POP News - Spring 2013, Volume 2, Issue 5

Table of contents

Message from the Scientific Director

Earlier this year, Canada lost one of its leading population health researchers. On behalf of CIHR-IPPH and our advisory board, I would like to pay my deepest respects to the late Clyde Hertzman. CIHR greatly valued Dr. Hertzman’s many contributions, including his role as a member of IPPH’s inaugural advisory board. His contributions to early child development and population health thinking in Canada and globally have left an indelible footprint and he will be sorely missed. The Clyde Hertzman Legacy Fund has been established in his memory to support the expansion of a new innovative early childhood development indicator and community development tool called the Heart-Mind Index.

This issue of POP News features a number of articles related to our strategic research priority on population health intervention research (PHIR). A working definition of PHIR is “the use of scientific methods to produce knowledge about policy, program and resource distribution approaches that operate within or outside of the health sector and have the potential to impact health at the population level.” Our Institute has been serving as the secretariat for the Population Health Intervention Research Initiative for Canada (PHIRIC) since 2006.

Andrea Hill and Erica Di Ruggiero have written a reflective piece on PHIRIC based on an interview with co-chairs Stephen Samis and Jeannie Shoveller. Please take a moment to visit the PHIRIC website, which has been recently revamped. Other articles in this issue highlight PHIR that our Institute has co-funded with other partners through both the Applied Public Health Chairs program and the Programmatic Grants in Health and Health Equity. These articles describe critical dimensions of population health interventions including scale-up, alternate delivery systems and intersectoral collaboration. Finally, we have included an article about an evaluation of a school-based intervention that was designed to encourage enrolment of low-income students in post-secondary institutions.

Two articles are featured in our Student Corner. Maxwell Smith investigates the public health foundations of emergency preparedness while Rodrigue Deuboué Tchialeu provides reflections on the Advancing Population and Public Health Economics Workshop that our Institute co-hosted with partners in January.

Some recent global health events are also described in this issue. The first scientific meeting of international hypertension research teams supported by the Global Alliance for Chronic Diseases (GACD) was hosted by CIHR in Ottawa last December. An Ambassador’s dinner was held to honour the 15 countries involved in this global initiative. More recently, our Institute and the Institute of Health Services and Policy Research held a Best Brains Exchange in Beijing, China this March on primary health care human resources policy development in collaboration with Felix Li, Minister Counsellor (Health) with the Canadian Embassy. This was the first international Best Brains Exchange.

Some of our early-career researchers may be interested in an upcoming Young Researchers’ Forum being held at the European Public Health Conference and co-sponsored by IPPH and the Association of Schools of Public Health in the European Region (ASPHER).

I would like to end by reminding readers that questions and comments from the research community are always welcome. We look forward to hearing from you.

Applied Public Health Chair Feature
Science and Partnership: Informing BC’s Online Sexual Health Services

Article by Jeannie Shoveller (Applied Public Health Chair for the Canadian Institutes of Health Research and Public Health Agency of Canada and Professor at University of British Columbia’s School of Population and Public Health) and Mark Gilbert (Physician Epidemiologist with the Clinical Prevention Services Division at the B.C. Centre for Disease Control and Clinical Assistant Professor at University of British Columbia’s School of Population & Public Health). As a CIHR-IPPH Applied Public Health Chair, Shoveller helps stimulate innovative approaches in public health intervention research, mentorship, education and knowledge translation.

Interventions targeting populations at risk for sexually transmitted infections (STIs) and HIV are currently experiencing unprecedented reach through the internet. Globally, pilot programs for internet-based sexual health services, such as online testing and partner notification, have shown promising results particularly among young people aged 15-24 and among gay, bisexual and other men who have sex with men (MSM). These online services may lead to more appropriate use of sexual health clinics and may help ease current workload pressures by, for example, offering opportunities for asymptomatic clients to seek online services instead of presenting for clinical care.

Recently, the B.C. Centre for Disease Control (BCCDC) established the Online Sexual Health Services (OSHS) program that offers internet-based sexual health services in various stages of development and implementation. These services include:

  • testing services, such as online risk assessment questionnaires and downloadable lab test requisition forms;
  • counselling and education, such as referrals to other services and sexual health counsellors who communicate online through chat, forums and email; and
  • partner notification, such as online greeting cards sent anonymously peer-to-peer or with personal messages.

Underpinning the OSHS is a research program co-led by Jeannie Shoveller and Mark Gilbert. Together, they lead and foster a productive, interdisciplinary research and practice partnership that uses multiple study designs and methods to inform the development, implementation and evaluation of the OSHS. Since 2010, Shoveller and Gilbert have co-held several CIHR grants related to the OSHS, have co-supervised four graduate trainees working directly on the initiative and have co-authored and co-presented their work in national and international venues.

Most recently, Shoveller and Gilbert have received funding from CIHR to study the future scaling-up of the online testing service across B.C. to:

  1. Investigate acceptability of the OSHS among young clients (aged 15-24 years) who are currently using the service, prospective youth clients and service providers across the five Health Authorities in B.C.;
  2. Identify how social, structural and relational factors affect use of the OSHS and to describe the potential scope, capacity and limits of the OSHS to complement existing STI/HIV services in a variety of social and geographic areas of B.C.;
  3. Describe the characteristics of the OSHS youth client base and to examine the diffusion of the OSHS into vulnerable population subgroups of youth, such as youth who identify as lesbian, gay, bisexual or transgendered (LGBT); racialized youth; immigrant youth and street-involved youth.

Findings from this study will inform the province-wide implementation of the OSHS. While the program is an internet-based intervention, there are important client interfaces with “real-life” service provision sites. For example, OSHS clients who require testing will need to interact with specimen collection sites, such as private laboratories, and, in the event of a positive test result, clients will be invited to visit a health service provider such as a clinic or doctor’s office to receive treatment and counselling. Shoveller’s and Gilbert’s research will foster a better understanding of how the OSHS can best be implemented to fit with the realities of clients and service providers, while gathering new insights into the ways in which it can complement existing sexual health services across B.C.

Gilbert and Shoveller, along with colleagues, students and members of the target populations (youth and MSM), will be involved throughout all stages of the research process, using integrated knowledge translation (IKT) techniques. These include shaping research questions and methodology; collecting data and developing tools; interpreting study findings; crafting KT messages; and disseminating and applying research findings. The aim is to develop and reproduce genuine reciprocity and avoid the artificiality that sometimes accompanies partnership agreements. This artificiality occurs when researchers assume they are providing decision-makers with knowledge, without adequately accounting for the fact that knowledge is co-produced. While IKT does not demand that decision-makers become researchers (or vice-versa), Shoveller’s and Gilbert’s experience demonstrates that co-development and co-implementation of effective research, practice and community partnerships produces evidence that is relevant and credible. Mentoring the next generation of researchers to productively engage in IKT also holds a special place in the OSHS initiative as both Shoveller and Gilbert agree that showing students how to work effectively in a genuine team is one of the best outcomes of their work.

The generation and use of credible evidence within effective program design and implementation of population health interventions presents an important opportunity, particularly for those who are interested in conducting population health intervention research. The research partnership that Shoveller and Gilbert have built around the OSHS offers some much-needed empirical evidence for shaping online sexual health interventions and points to the promise of using IKT techniques.

Shoveller’s and Gilbert’s B.C.-based team recognize they are working in a time when technologies and online consumer preferences are changing rapidly, when Canada’s health system landscape is evolving and when the internet has become a place where many people initiate contact with the health system to address health concerns. The research team hopes to continue working within these realities to promote and protect sexual health and well-being of populations in B.C.

Select publications:

Davis WM, Shoveller JA, Oliffe JL, Gilbert M. ‘It’s not a good message to send’: Examining young people’s perspectives on the use of reverse discourse in web-based sexual health interventions. Culture, Health & Sexuality, 2012; doi: 10.1080/13691058.2012.714800.

Hottes TS, Farrell J, Bondyra M, Haag D, Shoveller J, Gilbert M. Internet-based HIV and sexually transmitted infection testing in British Columbia, Canada: Opinions and expectations of prospective clients. Journal of Medical Internet Research, 2012; 14(2): e41.

Shoveller JA, Knight R, Davis W, Gilbert M, Ogilvie G. Online sexual health services: Examining youth’s perspectives. Canadian Journal of Public Health, 2012; 103(1): 14-8.

Falasinnu T, Hottes TS, Gilbert M, Shoveller J. A critical review of risk factors predictive of sexually transmitted infection outcomes: gender differences, selective screening criteria, and the “high-risk” population approach. Advancing Excellence in Gender, Sex and Health Research Conference. 29-31 October 2012. Montreal, Canada. Poster presentation.

Davis W, Shoveller J, Oliffe J, Gilbert M. Interrogating gendered stereotypes: Young people’s descriptions of online sexual health approaches. Advancing Excellence in Gender, Sex and Health Research Conference. 29-31 October 2012. Montreal, Canada.

Programmatic Grant Feature: Equity Lens in Public Health

Article by Bernadette Pauly (Associate Professor at University of Victoria’s School of Nursing and Scientist for Centre for Addictions Research of B.C.).

In Canada and around the world, people on low incomes have significantly poorer health than those with high incomes. The lower people are positioned in society in terms of income and social status, the more likely they are to face unfair disadvantages when it comes to health. For example, people who are discriminated against because of gender or ethnicity face additional challenges that affect their health. These health differences, which originate from unfair differences in how society is organized, are known as health inequities.

The Equity Lens in Public Health (ELPH) research program aims to produce new knowledge about the role public health plays in reducing health inequities. In the ELPH program, researchers are examining and learning about the integration of an equity lens in public health during a time of health care system change in British Columbia.

Nationally, there have been many calls for renewal of public health in Canada. A new phase of public health renewal in B.C. began in 2005 with the introduction of the Framework for Core Functions in Public Health that strives to strengthen the link between public health, primary care, and chronic disease management. The introduction of this framework and other public health renewal processes present an excellent opportunity to study a series of natural experiments and inspired the creation of the Core Public Health Functions Research Initiative (CPHFRI) in BC. The ELPH program of research falls under the CPHFRI umbrella.

The research team has identified two key public health areas for study through the ELPH: preventing harms of substance use, promoting mental health and prevention of mental illness. These two core program areas in public health are outlined in the provincial policy document Healthy Minds, Healthy People: A Ten Year Plan to Address Mental Health and Substance Use in B.C. Together, this document and the Framework for Core Functions in Public Health represent major policy-level population health interventions and are the focus for exploring the potential of public health policy and services to reduce health inequities in B.C.

ELPH brings together partners from the six provincial health authorities as well as B.C.’s Ministry of Health, the Public Health Association of B.C., the Public Health Agency of Canada, University of Victoria, University of British Columbia and the National Collaborating Centre on the Determinants of Health. Bernie Pauly, Marjorie MacDonald and Trevor Hancock of University of Victoria are principal investigators while Warren O’Briain of the B.C. Ministry of Health is the principal knowledge user.

The five-year program of research encompasses four interconnected studies:

  1. Assessing health equity priorities and strategies across health authorities over time
    This study investigates the status of health equity initiatives across the six B.C. health authorities. Baseline analyses of each health authority at the beginning of the study will be compared with follow-up analyses completed at the end. The main research methods for this study are document review and situational analysis.
  2. Intersectoral collaboration for health inequities reduction
    This study aims to map the professional relationships between public health workers in the areas of mental health promotion and prevention of substance use harms. This will show where people and organizations are working together to address health equity in the selected areas. The main research method for this study is social network analysis.
  3. Assessing the theoretical relevance and practical utility of health equity tools
    The purpose of this study is to identify and analyze existing health equity tools and to decide how useful they are both for practical use and in terms of their fit with current ideas about health equity. The research team is systematically developing an inventory of health equity tools that will be assessed for theoretical and practical relevance. To identify criteria for assessing theoretical relevance, the team is reviewing theories of health equity. Concept mapping is being used to identify criteria to assess practice relevance. Concept mapping activities include brainstorming sessions and then sorting and rating the statements from the brainstorming. The process will be used to develop a framework of participants’ understanding of a particular concept.
  4. Power and ethics in public health
    The research team knows from working with knowledge user partners that they face ethical concerns in the development of public health programs and services to reduce health inequities. In this fourth study, the team will explore the specific ethical concerns encountered by public health nurses and other practitioners in the promotion of mental health and prevention of substance use harms. To do this, researchers are identifying ethical issues from the perspective of those involved in program delivery. The outcome will be a description of the process and ways that public health practitioners manage ethical issues and concerns in their everyday practice. This will contribute to the development of public health ethics resources and possibly an ethics framework for public health.

Throughout this project, the research team is using an integrated model of knowledge exchange through which both academic researchers and knowledge users produce and use knowledge. The research questions were developed though collaboration of knowledge user partners and academic researchers. As a team, researchers identified a range of roles and responsibilities related to the production and dissemination of project findings that engage everyone throughout the research process. The team is developing specific knowledge exchange activities and products including webinars, a website, newsletters, conference presentations and an equity training workshop. There will also be a policy forum at the end of the grant.

Paving the way for population health intervention research

Article by Andrea Hill (student with the Canadian Institutes of Health Research-Institute of Population and Public Health) and Erica Di Ruggiero (Associate Director with the Canadian Institutes of Health Research-Institute of Population and Public Health).

Efforts by Canadian health researchers and funding agencies to shape a research community where population health intervention research is well understood and well funded have yielded impressive results over the last six years and identified key areas for future work.

Population health intervention research involves 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. For example, studies looking into the health impacts of mandatory physical activity policies in schools or new vaccination programs would be classified as population health intervention research.

But population health intervention research isn't a term that appears in the media or that is frequently taught in universities. Until more recently, it wasn’t even a term used by many researchers doing this kind of work.

That started to change in 2006 when staff from the Canadian Institutes of Health Research-Institute of Population and Public Health joined forces with representatives from other CIHR institutes, the Public Health Agency of Canada, the Institut national de santé publique du Québec, the Social Research and Demonstration Corporation and researchers. These individuals and organizations formed the Population Health Intervention Research Initiative for Canada (PHIRIC), which was viewed as a 10-year initiative to increase the quantity, quality and use of population health intervention research across the country.

Now, more than halfway through the initiative's envisioned term, the current co-chairs reflect on PHIRIC's many successes and the work that still needs to be done.

"Through PHIRIC there has been a vocabulary and a lexicon established that researchers and decision makers can use and we can now communicate more effectively with one another," said Jean Shoveller, professor at University of British Columbia's School of Population and Public Health, member of the Institute of Population and Public Health’s Advisory Board and one of the PHIRIC co-chairs. "There is now a methodological tool box for population health intervention research that also has its own lexicon."

Achievements include the creation of novel funding tools to support population health intervention research and publications such as the Frequently Asked Questions About Population Health Intervention Research article that appeared in the winter 2012 issue of the Canadian Journal of Public Health. PHIRIC has also outlined population health intervention research competencies and developed guidelines for peer reviewing population health intervention research (peer review publications forthcoming). Together, these resources are raising the profile of population health intervention research and giving researchers and funding bodies the tools they need to start doing and funding this research.

"I also think that a great accomplishment has been really reorienting the idea of intervening in sectors other than health and recognizing and being able to effectively capture the health impacts of non-health interventions," adds Shoveller.

For example, CIHR, in collaboration with the PHAC and other partners, funded 15 applied public health chairs to support and develop high-quality population health intervention research. One such chair, Dr. James Dunn, primarily studies how housing interventions and policies that are not typically viewed as health interventions affect the health of populations. Dunn, who is also an associate professor at McMaster University and scientist at St. Michael's Hospital in Toronto, is currently looking into how Toronto's Regent Park neighbourhood redevelopment is impacting the health of tenants.

In addition, the population health intervention research rapid funding mechanism sponsored by the Institute of Population and Public Health since 2006 aims to support the prompt initiation of population health intervention research on rapidly unfolding programs, policies and resource distribution approaches that are initiated by others and have the potential to impact health and health equity at the population level. Through this initiative, 34 projects have been funded for a total of $12.5 million. One such grant awarded to Dr. Robert Hogg, a health sciences professor at Simon Fraser University, is allowing him and his research team to evaluate the health impacts of a supportive housing intervention in British Columbia for people in living with HIV and a risk of homelessness. This grant was co-funded by the Institute of Population and Public Health and the Public Health Agency of Canada.

"We need to facilitate researchers’ access to research funding opportunities that are well-suited to population health intervention research and that are structured in such a way as to afford the talented researchers in this area the necessary flexibility and scope of supports," Shoveller said. "For example, the policy, regulatory or legal environment doesn't stand still and the scope of the work also requires sufficient support."

Samis points out that there is increasing pressure on research funding organizations to show that research they support leads to improved population health and provides value for money.

"Population health intervention research lends itself very well to some of those kinds of challenges,” he said.

Samis suggested that a next step for PHIRIC may be identifying key decision makers, finding out how they're currently using population health intervention research and asking them how they would like to further use this research. Knowledge of each others’ needs, abilities and timelines would both help researchers produce relevant population health intervention research and help decision makers utilize the results. To date, PHIRIC has been involved in a number of conferences and symposia to disseminate population health intervention research. These include the International Conference to Advance a Population Health Agenda which was help in Montreal in the spring of 2012 and the Stimulating Methodological and Theoretical Innovation in Population Health Intervention Research workshop help in Toronto in late 2010.

Another area for PHIRIC to focus on over the next four years will be to promote population health intervention research to funding bodies that may not presently see themselves as champions of population health intervention research. Once this is done, tools like the peer review guidelines for population health intervention research can help those funders, along with groups already funding the research, to appropriately assess population health intervention research funding competitions.

All are challenges the co-chairs say the initiative is ready and able to take on as it looks ahead to 2016.

Future to Discover: SRDC Report Overview

Article by Emma Cohen (Knowledge Translation and Communications Officer for the Canadian Institutes of Health Research-Institute of Population and Public Health).

Just as it can be hard to convince a 25-year-old to save for retirement, it can be difficult to motivate some youth to think about post-secondary education and the best time to broach the topic is not well known.

Though many Canadians are actively pursuing higher education, youth from low income families and youth whose parents have low levels of education are typically underrepresented in post-secondary institutions, explained Jean-Pierre Voyer, President and CEO of the Social Research and Demonstration Corporation (SRDC) and a member of the Population Health Intervention Research Initiative for Canada (PHIRIC) Planning Committee.

To combat this disparity, the Canada Millennium Scholarship Foundation set up two interventions in Manitoba and New Brunswick schools in the mid- to late-2000s to target these population subgroups. “Learning Accounts” in New Brunswick provided post-secondary education bursaries of up to $8,000 for students in Grade 10 and higher. “Explore Your Horizons,” which was implemented in both provinces, offered 40 hours of after-school educational workshops aimed at developing skills related to career options over the course of Grades 10 to 12.

SRDC was commissioned to study whether these interventions were effective in promoting participation in post-secondary institutions. The study, known as Future to Discover, measured education outcomes in students, which are recognized as key determinants of health by the Public Health Agency of Canada.

A total of 5,429 students were randomly assigned to one of three experimental groups (Learning Accounts only, Explore your Horizons only or both) or a control arm (no intervention), allowing the investigators to measure the impact of the individual programs, the relative impact of one versus the other and the incremental impact of offering both.

In general, data indicated both interventions had positive effects on post-secondary enrolment, but there were some surprising results.

Firstly, the evaluation showed the importance of language. The combined interventions in New Brunswick significantly reduced rate of high school dropout and increased rate of graduation in the Anglophone schools studied, which were selected for the study because they had high concentrations of low income families. All Francophone schools in New Brunswick, regardless of concentration of low income families, were included in the study. Incidence of high school dropout and graduation in these schools was not impacted by the combined interventions.

Secondly, the evaluation indicated the importance of gender for interventions. Though investigators did not take gender into account when assigning students to experimental groups, gender was accounted for in a subsequent subgroup analysis. It was found that boys were more sensitive to the interventions, particularly to Learning Accounts, than girls. Voyer said this could be related to the New Brunswick labour market where it’s common for boys to enter “boy-oriented” occupations that require an apprenticeship such as mining, construction, forestry and even manufacturing sectors where it is well known that there’s more room for growth in salary and earnings if you have a college degree.

Thirdly, the evaluation showed that when learning account bursaries were used, they were most often applied to college tuitions, as opposed to for university or other post-secondary institution fees. Voyer said this could be because, from a cost-benefit analysis, it makes more sense to apply $8,000 towards two years of college than towards four years of university.

“The intent was to make youth aware of the existence of funding if they continued in post-secondary education so they could change their trajectory, pick the right courses, and remain motivated,” Voyer said.

Although the interventions appear to have had an impact on enrolment in post-secondary institutions, Voyer cautioned against generalizing the findings and thinks the interventions could have different outcomes in different settings due to other factors in the social and political landscapes.

Both interventions studied were active from 2004 to 2008 and bursaries from the Learning Accounts intervention continued to be paid out until 2011. The Future to Discover Evaluation report was published online in November 2012.

Student Corner: Investigating the Moral Foundations of Public Health Emergency Preparedness and Response

Article by Maxwell J. Smith (Ph.D. candidate at the Dalla Lana School of Public Health and Joint Centre for Bioethics at the University of Toronto and CIHR Fellow in Public Health Policy). Smith is currently a Visiting Researcher at the Fondation Brocher (Hermance, Switzerland) and is supported by a CIHR Frederick Banting and Charles Best Canada Graduate Scholarship and CIHR Douglas Kinsella Doctoral Award for Research in Bioethics.

The goal of public health, in its simplest terms, is to promote and protect the health of populations and to minimize threats to the health of populations. Intuitively, it appears this goal aims to maximize the greatest amount of good (i.e. health) for the greatest number of people (i.e. the population). However, many public health scholars believe that considerations and ideals aligned with social justice, such as human rights, liberty, equity and concern for the most disadvantaged, are fundamental to the vision of public health and may conflict with the goal of maximizing the greatest good for the greatest number. This has prompted me to further explore the ethical goals and moral foundations of public health.

I have been involved in bioethical research studying the ethical considerations involved in pandemic preparedness and response and have become particularly interested in the moral foundations of public health emergency preparedness and response. Interest in this area has grown over the last decade, largely as a result of the outbreak of severe acute respiratory syndrome (SARS), Hurricane Katrina, devastating earthquakes in Haiti and Japan and the presence and persistent threat of pandemic strains of influenza and other infectious diseases.

Logistical and ethical guidelines have been developed to guide population health interventions that may be used during public health emergencies. For example, much of the academic literature and many planning documents discuss how to prioritize prophylactic measures, such as vaccines, to particular groups; parameters surrounding use of restrictive measures, such as quarantine and isolation; and criteria for triaging patients into hospital emergency departments and critical care units. However, it is unclear to me whether the guidance documents developed for public health emergency planning and response reflect, or ought to reflect, the traditional values and goals of public health.

My doctoral research is exploring the ethical values and goals promoted in public health emergency planning and response and compares and contrasts them with the values and goals of quotidian public health: the practice of public health in non-emergency scenarios.

As a Visiting Researcher at Fondation Brocher on Lake Geneva, Switzerland, I am analyzing documents in public health emergency preparedness and response, including plans, guidelines, and ethics frameworks. Following this, I will conduct interviews with key decision-makers and planners, including front-line health care workers and policy-makers involved in public health emergency preparedness and response.

Through this research, I will explore whether the values and goals of public health emergency preparedness and response more explicitly seek to maximize population health outcomes than the goals of quotidian public health – a situation that may temper public health goals that aim to achieve health equity and protect those who are most systematically disadvantaged. If this is the case, I will explore whether or not this is ethically justifiable.

Student Corner: Reflection on the Advancing Population and Public Health Economics Workshop

Article by Rodrigue Deuboué Tchialeu, PhD candidate with University of Ottawa’s Institute of Public Health. Rodrigue received a Canadian Institutes of Health Research-Institute of Population and Public Health travel award to attend the Advancing Population and Public Health Economics workshop in Toronto from January 15-16, 2013. This workshop was attended by researchers and professionals with expertise in the area of population and public health economics who discussed key areas for research and capacity-building in the field, including how to enhance the conduct, funding, dissemination and use of economic evidence in the development and evaluation of policies and programs affecting population and public health. The annotated bibliography used to inform the workshop is available online and a report of workshop proceedings is forthcoming.

The Advancing Population and Public Health Economics workshop hosted by the Canadian Institutes of Health Research-Institute of Population and Population Health and partners in January 2013 explored ways to enhance the meaningful integration of economic analysis and economic evidence in population and public health research.

Adding economic components to population and public health research can make it more relevant and useful for decision makers, participants agreed. At present, some members of the research community feel decision makers do not fully understand the significance of evidence showing the effectiveness of population and public health interventions at the community, municipal, provincial/territorial and federal levels. Involving both policy makers and economists throughout the research process could help increase the impact of population and public health research.

Workshop participants widely agreed that economists should be included in population and public health research from the beginning in order for a health economic perspective to be more effectively integrated into the research process. In other words, economists should be included at the study design phase, not just the analysis phase. But this is not always easy and participants identified some barriers to the increased integration of economists in population and public health research. These included the fact that there is uneven support both for interdisciplinary research across academic departments and for co-authorship in public health research journals compared with publication in top-impact economics journals where economists are the main authors. Such barriers need to be addressed to increase the integration of health economists in public health research teams. Dr. Nancy Edwards, scientific director for the Canadian Institutes of Health Research-Institute of Population and Public Health, drew attention to the fact that there is a gap in training for health economics within population and public health programs in Canada.

In order for economic components to be incorporated in population and public health research, participants said researchers need the ability to talk the same language across disciplines using shared definitions of key terms such as equity, equity in health, fair and inequalities. This could aid in the development of economic analysis tools that are most suitable for population health.

Participants also said there is a need for more modeling that can mirror the complexity of multiple trans-disciplinary population health interventions. This need could be met by offering training to economists from a public health sector perspective so these economists are well-suited to partner on population and public health research. Such training is currently being done in the United Kingdom.

Prior to this workshop, I was already interested in health economics issues, particularly the financing of health systems at the global level, and my participation in the workshop solidified my interest in health economics. My involvement in the workshop encouraged me to further my knowledge of health economics analysis techniques, particularly modeling and micro-simulations. These concepts and tools will be of great interest for my research project looking at health system requirements when scaling up interventions to control the hypertension epidemic in developing countries. One of the main outcomes will be to model the health system requirements of a successful supply-chain which will allow us to determine the necessary drug supply and human resource requirements for the supply chain.

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