9.5 Conclusion: Turning Theory Into Practice, Informing Theory From Practice

The overall objectives of this initiative were to document what the regions have learned and accomplished in mobilizing a population health approach, and to use the knowledge gained through the mobilization strategy to inform the theory and practice of population health internally and externally. The work used an Analytical Framework based on the state of current knowledge about population health mobilization to examine how and to what extent that knowledge has been carried into practice, and to identify new knowledge that has emerged from the regional experiences. In this section, we turn our attention to the framework, commenting on how the case studies might inform its evolution. Key learnings are indicated in bold, while suggested next steps are underlined.

The Analytical Framework for the case studies focussed on the eight key elements defined in the population health key elements template.¹² Learnings about several of these have emerged form the case studies:

• Determinants of health.
  The Framework emphasizes action on the determinants of health whose causal forces are located both within and outside the health sector. The case studies selected have shown that population health mobilization has addressed most of the determinants identified in the existing model; however, the studies have highlighted the efforts required to address income and social status and their close cousins in education and employment. These determinants have been shown to present some of the most intractable problems for improving population health, complicated by the jurisdictional issues that are associated with the inter-governmental collaboration required for effective action. Moreover, the case studies have shown that working on the interaction among determinants is both necessary and complex. For example, it is impossible to address fathering capacities and involvement, as in the Ontario case, without addressing healthy workplace policies; in the Vancouver Agreement, it has been impossible to address drug addiction without addressing the physical, social and economic conditions that have allowed it to flourish. Moreover, it seems that the closer population health-driven interventions are to the local level (municipal and neighbourhood), the more determinants they involve, the more complex they are. These observations suggest that in the mobilization of population health, the importance of specific determinants varies across situations and according to their interactions with other determinants, and that more work is required to explain the dynamics underlying the interaction among determinants, so that we can better understand when each will be most important and require most attention. Such efforts would have direct implications for the nature and types of intersectoral collaboration that need to be supported in mobilization practice.

• Upstream investment.
  In order to address root causes to increase potential benefits for health outcomes, regional mobilization of the population health approach has intended to direct efforts and investments upstream in the causal chain. In practice, this investment has concentrated on building the infrastructure necessary to support work on root causes, with that infrastructure consisting most importantly of relationships and attitudes toward partnership and long-term social change. It seems that the analyses of root causes and their links to health determinants have invariably led population health champions to see a need to strengthen this generic infrastructure, which would then facilitate the attack on the root causes of many types of health issues. In doing this, the champions have used their personal and professional qualities and experience to develop the levels of trust and forms of support and communication that their particular environments have required. The current conception of upstream investment in population health mobilization could more explicitly capture the importance of, and successful strategies for, building the infrastructure for population health. In addition, because it is too soon to tell how effective this overall investment effort will be in improving population health outcomes, the Analytical Framework may be used as a monitoring tool for assessing growth in the strength, quality and comprehensiveness of the infrastructure.

• Basing decisions on evidence.
  In all of the cases studied, extensive use was made of informal and formal qualitative and quantitative evidence about the nature of health problems. In some cases, this has been conducted through literature reviews while in others it has been done through consultations with local, national or international experts, stakeholders and/or information sources. It seems that information has been most readily available in terms of problem definition and generation of main action strategies; whereas relevant evaluative information has been more difficult to find. Participants in many cases spoke of feeling that they were breaking new ground, sometimes without a lot of evidence to back decisions. They reaffirmed the need to develop the capacity to monitor trends, identify emerging issues and generate knowledge about responding to them.

• Multiple strategies.
  The regional mobilization of population health has involved multiple, interconnected strategies in multiple settings, acting to improve health over the life span. However, in many of the initiatives studied, the mobilization work has aimed to support or enable the use of multiple strategies and settings, by ensuring that partners could access strategies and settings that were called for in specific actions. Decisions about specific strategies and settings that would be most useful to a particular initiative have tended to be made at the local implementation level. To develop knowledge about how this enabling work has been carried out, the Analytical Framework could include an additional dimension focussing on how population health mobilization can help ensure that partners will be able to identify which of all possible sets of strategies would be expected, based on current evidence, to be most effective; and be able to access and use them in local initiatives.

• Collaboration across sectors and levels.
  The case studies have clearly shown that collaboration across sectors and levels can bring major gains to population health mobilization. Without necessarily playing the lead role, Health Canada has acted as a full partner bringing specific, unique resources and expertise to the collaborative work. Its particular contribution to the development of collaborations has often come through its capacity to align its energies with evolving partnership momentum and to enhance collaborations through supporting the interactions among partners. One of the lessons learned from the case studies is that while multi-sector and multi-level collaboration is a shared goal, in practice it makes sense to approach the development of collaborative relationships incrementally, either phasing in new sectors and levels over time as opportunities arise and evidence of the value of partnerships becomes more salient, or joining force with initiatives led from outside health but with significant health impact. Action outside the health sector, seen by many at the outset as a key defining criterion of having achieved population health mobilization, was determined in some case study initiatives to be not a fruitful immediate goal, and that priority should be placed on strengthening partnerships within the health sector first. In a long-term view, it is felt that gaining collaboration outside the health sector would be best accomplished as part of a long-term, developmental process. The population health framework could thus benefit future mobilization efforts if it included some analysis of possible sequences in the evolution of collaboration, providing initiatives with an understanding of the factors that determine more and less propitious moments and methods for developing collaborations outside the health sector.

• Citizen engagement.
  The case study initiatives have varied greatly in their focus on citizen engagement, mainly as a function of their relative closeness to direct service delivery or policy implementation. While all were concerned that citizens could have meaningful input into the development of health priorities, strategies and review of outcomes, in practice citizen participation was engaged through a wide variety of mechanisms and on a continuum of intensity. The levels and types of citizen engagement sought, especially at the broader public level, have not always been examined in light of how they could help further project goals. In its current form, the key elements template and the Analytical Framework allow documentation of levels of citizen engagement, but more could be done to develop a framework to help initiatives decide when and how various levels and types of participation will be most appropriate and helpful

• Accountability and knowledge development.
  In all of the case studies, using evaluation and other tools to increase accountability for health outcomes has been seen as a key element to population health mobilization. However, the initiatives have varied in the extent to which they had been able to develop tools and systems for evaluation and monitoring; and in some cases it has been felt that this is an area in which more sharing and support is needed. Accountability in multi-partner initiatives has been shown to present additional complexities; in most cases, these initiatives have represented innovations in terms of joint responsibility for outcomes and participants felt that there were few evaluation or monitoring models from which to draw lessons. Also, in terms of knowledge development, some of the case studies had begun to make specific efforts to gather up, critically assess and share their learnings, although additional supports and resources for systematically moving mobilization experiences into the evidence base would be beneficial.

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12. Diane Alfred, The Population Health Key Elements Template: A Framework to Define a Population Health Approach, Health Promotion and Programs Branch, Health Canada, 1999.

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