From a public health point of view, ‘vulnerable groups’ have been found to have high incidence and prevalence rates for certain diseases. Yet defining these groups in a static manner ignores the subjective, interactional and contextual dimensions of vulnerabilities, as well as their dynamic nature, as described by social scientists such as Delor & Hubert[1]. Two individuals in the same difficult situation do not necessarily take the same risks, and a given individual does not necessarily have the same vulnerability in different contexts, in different relationships, and at different points of his or her trajectory. In reality, everyone is likely to be ‘vulnerable’ at a given moment in his or her life. Vulnerability can be a transitory situation secondary to particular circumstances, and not a permanent state.

The concept of ‘vulnerability’ refines our problem analysis, as (members of) vulnerable groups can actually be quite resilient, e.g. many Roma people can count on a large social network, some sex workers get organized in a collective movement that opposes criminalization (of their work and / or their clients) through legal action, etc. Taking into account personal and collective resilience allows us to go beyond ‘perceived’ and ‘prescribed’ vulnerability in order to deliver the best possible care and to further help empower individuals and groups.

Therefore, when tackling health inequalities through targeted actions, the concept of ‘vulnerability’ seems more useful, inclusive and yet at the same time more precise than ‘vulnerable groups’. This approach is complementary to a ‘social determinants’ / ‘health inequalities’ point of view. The advantage of a ‘vulnerabilities’ approach, however, is that it also allows us to analyze very specific situations and factors, from a bottom-up perspective, that are not captured in population studies on social determinants.

Reflecting about the meaning of ‘vulnerabilities in health’ should, of course, not take away the attention to structural factors such as restrictive laws, xenophobia etc. Even ‘internal’ and ‘individual’ factors of vulnerability are socially determined and do not imply individual responsibility. Multiple studies have shown that independent personal lifestyle choices explain at best 14 to 28% of the level of health inequalities[2].

Many vulnerabilities can be approached from a structural / collective point of view, but also from an individual one.

Vulnerabilities that are (mainly) structural and / or institutional

  • Legal, administrative, financial (and geographical) barriers to access healthcare[3],
  • Quality, continuity and comprehensiveness of care (e.g. access to prevention), as well as the strength (and resilience) of a healthcare system (e.g. when faced with disaster, economic crisis, etc.),
  • The international geopolitical and migration context,
  • The difficulties that specific groups (e.g. asylum seekers, undocumented migrants, destitute EU citizens, Roma, sex workers, drug users, people in detention centers, etc.) face in accessing education, housing, work & revenues, and justice,
  • Labor exploitation,
  • Migration policies that criminalize migrants and lead to (structural) violence, existence of trafficking schemes, etc.
  • Loss of civil rights,
  • The level of social cohesion in a given community.

As a consequence…

  • Internalized xenophobia, racism, discrimination and stigma, e.g. by migrants & ethnic minorities, women, sexual minorities, people living with HIV or hepatitis, people living with a handicap, drug users, sex workers (e.g. having to hide your activity to your family and friends), etc.
  • Living as an undocumented migrant: constant fear of being arrested (and expelled),
  • Constant stress due to the fact that an asylum decision takes years,
  • Constant insecurity in the face of an uncertain future: housing, financial resources, expulsion, arrest, loss of contact with one’s family,
  • Feeling (and often knowing) you can’t rely on the police to protect you,
  • Rejected, neglected, abused children with disabilities in their family, then by the rest of society
  • Beliefs and conceptions about well-being, health and illness.

Vulnerabilities that are (mainly) individual (individual differences in resilience)

  • Underestimating one’s own risk of being vulnerable (perceived vulnerability),
  • Mental health impacts of substance addiction, of suffering violence, etc.
  • Loss of dignity, self-esteem or autonomy (e.g. feeling like you always have to rely on services),
  • Being uprooted as a result of migration, internalized feelings of alienation,
  • Loss of control over one’s own life,
  • Mental health impacts of having to live separated from one’s children,
  • Social capital / social isolation,
  • Information capital, e.g. knowing your rights,
  • Loss of resilience and reliance.

However, many vulnerability factors are both structural and individual:

  • For example, some groups are more at risk of suffering violence (e.g. migrant women) than others, but the impact on the individual depends mostly on the person’s social capital, individual resilience, self-esteem etc.
  • The prevalence of specific chronic diseases and multi-morbidity is largely socially determined. But suffering from HIV and HBV at the same time makes you more vulnerable, on an individual level…

[1] Delor F., Hubert M. Revisiting the concept of ‘vulnerability’. Social Science & Medicine 50 (2000) 1557-1570.

[2] Stronks K., et al. (1996). Behavioural and structural factors in the explanation of socio-economic inequalities in health: an empirical analysis. Sociology of health & illness 18:653-674.

Richter M., Mielck A. (2000). ZfG 8:198-215.

Laaksonen M. et al. (2005). Influence of material and behavioural factors on occupational class differences in health. Journal of epidemiological community health 59:163-169

Van Lenthe F.J. et al. (2002). Material and behavioural factors in the explanation of educational differences in incidence of acute myocardial infarction: the Globe study. Annals of epidemiology 12:535-542.

Giesecke, J., Müters S. (2006). Strukturelle und verhaltensbezogene Faktoren gesundheitlicher Ungleichheit: Methodische Überlegungen zur Ermittlung der Erklärungsanteile. In Richter, M., Hurrelmann K., (Ed) (2009). Gesundheitliche Ungleichheit. Grundlagen, Probleme, Perspektiven. Wiesbaden, Verlag für Sozialwissenschaften, pp. 353-366.

[3] Although healthcare access & quality issues are excluded from analytical frameworks on social determinants (« They only account for 25% of health inequalities at population level »), we specifically include them as a structural vulnerability factor.