National Women's Hall of Fame. NP PRACTICE ... cated that women older than 75 years were more ..... Washington, DC: National Academy. Press; 2003. 5.
THE OFFICIAL JOURNAL FOR NURSE PRACTITIONERS A Peer-Reviewed Journal VOL. 15 NO. 11/12
WWW. WEB NP ONLINE . COM
NOVEMBER/DECEMBER 2011
The American Journal for Nurse
Practitioners
WELL-BEHAVED WOMEN DON’T MAKE HISTORY Dr Loretta C. Ford Is Inducted Into the National Women’s Hall of Fame
CARDIOLOGY
I 64-Slice CT Versus Coronary Angiography
I Implantable Cardioverter-Defibrillator Therapy
ISSUES IN PHARMACOTHERAPY Focus on Beta Blockers in Seniors
NP PRACTICE Vulnerable Populations Conceptual Model
PRIMARY CARE CAM Strategy for Hypertension
AJNP 2011 EDITORIAL INDEX
NP RESEARCH
Use of the Vulnerable Populations Conceptual Model to Assess the Impoverished Elderly Mary Atkinson Smith, DNP, FNP-BC The author has identified the impoverished elderly as a vulnerable population, and discusses application of the vulnerable populations conceptual model (VPCM) to assess the risks and health status of this group. Using this model to assess the impoverished elderly can assist popu-
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lation-focused nurse practitioners in many areas, including shaping clinical practice, guiding research design, and influencing health policy. The VPCM shows the interrelationships and influences of resource availability, relative risk, and health status among the low-income elderly.
W
ithin a healthcare setting, vulnerable populations are those who are at increased risk for experiencing inadequate access to health care, lowquality health care, harm, neglect, and unfavorable health outcomes.1,2 Findings about these disparities for vulnerable populations were first reported by the US Department of Health and Human Services (DHHS) in 1976.2 Many studies linking low socioeconomic status to poorer health outcomes have been reported since that time.3 In recent years, vulnerable populations and healthcare disparities have gained more attention from the US government. For example, in 2003, the Institute of Medicine identified factors that contribute to the development of healthcare disparities, including patient-level factors (eg, mistrust), practitioner-level factors (eg, stereotyping or prejudice), and healthcare system factors (eg, lack of insurance coverage).4 Healthy People 2020 includes goals of achieving health equality, eliminating health disparities, and improving health in all groups.5 To properly assess a vulnerable group such as the impoverished elderly, Nyamathi et al6 suggested using a
THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS NOVEMBER/DECEMBER 2011 VOL. 15 NO. 11/12
population-based framework called the vulnerable populations conceptual model (VPCM). The purpose of this article is to identify the impoverished elderly as a vulnerable population and discuss application of the VPCM to assess the risks and health status of this group.
Demographics and Related Trends The impoverished elderly have been recognized as a vulnerable population in the current literature.7 The World Health Organization defines the elderly as persons aged 65 years or older.8 According to a recent report released by the Census Bureau, 16.1% of elderly persons in the United States live in poverty.9 A 2008 report by the Center for American Progress indicated that women older than 75 years were more likely than similarly aged men to be poor (13.6% vs 6%).10 According to Bolla,11 who defined poverty as an insufficiency of financial resources that leads to an inability to meet fundamental living expenses, these aforementioned figures represented a slight decrease in the poverty rate among the elderly, a decrease that was attributed to improvements in social welfare programs such as Social Security and the Supplemental Security Income Program. The American Geriatric Society Foundation for Health in Aging reported that in the 1960s, 35% of persons aged 65 years or older lived below the federal poverty level, with only 60% receiving Social Security pensions.12 By the mid-1990s, 93% of persons in this age group were receiving pensions and 97% were covered by Medicare. A Congressional Research Service report in 2006 showed that
the United States was experiencing an accelerated growth in the elderly population,13 a trend that is expected to continue over the next decade. In 2008, the US Census Bureau projected that the number of US seniors (ie, elderly persons) would rise from 35.2 million to 62 million by 2025.14 In 2011, Baby Boomers (persons born between 1946 and 1964) have just started becoming seniors; by 2030, this population will have grown faster than all other populations in all states.15 In 2007, the US Census showed that 15.5% of persons aged 65-74 years and 10.3% of persons aged ≥75 years were living in poverty.16 Among seniors living in poverty, 8.3% were white, 28.5% were African American, and 12.3% were of another racial background.16 Poverty affects a larger proportion of elderly rural residents than their urban counterparts.17 In addition, poor elderly rural residents have less access to transportation and healthcare services.1 The US government recently adopted the use of a new supplemental poverty measure to be used along with the traditional poverty measure. The new poverty measure takes into account factors that the traditional measure did not, including the rising cost of health care, access to transportation, and geographic differences in living costs. The new measure will be not be released until Fall 2011; however, the Huffington Post reported that demographers think this new supplemental policy measure will show even higher numbers of elderly Americans living in poverty than previously identified.18 The new measure indicates that 18.7% of US seniors live in poverty, versus 9.7% according to the traditional measure.18
Application of the Vulnerable Populations Conceptual Model The VPCM is a population-based framework developed by Flaskerud and Winslow19 based on work by Aday,20 Link and Phelamn,21 Mann and Tarantola,22 and Stanhope and Lancaster.23 The VPCM was the product of UCLA faculty members’ extensive research and clinical practice involving vulnerable population groups.6 This model highlights the interactive relationship among (1) availability of resources, (2) relative risk, and (3) health status. The author has designed Table 1 and Table 2 to show how the VPCM can be applied to the impoverished elderly population. Population-focused NPs may find that use of this model leads to a more thorough assessment of the vulnerability of the impoverished elderly. A thorough vulnerability assessment is crucial because lowincome elderly persons experience limitations in resources, resulting in higher risks for morbidity and premature death.7
Individual Model Concepts The VPCM comprises three concepts: resource availability, relative risk, and health status. These concepts are discussed individually. The author also shows how these concepts are interrelated. Resource Availability—The VPCM defines resource availability as the presence and distribution of socioeconomic and environmental resources, which include income, jobs, education, housing, availability of health care, quality of health care, and patterns of family and community life.1 A lack of socioeconomic and environmental resources increases the relative risk for poor health outcomes.6 Poverty, a lack of sufficient
VOL. 15 NO. 11/12 NOVEMBER/DECEMBER 2011 THE AMERICAN JOURNAL FOR NURSE PRACTITIONERS
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NP RESEARCH
TABLE 1
INTERACTIVE CONCEPTS OF THE VULNERABLE POPULATIONS CONCEPTUAL MODEL
Concept
Description
Indicators
Resource Availability
Determined on community and individual level Includes access, financial, and geographic factors
Health care Education Housing Income Jobs
Relative Risk
Addresses risk factors that are behavioral or biological
Lifestyle choices Health-promotion practices Exposure to high-risk activities Quality of health care
Health Status
Determined by disease incidence and prevalence and morbidity and mortality rates Directly affected by resources and their availability
Increased presence of disease Increased rates of premature death Delay in disease diagnosis
financial resources to meet one’s basic needs, leads to even greater vulnerability in the elderly because they are less able than their younger counterparts to rely on other resources (eg, education) to improve their life. According to the US Census Bureau in 2008, the poverty threshold of a person aged ≥65 years was $10,326 per year; 3.4 million elderly persons in this country lived below this threshold.14 Poverty thresholds are also used by the DHHS to determine financial eligibility for specific federally funded programs. Many seniors have incomes barely above this threshold and are ineligible for assistance programs, rendering them incapable of meeting their living expenses. According to the National Council on Aging in 2010, 96% of persons aged 65-69 years with incomes below the poverty threshold had retirement savings
