Vulnerability and Primary Health Care: An Integrative Literature Review

Type of Study and Methodological Procedures

An integrative literature review was carried out. This approach was chosen since it allows for the integration of concepts, ideas, and opinions in a broader approach for the phenomenon studied. ⁵ The review was based on 6 steps: identification of the theme and selection of the research question, establishment of inclusion and exclusion criteria, identification of the pre-selected and selected studies, categorization of the selected studies, analysis and interpretation of the results, and presentation of the knowledge review/synthesis. ⁶

Inclusion and Exclusion Criteria

The inclusion criteria defined for the literature search were: full, peer-reviewed articles available in English, related to vulnerability and primary health care, with the explicit concept of vulnerability and published prior to July 31, 2020. Dissertations, theses, reviews, editorial notes, and articles without access to the abstract and the full text were not included.

Data Sources

The electronic bibliometric databases accessed, in the period from August to September 2020, were: National Library of Medicine through the PubMed portal, Scopus, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Latin American and Caribbean Health Sciences Literature (LILACS). For the search strategy in the 5 databases, the following keyword was considered: “Vulnerability”; “Vulnerabilities”; “Primary Health Care”; “Primary Healthcare”; and “Primary Care,” with the use of the Boolean operators “OR” and “AND.” DECS/MESH referred to these controlled descriptors. In the 5 databases, descriptors and the keyword were used in the English language (Table 1).

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Table 1.

Database Search Strategy and Frequency of Results.

Database	Search strategy	Number of articles	%
PubMed	(vulnerability OR vulnerabilities) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)	1636	57.0
Scopus	TITLE-ABS-KEY (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”) AND TITLE-ABS-KEY (vulnerability OR vulnerabilities)	626	21.8
Embase	(vulnerability OR vulnerabilities) AND (“primary health care” OR “primary care” OR “primary healthcare”)	374	13.0
CINAHL	(vulnerability OR vulnerabilities) AND (“Primary Health Care” OR “Primary Healthcare” OR “Primary Care”)	130	4.6
LILACS	(tw:[vulnerability OR vulnerabilities]) AND (tw:[“primary health care” OR “primary healthcare” OR “primary care”])	103	3.6
Total		2.869	100

Table 1.The step for the selection of the studies was performed blindly by 3 reviewers using the Rayyan software. ⁷ Initially, the title and abstract were read, applying the inclusion criteria. Dissenting opinions regarding the inclusion of some articles were resolved by the 3 reviewers, in a consensual and face-to-face way, resulting in the composition of the final sample. Subsequently, the 3 reviewers read the selected articles in full. Data from the studies were extracted using a validated instrument ⁸ and the articles were classified according to the level of evidence. ⁹

Analysis

We describe the articles included according to the year of publication, title, authors, country, study design and 7 levels of evidence. Thematic analysis and synthesis of the evidence was conducted to examine the theoretical basis of vulnerability and its use in PHC. As this is a review article, the Prisma checklist was applied in the development of the study, observing the items relevant to the integrative review. ¹⁰

Results

The database search resulted in a total of 2869 articles. With the removal of duplicates, 1201 articles were obtained. After reading the titles and abstracts, 1163 articles were excluded as they did not fulfill the inclusion criteria, leaving 38 articles eligible for review. In-depth reading of the 38 articles led to the exclusion of 19 (50.0%) that did not answer the guiding question and/or for the following 5 reasons: 3 (15.8%) discussed the concept of vulnerability in relation to environmental conditions only; 8 (42.1%) did not discuss the concept of vulnerability in the PHC scenario, 5 (26.3%) discussed the concept of vulnerability applied to specific groups, such as pregnant women or older adults, without being related to the specific PHC scenario, 2 (10.5%) did not directly discuss the concept of vulnerability and 1 (5.3%) was a literature review (Figure 1).

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Figure 1.

PRISMA flow diagram (adapted) of the selection process of the articles.

Accordingly, 19 articles constituted the final sample of the study. Of these 19 articles, ten (52.6%) were published in Brazil, 3 (15.8%) in the United States, 2 in Canada (10.5%), 2 in England (10.5%), 1 in the Netherlands (5.3%), and 1 in New Zealand (5.3%). Regarding the chronology, there was an increase in productions on the theme of vulnerability in PHC over the years, a fact also observed in Brazil, between the years 2015 and 2018. Of the 19 articles selected, 2 (10.5%) were characterized as level of evidence V and 17 (89.5%) as level VI, with a predominance of cross-sectional, descriptive studies, using qualitative analysis. Table 2 shows the articles included in this review according to the year of publication, title, authors, country, study design, and level of evidence.

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Table 2.

Descriptive Analysis of the Articles Selected According to the Year of Publication, Title, Authors, Country, Design, and Level of Evidence.

Author	Title	Study country	Design	Level of evidence
Baker et al 11	Inequalities in morbidity and consulting behavior for socially vulnerable groups.	England	Cross-sectional study	VI
Shi et al 12	Vulnerability and the Patient–Practitioner Relationship: The Roles of Gatekeeping and Primary Care Performance	EUA	Cross-sectional study (survey)	VI
Stevens et al 13	Disparities in Primary Care for Vulnerable Children: The Influence of Multiple Risk Factors	EUA	Descriptive study with a quantitative approach	V
da Silva et al 14	Evaluation of the vulnerability of families assisted in Primary Care in Brazil	Brazil	Observational and cross-sectional epidemiological study	VI
Drewes et al 15	Variability in vulnerability assessment of older people by individual general practitioners: a cross-sectional study	Netherlands	Cross-sectional study	VI
Guanilo et al 16	Assessing the vulnerability of women to sexually transmitted diseases STDs/HIV: Construction and validation of markers	Brazil	Methodological development study	V
Souza et al 17	Vulnerability of families of elderly citizens cared for by the Family Health Strategy	Brazil	Cross-sectional study	VI
Silva et al 18	Vulnerability in the child development: influence of public policies and health programs	Brazil	Exploratory study, with a qualitative approach	VI
Pasqual et al 19	Health care for women over 50: programmatic vulnerability in the Family Health Strategy	Brazil	Evaluation study	VI
Costa et al 20	Public health agendas addressing violence against rural women—an analysis of local level health services in the State of Rio Grande do Sul, Brazil	Brazil	Exploratory and descriptive study, with a qualitative approach	VI
Athié et al 21	Anxious and depressed women’s experiences of emotional suffering and help seeking in a Rio de Janeiro favela	Brazil	Qualitative study	VI
Dias et al 22	Family vulnerability of children with special needs of multiple, complex, and continuous care	Brazil	Cross-sectional study	VI
Loh 23	The importance of recognizing social vulnerability in patients during clinical practice	New Zealand	Descriptive study	VI
Haidar et al 24	The influence of individuals’ vulnerabilities and their interactions on the assessment of a primary care experience	Canada	Cross-sectional study, with a quantitative approach	VI
Coyle and Atkinson 25	Vulnerability as practice in diagnosing multiple conditions	England	Descriptive study, with a qualitative approach	VI
FernandesBolina et al 26	Factors associated with the social, individual, and programmatic vulnerability of older adults living at home	Brazil	Population-based, observational, cross-sectional study	VI
Andrade et al 27	Programmatic vulnerability related to diseases caused by Aedes aegypti.	Brazil	Quantitative, exploratory and descriptive study	VI
Oldfield et al 28	Group Well-Child Care and Health Services Utilization: A Bilingual Qualitative Analysis of Parents’ Perspectives	EUA	Qualitative study	VI
Nguyen et al 29	Social Vulnerability in Patients with Multimorbidity: A Cross-Sectional Analysis	Canada	Cross-sectional study	VI

The thematic analysis of the eligible articles produced 2 major themes: “Theoretical foundations of the concept of vulnerability” (Table 3) and “The use of the concept of vulnerability in PHC” (Table 4). In the second major theme, 2 sub-themes emerged: (a) Evaluation of health policies, programs, and services; and (b) Classification of individuals, groups, and families (Table 4).

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Table 3.

Description of the Articles According to Concept and Theoretical Framework.

Theme 1. The concept of vulnerability and its theoretical foundations
Author	Concept of vulnerability	Theoretical foundation
Baker et al 11	Vulnerability conceptualized as a situation resulting from the interaction of factors such as poverty, racism, lack of social support, cultural differences, and social exclusion, with an impact on health.	Baker et al 11
Shi et al 12	Vulnerability conceptualized as a convergence of risk, measured by 3 dimensions: predisposition (race, ethnicity); available resources (income and insurance coverage, characteristics of the community), and need (self-perceived health status).	Aday30,31
Stevens et al 13	Vulnerability conceptualized as a situation resulting from multiple overlapping risk factors: race, poverty, parenting, mother’s language, and health insurance coverage.	Aday 30
da Silva et al 14	Vulnerability conceptualized as the relationship between individual, collective, social, and resource availability aspects that can result in susceptibilities to illness or health problems.	Ayres et al 32
Drewes et al 15	Vulnerability conceptualized as frailty related to decreased functions in the functional, somatic, social, and/or psychological domains in older adults.	Fried 33
Guanilo et al 16	Vulnerability conceptualized as the relationship between individual, social, and institutional aspects (programmatic) and the political commitment of governments.	Ayres et al 32 Mann et al 34
Souza et al 17	Vulnerability conceptualized as the state of individuals or groups that have their capacity for self-determination reduced, and may have difficulties in protecting their own interests due to deficits in power, intelligence, education, resources, strength, or other attributes.	Barchifontaine 35 Ayres et al 32
Silva et al 18 (2015)	Vulnerability conceptualized as the chance of suffering impairments or delays in childhood development, due to individual, social, and programmatic factors.	Ayres et al 32
Pasqual et al 19	Programmatic vulnerability conceptualized as the way and the sense in which technologies already operating, such as health policies, programs, services, and actions, impact on a given situation.	Ayres 36
Costa et al 20	Programmatic vulnerability conceptualized as the way in which institutions operate, especially those of health care, reproducing, or deepening socially given conditions of vulnerability.	Ayres et al 32
Athié et al 21	Vulnerability conceptualized not only as an instability between a human being and a challenge of the environment, but also as a concept that links a vulnerable person to a coercive situation, a relationship established between the oppressor and the oppressed.	Oviedo 37
Dias et al 22	Individual vulnerability conceptualized as the existence of factors of the individual that favor the occurrence of the harm; the program related to access to health services, its organization, the relationship between professionals and users, disease control, and prevention plans and the resources provided to serve the population; and social factors related to the environmental and economic conditions to which the individual is subject.	Ayres et al 32
Loh 23	Vulnerability conceptualized as the grouping of multiple risk factors that reinforce each other, resulting from the lack of material and social resources essential to well-being, the presence of risk behaviors and the influence of environmental factors. It can be a chronic and cumulative characteristic and its traits can be passed on to family generations, as well as being interpreted as an antonym for resilience.	Shi et al 38 Mechanic et al 39 Seery et al 40
Haidar et al 24	Vulnerability consisting of five types: self-reported (subjective), biological, material conditions, relational, or cultural.	Aday30,31
Coyle and Atkinson 25	Vulnerability conceptualized as a universally shared characteristic of human beings, which becomes amplified for some people through inherent disabilities or external structures of inequalities, in addition to the practices of the services.	Fineman 41 Kittay 42 Levinas 43 Butler et al 44
Fernandes Bolina et al 26	Vulnerability constituted by the individual, social, and programmatic dimensions, used to identify susceptibilities to problems and health damage of people or communities.	Ayres et al 32
Andrade et al 27	Vulnerability constituted by the individual, social, and programmatic dimensions.	Ayres et al 32
Oldfield et al 28	Vulnerability conceptualized as structural vulnerability: poverty or racial/ethnic discrimination.	Bourgois et al 45
Nguyen et al 29	Social vulnerability conceptualized as a term that allows a holistic and integrative approach to measure the social circumstances of individuals.	Andrew et al 46

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Table 4.

Description of the Articles According to Use and Categorization of the Use of the Concepts in PHC.

Theme 2. The use of the concept of vulnerability in PHC
Sub-theme A. Evaluation of health policies, programs, and services		Sub-theme B. Classification of individuals, groups, and families
Author	Use of the concept	Author	Use of the concept
Baker et al 11	Characterization of seeking access to health services, through the analysis of the health condition of vulnerable groups.	da Silva et al 14	Classification of families according to the degree of vulnerability.
Shi et al 12	Elaboration of a measurement instrument to assess the users’ perception of the doctor-patient relationship and the performance of PHC.	Drewes et al 15	Classification of older adults according to the degree of vulnerability, from the perspective of physicians.
Stevens et al 13	Analysis of the disparities and equity in the health status of children and adolescents considering 3 aspects: access, continuity, and coverage.	Guanilo et al 16	Construction of vulnerability markers to identify women more susceptible to illness (STI/AIDS).
Silva et al 18	Childhood development assessment, from the programmatic dimension, from the perspective of nurses.	Souza et al 17	Classification of families according to the degree of vulnerability through the construction of the Family Development Index
Pasqual et al 19	Evaluation of the care process provided to women, from the age of 50, in a Family Health Unit.	Dias et al 22	Analysis of the family vulnerability of children with special needs for multiple, complex, and continuous care.
Costa et al 20	Study of the confrontation of violence against rural women, based on the analysis of public agendas.	Coyle and Atkinson 25	Instrument for the diagnosis of multiple conditions (mental illnesses and disabilities) in people seen at a Mental Health Center.
Athié et al 21	Analysis of women’s access to mental health care, based on their narratives in relation to suffering and the care.	Fernandes Bolina et al 26	Analysis of the dimensions of vulnerability in older adults associated with socioeconomic factors.
Loh 23	Analysis of the health system’s response to the patient’s vulnerability in the family medicine setting.	Nguyen et al 29	Description of social vulnerability in patients with multimorbidity, using a vulnerability index, to examine its correlation with the number of chronic conditions and to investigate the chronic conditions associated with the state of greatest social vulnerability.
Haidar et al 24	Analysis of the influence of vulnerability on the evaluation of the experience of care in a universal health system.
Andrade et al 27	Quality measure of the health service provided by the city to cope with diseases related to Aedes aegypti.
Oldfield et al 28	Analysis of the participants’ perception of the use of health services, addressing predisposing factors, facilitators, and the need to use health services.

Theme 1: Theoretical Foundations of the Concept of Vulnerability

The thematic analysis revealed that the authors included in this review, in order to conceptualize vulnerability, were supported by different theoretical references that, at times, complement each other and at other times differ due to the opposition of ideas. In 9 articles (47.4%) cited Ayres et al^32,36 3 articles (15.8%) used Aday^30,31 as a reference. In 4 articles, the vulnerability concept was composed of more than one theoretical framework, with the following authors cited in the selected articles: Baker et al ¹¹ ; Fried et al ³³ ; Mann et al ³⁴ ; Barchifontaine ³⁵ ; Oviedo and Czeresnia ³⁷ ; Shi et al ³⁸ ; Mechanic and Tanner ³⁹ ; Seery et al ⁴⁰ ; Fineman ⁴¹ ; Kittay ⁴² ; Levinas ⁴³ ; Butler et al ⁴⁴ ; Bourgois et al ⁴⁵ ; Andrew et al ⁴⁶ (Table 3). The articles based on the concept proposed by Aday^30,31 presented vulnerability as a result of the combination or overlap of several risk factors that in a given period of time can lead to physical, psychological, and/or social health problems. The risk factors cited by the authors included: race, ethnicity, income, insurance coverage, self-perceived health, parenting, and the mother’s language. There was also a typification of vulnerability considering the subjective, biological, material, relational, and cultural components. Aday’s ³¹ discussion of vulnerability also considers that health care centered on economic practices, fragmented care, and limited access affects more specific population groups.

Similarly, Shi et al, ¹² Stevens et al, ¹³ and Haidar et al, ²⁴ supported by the concept of Aday, ³⁰ recognized that isolated or overlapping risk factors impact the behavior of seeking health services and the condition of being healthy or recovering from a health problem. For these authors, health care directed toward vulnerable populations has to go beyond the needs of physical, social, and psychological health. It is essential to consider other elements of existing programs and policies that will support care and access to it, in the organizational and financial components, as well as to analyze the quality of the service provided and, consequently, its result. Accordingly, the authors emphasized that quality health care, provided in primary care,^12,13 mainly in the public health systems, has a potential to reduce the vulnerability resulting from various risk conditions, through the attributes of accessibility and continuity of care.

Loh ²³ used the concept of Shi et al, ³⁸ who also stated that vulnerability involves a set of risk factors that reinforce each other, being derived from the absence of material and social resources essential to human well-being, from the presence of risk behaviors and from the influence of environmental factors. These authors criticized the dichotomous models of vulnerability analysis and proposed another format in which individual and community risk factors converge. Loh ²³ also cited Mechanic and Tanner ³⁹ when highlighting that vulnerability can become chronic and cumulative during the life of individuals and that in vulnerable families traces of vulnerability can be transmitted between successive generations. The author used the researchers Seery et al ⁴⁰ to present resilience as an antonym for vulnerability. Resilience would involve successful adaptations to stress or traumatic life events, collaborating to avoid unfavorable outcomes in the person’s health.

To study social vulnerability, Nguyen et al ²⁹ used the definition by Andrew et al. ⁴⁶ These authors argue that the term social vulnerability allows a holistic approach to the measurement of individuals’ social circumstances. Therefore, for them, social vulnerability would be different from the categorization by socioeconomic status or by the social determinants of health. The measurement of social vulnerability would be carried out using an index formed by various aspects of the social circumstances, consisting of 6 components: communication to engage in wider community, living situation, social support, social engagement and leisure, empowerment and life control, and socioeconomic status.

Nine Brazilian articles^{14,16 -20,22,26,27} presented the concept of vulnerability supported by the theoretical framework of Ayres et al^32,36 characterized by the interactions between individual, social, and programmatic dimensions and the context where people live.

According to da Silva et al, ¹⁴ this concept was first proposed in the Acquired Immunodeficiency Syndrome (HIV) epidemic to counter the concept of risk that placed the responsibility for the illness on individuals, increasing stigma, and prejudice.

Guanilo et al ¹⁶ deepening this discussion, asserted that Ayres et al ³² expanded the concept proposed by Mann et al. ³⁴ The authors stated that the situation of vulnerability is inversely proportional to the degree of personal responsibility, being constituted by factors associated with access to information and the social and health services, dependent on institutional and community programs, and with the factors related to social issues that increase, sustain or reduce individual responsibility.

As Mann et al ³⁴ suggested that vulnerability is the antithesis of responsibility, the concept takes on a preventive characteristic relating individual susceptibility to a given infection (in this case, the HIV). The authors said that the more responsible the individual was for the prevention of infection, the less susceptible s/he would be, that is, the more s/he participates in the prevention process, the less vulnerable the person would be. From this perspective, the authors indicated that the increase in individual responsibilization comes from factors associated with access to information and health services, the environment and social influences, understood by the context in which the person is inserted, which can sustain or resolve individual responsibility, influencing behaviors.

Mann et al ³⁴ also created the figure of the 3-dimensional cube relating vulnerability to 3 dimensions: individual, social, and health programs. From 8 pre-established indicators, countries were characterized as to the degree of social vulnerability, including, percentage of GDP, health expenditure, access to information (eg, number of radios and televisions), child mortality, and the development index, among others, which would define whether social vulnerability would be characterized as low, medium, or high.

Regarding the health programs dimension, defined here by the national program to combat AIDS, indices were listed that assessed the program’s capacity to reduce vulnerability to HIV/AIDS, such as planning and coordination, responding to treatment needs and obtaining resources. From this, a program could be classified on a scale of low, medium, or high vulnerability. ³⁴ However, even if an individual is living in the same society, subject to the actions of the same political program of protection and care, the individual characteristics are the person’s own, as are the interactions between the individual, the society and the program, which will determine the overall degree of vulnerability. ³⁴ Therefore, the great difference of Ayres et al ³² was the expansion and adaptation of a concept used to estimate the prevention capacity for a given infection to a broader concept, capable of analyzing the condition of an individual or group inserted in a different reality, such as women in situations of violence, populations deprived of liberty and older adults, among others.

Oldfield et al ²⁸ resorted to the concept of structural vulnerability defined by Bourgois et al ⁴⁵ with poverty or racial/ethnic discrimination, exemplified by the limited proficiency of a language among family members, being associated with decreased access and quality of health care. More broadly, Baker et al ¹¹ started from the principle that vulnerability does not result only from economic conditions, but from a sum of characteristics and situations to which certain population groups are exposed (eg, single mothers, older adults, unemployed people, and ethnic minorities) and that consequently impact on both their health and on seeking the care provided in PHC. The authors highlighted mental health as an important problem in this population, resulting mainly from deficient social support, exclusion, social dissonance, or racism. In view of this, vulnerability can be understood as a product of the history, way of life, and culture of our society.

In addition to instability between the individual and the environment, Athié et al ²¹ recognized vulnerability as being associated with the links of interpersonal dependence that permeate the relations of power and coercion, from the perspective of Oviedo and Czeresnia. ³⁷ Vulnerability would represent an inherent characteristic of the human being, considering the vulnerable character of life and the duality between life and death that accompanies human existence. Therefore, vulnerability can be biological, existential, and social, being characterized by events that affect the natural course of life, in the biological aspect, and limit the exercise of freedom and autonomy, in the existential and social field. ³⁷

The concept of vulnerability, comprehended as frailty, in the presence of motor, physical, psychological dysfunctions, in the involvement of diseases or “deficits in social capacities” in older adults, which can lead to a decrease in the capacity to face adversity, causing “frailty at the existential and social level” was exposed by Fried et al. ³³ Similarly, Souza et al ¹⁷ suggested the vulnerability concept based on the reduction in the capacity for self-determination and the protection of one’s own interests, due to deficits in power, strength, cognition, and other attributes, using Barchifontaine ³⁵ as a conceptual framework. This framework is in line with the understanding of Oviedo and Czeresnia ³⁷ regarding the duality of life and death, since vulnerability can affect the ability of individuals to respond to the biological, economic, and social perturbations present throughout life.

Vulnerability represented by the intrinsic physical and mental characteristics of people, by the external structures that promote inequality, and even by means of institutional medical practices, such as the diagnosis, was exposed by Coyle and Atkinson. ²⁵ Four types of vulnerability were presented in the social context of care and well-being: vulnerability as embodied difference; as entrenched inequality; as universal; and as a resource for resistance. This typology was supported by the concepts of vulnerability by Fineman ⁴¹ ; Kittay ⁴² ; Levinas ⁴³ ; and Butler et al, ⁴⁴ respectively. There is a difference between the individual, social, and political approaches, with the argument that these various positions are not necessarily opposed. The possibility that vulnerability is a resource for resistance was emphasized, from a philosophical and feminist ethics perspective of care.

Theme 2: The Use of the Concept of Vulnerability in PHC

In the theme “The use of the concept of vulnerability in PHC,” the thematic analysis resulted in the elaboration of 2 sub-themes:

Sub-Theme A: Evaluation of Health Policies, Programs, and Services

In 11^{11 -13,18 -21,23,24,27,28} (57.9%) of the 19 articles analyzed, the vulnerability concept was used to assess the response of health policies, programs, and services in relation to individuals or groups identified with some situation of vulnerability, within the context of PHC (Table 4).

Some authors discussed the response capacity of the health services according to specific groups’ access to health care. Athié et al ²¹ investigated the experiences of women with common mental disorders (anxiety, depression) in relation to emotional suffering and seeking care. The analysis of the participants’ narratives was based on the perspective of vulnerability and accessibility to mental health actions in PHC.

Stevens et al ¹³ concluded that children and adolescents recognized as more vulnerable, due to the juxtaposition of multiple family and community risk factors, had a worse state of health, exacerbated by the finding of difficulty in access and continuity of health care, especially in PHC. Baker et al ¹¹ identified the health requirements of vulnerable groups to assess care by general practitioners and, despite finding worse health conditions among these groups, emphasized that there was no greater demand for the service by this population. However, they recognized that the guarantee of accessibility alone does not reflect an improvement in the health condition of these groups and that actions should consider, in addition to low income, disaggregation, and cultural diversity.

Five articles described in Table 4 discussed the evaluation of services regarding the response to certain situations of vulnerability from the perspective of the programmatic dimension. Silva et al ¹⁸ used the concept to evaluate the actions of health services and public policies regarding care for children and adolescents in relation to childhood development. Programmatic vulnerability was also addressed in the descriptive epidemiological article by Pasqual et al ¹⁹ to assess the care provided to women (over 50 years of age) in a PHC unit. They found worrying aspects of vulnerability associated with the low coverage of health actions recommended by the municipal health policy to address chronic and gynecological diseases in this population. Similarly, Costa et al, ¹⁹ through an exploratory-descriptive, qualitative study, analyzed the local public health agendas aimed at confronting violence against rural women. The study was based on the recognition that the lack of local public health agendas for policies and programs related to women’s health affected, in particular, rural women in situations of violence, making it difficult to confront the violent situations.

Loh ²³ described and discussed the medical practice in relation to vulnerable patients, highlighting the importance of recognizing social vulnerability, at the time of the medical consultation and for the doctor-patient relationship. The author stated that some conditions, such as living on the street, adolescent pregnancy, or child abuse, do not necessarily produce poor health conditions due to a direct cause-effect relationship, but because they are indicative of more upstream adversities. It is important to note that the author emphasized that it is not enough to merely guarantee access, but that health services must be structured to provide integrative care to vulnerable patients.

This in-depth view of the health service was studied by Andrade et al ²⁷ who evaluated, through the perception of health managers, the quality of the service offered to the population in controlling and combating specific diseases, such as arboviruses. The authors explored the concept of vulnerability from the perspective of the quality of health service, which covers the interrelationship between the different actors involved (population served, providers, and health managers) and their specific and collective roles that contribute to qualify or weaken the service provided to individuals and the community.

The vulnerability concept was also used to analyze users’ perceptions of the performance of health services in the 3 articles described below.

Shi et al ¹² recognized that a continuous and trusting relationship between healthcare providers and the patient has a positive effect on health, even in vulnerable populations. However, they emphasized that the model of organization and regulation of the health service, provided through corporate or private healthcare plans, can impair this positive perception of the care received. On the other hand, they emphasized that, regardless of the care model, quality primary care considerably reduces the care inequalities in the most vulnerable groups, especially in relation to accessibility and continuity.

Haidar et al ²⁴ analyzed the influence of 5 individual vulnerabilities and the interaction between different types, in the evaluation of the experience of primary care, in a universal healthcare system. The study confirmed that individual vulnerabilities were generally associated with a positive assessment of the primary care experience, with the exception of cultural vulnerability. Therefore, these Canadian authors found the existence of vulnerability to be a protective factor against poor assessment of the PHC experience, within a universal healthcare system.

Finally, the authors Oldfield et al ²⁸ supported by the concept of structural vulnerability, elected a population group of parents and family caregivers and proposed a group approach to childcare in a PHC center in the United States of America. They analyzed the participants’ perception regarding the use of health services, addressing predisposing factors, facilitators, and needs for the use of health services, according to Andersen’s theoretical model.

Sub-Theme B: Classification of Individuals, Groups, and Families

Of the selected articles, 8^{14 -17,22,25,26,29} used the vulnerability concept to classify individuals, groups, or families, with 5 of these studies carried out in Brazil.^{14,16,17,22,26}

Da Silva et al ¹⁴ used the concept of vulnerability to classify families from different territories in relation to the degree of vulnerability, based on individual, social, and programmatic dimensions. Other authors classified older adult families, as in the study by Drewes et al ¹⁵ which analyzed the degree of vulnerability, from the perspective of PHC doctors, using a questionnaire, while Fernandes Bolina et al ²⁶ assessed the vulnerability condition of older adults using the individual, social, and programmatic dimensions, associated with socioeconomic factors. Dias et al, ²² in a cross-sectional and quantitative study, identified the family vulnerability of children with multiple, complex, and continuous care needs, through the application of a family vulnerability index. The results showed that this population and their families were vulnerable in the social, individual, and programmatic dimensions.

Some authors used the concept to construct vulnerability indices and markers. These indicators associated individuals or groups of individuals with specific diseases, as in the case of the authors Guanilo et al ¹⁶ who presented the construction and validation of markers for the vulnerability of women to sexually transmitted diseases (STDs) and HIV. Souza et al ¹⁷ classified the older adult families of a territory using a Family Development Index, which aims to categorize families according to the degree of vulnerability. Nguyen et al ²⁹ presented the creation of a vulnerability index to assess the correlation between the number of chronic conditions in patients with multimorbidity and the state of greater social vulnerability.

Coyle and Atkinson ²⁵ proposed a combined approach to vulnerability, through a dialogical analysis between the experiences of diagnosis in PHC and the reports of people with multiple health problems and/or disabilities attended in a social institution. The authors promoted a reflection on how the communication of the diagnosis in the medical practice can be characterized as a situation of institutional vulnerability if physicians rely on a restricted concept that places patients with multiple health problems as people with limited capacity and in need of paternalistic protection. The article also presents vulnerability as a resource for people’s resistance to adversity.

Three aspects of the use of the vulnerability concept were identified in the selected articles, characterized by the classification of groups and families, construction of markers and indices, or the evaluation of services, considering the political dimensions, the access and the experience of the care in PHC.