Implementing the Population Health Approach
Health promotion is one of the ways to take action on population health. It has long been recognized as a way of taking action on the social, physical, economic and political factors that affect health. It also emphasizes the need to work with other sectors to ensure that the collective policy environment becomes one that supports health. Health promotion is a concept that has been endorsed within Health Canada's Health Promotion and Programs Branch (now the Population and Public Health Branch) to assist in the development of programs and policies that support healthy living.
In 1986, the World Health Organization took the lead in providing scope for health promotion by creating a working definition and framework for health promotion action. Health promotion is defined as, "...the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs and to change or cope with the environment". Health promotion is a dynamic process that facilitates the engagement of all people and all groups in various social contexts. It does so using five main health promotion strategies:
build healthy public policy;
create supportive environments;
strengthen community action;
develop personal skills and;
re-orient health services.
What is central to health promotion strategies is that they encompass values that foster empowerment and community development, increase the learning capacity of individuals, and inevitably modernize health systems. Fundamental values such as these permit health promotion processes to continue to be adaptive and sustainable throughout the changing health environment.
Health promotion reaches social, economic and personal development spheres. Health promotion goes beyond healthy life-styles; it achieves well-being. Through advocacy, individuals are able to seek out favourable conditions that permit them to attain their health goals (WHO, 1986). Enabling occurs when there is a supportive environment and access to information about life skills in such a way that individuals are able to make healthy choices.
Enabling is achieved when people achieve a state where they feel that they have the capacity to influence their lives or better their living conditions. Health promotion enables people to realize their potential and advocate for change in their environments (WHO, 1986).
Health promotion is inclusive. It considers the individual's and the community's health needs in the context of their environments, and permits them to increase their personal capacities by examining how the determinants of health directly impact health behaviours. The determinants of health include income and social status, social support networks, education, employment and working conditions, social environments, physical environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender and culture (Health Canada, 1996, p.4- see Towards A Common Understanding: Clarifying the Core Concepts of Population Health).
Health promotion strategies are aimed at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential (WHO, 1986- see Ottawa Charter For Health Promotion).
An upcoming Health Canada guidance document, Integrating Population Health and Risk Management Decision-Making, describes the general concepts of population health and risk management, explains the linkage between the two, and provides an example illustrating how a population health approach may be integrated into the risk management decision-making process.
A traditional approach to health care focuses on the health of individuals, on particular diseases, and on responding to illness through direct patient care. A population health approach addresses a range of factors that contribute to health, and their complex interactions, both in the population as a whole and in specific subgroups.
The incorporation of a population health approach into the risk management decision-making process allows Health Canada to consider and respond to risk using a broader perspective, and to do so in a consistent and comprehensive manner. Taking a broader approach can help ensure that the risks that are most important from a population health perspective are identified, that effective risk management strategies are developed and that resources are allocated appropriately. A broader approach also implies increased consultation with experts, the general public and other stakeholder groups (i.e. parties who are concerned about or affected by the issue). This will ensure that their valuable input and perspectives are taken into consideration early in the decision-making process.
Implications for Risk Management Decision Making
Taking a population health approach to risk management decision making means:
making a greater effort to identify sub-populations for which a health issue is of particular concern;
incorporating information on social, cultural, economic, and other health determinants into risk assessments, when these factors are demonstrated to have an impact on the level of risk for specific populations;
considering a greater variety of potential risk management options, particularly non-regulatory ones, where they offer an acceptable level of health protection;
paying greater attention to the unintended impacts of potential risk management options, particularly on social, cultural, and other factors that affect health;
making greater use of multi-faceted risk management strategies, where possible, to improve effectiveness with different populations;
involving a variety of partners in implementing strategies, and implementing these strategies on several levels, in several sectors, and using several methods, where possible, to improve effectiveness;
and considering the effectiveness of risk management strategies, both in terms of traditional measures, and in terms of their impact on a variety of health determinants.
This approach has been evolving in practice over the past several years. Its integration within the risk management decision-making framework will help to ensure that it is applied routinely and consistently across all health protection issues (unless limited by legislative or other requirements or commitments).
Prevention of health problems (e.g., disease, injury) occurs at three levels:
Primary prevention involves activities aimed at reducing factors leading to health problems.
Secondary prevention activities involve early detection of and intervention in the potential development or occurrence of a health problem.
Tertiary prevention is focused on treatment of a health problem to lessen its effects and to prevent further deterioration and recurrence.
Because injury, chronic illness, infectious diseases, acute trauma and other health problems can significantly impact the population, population based prevention strategies are warranted. Prevention activities occur primarily in the health care, public health and primary care systems.
Since the factors leading to health problems are complex and include for example behavioural, socio-economic, cultural and other influences, the population health approach provides a framework for developing prevention strategies where all the determinants of health and their interactions are considered.
Accountability is the obligation to answer for responsibilities conferred. It involves providing detailed information about how responsibilities have been carried out and what outcomes have or have not been achieved. A key element of accountability is transparency, which results from conducting one's activities in a manner that can be easily observed and understood by the public. This includes responding appropriately to requests for information and reporting to the public. For example, Toward a Healthy Future: Second Report on the Health of Canadians by the Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) reports and comments on the state of the nation's health. It alerts policy makers, practitioners and the public to current and future challenges in health.
Evaluation is a way of measuring if a program is doing what it says it will do. The World Health Organization European Working Group on Health Promotion Evaluation defines evaluation as "the systematic examination and assessment of the features of an initiative and its effects, in order to produce information that can be used by those who have an interest in its improvement or effectiveness".
Evaluation is an analytical process that involves the collection and reduction of data of all (or some) phases of a program. It culminates in the synthesis and analysis of qualitative and/or quantitative information into a report containing recommendations. Evaluation helps make decisions about the needs or continuity of a program; the need for modifications to the program; and the need to provide cost/benefit data about the program. Evaluations can consider the process or processes for the delivery of the program, its outputs, impacts and its outcomes.
Process or formative evaluation will tell you how the project is operating. It seeks to determine if the outputs (e.g., the goods and services produced, information provided, reports produced, strategies developed and implemented) support the intents and objectives of the program.
Impact or outcome evaluation will tell you about the effects of a program and to what extent the outcomes (e.g., the benefits and changes resulting from the outputs) result from the overall program design. It gathers information related to the anticipated results, or changes in participants, to determine if these did indeed occur. It may also be used to test the effectiveness of a new program relative to the results of an existing form of service.
Increasingly, the federal government is emphasizing and taking measures to inform Canadians about the achievements and results of public spending. To provide Canadians with relevant information and report on program investments and results, the federal government is developing and implementing practices for accountability. These practices require that all policy documents to Cabinet and submissions to Treasury Board Ministers feature, first of all, a performance measurement and reporting strategy and, secondly, a performance and accountability framework.
This directive shifts the emphasis for measuring and reporting on federal government expenditures from a focus on process and activity to one of outcomes and results.
Health Canada supports this emphasis on accountability. It has developed a policy and a program that adopt a corporate approach to measure and report on program outcomes. This initiative is known as the Federal Government Accountability Initiative for Health Canada Programs and Policies.
The Population and Public Health Branch (PPHB) is well positioned to contribute to the accountability initiative. It is developing a Promotion of Population Health Evaluation Framework. This framework relates directly to the federal government emphasis on accountability. It is supportive of, and congruent with the Health Canada Accountability Initiative. It is also the basic tool for building a performance measurement structure at PPHB that contributes to the three key federal government accountability and reporting mechanisms:
Planning, Reporting and Accountability Structure (PRAS)
Report on Plans and Priorities (RPP)
Departmental Performance Report (DPR)
CAPC is one in a series of steps taken in response to the United Nations Convention of the Rights of the Child. The program, delivered through Health Canada regional offices, funds community groups to work together to establish and deliver services that address the developmental needs of at risk children (0 - 6 years).
CAPC projects and programs are evaluated at the national, regional and local levels to provide information on the development of programs and on their impact on the children and families participating in CAPC programs.
At the national level, the evaluation is composed of two parts: a process evaluation and an impact evaluation. Process or formative evaluation is an ongoing dynamic process where information is added continuously (typically using a qualitative approach), organized systematically, and analysed periodically during the evaluation period. A process evaluation will tell you how the project is operating. The CAPC process evaluation collects data on the development and evolution of projects over time. Project managers complete questionnaires at three key points: when funding is initially received, when new programs start up, and every 6 months thereafter.
Impact or outcome evaluation gathers information related to the anticipated results, or changes in participants, to determine if these did indeed occur. It may also be used to test the effectiveness of a new program relative to the results of an existing form of service. An impact evaluation will tell you about the effects of a project. The CAPC impact evaluation is a longitudinal study of CAPC participants to determine the effects of CAPC programs on various aspects of child development. Two questionnaires are used to collect data at three time points: at program entry, 9 months later, and 24 months later. The National Longitudinal Survey of Children and Youth (NLSCY) is used as a comparison group in the CAPC national evaluation.
CAPC National Evaluation Fact Sheets contain information on obtaining evaluation data for researchers and the general public.
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