Principal investigator: Viviane Pires Ribeiro
Article title: The concept of vulnerability and its meanings for public health and social assistance policies.
Article authors: Michelly Eustáquia do Carmo and Francini Lube Guizardi
Location of the intervention: Brazil
Sample size: 46 studies mapped
Sector: Health Insurance
Type of Intervention: Critical reflection on vulnerability, social security and citizenship.
Main Variable of Interest: Vulnerability
Evaluation method: Others
Evaluation Context
The beginning of the regulation of Brazilian social assistance public policy occurred in a scenario of conflicts and contradictions, following the regulations of public health policy. The National Social Assistance Policy (PNAS), established in 2004, explicitly stated in its text that social vulnerability – expressed by different situations that can affect individuals in their life contexts – is the field of action for its policies.
Vulnerability is not strictly conditioned by the absence or precariousness of access to income, but also by the fragility of affective-relational bonds and unequal access to public goods and services. Concepts of vulnerability emerge in the health field, reorganizing prevention and promotion practices towards a more contextualized approach that is attentive to the social aspect. Similarly, in social assistance, the concept of vulnerability is qualified by the term "social," which indicates the evolution of understanding regarding the deprivations and inequalities caused by poverty.
Intervention Details
The critical reflection study, with a comprehensive-interpretative approach, carried out by Carmo and Guizardi (2018), sought to understand and interpret, through a literature review, the conceptions of vulnerability in non-contributory policies that comprise social security, produced in the last two decades in Brazil. The objective was to problematize the implications of the conception of vulnerability in public practices aimed at the production of citizenship, in order to understand the tensions and polarizations that pressure the materiality of the State model proposed by the 1988 Federal Constitution and the repercussions of these conceptions on the population using health and social assistance services.
To achieve the goal of discussing the concepts of vulnerability that appear in public health and social assistance policies, the authors chose to consult the virtual library of electronic journals of the Coordination for the Improvement of Higher Education Personnel (Capes Journals Portal), due to its extensive collection of complete and free documents, which includes important search databases for public health and social assistance.
Methodology Details
Carmo and Guizardi (2018) used studies that were fully available for public access, and their selection took place between August and November 2016. Thus, the mapping of studies was developed in two phases. The first phase was an advanced search in the Capes Periodicals Portal using terms located anywhere in all types of materials produced in any language. With the descriptors Vulnerability AND CitizenshipWhen used without quotation marks, the authors admitted that the search included studies produced in any year, resulting in 44 works, including articles, textual resources, and theses.
In the second phase, an advanced search was conducted using the descriptors. Vulnerability AND "Social Security"The search included all types of materials produced on any date, resulting in one article and one textual resource. The textual resource was excluded because it did not contain the full work available for reading. Of the total of 45 works, 24 were excluded after reading the titles and abstracts, as they did not address the research topic. No duplicate studies were detected in any of the search phases. After reading all 21 works, five were excluded for not presenting a theoretical contribution to discussing concepts of vulnerability.
To organize the materials found, the authors outlined two operational categories based on a preliminary reading of the studies. The organization of the studies took into account the aspects expressed in the operational categories: (1) context of the studies (location and date of production, area of knowledge, theme addressed); (2) common bibliographic references. After a detailed reading of the works, the following categories of analysis were defined to proceed with the investigation: (1) conceptions of vulnerability in health and social assistance; (2) influences of conceptions of vulnerability on social practices.
Results
The results found by Carmo and Guizardi (2018) show that there is not a vast body of research that addresses the specific theme of the study. Of the 46 studies mapped, only 16 deal with the concept of vulnerability or its implications in the design of public policies to guarantee citizenship rights.
Of the works selected by the authors, 12 were produced in Brazil, one in Spain, and three in Portugal, one of which was conducted in a Brazilian city. The municipality was the research locus for 11 of the selected works; three studies had a national focus and two addressed the international context. The search mechanism automatically led to studies whose recent production was concentrated between the years 2000 and 2014.
According to Carmo and Guizardi (2018), the understanding and use of the term vulnerability evolved with the new way of dealing with the AIDS epidemic in the 1980s. It became accepted that susceptibility to contagion was due more to a set of economic, social, and cultural factors than to individual behavior. Considering factors that transcend the biological when discussing vulnerable individuals was the key theme observed in studies conducted in the health field. Whether in relation to the environment, adolescents, or the homeless population, it can be considered that the production of citizenship and healthy ways of living are linked to the fair distribution of power and knowledge, given the urgency of looking at individuals in their entirety.
In studies within the field of social assistance, it has become evident that poverty does not explain vulnerability, but it is the phenomenon that led to its conceptual refinement, even if this task has not resulted in clearer conceptions. Taking advantage of the impossibility of restricting the genesis of exclusionary and subjugating processes to the issue of the absence or insufficiency of income, vulnerability has been emerging as a category that more broadly addresses the problem, allowing for intersectoral approaches among public policies. However, the incorporation of vulnerabilities into the scope of public social assistance policy, with the aim of overcoming them, is a process that reveals contradictions, since, starting from a direction set by the guidelines of international organizations, it can either diminish or even intensify the vulnerability of individuals. Therefore, any effort to understand the influence that the concept of vulnerability exerts on policy formulation, professional practices, society, and the self-representation that users have is justified.
Lessons in Public Policy
Carmo and Guizardi (2018) highlight that the term vulnerability has been incorporated into the lexicon of Brazilian non-contributory social security public policies, guiding the scope of their offerings. However, according to the authors' findings, the conceptual imprecision of the term still persists, demanding more in-depth research. Although there is considerable scientific production on vulnerability over the last two decades, little research has been done on the connection between the different concepts that the word vulnerability can encompass and its relationship with the production of citizenship within the scope of public health and social assistance policies.
In this sense, critical reflection based on a literature review on vulnerability, social security, and citizenship in the areas of health and social assistance revealed quite synergistic points of convergence regarding the idea of a concept that represents the multiple determinants that affect the contexts of citizens who experience fragile or nonexistent access to rights.
However, even though the term vulnerability carries inaccuracies resulting from the conceptual construction process in which it is found, there is progress in the discussion of dynamic and multi-determined reality. The understanding of vulnerability as a parameter for reflection and action implies the recognition of the concomitance of ethical, political, and technical factors surrounding the incidence of risks in territories and the human capacity to confront them.
Reference
CARMO, Michelly Eustáquia do; GUIZARDI, Francini Lube. The concept of vulnerability and its meanings for public health and social assistance policies. Cadernos de Saúde Pública, v. 34, p. e00101417, 2018.
