CIHR-IPPH and CPHI-CIHI Population Health Intervention Research Casebook - 2011

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The Canadian Population Health Initiative (CPHI), part of the Canadian Institute for Health Information (CIHI), explores patterns of health within and between population groups to foster a better understanding of factors that affect the health of individuals and communities. CPHI also seeks out and summarizes evidence about 'what works' at a policy and program level to reduce inequities, improve the health and well-being of Canadians and contribute to improvements in Canada's health system. Please visit the CPHI website for more information on our products and current activities.

The Institute of Population and Public Health (IPPH) is one of 13 Institutes that comprise the Canadian Institutes of Health Research (CIHR), Canada's major federal funding agency for health research. IPPH aims to improve the health of populations and promote health equity in Canada and globally through research and its application to policies, programs and practice in public health and other sectors. Population health interventions are one of four strategic research priorities for IPPH. The past 10 years of the Institute's existence have seen a growing investment in population health intervention research. Please visit the IPPH website for more information on the Institute strategic priorities.

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Canadian Institutes of Health Research - Institute of Population and Public Health, Canadian Institute for Health Information - Canadian Population Health Initiative. Population Health Intervention Research Casebook, 2011.

Table of Contents



Acknowledgements

The Institute of Population and Public Health (IPPH) of the Canadian Institutes of Health Research (CIHR) and the Canadian Population Health Initiative (CPHI) of the Canadian Institute for Health Information (CIHI) would like to acknowledge the following individuals for their generous contributions of time and expertise to the Population Health Intervention Research Casebook:

  • The Core Project Leads and Casebook Editors, Emma Cohen (CIHR-IPPH) and Andrew Taylor (CIHI-CPHI), and other Core Implementation Team members Kelly Hogan (CIHI-CPHI), Emily Maddocks (CIHI-CPHI), Ashley Page (CIHR-IPPH), and Sarah Viehbeck (CIHR-IPPH).
  • The Casebook Advisory Committee: François Benoit (National Collaborating Centre for Healthy Public Policy), Tim Hutchinson (Public Health Agency of Canada), Yumna Choudhry (Canadian Institutes of Health Research), and Brenda Roche (Wellesley Institute).
  • Casebook Abstract Reviewers: Jino Distasio, Hillel Goelman, Carolyn Gotay, Scott Leatherdale, Florence Morestin, Cameron Norman, Candace Nykiforuk, Louise Potvin, Dawn Sheppard, and Sarah Viehbeck.
  • The authors, research teams and communities involved in the eight featured cases
  • Expert External Commentators: Ted Bruce (Vancouver Coastal Health) and Penny Hawe (University of Calgary).
  • Erica Di Ruggiero, Associate Director, CIHR-IPPH, Nancy Edwards, Scientific Director, CIHR-IPPH, Keith Denny, Manager, CIHI-CPHI, and Jean Harvey, Director, CIHI-CPHI, for their advice, feedback, leadership and support.
  • The authors who contributed photographs. All photographs used with permission.

Production of this report was made possible by financial contributions from the Canadian Institutes of Health Research and Health Canada. The views expressed herein do not necessarily represent the views of the Canadian Institutes of Health Research, the Canadian Institute for Health Information, or Health Canada.

The contents of this publication may be reproduced in whole or in part, provided the intended use is for non-commercial purposes and full acknowledgement is given to the Canadian Institutes of Health Research and the Canadian Institute for Health Information.

Foreword

Population health intervention research examines the impacts of policies, programs and resource distribution approaches on the health of whole populations. It is an emerging field of research that is critical in advancing efforts to reduce health inequities. Population health intervention research builds on several decades of research in important areas such as health promotion, health education and community interventions.

This casebook showcases population health intervention research in Canada. Importantly, the case studies, which were selected through a peer-review process, reveal some of the intriguing, yet often unanswered questions that surround population health intervention research, for example, how did the research question(s) arise; how were partners involved; how did local context shape the interventions; and what challenges were encountered in scaling up and sustaining interventions?

The casebook was a joint initiative of CIHR's IPPH and CIHI's CPHI.

IPPH and CPHI work in partnership to promote, advance and support population and public health research, infrastructure development, capacity building and knowledge exchange to improve the health of individuals, communities and global populations. We also implement proactive, ongoing external relations with population and public health researchers, research funders and research organizations across disciplines and sectors. This partnership approach facilitates the development of a strong pan-Canadian population health research network.

A key activity for our organizations is to showcase the experiences of those researching or working to address population health issues. This casebook describes research related to healthy weights and mental health exploring what works and what does not work about program and policy interventions to address health equity issues at a population level. In addition, the casebook illustrates that population health intervention research remains a nascent field. It raises important questions such as: what does a population health intervention approach mean when we are targeting vulnerable populations; how do we support research that involves complex interventions in non-health sectors or multilevel interventions that cut across the socio-ecological systems; and what kinds of knowledge synthesis approaches are most appropriate for this kind of research? We hope this casebook will help fuel discussions about these important topics among researchers who are applying and developing methods to answer such questions and decision makers who are using evidence to make difficult decisions about how to use scarce resources in ways that more equitably improve health status.

We would like to take this opportunity to acknowledge those individuals who generously contributed their time and expertise to develop this casebook, including IPPH and CPHI staff, the Population Health Intervention Research Casebook Advisory Committee members, and abstract peer reviewers. We would also like to thank the authors, research teams, and communities involved in the eight featured cases. Lastly, we offer thanks to our two commentators, whose insights on population health intervention research raise critical issues that are pertinent to all engaged in this arena of research.

We hope this casebook will become a valuable resource for promoting awareness of population health research evidence in Canada and beyond.

Sincerely,

Nancy Edwards

Scientific Director, Institute of Population and Public Health
Canadian Institutes of Health Research

Jean Harvey

Director, Canadian Population Health Initiative
Canadian Institute for Health Information

Population Health Intervention Research: Introducing the Cases

A population health perspective looks at health in broad terms and addresses questions such as what are the most important factors affecting people's health; why are some people healthier than others; and what can be done to improve the health of all peoples and communities. Population health interventions are intended to shift the risk of entire populations or communities by focusing on community and societal-level factors which influence the distribution of risk and illness in a society (Hawe & Potvin, 2009).

Population health intervention research uses scientific methods to produce knowledge about policy and program interventions that operate within or outside of the health sector1 and have the potential to impact health at the population level (Hawe & Potvin, 2009). Population health intervention research is a research process that involves knowledge production and is about designing and testing solutions to problems and getting solutions into place (Hawe & Potvin, 2009). It can involve aspects of program evaluation and integrates knowledge translation activities, but also extends and builds on these activities.

There have been several recent investments in population health intervention research in Canada. For example, the Population Health Intervention Research Initiative for Canada (PHIRIC) aims to increase the quantity, quality and use of population health intervention research through a strategic and deliberate alignment of initiatives by key organizations responsible for public health research, policy and practice. Apart from this initiative, examples of national organizations that have made strategic funding investments in population health intervention research include the CIHI, CIHR, the Heart and Stroke Foundation of Canada, and the Public Health Agency of Canada (Di Ruggiero, Rose & Gaudreau, 2009). In addition, the Public Health Agency of Canada has invested in six National Collaborating Centres for Public Health which have a knowledge synthesis, translation and exchange mandate that can promote population health intervention research.

The objectives of this casebook project are listed in the text box.

Casebook Objectives

  • Increase awareness and understanding of the value of population health intervention research.
  • Highlight different theoretical and methodological approaches to population health intervention research.
  • Illustrate lessons learned from both successful and less successful initiatives.
  • Demonstrate the impact that population health intervention research can have in informing research, policy, program and practice changes to improve health and health equity and illustrate the 'how' behind this impact.
  • Facilitate knowledge translation, including the uptake and adoption of population health intervention research, by a primary audience of program planners and policy decision makers as well as other groups.

The examples in this casebook illustrate the range of research projects that identify as population health intervention research and showcase some of the theoretical and methodological approaches as well as tools used in this field. The cases are not prescriptive; they are examples intended to stimulate reflection and discussion. Each case describes a research project that demonstrates impact and lessons learned; illustrates uptake by program planners and policy decision makers; and identifies implications for research, policy and practice. The variability of these cases demonstrates that population health intervention research involves a wide range of research, knowledge translation, and population health approaches. For example, some cases describe targeted strategies focused on vulnerable populations whereas others reflect a universal approach.

The primary audiences for the casebook are program planners and policy decision-makers including those working across health and non-health sectors in community organizations, national/provincial non-government associations, frontline workers, and federal, provincial, territorial, and municipal level governments. Secondary audiences include students, academics, researchers, research funders, and others working both inside and outside of the health sector interested in program planning and policy development to improve the health and well-being of Canadians. We hope that this casebook will become a valuable resource for the diverse population health intervention research communities in Canada and beyond.

Health equity is the overarching theme guiding this casebook. Health equity means that people should not be prevented from attaining their full health potential because of their race, ethnicity, religion, gender, age, social class, socio-economic status, or other circumstance (Dahlgren & Whitehead, 2006). Inequities in health are the result of daily living conditions and the inequitable distribution of money, resources and power (World Health Organization, 2008)—in other words, of circumstances that are modifiable and amenable to change.

Beyond health equity, the cases in this report explore implementation processes. Population health interventions are implemented within a variety of organizational, policy and program delivery systems-not just within the public health sector. The cases describe the development of initiatives designed to increase infrastructure for population health intervention research, community engagement, community-based research, multilevel and intersectoral partnerships and collaboration, scaling-up of promising initiatives and the ethical frameworks underlying population health intervention research.

The original call for case abstracts indicated that we were interested in cases that explored mental health and healthy weights, but that we would consider submissions that addressed other population and public health issues. In this casebook, the term mental health covers mental illness prevention, mental health promotion, individual or community resilience, and healthy individual, family or community coping and development. Healthy weights is also defined broadly to encapsulate prevention of obesity, promotion of wellness, nutrition and physical activity, food security, and prevention of chronic conditions such as diabetes that are related to overweight and obesity. These topics provide a starting point for helping to understand population health intervention research but do not serve as the only points of interest in this field.

Following the open call for cases, and an expert peer-review process, eight cases were selected to showcase examples of population health intervention research in Canada. Based on the submissions, we identified three categories that help to organize the casebook content:

  • Implementation processes supporting population health intervention research - Some of the cases show how population health intervention research is supported through a variety of implementation processes such as intersectoral collaboration, knowledge synthesis and the development of decision-making tools.
  • Evaluating setting - specific programs-Population health intervention research can involve systematic evaluation. Some of the cases demonstrate unique methods and strategies for the evaluation of programs working to improve health in school-based settings.
  • Researching multi-component, community-wide interventions - The remaining cases highlight how researchers are partnering with communities to explore interventions that employ a number of strategies and work across multiple levels to effect community-wide change and improve the health of disadvantaged populations.

This process has highlighted the fact that researchers from very different backgrounds identify as population health intervention researchers. As such, we hope the casebook will showcase varying interpretations of population health intervention research and foster inclusiveness in this field.

At a glance - Implementation processes supporting population health intervention research

Research from the Centre for Research on Inner City Health in Toronto, Ontario focuses on a review of community-based programs designed to meet the needs of homeless adults with concurrent mental health and substance use disorders. The authors took an integrated knowledge translation and realist-informed approach to conduct a community-partnered evidence synthesis. This involved a review of evaluations from community-based programs in addition to key informant interviews to identify promising program strategies and contextual factors that support the strategies' success.

Peel Region is an Ontario suburban area with a number of new immigrants, visible minorities and spoken languages, and some of the lowest active transportation rates in Canada. To explore the health impacts of urban planning and create an assessment tool for new urban development, a collaborative project involving researchers, local public health departments and other municipal partners was conducted in the region of Peel. The project addresses challenges related to social and physical environments, physical activity and active living. It involved reviewing literature to derive built environment elements and measures for an initial tool, holding consultations to identify planning challenges and to refine the tool, reviewing existing standards and bylaws, and conducting studies to validate and assess the feasibility of the tool.

The concluding case in this category describes the creation of a population health intervention research tool, which has been successful in the Eastern Townships of Québec and could be useful for other regions interested in community development as a strategy to tackle healthy weights, mental health or other population health issues. Through a user-friendly presentation of qualitative and quantitative information on community health, well-being, and characteristics, a 'Scorecard' tool helps promote community development and fosters intersectoral collaboration. Taking a population health approach, it also contributes to the promotion of health equity and supports the implementation of policies and programs that act on structures in the physical and social environment rather than targeting individual behaviors, habits or skills. The case provides an example of how actors from within and outside the health sector are working together to improve the health and well being of communities.

At a glance - Evaluating setting-specific programs

Healthy Transitions is a school-based mental health promotion intervention research project aimed at youth in Ottawa, Ontario that involves intersectoral collaboration between health and education professionals. The program comprised screening, referral, educational and evaluation components. Trained facilitators provided classroom sessions to encourage students to communicate their thoughts and feelings. Screening protocols were used to identify youth in need of further support or referral. Educational workshops were also available to parents and teachers. Surveys were conducted throughout the program to monitor and evaluate intervention impact.

The Heart Healthy Kids (H2K) program involved collaboration between schools, public health departments and community groups; and focused on elementary school children in Halifax, Nova Scotia. This school-based physical activity intervention employs activity challenges, educational sessions, and adult and peer mentoring. The mentoring aspect aimed to improve physical activity by enacting culture change and creating more supportive environments. In evaluating the effectiveness of the intervention, researchers used a mixed methods approach to measure physical activity levels, heart health knowledge and cardiovascular fitness. They also conducted qualitative focus group activities to determine the effectiveness of mentoring and to further explore health outcomes.

At a glance - Researching multi-component, community-wide interventions

The Healthy Foods North project describes a multilevel (individual, household, community and environment) intervention that addresses nutrition and lifestyle in Inuit and Inuvialuit communities in Nunavut and the Northwest Territories. Researchers used mixed methods for the formative research phase to understand the needs and preferences of the populations under study. Subsequently, they implemented a population health intervention in partnership with community members, decision makers and private businesses consisting of food store (for example, educational programs to promote stocking of healthy foods) and community-based (for example, cooking classes) activities. To evaluate the impact of the intervention, the research team collected pre- and post-intervention health data from community members using both quantitative and qualitative tools.

The KidsFirst project evaluated the effectiveness of an early intervention program that targets vulnerable young children and their families in at-risk Saskatchewan communities. It involved community-based intervention research using an integrated knowledge translation approach to evaluate the effectiveness of KidsFirst, an intervention that implements intensive home visiting, reorients health, early learning and childcare service delivery, addresses families' basic needs, integrates families into communities and focuses on community development. The evaluation assessed the project's intervention effects and how those effects were produced by analyzing program data, vital statistics, health care utilization data, and data collected through interviews and focus groups.

Researchers in Northern Ontario implemented school nutrition programs in remote Fort Albany, Kashechewan, and Attawapiskat First Nations communities to promote healthy weights and improved nutrition. They first assessed community context and monitored changes in food and nutrient intake. Subsequently, with the goals of empowerment and sustainability, the research team adopted a community-based approach to implement school nutrition programs that consisted of providing healthy foods at schools, developing healthy school food policies, modifying student curricula, and providing parent and community education programs. Process and impact evaluations of these programs and policies were based on a variety of methods including case documentation, interviews, and focus groups.

General reflections

The cases described in this casebook incorporate a range of innovative approaches including mixed methods designs, community engagement approaches, realist-informed reviews, and geospatial analyses. They vary on a few other parameters, reflecting, for example, small- to large-scale projects, population subgroups to entire populations and communities, and different settings and contexts including schools, rural and remote regions, and whole communities from across Canada. The range of cases presented in this book helps to highlight the continuum of potential uptake or scale-up that may result from population health intervention research projects. Some projects are building to apply similar research in additional settings or communities, while others show evidence of influencing changes to policy-related activities and development.

These cases illustrate some key lessons and important considerations for informing future population health intervention research, practice and policy in Canada.

Key Lessons across Cases

  • Engage communities under study, including families, schools, decision makers, governments and the private sector working inside and outside of health, to achieve meaningful interventions, uptake of results and sustainability of interventions over time.
  • Build relevant and creative partnerships and relationships over a long period through consistent communication and balancing of priorities between researchers and their community partners.
  • Adapt interventions, tools and research methods to meet the needs of different populations, contexts and communities.
  • Move beyond individual factors to address broader family, community and social structures that perpetuate health inequities.

There is still a need to raise further awareness and understanding of population health intervention research, including the diverse theories, methods and disciplines that underpin this growing field, and the different contexts in which intervention studies unfold. We hope this collection of cases will provide useful lessons learned about population health intervention research experiences. We have developed a set of overarching questions to guide your reading and fruitful discussion of the eight cases. The challenge remains for researchers, practitioners, decision makers and local communities to continue working together to promote the generation and use of population health intervention evidence in Canada and beyond.

Emma Cohen

Knowledge Translation and Communications Officer, Institute of Population and Public Health
Canadian Institutes of Health Research

Andrew Taylor

Program Lead, Canadian Population Health Initiative
Canadian Institute for Health Information

References

Dahlgren, G., & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. Copenhagen: World Health Organization.

Di Ruggiero, E., Rose, A., & Gaudreau, K. (2009). Canadian Institutes of Health Research Support for Population Health Intervention Research in Canada. CJPH 100 (Suppl 1) I15-I19.

Hawe, P., & Potvin, L. (2009). What is population health intervention research? CJPH 100 (Suppl 1) I8-I14.

World Health Organization. (2008). Closing the Gap in a Generation. Commission on Social Determinants of Health. Geneva: World Health Organization. Retrieved from the World Health Organization website.

Discussion Questions

Given the need to raise further awareness and understanding of population health intervention research, including the diverse theories, methods and disciplines that underpin this growing field, and the different contexts in which intervention studies unfold, please consider these overarching questions to guide your review of the eight cases:

  1. To what extent do the interventions described in the cases address underlying structural conditions affecting health and health inequities?
  2. What approaches have these researchers used to examine the context(s) for their interventions?
  3. How did the teams collaborate with other sectors both within and outside of the health system in their population health interventions and related research?
  4. What is the role of program evaluation in population health intervention research?
  5. What are some of the factors and challenges that should be considered in determining the potential scale-up of the population health interventions described in these cases?
  6. How might you apply the lessons learned and experiences from the featured cases to your own context or work?

Notes

  1. For example, school health programs are implemented in the education sector, while occupational health initiatives must engage unions as well as the particular sectors in which the populations are employed.