Population Health Intervention Research Initiative for Canada: progress and prospects

System-level change processes embed and become successful when the motives and perceived benefits of different people, organisations and processes harmonise. This paper describes how such an alignment of interests was achieved in the population health intervention research field in Canada and the strategies that are now taking it forward. The Population Health Intervention Research Initiative for Canada is a collaboration of research funders, non-governmental organisations, policy makers, researchers and trainees trying to shift the knowledge base for population and public health from a system that currently privileges description and analysis of health problems to one that caters more strongly to identifying and studying the outcomes of the policies and programs that will reduce health problems and health inequities and embed these into everyday practice. This paper outlines progress to date and new horizons for action.

Canada has a strong history in population and public health. Some of the best known outputs include the work produced under the rubric of the Canadian Institute for Advanced Research program on population health in a 10-year period spanning the 1980s and 1990s. The Institute is an interdisciplinary private not-for-profit research institute that provides leading scholars with the time, direction, freedom and inspiration to pursue fundamental questions concerning society, technology and the very nature of humanity and the universe. ¹ The population health program yielded outputs that were highly successful in reframing mainstream thinking about health (particularly that seen in government documents) and for putting social determinants of health into prominence. ^{2 , 3}

While not without its critics, ^{4 , 5} the program was pivotal in generating funding and institutional structures to facilitate population and public health research. For example, federal funding for the Canadian Population Health Initiative, based within the Canadian Institute for Health Information (1999), helped to ensure that population health had a strong presence when Canada’s Medical Research Council was redesigned as the Canadian Institutes of Health Research in 2000. Population and public health became the strategic focus of one of the 13 virtual institutes, the Institute of Population and Public Health. The field of social, cultural, environmental and population health was also made one of the four ‘pillars’ for categorising research across the Canadian Institutes of Health Research. The other three pillars are biomedical research, clinical research and health services research. The mission of the Institute of Population and Public Health is to improve the health of populations and promote health equity in Canada and globally by supporting research and encouraging its application to policies, programs and practices in public health and other sectors through strategic research investments. It also acts as a resource, guide and catalyst on population health research to the other Institutes and the Canadian Institutes of Health Research as a whole. Box 1 explains the pan-Canadian health agencies in Canada referred to in this article.

Box 1.  Brief guide to some key pan-Canadian health agencies

The Population Health Intervention Research Initiative for Canada grew out of a meeting of key people and organisations held in Banff in September 2006 which noted that, within the Canadian public and population health research context, sophisticated analytic descriptions of increasingly sick populations receive emphasis (some might say too much emphasis). Insufficient attention, however, was being given to interventions to improve population health. This tendency had also been observed in the United Kingdom. ⁶ A 2001–2006 review of grants awarded at the Canadian Institutes of Health Research showed that only 6% evaluated the impact of policies or programs to improve health. ⁷ The Population Health Intervention Research Initiative for Canada was established to increase the quantity and quality of use of population health intervention research, as well as to align and embed activities supporting this across the knowledge production and knowledge use system.

Population health intervention research is defined as the use of scientific methods to produce knowledge about policy and program interventions that operate within or outside the health sector and have the potential to impact health at the population level. ⁸ Impact at the population level does not only mean improving health or reducing health risks; it also means designing/implementing interventions which change the conditions of risk in order to shift the distribution of health risk, ⁹ in keeping with the ideas of Geoffrey Rose. ¹⁰ To be truly effective, a population health intervention should reduce risk exposure in successive cohorts of people within the setting(s) under investigation. Thus, as well as population health intervention research being an umbrella term that incorporates fields like health promotion research, health impact assessment, policy analysis and evaluation research, population health intervention research is designed to improve understanding of interventions addressing ‘upstream’ determinants of health, where some of the greatest long term gains may be realised.

A special supplement of the Canadian Journal of Public Health in 2009 documented the purpose of the Population Health Intervention Research Initiative for Canada, the rationale and the collaborating partners. ^{7 , 11 – 16} This represented championship at the level of provincial health delivery systems, pan-Canadian health research agencies, university-based researchers, non-governmental organisations, and support at the Public Health Agency of Canada.

The Population Health Intervention Research Initiative for Canada is stewarded by a planning committee made up of non-governmental organisations, health research funding agencies, researchers and public health policy makers and delivery organisations. It meets twice a year. The strategic plan encompasses four areas (Box 2).

Box 2.  Population Health Intervention Research Initiative for Canada: strategic objectives

The fundamental strategy is to work systematically on both the ‘demand’ and ‘supply’ sides of the population health intervention research equation, creating activities that increase the capacity to fund (e.g. operating grants and peer review guidelines) and conduct (e.g. training) population health intervention research as well as activities that encourage uptake and use, such as requirements for researcher–policy maker partnerships in knowledge production.

Population Health Intervention Research Initiative for Canada meetings provide opportunities to brainstorm new ideas and to align activities within each organisation in ways that maximise synergy and benefits. The Population Health Intervention Research Initiative for Canada is not an organisational structure that makes research funding decisions or develops Requests for Applications. The strategy is more high level and horizontal (e.g. planning symposia and communication tools, identifying infrastructure gaps, and alignment of activity where there is mutual interest). The Population Health Intervention Research Initiative for Canada (PHIRIC) has catalysed work on new criteria for peer review of intervention research to allow greater consideration of process evaluation as well as the relevance of the intervention to the population group. PHIRIC has also been a forum where agencies have reported on their own initiatives in line with PHIRIC objectives. An example is the Public Health Agency of Canada which has guided the focus of their investments away from smaller grants dispersed widely, towards larger targeted grants in priority areas (mental health promotion and obesity). This, along with new funding guidelines and procedures, has allowed for the development and testing of promising innovations and the building of stronger data systems to track and sustain them (Box 3).

Box 3.  Examples of alignments and strategies to foster population health intervention research during the early years of the Population Health Intervention Research Initiative for Canada

PHIRIC is not a research or training body itself – it is a collaboration and coordination mechanism. While catalysed and supported by the Canadian Institutes of Health Research’s Institute of Population and Public Health (which provides the secretariat functions), the key strength of PHIRIC is that it ‘belongs’ to no particular organisation and has no earmarked special funding. Rather, PHIRIC is about levering and growing commitments towards population health intervention research in participating organisations’ own budgets, in various ways, organically. For example, the PHIRIC definition for population health intervention research has been adopted into numerous Requests for Applications across multiple agencies. The peer review guidelines have been designed and tested collaboratively across key agencies, also with the view to wide uptake upon completion.

An economic evaluation on the return on investment in PHIRIC operations has conservatively estimated that for every dollar invested, that is, direct and indirect costs of the secretariat and in terms of the key participating people and organisations (including travel and meeting costs for the planning committee, symposia/events, consultancy advice, administration and communication functions and people’s time attending meetings and working on key tasks), another $30 is being leveraged for packages of intervention research and training across Canada within the participating key agencies. These are for a broad range of beneficiaries, of the kind illustrated in Box 3. ¹⁷

PHIRIC has moved through the classic, ‘text book’ stages of collaborative problem-solving over time. ¹⁸ At the beginning, the focus had to be on getting the ‘right’ organisations assembled, relying on broad and undifferentiated structures for engagement so as to maximise information exchange and identify common values. ¹⁸ After the mission was identified and the tasks were set, different structures allowed for more focused, efficient, coordinated workflow (e.g. working groups). ¹⁸ PHIRIC now has working groups in training, communication, evaluation and peer review. For example, the Evaluation Working Group will be collecting data that will allow us to assess: the leadership and championship role of population health intervention research at an organisational and system level; the extent to which there have been changes in the appraisal and support of evaluation of funding population health intervention studies; and the evaluation of training in population health intervention research, evaluation and knowledge exchange. The Training Working Group is pooling ideas and refining ways of measuring population health intervention research competencies. The Communication Working Group is designing fact sheets, webinars, case studies and a video.

Participation within the PHIRIC planning committee will be reviewed as activities grow and new constituencies form as a consequence. For example, right now there is no organised group of population health intervention research scientists in Canada, and so the researchers who happened to have been involved in PHIRIC’s early development bore no formal communication responsibility or representational accountability to their peers. This is likely to change with symposia, publications and granting rounds now bringing the field into stronger definition.

Next steps for PHIRIC are about connecting more broadly with the intervention research in sectors other than health, and the researchers conducting it. In a nascent field like population health intervention research, we need to appreciate which words and phrases about evaluation research and integrated evidence into policy strike a chord (and which do not). Under the leadership of the Canadian Institutes of Health Research’s Institute of Population and Public Health a symposium and workshop in late 2010 also showcased intervention studies and spotlighted some of the debates on advancing the science of this field and building links with research in related fields (e.g. implementation systems and improvement science).

PHIRIC resisted having any formal priority areas early in its development, for fear that these might bow to pressure to mimic standard chronic disease domains, create ‘winners and losers’ in this process and potentially take PHIRIC away from a whole-system focus. This decision proved wise, allowing organisations at the PHIRIC table to follow their own priority concerns and develop stronger investment in intervention research in whatever domains resonated with their stakeholders and partners. Most likely, PHIRIC’s strength will continue to come from strategies that have worked previously – that is, finding like-minded people and initiatives, building partnerships and opening up possibilities to consolidate resources.

The question of priorities has risen again recently. This time, system-focused priority areas have been readily embraced. The leading idea is that PHIRIC must create stronger system-level demand for population health intervention research. The unharnessed lever for the demand is public interest.

Right now, Canada is better at tracking the uneven distribution of Canadians’ health problems than at accounting for this distribution, in part, by the uneven distribution of known effective solutions (both on the treatment and prevention side). ^{19 , 20} Yet, where data systems within some authorities are strong, convincing causal stories can be made linking reminder systems with immunisation rates, ²¹ mobile services with uptake of mammography ²¹ and workplaces with comprehensive tobacco control policies with higher smoking quit rates among their employees. ²²

Hence, PHIRIC’s newest vision is to prompt more public awareness about which preventive policies and programs are being routinely delivered to whom with what effects. Hopefully then the public may come to demand better preventive policies and programs with the same vigour they currently reserve for accessing health care. ^{19 , 20} Increased public accountability would in turn prompt better investment in data systems across the sectors, to track the distribution of these policies and programs. Better data systems about delivery of or exposure to policies and programs that have the potential to improve health at the population level will in turn invite more research linking these exposures with outcomes and their distribution. This goal is now within PHIRIC’s sights. This is just one aspect of population health intervention research, but one firmly in the interests of many partners.

It might be easy to think that PHIRIC is possible simply because of Canada’s historic commitment to the field of population and public health research. While this provided one ready constituency to harness, we chiefly attribute the success of PHIRIC to its organisational form. PHIRIC is a loosely structured alliance that relies on no particular champion or funding stream, enabling each agency and group taking part to work out how to make their own agenda more ‘PHIRIC-like’. For example, for a funder this means creating population health intervention research and training funding streams. For a health delivery agency it means making a stronger commitment to planning and evaluation. Both benefit from better intervention research review criteria and relevant options in knowledge translation. As such, PHIRIC fits the criteria of a 21st century networked organisation. ²³ It is carried forward by many actors, it adjusts its shape to fit the circumstances, and it is powered by events and forums that bring supply and demand for intervention research together. This heterogeneity creates strength and allows vision beyond what each actor could achieve alone.