Vulnerable Population PPT

What are vulnerable populations?

groups of patients more likely to develop health problems as a result of excess health risks, who are limited in access to health care services, or who depend on others for care

Vulnerable Populations

Some clients are:

• More likely to develop health problems as a result of exposure to have worse outcomes from those health problems than the population as a whole

• More sensitive to risk factors because they are often exposed to cumulative risk factors

• More likely to suffer from health disparities (wide variations in health services and health status)

• Vulnerability results from the combined effects of limited physical, environmental, personal, and biopsychosocial resources

What is resilience?

the ability to resist the effects of vulnerability. It is important to learn what factors make some people more resilient than others

Who are Vulnerable?

• Poor and homeless

• Some pregnant women

• High risk children

• Migrant workers, immigrants, & refugees

• Severely mentally ill individuals (e.g. schizophrenia)

• Elderly

• Veterans

• Transgendered persons

• Persons with substance use disorders

• Abused individuals and victims of violence

• Persons w/ communicable diseases and those at risk *homeless individuals at increased risk of diseases such as Tuberculosis

• Persons with HIV+/Hep B and C/STDs

• Victims of Sex Trafficking

• People with chronic illnesses

More

• Certain population groups as listed here are more vulnerable to the effects of risk factors than the population as a whole.  Note: pregnancy alone does not make a person vulnerable, but high-risk mothers (e.g. drug addicts, adolescent, women in abusive relationships who are pregnant are vulnerable).

• These individuals are more likely to suffer from health disparities – wide variations in access to and quality of health services and health status.

• Typically these individuals are underserved and disadvantaged, as they have fewer resources for promoting health and treating illness than does the average person.

What contributes to health disparities?

• Environmental hazards

• Social hazards

• Poverty

• Personal behavior

• Multiple health conditions

• Cumulative Risk factors

Health Disparities

• POVERTY is considered to be perhaps the PRIMARY cause of vulnerability, because it interacts with and sometimes causes so many of the other risk factors (e.g. stress, exposure to environmental risks, domestic violence, substance abuse, etc.)

• It is particularly fitting when we talk about vulnerable populations since these individuals typically have multiple cumulative risks (higher probability of illness) and as such they are particularly sensitive to the effects of those risks.

• Their risks may be from:

  • environmental hazards (e.g. peeling lead paint, mold)

  • social hazards (e.g. crime, violence, low literacy)

  • personal behavior (e.g. diet,  little exercise, smoking)

  • biological or genetic makeup (e.g. congenital addiction, compromised immune system).

• Cumulative risk factors work together, affecting each other and affecting the individual

Effects of Poverty

• Chronic illness - environmental and biological factors contribute (worse housing, more pollution, more marketing of dangerous products like tobacco to lower SES groups) (health problems are more complex due to multiple chronic illnesses)

• More complex health problems

• Infant morbidity and mortality

• Life expectancy

Hospitalization rates three times more than for persons not living in poverty.

Socioeconomic Gradient

• Higher income = lower morbidity and mortality

• The worse off financially a person is, the more likely he/she is to suffer poor health outcomes and early death

• Persons disproportionately affected by poverty are more likely to suffer:

  • diabetes morbidity and mortality

  • cancer mortality

  • suicide

  • respiratory diseases

  • M.I.

• Also applies to behaviors linked to health. Those who are disproportionately affected by poverty are:

  • more likely to smoke

  • less likely to breastfeed

What is the most important factor related to poor quality of care?

Lack of health insurance is the MOST significant factor related to poor quality of care!

Differences in Access to Care for Many Minorities

• Inadequate or no health insurance

• Problems getting healthcare

• Lower quality of care

• Fewer choices in where to go for care, clinics and hospials already overburdended

• Lack of a regular health care provider

• Fewer numbers of health care providers in minority neighborhoods, leading to difficulty in establishing a medical home

• Transportation issues often limit choices in where to go for care

• Residential segregation (technically illegal, but practically exists in almost every community).  Areas with higher concentrations of people of color are often subjected to increased marketing of alcohol and tobacco, decreased access to clinics and pharmacies.

• When care is available, it is often in publicly-funded clinics, who are at the mercy of fluctuation in levels of governmental funding and periodic budget cuts

Differences in Quality of Care for Many Minorities

• Patient safety

• Timeliness and effectiveness of care

• Patient centeredness

• Communication issues

Bias/Stereotyping

Stereotyping often leads to biased clinical decision making. Stereotyping refers to the process by which people use social categories (e.g., gender or race/ethnicity) in acquiring, processing, and recalling information about others. Both implicit and explicit negative attitudes and stereotypes of healthcare providers significantly shape interactions with patients, influence how information is recalled, and guide expectations and inferences in systematic ways. Stereotyping often occurs subconsciously, unlike prejudice or discrimination

Prejudice

unjustified negative attitudes based on a person’s group membership, is another source of biased clinical decision making

Discrimination

to the actual mistreatment of individuals based on race, gender, ethnicity, etc

Language Issues

misunderstandings that occur due to language barriers may lead the client to feel that he/she was the victim of discrimination

Cultural Issues

care providers may feel uncomfortable providing care to racial or ethnic groups with whom they are unfamiliar (this is why working for greater cultural competence is important!), and patients who are of a different racial or ethnic group may not trust information or advice given to them by provider(s) of different ethnic groups, especially if they have experienced overt discrimination or racism by members of that group in the past.

What are the effects of health disparities?

• Poorer health outcomes: Some populations are more likely than others to suffer negative outcomes from health problems.

• Cycle of vulnerability:

  • Chronic stress

  • Sense of powerlessness

  • Sense of social isolation

  • Without effective intervention, predisposing factors lead to poor health outcomes, which in turn worsen the predisposing factors

  • This leads to a cycle of vulnerability that is difficult to break out of without assistance.

  • Vulnerability leads to the presence of chronic stress, adding yet another burden with which these groups must cope.

  • The chronic nature of these problems often leads to feelings of hopelessness.

  • Hopelessness results from an overwhelming sense of powerlessness and social isolation.

    This is why it is very difficult for families facing severe vulnerability to simply “snap out of it,” “just work harder,” or “pull themselves up by their bootstraps!”  Most of us cannot even imagine the obstacles these families are facing.

Assessment Issues for Clients at Increased Risk for Poor Health Outcomes

• Socioeconomic resources

• Preventive health needs

• Congenital & genetic predisposition to illness

• Level of stress

• Environmental hazards

Assessment issues:  Which factors are problematic for  individuals, families, and/or groups at higher risk of poor health outcomes?

Since clients at high risk often experience multiple stressors, assessment must balance the need to be comprehensive while focusing only on information that the nurse needs and that the client is willing to provide.

1.  When possible, assessment includes evaluation of clients’ preventive health needs, including age-appropriate screening tests such as BP, serum cholesterol, mammograms, prostate examinations, recommended immunizations, and glaucoma screening.

2.  Assess for congenital and genetic predisposition to illness and either provide education and counseling as appropriate or be referred to other health professionals as necessary.

3. The level of stress the person or family is having should be assessed. Does the family have healthy coping skills?

4.  Assess the living environment & neighborhood surroundings for environmental hazards such as lead-based paint, asbestos, water and air quality, industrial wastes, and the incidence of crime.

Interventions for Medically Underserved Clients

• FIRST, clarify your own views/values/beliefs about clients who are medically underserved

• Trend toward “one-stop shopping” services

• You need to do more than “telling” the client what they need to do

• Wrap-around services:  health services accompanied by social and economic services  either directly or through referrals (such as subsidized transportation, Meals on Wheels, or childcare) and more . . .

• Don’t just “tell” people what they need to do – help them figure out what would support them in actually doing it!

Intervention Notes

• Your own views, values, and beliefs about medically underserved clients will significantly impact the type and quality of care you provide.  It’s important for all of us to be honest with ourselves and identify any bias, stereotypes, etc. so that we can work to address them and minimize their impact on the care we provide.  This is the VERY FIRST STEP we should take when thinking about working with medically underserved populations (e.g. the homeless, transgendered individuals, people experiencing abuse), and you can start now!  This will impact every aspect of the care you provide to those in vulnerable populations.

• ”One-stop” services:  because it is often difficult for medically underserved populations to access care, forward-thinking sites that provide care to medically underserved citizens will try to provide as many relevant services in the same facility on the same visit, since it may be a while until the patient seeks care again (due to transportation issues, difficulty getting time off of work, child care issues, frustration with “the system”, etc.)

• Some facilities even partner with other community agencies to provide services which make it easier for clients to obtain health care (e.g. transportation vouchers to help clients to get to the clinic)

• Referrals:  the nurse should have a referral list handy for needed services not provided by his/her facility (e.g. homeless shelters, food and clothing banks, “Meals on Wheels”,low-cost counseling services, drug/alcohol treatment, domestic violence shelters, etc.), but should also remember that it may be very difficult for clients to attend multiple appointments at multiple referral agencies (thus the importance of “one stop shopping” services whenever possible.

• Remember, simply “telling” someone what they need to do (Stop smoking!  Lose weight! Practice safe sex!  Get a job! Etc.) is not going to be helpful if the client does not have the understanding of why it’s important, the resources to actually move toward making the change, etc.  Does a client understand what “safe sex” is?  Do they understand why it’s important?  Do they have access to condoms?  Do they know how to use them properly?

Interventions with Groups Experiencing Disadvantage

• Referrals – nurse must be sure to know criteria in order to refer clients appropriately (know what’s available in your community!)

• Try to provide as many services as possible in one place and only refer out when absolutely necessary!

• Healthy People 2030 has many goals aimed at vulnerable populations and addressing the social determinants of health

• Goal of care - break the cycle of vulnerability

Caring for Victims of Human Trafficking

• The most important thing to do is separate the suspected victim from the companion

• Never ask directly (in front of another person) is a patient is a trafficking victim

• Assessment:

  • Observe for signs of trauma including emotional symptoms and physical signs

  • Questions to use to screen suspected victims

Human Trafficking Notes

• The most important thing to do is separate the suspected victim from the companion, because typically victims won’t speak openly in a companion’s presence.

  Common assessment findings include:  bruising, scars, lacerations, often on the low back; genital mutilation or scarring, reproductive tract fistulas, vaginal or anal trauma, pelvic inflammatory disease, poorly healed fractures, TB.  Psychosocial symptoms would include: an exaggerated startle response, panic or anxiety, flat affect, withdrawal or refusal to engage in conversation. 

• Questions to use to screen suspected victims include:  Where do you sleep?  Do you get enough to eat?  Have you been physically harmed or threatened?  Has your family been threated?  Are you free to talk to anyone you wish, including people outside your home or job?  Can you come and go as you please?  Are you ever forced to perform sex acts or to work?  Do you keep the money you earn?  Do you keep your own identification papers?  Where are you from?  Do you know where you are right now? 

• Establishing trust is extremely important.  Many times victims will resist help.  Social Services or case management need to be notified if the nurse has suspicions about human trafficking.