# Reframing vulnerable ‘groups’: a qualitative analysis of cross-cutting precarity during France’s COVID-19 response

Jacob Osborne, Michel Dückers, Tamara Giles-Vernick

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Jacob Osborne, Michel Dückers, Tamara Giles-Vernick. Reframing vulnerable ‘groups’: a qualitative analysis of cross-cutting precarity during France’s COVID-19 response. Critical Public Health, 2025, 35 (1), pp.2592011. 10.1080/09581596.2025.2592011. pasteur-05444609

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# Reframing vulnerable ‘groups’: a qualitative analysis of cross-cutting precarity during France’s COVID-19 response

Jacob Osborne, Michel Dückers & Tamara Giles-Vernick

**To cite this article:** Jacob Osborne, Michel Dückers & Tamara Giles-Vernick (2025) Reframing vulnerable ‘groups’: a qualitative analysis of cross-cutting precarity during France’s COVID-19 response, *Critical Public Health*, 35:1, 2592011, DOI: 10.1080/09581596.2025.2592011

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# Reframing vulnerable 'groups': a qualitative analysis of cross-cutting precarity during France's COVID-19 response

Jacob Osborne<sup>a,b</sup> <sup>ID</sup>, Michel Dückers<sup>a,b,c</sup> <sup>ID</sup> and Tamara Giles-Vernick<sup>d</sup> <sup>ID</sup>

<sup>a</sup>Nivel – Netherlands Institute for Health Services Research, Utrecht, The Netherlands; <sup>b</sup>Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, The Netherlands; <sup>c</sup>ARQ National Psychotrauma Centre, Diemen, The Netherlands; <sup>d</sup>Anthropology & Ecology of Disease Emergence Unit, Institut Pasteur/Université Paris Cité, Paris, France

## ABSTRACT

France implemented wide-ranging responses to control SARS-CoV2 transmission during the COVID-19 pandemic. Some measures targeted specific social groups considered to be ‘vulnerable’. Yet how diverse populations experienced and shared existing vulnerabilities within these public health responses remains poorly understood. Theoretical grounding of the present analysis relies on Florencia Luna’s ‘layers’ of vulnerability and David Napier and Anna Volkmann’s ‘vulnerability vortex’. Between January and July 2021, the research team led 156 ethnographic interviews among diverse participants residing in the Paris-Seine-Saint-Denis area and the Vendôme territory. We conducted thematic analysis of these interviews to elucidate the dynamic, situational experiences of vulnerability. We present in-depth cases of three participants, elaborating how differently situated people coped with the pandemic and its effects and showing that access to public services or informal forms of support was predicated on existing and dynamic forms of vulnerability, which came sharply into focus during the pandemic. Categorical boundaries between groups, we argue, were not useful in understanding some root causes of vulnerability. Rather, the consideration of existing and emerging cross-cutting forms of precarity and marginality was useful for understanding how individuals coped with the pandemic.

## ARTICLE HISTORY

Received 14 February 2025

Accepted 14 November 2025

## KEYWORDS

France; vulnerability; informal care; Covid-19

## Introduction

In the debates following the COVID-19 pandemic, much has been written about pandemic public health measures and their consequences (Bennhold, 2021; Branje & Morris, 2021). From early to mid-2020, the number of infections skyrocketed, albeit unevenly throughout the world. States and their public health systems shouldered the imperative to act—to stem transmission, to provide care for the sick, to ensure to the greatest extent possible that their publics received basic necessities to live. Globally, distinct groups were identified as being more vulnerable to severe disease development (the elderly, the immunocompromised) (Oke et al., 2020), whereas others were said to have a greater vulnerability because they belonged to a distinct minority or social group (Agence nationale de la recherche, n.d.; CDC, 2024). Less explored, and what this paper illuminates, is how the effects of and response to the pandemic intersected with existing forms of precarity present across ‘vulnerable groups’, especially as individuals belonging to these groups described the dynamics of precarity within their rapidly changing circumstances.

Particularly important here are the cross-cutting, historically situated social and structural forms of vulnerability that allow individuals to prevent and cope with an infectious threat. Osborne et al. (2021) describe these aspects, derived from concepts and methods from the social sciences, which contribute more granular understandings of vulnerability within infectious diseases. How groups are (de)constructed in a particular context and to what extent existing forms of vulnerability are shaped by official and

<figure><img src="image_11.png" /></figure>
unofficial responses to infectious diseases are questions that can be directly taken up by interdisciplinary approaches to social sciences of infectious diseases.

Accounting for the causes, aggravating factors, and manifestations of vulnerability have been described through concepts such as structural vulnerability (Smith, 2020) and institutional vulnerability (Fuchs & Thaler, 2018). Napier and Volkmann (2023) describe a 'vulnerability vortex', where vulnerability is a dynamic process, 'in which distinct sets of cultural, social, environmental, and biological risk factors come together to make it more likely than not that a person will experience poorer health in the future'. Vulnerability to COVID-19 cannot rely on a fixed understanding of risk or of groups. It must attend to the underlying contributors to vulnerability and how crises/emergencies exacerbate them. Along these lines, we also frame vulnerability in terms of 'layers' (Luna, 2009) to elucidate the intersecting social, structural, and historical dynamics that conjugate and contribute to increased risk of acquiring COVID-19, to the maintenance of good health and well-being, or to the experience of social isolation. By considering the social, structural, and environmental factors that contribute to vulnerability, we acknowledge the effects that pandemics and other biological threats have on societies, in contrast to biomedical notions of vulnerability, which address only fixed demographic and health factors that individuals within specific groups share (Napier & Volkmann, 2023).

France provides a relevant example for examining these questions about vulnerability. The French official response to the COVID-19 pandemic relied on curfews and closures of businesses and public spaces to curtail contact and thus the risk of transmission (Desson et al., 2020). In March, 2020, President Emmanuel Macron declared that the country was 'at war' with the virus (Or et al., 2022), although contemporaneous analyses described the early failures of the state in contributing to later lockdowns (Beaudevin et al., 2021). As in other countries, specific groups were identified and acted upon (Agence nationale de la recherche, n.d.; Roederer et al., 2021), prompting the need to understand informal forms of crisis support and their social and historical contexts, especially as formal structures were disrupted. Here, we look beyond pre-determined 'vulnerable groups'; we draw on Luna (2009) and Napier and Volkmann (2023) to consider the 'layered' dynamics of formal and informal structures and social and historical contexts and processes and to illuminate how pre-existing vulnerabilities conjugated with official and unofficial pandemic responses to propel certain participants into an inability to cope.

This study is part of Sonar-Global, a multi-country project engaging social sciences in the prevention and response to infectious threats and AMR (Giles-Vernick et al., 2019). Project partners in France implemented a vulnerability assessment among participants in one urban and one rural location in France. The research team set out to identify locally meaningful definitions of vulnerability during the COVID-19 pandemic in France, highlighting the relational and dynamic processes by which individuals are marginalized, excluded, and at heightened risk of reduced health and wellbeing. This article uses qualitative data to describe the experiences of some study participants to illustrate the layers of vulnerability that were present before the pandemic and how these conjugated with emerging forms of vulnerability during the pandemic. In doing so, we also comment on broader practice-based questions, developing this evidence for the use of qualitative methods in responding to pandemic threats.

## Materials and methods

This paper uses data collected from a large-scale vulnerability assessment carried out within the Sonar-Global project. Interviews were carried out in Île-de-France (Paris and Seine-Saint-Denis department) and the Communauté d'agglomération Territoires Vendômois, hereafter referred to as 'the Vendôme territory', approximately 100 km from Paris. The vulnerability assessment was adapted from a global version used across five European countries within the project (Napier, 2014).

To recruit participants, the team conducted interviews with local NGOs and associations to identify characteristics that could indicate heightened risk for difficulties coping during the pandemic (e.g., asylum-seeking, elderly, low income, homeless) (Giles-Vernick, 2021). These NGOs and associations identified some potential participants for the team (composed of 4 to 6 researchers during the data collection period) to interview. We also recruited participants via a combination of snowball sampling to include those who were not connected to NGOs, but also by simply approaching potential participants on the street (convenience sampling) or through extended personal networks to include those
<figure><img src="image_12.png" /></figure>

experiencing vulnerabilities in other ways (purposive sampling). The combination of non-probability sam-
pling methods was important to our approach, permitting us to find more varied and indeed unex-
pected experiences of vulnerability. Researchers experienced in qualitative data collection conducted the
interviews in pairs, in in French, Wolof, Italian, Spanish, or English. Due to pandemic restrictions, some
interviews were conducted online, and when possible, in person. The team's conception of vulnerability
remained open throughout the process, iteratively developing it through consultations throughout the
interviews and data analysis.

Research team members fluent in the language in which the interview was conducted transcribed the interviews. Translations into English were checked by Tamara Giles-Vernick. Coding was inductive and deductive. We developed themes developed based on the data, but also influend by concepts relating to vulnerability described here (e.g., historical factors, systems, structures, relation to COVID-19, location, etc.) (Guest et al., 2012). Results and thematic analysis were discussed with regularity among authors to confirm findings and account for any questions arising from translation.

Ethical approvals for this study were provided by the Institut Pasteur Institutional Review Board (IRB) (n° IRB2020-011 VRF COVID, 7 December 2020, renewed 26 November 2021). This study adhered to the Declaration of Helsinki. All participants received an information notice in French and a verbal explanation of their rights in the language in which they were most fluent. They provided oral consent for participation in interviews. The team obtained oral consent because the people interviewed included migrants, sometimes without legal status in France, or other marginalized or excluded persons who might have feared signing an informed consent form because of their situations. The Institut Pasteur IRB approved the use of informed oral consent. The written information notice and verbal text for consent requested each participant's consent to participate and their consent to publish fully anonymized details of the interviews we conducted. The Institut Pasteur IRB evaluated and approved the information notice and the verbal text requesting consent to participate and consent to publish fully anonymized details. Participant consent was documented through each informant's participation in an interview.

Results

Participants represented wide-ranging demographic groups in both locations. In total, 156 vulnerability
assessment interviews were carried out, 112 in Île-de-France and 44 in Vendôme. Eighty-five were born
in France, whereas others represented nearly every other region of the world, mostly from Africa (39) and
Europe (15). Participants ranging from 21 to 95 years old (median age = 43) included 61 men, 91 women,
and four non-binary individuals.

Three vignettes presented below were selected to illustrate how these participating interviewees experienced vulnerability. Aligned with discourses typically deployed during COVID-19, two vignettes represent participants typically considered to belong to vulnerable ‘groups’—Jean as a low-income asylum-seeker and Hugo as an older adult. Sophie, a young French student, would not have fallen into one of those categories, but her account of her mental health and integration challenges nevertheless highlighted additional layers of vulnerability that made her unable to cope. We also chose these cases because they vividly illustrated the cross-cutting precarities that characterized many of our participants. All names have been pseudonymized.

Throughout the vignettes, we pay particular attention to the three participants' accounts and integrate
supporting quotes from others with similar experiences. This presentation reveals a flexible framing of
vulnerability, drawing out commonalities across diverse participants concerning access to public services,
the role of location and neighborhood integration, and factors that illuminate multidimensional vulner-
abilities in the French response to the COVID-19 pandemic.

Jean

Jean, aged 24, was born in the capital city of an African country. In 2020 he moved to Paris, where he sought asylum and at the time of our interview, was awaiting official refugee status from the French government. In the meantime, he had moved into an apartment provided by a Centre d'Accueil des Demandeurs d'Asile (CADA, or Welcome Centers for Asylum Seekers). CADA are legally recognized
establishments providing housing and social assistance for those seeking asylum in France. CADA thus offer housing for asylum seekers, with regulations controlling their size and staffing per resident (Country Report: Conditions in reception facilities, 2024), and they also provide health, social, and language learning support (Centres d'Accueil pour Demandeurs d'Asile (C.A.D.A), n.d.).

Jean lived with five other asylum seekers in CADA housing, where he shared a room with one person and had access to a balcony. Because he was waiting for his asylum status, he could not legally accept employment and received only a 200-euro monthly allowance from the French Office for Immigration and Integration (OFII), the agency that administers the reception and integration of migrants in France. This allowance, he said, was insufficient in several ways. He explained that he often skipped meals to save money, could not buy sheets to cover his mattress, and was not able to continue his university studies. He was aware of the possibility of working illegally but insisted that he was unwilling to break the law, even if it meant making some sacrifices.

Of his neighborhood, Jean said that he did not feel well integrated and did not know of support services or organizations on which he could rely: 'I don't know because I'm new here, so I don't understand the environment well and I don't really know if help exists, if there is any solidarity'. In fact, the only source of support of which he was aware was CADA support for asylum seekers. It had, however, been a trusted source of support for him and other asylum seekers living there: 'already for us when we have problems with our Navigo passes (a travel card that permits the bearer to ride all public transport in the Paris region) or health problems, they are the ones we turn to'.

Jean's favorable description of the CADA was nearly universal amongst interviewees who had experience with these structures. For asylum seekers in France, the CADA may be the sole source of structural support. Conversely, in the case of a Haitian immigrant who had lived in France for 38 years, a sense of belonging in her Paris neighborhood was more strongly established, allowing for informal mutual support in times of need:

> 'When someone needs something, we can go get it, I can be at work and a neighbor tells me they need something at LIDL and at lunchtime I can go get it... You see? 'Cause we all have our phone numbers, we text each other, someone can say: can you come back with a baguette, things like that.'

Haitian woman, 54, Paris

Jean, because of his asylum-seeking status, COVID-19 illness, and his general lack of economic and social resources, could be considered a vulnerable person. He, however, considered himself relatively 'healthy':

> 'Interviewer: Overall, do you consider yourself a healthy person?

> Jean: Yes, overall since I don't have any illness and that's it. I consider myself a healthy person.

> Interviewer: What does being healthy mean to you?

> Jean: For me it's having peace in my heart, having fairly tranquil psychological health, i.e. not thinking too much, not being stressed, that's it, and then also not having an illness itself, an illness that everyone knows. So that's it.

> For me, to be in good health is not to have a known illness – to be psychologically well, not to stress, that's it, to have a peaceful mind.'

However, this 'peace of mind', as Jean put it, was not shared by those who were not integrated into the asylum system. A 24-year-old man of Senegalese origin who experienced homelessness said, 'I don't see any help or even when we do research to see if there is help, we don't find it'. Another participant observed of her acquaintances, who did not or no longer had access to this support:

> 'I personally know a lot of people who are here in France currently and who are in precarious situations. They don't have housing, they don't have work, they don't have a regular situation in France. They are looking for papers. And as long as these problems are not resolved, we will say that they are not in good health.'

French-Guinea-Bissau woman, 26

Jean's own definition of good health included a peaceful life, free from (visible) disease and stress. Despite his difficulties making do financially and his inability to study or to legally accept employment, he considered himself to be relatively well cared for. For him, the support received by the asylum system via the CADA, although not overly generous, was sufficient for getting by. The discontent he expressed during the interview was therefore not as much due to his circumstances in life (i.e., foreigner, asylum-seeker, racial minority), but the larger set of barriers that if he surmounted, would better allow him to get on with his life:
<figure><img src="image_13.png" /></figure>

What is missing in my life is to have regularized my life and to be able to live how I want to, i.e., have a job that would allow me to have remuneration in order to better integrate myself into society.

Jean and many others in similar legal positions expressed a genuine feeling of stress about their asylum status, about the delays and uncertainties that the process of requesting asylum entailed. While Jean could be considered ‘vulnerable’ in relation to his social-political status as asylum-seeking, his experience during the pandemic showed the importance of stable structural forms of support.

## Sophie

Before the pandemic, students were not considered to be vulnerable, but 23-year-old Sophie described changes in her circumstances that led to difficulties with coping. Sophie was French and grew up in a rural setting distant from Paris. She described her family as working-class farmers. She explained that she was politically involved, self-identifying as ‘anarchist or libertarian communist’. At the time of her interview, she was living in an apartment with a friend in Paris.

> I remember when I arrived in Paris..., I was shocked by constant stimulation by noise, lights, advertising. It wasn't even that much... I don't really think that the cliché of Parisians walking quickly, whatever, is really true. But on the other hand, I find that the city itself is exhausting.

Sophie's feeling of connection to her place of residence was challenged by its difference to how she had grown up and the fact that her stay there was relatively transient as a student: 'I feel a neighborhood life, but I wouldn't go so far as to say that I belong there completely because I haven't been there long enough'.

Sophie estimated her monthly income to be 1200 euros, including her salary from her part-time job as a social worker, some public allowances, and occasional support from her family. Since the pandemic's beginning, Sophie's monthly income declined by 500 euros because of her inability to work, the result of her chronic illness and French lockdown measures. However, she saw her position as one of privilege: 'I have no risk of being on the street, I have no risk of being kicked out of my apartment'. In fact, financial need was not what she considered to be the main driver of resilience and the ability to cope:

> I believe that the fact of being able to form a community and a group, and to have social relations and to be able to talk precisely about everything that we are talking about here, that creates strength, courage, resilience. It's important, and given that it was affected there by my depression, all that. Well, it's something that I have to rebuild now. It's like I have to learn again.

Sophie's status as a relative newcomer to Paris contributed to her feelings of isolation and depression during lockdown periods. Although a strict curfew was implemented to control COVID-19 transmission, Sophie had an exception due to the nature of her work. However, the lack of social control on the streets was a cause of insecurity for her:

> I had strategies in place to spot women who were in a train car and then to travel with them; every evening I called a different friend on the phone so that I wouldn't walk without talking to anyone. I was in survival mode...in fact, I think that I am someone with a fragile foundation, but... I can no longer go out at night alone. It's no longer possible, it's no longer possible. And that really traumatized me. This curfew thing.

Sophie said that she entered ‘survival mode’ just to walk home from the metro in the neighborhood where she lives. When asked how this ‘survival mode’ affected her mental health and ability to cope, she said that her symptoms worsened to the point of urgent medical need: ‘I was hospitalized for severe anxiety and depression, but especially anxiety. I think anxiety wasn’t a symptom I had before’.

Sophie's underlying mental health issues and lack of integration meant that for her, traversing the streets alone at night was unsafe. Other interviews with individuals newly arrived in their neighborhoods or in France displayed a similar sense of anxiety or insecurity. Some foreign-born people of color in France explained that they faced difficulties in integrating themselves into their places of residence. Especially where perceived racism was high, public spaces could be interpreted as sites of heightened danger:
White people don't respect Africans. When they see two or three black people, they come to check them. So, I avoid outdoor spaces because I don't know those who gather there what they are up to there.

*Senegalese man, 50, Paris*

Sophie's difficulties with mental health issues led to a serious outcome. Her account shows how unexpected factors, such as change of residence, could be exacerbated by pandemic measures that contributed to increased social isolation, regardless of belonging to a 'group'. Her experience, however, cannot be attributed to social isolation and lack of solidarity in urban settings, as the following case, which explores the narrative and rural context of a rural Vendôme participant, will illustrate.

## Hugo

Having lived his entire life in a Vendôme territory village, Hugo saw himself as a 'local' in every way. At 67 years old, he lived in a house with a private garden, with his girlfriend, a dog, two cats, and a dozen chickens. Separated from his wife, Hugo had adult children whom he saw regularly. Describing his health, he said, 'I never have a headache. I'm in great shape', and attributed that partly to good luck: 'maybe it's the lottery because my mom never had any pain until she died at 81... and there are friends who are my age, they always have something'.

Hugo expressed ambivalence when asked to describe his village: 'there are some who will come, they will not like it, you must come and then judge it for yourself'. He said that it is a healthy environment in general:

**Interviewer:** We talked about individual behavior or luck [in affecting health]. But what is the impact of the environment?

**Hugo:** Well, it's already the fact of living here, in the countryside.

**Interviewer:** Because elsewhere, in town, what will you find there?

**Hugo:** More pollution, anyway. There is more pollution. Then, as soon as we go outside in town, there are people, all that, and we are always in a crowd... whereas here...

**Interviewer:** Are we less likely to be infected with something?

**Hugo:** Oh yes!

Concerning COVID-19, he maintained that rural inhabitants, living in a less demographically dense setting, were not as concerned as those elsewhere with protecting themselves against the virus:

> It's the countryside, there are some people who are always going everywhere, they hang out everywhere, and they don't have a mask. They believe they aren't at risk. After all, it's true here there are 100 inhabitants, and 100 inhabitants is nothing at all. And the houses aren't close to each other, there is space between them.

He later said that the village had changed, with many Parisians moving there and seemingly outnumbering older, local inhabitants. Consequently, he felt less socially integrated into the village where he was born. The influx of new urban residents in a village of 100 people had diminished the social support on which Hugo previously relied. 'Now it's a little less because there are Parisians and a lot of people we don't particularly know', adding that in terms of mutual aid between residents, 'it's a bit every man for himself'.

In contrast to the stereotype of rural settlements where inhabitants all know and support one another, other participants in the Vendôme territory did not find this mythologized rural camaraderie or social support. One Parisian woman who had relocated to this territory six years earlier described her difficulties developing close social relations with her neighbors:

> In Vendôme, in the area people are very cautious and closed, I would say not selfish but a little. They're in their own little group and they're very judgmental, it's not very healthy actually. I don't know how to define it but the environment of Vendôme makes it strange.

*French woman, 42, Vendôme*

The reduced or nonexistent informal support networks described above by Hugo and the Parisian inhabitant in Vendôme contributed to some participants' increased sense of alienation and lack of support from their environments, especially if formal institutional systems were inadequate, as participants from
<figure><img src="image_14.png" /></figure>

both rural and urban settings indicated. From the 'every man for himself' attitude that Hugo mentioned to the 'not very healthy' closed-off character of small-town life described by the Parisian transplant to Vendôme, the relational forms of support that individuals may turn to in times of crisis or need were also observed in other contexts, including in Paris:

> In fact, I think it's more family assistance, rather than public assistance. And I think that's why we don't see it, afterward maybe they're very lonely people, not helped at all, but I'm not aware of them at all.

French nurse, woman, 27, Paris

This nurse evoked the social support described by the other two participants as a kind of 'family assistance', in which loneliness and its associated social ills are a domain where informal care networks contribute to resilience. These forms of assistance can be tenuous, as they were for Hugo.

Nonetheless, some informal resources provided stronger support during COVID-19 than public services in both our urban and rural sites. For instance, a 79-year-old woman residing in a nursing home, expressed happiness that her children lived close by, could visit her, and would take care of her expenses. She expressed surprising optimism about her experience after falling ill with COVID-19: 'I didn't have a bad time with COVID.... As far as I was concerned, I wasn't feeling well and then I didn't think about that thing for a second'. Despite being diabetic, having recently suffered from a fall, and recovering from cancer, she still considered herself relatively healthy, which seems to have resulted from her sense that she was supported socially.

In another example of a positive account of the role of local informal networks, one Chinese student spoke about an initiative at her church that provided both her and those in need with a meal and a place to experience 'friendship':

> First, it's the church. There is also help, free friendly drinks open to people who need it. I sometimes participate as a volunteer. It's to welcome people who... it's not so much the poor, but rather people who are alone, or a bit sick, like that. And therefore, people who really need to talk to someone... Maybe 20 or 30 people are invited to the meal at the restaurant.... We called it the friendship meal.

Chinese student, woman, 36, Paris

In all, Hugo's example reveals another category of vulnerable people who demonstrated a kind of vulnerability that depended less on group characteristics than on other historically significant factors. In Hugo's case, his changing rural environment, characterized by an influx of urban inhabitants whom he did not know, reduced his networks of social support and left him feeling socially isolated.

## Discussion

The experiences of Jean, Sophie, Hugo, and others described here provide a detailed view of the 'layers' (Luna, 2009) and processes of vulnerability that existed long before the pandemic's onset in France. Structural problems associated with the asylum-seeking procedure, a worsening picture of mental health among students, and what was experienced as a deterioration of neighborly social ties in Vendôme showed that for many, the ability to cope with the pandemic and its associated public health measures did not rest on factors relating to their belonging to a distinct 'vulnerable' group. Instead, their inability to cope resulted in part from social, historical, and structural conditions that converged with the pandemic and its control measures (Napier & Volkmann, 2023).

Here, we also call into question the usefulness of identifying delimited 'vulnerable' groups when deploying responses to the pandemic. Some individuals who were part of predetermined 'vulnerable groups' were less or *differently* vulnerable than what might have been expected given their group's features. Jean, although struggling with legal restrictions on his ability to participate in civil life, found that the CADA, a part of the asylum system, provided stable, reliable support for his practical and health needs. Older adults such as Hugo were optimistic about their health but faced other challenges relating to changes in their social environments that preceded COVID-19 and were exacerbated with the pandemic's onset. These differences were partially attributable to the changing character of the rural location in which people like Hugo were living, but some inhabitants of urban settings faced similar challenges, as was the case with Sophie. Factors contributing to vulnerability may therefore not be related to an
<figure><img src="image_15.png" /></figure>

urban-rural divide, as such; in fact, forms of vulnerability may be more similar between urban and rural environments than typically imagined.

Sophie's account of mental health and detachment from her social environment showed that even if one does not belong to a pre-determined risk group, certain individual features may lead to serious health outcomes during a health emergency. Many university students in France experienced decreased mental health during COVID-19 lockdowns, especially if they did not relocate to their families' residences (Husky et al., 2020) or where informal support was not present (Bourion-Bédès et al., 2021). Not all students, however, experienced the same difficulties, including those in this study. The Chinese student active in her church indicated that her network did not disappear when the pandemic started but gained new importance for her and for other inhabitants of her neighborhood.

It was clear from interviews with a wide range of participants that the pandemic response was not always experienced equally across categories of people, and that some factors exacerbated participants' vulnerabilities. In addition, we identified common forms of vulnerability across social categories. Students and asylum-seekers, for example, do not typically receive the same forms of support, although our findings showed that individuals belonging to these groups shared a sense of social disconnection from their places of residence, limiting their available resources and capacity for informal support systems. This finding echoes Green's insights into the role of place in constituting 'locational' social relations (S. Green et al., 2024), as well as historical examples of pandemics in which social relationships and other resources reflected citizens' (in)abilities to cope (de Graaf et al., 2021).

In the vignettes and supporting accounts presented here, the vulnerability 'vortex' (Napier & Volkmann, 2023) was embedded in a structural and social articulation of existing forms of vulnerability. Indeed, these 'layers' of vulnerability (Luna, 2009) were present before the pandemic, but were foregrounded during in a health emergency when public and informal forms of support were tested. During such emergencies, when boundaries between groups and access to scarce resources are contested, a more contextual understanding of 'publics' (Breslin et al., 2022; J. Green et al., 2022) should be considered alongside the typical groups considered to be biomedically or economically at risk (Lupton, 2022).

## Limitations, strengths, and recommendations

One limitation of this study is that its participants were not representative of either location. Nevertheless, obtaining a representative sample was not the aim of data collection; instead, our goal was to examine the range of vulnerabilities experienced by participants on the ground. The team recruited and conducted relatively few interviews among specific socio-demographic profiles, but within a large (for a qualitative study) pool of participants with many different backgrounds. Future studies could complement ethnographic investigation and analysis with a larger, more representative sample of the population. One strength of this study, however, was its flexibility to explore vulnerability in an adaptive manner, allowing the research team to recruit participants who indicated unanticipated forms of vulnerability as they arose during the interview process. Another strength was the use of qualitative data collection that was informed by engagement with NGOs, associations, and those working with populations who are often at-risk in various ways. These engagements allowed the team to include individuals and groups from every socio-economic status, various ethnic groups, wide ranging ages, and urban and rural settings.

Some concrete public health lessons can be applied from the study's findings. First, better attention should be paid to dynamics of vulnerability, reflected in the role of informal forms of care and social networks, including community services, in the response to infectious diseases. Examples from studies of community engagement (Wilkinson et al., 2017) can serve as guidance for strengthening ties between centralized public health responses and local group dynamics that occur during pandemics and in non-pandemic periods. Additionally, future pandemic responses would benefit from investment in formal qualitative data collection systems, especially where data from questionnaires or other health registers from general practitioners or hospitals may fall short in capturing the complex layering of factors contributing to vulnerability. In addition to the continuous monitoring of vulnerabilities through qualitative data gathering, more can be done to strengthen community-based and locally relevant support that extend beyond formal systems, via their connection to local neighborhood networks, social clubs, and volunteer initiatives.
<figure><img src="image_16.png" /></figure>

From a public health perspective, the challenge is to observe and intervene timely and proportionally in local contexts before a health crisis can expose pre-existing problems in ways both new and urgent.

## Conclusion

This study showed that conditions of vulnerability and the structures and relations that reinforce them are not fixed. During the COVID-19 pandemic in France, some structures such as the CADA providing public assistance showed strength in meeting changing public health needs, whereas the absence of formal and informal support, such as mental health services, led to worsening health and social conditions and outcomes. Variously situated people continued to miss out on publicly provided services and/or did not benefit from the support of established neighborhood or other informal social networks. As such, new forms of vulnerability emerged from the pandemic and reinforced existing ones. We would encourage continuous qualitative data collection on dynamic vulnerabilities during emergencies and in 'peace time' to track the changing and cross-cutting nature of these fragilities; support for protective place-based and other informal social support; and strengthen equitable access to affordable public services.

## Author contributions

JO: Conceptualization, Methodology, Writing—original draft, Writing—review & editing; MD: Funding acquisition, Supervision, Validation, Writing—review & editing; TGV: Data curation, Funding acquisition, Investigation, Project administration, Supervision, Validation, Writing—review & editing. All authors approved the final version to be published.

## Disclosure statement

No potential conflict of interest was reported by the author(s).

## Funding

This project has received funding from the EU Horizon 2020 Research and Innovation Programme under Grant Agreement No. 825671.

## ORCID

Jacob Osborne http://orcid.org/0000-0003-1889-3815

<figure><img src="image_17.png" /></figure>

Michel Dückers http://orcid.org/0000-0001-7746-053X

<figure><img src="image_18.png" /></figure>

Tamara Giles-Vernick http://orcid.org/0000-0003-2873-8544

<figure><img src="image_19.png" /></figure>

## Data availability statement

The data that support the findings of this study are available from the corresponding author, TGV, upon reasonable request.

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