Introduction To Public Health - Define Pop Health

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1.

1 Defining Population Health


Learning Outcomes
By the end of this section, you should be able to:
• 1.1.1 Define population health.
• 1.1.2 Explain the origin of the population health approach.
• 1.1.3 Identify the components of population health.
Population health is a comprehensive approach that spans the entire health care
continuum, from public health prevention to disease management. Population health aims
to support the health of people through diverse activities, including care coordination,
health care research, population-level data analysis, and health programming. Activities
carried out to improve population health generally support the health status and health
outcomes of groups of people rather than one client at a time. Population health
interventions take a more holistic approach than those that are generally used in the care
of individual clients. Population health considers the impact of public policy and law as well
as environmental, social, behavioral, and other factors that might facilitate or hinder health
for all people. The requisite knowledge of these disciplines and health areas comes
together to address many factors that can influence health.
Consider tobacco use, which, as the leading cause of preventable death in the United States,
kills an estimated 1,300 Americans each day. Individual counseling and interventions such
as prescription medications and nicotine gum can help individuals quit smoking. While a
population health approach to addressing tobacco smoking cessation would support the
availability of individual tools, it would also consider the broader factors contributing to
smoking rates and smoking uptake across the population. A population health approach to
smoking cessation might include the following:
• Developing community-wide antismoking campaigns
• Advocating for schools, businesses, restaurants, and other public places to develop
smoke-free policies
• Researching the reasons that community members start or do not quit smoking
• Analyzing population-level data to identify trends in smoking
• Passing legislation to increase taxes on tobacco products to discourage their
purchase and fund population health programs focused on cessation
Overall, a population health approach that considers the multifaceted facilitators and
deterrents of smoking can help reduce smoking rates, thereby improving the health of
smokers and the population at large.
Drunk driving is another example of a serious public health problem. The National
Highway Traffic Safety Administration estimates that in the United States, one person is
killed due to drunk driving every 39 minutes. Drunk driving impacts not only the life of the
victim but also the lives of their friends, family, and community, and those of the driver as
Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
well. Individual-level interventions that work to improve the health of drivers and of
community members to whom a driver may pose a risk include individual counseling,
installing breathalyzer car ignition devices, and levying fines or revoking driver’s licenses
to hold drivers accountable and prevent future drunk driving occurrences. Population
health interventions go beyond those aimed at specific drunk drivers. A population health
approach to drunk driving reduction could include the following:
• Developing and implementing stricter laws and regulations regarding alcohol use
and driving
• Leading campaigns to raise awareness about the dangers and penalties of drunk
driving
• Collaborating with taxi companies and ride-share programs on weekends and
holidays to offer free or reduced rides
• Training servers, bartenders, and liquor store employees on the responsible service
and sale of alcohol
• Identifying high-risk areas for drunk driving accidents to increase signage and
safety checks in these areas
Population health involves collaborative efforts among health care professionals,
communities, industries, academia, and governmental organizations to improve health
outcomes among a population (AACN, 2021). A myriad of efforts in population health can
explain or address why some populations are healthier than others and help determine
how resources might be allocated to have the greatest impact on improving health across
the population. As the smoking cessation and drunk driving examples illustrate, population
health approaches focus on implementing education, policy, and programming that provide
optimal outcomes for the money, time, and other resources invested.
There is no definitive history of exactly when population health emerged and evolved into
what health care providers, teams, and organizations know it as today (Szreter, 2003).
Scholars note several defining moments from the 18th century through the modern day,
such as observations of differences in health conditions between the wealthy and the
impoverished, among people employed in various industries, and between those with and
without access to clean water (Bynum, 1983; LaBerge, 1993; Porter, 1991). These historical
moments allowed for recognition of the relationship between a healthy human population
and a healthy, functioning society. Although population health concepts and principles have
been relevant for centuries, in the United States the passage of the Patient Protection and
Affordable Care Act (ACA) in 2010 is credited with beginning to shift the focus of health
care services from treating diseases in individual people to promoting health among
populations (Ariosto et al., 2018). Emphasizing preventive efforts and proactively
facilitating health instead of reactively treating diseases as they occur is a central tenet of
population health. The shift is essential, as many recognize that a U.S. health care system
that spends an estimated 75 to 90 percent of its resources addressing diseases and
hospitalizations and invests very little in preventive efforts is a system that is failing
(Raghupathi & Raghupathi, 2018; Shrank et al., 2019; Centers for Disease Control and
Prevention [CDC], 2023). By shifting the focus from reactive disease treatment to proactive
health promotion, population health offers a more positive path forward. Under a
Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
population health–focused system, health care professionals are encouraged to work
collaboratively to promote early intervention, provide health education, empower clients,
and effect social change to reduce the burden of disease for individuals and the health care
system at large.

The Quintuple Aim


Population health can impact numerous specific conditions, diseases, and health risks
through interventions that cross disciplines and support a great breadth and depth of
positive health change. As a field of study and practice, population health works toward
specific aims developed by the Institute for Healthcare Improvement (IHI). In 2007, the IHI
developed a framework called the Triple Aim to support optimal performance of the health
care system (Berwick et al., 2008). In 2014, the IHI updated the framework to the
Quadruple Aim to acknowledge that the health of providers and other health care
professionals must be supported to achieve population health goals (Bodenheimer &
Sinsky, 2014). Today, the four aims consist of:
1. improving the client experience of care (including quality and satisfaction),
2. improving the health of populations,
3. reducing the per capita cost of health care, and
4. improving the well-being of health care professionals.
Recently, experts have suggested a revision to create the Quintuple Aim, which would
include a fifth aim of advancing health equity. In both the fourth and suggested fifth aim
expansions, experts have posited that improving population health, client experience, and
health cost would be impossible without addressing provider health and burnout or health
equity (Bodenheimer & Sinsky, 2014; Nundy et al., 2022). Concepts of the Quintuple Aim
can guide evaluations of population health programs and initiatives. For example,
telemedicine connects to the goals of improving the health of populations, improving the
well-being of health care professionals, and advancing health equity. Its services offer
several conveniences to clients and clinicians, such as the flexibility to dial in from home
and save on commuting fees. These services also remove barriers to receiving care and
increase equity in opportunity for clients to see primary care providers and specialists.
This can help reduce inequities and disparities with regard to receiving screenings,
diagnoses, and treatments for health conditions, which in turn can help improve population
health. Whether a population, community, or health system elects to use the version with
three, four, or five aims, this framework encourages consideration of the interplay among
the different aims and innovative approaches to improving health and health outcomes for
the population.

Components of Population Health


Population health takes a comprehensive approach that accounts for the complex dynamics
among differences in health status, community resources, personal characteristics, familial
circumstances, and other factors that can trigger or aggravate health conditions. By
recognizing the complex interplay of these numerous and wide-ranging factors, population
health takes a holistic view to promote the well-being of all.
Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
Regardless of the situation or specific factors, a guiding theme of population health is the
importance and value of taking proactive rather than reactive approaches to improving
health. An analogy to summarize population health involves an overflowing sink. Imagine a
kitchen faucet is left running unattended, creating a giant puddle on the floor. Better get a
mop! Without population health, much of health care focuses on “mopping the floor”
instead of “turning off the faucet” (Kaminski, 2021). In other words, health care as a system
largely deals with floods—that is, helping clients who are already sick—instead of turning
off the water, or addressing the situations and circumstances that make clients sick in the
first place. Health care providers, nurses, policymakers, and the health care system at large
should focus on the causes of health problems to prevent them before they occur, instead of
focusing primarily on treating diseases as they happen. Of course, clients, families, and
communities need access to treatment for their health conditions—but what if there was a
way to prevent the conditions from happening in the first place?
Four key health concepts have been essential in advancing population health: outcomes,
disparities, determinants, and risk factors.
Outcomes are all possible results. Health outcomes are indicators or data points that reflect
the degree to which health interventions, care, policies, and behaviors are effective in
supporting the health status of populations. Examples of health outcomes include mortality
rates, life expectancy, disability rates, birth rates, health care costs, and health-related
quality of life measures. Outcomes may come from exposure to interventions that aim to
prevent or treat a condition, or they may result from exposure to health risks or situations
detrimental to health. For example, creating a policy that allows people under a certain
income level to have free health insurance may produce a range of outcomes, including
insuring a greater percentage of the population and increasing the number of people who
attend wellness exams—and, consequently, increasing the number of people who smoke
who may be offered smoking cessation resources. On the other hand, removing or relaxing
policies that prohibit smoking in public places may produce quite a different range of
outcomes, including making it more difficult for people to quit smoking, exposing more
people to secondhand smoke, and increasing rates of children who start smoking.
Disparities are inequalities or differences. A related concept is health inequities, which are
avoidable inequalities related to health that stem from a form of injustice (Kawachi et al.,
2002; McCartney et al., 2019). For example, children attending the Lincoln School may have
higher rates of asthma than children attending the Washington School. The children are all
the same age and have the same racial and ethnic distribution, but the parents of children
at the Washington School have a higher average income and donated money so that each
classroom could have an air conditioner. There is a disparity in access to clean air, as well
as in rates of asthma, between children at these two schools.
Determinants are the innumerable factors that influence health and generally include
nonmedical events, characteristics, or other entities that change a health condition or the
level of a health problem (Kindig, 2007; Office of Disease Prevention and Health Promotion,
2022). Within population health, determinants of interest include medical care, public
health interventions, income, education, employment, social support, culture, clean air and
water, outdoor space, genetics, and behavior (Kindig, 2007). Determinants can interact
Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
with each other to bolster health or worsen a problem (Figure 1.2). For example, when a
client is unable to finish high school, they may not qualify for a full-time job that pays a
living wage and offers access to a health insurance plan. Such a situation would
undoubtedly impact the client’s ability to seek care when needed and to engage in health
promotion efforts.
Social determinants of health are additional factors that influence the health of populations,
families, and individuals. Social determinants of health are conditions and social factors
that affect outcomes and risk related to health, functioning, and quality of life. Conditions or
factors in hospitals, clinics, workplaces, homes, towns and cities, schools, and beyond
influence health outcomes for the population. Economic stability, education access and
quality, health care access and quality, neighborhood and built environment, and social and
community context are five domains that shape the social determinants of health (Office of
Disease Prevention and Health Promotion, 2022).
Risk factors are aspects of personal behaviors, lifestyle choices, exposures, or attributes
that generally increase the likelihood of acquiring or the severity of a health condition. Risk
factors are similar to determinants but tend to be more specific. Consider respiratory
disease determinants and risk factors. Air quality and environmental pollution are
determinants of respiratory disease, while smoking is a risk factor for respiratory disease.
Some determinants may be risk factors; however, other determinants may reduce health
risk.

Figure 1.2 This photo was taken during the 2018 Klondike Fire in Oregon. In addition to
threatening human lives and homes, wildfires severely impact air quality, release harmful
pollutants, and devastate wildlife and ecosystems. (credit: “Forest road 2512 and smoke-

Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
filled air, Klondike Fire” by U.S. Forest Service-Pacific Northwest Region/Flickr, Public
Domain)

Healthy People 2030

Tobacco Use
Healthy People 2030 developed 25 measurable objectives, one developmental objective,
and one research objective to address tobacco use. Since creating these objectives, three
targets have been met or exceeded: reducing cigarette smoking in adolescents, reducing
the use of smokeless tobacco products among adolescents, and reducing the lung cancer
death rate.

Additionally, population health focuses on upstream, midstream, and downstream


approaches to improve health outcomes (Figure 1.3) (Salmond & Allread, 2019).
• Upstream interventions involve enacting policies that change regulations, increase
access, or provide economic incentives to impact health across a population.
Examples include policy changes regarding the fast food or tobacco industry,
provision of universal health care, and compensation for hospitals with lower
inpatient admission rates (Porter et al., 2022).
• Midstream approaches are those that happen within specific organizations. For
example, a workplace may provide healthy lunches to employees each day (Porter et
al., 2022).
• Downstream interventions focus on the behavior of individual people to modify the
risk of disease, prevent illness, or manage chronic conditions (Brownson et al.,
2010; Fornili, 2022). For example, a nurse might counsel a client with hypertension
about consuming a low-salt diet.

Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction
Figure 1.3 Population health involves the complex interactions of upstream, midstream,
and downstream interventions. (attribution: Copyright Rice University, OpenStax, under CC
BY 4.0 license)
These key components interact in complex and evolving ways as population health and the
health status of the population change over time. By employing upstream interventions,
such as policy changes and universal health care, population health addresses the societal
factors that impact the health of the population on a broad scale and ultimately the health
of individual clients. Midstream approaches can contribute to fostering healthier
environments in diverse settings. Downstream interventions, such as those that focus on
individual behavior to support health, are also important in a population health model, as
members of the population will never be fully free of health conditions requiring treatment.
Together, upstream, midstream, and downstream approaches offer a framework for
population health programming and interventions that can create positive health
outcomes.

Adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper, and Susan M.
Schwartz and licensed under CC BY 4.0. Access for free at
https://openstax.org/books/population-health/pages/1-introduction

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