Summary / Explanation

Introduction                                                                                                                                                                The Office of Disease Prevention and Health Promotion's (ODPHP) Healthy People 2030 vision is for "a society in which all people can achieve their full potential for health and well-being across the lifespan." To achieve this, 3 areas, "well-being, healthy life expectancy, and summary mortality and health," were identified to measure the health of the population (ODPHP. Healthy People 2030).

In a seminal paper, Kindig and Stoddart defined population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group."[1] This definition embodies both outcomes or results and determinants or contributing factors. Compared to a more traditional approach of focusing on individual factors such as genetics and lifestyle, population health embraces additional determinants that may include healthcare policies, public health, and social and physical milieu.[1] Population health determinants can serve as a preventative approach and address root causes rather than symptoms like a biomedical approach.[2]                                                                                                                                                                                                                                                    Results from a recent scoping review found 57 frameworks, or organizational structures, to define the components of population health.[2] In addition to individual health status and health behavior, other crucial factors were identified, including social determinants of health and healthcare system performance.[2] The following sections will discuss several determinants of health. These factors do not make up a complete list of population health determinants, and their categorization varies in the literature, they also do not exist in isolation but rather in a complex, interrelated matrix (ODPHP. Healthy People 2030).[1]

Determinants of Health

Genetics and biology: The link between genetic factors and their physiologic outcomes in health and disease is part of population health. Links of family history to certain conditions (such as heart disease and depression) have been well-established.[3] This category can also include how extrinsic factors affect an individual's genome, such as smoking-induced deoxyribonucleic acid methylation at specific genomic loci.[3] The Framingham Heart Study, which began in Framingham, Massachusetts in 1948 (and is still ongoing), is considered the longest population-based cardiovascular study.[4][5] Landmark studies resulted from it, including those that identified key genetic factors, such as male sex and elevated cholesterol and blood pressure, as major risk factors for cardiovascular disease.[4][5] The study's data are part of a study that found hundreds of new loci for high blood pressure traits.[6]

Individual behavior and lifestyle: Individual behavior and lifestyle include intrinsic factors such as a patient's ability and motivation to engage in their health care and access to technology.[7] Extrinsic factors relating to individual behavior can include healthcare system factors like the ability to schedule appointments and the attitude and perceived skills of the healthcare providers.[7] Exposure to things such as tobacco, poor diet, alcohol, and firearms all fall under this domain.[7] The Framingham study established links between smoking, lack of physical activity, and cardiovascular disease.[4]

Social determinants: The World Health Organization defines the social determinants of health (SDOH) as "the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life" (ODPHP. Healthy People 2020 and 2030).[8] SDOH are nonclinical and nonbiological social factors that impact health. SDOH includes fundamental causes of disease such as racism and discrimination, unequal distribution of power, income, wealth, education, and societal values of equity and fairness that impact health directly and indirectly via intermediate structural factors, including healthcare access, healthcare quality, support services, housing and transportation and intermediate individual factors" (ODPHP. Healthy People 2020 and 2030).[8][9][10][11] Examples of SDOH domains include:

• Policy: The Institute of Medicine considers policy development a critical element of public health.[12] The government or healthcare organizations work to improve the health of a population. Examples include the Affordable Care Act, tobacco sales taxes, and car seatbelts (ODPHP. Healthy People 2020).[13] These are intended to be implemented in the population as a whole.                                                                                                                                    
• Healthcare systems and services: This category relates to how healthcare is delivered and accessed by a population. Healthcare systems can be evaluated for their quality, patient-centeredness, and cost-effectiveness.[2]                                                                               
• Physical environment factors: The physical environment of a population includes factors such as sanitation, quality housing, air pollution, and crowding. Personal control, socially supportive relationships, and restoration from stress and fatigue are all affected by the properties of the physical environment.[14]
• Ecological factors: Ecological factors also affect health based on the interconnectedness of living organisms and their environment.[15] Changes in the ecosystem brought about by climate change, loss of biodiversity, and ocean acidification, to name a few, can impact pollution, the availability and quality of clean air, water, food—and, subsequently, health.[16] Societal vulnerabilities in the form of infectious disease outbreaks and spread in nontraditional geographic regions have been documented as being due to increasing climate hazards such as severe flooding, extreme temperatures, and drought.[17]

The complex interrelatedness of these domains allows professionals working in population health to formulate a varied definition of population health.[2] This insight allows for inherent uniqueness when comparing various populations and targeting factors important for each one.[2] For clinicians, understanding the determinants of population health provides awareness of factors that can directly and indirectly affect the delivery of health care and influence individualized patient and population health outcomes. The more healthcare professionals educate themselves on determinants of population health, the more opportunities there will be to investigate, address, and overcome the barriers to providing optimized, versatile, and individualized patient care. Collectively, these efforts will lead to improved outcomes for patients and their communities.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Kindig D, Stoddart G. What is population health? Am J Public Health. 2003 Mar;93(3):380-3. [PMC free article: PMC1447747] [PubMed: 12604476]

2.

Chan SL, Ho CZH, Khaing NEE, Ho E, Pong C, Guan JS, Chua C, Li Z, Lim T, Lam SSW, Low LL, How CH. Frameworks for measuring population health: A scoping review. PLoS One. 2024;19(2):e0278434. [PMC free article: PMC10863900] [PubMed: 38349894]

3.

Shi Y, Zhong S. From genomes to societies: a holistic view of determinants of human health. Curr Opin Biotechnol. 2014 Aug;28:134-42. [PMC free article: PMC4111965] [PubMed: 24686286]

4.

Andersson C, Nayor M, Tsao CW, Levy D, Vasan RS. Framingham Heart Study: JACC Focus Seminar, 1/8. J Am Coll Cardiol. 2021 Jun 01;77(21):2680-2692. [PubMed: 34045026]

5.

Mahmood SS, Levy D, Vasan RS, Wang TJ. The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective. Lancet. 2014 Mar 15;383(9921):999-1008. [PMC free article: PMC4159698] [PubMed: 24084292]

6.

Evangelou E, Warren HR, Mosen-Ansorena D, Mifsud B, Pazoki R, Gao H, Ntritsos G, Dimou N, Cabrera CP, Karaman I, Ng FL, Evangelou M, Witkowska K, Tzanis E, Hellwege JN, Giri A, Velez Edwards DR, Sun YV, Cho K, Gaziano JM, Wilson PWF, Tsao PS, Kovesdy CP, Esko T, Mägi R, Milani L, Almgren P, Boutin T, Debette S, Ding J, Giulianini F, Holliday EG, Jackson AU, Li-Gao R, Lin WY, Luan J, Mangino M, Oldmeadow C, Prins BP, Qian Y, Sargurupremraj M, Shah N, Surendran P, Thériault S, Verweij N, Willems SM, Zhao JH, Amouyel P, Connell J, de Mutsert R, Doney ASF, Farrall M, Menni C, Morris AD, Noordam R, Paré G, Poulter NR, Shields DC, Stanton A, Thom S, Abecasis G, Amin N, Arking DE, Ayers KL, Barbieri CM, Batini C, Bis JC, Blake T, Bochud M, Boehnke M, Boerwinkle E, Boomsma DI, Bottinger EP, Braund PS, Brumat M, Campbell A, Campbell H, Chakravarti A, Chambers JC, Chauhan G, Ciullo M, Cocca M, Collins F, Cordell HJ, Davies G, de Borst MH, de Geus EJ, Deary IJ, Deelen J, Del Greco M F, Demirkale CY, Dörr M, Ehret GB, Elosua R, Enroth S, Erzurumluoglu AM, Ferreira T, Frånberg M, Franco OH, Gandin I, Gasparini P, Giedraitis V, Gieger C, Girotto G, Goel A, Gow AJ, Gudnason V, Guo X, Gyllensten U, Hamsten A, Harris TB, Harris SE, Hartman CA, Havulinna AS, Hicks AA, Hofer E, Hofman A, Hottenga JJ, Huffman JE, Hwang SJ, Ingelsson E, James A, Jansen R, Jarvelin MR, Joehanes R, Johansson Å, Johnson AD, Joshi PK, Jousilahti P, Jukema JW, Jula A, Kähönen M, Kathiresan S, Keavney BD, Khaw KT, Knekt P, Knight J, Kolcic I, Kooner JS, Koskinen S, Kristiansson K, Kutalik Z, Laan M, Larson M, Launer LJ, Lehne B, Lehtimäki T, Liewald DCM, Lin L, Lind L, Lindgren CM, Liu Y, Loos RJF, Lopez LM, Lu Y, Lyytikäinen LP, Mahajan A, Mamasoula C, Marrugat J, Marten J, Milaneschi Y, Morgan A, Morris AP, Morrison AC, Munson PJ, Nalls MA, Nandakumar P, Nelson CP, Niiranen T, Nolte IM, Nutile T, Oldehinkel AJ, Oostra BA, O'Reilly PF, Org E, Padmanabhan S, Palmas W, Palotie A, Pattie A, Penninx BWJH, Perola M, Peters A, Polasek O, Pramstaller PP, Nguyen QT, Raitakari OT, Ren M, Rettig R, Rice K, Ridker PM, Ried JS, Riese H, Ripatti S, Robino A, Rose LM, Rotter JI, Rudan I, Ruggiero D, Saba Y, Sala CF, Salomaa V, Samani NJ, Sarin AP, Schmidt R, Schmidt H, Shrine N, Siscovick D, Smith AV, Snieder H, Sõber S, Sorice R, Starr JM, Stott DJ, Strachan DP, Strawbridge RJ, Sundström J, Swertz MA, Taylor KD, Teumer A, Tobin MD, Tomaszewski M, Toniolo D, Traglia M, Trompet S, Tuomilehto J, Tzourio C, Uitterlinden AG, Vaez A, van der Most PJ, van Duijn CM, Vergnaud AC, Verwoert GC, Vitart V, Völker U, Vollenweider P, Vuckovic D, Watkins H, Wild SH, Willemsen G, Wilson JF, Wright AF, Yao J, Zemunik T, Zhang W, Attia JR, Butterworth AS, Chasman DI, Conen D, Cucca F, Danesh J, Hayward C, Howson JMM, Laakso M, Lakatta EG, Langenberg C, Melander O, Mook-Kanamori DO, Palmer CNA, Risch L, Scott RA, Scott RJ, Sever P, Spector TD, van der Harst P, Wareham NJ, Zeggini E, Levy D, Munroe PB, Newton-Cheh C, Brown MJ, Metspalu A, Hung AM, O'Donnell CJ, Edwards TL, Psaty BM, Tzoulaki I, Barnes MR, Wain LV, Elliott P, Caulfield MJ., Million Veteran Program. Genetic analysis of over 1 million people identifies 535 new loci associated with blood pressure traits. Nat Genet. 2018 Oct;50(10):1412-1425. [PMC free article: PMC6284793] [PubMed: 30224653]

7.

van Kessel R, Ranganathan S, Anderson M, McMillan B, Mossialos E. Exploring potential drivers of patient engagement with their health data through digital platforms: A scoping review. Int J Med Inform. 2024 Sep;189:105513. [PubMed: 38851132]

8.

Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke. 2020 Nov;51(11):3433-3439. [PMC free article: PMC7732185] [PubMed: 33104471]

9.

Gómez CA, Kleinman DV, Pronk N, Wrenn Gordon GL, Ochiai E, Blakey C, Johnson A, Brewer KH. Addressing Health Equity and Social Determinants of Health Through Healthy People 2030. 2021 Nov-Dec 01J Public Health Manag Pract. 27(Suppl 6):S249-S257. [PMC free article: PMC8478299] [PubMed: 33729197]

10.

Marmot M. Social determinants of health inequalities. Lancet. 2005 Mar 19-25;365(9464):1099-104. [PubMed: 15781105]

11.

Schulz AJ, Kannan S, Dvonch JT, Israel BA, Allen A, James SA, House JS, Lepkowski J. Social and physical environments and disparities in risk for cardiovascular disease: the healthy environments partnership conceptual model. Environ Health Perspect. 2005 Dec;113(12):1817-25. [PMC free article: PMC1314928] [PubMed: 16330371]

12.

Institute of Medicine (US) Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public's Health in the 21st Century. National Academies Press (US); Washington (DC): 2002. [PubMed: 25057638]

13.

Zhao J, Mao Z, Fedewa SA, Nogueira L, Yabroff KR, Jemal A, Han X. The Affordable Care Act and access to care across the cancer control continuum: A review at 10 years. CA Cancer J Clin. 2020 May;70(3):165-181. [PubMed: 32202312]

14.

Evans GW. The built environment and mental health. J Urban Health. 2003 Dec;80(4):536-55. [PMC free article: PMC3456225] [PubMed: 14709704]

15.

Parkes MW, Poland B, Allison S, Cole DC, Culbert I, Gislason MK, Hancock T, Howard C, Papadopoulos A, Waheed F. Preparing for the future of public health: ecological determinants of health and the call for an eco-social approach to public health education. Can J Public Health. 2020 Feb;111(1):60-64. [PMC free article: PMC7046913] [PubMed: 31792844]

16.

Li AM. Ecological determinants of health: food and environment on human health. Environ Sci Pollut Res Int. 2017 Apr;24(10):9002-9015. [PMC free article: PMC7089083] [PubMed: 26552789]

17.

Semenza JC, Rocklöv J, Ebi KL. Climate Change and Cascading Risks from Infectious Disease. Infect Dis Ther. 2022 Aug;11(4):1371-1390. [PMC free article: PMC9334478] [PubMed: 35585385]

Disclosure: Emily Orille declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Steck declares no relevant financial relationships with ineligible companies.

Disclosure: Grace Brannan declares no relevant financial relationships with ineligible companies.