Population Health as a Framework for Public Health Practice: A Canadian Perspective

Abstract

I explored the discourse on population health within 3 diverse regional health authorities in Manitoba, Winnipeg, with a focus on the public health sector. At all study sites, population health was viewed primarily as an epidemiological tool for population health assessment and surveillance rather than as an approach to taking action on the broad determinants of health. My findings suggest that concerns about the limitations of population health as a framework for public health efforts to reduce inequities in health are warranted.

In 2003, Friedman and Starfield1 suggested that discussions about the population health perspective have been more highly valued in public health policy and practice in Canada than in the United States. There is no question that the population health perspective has influenced Canadian health policy—at least in theory. By the mid-1990s, the Canadian federal, provincial, and territorial ministers of health had all endorsed a population health approach to health care.2 In 2000, 94% of the senior Canadian federal and provincial civil servants surveyed in the health sector stated that they were quite or very familiar with ideas about the broad determinants of population health.3 However, evidence indicates that knowledge about these determinants has not always influenced Canadian health policy or program decisions in practice.3^–6

Here, I describe the findings of a study that examined, among other things, the discourse on population health at the regional level in a Canadian province. In Canada, fiduciary responsibility for health care lies with the provincial and territorial governments, most of which have further designated authority and responsibility for the planning and delivery of health care services to the regional level over the past decade. These findings provide “food for thought” for those who are contemplating applying a population health framework to public health planning in the United States and elsewhere.

METHODS

The findings I report were part of a larger, descriptive exploratory study that focused on the perspectives of frontline public health practitioners regarding organizational capacity for health promotion in 3 geographically and demographically diverse health regions in the province of Manitoba, Winnipeg. In Manitoba, each of the 11 health regions has its own regional health authority, which is responsible for assessment of regional health status and health needs, determination of regional priorities, and management of the organization and delivery of programs and services.

Data were collected primarily using the key informant interview method; data were supplemented by analyzing key documents (e.g., annual health plans, community health needs assessment reports, policy manuals). Key participants were selected using purposive sampling, with a focus on the public health sector. In the context of Canada’s universally funded health care system, the term public health sector is not used here as the opposite of the private health sector. Instead, the public health sector refers to the range of services, programs, and strategies outside of the acute-care sector that encompass health promotion, disease prevention, health protection, and healthy public policy.

Sixty-one semistructured interviews were conducted with board members, administrators, public health program managers, and frontline public health practitioners (primarily public health nurses) in each regional health authority over a 6-month period. Because the provincial government had adopted a population health framework for health promotion,7 all of the interviews began by asking the participants a series of questions about the “population health approach” in health care (see box on this page). I have summarized the responses to these questions. The findings regarding capacity for health promotion in public health practice—focusing on the perspectives of public health nurses—are reported elsewhere.8

Interview Questions Related to Population Health T.

“When you hear someone referring to a population health approach to health care, what does that term mean to you?”

“To what extent is a population health approach or perspective being used in this regional health authority? In your daily work/practice?”

“Which determinants of population health are you most/least likely to influence in your day-to-day practice?”^a

^aThis question was only posed to public health nurses.

I transcribed the interviews and performed a thematic question analysis. For all questions, only those response-types that were of similar content at all 3 study sites were included in the analysis. I categorized participants’ responses to the question about the definition of population health according to the focus of the definition provided (see Results section).

RESULTS

The results of this study confirmed that the population health perspective has influenced public health thinking at the regional level in the province of Manitoba. In all 3 regional health authorities, regional health assessments were based on a population health framework, and the terms population health and determinants of health appear in health policy and planning documents. However, when asked to define a “population health approach” in health care, most key participants described it as an approach to using epidemiological evidence or evidence from populationwide surveys or consultations as a tool (1) for health assessment, surveillance, or planning of services for the population(s) within their region, and (2) for understanding the broad factors influencing population health in their regions (Table 1 ▶). By comparison, relatively few key participants defined population health as an approach to health promotion that emphasizes taking action on the determinants of health. The need to reduce social and economic inequalities in health status was barely acknowledged as a key element of a population health perspective. (Only 2 of 61 participants even mentioned this!)

TABLE 1—

The Meaning of a Population Health Approach in Manitoba Regional Health Authorities

Type of Definitiona	Typical Example
1. Assessment and surveillance of health of whole population and subpopulations	“You’re looking at a broad picture . . . how healthy is your population, as opposed to individual health?”
2. Recognition of determinants of population health	“It means simply those factors, those determinants, that on a collective basis, not individual basis, in fact improve one’s health.”
3. Combination of types 1 and 2	“For me, that would mean taking into consideration the entire population and not just an individual. But also taking into consideration different factors that might contribute to health in society, and how those factors relate to each other.”
4. Tool for planning services to meet regional health needs	“I see it as more of a numbers game. You know, O.K., we got 50 000 in the population. How many have diabetes, how many are schizophrenic . . . what are the age groups? It helps me to determine sort of where the need is, where the hot spots are . . . what is going on in various communities and how to address it or do some planning and to use that information over maybe a 3- to 5-year period to see whether we’ve made impact or change.”
5. Emphasis on health promotion and illness or injury prevention	“Well, I think that the population health approach seems to be a positive way of looking at things, and I feel that people are sort of making a conscious effort to look at health and how to prevent things instead of how to treat them.”

^aDetermined according to the area of focus of the participant’s response.

Dunn has suggested9 that considerable confusion remains about what population health is and that the term can refer to many kinds of activity. Only 2 respondents stated that they were not sure how to define the concept; however, it is clear that there was no uniform understanding of a population health approach at the study sites.

In response to questions about how a population health perspective was influencing regional health authority policy and practice, most participants gave examples of planning or program activities within the organization that they believed were influenced by a population health perspective. However, many individuals struggled to clarify what the organization’s role was (and what their own individual roles were) in addressing determinants of population health in their regions. The following response, from a program manager, was typical: “Of those determinants, how much is actually within the capacity or the control of a regional health authority, let alone an individual public health nurse? So you can quickly feel overwhelmed by the magnitude of the problem.” Although virtually all public health nurses identified low income as the key determinant of health affecting the people whom they dealt with in their practice, these same nurses stated that low income was the determinant of health that they were least likely to influence. Managers and frontline practitioners identified lack of time, skills, or comfort with engaging in strategies to address the broad determinants of health, such as community development and healthy public policy advocacy, as challenges to overcome.

These findings lend credence to the observation that despite Canada’s reputation as a leader in population health, actual public health practice in Canada does not adequately address poverty and other societal determinants of health.6^,10

DISCUSSION

The population health perspective that is prevalent in Canada has been criticized for its biomedical focus and reliance on epidemiological indicators, an absence of values of equity, and a lack of emphasis on social change.11^–15 As a result, it has been argued that despite its positive role in expanding the health research agenda beyond health care to the social and economic determinants of health, population health is inadequate as a framework for public health efforts to reduce social and economic inequalities in health.16 The findings in this study suggest that this concern is warranted. The focus on population health as an epidemiological tool, the absence of values of equity, and a lack of emphasis on social change were salient features of the population health perspective articulated at the study sites.

Does this mean that we need to discard population health as a framework for public health practice? Not at all. A group of Canadian researchers recently called for a “critical population health” research perspective, which requires asking more critical questions about the social and economic causes and consequences of health inequalities that are observed and seeks to create an equitable distribution of the social and economic conditions that are required to reduce these health inequalities.17^,18 A critical population health approach to public health practice is equally essential. Such an approach would not only link what is known about societal determinants of health with action strategies to address these determinants but also focus all decisions related to public health program planning, delivery, and evaluation and staff development through an equity lens. Several conceptual frameworks that could provide the basis for a critical population health approach to public health practice have been formulated.19^–24 More work needs to be done to develop strategies for integrating this type of conceptual framework into public health practice at the regional and local levels. Otherwise, the current gap between knowledge and action in promoting population health25 will likely remain.