Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009

Vulnerable Population and

Vulnerability vs. Risk socioeconomic problems
risk – based on the natural history of disease model – difficult to maintain a job
– antipsychotic medications
physiology and environment – counseling
personal habits, social environment physical environment – group therapy
Vulnerable Population – vocational assistance
• a subgroup of the population more likely to develop health Substance Abusers
problems as a result of exposure to risk or to have worse outcomes • legal substances
from these health problems than the population as a whole • illegal substances
• cumulative risks make them more sensitive to the adverse health problems
effects of individual risk factors and
• Vulnerability implies that certain people are more sensitive to socioeconomic problems
risk factors than others – heart problems
Vulnerable Population Groups – liver CA
1. Poor and Homeless Persons – HIV
2. Pregnant Adolescents – crime
3. Migrant Workers – communicable diseases
4. Severely Mentally Ill Individuals – family breakdown
5. Substance Abusers
6. Abused Individuals Abused Individuals
7. People with Communicable Diseases and Those at Risk • physical
8. HIV, Hepatitis and STDs • emotional
• sexual
Poor People • neglect

• hazardous environments domestic violence – a pattern of regularly occurring abuse and violence, or
• high-risk jobs the threat of violence, in an intimate relationship
• eat less-nutritious diets • child abuse – 2.9M (1992)
• multiple stressors – neglect, physical, sexual
• no extra resources – 1994, rising faster
• no adequate resources to manage daily life – posttraumatic symptoms
Homeless – emotional problems
• fewer resources than poor people – addictive behaviors
• must struggle with even more demands as they try to manage – dysfunctional families
daily life – financial strain
• do not have the advantage of shelter
• find a place to sleep, to stay, food to eat before thinking about People with Communicable Diseases and Those at Risk
health care • immunization status
• PROBLEMS: • drug resistance of bacteria
• foot problems – measles outbreak
• dental problems – drug-resistant S. aureus
• hypothermia – tuberculosis (TB)
• exacerbations of chronic health problems – HIV, AIDS, CA, very young, very old
• violence HIV, Hepatitis, STDs
• trauma • infectious diseases
Pregnant Adolescents – TB
• adolescent mother, infant, future children – Pneumocystis carinii pneumonia
• lower socioeconomic status • CA
• interrupted education for one or both parents – Kaposi’s sarcoma
• limited job opportunities – herpes simplex virus 2 ◊ cervical CA
• additional expenses associated with childrearing
• socioeconomic problems
• long-term cycle of economic problems
– work, family, life-style disruptions
• PROBLEMS:
– loss of insurance
• low-birth-weight infants
– social, psychological, emotional problems
• toxemia
• pregnancy-induced hypertension
Trends in Health Care
• anemia
Migrant Workers • colonial times ◊ chronic physical or mental conditions were cared
• occupational risks for in the community
– hazardous work • 19th century ◊ institutional care
– poor working conditions
• socioeconomic risks from poverty and homelessness • latter part of 20th century ◊ renewed emphasis on care
• crowded living conditions • more outreach and case finding to make access easier and
• traveling to work in crowded buses more culturally competent
• malnutrition • more comprehensive, family-centered services
• episodically homeless/ • more accessible – school, church, neighborhood, workplace
hidden homeless Public Policies Affecting
Vulnerable Populations
• Legislation that Provided Direct and Indirect Financial Subsidies
Migrant Workers to Certain Vulnerable Groups
• PROBLEMS:
– access to health care – Social Security Act of 1935
• illegal immigrants may have no legal – Medicare and Medicaid Social Security Act
access to health services, depending on the Amendments of 1965
laws in a particular state
Public Policies
Severely Mentally Ill • Social Security Act of 1935
• major psychosis: schizophrenia, bipolar disorder – largest federal support program for elderly and poor
health problems
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 Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009
– ensure a minimal level of support for people who
had a level of vulnerability to problems resulting from
inadequate financial resources
– direct payment to eligible individuals
• Medicare and Medicaid Social Security Act Amendments of
1965
– provide for the health care needs of elderly, poor
and disabled
– created third-party payers at the federal and state
levels who provided financial assistance by paying for
health services
• Legislation that Provided Financial Support for Building Health
Care Facilities
– Hill-Burton Act of 1946
– Community Mental Health Centers Act of 1963
– Stewart B. McKinney Homeless Assistance Act of
1988
• Hill-Burton Act of 1946
– provided financial support to build hospitals that
would provide care to indigent people
• Community Mental Health Centers Act of 1963
– construct community mental health centers
– train mental health professionals who would provide
community-based care for the severely mentally ill
individuals who were discharged from state mental
hospitals
• McKinney Homeless Assistance Act of 1988
– clinics
– educational services
– social services for homeless individuals and
families
• Legislation that Affected How Health Care Resources were
Used
– National Health Planning and Resources
Development Act of 1974
– Tax Equity and Fiscal Responsibility Act of 1982
Public Policies
• National Health Planning and Resource Development Act of
1974
– intended to provide local mechanisms for planning
which types of health services and facilities were really
needed
– duplication of expensive facilities and services
would be avoided
– Goal: reduce the increasing cost of health services
– community health needs assessment provide
balanced services so all would have access to the care
they needed
• Tax Equity and Fiscal Responsibility Act of 1982
– designed to limit the rapid increase in health care
costs
– did not focus on community planning
– mandated that payment for hospital services for all
Medicare patients would no longer be done in a
retrospective cost basis
– Health Care Financing Administration (HCFA)
would no longer simply pay bills that were submitted to
them for Medicare enrollees
– a list of diagnosis-related groups was developed
and determining what they would pay for caring for
people with these diagnoses
– emphasis on shorter hospital stays, cost-effective
treatments, community-based care and care in the home
Implementation Issues
Health Risk
• multiple cumulative risks
• sensitive to the effects of the risks
– environment (lead exposure)
– social (crime and violence)
– biological or genetic make-up (congenital addiction
or compromised immune status)
• co-morbidities/multiple illnesses
Predisposing Factors
1. Socioeconomic Status
– poverty
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– 1 out of 8 Americans lives in a family with an income
below the Federal poverty level (Healthy People 2000)
– Federal Poverty level (family of 4) - $22,050 (2009)
*medically indigent – people who do not have the financial resources to
pay for medical care
• health care reimbursement policies
– market model vs. human service model
• people who have the resources to purchase
services are the ones entitled to those services
– Social Darwinism vs. health as a basic right
*groups who are unable to afford adequate preventive services are likely to
develop chronic diseases ◊ drain on human capital
Predisposing Factors
2. Age-related Causes
– extreme ages
– prone to infections and communicable diseases
– less effective immune system
3. Health-related Causes
– alteration in normal physiologic status predisposes
individuals to vulnerability
– HIV, hepatitis, STDs
– physiologic alterations ◊ accidents, injuries, congenital
problems ◊ mental or physiological disability
4. Life Experiences
– childhood experiences influence the development of
psychological vulnerability or resilience
– disaster ◊ counseling
1. events are outside their control
– extroversion and flexibility – protective factors against
early adversity
Outcomes of Vulnerability
• negative – lower health status
• positive – with effective interventions ◊ improved health and
empowerment
• Poor Health Outcome
• worse health outcomes than others in terms of
morbidity and mortality
• high prevalence of chronic illnesses
• high levels of communicable diseases
• high mortality rates from crime and violence
2. Chronic Stress
– manage health problems with inadequate resources
– domino effect ◊ hopelessness
3. Hopelessness
– results from an overwhelming sense of powerlessness
and social isolation
Cycle of Vulnerability
predisposing factors + outcomes of vulnerability = a cycle in which the
outcomes reinforce the predisposing factors ◊ more negative outcome
break the cycle
NURSING
• Nursing Process
– assessment – vulnerable individuals, families, groups
and communities
– nursing diagnoses – strengths and needs
– planning appropriate therapeutic
– intervention nursing interventions
– evaluation – effectiveness of interventions
Assessment Issues
• Socioeconomic Considerations
– assess client’s perceptions of his or her
socioeconomic resources
– identify people who can provide support and financial
resources
– support: information, caregiving, emotional support,
transportation, shopping, babysitting
– financial resources: health services and medications,
eligibility for third-party payment
– ask about the perceived adequacy of both formal and
informal support networks
 Dr Aubrey Go on Vulnerable Population (notes in-class) 2 hr Nursing 205 Fundamentals Lecture 1300-1500 Monday August 17th 2009
• Physical Health Issues
– preventive health needs
– screening tests – immunization status, blood
pressure, weight, serum cholesterol, Pap smears, breast
exams, mammograms, prostate exam, glaucoma
screening, dental evaluation
– preventive screening for diseases that they are high
risk
• Biological Issues
– congenital and genetic predisposition
– education
– counseling
– referral to other health professionals
• Psychological Issues
– stress levels
– healthy or dysfunctional family dynamics
– stressors
– coping styles
– levels of self-efficacy
– overall sense of well-being
– level of self-esteem
– depression
– anxiety
• Lifestyle Issues
– dietary patterns
– exercise
– rest
– use of drugs, alcohol, caffeine
– cultural preferences
• Environmental Issues
– exposure to environmental hazards
– living environment
– neighborhood surroundings
– pollution, industrial wastes, crime
* nurses should establish partnerships

Nursing Roles (CHN) When Working

with the Vulnerable
• case finder
• health teacher
• counselor
• direct care provider
• monitor and evaluator of care
• case manager
• advocate
• health program planner
• participant in developing health policies
Case Management
• involves linking client with services and providing direct
nursing services, such as teaching, counseling, screening, and
immunizing
• brokering health services is accomplished by making
appropriate referrals and by following up with clients to ensure that
the desired outcomes from the referral were achieved
Levels of Prevention
• Primary
– prophylaxis
– vaccination
• Secondary
– health screenings
• Tertiary
– therapy group
– enhance level of self-esteem
Evaluation of Nursing Interventions with Vulnerable Population
• extent to which client health outcomes were achieved (goals
and objectives)
• basis for revision to make it more effective
• case closed or program is completed – gives nurses data to
use in the future
• incidence data, prevalence data, survey data, service
utilization data – used to evaluate health programs for vulnerable
populations

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