The Vulnerable Project: Addressing health inequalities through implementation research
Many EU citizens still face health disparities due to limited access to medical care. Implementation research is helping policymakers solve this life or death problem for isolated and vulnerable people.
Sofia, a 32-year-old single parent with three children, cannot afford to heat her tiny flat. This aggravates her asthma and Sofia says she doesn’t know where the next meal is coming from. What makes Sofia’s situation shocking is that she isn’t unemployed. She has a job and is an example of the burgeoning and vulnerable group of ‘in-work’ poor.
Emilie visits a food bank each week. Emilie is typical of the in-work poor: she is divorced with two children and works in a chemist but during time off, she comes to collect the food she needs to keep the family going. She says she doesn’t want her colleagues at work to know she relies on a food bank. Emilie lives in Germany. It’s surprising that even Germany, the richest country within the European Union, has problems with deprivation. This affluent country has a network of over 900 food banks used by some 1.5 million people.
The in-work poor are a significant group: in 2007 an estimated 8 percent of European workers were at risk of poverty but by 2017 that had risen to 10 percent. This belies the assumption that the best way out of poverty is to get a job. Factors such as non-standard forms of work, levels of taxation, single-parent households and costs of childcare have all contributed to the increase in the number of workers experiencing in-work poverty.
The difficulties of making ends meet are bound to take their toll on health. New research has shed light on some of the healthcare challenges for people like Sofia and Emilie. It aims to understand and actively address the health inequalities of isolated and vulnerable people within and across EU member states. This research, led by ICF, has proved innovative. Initial findings of the VulnerABLE Project have confirmed some long-standing assumptions while revealing some surprising new insights.
Insights and surprises
The two-year VulnerABLE Pilot Project provided useful insights into the specific health issues of the target groups. Some findings confirmed assumptions but there were numerous surprises, too.
Many vulnerable and isolated EU citizens do not have a positive perception of their health: just 31 percent of those surveyed as part of this project considered their health was very good, while 28 percent regarded it as very bad. Elderly people and those with physical, mental and learning disabilities are more likely to report very bad health (38 percent and 39 percent respectively). Perhaps more surprising is the benefit of having work, even when it does not pay well: the in-work poor were significantly less likely to report very bad health (17 percent) than the average respondent.
The chart below shows various factors that affected people’s health in the nine groups surveyed; lack of money (62 percent) and feelings of stress (53 percent) were the most common. Although lack of money might be expected, the significant role of stress is perhaps more surprising.
Survivors of domestic violence and people with unstable housing, along with members of vulnerable families, were most likely to portray other signs of psychological stress. They were, for example, more likely to feel particularly tense (most or all of the time), lonely and depressed. Additionally, people with disabilities felt significantly more depressed or downhearted (32 percent) than the average respondent.
The four main barriers to accessing healthcare and reasons for dissatisfaction were:
- long waiting times,
- perceived ineffectiveness of medical treatment,
- cost of treatment, and
- dissatisfaction with the attitude of the health professional.
The access to healthcare also differed across target groups but generally held no surprises. Members of vulnerable families, persons living in isolated or rural areas and the group of older people experienced above-average difficulties with accessing the healthcare they needed.
Prohibitive costs were mentioned as the main reason for not visiting medical practitioners or getting medication. An inability to afford these was reported most often by members of vulnerable families, and next by those living in isolated or rural areas.
A surprise came from the in-work poor who reported more problems with the costs of dental care. Perhaps another unexpected outcome is that people with physical, mental, and learning disabilities were significantly less affected than other groups by the cost of healthcare.
The VulnerABLE Project found that people within the nine groups often experienced more than one factor that made access to healthcare harder. A limited income, coupled with one additional factor, such as the onset of ill-health, could cause an individual and their family real hardship.
Innovative research
Delivering the project involved a reference to ‘implementation research’ to link research conclusions with policy guidance. This approach, growing in clinical situations, leads to quick translation from research into effective new patient treatments. Linking research to actions also brings cost, organizational, and efficiency savings. For the VulnerABLE Project, the final phase illustrated the benefits of this linkage by publishing, “Policy Guidance – A Framework for Action”. This helped policymakers to connect the research findings to positive action.
This approach also profited from pulling together a variety of research methods which helped to amplify the strength of the findings, including:
- A large evidence base, drawn from a survey and a variety of complementary sources.
- A range of best practice examples collected by the research team from across the EU member states.
- Conducting interviews through professionals already trusted by the target groups.
- Organizing focus groups with medical practitioners and other organizations to share experiences and increase the knowledge base.
- Implementing findings through capacity-building workshops and action plans.
Partnerships between ICF, EuroHealthNet, UCL Institute of Health Equity, European Public Health Alliance and Social Platform meant that the project was designed, carried out and delivered to carry the all-important research findings and initiatives safely through into implementation and effective action for the target groups. This approach added value to the project and the findings showed that an integrated approach was a cost-effective and powerful way of addressing the health issues of many vulnerable groups of people.
Only the beginning
It is early days for the VulnerABLE Project–the research has been delivered and the targeted areas for actions have been shared. It is vital that policymakers keep in mind the European Commission’s view that unequal access to healthcare is avoidable, unnecessary, and unfair.
The changes that policymakers are introducing as a result of the project are still ongoing and it is too soon to evaluate them. What is already evident is that the way this project was organized to include a very wide range of research data and novel approaches increases its potential success in countering health inequalities. Linking research findings to effective methods of implementation has helped to provide a foundation for tackling health inequalities and improving access to healthcare across EU member states. For all vulnerable and isolated people in the EU, it is important that this project fulfills its initial promise.
The scope of the VulnerABLE Project
- Older people,
- At-risk children and families (especially lone-parent families),
- People living in rural/isolated areas,
- People living with physical and learning disabilities or poor mental health,
- People experiencing long-term unemployment or economic inactivity,
- In-work poor,
- Victims of domestic violence and intimate partner violence,
- People in insecure housing situations or homeless,
- Prisoners and ex-prisoners.
In the last 20 years, the overall impression is that healthcare has improved within the EU. This is generally correct, but since 2011 the rate of improvement in life expectancy has slowed considerably. Even before 2011, pronounced pockets of health deprivation were apparent, with large disparities in life expectancy and health in general. These disparities are linked to sex and socioeconomic status.
The EU’s VulnerABLE Project looked at nine groups of vulnerable and isolated people and the reasons why they were likely to experience poor health. The research identified the barriers to accessing healthcare and the availability of the healthcare they needed most.
Vulnerability is a social concept and it isn’t static. It may result from issues such as redundancy, illness, a difficult pregnancy, and becoming old and frail. There is no recognized EU figure for vulnerable people within the member states but an estimate can be drawn from associated EU statistics about poverty and social exclusion.
In 2016, there were just under 120 million people, about 23 percent of the EU population, who were at risk of poverty or social exclusion. This means roughly one in four people in the EU has experienced at least one of the following three forms of poverty: monetary poverty, severe material deprivation, or living in households with very low work intensity. This is a surprisingly large number of people experiencing health inequalities in some of the world’s most developed nations.
The VulnerABLE Project confirmed the point, outlined by Solidarity in Health, published by the European Commission in 2009, that health inequalities between population groups are due to differences in a wide range of factors that affect health. These include: “living conditions; health-related behavior; education, occupation and income; health care, disease prevention, and health promotion services, as well as public policies influencing the quantity, quality, and distribution of these factors.”
