson.

Introduction

The healthcare system can be difficult to navigate, and identifying the vulnerable patient is crucial to ensure adequate care is provided. Members of the vulnerable population are at risk for acute and chronic illnesses, and health disparities that can affect socio-economic status, housing, etc. One can become a member of the vulnerable population for several reasons, and this course seeks to inform the healthcare provider of common and not-so-common vulnerable populations that may require treatments for medical and psychological conditions, and to identify the process to effectively advocate for a vulnerable patient.

Vulnerable Populations and Health Disparities

Vulnerability is a general term that identifies susceptibility and one who is at risk for health problems. A vulnerable person is one who is at risk for poor social, psychological, or physical health. Any person can become vulnerable at any given time; for instance, a patient in an emergency room may become vulnerable when  care is provided by an unknown provider, and a nurse in the same emergency room may become vulnerable when they experience a violent outburst from a patient.

For some, being a member of a vulnerable population does not constitute vulnerability. This stems from a belief that strengths should be focused on rather than weaknesses. These individuals believe that the term ‚Äėvulnerable population‚Äô is a patronizing label placed by the government and health care professionals to identify those who are incapable of taking care of themselves.

In terms of healthcare, vulnerable populations are those who are at a higher than normal risk for developing health problems as a result of lack of economic resources, sociocultural status, lack of access to healthcare, or characteristics such as age, gender, and ethnicity.

High-Risk Mothers and Infants

This population is vulnerable because of limited access to healthcare, teenage pregnancy, limited or poor education, and poor prenatal care, allowing susceptibility to infants with low birth weights and infant mortality.

  • Approximately 200,000 babies are born to women aged 15‚Äď19 years, for an average birth rate of 19 per 1,000 women in this age group.
  • Pregnancy and birth are significant contributors to high school dropout rates among girls.
  • Only about 50% of teen mothers receive a high school diploma by 22 years of age, whereas approximately 90% of women who do not give birth during adolescence graduate from high school.
  • The children of teenage mothers are more likely to have lower school achievement and to drop out of high school, have more health problems, be incarcerated at some time during adolescence, give birth as a teenager, and face unemployment as a young adult.
Chronic Illness and Disability

The vulnerable within this population experience higher than normal death rates as a result of heart disease, stroke, and cancer in comparison to the middle class, and have a higher prevalence of suffering from chronic diseases such as arthritis, hypertension, and asthma. African Americans are more likely to have health complications and succumb from chronic diseases.

  • There are 36 million people who have at least one disability, about 12 percent of the total U.S. population.
  • 21 percent of the population age 16 and older with a disability are below the poverty level.
  • 28 percent of people age 25 and older with a disability have less than a high school level education.
  • 72 percent of disabled people age 16 and older who are unemployed.
Mental Illness

Mental illness has a broad definition and vulnerability within this population is high because of age-specific disorders, serious emotional disorders, anxiety, and depression. Rates for depression increase for both males and females during adolescence, but rates for depression rise more acutely for girls after age 13.

  • 19.1 percent of U.S. adults experienced mental illness in 2018; approximately 47.6 million people. This represents 1 in 5 adults.
  • 4.6 percent of U.S. adults experienced serious mental illness in 2018; approximately 11.4 million people. This represents 1 in 25 adults.
  • 43.3 percent of U.S. adults with mental illness received treatment in 2018. 
  • 64.1 percent of U.S. adults with serious mental illness received treatment in 2018.
  • People with depression have a 40% higher risk of developing cardiovascular and metabolic diseases than the general population. People with serious mental illness are nearly twice as likely to develop these conditions.
  • 19.3 percent of U.S. adults with mental illness also experienced a substance use disorder in 2018 approximately 9.2 million individuals.
  • Mental illness and substance use disorders are involved in 1 out of every 8 emergency department visits by U.S.  adults; an estimated 12 million visits per year.
  • The rate of unemployment is higher at 5.8% among U.S. adults who have mental illness compared to those who do not; approximately 3.6%.
  • 20.1 percent of people experiencing homelessness in the U.S. have a serious mental health condition.
  • 37 percent of adults incarcerated in the state and federal prison system have a diagnosed mental illness.
Persons Who Abuse Alcohol and Other Substances

There is a wide array of substances that can be abused, such as alcohol, cigarettes, inhalants, street drugs, and prescription drugs. Substance abuse can lead to accidents, reckless activity, criminal activity, and chronic diseases. Young males are most likely to be a part of this vulnerable population.

  • According to the National Survey on Drug Use and Health (NSDUH), 19.7 million Americans aged 12 and older battled a substance abuse disorder in 2017.
  • Almost 74% of adults suffering from a substance abuse disorder in 2017 struggled with an alcohol use disorder.
  • About 38% of adults in 2017 battled an illicit drug use disorder. That same year, 1 out of every 8 adults struggled with both drug and alcohol use disorder use disorders simultaneously.
  • In 2017, 8.5 million American adults suffered from both a mental health disorder and a substance use disorder, or co-occurring disorders.
  •  Drug abuse and addiction cost American society more than $740 billion annually in lost workplace productivity, healthcare expenses, and crime-related costs.
Persons Who are Homeless

This vulnerable population is at high risk for lack of healthcare, chronic diseases, and being subject to violence.

  • The National Alliance to End Homelessness states that there are 564,708 people experiencing homelessness on any given night in the US. 36,907 (6.38%) are children, 47,725 (8.33%) are veterans, and 269,991 (47.6%) are disabled and unable to work.
  •  According to the National Coalition for the Homeless, two trends are largely responsible for the rise in homelessness in America over the past 20-25 years: a growing shortage of affordable rental housing and a simultaneous increase in poverty. Persons living in poverty are most at risk of becoming homeless.
  • Many factors can contribute to a person becoming homeless. These factors include (but are not limited to):
    ‚ÄĘPoverty
    ‚ÄĘ Lack of affordable housing
    ‚ÄĘ Job loss
    ‚ÄĘ Lack of health care
    ‚ÄĘ Mental illness
    ‚ÄĘ Substance abuse
    ‚ÄĘ Domestic violence
Persons Living with HIV and AIDS

As a result of education and increased knowledge about the disease, the rate of HIV and AIDS transmission has decreased. There have also been great strides in treating those afflicted with HIV and AIDS. Although these improvements are apparent, those diagnosed with HIV and AIDS remain a vulnerable population as a result of stigma and socio-economic barriers.

  • Approximately 1.1 million people in the U.S. are living with HIV today. About 15 percent of them (1 in 7) are unaware they are infected.
  • In 2017, 17,803 people in the U.S. and 6 dependent areas received a stage 3 (AIDS) diagnosis.
  • In 2017, 38,739 people received an HIV diagnosis in the U.S.
  • Gay, bisexual, and other men who have sex with men bear the greatest burden by risk group, representing an estimated 26,000 of new HIV infections per year.
  • In 2017: Gay and bisexual men accounted for 66% (25,748) of all HIV diagnoses and 82% of HIV diagnoses among males. Black/African American gay and bisexual men accounted for the largest number of HIV diagnoses (9,807), followed by Hispanic/Latinos (7,436) and whites (6,982).
  • Heterosexuals and people who inject drugs also continue to be affected by HIV. In 2017: Heterosexuals accounted for 24% of HIV diagnoses. Heterosexual men accounted for 7% (2,829) of HIV diagnoses. Heterosexual women accounted for 16% (6,341) of HIV diagnoses. People who inject drugs accounted for 6% of HIV diagnoses.
Persons at Risk for Suicide or Homicide

Although anyone could be a part of this vulnerable population, the rates of suicide and homicide vary by age, sex, and race. Elderly white males are most likely to commit suicide, and young African American and Hispanic males are more likely to be victims of homicide.

  • Homicide: The deliberate and unlawful killing of one person by another
    • Number of deaths: 19,510
    • Deaths per 100,000 population: 6
  • Suicides: the action of killing oneself intentionally
    • Number of deaths: 47,173
    • Deaths per 100,000 population: 14.5
    • Cause of death rank: 10
Abusive Families

This vulnerable population includes the elderly, children, and spouses (usually women) as they are usually the targets of abuse. Older children of abusive families or more likely to be injured, and female children over the age of 3 are at increased risk for sexual abuse.

  • On average, nearly 20 people per minute are physically abused by an intimate partner in the United States.
  • 1 in 4 women and 1 in 9 men experience severe intimate partner physical violence, intimate partner sexual violence, and/or intimate partner stalking.
  • Victims of intimate partner violence lose a total of 8.0 million days of paid work each year. The cost of intimate partner violence exceeds $8.3 billion per year.
  • Between 21-60% of victims of intimate partner violence lose their jobs due to reasons stemming from the abuse.
  • Women abused by their intimate partners are more vulnerable to contracting HIV or other sexually transmitted infections.
  • Studies suggest that there is a relationship between intimate partner violence and depression and suicidal behavior.
  • Physical, mental, sexual, and reproductive health effects have been linked with intimate partner violence including, adolescent pregnancy, unintended pregnancy in general, miscarriage, stillbirth, intrauterine hemorrhage, nutritional deficiency, abdominal pain and other gastrointestinal problems, neurological disorders, chronic pain, disability, anxiety and post-traumatic stress disorder, as well as noncommunicable diseases such as hypertension, cancer and cardiovascular diseases.
  • Victims of domestic violence are also at higher risk for developing addictions to alcohol, tobacco, or drugs.
  • More than 800,000 children are confirmed as victims of abuse or neglect each year in the U.S.
  • Neglect is the most common form of child maltreatment, followed by physical abuse.
  • Younger children (ages 0-6) are the most vulnerable to abuse.
  • One in four girls and one in seven boys will be sexually assaulted before they reach the age of 18.
Immigrants and Refugees

This population is vulnerable as a result of diversity in languages, food choices, health practices, cultural definitions of health, and previous experiences in westernized healthcare systems.

  • In 2018, there were 28.2 million foreign-born persons in the U.S. labor force, comprising 17.4 percent of the total.
  • Hispanics accounted for nearly half of the foreign-born labor force in 2018, and Asians accounted for one-quarter.
  • Foreign-born men were more likely to participate in the labor force than native-born men (77.9 percent versus 67.3 percent), while foreign-born women were less likely to participate than native-born women (54.3 percent versus 57.6 percent). 
  • Foreign-born workers were more likely than native-born workers to be employed in service occupations and less likely to be employed in management, professional, and related occupations.
  • The median usual weekly earnings of foreign-born full-time wage and salary workers were $758 in 2018, compared with $910 for their native-born counterparts. (Differences in earnings reflect a variety of factors, including variations in the distributions of foreign-born and native-born workers by educational attainment, occupation, industry.
The Terminally Ill

Nurses have always been at the forefront of palliative treatment and care. Palliative care includes tending to physical comfort and tending to the mental and emotional well-being of the terminally ill patient. The loss of strength, body function control, and the pain and fear of the unknown are heavy burdens for the terminally ill. There is a shift in thought; plans and imminent reality can cause the ill patient to view the world differently, and this may lead to suffering.  Suffering is caused by severe distress as one searches for the meaning in life, and whether that meaning was fulfilled.

Meaning is defined as ‚Äúpurpose and significance‚ÄĚ. The meaning of life and death is different for everyone. The terminally ill patient may strive to make sense of the world, relationships with others, personal experiences, and private thoughts. The patient‚Äôs personal meaning of their own dying experience can assist in shaping the acceptance of the terminal illness. One of the best ways that the nurse can help the terminally ill patient through the dying experience is to listen. The nurse must listen to the patient and allow them to find comfort in life review through reminiscing, thoughts of an open-ended future, and allow the patient to come to their own conclusions of the meaning of life.

Immigrant Vulnerability

Immigration is an ancient phenomenon, and with globalization the phenomenon of immigration is increasing and becoming more diversified. By the year 2050, the immigrant population is expected to be 40% Hispanic, 30% Asian and pacific Islands, 20% non-Hispanic whites, and 10% African or African American. As a result, the demand for culturally competent care is acute.

After resettlement, the immigrant‚Äôs risk for poor health is increased. There are many factors that contribute to the risk, including the transition to a new environment, lack of help seeking as a result of health perceptions, inability to communicate with health professionals and the health professionals‚Äô inability to grasp the circumstances of the immigrant‚Äôs life. Although the immigrant‚Äôs transition and resettlement add to vulnerability, it is not a static, self-contained experience. Immigrant vulnerability has an ongoing interaction with political, cultural, social, and economical structures of the receiving country.  Improved health is associated with language and occupational accommodation during the resettlement period, and ethnocultural communication in the area where immigrants settle. Nurses can improve vulnerability of the immigrant by exhibiting advocacy during culturally competent care, and having an awareness of the social, political, economic and cultural structures that affect the immigrant patient.

Nontraditional Vulnerable Populations

When discussing vulnerable populations in health-related settings, certain groups automatically come to mind. Those groups are usually age-specific, of low socioeconomic status, having a cognitive or physical impairment, or of an ethnic background. More recently, issues such as sexual preference, gender and identity, and cultural diversity have all become a focal point in discussing vulnerable populations. Likewise, international students have also been identified as a vulnerable population.

Before an international student arrives in the United States, they must be accepted for a specific program of study and prove that they have the minimum amount of funds required for their studies and relevant expenses and obtain health insurance. They are not covered by Medicare unless they contract a chronic illness while in the United States. Because of the requirement to grant entry into the United States for educational purposes, the international student often is educated, health secured, and financially stable. But what are the international students’ impressions of the United States healthcare system?

  • It is unaffordable or overly expensive
    • Although international students are insured, many believe health services and medications are overly expensive and that a co-pay for services is unwarranted.
  • Inaccessible and administratively convoluted
    • Many international students perceive health services to be inaccessible with difficulty scheduling appointments within a reasonable time frame. Many also believe that there is limited availability of health professionals. As a result, many international students opt not to seek health services.
  • It is hostile, vague and ambiguous
    • International students have difficulty communicating with healthcare providers, and perceive them as being impersonal, resulting in their feelings of ambiguousness about their rights as a patient.
  • Difficult to deal with insurance companies, claims and payments
    • Fear of rising premiums and payments as a result of filing too many claims prevents international students from accessing a healthcare system.
Vulnerability in Literacy

Literacy is defined as the use of printed information, and comprehension and retention of verbal and gestural information that is used to meet one‚Äôs goals, develop knowledge and abilities, and maneuver within a society. Literacy has itself been described as currency. Those who are illiterate are less likely to meet the needs of daily living and are more likely to have increased health risks and chronic health conditions. People with poor reading skills who lack basic literacy functions such as following directions to complete a task, are more likely to have low social and economic status outside of their immediate social group. For instance, accessing health care often requires complex language skills in order to negotiate points of entry into a healthcare system, identify and evaluate healthcare providers, communicate needs in order to obtain an appointment, use clock and calendar skills travel to a provider,  and interpret written instructions and/or results. Illiteracy has been correlated with poorer health as a result of lack of adherence to medical regimens, and those with low economic status are more likely to receive substandard care, less information about their illness, and be presented with less options for treatment.

Cultural Competence

In healthcare, cultural competence describes being sensitive to the differences in culture of another and acting in a way that is respectful to both the values and traditions while performing an activity that is necessary for well-being. Cultural competence happens on affective, behavioral, and cognitive levels, and self-awareness is a crucial indicator of success. Nurses recognize the need to understand cultural differences, which allows them to exhibit cultural competence when assisting in the healing process of patients. A nurse should set aside feelings of ethnocentrism and accept that every cultural belief of health is equally valid. Cultural blurring, as in blurring the lines, is a technique that bridges that gaps in cultural differences by enabling the nurse to recognize identifiable descriptors of the patients that are culturally like their own.

There are many methods for developing cultural competence, such as:

  • Cross cultural communications exercises that help healthcare providers overcome barriers.
  • Immersion programs that enable healthcare providers to experience different cultures outside of their usual environment, such as food travel courses that expose the healthcare provider to different diet preferences and practices.
  • Didactic materials help improve knowledge about different ethnic groups. These are a useful point of reference for healthcare providers functioning in high-acuity settings. For example, Culture Clues, documents that allow healthcare providers to see dominant preferences of various cultural groups were created by the University of Washington in Seattle. The documents cover perceptions of illness, decision making, comfort, and kinship patterns, and are written in a variety of languages for various cultures. Didactic materials are also used internationally to better provide culturally competent care to vulnerable populations in need.
The Nurse-Patient Relationship

The Nurse-Patient relationship works to bring both participants to the same ethical context through understanding and agreement. The patient will engage with the nurse, with the assumption that the nurse has agreed to act in the role as a healthcare professional. In engaging with the nurse, the patient agrees to allow the nurse to provide care and advocacy for them. The agreement created from the nurse: patient relationship is a shared state of awareness established by a decision from each person and helps to understand what is expected from both the nurse and the patient.

Nurse Advocacy

Since the early 1850s when Florence Nightingale first became a nurse, patient advocacy has been an important nursing responsibility. Nightingale laid the foundation for patient advocacy by consistently insisting on quality of care, which included a safe and clean environment and basic human rights for all. The American Nurses Association (ANA) Code of Ethics for Nurses clearly identifies a professional nursing responsibility to protect the rights of patients. The American Nurses Association (ANA) provides the definition of nursing practice as: ‚ÄúThe protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.‚ÄĚ The ANA also addresses the importance of advocacy in its Code of Ethics, specifically in Provision 3: ‚ÄúThe nurse promotes, advocates for, and protects the rights, health, and safety of the patient.

The advocacy process has four stages:

  1. The assessment of needs
    •  Focuses on the patient, setting, situation, risks, and available healthcare resources. Creating a therapeutic relationship with a patient is essential to understanding their interests and personal values, and what is needed from their healthcare provider. This requires the nurse to assess the patient‚Äôs level of awareness, cognitive function, and understanding of his or her patient rights.
  2. Identify the patient’s specific goals
    • The goal of patient advocacy is to foster a partnership between the patient and healthcare provider while empowering the patient in the decision-making process. For example, a nurse may translate hospital policies and clinical information into layman‚Äôs language for better patient understanding.
  3. Implement the advocacy plan
    • Nurse advocates facilitate communication with all members of the healthcare team regarding the patient‚Äôs preferences. They incorporate the patient‚Äôs identified goals into a plan of care and provide objective guidance. The nurse advocate also supports the patient by negotiating and compromising when conflicts of interest arise and maintain safety and care coordination throughout the entire course of the illness.
  4. Evaluate the outcome of advocacy behaviors
    • The ANA Scope and Standards of Practice suggests that evaluations be criterion-based, ongoing, systematic, and focused on gaining the expected outcomes. These evaluations should include the patient and members of the healthcare team.
Discussion

At its best, advocacy is proactive behavior that improves or corrects a situation, rather than a report of something that’s gone wrong. Assuring that a patient maintains their autonomy in directing their own healthcare decisions is a challenging nursing role that takes moral courage as well as clinical skill and knowledge. In order to ensure patient advocacy within a vulnerable population, the nurse advocate must first identify what vulnerable population the patient belongs to. Once the vulnerable population is identified, barriers to care that the patient may experience can be challenged and overcome with the use the four stages of advocacy,

Conclusion

A Nurse who identifies a patient within a vulnerable population has an obligation to advocate and defend a patient’s rights and interests and ensure the patient’s safety within a healthcare system. This includes patients who are at risk mothers and infants, the mentally ill, those who are homeless, substance and alcohol abusers, immigrants, the illiterate, and many others who are fearful of healthcare professionals. Nurse advocates must follow the patient’s directives, not their own or the family’s. As an advocate who follows the 4 stages of advocacy, the nurse will ultimately ensure that a patient’s autonomy and self-determination are respected.

Case Study Response

Mr. Simpson has many identifiable factors that place him within a vulnerable population of chronic illness and possible homelessness. They are as follows:

  • He lost his job and health insurance
  • He is a diabetic and has not had any medications for one month
  • He is a cancer survivor with new complaints of severe headaches
  • He has exhausted all financial resources and cannot pay rent

Using the four stages of advocacy, the nurse would first conduct a needs assessment by listening to the requests of Mr. Simpson. The nurse would then develop a plan to attain his goals, such as identifying who the members of Mr. Simpson‚Äôs healthcare team are, and instituting communication amongst his health care providers to better utilize resources for care.  The nurse advocate would then initiate the plan developed, such as contacting social services to assist Mr. Simpson in gaining housing, and by attempting to schedule an earlier appointment with another medical provider who may be available to treat Mr. Simpson. Last, the nurse would evaluate the outcome of his or her advocacy behaviors. Through advocacy, the nurse should be able to better assist Mr. Simpson and ensure that he receives the appropriate care needed.

References
  1. American Nurses Association. (2019). What is Nursing & What do nurses do? Retrieved from https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/
  2. CDC National Center for Health Statistics. (2016, May 30). Suicide and Self-Inflicted injury. Retrieved from https://www.cdc.gov/nchs/fastats/suicide.htm
  3. Chesnay, M. D., & Anderson, B. A. (2015). Caring for the vulnerable. Burlington, MA: Jones & Bartlett Publishers.
  4. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. (2019, March 1). About Teen Pregnancy. Retrieved from https://www.cdc.gov/teenpregnancy/about/index.htm
  5. Institute on Disability. University of New Hampshire. (2019). 2018 Annual report on people with disabilities in America. Retrieved from https://disabilitycompendium.org/sites/default/files/user-uploads/Annual_Report_2018_Accessible_AdobeReaderFriendly.pdf
  6. Lois, G. (2018). Understanding the nurse’s role as a patient advocate. Nursing, 48(4), 55-58. doi: 10.1097/01.nurse.0000552710.96243.3810.1097/01.NURSE.0000531007.02224.65
  7. Lois, G.Retrieved from https://journals.lww.com/nursing/Pages/ArticleViewer.aspx?year=2018&issue=04000&article=00015&type=Fulltext
  8. Martin JA, Hamilton BE, Osterman MJK. Births in the United States, 2017. NCHS d data brief. 2018 (318):1-8
  9. National Alliance on Mental Illness. (2019). Mental health by the numbers. Retrieved from https://www.nami.org/Learn-More/Mental-Health-By-the-Numbers
  10. National Coalition Against Domestic Violence. (2019). National statistics. Retrieved from https://www.ncadv.org/statistics
  11. Scott, P. A. (2017). Key Concepts and Issues in Nursing Ethics. Basingstoke, England: Springer.
  12. Thomas, S. (2019, October 17). Addiction Statistics | Drug & Substance Abuse Statistics. Retrieved from https://americanaddictioncenters.org/rehab-guide/addiction-statistics
  13. The U.S. Department of Housing and Urban Development OFFICE OF COMMUNITY PLANNING AND DEVELOPMENT. (2018, December). The 2018 Annual homeless assessment Report (AHAR) to congress. Retrieved from https://files.hudexchange.info/resources/documents/2018-AHAR-Part-1.pdf
  14. US Department of Labor. (2019, May 16). Bureau of labor statistics. Retrieved from https://www.bls.gov/news.release/pdf/forbrn.pdf
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