IMAGINE that!
You can use a population health approach
in your planning, programs and practice!
the northern way of caring
Visit us online: www.northernhealth.ca
A Population Health Primer for Northern Health
By Theresa Healy & Julie Kerr, Population Health
POPULATION HEALTH PRIMER…
Investing upstream and for the long haul
Multiple, strength based strategies
Addressing the determinants of health
Grassroots engagement
Intersectoral collaboration
Nurturing healthy public policy
Evidence based decision making
“We are members of a great body.
We must consider that we were born for the
good of the whole.” Seneca. 4BC—65AD
Produced by:
©Population Health, Northern Health
Centre for Healthy Living
1788 Diefenbaker Drive
Prince George, BC V2N 4V7
Phone 250.565.7390• Fax 250.565.2144
Theresa Healy and Julie Kerr
Contact us at:
[email protected]
[email protected]
IMAGINE POPULATION HEALTH PRIMER - 2
TABLE OF CONTENTS
IMAGINE: An Introduction to Population Health Principles ......3
The determinants of health ..................................5
Investing upstream and for the long haul .........................7
Tools for thought: Ripple in the Pond ......................8
Multiple, strength based strategies ................................9
Tools for thought: Selecting the right tools .............. 10
Addressing the determinants of health .......................... 11
Tools for thought: DOH Review............................. 12
Grassroots Engagement ............................................ 13
Tools for thought: Sociogram ............................... 14
Intersectoral collaboration ........................................ 15
Tools for thought: Understanding Partnership ........... 16
Nurturing healthy public policy ................................... 17
Tools for thought: Identifying Policy Opportunities ..... 18
Evidence based decision making .................................. 19
Tools for thought: Literature review ...................... 20
Weaving it all together ............................................. 21
Tools for thought: Population Health Check List ........ 22
Resources consulted ................................................ 23
Back page - Contact information ................................ 25
Acknowledgements
We want to acknowledge
that we stand on the
shoulders of giants in
producing this work. Dr
Lorna Medd, Dr. David
Bowering, and Ms. Joanne
Bays were all involved in the
brainstorming sessions that
developed the IMAGINE
acronym.
Many
other
colleagues and friends have
contributed insights, work
and ideas to this primer.
Many community activists
and champions have lived
and breathed this work in
the practical laboratory of
everyday life. To all of these
supporters we offer our
sincere thanks.
POPULATION HEALTH PRIMER… 3
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IMAGINE: An Introduction to Population Health
Principles
A challenge to think and act differently in how we
approach health care issues and services
We use the word IMAGINE to remind us of the seven major
principled activities of population health:
Invest upstream and for the long haul; use
Multiple, strength-based strategies;
Address the determinants of health; garner
Grassroots engagement; lead
Intersectoral collaboration;
Nurture healthy public policy; employ
Evidence based decision making.
We also view it as a call to action for all of us who envision a
healthier future to articulate and work for the healthy
communities that are the foundation of a well society.
Northern Health is leading a new edge of thinking and
practice in adopting a population health approach as one of
the four pillars in its strategic plan looking to 2015. This
primer is designed to introduce NH practitioners to the basic
concepts of population health as our Population Health and
Healthy Community Development programs conceive and
apply them. Currently under development are two sequels.
The next primer will introduce stories of success from NH
practice as examples of IMAGINE in action, or IMAGINEaction, so to speak. The third primer will seek to demystify
the use of research and evaluation as we purpose to
continuously improve the effectiveness of our service delivery
from a population health perspective, using the IMAGINE
principles.
Canada has long been a world leader in the field of population
health beginning with Jake Epp’s work, the Ottawa Charter,
and Alma Alta. There is a long standing and honorable history
of involvement in the improvement of living conditions that
directly impact the health and wellbeing of members of
Population health is the theory and practice of improving the
health of groups of people rather than of individuals.
society. This longstanding concern with uncovering the links
between poverty and disease sees a need for health
organizations to champion social justice efforts and to have
an impact on the broader determinants of health. This has
led to improved health and well being for a wide segment of
the population. In fact, it has been argued that more lives
have been saved because of advances in this area than in any
other branch of medicine.
Dr. David Butler Jones, Canada’s first National Public Health
Officer, has identified an “aligning of a constellation of
factors that promises a brighter future for those working in
population health. Reports and discussion papers from the
World Health Organization, the Conference Board of Canada
and the Health Officers Council of BC, related to the
underlying determinants of health, were released within
weeks of each other in the fall of 2008 and have received
broad media and political attention.
This growing interest in the broader determinants of health is
an opportunity to embrace population health and integrate it
into the core activities of the health care sector. The
challenge is for front line health care providers, community
health activists and policy makers to understand and
champion population health principles and practices as
preferred practice. This primer is a beginner tool to set you
on this exciting journey.
Population health is a relatively new term that has not yet
been precisely defined. Is it a concept of health or a field of
study of health determinants? We propose that the definition
be “the health outcomes of a group of individuals, including
the distribution of such outcomes within the group,” and we
argue that the field of population health includes health
outcomes, patterns of health determinants, and policies and
interventions that link these two. We present a rationale for
this definition and note its differentiation from public health,
health promotion, and social epidemiology. We invite
critiques and discussion that may lead to some consensus on
this emerging concept. (American Journal of Public Health.
2003;93: 380–383)
IMAGINE POPULATION HEALTH PRIMER - 4
Key questions to ask: What are the causes
of poor health? How do we address those
causes before they lead to health
problems?
The issues that population health addresses are critical in BC.
While averages suggest that the BC population, in general, is
enjoying improving health status, the averages conceal - as the
Provincial Health Officer’s report states - some very dangerous
inequities:
While on the whole, British Columbians are among the
healthiest people in the world, there is a relatively large
number of disadvantaged people in the province – the
unemployed and working poor, children and families living
in poverty, people with addictions and/or mental illness,
Aboriginal people, new immigrants, the homeless, and
others – all of whom experience significantly lower levels
of health than the average British Columbian. In fact, BC
has the highest rates of poverty (particularly child poverty)
in Canada. This presents a paradox: despite having, by
some measures, the best overall health outcomes in
Canada, BC also has the highest rates of socioeconomic
disadvantage in the country.
Figure 1: Nancy Hamilton and Tariq Bhatti, Health Promotion
Development Division, Health Canada, Feb. 1996
“I am in public health because I am an optimist. And I think
there are reasons for that optimism. We have never had
such a constellation coming together as we have right now in
recognizing the interconnectivity of these (social
determinants of health) issues and that we can’t do it
alone… Given the economic challenges we are facing, that
spirit of cooperation and collaboration, the skills we have in
those areas, are even more necessary.” Dr, David ButlerJones, Dec 2nd presentation to the Public Health Association
of BC (PHABC), Dec 2, 2008
Since the 1990s, British Columbia has employed the innovative and
well tested Healthy Communities methodology as a way to redress
health inequities, and the province has recently revived the model.
Provincially, there are multiple networks, councils, initiatives and
programs aimed at reducing health inequities and improving health
outcomes for all. The province’s decision to include public health
as a core program has been matched in Northern Health by the
inclusion of population health as one of the four pillars of Northern
Health's strategic plan looking to 2015.
POPULATION HEALTH PRIMER… 5
The determinants of health
The determinants of health are those factors in our daily lives
that directly and indirectly impact the state of health we can
enjoy. Dennis Rapheal argues that the determinants of health
are, “in a nutshell, about how a society chooses to distribute
resources.” (from a lecture for Nursing 5190, The Politics of
Population Health http://msl.stream.yorku.ca/mediasite/
viewer/?peid=ac604170-9ccc-4268-a1af-9a9e04b28e1d). While
we need to address ill health, we also have to address the
underlying causes of ill health. It makes more sense, morally,
physically, financially and emotionally to prevent disease than
to struggle to cope with the effects of disease and sickness
upon individuals, families and communities. Figure 2, below,
illustrates the interconnected nature of these influencing
factors.
In essence, the determinants of health lay out the range of
possible factors that influence how healthy we will be:
genetic predispositions, lifestyle choices, opportunities and
challenges that enhance or limit quality of life and ultimately
impact on health outcomes. Some, particularly the genetic or
biological ones, are limits that we have little control over, for
better or for worse. Others we can—and should—try to
reverse. But research clearly demonstrates that individual
behaviour change is difficult to achieve unless a combination
of education, legislation and enforcement is mobilized in the
society at large to make healthy choices possible, socially
acceptable, and easy.
It requires political will and a
collective commitment to addressing the needs of the most
disadvantaged, to improving early childhood development
opportunities and education for all, to facilitating stronger
networks of support and creating a truly inclusive society.
Health inequities are differences in health status experienced
by various individuals or groups in society. These can be the
result of genetic and biological factors, choices made, or by
chance; but often they are because of unequal access to key
factors that influence health, like income, education,
employment and social supports. The State of Public Health
in Canada 2008. p3
What lies
beneath
Diet
Exercise
Tobacco
Isolation
Poverty
Literacy
Housing
Addictions
Racism
Mental Health
Colonization
Figure 2: Factors that influence our health, as found in The Report on the
State of Public Health In Canada, 2008. Dahlgreen & Whitehead, European
strategies for tackling social inequities in health: Leveling up Part 2, World
Health Organization, 2006
Abuse
The tip of the iceberg, we
can see and measure
and direct people to
change; individual
focus
Beneath the surface are
the things that impact
and influence lifestyle,
choices and capacities
of change we can see
and measure and direct
people to change;
needs a collective
focus. Higher levels are
barriers to be
addressed. The deeper
we go, the more
complex and difficult
the issues
Adapted from R.A. Dovell,
Population Health
Confernece 2002
IMAGINE POPULATION HEALTH PRIMER - 6
Inequities are killing people on a "grand
scale" reports WHO's Commission:
"(The) toxic combination of bad policies, economics,
and politics is, in large measure, responsible for the
fact that a majority of people in the world do not
enjoy the good health that is biologically possible,"
the Commissioners write in Closing the Gap in a
Generation: Health Equity through Action on the
Social Determinants of Health, 2008.
The impacts of the determinants of health demonstrate that
there are two types of health status. One is acquired
through hereditary means – including class and status, while
the other derives from environmental conditions. As
Romanow’s advice famously states, there is a sure fire
recipe to acquire and sustain good health. (see figure 3
below)
In summary
•
Canada has a commitment to and is a leader in
recognizing the complex interdependencies of the
determinants of health on the potential well being and
health of populations.
•
British Columbia has been making important changes at
the policy level which support the work of population
health.
•
Northern Health has adopted population health as one
of four pillars in its strategic plan.
•
Taken together, the signs point to a need to be familiar
with and actively apply the principles of population
health as a way to redress health inequity and ensure
scarce resources are put to their best use.
“The Minister of Finance
can choose
what level of poverty we
will live with.”
M.Marmot, 2008
Figure 5: Text and illustration from Social Determinants of Health in Canada,
presentation by Elizabeth Gyorfi-Dyke, CHPA, 2005
POPULATION HEALTH PRIMER… 7
I
Investing upstream, for the long haul
“Ultimately, health is political; it is the
allocation of resources that has the greatest
impact on health.” Helena Bryant
Investing upstream and for the long haul refers to the
necessity of looking beyond the immediate acute care focused
model of health care service. While there is no denying the
importance of providing a system of care to those who are
sick, the reality is that “if we build it they will come.”
Planning for and resourcing thousands of acute care beds
assumes and prepares for an ailing population, while investing
significant time, energy, expertise and money into
preventative health would decrease the need for those beds
substantially.
Population health is a key approach for building a more
sustainable health care system that proactively supports
wellness while maintaining a contingency plan to treat
illnesses. The BC Public Health Association has proposed that
the provincial government adopt a “6% solution,” which
would mean a doubling of the current investment of 3% of the
total health care budget currently being spent on health
promotion and disease prevention. This would require all
health authorities to reallocate a small portion of their
budgets and make a deliberate increased investment in public
health initiatives. It would force us to ask ourselves some
challenging questions about our existing practices. What
could we stop doing? What could we take a break from doing?
How can we deliver needed downstream services more
efficiently to free up resources for prevention efforts? As we
experience financial savings that result from more effective
prevention work, where should those dollars be reinvested?
What will give us the biggest population health outcome bang
for our limited bucks?
Marc Lalonde’s work in New Perspectives on the Health of
Canadians envisioned a balance between investing in the
"upstream" of public health and illness prevention as well as in the
"downstream" of health care delivery.
Northern Health’s mission, vision, values and
principles overtly support us in asking these
questions. Furthermore, there are people
within Northern Health that have been trained
as internal experts to assist us in reviewing our
services and programs in this way. There are
processes that have been developed within the
business sector that are now being applied to
health care settings as population health
planning tools. PBMA and Lean are two such
methodologies that have been adopted within
Northern Health and there are people and
practical tools available to assist managers, leaders and teams
in applying these methods to their service planning and
evaluation (See next page for more detail). Albert Einstein
said that the definition of insanity is doing the same thing
over and over again and expecting a different result. The
time has come for us to think and act in a radically different
manner as we plan and deliver our services.
The most challenging part about allocating more resources
upstream is proving that the reallocation has had a significant
positive outcome on health. It is much easier to count
numbers of people with illnesses and report on service
utilization than it is to demonstrate that fewer services were
required and people did not get an injury or disease.
Evidence of population health outcomes takes upwards of 2030 years to accumulate, especially since the preventive
measures taken in early childhood have the largest impact on
health in the adult years.
An example of this was encountered in a First Nation in the
northeast recently, when a Spectra Energy employee pointed
out that a Head Start early childhood development program
started on a reserve 30 years ago has resulted in a thriving
young workforce in that community today. Because youth in
this community have completed high school, avoided
addictions and remained healthy into young adulthood, they
are now able to earn a good, secure income, provide an
increasingly high quality of life for their families and break
the cycle of poverty. The positive impacts are being felt
within the First Nation, the energy sector, in reduced
unemployment rates, and in decreased negative outcomes for
the entire area.
IMAGINE POPULATION HEALTH PRIMER - 8
PBM-what?!?!?!
Due to resource scarcity, health organizations worldwide
must decide what services to fund and, conversely, what services not to fund. One approach to priority setting, which has
been widely used in Britain, Australia, New Zealand and Canada, is program budgeting and marginal analysis (PBMA).
To date, such activity has primarily been based at a micro
level, within programs of care.
Health Serv Manage Res 2005;18:100-108
doi:10.1258/0951484053723117
© 2005 Royal Society of Medicine Press
Tools for thought: Ripple in the Pond
Imagine an intervention of your program as a pebble
tossed in a pond. Visualise where the ripples have the
potential to reach.
Describe the intervention
Lean - it might not be what you think!
Who (or what) will be
impacted first?
Lean isn’t about being skinny; lean is not “mean.”
Lean does not mean cutting staff in the name of
cutting costs (see “lean is not mean”). “Lean” is
the set of management principles based on the
Toyota Production System (TPS). Lean has been
applied in manufacturing, as well as in service industries. Lean has 2 essential components:
What are the secondary
impacts?
Identify more remote
impacts or “trickle down”
effects
1. Eliminate waste and non-value-added (NVA)
activity
2. Have respect for people
If you want to learn more about these and
other quality improvement tools that may
help you to plan upstream interventions,
contact NH’s Corporate Planning team.
Now, with an objective, constructively critical eye, consider
whether the impacts of the intervention you are analyzing are
more upstream/preventative in nature or more downstream/
reactive. Is your intervention decreasing the likelihood of
health problems, or is it treating an injury or illness after the
fact? Is there another intervention you could be undertaking
that would have more upstream impacts? Should this be done
instead of what you’re doing, or in addition to it?
POPULATION HEALTH PRIMER… 9
M
Multiple, strength based strategies
Looking for more than one
tool and method and focusing
on strengths increases the
potential for successful
intervention.
Working with communities is not easy. The human factor
means work always takes longer than planned and that
process issues are as important as content. Neglecting process
almost always guarantees problems. Thus, having an array of
tools in your toolbox for population health work is a necessity.
This section of the primer is a brief orientation to some of the
most effective tools in the world of community development
and organizational change. They lend themselves very well to
the community capacity building work that is the heart and
spirit of population health. There is also a list of hyperlinks
that will take you to a major resource for each one.
Appreciative Enquiry
Appreciative Enquiry is a foundational approach that asks how
we can enter the worlds of other people with our desire to
support positive change. Appreciative Enquiry argues that
change begins the moment we start asking questions. There is
a vast difference between “What’s wrong with your
community?”, which is likely to elicit a litany of complaints
and negative feelings about one’s home town and “What do
you like about your community?”, which allows people to
focus on those positive attributes that contribute to resiliency
and commitment. In terms of respect and engagement,
entering communities and asking what they value, rather than
arriving armed with data about what’s wrong and what must
be changed, will receive a warmer reception. Appreciative
Enquiry provides a respectful and strength focused platform
on which to open the dialogues that communities need to
undertake to identify for themselves the issues they deem
important. Interestingly, Appreciative Enquiry requires the
major shift to come first from within the
practitioner, not the community. For more in
depth discussion, see http://www.appreciativeinquiry.org/
World Café
World Café is a community consultation method
that encourages groups of people to engage in
deep and meaningful conversation. It spells out a process and format
that supports exploration and discovery. In light of the speed at which
the world is changing and the intrusion of technology into human
communication, World Café lays out what we need to communicate
face to face more effectively. It relies on our innate human desire to
relate, learn and understand and the universal familiarity of a café
table. Skilled facilitators engage minds while table top toys and art
supplies engage hands and creatively ensure that the outcomes of
World Café discussions are fruitful and inspiring, even among strangers.
Visit: www.theworldcafe.com and see also The World Café: Shaping
Our Futures Through Conversations That Matter by Juanita Brown and
David Isaacs with the World Café Community; Forward by Meg
Wheatley, Afterword by Peter Senge
Open Space
Created by Harrison Owen, who observed that his most meaningful
education at conferences and workshops happened during coffee and
meal times, this process calls on people to be self organizing. The
agenda for the work is created from the passions and interests of those
present in the room. Experienced initially by some participants as
uncomfortable, the Open Space quickly becomes an energizing and
dynamic process that can be highly productive. It requires a skilled
facilitator and non-traditional facilitation techniques. The process asks
participants to nominate topics for discussion; the nominator then
becomes the host for that discussion. The underlying principle is that
personal passion implies responsibility and may often provoke conflict.
An important tenet is to see conflict not as something to be avoided
but something to be welcomed and handled well as a companion of
passion. With only four principles and one rule, Open Space supports
individual initiative and collective creation. See: http://
www.openspaceworld.org/
“Turn your face to the sun and the
shadows fall behind you.”
Maori proverb
IMAGINE POPULATION HEALTH PRIMER - 10
Community Development; Community Capacity Building;
Capability Approaches; Integral Capacity Building Framework
These terms refer to a broad range of methods and
approaches that conceive of communities and their members
as vital participants in the successful working of population
health. The Quick Links resource section on page 25 of this
primer includes a list of reliable sources to check out for more
information and new developments in each of these dynamic
approaches.
Briefing workshop
An amazingly simple way to get a group to cycle through the
major stages of a research project in a short time with
immediate and useful data and feedback.
Word clouds
Wordle is an easy to use web based tool. You enter a list of
words generated by a group on a topic or pick words out of a
website or article. The resulting artistic presentation is also a
visual representation of what is important. See
www.wordle.net
Tools for thought: Selecting the right tools
from your tool box
The methods that you can choose from as tools to help
develop multiple, strength based approaches are many. Each
will contribute different supports in different ways. You need
to be aware of limiting and facilitative factors that can
determine which tool is the best for your task at hand. The
following check list should help you determine what will work
best for you.
1. What sort of process are you looking at? Do you want to
gather information or develop a team? If you are
gathering information, what sort of data are you after?
Some methods can multitask and contribute to more than
one outcome.
2. Who are you working with? If it is a group struggling with
literacy issues or a group that is suspicious of your
organization, you will need to adopt non-written
approaches for the first group and devote time to
relationship building with the second.
3. Who is the intended audience for the results? The validity
and credibility of the tools you choose will be assessed
differently by different audiences. A community group
may value the stories and hearing their own voices and
concerns resonating in the data. A funding body may want
more numerical and statistical information.
Some key questions to think about:
What do I want to get from the strategies I use?
_____________________________________________________
_____________________________________________________
Who will I be working with?
_____________________________________________________
_____________________________________________________
Who is the audience?
_____________________________________________________
_____________________________________________________
A word cloud generated from the IMAGINE acronym and principles
using the tool found at www.wordle.net
What are some facilitators I can rely on? What are some
potential barriers I can anticipate and prepare for?
_____________________________________________________
_____________________________________________________
POPULATION HEALTH PRIMER… 11
A
Addressing health determinants
Addressing the determinants of
health requires a shift in thinking for
many of us in the health care field.
Rather than focusing on the person in
front of us, their symptoms and needs,
we step back to consider the context
within which the person lives, demographic
trends and clusters of health concerns emerging
in our region.
The factors and elements in a person’s life influence or
determine how healthy they can be. If we improve these
factors, we can improve health status and health care
outcomes. The Canadian Population Health Initiative
estimated that personal lifestyle factors have a very strong
or strong impact on the health of Canadians: a person’s eating
habits (72%), amount of exercise a person gets (65%), whether
a person smokes (80%). At the same time, the broader
determinants affect one in three Canadians, who report
social and economic conditions (a person’s level of income –
33%; availability of quality housing –34%; a person’s level of
education—33%; safety of communities—35%) influenced the
health of Canadians (CPHI, 2005).
The World Health Organization argues that prevention of the
chronic diseases that are increasing globally is best achieved
by acknowledging misconceptions, such as that chronic
diseases affect only the wealthy and the aged and are
expensive and problematic to address. As Dr. Butler-Jones
notes in the Chief Public Health Officer’s Report for 2008
CPHO report:
As we strive to achieve good health for as long as possible,
it is important to note that, while some health challenges
can be related to our genetic make-up, evidence shows
that Canadians with adequate shelter, a safe and secure
food supply, access to education, employment and
sufficient income for basic needs adopt healthier
behaviours and have better health. (The Chief Public
Health Officer’s Report on the State of Public Health in
Canada 2008: Helping Canadians achieve the best health
possible p.3)
Addressing the determinants of health requires
understanding:
1) How these determinants impact the potential of individuals, families
and communities to understand the implications of issues to their
health, 2) The constraints and limitations that inhibit participation or
involvement in health promotion activities, and 3) The ingenuity
required to develop alternatives to reduce the impact of those
constraints.
The necessary creativity and innovation is grounded in the vital
expertise of front line practitioners. However, to move innovative and
promising initiatives developed by frontline practitioners into
sustainable and broad ranging practice, beyond the working life span of
particular individuals, requires the development of policies and
enforcement structures that ensure organizational commitment to
emerging best practices. Policies can and should be developed within
the health authority for each of the social and environmental
determinants (omitting biology and genetics).
Many examples of such policies and practices operate in ad hoc or issue
specific ways (such as social support initiatives within mental health,
for example, or peer support groups for those struggling with
addictions). Such program initiatives have direct and meaningful
lessons for program policies. The challenge for practitioners is to
broaden the impact of such innovations beyond specific program areas
and make them foundational to all the services we deliver.
We know what makes us ill.
When we are ill we are told
That it’s you who will heal us.
When we come to you
Our rags are torn off us
And you listen all over our naked body.
As to the cause of our illness
One glance at our rags would
Tell you more.
It is the same cause that wears out
Our bodies and our clothes.
Bertolt Brecht, A Worker’s Speech to a Doctor, 1938.
Quoted by Dennis Raphael, Social Determinants of Health:
Why is There Such a Gap Between Our Knowledge and Its
Implementation?
Ryerson, Toronto, 2002
IMAGINE POPULATION HEALTH PRIMER - 12
Tools for Thought:
Determinants Review
Examples of policies that address income and social status
might include income support; incentive and subsidy
commitments; partnerships in developing safe, affordable
housing alternatives; including provision of healthy snacks and
refreshments at programs such as immunization clinics or
educational workshops; alternative communication and
outreach strategies that address trust and social alienation
issues; readiness assessments and support to ensure cultural
and social respect. Improving social support networks might
include peer support and family support training network
development.
It is clear that such initiatives toward
addressing the determinants of health and reducing inequities
could have quite direct health impacts, for example, by
reducing youth suicide rates in a community. A multitude of
indirect impacts may also occur, as depicted in the
complexity model below.
Social
Structures
Early
life
Genetics
Culture
Health
Consider the population you serve. Which of the health
determinants can you identify as key in their lives?
Prioritize them and then consider in what ways your
program and services can address them. For example, if
your first determinant was poverty, you may be able to
advocate for free entry to programs, offer nutritious
snacks with programs, develop income supplement
options, transportation, etc.
Determinant #1: ___________________________________
Ways to impact this: ________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Material
Conditions
Determinant #2:____________________________________
Ways to impact this: ________________________________
__________________________________________________
__________________________________________________
Work
Social
Environment
Your
Determinant #3: ___________________________________
Psychological
Health
Behaviours
Brain
Neuroendocrinal
and immune
response
Pathophysiological and
organ impairment
Well being and mortality
Mortality
Morbidity
Figure 3: Lynch JW, Kaplan GA, Pamuk ER, et al. (1998) Income inequality and mortality in
metropolitan areas of the United States.Am J Public Health. 88: 1074-1080.
Ways to impact this: ________________________________
__________________________________________________
__________________________________________________
__________________________________________________
Determinant #4: __________________________________
Ways to impact this: ________________________________
__________________________________________________
__________________________________________________
__________________________________________________
POPULATION HEALTH PRIMER… 13
G
Lack of education, lack of self esteem, a sense of
powerlessness, alienation from social and political supports all
combine to convince people that they are not qualified or
competent to act on their own behalf. Only experts, the
highly educated, or governments are seen as the authorities
who can and should act on issues. When the experts do act,
however, and regardless of the best of their intentions and
the high level of knowledge and expertise they bring, their
efforts are ridiculed, fail or miss the mark, and no one is
happy.
Grassroots engagement
Grassroots engagement is the
most critical component of a
successful population health approach.
Research consistently shows us that,
across disciplines, time and place,
where people have a hand in shaping solutions,
they are more committed to and involved in the
success of those solutions.
Community engagement, for Northern Health, is the active
mobilization of organized groups around the common goal of
improving health. Engaged communities can support and
sustain reforms, and disengaged communities can jeopardize
them. Engagement is defined as:
...the mobilization of constituencies organized as
groups and the meshing of constituency groups into an
active relationship around a common mission, goal, or
purpose… Such engagement, ultimately, results in a shared
culture of action and mobilization in which participating
groups are evaluated by what they do rather than by
what they say. (Adapted from “Engaging Communities”,
VUE Number 13, Fall 2006).
Community organizing
Grassroots community organizing has been long used as a civic
engagement tool, particularly for disadvantaged or
marginalized people, to gain influence over the social and
political institutions and agencies that impact their lives. It
has a longstanding and diverse history, from neighborhood
based groups (e.g. Saul Alinksy) to the broader political
activities of the civil rights movement. Community organizing
is a process whereby people are brought together, acting in a
common self-interest to achieve common aims. It is one of
the basic tools for grassroots engagement.
Mobilizing populations
If we subscribe to Paulo Frieire’s Pedagogy of the Oppressed
concepts, we believe that people hold the keys, the solutions,
to the challenging situations in their own lives. What they lack
are the means to share their knowledge in constructive ways.
Finding the key: Personal Passion
Principles for meaningful engagement:
•
•
•
People must be able to share what they know about an issue in an atmosphere of respect
•
Opportunities to engage with tools for change, with each other and with the system must
be regular and ongoing
•
Address assumptions: consultation does not necessarily mean agreement. Be frank about
what is negotiable and what is not.
They must be encouraged to learn and grow and acquire new skills
They must be encouraged to translate their knowledge into effective actions to improve
their own lives and health and the lives and health of their community
Teachers working with the youngest students know that, if
you use the things that matter to them as content, you can
encourage them to learn. Grassroots engagement starts from
that same basic premise: speak to people’s passions and they
will want to be involved. A lecture on the personal dangers of
smoking, accompanied by statistics on the poor health
outcomes in a community, is more likely to depress and
alienate the audience from a community than encourage them
to tackle the problem of tobacco. Understanding the issues
that worry the community most—such as access to affordable
and healthy food, or closing down the crack houses in a
neighborhood—and helping people to find resources to
respond to those issues, builds a relationship of reciprocity
and mutual respect. This may create opportunities at a later
date to help the community collectively mobilize against
tobacco use. The simple fact is that community members are
likely to make better choices and have more successful
programs if you find ways to motivate and inspire
involvement.
IMAGINE POPULATION HEALTH PRIMER - 14
There are many guides to assist you in determining how to
encourage the involvement of “ordinary people” in your
programs. Check the resource guide at the end of this
primer for some ideas. A basic plan would include the
following steps:
1. Define your aims and goals for involving grassroots
community members
2. Identify tools for engaging citizens (see tools for
thought box on page 11, on consultation methods)
3. Identify the groups or individuals that need to be
involved (see tools for thought on this page)
4. Develop your plan for recruiting and retaining
participants
5. Create a positive and supportive environment for
ongoing engagement
6. Identify evaluation criteria and decide on next steps
7. Maintain open lines of communication
Tools for thought: Sociogram
The mental mind map, shown on the right, helps you visualize
links and connections you already have or might need to build
for grassroots engagement. Your connections can be
organizations or individuals. They may be paid service
providers or volunteer community activists. They may include
people who use your services and who are invested in helping
you to improve them. They may include First Nations
governments, city planners, researchers, youth, and elders. If
you’re a manager, they may be your front line staff or
contracted service providers. The more people you can
engage from the grassroots, the less resistance you may
experience and the more successful your initiative is likely to
be. Inclusion, finding ways to engage people, may sometimes
look very different from the traditional gathering in a room
around a table. Be prepared to be innovative and go to where
the people are gathered already and ask permission to visit
their space.
POPULATION HEALTH PRIMER… 15
I
Intersectoral collaboration
Intersectoral collaboration calls for new work
in breaking down the silos that separate many
people working, with the best of intentions,
within their own particular disciplines and
fields .
Largely through the work of the World Health Organization, it is
now widely accepted that the definition of health includes
more than not being sick. Health is a resource for everyday
life—the ability to realize hopes, satisfy needs, change or cope
with life experiences, and participate fully in society. Health
has physical, mental, social and spiritual dimensions and,
therefore, achieving the vision of improved health in northern
BC requires commitment beyond our systems of public health
and health care alone. All individuals, sectors, systems,
agencies, political structures and institutions in the community
share responsibility for—and reap the rewards of—improved
health.
If we accept this premise, then we have to accept that we
cannot do this work alone. Embracing the determinants of
health and a population health approach requires a new
concept: intersectoral collaboration. Increasingly, health care
service providers need to look to external, and perhaps
unexpected, partners to help promote health and influence
public policy, making healthy choices easier for people and
more widely supported in the society at large. For example,
early childhood educators and schools play a pivotal role in the
healthy development of children and can also be a support to
help families to live in healthier ways. Faith organizations can
play a pivotal role in promoting social justice and can be a
point of entry in accessing populations, such as new
Dr. Trevor Hancock, a consultant for the BC Ministry of Health,
tells the story of the Welsh hospital that sent their carpenter out
into the community to retrofit seniors’ homes: “It doesn’t look like health
care but the rate of falls requiring seniors to be hospitalized fell dramatically.”
immigrants,
to
encourage
proactive
engagement
with
health services.
In
fact, once we embrace
the determinants of
health, we can see
many potential partners
doing really good work
that aligns very well
with
a
population
health approach. The
challenge is, how do we
as health care providers
find opportunities to
work in new and
mutually
supportive
ways with others, who may or may not have a health care
background, but who do share our goals and objectives?
Intersectoral collaboration is, in a nutshell:
“A recognized relationship between part or parts of the health
sector with part or parts of another sector which has been
formed to take action on an issue to achieve health outcomes …in
a way that is more effective, efficient or sustainable than could
be achieved by the health sector acting alone.” WHO
International Conference on Intersectoral Action for Health, 1997.
The tool on the page opposite lays out some simple first steps. If
we remember that the first and logical place to start is to focus
on respectful and equitable relationships, believing that everyone
brings something to the table, the odds of successful intersectoral
collaboration improve in our favour.
Managing partnerships is important for effective health services
delivery. Partners or stakeholders might include the community,
civil society organizations, other sectors, district, regional and
national authorities, donors, private providers, and others. WHO
(World Health Organization), Managing partnerships.
IMAGINE POPULATION HEALTH PRIMER - 16
Intersectoral collaboration can take many forms—we have
identified four in our Healthy Community development
work:
Sponsorship—A commitment to provide some material support
in return for acknowledgment, verbal and written, in the
proceedings.
Cooperation—An agreement to work together to carry out a
task, initiative or project, dividing labour and delegating
responsibilities.
Collaboration—This is a more formal understanding and
usually involves shared power and decision making. It is often
short term.
Partnership - This is a full-fledged, long term and ongoing
agreement to work together, equitably sharing resources,
decisions and work.
Tools for thought: Understanding partnership
This tool helps you determine current and potential levels of
collaboration.
Approaching and Opening Intersectoral Collaboration Opportunities
Level of partnership
Currently no existing
partnerships
Strategies for connecting
•
Identify local events or activities and
approach, offering concrete support.
•
Initiate conversations about repeating the
offer in other venues.
Some informal contacts
•
Ask for opportunity to discuss progress of
informal work with a view to increasing levels
of involvement.
Formal agreements and
structures
•
Memorandum of understanding or similar
document has been drafted and signed by all
parties; usually spells out agreed upon
expectations and deliverables.
Jointly developed action
plan
•
Ongoing team work and joint planning are
agreed upon.
•
Meeting agendas created jointly and tasks
such as chairing and minute taking are
rotated.
Approaching and opening intersectoral collaboration opportunities.
Adapted from Jim Frankish, and Glenn Moulton, “Intersectoral
Collaboration on the Non-Medical Determinants of Health: The Role of
Health Regions in Canada”
Intersectoral collaboration opportunities. Adapted from Jim Frankish,
and Glenn Moulton, “Intersectoral Collaboration on the Non-Medical
Determinants of Health: The Role of Health Regions in Canada”
Key points:
Setting the Context: Understand the impetus for the partnership
Players: Know who should be involved and how
Process: Identify steps you can take and ways to connect parallel
processes and activities.
Value Added: Stress how the partnerships can help ensure sustainability
and extend to other mutual interest areas.
Impacting Multiple Planning & Policy Processes: The outcome may be
more integrated community capacity to respond (engaging both elected
officials and senior administration).
Model Replication: Remember the model can help build cohesion,
reduce friction, and look at issues from a “how could we” appreciative
perspective.
POPULATION HEALTH PRIMER… 17
N
Nurturing healthy public policy
Lasting change lies in our
capacity to make sure the
community has a memory for
what works. Healthy public
policy is one way of ensuring
that the legacy of good work builds
Canada beyond what Monique Begin
called “a nation of pilot projects.”
The role of policy within any institution, organization or
government is to document and ensure adherence to
corporate values, philosophies, ideologies and priorities by
prescribing how the representatives of that corporate body
will behave in practice. It commits the members of that
corporate body to allocating resources to make adherence to
policy possible, and it calls for attention to be paid to
ensuring people have the training, skills, structural support
and capacity to uphold a standard. It allows the people who
interface with or depend on an organization to predict what
to expect and how to effectively engage with its structures.
Policy is the vehicle that enables organizations and
governments to “put their money where their mouth is.” If a
government claims to value its children, but does not pass
legislation and allocate resources to ensure children are safe,
well-educated, appropriately fed and given access to early
developmental opportunities, if it does not ensure parents a
living income and does not plan for affordable housing for
families, then it is reasonable to conclude that, in fact, the
government does not value its children. If an employer claims
to value its workers, but does not implement policy to ensure
safe working conditions and provide a healthy workplace, the
Sustainability of community driven efforts and service providers’ best practices
requires a matching level of understanding and action within the institutions and
agencies responsible for population health measures. Healthy public policy is the
key to ensuring that good ideas and effective practices live on.
workers will likely not feel valued and will experience higher
rates of illness, stress, accidental injury and lack of
engagement. As a result, the employer will deserve a
reputation for not valuing its people.
Evidence suggests that the alignment of policies that address
the health inequities generated by the determinants of health
can result in a multiplication effect; the impact of policies
can be increased and the time for such improvements to be
visible can be reduced because the determinants of health
are so closely connected and build on each other (Evidence
into Action, Saskatoon Health Authority 2008). Therefore,
advocating for policy changes that address underlying
determinants of health, such as child poverty, becomes an
important component of population health and healthy
community development work.
Consider, as an example, the achievements that have been
made in addressing the negative impacts of tobacco use.
Without legislation and policy, we would still be subjected to
second hand smoke in restaurants and on airplanes and
advertising would still be promoting tobacco use as a pathway
to success. There still is a tobacco use health problem in
Canada, but not to the extent seen in countries that have not
created legislation and enforcement to curtail public
smoking.
Revisit: Build in a policy Review
Take some time to review your program Policy manual.
Does it reflect the values, philosophical underpinnings and
priorities of your program area and team? Do your policies
reflect a health inequities lens or pay attention to
underlying determinants of health, either for your staff or
for the population you serve? Have there been shifts in NH
policy or in the legislative landscape that are not reflected
in your existing policy manual?
IMAGINE POPULATION HEALTH PRIMER - 18
Tools for thought: Identifying policy opportunities
One way of thinking about opportunities for policy development is to think about populations by their place on the life stage continuum. For example,
what polices could be developed that would improve the long-term health odds for children in their early years, or that would improve health outcomes
for seniors approaching later stages of life? Alternatively, it can be useful to look for transition points on the life course when people, by virtue of being
at a critical developmental juncture, are open to learning and making lifestyle changes. Graduation from high school, becoming a new parent, retiring
and empty nesting are all good examples of transition points where policy intervention may be particularly well-received and effective.
POPULATION HEALTH PRIMER… 19
E
Evidence based decision making
Allocation
of
resources
and
decisions about strategies and
direction will only ever be as
good as the evidence provided
for their rationale. As Arthur C.
Clarke wrote in 2001: A Space Odyssey:
“The only hard decision is what to do
next.”
Evidence based decision making is the process of
systematically reviewing, appraising and applying the best
research findings to ensure optimal decisions. Evidence is
defined as any data or information used to identify problems,
to assess their magnitude, to explain them and to make
decisions, based on the evidence, for their resolution. This
“evidence based” approach was articulated in the 1990s, but
the concept dates back to the 1980s, when the focus within
health care shifted from trust, conviction and authority to the
use of the best available research and practice. (Robust
Decision Making, “Evidence based practice in decision
making”)
The assumption underlying evidence based decision making is
that assessing the results from a multitude of sources allows
decisions to be based on a foundation of research that has
been reviewed and considered statistically significant. This
review, conducted to specific standards,
allows busy
practitioners to rely on up to date and relevant research
findings, without having to carry out the necessary review
work themselves. As a result, better value for the money
invested in health care can be expected and better health
care means better health outcomes for individuals. There
have, however, been some drawbacks. While advances in
“We need to commit to ongoing evaluation and monitoring of
interventions undertaken to reduce health inequity. Some can affect
change quite quickly. Others will take more time. But we need to
have the ongoing measures to show the commitment is still there
and the inequities are not going away. And we need more frequent
reports than every five years to show those changes.” Dr. Cory
Neudorf, Board of the Canadian Public Health Association and
Medical Health Officer, Saskatoon. Presentation to Responding to
Health Inequities: The Role of Public Health, May, 2009
technology have increased access to a global data bank of
research, findings must still be applied within a local
context. Further, much of the necessary technological and
financial infrastructure needed to ensure evidence banks are
relevant and timely to quality improvements are still not in
place. The necessary cooperation between government,
academic and commercial interests is still lacking. As a
consequence, while there is agreement about the need for
quality information on which to base decisions, the
governance and oversight to put evidence based materials in
the hands of policy makers and practitioners is not yet fully
developed. In spite of the very real potential contained in
systematic, evidence-based approaches to practice and policy,
“(e)vidence alone will never resolve the numerous complex
decisions involved in taking care of individuals or making
health care decisions for diverse populations.” (Clancy and
Cronin)
Drawbacks aside, evidence based approaches are clearly
important. For front line practitioners, clinicians and policy
makers, the challenge lies in understanding the rules
underlying evidence based material and applying some basic
rules of literature review when reading the evidence case.
Cultural competency is also a key trait for developing
evidence based decision making. The medical model is not the
only source of information for our decision making processes.
“Research findings derived from a single study are rarely definitive, while replication of results in multiple studies offers assurance that the findings are reliable.
Systematic reviews, based on quantitative techniques to evaluate and synthesize a body of research in a particular area, represent a core component of efforts to
incorporate science into clinical decisions, yet there is a recognized need to expedite this process to keep up with the continuously growing literature and the need
to transfer knowledge to the consumer and clinician at the point of care.” Carol M. Clancy and Kelly Cronin, Health Affairs, 24, no. 1 (2005): 151-162
10.1377/hlthaff.24.1.151 (abstract at:
IMAGINE POPULATION HEALTH PRIMER - 20
We must incorporate respect for other cultural bases of
knowledge, such as traditional healing and medicines, in
decision making and evidence gathering.
Clearly, objective evidence is an important tool. An evidence
based decision making process provides a more rational,
credible basis for the decisions we make. A case for our
practice decisions must be built on objective evidence that is
difficult to refute. Objective evidence can help make the
case where competing interests may have undue influence.
Ultimately, a case built on credible, objective evidence
strengthens our purpose and effectiveness. Note: some
community development approaches, such as Capabilities
Approach “may provide a richer evaluative space enabling
improved evaluation of many interventions.” This is an
important consideration for evidence based development.
Tools for thought: Literature Review for an Evidence
Based Case—Basic guidelines
A basic literature review should tell you what is known about
a topic, what is missing, new or unexplored and what questions need to be considered. You should also emerge with a
strong sense of who are the leading researchers in the area
and what controversies or consensus have developed. Then,
following the cycle below, you can build the evidence case.
PHASE ONE: IDENTIFY
THE TOPIC
Steps:
Phase Four: Feedback and Evaluation
What is it that you
want to know about?
What do you already
know about the
situation?
What local resources
exist that can help?
What are the measures
for your program?
What unintended consequences did your
decision produce?
Are you satisfied with
the results or do you
need to change the
decision?
Phase Two: Develop
and Evaluate
Sources
Steps:
What credibility do the
sources have?
What’s missing? What
additional evidence do
you need?
How and where can
you get that?
PHASE THREE:
IMPLEMENTATION
Steps:
Review the evidence.
What are the
implications? How does
the evidence impact your
decision making?
Adapted from Voice: The SRC Tool box; Courtesy of the North Carolina Division of
Vocational Rehabilitation Services, George McCoy, Director
POPULATION HEALTH PRIMER… 21
W
Weaving it all together
Change
is
never
easy.
Finding the balance between
the
best
of
the
scientific
and
corporate
world of medicine and the
emerging fields of organizational change
and community development is going to
be a challenge. The good news is that
there are many practitioners who are
seeking this balance as part of their own
commitment to personal and professional
excellence.
The complexities of applying a population health approach
lead some to argue that population health implementation
challenges are too large and many to overcome. Change
can be difficult and in a fast-paced, ever-shifting health
care environment, where skilled human resource shortages
are being felt and demand for service is increasing, it may
seem like the requirement to shift to a population health
approach is just one more impediment to productivity.
The current economic downturn may also lead many to
argue that there are no resources and “now is not the time”
to invest in upstream approaches to health. However, as Dr.
Marmot, head of the WHO commission on the determinants
of health said in 2008, the “…largest gains in life
expectancy in the United Kingdom came in the 2 decades of
world war.” The reality is that economic crisis can actually
kick start the implementation of this emerging approach,
which is well-supported by evidence. There is an increased
need to access the savings and improved health outcomes
that can be realized through prevention and a population
Health care is a misnomer. Currently, our conception of health care is actually sick
care. Population health issues the challenges to shift our thinking so that health care
is truly about supporting, enhancing and restoring health. This will free up scare
resources so that the services required when people are sick are available to them,
reducing wait lists and the social and emotional burdens of disease.
IMAGINE-action
(IMAGINE in action)
“In health promotion, a settings-based approach is seen as a
more effective way to improve people’s health and health
behaviour because the emphasis is on changing settings (e.g.,
workplace, schools) instead of individuals.” (Whitelaw, Baxendale, Bryce, Machardy, Young, & Witney, 2001).
based approach to health service delivery, and
methodologies supporting this approach are actually costeffective and reasonably easy to implement.
Some health practitioners, particularly those in more acute
settings, have trouble seeing how the upstream thinking of
population health fits with their work. But it doesn't matter
where you deliver your services; there is always somewhere
further upstream to look, even in palliative care. In Northern
Health we are fortunate to have a strong foundation to
support every practitioner who wishes to apply a population
health approach. In fact, by adopting this as one of the four
strategic initiatives, Northern Health has given all staff and
physicians delivering services in the region a mandate
to employ this broader view in planning and
providing services. It may feel uncomfortable,
at first, given the depth and intensity of our
various professional training programs, to
devote time and effort to population health. In
doing so, however, we achieve better results
for a broader range of people than we do by
focusing on individual points of professional
care alone.
We also benefit from the
opportunity to work in more collaborative,
interdisciplinary ways, and this can enhance the
Implementing the Population Health Approach:
http://www.phac-aspc.gc.ca/ph-sp/implement/indexeng.phpaspc.gc.ca/ph-sp/implement/index-eng.php
IMAGINE POPULATION HEALTH PRIMER - 22
challenge and reward experienced at work, leading to greater
job satisfaction.
Even with the most seemingly intractable issues, it is possible
to make a difference. For example, Ireland set a measurable
goal to reduce poverty from 15% to 10% within 10 years.
Within 4 years, the rate fell to 5%. The target was achieved
and exceeded by the setting of clear goals, coupled with
increases in social assistance payments, educational initiatives
and employment programs. (Neudorf, Presentation to
Responding to Health Inequities: The Role of Public Health,
May, 2009 )
If you’re not sure where to start, the population health check
list (this page) is an excellent jumping off point to help you
think about population health and using the IMAGINE tools.
Programs within Northern Health have effectively used this to
transform their services, as well as to envision new programs
from the ground up. You will also find tools on i-Portal to
assist you. And your Population Health Team is only a phone
call away (250-649-7061). We hope this primer is useful to
you and that you will enjoy the challenge of IMAGINE-action
in your work. IMAGINE that: you can apply a population
health approach in your planning, programs and practice!
Tools for thought: Population Health Check List
First steps
1. Identify the population of interest: Who is the group you are
working with or want to work with?
2. Describe this population of interest fully including:
Demographics
Health Status
Indicators
Impact of health determinants
Cultural characteristics and issues
3. Identify risks and predictors of disease: What are shared
ailments and issues that matter to this group?
4. Identify points of access: Where can you reach them? Who might be
gatekeepers?
5. Engage the community of interest: Where do they think the
issues lie? Where do they want to start?
Quick tips
•
•
•
•
Choose an intervention with a high likelihood of success–
involving people in designing the intervention increases the
chance of its success
Develop the intervention—look for the key facilitators in the
group
Implement and evaluate—make sure you are recording what is
working and what is not
Document the process—Tell your story and share the lessons
Inclusion matters! Remember the old saying, “If you aren't at the table, you're likely on the menu!”
So make sure any efforts include the voices, insights or presence of those we are trying to help.
POPULATION HEALTH PRIMER… 23
Resources Consulted
Annenberg Institute, “Engaging Communities” VUE Number 13,
Fall 2006. found at: http://www.annenberginstitute.org/VUE/
fall06/Fruchter.php
Anne-Emanuelle Birn, & Kirby Randolph, PhD, Introduction:
History, public health, and social justice -- the Spirit of 1848 &
reproductive health, APHA 15th Annual Meeting, Scientific Session,
2007
Bennet, Carolyn. Building a national health care system, CMAJ •
April 27, 2004; 170 (9).
http://www.cmaj.ca/cgi/content/
full/170/9/1425?eaf
Butler- Jones, Dr. David. The State of Public Health in Canada
2008. Mohan and Patrick-Mohan “Throw the Money Upstream: An
Alternative Strategy to Improve Public Health.” Nonprofit and
Voluntary Sector Quarterly.2008; 37: 34S-43S
Justice as the Foundation of Public Health:
Mohamed Khalil, et al. “Upstream Investments in Health Care:
National and Regional perspectives. ABFM Journal of Family and
Community Medicine, 2005; 12(1)
Nancy Krieger, PhD, “A Vision of Social Justice as the Foundation
of Public Commemorating 150 Years of the Spirit 0f 1848,
American Journal of Public Health
Horace Miner, Body Ritual among the Nacirema," American
Anthropologist 58 (1956): 503-507; as PDFat: <http://
www.aaanet.org/pubs/bodyrit.pdf
Dr. Cory Neudorf, Overcoming Health Disparities: What Policy
Analysts Can Do So That Political Leaders Can Act. May 2009
PHABC, Health Inequities in British Columbia: Discussion Paper,
November 2008
Carolyn M. Clancy and Kelly Cronin, Evidence-Based Decision
Making: Global Evidence, Local Decisions, Health Affairs, the
Policy Journal of the Health Sphere; 24, no. !(2005) 151-162
Provincial Council of Medical Health Officers, Health Inequities in
British Columbia Discussion Paper.. November 2008. found at:
http://www.phabc.org/files/HOC_Inequities_Report.pdf?
NSNST_Flood=0c0578ae53354aa1af6b46607bfb3bbe
Coast et al. Editorial “Should the capability approach be applied
in Health Economics?” Health Economics Vol 17, Issue 6, may
2008.
Dennis Raphael, ed. Social Determinants of Health: Canadian
Perspectives, 2nd edition, edited by Forewords by Carolyn
Bennett and Roy Romanow. http://tinyurl.com/5l6yh9
Delaney, Faith. Muddling through the middle ground: theoretical
concerns in intersectoral collaboration and health promotion
Health Promot. Int. 9: 217-225.
Dennis Raphael, Poverty and Policy in Canada: Implications for
Health
and
Quality
of
Life,
found
at:
http://tinyurl.com/2hg2df
The Chief Public Health Officer’s Report on the State of Public
Health in Canada 2008 Helping Canadians achieve the best health
possible found at: http://www.phac-aspc.gc.ca/publicat/2008/
cpho-aspc/index-eng.php
Robust Decision Making, “Evidence based practice in decision
making” found at: http://www.robustdecisions.com/decisionmaking-technology/evidence-based-practice.php
Evans, Barer, and Marmor, Why Are Some People Healthy and
Others Not? The Determinants of Health of Populations,
Population Health Program, Canadian Institute for Advanced
Research
Frankish, CJ et al. "Health Impact Assessment as a Tool for
Population Health Promotion and Public Policy." Vancouver:
Institute of Health Promotion Research, University of British
Columbia, 1996.
Hamelin, Christopher. Public Health and Social Justice in the Age
of Chadwick, Cambridge University Press, 1998. A Vision of Social
Dr. David Ullman. Making Robust Decisions: Decision Management
for Technical, Business, and Service Teams, 2006
World Health Organization. Commission on the Social Determinants
of Health, Closing the Gap in a Generation: Health Equity through
Action on the Social Determinants of Health, November 2008. found
at: http://www.who.int/social_determinants/en/
IMAGINE POPULATION HEALTH PRIMER - 24
Your feedback and contributions to this
primer are always welcomed. Please
send any ideas or suggestions to:
Social justice is a matter of life and death. It
affects the way people live, their consequent
chance of illness, and their risk of premature
death. …. Within countries there are
dramatic differences in health that are
closely linked with degrees of social
disadvantage. Differences of this magnitude,
within and between countries, simply should
never happen. These inequities in health,
avoidable health inequalities, arise because
of the circumstances in which people grow,
live, work, and age, and the systems put in
place to deal with illness. The conditions in
which people live and die are, in turn,
shaped by political, social, and economic
forces.
Social and economic policies have a
determining impact on whether a child can
grow and develop to its full potential and live
a flourishing life, or whether its life will be
blighted. Increasingly the nature of the
health problems rich and poor countries have
to solve are converging. The development of
a society, rich or poor, can be judged by the
quality of its population’s health, how fairly
health is distributed across the social
spectrum, and the degree of protection
provided from disadvantage as a result of illhealth. WHO Commission, WHO, CDSH Closing
the gap in a generation: health equity
through action on the social determinants of
health. Final Report of the Commission on
Social Determinants of Health. 2008
Population Health
Northern Health
Centre for Healthy Living
1788 Diefenbaker Drive
Prince George, BC V2N 4V7
Community Development Frameworks Quick Links
British Columbia Healthy Communities (Integral Capacity Building Framework):
http://www.bchealthycommunities.ca/Images/PDFs/Capacity%20Building%20Framework%
20April%202006.pdf
The Scottish Government has an excellent set of resources for community capacity
development at: http://www.scotland.gov.uk/Topics/Education/Life-Long-Learning/
LearningConnections/policytopractice/ccb
A paper on the Capability Approach is found at: http://www.capabilityapproach.com/
pubs/323CAtraining20031209.pdf
UNESCO Capacity Building Framework,
images/0015/001511/151179eo.pdf
2006:
http://unesdoc.unesco.org/
POPULATION HEALTH PRIMER… 25
IMAGINE
A CALL TO ENVISION THE FUTURE THROUGH OUR ACTIONS TODAY
We believe the IMAGINE acronym highlights the key activities and directions for improving health outcomes before acute and chronic
conditions can take hold and impose their dreadful burdens of reduced quality life, increased pain and disease and premature death. We
have found it really helpful as an aide to keeping our eye on the prize and not getting shaken from our path by competing agendas and
external threats and pressures.
COMING SOON:
We will be producing sequels to the IMAGINE Primer. First up, a collection of stories from around the Northern Health region that will
illustrate and exemplify each of the IMAGINE principles in action. The next publication will be an Evaluation primer that uses the IMAGINE
principles to assist in developing measures and methods for more effective capture of the intangibles of successful health promotion and
disease prevention work. Further ideas for the Healthy Community Development printing press are most welcome.
Read our other materials:
You can access other reports and documents produced by Northern Health’s Population Health and Healthy Community Development
Program at http://iportal.northernhealth.ca/ClinicalResources/pophealthdata/Pages/default.aspx
10-400-3190 Rev09/09