Health Promotion in Vulnerable Populations




Health Promotion in Vulnerable Populations


this chapter will enable the reader 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


7. Describe approaches to ensure culturally competent health promotion programs.

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 polit- ically marginalized, disenfranchised, and often denied their human rights. Vulnerable popula- tions may include people of color, the poor, non-English-speaking persons, recent immigrants and refugees, homeless persons, mentally ill and disabled persons, gay men and lesbians, and substance abusers.

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


Chapter12 • HealthPromotioninVulnerablePopulations 257

activities. Taking into account the factors that reflect the health determinants of vulnerable popu- lations is key to promoting positive health behaviors.

In spite of improvements in health and spending more money on medical care than any other nation, the United States ranks near the bottom on key indicators of health, and health disparities continue to persist, based on an individual’s racial/ethnic background and socioeconomic (income and education) characteristics (Braverman, Egerter, & Mockenhaupt, 2011). Blacks, Hispanics and other racial/ethnic minorities are more likely to be socioeco- nomically disadvantaged, a more likely explanation for health differences by race and ethnicity. Health disparities are the differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among groups who are defined by certain characteristics. Health disparities disproportionately affect individuals who are members of the racial, ethnic minority, underserved, and other vulnerable groups mentioned previously, as well as persons who live in geographic (rural) areas where they are socially and physically isolated. Elimination of disparities to improve the health of all groups is an overarching goal of Healthy People 2020, and determinants of health and health dispari- ties are included as outcome measures of the national health objectives. (See the Healthy People 2020 website for details.) Although the major causes of health disparities need the input of society and government, development of empowering health promotion programs tailored for diverse individuals and communities is a major responsibility of nurses and other health care professionals.

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 disparities in health across populations, genders, and geo- graphic areas—can be achieved by empowering individuals and communities to challenge and change the distribution of social resources and advocate for social policies for equal access for all.

Inequities in health are well documented and are considered to be the result of complex interactions among multiple factors:

• Biologicalvariations • Healthcareaccess • Personalhealthbehaviors • Socialandeconomicresources • Culture

One way to view health disparities is by examining the range of risk factors that increase the potential for inequalities (Table 12–1). The risk factors include personal health behaviors, popu- lation characteristics, health care characteristics, the social and physical environments, and the types of diseases that are disproportionately diagnosed in vulnerable groups (Koh, Oppenheimer, Massin-Short, Emmons, Geller, & Viswanath, 2010).

258 Part5 • HealthPromotioninDiversePopulations taBle 12–1 Range of Potential Risk Factors for Health Disparities

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Potential Risk Factor

Personal Health Behaviors Population Characteristics Health Care Characteristics Residential Physical Environment

Social Residential Environment Diseases


Tobacco use, illicit drug use, personal hygiene, dietary habits, physical inactivity, unsafe sexual practices.

Race, ethnicity, immigration status, education, social position, occupation, employment, income, age, sexual orientation, health literacy.

Insurance, access to health care services, access to prevention and screening services, regular physician, medication affordability.

Housing density, housing quality, traffic density, air pollutants, hazardous wastes, drinking water quality, urban or rural, zoning policies, proximity to health care services, and proximity to quality food.

Civic engagement, crime rate, isolation, neighborhood cohesion, neighborhood social capital.

Obesity, hypertension, cardiovascular diseases, diabetes, mental illness, HIV/AIDS, cancer, respiratory illnesses, foodborne and waterborne illnesses.

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The most important social determinants of health inequities are considered to be structural influences, or factors that generate and reinforce social stratification and social class divisions in a society and define one’s socioeconomic position (Solar & Irwin, 2010). 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. These determinants are shown in the model in Figure 12–1 that describes the social determinants of health. This model was first drafted at the World Health Organization (WHO) Commission on Social Determinants of Health Meeting in 2005 (Solar & Irwin, 2010). The model depicts how governance structures or the sociopolitical context influences one’s socioeconomic position through the distribution of resources. 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

· Behavioralfactors:nutrition,physicalactivity,tobaccouse,alcoholuse

· Psychosocial factors: stressful living conditions and relationships, social supports, coping


Intermediary determinants are reflective of an individual’s place in the social hierarchy, which results in differential exposure and vulnerability to health-compromising conditions (Solar & Irwin, 2010). All of these factors determine one’s health status and well-being.

Chapter12 • HealthPromotioninVulnerablePopulations 259


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Socioeconomic Position

Material Circumstances

(Living and Working, Conditions, Food Availability, etc.)

Behaviors and Biological Factors

Psychosocial Factors

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Social Policies

Labour Market, Housing, Land

Social Class Gender Ethnicity (racism)


Macroeconomic Policies

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Education Occupation Income

Public Policies

Education, Health, Social Protection


Culture and Societal Values

Social Cohesion & Social Capital

Health System

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fiGure 12–1 WHO Framework Describing Structural Determinants of Health Source: Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). Accessed at sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf

socioeconomic Determinants

The key components of socioeconomic position depicted have been substantiated to be the root of health inequities, measured at the population level (Solar & Irwin, 2010). Low economic status is the most consistent predictor of life expectancy, morbidity and mortality, and health status (Braverman, Cubbin, Egerter, Williams, & Pamuk, 2010). Although there is great diversity among minority populations, overall, minorities have substantially lower incomes and educational levels than do whites. Income is a powerful variable that explains health status. Low income and educa- tion result in economic hardship, such as the inability to meet one’s living expenses, while higher incomes and educational levels facilitate access to care, better housing in safer neighborhoods, increased opportunities for healthy food purchases, and access to club memberships and health- promotion programs. In addition, low-status occupations expose individuals to physical health hazards. Educational attainment also is lower in minority groups. High-risk behaviors have been correlated with lower educational levels. More-highly educated persons are also more likely to obtain health-related information at understandable levels.

A socioeconomic gradient exists for almost every health indicator for every racial and ethnic group (Braverman, Egerter, & Mockenhaupt, 2011). The effects of low socioeconomic status are long lasting. Low socioeconomic status in childhood has been associated with poorer health in adulthood. The cumulative wear and tear of the adverse experiences of living in poverty, with its multiple challenges, results in chronic illnesses. Families who have been poor over several generations and suffer ongoing discrimination and frustration without

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substantial upward movement develop feelings of powerlessness and perceive their condi- tions differently than do recently arrived immigrants who are poor, but are hopeful about their future.

Access to care can be measured by the proportion of a population that has health insurance. Because of their socioeconomic situation, racial and ethnic minorities are much more likely to be underinsured or to lack health insurance. When they do have insurance, it is likely to be public insurance, primarily Medicaid. Health insurance contributes to the amount and type of health services obtained. Lack of health insurance has important implications for health promo- tion and prevention efforts, such as screening and access to wellness programs. Insurance status has also been correlated with self-reported health status. Those who rate their health as fair or poor are more likely to be uninsured than are those who rate their health as good or excellent. Poor individuals also experience greater barriers in accessing care, have more difficulty getting an appointment, and wait longer during health care visits. These factors are compounded by the fact that 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.

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 differ- ences. 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 (Braverman, Kumanyika, Fielding, LaVeist, Borrell, Manderscheld, & Troutman, 2011). The early literature on health disparities focused on racial/ethnic differences in health and “closing the gap”; however, “achieving health equity” is now more commonly discussed. Equity in health places emphasis on the multiple influences on individual and popu- lation health and draws attention to the many challenges that must be addressed. Promotion of health equity moves health promotion to a political activity, as it moves from the individual level to a broader focus on strategies to also change the distribution of social and economic resources (Raphael, 2011a).

Health equity can be achieved only through interventions that address the multiple health determinants:

• Social:networks,connections,institutionallinks • Economic:money,time,prestige • Sociocultural:skills,education,knowledge,language,religion,familybackground • Political:power,distributionofresources

A study of the economic value of improving the health of less-educated American adults if they were to experience mortality rates and health status similar to those of adults with a col- lege education was commissioned by the Robert Wood Johnson Foundation in 2007 (Schoeni, Dow, Miller, & Pamuk, 2011). In spite of limitations, results showed an annual economic value of $1.2 trillion. The economic burden of health disparities over a three-year period was estimated to be $1.24 trillion. Although these analyses do not uncover the causal pathway of education on health or account for costs in eliminating disparities, the results from these and other studies document the important role of socioeconomic characteristics in health.

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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 (Trickett & Beehler, 2013). Multilevel interventions have been called fourth-generation health disparities research (Thomas, Quinn, Butler, Fryer, & Garcia, 2011). 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 mul- tiple sources, such as interdisciplinary health care teams, community organizations, and local and state governments.

Community empowerment

At the community level, empowerment is a key strategy for reducing health inequities. (See Chapter 11 for a discussion of individual empowerment and Chapter 14 for more discussion on community empowerment.) 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 (Wiggins, 2011). It involves a shift in power between individuals and other social groups. 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. For example, they may work together to advocate for after-school programs for youth, parks for leisure activities for families, or increased law enforcement presence; or they may work to bring affordable health screening services to the neighborhood for those without transportation. Community agencies can advocate for local school board participation. In addition, they can empower community members to take an active role in promoting healthy and safe schools and neighborhoods.

Empowered communities believe in their capacity to change inequities and use that capacity to bring about change. Empowered community members feel a sense of community, which increases a sense of caring and support for each other and facilitates participation in change, such as working to obtain affordable housing, public transportation, safe walking places, and access to healthy foods. Empowered communities work with external powers to address community needs. For example, they may lobby and engage in policy decisions that impact the health of their communities. The ultimate goal of community empowerment is to create relationships and policies to promote health equity (Wiggins, 2011).

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. Empowered com- munity members can organize walking groups, community lectures, and health fairs. Community members need to be able to participate in decisions that influence their health and the health of the community. Empowerment means having a political voice to garner resources to change the community.

Community-based organizations (CBOs) are logical places to begin to bring about com- munity change, as these organizations are enmeshed in the life of the community (Griffith et al., 2010). 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

262 Part5 • HealthPromotioninDiversePopulations

community issues. Leaders of CBOs can represent and advocate for the community. Empower- ing CBOs enables members to establish new projects and programs, as well as use their collective power to advocate for policy changes. Empowered CBOs are able to build community capacity, as they know the strengths, weaknesses, and availability or lack of resources within their community.

Community-based participatory research

Community-based participatory research (CBPR) is a method that integrates research with social action (Masuda, Poland, & Baxter, 2010). 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.

policy advocacy

The socioeconomic and structural gradients in this country and their relationship to differences in health mandate that policies be created to address the social determinants of health inequities (Braverman, Cubbin, Egerter, Williams, & Pamuk, 2010). Canada, England, and Australia are considered leaders in implementing health-promoting public policies through legislation, fiscal measures, taxation, and organizational change (Raphael, 2011b).

Public policies influence the prerequisites of health in three key areas: early childhood development, employment, and income (Raphael, 2011a). Public policies to address these key areas have all been associated with lower rates of poverty and income inequities, Notably, the United States has the second lowest percentage of gross domestic product expenditures allocated in the form of public expenditures and the highest poverty rates in families and children among 21 selected countries (Raphael, 2011a). These rankings point to the need for policy to shift from a focus on individual health risk behaviors to the redistribution of economic resources to promote a healthy society for all.

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. In com- munity settings, nurses may become spokespersons for the poor in order for their voices to be heard. At the individual level, strategies to alleviate poverty include helping families obtain available benefits, providing information about available services and how to access them, targeting those in greatest need, teaching skills, and partnering individuals with community agencies to provide additional supports (Cohen & Reutter, 2007). At the community level, empowerment strategies promote community dialogue between community members, CBOs, and persons in positions to influence policies. Nurses can also work with their professional associations to place the elimination of health inequities on their agendas for action. Membership in organizations that promote agendas to reduce health inequities is another avenue for action. Political competence can be developed through courses and dia- logues 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.

Chapter12 • HealthPromotioninVulnerablePopulations 263

primary Care

Primary care offers an effective mechanism for achieving health equity, as interventions are directed at individuals versus diseases. Primary care was established as a framework for health in the 1960s with the World Health Organization Declaration of Alma-Ata. It includes first contact and continuous, coordinated, decentralized care to address health promotion and disease prevention. Primary care is complex and requires community engagement and respect for individual and family viewpoints. 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. Pri- mary care services in community health centers can reach socially disadvantaged, racial/ethnic minorities and isolated groups. 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. Primary care continues to increase in value with the passage of the Affordable Care Act, and nurses play a major role in promoting behavior change as primary care providers.

HealtH literaCy anD VulneraBle populations

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 (Berkman, Sheridan, Donahue, Halpen, & Crotty, 2011). In the United States, a third of the population is estimated to have limited health literacy skills. Vulnerable populations that are disproportionally affected include minorities, the elderly, individuals with less than a high school education, those who spoke another language prior to starting school, persons who do not speak English, and per- sons living in poverty. The importance of health literacy to understanding one’s health care and having adequate knowledge to promote healthy self-care led the U.S. Department of Health and Human Services (USDHHS) to publish a national action plan to address health literacy issues (USDHHS, 2010). This document has brought national attention to the problem of health literacy and has been important in the development of strategies and programs to decrease health literacy. 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.

medical Health literacy or Health literacy

Health literacy is considered to be a constellation of skills an individual needs to function effectively in the health care environment and act appropriately on health information. Multi- ple definitions of health literacy exist in the literature. (For a review see Sorensen, Van den Broucke, Fullam, Doyle, Pelikan, Slonska, & Brand, 2012.) A commonly cited definition of health literacy in this country is the Institute of Medicine (IOM) one, which describes health literacy as an individual’s capacity to obtain, process, and understand basic information and services needed to make appropriate health care decisions (IOM, 2004). This definition was adopted by the Centers for Disease Control and Prevention (CDC). Other common descrip- tions of health literacy include medical health literacy, clinical health literacy, or functional

264 Part5 • HealthPromotioninDiversePopulations

health literacy, as health literacy refers to the skills needed to function in the health care system. These skills include basic reading and writing (print literacy), using quantitative information (numeracy), and speaking and listening effectively (oral literacy). Medical health literacy enables persons to read and understand health information such as specific instructions or prescriptions and consents, to make appointments, to complete medical forms, and to self- manage chronic conditions.

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). This broader definition includes persons who are not in the health care system and indicates that individuals must have the knowledge, skills, and self-confidence needed to take action to improve their personal health as well as the health of the communities in which they reside. Within this definition, three typologies of health literacy have been identified:

· Functional:basicreadingandwritingskillstounderstandanduseinformation

· Interactive: cognitive skills to interact with health care professionals, interpret and apply


· Critical:cognitiveskillstoanalyzeinformationtobeabletoexertcontroloverone’shealth

Clients with low health literacy need specific skills to manage their health effectively, including reading, writing, and numeracy skills, as well as the following (Frisch, Camerini, Diviani, & Schulz, 2012):

• Whentoseekhealthinformationorcare • Wheretoseekhealthinformation • Verbalcommunicationskills • Assertivenessskills

• Skillstoprocessandretaininformation • Skillstoapplyinformation

Health literacy involves an individual’s cognitive, emotional, and social skills outside the control of the health care system (Peerson & Saunders, 2009). Health literacy involves the ability to access information and use it in one’s everyday life. Medical health literacy is more limited, as it focuses on the ability to read, understand, and carry out health care instructions. Vulnerable groups need to be taught health literacy skills to become empowered to navigate the health care system as well as participate in preventive and health-promoting behaviors.

strategies to promote Health literacy

Addressing the literacy needs of vulnerable populations is a basic component of designing health promotion programs and interventions. Numerous resources for developing literacy and cultur- ally appropriate messages are available on federal websites. In addition, the federal plain language guidelines are available online. These guidelines were written to support the Plain Writing Law of 2010 that mandates plain language usage in all public documents, presentations, and electronic communications. Plain language is a strategy for making information easier to understand. The key elements include the following:

• Presentingthemostimportantinformationfirst • Breakingcomplexinformationintosmall,understandablechunks

Chapter12 • HealthPromotioninVulnerablePopulations 265 • Usingsimplelanguageanddefiningtechnicalterms

• Usingtheactivevoice

oral messaGes. Strategies for delivering clear messages incorporate plain language princi- ples. Some of the major strategies to keep in mind are listed in Table 12–2. 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 narra- tives and visual illustrations to capture attention and reinforce content. Tailored cultural mes- sages that use the client’s personal information are more effective than standard communication. In addition, communication channels that are familiar to the client and are easily assessable are more effective.

Culturally tailoreD messaGes. Culture influences how individuals understand and respond to information. For low-literacy, culturally diverse populations, only terms that the indi- vidual or groups are comfortable with should be used. Do not assume that all minority groups are alike. Consider the subpopulation and geographic location. Mexican Americans in the Southwest, for example, may respond differently from Puerto Rican Americans in the Northeast. Differences also 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.

taBle 12–2 Health Literacy Teaching Strategies

• Begin with warm greeting and welcoming attitude. • Focus on specifically what needs to be done or known. • Use plain, non-technical language and avoid jargon. • Use terms and analogies that are familiar. • Cover most important points first. • Stick to one idea at a time. • Clearly state what needs to be done. • Repeat key points. • Use pictures, illustration or demonstrate with models. • Use teach-back method. • Highlight the positive. • Avoid long lists. • Limit use of statistics and general terms. • Invite and encourage questions. • Avoid questions with yes/no responses.

Source: Dewalt, D. A., Callahan, L. F., Hask, V. H., Broucksou, K. A., Hink, A., & Brach, C. Health Literacy Universal Precautions Toolkit, AHRQ publication No. 10-0046-EF, Rockville, MD: Agency for Healthcare Research and Quality, April, 2010.

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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. Instead, they are asked to state or demonstrate how they will use the information. 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 instruc- tions 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. Statements such as “Do you understand?” or “Do you have any questions?” are replaced with statements such as “Show me how you will do it when you get home” or “Tell me so I know you understand.” This method has been shown to be an effective tool for pharmacists to verify understanding of medications (Watermeyer & Penn, 2009).

Written messaGes. Written information should be attractive and easy to read. (See the fed- eral government’s plain language website.) Strategies for effective written messages include the following:

• Writespecificallyforyourtargetaudience. • Usepositivewordsand“must”whenstatingarequirementinsteadof“shall.” • Usealargefont. • Avoidusingfancyscriptandallcapitalletters. • Useheadingsandbulletsandleavelargeamountsofwhitespacebetweensections. • Writeshortsentences. • Avoidjargon,legal,ortechnicallanguage. • Presentnumericalinformationintables.

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 supple- ment written or verbal information.

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 (Sarkar, Karter, Liu, Adler, Nguyen, López, & Schillinger, 2010). As mentioned in an earlier chapter, this disparity is referred to as the “digital divide.” 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:

· Engageuserswithinteractivecontentusingplainlanguage.

· Incorporateaudioandvideofeaturesandorganizeinformationtominimizesearchingand


· Providesimplesearchoptions.

· Applyuser-centereddesignprinciples.

· Conductusabilitytesting.

Chapter12 • HealthPromotioninVulnerablePopulations 267 Usability is a measure of the user’s experience and satisfaction in interacting with a webpage.

Usability questions to ask might include the following:

• Howfastcantheparticipantlearntousethewebsite? • Howfastcantheparticipantaccomplishtasks? • Cantheparticipantrememberhowtoaccessthesitethenexttimesheorhevisits? • Howoftendoestheparticipantmakemistakes? • Howwelldoestheparticipantlikethesite?

Persons with limited literacy skills need opportunities to learn the skills needed to obtain online health information. They also need access to computers in public places within the community, such as public libraries.

Health Literacy Training for Health Professionals

Health literacy is a key component of effective communication between individuals and health professions. In order for health literacy to become an effective component of all health promo- tion activities, nurses and other health professionals need to understand and apply health lit- eracy principles and strategies in their communication and in the design of written health information and websites. However, a gap exists between professional awareness of low health literacy and effective communication practices to address low health literacy (Coleman, 2011). Health literacy is not being adequately addressed in many nursing and health professional schools and continuing education programs.

An assessment is the first step to identify health literacy training needs. This should be following by training, which can be incorporated into orientation programs, didactic courses, and ongoing staff meetings. Health literacy skills can also be added to position descriptions in the work environment. One successful strategy that has been implemented with students is an interdisciplinary international program that combines service learning with cultural immersion (Smit & Tremethick, 2013). These programs provide opportunities for students to learn how to work with diverse cultures by practicing in diverse cultural settings.

At the national level, the United States Department of Health and Human Services (USDHHS) Office of Disease Prevention has responded to the need for information for health care organizations and professionals with a website that provides information and resources to learn about health literacy and how to implement health literacy strategies in practice. In addition, videos are available that show interviews with individuals to illustrate health literacy issues. PowerPoint presentations also can be downloaded to teach health literacy skills. The Centers for Disease Control (CDC) has an online course to teach health professionals and students about health literacy. Resources available on the CDC website can be used in workshops or small groups, or they can be reviewed individually.

The National Action Plan to Improve Health Literacy (USDHHS, 2010) is a frame- work for organizations to use to identify priorities, strategies, and activities for health literacy. The plan reinforces the critical role of health care professionals in improving health literacy and suggests learning strategies, which include participation in ongoing training and education in health literacy. Organizational assessments should be conducted with follow-up training and development, as well as implementation of policies to promote health literacy.

268 Part5 • HealthPromotioninDiversePopulations HealtH Care professionals anD Cultural CompetenCe

Expertise in cultural competence and sensitivity to differences among cultures is a needed skill, considering the diversity of vulnerable populations and the number of interacting factors operat- ing to create health disparities. Cultural competence is defined as appropriate and effective communication that requires one to be willing to listen and learn from members of diverse popu- lations. It also includes the provision of information and services in appropriate languages, at appropriate comprehension and literacy levels, and in the context of the individual’s health beliefs and practices. In culturally competent health promotion programs, the beliefs, interpersonal style, attitudes, and behaviors of individuals and families are respected and incorporated into all program activities. Culturally competent nurses continually adapt their practice to be consistent with the culture of their clients. Culturally competent health professionals are aware of their own cultural values and beliefs and recognize how these influence their attitudes and behaviors toward another group.

Continuum of Cultural Competence

Cultural–linguistic competence has been described by various authors, using a continuum of interpersonal behaviors. Bushy’s (1999) classic continuum, which addresses individuals, ranges from ethnocentrism at one end to enculturation at the other end of the spectrum. Eth- nocentrism refers to assumptions or beliefs that one’s own way of behaving or believing is most preferable and correct and the standard by which all cultural groups will be judged. This view devalues the beliefs of other cultural groups or treats them with suspicion or hos- tility. 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. 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. Enculturation, the final anchoring point, 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 indi- viduals in the cultural group and incorporates members of the culture to deliver and evaluate the intervention.

A similar cultural competence continuum is used for health care organizations and sys- tems in which services and care are delivered. It ranges from cultural destructiveness to cul- tural proficiency (Cross, 2011). The two continua are shown in Figure 12–2. Cultural destructiveness, the most negative anchoring point, represents attitudes, beliefs, and behaviors that are damaging to the culture and individuals within the culture. Cultural incapacity refers to cultural bias due to the lack of capacity to assist vulnerable individuals and communities. Agencies that are characterized by this dimension have patronizing and paternalistic attitudes, low expectations for minority groups, and may implicitly practice segregation and paternalis- tic attitudes. Cultural blindness occurs in uninformed organizations that may have the right intentions and may profess cultural equality and a philosophy of being unbiased. However, the system espouses the belief that the dominant culture should be universal and encourages assimilation, ignoring the other culture’s strengths. Cultural precompetence refers to being aware of limitations in cross-cultural communication and relationships and having a desire to provide fair and equitable services. Although intentions are good, the system lacks the knowl- edge needed to implement culturally competent programs and services. These agencies may


Cultural ** Destructiveness

Cultural Awareness

Cultural Incapacity

Cultural Knowledge

Cultural Blindness

Cultural Change

Cultural Competence

+ Enculturation

+ Cultural Proficiency

Chapter12 • HealthPromotioninVulnerablePopulations 269

fiGure 12–2 Two Continua of Cultural Competence social support. In J. G. Sebastian & A. Bushy (Eds.), Special Populations in the Community: Advances in

Reducing Health Disparities. Gaithersburg, MD: Aspen Publications, Inc. Cross, T. L., (2008). Cultural Competence Continuum. Accessed at http://pbsnetwork,org/up_content/uploads/2011/04/Cultural- Competence-Continuum, Accessed September 3, 2013.

pay attention to culture differences and begin to try to adapt practices that take cultural differences into account. Cultural competency is evident when diversity is valued and differences are respected and accepted. Systems develop awareness of cultural practices as self-assessments are implemented. Advanced cultural competence or cultural proficiency, the final anchoring point, occurs when individuals and systems are committed to culturally competent practice and hold cultural diversity in high esteem. System personnel have the knowledge and skills to implement culturally sensitive principles, and policies and practices reflect culture competence.

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. Acquisition of cultural competence skills is an ongoing process to ensure delivery of health promotion interventions that are appropriate, acceptable, and meaningful for persons of diverse backgrounds. Diversity is embedded in cultural competence, but it is just one component. Accepting and understanding differences in customs and patterns of thinking are ways in which diversity is valued.

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 (Hong, Garcia, & Soriano, 2013). 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, practice interviews, and client encounters.

strategies for Culturally Competent Communication

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 (Teal & Street, 2009; see Table 12–3). 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

Cultural Pre-Competence

Sources: *Bushy, A. (1999). Resiliency and **

270 Part5 • HealthPromotioninDiversePopulations taBle 12–3 Culturally Competent Communication Techniques and Illustration of Their Use

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Nonverbal Behaviors

Be on time; don’t rush.

Be attentive;

· –  Do not interrupt.

· –  Indicate interest with body language.

· –  Do not write notes during encounter.

· –  Respect preferences for physical space.

· –  Make eye contact but do not stare.

Limit gestures.

Show nonjudgmental expressions.

Verbal Behaviors

Communicate in client’s preferred language.

Address with client’s last name unless asked to do otherwise.

Indicate interest in client.

(“Tell me about yourself.”)

(“How are you feeling?”)

Use nonjudgmental language such as “how,” “what,” etc.

Reflect client’s observed emotions.

(“How are you feeling about your weight?”)

(“You seem sad, tired, frustrated.”)

Reflect what the client states about the problem.

“Sounds like you think …”) Summarize.

Ask for feedback.

(“Did I get that right?”)

(“What else do you want to talk about?”)

Invite questions about proposed behavior change plan.

(“Do you understand or have questions?”)

(“Stop me if you’re not sure what I’m saying.”)

Addressing Cultural Influences

Assess causes of negative perceptions.

Include others present in the discussion.

Explore changes in client’s life.

Assess education and knowledge levels.

Assess social factors that can influence ability for self-care (SES, family, living arrangement, stressors, literacy, language).

Ask client’s preferences for information and decision making.

Ask for client’s understanding of proposed plan.

Acknowledge client’s perspective.

Invite questions (“Do you understand?” “Do you have questions?”) Observe body language, facial expression that may indicate discomfort with plan.

Use plain language consistent with client’s education, knowledge, and health literacy level.

Working Together

Assess client’s priorities.

Assess client’s acceptance of the proposed plan.

(“How do you feel about this plan?”)

Assess client’s confidence in carrying out plan.

(“Do you think you can do this?”)

(“What things or persons can help you?”)

Assess concerns and expectations.

(“What worries you most about this plan?”)

Assess client’s reluctance to commit to the change.

(“You seem hesitant about making the change. Let’s talk about your concerns.”) Include family in making the plan.

(“What else do you need to know that we haven’t talked about?”)

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Chapter12 • HealthPromotioninVulnerablePopulations 271

active listening and focusing on the client. Recognizing cultural differences entails 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 under- standing are useful strategies. Differences are acknowledged, and information and priorities are based on client input and preferences. 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 communica- tion model. Advanced communication skills and cultural awareness enable the nurse to avoid stereotyping clients and ignoring cultural issues. If the nurse is working with a translator, an addi- tional layer of complexity is added. Translators must be both content and contextual experts who are using the client’s local language. Translators should be immersed in the same native language and community as the client, if possible, and understand the dialect and context in which the words are being used.

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

Assessment of characteristics of vulnerable populations that may affect successful health pro- motion 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. It may also result in errors and/or inappropriate care. Even in some English-speaking minority clients, communi- cation may be problematic, as clients may not fully understand the information and may avoid further verbal communication to get their questions answered. The National Institutes of Health Office of Minority Health’s national standards for culturally and linguistically appropriate services (CLAS) address the need to offer language assistance services, including interpreters, and to offer verbal and written notices of clients’ rights in their preferred language. These standards can be accessed at their website.

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. Research on “walkability” indicates that attractive, aesthetically pleasing settings are more conducive to physical activity. Fear due to drug sales or violence may be a major factor in limiting outside activities. Poor neighborhoods have fewer services available, such as clinics or community centers and public transportation. In addition, limited grocery stores result in higher prices paid for fresh fruits and vegetables that may be scarce and of lesser quality.

Cultural factors that may affect the success of health education also should be identi- fied. 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. For example, prayer and chanting, dancing rituals, and purification ceremonies are important in the Native American culture to reestablish harmony in one’s physical, men- tal, and spiritual life. The cultural, religious, or spiritual framework must be respected in the health promotion encounter.

272 Part5 • HealthPromotioninDiversePopulations

Communication, body language, and word meanings vary across cultures. In low-literacy groups, abstract concepts may not be understood, so traditional written communication is not appropriate. Health promotion programs are more successful when they are delivered in the lan- guage of the participants. Persons who represent the target culture and speak the same language should be involved in developing and implementing the intervention. In addition, culturally spe- cific newspapers and radio and television stations can be targeted to deliver health messages in the appropriate language.

Family relationships and the concept of family also differ across cultures. In some cultural groups, the family is an extension of the individual. It is also common for the family to include more than the immediate relatives. Traditionally, the needs of the family have had priority over the needs of the individual in some cultures, such as Asians and Hispanics. In these groups, support from family members is more important than external support, so family members should be intimately involved to support the individual and participate in the interventions and programs. Family-oriented approaches, using family and extended family networks, are more likely to be successful in behavior change in African American and Hispanic cultures. In cul- tures in which the woman’s role is subordinate, the value of the behavior change of the woman for the entire family needs to be emphasized. Family networks may also include church rela- tionships, as they offer social support and communication networks. In these cultures, the church is an effective place to implement health-promotion programs. Educational strategies should capitalize on the powerful effects of family networks to promote behavior change.

Time orientation refers to how the perception of time varies among cultures. A present ori- entation is common in vulnerable populations, as the focus is on surviving in the present, so the future may have less meaning. Vulnerable persons with a present orientation have more difficulty changing behaviors, as current, day-to-day needs take priority. Knowledge of an individual or culture’s dominant time orientation as well as values related to “clock” time helps to eliminate misunderstandings, such as missed appointments or tardiness.

Health care system factors also are important to assess prior to health promotion efforts. Vulnerable populations have problems accessing care and participating in health-promoting programs due to costs, distance, transportation, and language. Missed appointments or program sessions may not mean that the individual is not interested. Trans- portation or child care may not be available, or bilingual support may be inadequate. 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. Culturally sensitive approaches enhance access and acceptance of health interventions. Focus group or individual interviews in the target community may reveal missed culturally relevant information on which to base interventions. Community priorities and availability of community resources also should be identified. Churches or other sites within the community should be used whenever possible to facilitate easy access as well as offer a familiar environment. The Office of Minority Health Resources Center’s standards for culturally and linguistically appropriate health care services are relevant for the delivery of health promotion programs. These are summarized in Table 12–4.

strategies for Culturally Competent interventions

Strategies to make health promotion programs and materials more culturally appropriate are available. These strategies can be classified into six categories: (1) peripheral, (2) evidential, (3) linguistic, (4) constituent involving, (5) sociocultural, and (6) cultural tailoring.

Chapter12 • HealthPromotioninVulnerablePopulations 273 taBle 12–4 Recommended Standards for Culturally Appropriate Health

Promotion Programs

1. Acquire the attitudes, behaviors, knowledge and skills needed to work respectfully and effectively with individuals in a culturally diverse environment.

2. Use formal mechanisms to involve communities in the design and implementation of health promotion programs.

3. Develop strategies to recruit and retain culturally competent staff who are qualified to address the health promotion needs of the racial and ethnic communities.

4. Provide ongoing education and training in culturally and linguistically competent program delivery.

5. Provide all participants with limited English proficiency programs conducted in their primary language.

6. Translate and make available signage and commonly used written educational material.

7. Ensure that the participants’ birthplace, religion, cultural dietary patterns, and self-identified

race-ethnicity are documented. 8. Undertake assessments of cultural competence, integrating measures of satisfaction, quality and

outcomes of health promotion programs.

Source: Reprinted from Public Health Reports, 115, D. Chin, “Culturally Competent Health Care,” 25–33, Copyright 2000, with permission from Royal Institute of Public Health.

Peripheral strategies involve 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 receptiv- ity of the information.

Evidential strategies are those used to present information in a way that increases the per- ceived relevance of the topic for the specific cultural group. For example, provision of informa- tion on the prevalence of diabetes has been used to raise awareness to 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.

When materials and programs are provided in the cultural group’s dominant language, lin- guistic strategies are applied. Strategies, such as translating materials or delivering the program in the target culture’s native language, are essential. Guidelines are available for translating informa- tion from one language to another.

Constituent-involving strategies are implemented to capitalize on the experiences of those within the target population. For example, using peers or lay helpers, as well as professional members of the target population, facilitates culturally competent teaching. Lay health advisors serve as role models and advocate for community members. They have been used extensively in the Hispanic/Latino community to eliminate health disparities.

Sociocultural strategies build on the group’s values and beliefs. Implementing sociocultural strategies facilitates the cultural meaningfulness of the material or programs. For example, inter- ventions to change dietary behaviors for African Americans may be more successful when the beauty salon or barber shop is used, as these places have meaning and familiarity. Programs that are culturally meaningful and delivered in familiar locations have been shown to be more effec- tive to change behavior in vulnerable populations.

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274 Part5 • HealthPromotioninDiversePopulations

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 tar- get. When unique individual differences are evident, cultural tailoring strategies that focus on the individual are needed.

In summary, multiple strategies facilitate the development and implementation of culturally appropriate interventions. Effective communication is a core concept. Using interpreters, bilingual staff, and lay health advisors; integrating the cultural values of the family and community; culturally tailoring health information; and attending to health literacy issues are key strategies to promote health in vulnerable groups.

ConsiDerations for praCtiCe in VulneraBle populations

Nurses have multiple opportunities and challenges with vulnerable populations because of the diversity, poverty, and other socioeconomic factors that increase their risks for diseases and chronic illness. When working with diverse populations, nurses first examine their own attitudes and values and how these may either facilitate or impede culturally appropriate client encounters. A commitment to becoming culturally competent is necessary to effectively promote healthy behaviors with vulnerable groups. Culturally competent communication skills and knowledge are necessary to design culturally and literacy appropriate programs. These skills can be learned through courses and practice. Factors such as potential language difficulties, educational level, poverty, unsafe housing or neighborhoods, and different cultural beliefs are challenges that need to be confronted to change lifestyles. Collaborative partnerships with other health care profes- sionals and organizations within the community are critical. The significant role of public policy in reducing health inequities stresses the need for nurses to learn policy analysis and advocacy to represent the voices of vulnerable groups and lobby for policies and changes that promote health equity for all.

opportunities for researCH in VulneraBle populations

Although evidence documents the adverse health outcomes caused by health disparities, research to eliminate disparities and promote health equity is limited due to the multiple determinants and the complex, multilevel interventions needed. Multiple methodologies, including community-based participatory research, and many stakeholders are needed to support multi- level interventions that target sociocultural, behavioral, and environmental systems. The effects on health outcomes of changing policies that increase socioeconomic status and access to quality services and care need rigorous investigation. Appropriate health literacy interventions that target subpopulations such as children and adolescents, the elderly, and rural residents should be designed and tested, as these subgroups have received less attention.

Interdisciplinary research teams are crucial in research to address the complex social determinants of health inequities. Community interventions that partner with stakeholders should be implemented to evaluate changes that target living conditions within the community. Health policy research also is a priority, and the effects of policy in achieving health equity must be evaluated.

Chapter12 • HealthPromotioninVulnerablePopulations 275

Vulnerable groups traditionally have been underrepresented in research for many rea- sons, including unsuccessful recruitment and retention strategies, lack of culturally sensitive interventions and measures, literacy levels, and lack of trust. Recruitment of communities for interventions that evaluate large-scale changes, such as improved living conditions, is an even bigger challenge. However, research is needed to evaluate large-scale change in order to influence policy.



Although great progress has been made in the health of the American people due to basic improvements—such as safe drinking water, sanitation, the availability of nutritious food, and advances in medical care—evidence shows that, in addition to these improvements, structural factors that define a person’s social class and socioeconomic position in society are powerful predictors of health status. At all levels of income, health and illness follow a social gradient, with lower socioeconomic

Learning Activities

1. Develop a plan describing the steps you would take to become culturally competent in a cul- ture different from your own.

2. Design a program to promote physical activity in low-income Mexican American families using health literacy strategies discussed in the chapter.

3. Describe strategies you would use to address environmental barriers to promoting physical activity, such as unsafe places to walk, that the families in Learning Activity 2 might face.

4. Identify an issue in a poverty-stricken commu- nity, such as unsafe housing. Describe how you


Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpen, D. J., & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine155, 97–107.

levels associated with poorer health. Vulnera- ble populations have diverse threats to health that require attention from clinicians, researchers, and policy-makers. Although the contributing factors are multiple and complex, many components are amenable to change. Nurses, as primary care providers, are well positioned to take a leadership role in design- ing and implementing culturally competent health promotion programs to promote health equity for diverse populations.

would advocate at local and state levels to pro- mote change that targets resources to provide safe housing for the community.

5. Using the guidelines found in the Making Health Literacy Real Toolkit (see the CDC website), conduct a health literacy assessment on an organization, such as the county health department. Identify potential barriers and strategies to overcome in improving health lit- eracy in the organization.

Braverman, P., Cubbin, C., Egerter, S., Williams, D., & Pamuk, E. (2010). Socioeconomic disparities in health in the United States. What the patterns tell us. American Journal of Public Health100, S186–S196.

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