Population Health Intervention Research Casebook Commentary[ Table of Contents ]
Setting the stage for an expert commentary
Penny Hawe, Founding Director, Population Health Intervention Research Centre, University of Calgary, and Ted Bruce, Executive Director, Population Health, Vancouver Coastal Health, were invited to reflect on the current state of population health intervention research in Canada from the perspective of a researcher and public health decision maker, respectively. Given the diverse approaches to this nascent field of research, we conclude the casebook with their insights to demonstrate how the voices of researchers and decision makers can work together and to reflect on the potential for growth in population health intervention research and the infrastructure needed to develop and support it.
How do you see population health intervention research differing from other approaches to health research?
Ted Bruce (Ted): Unlike traditional health promotion or health education approaches that often target individual risk factors, population health intervention research looks further upstream at policies and barriers that affect the capacity for whole populations to make change. Population health intervention research is not just about evaluating a specific program aimed at individuals; it is also about looking at the broader policy framework within which an intervention is being developed. It is the whole context.
Penny Hawe (Penny): Yes, I agree. Though health promotion people would say they have been in the policy arena since the 1986 Ottawa Charter for Health Promotion and are dealing with structural issues. But to truly realize the value of research in sectors like taxation policy or the environment, we have to give it more encouragement. Population health intervention research is trying to do that. It's about making the tent broader and privileging a type of research about structural solutions to ill health that has not been in the spotlight.
In what ways do the projects presented in the casebook add to our understanding of population health intervention research?
Ted: The range of cases shows us that population health intervention research is emerging and transitioning to a more exciting and effective level.
The research is becoming more sophisticated and we are developing a greater understanding of how to use it; models of good practice that consider policy and social determinants are starting to be documented and evaluated. There is still room for improvements around the articulation of the intervention's policy focus and how interventions will influence fundamental determinants of health.
Research is developing a more comprehensive focus, moving from looking at specific program elements to looking at complex elements in which the program is situated. For example, a program might be designed to help an individual get into the job market, but population health intervention research would focus on why individuals from a certain population group might not be able to get into the job market in the first place and try to address that.
This shift to more upstream interventions is what is exciting.
Penny: I am going to sound a little more negative! The cases add to our understanding of doing population health intervention research, but they reflect just part of the definition of what population health intervention research is. But that's because of how the case studies were set up. You invited applications in obesity and mental health. You defined sectors outside of health in terms of examples of schools or unions collaborating with health sector people to deliberately improve health. Look, don't get me wrong, I love this stuff. It's what I do in my own work. But you didn't get descriptions of the impact of employment policies on health. You didn't get researchers looking at global trading networks and health, for example. So I am just commenting on the selection bias.
That said, we can take away some lessons from the casebook.
Researchers were hampered by not having enough data on the people and infrastructure they were working with. This is partly because our routine data collection systems are essentially designed to support health care administration. Population health intervention research needs whole new data structures.
The value of partnerships and relevant research is also important. Academics listened to the policy makers. They were asking questions that were relevant to what policy makers wanted to know. They were involving partners in analysis and interpretation and in study design too. If population health intervention research is going to be successful it will be driven by these policy level interface questions.
Many of the cases were unable to bring about longer-term changes because the system did not seem ready to invest in getting these health outcomes on a regular basis, even after investigators had shown how it could be done. It's this screwy idea that we all still seem to retain about prevention. As a society, we regularly allocate resources to treatment services but we expect innovative preventive interventions to be sustained by community volunteers. I want to be part of a society that starts allocating our resources differently.
What competencies and skills are needed by population health intervention research teams, including researchers and decision makers?
Penny: Population health intervention research competency identification and development is being supported through some recent Strategic Training Initiative in Health Research grants.1
We need to develop well-rounded researchers with broad research, communication and policy analysis skill sets, although good population health intervention research can also be done using secondary data sets, where you don't need to get up close and personal with anyone!
Ted: Population health intervention research is not a bounded discipline; there are going to be people working, for example, in urban planning and ecology who are doing population health intervention research work. So population health intervention researchers must be interdisciplinary in nature, or at least be able to work in a cross-disciplinary environment. That does take a certain amount of competency and courage. Other key competencies include good community engagement competencies and a certain level of knowledge around community development including being a strong communicator at different levels, whether it is working in the community or with different levels of government. There is also the importance of being a team player. Not everybody has the full range of knowledge and competencies required to move some of these agendas forward.
Given the diverse and sometimes political environment, leadership skills are essential. This includes specialized knowledge and understanding approaches to advocacy, understanding decision making processes in complex environments, and understanding models of change.
Penny: The other skill I'd throw in is journalism. Imagine how exciting it would be if journalists were writing about population health as a science with the same excitement as they write about genes or asteroids. I know journalism is not a population health intervention research competency, but without it population health intervention research will not thrive.
Discuss the importance of population health intervention research for promoting health equity and effecting change.
Ted: For me, fundamentally, population health intervention research is looking at the question of equity-and population health intervention research must consider the inequitable distribution of power and resources. Even though health promotion programs may be aimed at vulnerable populations with inequitable health status, they may not be looking at the fundamental change of power relationships or policy that is going to bring about a real change in health status.
Penny: I agree. What also worries me is how far down the path of biological explanation some people are going to go to account for the mechanism for why some people are healthy and others are sick. Do we really need to have brain scans of kids showing how horrible it is to be bullied or to live in tough circumstances? Some concerted action is needed on social and population health science data alone. Biological plausibility is terrific, but not if it delays action.
What are the key success factors and challenges for moving forward with a population health intervention research agenda?
Ted: We need to clarify what we mean by population health intervention research. Researchers need to clarify the policy target at the outset and be explicit about the overarching policy framework that is affecting the population's health. Also, there needs to be more longitudinal research. Funding tends to be of a temporal or short-term nature, yet the work we are doing needs to be longitudinal if we are going to have an impact. We do have some dedicated research funding initiatives around population health intervention research, and we cannot lose that. Research should be embedded into the community since the community ultimately must support and sustain the intervention. The field must focus on improvements to our social and cultural environments for improving the health of populations, understanding the context for interventions-what are the barriers or what made them successful-and understanding the elements that would be required for policy change over time.
Penny: I do not think that we should tie funding to the traditional goals and risk factors that we have always had. I think we need to let the field innovate a bit more through having funding competitions and opportunities where the approach is left open.
Identify some key future policy needs, concerns or issues in Canada and reflect on how population health intervention research may contribute to addressing them.
Ted: If we do not address income and power inequalities in society we are going to suffer on all kinds of measures as a society and as individuals. That, to me, has to be one of the highest priorities that we attend to in population health. I think the health sector is in a special place to be able to talk about that in a language that is not threatening or ideological. We need to be at the table to help people understand what makes healthy societies and healthy people.
In parallel to this, we need to focus on protective factors that are in place across communities. We need to look at why some communities do better than others even in the face of some pretty miserable circumstances and explore some of those protective factors and policies such as strong social support systems.
Penny: Yes, and we need to learn how to reframe the social determinants of health so it is not dismissed as ideological. That's been a barrier. We also have to start incorporating more cost-benefit analyses into research studies. We have to show exactly how building equitable societies and a sustained prevention system will deliver better outcomes.
I would also like us to rethink the priority we give to future sustainability as a criterion for researching which new interventions may be worthwhile. In basic science and health care, we never seem to say, "I am sorry. You cannot do this innovative stuff because we may not be able to afford to implement the results." But in public health we often shoot ourselves in the foot at the start and say to researchers: "You are only allowed to generate a particular type of knowledge," one at present grounded in an under-resourced, under-valued system where only minimal remedies are seen as feasible. I think we need to raise our sights and give society the ammunition to build a better system.
- Please visit the Canadian Institutes of Health Research Strategic Training Initiative web site for more information.
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