What is population health

What is population health?

The population health perspective taken by this blog is a broad one, as the model below illustrates (1) [This model was adapted from the original Evans and Stoddart field model (2) and expands on Kindig and Stoddart (3)].

 

Policies and programs produce changes in health determinants or factors, then produce the health outcomes in the left hand box.

  Kindig_clr_v4

Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. (3,4) These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. The health outcomes of such groups are of relevance to policy makers in both the public and private sectors.

(This is an adaption of the original Evans and Stoddart field model4)   Note that population health is not just the overall health of a population but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy—even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced. The right hand side of the figure indicates that there are many health determinants or factors, such as medical care systems, individual behavior, genetics, the social environment, and the physical environment. Each of these determinants has a biological impact on individual and population health outcomes.   Isn’t this so broad to include everything? Population health, as defined above, has been critiqued as being so broad as to include everything—and that it therefore is not useful in guiding research or policy. But we believe that a broad guiding synthesis of knowledge is essential. Integration of knowledge about health and its multiple factors otherwise would seldom occur. Policy managers typically have responsibility for a single sector; advocacy groups typically often have an interest in only one disease or factor. No one in the public or private sectors currently has responsibility for overall health improvement. The importance of a population health perspective is that it forces review of health outcomes in a population across factors. For population health research, specific investigations into a single factor, outcome measure, or policy intervention are relevant, and may even be critical in some cases, but must should be recognized as only a part and not the whole.   What is the difference between population health and public health? The distinction between public health and population health is sometimes confusing. For those who would define public health as the “health of the public,” there would be little difference from the population health definition offered here. However, not everyone believes that  governmental public health activity in the United States has a mandate to address all the  determinants of health, such as , education and income, since they are outside of public health authority and responsibility. The broader definition of the “public health system” offered by the Institute of Medicine5 reaches beyond this view towards a “new generation of intersectoral partnerships” is consistent with the population health framework of this blog.   References 1.    Kindig, DA and G Stoddart. 2003. What is population health? American Journal of Public Health 93:366-369. 2.    Kindig DA. Understanding Population Health Terminology. Milbank Quarterly 2007; 85 (1) 139-161. 3.    Kindig D, Asada Y., Booske B.  A Population Health Framework for Setting National and State Health Goals. JAMA 2008; 299:2081-2083. 4.    Evans R, Stoddart GC. Consuming Health Care, Producing Health. Soc. Sci. Med. 1990; 33:1347-1363. 5.    Institute of Medicine 2002. The Future of the Public’s Health in the 21st Century. Washington, DC, The National Academies Press. What Are Population Health Outcomes? Many health improvement models have identified two broad outcome goals: increasing overall or mean population health and eliminating disparities within the population. For example, the goals of Healthy People 2010 are to “increase the quality and years of healthy life” as well as “eliminate health disparities.” The outcomes component of our population health modelpopulation health model is shown in the left hand side of the figure below1,2     For overall or mean population health, two components are displayed: mortality (length of life), and health-related quality of life, or morbidity. Healthy People 2010 defines defined health-related quality of life as “a personal sense of physical and mental health and the ability to react to factors in the physical and social environments.”3 Simply put, the one goal of population health improvement is to increase years of life and the quality of those life years.   Another goal is We also want to reduce the differences or disparities in these health outcomes among different subgroups in the population.4 The figure indicates a number of subgroups that are associated with significant differences or disparities in both mortality and health-related quality of life. Those featured here are race/ethnicity, socioeconomic status (SES), gender, and geography. Many other subgroups besides these are associated with population health disparities. All differences are not necessarily of policy interest or are equally important in all situations.5   It is important to note that in this figure each quadrant is arbitrarily sized equally, as are the components within disparities (i.e., race/ethnicity, SES, geography, and gender). The relative importance of each cell is not a research question but a value choice for different nations, states, or other population groups to make. Some may focus more on years of life and others more on the quality of those years. Some may think that socioeconomic disparities are the most important while others could prioritize disparities of gender or geography. In the Health of Wisconsin State Report Card, an overall grade for health disparity was given based on a multidomain index across four disparity domains.6   References 1.    Kindig, DA. Understanding Population Health Terminology. Milbank Quarterly 2007 85 (1) 139-161. 2.    Kindig DA, Asada, Y, Booske B. A Population Health Framework for Setting National and State Health Goals. JAMA 299 (17) 2081-2083, 2008 3.    Healthy People 2010. Office of Disease Prevention and Health Promotion. US Dept. of Health and Human Services. http://www.healthypeople.gov. Accessed April 19, 2010. 4.    Kawachi, I, S.V. Subramanian, and N. Almeida-Filho. 2002. A Glossary for Health Inequalities. Journal of Epidemiology and Community Health 56:647–52. 5.    Graham, H. 2004. Social Determinants and Their Unequal Distribution: Clarifying Policy Understandings. Milbank Quarterly 82(1):101–24. 6.    Booske, BC, Rohan, A, Kindig, DA., Remington, PL  2010. Grading and Reporting on Health and Health Disparities. Preventing Chronic Disease 7(1): 1-7  What Are Population Health Determinants or Factors? Health outcomes, however defined and measured, are produced by determinants or factors. They often are sorted into the five categories presented on the right in the following model.   Medical Health care determinants generally include access, cost, quantity, and quality of health care services. Individual behavior determinants include choices about lifestyle or habits (either spontaneously or through response to incentives) such as diet, exercise, and substance abuse.Social environment determinants include elements of the social environment such as education, income, occupation, class, social support. Physical environment determinants include elements of the natural and built environment such as air and water quality, lead exposure, and the design of neighborhoods. Genetic determinants include the genetic composition of individuals or populations. The subcomponents of these determinants or factors can be measured in many different ways. The County Health Rankings includes many such measures in each category that are available at the county level. A series of articles commissioned by the MATCH project, to be published in the online journal Preventing Chronic Disease starting in June 2010, outline current thinking regarding conceptualizing and measuring each of these categories. In the model above, each category is depicted as the same size, implying that they each contribute equally to health outcomes. Although useful for illustration, in reality those determinants will carry different weights (and hence would be different sizes). Differences exist depending on the population studied, and because cross-sectoral economic analysis is complicated by interactions between determinants and the latency over time of their effects. In the MATCH County Health Rankings, health care is weighted 20%, behaviors 30%, the social environment 40%, and the physical environment 10%. An explanation of the process used to assign these particular weights is available. However, Establishing more solidlydetermining the correct weights for each category and the policies and programs underpinning them is remains the a major challenge for population health research. It is important, too, to realize the presence of “reverse causality,” which is why there is a small arrow in the above model going from outcomes to determinants/factors. This reflects the fact that outcomes such as morbidity can produce a change in a determinant or risk factor. For example, childhood illness can be responsible for lower educational attainment. In this case, the definitions of outcomes and determinants are reversed; morbidity would be the determinant or factor and educational attainment the outcome. Separating out the different directions of causality is an important and difficult research challenge. PROGRAMS AND POLICIES The population health perspective taken by this blog is a broad one, in which population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.1,2 These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. The health outcomes of such groups are of relevance to policy makers in both the public and private sectors.   We find the model below useful in thinking about population health.3 Here we see that programs and policies produce changes in health determinants or factors, which then produce the health outcomes in the left hand box.     (This is an adaption of the original Evans and Stoddart field model4)   Note that population health is not just the overall health of a population but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy—even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced. The right hand side of the figure indicates that there are many health determinants or factors, such as medical care systems, individual behavior, genetics, the social environment, and the physical environment. Each of these determinants has a biological impact on individual and population health outcomes.   Isn’t this so broad to include everything? Population health, as defined above, has been critiqued as being so broad as to include everything—and that it therefore is not useful in guiding research or policy. But we believe that a broad guiding synthesis of knowledge is essential. Integration of knowledge about health and its multiple factors otherwise would seldom occur. Policy managers typically have responsibility for a single sector; advocacy groups typically often have an interest in only one disease or factor. No one in the public or private sectors currently has responsibility for overall health improvement. The importance of a population health perspective is that it forces review of health outcomes in a population across factors. For population health research, specific investigations into a single factor, outcome measure, or policy intervention are relevant, and may even be critical in some cases, but must should be recognized as only a part and not the whole.   What is the difference between population health and public health? The distinction between public health and population health is sometimes confusing. For those who would define public health as the “health of the public,” there would be little difference from the population health definition offered here. However, not everyone believes that  governmental public health activity in the United States has a mandate to address all the  determinants of health, such as , education and income, since they are outside of public health authority and responsibility. The broader definition of the “public health system” offered by the Institute of Medicine5 reaches beyond this view towards a “new generation of intersectoral partnerships” is consistent with the population health framework of this blog.   References 1.    Kindig, DA and G Stoddart. 2003. What is population health? American Journal of Public Health 93:366-369. 2.    Kindig DA. Understanding Population Health Terminology. Milbank Quarterly 2007; 85 (1) 139-161. 3.    Kindig D, Asada Y., Booske B.  A Population Health Framework for Setting National and State Health Goals. JAMA 2008; 299:2081-2083. 4.    Evans R, Stoddart GC. Consuming Health Care, Producing Health. Soc. Sci. Med. 1990; 33:1347-1363. 5.    Institute of Medicine 2002. The Future of the Public’s Health in the 21st Century. Washington, DC, The National Academies Press. What Are Population Health Outcomes? Many health improvement models have identified two broad outcome goals: increasing overall or mean population health and eliminating disparities within the population. For example, the goals of Healthy People 2010 are to “increase the quality and years of healthy life” as well as “eliminate health disparities.” The outcomes component of our population health modelpopulation health model is shown in the left hand side of the figure below1,2     For overall or mean population health, two components are displayed: mortality (length of life), and health-related quality of life, or morbidity. Healthy People 2010 defines defined health-related quality of life as “a personal sense of physical and mental health and the ability to react to factors in the physical and social environments.”3 Simply put, the one goal of population health improvement is to increase years of life and the quality of those life years.   Another goal is We also want to reduce the differences or disparities in these health outcomes among different subgroups in the population.4 The figure indicates a number of subgroups that are associated with significant differences or disparities in both mortality and health-related quality of life. Those featured here are race/ethnicity, socioeconomic status (SES), gender, and geography. Many other subgroups besides these are associated with population health disparities. All differences are not necessarily of policy interest or are equally important in all situations.5   It is important to note that in this figure each quadrant is arbitrarily sized equally, as are the components within disparities (i.e., race/ethnicity, SES, geography, and gender). The relative importance of each cell is not a research question but a value choice for different nations, states, or other population groups to make. Some may focus more on years of life and others more on the quality of those years. Some may think that socioeconomic disparities are the most important while others could prioritize disparities of gender or geography. In the Health of Wisconsin State Report Card, an overall grade for health disparity was given based on a multidomain index across four disparity domains.6   References 1.    Kindig, DA. Understanding Population Health Terminology. Milbank Quarterly 2007 85 (1) 139-161. 2.    Kindig DA, Asada, Y, Booske B. A Population Health Framework for Setting National and State Health Goals. JAMA 299 (17) 2081-2083, 2008 3.    Healthy People 2010. Office of Disease Prevention and Health Promotion. US Dept. of Health and Human Services. http://www.healthypeople.gov. Accessed April 19, 2010. 4.    Kawachi, I, S.V. Subramanian, and N. Almeida-Filho. 2002. A Glossary for Health Inequalities. Journal of Epidemiology and Community Health 56:647–52. 5.    Graham, H. 2004. Social Determinants and Their Unequal Distribution: Clarifying Policy Understandings. Milbank Quarterly 82(1):101–24. 6.    Booske, BC, Rohan, A, Kindig, DA., Remington, PL  2010. Grading and Reporting on Health and Health Disparities. Preventing Chronic Disease 7(1): 1-7  What Are Population Health Determinants or Factors? Health outcomes, however defined and measured, are produced by determinants or factors. They often are sorted into the five categories presented on the right in the following model.   Medical Health care determinants generally include access, cost, quantity, and quality of health care services. Individual behavior determinants include choices about lifestyle or habits (either spontaneously or through response to incentives) such as diet, exercise, and substance abuse.Social environment determinants include elements of the social environment such as education, income, occupation, class, social support. Physical environment determinants include elements of the natural and built environment such as air and water quality, lead exposure, and the design of neighborhoods. Genetic determinants include the genetic composition of individuals or populations. The subcomponents of these determinants or factors can be measured in many different ways. The County Health Rankings includes many such measures in each category that are available at the county level. A series of articles commissioned by the MATCH project, to be published in the online journal Preventing Chronic Disease starting in June 2010, outline current thinking regarding conceptualizing and measuring each of these categories. In the model above, each category is depicted as the same size, implying that they each contribute equally to health outcomes. Although useful for illustration, in reality those determinants will carry different weights (and hence would be different sizes). Differences exist depending on the population studied, and because cross-sectoral economic analysis is complicated by interactions between determinants and the latency over time of their effects. In the MATCH County Health Rankings, health care is weighted 20%, behaviors 30%, the social environment 40%, and the physical environment 10%. An explanation of the process used to assign these particular weights is available. However, Establishing more solidlydetermining the correct weights for each category and the policies and programs underpinning them is remains the a major challenge for population health research. It is important, too, to realize the presence of “reverse causality,” which is why there is a small arrow in the above model going from outcomes to determinants/factors. This reflects the fact that outcomes such as morbidity can produce a change in a determinant or risk factor. For example, childhood illness can be responsible for lower educational attainment. In this case, the definitions of outcomes and determinants are reversed; morbidity would be the determinant or factor and educational attainment the outcome. Separating out the different directions of causality is an important and difficult research challenge. PROGRAMS AND POLICIES<br Note that population health is not just the overall health of a population but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy—even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced. The right hand side of the figure indicates that there are many health determinants or factors, such as medical care systems, individual behavior, genetics, the social environment, and the physical environment. Each of these determinants has a biological impact on individual and population health outcomes.

Isn’t this so broad to include everything?

Population health, as defined above, has been critiqued as being so broad as to include everything—and therefore not very useful in guiding specific research or policy. The truth is, no one in the public or private sectors currently has responsibility for overall health improvement. Policy managers, for example, tend to have responsibility for a single sector while advocacy groups likewise focus on a single disease or factor.

The inherent value of a population health perspective is that it facilitates integration of knowledge across the many factors that influence health and health outcomes. For population health research, specific investigations into a single factor, outcome measure, or policy intervention are relevant, and may even be critical in some cases–but they should be recognized as only a part and not the whole.

 

What is the difference between population health and public health?

The distinction between public health and population health deserves attention since it has been at times both confusing and even divisive. Traditionally, public health has been understood by many to be the critical functions of state and local public health departments such as preventing epidemics, containing environmental hazards, and encouraging healthy behaviors.

The broader current definition of the public health system offered by the Institute of Medicine reaches beyond this narrow governmental view. Its report, The Future of the Public’s Health in the 21st Century, calls for significant movement in “building a new generation of intersectoral partnerships that draw on the perspectives and resources of diverse communities and actively engage them in health action (5).”

However, much of U.S. governmental public health activity does not have such a broad mandate even in its “assurance” functions, since major population health determinants like health care, education, and income remain outside public health authority and responsibility. Similarly, current resources provide inadequate support for traditional–let alone emerging–public health functions. Yet for those who define public health as the “health of the public,” there is little difference from the population health framework of this blog.

 

References:

1. Kindig D, Asada Y, Booske B. (2008). A Population Health Framework for Setting National and State Health GoalsJAMA, 299, 2081-2083.

2. Evans R, Stoddart GC. (1990). Producing Health, Consuming Health CareSoc. Sci. Med. 33, 1347-1363.

3. Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93, 366-369.

4. Kindig DA. (2007). Understanding Population Health Terminology. Milbank Quarterly, 85(1), 139-161.

5. Institute of Medicine. (2002). The Future of the Public’s Health in the 21st Century. Washington, DC, The National Academies Press.

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