Erica Di Ruggiero

A critical examination of representations of context within research on population health interventions

Abstract Research that fulsomely characterizes context improves our understanding of the processes of implementation and the effectiveness of interventions to improve the health of populations and reduce health inequalities. Context could be a key aspect to understanding what population health interventions best address underlying conditions that contribute to systematic differences in health status at the population level. Here, we present a ‘snapshot’ of representations of context in population health intervention research published recently in some influential journals in the field of public health. In general, we found that context was treated as a ‘black box’, or as something that needs to be ‘controlled for’. Context also was used to help explain intervention ‘failure’. There were few in-depth descriptions of the hypothesized pathways or mechanisms through which context and intervention (in combination or separately) influence population health. Recognizing that research on population health interventions can be less straightforward than research conducted under more ‘controlled’ (i.e. de-contextualized) conditions, we suggest that there is a great need for new theoretical and methodological work in this area.

Exploring which context matters in the study of health inequities and their mitigation

Aim: This commentary argues that contextual influences on health inequities need to be more thoroughly interrogated in future studies of population health interventions. Methods: Case examples were chosen to illustrate several aspects of context: its historical, global, and dynamic nature; its multidimensional character; and its macro- and micro-level influences. These criteria were selected based on findings from an extensive literature review undertaken for the Public Health Agency of Canada and from two invitational symposia on multiple intervention programmes, one with a focus on equity, the other with a focus on context. Findings: Contextual influences are pervasive yet specific, and diffuse yet structurally embedded. Historical contexts that have produced inequities have contemporary influences. The global forces of context cross jurisdictional boundaries. A complex set of social actors intersect with socio-political structures to dynamically co-create contextual influences. Conclusions: These contextual influences raise critical challenges for the field of population health intervention research. These challenges must be addressed if we are going to succeed in the calls for action to reduce health inequities. Implications for future public health research and research-funding agencies must be carefully considered.

Ottawa Statement from the Sparking Solutions Summit on Population Health Intervention Research

The Cape Town Statement was released on October 3, 2014 following the Third Global Symposium on Health Systems Research. The Statement covered a number of action themes, including health systems development, capacity development for research, cutting-edge and innovative research methods, and learning communities and knowledge translation. Following the Cape Town Statement’s release, a call to action that included action themes and recommendations for implementation research and delivery science (IRDS) was issued. Directed at health policy-makers and managers, funding organizations, researchers and academic institutions, journal editors and publishers, and civil society organizations, it aimed to facilitate the development of responsive health systems that are effective, efficient, equitable, and people-centered. This call to action is in keeping with the tenets of population health approaches throughout North America, much of Europe, and in many other places around the world. While the Cape Town Statement focused on health systems, the Ottawa Statement emphasizes the science of population health interventions. These include policies, programs and resource distribution approaches that are designed to have impact at the population level by changing the underlying conditions of risk and reducing health inequities. Examples of such interventions with a primary prevention orientation include organizational changes in workplace design, housing policies to reduce homelessness, immunization programs, and tax policy that discourages consumption of tobacco and other harmful products at a population level. Thus, population health intervention research (PHIR) is not clinical or laboratory-based. Rather, it is defined as research that involves the use of scientific methods to produce knowledge about interventions that operate within or outside of the health sector and have the potential to impact the health of populations and health equity (Population Health Intervention Research Initiative for Canada [PHIRIC]).

The politics of agenda setting at the global level: Key informant interviews regarding the International Labour Organization Decent Work Agenda

BackgroundGlobal labour markets continue to undergo significant transformations resulting from socio-political instability combined with rises in structural inequality, employment insecurity, and poor working conditions. Confronted by these challenges, global institutions are providing policy guidance to protect and promote the health and well-being of workers. This article provides an account of how the International Labour Organization’s Decent Work Agenda contributes to the work policy agendas of the World Health Organization and the World Bank.MethodsThis qualitative study involved semi-structured interviews with representatives from three global institutions – the International Labour Organization (ILO), the World Health Organization and the World Bank. Of the 25 key informants invited to participate, 16 took part in the study. Analysis for key themes was followed by interpretation using selected agenda setting theories.ResultsInterviews indicated that through the Decent Work Agenda, the International Labour Organization is shaping the global policy narrative about work among UN agencies, and that the pursuit of decent work and the Agenda were perceived as important goals with the potential to promote just policies. The Agenda was closely linked to the World Health Organization’s conception of health as a human right. However, decent work was consistently identified by World Bank informants as ILO terminology in contrast to terms such as job creation and job access. The limited evidence base and its conceptual nature were offered as partial explanations for why the Agenda has yet to fully influence other global institutions. Catalytic events such as the economic crisis were identified as creating the enabling conditions to influence global work policy agendas.ConclusionsOur evidence aids our understanding of how an issue like decent work enters and stays on the policy agendas of global institutions, using the Decent Work Agenda as an illustrative example. Catalytic events and policy precedents were found to contribute positively to agenda setting. Questions remain, however, across key informants about the robustness of the underlying evidence base for this Agenda and what meaningful impacts have been realized on the ground as a result.

Population Health Intervention Research Initiative for Canada: progress and prospects

Actions in Canada are being designed to transform the way research evidence is generated and used to improve population health. Capacity is being built in population health intervention research. The primary target is more understanding and examination of policies and programs that could redress inequities in health. The Population Health Intervention Research Initiative for Canada is a loosely-networked collaboration designed to advance the science of the field as well as the quantity, quality and use of population health intervention research to improve the health of Canadians. In the first few years there have been new training investments, new funding programs, new working guidelines for peer review, symposia and new international collaborations. This has been brought about by the strategic alignment of communication, planning and existing investments and the leveraging of new resources.

Global health research case studies: lessons from partnerships addressing health inequities

The ten case studies included in this collection do not describe individual research projects. Instead they each provide an in-depth account of a defined program of research that acts as a platform for theoretically linked research projects. The programs are an integrated blend of knowledge generation capacity building and knowledge translation activities that have evolved towards increasing complexity and sophistication. In particular attention to capacity building and knowledge translation increases as the programs mature over time. The programs of research are animated by a core alliance of individuals whose international partnerships are rooted in mutual trust and the articulation of a common goal: health equity. (Excerpt)

Public health agenda setting in a global context: the International Labor Organization's decent work agenda.

We drew on two agenda-setting theories usually applied at the state or national level to assess their utility at the global level: Kingdons multiple streams theory and Baumgartner and Joness punctuated equilibrium theory. We illustrate our analysis with findings from a qualitative study of the International Labor Organizations Decent Work Agenda. We found that both theories help explain the agenda-setting mechanisms that operate in the global context, including how windows of opportunity open and what role institutions play as policy entrepreneurs. Future application of these theories could help characterize power struggles between global actors, whose voices are heard or silenced, and their impact on global policy agenda setting.

Sustainable partnerships for NCD prevention: implications for public health

While largely preventable, the global burden of non-communicable diseases (NCDs) remains overwhelming, calling for collaboration across public and private sectors. Globally, 70% of all deaths are attributable to non-communicable diseases (NCDs). NCDs disproportionately affect people in developing countries where three-quarters of these deaths occur (World Health Organization 2017a). Concerted action is required to tackle the multiple risk factors of NCDs particularly unhealthy diets and their social, cultural, economic, commercial and environmental determinants. Buse and Hawkes (2015) argue that only a paradigm shift in global health efforts can support the prevention of NCDs and contribute meaningful progress towards the Post-2015 Development Agenda. They identify five challenges, including shifting the focus from treatment towards prevention, enhancing intersectoral and coordinated leadership that acts on the socioeconomic, political and legal drivers of health, and implementing effective means to tackle the commercial determinants of health. While the 17 Sustainable Development Goals (SDGs) reflect a more holistic view of health compared to their predecessor, the Millennium Development Goals, they also reveal several inherent tensions. For example, SDG3 on health and well-being includes as a target the reduction of one-third premature mortality from NCDs, while SDG17 encourages partnerships between academic, public, private and civil society actors to achieve these goals (United Nations 2016). This encouragement to partner may lend legitimacy to public/private partnerships, without recognizing that these efforts can also compromise and conflict with public health goals, especially when involving industries that directly or indirectly profit from the consumption of products shown to contribute to NCDs (e.g. tobacco, alcohol, unhealthy foods) (Kickbusch et al. 2016). The constant push and pull for multi-stakeholder partnerships that include the commercial sector raises a number of challenges for researchers, practitioners and policy-makers whose mandate is to protect and promote population health, despite potentially lucrative opportunities to expand programs. These challenges relate to issues of governance, transparency, accountability and conflicts of interest. Global institutions such as the World Health Organization (WHO) have responded by offering member states guidance and tools for managing conflicts of interest (COI). The WHO tool for managing COI in nutrition programs is one such guiding framework for public health policy development (World Health Organization 2017b). Others have recommended several ‘tests’ for public policy makers to consider before engaging in corporate partnerships (e.g. Are the corporate social responsibility activities of the corporation independently audited? Is their role limited to implementation and not policy development, which should be the purview of government?) (McKee and Galea 2014). Lima and Galea (2018) have proposed a framework for systematically analyzing the actions of corporations, using a multi-dimensional power lens. They outline different vehicles (e.g. political and legal environments) via which commercial power can exert influence on population health. For researchers, Brisbois et al. (2016) suggest assessing the potential effects on researcher autonomy and agency, impact on the research agenda, and unintended consequences when considering the ultimate root causes of the public health challenge. Despite such efforts, scholarship that documents the real world experiences of engagement between the public and private sectors, and that rigorously evaluates the challenges and opportunities from these interactions is still limited, & Erica Di Ruggiero e.diruggiero@utoronto.ca

Building the field of population health intervention research: The development and use of an initial set of competencies

Population health intervention research (PHIR) is a relatively new research field that studies interventions that can improve health and health equity at a population level. Competencies are one way to give legitimacy and definition to a field. An initial set of PHIR competencies was developed with leadership from a multi-sector group in Canada. This paper describes the development process for these competencies and their possible uses. Methods to develop the competencies included key informant interviews; a targeted review of scientific and gray literature; a 2-round, online adapted Delphi study with a 24-member panel; and a focus group with 9 international PHIR experts. The resulting competencies consist of 25 items grouped into 6 categories. They include principles of good science applicable though not exclusive to PHIR, and more suitable for PHIR teams rather than individuals. This initial set of competencies, released in 2013, may be used to develop graduate student curriculum, recruit trainees and faculty to academic institutions, plan non-degree professional development, and develop job descriptions for PHIR-related research and professional positions. The competencies provide some initial guideposts for the field and will need to be adapted as the PHIR field matures and to meet unique needs of different jurisdictions.

The relaunch of IJPH’s knowledge synthesis, translation, and exchange section

In 2011, Potvin and Abel’s Editorial launched a new section on knowledge synthesis, translation, and exchange (KSTE) for IJPH. 7 years later, the Journal is seeking to further increase the number and diversity of submissions with relevance to public health. At the core of this effort is continued openness to publish manuscripts, commentaries, and editorials that span the breadth of KSTE and pertain to public health. Scholarship that applies different methods of synthesis and evaluates diverse knowledge translation and exchange strategies for improving evidence-informed decision-making in public health has exploded in recent decades (Di Ruggiero et al. 2017). Research efforts in this realm are inherently complex, as they generate, synthesize, and translate public health evidence regarding the determinants of health and health equity alongside interventions (e.g. policies, programs, and laws) that aim to influence the distribution of risk at a population level (Hawe and Potvin 2009). As a result, a plurality of concepts, theories, models, frameworks, and methods is being used—and, in some instances, raising conflicting perspectives about what constitutes ‘‘good evidence’’ in public health. Their application also raises fundamental questions about who and what, and under what contextual circumstances knowledge is generated, disseminated, and used or not, and with what kind of measurable impacts. For instance, whose decisions are actually being influenced and how? At what level (e.g., individual, organizational/institutional, network, and/or system levels), and in which sectors (within and outside of health)? What is the relative contribution of the historical, social, cultural, institutional, and/or political context in public health decision-making? While generally poorly described, attention to context, how it is characterized as a phenomenon (through the application of appropriate theories, for example), how it is treated in the synthesis of knowledge, and elucidated through high-quality empirical studies to shed light on the contextual influences of knowledge use, is another topic requiring further study (Shoveller et al. 2016). There are also questions related to the ethics of KSTE, drawing much needed attention to the role of values, assumptions, culture, power, and voice in decision-making. Finally, research addressing equity considerations, including social gradients in intervention effects, is crucial to monitoring global, national, and subnational public health interventions (Welch et al. 2013). With this broad set of questions and issues as a backdrop, the IJPH is pleased to relaunch its KSTE section: Systematic reviews, meta-syntheses and meta-analyses, narrative reviews, realist reviews, scoping reviews, and practice guidelines are all examples of knowledge syntheses using qualitative and/or quantitative methods that need to be reproducible and transparent. The Journal invites submissions that rigorously apply any of these review methods with relevance to public health and related interventions. Reviews can follow methods set out by the Cochrane Collaboration, including its Public Health Group, the Campbell Collaboration) or other synthesis approaches such as realist reviews (Pawson et al. 2005) and scoping reviews (Arksey and O’Malley 2005). Each can present different challenges related to the state, heterogeneity, and complexity of the evidence base being synthesized. The evaluation of knowledge translation and exchange (KTE) strategies, tools, governance mechanisms, and other approaches that can facilitate or hinder the dissemination, utilization, or integration of knowledge into decisionmaking in health and other sectors (e.g.. environment, education) is also an important area of interrogation. Submissions that assess these and other KTE strategies with relevance to public health are also welcomed. As part of the KTSE section’s relaunch, I have invited experts to reflect on substantive issues in the field. Their This editorial is part of the section ‘‘Knowledge Synthesis, Translation and Exchange’’.