Frohlich & Potvin - The Inequality Paradox: The Population Approach and Vulnerable Populations

In Western societies

• Inequalities in health seem to have increased

• Interventions based on population approaches may have led to unintended exacerbations of health disparities

Lalonde’s notion of populations at risk

• Lalonde Report

  • 4 health fields

    • Human biology

    • Social and physical environment

    • Lifestyle

    • Health care organization

  • Public health interventions should focus attention on high-risk population

• Critiques:

  • His profile of populations at risk was based on risk factors rooted in behaviours that he considered self imposed, individual-level life style choices

  • Led to victim blaming and stigmatizing these populations

  • The distribution of newly emerging risk in society remains unaffected by the intervention

  • The focus on populations at risk doesn’t address the conditions influencing incidence or the shape of each population’s distribution

Rose’s population approach

• The distribution of risk exposure in a population is shaped by contextual conditions

• Most cases in a population are represented by individuals with an average level of risk exposure

• Population approaches to intervention based on Rose’s ideas involve:

  • Mass environmental control methods

  • Interventions aimed at changing behavioural norms

• Critiques:

  • Doesn’t address the underlying mechanisms that lead to different distributions of risk exposure between socially defined groups within populations (the fundamental causes linked to one’s position in the social structure)

The notion of vulnerable populations

• A focus on vulnerable populations is complementary to a population approach and necessary for addressing social inequalities in health

• Population at risk: a higher measured exposure to a specific risk factor

• Vulnerable population: subgroup or subpopulation who, because of shared social characteristics, is at higher risk of risks because of their position in the social strata

  • Examples in Canada

    • People of aboriginal descent

    • People with income lower than the poverty threshold

    • People who have not completed secondary education

• Fundamental cause mechanism

  • Life course: a person’s position in a health indicator distribution is the result of all previous experiences, including those that may not be directly related to health

  • Concentration of risks: exposure to multiple risk factors and a greater number of comorbidities are more frequent in some vulnerable populations

• Vulnerable populations are those who concentrate numerous risk factors throughout their life course be cause of shared fundamental causes associated with their position in the social structure

• Individuals from vulnerable populations are the least able to positively respond to population-approach interventions

• Inverse care law: those with the most resources at hand to adapt to new situations will be the first to derive maximum benefits from population-approach interventions