1Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarifi cation from social subjects’ perspective

Modelo de vulnerabilidade em saúde: esclarecimento conceitual na perspectiva do sujeito-socialModelo de vulnerabilidad en salud: esclarecimiento conceptual en la perspectiva del sujeto social

Raquel Sampaio Florêncio1 https://orcid.org/0000-0003-3119-7187

Thereza Maria Magalhães Moreira1 https://orcid.org/0000-0003-1424-0649

1Universidade Estadual do Ceará, Fortaleza, CE, Brazil. Confl icts of interest: nothing to declare.

AbstractObjective: To clarify health vulnerability from the proposition of a conceptual model.

Methods: Concept clarifi cation was applied according to Meleis’ proposal, supported by review and critical refl ection. 101 articles were selected in fi ve databases using the search equation “vulnerability” AND “health”, whose fi ndings were submitted to category and similar analysis. This was processed in the software Iramuteq to identify the essential element, concepts and subconcepts of vulnerability in health - and later construction of a model.

Results: From the review and later stages, health vulnerability was redefi ned and a model was constructed based on the relationship of three components: 1) The social subject, with its concepts and subconcepts; 2) The condition of precariousness and agency; 3) Processes of potentiation or weakening of vulnerability in health. The phenomenon was described, the social subject was identifi ed as an essential element, and the main attributes were known with constitutive and operational defi nitions, making it possible to identify the presence of vulnerability in health.

Conclusion: The concept was clarifi ed through the construction of a model, providing support for the elaboration of research in the health area and future development of medium or long-range theories of the phenomenon of interest.

ResumoObjetivo: Esclarecer a vulnerabilidade em saúde a partir da proposição de um modelo conceitual.

Métodos: Aplicou-se o esclarecimento de conceito segundo proposta de Meleis, subsidiado por revisão e por refl exão crítica. Selecionaram-se 101 artigos em cinco base de dados por meio da equação de busca “vulnerability” AND “health”, cujos achados foram submetidos à análise categorial e de similitude. Essa foi processada no software Iramuteq para identifi cação do elemento essencial, conceitos e subconceitos da vulnerabilidade em saúde - e posterior construção de um modelo.

Resultados: A partir da revisão e etapas posteriores, a vulnerabilidade em saúde foi redefi nida, e foi construído um modelo com base na relação de três componentes: 1) O sujeito-social, com seus conceitos e subconceitos; 2) A condição de precariedade e agenciamento; 3) Processos de potencialização ou fragilização da vulnerabilidade em saúde. O fenômeno foi descrito, identifi cando-se o sujeito-social como elemento essencial, e foram conhecidos os principais atributos com as defi nições constitutivas e operacionais, tornando possível identifi car a presença da vulnerabilidade em saúde.

Conclusão: O conceito foi esclarecido por meio da construção de um modelo, fornecendo subsídios à elaboração de pesquisas na área da saúde e ao futuro desenvolvimento de teorias de médio ou longo alcance do fenômeno de interesse.

KeywordsHealth vulnerability; Pubic Health; Models,

theoretical; Concept formation; Social vulnerability; Health promotion

DescritoresVulnerabilidade em saúde; Saúde pública; Modelos

teóricos; Formação de conceito; Vulnerabilidade social; Promoção da saúde

DescriptoresVulnerabilidad en salud; Salud pública; Modeos

teóricos; Formación de concepto; Social vulnabilidad; Promoción de la salud

SubmittedFebruary 25, 2020

AcceptedOctober 20, 2020

Corresponding authorRaquel Sampaio Florêncio

Email: raquelsampy@hotmail.com

How to cite: Florêncio RS, Moreira TM. Health vulnerability

model: conceptual clarifi cation from social subjects’ perspective. Acta Paul Enferm.

2021;34:eAPE00353.

DOI http://dx.doi.org/10.37689/acta-

ape/2021AO00353

Original Article

2 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

Introduction

The term vulnerability, already used for some time in several situations, was incorporated into discourse and practices in the health field, with a view to a more comprehensive reading of complex health and disease processes; therefore, aiding to more effective and comprehensive social responses. It is also em-phasized that the concern with vulnerability found full validity in the health field from the 1980s at the time of the Acquired Immunodeficiency Syndrome (AIDS) epidemic.(1)

Then, the concept of vulnerability in health (VH) was used as a reference for discussions held in the scientific field of various themes and with dif-ferent meanings, whose diversity of applications is due to some situations, especially: the existence of different epistemological orientations; the choice of geographic locations for analysis of the vulnerability process; the direction for specific situations.(2-4)

The term also covers a number of qualifications, the definitions of which have specificities. These conceptions are fostered in several areas of knowl-edge and bring in common the fact that VH is al-ways occurring in the territory where people live.(3) This extended use of concept directs paths and perspectives to ambiguities and contradictions,(1,4) requesting new or complementary definitions and reflections about the concept, which is broad, com-plex and subjective.(5)

In a critical analysis of VH frameworks, it was noticed that the more used conceptual frame-works(4,6) do not bring definitions of the elements related to concepts and subconcepts, making it nec-essary to contribute to the construction of a the-

oretical framework on the subject and to provide the development of a conceptual model for identi-fication, assessment, and intervention in situations of vulnerability by health professionals. It is known that it was not the authors’ objective(4,6) to construct a theory about VH, but to think about concept, bringing it closer and linking it to health promotion and, in the case of the Brazilian reference, consider-ing principles of hermeneutics. Thus, their previous writings provided a basis for the construction of a conceptual model of VH by indicating how other concepts could be articulated.

For these authors,(4,6) VH comprises the ethical perspective of different degrees and natures of sus-ceptibility of individuals and collectivities that lead them to suffering, illness/injury and finitude, accord-ing to particularities formed by a set of social, pro-grammatic and individual aspects, which put them in relation to the problem and with the resources to cope with them. From this definition and its uses, it is understood that there is an open field to rethink, redefine and propose ways of using VH.

Defining, clarifying, assessing, operationaliz-ing and submitting concepts to theoretical and empirical assessments are essential and vital pro-cesses in advancement of knowledge. Concept de-velopment(7) presents five levels: exploration, clari-fication, analysis, and integrated approach. In this study, the second level is brought, because the con-cept of VH already exists, but it is not understand-able in publications, because several meanings are pointed out with contradictions regarding the orig-inal frameworks. Thus, this study aimed ‘to clarify health vulnerability from the proposition of a con-ceptual model’.

ResumenObjetivo: Esclarecer la vulnerabilidad en salud a partir de la proposición de un modelo conceptual.

Métodos: Se aplicó el esclarecimiento de concepto según la propuesta de Meleis, respaldado con revisión y reflexión crítica. Se seleccionaron 101 artículos en cinco bases de datos por medio de la ecuación de búsqueda “vulnerability” AND “health”, cuyos resultados fueron sometidos al análisis categorial y de similitud. Este fue procesado con el software Iramuteq para la identificación del elemento esencial, conceptos y subconceptos de la vulnerabilidad en salud y la posterior construcción de un modelo.

Resultados: A partir de la revisión y etapas posteriores, la vulnerabilidad en salud fue redefinida y se construyó un modelo basado en la relación de tres componentes: 1) El sujeto social, con sus conceptos y subconceptos, 2) La condición de precariedad y gestión, 3) Procesos de potencialización o debilitamiento de la vulnerabilidad en salud. El fenómeno se describió con la identificación del sujeto social como elemento esencial y se conocieron los principales atributos con las definiciones constitutivas y operativas, lo que permitió identificar la presencia de la vulnerabilidad en salud.

Conclusión: El concepto fue esclarecido mediante la construcción de un modelo y respalda la elaboración de estudios en el área de la salud y el desarrollo futuro de teorías de medio o largo alcance del fenómeno de interés.

3Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

Methods

The study was designed considering the adapt-ed stages of conceptual clarification according to Meleis(7) in conjunction with a review(8,9) and its subsequent update.

As a way to carry out the research, the main questions to be answered were established in cor-respondence with the methodological framework phases. It is reiterated that for this study phases two to five were considered, where the first was devel-oped in a previous study.(8,9)

Soon after defining the questions, articles published in the Latin American & Caribbean Literature in Health Sciences (LILACS), Spanish Bibliographic Index of Health Sciences (IBECS), Nursing Database (BDENF - Base de Dados de Enfermagem), Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and in the PubMed portal were searched. “Vulnerability” AND “health” were the keywords contained in the search equation to search for publications. This equation was used at all times of collection and in all sources. The final search took place in December 2019, with the update of the original study.

Articles containing the term ‘vulnerability’ in their title, with no date limit, electronically avail-able in full were included. Studies without explicit definition of VH, with gray literature, theoretical, case and review studies were excluded.(8)

The search was performed by two researchers, and studies were selected carried out from a thor-ough reading of titles and abstracts so that those who met the mentioned inclusion and exclusion criteria were for final selection. From the search equation, 27,035 publications were found, of which 26,934 did not meet the criteria: 7,873 due to duplications; 15,083 because they did not have vulnerability in the title; 1,819 because they had no full text; 316 because they did not have explicit definition of VH; 1,572 because they did not approach VH; 271 be-cause they were gray literature. Of this total, 101 articles were selected for full reading and analysis (Chart 1).

According to the aspects of an observation script, the publications and data of the 101 articles were

interpreted, organized and synthesized through a synoptic table with the description of author, theme, journal, year, type of study, and place.(8)

Chart 1. Correspondence between the phases of conceptual clarification and the guiding questions of the studyClarification phase Guiding question

1 - Description of phenomenon inherent to concept(8,9)

What are the characteristics of the studies that have been published on the theme?(8) What are the meanings and uses of health vulnerability described by studies?(9)

2 - Systematization of observations and descriptions of the phenomenon

What are the essential elements of the concept of VH?What are the processes or situations produced by the vulnerability?

3 - Development of constitutive and operational definitions, asking themselves and others: How will I know the concept when I ‘see it’?

What characteristics/attributes are indicated as referring to the concept and contribute to its recognition?

4 - Model construction What is the relationship between the concepts and subconcepts that allow the construction of a conceptual model that clarifies VH?

5 - Assumption development

Initially, analyzed categories were constructed based on descriptive statistics to quantify the gen-eral and methodological aspects of the publications. Subsequently, the definitions of VH and the main results of the articles were identified. From a thor-ough reading, critical analyses were performed and the definitions of VH were extracted, which consti-tuted the main corpus of the study. The Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ) was used to help in the similitude analysis phase, with the aim of identifying the essential elements of VH from the definitions.

Regarding the inspirations of the concept, these have already been contemplated on other occasions.(4,6) Furthermore, in this study, it was assumed that the VH phenomenon has no antecedents that trigger it, because it is not a cause and effect. Thus, constitutive and operational elements (related to the essential el-ement, concepts and sub-concepts) were defined to allow to identify VH at the time of its presence, as well as the situations produced by VH. For that, the articles were kept, and after extracting the main clip-pings of the results, these were categorized by similar keywords and recategorized until they resulted in at-tributes, their definitions and production involved in VH (precariousness or agency).

Attributes are words or expressions that appear repeatedly in the literature, that show the essence of

4 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarifi cation from social subjects’ perspective

the concept. Th ey constitute characteristics that ex-press the concept, which act as diff erential elements to discriminate what is and what is not the presence of a concept. When it is very abstract, its attributes also have a high degree of abstraction. Constitutive defi nition is conceived in terms of concepts prop-er to the theory in which it is inserted. Finally, the defi nition is operational when there is a defi nition, no longer in terms of other concepts, but in terms of concrete operations, i.e., of behaviors, attitudes or sensations by which the construct is expressed.(7,10)

Th us, the construction of the VH conceptu-al model began. It was developed by critically re-fl ecting on the results of the previous stages, and the essential elements, their concepts and related sub-concepts were given visibility, as well as the product of these relationships and their articula-tions. Finally, this process had three stages: theoreti-cal construction (performed in all previous stages of clarifi cation), model design (using artistic resources: graphic design with elements of music), its explana-tion, and refl ection.

Results

For the phase of systematization of the observa-tions and descriptions of the phenomenon, fi gure 1 was arrived at, which showed that, at fi rst, the essential elements of the concept were constitut-ed of the individual and the social. However, af-ter refl ective analysis, it was interpreted as subject and social.

To contextualize these fi ndings, it was under-stood that these essential elements correspond to VH attributes/characteristics, which are support-ed by other concepts and subconcepts. From the previous tables, there was recategorization, being assigned a constitutive and operational defi nition to facilitate the understanding of how to identify situations of VH (Appendix 1). Some remained as previously thought, others were grouped and others modifi ed.

Chart 2 represents a synthesis of the concepts and sub-concepts that make up the essential ele-ments of VH and their defi nitions.

Figure 1. Essential elements of the concept of vulnerability according to the review

In addition to the need to present these defi -nitions, it was understood that there would be an answer in the experience of these aspects that could produce precarious conditions or agency. In studies that point to precariousness, it has diff erent scenari-os and violence is an expressive condition discussed. But there is the possibility of changing the direction of these processes, and the agency is responsible for this. Several aspects favored this condition such as support networks, coping, refl ections, spirituality, positive feelings and health promotion practices.

Th us, based on the articulation and refl ection of the elements of the review, VH was understood as a condition of human life expressed in all its dimen-sions from (re)arrangements of the power relations that constitute the social-subject, producing precar-iousness when agency movements are not potenti-ated for health promotion.

Furthermore, in fi gure 2, it was possible to ob-serve the main components of the VH conceptu-al model and its relationship, rescuing: 1) Social-subject, with its concepts and sub-concepts; 2) Condition of precariousness and agency; 3) VH potentiation or fragility processes.

Figure 2 shows a relationship between the sub-ject and social elements, with their main concepts, in an intimate relationship, which, together with precariousness and agency, confi gure VH processes. Th ese take on various nuances and reconfi gure VH again, in a continuum of diverse movements and in multiplicities resulting from the tensions produced in the relations between social subjects, its essential element.

5Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

Discussion

Reference authors(4,6) considered that VH consist-ed of two dimensions (individual and contextu-al) and three dimensions (individual, social, and programmatic). Based on the results presented by IRAMUTEQ, from the similitude analysis, the structure, the central nucleus and the peripheral system of the interpretation of VH were identi-fi ed, in which the two major organizing axes are the individual and the social. Th ese elements un-derwent a critical analysis, i.e., approximation of the content with subject ideas by Michel Foucault and Judith Butler, where the individual became the subject’s dimension and the social remained as such, according to the analytical categories of the articles.

Th is adaptation occurred, because it is understood that subjects are a product of power relations, they are formed and constituted by them, not their producers. Th ere is no essential subject who would be alienated by ideologies, by power relations that would cover up their view of reality.(11-15) If we think that subjects are always in this movement, it would be controversial to call them individuals, as this term denotes disconnec-tion. When we think about power, we think about relationship. If at the same time it prohibits and in-duces, censors and produces (discourses, truths, and realities), if it aff ects and is aff ected, we can understand that power only exists in the relationship, power is by nature relational, it is a power in motion.(11-15)

Th us, characterized the essential elements separately, which were later understood as social subjects, we went in search of their concepts and sub-concepts as a way to identify VH when it hap-pens. Th ese stimulate refl ection on power relations as hegemonic eff ects of continuously sustained stra-tegic positions and coping, understood as coping with social forces in constant antagonism to the established strategic positions. Th ey are articulat-ed according to their operational defi nitions that demonstrate how VH situations may be being ex-perienced and produced.

In understanding VH, the power relationship between the subject and the social is an open fi eld

Chart 2. Defi nitions of the essential elements and their concepts and subconcepts of VHSubject

Human life constituted from intersubjective relationships, where there is room for the manifestation of freedom in the tension between knowledge and power and for possibilities of re-creation of one’s own in the fi eld of health.

Functional literacy Learning, Cognition, Knowledge, Schooling

Behavior Attitude, Self-Care, Lifestyle, Work Practices, Routine and Daily Life, Communication

Interpersonal relationships Family relationships, Friendship relationships, Working relationships, Affective-sexual relationships

Psycho-emotional situation Self-Esteem, Acceptance, Concentration, Beliefs, Desires, Sexual Orientation, Mental Health, Perceptions, Feelings, Values

Physical situation Age, Gender, Race/color, Physical aspects related to work, Impact of illness at work, Health-disease situation

SocialAppearance scene that presupposes the different forms of the subject interacting with other lives or institutions in the health fi eld; it is the space of expressing oneself, of recognizing oneself and of

recognition by and with the other.

Socioeconomic factors Material Goods, Housing, Income, Social Class, Work, Education

Demographic identity Ethnicity, Origin, Migration

Culture Cultural formation, Social constructions, Cultural differences, Popular knowledge

Family context Marital/family status, Characteristics of members, Family types

Social networks and media Social support

Gender Gender inequality, Traditional roles, Male chauvinism

Violence Discrimination, Sexual violence, Physical violence, Verbal violence, Psychological violence

Social control Social participation

Ecosystem Waste, Environment, Climate

Access to fundamental rights First, second, third and fourth generations fundamental rights

Programmatic situation - emphasis on health Infrastructure, Work Process

Status Public Policies, Financing

Figure 2. Conceptual model of health vulnerability

6 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

of responses, reactions, results, and possible inven-tions. Thus, it is understood that there is a response that can produce conditions of precariousness or agency.

The precarious condition can take different forms, from the beginning, maintenance or com-plication of a disease, to, for example, affecting the quality of life and mental health. Moreover, it can be configured in a sphere of social inequities, pro-duction of power relations that represent the pre-carious condition. The conceptions of an important author about precariousness(12-14) refer the term to a politically constructed condition whereby certain populations are asymmetrically exposed to contexts of violence, danger, illness, forced migration, pov-erty, or death. As a process and movement, precar-iousness reinforces VH situations and vice versa, as many lives are not considered lives by the State or groups of greater political and economic power.

In the midst of this precariousness, subjects can obtain means to raise awareness of submission to the orders of power and resist VH through agen-cy. Therefore, there is a seizure of control over life that reverberates in the condition of VH, as there is the possibility of movement of relationships to-wards a better condition of health and life, i.e., less vulnerability. Despite the precariousness of making and producing subjects invisible to public health policies, this concept of subject, for Butler, makes possible the condition of the agency, understood as power, capacity for action, as it is productive for the compression of social action, especially subordinate subjects to a hegemonic social order. Butler charac-terizes the agency as a practice of articulation and reframing the power to do.(12,14)

The aforementioned conscience generates the conditions of resistance and reflexivity, allowing social subjects to oppose the abuses of normalizing power that limits and controls the desires of their own possibility, producing agency.(15) They are not an exclusively individual characteristic, but are em-bodied in the social context, promoting health and living lives. Subjects are performative, i.e., a ritual-ized production, a ritual reiteration of norms, but that do not totally determine it. This incomplete-ness enables the process of rupture and the regis-

tration of new meanings and, consequently, the change in practices and contexts.(12,15) That is, so-cial-subjects resist not to be in a condition of VH or not to perpetuate it; they find the potential to reframe norms, discourses, experiences, experiences and social practices.(15)

Thus, there is a need for intersectorality to be in the field of health care, since vulnerability is a construct that occurs in relationships with dif-ferent people and in/over/with different spaces. Considering these aspects, health promotion and life production are an important background in the discussions about VH. The first inspirations for the development of the VH concept came from the need to think about health promotion and not just prevention, with intersectorality implicit, not ad-dressing a specific disease or disorder, but the pro-duction of life.(4,12,16-18)

Based on all these elements discussed, a (re)definition of the concept of VH was constructed. It is the starting point for thinking about a represen-tation of the conceptual model, a complex phase, since the essential elements of VH are neither hi-erarchical nor dissociated, it has diverse, intercon-nected, multiple elements. Each has its characteris-tic, concepts and sub-concepts, but they only exist in the presence of the other, at the same time that their characteristics can be confused. It is a social subject and a social subject. What is in between is difficult to represent and this transition is almost imperceptible.

According to authors,(4) people are not vulner-able, they are always vulnerable to something, in some degree and form and at a certain point in time and space. However, it is believed that the subject or groups experience processes or are in a condition of VH. Adjective and objectification are not sought, but relationships, and the use of the term vulnera-ble should therefore be rethought.(19) Furthermore, some authors(20) use the term ‘marker’ when they want to characterize any attribute or situation of VH. However, it denotes a fixed, marked, difficult to transform, i.e., non-situational situation.

Unlike theories, conceptual models repre-sent a concept analogically. In this sense, there are advances in studies in this perspective, in

7Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

which theoretical essays on VH are identified in the literature, as well as their applicability in the construction of instruments/scales.(2,20-24) So, to account for the clarification framework, a way of presenting the concept was produced. Analogously, when one think of a song and its musical notes, they don’t know where one ends and the next begins when they listen to them. In this case, the human senses cannot reach the pas-sage from one to another. Thus, a figure was con-structed that represents VH in this perspective of the interplay and the power relations.

In this analogy to musical elements, social sub-jects make up a set of musical notes. These make up a melody, VH, which has harmonic variations. Rescuing these concepts to VH, these variations can be translated into a continuum of precarious or agency conditions. These productions are the result of the relationship between the notes, i.e., interaction between the elements of the concept, established by power relations in the production of health. The precarious conditions enhance the vul-nerability processes, while the agency weakens it, transforming them. Lives then resist, recreate and (re)become visible and livable.

So, when there is movement, there is power and it does not weigh only with the strength that says no or has precariousness as a product, but it also permeates, produces things, induces pleasure, forms knowledge, produces speech, i.e., produces power-ful lives, resistant in agency processes.(11)

Figure 2 represents the conceptual model of VH from the perspective of the multiple possi-bilities of music that can be produced. Musical notes are each of the concepts and sub-concepts of the essential element, where the different shades of blue are configured, while the subject and the shades of green, the social. These are in relation, shown by the dotted lines, which define the non-permanent or almost “fixed” character of that interaction and which can change each time they come into contact with other notes. The an-swer of this power relationship is (re)arrangement of the notes in a score, configuring the melody of the agency, defining a fragility of VH (‘decrease’), or the melody of the precariousness, potentiating

VH (‘increase’), conforming the several music possibilities called VH.

The dotted lines in the precariousness speak of the fragility and inequality of the relationships between the elements, resulting in processes of po-tentiation of VH. However, with the possibility of change to transform these situations. The continu-ous lines refer to stronger relationships, in the sense of having a higher quality of these and that reinforce the promotion of health, simultaneously or after the processes of fragility of VH. Relationships that have arisen from precariousness or agency can also be re-organized, giving way to other power relationships and other VH processes and other responses; this phenomenon can occur in sequence or at the same time, which characterizes and ratifies VH as a di-verse, dynamic and multiple phenomenon.

Conclusion

The proposed conceptual model clarifies the con-cept of VH, because its components are defined and related in analogy to music. In addition to the de-scription of the phenomenon and identification of the essential element, it was possible to know the main attributes (concepts and subconcepts) of so-cial subjects, so that it could be conjecture when VH was present and producing precariousness in a given situation or agency. The model provides sup-port for the development of research in health and the future development of medium or long-range theories of VH. The proposed model is another step to boost the concept and stimulate the coherent use of the concept by researchers and health profession-als, taking it as what it is, a condition of human life from social subjects’ perspective.

Acknowledgments

We would like to than the Coordination for the Improvement of Higher Education Personnel (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) for granting the doctoral scholar-ship for RSF.

8 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

Collaborations

Florêncio RS and Moreira TMM declare that they contributed to the conception of the study, analysis and interpretation of the data, writing of the article and approval of the final version to be published.

References

1. Oviedo RA, Czeresnia D. O conceito de vulnerabilidade e seu caráter biossocial. Interface (Botucatu). 2015;19(53):237-250.

2. Schumann LR, Moura LB. Vulnerability synthetic indices: a literature integrative review. Ciênc saúde coletiva. 2015;20(7):2105-20.

3. Feitosa MZ, Sousa LC, Paz AF, Barreto EH, Bomfim ZÁ. Afetividade, território e vulnerabilidade na relação pessoa-ambiente: um olhar ético político. Fractal. Rev Psicol. 2018;30(2):196–203.

4. Ayres JR, Calazans GJ, Saletti Filho HC, França Júnior I. Risco, vulnerabilidade e práticas de prevenção e promoção da saúde. In: Campos GW, Minayo MC, Akerman M, Drumont Júnior M, Carvalho YM, organizadores. Tratado de saúde coletiva. 2a ed. São Paulo: Hucitec; 2012.

5. Barbosa KT, Oliveira FM, Fernandes MD. Vulnerability of the elderly: a conceptual analysis. Rev Bras Enferm. 2019;72 Suppl 2:337–44.

6. Mann J, Tarantola DJ, Netter TW. Aids in the word. Cambridge: Harvard University Press; 1992.

7. Meleis AI. Theoretical nursing: development and progress. 5th ed. Pennsylvania: Lippincott Williams & Wilkins; 2012.

8. Florêncio RS, Moreira TM, Pessoa VL, Cestari VR, Silva VM, Rabelo SM, et al. Mapping studies on vulnerability in health: a scoping review. Research, Society and Development. 2020;9(10):e2079108393.

9. Florêncio RS. Vulnerabilidade em saúde: uma clarificação conceitual [tese]. Fortaleza: Universidade Estadual do Ceará; 2018.

10. Pasquali L. Psicometria: teoria dos testes na psicologia e na educação. Petrópolis: Vozes; 2003.

11. Foucault M. Microfísica do poder. Rio de Janeiro: Graal; 2011. 295 p.

12. Butler J. Frames of War. When is life grievable. New York: Verso; 2009.

13. Butler J. Vida precária. Contemporânea: Rev Sociol  UFSCar. 2011;1:13–33.

14. Butler J. Cambio   del   sujeto:   La   política   de   la resignificación radical de Judith Butler. Casale R, Chiachio C., organizadores. Máscaras del deseo: una lectura del deseo en Judith Butler. Buenos Aires: Catálogos; 2009. pp. 65–111.

15. Butler J. Mecanismos psíquicos del poder: teorías sobre la sujeción. 2a ed. Madrid: Ediciones Cátedra; 2010.

16. Silva Júnior JB. Health promotion: necessary and urgent action in the Americas [editorial]. Ciênc Saúde Coletiva. 2019;24(11):3994.

17. Sonaglio RG, Lumertz J, Melo RC, Rocha CM. Promoção da saúde: revisão integrativa sobre conceitos e experiências no Brasil. J Nurs Health. 2019;9(3):e199301.

18. Vieira LS, Belisário SA. Intersectoriality in the promotion of school in health: a study of the Health in School Program. Saúde Debate 2018;42(Spe 4):120-33.

19. Chaves SE, Ratto CG. Fronteiras da formação em saúde: notas sobre a potência da vulnerabilidade. Interface (Botucatu). 2018;22(64):189-98.

20. Padoveze MC, Juskevicius LF, Santos TR, Nichiata LI, Ciosak SI, Bertolozzi MR. The concept of vulnerability applied to Healthcare-associated Infections. Rev Bras Enferm. 2019;72(1):299–303.

21. de Groot N, Bonsel GJ, Birnie E, Valentine NB. Towards a universal concept of vulnerability: broadening the evidence from the elderly to perinatal health using a Delphi approach. PLoS One. 2019;14(2):e0212633.

22. Cestari VR, Moreira TM, Pessoa VL, Florêncio RS, Silva MR, Torres RA. The essence of care in health vulnerability: a Heideggerian construction. Rev Bras Enferm. 2017;70(5):1112–6.

23. Jesus IT, Orlandi AA, Grazziano ES, Zazzetta MS. Frailty of the socially vulnerable elderly. Acta Paul Enferm. 2017;30(6):614–20.

24. Maffacciolli R, Oliveira DL. Challenges and perspectives of nursing care to vulnerable populations. Rev Gaúcha Enferm. 2018;39:e20170189.

9Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

Appe

ndix

1. C

onst

itutiv

e an

d op

erat

iona

l defi

nitio

ns o

f the

con

cept

s an

d su

bcon

cept

s of

the

esse

ntia

l ele

men

ts o

f hea

lth v

ulne

rabi

lity

SUBJ

ECT

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Func

tiona

l lite

racy

: The

kno

wle

dge

and

com

pete

ncie

s of

the

subj

ects

to

acce

ss, u

nder

stan

d, a

sses

s an

d ap

ply

gene

ral i

nfor

mat

ion,

in o

rder

to m

ake

judg

men

ts a

nd m

ake

deci

sion

s in

th

e da

y-to

-day

inco

rpor

ated

thro

ugh

lear

ning

, cog

nitio

n, k

now

ledg

e an

d sc

hool

ing.

Lear

ning

: Pro

cess

of a

cqui

ring

new

info

rmat

ion

rela

ted

to v

ario

us a

spec

ts.

Low

sym

bolic

and

ling

uist

ic c

apita

l of p

eopl

e, le

arni

ng d

ifficu

lties

.

Cogn

ition

: Men

tal c

apac

ity o

r com

pete

nce

nece

ssar

y to

pro

cess

and

sei

ze in

form

atio

n, to

th

ink,

rem

embe

r, re

ad, p

erce

ive a

nd s

olve

pro

blem

s.De

crea

sed

cogn

ition

in s

peci

fic c

onte

xts,

inte

llect

ual d

isab

ility,

forg

etfu

lnes

s, d

ifficu

lties

in u

nder

stan

ding

the

inte

ract

ions

that

occ

ur

in h

ealth

cen

ters

, diffi

culti

es in

und

erst

andi

ng c

are,

lack

of u

nder

stan

ding

, ina

bilit

y to

und

erst

and

wha

t is

happ

enin

g to

them

, lac

k of

in

form

atio

n el

abor

atio

n an

d its

pra

ctic

al a

pplic

atio

n, n

ot u

nder

stan

ding

vio

lenc

e, n

ot u

nder

stan

ding

the

need

for t

reat

men

t.

Know

ledg

e: W

hat t

he s

ubje

ct k

now

s ab

out s

omet

hing

or e

ven

a se

t of i

nfor

mat

ion

stor

ed

thro

ugh

expe

rienc

e or

lear

ning

. It i

s co

gniti

ve a

bilit

y th

at a

llow

s ap

prop

riate

judg

men

ts a

nd

deci

sion

-mak

ing

or n

ot in

the

face

of a

situ

atio

n.

Lack

of i

nfor

mat

ion

abou

t the

dis

ease

, non

-rec

ogni

tion

of d

iffer

ence

s in

pre

vious

hea

lth c

ondi

tions

, non

-aw

aren

ess

of ri

sk, n

on-

awar

enes

s of

righ

ts a

nd re

spon

sibi

litie

s, o

ther

issu

es th

at c

once

rn p

opul

ar k

now

ledg

e an

d fo

rmal

kno

wle

dge.

Educ

atio

n: It

is th

e pe

riod

of e

duca

tion,

stu

dy o

r lea

rnin

g of

sub

ject

s in

sch

ool.

Low

edu

catio

n.

Beha

vior

: The

act

ions

of t

he s

ubje

cts

in re

latio

n to

thei

r soc

ial e

nviro

nmen

t, re

late

d to

atti

tude

, car

e or

oth

ers,

ca

re p

ract

ices

and

wor

k, ro

utin

e an

d da

ily li

fe o

r way

of b

eing

and

co

mm

unic

atio

n.

Attit

ude:

It is

a le

arne

d/ac

quire

d pr

edis

posi

tion

to re

spon

d co

nsis

tent

ly to

a s

ocia

l sce

ne.

Nega

tive

attit

ude

abou

t the

wor

k sc

enar

io, n

on-u

se o

f pre

vent

ion

mat

eria

l, at

titud

e of

pas

sivit

y of

wom

en in

rela

tion

to th

eir

indi

vidua

l pro

tect

ion,

with

draw

al fr

om re

turn

ing

to th

e he

alth

ser

vice,

see

king

to s

olve

thei

r pro

blem

s us

ing

only

third

par

ties

and

hom

e pr

actic

es, n

ot s

eeki

ng a

dequ

ate

care

, not

see

king

hea

lth s

ervic

e, re

sign

atio

n, n

ot re

adin

ess

for c

hang

e.

Self-

care

: Dec

isio

n-m

akin

g pr

oces

s th

at in

volve

s th

e ch

oice

and

exe

cutio

n of

beh

avio

rs fo

r th

e he

alth

of t

he s

ubje

ct h

imse

lf, p

erfo

rmed

by

him

, aris

ing

from

his

ow

n be

lief o

r fro

m th

e in

dica

tion

of s

ome

heal

th p

rofe

ssio

nal.

Actio

ns o

f acc

ess

to d

rug

and

non-

drug

trea

tmen

t irre

gula

r or a

bsen

t, fin

anci

al d

ifficu

lties

for t

reat

men

t ade

fore

go, d

isco

ntin

uity

of

treat

men

t, no

n-ad

optio

n of

sel

f-ca

re. H

ealth

and

risk

pro

mot

ion

prac

tices

, abs

ent o

r defi

cien

t pre

vent

ion

stra

tegi

es, v

ario

us h

ealth

be

havio

rs.

Life

styl

e: W

ay o

f livi

ng th

at c

hara

cter

izes

the

subj

ect,

invo

lving

the

adop

tion

of h

ealth

y at

titud

es a

nd b

ehav

iors

or n

ot.

Unhe

alth

y fo

od a

nd p

urch

ase,

abs

ent o

r ins

uffic

ient

leis

ure

activ

ity, a

bsen

t or i

nsuf

ficie

nt p

hysi

cal a

ctivi

ty, e

xces

sive

cof

fee

inta

ke, i

rregu

lar h

untin

g an

d fis

hing

, im

prop

er c

olle

ctio

n an

d us

e of

nat

ural

pro

duct

s, u

se o

f lic

it an

d illi

cit d

rugs

, stre

ss, f

ragi

le

rela

tions

hips

, sle

ep p

robl

ems,

inst

rosp

ectio

n.

Wor

king

pra

ctic

es: A

ny a

ctio

n ta

ken

with

in th

e sc

ope

of th

e w

ork.

Unsa

tisfa

ctor

y or

unp

rodu

ctive

wor

k pe

rform

ance

and

wor

k ta

sks.

Rout

ine

and

ever

yday

life

: Sys

tem

atic

way

thro

ugh

whi

ch d

ay-t

o-da

y ac

tiviti

es a

re c

arrie

d ou

t.Di

srup

tion

of d

aily

life,

dai

ly de

nsity

, rou

tine

impa

ired

by d

isea

se, g

ener

al ro

utin

e, d

aily

chal

leng

es, c

usto

ms

and

habi

ts o

f pre

vent

ion

and

risk.

Com

mun

icat

ion:

Ver

bal o

r bod

ily a

ctio

n of

a s

ubje

ct th

at s

igna

ls in

form

atio

n to

ano

ther

or

othe

r sub

ject

s.Co

mm

unic

atio

n di

fficu

lties

, com

mun

icat

ion

barri

ers,

inef

fect

ive c

omm

unic

atio

n, c

reat

ion

of a

dis

tinct

ion

betw

een

peop

le d

ue to

the

lang

uage

use

d.

Inte

rper

sona

l rel

atio

nshi

ps:

Inte

ract

ion

betw

een

subj

ects

who

co

mm

unic

ate

verb

ally

or n

on-v

erba

lly,

in a

mov

emen

t of r

espo

nses

to

certa

in ty

pes

of p

ower

in s

ituat

ions

in

the

fam

ily, a

t wor

k, in

frie

ndsh

ip a

nd

in a

ffect

ive-s

exua

l life

.

Fam

ily re

latio

ns: B

ehav

iora

l, ps

ycho

logi

cal a

nd s

ocia

l int

erac

tions

bet

wee

n th

e va

rious

fa

mily

mem

bers

.Fa

mily

reje

ctio

n, c

ondi

tions

of s

peci

fic fa

mily

rela

tions

hip,

vio

lent

fam

ily re

latio

nshi

p, la

ck o

f fam

ily a

nd s

choo

l rel

atio

nshi

p, d

ifficu

lty

in re

porti

ng s

exua

l cho

ice

to s

omeo

ne in

the

fam

ily, c

onfli

ctin

g fa

mily

rela

tions

hips

, fam

ily re

latio

nshi

ps w

ith a

spec

ts o

f hos

tility

and

di

squa

lifica

tion,

fam

ily re

sist

ance

in th

e or

gani

zatio

n of

dai

ly lif

e ar

ound

chr

onic

con

ditio

ns, f

ragi

le fa

mily

bon

d, la

ck o

f dia

logu

e in

th

e fa

mily

, lac

k of

trus

t in

fam

ily m

embe

rs ,

finan

cial

abu

se, p

hysi

cal a

nd s

exua

l abu

se, v

erba

l abu

se, t

hrea

ts fe

lt, fa

mily

exp

ress

ions

of

dai

ly di

fficu

lties

resu

lting

from

chr

onic

hea

lth c

ondi

tions

, fam

ily n

egle

ct.

Frie

ndsh

ip re

latio

nshi

ps: B

ehav

iora

l, ps

ycho

logi

cal a

nd s

ocia

l int

erac

tions

bet

wee

n fri

ends

.Lo

ss o

f con

tact

with

frie

nds

who

live

nea

r the

hou

se, r

emov

al o

f frie

nds

due

to il

lnes

s.

Wor

king

rela

tions

hips

: Beh

avio

ral,

psyc

holo

gica

l and

soc

ial i

nter

actio

ns b

etw

een

mem

bers

of a

wor

k co

ntex

t.Ex

cess

ive a

ffect

ive b

urde

n on

wor

k re

latio

nshi

ps, i

neffe

ctive

inte

rpro

fess

iona

l rel

atio

nshi

ps, a

busi

ve re

latio

nshi

ps a

t wor

k (s

exua

l ha

rass

men

t).

Affe

ctiv

e-se

xual

rela

tions

: Beh

avio

ral,

psyc

holo

gica

l and

soc

ial i

nter

actio

ns b

etw

een

subj

ects

in a

rela

tions

hip

of c

onst

ruct

ion

of a

ffect

ion,

sex

ual o

r not

.Fr

agile

inte

rsub

ject

ive re

latio

nshi

ps, n

ot ‘b

eing

with

’, no

t find

ing

othe

rs a

s hu

man

bei

ngs,

dis

tanc

ing

peop

le a

fter a

dis

ease

, ref

usal

of

the

partn

er to

use

con

dom

s, p

erfo

rmin

g se

x w

ithou

t a c

ondo

m a

fter c

oerc

ion,

hom

osex

ual r

elat

ions

hips

, ins

tabi

lity

of m

an-w

oman

re

latio

nshi

ps, c

omm

erci

al s

exua

l rel

atio

nshi

p, tr

ust i

n th

e pa

rtner

as

a ju

stifi

catio

n fo

r non

-pre

vent

ion,

con

flict

ing

affe

ctive

bon

ds.

Cont

inue

...

10 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

SUBJ

ECT

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Psyc

ho-e

mot

iona

l situ

atio

n: A

co

nditi

on o

f sub

ject

ive e

xper

ienc

e in

a s

peci

fic c

onte

xt th

at in

volve

s fro

m s

elf-

este

em, a

ccep

tanc

e,

conc

entra

tion,

bel

iefs

, des

ires,

sex

ual

orie

ntat

ion,

feel

ings

, wel

l-bei

ng,

perc

eptio

ns, d

esire

s, v

alue

s to

men

tal

heal

th in

gen

eral

.

Self-

este

em: S

atis

fact

ion

with

one

’s w

ay o

f bei

ng, t

hink

ing

or w

ith p

hysi

cal a

ppea

ranc

e,

expr

essi

ng c

onfid

ence

in th

eir a

ctio

ns a

nd o

pini

ons.

Decr

ease

d se

lf-es

teem

, low

sel

f-es

teem

due

to la

ck o

f pro

fess

iona

l kno

wle

dge,

loss

of s

elf-

este

em.

Acce

ptan

ce: R

ecog

nitio

n of

the

need

to h

ave

an a

ttitu

de in

the

face

of a

n un

expe

cted

, un

wan

ted

stat

e of

hea

lth o

r its

con

sequ

ence

s.No

n-ac

cept

ance

of t

reat

men

t, no

n-ac

cept

ance

of t

he d

isea

se, n

on-a

ccep

tanc

e of

pre

gnan

cy, n

on-a

ccep

tanc

e of

a h

ealth

or l

ife

cond

ition

.

Focu

s: A

bilit

y to

dire

ct a

ttent

ion

and

thou

ght t

o a

spec

ific

idea

, sub

ject

, or a

ctio

n.Di

fficu

lty c

once

ntra

ting,

inab

ility

to c

once

ntra

te.

Belie

fs: W

hat i

s co

nsid

ered

true

, i.e

., be

lievin

g in

the

truth

or t

he p

ossi

bilit

y of

som

ethi

ng.

Belie

f in

the

safe

ty o

f mis

guid

ed p

reve

ntio

n eq

uipm

ent,

belie

fs a

bout

mis

guid

ed p

reve

ntio

n pr

actic

es, d

isbe

lief i

n pr

even

tion

mat

eria

l, di

sbel

ief t

hat w

ill un

derg

o he

alth

cha

nge,

mis

take

n be

lief i

n th

e tra

nsm

issi

ble

char

acte

r of d

isea

ses,

mis

take

n be

liefs

of t

he

fam

ily a

bout

the

dise

ase,

bel

ief i

n he

alin

g, b

elie

f in

the

incu

rabl

e ch

arac

ter o

f dis

ease

s, b

elie

f in

treat

men

t, be

liefs

rela

ted

to re

ligio

n.

Wis

hes:

Will

to h

ave

or g

et s

omet

hing

.Th

e ch

ild’s

des

ire fo

r oth

er fo

ods

cons

umed

by

the

fam

ily, d

esire

to fi

ll so

me

defic

it, u

nwan

ted

preg

nanc

y.

Sexu

al o

rient

atio

n: D

iffer

ent f

orm

s of

affe

ctive

and

sex

ual a

ttrac

tion

of e

ach

one.

Diffi

culti

es d

ue to

sex

ual o

rient

atio

n, d

ifficu

lty in

ass

umin

g se

xual

iden

tity

unde

r 18

year

s, le

avin

g ho

me

due

to s

exua

l orie

ntat

ion.

Men

tal h

ealth

: Sta

te o

f wel

l-bei

ng in

whi

ch a

n in

divid

ual i

s ab

le to

use

thei

r ow

n sk

ills,

reco

ver f

rom

rout

ine

stre

ss, b

e pr

oduc

tive

and

cont

ribut

e to

thei

r com

mun

ity.

Impa

ired

wel

l-bei

ng, s

tigm

a, h

igh

psyc

holo

gica

l dem

ands

, psy

chic

sta

te, p

sych

olog

ical

impa

ct, e

mot

iona

l and

psy

chos

ocia

l pr

oble

ms,

diffi

culti

es in

livin

g w

ith a

dis

ease

that

has

no

cure

, iso

latio

n st

rate

gies

, exc

essi

ve a

ttent

ion

to o

rgan

ic p

roce

sses

, ex

cess

ive s

ensi

tivity

to e

very

day

even

ts, t

ake

ever

ythi

ng th

at g

oes

wro

ng, l

oss

of c

ontro

l, ex

trem

e ch

ange

s in

em

otio

n fo

r sho

rt pe

riods

of t

ime,

unw

ante

d th

ough

ts, h

igh

expe

ctat

ions

of s

ympt

om re

lief,

disc

onne

ct fr

om e

mot

ions

like

nur

ses

to p

rote

ct

them

selve

s, fo

cus

on a

spec

ts n

egat

ive, i

nabi

lity

to e

xpre

ss fe

elin

gs, a

ge-r

elat

ed im

mat

urity

, diffi

culty

mak

ing

deci

sion

s, e

mot

iona

l im

pact

of t

he d

isea

se o

n th

e re

side

nt, e

xpec

ting

the

wor

st w

ithou

t rea

son,

em

otio

nal t

raum

atic

effe

cts

of th

e di

agno

sis,

ps

ycho

logi

cal d

ifficu

lties

in b

reas

tfeed

ing,

em

otio

nal d

ifficu

lties

with

pre

gnan

cy, e

mot

iona

l asp

ects

exp

erie

nced

as

a re

sult

of th

e di

seas

e, a

ffect

ive a

spec

ts e

xper

ienc

ed in

cur

rent

illn

ess,

not

refle

ctin

g on

bei

ng c

ared

for b

y nu

rses

, diff

eren

t typ

es o

f pat

ient

, ab

senc

e or

insu

ffici

ency

of d

istin

ctive

ass

essm

ent r

egar

ding

the

rais

ing

of o

ther

chi

ldre

n, a

bsen

ce o

r ins

uffic

ienc

y of

neg

otia

tion

abou

t pre

vent

ion

prac

tices

, ina

bilit

y to

dis

crim

inat

e th

e pr

esen

ce ri

sk o

r vul

nera

bilit

y, de

pend

ence

on

serv

ices

, rea

sons

for n

ot

perfo

rmin

g a

prev

entiv

e ex

am, r

easo

ns fo

r ris

ky b

ehav

ior,

beha

viora

l rea

son

for n

ot lo

okin

g fo

r the

hea

lth s

ervic

e, d

epre

ssio

n,

psyc

hoso

cial

stre

ssor

s, le

vel o

f stre

ss a

t wor

k, s

tress

, psy

chic

con

sequ

ence

of v

iole

nce,

dis

satis

fact

ion

with

wor

k, la

ck o

f sen

se o

f w

ork,

sub

ject

ive h

ealth

pro

blem

s, m

enta

l hea

lth p

robl

ems,

dis

abilit

y at

war

.

Perc

eptio

ns: M

enta

l pro

cess

thro

ugh

whi

ch th

e su

bjec

t attr

ibut

es a

mea

ning

to s

enso

ry

stim

uli,

mak

ing

them

con

scio

us, f

rom

a h

isto

ry o

f pas

t exp

erie

nces

.No

n-pe

rcep

tion

of ri

sk b

ehav

ior,

non-

perc

eptio

n of

risk

, non

-per

cept

ion

of th

reat

to h

ealth

, per

cept

ion

of n

on-r

isk

beha

vior,

inco

here

nt id

eas

abou

t pre

vent

ion

prac

tices

, non

-per

cept

ion

of th

e ne

ed to

ado

pt p

reve

ntive

mea

sure

s, n

on-p

erce

ptio

n of

pr

obab

ility

of il

lnes

s in

the

face

of r

isky

beh

avio

r, no

t per

ceivi

ng th

e pr

obab

ility

of e

xpos

ure

to th

e di

seas

e, n

ot p

erce

iving

the

dise

ase

asso

ciat

ed w

ith th

e ris

k gr

oups

, not

per

ceivi

ng th

e pr

obab

ility

of h

avin

g a

dise

ase,

not

per

ceivi

ng th

e ch

ance

of b

eing

sic

k,

not p

erce

iving

the

prob

abilit

y of

get

ting

sick

, no

perc

eptio

n of

hea

lth p

robl

ems,

non

-per

cept

ion

of th

e di

seas

e as

an

even

t tha

t pr

omot

es a

sses

smen

t of e

xper

ienc

es, n

on-p

erce

ptio

n of

the

dist

inct

ion

betw

een

age

grou

p be

fore

a d

isea

se, n

on-p

erce

ptio

n of

the

effe

ct o

f the

dis

ease

on

the

elde

rly, n

on-p

erce

ptio

n of

frag

ility,

non-

perc

eptio

n of

the

rela

tions

hip

betw

een

deat

h an

d lif

e in

rela

tion

to d

isea

se, n

ot re

pres

entin

g th

e di

seas

e as

soci

ated

with

pro

mis

cuity

and

irre

spon

sibi

lity

of w

omen

, not

per

ceivi

ng n

eglig

ence

as

form

s of

abu

se, n

ot p

erce

iving

wor

king

con

ditio

ns, n

ot p

erce

iving

low

leve

ls o

f qua

lity

of li

fe, n

ot p

erce

iving

exp

erie

nce,

exp

erie

ncin

g vu

lner

abilit

y, no

t per

ceivi

ng th

e re

ason

s fo

r the

vul

nera

bilit

y of

the

othe

r, em

otio

nal r

easo

n (p

erce

ptio

n ) s

earc

h fo

r hea

lth s

ervic

es,

emot

iona

l rea

sons

(per

cept

ion)

for n

on-p

reve

ntio

n pr

actic

es, n

on-p

erce

ptio

n of

vul

nera

bilit

y, no

n-pe

rcep

tion

of it

s im

porta

nce

in

build

ing

a fu

ture

for c

hild

ren,

non

-per

cept

ion

of a

ppre

ciat

ion

and

auto

nom

y, no

n-pe

rcep

tion

of th

e ro

le p

laye

d , r

easo

ns (p

erce

ptio

n)

of n

on-p

reve

ntio

n, d

ecre

ased

per

cept

ion,

per

cept

ion

of b

eing

out

side

the

grou

p, p

erce

ptio

n of

the

heal

th u

nit a

s a

plac

e of

car

e fo

r pa

tient

s, n

egat

ive s

elf-

perc

eptio

n of

hea

lth, f

ragm

enta

tion

of th

e ph

ysic

al a

nd m

enta

l bod

y, di

stor

ted

self-

imag

e.

Feel

ings

: Sta

tes

and

the

reac

tions

that

the

hum

an b

ody

is a

ble

to e

xpre

ss in

the

face

of

the

even

ts th

at th

e su

bjec

ts e

xper

ienc

e, w

heth

er p

ositi

ve o

r neg

ative

.In

grat

itude

, dis

trust

, dep

ende

nce

on o

ther

s, p

erso

nal s

treng

th, n

o ho

pe o

f hea

ling,

anx

iety,

wor

ry, f

ear,

desp

air,

emba

rrass

men

t, im

pote

nce,

unc

erta

inty,

suf

ferin

g, p

ity, a

nger

, fee

ling

unpr

epar

ed, f

eelin

gs, v

ario

us fe

elin

gs, f

ear,

inse

curit

y, sa

dnes

s, fe

elin

g th

at th

e st

aff f

eel t

hrea

tene

d, fe

elin

g th

at th

e re

sour

ces

them

selve

s ar

e in

suffi

cien

t to

face

situ

atio

ns, f

eelin

g th

at th

ey a

re lo

sing

con

trol o

ver

impo

rtant

situ

atio

ns, h

elpl

essn

ess,

dis

com

fort,

hel

ples

snes

s.

Valu

es: A

set

of i

ntrin

sic

char

acte

ristic

s re

late

d to

the

soci

al n

orm

s of

a g

iven

subj

ect,

whi

ch d

eter

min

es h

ow h

e be

have

s an

d in

tera

cts

with

oth

er s

ubje

cts

and

with

the

envir

onm

ent.

Inco

here

nt v

alue

s on

pre

vent

ion

prac

tices

.

Cont

inue

...

Cont

inua

tion.

11Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

SUBJ

ECT

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Phys

ical

sta

tus:

The

cha

ract

eris

tics

of th

e su

bjec

t in

rela

tion

to th

eir

phys

ical

, phy

siol

ogic

al o

r pat

holo

gica

l at

tribu

tes.

Age:

Tim

e, in

yea

rs, m

onth

s an

d da

ys, e

laps

ed fr

om b

irth

to th

e tim

e of

whi

ch w

e sp

eak.

Age

of fi

rst s

exua

l int

erco

urse

, eld

erly,

age

whe

n th

ey le

ft ho

me

for t

he fi

rst t

ime,

beg

inni

ng o

f sex

ual a

ctivi

ty w

ith lo

wer

age

in th

is

popu

latio

n se

gmen

t, be

ginn

ing

of s

exua

l life

bef

ore

15 y

ears

, pro

duct

ive p

erio

d. D

epen

ding

on

the

cont

ext.

Sex:

A s

et o

f stru

ctur

al a

nd fu

nctio

nal c

hara

cter

istic

s ac

cord

ing

to w

hich

a li

ving

bein

g is

cl

assi

fied

as m

ale

or fe

mal

e.De

pend

ing

on th

e si

tuat

ion,

em

phas

is o

n be

ing

a w

oman

.

Race

/col

or: C

ateg

ory

used

to re

fer t

o a

grou

p of

peo

ple

who

se p

hysi

cal c

hara

cter

istic

s ar

e co

nsid

ered

soc

ially

sig

nific

ant:

whi

te, b

lack

, bro

wn,

indi

geno

us o

r yel

low.

Depe

ndin

g on

the

situ

atio

n, e

mph

asis

on

bein

g bl

ack.

Wor

k-re

late

d ph

ysic

al a

spec

ts: A

ll ac

tivity

per

form

ed in

the

wor

k th

at re

quire

s ac

cess

to

the

char

acte

ristic

s of

the

body

.Ph

ysic

al e

xerti

on a

t wor

k, re

petit

ive m

ovem

ents

at w

ork,

phy

sica

l wor

k po

stur

e, ti

me

stan

ding

at w

ork,

pai

n or

dis

com

fort

as a

resu

lt of

wor

k.

Impa

ct o

f illn

ess

at w

ork:

Any

con

sequ

ence

of t

he d

isea

se a

ffect

ing

wor

k.Di

fficu

lty in

rem

aini

ng in

occ

upat

iona

l act

ivity

due

to il

lnes

s, d

ifficu

lties

for o

ccup

atio

nal a

ctivi

ties

due

to il

lnes

s, lo

ss o

f em

ploy

men

t du

e to

illn

ess.

Heal

th-d

isea

se s

tatu

s: C

hara

cter

istic

s re

late

d to

the

hist

ory

or c

urre

nt c

ondi

tion

in th

e he

alth

-dis

ease

pro

cess

, whe

ther

in th

e ge

nera

l hea

lth c

onte

xt, s

igns

and

sym

ptom

s,

diag

nosi

s, te

sts,

trea

tmen

t, co

mor

bidi

ties

or p

rogn

osis

rela

ted

to a

dis

ease

.

Hosp

ital a

dmis

sion

s, a

ttend

ance

at e

mer

genc

y se

rvic

es, c

onsu

mpt

ion

of e

xces

sive

hea

lth c

are,

ann

ual n

umbe

r of v

isits

to th

e he

alth

se

rvic

e, v

isit

by s

ever

al p

rofe

ssio

nals

, pro

pens

ity to

vis

it m

edic

al s

peci

alis

ts, v

isit

five

or m

ore

diffe

rent

clin

ical

dep

artm

ents

, vis

it th

e m

ost i

mpo

rtant

pro

vider

sev

en ti

mes

a y

ear,

heal

th h

isto

ry, f

amily

his

tory

of i

llnes

s, u

nkno

wn

caus

es o

f illn

ess,

con

tact

with

co

ntam

inan

ts, e

xpos

ure

and

susc

eptib

ility

to il

lnes

s, e

xpos

ure

to w

ar, p

oor h

ealth

, poo

r hea

lth, p

oor c

urre

nt h

ealth

, med

ical

fact

ors,

ne

ed n

euro

psyc

holo

gica

l ass

essm

ent,

poor

hea

lth c

ondi

tions

, com

orbi

dity

inde

x, c

omor

bidi

ty, p

hysi

cal d

isab

ility,

war

dis

abilit

y, di

sabi

lity,

acci

dent

s, re

port

of il

lnes

s, p

hysi

cal a

nd s

enso

ry d

ifficu

lties

, dia

gnos

tic d

ata,

chr

onic

con

ditio

ns, h

isto

ry o

f illn

ess,

obe

sity,

nu

tritio

nal s

tatu

s di

abet

es, i

mm

unos

uppr

essi

ve d

isea

se a

nd tr

eatm

ent,

dise

ase

stag

e, d

iagn

osis

num

ber p

rimar

y sy

mpt

oms,

di

seas

e pr

eval

ence

, hea

lth p

robl

ems,

dem

entia

dis

ease

pro

cess

, typ

e of

dis

abilit

y, pe

ople

with

dis

abilit

ies,

tim

e of

dia

gnos

is, t

ime

of d

iagn

osis

of t

he d

isea

se, w

itnes

sing

the

inev

itabl

e w

orse

ning

of t

he d

isea

se, n

umbe

r of p

regn

anci

es, d

epen

denc

e, lo

w im

mun

ity,

prol

onge

d ex

posu

re to

risk

fact

ors,

hig

h ph

ysic

al d

eman

ds, d

isea

se p

rope

nsity

, rea

sons

for r

isky

beh

avio

r - c

ondo

m la

tex

alle

rgy,

gene

ral s

igns

and

sym

ptom

s of

the

dise

ase,

som

atic

alte

ratio

n, s

leep

dis

orde

rs a

nd d

isor

ders

, sex

ual d

isor

ders

, tir

ed e

ven

afte

r sl

eepi

ng, w

eigh

t los

s, p

ain,

fatig

ue, n

ippl

e cr

acks

, wea

knes

s, c

hang

es in

phy

sica

l app

eara

nce

due

to il

lnes

s, p

hysi

cal d

ifficu

lties

w

ith p

regn

ancy

, phy

sica

l con

sequ

ence

s of

trea

tmen

t, ty

pe o

f med

icat

ion,

ada

pted

trea

tmen

t, al

tern

ative

trea

tmen

t: te

as a

nd ju

ices

, ph

arm

acol

ogic

al tr

eatm

ent,

prev

entiv

e tre

atm

ent,

psyc

hiat

ric tr

eatm

ent,

treat

men

t use

d, m

edic

atio

n us

e, tr

eatm

ent d

ata,

indi

cate

s tre

atm

ent,

spec

ific

clin

ical

exa

min

atio

n, m

edic

al e

xam

inat

ion,

pre

vious

exa

min

atio

n of

the

dise

ase,

clin

ical

test

s us

ed fo

r dia

gnos

is,

daily

col

lect

ion

of g

ener

al la

bora

tory

test

s, la

ck o

f int

eres

t in

carr

ying

out d

iagn

ostic

test

s, te

st re

sults

, pos

itive

test

resu

lt, p

rogn

ostic

fa

ctor

, low

sur

vival

, com

plic

atio

ns.

Cont

inue

...

Cont

inua

tion.

12 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

SOCI

AL

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Soci

oeco

nom

ic s

tatu

s: A

set

of

econ

omic

, soc

iolo

gica

l, ed

ucat

iona

l an

d la

bor c

hara

cter

istic

s th

at q

ualif

y a

subj

ect o

r gro

up w

ithin

a s

ocia

l hi

erar

chy.

Mat

eria

l goo

ds: E

very

thin

g th

at h

as a

con

cret

e fo

rm a

nd s

ome

utilit

y, be

ing

able

to s

atis

fy

a ne

ed o

f the

sub

ject

.No

t hav

ing

a m

icro

com

pute

r, m

otor

cycl

e, a

utom

obile

for p

rivat

e us

e or

hom

e ow

ners

hip,

mat

eria

l dep

rivat

ion,

dep

rivat

ion

of m

ater

ial

reso

urce

s, v

ario

us d

epriv

atio

ns.

Hous

ing:

Com

mon

des

igna

tion

of h

ousi

ng, w

hich

may

or m

ay n

ot b

e m

ater

ializ

ed a

s a

hous

e, s

ince

the

stre

et is

ofte

n co

nsid

ered

the

plac

e of

resi

denc

e.Hi

gh p

ropo

rtion

of r

esid

ents

per

dor

mito

ry, p

reca

rious

hou

sing

con

ditio

ns, p

reca

rious

cha

ract

eris

tic o

f the

room

s, li

ving

at h

ome

with

a

smal

l num

ber o

f dor

mito

ries,

inst

itutio

naliz

ed li

ving,

hou

sing

nee

ds.

Inco

me:

Sou

rce

of m

oney

thro

ugh

whi

ch o

ne c

an b

uy g

oods

and

ser

vices

, i.e

., it

is

rem

uner

atio

n re

ceive

d m

ainl

y af

ter a

per

iod

of w

ork

or th

roug

h so

cial

pro

gram

s.In

com

e fo

r dis

ease

s, lo

w fa

mily

inco

me,

sm

all n

umbe

r or a

bsen

ce o

f fam

ily m

embe

rs w

ith in

com

e, s

mal

l or a

bsen

t am

ount

of

peop

le w

ith p

aid

wor

k, in

abilit

y to

gen

erat

e in

com

e, re

ceip

t of s

ocia

l ass

ista

nce

subs

idie

s fro

m th

e go

vern

men

t, re

ceip

t of s

ickn

ess

bene

fit, r

ecei

pt o

f soc

ial b

enefi

t, in

serti

on in

ass

ista

nce/

bene

fit p

rogr

am, fi

nanc

ial p

robl

ems,

eco

nom

ic d

ifficu

lties

, fina

ncia

l co

nditi

on.

Soci

al c

lass

: Gro

up o

f sub

ject

s w

ith c

hara

cter

istic

s in

com

mon

from

the

econ

omic

, be

havio

ral a

nd id

eolo

gica

l rep

rese

ntat

ion

poin

t of v

iew

of t

he w

orld

aro

und

them

, in

a re

latio

nshi

p of

hie

rarc

hy w

ith o

ther

gro

ups.

Dive

rse

soci

al s

tatu

s, u

nfav

orab

le s

ocia

l pos

ition

, low

soc

ioec

onom

ic s

tatu

s, e

cono

mic

cla

ss, f

amily

eco

nom

ic s

tatu

s, lo

w s

ocia

l cl

ass,

low

pur

chas

ing

pow

er, p

over

ty c

ondi

tion.

Wor

k:It

is th

e ac

tivity

upo

n w

hich

the

hum

an b

eing

em

ploy

s hi

s in

telle

ctua

l or p

hysi

cal

stre

ngth

to p

rodu

ce th

e m

eans

for h

is li

velih

ood.

Retir

emen

t, un

empl

oym

ent,

empl

oym

ent,

occu

patio

n, in

form

al o

ccup

atio

n, o

ccup

atio

n: s

tude

nt, o

ccup

atio

n: o

utsi

de th

e m

arke

t, sm

all a

mou

nt o

f sta

ff w

orki

ng w

ith a

sig

ned

portf

olio

, sm

all n

umbe

r of p

eopl

e w

orki

ng m

ore

than

6 m

onth

s in

em

ploy

men

t, ab

senc

e or

lack

of p

erm

anen

t edu

catio

n fo

r wor

k -

qual

ifica

tion

for w

ork,

abs

ence

or l

ack

of p

erm

anen

t edu

catio

n, n

ot re

ceivi

ng tr

aini

ng, n

ot

rece

iving

trai

ning

in h

ealth

and

saf

ety

at w

ork,

form

s of

bon

ding

wea

kene

d an

d pr

ecar

ious

, con

ditio

n of

the

dive

rse

orga

niza

tion,

ex

cess

ive w

orkl

oad,

exc

essi

ve w

orkl

oad,

unh

ealth

y an

d pr

ecar

ious

wor

k co

ntex

ts, e

xces

sive

wor

king

hou

rs, l

ack

of c

ontro

l ove

r w

ork,

pla

ces/

wor

king

con

ditio

n, a

bsen

ce o

r lac

k of

saf

ety

in th

e w

orkp

lace

, inc

iden

ts a

nd w

ork

acci

dent

s ar

e in

vest

igat

ed, p

ress

ure

at w

ork,

wor

k at

wor

k, w

ork

at w

ork

, joi

nt w

ork

diffi

culti

es, d

iffer

ent t

ypes

of w

ork,

wor

king

tim

e in

the

com

pany

, nig

ht s

hifts

, in

suffi

cien

t hum

an re

sour

ces,

und

erem

ploy

men

t, w

ork

sect

or, u

ninf

orm

ed a

nd in

effe

ctive

wor

kfor

ce, d

omes

tic o

verlo

ad, h

igh

nois

e le

vels

at w

ork,

wor

kloa

d an

d m

enta

l ove

rload

of w

ork,

lack

of f

reed

om o

f exp

ress

ion

at w

ork,

lack

of f

reed

om to

com

mun

icat

e w

ith

man

agem

ent,

exce

ssive

wor

k ru

les,

non

-con

tribu

tion

to s

ocia

l sec

urity

.

Educ

atio

n: T

each

ing-

lear

ning

pro

cess

es e

xper

ienc

ed in

the

fam

ily, s

choo

l or o

ther

in

stitu

tion

sign

ifica

nt fo

r the

sub

ject

s. T

his

proc

ess

can

take

pla

ce in

the

sphe

re o

f for

mal

ed

ucat

ion

or p

opul

ar e

duca

tion.

Diffi

culti

es w

ith e

duca

tion,

lack

of i

nves

tmen

t in

educ

atio

n.

Dem

ogra

phic

iden

tity:

A s

et o

f ch

arac

teris

tics

of a

pop

ulat

ion

that

liv

es in

a g

iven

terri

tory

and

pro

duce

s m

ovem

ents

in th

at s

pace

.

Ethn

icity

: Gro

up d

efine

d by

the

sam

e or

igin

, lin

guis

tic a

nd c

ultu

ral a

ffini

ties.

Ethn

ic g

roup

, min

ority

eth

nic

grou

ps

Orig

in: S

omeo

ne’s

pla

ce o

f orig

in.

Natio

nalit

y, or

igin

, orig

in: r

ural

are

a, o

rigin

: urb

an a

rea,

loca

lity,

leng

th o

f sta

y at

the

plac

e of

orig

in, d

omes

tic h

abita

t.

Mig

ratio

n: D

ispl

acem

ent o

f ind

ividu

als

with

in a

geo

grap

hic

spac

e.Im

mig

ratio

n, d

epen

ding

on

the

situ

atio

n: c

ount

ry o

f des

tinat

ion,

situ

atio

n of

refu

ge.

Cultu

re: T

he fo

rms

of e

xpre

ssio

n of

th

e or

gani

zatio

n of

a p

eopl

e, th

eir

cust

oms

and

tradi

tions

exc

hang

ed

and

trans

form

ed fr

om g

ener

atio

n to

gen

erat

ion

that

, fro

m a

com

mon

ex

perie

nce

and

tradi

tion,

are

pr

esen

ted

as th

e id

entit

y of

this

pe

ople

.

Cultu

ral f

orm

atio

n: H

ow th

e cu

lture

orig

inat

ed a

nd s

ettle

d in

to a

spe

cific

gro

up.

Cultu

ral f

orm

atio

n of

the

dive

rse

popu

latio

n.

Soci

al c

onst

ruct

ions

: All

cultu

ral e

xpre

ssio

ns a

bout

pre

vent

ion

and

how

they

wer

e bu

ilt.

Soci

al c

onst

ruct

ions

on

prev

entio

n pr

actic

es.

Cultu

ral d

iffer

ence

s: D

iffer

ent t

ypes

of c

ultu

re e

xist i

n re

latio

n to

a p

opul

atio

n or

gro

up.

Cultu

ral d

iffer

ence

s.

Popu

lar k

now

ledg

e: W

ays

in w

hich

the

subj

ects

pro

duce

mea

ning

s by

soc

ial a

nd c

ultu

ral

expe

rienc

es in

sea

rch

of e

xpla

natio

ns th

at re

late

asp

ects

suc

h as

nat

ural

, mag

ical

-re

ligio

us, o

r soc

iopo

litic

al a

spec

ts in

ord

er to

give

mea

ning

to e

vent

s.

Cultu

ral f

orm

atio

n of

the

dive

rse

popu

latio

n, in

cohe

rent

soc

ial c

onst

ruct

ions

on

prev

entio

n pr

actic

es, c

ultu

ral d

iffer

ence

s.

Fam

ily c

onte

xt: T

he w

ay

rela

tions

hips

in a

fam

ily h

appe

n.M

arita

l/fam

ily s

tatu

s: R

elat

iona

l cha

ract

eris

tic a

risin

g fro

m th

e es

tabl

ishm

ent o

f a fo

rmal

un

ion

or n

ot b

etw

een

subj

ects

.De

pend

ing

on th

e si

tuat

ion:

bei

ng m

arrie

d or

bei

ng s

ingl

e, ti

me

of s

tabl

e un

ion,

livin

g al

one,

num

ber o

f chi

ldre

n, m

othe

r of c

hild

up

to 2

yea

rs o

ld, f

amily

situ

atio

n (w

ith w

hom

she

live

s).

Mem

ber c

hara

cter

istic

: Attr

ibut

es o

f the

mem

bers

of a

fam

ily fo

r who

m th

e ca

re a

nd

atte

ntio

n ne

cess

ary

for t

heir

harm

ony

are

spen

t.Ch

ild o

r ado

lesc

ent u

p to

14

year

s ol

d in

the

hous

e, C

hild

ren,

ado

lesc

ent o

r you

ng p

erso

n up

to 1

7 ye

ars

in th

e ho

use,

bei

ng fa

mily

of

the

child

with

onc

olog

ic p

ain,

eld

erly

in th

e ho

use,

eld

erly

in th

e ho

use

with

oth

er e

lder

ly, e

lder

ly pe

rson

suf

fere

d fa

ll, fa

mily

m

embe

r with

dis

abilit

ies,

fam

ily m

embe

r with

diffi

culty

in c

omm

unic

atio

n an

d so

cial

func

tioni

ng, f

amily

mem

ber w

ith b

ehav

iora

l and

ps

ycho

logi

cal d

ifficu

lties

, fa

mily

mem

ber w

ith le

arni

ng d

ifficu

lties

, fam

ily m

embe

r with

epi

leps

y or

con

vuls

ion,

num

ber o

f peo

ple

with

chr

onic

dis

ease

s, a

lcoh

olic

fath

er, l

ow s

choo

ling

of p

eopl

e in

the

hous

e, lo

w s

choo

ling

of th

e he

ad o

f the

fam

ily.

Fam

ily ty

pes:

Sev

eral

con

text

s ex

perie

nced

by

a fa

mily

with

rega

rd to

thei

r org

aniza

tion,

w

heth

er re

latio

nal o

r fina

ncia

l.Ex

tend

ed fa

milie

s, e

xten

ded

and

sing

le-p

aren

t fam

ilies,

num

ber o

f peo

ple

in th

e ho

useh

old,

ove

rcro

wdi

ng a

t hom

e, fe

mal

e he

ad o

f th

e fa

mily

afte

r situ

atio

n of

soc

ial d

ifficu

lty, p

atria

rchy

, fem

ale

sing

le p

aren

thoo

d.Co

ntin

ue...

Cont

inua

tion.

13Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

SOCI

AL

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Soci

al m

edia

: Soc

ial s

truct

ure

com

pose

d of

peo

ple

or o

rgan

izatio

ns,

conn

ecte

d by

one

or s

ever

al ty

pes

of re

latio

nshi

ps, w

ho s

hare

com

mon

va

lues

and

obj

ectiv

es o

f offe

ring

supp

ort i

n a

situ

atio

n of

nee

d of

the

subj

ect o

r soc

iety.

Soci

al s

uppo

rt: V

arie

ty o

f rea

l or p

erce

ived

reso

urce

s av

aila

ble

and

offe

red

to a

sub

ject

th

roug

h th

eir t

ies

with

oth

ers

in v

ario

us a

reas

(pro

fess

iona

l, fa

mily

or w

ithin

the

scop

e of

fri

ends

hip)

.

Need

for s

uppo

rt fro

m h

ealth

pro

fess

iona

ls, l

ack

of s

uppo

rt fro

m h

ealth

pro

fess

iona

ls, a

bsen

ce o

f soc

ial s

uppo

rt an

d ad

equa

te

rece

ptio

n -

form

al c

areg

iver,

redu

ced

soci

al c

ircle

, abs

ence

or i

nsuf

ficie

ncy

of s

ocia

l sup

port,

abs

ence

or i

nsuf

ficie

ncy

of s

ocia

l su

ppor

t pro

vided

by

form

al c

areg

ivers

, abs

ence

or i

nsuf

ficie

nt in

stitu

tiona

l sup

port,

frag

ility

in th

e su

ppor

t pro

vided

dur

ing

pren

atal

ca

re, n

eed

for f

amily

sup

port,

non

-mon

itorin

g by

a fa

mily

mem

ber f

or h

ealth

car

e, a

bsen

ce o

r ins

uffic

ienc

y of

fam

ily s

uppo

rt,

abse

nce

or in

suffi

cien

cy o

f pat

erna

l sup

port,

rece

iving

vis

its in

suffi

cien

t or e

xces

sive

fam

ily m

embe

rs, a

bsen

ce o

r ins

uffic

ienc

y of

fam

ily in

serti

on in

car

e, a

bsen

ce o

r ins

uffic

ienc

y of

fam

ily m

embe

r par

ticip

atio

n in

chi

ld c

are,

wea

k or

abs

ent f

amily

net

wor

ks,

rece

iving

vis

its fr

om in

suffi

cien

t or e

xces

sive

frie

nds,

info

rmal

sup

port

netw

orks

of c

olle

ague

s, n

ot a

ccom

pany

ing

frien

ds in

hea

lth

care

, abs

ence

or i

nsuf

ficie

ncy

of p

revio

usly

rece

ived

supp

ort,

abse

nce

or in

suffi

cien

cy o

f soc

ial s

uppo

rt ne

twor

ks, a

bsen

ce o

r in

suffi

cien

cy o

f soc

ial s

uppo

rt if

som

eone

nee

ds c

ompa

ny, a

bsen

ce o

r ins

uffic

ienc

y of

soc

ial s

uppo

rt if

som

eone

nee

ds m

oney

or

finan

cial

aid

, abs

ence

or i

nsuf

ficie

ncy

of s

ocia

l sup

port

if ne

ed to

rece

ive h

ealth

car

e, a

bsen

ce o

r ins

uffic

ienc

y of

soc

ial s

uppo

rt if

som

eone

nee

ds to

leav

e ho

me,

abs

ence

or i

nsuf

ficie

ncy

of s

ocia

l sup

port

to p

erfo

rm d

omes

tic ta

sks,

abs

ence

or i

nsuf

ficie

ncy

of

soci

al s

uppo

rt w

hen

som

eone

nee

ds m

ater

ial g

oods

, abs

ence

or i

nsuf

ficie

ncy

of s

uppo

rt fo

r pre

vent

ion

prac

tice

, with

out a

car

egive

r w

hen

they

nee

d fo

llow

-up

for c

onsu

ltatio

ns o

r hos

pita

lizat

ions

, per

cept

ion

of s

ocia

l sup

port,

dep

ende

nce

on o

ther

s fo

r the

ir ca

re a

nd

supp

ort.

Gend

er: I

t is

an id

entit

y ca

tego

ry

of w

hat i

s cu

ltura

lly c

onst

ruct

ed a

s fe

min

ine

or m

ale,

with

out,

how

ever

, re

sulti

ng e

xclu

sive

ly fro

m b

iolo

gica

l se

x, s

ince

gen

der i

s an

inte

ntio

nal

act,

a pe

rform

ative

ges

ture

that

pr

oduc

es m

eani

ngs.

Gend

er in

equa

lity:

Diff

eren

t tre

atm

ent g

iven

to s

ubje

cts

due

to g

ende

r iss

ues

eith

er b

y in

divid

uals

or i

nstit

utio

ns.

Gene

ral g

ende

r ine

qual

ities

, rea

son

for d

ropp

ing

out o

f stu

dies

: bei

ng tr

ansv

estit

e, g

ende

r bel

ief o

f soc

iety

abo

ut p

eopl

e w

ith

disa

bilit

ies.

Trad

ition

al ro

les:

Set

of e

xpec

ted

beha

viors

cha

ract

eris

tic o

f a c

erta

in p

ositi

on in

soc

iety.

Trad

ition

al g

ende

r rol

es, r

epre

sent

atio

n of

wom

en a

s ca

refu

l and

pre

cario

us a

nd w

ith a

sin

gle

partn

er.

Mal

e ch

auvi

nism

: A s

et o

f atti

tude

s an

d be

havio

rs th

at re

sult

in th

e ov

erva

luat

ion

of m

ale

char

acte

ristic

s.Se

xual

pra

ctic

es o

f sub

mis

sion

to m

en, a

ttitu

des

and

sexis

t ide

as b

y w

omen

: pow

er o

f con

dom

use

is e

xclu

sive

to th

e m

an,

accu

sativ

e at

titud

e of

pro

mis

cuity

, irre

spon

sibi

lity

of w

omen

tow

ards

oth

er w

omen

, atti

tude

of s

ubm

issi

on to

the

partn

er, i

nflue

nce

of

sexis

t and

pat

riarc

hal c

onst

ruct

s on

sex

and

mar

riage

, ide

a th

at th

e si

ck w

oman

is ir

resp

onsi

ble

and

prom

iscu

ous.

Viol

ence

: It i

s th

e in

tent

iona

l use

of

phy

sica

l or a

ctua

l for

ce o

r pow

er

agai

nst o

nese

lf, a

gain

st a

noth

er

pers

on o

r aga

inst

a g

roup

or

com

mun

ity, t

hat r

esul

t or a

re li

kely

to

resu

lt in

inju

ry, d

eath

, psy

chol

ogic

al

harm

, poo

r dev

elop

men

t, or

de

priva

tion.

Disc

rimin

atio

n: A

ctio

n ba

sed

on p

reju

dice

that

dis

tingu

ishe

s a

pers

on o

r gro

up fr

om

othe

rs in

a p

ejor

ative

way

.Di

scrim

inat

ion

in e

mpl

oym

ent,

disc

rimin

atio

n: in

stitu

tiona

l vio

lenc

e, e

thni

c-ra

cial

dis

crim

inat

ion,

dis

crim

inat

ion

in th

e fa

mily

en

viron

men

t and

in th

e gr

oup

of n

eigh

bors

, dis

crim

inat

ion

in th

e la

st y

ear,

raci

al d

iscr

imin

atio

n: u

nequ

al tr

eatm

ent,

disc

rimin

atio

n,

disc

rimin

atio

n: fa

mily

env

ironm

ent a

nd in

gro

ups

of fr

iend

s an

d ne

ighb

ors

and

heal

th p

rofe

ssio

nals

, dis

crim

inat

ion:

relig

ious

en

viron

men

t, di

scrim

inat

ion:

lack

of c

hara

cter

, dis

crim

inat

ion:

com

mer

ce a

nd le

isur

e pl

aces

, dis

crim

inat

ion:

phy

sica

l app

eara

nce;

th

ose

aris

ing

from

issu

es o

f cha

ract

er, o

ther

s re

late

d to

inte

llect

ual c

apac

ity, d

iscr

imin

atio

n: in

com

mer

ce a

nd le

isur

e pl

aces

, di

scrim

inat

ion:

inte

llect

ual d

isab

ility,

disc

rimin

atio

n by

teac

hers

or c

olle

ague

s, s

tigm

a an

d di

scrim

inat

ion,

situ

atio

ns o

f dis

crim

inat

ion

perp

etra

ted

by d

iscr

imin

atio

n: o

ffens

es a

nd p

oor q

ualit

y ca

re, s

uffe

r dis

crim

inat

ion,

neg

ative

ste

reot

ypes

tow

ards

bla

cks,

hos

tility

(s

uffe

ring

host

ility

reac

tion)

, hom

opho

bia,

relig

ious

hom

opho

bia

and

hom

opho

bia

in e

mpl

oym

ent ,

be

labe

led

by s

omeo

ne, p

reju

dice

, di

scrim

inat

ion

suffe

red,

raci

sm, i

nstit

utio

nal r

acis

m, v

ictim

of r

acia

l pre

judi

ce, p

reju

dice

in re

latio

n to

the

dise

ase,

suf

fer p

reju

dice

s in

rela

tion

to s

exua

lity,

suffe

r pre

judi

ces

to li

ve m

othe

rhoo

d.

Sexu

al v

iole

nce:

Sex

ual v

iole

nce

is a

ny s

exua

l act

or a

ttem

pt to

obt

ain

a se

xual

act

by

viole

nce

or c

oerc

ion,

unw

ante

d se

xual

com

men

ts o

r adv

ance

s, a

cts

to tr

affic

a p

erso

n or

ac

ts d

irect

ed a

gain

st a

per

son’

s se

xual

ity, r

egar

dles

s of

the

rela

tions

hip

to th

e vic

tim.

Sexu

al v

iole

nce,

mar

ital v

iole

nce.

Phys

ical

vio

lenc

e: In

tent

iona

l use

of p

hysi

cal f

orce

aga

inst

one

self,

aga

inst

ano

ther

pe

rson

, or a

gain

st a

gro

up o

r com

mun

ity fo

r the

pur

pose

of c

ausi

ng in

jury

or d

eath

.Hi

gh h

omic

ide

rate

s, p

hysi

cal v

iole

nce,

mar

ital v

iole

nce.

Verb

al v

iole

nce:

Any

act

whe

re th

e ag

gres

sor m

akes

offe

nsive

rem

arks

abo

ut a

noth

er

pers

on.

Offe

nsive

ver

baliz

atio

n w

ith s

hout

ing

and

curs

ing,

am

ong

othe

rs.

Psyc

holo

gica

l vio

lenc

e: U

nequ

al re

latio

nshi

p of

pow

er, i

n w

hich

age

nts

exer

cise

aut

horit

y ov

er v

ictim

s, s

ubje

ctin

g th

em to

psy

chol

ogic

al a

buse

in a

con

tinuo

us a

nd in

tent

iona

l m

anne

r.

Use

of p

ower

to in

timid

ate

or a

buse

, bul

lying

, int

imid

atio

n an

d ha

rass

men

t in

the

wor

kpla

ce, d

ingh

ies,

vio

lenc

e as

a d

aily

even

t, in

stitu

tiona

l vio

lenc

e.

Cont

inue

...

Cont

inua

tion.

14 Acta Paul Enferm. 2021; 34:eAPE00353.

Health vulnerability model: conceptual clarification from social subjects’ perspective

SOCI

AL

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Soci

al c

ontr

ol: D

emoc

ratic

stra

tegy

of

citi

zen

parti

cipa

tion

in th

e ex

erci

se

of p

ower

, pla

cing

the

soci

al w

ill as

an

asse

ssm

ent f

acto

r for

the

crea

tion

and

goal

s to

be

achi

eved

in th

e co

ntex

t of p

ublic

pol

icie

s.

Soci

al p

artic

ipat

ion:

Per

form

ance

of a

sub

ject

or g

roup

in th

e th

eore

tical

and

pra

ctic

al

plan

es o

f soc

ial m

ovem

ents

for d

ecis

ion

mak

ing

that

has

resu

lted

for t

he c

olle

ctive

.No

n-pa

rtici

patio

n in

any

org

anize

d ac

tivity

, non

-par

ticip

atio

n in

the

soci

al m

ovem

ent,

non-

parti

cipa

tion

in s

uppo

rt gr

oups

and

go

vern

men

tal a

nd n

on-g

over

nmen

tal o

rgan

izatio

ns, n

on-p

opul

ar p

artic

ipat

ion

in d

isea

se c

ontro

l, no

n-so

cial

par

ticip

atio

n, n

on-

indu

stria

l/uni

on in

volve

men

t.

Ecos

yste

m: I

t is

the

set o

f re

latio

nshi

ps th

at li

ving

bein

gs a

nd

the

envir

onm

ent,

com

pose

d of

the

elem

ents

soi

l, w

ater

and

atm

osph

ere

(abi

otic

fact

ors)

mai

ntai

n si

ngs

with

ea

ch o

ther

.

Was

te: E

very

thin

g th

at is

not

use

d in

hum

an a

ctivi

ties,

com

ing

from

indu

strie

s, s

hops

and

re

side

nces

, i.e

., ga

rbag

e, m

ater

ial t

hat r

emai

ns a

fter a

n ac

tion

or p

rodu

ctio

n pr

oces

s.In

adeq

uate

hom

e w

aste

dis

posa

l, st

reet

was

te, i

nsuf

ficie

nt re

cycl

ing

and

use

of u

sed

mat

eria

ls, i

nade

quat

e pa

ckag

ing

and

was

te

dest

inat

ion.

Envi

ronm

ent:

Natu

ral a

nd s

ocia

l spa

ce (b

uilt)

whe

re th

e hu

man

bei

ng a

nd a

ll ot

her l

iving

be

ings

live

.M

ater

ial e

lem

ents

, cha

ract

eris

tic o

f act

ivitie

s on

var

ious

land

, lan

d te

nure

, typ

e of

agr

icul

ture

, agr

ibus

ines

s, u

se o

f hou

sing

by

the

fam

ily, e

cono

mic

dep

ende

nce

on a

gric

ultu

ral a

ctivi

ties,

unb

alan

ced

ecos

yste

m, s

patia

l and

tem

pora

l dyn

amic

s of

def

ores

tatio

n,

plac

e of

repr

oduc

tion

of th

e ve

ctor

, pol

lutio

n, d

am d

isru

ptio

n.

Clim

ate:

Diff

eren

t wea

ther

sta

tes

that

repe

at a

nd s

ucce

ed in

the

atm

osph

ere

thro

ugho

ut

the

year

in a

give

n re

gion

, con

sist

ing

of e

lem

ents

suc

h as

tem

pera

ture

, atm

osph

eric

pr

essu

re, r

ain,

sno

w, a

nd h

ail a

nd w

inds

.

Dive

rse

clim

atic

fact

ors,

abs

ent o

r ins

uffic

ient

nat

ural

ven

tilat

ion.

Acce

ss to

fund

amen

tal r

ight

s: T

he

poss

ibilit

y of

the

subj

ect e

njoy

fully

an

d re

spec

tfully

all

his

right

s.

Firs

t gen

erat

ion

fund

amen

tal r

ight

s: R

ight

to li

fe, f

reed

om, p

rope

rty, f

reed

om o

f ex

pres

sion

, pol

itica

l and

relig

ious

par

ticip

atio

n, in

viola

bilit

y of

dom

icile

, fre

edom

of

asse

mbl

y, am

ong

othe

rs.

Abse

nt o

r ins

uffic

ient

acc

ess

to s

ocia

l and

pol

itica

l par

ticip

atio

n.

Seco

nd g

ener

atio

n fu

ndam

enta

l rig

hts:

Sec

ond-

dim

ensi

on ri

ghts

are

thos

e in

whi

ch th

e St

ate

has

resp

onsi

bilit

y fo

r the

real

izatio

n of

an

idea

l of d

igni

fied

life

in s

ocie

ty. L

inke

d to

th

e va

lue

of e

qual

ity, t

he fu

ndam

enta

l rig

hts

of th

e se

cond

dim

ensi

on a

re s

ocia

l, ec

onom

ic

and

cultu

ral r

ight

s.

Abse

nce

or in

suffi

cien

cy o

f hea

lth in

sura

nce,

abs

ence

or i

nsuf

ficie

ncy

of a

cces

s to

hea

lth c

are,

abs

ence

or i

nsuf

ficie

ncy

of a

cces

s to

hea

lth s

ervic

es, a

bsen

ce o

r ins

uffic

ienc

y of

acc

ess

- us

e of

pub

lic h

ealth

ser

vices

, lon

g tim

e to

reac

h th

e ne

ares

t hea

lth s

ervic

e,

abse

nce

or in

suffi

cien

cy o

f acc

ess

to re

habi

litat

ion,

hig

h ex

pend

iture

on

heal

th, d

imin

ishe

d re

sour

ces

for p

aym

ent f

or h

ealth

se

rvic

es a

nd/o

r pur

chas

e of

med

icin

es, a

bsen

ce o

r ins

uffic

ienc

y of

acc

ess

to d

iagn

osis

and

trea

tmen

t, ab

senc

e or

insu

ffici

ency

of

acc

ess

to p

reve

ntio

n su

pplie

s, d

ista

nce,

acc

ess

to th

e se

rvic

e: d

istri

butio

n of

pas

swor

ds, a

cces

s to

the

serv

ice:

wai

ting

in lo

ng

lines

, acc

ess

to th

e se

rvic

e: la

ck o

f hea

lth s

ervic

es, a

cces

s to

the

serv

ice:

lack

of b

eds,

acc

ess

to th

e se

rvic

e: la

ck o

f sol

utio

ns fo

r ne

eds,

acc

ess

to th

e se

rvic

e: q

ueue

s , a

cces

s to

the

serv

ice:

wai

ting

time,

acc

ess

to th

e se

rvic

e: d

ifficu

lty in

tran

spor

t, ab

senc

e or

insu

ffici

ent a

cces

s to

sup

port

serv

ices

(hea

lth p

lan)

, acc

essi

bilit

y ab

sent

or i

nade

quat

e ph

ysic

al a

ctivi

ty, la

ck o

f prio

rity

in c

are,

de

man

d fo

r hea

lth s

ervic

es, d

ifficu

lties

with

edu

catio

n, a

cces

s -

lack

of i

nves

tmen

t in

educ

atio

n, a

cces

s to

soc

ial a

ssis

tanc

e -

acce

ss to

abs

ent o

r ins

uffic

ient

soc

ial b

enefi

ts, a

bsen

ce o

r ins

uffic

ient

acc

ess

to p

rogr

ams

assi

stan

ce, a

bsen

ce o

r ins

uffic

ienc

y of

ac

cess

to s

uppo

rt se

rvic

es (s

ocia

l ben

efit),

abs

ence

or i

nsuf

ficie

ncy

of a

cces

s to

soc

ial g

oods

, abs

ence

or i

nsuf

ficie

ncy

of a

cces

s to

mat

eria

l goo

ds, a

bsen

ce o

r ins

uffic

ienc

y of

acc

ess

to s

ymbo

lic g

oods

, abs

ence

or i

nsuf

ficie

ncy

of a

cces

s to

cul

ture

, ab

senc

e or

in

suffi

cien

cy o

f acc

ess

to ju

stic

e, a

bsen

ce o

r ins

uffic

ienc

y of

acc

ess

to li

ght,

abse

nce

or in

suffi

cien

cy o

f acc

ess

to le

isur

e, la

ck o

f gr

een

spac

e, a

bsen

ce o

f opp

ortu

nitie

s in

the

labo

r mar

ket,

abse

nce

or in

suffi

cien

cy o

f wor

k op

portu

nitie

s, n

ot fi

ndin

g w

ork,

abs

ence

or

insu

ffici

ent a

cces

s to

regu

late

d w

ork.

Third

gen

erat

ion

fund

amen

tal r

ight

s: L

inke

d to

the

valu

es o

f fra

tern

ity o

r sol

idar

ity, t

hey

are

thos

e re

late

d to

dev

elop

men

t or p

rogr

ess,

the

envir

onm

ent,

the

self-

dete

rmin

atio

n of

pe

ople

s, a

s w

ell a

s th

e rig

ht to

pro

perty

ove

r the

com

mon

her

itage

of h

uman

ity a

nd th

e rig

ht o

f com

mun

icat

ion.

Lack

of o

r ins

uffic

ient

acc

ess

to c

omm

unic

atio

n, a

bsen

ce o

r lac

k of

acc

ess

to m

edia

and

abs

ence

or l

ack

of a

cces

s to

the

Inte

rnet

.

Four

th g

ener

atio

n fu

ndam

enta

l rig

hts:

The

y un

ders

tand

the

right

s to

dem

ocra

cy,

info

rmat

ion

and

plur

alis

m. T

his

right

is a

bout

the

futu

re o

f citi

zens

hip

and

the

prot

ectio

n of

lif

e fro

m th

e ge

netic

app

roac

h an

d its

cur

rent

con

sequ

ence

s.

Lack

of o

r ins

uffic

ient

acc

ess

to in

form

atio

n.

Cont

inue

...

Cont

inua

tion.

15Acta Paul Enferm. 2021; 34:eAPE00353.

Florêncio RS, Moreira TM

SOCI

AL

Conc

ept/C

onst

ituen

t Defi

nitio

nSu

bcon

cept

/Con

stitu

ent d

efini

tion

Oper

atio

nal d

efini

tion

Prog

ram

mat

ic s

ituat

ion

- em

phas

is o

n he

alth

: Cha

ract

eris

tics

and

proc

esse

s of

inst

itutio

ns th

at

prov

ide

diffe

rent

type

s of

ser

vices

to

the

popu

latio

n, e

spec

ially

thos

e re

late

d to

hea

lth.

Infr

astr

uctu

re: A

set

of e

lem

ents

that

ena

ble

the

prod

uctio

n of

goo

ds a

nd s

ervic

es.

Poor

gen

eral

infra

stru

ctur

e, a

bsen

ce o

r ins

uffic

ienc

y of

edu

catio

nal m

ater

ial f

or p

reve

ntio

n, m

edic

atio

n no

t ass

ured

, abs

ence

or

insu

ffici

ency

of r

oom

to c

arry

out

edu

catio

nal a

ctivi

ties,

qua

ntity

of s

uppl

ies

abse

nt o

r ins

uffic

ient

, pro

blem

s of

sys

tem

s, a

vaila

bilit

y of

test

s de

crea

sed

or a

bsen

t, av

aila

bilit

y of

mat

eria

ls d

ecre

ased

or a

bsen

t, ab

senc

e or

insu

ffici

ency

in th

e di

strib

utio

n of

sup

plie

s,

abse

nce

or in

suffi

cien

cy o

f offi

ces

that

allo

w p

rivac

y, ab

senc

e or

insu

ffici

ency

of d

iagn

ostic

test

s of

fere

d by

the

serv

ice,

abs

ence

or

insu

ffici

ency

of o

fferin

g sp

ecifi

c te

sts,

non

-ava

ilabi

lity

of m

ater

ial f

or in

divid

ual u

se fo

r the

stra

tegy

of h

arm

redu

ctio

n, a

bsen

ce

or in

suffi

cien

cy o

f car

ryin

g ou

t any

exa

min

atio

n to

det

ect d

isea

se, a

bsen

ce o

r ins

uffic

ienc

y of

car

ryin

g ou

t clin

ical

exa

min

atio

n,

abse

nce

or in

suffi

cien

cy o

f car

ryin

g ou

t tes

ts, a

bsen

ce o

r ins

uffic

ienc

y of

car

ryin

g ou

t tre

atm

ent,

abse

nce

or in

suffi

cien

cy o

f sup

ply

of e

quip

men

t of i

ndivi

dual

pro

tect

ion

(PPE

), ab

senc

e or

insu

ffici

ent s

uppl

y of

det

ectio

n te

sts

for s

exua

lly tr

ansm

itted

infe

ctio

ns,

decr

ease

d or

abs

ent n

umbe

r of l

abor

ator

y te

sts,

abs

ence

or i

nsuf

ficie

nt tr

aini

ng, a

bsen

ce o

r ins

uffic

ient

trai

ning

on

the

use

of

PPE,

defi

cien

cy in

thei

r tra

inin

g pr

ofes

sion

al, d

efici

enci

es in

the

assi

stan

ce m

odel

, defi

cit o

f pro

fess

iona

l kno

wle

dge,

defi

cit o

f pr

ofes

sion

als

in u

nder

stan

ding

peo

ple’

s so

cial

nee

ds, a

bsen

ce o

r ins

uffic

ienc

y of

pro

fess

iona

ls tr

aine

d fo

r a s

peci

fic c

ondi

tion,

late

di

sclo

sure

of t

he d

isea

se, t

ype

of c

onsu

ltatio

n: q

uick

, with

out c

omm

unic

atio

n, w

ithou

t hum

aniza

tion

, pro

fess

iona

l wea

knes

ses,

un

prep

ared

ness

of p

rofe

ssio

nals

with

the

dise

ase,

abs

ence

or i

nsuf

ficie

ncy

of p

repa

ring

a te

chni

cal o

pini

on o

n pr

even

tion

mat

eria

l, un

prep

ared

ness

in th

e ca

re o

f peo

ple

with

dis

abilit

ies,

tech

nica

l unp

repa

redn

ess,

sca

rcity

of s

cien

tific

info

rmat

ion,

em

otio

nal,

as

wel

l as

phys

ical

and

inte

llect

ual p

rofe

ssio

nal h

ealth

pro

fess

iona

ls, n

urse

s fo

cusi

ng o

n te

chno

logi

cal a

nd s

peci

alize

d as

pect

s of

car

e,

faci

ng d

ifficu

lties

in a

ppro

achi

ng p

atie

nts

in th

e fa

ce o

f dia

gnos

is, l

ack

of a

war

enes

s an

d tra

inin

g of

hea

lth p

rofe

ssio

nals

, lac

k of

in

vest

men

t in

thei

r pro

fess

iona

l qua

lifica

tion/

reha

bilit

atio

n.

Wor

king

pro

cess

: Pro

duct

of t

he a

rticu

latio

n of

soc

ial a

ctor

s in

ser

vices

(use

r, pr

ofes

sion

al

and

man

ager

) and

the

rela

tions

hip

esta

blis

hed

with

the

wor

k ob

ject

, on

whi

ch th

e w

orke

r’s

actio

n is

invo

lved.

Abse

nce

or in

suffi

cien

cy o

f med

ical

or n

ursi

ng c

onsu

ltatio

n, c

are

not c

ente

red

on th

e pe

rson

, abs

ence

or i

nsuf

ficie

ncy

of c

are

for t

he

sick

chi

ld’s

fam

ily: n

urse

, abs

ence

or i

nsuf

ficie

ncy

of p

rimar

y he

alth

car

e, a

bsen

ce o

r ins

uffic

ienc

y of

car

e w

ithin

ser

vices

, abs

ence

, in

suffi

cien

t or i

nade

quat

e ch

ild c

are,

pai

d ca

re, l

ack

of in

form

atio

n to

pat

ient

s ab

out p

roce

dure

s, a

bsen

ce o

r ins

uffic

ienc

y of

act

ive

sear

ch fo

r fam

ily m

embe

rs, a

bsen

ce o

r ins

uffic

ienc

y of

act

ive s

earc

h fo

r pat

ient

s, a

bsen

ce o

r ins

uffic

ienc

y of

dis

ease

not

ifica

tion,

ab

senc

e or

insu

ffici

ency

of l

iste

ning

act

ive b

y pr

ofes

sion

als,

exc

essi

ve in

volve

men

t by

heal

th p

rofe

ssio

nals

, suf

ferin

g to

geth

er a

nd

putti

ng o

nese

lf in

pla

ce, a

bsen

ce o

r ins

uffic

ienc

y of

hom

e vis

its a

nd th

e ap

proa

ch o

f the

hea

lth p

rofe

ssio

nal,

diss

atis

fact

ion

with

the

atte

ntio

n of

the

team

, nee

d to

impr

ove

the

qual

ity o

f car

e fo

r peo

ple

in h

omes

, pro

fess

iona

ls’ l

ack

of in

tere

st in

spe

cific

dem

ands

th

ose

of p

eopl

e, m

echa

niza

tion

of p

roce

dure

s ca

rried

out

by

prof

essi

onal

s, d

ifficu

lties

in p

rogr

ams

and

publ

ic p

olic

ies

with

rega

rd

to re

sour

ce m

anag

emen

t and

com

mitm

ent t

o th

e or

gani

zatio

n, re

port

on h

ealth

con

ditio

ns in

citi

es b

y he

alth

ser

vices

, abs

ence

or

insu

ffici

ency

of q

ualit

y of

hea

lth s

ervic

es, a

bsen

ce o

r ins

uffic

ienc

y of

refe

renc

e/co

unte

r-re

fere

nce,

abs

ence

or i

nsuf

ficie

ncy

of p

rofe

ssio

nals

follo

win

g pr

otoc

ols,

abs

ence

or i

nsuf

ficie

ncy

of b

iosa

fety

pro

toco

l, ab

senc

e or

insu

ffici

ency

of h

ealth

edu

catio

n pr

ogra

ms,

abs

ence

, ina

dequ

acy

or in

suffi

cien

cy o

f dis

ease

not

ifica

tion

flow,

org

aniza

tiona

l wea

knes

ses

in th

e he

alth

sys

tem

, ab

senc

e or

insu

ffici

ency

of a

ctive

and

effe

ctive

hea

lth a

nd s

afet

y co

mm

ittee

, abs

ence

or i

nsuf

ficie

ncy

of s

peci

fic p

rogr

ams,

abs

ence

or

insu

ffici

ency

of o

rgan

izatio

n co

nsul

tatio

n sc

hedu

le, h

igh

aver

age

test

resu

lts, l

ack

of in

stitu

tiona

l ass

ista

nce,

lack

of r

ecog

nitio

n in

hu

man

righ

ts s

ervic

es.

Stat

e: S

truct

ure,

i.e.

, the

larg

est

gove

rnm

enta

l ins

titut

ion

that

sho

uld

prov

ide

the

‘livin

g w

ell’

of th

ose

who

m

ake

up s

ocie

ty.

Publ

ic p

olic

ies:

A s

et o

f suc

cess

ive in

itiat

ives,

dec

isio

ns a

nd a

ctio

ns o

f the

pol

itica

l reg

ime

in th

e fa

ce o

f soc

ially

pro

blem

atic

situ

atio

ns th

at s

eek

to s

olve

them

, or a

t lea

st b

ring

them

to

man

aged

leve

ls.

Abse

nt o

r ins

uffic

ient

gov

ernm

ent a

nd p

ublic

hea

lth, a

bsen

t or i

nsuf

ficie

nt c

are

polic

ies.

Fina

ncin

g: S

ourc

es o

f res

ourc

es th

roug

h w

hich

exp

endi

ture

s ta

ke p

lace

in v

ario

us s

ecto

rs

of s

ocie

ty, in

clud

ing

heal

th.

Unde

rfund

ing

of th

e he

alth

sec

tor,

inad

equa

te re

sour

ce m

anag

emen

t and

com

mitm

ent t

o or

gani

zatio

n.

Cont

inua

tion.