摘要：The prevailing approach to improving population health focuses on shifting population means through a few targeted and universal interventions. The success of this approach for eliminating health disparities depends on an assumption about the distribution of demand for such interventions. We explored whether long tail thinking from business might yield greater progress in eliminating disparities. We examined 2011 to 2013 data from 513 state and local health agency representatives in 47 states who used an online system to create 4351 small media and client reminder products promoting colorectal cancer screening. Products in the long tail were more likely to target minority groups with higher rates of colorectal cancer and lower rates of screening than Whites. Long tail thinking could help improve the public's health and eliminate disparities. The prevailing approaches to improving population health emphasize “shifting the mean” through prevention efforts that target large groups at high risk or through mass environmental control interventions that encourage small but universal changes in individual behavior. 1 This approach has led to the search for “blockbuster” public health interventions that can have the largest effects on determinants of population health and individual behavior. An underlying assumption in both approaches is that prevention opportunities tend to focus on a few groups or a generalized public. The implication is that people falling outside this limited number of groups either collectively have a small impact on population health or can effectively be lumped into one of the larger groups. In popular terms, we often see this as the “80/20” rule, in which 80% of a problem can be solved by understanding and solving 20% of the cases. Whether this holds for population health and the elimination of health disparities depends on understanding the shape of the underlying distribution of prevention opportunities. In a compelling critique, Frohlich and Potvin argue that the prevailing population approach may have the unintended consequence of exacerbating health disparities. 2 Disease risk, they point out, varies not just by behavioral risk factors but also by socially defined groups that vary in their exposure to fundamental risks, for example, low education and low socioeconomic status. Broadly targeted population interventions that focus primarily on behavioral determinants may not be as effective under these conditions or with these groups. Frohlich and Potvin propose that population approaches be complemented by a “vulnerable subgroups” approach that is intersectoral to address core risks that lie outside the realm of health and that is participatory to involve vulnerable groups in developing appropriate, population-specific solutions. We have considered whether long tail thinking applied to public health might lead to vulnerable subgroup approaches that yield greater progress in reducing health disparities. Long tailed thinking stems from new business models that recognize that selling small quantities of many niche items can be more profitable than is selling a few blockbuster items. In The Long Tail , Anderson’s bestselling book on the future of business, he argues that (1) niche markets—subsets of consumers interested in particular products—are more accessible today than ever, and (2) although the demand for any given niche-focused product will be limited, there are so many niches that collectively these products make up a huge market. 3 In business, the term “long tail” refers to a distribution of product sales in which a few products in the head of the distribution are blockbuster successes that have widespread appeal and generate substantial sales, followed by a much greater number of niche products that each have narrower appeal and generate only nominal sales (i.e., the long tail of the distribution; Figure 1 ). Anderson demonstrates that in many cases this long tail of niche products generates sales and profits that rival those of products with mass appeal and explains how new thinking and new technologies make it possible to realize these profits. Open in a separate window FIGURE 1— The long tail of niche-targeted products: 2011–2013. Understanding how and why businesses profit from this long tail of niche products has the potential to transform our thinking about strategies to improve the public’s health. Its implications are particularly profound for helping reduce health disparities—the inequalities in health outcomes that disproportionately affect a long and diverse “tail” of “niche” populations whose needs may not be adequately addressed by approaches designed for the general population. Focusing collectively on the universe of disparity niches may yield significant population health benefits. But it would also require new approaches and new tools, as the economies of scale in distributing a few products to many people are lost. We have described the long tail perspective, examined how its key tenets apply to public health using 2011 to 2013 data from a national online health communication system, and discussed the implications of both for public health.
