Population health

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Income inequality and mortality in 282 metropolitan areas of the United States. Mortality is correlated with both income and inequality. Inequality and mortality in metro US.jpg
Income inequality and mortality in 282 metropolitan areas of the United States. Mortality is correlated with both income and inequality.

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". [1] According to Akarowhe (2018), the working definition of population health is expressed thus; population health is an art, process, science and a product of enhancing the health condition of a specific number of people within a given geographical area - population health as an art, simply means that it is geared towards equal health care delivery to an anticipated group of people in a particular geographical location; as a science, it implies that it adopt scientific approach of preventive, therapeutic, and diagnostic service in proffering medical treatment to the health problem of people; as a product, it means that population health is directed toward overall health performance of people through health satisfaction within the said geographical area; and as a process it entails effective and efficient running of a health management/population health management system to cater for the health needs of the people.[ citation needed ] It is an approach to health that aims to improve the health of an entire human population. This concept does not refer to animal or plant populations. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions". [1] A priority considered important in achieving the aim of Population Health is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health, SDOH. The SDOH include all the factors (social, environmental, cultural and physical) that the different populations are born into, grow up and function with throughout their lifetimes which potentially have a measurable impact on the health of human populations. [2] The Population Health concept represents a change in the focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations. The World Health Organization's Commission on Social Determinants of Health, reported in 2008, that the SDOH factors were responsible for the bulk of diseases and injuries and these were the major causes of health inequities in all countries. [3] In the US, SDOH were estimated to account for 70% of avoidable mortality. [4]

Health is a state of physical, mental and social well-being in which disease and infirmity are absent.

Population health, a field which focuses on the improvement of the health outcomes for a group of individuals, has been described as consisting of three components: "health outcomes, patterns of health determinants, and policies and interventions". Policies and Interventions define the methods in which health outcomes and patterns of health determinants are implemented. Policies which are helpful "improve the conditions under which people live". Interventions encourage healthy behaviors for individuals or populations through "program elements or strategies designed to produce behavior changes or improve health status".

Contents

From a population health perspective, health has been defined not simply as a state free from disease but as "the capacity of people to adapt to, respond to, or control life's challenges and changes". [5] The World Health Organization (WHO) defined health in its broader sense in 1946 as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." [6] [7]

World Health Organization Specialized agency of the United Nations

The World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of the League of Nations.

Well-being, wellbeing, or wellness is the condition of an individual or group. A high level of well-being means that in some sense the individual's or group's condition is positive.

Healthy People 2020

Healthy People 2020 is a web site sponsored by the US Department of Health and Human Services, representing the cumulative effort of 34 years of interest by the Surgeon General's office and others. It identifies 42 topics considered social determinants of health and approximately 1200 specific goals considered to improve population health. It provides links to the current research available for selected topics and identifies and supports the need for community involvement considered essential to address these problems realistically. [8]

The social determinants of health are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions, rather than individual risk factors that influence the risk for a disease, or vulnerability to disease or injury. The distributions of social determinants are often shaped by public policies that reflect prevailing political ideologies of the area. The World Health Organization says, "This unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements [where the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer], and bad politics."

The human role of economic inequality

Recently, human role has been encouraged by the influence of population growth there has been increasing interest from epidemiologists on the subject of economic inequality and its relation to the health of populations. There is a very robust correlation between socioeconomic status and health. This correlation suggests that it is not only the poor who tend to be sick when everyone else is healthy, heart disease, ulcers, type 2 diabetes, rheumatoid arthritis, certain types of cancer, and premature aging. Despite the reality of the SES Gradient, there is debate as to its cause. A number of researchers (A. Leigh, C. Jencks, A. Clarkwest—see also Russell Sage working papers) see a definite link between economic status and mortality due to the greater economic resources of the better-off, but they find little correlation due to social status differences.

Epidemiology is the study and analysis of the distribution, patterns and determinants of health and disease conditions in defined populations.

Economic inequality divergence in economic well-being within a group

There are a wide variety of types of economic inequality, most notably measured using the income distribution and the distribution of wealth. Besides economic inequality between countries or states, there are important types of economic inequality between different groups of people.

Social status position within social structure

Social status defines being liked. Some writers have also referred to a socially valued role or category a person occupies as a "status". Status is based in beliefs about who members of a society believe holds comparatively more or less social value. By definition, these beliefs are broadly shared among members of a society. As such, people use status hierarchies to allocate resources, leadership positions, and other forms of power. In doing so, these shared cultural beliefs make unequal distributions of resources and power appear natural and fair, supporting systems of social stratification. Status hierarchies appear to be universal across human societies, affording valued benefits to those who occupy the higher rungs, such as better health, social approval, resources, influence, and freedom.

Other researchers such as Richard G. Wilkinson, J. Lynch, and G.A. Kaplan have found that socioeconomic status strongly affects health even when controlling for economic resources and access to health care. Most famous for linking social status with health are the Whitehall studies—a series of studies conducted on civil servants in London. The studies found that, despite the fact that all civil servants in England have the same access to health care, there was a strong correlation between social status and health. The studies found that this relationship stayed strong even when controlling for health-affecting habits such as exercise, smoking and drinking. Furthermore, it has been noted that no amount of medical attention will help decrease the likelihood of someone getting type 1 diabetes or rheumatoid arthritis—yet both are more common among populations with lower socioeconomic status. Lastly, it has been found that amongst the wealthiest quarter of countries on earth (a set stretching from Luxembourg to Slovakia) there is no relation between a country's wealth and general population health —suggesting that past a certain level, absolute levels of wealth have little impact on population health, but relative levels within a country do. The concept of psychosocial stress attempts to explain how psychosocial phenomenon such as status and social stratification can lead to the many diseases associated with the SES gradient. Higher levels of economic inequality tend to intensify social hierarchies and generally degrades the quality of social relations—leading to greater levels of stress and stress related diseases. Richard Wilkinson found this to be true not only for the poorest members of society, but also for the wealthiest. Economic inequality is bad for everyone's health. Inequality does not only affect the health of human populations. David H. Abbott at the Wisconsin National Primate Research Center found that among many primate species, less egalitarian social structures correlated with higher levels of stress hormones among socially subordinate individuals. Research by Robert Sapolsky of Stanford University provides similar findings.

Richard G. Wilkinson English academic

Richard Gerald Wilkinson is a British social epidemiologist, author, advocate, and left-wing political activist. He is Professor Emeritus of Social Epidemiology at the University of Nottingham, having retired in 2008. He is also Honorary Professor of Epidemiology and Public Health at University College London and Visiting Professor at University of York. In 2009, Richard co-founded The Equality Trust. Richard was awarded a 2013 Silver Rose Award from Solidar for championing equality and the 2014 Charles Cully Memorial Medal by the Irish Cancer Society.

The Whitehall Studies investigated social determinants of health, specifically the cardiovascular disease prevalence and mortality rates among British civil servants. The initial prospective cohort study, the Whitehall I Study, examined over 17,500 male civil servants between the ages of 20 and 64, and was conducted over a period of ten years, beginning in 1967. A second cohort study, the Whitehall II Study, was conducted from 1985 to 1988 and examined the health of 10,308 civil servants aged 35 to 55, of whom two thirds were men and one third women. A long-term follow-up of study subjects from the first two phases is ongoing.

London Capital of the United Kingdom

London is the capital and largest city of England and the United Kingdom, with the largest municipal population in the European Union. Standing on the River Thames in the south-east of England, at the head of its 50-mile (80 km) estuary leading to the North Sea, London has been a major settlement for two millennia. Londinium was founded by the Romans. The City of London, London's ancient core − an area of just 1.12 square miles (2.9 km2) and colloquially known as the Square Mile − retains boundaries that follow closely its medieval limits. The City of Westminster is also an Inner London borough holding city status. Greater London is governed by the Mayor of London and the London Assembly.

Research

There is well-documented variation in health outcomes and health care utilization & costs by geographic variation in the U.S., down to the level of Hospital Referral Regions (defined as a regional health care market, which may cross state boundaries, of which there are 306 in the U.S.). [9] [10] There is ongoing debate as to the relative contributions of race, gender, poverty, education level and place to these variations. The Office of Epidemiology of the Maternal and Child Health Bureau recommends using an analytic approach (Fixed Effects or hybrid Fixed Effects) to research on health disparities to reduce the confounding effects of neighborhood (geographic) variables on the outcomes.

Maternal and Child Health Bureau

The Maternal and Child Health Bureau (MCHB), is one of six Bureaus within the Health Resources and Services Administration, an agency of the U.S. Department of Health and Human Services located in Rockville, Maryland.

The importance of family planning programs

Family planning programs (including contraceptives, sexuality education, and promotion of safe sex) play a major role in population health. Family planning is one of the most highly cost-effective interventions in medicine. [11] Family planning saves lives and money by reducing unintended pregnancy and the transmission of sexually transmitted infections. [11]

For example, the United States Agency for International Development lists as benefits of its international family planning program: [12]

Population health management (PHM)

One method to improve population health is population health management (PHM), which has been defined as "the technical field of endeavor which utilizes a variety of individual, organizational and cultural interventions to help improve the morbidity patterns (i.e., the illness and injury burden) and the health care use behavior of defined populations". [13] PHM is distinguished from disease management by including more chronic conditions and diseases, by use of "a single point of contact and coordination", and by "predictive modeling across multiple clinical conditions". [14] PHM is considered broader than disease management in that it also includes "intensive care management for individuals at the highest level of risk" and "personal health management... for those at lower levels of predicted health risk". [15] Many PHM-related articles are published in Population Health Management, the official journal of DMAA: The Care Continuum Alliance. [16]

The following road map has been suggested for helping healthcare organizations navigate the path toward implementing effective population health management: [17]

Healthcare reform and population health

Healthcare reform is driving change to traditional hospital reimbursement models. Prior to the introduction of the Patient Protection and Affordable Care Act (PPACA), hospitals were reimbursed based on the volume of procedures through fee-for-service models. Under the PPACA, reimbursement models are shifting from volume to value. New reimbursement models are built around pay for performance, a value-based reimbursement approach, which places financial incentives around patient outcomes and has drastically changed the way US hospitals must conduct business to remain financially viable. [18] In addition to focusing on improving patient experience of care and reducing costs, hospitals must also focus on improving the health of populations (IHI Triple Aim [19] ).

As participation in value-based reimbursement models such as accountable care organizations (ACOs) increases, these initiatives will help drive population health. [20] Within the ACO model, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases. [21] Providers get paid more for keeping their patients healthy and out of the hospital. [21] Studies have shown that inpatient admission rates have dropped over the past ten years in communities that were early adopters of the ACO model and implemented population health measures to treat "less sick" patients in the outpatient setting. [22] A study conducted in the Chicago area showed a decline in inpatient utilization rates across all age groups, which was an average of a 5% overall drop in inpatient admissions. [23]

Hospitals are finding it financially advantageous to focus on population health management and keeping people in the community well. [24] The goal of population health management is to improve patient outcomes and increase health capital. Other goals include preventing disease, closing care gaps, and cost savings for providers. [25] In the last few years, more effort has been directed towards developing telehealth services, community-based clinics in areas with high proportion of residents using the emergency department as primary care, and patient care coordinator roles to coordinate healthcare services across the care continuum. [24]

Health can be considered a capital good; health capital is part of human capital as defined by the Grossman model. [26] Health can be considered both an investment good and consumption good. [27] Factors such as obesity and smoking have negative effects on health capital, while education, wage rate, and age may also impact health capital. [27] When people are healthier through preventative care, they have the potential to live a longer and healthier life, work more and participate in the economy, and produce more based on the work done. These factors all have the potential to increase earnings. Some states, like New York, have implemented statewide initiatives to address population health. In New York state there are 11 such programs. One example is the Mohawk Valley Population Health Improvement Program (http://www.mvphip.org/). These programs work to address the needs of the people in their region, as well as assist their local community based organizations and social services to gather data, address health disparities, and explore evidence-based interventions that will ultimately lead to better health for everyone. Following a similar approach, Cullati et al. developed a theoretical framework for the development and onset of vulnerability in later life based on the concept of "reserves". [28] The advantages to use the concept of reserves in interdisciplinary studies, as compared with related concepts such as resources and capital, is to strengthen the importance of constitution and sustainability of reserves (the “use it or lose it” paradigm) and the presence of thresholds, below which functioning becomes challenging.

Statistics

In the United States, the National Center for Health Statistics is responsible for the collection of data on the health of citizens.

See also

Related Research Articles

Health care reform is for the most part governmental policy that affects health care delivery in a given place. Health care reform typically attempts to:

Health care Prevention of disease and promotion of wellbeing

Health care, health-care, or healthcare is the maintenance or improvement of health via the prevention, diagnosis, and treatment of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health professionals in allied health fields. Physicians and physician associates are a part of these health professionals. Dentistry, midwifery, nursing, medicine, optometry, audiology, pharmacy, psychology, occupational therapy, physical therapy and other health professions are all part of health care. It includes work done in providing primary care, secondary care, and tertiary care, as well as in public health.

The National Center for Health Statistics (NCHS) is a principal agency of the U.S. Federal Statistical System which provides statistical information to guide actions and policies to improve the health of the American people.

Health equity synonymous with health disparity refers to the study and causes of differences in the quality of health and healthcare across different populations. Health equity is different from health equality, as it refers only to the absence of disparities in controllable or remediable aspects of health. It is not possible to work towards complete equality in health, as there are some factors of health that are beyond human influence. Inequity implies some kinds of social injustice. Thus, if one population dies younger than another because of genetic differences, a non-remediable/controllable factor, we tend to say that there is a health inequality. On the other hand, if a population has a lower life expectancy due to lack of access to medications, the situation would be classified as a health inequity. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" between populations with a different race, ethnicity, sexual orientation or socioeconomic status.

In the healthcare industry, pay for performance (P4P), also known as "value-based purchasing", is a payment model that offers financial incentives to physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures. Clinical outcomes, such as longer survival, are difficult to measure, so pay for performance systems usually evaluate process quality and efficiency, such as measuring blood pressure, lowering blood pressure, or counseling patients to stop smoking. This model also penalizes health care providers for poor outcomes, medical errors, or increased costs. Integrated delivery systems where insurers and providers share in the cost are intended to help align incentives for value-based care.

Case management is a managed care technique within the health care coverage system of the United States. It involves an integrated system that manages the delivery of comprehensive healthcare services for enrolled patients. Case managers are employed in almost every aspect of health care and these employ different approaches in the control of clinical actions.

Race and health refers to how being identified with a specific race influences health. Race is a complex concept that changes across time and space and that depends on both self-identification and social recognition. In the study of race and health, scientists organize people in racial categories depending on different factors such as: phenotype, ancestry, social identity, genetic makeup and lived experience. “Race” and ethnicity often remain undifferentiated in health research.

The healthcare reform in China refers to the previous and ongoing healthcare system transition in modern China. China's government, specifically the National Health and Family Planning Commission, plays a leading role in these reforms. Reforms focus on establishing public medical insurance systems and enhancing public healthcare providers, the main component in China's healthcare system. In urban and rural areas, three government medical insurance system, Urban Residents Basic Medical Insurance, Urban Employee Basic Medical Insurance and New Rural Co-operative Medical Scheme cover almost everyone. Various public healthcare facilities, including county or city hospitals, community health centers, township health centers, were founded to serve diverse needs. Current and future reforms are outlined in Healthy China 2030.

The Hopkins Center for Health Disparities Solutions (HCHDS), a research center within the Johns Hopkins Bloomberg School of Public Health, strives to eradicate disparities in health and health care among racial and ethnic groups, socioeconomic groups, and geopolitical categories such as urban, rural, and suburban populations.

People's Health Movement (PHM) is a global network of grassroots health activists, civil society organizations and academic institutions particularly from developing countries. PHM currently has bases in more than 70 countries that include both individuals and well-established circles with their own governance structures. It has chapters in South Asia, Africa, Pacific (Australia), South America, Central America, North America, Europe and several other countries. PHM works towards the revitalisation of Primary Health Care (PHC), as described in the Alma-Ata Declaration of 1978.

An Accountable Care Organization (ACO) is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation. The organization is accountable to patients and third-party payers for the quality, appropriateness and efficiency of the health care provided. According to the Centers for Medicare and Medicaid Services, an ACO is "an organization of health care practitioners that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it".

Structural inequality is defined as a condition where one category of people are attributed an unequal status in relation to other categories of people. This relationship is perpetuated and reinforced by a confluence of unequal relations in roles, functions, decisions, rights, and opportunities. As opposed to cultural inequality, which focuses on the individual decisions associated with these imbalances, structural inequality refers specifically to the inequalities that are systemically rooted in the normal operations of dominant social institutions, and can be divided into categories like residential segregation or healthcare, employment and educational discrimination.

In 1995, Jo C. Phelan and Bruce G. Link developed the theory of fundamental causes. This theory seeks to outline why the association between socioeconomic status (SES) and health disparities has persisted over time, particularly when diseases and conditions previously thought to cause morbidity and mortality among low SES individuals have resolved. The theory states that an ongoing association exists between SES and health status because SES "embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections that protect health no matter what mechanisms are relevant at any given time." In other words, despite advances in screening techniques, vaccinations, or any other piece of health technology or knowledge, the underlying fact is that those from low SES communities lack resources to protect and/or improve their health.

The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. The majority of people around the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.

Chronic disease in Northern Ontario is a population health problem. The population in Northern Ontario experiences worse outcomes on a number of important health indicators, including higher rates of chronic disease compared to the population in the rest of Ontario.

The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. According to the model, information about quality of care can be drawn from three categories: “structure,” “process,” and “outcomes." Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment. Process denotes the transactions between patients and providers throughout the delivery of healthcare. Finally, outcomes refer to the effects of healthcare on the health status of patients and populations. Avedis Donabedian, a physician and health services researcher at the University of Michigan, developed the original model in 1966. While there are other quality of care frameworks, including the World Health Organization (WHO)-Recommended Quality of Care Framework and the Bamako Initiative, the Donabedian Model continues to be the dominant paradigm for assessing the quality of health care.

Gender disparities in health

WHO has defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Identified by the 2012 World Development Report as one of two key human capital endowments, health can influence an individual's ability to reach his or her full potential in society. Yet while gender equality has made the most progress in areas such as education and labor force participation, health inequality between men and women continues to plague many societies today. While both males and females face health disparities, girls and women experience a majority of health disparities. This comes from the fact that many cultural ideologies and practices have structured society in a way whereby women are more vulnerable to abuse and mistreatment, making them more prone to illnesses and early death. Women are also restricted from receiving many opportunities, such as education and paid labor, that can help improve their accessibility to better health care resources.

Mental health inequality refers to the differences in quality of mental health and mental health care for different identities and populations. Mental health can be defined as well-being and/or the absence of clinically defined mental illness. There are social economic factors that influence individuals or groups of people of a certain demographic. This can be a factor to mental health care access. Inequalities may include presence of mental health, access to mental health care, quality of mental health care, and mental health outcomes between populations with different race, ethnicity, sexual orientation, sex, gender, socioeconomic statuses, education level, and geographic location.

References

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Further reading