Hidden biases in public health research: why we are failing our most vulnerable populations

In an era of increasingly personalised healthcare, ensuring that public health research reflects the rich diversity of European society is not just important – it is essential. The growing worldwide migration, largely driven by geopolitical conflicts and climate change, and the rise of superdiverse societies have significantly influenced European communities in recent years. This shift creates an urgent need for health systems to provide high-level care to diverse populations with varied health needs. This diversity recognises multicultural and religious differences and encompasses a wide range of socio-economic backgrounds, languages, varying levels of health literacy, single-parent families, the unemployed with lower educational attainment and those who may face marginalisation due to gender issues.  

Regrettably, certain populations remain underrepresented in public health research, leading to treatments and preventive measures that fail to address their specific needs. This gap in representation not only perpetuates healthcare inequalities, but also exacerbates them, as interventions and policies remain insufficiently tailored to the health challenges faced by these groups. Despite growing rhetoric around inclusivity, European health research remains largely skewed towards privileged, predominantly white (male) populations. To foster an inclusive healthcare system, we must enforce accountability, ensuring that research and policy development are fully attuned to the needs of all, especially those most in need of equitable and effective healthcare solutions. 

 The so-called healthy bias 

The presence of healthy bias in population studies poses a significant challenge in public health research. Individuals who voluntarily participate in studies often have better health outcomes than the general population, resulting in skewed research findings. This bias leads to misleading conclusions about disease prevalence and the effectiveness of interventions, as the data does not accurately represent the true health status of the broader population. Despite the well-documented nature of this bias, policymakers and research institutions have been slow to implement corrective measures. Addressing this issue is not just a technical challenge, but an ethical imperative, as failure to do so compromises the reliability of public health recommendations and policies, leaving the most vulnerable at risk of further marginalisation. 

Challenges in representation 

One of the most significant challenges in public health research is recruiting participants from underrepresented groups. A lack of trust in the government and medical field often stems from historical inequalities and misconduct, which pose a substantial barrier. Additionally, language barriers and low health literacy further discourage these groups from participating in studies or accessing preventive care. Without addressing these underlying issues, efforts to include underrepresented groups will fall short, perpetuating disparities in health outcomes and the effectiveness of interventions. However, overcoming this challenge requires more than just competency in diversity – it demands the cultivation of a critical consciousness in healthcare professionals. Healthcare providers must go beyond superficial training and develop a deeper understanding of the socio-cultural contexts in which their patients live. Enhanced diversity training can significantly improve healthcare providers’ ability to address these contexts effectively and deliver more equitable care. Dialogue and reflection on diversity-sensitive working are crucial in creating an inclusive environment that meets the needs of all patients. 

A targeted approach is necessary to recruit underrepresented groups effectively. This includes focused communication campaigns that consider cultural sensitivities and language preferences and the involvement of trusted community figures, including representatives, who can serve as intermediaries. By investing time and effort into creating targeted awareness and information campaigns, we can generate substantial interest and engagement from the groups we aim to reach. Transparent communication, active engagement and respect for the rights and needs of all participants will create more inclusive research environments. But this alone is not enough. The European Commission must move beyond rhetoric and commit to enforceable targets for the participation of underrepresented groups. Mandatory research quotas and substantial financial incentives must be implemented to ensure that no population is left behind. The European Commission should prioritise significantly increasing funding for inclusive research programmes. It is only by addressing these challenges head-on that we can expect to achieve more accurate and equitable health outcomes. 

The future of healthcare: the 4P-principle 

The future of healthcare is anchored in the 4P principle: predictive, preventive, personalised and participatory. This approach envisions treatments and preventive measures that are increasingly tailored to the individual patient, considering both genetic and lifestyle factors. Particularly for non-communicable diseases such as diabetes, cardiovascular diseases and cancer, this model offers a promising path toward early detection, targeted prevention, and more effective, personalised interventions based on the patient’s unique risk profile. Prevention is particularly crucial, not only in improving public health, but also in controlling the escalating costs of healthcare. By prioritising preventive measures, such as early screening, vaccination and lifestyle interventions, we can significantly reduce the burden of chronic diseases, which are responsible for the majority of healthcare expenditures. However, despite the clear benefits of prevention, there is currently a significant shortfall in investment at both local and national levels. This represents a critical missed opportunity, as prevention not only reduces the incidence of disease, but also promotes a healthier, more economically productive population. 

While the 4P-model offers a roadmap for the future of healthcare, many national systems remain anchored in outdated, reactive models of care, leaving little room for genuine personalisation or prevention. However, fully embracing the 4P model requires substantial financial investment, particularly in preventive measures, which are often costly but essential for long-term health outcomes. Europe must commit to a bold shift toward proactive health strategies, ensuring its citizens benefit from the promise of the 4P-model while recognising the upfront costs necessary to make this transformation. 

Inclusive preventive measures: the urgency to act now 

A multidisciplinary approach is essential to ensure that preventive measures and interventions reach all segments of society. Diversity and inclusion must be at the core of designing and implementing these measures, requiring communication strategies tailored to each population group and sensitive to cultural and language barriers. Moreover, as AI becomes increasingly integrated into healthcare, the risk of exacerbating disparities grows if the underlying data is based on non-inclusive research. 

Every population group, regardless of background or literacy level, must have access to healthcare and preventive measures that are most optimal and effective for them. This is not only a matter of equity, but a fundamental principle of international human rights, which mandates that all individuals must have equal access to the highest attainable standard of health, without discrimination. This demands a healthcare system fully attuned to the unique needs of each individual, where everyone’s health is valued equally. To this end, it is imperative that the European Commission and member states act swiftly to enhance representation in research and establish inclusive preventive measures. This is not just a matter of equity, but of urgency– without immediate, targeted efforts, Europe risks deepening the divide in health outcomes, further marginalising those most in need of inclusive healthcare.Mandatory quotas, comprehensive funding for outreach programs and the active engagement of diverse communities must form the cornerstone of any meaningful strategy to secure a healthy future for everyone. 

The views expressed in this #CriticalThinking article reflect those of the author(s) and not of Friends of Europe.