M. Tracy, MA (1); S. Viehbeck, PhD (c) (2); E. Cohen, MSc (2)
1. Public Health Agency of Canada
2. Canadian Institutes of Health Research - Institute of Population and Public Health
On November 29 and 30, 2010, the Canadian Institutes of Health Research (CIHR) - Institute of Population and Public Health (IPPH) and partners held an international symposium on Accelerating Population Health Intervention Research to Promote Health and Health Equity (the Symposium) in Toronto, Ontario. Over 130 participants came from the federal and provincial governments, universities, Canadian and international research funding agencies, and non-governmental organizations, including the National Aboriginal Health Organization and the Canadian Centre for Policy Alternatives. This event also engaged international representatives from the Prevention Research Centers of the US Centers for Disease Control and Prevention and the US National Cancer Institute, as well as from the UK’s Medical Research Council - Population Health Sciences Research Network, Australia’s National Health and Medical Research Council, and France’s Institut National du Cancer.
The purpose of the Symposium was to foster discussion and ultimately advance the understanding of Population Health Intervention Research (PHIR) from the point of view of researchers, policy makers and science editors. Editorial staff from Chronic Diseases in Canada (CDIC) attended the Symposium in order to consider the journal’s role in this field. Over the past three years, CDIC has been undergoing a shift from reporting primarily on epidemiological studies to focusing on publishing research on population health interventions and health promotion.
PHIR examines the policies, programs and events that influence the “upstream” determinants of health, including interventions designed for another primary purpose that also impact health. PHIR emphasizes disease prevention and suggests solutions to health inequities.
While the study of population health interventions is not necessarily new, relatively little of this research exists, particularly in comparison to more descriptive research. A review of public health research in the United Kingdom found that less than 0.4% of such research was related to interventions.1 Similar patterns have been found in prominent areas of chronic disease prevention.2 The establishment of the Population Health Intervention Research Initiative for Canada (PHIRIC) by the CIHR’s Institute of Population and Public Health and other partners places a new emphasis on the importance of this type of research—as was witnessed at the Symposium—by trying to build capacity to fund, conduct and use PHIR. While the Institute of Population and Public Health and the Institute of Nutrition, Metabolism and Diabetes champion this type of research through PHIRIC, other CIHR Institutes, health charity partners, and federal government departments also play a role. Indeed, as Ms. Marie DesMeules of the Public Health Agency of Canada (PHAC) mentioned in her Symposium presentation, “Shifting Gears: Accelerating Innovative and Promising Interventions,” PHIR requires us to have uncluttered mechanisms to work across governments and departments.
The Symposium offered researchers many opportunities to demonstrate different aspects of current PHIR. For example, Dr. Geoffrey Fong presented on the International Tobacco Control Policy Evaluation Project, which involves 20 countries and 16 funding models. The project is testing policies to see if they actually close the existing equity gap in terms of tobacco control. On a different scale, Dr. Evelyn Forget discussed a study that compared two communities in the 1970s in Manitoba—one that received a guaranteed minimum income and one that did not. In the community with the guaranteed income, hospitalizations for accidents, injuries and mental illness dropped, suggesting that interventions from outside of the health sector can have positive health impacts.
The study of “natural experiments,” in which researchers do not have control over the timing and nature of the intervention or to the allocation of those exposed to the intervention,3 present unique opportunities for PHIR. Dr. Patricia Martens contended that natural experiments are powerful stories that capture the imaginations of policy makers. They may be studied through a range of research designs; however, the appropriateness (or lack thereof) of randomized control trial (RCT) designs for their study was discussed at length on both days of the Symposium. Some panellists discussed that while RCTs have internal validity, they may be less suited to capturing the interactions between interventions and the contexts in which they are implemented. In PHIR, the context of social determinants of health is pre-eminent. For example, Dr. Jim Dunn presented three examples of natural experiments from housing and health research, including the Toronto-based Regent Park housing redevelopment study. A multidisciplinary team of researchers, community groups, tenants, and government agencies are working together to study this natural experiment as it unfolds.
PHIR spans a variety of possible study designs, methodological approaches, and disciplines, and can be conducted at different stages of a policy or program’s development or implementation. As such, reviewers need guidelines on what criteria to apply to assess excellence in PHIR, and how to apply these criteria. CIHR’s Institute of Population and Public Health is developing peer review guidelines as a tool for grant reviewers. A reviewer may need to assess, for instance, whether or not the researchers have considered questions of knowledge transfer, policy maker involvement and cost effectiveness. Ethical conduct of PHIR, as well as the ethics of population health interventions, including principles of equity, need also be considered.
Public health journals play an important role in translating and exchanging knowledge by facilitating the peer-reviewing and publishing of PHIR. Articles published by peer-reviewed journals are usually indexed; thus the information therein can be lifted out of “grey literature,” making research findings more readily available. The guidelines that the CIHR’s Institute of Population and Public Health is developing as a tool for its grant reviewers could be adapted by scientific journals for their peer review process. (The current list of questions given to CDIC peer reviewers, for example, provides little or no guidance regarding the unique criteria that should be considered when assessing PHIR papers.) Thus, journals can further support PHIR by recruiting editors skilled at assessing PHIR papers, by identifying capable peer reviewers, and by adopting peer reviewer guidelines that assist in judging PHIR manuscripts. Thanks to PHIRIC and a continued collaboration with the CIHR-Institute of Population and Public Health, CDIC is in an excellent position to fulfill this role.