1. Vulnerable Populations
KINE 3350
Dr. Green

2. Lesson Objectives
 Define vulnerable populations
 Review the reasons for studying vulnerable populations
 Determine the difference between vulnerability and equity
 Briefly review existing models of vulnerability
 Introduce three risk factors related to vulnerability

3. Who are Vulnerable Populations?
 Often described as disadvantaged, underprivileged, medically
underserved, poverty stricken, distressed populations, and the
underclasses.
 Vulnerability denotes susceptibility to poor health, but most health
research or policy focuses on distinct populations.
 Common Vulnerable Groups:
 Racial/ethnic minorities
 Lower socioeconomic (SES) families
 Children or adolescents
 The elderly or older individuals
 Homeless individuals
 Those with chronic conditions (i.e., diabetes)

4. Vulnerability Risks Overlap
 Vulnerable groups share common traits
 Racial/ethnic minorities are more likely to have lower SES (both family income and education).
 Low SES families are more likely to be homeless and/or have chronic conditions
 These commonalities call for a renewed concept of vulnerability that incorporates these
overlapping risks

5. Why Study Vulnerable Populations?
 Vulnerable populations have greater health needs.
 Greater risk of poor physical, mental, social, and emotional health
 Higher rates of both morbidity and mortality
 An increasing prevalence of vulnerability in the United States.
 Minority population is estimated to nearly equal the size of the non-Hispanic white population, and
already does in some U.S. counties.
 Number of individuals in poverty is increasing steadily

6. Why Study Vulnerable Populations?
 Vulnerable populations are created/remedied by social forces.
 Economic, social, and political factors are responsible for creating vulnerability (i.e., poverty rates
affected by economic policy, eligibility for public assistance are defined by policies in each state, etc.)
 Vulnerability is fundamentally linked with national resources.
 The U.S. continues to rank poorly in national health indicators compared to other countries.
 Poor health not only impacts families but detracts from national productivity and economic prosperity

7. Why Study Vulnerable Populations?
 Vulnerability and equity cannot coexist.
 Equality is a governing principle of the U.S. and public policies have been enacted to create some
protections where equity does not exist (i.e., civil rights legislation, woman suffrage.)

8. Who Gets the Heart?
 Look at the following chart and decide on a heart transplant case among 3 candidates who
will need an organ transplant very soon or death will result.
 All three candidates are from vulnerable populations.
 What factors influenced your decision?

9. Who Gets the Heart?
Rick Ripley Josie Morris Mikey Federici
51 38 18
Divorced, 3 children
ages 7, 11, & 16
Married, no children,
but hopes to adopt
Single, engaged,
undecided about
children
High blood pressure
and deaf in one ear
Heavy smoker and lost
arm in a kayaking
accident
Juvenile diabetes and
struggles with weight
Dairy farmer County Judge High School Graduate

10. Existing Models of Vulnerability
Individual and
Community Interaction
Model
Individual Models
•Determinants
•Social Resources
•Health Behaviors
•Socioeconomic Status
Community Models
•Social Resources
•Environmental Exposures
•Medically Underserved

11. What characteristics identify
specific populations as ‘more
vulnerable’ than others?
How do health-risk behaviors
contribute to vulnerability?
How do the lack of social and
personal resources influence
vulnerability?
Why is socioeconomic status
a vulnerability characteristic?
Individual Models
Determinants Social Resources Health Behaviors Socioeconomic Status
Individual Level Models
Individual models focus on person-level risk factor explanations for vulnerability.

12. Community Models
Social Resources Environmental Exposures Medically Underserved
How do the lack of
community resources create
vulnerable community
populations?
Community Level Models
Community models focus on community-level risk factor explanations for
vulnerability.
Note: These models emphasize that vulnerability is not
simply a matter of bad luck or lack of will.
How do the local community
physical environment and
occupational environment
create vulnerability?
How does the lack of medical
provider capacity impact
levels of vulnerability?

13. The Vulnerability Model
 Vulnerability for poor health is determined by a convergence of risks:
 Predisposing factors
the propensity of individuals to poor health
 Enabling factors
the means that individuals have available to obtain better health
 Need factors
specific illness or health needs

14. Future Chapters Focus on Three Risk Factors:
These are three of the most commonly cited risk factors for poor health
care access, quality, and health status.
Race/Ethnicity SES Health Insurance

15. The Community Determinants
and Mechanisms of
Vulnerability
KINE 3350
Professor Green

16. Lesson Objectives
 Review the trends and mechanism of three of the risk factors of vulnerability.
 Define race/ethnicity and its relation to health.
 Analyze the importance of cultural competency.
 Review SES and its impact on health outcomes.
 Demonstrate the role that health insurance plays in access to healthcare.

17. Trends and Mechanisms of the Three Risk
Factors
Race/Ethnicity SES Health Insurance

18. Race/Ethnicity
 Racial/ethnic differences are common determinants of disparity and conflict. In
many countries around the world, access to medical care breaks down across
racial/ethnic lines; and within a country, vulnerable populations are often made up
of minorities who are underserved in many ways.
 In medicine and health policy, it has been common to classify individuals as black,
white, Asian, or Hispanic, without regard for the many cultural differences within
groups.
 This has reflected primarily skin color, cultural heritage or language.
 The minority population as a percentage of the total US population (i.e., non-
whites) has grown considerably in the last two decades:
 1990: 24%
 2000: 30%
 2010: 35%

19. Trends in Race/Ethnicity

20. How is Race/Ethnicity Related to Health?
 Race/ethnicity often serves as a proxy for other factors that explain the link with
both health and health care experiences, including those originating from the
family as well as health and social systems.
 Socioeconomic status
 Differences in SES (family income, education, and occupation) explain some
racial/ethnic differences in health care experiences and health status
 Blacks and Hispanics, in particular, are more likely than whites to have lower
family income and lower education levels.
 Race/ethnicity is sometimes so closely intertwined with SES that it is often
difficult to separate the effects of each.

21. How is Race/Ethnicity Related to Health?
 Cultural Factors
 Perhaps offering the most potential for future research into disparities are cultural factors
including language, family preferences, or beliefs leading to various health behaviors or
health seeking practices.
 Racial/ethnic differences in family expectations or preferences for care are not well identified
and catalogued, but may uniquely affect experiences with care and how this care is reported
or rated.
 Health Needs
 Health needs drive the seeking of health care services and derive not only from both acute
and chronic illness, but recommendations for preventive or follow-up care received from a
physician.
 Since minorities tend to have poorer health status than whites, this greater need for care
raises a major problem: those who need care the most are often the least likely to receive it.

22. Cultural Competency
 Helps to combat discrimination or the differential action toward an individual or
group based on race, and is a manifestation of prejudice, stereotyping, and
assumptions about group abilities, motives, or intentions.
 The ability of providers and organizations to understand and integrate factors such
as race, ethnicity, nationality, language, gender, socioeconomic status, physical
and mental ability, sexual orientation, and occupation into the delivery and
structure of the health care system. The goal of culturally competent health care
services is to provide the highest quality of care to every patient, regardless of
race, ethnicity, cultural background, English proficiency or literacy.
 https://youtu.be/fqB3bpC4czs

23. Socioeconomic Status (SES)
 Because SES has a significant impact on health, it is essential to understand what
factors influence it and how modifying these factors could improve population
health well before public health efforts or medical care are required.
 Among factors, such as social and economic policy, a person’s place of residence
is one of many important influences on measures of SES:
 Education
 Occupation
 Income

24. Residence and Education
 Residence dictates which public school students can attend. Because public school funding
depends on the local tax base, a community’s resources partially determine the quality of a
public school.
 In areas of concentrated poverty public schools have:
 lower average test scores,
 more restricted curricula,
 fewer qualified teachers,
 less interaction with potential colleges and employers,
 higher levels of teen pregnancy,
 and higher dropout rates.

25. Residence and Occupation
 Residence further dictates employment opportunities by determining access to
convenient and well-paying jobs.
 Since the 1950s, higher-paying jobs have been migrating out of poor, urban areas
to more suburban or ex-urban areas.
 Racial/ethnic minorities living in urban areas have been the most affected by this
migration or “spatial mismatch”.
 Corporations expanding, relocating, or building new facilities have previously used
geographical racial composition or SES in deciding where to place these facilities.
 Communities with high unemployment can entangle themselves in a cycle of
poverty as fewer employment opportunities limit an economic escape and fewer
consistently employed adults are around to act as role models for young adults in
the next generation

26. Residence and Income
 Lack of education and employment opportunities in impoverished areas leads to
long-term difficulties with poverty.
 With high rates of poverty in an area, the costs to the welfare system increase and
the tax-base decreases, magnifying the difficulty of reinvesting dollars to improve
the conditions in the community.

27. Linking SES with Health Care and
Health
How does a persons’ SES affect health outcomes and
health care experiences?
There are two overarching theories:
The absence of access to material goods
The absence of social support and participation
These theories apply at both the individual and
community level.

28. Health Insurance
 The United States is one of only a couple developed nations that does not
guarantee its citizens access to health care through a system of universal
health coverage or a national health service.
 In 2000, the World Health Organization released a report ranking countries
on the quality of their health systems.
 The report ranked the United States 37th for health system performance
and 72nd for health outcome performance (out of 191 countries).
 This is despite the fact that the U.S. spends more than any other nation on
health care.

29. The Development of Federal and State
Health Insurance Programs
 Before the 1960s, the U.S. government was mostly uninterested in
assisting its citizens with the ability to access health care.
 In 1965, a monumental change occurred. As part of President Lyndon
Johnson’s Great Society, the federal government enacted two major health
insurance programs to help the poor (Medicaid) and elderly (Medicare).
 In 1997, the federal government took the next major incremental step
toward universal coverage by enacting a program to provide health
insurance coverage for children who are from low-income families but
were not categorically poor.

30. The Working Poor and Insurance
 The problem of lacking insurance coverage has evolved into an issue
primarily among the working poor.
 These individuals are generally employed in low-paying jobs that do not
offer health insurance coverage or enable individuals to purchase
insurance.
 But they also tend to earn too much to qualify the individual for
government assistance in programs like Medicaid.
 So while the U.S. has insured the poorest individuals, there are many families
living on meager wages without coverage.
 Because health insurance is closely tied to education, occupation, and
income, there are major demographic disparities in insurance coverage and
type.
 In 2008, Hispanics were the most likely to be uninsured (33.2%). Blacks
and Asians had similar rates of being uninsured (19.0% and 18.2%), much
higher than for whites (10.0%).

31. Linking Health Insurance with Health Care
and Health
 The uninsured are particularly vulnerable to financial barriers in accessing
health care. Once a person is insured, there are three mechanisms by
which insurance may be related to health and health care experiences:
 health plan policies may affect care-seeking and cost-sharing
behaviors of beneficiaries
 providers incentives and reimbursement strategies may influence
provider behavior
 perceptions of health insurance plans may create feelings of stigma
and affect the use of services and reports of quality

32. Interconnections Between Risk Factors
 The generic model can be interpreted as
follows:
 Because of a long history of exclusion
from educational resources, African
Americans and Hispanics remain less
likely than other racial/ethnic groups to
obtain higher education.
 Without higher education, employment
opportunities for these individuals are
frequently limited to low-wage or service
sector jobs.
 These jobs tend not to pay sufficiently
well to support a family and also
frequently do not provide health
insurance coverage.
 Lacking insurance creates barriers to
obtaining high quality medical care and
increased chances that needed care will
not be obtained.
 This likely means more sick days from
work or more school days missed due to
illness.
 This also means health problems go
untreated and a host of health-related
barriers to achieving at school may
remain unaddressed.