Vulnerable Populations



Vulnerable Populations


Marilyn Grace O’rourke, DNP, APHN-BC



OBJECTIVES


At the completion of this chapter, the reader will be able to:


• Define the concepts of vulnerability, risk, cumulative risk, relative risk, social determinants of health, social equity, and health disparities.


• Discuss individual and societal factors that contribute to vulnerability.


• Discuss the roles of Healthy People 2010 and Healthy People 2020 in reducing health disparities.


• Recognize current critical issues contributing to vulnerability.


• Describe nursing strategies at the individual, family, group, and societal levels to reduce health disparities in vulnerable populations.



PROFILE IN PRACTICE: VULNERABLE ADOLESCENTS



I am a family nurse practitioner in a school-based health center located in an inner-city high school. I have worked in this health center for 14 years. What I have learned is that I cannot begin to know what some of the young people’s lives are like, and so I listen to them. Gang recruitment, drug dealing (going on right outside the school windows), mothers and fathers in prison, and mothers and fathers on drugs are often part of their experience. In some cases the students “don’t know, don’t care” where their parents are. In this setting, physical health is not the only type of health I deal with. Sometimes the problems are about emotional and mental health. Thus I have learned that it is important to ask questions and let the young person tell his or her story. Poverty, depression, and disappointment are bound to affect a young person’s ability to learn and are often underlying factors for the headaches and stomach aches that bring the adolescents into the health center. I am waiting there—someone who is willing to listen and who wants to listen.


Sometimes the stories are painful for me to hear. Once I asked a young man, as gently as I could, why he had body odor and why his clothes smelled. Without asking, I could have just assumed that he had poor hygiene and was too lazy to care for himself or his clothes. Because I asked, I heard his story. He proceeded to tell me about the financial problems facing his mother and siblings. Their utilities had been disconnected because his mother was unable to pay the bills. He asked me not to tell anyone his situation. He did not want anyone to know. He said he had a plan. He would get a summer job and pay the bills and have all the utilities reconnected. In the fall when school started, he returned to the health center to tell me he had done exactly what he said he would. I smiled but thought to myself, “Why should a 16-year-old have to bear this burden? Why should his summer be spent working to pay the water and gas bills?”


One question that I frequently ask is, “Have you ever had sex?” Later in the conversation I will ask, “Have you ever been raped?” Too often the answer is yes. Recently, a 16-year-old girl reported going to spend the night with her aunt and female cousin. At some point during the night, her cousin’s drunken boyfriend came into her room and raped her. She did not tell anyone about the rape except her 14-year-old sister. But she did not want to tell her mother—especially not her mother. She wanted to protect her mother from this stress because she and her mother were facing eviction at the end of the week, and her mother did not know where the family was going to live.


“Ms. Wardlaw, come and see what we want. You know you got to take care of your girls,” said one young lady who came into the health center, interrupting my paperwork. She wanted me to come and address the pressing concerns of the group in the waiting area. I smiled because I wanted her to feel that I was here for her and her friends. I want to help them graduate and go on to live healthy and successful lives.




PROFILE IN PRACTICE: HOMELESS MEN



I work as a family nurse practitioner in a small urban shelter for homeless men. When I was considering taking the position, my introduction consisted of a morning spent observing the nurse practitioner who was covering the shelter on a somewhat irregular basis. The shelter’s health program had been founded several years before, but the nurse who created it had retired out of state, and the program had been dormant for lack of funding to hire a replacement. Now they were ready for a new nurse. Was I the right person for the job? My nursing background was in home care. I enjoyed the opportunity to work with a patient one on one, on his or her own turf, really individualizing the care. After becoming a family nurse practitioner, I had most recently worked in a small geriatric clinic serving a mostly poor, minority population. If nothing else, I was used to figuring out what was “doable,” knowing that although economic considerations should not be a deciding factor, all too often they do limit the options.


So I was used to working largely independently, individualizing care to a patient’s situation, finding cost-effective, practical solutions, and especially advocating for the patients to ensure their needs were met. I found all these experiences had prepared me pretty well for working in the field of homeless health care. As I watched, I thought, “Yes, I can do this. I want to do this.” I saw that there was much that could be done despite limited resources. I consider it an extra blessing to have a job where I really feel like I can make a difference. Still, I had a lot to learn, and I am still learning.


For each new client, I perform a basic assessment of health needs and develop an initial plan to help meet those needs. I know that I may have the opportunity to work with a homeless person over a period of time during his stay at the shelter. Or I may get only this one chance, depending on how long he is able or willing to remain. Since time and resources are both limited, it is necessary to focus on the client’s immediate priorities. Sometimes I cannot do everything I would like to do. But for someone who has completely lost contact with the health care system, even little things such as over-the-counter cold medication and simple foot care mean a lot.


I would characterize my experience thus far in terms of satisfactions and frustrations. For example, it is very satisfying to care for a client with an aching, abscessed tooth and be able to prescribe the pain medication and penicillin that will result in grateful relief. It is not so satisfying to realize that, despite having dealt with his immediate problem, I cannot offer him the long-term solution (he needs to see a dentist!) because the only clinic I know that treats homeless, uninsured people is so heavily overbooked that it is not taking new patients for at least 2 to 3 months. Where will he be then?


I remember John, who came to me with uncontrolled diabetes. He had not had any medication in weeks. His blood sugar was quite elevated, but he felt “okay.” I tried oral medications first, not expecting him to be able to manage insulin in his current circumstances, though he reluctantly admitted he had been on it before. His blood glucose did not budge, so eventually, after consulting with my collaborating physician, I put him on insulin anyway. After several weeks his diabetes was finally under somewhat better control. Then he left the shelter one weekend and did not return. His insulin is still in my refrigerator. In a few days or weeks, he will be right back where he started.


Of course, I also have many clients who are success stories. They leave with medication they did not have before, better control of and understanding of their health issues, and resources to continue obtaining primary care after they are no longer under my care. Finding and cultivating relationships with other resources in the community are essential parts of my practice. Ours is an emergency shelter. The intent is to help the men move on to something more permanent. I do what I can, knowing that sometimes the best I can do is to help these men who have fallen between the cracks of the health care system get plugged back into the system.


To be homeless is to be in survival mode. Finding somewhere to fill a prescription for free, and likely waiting a very long time for it, falls somewhere way behind having a meal and a place to sleep that night. Part of helping these men get their lives on track is showing them that they do not have to just survive day to day—that they can begin to make plans again and can be part of a society in which all too often they have become invisible. The shelter prides itself on respecting the dignity of each individual. We care about them, so they can again begin caring about themselves.




imageKey Concepts


DEFINITION OF VULNERABILITY


Why should nurses study the concept of vulnerability and the needs of vulnerable populations? Shi and Stevens (2005) give the following five reasons:




VULNERABILITY


What is meant by vulnerability, and what are vulnerable populations? To be vulnerable means to be susceptible to wounding or injury. Certainly, the infant and elderly woman in the waiting room fit this definition by virtue of their ages. But what about the others? What makes them vulnerable? Flaskerud and Winslow (1998) say that vulnerable populations are groups of people who have limited resources and are at increased risk for developing poor health. They list the poor, persons subject to discrimination or intolerance, those who are politically marginalized, women and children, ethnic people of color, immigrants, gays and lesbians, the homeless, and the elderly as vulnerable groups. Aday (2001) indicates that high-risk mothers and infants, the chronically ill and disabled, persons living with HIV/AIDS, the mentally ill and disabled, alcohol and substance abusers, the suicide and homicide prone, abusing families, homeless persons, racial and ethnic minorities, and immigrants and refugees fit into such groups. She divides these groups into three categories on the basis of where their principal needs lie: physical needs, psychological needs, or social needs. For example, Aday places homeless persons in the category of primarily having social needs, such as housing and employment. Depending on the circumstances involved, an individual could fit into multiple categories. For example, consider a person with a chronic illness who loses his employment because of absenteeism, begins drinking excessively, and becomes abusive toward his spouse; this person would fit into all three categories. Most literature says that anyone who is of low socioeconomic status (SES) as measured by education, occupation, and income is vulnerable to poorer health.


Aday gives the following reasons for placing the individuals she selected into vulnerable groups (2001):



Given these criteria, additional groups might be considered vulnerable: veterans returning from combat duty, victims of natural disasters, prisoners, migrant workers, pregnant teenagers, and the uninsured or underinsured. See Box 19-1 for a list of potential vulnerable groups of people.



BOX 19-1   Potentially Vulnerable Groups of People





RISK, CUMULATIVE RISK, AND RELATIVE RISK


To understand the challenges faced by vulnerable populations, an understanding of the concept of risk is helpful. Risk refers to the probability that some event or outcome will occur within a given time frame. Individuals vary as to how much they are at risk for a given health problem. Some risks reside within the individual, such as gender and state of wellness, whereas other risks exist in the environment, such as violence and pollutants. Women with a family history of breast cancer and polycystic breast disease are at higher risk for getting breast cancer. Multiple factors in a woman’s life may affect whether she gets breast cancer, such as her age at menarche, her age at her first pregnancy, and her history of using hormones.


Vulnerable populations are at increased risk for disease because of the interplay of the risk factors they face. If the woman described above has not received education regarding early detection, is homeless, and is uninsured with no regular source of health care, her risk for advanced breast cancer increases. Vulnerable populations are especially prone to these cumulative risks. Shi and Stevens (2005) describe these additional risks as not just adding to the probability of disease but multiplying the probability of becoming ill. As Rogers (1997) states, those who have a combination of high-risk factors are the most vulnerable.


Healthy People 2020 graphically depicts how these internal and external factors interplay to determine the health of individuals (Figure 19-1). For example, discriminatory policies, substandard health care, lack of access to health care, environmental pollution, unsafe occupations, poverty, lack of social support, lack of education, unhealthy behaviors, and other factors can all be accommodated by the model.


image
FIGURE 19-1 Action model to achieve Healthy People 2020 overarching goals. (From U.S. Department of Health and Human Services. [2008b]. Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Developing Healthy People 2020: Phase I report: Recommendations for the framework and format of Healthy People 2020 [p. 22]. [Online]. Retrieved from www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf.)

Relative risk is a ratio used in epidemiology to compare the risk for poor health among groups exposed to a risk factor versus those who are not exposed. Some will get the disease, and others will be more resilient and remain healthy. Members of vulnerable groups have been shown to have higher rates of disease than others and to have worse health outcomes. Perhaps their nutrition is not as good, or they are sleep deprived from working two jobs, or they have significant depression and fail to seek medical care. As a result, they are exposed to more risks and are likely to suffer more from a given risk than the general public. Flaskerud and Winslow (1998) say that a lack of resources increases relative risk, reduces the ability to avoid risks, and reduces the capacity to minimize any disease that may result.



SOCIAL DETERMINANTS OF HEALTH


Some may ask, “Why do these individuals not protect themselves better and make better choices?” Some studies on vulnerability examine personal factors that contribute to vulnerability (Lessick, Woodring, Naber, & Halstead, 1992; Rogers, 1997), but there are also very influential social factors involved. These are called the social determinants of health. They are defined as “the circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” (World Health Organization, 2010).


Social determinants of health can be divided into three main categories:



Geiger (2006) also lists income levels, rates of employment, educational opportunities, workplace safety, safe water, nutritious food, clean air, good sanitation, and uncontaminated soil as important factors. See Box 19-2 for some examples of social determinants of health.



BOX 19-2   Examples of Social Determinants of Health



Related posts:

  1. Diversity in Health and Illness
  2. Ethical Dimensions of Nursing and Health Care
  3. Historical Development of Professional Nursing in the United States
  4. Socialization to Professional Nursing

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Oct 26, 2016 | Posted by in NURSING | Comments Off on Vulnerable Populations

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