Guidance

Vulnerabilities: applying All Our Health

Published 29 March 2022

The Public Health England team leading this policy transitioned into the Office for Health Improvement and Disparities (OHID) on 1 October 2021.

Introduction

This guide is part of All Our Health, a resource which helps health professionals provide better access to health and care, and promote wellbeing as part of their everyday practice. The information below will help front line health and care staff use their trusted relationships with patients, families and communities to address the impact of vulnerabilities. We recognise that health and care staff as individuals may also experience similar issues in their personal lives.

This guide also recommends important actions that managers and staff holding strategic roles can take.

View the full range of All Our Health topics.

The meaning of vulnerability and other terms

To aid the understanding of this guidance we have defined some of the terms used.

Vulnerability

Being vulnerable is defined as in need of special care, support, or protection because of age, disability, risk of abuse or neglect.

Childhood vulnerability

There is no commonly used definition of childhood vulnerability. A child can be vulnerable to risks and poor outcomes due to individual characteristics, the impact of action or inaction by other people and their physical and social environment.

Vulnerable adults

The NHS defines vulnerable adults as any adult (person over the age of 18) unable to take care of themselves or protect themselves from exploitation.

Many factors can influence adult vulnerability, experiences of vulnerability in childhood may negatively impact adults in later life – particularly if someone has fewer protective factors in place, such as a supportive family or a stable household income.

Vulnerable background

Children and young people’s physical, emotional and mental wellbeing are significantly shaped by the social determinants of health into which they are born, live, learn and grow. Traumatic events and adverse circumstances occurring in childhood are associated with long-term impact on outcomes at population level. This does not mean that every child experiencing trauma and adversity will experience poorer outcomes. Multiple factors influence outcomes – the presence of protective factors such as a supportive family will also be key influences.

Protective and risk factors

A protective factor is something that decreases the potential harmful effect of a risk factor.

Risk factors can increase the likelihood that a person may become vulnerable, however they may be a contributing factor and not necessarily a direct cause. Risk factors are not determinative and not everyone who is identified as at risk become vulnerable.

Risk and protective factors can be found in every area of a child or adolescent’s life, exerting different effects at different stages of development.

There is a complex interrelationship between the experiences an individual child has in a family and those they experience in the wider community. Negative experiences – both at home and in the community – may mean that children are not only at greater risk of poorer outcomes because of these experiences, but also of engaging in harmful activities as they grow up which increase their risks further. This can perpetuate inequality throughout life and from one generation to the next. It emphasises the importance of addressing the risk factors which make children more vulnerable at an individual level, but also in terms of the causes of wider risk factors in families and within a community.

Trauma

Trauma results from an event, series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful, or life threatening. This has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional or spiritual wellbeing.

Re-traumatisation

Re-traumatisation is the re-experiencing of thoughts, feelings or sensations experienced at the time of a traumatic event or circumstance in a person’s past. Re-traumatisation is generally triggered by reminders of previous trauma which may or may not be potentially traumatic themselves.

Trauma informed practice

Trauma informed practice is an approach which is grounded in the understanding that trauma exposure can impact an individual’s neurological, biological, psychological and social development – thus shaping a person’s world view and relationship development.

Being trauma informed means assuming that people are more likely than not to have a history of traumatic experiences, and that these experiences may impact on their ability to feel safe within or develop trusting relationships with services and their staff.

Trauma informed practice is not designed to treat trauma related difficulties. It seeks to address the barriers that those affected by trauma can experience when accessing care and services by using the six principles of trauma informed practice:

• safety
• trust
• choice
• collaboration
• empowerment
• cultural consideration

Addressing vulnerabilities in professional practice

Vulnerability, traumatic experiences, and wider inequalities can impact on people’s health and wellbeing from childhood and across the life course. As health and care professionals, having an awareness that this impact is not always visible and understanding how best to support individuals accessing services who may be vulnerable, will enable care to be provided that is accessible, appropriate and effective.

Many definitions of vulnerability and vulnerable populations already exist with differing perspectives or contexts depending on the setting and experiences. Groups and individuals may be impacted by multiple vulnerabilities. Vulnerability may be temporal in nature, so specific populations may be at greater risk of poor health outcomes in times of crisis. Vulnerability is complex and multifaceted – addressing vulnerabilities requires an approach that reflects this dynamic.

This section of the guidance promotes an understanding of vulnerabilities and their effects across the life course. The approach considers both the adversities people experience and factors likely to make them more vulnerable to poor outcomes.

The impact of vulnerability

The cost of late intervention is estimated at £16.6 billion a year. While not all late intervention is avoidable, there are considerable resources being spent tackling issues that could have been dealt with sooner, and at less cost to the individual and to services. Some social determinants of health make people more vulnerable – addressing these factors should also reduce health inequalities more generally.

A lack of awareness about the impact of vulnerability can lead to:

• social exclusion
• a lack of support or onward referral
• the potential for re-traumatisation

There can be a link between the experience of trauma, sometimes from childhood, and the risk of a range of poor outcomes.

Vulnerability is complex and multifaceted, below are examples of some of the impacts vulnerability can have on an individual:

• more likely to have lower educational attainment
• poor mental and physical health outcomes
• 4 times more likely to have special educational needs (SEN) than child population overall
• more likely to become teenage parents
• association between children in care and offending
• isolation and loneliness
• more likely not to be in education, employment or training
• more likely to live in poverty and experience developmental delays
• more likely to have communication difficulties
• youth custody disproportional health needs (mental health, alcohol, and learning disability (LD)
• witnessing violence – increased risk smoking, obesity, depression and sexual behaviour
• housing – poor respiratory and mental health

The presence of protective factors can make an individual less likely to experience poor outcomes, even when risk factors are present. When seeking to reduce the number of individuals experiencing the harmful effects of vulnerable circumstances or trauma, interventions need to consider building protective factors as well as reducing risk factors.

Vulnerabilities have become an even more important consideration in professional practice since COVID-19, as it has highlighted existing inequalities as well as having widespread economic and social impacts. Those who were not previously identified as vulnerable, may have become so as a result of the pandemic. Increased levels of loneliness, social isolation and reduced personal resilience have impacted young people and older adults, as well as the wider population. More generally, the underlying wider community and social conditions which can make at risk groups more vulnerable, which existed before the pandemic, are likely to remain.

Addressing vulnerabilities

By adopting a life course approach, we can:

• prevent vulnerability and adverse experiences
• intervene early when vulnerabilities arise
• mitigate the negative impact of these circumstances throughout the life course by creating a healthy and supportive environment

Intervention should be based on place and address the social determinants which create health inequalities.

Individuals will process traumatic events in different ways as a result of the interaction between their own neurobiology, previous experiences of trauma and the type of support available to them, as well as the broader social context in which they live.

Risk and protective factors

Risk and protective factors may be found at an individual, family or environment level and can change over time depending on factors such as age. These factors are at the core of prevention strategies.

Risk factors: individual

Risk factors in individuals include:

• genetic or biological
• perinatal trauma
• early malnutrition
• behavioural and learning difficulties
• alcohol and substance misuse
• traumatic brain injury
• gender

Risk factors: relationship

Risk factors in relationships include:

• low family income
• poor parenting and inconstant discipline
• family size
• abuse – emotional, physical or sexual
• emotional or physical neglect
• household alcohol or substance misuse
• household mental health
• family violence
• family breakdown
• household offending behaviour

Risk factors: community

Risk factors in communities include:

• unsafe or violent communities
• low social integration and poor social mobility
• lack of possibility for recreation
• lack of infrastructure for the satisfactions of needs and interest of young people

Risk factors: society

Risk factors in societies include:

• socio-economically deprived communities
• high unemployment
• homelessness or poor housing
• a culture of violence, norms and values which accept, normalise and glorify violence
• discrimination
• difficulties accessing services

Protective factors: individual

Protective factors in individuals include:

• healthy problem solving and emotional regulation skills
• school readiness
• good communication skills
• healthy social relationships

Protective factors: relationship

Protective factors in relationships include:

• stable home environments
• nurturing and responsive relationships
• strong and consistent parenting
• frequent shared activities with parents
• financial security and economic opportunities

Protective factors: community

Protective factors in communities include:

• a sense of belonging and connectedness
• safe community environments
• community cohesion
• opportunities for sports and hobbies

Protective factors: society

Protective factors in societies include:

• good housing
• high standards of living
• opportunities for valued social roles

Resilience is the capacity to bounce back from adversity – protective factors increase resilience, whereas risk factors increase vulnerability.

Resilient individuals, families and communities are more able to deal with difficulties and adversities than those with less resilience. It is important that resilience is strengthened at both an individual and societal level.

The purpose of trauma informed practices

There has been growing interest around trauma informed practices as an approach to mitigate the barriers that those affected by trauma can experience when accessing care and services.

Trauma informed practice aims to create safety for people accessing services by understanding the effects of trauma and its close links to health and behaviour. It is not about eliciting or treating people’s trauma, but about creating a safe space that enables people to access the services they need for their health and wellbeing. By adopting this approach with everyone accessing health and care services, professionals will enhance access for all – most notably for those who may find it more difficult to get the support they need.

Core principles for health and care professionals

When working to address the impact of vulnerabilities, all health and care professionals should:

• understand specific activities and interventions that can address the impact of vulnerabilities
• think about the resources and services available in your area that can help people who are vulnerable or have experienced trauma
• understand the principles of trauma informed practice

Taking action

This section of the guide sets out how strategic leaders, managers and clinicians can adopt a public health informed approach to reduce inequalities and improve health and wellbeing outcomes for the most vulnerable in our communities.

The aim is to think about what has happened to a person instead of what is wrong, and understand how trauma might impact how a person responds to you and others and why they make the decisions they do.

Applying the principles of trauma informed practice can help you to build a trusting relationship with someone accessing your services.

Principles of trauma informed practice

Consider applying the principles of trauma informed practice.

Safety

The list below includes ways to apply this principle – you should:

• put measures in place so that individuals feel emotionally and physically safe
• consider the wider impact of your actions
• ask what they need to feel safe and how you can create a safe environment for them
• keep the person informed
• do what you say you will do when you say you will do it

Trustworthiness

The list below includes ways to apply this principle – you should:

• be transparent and do what you say you will do
• explain what will happen next
• give relaxed, unhurried attention – listen effectively
• not overpromise – always manage expectations

Choice

The list below includes ways to apply this principle – you should:

• listen to what the person wants
• if there is a choice – give it
• always explain clearly and transparently what will happen next
• validate any concerns as understandable and normal

Collaboration

The list below are ways to apply this principle – you should:

• ask what they need
• be clear about what will happen and what they have control over and choice in – empower them where possible
• understand local services and support agencies so that you can suggest places to go to access help

Empowerment

The list below are ways to apply this principle – you should:

• validate people’s feelings and engage with them in a non-judgemental manner
• listen to what they need and ensure they are signposted or referred to appropriate support
• not take over – encourage and empower people to take positive action themselves (with your support if they want it)

Cultural consideration

The list below are ways to apply this principle – you should:

• open non-judgemental attitude
• have an awareness of your own cultural values and an awareness and acceptance of cultural differences
• consider how you can expand your own cultural awareness – familiarise with the worldviews of cultural groups other than your own
• ask people about their culture to understand their preferred language, how healthcare decisions are made in their family and whether their culture prohibits any healthcare procedure or tests

Training

Psychological First Aid (PFA) is a globally recommended training for supporting people during crisis and emergency situations. These 2 courses equip staff, volunteers and community members to provide practical and emotional support, as well as recognising people at risk of distress:

• PFA for those supporting children and young people
• COVID-19: PFA

Supervision

Staff members should consider their own wellbeing and need for support, including accessing supervision where available.

Team leaders or managers

Having an awareness of vulnerabilities when providing healthcare is about more than access to health or care. It is about considering the wider determinants of health, and shaping services which focus on improving the health of those who face the greatest disadvantage and are at higher risk of poor outcomes over the life course.

As a team leader or manager you should:

• be aware of how health inequalities impact on people’s lived experience
• build protective factors and promote resilience where possible
• be open to consider how certain practices and policies may unintentionally increase harm – particularly to those who have experienced trauma and discrimination and take action to change these
• create a working culture which is respectful and inclusive of people’s diverse life histories and models to staff – an approach which is followed through in their work with individuals
• identify staff learning and development needs in relation to vulnerabilities and trauma informed practice – provide access to appropriate training
• provide a psychologically safe environment for staff by ensuring adequate supervision is available
• consider your own wellbeing and need for support, including accessing supervision where available

Senior or strategic leaders

To shape service provision to be as accessible as possible to those at greatest disadvantage in the local population, senior or strategic leaders should:

• engage in full partnership – working to achieve the best outcome for the vulnerable child or adult
• embed a person centred engagement and risk management approach
• understand the wider health and wellbeing needs of your local population using the fingertips tool or other available data
• invest in workforce development and training to embed a system of trauma informed practice
• consider your own wellbeing and need for support, including accessing supervision where available

Understand local needs

A good understanding of needs and assets within the local area is important to develop responses and identify who might benefit from these approaches, including:

• Joint Strategic Needs Assessment (JSNA)
• Public Health Outcomes Framework
• Child Health Profiles
• Productive Healthy Ageing Profile
• local intelligence

Health professionals are in a good position to engage with their communities and other stakeholders to learn about what is happening locally, and develop good knowledge of local services and other community assets.

Specific data sets relating to risk factors, protective factors and outcomes are available on fingertips – a large public health data collection.

Measuring impact

As a health and care professional, there are a range of reasons why it makes sense to measure your impact and demonstrate the value of your contribution. This could be about sharing what has worked well in order to benefit your colleagues and local people, or help you with your professional development.

The Everyday Interactions Measuring Impact Toolkit provides a straightforward and easy way for health care professionals to record and measure their public health impact in a uniform and comparable way.

The evaluation in health and wellbeing page provides a helpful overview of what evaluation is, when it should be undertaken and the different types of evaluation.

The Child Health Profiles and Public Health Outcomes Framework also include a number of indicators related to county lines exploitation, such as:

• 16 and 17 year olds not in education, employment or training (NEET)
• school absence and exclusion
• first time entrants to the youth justice system
• children in low income households
• children in care
• emotional wellbeing of children in care
• substance and drug misuse
• children with social, emotional and mental health needs
• violent crime – including sexual violence

Further reading, resources and good practice

Advice for individuals and members of the public

Better Health is a nationwide programme that motivates and supports adults to take action to improve their mental and physical health – including helping them to eat well, move more and quit smoking.

Every Mind Matters is a national campaign and NHS-endorsed digital platform which aims to equip young people and adults to take simple steps to look after their mental health, improve their mental wellbeing and support others to do so.

NHS UK is the UK’s biggest health information service which provides advice, tips and tools to help you make the best choices about your health and wellbeing.

Hourglass is a national charity with a mission to end the harm of older people in the UK.

Professional resources and tools

There are a number of resources and tools available for health and care professionals.

ACE’s online learning has been commissioned by the West Midlands Police and Crime Commissioner, and is funded through the Home Office early intervention youth fund.

Barnardo’s is a non-profit organisation that provides support to children and young people against abuse and exploitation.

An op-ed on elder abuse in the UK provides insight into the public health problem in the UK.

NHS England have developed a good practice guide to support implementation of trauma informed care in the perinatal period.

No child left behind is a public health informed approach focused on improving outcomes for vulnerable children.

Preconception care resources provides information, intelligence and tools with evidence based approaches for how preconception care can be embedded.

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) trauma and justice initiative have developed a concept of trauma and guidance for a trauma informed approach to develop a shared understanding of these concepts that would be acceptable and appropriate across an array of service systems and stakeholder groups.

White Ribbon UK is the leading charity engaging with men and boys to end violence against women – they provide reports and resources on tackling violence.

Women’s Aid is the national charity working to end domestic abuse against women and children, providing resources and support for survivors of domestic abuse and those seeking refuge.

E-learning

Health Education England resources include:

• domestic violence and abuse e-learning for health visitors and nurses
• alcohol – reducing violence in the community
• volunteer learning

Making Every Contact Count (MECC) brief intervention training ensures that individuals have the skills, knowledge and confidence to make every contact count. 

MindEd have developed an adverse childhood experience e-learning programme for professionals and volunteers.

Best practice examples

Blackpool Better Start developed a good practice guide to support the implementation of trauma informed care in the perinatal period for all staff working with perinatal women in maternity and mental health services, although it may be more pertinent to certain roles.

The Family Nurse Partnership blog page includes various posts on mental health, child development, domestic violence and more.

The World Health Organisation Collaborating Centre for Public Health Nursing, Midwifery and Allied Health Professions published a number of case studies and good practice examples.