Beyond the divides: Towards critical population health research

Abstract

The term ‘population health’ has supplanted that of public health and health promotion in many Anglophone countries. The ideas underlying the term are not new and owe much to the legacies of nineteenth-century public health radicalism, Latin American social medicine and, more recently, social epidemiology. Its influential modeling by the Canadian Institute for Advanced Research in the early 1990s, however, was criticized for a lack of theory, reliance on large data sets, a simplistic modeling of the healthcare/economy relationship, little attention to the physical environment and an absence of human agency. While researchers working under the rubric of population health have addressed many of these early limitations, there has yet to be an articulation of what comprises a critical population health research practice. This article, based on the discussions and work of an interdisciplinary group of researchers in the Saskatchewan Population Health and Evaluation Research Unit (SPHERU) in Canada, argues that such a practice proceeds from a theoretical engagement (theories of knowledge, society and social change), community engagement (a politicization of research knowledge) and policy engagement (which must extend beyond the simplistic notions of ‘knowledge translation’ that now permeate the research communities). A critical population health research practice, it concludes, is a moral praxis built upon explicit social values and analyses.

Acknowledgements

The authors would like to thank the two anonymous reviewers for helpful comments.

Notes

 Kindig & Stoddart (2003) lament the elision of population health with its list of determinants, hoping to claim a unique theoretical space for the concept itself. This, to us, seems an unnecessary effort to define a field of inquiry that has been livelier precisely for its contestable boundaries.

 Blomley (1994), for example, argues that population health proponents sometimes distance themselves from explicit social, political and economic analyses and values in order to avoid controversy and to gain the support of policy-makers and the general public from across the political spectrum.

 Kindig's & Stoddart's (2003) recent paper reveals this bias when they describe population health methods as those allowing an ‘examination of systematic differences in outcomes across populations’ (p. 381), including biological pathways and life-cycle impacts. Still excised is the importance, or meaning, people attach to these differences, and their understanding of sociopolitical cause and consequence.

 Tariq Bhatti and Nancy Hamilton, working with Health Canada's then newly minted Population Health Branch, partly overcame this deficit by creating a complicated model in which health-promotion strategies, which focus on individuals or communities, were laid alongside population health determinants (Hamilton & Bhatti, 1996). Most health promotion practice in Canada, however, remains localized or constrained by health behaviour change programs, i.e. its advocacy and policy change potential is modest at best.

 As with the early (1980s) days of health promotion, when many of its practitioners contended with their marginal status in the health system through a critique of medicine's limited impact on health gains, population health's early focus on the declining marginal utility of public health expenditures unintentionally aligned with the neo-liberal agenda of the ‘minimalist state’.

 ‘First Nations’ refers to Canada's pre-European indigenous population.

 Several years ago, Labonte was involved in developing a ‘story/dialogue method’ for health promotion research and evaluation (Labonte et al., 1999). Method workshops with Maori groups in Aotearoa/New Zealand changed the title, though not necessarily the techniques, to ‘narrative methods’, since ‘stories’ in Maori epistemology were not subject to questioning.

 Some years ago an ‘action researcher’ studying health issues amongst rural farmers claimed she was really a ‘facilitator’ and the farmers were their own researchers, to which one of us replied that they were researchers in the same way that her growing tomatoes on an apartment balcony made her a farmer. Denying professional expertise can be as disempowering in community research relations as denying the importance of ‘lay’ knowledge.

 While research on social determinants of health is increasingly engaging in political and theoretical analyses, a study of recent Canadian research into income as a health determinant found that over two-thirds of the 241 studies reviewed invoked no theory or explanation for why or how income affected health outcomes (Raphael et al., 2004).

 Political neutrality, at least in a partisan sense, does not necessarily render the researcher immune from political censure if the message renders criticism of particular government policies. A media story of global health research findings highlighted a critical (and empirically defensible) assessment of a policy announcement by a Canadian Prime Minister. The SPHERU researcher was summoned to the granting body and dressed down for improper handling of the media, despite the research being funded as a grant, not a contract, with all the usual caveats distancing the findings and their implications from the funder.

 The percentage of Canadian children living in low-income (poverty) families has fallen every year since 1996 and in 2001 was its lowest since 1980. Income inequality, however, has risen every year since 1994, and grew more rapidly in post-tax/transfer inequalities than market inequalities, indicating a retreat from the redistributive state (CPHI, 2004). Fewer Canadian children are now growing up poor but in a context of widening gaps in income and the power it affords. Relative deprivation is no less a material threat to health than material deprivation; it robs people of the capacity to participate equitably in the social roles of their society.