Unit 12 Health Promotion in Vulnerable Populations.pptx

Unit 12
Health Promotion in
Vulnerable Populations
1
Prepared by Dr. Gamil Alrubaiee

Learning Objectives
At the end of this lecture the student will be able to:
1. Discuss the social and economic determinants of health and their role in health
disparities.
2. Describe the concept of equity in health.
3. Discuss approaches to address health inequities in diverse populations.
4. Examine strategies to promote health literacy.
5. Describe the continuum of interpersonal skills necessary for cultural competence.
6. Review strategies that facilitate culturally competent communication in vulnerable
populations.
7. Describe approaches to ensure culturally competent health promotion programs.
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Introduction
 Vulnerable populations are diverse groups of individuals who are at
greatest risk for poor physical, psychological, and/or social health outcomes.
 Vulnerable populations are more likely to develop health problems, usually
experience worse health outcomes, and have fewer resources to improve
their conditions.
 Various terms have been used to describe vulnerable populations, including
underserved populations, special populations, medically disadvantaged,
poverty-stricken populations, and American underclasses.
 Vulnerable groups include persons who experience discrimination, stigma,
intolerance, and subordination, and those who are politically marginalized,
disenfranchised, and often denied their human rights.
 Vulnerable populations may include people of color, the poor, recent
immigrants and refugees, homeless persons, mentally ill and disabled
persons, and substance abusers. 3

Introduction
• The values, attitudes, culture, and life circumstances of individuals who are
poor, socially marginal, or culturally different from traditional mainstream
society, and the communities in which they reside, must all be considered
when planning health promotion and prevention activities.
• It is critical to promote positive health behaviors by taking into account the
factors that reflect the health determinants of vulnerable populations.
• Despite improvements in health and spending more money on medical care
than any other country, the United States ranks near the bottom on key
health indicators, and health disparities persist, depending on an individual's
racial/ethnic background and socioeconomic (income and education)
characteristics.
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Determinants of Health Disparities and Health Inequities
• Social determinants of health are the structural and economic conditions in
which people are born, live, work, and age (World Health Organization,
2013).
• These conditions are also responsible for health inequities and are shaped
locally, nationally, and globally by economic distribution, social policies,
and politics. In other words, money, power, and resources are responsible
for the major inequities in health.
• Health inequities are avoidable inequalities in health between groups of
persons that arise from social and economic conditions which increase their
risks for illness and access to health promoting and preventive services.
• Health equity—the absence of health disparities across populations,
genders, and geographic areas—can be achieved by empowering
individuals and communities to challenge and change the distribution of
social resources, as well as advocate for social policies that ensure equal
access for all.
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• Health inequities are well documented and are thought to be the result of
complex interactions between multiple factors:
1. Biological variations
2. Health care access
3. Personal health behaviors
4. Social and economic resources
5. Culture
• One approach to investigating health disparities is to look at the various risk
factors that increase the possibility of inequalities. Risk factors include personal
health behaviors, population characteristics, health care characteristics, the social
and physical environments, and the types of diseases that are disproportionately
diagnosed in vulnerable groups.
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• The most important social determinants of health inequities are thought to
be structural influences, or factors that generate and reinforce social
stratification and social class divisions in a society, as well as define one's
socioeconomic position.
• Socioeconomic position provides access to power, prestige, and resources
and is based on a person’s income, education, and occupation. Other
important structural determinants include gender, social class, and race/
ethnicity.
• Other important structural determinants include gender, social class, and
race/ ethnicity. These determinants are shown in the model of WHO that
describes the social determinants of health.
• The model depicts how governance structures, or the sociopolitical context
influences one’s socioeconomic position through the distribution of
resources.
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• Socioeconomic position shapes intermediate health determinants.
• Intermediary determinants that are determined by socioeconomic position
include the following:
Material characteristics: neighborhood, housing, physical working conditions, buying potential
Behavioral factors: nutrition, physical activity, tobacco use, alcohol use
Psychosocial factors: stressful living conditions and relationships, social supports, coping resources
• Intermediary determinants are reflective of an individual’s place in the social
hierarchy, which results in differential exposure and vulnerability to health-
compromising conditions.
• All of these factors determine one’s health status and well-being.
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WHO Framework Describing Structural Determinants of Health
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Socioeconomic Determinants
• The key components of socioeconomic position have been shown to be the
source of population-level health disparities.
 Minorities have substantially lower incomes and educational levels
 Income is a powerful variable that explains health status.
 High-risk behaviors have been correlated with lower educational levels.
 The effects of low socioeconomic status are long lasting.
 The cumulative wear and tear of the adverse experiences of living in poverty, with its multiple
challenges, results in chronic illnesses.
 Minorities of all races and ethnicities are far more likely to be underinsured or without health
insurance.
 Poor individuals also experience greater barriers in accessing care, have more difficulty getting an
appointment, and wait longer during health care visits.
 Many communities of poverty mistrust the government and government-controlled programs.
• Socioeconomic barriers to accessing care exist for vulnerable populations.
• These barriers have been repeatedly documented and need to be addressed
to improve access to quality health care.

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Promoting Equity in Health
• Achieving equity in health means that everyone has the opportunity to attain
their full health potential, and no one is disadvantaged because of social,
demographic, or geographic differences.
• Health disparities can be eliminated through the promotion of health equity,
which minimizes avoidable differences between groups of people who have
diverse levels of underlying social advantage.
• Health equity can be achieved only through interventions that address the
multiple health determinants:
Social: networks, connections, institutional links
Economic: money, time, prestige
Sociocultural: skills, education, knowledge, language, religion, family background
Political: power, distribution of resources

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Multilevel interventions
• Successful outcomes result from multilevel interventions and programs that
are directed to individuals, communities, and social policies.
• Multilevel interventions address several factors to effect change in
individuals and their socioeconomic context.
• Multilevel interventions go beyond individual-focused strategies to
structural and socioeconomic influences to promote change.
• These types of interventions incorporate both qualitative and quantitative
methods to implement programs and evaluate outcomes.
• They are complex, pose many challenges, and require input from multiple
sources, such as interdisciplinary health care teams, community
organizations, and local and state governments.

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Community Empowerment
• At the community level, empowerment is a key strategy for reducing health
inequities.
• Community empowerment is a social action process that enables individuals,
communities, and organizations to gain control over their lives within their social
and political context to promote equity.
• Local community organizations empower individuals by working together to
build trust and improve neighborhood programs.
• They also work with community members to advocate for new programs and
resources for their neighborhoods. E.g., after-school programs for youth, parks for leisure activities
for families
• The ultimate goal of community empowerment is to create relationships and
policies to promote health equity.

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Community Empowerment
• Focusing on working conditions, household and neighborhood hazards, and
availability of community resources such as healthy foods and physical activity
areas brings attention to environmental factors that can be changed within
communities and work sites.
• Community-based organizations (CBOs) are logical places to start bringing about
community change because they are deeply embedded in the life of the community.
• They are organizational sites where community members meet to socialize or
address their concerns.
• CBOs are places where individuals can learn skills that empower them to address.
• Leaders of CBOs can represent and advocate for the community.
• Empowered CBOs are able to build community capacity, as they know the
strengths, weaknesses, and availability or lack of resources within their community.

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Community-based participatory research
• Community-based participatory research (CBPR) is a method that integrates research with
socialaction.
• It is an effective way to build community capacity, as the method functions to transform
power structures to create knowledge and promote actions for social change through
community engagement.
• CBPR has been successfully implemented to expose power inequities in disadvantaged
communities.
• This strategy enables community voices to be heard.
• Wallerstein and Duran (2010) have identified barriers to implementing CBPR and
strategies to address these barriers.

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Policy advocacy
 The socioeconomic and structural gradients in this country, as well as their
relationship to health disparities, necessitate the development of policies to
address the social determinants of health inequities.
 Public policies influence the prerequisites of health in three key areas: early
childhood development, employment, and income.
 Public policies to address these key areas have all been associated with lower
rates of poverty and income inequities.
 Nurses and all other health professionals need to become knowledgeable
about the political economy of health and public policy analysis to be able to
advocate for health policies that promote healthy communities and equitable
socioeconomic conditions.

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Policy advocacy
 Political competence can be developed through courses and dialogues with
knowledgeable others.
 Working in collaboration with all stakeholders enables nurses to raise
awareness of health inequities, advocate for change, and take action, such as
lobbying to promote change.
Primary Care
 Primary care offers an effective mechanism for achieving health equity, as
interventions are directed at individuals versus diseases.
 Primary care is complex and requires community engagement and respect for
individual and family viewpoints.

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Primary Care
 It is an efficient, rational way to provide care for all people.
 Investments in a primary care infrastructure have been shown to impact
health equity.
 Nurses are leading primary health care interdisciplinary teams and
conducting community-based initiatives to:
Promote community participation in health.
Provide health care and education, and
Advocate for communities.

Health literacy and Vulnerable Populations
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 Vulnerable populations are adversely affected by low health literacy, which has
been associated with worse health status, poorer health knowledge and
comprehension, increased hospitalizations and use of medical services, and
decreased participation in preventive activities, such as mammogram screening
and influenza immunizations.
 Minorities, the elderly, people with less than a high school diploma, people
who spoke another language before starting school, people who do not speak
English, and people living in poverty are among the vulnerable populations.
 Health literacy is an empowerment tool, as persons with higher health literacy
are able to access and analyze information to make better health care decisions,
which results in positive health outcomes.

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 Health literacy is defined as a set of skills required for an individual to
function effectively in the health care environment and act appropriately on
health information.
 It can also be defined as an individual’s capacity to obtain, process, and
understand basic information and services needed to make appropriate health
care decisions (IOM, 2004).
 Other common descriptions of health literacy include medical health
literacy, clinical health literacy, or functional health literacy, as health literacy
refers to the skills needed to function in the health care system.
 The World Health Organization adopted a broader definition, as it defines
health literacy as the cognitive and social skills that determine the motivation
and ability of an individual to gain access to, understand, and use information
in ways that promote and main- tain good health (Kumareson, 2013).

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 Within this definition, three typologies of health literacy have been identified:
Functional: basic reading and writing skills to understand and use information.
Interactive: cognitive skills to interact with health care professionals, interpret and apply
information.
Critical: cognitive skills to analyze information to be able to exert control over one’s health.
 Clients with low health literacy require specific skills to effectively manage their
health, such as reading, writing, and mathematical skills, as well as the following.
When to seek health information or care
Where to seek health information
Verbal communication skills
Assertiveness skills
Skills to process and retain information
Skills to apply information

Strategies to Promote Health literacy
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 Addressing vulnerable populations' literacy needs is a fundamental
component of designing health promotion programs and interventions.
 The key elements include the following:
Presenting the most important information first.
Breaking complex information into small, understandable parts.
Using simple language and defining technical terms.
Using the active voice.

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Oral messages
 Strategies for delivering clear messages incorporate plain language principles.
 Messages need to reflect the age, language, literacy level, and cultural diversity
of the target individual or group.
 Messages must be relevant to the key beliefs, attitudes, and values of the
group, using familiar and acceptable language and images.
 Messages may need to be presented multiple times using narratives and visual
illustrations to capture attention and reinforce content.
 Tailored cultural messages that use the client’s personal information are more
effective than standard communication.
 Communication channels that are familiar to the client and are easily
assessable are more effective.

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Culturally tailored Messages
 Culture influences how individuals understand and respond to information.
 For low-literacy, culturally diverse populations, only terms that the individual
or groups are comfortable with should be used.
 Do not assume that all minority groups are alike.
 Consider the subpopulation and geographic location.
 Differences exist within the same culture or ethnic group, depending on the
age, gender, class, or religious practices.
 Collaboration with organizations in the participant’s community enables the
nurse to learn local beliefs and attitudes.
 If an interpreter is needed to convey information, someone from the same
community who has experience in translating and knows the local language
should be chosen instead of relatives or minors.

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Teach-Back Method
 The “teach-back” technique is an effective method to assess and verify an
individual’s understanding of information provided during an interaction.
 This method goes beyond asking clients if they understand.
 For example, after a demonstration that shows how to wear a pedometer and
reset the steps, the client is asked to do the procedure.
 If it is not performed correctly, the information is clarified, or another approach
is implemented to teach the information.
 The client should practice until the skill is mastered, or the instructions are
understood.
 It is important not to rush, and to remain patient and provide positive feedback
with each step of the procedure or activity being demonstrated.

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Written Messages
 Written information should be attractive and easy to read.
 Strategies for effective written messages include the following:
Write specifically for your target audience.
Use positive words and “must” when stating a requirement instead of “shall.”
Use a large font.
Avoid using fancy script and all capital letters.
Use headings and bullets and leave large amounts of white space between sections.
Write short sentences.
Avoid jargon, legal, or technical language.
Present numerical information in tables.
 Nonprint materials also can be used to communicate information. For example,
videos are helpful for demonstrating procedures such as how to wear a
pedometer. Pictures can supplement written or verbal information.

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Internet messages
 Persons with limited health literacy are less likely to use the Internet and online
health information, although this information may lower literacy demands
through the use of audio, video, and graphic information.
 Limited Internet use is thought to be due to absent or limited computer access,
lack of computer training, and lack of skills or family support for skill
building.
 These issues can be addressed with hands-on training and design features that
facilitate navigation of the Internet. Other strategies include the following:
Engage users with interactive content using plain language.
Incorporate audio and video features and organize information to minimize searching
and scrolling.
Provide simple search options.
Apply user-centered design principles.
Conduct usability testing.

Continuum of Cultural Competence
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 Bushy's (1999) classic continuum, which addresses individuals, ranges from
ethnocentrism at one end of the spectrum to enculturation at the other.
 Ethnocentrism refers to the assumption or belief that one's own way of
behaving or believing is the most preferable and correct, and that it will be
used to judge all cultural groups.
 This view devalues the beliefs of other cultural groups or treats them with
suspicion or hostility.
 Cultural awareness, the next stage on the continuum, refers to an appreciation
of and sensitivity to another person’s values, beliefs, and practices.
 Next, cultural knowledge refers to gaining understanding of and insight into
different cultures

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 The continuum progresses to cultural change and then cultural competence,
the level at which health care providers are aware, sensitive, and
knowledgeable about another’s culture and have the skills to conduct culturally
competent health promotion activities.
 The final anchoring point is enculturation, which refers to fully internalizing
the values of the other culture. Enculturation is evident when the nurse
develops culturally sensitive health promotion programs in collaboration with
individuals in the cultural group and incorporates members of the culture to
deliver and evaluate the intervention.
 Cultural competency is evident when diversity is valued, and differences are
respected and accepted.

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 Developing cultural competence is not a linear process. Progress depends on
attitudes, life experiences, exposures to other cultures, and receptivity to
learning about new cultures. Progress also depends on institutional policies
and practices.
 These continua offer a mechanism for assessment of individuals and systems to
facilitate designing training courses and workshops that are tailored to the level
of cultural competence.
 Cultural competency programs have three essential components: awareness,
knowledge, and skills.
First, awareness of one’s own cultural beliefs, values, and biases is the focus.
Second, cultural knowledge and life experiences of the other’s culture as well as cross-
cultural communication are taught.
The third component incorporates the development of skills. These skills, including
verbal and nonverbal communication skills, need to be practiced under supervision,
using role-playing or other teaching strategies, such as videotaping.

Strategies for Culturally Competent Communication
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 Culturally competent communication skills build trust relationships with
diverse clients. Trust is necessary to obtain valid information to develop
interventions or manage issues of concern.
 The culturally competent communication model emphasizes verbal and
nonverbal skills, recognition of potential cultural differences, incorporation
of cultural knowledge, and negotiation and collaboration.
 Verbal skills should reflect respect and empathy, nonjudgmental concern and
interest, reflections, and follow-up questions.
 Nonverbal behaviors should also reflect respect, concern, and interest in the
client’s well-being. Skills include active listening and focusing on the client.

Strategies for Culturally Competent Communication
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 Recognizing cultural differences requires monitoring potential cultural
misunderstanding to prevent crossing cultural boundaries. Observing the
client’s reactions, asking for the client’s perceptions, and exploring client
preferences and understanding are useful strategies.
 Communication skills for negotiation and collaboration require awareness
and adaptability to come to a shared understanding and agreed-upon
priorities. Shared decision making is vital, as the client is a partner in a
culturally competent communication model.
 Advanced communication skills and cultural awareness enable the nurse to
avoid stereotyping clients and ignoring cultural issues.
 In summary, health professionals must challenge their own practices and
cultural values and develop effective culturally competent communication
skills to avoid reinforcing stereotypes to be able to successfully manage
client encounters.

Considerations in Designing Culturally Competent programs
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 Assessment of characteristics of vulnerable populations that may affect
successful health promotion is the first step to achieving goals established in
partnership. These factors include demographic, cultural, and health care
system variables.
 Because language is an obvious demographic difference among diverse groups,
knowledge of the language spoken is a key feature in the delivery of programs.
Inability to communicate in the dominant language creates barriers in
accessing programs and health care.
 Geographic location is another major factor to consider, as the physical
environment plays a significant role in promoting healthy behaviors. Poor
urban neighborhoods are associated with areas that are unsafe.

Considerations in Designing Culturally Competent programs
36
 Cultural factors that may affect the success of health education also should be
identified. Social customs and norms—including touching, shaking hands, eye
contact, and smiling—may have different connotations.
 Religious or spiritual practices also need to be considered.
 Family relationships and the concept of family also differ across cultures.
 Time orientation refers to how the perception of time varies among cultures.
 Health care system factors also are important to assess prior to health
promotion efforts.
 Due to cost, distance, transportation, and language barriers, vulnerable
populations have difficulty accessing care and participating in health-
promoting programs.
 Program acceptance depends on multiple factors, including lack of trust,
prior interactions with health care providers, and a failure to incorporate the
client’s cultural values.

Strategies for Culturally Competent interventions
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 Strategies to make health promotion programs and materials more culturally
appropriate are available.
 These strategies can be classified into six categories:
 Peripheral.
 Evidential.
 Linguistic.
 Constituent involving.
 Sociocultural.
 Cultural tailoring.

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1. Peripheral strategies
 It involves packaging programs or materials to reflect the target culture.
 Colors, images, pictures, or titles are used to reflect the social and cultural world of
the targeted group. Thus, the information is viewed as familiar and comfortable.
 Materials that are matched to one’s culture also help establish credibility and create
interest, increasing acceptance and receptivity of the information.
2. Evidential strategies
 Are those employed in the presentation of information in order to increase the
perceived relevance of the topic for the specific cultural group.
 For example, providing diabetes prevalence information has been used to raise
awareness and promote lifestyle change in high-risk groups.
 The message becomes more meaningful when it is perceived to be directly
applicable to those receiving the message.

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3. Linguistic strategies
 Are used when materials and programs are provided in the dominant language
of the cultural group.
 Strategies such as translating materials or delivering the program in the native
language of the target culture are critical.
4. Constituent-involving strategies
 Are implemented to capitalize on the experiences of the target population.
 Using peers or lay helpers, as well as professional members of the target
population, for example, makes culturally competent teaching possible.
 Lay health advisors serve as role models and advocates for members of the
community.

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5. Sociocultural strategies
 Build on the group’s values and beliefs.
 Facilitates the cultural meaningfulness of the material or programs.
 Programs that are culturally meaningful and delivered in familiar locations have been
shown to be more effective to change behavior in vulnerable populations.
6. Cultural tailoring strategies
 Are any combination of change strategies intended to reach an individual based on
characteristics unique to that person.
 Targeted strategies differ from tailored strategies; the group is the focus when
targeted strategies are used.
 Both targeted and tailoring strategies are important.
 When individual differences are small, the group can be the major target. When
unique individual differences are evident, cultural tailoring strategies that focus on
the individual are needed.

Summary
 Despite significant progress in people's health due to basic
improvements such as safe drinking water, sanitation, the availability of
nutritious food, and advances in medical care, evidence shows that
structural factors such as a person's social class and socioeconomic
position in society are powerful predictors of health status.
 Health and illness follow a social gradient at all income levels, with
lower socioeconomic levels associated with poorer health.
 Vulnerable populations face a variety of health threats that necessitate
the attention of clinicians, researchers, and policymakers. Although the
contributing factors are numerous and complex, many of them are
modifiable.
 As primary care providers, nurses can take the lead in developing and
implementing culturally competent health promotion programs that
promote health equity for diverse populations.
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Unit 12 Health Promotion in Vulnerable Populations.pptx

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