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. [2] 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. [3] 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. [4] In the US, SDOH were estimated to account for 70% of avoidable mortality. [5]


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". [6] 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." [7] [8]

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. [9]

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.

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.


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.). [10] [11] 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.

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. [12] Family planning saves lives and money by reducing unintended pregnancy and the transmission of sexually transmitted infections. [12]

For example, the United States Agency for International Development lists as benefits of its international family planning program: [13]

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". [14] 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". [15] 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". [16] Many PHM-related articles are published in Population Health Management, the official journal of DMAA: The Care Continuum Alliance. [17]

The following road map has been suggested for helping healthcare organizations navigate the path toward implementing effective population health management: [18]

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. [19] 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 [20] ).

As participation in value-based reimbursement models such as accountable care organizations (ACOs) increases, these initiatives will help drive population health. [21] Within the ACO model, hospitals have to meet specific quality benchmarks, focus on prevention, and carefully manage patients with chronic diseases. [22] Providers get paid more for keeping their patients healthy and out of the hospital. [22] 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. [23] 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. [24]

Hospitals are finding it financially advantageous to focus on population health management and keeping people in the community well. [25] 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. [26] 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. [25]

Health can be considered a capital good; health capital is part of human capital as defined by the Grossman model. [27] Health can be considered both an investment good and consumption good. [28] Factors such as obesity and smoking have negative effects on health capital, while education, wage rate, and age may also impact health capital. [28] 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". [29] 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.


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, treatment, recovery, or cure 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, pharmacy, midwifery, nursing, medicine, optometry, audiology, 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.

Maternal death the death of a woman while pregnant or within 42 days of termination of pregnancy

Maternal death or maternal mortality is defined by the World Health Organization (WHO) as "the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes."

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.

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."

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.

Social epidemiology focuses on the patterns in morbidity and mortality rates that emerge as a result of social characteristics. While an individual's lifestyle choices or family history may place him or her at an increased risk for developing certain illnesses, there are social inequalities in health that cannot be explained by individual factors. Variations in health outcomes in the United States are attributed to several social characteristics, such as gender, race, socioeconomic status, the environment, and educational attainment. Inequalities in any or all of these social categories can contribute to health disparities, with some groups placed at an increased risk for acquiring chronic diseases than others.

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.

Research on race and health in the United States shows many health disparities between the different racial/ethnic groups. Different outcomes in mental and physical health exist between all census-recognized racial groups, but these differences stem from different historical and current factors, including genetics, socioeconomic factors, and racism. Research has demonstrated that numerous health care professionals show "implicit bias" in the way that they treat patients. Certain diseases have a higher prevalence among specific racial groups, and life expectancy also varies across groups. This article is directed towards some of the historical and societal factors that impact the health of various minorities groups in the United States. Race and health in the United States is a topic that has been researched many times, but the causes of disparate outcomes remain something that can be further explored.

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.

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".

Mental health inequality refers to the differences in the quality, access, and health care different communities and populations receive for mental health services. Globally, the World Health Organization estimates that 350 million people are affected with depressive disorders. Mental health can be defined as an individual's well-being and/or the absence of clinically defined mental illness. Inequalities that can occur in mental healthcare may include mental health status, access to and quality of care, and mental health outcomes, which may differ across populations of different race, ethnicity, sexual orientation, sex, gender, socioeconomic statuses, education level, and geographic location. Social determinants of health that can influence an individual's susceptibility to developing mental disorders and illnesses include, but are not limited to, economic status, education level, demographics, geographic location and genetics.


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