Social and Physical Environment

Geographic location, living conditions, and the social context of people’s lives all exert influence on susceptibility to risk during an influenza pandemic by influencing exposure, ability to meet basic daily needs, and access to supportive care. For example, social environment can refer to

living in crowded housing [17-19], high levels of social interaction [20-21], being reliant on others to assist with daily personal care [22], or lifestyle factors such as injection drug use [23]. It can also include the need for assistance from a food bank for daily nourishment [14, 18].

Two ethnicities (Asian and Hispanic) in the US are more likely to live in crowded social environments, regardless of income. Minority groups also tend to use public transportation more regularly, which is another source of crowding, putting them at higher risk of exposure during pandemic [17].

While high levels of social interaction is considered to heighten risk during pandemic, being ‘hard-to-reach’ is an additional dimension of vulnerability. Hard-to-reach can imply geographic remoteness or social isolation where people live on the outskirts of mainstream society. Ompad et al. [60] identified some examples of hard-to-reach people which included active injection drug users, sex-trade workers, immigrants without documentation, and socially isolated elderly people. Vlahov et al. [64] also identified the same groups, with the addition of ‘disenfranchised’ groups and people living in poorly-resourced urban communities.

Several provincial pandemic plans acknowledge the need to plan for interagency coordination to ensure continuity of essential services for vulnerable populations including people who are homeless, people who have mental illness, and drug users [68-69]. Homeless or transient populations are at elevated risk during pandemic due to their reliance on crowded shelters, limited financial resources to purchase supplies, and clustering vulnerabilities (such as mental illness and substance addiction) [11, 24, 70-71]. Overcrowded living conditions act as a vehicle for the spread of infection [72], and daily dependence on soup kitchens and food banks and needle-exchange programs are additional social risk factors [23, 53]. The Ontario Pandemic Plan
[73] also addresses many of these concerns, with additional discussion about substance dependency and how disruption in substance acquisition could lead to increased crime and demands on law enforcement. At least one jurisdiction has facilitated coordinated planning among interdependent agencies to ensure essential services remain available for people who are homeless, when illness rates and workforce absenteeism are high [53].

Aboriginal populations, particularly those who live in remote communities, are also considered to be at high risk during pandemics. Physical environment, particularly geographic location and inadequate housing, combined with lower socioeconomic status and food insecurity, all interact to exacerbate social risk for many Aboriginal people [74-75]. In some families, additional clustering of risk factors such as limited access to health care, chronic health conditions (eg. Diabetes), substance abuse and violence also contribute to poor health outcomes. People coping with challenging lifestyles often struggle daily to meet survival needs [18, 52], and lack of awareness about health services and preventive health behaviours can manifest into increased exposure and inadequate treatment [63].

The pandemic plan for the province of Quebec [76] addresses the needs of individuals who are socially isolated and not receiving care from friends and family. It proposes the implementation of home support services to check on these individuals and prioritize their admission to a care facility if required. In addition to the high risk groups identified earlier, the pandemic plan for the province of Ontario [73] also emphasizes the vulnerability of people who do not have a primary

care provider. The link with a primary care provider is important as they are regarded as trusted experts and can provide prompts for people to follow vaccination guidelines or preventive health behaviours [77].

The WHO [3] emphasizes the need to provide pandemic guidelines for household caregivers. In an investigation of elderly persons with dementia and their caregivers in the U.S., Thorpe et al.,
[22] found that older adults were less likely to receive the annual influenza vaccination if their caregiver was experiencing distress or depression, and/or if they had inadequate financial resources. Another study found that the vaccine response of caregivers under stress is often less effective in terms of the development of immunity [78]. The impact of stress on vaccine effectiveness could be extrapolated to other vulnerable groups as well. Geographic location can be a barrier to obtaining preventative health services, especially on an annual basis [22, 79].

Nursing homes and other institutional care facilities provide social and physical environmental contexts which can exacerbate vulnerability during pandemic [4] in addition to the already existing underlying risks of residents (e.g. frailty, underlying medical conditions). They represent close living arrangements, and the residents or patients are particularly vulnerable when absenteeism among facility staff is high, which is expected during pandemic [29]. This vulnerability extends to the issue of whether staff are able to provide adequate care, given reduced human resources, and the stress and burnout experienced by staff when demands are high [32, 80].

The prison population can be at particularly high risk during a pandemic in terms of exposure and access to care [30, 81]. It is important to consider that if an outbreak were to occur, there is a network of social workers and psychologists that interact with the inmates on a regular basis, and confined spaces and restricted movement in prison systems may increase virus transmission during an outbreak, particularly in prisons which are overcrowded. The absenteeism expected during pandemic (approximately ¼ of the workforce) [49] would likely affect the correctional sector as well, reducing the number of guards, parole officers, health care professionals, social workers, psychologists, and other essential workers in the prison system. This effect on human resources will influence inmates, staff and security, as well as people recently discharged from correctional institutions who require community support.