vulnerable populations

Rural Public Health

science and practice of preventing disease, prolonging life, and promoting health and well-being in rural communities.

Rural public health seeks to protect the health of communities and works with rural healthcare systems to improve the overall quality of life for every individual.

Rural

• defined as communities with fewer than 10,000 residents and a county population density of less than 98 persons per square mile.

• According to the U.S. Department of Commerce’s Census Bureau (USCB) in 2022, the 60 million U.S. residents living in rural areas in 2020 made up 19.3  percent of the U.S. population. A typical rural county contains less than 10 percent of the population of a typical urban county.

• rural areas can be based on administrative, land use, or economic concepts, including a combination of these three themes. 

 frontier

used to describe sparsely populated rural places that are isolated from populated centers and services, with 6 or fewer people per square mile.

urban

describes densely developed areas that encompass residential, commercial, with communities having more than 99 persons per square mile.

The governmental agencies that use the statistical criteria to identify areas as “rural” are the:

• Office of Management and Budget (OMB)

• U.S. Department of Commerce’s Census Bureau(USCB)

• U.S. Department of Agriculture (USDA)

• USDA’s Economic Research Service (ERS)

• CDC ‘s Office of Rural Health (ORH)

Rural Demographics

• Higher portion of residents under age 18 years of age and over 65 years of age.

• Tend to have more residents who are married or widowed.

• May have fewer years of formal education than their urban counterparts.

• Rural families tend to be poorer than those in urban areas.

• The working poor in rural areas are at risk of being underinsured or uninsured.

Characteristics of Rural Life

• Small (often family) enterprises, fewer large industries.

• Economic orientation to land, nature( ex: agriculture, mining, lumbering, fishing, and marine related).

• More space; greater distances between residents and healthcare services.

• Cyclical or seasonal work, or leisure activities.

• Informal professional and social interactions.

• Access to extend kinship systems.

• Lack of anonymity.

• Challenges can occur in maintaining confidentiality stemming from familiarity among residents.

• More high-risk occupations.

• Town as the center of trade.

• Churches and schools as socialization centers.

• Preference for interacting with locals (insiders).

• Mistrust of newcomers to the community(outsiders).

Rural communities are slower to change traditional cultural values and are reluctant to adopt societal influences.

Core rural concepts:

• Work belief and health.

• Distance.

• Isolation.

• Hardiness.

• Self-reliance.

• Familiarity.

• Informal networks.

• Insider/outsider and old-timer/newcomer

Work belief and health

• Health is defined in terms of the ability to do work.

• Expectations of healthcare: treatment that will allow client to return to work as soon as possible.

• Orientation to healthcare:

Present-time

Crisis-oriented

Distance

• Is a barrier that might influence the likelihood of deferring healthcare until one is very ill.

• Recovery time and optimal rehabilitation are compromised by inadequate and untimely treatment of illness.

Isolation

• Relativeness is when isolation is dependent on something else, one must be isolated from something.

• Perception is consciousness or awareness. PEople may not perceive themselves to be isolated, because they may seek isolation in rural community.

Hardiness

• Capable of enduring fatigue, hardship, or exposure.

• Requiring great physical courage, vigor, or endurance.

• Elements determined through qualitative research studies: control, commitment, and challenge.

• These are a constellation of personality characteristics that function as a resistance resource during stressful life events.

Self-reliance

• Capacity to provide for one’s own needs.

• Makes decision independently.

• Is own source of emotional strength.

• Manages life tasks.

• Believes in self and capabilities.

• Is learned, starting as a child, continues into adulthood.

Familiarity

• In-depth interpersonal knowledge.

• Can be both positive and negative.

  • Positive - know a family and their history well and can give good care. Trust present.

  • Negative- Limited privacy in a rural community. May impede health seeking behaviors.

Informal Networks

• Natural interpersonal linkages.

• A series of channels through which people request support and make demands.

insider

• Member of a group

• Has access to privileged information

• An awareness of implicit assumptions and social context

• A long time resident

old timer 

• Age

• Length of time in a community

• Establishment of relationships within the community

outsider

• Differentness

• Unfamiliarity

• Unconnectedness

newcomer

• Newly arrived

• Unaware of history of area

• Existence/presence may result in change

Physical Environment & Occupational Health

• Less populated areas have limited employment opportunities.

• High-risk industries found primarily in rural areas: forestry, mining, fishing, agriculture.

  • Health risks include machinery and vehicular accidents, trauma, dermatitis, infectious disease, eye problems, cancer, respiratory disease stemming from repeated exposure to toxins, pesticides, and herbicides.

• Lack of Occupational Safety and Health Administration (OSHA) regulation for farming and ranching, because they are considered small enterprises; therefore safety standards are not enforced. There also is no worker’s compensation insurance for agriculture.

Rural Communities: Communication

• Internet service is not always available in some rural areas.

• There is great potential for connecting rural providers and residents with healthcare resources outside their community via:

  • Telehealth

  • Video conferencing

Health professional shortage areas (HPSAs):

geographic areas,  population groups, or medical facilities with shortages of healthcare professionals that may not allow  a full complement of healthcare services.

Medically underserved areas (MUAs)

areas that are determined through calculation of  a ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with incomes below the poverty level, and percentage of the population aged 65 or older.

Medically underserved populations (MUPs)

Those populations that face economic barriers (low-income or Medicaid-eligible populations) or cultural and /or linguistic access barriers to primary medical care services.

health Factors and Effects of Living in Rural Geopolitical Areas

• Only about 10% of physicians practice in rural America despite the fact that 19.3% of the population lives in these areas.

• There are 2,157 health professionals shortage areas(HPSAs) in rural and frontier areas of all states and the U.S. territories compared with 910 in urban areas.

• Rural residents are less likely to have employer-provided healthcare coverage or prescription drug coverage, and the rural poor are less likely to be covered by medicaid benefits than their urban counterparts.

• Rural residents are nearly twice more likely to die from unintentional injuries, other than motor vehicle accidents, than urban residents.

• Rural residents tend to be poorer. On average, per capita income is $7,417 lower than urban areas, and rural Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of children live in poverty.

Ranking of Rural Health Priorities based on Healthy People 2030 Goals

1. Access to quality healthcare.

2. Heart disease.

3. Diabetes.

4. Mental health disorders.

5. Oral health.

6. Tobacco use.

7. Substance use.

8. Education and community-based programming.

9. Maternal, infant, and child health.

10. Nutrition and obesity.

11. Cancer.

12. Public health infrastructure.

13. Immunization and infectious disease.

14. Injury and violence prevention.

When it comes to elder care in rural communities, seven factors compound prevention and health promotion efforts to identify and reduce modifiable risk:

1. Availability: Insufficient number and diversity of formal services and providers; lack of acceptable services and human service infrastructure.

2. Accessibility: Shortages, appropriate, and affordable transportation; cultural and geographic isolation.

3. Affordability: Poverty and inability to pay for services.

4. Awareness: Low levels of information of dissemination; literacy issues.

5. Adequacy: Lack of service standards and evaluation; evidenced-based practice compromised.

6. Acceptability: Reluctance to ask for help.

7. Assessment: Lack of basic information on what is needed using research rigor and analyses.

Nursing Practice in Rural Areas

• Nurses working in rural areas can use many community health nursing skills.

• One of the first and most important is that of prevention.

• Given the barriers to receiving healthcare in rural areas, the ideal situation is to prevent health disruptions whenever possible.

• Nurses must consider belief system and lifestyles of a rural population when assessing, planning, implementing, and evaluating community services.

• Case management and community health primary health care (COPHC) are two effective models to use to address some of those deficits and resolve rural disparities.

The steps of the COPHC are as follows:

1. Define and characterize the community.

2. Identify the community’s health problems.

3. Develop or modify health care services in response to the community’s identified needs.

4. Monitor and evaluate program process and client outcomes.

Characteristics of Nursing Practice in Rural Areas

• Variety and diversity in clinical experiences.

• Broader and expanding scope of practice.

• Generalist skills with specialty knowledge of crises assessment and management across disciplines and specialties.

• Flexibility and creativity in delivering care.

• Sparse resources; such as, materials, professionals, equipment, fiscal.

• Professional or personal isolation.

• Greater independence and autonomy.

• Role overlap with other disciplines.

• Slower pace.

• Lack of anonymity.

• Increased opportunity for informal interactions with clients and co-workers.

• Opportunity for client follow-up on discharge in informal community settings.

• Discharge planning allowing for integration of formal and informal resources.

• Care for clients across the lifespan.

• Exposure to clients with a full range of conditions and diagnoses.

• Status in the community (viewed as prestigious).

• Opportunity for community involvement and informal health education.

Need for Nursing Services in Rural Areas

• School nurses.

• Family planning services.

• Prenatal care.

• Care for individuals with AIDS and their families.

• Emergency care services.

• Children with special needs, including those who are physically and mentally challenged.

• Mental health services

• Services for older adults (especially frail older adults and those with Alzheimer’s Disease), such as adult daycare, hospice care, respite care, homemaker services, and meal deliveries to older adults who remain at home.

CDC’s Rural Public Health Strategic Plan

• In 2023, CDC established Office of Rural Health (ORH) to advance rural public health and lead the development of the CDC’s Rural Public Health Strategic Plan.

• The plan defines actionable steps CDC can take to collaborate the agency and with external and federal partners to improve and advance rural public health.

• The purpose: To improve the health of rural communities by advancing the best rural public health science and practices through a coordinated, transparent, and strategic approach.

The Vision of CDC’s Rural Public Health Strategic Plan

• Collaboration- Recognize and embrace the value of partnerships and relationships for addressing unique health challenges facing rural communities.

• Innovation- Advance and promote solutions and interventions to meet the evolving public health needs of rural communities and to reduce health disparities.

• Leadership-  Provide transparent, purposeful public health leadership in pursuit of improved health outcomes for rural communities.

• Scientific Curiosity- Continue to ask and answer questions that provide insight into and contribute to the improved health of rural communities.

• Empowered Decision making- Expand rural public health resources to help those entrusted with improving the health of rural communities.

Key priorities of CDC’s Rural Public Health Strategic Plan

• Advance results-based engagement with partners and communities to address rural public health challenges.

• Strengthen rural public health infrastructure and workforce.

• Advance rural public health science.

• Improves public health preparedness and response capacity.

migrant worker

person who migrates within a home country or outside it, to pursue work.

Migrant workers usually do not have an intention to stay permanently in the country or region in which they work.

Migrant workers who work outside their home country are also called foreign workers.

Characteristics of Migrant Workers

• The majority are foreign born and predominantly Mexican (75%).

• Average age is 33 years old.

• 79% are male.

• 75% earn less than $10,000 annually. 

• Many migrant workers send a portion of their earnings to family members in their country of origin.

• Average education is equivalent to 7th grade.

• Majority are married with an average of two children.

• 81% speak Spanish as their native language, with nearly half unable to speak or read English.

• Workers travel throughout the country seeking employment. The cyclical nature of agricultural work and the dependance on the weather and economic conditions results in considerable uncertainty.

Issues With Migrant Health

• Poor and unsanitary working and housing conditions make migrants farm workers susceptible to health problems no longer seen as dangers to the general population or seen at a lower rate.

• The agriculture industry is one of the most dangerous occupations in the U.S.. The workers not only heavy equipment and perform manual labor, they are exposed to other hazards, including pesticide exposure, heat and sun exposure, skin disorders, infectious diseases, lung problems, hearing and vision disorders, broken bones and strained muscles.

• Migrant workers have identified diabetes, poor dental health, obesity, and depression as major health problems.

• The Migrant Health Act signed in 1962, provides primary and supplemental health services to migrant workers and their families at 154 migrant health centers in 42 states.

• Migrant health centers serve more than 750,000 people in the U.S. It is estimated that the number served by these clinics represents only a small proportion of migrant workers.

• Some reasons for lack of care are poverty of the workers, their constant mobility, language barriers, and lack of transportation.

• Migrant workers and their families tend to use hospital emergency rooms and private physicians more often than the migrant health clinics.

Migrant workers who are lawfully in the U.S. may receive coverage under the?

• Affordable Care Act. Legal farmworkers whose income is 138% of the federal poverty line may receive Medicaid. Workers unauthorized can not receive health insurance.

• Migrant workers are a vulnerable and underserved population, with an average life expectancy of 49 years, compared to 77.2 years for most Americans. 

• TB rates tend to be six times higher for migrant workers and are at risk for contracting viral, bacterial, ad parasitic infections.

• Migrants disproportionately suffer from the effects of COVID 19 due to economic hardships brought on by the shutdowns and social distancing; contagion risk due to overcrowding, predisposed health issues, lack of access to health care, and uninsured status; and as targets for hate and discrimination.

The following factors limit adequate provision of health care services:

• Lack of knowledge about services - because of their isolations and lack of fluency in English, migrant farmworkers lack usual sources for information about available services.

• Inability to afford care- The medicaid program, is often not available to migrant farmworkers, especially if they are undocumented workers. The workers do not remain long enough in a geographic area to be considered for benefits or may lose benefits when they relocate to a state with different eligibility standards.

• Availability of services- many legal immigrants and undocumented immigrants are ineligible for services.

• Transportation- Health care services may be located far away from where they are working or their temporary home. Transportation can be unavailable, unreliable, or expensive.

• Hours of service- Many health services are available only during working hours, therefore seeking medical care leads to lost earnings.

• Mobility and Tracking- While migrant workers and their families move from job to job, their health records typically do not go with them. This leads to fragmented services in areas such as  chronic illness management and immunizations.

• Language barriers- Immigrant adults speak primarily the language of their native country, and they may not be able to read or writer English. It is important for the nurse to verify with client if they understand what is being asked or told.

• Discrimination- Although the migrant workers and their families bring revenue into the community, they are often perceived as poor, uneducated, transient, and ethically different.

• Documentation- Many migrant workers and their families are legal residents of the U.S.. However, some workers are undocumented and not in compliance with Immigration and Naturalization Service regulations. Some illegal workers fear that securing services in a federally funded or state funded clinic may lead to discovery and deportation.

• Cultural aspects of health care- Although certain health beliefs and practices have been identified with Mexican culture, the nurse must remember that beliefs and practices differ among regions and localities of a country and among individuals.

Children of Migrant Workers

• The children often suffer from health care deficits, including malnutrition, infectious diseases, dental caries, inadequate immunizations status, pesticide exposure, injuries, overcrowding, exposure to lead in poor housing conditions, and disruption of their school and social life.

• Children 12 to 13 years of age can work on a farm with their parent’s consent or the parent has to work at the same farm.

• Children as young as 12 years of age can work on a farm with fewer than seven full time workers.

• Federal law does not protect children from overworking or regulate the time of day they work. Some children work before and after school or work late into the evening interfering with adequate sleep.

• Some migrant children, as young as eight years old, stay home to care for younger children.

Public Health Nursing in Migrant Settings

• Due to the instability and insecurity inherent in a mobile lifestyle, long term health goals are difficult to establish and long term follow up of any chronic illness is problematic.

• Community/public health nurses provide much-needed services using community resources, innovative thinking, tenacity, and sensitivity.

• Strategies for improving the health status and resource use of migrant workers and their families include the following:

• Improving existing services

• Advocating and networking

• Practicing cultural sensitivity

• Using lay personnel for community outreach

• Utilizing unique methods of health care delivery

• Employing information tracking systems

Public Health Nursing in Migrant Settings

• Public health nurses are the major providers of migrant health services and have a crucial role in the development and management of interventions.

• In response to the growing need for available, accessible, and affordable health care for farmworker families, nurses are called on not only to understand the migrant lifestyle but also to help migrant families overcome the barriers to health care.

• With a scarcity of health resources, the public  health nurse who provides care to this population.

• Providing care for migrant workers and their families presents a challenge, requiring nurses to be innovative and to go beyond the boundaries of traditional health services.

• By aligning with the goals of Healthy People 2030 to improve the health of one of the most underserved populations, the community health nurse will also be improving the health of the nation as a whole.

vulnerable Populations

• Perspectives about individual responsibility for health and well-being are influenced by prevailing cultural attitudes.

• Consider your own beliefs and attitudes, client’s perceptions of their health condition, and the social, political, cultural, and environmental factors that influence the client’s situation.

• those groups with increased risk for adverse health outcomes.

Vulnerability:

• susceptibility to actual or potential stressors that may lead to an adverse effect. Vulnerability to poor health does not mean that some people have personal deficiencies. Rather, it results from the interacting effects of many internal and external factors over which people have little to no control.

Risk

• an epidemiologic term that means some people have a higher probability than others:

-poor or lacking policy

-social hazards

-environmental hazards

-biological or genetic makeup

disfranchisement

•  refers to a feeling of separation from mainstream society. The person does not seem to have an emotional connection with any group in particular or with larger society. 

Vulnerable populations are at risk for disenfranchisement because?

• their social supports are often weak, as are their linkages to formal community organizations such as churches, schools, and other types of social organizations. They also may have few informal resources of support, such as family, friends, and neighbors.

• In many ways vulnerable groups have limited control over potential and actual health needs. In many communities, these groups are in the minority and disadvantaged because typical health planning focuses on the majority.

Vulnerability comes from:

feeling of lack of power, limited control, victimization, disadvantaged status, disenfranchisement, and health risks.

Vulnerability can be reversed by obtaining resources to increase resilience. 

Useful nursing interventions to increase resilience include case finding, health education, care coordination, and policy making related to improving health for vulnerable populations.

Health disparities

considered the unintended effects of SDOH on quality, access, and outcomes for care for certain groups of individuals in communities.

Health disparities can be defined as the variation in rates of disease occurrence and disabilities between socioeconomic and/or geographically defined population groups.

Because socioeconomic an/or geographically defined population groups are complex and unique entities, addressing determinants and disparities nationally and globally is challenging.

Health care disparity

• typically refers to differences between groups in health coverage, access to care, and quality of care.

Health inequities

•  systemic, avoidable, and unjust disparities in health status and mortality rates across population groups that are rooted in underlying injustices and social and economic conditions.

Social Determinants of Health (SDOH

• the conditions in which people are born, grow, live, work, and age. SDOH is mostly responsible for health inequities.

Vulnerable Populations of Concern to Nurses

• Poor or low-income

• Homeless persons

• Pregnant adolescents

• Malnourished

• Low educational level

• Illiterate

• People of color

• LGBTQIA+

• Developmentally delayed

• Migrant workers and immigrants

• Those with severe mental illness

• Veterans

• Uninsured

• Poor healthcare access

• Children

• Elderly

• Persons with substance abuse disorder

• Abused individuals

• Victims of violence

• Persons with communicable disease and those at risk

• High exposure to toxins

• Incarcerated

• Those with chronic disease

Outcomes of Vulnerability

• Outcomes of vulnerability may be negative, such as lower health status than the rest of the population, or they may be positive with effective interventions.

• Vulnerable populations often have worse health outcomes than other people in terms of morbidity and mortality.

• They have a high prevalence of chronic illnesses, such as hypertension, high levels of communicable diseases, including TB, hepatitis B, sexully transmitted diseases, as well as upper respiratory tract infection, including influenza.

• They also have mortality rates than the general population because of factors such as poor living conditions, diet, and health status, as well as crime and violence, including domestic violence.

• There is often a cycle to vulnerability. That is, poor health creates stress as individuals and families try to manage health problems with inadequate resources.

• Sometimes when one problem is solved, another one quickly emerges. This can lead to feelings of hopelessness, which results from an overwhelming sense of powerlessness and social isolation.

• Nursing interventions should include strategies that will increase resources or reduce health risks to decrease health disparities between vulnerable populations and populations with more advantages.

Poverty

• condition of lacking basic human needs such as nutrition, clean water, health care, clothing and shelter because of the inability to afford them. This is also referred to as absolute poverty or destitution.

Relative poverty

• the condition of having fewer resources or less income than others within a society or country.  In general, the U.S. has some of the highest  relative poverty rates among industrialized countries, reflecting the high inequality of incomes.

Current poverty measures

• began in 1960s. Based on research indicating that families spent about 1/3 of incomes on food – the official poverty level was set by multiplying food costs by three; updated annually for inflation but have otherwise remained unchanged

Poverty and Vulnerability

• Food now comprises only 1/7 of an average family’s expenses, while the costs of housing, child care, health care, and transportation have grown disproportionately.

• In addition, the current poverty measure is a national standard that does not adjust for the substantial variation in the cost of living from state to state and between urban and rural areas.

Factors affecting the growing number of poor persons:

• Decreased earnings

• Increased unemployment rates

• Changes in the labor force

• Increase in female-headed households

• Inadequate education and job skills

• Inadequate antipoverty programs and welfare benefits

• Weak enforcement of child support statutes

• Dwindling Social Security payments to children

• Increased numbers of children born to single women

Poverty and Health: Effects Across the Lifespan

• Higher rates of chronic illness

• Higher infant morbidity and mortality

• Shorter life expectancy

• More complex health problems

• More significant complications and physical limitations resulting from chronic disease

• Hospitalization rates three times more than for persons with higher incomes

Social Security Act of 1935

created largest federal support program for elderly and poor Americans

Social Security Act Amendments of 1965, Medicare, and Medicaid

• provided for health care needs of elderly, poor, and disabled people

Health Insurance Portability and Accountability Act of 1996

• intended to help people keep their health insurance when moving from one place to another.

Title XXI of the Social Security Act (1997)

provides for the Children’s Health Insurance Program (CHIP) to provide funds to uninsured children

Balanced Budget Act of 1997

• influenced the use of resources for providing health services

Patient Protection and Affordable Care Act of 2010

• provisions for reducing the growth of future Medicare expenditures. 

 Nursing Roles When Working with Vulnerable Population Groups

• Case manager

• Health educator

• Counselor

• Direct care provider

• Population health advocate

• Community assessor and developer

• Monitor and evaluator of care

• Advocate 

• Health program planner

• Participant in developing health policies

Nurses and Vulnerable Populations

• Promote social justice

• Advocate for policy changes

• Provide safe and quality care

• Provide culturally and linguistically appropriate care.

• Break the cycle

The nursing process guides nurses in assessing?

• vulnerable individuals, families, groups, and communities; developing nursing diagnoses of their strengths and needs; planning and implementing appropriate therapeutic nursing interventions in partnership with vulnerable clients; and evaluating the effectiveness of interventions.

• Nurses who work in the community settings typically have considerable involvement with vulnerable populations.

• The relationship with the client will depend on the nature of the contact. Some will be seen in clinics and others in homes, schools, and at work. Regardless of the setting, the following key nursing actions should be used:

• Create a trusting environment.

• Show respect, compassion, and concern.

• Do not make assumptions.

• Coordinate services and providers.

• Advocate for accessible health care services.

• Focus on prevention.

• Know when to “walk beside’ the client and when to encourage the client to “walk ahead.”

• Know what resources are available.

• Develop your own support network.

How to Use Case Management in Working With Vulnerable Populations

• Know available services and resources.

• Find out what is missing; look for creative solutions.

• Use your clinical skills.

• Develop long-term relationships with the families you serve.

• Strengthen the family’s coping and survival skills and resourcefulness.

• Be the roadmap that guides the family to services, and help them get the services.

• Communicate with the family and the agencies who can help them.

• Work to change the environment and the policies that affect your clients.