[Evaluating population health interventions : The contributions of theory-driven evaluations]

Population health intervention research has been characterized by the deployment of scientific methods designed to produce knowledge on policy and program interventions directly or indirectly involving the health sector, and potentially affecting population health. The proposed solutions encompass a multitude of interventions of variable types, scale, focus and implementation, rendering them particularly complex and difficult to understand. This complexity raises major conceptual and methodological issues because in reality, we assess not an intervention, but rather a set of interventional elements interacting with those specific to the context in which they appear. It is the interactions that produce effects, to the extent that it makes little sense to speak of an intervention, and more sense to consider an interventional system defined by the interactions. To grasp the numerous elements brought into play, it behooves us to amalgamate evaluation paradigms and approaches. In a precise context, theory-driven evaluations are of pronounced interest. This article presents the main principles of this type of evaluation by focusing on its capacity to shed light on the stakes involved in intervention/context interplay, and by putting forward conclusions transferable to population health research.

Core competencies for strategic grantmaking: lessons learned from the Innovation Strategy

SETTING

The Public Health Agency of Canada Innovation Strategy (PHAC-IS) was a national strategic funding program designed to test, deliver, scale up and evaluate complex population health interventions to determine how they bring about change, the context in which they worked best and for which populations.

INTERVENTION

The PHAC-IS experience provides an opportunity to reflect on the core competencies (skills, knowledge and attitudes) for strategic grantmakers to meet the goals of a national strategic funding program focused on population health intervention research.

OUTCOMES

A literature review, PHAC-IS content analysis, a document review and semi-structured interviews provided insight into a set of core competencies-organized by specific domains-that fostered a team focused on continuous improvement to apply learning and evidence from the funded projects to advance the goals of the strategic funding program.

IMPLICATIONS

Given its multiple complexities and based on the experience of the PHAC-IS team, it is proposed that funding programs aimed toward bringing change at individual and systems levels for population health promotion may draw upon a set of competencies incorporating the fields of strategic grantmaking; intervention research and evaluation; and public administration. The authors suggest that competency in the field of cultural safety is also pertinent to the successful management and leadership of public health programs, innovations and knowledge mobilization.

Misclassification errors from postal code-based geocoding to assign census geography in Nova Scotia, Canada

OBJECTIVES

Postal codes are often the only available geographic identifiers in many sources of health data in Canada. In order to conduct geographic analyses, postal codes are routinely geocoded to census geography to link to ecological data. Despite common use of this method, the extent of geographic misclassification errors is poorly understood. We estimated misclassification errors in the geocoding of postal codes to assign census geography in Nova Scotia, Canada.

METHODS

We examined differences between counts and match rates for postal-code geocoded and actual locations of buildings in Nova Scotia at two census administrative area levels: dissemination areas (DAs) and census subdivisions (CSDs). Actual locations were based on the data collected by the provincial government containing actual latitude/longitude of buildings. Variation in misclassification by rurality, using Statistics Canada's classification, was also assessed.

RESULTS

Outside two urban areas (Halifax Metro and Sydney) which had <10% differences in counts, many DAs had >30% differences. Match rates showed similar patterns, with the vast majority of non-urban DAs having <40% match rates. Even in major urban areas, 10% of DAs had large misclassification errors. Misclassification errors at the CSD level were still too great to estimate counts or rates without further area aggregation.

CONCLUSION

Routine use of postal code geocoding should be replaced with geocoding of location information using additional identifiers such as civic addresses or latitude and longitude. If data holders did this in-house before providing data to researchers, the accuracy and capacity of geographic analysis would be enhanced while protecting confidentiality.

[Immigrant health in Canada: current state of knowledge, interventions and issues]

This article presents a synthesis of current research, presented during a symposium entitled, ‘Immigrant health in Canada: Current state of knowledge, interventions and issues,’ organized by the Public Health Agency of Canada. We begin with a general overview of the health of immigrants in Canada. We then analyze the role of community health workers in tackling health inequalities in this population, and certain ways of adapting health services to respond to the growing linguistic and cultural diversity present in Canadian society. We conclude with a discussion of one initiative developed by elderly-friendly local authorities. Throughout the symposium, the speakers emphasized an approach based on the determinants of health, which aims to improve health outcomes of the targeted populations, provide appropriate services and reduce health inequalities.

Why are some books important (and others not)?

The book Why Are Some People Healthy and Others Not? The Determinants of Health of Populations represented a milestone in our evolving understanding of the determinants of population health. Building on Marc Lalonde's earlier A New Perspective on the Health of Canadians, it created a theoretical framework that could incorporate emerging evidence from a wide range of disciplines. Central to its authors' approach was the observation of heterogeneity, of the systematic differences in health observed when populations are partitioned on characteristics such as income, education, geographic region, etc. The universal observation of a social gradient, of a strong correlation between socio-economic class and health, led to a focus on how the social environment might influence health. Social position strongly influences both the stresses to which individuals are subject, and the resources available to cope with them. Furthermore, healthy and unhealthy responses to stress become "embedded", learned or conditioned both behaviourally and biologically, thus influencing health over the whole life course. The book's impact has been remarkable, not merely in academic citations but through its authors' subsequent work and strategic positions in Canadian health research organizations. The concept of "Population Health" has become part of our shared intellectual heritage.

The skin cancer prevention framework: a comprehensive tool for population-level efforts in skin cancer

The Skin Cancer Prevention Team (SCPT) required a comprehensive approach for guiding its efforts in population-level skin cancer prevention. After identifying and reviewing several models, it concluded that an appropriate population-level model applicable to the Alberta context did not exist. Thus, the SCPT, under the Alberta Health Services - Cancer Prevention Program, developed and evaluated a model for Alberta. Three inclusion criteria for a comprehensive framework were identified: 1) use an ecological approach to population health; 2) function as a dynamic tool for planning, implementing and evaluating population-level efforts; and 3) address weaknesses in existing theory in population health and health promotion. Theoretical constructs were layered together, on the basis of the criteria, to develop an omnibus framework. The resulting Framework represents a layering of several constructs used in popular health promotion and population health theories. It merges principles of the realist approach to scientific enquiry with principles of ecological theory. The Framework outlines a three-step, dynamic process for planning, implementing and evaluating population-level efforts. It also provides insight into the larger, unifying influences for changes in health outcomes and the complex mechanisms of behaviour change processes at the population level.

The imperative of strategic alignment across organizations: the experience of the Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation

The Canadian Cancer Society's Centre for Behavioural Research and Program Evaluation (CBRPE) is a national asset for building pan-Canadian capacity to support intervention studies that guide population-level policies and programs. This paper briefly describes CBRPE's experience in advancing this work in the field of prevention. The aim is to illuminate issues of central importance for advancing the goals of the Population Health Intervention Research Initiative for Canada. According to our experience, success in building the population intervention field will depend heavily on purposeful alignment across organizations to enable integration of research, evaluation, surveillance, policy and practice. CBRPE's capacity development roles include a) a catalytic role in shaping this aligned inter-organizational milieu and b) investing our resources in building tangible assets (teams, indicators, data systems) that contribute relevant capacities within this emerging milieu. Challenges in building capacity in this field are described.

What is population health intervention research?

Population-level health interventions are policies or programs that shift the distribution of health risk by addressing the underlying social, economic and environmental conditions. These interventions might be programs or policies designed and developed in the health sector, but they are more likely to be in sectors elsewhere, such as education, housing or employment. Population health intervention research attempts to capture the value and differential effect of these interventions, the processes by which they bring about change and the contexts within which they work best. In health research, unhelpful distinctions maintained in the past between research and evaluation have retarded the development of knowledge and led to patchy evidence about policies and programs. Myths about what can and cannot be achieved within community-level intervention research have similarly held the field back. The pathway forward integrates systematic inquiry approaches from a variety of disciplines.