Addressing the needs of vulnerable populations in healthcare. Evidence from mixed methods systematic reviews

Background: Vulnerability in relation to healthcare issues can be considered in terms of both a categorical approach based on certain individual intrinsic characteristics and a situational approach as individuals navigate the healthcare system. Vulnerability is also related to being socially and structurally disadvantaged and the link between healthcare inequalities and systematic differences in health between different groups has been widely acknowledged. Although vulnerable populations have been a focus in healthcare research for over 50 years little research has been conducted that has explored the link between chronic illness and healthcare inequalities. Methods: The aim of this work is to understand the needs, characteristics and situations that perpetuate health inequalities for vulnerable groups and to explore how health inequalities can be ameliorated. The methodology underpinning this work draws on the discipline of evidence synthesis, specifically mixed methods systematic reviews (MMSRs). This offers a deeper understanding of findings from both qualitative and quantitative research. The findings were brought together and framed in an innovative way using the vulnerable populations conceptual model (VPCM) developed by Flaskerud and Winslow (1998). The VPCM model describes the relationships between the concepts of resource availability, relative risk and health status. This approach enabled an exploration of the healthcare inequalities that were encountered on navigating the healthcare system either when accessing healthcare (Edwards et al. 2020, 2021a), including admission and discharge (Edwards et al. 2015) or whilst experiencing care in the acute hospital setting (Edwards et al. 2017, 2021b) while at the same time acknowledging the impact of social or structural disadvantages. Results: The MMSRs (n=5) that were included explored access to cancer services for adults with physical disabilities (Edwards et al. 2020), end-of-life care for adults with severe mental illness (Edwards et al. 2021a), inpatient care for young people with complex mental health needs (Edwards et al. 2015), mealtime assistance for older adults in hospital settings (Edwards et al. 2017) and continence care in acute settings for people living with dementia (Edwards et al. 2021b). It was explored further what it is that makes patients, who are already vulnerable due to the inherent nature of their conditions, more or less vulnerable as they navigate the healthcare system (situational vulnerability), whilst at the same time acknowledging the interplay of environmental and healthcare resources. What is evident across the wider evidence base is that vulnerable populations can encounter substantial challenges navigating healthcare systems. Resource availability was often conceptualised as interactions and/or relationships with healthcare professionals. This is of concern as the VPCM proposes that those who lack available resources are at increased risk of negative health outcomes (delays in diagnosis, higher rates of morbidity and pre-mature mortality). Implications: Using the VPCM model in this way has potential value to inform healthcare practice and policy about the opportunities and resources needed to protect the health status of vulnerable populations. Flaskeurd and Winslow (1998) suggest that the VPCM provides an opportunity to consider clinical practice interventions with vulnerable populations. In considering these resource issues and the interplay between a relative risk and health status we can start to understand the unique challenges to implementing such interventions for vulnerable populations. When caring for potentially vulnerable persons, it is crucial that healthcare professionals understand the unique challenges involved and that they take measures to improve the quality of their interactions so that equitable care and treatment can be provided