# Principles of Public Health Practice/‘Vulnerable’ groups

We are embarking on a difficult journey over the next three weeks. We will be looking at vulnerable groups and just why they might be vulnerable. Who has done the wounding? We will also explore something of the health care system and public health's relationship with such a system. Finally, we will be considering the future or futures of public health. Three tough topics; but, you should be able to apply what you have already learned in a more sophisticated manner than when you began to consider the principles of public health practice.

## Learning activity instructions

Each week we hold a lectorial and a tutorial. A lectorial is a short lecture followed by a group activity, and the tutorials are for discussion and practising group activities.
Lectorial
* View the playlist here.
* Review the story, the background information and scan the references and resources.
* Attend the lectorial and be prepared to consider how vulnerability might be viewed both positively and negatively.
Tutorial
* Prepare to attend the tutorial sessions by considering more carefully the issue of stigma. Keep working over the next few weeks on this concept. It is not always easy to be aware of how stigma influences us and how we influence others because of it.
* Attend the tutorial session to view and comment on the recorded presentations.
* Progress your final assessment (instructions shortly).

## 'Vulnerable' groups

One aspect of being a member of a vulnerable group has to do with not having your just claims heard and responded to. Your claim can be dismissed because of a stain that is superimposed on you. At one time, having a mental illness often meant that you were painted as dangerous and deranged. Bizarre behaviours associated with the temporary loss of higher cognitive functioning and radical changes in perception were seen as a revelation of your true character or a permanent state of your "soul", however that might have been conceived.
I can point you to a very enlightening little book that will help you delve into this topic. It was written by William Ryan and is titled, Blaming the Victim (revised, 1976). Ryan cuts through the cant that is often offered by the middle-classes for the plight of the under-classes. It is relatively easy to highlight the personal characteristics that perpetuate the poverty of a person. We seem to have a harder time identifying the unjust relations that the poor often have with other members of a given society. Many of us might be the very people who are keeping others down. Must of us do not like bearing the stigma of colluding with the oppressors. In fact, we manage that stain by ensuring that it wipes off on another, the victim.
But, a stigma is not merely about a stain.
It is an injury to a basic understanding of who we are and how we value ourselves before others. Richard Sennett and Jonathan Cobb have explored this in their The Hidden Injuries of Class (1973). To be vulnerable is to be wounded is some way. That is what the Latin root of the word means (vulnera, pl. for wounds). Working with vulnerability means wondering how you or I might have been part of the original wounding or re-wounding. Such wounding allows us to control others to our, often unacknowledged, advantage. The wound is a tender spot that we can poke a finger into to get people moving the way we wish for them to go. You will have examples of this from your own life.
We may not have been part of the original wounding. Yet, it is very likely that we bear some fault for re-wounding. That is almost unavoidable. We cannot give up the important gains that we have made in terms of our knowledge and capacities for performance. But, we can give them over; we can transfer the knowledge and the capacities. We can allow others the spotlight of positive appraisal. We can support the leadership of others whom society might not otherwise acknowledge.
All things considered, interventions that turn the tables on who is in control have a better chance of succeeding. Perpetuating the the status quo is just another form of wounding. At least, that is my contention. I offer it having worked with Mibbinbah Limited, the only Indigenous male health promotion charity in Australia, since its inception in 2009.

## Background

An approach to the issue of vulnerability was described above. It was offered to get participants to start thinking about the concerns of woundedness and stigma. However, you will need to go further in terms of being more specific about what vulnerability and stigma might mean in terms of our public health practice. Shi and Stevens (2010) offer an extensive exploration of what it means for people to be members of vulnerable or at risk populations. Just remember that members of populations are still people. They are individuals, members of families and groups, as well as of communities and their larger societies.
After an introduction to a general framework for study, you will find some materials that will elaborate key issues relating to labelling and stigma as it relates to public health practice. Examples from a global perspective are provided to help you consider these issues in a variety of contexts. This should begin to help you broaden your perspectives as you reflect on lives that might be lived differently than you are typically familiar with.
Finally, a large selection of resources are provided that may provide insights into how we might work with various vulnerable groups. They cover the various dimensions of public health such as protection, prevention and promotion. They also touch on the personal, social and environmental dimensions. They also engage vulnerable communities in terms of the prerequisites of health, as well as the health care system.
Try to review the variety to see what the various factors and dimensions consist of in differing circumstances. If you see something that will help you with your assessments, use it. If not, use what is hear to better consider your search parameters and get stuck into your search for supporting materials.
References and Resources
Introduction:
A general framework to study vulnerable populations (2010, Second Edition) In, Vulnerable Populations in the United States. Shi, L. and Stevens, G.D., John Wiley Press.
http://media.johnwiley.com.au/product_data/excerpt/59/04705993/0470599359-160.pdf
Labelling and Stigma:
Some definitions:
http://www.healthknowledge.org.uk/public-health-textbook/medical-sociology-policy-economics/4a-concepts-health-illness/section3
http://www.healthknowledge.org.uk/public-health-textbook
Some examples:
The Shifting Global Health Landscape: Implications for HIV/AIDS and Vulnerable Populations (Stigmatisation), Issue Brief (July 2010) amfar: The Foundation for AIDS Research, Washington, DC.
http://www.amfar.org/uploadedFiles/_amfarorg/Around_the_World/Vulnerable-Populations.pdf
Stigma, prejudice and discrimination in global public health (Estigma, preconceito e discriminação na saúde pública global), Cadernos de Saude Publica 28(1), Rio de Janeiro, January 2012. Richard Parker, Mailman School of Public Health, Columbia University, New York, USA.
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2012000100017
Key Issues and Strategies:
Communicating effectively with vulnerable populations during water contamination events (2010) Phyllis A. Nsiah-Kumi, Journal of Water and Health 6.51.
http://www.iwaponline.com/jwh/006/s063/006s063.pdf
Identifying and protecting vulnerable populations in Public Health Emergencies: Addressing gaps in education and training. Wingate, M.S., Perry, E.C., Campbell, P.H., David, P., Weist, E.M. (2007) Public Health Reports 122(3):422-426.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847489/
Identifying vulnerable populations using a Social Determinants of Health Framework: Analysis of National Survey Data across six Asia-Pacific countries. Ward, P.R., Mamerow, L. and Meyer, S.B. (2013) PLOS| One.
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0083000
Health literacy and vulnerable groups: What works? Thomacos, N. & Keleher, H. (2009) Melbourne: Department of Health Social Science, Monash University.
http://www.enliven.org.au/Documents/Plans%20&%20Projects/What%20we%20have%20done/Reports/SEHCP%20Health%20Literature%20&%20Vulnerable%20Groups%202011.pdf
Focus on vulnerable populations and promoting equity in health service utilization—an analysis of visitor characteristics and service utilization of the Chinese community health service, Dong, X., Liu, L., Cao, S., Yang, H., Song, F., Yang, C., Gong, Y., Wang, Y., Yin, X., Xu, X., Xie, J., Sun, Y. and Lu, Z. (2014) BMC Public Health 14(503).
http://www.biomedcentral.com/1471-2458/14/503
Opportunities for Engaging Low-Income, Vulnerable Populations in Health Care: A Systematic Review of Homeless Persons’ Access to and Use of Information Technologies. McInnes, D.K., Li, A.E., and Hogan, T.P. (2013) American Journal of Public Health 103(S2).
http://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2013.301623
Health security among internally displaced and vulnerable populations in eastern Burma. Mahn, M., Teela, K.C., Lee, C.I. and O’Connor, C. (2008) In, Dictatorship, disorder and decline in Myanmar, Skidmore, M. and Wilson, T. (Eds.) ANU E Press.
http://press.anu.edu.au//myanmar02/pdf/ch12.pdf
Victorian Public Health and Wellbeing Plan 2011–2015 (2011) Prevention and Population Health Branch, Victorian Government, Department of Health, Melbourne, Victoria.
http://docs.health.vic.gov.au/docs/doc/8532A3E8DAD73048CA2578FE000571F5/$FILE/vic-public-health-wellbeing-plan.pdf

## Learning Outcomes

Which ‘vulnerable’ groups are most likely to benefit from public health interventions, and which might resist regardless and why?
Upon completion of this topic, through your own investigations, group preparation, tutorial participation and lectorial explorations, you should be able to:
   * Outline a typical definition of vulnerability from a public health perspective and discuss the definition's strengths and weaknesses.
   * List a number of groups which might be typically described as vulnerable from the point of view of public health practice and describe their characteristics.
   * Provide both an argument and a counter argument for why each of a number of groups might be considered vulnerable.
   * Articulate reasons why it might be practically beneficial for a group to consider itself vulnerable and why it MAY NOT be beneficial.