Vox Populi

Can a population health approach to healthcare exist beyond the bounds of organized medicine and public health? Technically, at least right now, the answer appears to be no. Although there is no single agreed-upon definition of population health, the one many point to was posited by Kindig and Stoddart in their seminal 2003 paper titled “What Is Population Health?”:

“We propose that the definition be ‘the health outcomes of a group of individuals, including the distribution of such outcomes within the group,’ and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.”

Without a way to quantify and track health outcomes not just of groups, but of the distribution of health outcomes within those groups, a healthcare solution cannot properly be called population health. Still, this strikes me as rather limiting; is preventative, segmented care only the domain of public health professionals, physicians, and academics…or can anyone with the right mix of ambition and good intentions take it upon themselves to intervene and improve upstream negative social determinants of health (SDOH) irrespective of metrics?

And if such interventions prove successful, can they not in turn be thought of as adjuncts to a population health model of care delivery? To me, any endeavor that helps people live their best life is worth trying, whether or not it proceeds within a deploy-measure-iterate model such as that outlined in the Institute for Healthcare Improvement’s “10-Step Path to Progress” in population health (details on page 7 of the document).

That being said, let me be clear that I’m not a physician or a mental health professional, and the thoughts in this post are strictly the result of my own research. None of this should be taken at face value, and in some cases – for instance, if one has profound mental health issues – seeking help from a trained professional is the right way to go. It’s clear that depending on one’s circumstances, agency in one’s own healthcare will vary.

But for those who feel a persistent, non-clinical level of melancholy, I’m encouraged that the possibility exists to take the upper hand and improve levels of contentment. This mindset aligns with the “self-care” movement, which has been defined as “the ability to care for oneself through awareness, self-control, and self-reliance in order to achieve, maintain, or promote optimal health and well-being.” This outlook reflects a growing awareness that people don’t have to necessarily fill a prescription to optimize their experience of life.

Part and parcel of this DIY approach (again, within reason) is, I believe, a loosening of the definition of population health – or at least an expansion of the definition that includes grassroots initiatives that may not tick every box of an improvement regimen. One aspect of this more inclusive description involves not always assigning metrics to every aspect of one’s life. While some people are motivated by numbers (as we’ll see in a moment), for those who don’t look at health maintenance as a competition, moving the needle on improving population health will likely be more qualitative. 

Health By the People, For the People

To set the stage for our discussion, let’s talk for a minute about how metrics in self-care can induce health improvements. For those who like to quantify improvement in a way that keeps them in the driver’s seat, the healthcare landscape of today truly differs from that of even a few years ago. With respondents to a recent survey from the Deloitte Center for Health Solutions saying they’d “be ‘likely to’ or ‘maybe would’ use retail clinics for preventive care (55%) or mental health care (47%),” it’s becoming clearer every day that people are more willing to try new approaches to healthcare that are more tailored to their own lifestyles. 

Put another way, a clear majority of people are willing to at least entertain the idea of seeking healthcare at places like CVS and Walmart, and nearly half of respondents said the same thing about mental healthcare. This makes a sort of sense, given that Walmart stores are often closer to many people’s homes than their doctor’s office.

This is a big change, and it doesn’t stop with retail medicine. According to Insider Intelligence, “use of wearable technology has more than tripled in the last four years and “more than 80% of consumers are willing to wear fitness technology,” signaling broad interest in people monitoring their own health. This includes tech we’re all familiar with like FitBits and smart watches, but extends to wearable electrocardiogram and blood pressure monitors, and even self-adhesive patches that collect data on a person’s biological signals.   

Opinions may vary on the effectiveness of self-monitoring tech, and I need to do more research before coming to a conclusion on it. But the more I read about it, the more optimistic I’m becoming that many of us can (or will soon be able to) exercise a degree of control over our health status with the help of personalized health technology. 

Another way in which people are practicing so-called DIY population health is by banding together to overcome certain shared barriers. And these barriers, while related to medical conditions, often reside outside of clinical settings. In addition, given their improvised nature, the practitioners of this approach often don’t have the means to collect and analyze data to track health improvement. Although stories of success don’t always guarantee a one-size-fits-all approach, a couple of real-life examples illustrate how this organic, crowd-sourced approach to addressing negative SDOH can be done well. 

Men’s Sheds

One interesting illustration of this can be found in England. In that country, as in the United States, an epidemic of loneliness has swept through in recent years. Made worse by the COVID-19 pandemic, many vulnerable groups have been hit particularly hard. One of these groups, the elderly, are in a class by themselves: the NHS states that “more than 2 million people in England over the age of 75 live alone, and more than a million older people say they go over a month without speaking to a friend, neighbour or family member.”

One of these people was Philip Jackson, a man born in England who moved to Australia in adulthood before returning to his homeland in old age. Although Jackson expected a level of familiarity in returning to his native town, he was met by the unwelcome fact that everyone he’d grown up with had either left town due to a decline in industry or passed away. This left Jackson unexpectedly rootless and lonely. 

But then something interesting happened: realizing he wasn’t the only lonely person of a certain age, Jackson recalled hearing about The Australian Men’s Shed Association. The organization, which grew out of a desire to help men form social bonds with other men through “communal woodworking” and thus improve their mental and physical health, defines their modus operandi this way: “A good Men’s Shed has a Management Committee that has developed a safe and happy environment where men are welcome to work on community projects, specific Men’s Shed projects or a project of their choice in their own time and where the only ‘must’ is to observe safe working practices….all in a spirit of mateship.”

It is this “spirit of mateship” that Jackson was sorely missing. Through the help of a grant and generous donations, he was able to set up a site and stock it with woodworking equipment in hopes that it would attract like-minded men in his town (he also set up a “She-Shed,” a communal space for local women who also shared his interest in woodworking). In time, community involvement in the shed grew to the point where it now boasts a membership ranging in ages from 22 to 87 and from all walks of life.

They “make everything from ornaments, dog kennels, bird and plant boxes through to wheelbarrows,” but more than that, says Jackson, it’s an excuse for people to break out of their usual routine and establish friendships in a comfortable environment. During COVID, Jackson took the lead on checking in on everyone to ensure they were OK, going so far as to set up live chats online to keep up people’s morale.

Looked at one way, the idea of establishing a Men’s Shed (and a She-Shed) in a community is nothing more than an expression of civic pride, a way to cultivate a sense of fellow spirit in a world that sometimes feels out of balance. But I contend that it goes deeper than that: if you look past the fact that no one in the Men’s Shed movement seems especially concerned with measuring the happiness and health levels of its members, to me this is an organic example of population health in action.

Caregiver Support

In some cases, the more specific and non-traditional a person’s circumstances are, the more the need may exist for them to improvise when seeking both mental and physical healthcare (within reason, of course). People facing unique challenges may not fit into traditional population health care delivery models, particularly if they themselves are caregivers.   

Just such an example was featured on NPR recently: the story involves a woman named Jacquelyn Revere who has attracted a large following on TikTok by authentically talking about her life providing care for her mother, who had Alzheimer’s.  In her late 20s Revere was forced to move back home when her mother, who herself was caring for Revere’s ailing grandmother, was diagnosed with Alzheimer’s. Like the 16 million Americans who annually provide more than 17 billion hours of unpaid care for loved ones suffering with Alzheimer’s disease and other dementias, Revere was asked to put her life on hold.

Understandably, dealing with multi-generational health issues became hard for Revere to navigate. And it wasn’t just her loved ones’ health that worried her. As with so many people facing mounting doctor’s bills, she worried about bills going unpaid and ultimately losing their home – in other words, upstream social determinants outside the clinical sphere. 

When she tried explaining her predicament to friends her age, they just couldn’t relate. And support groups were no help either, as they were often composed of much older, more financially secure people. Because of her relative young age and financial burden, it is perfectly possible that in these early days of understanding upstream SDOH – not to mention the lack of a social safety net for younger people in our society in general and for caregivers in particular – there may not be a segmented population into which Revere neatly fits.

Finding these traditional means of support lacking, Revere turned to social media. TikTok became her platform of choice, allowing her to search for and ultimately find a community more in line with her own experiences. Taking the initiative to connect, she began posting under the handle @MomOfMyMom about her daily struggles, helping to build the community she could never find offline. In time she attracted over 650,000 followers who discuss everything from early signs of their loved ones’ cognitive decline to how to provide basic daily care.

Unfortunately, Revere’s mother passed away recently, and she has used TikTok as a means to express her grief. The platform has acted as a way for people to pay their respects, and because of this, Revere doesn’t have to hurt in isolation. In addition, the platform allows her to continue her work providing emotional support to other dementia caregivers online who may not have cultivated as big a following as hers. Social media has allowed Revere to connect and grow with a similar “population” of caregivers that just wouldn’t have been otherwise possible.

Revere’s example reminds us that when the system fails us, we can still rise above our circumstances to help others. From veterans’ groups organizing volunteer transportation for fellow veterans to attend doctor’s appointments, to a green building consultant on a mission to help land developers create sustainable buildings with people’s mental and physical wellbeing in mind, population-level health initiatives are showing up everywhere, and many times outside of their traditional confines. It will be interesting to see if and how such efforts are integrated into our understanding of population health going forward.

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