Vulnerability in an Influenza Pandemic: Looking Beyond Medical Risk

Modern emergency management frameworks include recognition of the need to plan for the needs of the most vulnerable or at-risk people in a community [1-3]. However, identification of people at-risk has been an ongoing issue challenging the emergency management sector for decades, particularly in the context of an influenza pandemic [4-7]. As witnessed during the 2009 H1N1 pandemic and the 2003 SARS outbreak, much attention is directed toward protecting members of the population who are at heightened risk for medical complications from the virus or bacteria. However, it is also important to acknowledge vulnerability through the lens of the social determinants of health, which influence daily resilience and can exacerbate the impacts of a disaster [8-9]. The purpose of this paper is to summarize the literature on how the social determinants of health influence risk during influenza pandemics, with a focus on social vulnerability, rather than risk of medical complications. The literature reviewed for this paper indicates that in the context of pandemic, there is a social gradient of risk, based on social vulnerabilities that are likely to lead to increased exposure to the contagion, risk of basic human needs not being met, insufficient support, or inadequate treatment. With this in mind, the organization of this review of the literature follows most categories within the Social Determinants of Health Framework outlined by Mikkonen and Raphael [10]. The categories of risk have been divided into: a) Income and Income Distribution; b) Social and Physical Environment; c) Education and Literacy; d) Employment and Working Conditions; e) Early Life Income and Child Development; f) Ethnicity, Culture and Language; g) Age and Disability; h) Gender; and i) Access to Health Services. Income and income distribution are the most salient determinants within the Social Determinants of Health Framework [10], particularly as they intersect with the other determinants to exacerbate risk [6]. Lack of access to financial resources influences exposure, access to supportive care, an individual’s social safety net during pandemic, as well as health care seeking behaviour [11-16]. Geographic location, living conditions, and the social context of people’s lives all exert influence on susceptibility to risk during pandemic by influencing exposure, ability to meet basic daily needs, and access to supportive care. Social environment can refer to living in crowded housing [17-19], high levels of social interaction [20-21], being reliant on others to assist with daily personal care [22], or lifestyle factors such as injection drug use [23]. People with low literacy levels have been identified by Enarson and Walsh [24] as a high risk population. In the context of pandemic, the ability to understand public health risk communication and act on the recommendation is critical to reducing exposure, monitoring symptoms, and seeking appropriate care. Semenza & Giesecke [25] also identified people with low educational levels as a high risk group that suffers disproportionately from a number of diseases, including respiratory ailments like influenza. An important category of risk during pandemic is an individual’s employment and working conditions. Type of employment, income security, whether an individual has access to benefits (and hence a social safety net if an employee is sick or needs to stay home to provide caregiving), workplace exposure, demands for essential service workers, and challenges associated with managing multiple role conflicts, all contribute to vulnerability and resilience in pandemic [8, 17, 26-38]. In terms of pandemic planning, very few plans directly address the specific needs of children [39-40], yet they are identified as a high risk population because of functional needs for supervision, transportation, psychosocial supports, and communication, and their inability to live independently [17, 24, 41]. Childrens’ immune systems are less developed than those of adults, therefore they are often identified as a population at high risk for severe illness during pandemic or complications from vaccination [42]. However, their psychosocial risks are related to their maturational development and capacity to cope with the social impacts of pandemic or another type of bioevent [43-44]. Risk during pandemic is influenced by ethnicity, culture and language [11, 24, 40, 43, 45-46]. In this review, the general findings related to ethnicity, culture and language as risk factors during pandemic include: a) lower vaccination and health care seeking behaviours among ethic groups, particularly immigrants; b) lack of knowledge about risk and mistrust of health care professionals influenced attitudes and beliefs toward vaccination and accessing care; c) higher hospital admission rates among Aboriginal populations; d) language and cultural barriers negatively influence reception and comprehension of health information; and d) discrimination and stigmatization toward Asian populations during outbreaks which originated from Asia. Enarson and Walsh [24] identified the elderly as one of 10 high risk populations in Canada, and there is a growing recognition that the needs of the elderly and people who have disabilities are not addressed adequately in most emergency plans [40]. Loss of autonomy, limited financial resources, reduced mobility and social isolation are all factors which lead to vulnerability in both these populations [16, 25]. For anyone who is reliant on other people for personal care and support for daily living, the socio-economic impacts of a pandemic will present significant challenges in securing appropriate supports. Gender was an obvious theme through the literature, but rarely identified as such. It is included as a risk factor determining vulnerability for pandemic because of its intersection with all the other social determinants of health and the recognition for the need to consider gender as a cross-cutting theme in pandemic vulnerability [47]. The final category presented to identify people at heightened risk during pandemic is their access to health services. This refers to whether an individual has access to vaccination, treatment for influenza, and health care for other conditions, while a pandemic is occurring. Access to health services is a critical issue during pandemic and requires an ethical framework based on equity [48]. It is understood that health care resources will be depleted within just a few weeks of managing the increased demands for care during pandemic [48], yet the duration of a pandemic is often long, and a second wave, which presents additional demands on an exhausted health care system, is likely [49-50]. The findings from this review suggest a need for more research into the intersection of the social determinants of health in the preparation for, response during, and recovery from a pandemic. Future research should extend the knowledge on each of these determinants to devise solutions to address these risk factors and assist decision makers and service organizations in their attempts to meet the identified needs of the populations impacted negatively by pandemic influenza.

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