Vulnerability and Health Promotion in the Homeless Population

John DeOpsomer

Winner of the Braun Award for Writing Excellence in the College of Health and Human Services, Category I

Nominated by Robert Kelch, Assistant Professor of Nursing

John DeOpsomer is a senior at SVSU studying for his bachelor of science in nursing. When he graduates in Fall 2022, he plans to provide for those in his community in most critical need of care: those in an intensive care unit. OriginallyfromBayCity,Michigan,andagraduateofEssexville’sGarber High School, he has had the honor of serving as the representative of his cohort at the Student Develop meetings held by the nursing faculty each semester. He is also amemberoftheThompsonScholarsandisverygrateful forthegenerousefforts the Thompsons make to help college students afford their education.

Thispiecewas written in Fall 2021for Professional IntegrationIII (NURS 391), a class in the third semester of the nursing program. The course was collectively taught by Dr. Robert Kelch,assistant professor of nursing; Dr. Sherry Kaufman, assistant professor of nursing; and Dr. Tami Pobocik, professor of nursing. The primaryfocusoftheclass concernedcommunityhealthandhomecare.Students were given the concept of vulnerability and had to choose two related concepts, one being a specific population of people and the other of the student’s choice. According to John, one of the biggest challenges of writing this piece was ensuring the audience would understand the importance of health promotion for the homeless population even if his readers had no formal education in health. Another challenge, John asserts, was ensuring he accurately covered the topic, doing it justice in the page constraints he was given. Through this piece, John notes, he has furthered his understanding of the hardships the homeless population faces and how healthcare professionals should approach the topic of vulnerability to ensure these individuals are cared for appropriately.

Life is complex, and the situations in which humans find themselves can vary greatly. People may go from living stable lives to finding that everything changes around them, leaving them vulnerable to disaster and undesired health outcomes. Such vulnerability is an important and highly discussed concept in the field of nursing, and a person’s status within this classification can constantly shift. However, some individuals are in a constant state of vulnerability, unable to grab hold of a metaphorical lifeline to save themselves One such population is the homeless. Through health promotion, nurses can encourage these individuals to improve their situation and provide them with education and resources to do so. This paper examines the concepts of vulnerability and health promotion in the homeless population to further the audience’s understanding of this complex problem and how healthcare workers can respond to it

Defining Vulnerability and Health Promotion

As frontline healthcare workers, nurses have an obligation to partake in health promotion for patients, especially those from vulnerable populations, for them to be effectively treated. StanhopeandLancaster (2020)definevulnerabilityas “susceptibilitytoactual orpotentialstressors that may lead to an adverse effect” (p. 701), and those considered vulnerable have a greater risk for poor health The homeless population fits this definition unequivocally. Whereas vulnerability describes the status of an individual, health promotion is a way in which the field of health attempts to promote positive outcomes for vulnerable individuals The World Health Organization (2021) defines health promotion as “the process of enabling people to increase control over, and to improve, their health” (para. 1). Through this process, vulnerable populations can be provided the education and resources necessary to better their situation and effectively care for themselves.

Vulnerability Model

The Vulnerability Model is a conceptual nursing model used to examine the factors that contributeto vulnerability in patients or populations. Accordingto Lange (2021),it is based onfour domains: biological domain, environmental domain, behavioral domain, and sociocultural domain. These domains represent important influences in a person’s life, and each domain has specific associated factors that affect a person’s state of vulnerability. Using this model as a guide, this paper will examine and describe the homeless population through each domain to portray their vulnerability status and need for health promotion.

Biological Domain

The factors contributing to vulnerability related to the biological domain are focused on inherent things people cannot change, including the presence of mental illness, sexual identity, age, race, and genetic predisposition to disease. The homeless population has no more reprieve from these factors than any other classification of people, but one specific biological factor that is very pervasive in the homeless population is mental illness. According to Gutwinski et al. (2021), the prevalence rate of homeless people living with mental disorders is 76.2%, with 12.4% being classifiedashavingschizophreniaspectrum disorders, 12.6%ashavingmajordepressiondisorders, 4.1% as having bipolar disorders, 36.7% as having alcohol use disorders, and 21.7% as having drug use disorders; additionally, 25.4% fall under the blanket category of personality disorders. These high rates, with some individuals falling into more than one category, indicate a need for mental health promotion for this population.

Mental health can be managed and treated when known, but when inadequate emphasis is placed on finding and treating those with disorders, this population is extremely vulnerable. Unmanaged mental health conditions can lead to adverse outcomes like violence and self-inflicted harm and, in a worst-case scenario, death. Nurses can utilize health promotion to help these individuals find the resources and information they need to be treated adequately Resources like mental health centers, psychiatric services, and counseling can improve the lives of these individuals.

Environmental Domain

The environment in which one lives, works, or spends time recreationally can have a large influence on vulnerability. Factors associated with the environmental domain that contribute to vulnerability include a lack of housing and domestic abuse. A lack of affordable housing, in particular, is a significant issue in the homeless population today. According to Martin (2015), poverty has been increasing and the availability of low-income housing units has been decreasing since the 1980s, making housing acquisition for the homeless population very difficult. Reasons contributing to this issue relate tothe negative characteristics that these individuals have in the eyes of employers and that prevent them from getting jobs, including a lack of job skills and previous work experience, minimal education or formal job training, a history of mental illness, inadequate records of previous work history, and substance abuse Nurses must engage in health promotion to help prevent this crisis. By performing primary preventative interventions, such as working with policymakers to resolve the housing crisis, nurses can promote resilience rather than vulnerability in these individuals.

Behavioral Domain

Although many might think the biological and environmental domains are some of the most important factors in contributing to vulnerability, as they fit into the classic debate concerning nature versus nurture, behavioral practices have a significant influence as well. Individuals have free will, and, as such, activities in which they choose to participate are also important factors contributing to vulnerability. Factors in this domain that may lead to vulnerability include alcohol abuse, drug abuse, poor diet, inadequate physical activity, risky sexual practices, and inadequate rest. Substance abuse, in fact, is a very common factor that keeps the homeless population vulnerable to a poor health status. Gutwinski et al. (2021) found that of the homeless population with mental disorders, around 37% of them were plagued with disorders related to alcohol abuse and 22% with disorders related to drug abuse, with the alcohol abuse prevalence being almost ten times the 3.4% prevalence rate seen within the general population Substance abuse has extremely detrimental effects on the health of an individual, and these significant rates of substance abuse in the homeless population must be addressed. Health promotion for these individuals can include counseling, therapy, and rehabilitation programs that may greatly help these individuals get back on track and take more control over their health. Without this health promotion, they may stay stuck within the same cycle and worsen their health status. Street nurse programs have been developed that work to help substance abusers take greater control of their health not only through education, but by providing them the means to take their drugs safely and prevent the spread of such illnesses as hepatitis and human immunodeficiency virus (HIV)

Sociocultural Domain

Along with behavioral practices, sociocultural status is also an important aspect of life that can affect the vulnerability of an individual or population. The factors of this domain include limited education, family structure, and social support. Many homeless people lack these fundamentals, either currently or in their early years. Family structure and social support, in particular, have significant influence on the vulnerability of the homeless. According to Heerde et al. (2021), family dysfunction in adolescents’ lives significantly influences whether adolescents will live in homelessness in their young adult years. These dysfunctional characteristics related to family include permissive parenting styles, such as lenient rules or a lack thereof, as well as little to no parental supervision; low-quality relationships between the parents and adolescent; and a nontraditional family structure. Because family relationships and social support during a youth’s formative years, the stage of life in which significant development occurs, are very crucial as to whether homelessness will occur in young adulthood, nurses must ensure health promotion is utilized for families with children. If theories of child development and good parenting techniques that relate to these precursors to homelessness in young adulthood are actively taught, risk factors associated with the sociocultural domain that contribute to the vulnerability of the homeless may be decreased for these youth.

Cultural Consideration

The homeless population is a very common cultural group that nurses care for in their communities. Nurses must do everything in their power to understand this community of people and their specific wants and needs. By using their knowledge of vulnerability in this community, nurses can better relate to the people they serve, ensuring that the proper care and treatment are provided and that individuals’ needs are met. One specific consideration that nurses must know to provide culturally competent care involves the common medical conditions that plague this population, including mental health conditions, substance abuse disorders, and communicable and non-communicable diseases. According to Beijer and Andréasson (2009), the incidence of disease in the homeless is almost double that in the general population, and many of these conditions are treated through emergency care Common health problems include injury and poisoning, diseases of the liver and pancreas (including hepatitis C, diabetes, and nutrition-related anemias), skin disorders, and cardiovascular and respiratory diseases (particularly tuberculosis)

Along with these common ailments, nurses should consider those that specifically affect homeless veterans. According to Stanhope and Lancaster (2020), about 9% of homeless people are veterans affected bymany post-combat issues,including post-traumatic stress disorder (PTSD) and traumatic brain injuries, which can lead these individuals to become closed off, remain unmarried, and socially isolate themselves from others. Knowing this, nurses should communicate with these individualsempatheticallyandwithoutbeingjudgmental.Nursesshouldalsoavoiddiscussionsthat may trigger PTSD and assess for signs or ideations of self-harm. Nurses should provide health promotion to help these individuals get the treatment they need to address these issues through the following: education aboutcommon diseases seen in the population, nutritional education, physical screenings and assessments for health conditions, depression screenings, and information about primary care and ways to avoid the high costs of emergency care (as will be discussed below).

Another cultural consideration nurses should keep in mind involves the hygiene and nutritional status of these individuals. According to Heerde and Patton (2020), the homeless population lacks adequate medical care, medications necessary for survival, and hygiene and sanitation resources. Because of a lack of housing and financial resources, these people do not have immediate access to running water utilized in many hygienic activities, including showering, bathing, dental care, and handwashing. They also cannot afford to buy nutritious foods like fruits and vegetables, or they lack access to them because impoverished areas are often food deserts. Health promotion for this cultural consideration should include education about basic nutritional needs and social services for food acquisition like food stamps. Nurses should also provide informationaboutwheretoaccesscleanwater forhygienicneeds andeducationabouthandwashing and its importance in preventing illness.

Along with nutritional and hygienic needs, nurses should consider that the living situations of the homeless can constantly shift. According to Lange (2021), these people may be classified as chronically, temporarily, or episodically homeless Because ofthis, there aremanyfactors to which they can be exposed and that make them vulnerable to health risks; these include violence, poor weather conditions, and infectious diseases Those chronically homeless often will be exposed to more factors, whereas those that are labeled temporarily or episodically homeless may spend more time in shelters and homes of relatives and friends, leading to less exposure to inclement weather, microorganisms, and violence. Health promotion should include education about how infectious diseases can be caught and how adverse weather can affect immune systems, information about abuse and violence hotlines, and information about publicly and privately funded shelters

Furthermore, a very significant cultural consideration when caring for the homeless population is that they have a lack of access to health care According to Giddens (2021), homeless individualshavethisproblem duetolackofinsurance,highhealthcarecosts, lackoftransportation, sociocultural differencesbetweenprovider andpatient,biasedclinical decision-making,andpatient mistrust andsubsequent healthcarerefusal. Becausethehomelesstypically lackjobs,theirfinancial means to access health care is limited. Insurance is usually provided to employees by their employers, which can decrease the cost of medical bills. However, without jobs, these people have no access to insurance, creating hesitancy to seek treatment and an inability to afford medications.

When the homeless do seek treatment, it is often through emergency health centers, which usually amounts to a very costly price. Because of medical avoidance related to financial concerns and transportation access, these vulnerable individuals are less likely to get care related to disease prevention including screenings, education about nutrition and exercise requirements, and vaccinations usedtoprevent commondiseases,especially onesspreadbyriskybehavioral practices such as illegal drug use and unprotected sex.

Nurses should use health promotion by educating the homeless about safe sex practices and drug administration, providing information about social services and resources to help with medications and medical bills, and promoting vaccinations that prevent the acquisition of sexually transmitted diseases. By knowing these cultural considerations when implementing health promotion for the homeless population, nurses can more effectively help members of this group take greater control of their health and reduce their vulnerability to adverse health outcomes

Conclusion

Health promotion is critical if nurses and physicians aim to decrease the vulnerability of the homeless population Through this promotion, these individuals may be better equipped to take control of their health and prevent worse outcomes related to their health status. Nurses should work day in and day out to adopt and implement preventative measures to reduce the risk of homelessness and decrease people’s vulnerability to it. Using the Vulnerability Model as a guide, nurses can accomplish great things. In these unprecedented times of the pandemic, mental health diagnosesand crises have been flaring(asthey have many times before during darktimes of human history), and nurses need to be knowledgeable and prepared to meet these challenges head-on to prevent future generations of vulnerable populations.

References

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