Outlook: Newsletter of the Society of Behavorial Medicine

Spring 2022

Systems-Oriented, Population Health Approaches Are Needed to Improve Health: We Are All in This Together

Candyce Kroenke, ScD, MPH‚úČ; Population Health Sciences SIG Chair

As this year’s chair of the Population Health (PHS) SIG, I’ve thought a lot about population health science and its potential to inform and improve population health as our members considered our group’s interests and priorities. Our group discussed key foundational principles drawing on prior work by Kindig, Keyes and Galeo, and others such as Geoffrey Rose who wrote about improving population health by shifting the entire population distribution of a biologic marker of health (e.g., shifting blood pressure downward by 2 mmHg) rather than focusing on targeting and treating high-risk individuals, given that the majority of events in the population occur at the center of the distribution.

We sought not to reinvent the wheel but adapt previous definitions and principles to our work in a behavioral context. PHS SIG members agreed that population health-behavioral science can be characterized as multi/transdisciplinary, multilevel, incorporating social determinants, emphasizing health equity, policy-oriented, and having implications for behavioral outcomes. Our SIG also discussed next steps and strategies for moving our group’s activities forward including developing linkages to other organizations, additional member collaboration, and more public-facing content.

In the United States, we have prioritized a focus on individual behavior as underpinning health though we know that current approaches have undermined the health of the socioeconomically vulnerable. What is less well known is how this focus has broadly undermined the health of the population including those at the top of the socioeconomic distribution. A 2020 article showed that despite greater financial resources of the upper quintile of income in the US compared to the UK, health outcomes in the top quintile were worse in the US than those in the top quintile in the UK (Choi, JAMA Intern Med, 2020; 180: 1185-1193). A second article showed that health outcomes (e.g., infant and maternal mortality, acute myocardial infarction, colorectal cancer) of those in the US with the highest incomes were often worse than those of middle incomes in other (European) countries (Emanuel, JAMA Intern Med, 2020; 181: 339-344). These are striking findings given expectations that higher incomes typically result in better health outcomes.

A population health science, systems-oriented approach to behavioral research is critically needed and timely. Francis Collins at the end of his tenure as the Director of NIH noted that we need to invest more into understanding behavioral influences on health. Additional emphases on social determinants and on health equity may be key to improving population health both by improving the health of large, ‘at-risk’ population groups and because of the unavoidability that the systems we create ultimately affect all of us, with implications for our health behaviors and outcomes. Though Emanuel et al. implicated uneven systems of health care in explaining the often worse outcomes in privileged US citizens vs. middle income individuals in other countries, many other systems (e.g., food, energy, the social safety net) have produced environments that often both constrain and distort behaviors (e.g., obesity epidemic, opioid and rising alcohol consumption), leading to poorer health outcomes. 

Rather than a zero-sum game, we are all in this together, and solutions focusing on systemic approaches to ensuring health equity may lead to better population health. Emphases in population health on health equity and policy – institutional, community, and legislative – will be critical to its success. I invite you to get involved with our group to move our conversation and its activities forward. Please contact me (Candyce Kroenke, ScD – current Chair) at candyce.h.kroenke@kp.org or Jess Gorzelitz, PhD (next year’s Chair) at jessica.gorzelitz@nih.gov.



Choi H, Steptoe A, Heisler M, Clarke P, Schoeni RF, Jivraj S, Cho TC, Langa KM. Comparison of Health Outcomes Among High- and Low-Income Adults Aged 55 to 64 Years in the US vs England. JAMA Intern Med. 2020 Sep 1;180(9):1185-1193. doi: 10.1001/jamainternmed.2020.2802.

Emanuel EJ, Gudbranson E, Van Parys J, Gørtz M, Helgeland J, Skinner J. Comparing Health Outcomes of Privileged US Citizens with Those of Average Residents of Other Developed Countries. JAMA Intern Med. 2021 Mar 1;181(3):339-344. doi: 10.1001/jamainternmed.2020.7484.

Kindig D, Stoddart G. What is Population Health? American Journal of Public Health, 2003; 93(3): 380-383.

Kindig DA, Asada Y, Booske BA. Population Health Framework for Setting National and State Health Goals. JAMA, 2008; 299(17): 2081-2083.

Keyes KM, Galea S. Population Health Science. 2016. Oxford University Press, New York, NY.

Rose G, Sick Individuals and Sick Populations, International Journal of Epidemiology, Volume 30, Issue 3, June 2001, Pages 427–432, https://doi.org/10.1093/ije/30.3.427