1.                   Introduction

There have been numerous studies performed on different populations focusing on criteria of vulnerability and interventions to generate change in the susceptibleness of said populations. This paper explores research results from online articles regarding vulnerable populations, why a population is considered vulnerable, how culture and environment influences the population, and what health disparities exist in the vulnerable population. This paper will examine resources, risks, and health status of the vulnerable population according to the Vulnerable Population Conceptual Model. Also, discussion will include the DNP role and implications related to prevention and improvement of health-related issues applying the DNP Essentials.

2.                   Identification of Vulnerable Population

Merriam-Webster [1], defines population as a group of individuals having common characteristics or qualities (p. 1). Vulnerability is defined as a “general concept meaning susceptibility” [2]. Combination of these definitions lends to the definition of vulnerable population as that of individuals within a certain population who have similar characteristics that suggests the members of the population are at an increased risk for decreased health status physically, mentally, or emotionally [2]. Many factors increase the risk of populations, including age, race, gender, ethnicity, culture, demographics, education, socioeconomic status, and access to healthcare [2].

The vulnerable population this DNP student wishes to discuss is women substance abusers. According to the National Institutes of Health [3], 19.5 million females aged 18 and older have used illicit drugs in the past year. Illicit drugs, in this context, refers to use of any illegal drug (including marijuana) and misuse of prescription drugs [3]. Information provided by the National Institute on Drug Abuse, a sub-committee of the NIH [4], has shown that substance abuse among women can be related to the hormonal issues that challenge women throughout their life span. Women also give unique reasons for substance use including weight control, fighting fatigue, pain control, and self-medication for mental health issues [4]. Substance use among women is different than in men for many reasons. Women can and do become addicted even though they may use smaller amounts of a drug for a shorter time [4]. Women tend to respond with more cravings and may have increased relapse after treatment [4]. Other factors may also increase substance abuse in women including domestic abuse, divorce, loss of child custody to the other parent or to child protective services, or death of a partner or child [4]. These facts make women who use/abuse substances, both legal and illegal, a vulnerable population.

3.                   Cultural and Environmental Influences

Culture is defined as “Beliefs, social forms and materials of a racial, religious, or social group” and “shared attitudes, values, goals, and practices that characterize an institution” [5]. These values and beliefs guide a population’s behavior and influence, often without their awareness. Culture is central to a population’s approach to and behavior regarding the use/abuse of substances [6]. According to Abbott & Chase [6], the publication of DSM-IV provides a cultural formulation outline including cultural variations of recognized DSM disorders, culture-bound syndromes glossary, and culturally relevant case formation based on 5 major areas. Many things should be included when considering a population’s cultural identity including “Reference groups, involvement with culture of origin, language, and cultural factors of development” and “whether the person speaks his native language and what his first language was” [6]. For many years, women were considered inferior to men. Their roles consisted of household chores and child-rearing, and required women to be obedient wives [7]. With changes in society, women have become more active outside the home; however, culture is passed down from generation to generation. Some women may feel it necessary to continue to perform their duties in the home, along with having an outside job and various social responsibilities. The increase in duties can cause emotional turmoil for some women and this turmoil, in turn, can start the downward spiral of substance use/abuse. Ethnicity and race is also a factor in substance abuse [8]. In 2013, reports show that American Indians and Alaska natives held the highest rate of substance abuse with native Hawaiians and other Pacific Islanders running a close second. Caucasians and Hispanics ranked at similar rates with African Americans just behind them. Asians appeared to struggle the least with substance abuse; however, rates were still almost 5% in this group [8].

Environment, defined by Merriam-Webster [9], as “Circumstances, objects, or conditions by which one is surrounded” can also play a part in substance abuse (p. 1). Environment can be described in four domains: family domain, peer domain, work or school domain, and community domain [10]. The home life of a woman, regarding the social and circumstantial characteristics in lieu of genetics, has a large influence on whether or not the individual develops a substance abuse problem. Women socializing with friends and peers who are involved in substance abuse is a highly significant factor in the development of a substance abuse in women. Work may not play as significant role in substance abuse; however, there are some industries in which substance use/abuse is more common due to the lack of drug screens. School, on the other hand, can play a much greater role because the environment tends to be more social and demographics may be more concentrate. For both domains, work and school, stress is a key factor in substance abuse. The final environmental domain is community. Community involvement can increase the risk of or discourage substance abuse; however, very few communities remain untouched by substance abuse [10].

4.                   Health Disparities

The NIH mandated, in 1994, that women and ethnic minorities be included in research and the analysis of data collection for those groups [11]. This alone may still not be enough to adequately inform the public on drug abuse in women and minorities. To conduct good research on substance, abuse and to eliminate health disparities in this population, adequate measurement is crucial [11]. Addictions are sets of common, yet complex, diseases that are often chronic in nature with a relapsing course characterized by a compulsive and uncontrolled use of a drug that results in maladaptive or destructive outcomes [12]. Addiction changes the brain and replaces normal needs and desires with compulsive behaviors, thus making addiction a mental illness [3]. Substance abuse may attribute to the development of other mental illnesses by making the individual more susceptible [3]. Women who abuse substances experience more effects of physical exertion on their heart and blood vessels than men and the changes in the brain are different than those of men who abuse substances. Women who abuse substances are more likely to experience depression, anxiety, and panic attacks [4].

Substance use in pregnant women can cause short and long-term harm to the woman and her unborn child [4]. This can include miscarriage, stillbirth, migraines, seizures, and hypertension. The newborn can also experience withdrawal symptoms if the mother uses regularly during her pregnancy [4]. According to the Substance Abuse and Mental Health Services Administration [13], other comorbidities that may occur in women who abuse substances are HIV, AIDS, and viral hepatitis. Substance abuse can lead to unsafe sexual behaviors which can result in HIV, AIDS, syphilis, and Hepatitis B [13]. Hepatitis C is common among intravenous drug users and women who use IV drugs are no exception. In 2016, Louisiana ranked 1^st in the nation for primary and secondary syphilis, 3^rd in the nation for HIV, and 9^th in the nation for cases of AIDS [14]. Women have a higher risk than men of comorbidities, both mental and physical [15]. A recent study showed women are more likely than men to experience a mood disorder, a paranoid disorder, an eating disorder, major depression, and an antisocial personality disorder. Other physical disorders experienced by women abusing substances include gynecological infections, amenorrhea, hypertension, and pneumonia [15].

5.                   Resources, Risks, and Health Status

The Vulnerable Population Conceptual Model hypothesizes the interrelationship between resource, risk, and health status [16]. In analyzing this model, resource availability refers to income, jobs, health care access, education, and housing; relative risk refers to likelihood of the exposure to risk factors; and health status alludes morbidity and/or mortality [16]. There are some factors that seem to be strongly related to the inception of substance use in women more so than progression to abuse including the personality trait of risk-taking, obsession, anxiety, depression, and behavior control issues such as temper tantrums [15]. Other risk factors for substance abuse in women include being single, divorced or widowed; sexual or physical abuse or domestic violence as a child or as an adult; history of having adult responsibilities as a child; unemployment or low income; low educational level; having a partner who abuses drugs or alcohol; and sexual orientation with lesbians and bisexual females having a higher rate of substance abuse than heterosexual females [15].

Individuals with behavioral health problems, such as substance abuse, are at a greater risk for acquisition of comorbidities due to difficulty accessing health care and may also have difficulty with treatment compliance [17]. Substance use also predisposes a woman to suicide [15]. Reasons for addiction to substances can be contributed to an individual having a greater number of risk factors [18]. Two other factors that greatly increase the risk for addiction are genealogy/heredity and developmental stage [18]. Heredity accounts for almost half of an individual’s risk for addiction; in addition, the younger an individual initiates drug use, the more likely addiction will occur [18].

6.                   Clinical Prevention and Improved Outcomes

Substance abuse can be treated and successfully managed. Integration of primary care with behavioral health has shown to improve physical and behavioral health outcomes and reduce the comprehensive cost of health care for this population [17]. Furthermore, substance abuse is preventable [18]. APRNs should be knowledgeable and be able to identify women who have increased risk factors in order to prevent and treat substance abuse. The DNP prepared nurse should perform actions to promote positive changes in the health status of women substance abusers. The DNP prepared nurse can offer care based on evidence-based research to improve health outcomes and ensure patient safety in this vulnerable population.

Substance abuse treatment for women differs than that for men. Women usually report a shorter use time before entering treatment, but substance use is inclined to progress more quickly into addiction in women [4]. Withdrawal can be very intense for women and some treatments simply do not work as well for women as for men [4]. Women may be scared to seek treatment during pregnancy due to possible legal repercussions and may delay seeking treatment after they have children for lack of support with children, home care, work, and other responsibilities [4]. This fear can be even greater in single mothers who feel they must put the needs of their children before their own needs. Treatment programs should take this into consideration “and offer child care, job training, and parenting classes” [4].

7.                   Summary

This paper has explored the population of women substance abusers in need. Research proves that this population is vulnerable, shows how culture and environment influence the population, and discusses the health disparities that exist in this vulnerable population of women. The Vulnerable Population Conceptual Model was used to show resources, risks, and health status of the vulnerable population. Prevention and improvement of health-related issues were shown by applying the DNP Essentials I and II to the needs of this population. Substance abuse in women can be treated and prevented with focus from the DNP nurse. Bias and prejudice should be dismissed prior to providing care to this population. And it is compulsory for DNP nurses to be aware of all resources available to provide holistic care to vulnerable women.

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3.       National Institute on Health (2018) Comorbidity: Substance use disorders and other mental illnesses 2018.

4.       National Institute on Health (2018) Substance use in women: Sex and gender differences in substance use 2018.

5.       Merriam-Webster (2018) Culture 2018.

6.       Abbott P, Chase DM (2008) Culture and substance abuse: Impact of culture affects approach to treatment. Psychiatric Times 25: 43-46.

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10.    Skywood Recovery (2018) The role of environment in addiction and recovery.

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13.    Substance Abuse and Mental Health Services Administration (2018) Common comorbidities 2018.

14.    Louisiana Department of Health (2018) First quarter 2018 HIV/AIDS/Syphilis report 2018.

15.    Addiction Treatment Forum (2018) Drug addiction: It’s different-and riskier-for women 2018.

16.    Leight SB (2003) The application of a vulnerable populations conceptual model to rural health. Public Health Nursing 20: 440-448.

17.    Lewis V, Colla CH, Van Citters AD, Fisher ES (2014) Few ACOs pursue innovative models that integrate care for mental illness and substance abuse with primary care 2014.

18.    National Institute on Health (2018). Understanding drug use and addiction 2018.