Chapter 21: Vulnerable Populations: An Overview

vulnerability

susceptibility to actual or potential stressors that may lead to an adverse effect -with health, it results from the interacting effects of many internal an external factors over which people have little or no control -often can be cyclic and intergenerational

primary prevention related to rural health

teach workers how to reduce exposure to pesticides

seasonal farmworkers

work cyclically in agriculture but do not migrate

veterans

•Dept of Veterans Affairs estimates 21.6 million veterans in the U.S. •Veterans Health Administration responsible for providing health care coverage to veterans and dependents •Networks provide acute and long term care, home care, hospice, residential rehabilitative treatment, and counseling centers •High risk for trauma related PTDS symptoms and sequelae including alcohol and substance abuse, and suicide •Long term disabilities from combat injuries i.e. TBI, spinal cord injuries, amputations •Continuity of care between acute and outpatient settings essential •Coordinate referrals to available resources/services for mental health, alcohol and substance abuse

primary prevention

•Parenting classes - home visiting, anticipatory guidance for childhood G & D and age appropriate behaviors, parenting education and support groups •Schools - Antibullying campaigns, suicide prevention, healthy relationships •Communities - education about conflict resolution and coping strategies, community support groups, after school youth programs -give influenza vaccines to vulnerable populations who are immunocompromised •Older Adults - services to relieve caregivers, financial safeguards for assets i.e. durable POA

homelessness

•Poverty leading cause of this •Increasing numbers of homeless are families with children •Disproportionate numbers of vulnerable populations i.e. mentally ill, veterans, disabilities. •Defined as lack of regular night time residence •Numbers often inaccurate due to transient nature of homeless -counts assessing homeless numbers during specific time frame •Health care usually crisis oriented; high utilization of ER •Health issues are complex: acute physical and mental health chronic illnesses, infestations and communicable diseases, substance and alcohol abuse, injuries from violence, heat related illnesses and injuries, poor dental health, hunger and malnutrition •Addressing need of homeless is complex - priority must include securing long term safe, adequate sheltering

seasonal agricultural workers

•Temporary residence in communities; sometimes supporting families that live in permanent residences elsewhere •Often not covered under general labor laws i.e. minor children can work along side parents, even in unsafe conditions •Federally funded Migrant Health Centers designed to address health care needs but there are still gaps •Include undocumented immigrants not eligible for federally funded health care and other programs/services •Discrimination, not speaking English negatively impact ability to access and quality health care •Health care issues similar to homeless population; increased risks of acute and long term work related injuries from use of farm equipment and poisoning from use of pesticides

rural health issues

•Typically defined as less than 20,000 residents •Generally lack specialty services and often no community hospital •Shortage of HCP - more likely to see a nurse practitioner who cares for patients across the lifespan - this includes shortage of ST, HHA which also impact rural populations for availability of services •Lack of transportation and inaccessible terrain issues reduce access to health care •Socioeconomic and cultural factors act as barriers- i.e. lack of engagement/belief in healthy behaviors, non-belief in preventive health care •Emphasis should be on preventative health services •Federally qualified health centers designed to address health care needs of rural residents but there are still gaps in services

disabilities

-About 1/5 of the U.S population reports having a disability -Exact definitions of disabilities are determined by specific disciplines of care i.e. children with special health care needs, alcoholism, developmental disabilities/autism, physical disability due to injury or chronic disease -Refers to physical or psychological factor that impacts the way an individual interacts with the environment -Genetics, aging, environment, injury, alcoholism or substance abuse can lead to disabilities -Other terms used to describe disabled are challenged, compromised -Individuals with Disabilities Education Act (IDEA) ensures free public education and accommodations to prepare child for independent living, assists with education funding, and evaluates education effectiveness (Children with Special Health Care Needs)

vulnerable population groups

-poor and homeless persons -veterans -pregnant adolescents -migrant workers and immigrants -severely mentally ill individuals -substance abusers -abused individuals and victims of violence -persons with communicable disease and those at risk -persons who have HIV , hepatitis B, or have an STD

poverty and homelessness

-Insufficient means and resources to meet basic living expenses: food, shelter, clothing, transportation, and health care. -Causes for poverty are complex -Likely to work either be unemployed, in low paying jobs and may also be high risk jobs -Crisis poverty: transient, episodic need for sheltering -Persistent poverty: long term or intergenerational poverty -Neighborhood poverty: geographically defined area of poverty characterized by poor housing and large numbers unemployed -Poverty directly related to poor health outcomes -Higher rates of infant mortality and chronic disease -Higher rates of hospitalizations -Best defense against poverty is education -Poverty guidelines are issued each year in the Federal Register by the Department of Health and Human Services (HHS). -The guidelines are used for determining financial eligibility for certain federal programs.

tertiary prevention

-Mandated reporting of abuse/injury to appropriate agency/authorities -Forensic examinations to provide medical care and collect evidence for criminal prosecution of perpetrators -Referrals for long term health care needs - emotional, psychological, physical -Referrals to community domestic violence groups, support groups -Grief counseling

secondary prevention related to vulnerable populations

-conduct screening clinics to assess for things such as obesity, diabetes, heart disease, TB -develop a way for the homeless individuals to read their TB skin tests, if necessary, and to transfer the results back to the facility at which the skin test was administerd

tertiary prevention related to vulnerable populations

-develop community-based exercise programs for people identified as obese or who increased BP or increased blood sugar -provide directly observed medication therapy for people with active TB

barriers to health care in rural areas

-lack of health care providers and services and great distances to obtain services (due to spareness of population as it limits number and array of health care services) -lack of personal transportation -unavailable public transportation -lack of telephone services -unavailable outreach services -inequitable reimbursement policies for providers -unpredictable weather or travel conditions -inability to pay for care or lack of healthcare insurance -lack of know-how to procedure publicly funded entitlements and services -inadequate provider attitudes and understanding about rural populations (a demeaning attitude, lack of accurate knowledge about rural populations, or insensitivity about the rural lifestyle on the part of the nurse can cause difficulties relating to the client; insensitivity generates mistrust, causing rural clients to view professionals as outsiders) -language barriers (caregivers are not linguistically competent) -care and services not culturally and linguistically appropriate

characteristics of rural life

-more space, greater distances between residents and services -cyclical or seasonal work and leisure activities -informal social and professional interactions -access to extended kinship systems -residents who are related or acquainted -lack of anonymity -challenges in maintaining confidentiality stemming from familiarity among residents -small (often family) enterprises, fewer large industries -economic orientation to land and nature (agriculture, mining, lumbering, fishing, marine related) -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)

primary prevention related to vulnerable populations

-provide culturally and economically sensitive health teaching about balanced diet and exercise -develop portable immunization chart, such as a wallet card, that mobile population groups such as the homeless and migrant workers can carry on them

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 specialities -flexibility and creativity in delivering care (prevention is key) -sparse resources (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 panning 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) -viewed as a professional role model -opportunity for community involvement and informal health education

factors that affect health

1. income and social status: higher income linked with better health 2. education: low education linked to poor health 3. physical environment: safe water, clean air, healthy workplace and home 4. social support networks: family, friends, community, culture, customs, traditions, beliefs 5. genetics, personal behavior, coping skills 6. health services 7. gender

secondary prevention

Assessment in every clinical interaction (conducting screening clinics for vulnerable populations) Screening is important to identify s/s that may indicate victimization, abuse/neglect -unexplained bruises, injuries -behavior changes -changes in sleep patterns -changes in appetite -inappropriate dress -financial problems - bills not paid on time Referrals to community resources for at risk clients/families Mandated reporting of suspected child abuse/neglect and/or criminal activities Adults being neglected/abused is less clear - work with agencies to establish clear policies and procedures for assistance and services

examples of vulnerable populations

Individuals who are exposed to/experiencing -Violence and trauma/toxic stress -Alcohol and/or substance abuse -Mental illness -Poverty -Rural populations i.e. agricultural workers -Veterans -Disabilities - physical, developmental -Young or advanced age -Environment, including homelessness

determinants of health

WHO describes three: -social and economic environment -the physical environment -the person's individual characteristics and behaviors individuals are unlikely to be able to control many of these and this is directly related to vulnerability

health status

age is related to vulnerability because people at both ends of the age continuum are often less able physiologically to adapt to stressors -changes in physiology can predispose to vulnerability (ex: with single or multiple chronic diseases) -person's life experiences can impact vulnerability or resilience (vulnerable populations have an external locus of control, believing bad events are outside of their control and result from bad luck or fate, have difficulty seeking help for health problems)

education

although it is related to income, it seems to influence health separately -higher levels may provide people with more information for making healthy lifestyle choices -are better able to make informed decisions about health insurance and providers -may also influence the perception of stressors and problems situations and give people more alternatives -also affects health literacy

risk

an epidemiological term that mean some people have a higher probability than others of illness -however, not everyone at risk develops health problems -some individuals are just more likely than others -these people are more vulnerable than others -come from environmental hazards, social hazards, personal behavior, genetic or biological makeup

social determinants of health

are factors such as economic status, education, environmental factors, nutrition, stress, and prejudice that leads to resource constraints, poor health, and health risk -nursing interventions are designed to help vulnerable populations gain the resources needed for better health

rural nursing

began with the Red Cross Rural Nursing Service -before this, care of the sick in a small community was provided by informal social support systems -when self-care and family care were not effective in bringing about healing, women, who had skills in helping others heal and who lived in the community provided care -care of rural people are different from those of urban populations -scarcity of HCPs, poverty, limited access to services, lack of knowledge, and social isolation have plagued many rural communities for generation -major issue is the distance people must go to find healthcare services and providers -for migrant workers, a language barrier and cultural differences exists

rural

communities having fewer than 20,000 residents or fewer than 99 persons per square mile -defined generally either in terms of the geographic location and population density or the distance from or the time needed to commute to an urban center -access to healthcare is problem in these areas including farms that rely on migrant workers to harvest their crops and in urban areas, especially inner cites

secondary prevention related to rural health

conduct screening, such as urine testing for pesticide exposure

specific health problems of migrant workers

dental disease is one of the most common problems for all farmworkers -may not have dental insurance -may have long travel times to get dental care, have language problems, and be in areas where there is a shortage of dental providers -mexican amercians have higher rates of tooth decay and peridontal disease incidence of TB is higher than in the general population -more likely to die from the disease -higher rates in their countries of origin, crowded living conditions, and malnutrition depression and stress -areas of concern as this may be related to isolation, economic hazards, their legal status, poor living conditions, and weather conditions that interrupt their work -may also experience stress due to having to adjust to new culture, low self esteem, discrimination, frequent mobility, long work hours, and limited or non-existent benefits -migrant women at increased risk for anxiety and for domestic violence type 2 diabetes -due to factors such as poverty, stress, cultural and dietary practices, long term exposures to certain pesticides, and genetic predispositions -higher rate among hispanics

resilience

factors help these people resist the effects of vulnerability -not all members of vulnerable populations succumb to the health risks that impinge on them

health care of veterans

family members with military service member have been found to be more susceptive to domestic violence and child maltreatment, and returning service members may have difficulty reconnecting with their families that have stayed at home -children of deployed service members have greater psychological difficulties, anxiety, school, and peer problems, depression and suicidal ideation -the physical and psychological impact of both current and past wartime and military experiences has created a large population of veterans needing care -more veterans returning home with increased needs -for service people, stress comes from killing and watching friends die, personal danger to others, danger of accidents, and the need for constant vigilance related to difficulty determining who is the enemy -family members suffer from being left behind and having to cope with jobs, money, and missing their service member -nurses need to learn how many veterans are in the area and where and how they live (families or significant others, alone in adequate housing, or homeless) -many suffer from PTSD and major depression (may come and go and can start immediately after or years later) -CBT has found to help PTSD (helps people learn skills to understand how trauma changed their thoughts and feelings

migrant farmworker

federal status defines this as an individual whose principal employment within the past 24 months is in agriculture on a seasonal basis and who establishes for purpose of such employment a temporary abode

occupational and environmental health problems in rural areas

four high risk industries in rural areas: -forestry, mining, marine-related fields, and agriculture associated health risks in these areas: -machinery and vehicular accidents, trauma, some types of cancer, allergies, and respiratory conditions associated with repeated exposure to toxins, pesticides, and herbicides

health status of rural residents

health problems and health behaviors are not fully understood -people in this area have a poorer perception of their overall health and functional status than urban counterparts -rural residents assess their health status less favorably -rural adults are less likely to engage in preventative behavior which increases exposure to risk -more likely to smoke and report higher rates of alcohol use and obesity -less likely to engage in physical activity in their free time, wear seat-belts, or have regular BP or Pap smears, do regular breast self exams -more likely to have chronic conditions/chronic health problems -percentage of rural adults who receive medical treatment for both life-threatening illnesses and degenerative or chronic conditions is higher -tend to have overall poorer health status and are less likely to seek medical care (this is why home care services are helpful) -there are fewer physicians from whom care can be sought -less likely to have employer-sponsored health insurance or prescription drug coverage -greater risk of being involved in an accident -twice as likely to die from unintentional injuries and higher risk of gunshot death from hunting -providers most often seen by rural adults are general practitioners and APRNs (not specialists) -increased traveling time to care services

federal poverty guideline

in 2016, for a family of four was $24,300 for all states except for Hawaii and Alaska -however, many that live a little bit above this are unable to pay for their living expenses but are ineligible for assistance programs

extreme poverty

in the form of homelessness or marginal housing, is related to risk for physical, dental, and mental health problems; food insecurity, and limited access to healthcare -homeless and marginal housing must struggle with heavy demands as they try to manage daily life (do not have consistent housing and must cope with finding a place to sleep every night or moving frequently from one residence to another as well as finding food before even thinking about healthcare)

tertiary prevention related to rural health

initiate treatment for the symptoms of pesticide exposure such as nausea, vomiting, and skin irritation

factors limiting healthcare services in migrant workers

lack of knowledge about services -b/c of their isolation and lack of fluency in English inability to afford care -medicaid program not often available for migrant workers, especially undocumented ones -workers may not remain in the area long enough to be considered for benefits or may lose benefits when they relocate to a state with different eligibility requirements -salaries fluctuate monthly making them ineligible for periods -if they are not working, they are not paid so many avoid taking time off affordable care act or health insurance subsidies -many do not receive employer-manadated health insurance coverage due to exclusion of seasonal workers who are employed less than 120 days in the employer's tax year -undocumented workers are excluded from employers or private insurances availability of services -immigrants treated differently depending on whether they were in US before welfare reform of 1966 -many ineligible for services transportation -may be unavailable, unreliable or expensive -many migrant farmworkers do not have access to vehicles hours o service -many health services are available only during working hours; thus seeking healthcare leads to lost earnings mobility and tracking -their health records do not typically move with them even though they are constantly moving -leads to fragmented services in areas for treatment such as TB, chronic illness management, and immunizations language barriers -inability to speak English presents may barriers to getting adequate healthcare -immigrants speak primarily the language of their own country -may not be able to read or write in English and may be embarrassed to admit this -nurses need to verify they understand what they are being told -majority of seasonal farmworkers peak spanish, so have a lot of bilingual workers discrimination -they are often viewed by public as poor, uneducated, transient, and ethically different documentation -unauthorized individuals fear that getting services in a federally funded or state funded clinic may lead to discovery and deportation cultural aspects of health care

outcomes of vulnerability

may be negative such as lower health status than the rest of the population or the may be positive with effective interventions -they often have worse health outcomes in terms of morbidity and mortality -high prevalence of chronic illnesses -higher mortality rates because of poor living conditions, diet, health status, as well as crime and violence -often a cycle to vulnerability, poor health creates stress as individuals and families try to manage health problems with inadequate resources -vulnerable populations suffer from many forms of stress -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

access to care for migrant workers

migrant health centers: federally funded primary care centers to serve migrant populations mobile health clinics are an effective method of healthcare delivery in rural areas -can be managed by nurses or interprofessional team -goal is to take services to clients who needs them and would have difficulty accessing the services in a stationary clinic, which might be some distances away or might not be open when they seek care

factors contributing to vulnerability

results from the combined effects of limited resources -physical resources, environmental resources, personal resources (human capital), and biopsychosocial resources (presence of illness, genetic predispositions) all combine to form this

migrant lifestyle

often have unpredictable and difficult lifestyle -many leave home each year and travel distant locations to work -may be uncertain about next work or housing -may feel isolated in new communities and lack adequate resources to meet their needs -all can lead to stress -median pay is $9.66 per hour -rarely receive benefits -cyclic nature of agricultural work and its dependence on weather and economic conditions results in considerable uncertainty for migrant farmworkers

medically indigent

people who do not have the financial resources to pay for medical care -they may be self-employed or work in small businesses and cannot afford health benefits, others do not have adequate health insurance (deductibles or copayments are too high or few services covered) -under or uninsured are less likely to get medical treatment

issues in migrant health

poor and unsanitary working and housing conditions make farmworkers susceptible to health problems no longer seen as dangers to the general public or seen at a much lower rate -agriculture industry is one of the most dangerous occupations int he US -they are exposed to other hazards including pesticide exposure, heat and sun exposure, skin disorders, infectious diseases, lung problems, hearing and vision disorders, and strained muscles and bones -most have identified diabetes, poor dental health, obesity, and depression as major health problems

poverty

primary cause of vulnerability and its a growing problem in the US -chronic stress of factors such as poverty, unemployment, and poor education can lead to maladaptive physical responses and disease -it is a relative state -more likely to live in hazardous environments that are overcrowded and have inadequate sanitation, work in high risk jobs, have less nutritious diets, and have multiple stressors because they do not have resources to manage unexpected crises and may not even have adequate resources to manage daily life -reduces an individual's access to healthcare -removing barriers by providing extended clinic hours, low cost or free health services for people who are uninsured or underinsured, transportation, mobile vans, and professional interpreters can help improve access -often associated with depression and persons experience considerable stress and may develop mental health problems

levels of prevention

primary prevention: -primary care provider who coordinates health services and provides for their preventative services and health promotion -ex: give influenza vaccines to vulnerable populations who are immunocompromised secondary prevention: -conducting screening clinics for vulnerable populations -ex: nurses who work in homeless shelters, prisons, migrant camps and substance abuse treatment should know that these groups are high risk for acquiring communicable infections and need routine screening for TB tertiary prevention: -conducting therapy group with the residents of a group home for severely mentally ill adults -nurses who wok with abused women to help them enhance their levels of self esteem

health disparities

refer to the wide variations in health services and health status among certain population groups -seen with death by gender, age, race, socioeconomic status (poverty)

disenfranchisement

refers to a feeling of separation from mainstream society -one aspect of vulnerability -the person does not seem to have an emotional connection with any group in particular or with a larger society -some may be viewed as invisible to society such as the poor, homeless, or migrant workers -vulnerable populations are at risk for this because their social supports are often weak and few informal supports

human capital

refers to all the strengths, knowledge, and skills that enable a person to live a happy and productive life -people with little education have less of this because their choices are more limited than those of high education

the migrant health act

signed in 1962, provides primary and supplemental health services to migrant workers and their families -numbers served at these clinics represents only a small proportion of migrant workers -lack of care related to poverty of workers, their constant mobility, language differences, and lack of transportation

farmworkers health issues

the most common include: -pesticide exposure (to those that work in fields that have been treated with pesticides, residue from pesticides also enters the person's home (cross-contamination on clothes) and their food--risks include mild psychological and behavioral deficits (memory loss, difficulty with concentration, or mood changes) and acute severe poisoning (abdominal pain, nausea/vomiting/diarrhea, malaise, skin rashes, eye irritation) that can result in death---long term exposures can lead to birth defects, cancer, blood disorders, neurological problems, and reproductive effects) -heat and sun exposure (heat exhaustion = heavy sweating, cold/pale/clammy skin, fast, weak pulse, nausea/vomiting, fainting) -hazardous tools and machinery (accidents can occur from being struck by a vehicle or from hand tools, tractors, or other equipment) -infectious diseases (often caused by poor sanitation and crowded conditions) -musculoskeletal injuries (often bend, twist, carry, heavy items and have repetitive motions during long work hours that can lead to musculoskeletal injuries) -respiratory illnesses (exposed to organic and mineral dusts, animal and plant dusts, toxic gases, molds, and other respiratory irritants) -skin disorders -eye injuries

characteristics of migrant/seasonal farmworkers

the rural homeless, for example, may be season farmworkers or families whose farms are foreclosed -sometimes the family may be allowed by law to continue living in the house on the farm they once owned but no longer has a means of livelihood -migrant and seasonal farmworkers are one example of at risk group -they are essential to the agricultural industry in the US (US depends on these individuals) -majority are foreign born -large percentage can not speak english -migrant and seasonal farmworkers make up two distinct populations but share many demographic, cultural, and occupational characteristics -not all are documented workers (undocumented immigrants)

vulnerable populations

those groups (subgroup of the population) with increased risk for adverse health outcomes -due to exposure to risk or to have worse outcomes from these health problems than the rest of the population -More likely than general population to experience health disparities -More sensitive to risk factors - often experience cumulative risk factors -Often have multiple illnesses which affect the other -More likely to develop health problems as a result of exposure to risk or to have worse outcomes from those health problems than the population as a whole

cumulative risks

vulnerable populations often experience these and they are particularly sensitive to effects of these risks -additive effects of multiple risk factors