This resource provides a brief overview of different approaches to defining and conceptualising “vulnerability” in the context of COVID-19 response programming. We begin by providing some definitions, before touching on the concept of “intersectionality”. Based on this theory we then outline some populations and contexts that that might be more vulnerable to COVID-19 and its consequences. Finally, we present some practical actions for achieving an inclusive programme. Whilst this resource was written with COVID-19 in mind, many principles can be applied to other disease response programmes, even if some of the vulnerable populations and contexts may change.

If you would like to hear about experiences of designing and implementing inclusive programmes in the field, including challenges and practical recommendations, see our learning briefs on identifying populations at risk of exclusion and including people with disabilities, older people and their caregivers.

Vulnerability is a key concept to consider when designing and implementing infectious disease programmes, as it can influence healthcare access and health outcomes among other factors. Moreover, crises typically make existing vulnerabilities and power imbalances worse.

Whilst there has been an increasing focus on vulnerability within the global health sector in recent decades, there is no universal definition and approaches to the term vary. This can cause confusion and impede evidence-based learning, contributing to the pattern of response programmes failing populations who may be vulnerable e.g. COVID-19, natural disasters and Ebola.

Whilst there are numerous definitions, it is generally accepted that vulnerability is a dynamic and multifaceted phenomenon, which operates across multiple dimensions. In the health sector, it is typically conceptualised as either a determinant of poor health or a barrier to achieving good health. The concept is inextricably linked to the notion of power and populations experiencing high rates of vulnerability are invariably difficult to reach, under supported and “invisible” due to inadequate data.

For the purpose of this resource, we will define vulnerability as “the characteristics determined by physical, social, economic and environmental factors or processes which increase the susceptibility of an individual, a community, assets or systems to the impacts of hazards” (UNDRR).This definition speaks to the fact that vulnerability is considered to be the “human dimension of disaster” and is both a driver and outcome of risk. See this page from the United Nations Office for Disaster Risk Reduction (UNDRR) for further information.

As the formula demonstrates, risk is influenced by vulnerability, hazards, and exposure and can be developed through various routes. For instance, people with pre-existing health conditions have a higher hazard response to SARS-CoV-2 as they are more likely to develop serious complications. Groups who are prone to exclusion and discrimination also have a higher hazard response. Others might experience disproportionately high exposure to the virus – for instance, frontline health workers. Then you have groups who have both a higher hazard and exposure response, such as migrant workers, female health workers or older people, who are at risk of severe complications and face exposure via carers, health workers due to the living and/or working conditions. It is important to understand how vulnerability is developed in these groups, as different responses are required.

Whilst we will explore different groups and contexts individually, the reality is that people typically experience intersecting forms of inequalities and discrimination, which are inextricably linked and have an additive or multiplicative effect on vulnerability. For example, during the COVID-19 pandemic, we witnessed an increase in rates of sexual and gender based violence (SGBV). We know that women and girls generally experience disproportionately high rates of SGBV, but the degree of vulnerability (and therefore, risk) would be further increased if the person in question was a child, had a disability and lived in a camp located in a rural setting, as these factors are all associated with vulnerability to SGBV.

Therefore, it is crucial that programmes apply Crenshaw’s intersectional framework in order to move “beyond single or typically favoured categories of analysis to consider simultaneous interactions between different aspects of social identity, as well as the impact of systems and processes of oppression and domination”. Through applying an intersectional lens, we can effectively identify the whole spectrum of populations vulnerable to exclusion and discrimination and tailor response programmes to meet their specific needs.

Simpson’s intersectionality wheel provides a helpful toolkit when designing and implementing intersectional responses. The third wheel from the centre, societal forces (e.g., colonisation) are expressed through different forms of discrimination (e.g., racism) in the second wheel, which intersect with identity characteristics (e.g., race and citizenship status) in the inner most circle. The interplay between these different dimensions’ shapes unique forms of privilege and oppression. Please see UN Women’s intersectionality resource guide and toolkit for further practical guidance.

There are several key factors which are inextricably linked to COVID-19 vulnerability and are expressed throughout the groups and contexts explored below – these factors might heighten vulnerability through increasing exposure to the virus, increasing the risk of exclusion and discrimination (including from response programmes), or both.

Gender is an important identity factor, as women make up 67% of the health and social work force – a group which is disproportionately exposed to the virus, increasing risk. Moreover, women typically serve in fewer decision-making positions and experience numerous barriers in accessing essential services and education – factors which impede women’s ability to mitigate their increased risk. Women also make up a growing proportion of the ageing population and older women are more likely to have disabilities, often due to underlying health conditions. The risk of COVID-19 is also elevated in people with disabilities and the elderly and as we have highlighted, there is a significant intersection between the two groups, with one third of global elderly population having some form of disability. These are just some of the factors contributing to heightened COVID-19 vulnerability amongst women and girls. Conversely, males have a higher risk of getting severe symptoms or dying from COVID-19 (in 2022, the WHO announced that males account for 57% of COVID-19 deaths), but they are less likely to experience discrimination and exclusion (from response programmes and society as a whole). Whilst children are less likely to develop severe symptoms or die from the SARS-CoV-2 virus, they can transmit the disease and are more likely to be excluded from COVID-19 programmes, increasing risk.

Minority groups experience high rates of poverty, language barriers, social exclusion and discrimination and are more likely to have a vulnerable legal status, creating barriers to key services and information. Moreover, certain chronic conditions are more prevalent in some ethnic groups, contributing to the disproportionate burden of severe COVID-19 outcomes. Finally, inadequate WASH and healthcare access, communication barriers, government mistrust and certain cultural practices and beliefs have culminated in high COVID-19 mortality rates and a vaccine gap in indigenous populations. There is also a lack of disaggregated data across these groups, rendering them invisible to response programmes and impeding inclusivity efforts.

WaterAid’s marginalisation framework, pictured below, is another useful tool in understanding inclusion in WASH and illustrates the complexity of the phenomenon.

Below we define some key groups to consider in your COVID-19 response, along with some recommendations for further reading. For clarity, we have indicated which groups are at risk of the virus itself (yellow), those who have a lower COVID-19 risk but may experience discrimination and exclusion from COVID-19 responses, increasing personal risk (blue), and groups who are impacted by both (orange). Please note that this list is in no order and is not exhaustive; you may identify additional key groups within the context that you work.

Overview of key groups to consider in your COVID-19 response. Sources: various

In addition to considering specific groups, it is important to recognise that certain contexts make populations more vulnerable by default. Below we consider the dimensions of vulnerability in several key contexts (in no particular order) and signpost to some practical resources.

Whilst each type of vulnerable population experiences a unique set of challenges and needs, there are several key actions that your programme can adopt to enhance inclusivity:

For a more in-depth exploration of how inclusive programmes are being designed and implemented in the field, including lessons and recommendations from practitioners, see our learning brief on Identifying vulnerable populations in COVID-19 prevention and response programmes.

Author: India Hotopf
Review: Sue Cavill, Brian Reed, Angelica Fleischer, Claire Rosatao-Scott and Dani Barrington
Last update: 08.06.2023