Advance Population Health Research Articles

Identifying Veterans with a Higher Risk of Social Needs Using Cluster Analysis.

Many social need screening to advance population health and reduce health disparities, but barriers to screening remain. Improved knowledge of patient populations at risk for social needs based on administrative data could facilitate more targeted practices, and by extension, feasible social need screening and referral efforts. To illustrate the use of cluster analysis to identify patient population segments at risk for social needs. We used clustering analysis to identify population segments among Veterans (N=2010) who participated in a survey assessing nine social needs (food, housing, utility, financial, employment, social disconnection, legal, transportation, and neighborhood safety). Clusters were based on eight variables (age, race, gender, comorbidity, region, no-show rate, rurality, and VA priority group). We used weighted logistic regression to assess association of clusters with the risk of experiencing social needs. National random sample of Veterans with and at risk for cardiovascular disease who responded to a mail survey (N=2010). Self-reported social needs defined as the risk of endorsing (1) each individual social need, (2) one or more needs, and (3) a higher total count of needs. From the clustering analysis process with sensitivity analysis, we identified a consistent population segment of Veterans. From regression modeling, we found that this cluster, with lower average age and higher proportions of women and racial minorities, was at higher risk of experiencing ≥ 1 unmet need (OR 1.74, CI 1.17-2.56). This cluster was also at a higher risk for several individual needs, especially utility needs (OR 3.78, CI 2.11-6.78). The identification of characteristics associated with increased unmet social needs may provide opportunities for targeted screenings. As this cluster was also younger and had fewer comorbidities, they may be less likely to be identified as experiencing need through interactions with healthcare providers.

Fatalism or vigilance? Exposure to infant and maternal deaths and subsequent use of maternal health services in Malawi

In developing contexts, where formal health services are still expanding, understanding what factors discourage individuals from using health services is critical to advance population health. A long theorized, but rarely investigated, conjecture is that in high-mortality contexts, exposure to death can beget fatalism, or even foster distrust of formal healthcare, locking families into cycles of low use of health services. A counter perspective, however, suggests exposure to death can encourage individuals’ health vigilance, corresponding with their higher use of health services. We test these competing ideas by analyzing the associations between women’s intimate exposure to death in the context of pregnancy and delivery via (1) a sister’s maternal death and (2) an infant child’s neonatal death, and their subsequent use of maternal health services. We focus on the context of Malawi, a setting that features high maternal and infant mortality rates, similar to those observed across much of sub-Saharan Africa, as well as persistent gaps in service use. Specifically, we use Malawi Demographic and Health Survey (2015–16) data to examine if a sister’s maternal death or a child’s neonatal death corresponds with a woman’s odds of attending full antenatal care during a subsequent pregnancy or delivering the pregnancy at a formal health facility. Given the qualitatively distinct nature of losing one’s only or first child, we also assess if the effect of a child’s neonatal death varies by birth order. The results show that maternal and neonate death exposures correspond generally with women’s higher use of maternal health services, challenging the notion that exposure to death fosters fatalism or distrust. Although the results vary in significance, the nuanced findings highlight women’s vigilance in the face of health threats, emphasizing their resilience amid a high burden of familial loss.

The CanPath-HDRN Canada Collaboration: Enabling Multi-jurisdictional Research in Canada

ObjectiveTo highlight the partnership between the Canadian Partnership for Tomorrow’s Health (CanPath) and Health Data Research Network (HDRN Canada), which enables researchers to link CanPath’s health and lifestyle survey data to health records and related data across multiple regions. BackgroundCanPath is a population health study of over 350,000 Canadians from seven regional cohorts across all ten provinces, making it one of the world's largest population cohorts. HDRN Canada is a network of member organizations, including provincial, territorial, and pan-Canadian data centres. ApproachThis partnership leveraged collective expertise and resources to facilitate the linkage of CanPath’s harmonized data to multi-regional health and health-related administrative data held at HDRN Canada’ s data centres. Researchers can access these data for multi-regional projects through HDRN Canada’s Data Access Support Hub, which provides a single access portal. ResultsResearchers were able to successfully link CanPath’s survey data to provincial administrative health data. The collaboration’s streamlined process for data access enhances efficiency and facilitates pan-Canadian population health research. ConclusionThis collaboration demonstrates the feasibility and value of linking population health datasets while demonstrating the challenges and opportunities associated with accessing national administrative health data within a federated health data system. ImplicationsThe partnership between CanPath and HDRN Canada has significant implications for advancing population health research in Canada. By providing researchers with access to linked data from diverse sources, the partnership enables comprehensive investigations into health determinants, disease patterns, and clinical outcomes. This enhances the scope and depth of population health research in Canada, thereby leading to a better understanding of the most pressing health challenges.

An innovative linked Electronic Health Record derived data ecosystem for understanding the complexities of health and ageing.

ObjectiveWe describe the creation of an Electronic Health Record (EHR) derived linked data platform within the Australian National Centre for Healthy Ageing (NCHA). ApproachOur approach involved establishing a core set of EHR data suitable for research from the sole public health provider within a defined geographic region. Relevant items were selected based on published literature and consensus processes and curated within a specialised research data warehouse. Curation involved: data validation, quality assessment, internal linkage between episodes and data harmonisation/merging. An AI supported natural language processing pipeline was implemented to extract text-based data. Approvals were obtained from government agencies to link commonwealth claims data (primary care, medication, aged care, death) and state administrative hospital data, for all residents aged ≥60 years. Publicly available datasets were scoped for inclusion and collaborations established to incorporate local council data. ResultsA core of 113 curated items for >900,000 people over 10 years have been established across 4 hospitals and 10 community/outpatient services. Linked state and commonwealth data were obtained for 179,089 residents aged >60 years (Jan 2010-May 2021, linkage accuracy 98.4%). Environmental (greenery, air pollution, walkability) and Census data have been incorporated for each neighbourhood (Statistical Area 1). Data access, extraction and release has been tested through over 30 use-case projects in: dementia, residential aged care, medication use, homelessness, environmental impacts on health and ageing and health service redesign. ImplicationsThe NCHA Data Platform provides an international exemplar for the use of linked EHR data in advancing population health research.

Building a strong public health nursing workforce in Canada: A continuing education solution.

Building a strong public health nursing (PHN) work-force capable of advancing population health and reducing inequities is critical. Though undergraduate nursing education is expected to provide introductory knowledge and practice of PHN in Canada, this is not always sufficient to adequately prepare nursing graduates for the complexity of PHN practice. To be practice ready for the full scope of PHN roles and interventions, new baccalaureate nurses and new registered nurses in public health are required to apply PHN competencies, theory, and knowledge of nursing and public health sciences, and to practice within the mandates of provincial and territorial public health legislation. To advance practice readiness a formal continuing education program is essential to foster these critical roles in PHN. This article describes the development of a postgraduate continuing education program for preparation to practice in PHN.

Precision emergency medicine.

Precision health is a burgeoning scientific discipline that aims to incorporate individual variability in biological, behavioral, and social factors to develop personalized health solutions. To date, emergency medicine has not deeply engaged in the precision health movement. However, rapid advances in health technology, data science, and medical informatics offer new opportunities for emergency medicine to realize the promises of precision health. In this article, we conceptualize precision emergency medicine as an emerging paradigm and identify key drivers of its implementation into current and future clinical practice. We acknowledge important obstacles to the specialty-wide adoption of precision emergency medicine and offer solutions that conceive a successful path forward. Precision emergency medicine is defined as the use of information and technology to deliver acute care effectively, efficiently, and authentically to individual patients and their communities. Key drivers and opportunities include leveraging human data, capitalizing on technology and digital tools, providing deliberate access to care, advancing population health, and reimagining provider education and roles. Overcoming challenges in equity, privacy, and cost is essential for success. We close with a call to action to proactively incorporate precision health into the clinical practice of emergency medicine, the training of future emergency physicians, and the research agenda of the specialty. Precision emergency medicine leverages new technology and data-driven artificial intelligence to advance diagnostic testing, individualize patient care plans and therapeutics, and strategically refine the convergence of the health system and the community.

A Call for Nurses to Become Media Competent: An Interview With Barbara Glickstein.

In this column, Barbara Glickstein, a public health nurse, health reporter, and media strategist, shares insights about nurses' involvement and engagement in the media. She founded "Barbara Glickstein Strategies," a company that trains healthcare leaders to become media competent to advance population health and public policy.

Using Internet Databases to Advance Health Equity, Population Health, and Workforce Planning

Using Internet Databases to Advance Health Equity, Population Health, and Workforce Planning

Post-Acute Care: Advancing Population Health Interventions, Risk Assessment, and Implications for Readmissions and Cost-Effectiveness through Telehealth

Post-Acute Care: Advancing Population Health Interventions, Risk Assessment, and Implications for Readmissions and Cost-Effectiveness through Telehealth

Actioning the Learning Health System: An applied framework for integrating research into health systems

Health systems across the world experience pervasive gaps in the speed with which high quality evidence is generated, implemented and refined. A Learning Health System (LHS) approach that blends research with health care operations is to eliminate or reduce delays. This paper builds on existing LHS frameworks to deepen our practical understanding of the research-health systems operations interface and to provide actionable insights on how to realize a LHS in practice. We present a LHS action framework that describes how research and health care operations are linked and enacted in a comprehensive LHS approach to advance population health and health equity. Health systems seeking to implement a LHS approach can use this framework to identify capabilities necessary to enact the learning elements, including key questions and methods, to ensure a systematic approach to learning and achieving equity-centered quadruple aim metrics.

Arabic Web-Based Information on Oral Lichen Planus: Content Analysis.

The use of web-based health information (WBHI) is on the rise, serving as a valuable tool for educating the public about health concerns and enhancing treatment adherence. Consequently, evaluating the availability and quality of context-specific WBHI is crucial to tackle disparities in health literacy and advance population health outcomes. This study aims to explore and assess the quality of the WBHI available and accessible to the public on oral lichen planus (OLP) in Arabic. The Arabic translation of the term OLP and its derivatives were searched in three general search platforms, and each platform's first few hundred results were reviewed for inclusion. We excluded content related to cutaneous LP, content not readily accessible to the public (eg, requiring subscription fees or directed to health care providers), and content not created by health care providers or organizations (ie, community forums, blogs, and social media). We assessed the quality of the Arabic WBHI with three standardized and validated tools: DISCERN, Journal of the American Medical Association (JAMA) benchmarks, and Health On the Net (HON). Of the 911 resources of WBHI reviewed for eligibility, 49 were included in this study. Most WBHI resources were provided by commercial affiliations (n=28, 57.1%), with the remainder from academic or not-for-profit affiliations. WBHI were often presented with visual aids (ie, images; n=33, 67.4%). DISCERN scores were highest for WBHI resources that explicitly stated their aim, while the lowest scores were for providing the effect of OLP (or OLP treatment) on the quality of life. One-quarter of the resources (n=11, 22.4%) met all 4 JAMA benchmarks, indicating the high quality of the WBHI, while the remainder of the WBHI failed to meet one or more of the JAMA benchmarks. HON scores showed that one-third of WBHI sources had scores above 75%, indicating higher reliability and credibility of the WBHI source, while one-fifth of the sources scored below 50%. Only 1 in 7 WBHI resources scored simultaneously high on all three quality instruments. Generally, WBHI from academic affiliations had higher quality scores than content provided by commercial affiliations. There are considerable variations in the quality of WBHI on OLP in Arabic. Most WBHI resources were deemed to be of moderate quality at best. Providers of WBHI could benefit from increasing collaboration between commercial and academic institutions in creating WBHI and integrating guidance from international quality assessment tools to improve the quality and, hopefully, the utility of these valuable WBHI resources.

Measuring quality of dental care during pregnancy

BackgroundThe authors aimed to develop and validate 2 Dental Quality Alliance measures of dental care access during pregnancy (Utilization of Services During Pregnancy, Oral Evaluation During Pregnancy) using claims and enrollment data and to report performance on these measures for a sample of Medicaid and Children’s Health Insurance Program beneficiaries. MethodsThe authors used Transformed Medicaid Statistical Information System enrollment and claims data for 7,767,806 people enrolled in 5 state Medicaid programs and Children’s Health Insurance Programs during 2018. The authors used split-half reliability testing to assess measure reliability. The authors calculated 95% CIs to assess statistically significant variation in performance between programs. ResultsThe intraclass correlation coefficient used to assess agreement between the split samples was 0.992 (95% CI, 0.941 to 0.999; P < .0001) for Utilization of Services During Pregnancy and 0.983 (95% CI, 0.879 to 0.998; P < .0001) for Oral Evaluation During Pregnancy. Performance scores ranged from 20% through 34% of beneficiaries receiving any dental service during pregnancy (Utilization of Services During Pregnancy) and from 14% through 23% of beneficiaries receiving a periodic or comprehensive oral evaluation during pregnancy (Oral Evaluation During Pregnancy), with statistically significant differences between programs. ConclusionsThe measures reliably assessed access to dental services and can distinguish performance between programs. Practical ImplicationsThese measures can be used to advance population health by means of supporting national efforts to improve access to dental care during pregnancy.

Advancing Population Health Through Open Environmental Data Platforms.

Data stand as the foundation for studying, evaluating, and addressing the multifaceted challenges within environmental health research. This chapter highlights the contributions of the Canadian Urban Environmental Health Research Consortium (CANUE) in generating and democratizing access to environmental exposure data across Canada. Through a consortium-driven approach, CANUE standardizes a variety of datasets - including air quality, greenness, neighborhood characteristics, and weather and climatic factors - into a centralized, analysis-ready, postal code-indexed database. CANUE's mandate extends beyond data integration, encompassing the design and development of environmental health-related web applications, facilitating the linkage of data to a wide range of health databases and sociodemographic data, and providing educational training and events such as webinars, summits, and workshops. The operational and technical aspects of CANUE are explored in this chapter, detailing its human resources, data sources, computational infrastructure, and data management practices. These efforts collectively enhance research capabilities and public awareness, fostering strategic collaboration and generating actionable insights that promote physical and mental health and well-being.

How attitudes of state and community leaders regarding health equity and social determinants of health are associated with behavioral intentions to improve population health.

A critical driver of population health, well-being, and equity is making health a shared value, or the belief that health is a priority for oneself and one's community. For people in positions of influence, attitudes regarding their organization's perspective may result in decisions that advance health equity or reinforce inequities. Yet despite the potential role of leaders in influencing health and well-being, little is known about their attitudes regarding their organization's perspective on what shapes health, or how their attitudes translate into actions that improve population health. The objectives of this study are twofold: (1) to understand leaders' attitudes with regard to their organization's perspective on population health and (2) to identify the attitudes associated with leaders' perspectives regarding their organization's intention to engage in behaviors that advance population health. We designed a survey instrument grounded in the Theory of Planned Behavior and fielded the survey to 18,367 state and community leaders across all 50 U.S. states, 325 U.S. cities, and nine sectors from fall 2020 until spring 2022. We received surveys from 5,450 leaders, yielding a 32 percent response rate. Survey respondents viewed social determinants of health and health equity as important factors influencing population health. Additionally, two attitudes were most associated with leaders' intentions to promote population health-"self-efficacy" (a leader's confidence in taking action to promote health for all) and "behaviors valued by important others" (how much certain groups want the organization to take action that promotes health for all). Efforts to improve population health through leaders should focus on supporting leaders' self-efficacy and on increasing leaders' perceptions regarding behaviors valued by important others. Governmental entities and funders can use these data to support leaders' efforts in improving population health, well-being, and equity.

All talk…only a little action: a reflection on embedding equity into integrated care models in Ontario, Canada

Background: Ontario Health Teams (OHTs) are a recently introduced model of delivery intended to integrate services to deliver connected care to defined populations in Ontario, Canada. The Quadruple Aim advocates for improving patient experience, reducing cost, advancing population health, and improving the provider experience; it is meant to be a guide for OHTs for performance outcomes and as a framework for evaluation and reporting. The Quintuple Aim, incorporating an added focus on health equity, has recently been introduced to OHTs, where equity is also built into continuous quality improvement requirements. As embedded OHT research fellows, we recognize our key role in supporting equity in healthcare delivery and programs. However, we also observe the challenges to generating actionable initiatives to integrate equity into OHTs.&#x0D; Objective: The objective of this presentation is to describe equity initiatives being incorporated in four OHTs in Ontario, Canada and to identify the barriers and facilitators at the micro, meso and macro levels. This presentation is aimed at those involved in integrated care research, policy, practice, and education.&#x0D; Methods: We will use a multiple case study design to describe the contexts of four integrated care models representing large, mid, and small urban regions of the province. This work is guided by the Rainbow Model for Integrated Care, which conceptualizes different domains of integrated care. We will include multiple data sources from each OHT, including key documents, formal and informal community partnerships, the level and nature of engagement with equity-deserving groups in governance processes, the extent to which equity is emphasized in strategic plans and other documents, and the resources available, we share insights gleaned on barriers and facilitators to applying an equity lens. &#x0D; Key Results: We identify challenges related to data availability for health equity decision making and health systems planning. Specifically, difficulties exist in accessing meaningful and linked data to understand OHT attributed populations; these difficulties are compounded when seeking data specific to equity deserving groups and when attempting to link equity relevant indicators to health system indicators. Furthermore, meaningful engagement with equity deserving groups in order to build relationships requires time and resources that are difficult to source; such engagement is particularly challenging in an environment of limited financial resources, where frequent reporting and pressure to quickly deliver outcomes is emphasized. OHTs are collaborative governance models composed of representation from member organizations, patients, and academics; this collaborative approach to governance can be a facilitator to embedding equity deserving groups into the structure of OHTs.&#x0D; Next Steps: Ontario Health Teams require support in creating comprehensive equity approaches that are specific to the needs of their communities and teams; further work is needed to better understand the needs of OHTs in this regard.

Integrated Care: A Person-Centered and Population Health Strategy for the COVID-19 Pandemic Recovery and Beyond.

The COVID-19 pandemic has mandated a re-imagination of how healthcare is administered and delivered, with a view towards focusing on person-centred care and advancing population health while increasing capacity, access and equity in the healthcare system. These goals can be achieved through healthcare integration. In 2019, the University Health Network (UHN), a consortium of four quaternary care hospitals in Ontario, Canada, established the first stage of a pilot program to increase healthcare integration at the institutional level and vertically with other primary, secondary and tertiary institutions in the Ontario healthcare system. Implementation of the program was accelerated during the COVID-19 pandemic and demonstrated how healthcare integration improves person-centred care and population health; therefore serving as the foundation for a health system response for the COVID-19 pandemic recovery and beyond.

Priority actions for promoting population mental health and wellbeing

Mental health promotion is an essential strategy for improving population mental health and wellbeing and preventing poor mental health. This paper outlines the case for governments to invest in promoting population mental health and wellbeing by adopting a mental health promotion approach.Drawing on a synthesis of the international evidence, findings are presented on effective mental health promotion interventions that can be feasibly implemented across the life course in everyday settings and that have the potential to be scaled-up at a country level. Based on a review of 111 meta-analyses and 57 systematic reviews, both universal and targeted interventions are identified, that have been shown to enhance good mental health, reduce the risk of mental ill-health, and advance population health and wellbeing. The implications of the findings for policy and practice are outlined.The policy structures and processes that are needed to support the delivery of evidence-based strategies at a population level are considered, including investing in the systems and capacity to ensure their sustained implementation. In particular, the need for policy models to support intersectoral action at a whole-of-government and whole-of-society level is outlined.

Developing a Sample Frame from Multiple Sample Frame Sources and Fielding a Survey to State and City Leaders

A critical driver of population health, well-being, and equity is making health a shared value, or the belief that health is a priority for oneself and one’s community. For people in positions of influence, attitudes regarding their organization’s perspective may result in decisions that advance health equity or reinforce inequities, yet little is known about leaders’ attitudes regarding their organization’s perspective on what shapes health, or how their attitudes translate into actions that improve population health. We conducted a mixed-mode survey from fall 2020 to spring 2022. The objectives of the survey were (1) to understand leaders’ attitudes regarding their organization’s perspective on population health and (2) to identify the attitudes associated with leaders’ perspectives regarding their organization’s intention to engage in behaviors that advance population health. Findings from this survey will fill the gaps in the evidence base regarding what people in positions of influence think about social determinants of health and health equity, as well as their attitudes regarding their organization’s perspective. A major challenge for the study was identifying the sample frame, meant to provide a list of all U.S. leaders at the city and state level covering ten sectors. We identified five sample frame sources from which we pulled and constructed a sample frame. We sampled 17,400 organizations and obtained completed surveys from 5,450 leaders, achieving a 32 percent response rate. We used the best sample frame sources we knew of to develop our sample frame. The percent of contact information we obtained from the five sample frame sources was high, and rates of ineligibility were low. Response rates varied widely by sector. Survey respondents tended to be slightly more male and very slightly more White compared to the full eligible sample, and more liberal than the general population.

H.O.P.E. grows: An academic-public health partnership to reimagine public health services and increase mental health access among socially vulnerable populations.

To illustrate the process of developing and sustaining an academic-public health partnership for behavioral health integration through an expansion of the Aligning Systems for Health (ASfH) framework. Practice-informed primary data (2017-2023) from the Holistic Opportunity Program for Everyone (HOPE) Initiative based in Charlotte, NC. The unit of analysis in this descriptive case study is inter-organizational, specifically focusing on an academic-public health relationship. We illustrate the partnership process across the ASfH four core areas, including key challenges and insights. Utilized a Critical Moments Reflection methodology and review of HOPE program data. (1) Formal partnership structures and processes are essential to monitoring the four ASfH core components for on-going system alignment. (2) Aligning systems for health principally involves two ecologies: (i) the health program and (ii) the partnership. The vitality and sustainability of both ecologies require continuous attention and resource investment. (3) Relationships rest at the heart of aligning systems. (4) With comparative advantages in research methods, the academic sector is especially poised to collaborate with healthcare systems and human service organizations to study, develop, implement, and scale evidence-based health interventions. The academic sector shares overlapping purposes with the public health, healthcare, and social services sectors while providing complementary value. It is a critical sectoral partner in advancing population health and health equity.

The Role of Primary Care in Improving Population Health.

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.