Part 1 – Vulnerable Populations and the Social Economic Inclusion and Exclusion Framework

Google dictionary defines the term vulnerable as being ‘susceptible to physical or emotional attack or harm’ (Google, 2018). Extending this definition to a vulnerable population within the context of health care, the term vulnerability reflects a group of people who are more susceptible to adverse health outcomes and are more greatly impacted by the determinants of health.

In 2012, the Atlantic Center for Excellence in Women’s Health (ACEWH) and the Nova Scotia Advisory Commission on AIDS (NSACA) co-created a case study that outlined the need for specific considerations when creating public policy (ACEWH & NSACA, 2012). In this document, the authors outline a framework that can be used to assess how a population can become more susceptible to the determinants of health. The framework, known as the Social and Economic Inclusion and Exclusion Framework (SEI) considers positive and negative influences on an individual within their society. The positive, or ‘inclusion’ influences are those factors that create a sense of belonging within a society. Put another way, they are the factors that help an individual, or group of individuals to feel they are free to participate in their community. The negative influencers are the exclusion factors that lead to a sense of segregation and isolation from society. These have detrimental impacts and can increase the susceptibility to the determinants of health.

The ACEWH & NSACA (2012) further suggest that these inclusion and exclusion factors are indicators of the health of a society. Specifically, the document outlines that the presence of inclusion factors are suggestive of a vital community, reflect social cohesion, and can result in economic strength. On the flip side, exclusion factors are indicative of ‘social dislocation’ and can result in decreased prosperity in a society. Fewer opportunities are available, and the ability for an individual and/or a society to realize their full potential becomes limited. This analysis of the health of society supports Brook’s (2017) recommendation that a measure of tolerance be included in the definition of health.

With this framework in mind, we can consider a vulnerable population, and examine the inclusion and exclusion factors experienced by the individuals. For example, individuals within the LGBTQ population have likely experienced a sense of exclusion due to attitudes and fears that other individuals within society exhibit. These attitudes and behaviours can attach stigma to this population, which result in discrimination, and can reduce an individual’s sense of safety when accessing health care (Colpitts & Gahagan, 2016). Not only can individuals from this population feel excluded from society, but they may become further isolated and harmed as they choose not to attend to health needs as their health care system is unable to make them feel included, safe or valued.

Not all discrimination is overt, which can make it more difficult to see and understand. In her thought provoking TedTalk Helen Turnbull (2013) explains how human nature looks to include or exclude, based on how similar another is to ourselves, or, how another individual fits our idea of ‘typical’. Ms. Turnbull notes that these biases are often times subconscious, but not without their own ability to influence our behaviours and judgements.

As a health care professional, my ethical standards hold me to a higher expectation, that does not support these biases and resulting ‘excluding’ behaviours (NSCPT, 2005). This is where cultural sensitivity and diversity training, self-assessment and reflection become important practice for all involved in providing care to vulnerable populations. And, as when we consider chronic disease within a multilevel framework, change at the individual level is not enough. We must also consider community, organizational, and policy levels of influence, and how these include and exclude specific populations.

In part 2, I will consider how community- and organizational-level factors can impact on vulnerable populations. By reflecting on conversation with my colleague Geraldine Young, I will consider how Nova Scotia and Alberta are addressing these issues of inclusion and exclusion.

References

ACEWH & NSACA (2012). HIV/AIDS and Vulnerable and/or Marginalized Populations in Nova Scotia: Making the Case for Gender and Social Inclusion in Public Policies. Atlantic Centre of Excellence for Women’s Health and the Nova Scotia Advisory Commission on AIDS. Retrieved on November 9, 2018 from: https://novascotia.ca/aids/documents/HIV-AIDS-Vulnerable-Marginalized-Populations-Nova-Scotia-2013.pdf

Brook. R. H. (2017). Should the definition of health include a measure of tolerance? JAMA, 317 (6), 585-586. doi:10.1001/jama.2016.14372 (link https://0-jamanetwork-com.aupac.lib.athabascau.ca/journals/jama/fullarticle/2601506)

Colpitts, E. & Gahagan, J. (2016). “I feel like I am surviving the health care system”: understanding LGBTQ health in Nova Scotia, Canada. BMC Public Health, 16:1005. DOI: 10.1186/s12889-016-3675-8

Google (2018). Vulnerability definition. Retrieved November 12, 2018.

Turnbull, H. (2013). Inclusion, Exclusion, Illusion and Collusion: Helen Turnbull at TEDxDelrayBeach [video]. Retrieved November 9, 2018 from: https://youtu.be/zdV8OpXhl2g

NSCPT (2005). Nova Scotia College of Physiotherapists Code of Ethics. Retrieved November 12, 2018 from: https://nsphysio.com/resources/Physio_Code_of_Ethics.pdf