Population approach and vulnerable populations
Katherine L. Frohlich, and Louise Potvin, at Lea Roback Centre for Research on Health Inequalities, Department of Social and Preventive Medicine, University of Montreal, and le Groupe de Recherche Interdisciplinaire en Santé, Montreal, Quebec.
American Journal of Public Health - March 1 2008, Volume 98, Issue 3
“…….Using the concept of vulnerable populations, we examine how disparities in health may be exacerbated by population-approach interventions.
We show, from an etiologic perspective, how life-course epidemiology, the concentration of risk factors, and the concept of fundamental causes of diseases may explain the differential capacity, throughout the risk-exposure distribution, to transform resources provided through population-approach interventions into health. From an intervention perspective, we argue that population-approach interventions may be compromised by inconsistencies between the social and cultural assumptions of public health practitioners and targeted groups. We propose some intervention principles to mitigate the health disparities associated with population-approach interventions…”.
“…….In WESTERN SOCIETIES, significant efforts during the last half century to improve health systems have resulted in spectacular gains for a wide range of health indicators.1 A growing number of studies, however, show that these gains have not benefited everyone equally; inequalities in health seem to have increased, at least for some health outcomes.2–4 This unexpected consequence is particularly troublesome in the case of population-level interventions, which seek to improve the health of the entire population.
We distinguish between 3 intervention approaches: the populations-at-risk approach, based on:
- Lalonde’s notion of the health field5;
- Rose’s population approach6, which addresses the conditions shaping the distribution of individual risk in a population; and
- a vulnerable population approach that addresses the conditions that put social groups "at risk of risks"—that is, risks that generate exposure to other risks.
By shifting the focus to whole populations, population-level interventions, which are based on Geoffrey Rose’s population approach, represented an advancement over a population-at-risk approach.
We propose, however, that interventions based on population approaches are not free from criticism and may have led to unintended exacerbations of health disparities. Using the concept of vulnerable populations, we attempt to explain how this can be so. We begin by reviewing the notion of "populations at risk" and its relationship to Rose’s population approach and then proceed with a critique of Rose’s approach based on the notion of vulnerable populations. We conclude by suggesting that interventions addressing the needs of vulnerable populations should be used as a complement to population approaches…..”
Table 2 — Three different public health approaches to improving health
| Intervention Approach | Objective | Target for Intervention | Critiquesa |
| Populations at risk (Lalonde5) | Prevent disease in those individuals at higher risk | Reduce the specific risk exposure for individuals at higher risk through behavioral (or biochemical) changes | Blames the victim; does not prevent other individuals from becoming at risk |
| Population approach (Rose6) | Increase overall population health | Shift distribution of population risk exposure toward a lower mean through changes in environmental conditions that lead to increased risk | May increase health inequalities |
| Vulnerable populations (this essay) | Decrease health inequalities between socially defined groups | Shift to a lower level the risk exposure distribution of socially defined groups through changes in social and environmental conditions that make groups at higher risk of risks | May lead to positive discrimination; may lead to stigmatization; may be less efficient in terms of population health |
| aThe critiques directed at the populations-at-risk approach are empirically documented. The critique listed for the population approach is currently being researched, and those associated with vulnerable populations are speculative. |