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• Antenatal and Delivery Care in Afghanistan Knowledge and Perceptions of Services, Decision Making for Service Use, and Determinants of Utilization
• Early Maternal Morbidity and Utilization of Delivery Services by Urban Slum Women of Dhaka, Bangladesh
• An Assessment of Maternal Health Service Needs of Immigrant Women Living in East Calgary, Canada
• Health Seeking Behavior of Women and Their Families During Pregnancy, Delivery and Postpartum Period in Nepal

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• Comparison of Biomarker Surveillance of Measles Immunity to Conventional Indicators of Vaccination Coverage
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• Family Relationships and Social Interaction in Post-Conflict South Kivu Province, Eastern Democratic Republic of Congo A Mixed Methods Study with Women from Rural Walungu Territory
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• Factors Affecting School Enrollments in a Post-Repatriation Context: A Study of Household Roles, Attitudes and Forced Migration Processes in Urban Somaliland
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• Gender and Access to DOTS Program (Directly Observed Treatment, Short-Course) in a Poor, Rural and Minority Area of Gansu Province, China
• Empowering the Socially Excluded: A Study of Impact on Equity by Gender, Caste and Wealth in Access to Health Care in Rural Parts of Four North Indian States
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• The Economics of Non-Communicable Diseases in Rural Bangladesh: Understanding Education Gradients in Mortality and Household Wealth Impacts from an Adult Death

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• Measuring the Burden of Disease: Introducing Healthy Life Years
• Measuring the Burden of Injuries in Pakistan Epidemiological and Policy Analysis
• Strengths and Limitations of Population-Based Health Surveys in Developing Countries: A Case Study of National Health Survey of Pakistan: 1990-94
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• A National Burden of Disease Study for The United Arab Emirates (UAE): Quantifying Health Differentials Between Nationals and Migrants

• Open access
• Published: 16 June 2020

Defining and classifying public health systems: a critical interpretive synthesis

• Tamika Jarvis   ORCID: orcid.org/0000-0002-2823-2319 1 ,
• Fran Scott 1   na1 ,
• Fadi El-Jardali 1 , 2   na1 &
• Elizabeth Alvarez 1   na1  

Health Research Policy and Systems volume  18 , Article number:  68 ( 2020 ) Cite this article

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The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population. Several frameworks exist to conceptualise healthcare systems, highlighting the stark contrast of frameworks unique to public health systems. The objectives of this study were to define public health systems and assess differences between healthcare systems and public health systems within established health systems frameworks.

A critical interpretive synthesis was conducted. Databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. Data extraction, coding and analysis followed a best-fit framework analysis method. Initial codes were based on a current leading health systems and policy classification scheme – health systems arrangements (governance, financial and delivery arrangements).

A total of 5933 unique documents were identified and 67 were included in the analysis. Definitions of public health and public health systems varied significantly as did their roles and functions across jurisdictions. Public health systems arrangements generally followed those of health systems, with the addition of partnerships (community and inter-sectoral) and communication playing a larger role in public health. A public health systems framework and conceptualisation of how public health currently fits within health systems are presented.

Conclusions

Public health systems are unique and vital entities within health systems. In addition to examining how public health and public health systems have been defined within the literature, this review suggests that establishing the scope of public health is crucial to understanding its role within the larger health system and adds to the discourse around the relationship between public health, healthcare and population health. More broadly, this study addresses an important gap in understanding public health systems and provides conceptual and practical contributions as well as areas for future research.

Peer Review reports

Public health is generally understood to engage in population rather than in individual health activities and to undertake a population health approach recognising that genetic, behavioural and socio-economic factors (e.g. housing, social networks, education) influence health and well-being [ 1 , 2 ]. The introduction of the determinants of health has caused a shift towards understanding health from a holistic perspective as well as increased recognition of public health’s contributions to the health of the population [ 3 ]. Outside of global public health emergencies, such as Ebola or Zika Virus, attention to the role that public health plays in the protection and advancement of health has often taken a backseat to discussions of healthcare reform [ 4 , 5 ]. For many, health and the health system equate to healthcare, namely clinics and hospitals. In the context of the United States and Canada, considering, for example, that medical care consumes the largest amounts of the health budget in Canada and the United States, it is unsurprising that there is generally little public or political interest in strengthening or investing in public health systems [ 6 , 7 ]. For example, amid concerns that public health across Canada continues to be weakened through budgetary cuts and lack of investment in public health infrastructure, there remains little evidence related to understanding public health systems or what is currently done in practice in a comparative fashion [ 6 , 8 ]. Most public health research has focused on the evaluation of programmes aimed at individual or population-level interventions and understanding the causes and patterns of risk of ill health and disease rather than informing broader questions about the organisation, delivery or funding mechanisms of public health systems [ 7 , 9 , 10 , 11 ]. Amid the current novel coronavirus disease (COVID-19) pandemic, understanding how public health and broader health systems function, is crucial.

Health services and system researchers have not adequately acknowledged public health as a vital component and contributor to health systems, and achievements made by public health activities, such as communicable and non-communicable disease control, are often attributed to the delivery of primary healthcare services and advances in biomedical interventions [ 12 ]. While multiple health systems frameworks identify the components, functions and goals of healthcare systems, no clear or consistent definition of public health systems exist [ 13 , 14 ].

Defining public health systems can help determine how to best design systems and deliver programmes and services to support public health within the larger health system and other key institutions and move discussions about the relationship between public health and healthcare forward. As a first step, this paper addresses a priority research area that called for the development of a framework describing the key elements of public health systems [ 3 , 15 , 16 ]. A qualitative synthesis of the current literature was completed to investigate how public health systems have been defined and classified as well as the differences between healthcare systems and public health systems within established conceptual frameworks for health systems.

This qualitative review adopted the critical interpretive synthesis (CIS) approach as the overarching methodology while using a second and complimentary qualitative strategy, the best-fit framework synthesis (BFF), to guide structured data extraction and analysis. CIS differs from traditional systematic reviews in several ways; namely, (1) it is an iterative process that explicitly allows for the critical re-interpretation of existing literature and filling of conceptual gaps, and (2) it prioritises the inclusion of papers based on relevance to the research question, including grey literature, increasing the likelihood of capturing relevant documents [ 17 , 18 , 19 ]. The BFF is used to test, refine and/or generate relevant frameworks, theories or conceptual models using systematically retrieved empirical data. For this study, BFF was determined to be useful for the organisation, extraction and analysis of large amounts of data, as a priori or pre-identified codes allows researchers to utilise and generate codes and interpret themes but not be restricted by an existing framework, model or theory [ 20 ]. This study conformed with the recommended PRISMA guidelines [ 21 ] and was registered in PROSPERO (CRD42016049967).

Search strategy

Following pilot testing, the databases searched included EBSCOhost, OVID, Scholars Portal, Web of Science, Cochrane Library and Health Systems Evidence. The final search was conducted on 25 October 2016. Studies were not limited to date, language or study design. Additional sources were identified through reviewing the references of included documents to find relevant material and through internet searching to fill conceptual gaps using non-systematic searching. The initial search strategy can be found in Additional file  1 . As public health systems have not been clearly defined, our search strategy sought to include terms that may be used interchangeably within the literature but warrant clear definitions. For the purpose of this study, we define a system as “ a set of inter-connected parts that have to function together to be effective ” [ 22 ], a framework as “ a basic conceptual structure ” [ 23 ], a model as “ a standard or example for imitation for comparison ” [ 24 ], and classification as “ an arrangement of people or things into groups based on ways that they are alike ” [ 25 ].

Study selection

Records identified were screened, duplicates were removed, and titles and abstracts were independently reviewed for exclusion by two reviewers. Records were excluded that (1) did not describe local, state/provincial/territorial, or national public health systems, frameworks or critical components, (2) addressed publicly funded healthcare systems, unless it also addressed the role of public health, and (3) were in languages other than English, French or Spanish. Records were not restricted by date or country as we wanted to obtain a general picture of public health systems globally. To help address the compass question and maximise the diversity of papers, potentially relevant documents were purposively sampled and prioritised for inclusion if they were clearly relevant to the research topic, offered conceptual insights about full frameworks, and were able to provide a cross section of different jurisdictions [ 19 , 26 ]. Full-text documents were retrieved and assessed for eligibility with additional documents found through reference chaining of all included studies or internet searches to help fill conceptual gaps.

Data abstraction

A data extraction tool was developed to organise the key themes of relevant documents and bibliographic information, including title of document, author(s), study type, context of study, key topic areas, and further relevant references from paper. Documents were imported into NVivo 11 software to facilitate the coding and organisation of data. Seven documents were randomly selected and coded independently by two reviewers to ensure consistency. Disagreements were resolved by consensus.

Data analysis and synthesis

A current leading health systems and policy classification scheme, the health systems arrangements framework (based on the three key building blocks of governance, financial and delivery arrangements), was used to form the initial a priori codes [ 27 ]. Originally developed as a taxonomy of health system topics to classify documents for Health Systems Evidence, this framework was chosen as the BFF theoretical framework because it is comprehensive (e.g. includes the essential components of WHO’s health system building blocks [ 22 ]), easy to understand, and has been used in various international contexts for health systems and policy research and applied work, for example, to develop health systems guidance documents and to contextualise research for evidence-based decision-making in Peru and Uganda [ 28 , 29 , 30 ]. Codes were added inductively from the data and were linked into themes. Data analysis continued until there was data saturation and conceptual gaps were addressed [ 31 ].

Search results and study selection

Electronic database searches identified 5933 unique citations, 338 of which met inclusion criteria after title and abstract exclusion; 81 of these documents were purposively sampled and full-text review excluded 23 records. Nine additional documents were attained through reference chaining and internet searches. In total, 67 documents were included (Fig.  1 ). A description of these documents can be found in Additional file  2 .

PRISMA flow chart for inclusion/exclusion of documents [ 21 ]

The results are presented in four sections – defining public health and public health systems; roles and functions of public health; public health systems; and public health within health systems. High-level findings are presented in the text and more details are provided in the Additional files.

Defining public health and public health systems

Most documents defined public health via its functions; therefore, separate sections were created for defining public health and public health systems and for describing the roles and functions of public health.

• Public health

Seven definitions of public health were found (Additional file  3 ). Public health was described as a multidisciplinary area of practice, concept and set of values that engaged in a larger population health perspective. Eight documents used the definition of public health provided by WHO as an art and science whose organised efforts aim to prevent illness and disease as well as to protect and promote health within society [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. Five other definitions expanded or emphasised various priorities within public health practice and included values of equity and equality.

Public health systems

Public health systems were defined in 20 documents, with 10 unique definitions identified (Additional file 3 ). Eleven documents defined public health systems as all levels of governmental and non-governmental entities which share in the responsibility for ensuring healthy social and physical environments, and consist of a variety of organisations that contribute to the core functions of public health to protect and promote health within the community [ 12 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. Public health systems were also defined based on their composition, level of service, contributing actors, mission and activities, or a combination of these. Public health was largely seen as a governmental responsibility and included partnerships between formal (government) and informal (private sectors, volunteer) organisations.

Roles and functions of public health

Subsystem models of delivery, governance, finance, and roles and functions were identified, for example, Mays et al.’s [ 45 ] typology of public health delivery systems, but none provided a comprehensive public health system framework. Several frameworks identified essential public health functions (Additional file  4 ). The most frequent frameworks were the Institute of Medicine’s three ‘core’ public health functions of assessment, policy development and assurance [ 12 , 38 , 42 , 47 , 48 , 50 ] and the ‘Ten Essential Public Health Services’, which were developed to further refine the specific set of functions and services within public health systems in the United States but have been adapted elsewhere [ 40 , 42 , 44 , 48 , 51 , 52 , 53 , 54 , 55 , 56 ].

Roles and functions

Thirty-nine documents defined or highlighted what they identified as the ‘essential’ functions of public health. Additional file 4 provides a table as a way of organising what functions were found within the literature across a variety of countries, following the three core public health functions and 10 essential services. The following were listed as public health functions and services in more than half of the documents: health promotion ( n  = 30); health protection, which included air, water, and food quality and inspection as well as environmental and occupational health activities ( n  = 26); investigation and surveillance ( n  = 25); emergency planning, preparedness and response ( n  = 25); health assessment and monitoring ( n  = 24); injury and chronic disease prevention and management ( n  = 23); and linking with and providing personal clinical services, which included maternal and child health services, minority, rural, indigent, mental, clinical and community health improvement activities, to targeted and/or vulnerable populations ( n  = 22). Communicable disease control ( n  = 18); research ( n  = 16); regulation and enforcement ( n  = 16); resource and organisational management, including leadership, governance capacity, resource management and development of organisational structures ( n  = 14); establishment of partnerships and advocacy in communities ( n  = 13); evaluation of health services ( n  = 11); policy development and planning ( n  = 11); workforce strengthening ( n  = 9); programme implementation ( n  = 4); laboratory services ( n  = 3); hospital and long-term care facility licensing ( n  = 2); and vital statistics ( n  = 2) were also identified as being the responsibility of public health in various jurisdictions. Functions and services had to be interpreted and summarised, as there were different terms being used to represent the same activities between jurisdictions. For example, health protection and environmental health were both used to describe the responsibility for testing and monitoring the quality of air, food and water, and population health assessment was used to describe monitoring, surveillance or epidemiological activities.

It was found that public health system descriptions fit the health system arrangements framework well, with the addition of partnerships and communication, which affected each of the other parts of the system (Additional file  5 ). The health systems arrangements framework was refined to highlight differences between terms and components of public health systems (Table  1 ). While little to no evidence on certain features, such as commercial authority, remunerating providers and incentivising consumers, was available within the literature, these arrangements are still applicable to public health, and thus remain within the public health systems framework.

Governance arrangements

Policy authority.

Four levels of policy authority were identified within the public sector, namley international, national, state/provincial/territorial, and local. The degree of decentralisation within a country or state/province determined the responsibilities and structural organisation of agencies within public health systems [ 4 , 12 , 32 , 34 , 37 , 44 , 46 , 49 , 57 , 58 , 59 , 60 ]. Most national public health agencies were primarily responsible for providing guidance and acting as a source of expertise while giving states/provinces authority to organise public health [ 4 , 32 , 39 , 48 , 54 , 57 , 61 , 62 , 63 , 64 ]. Many state/provincial governments established overall priorities, strategic direction, policies, strategies, standards, and funding models for local public health agencies [ 4 , 34 ].

Organisational authority

Regional or local health units planned and implemented the majority of services, developed policies and communicated legislation [ 34 , 57 , 61 , 63 , 65 ].

Consumer and stakeholder involvement

In public health systems, consumers most often referred to targeted populations and communities rather than individuals, as is more common in healthcare systems. Stakeholders included other public sectors, communities, service providers in and outside of the health system, the private sector, and individuals [ 63 ]. Community partnerships and public engagement were identified as being important for individual and community health, accountability, and an influential factor in the operation of local public health agencies [ 33 , 41 , 47 , 56 , 61 , 63 , 66 , 67 ].

Delivery arrangements

In public health systems, the terms ‘programmes’ or ‘services’ seemed to better reflect the wide range of activities and roles of public health within the larger health system than the term ‘care’.

How are programmes and services designed to meet consumers’ needs

Public health functions were carried out by all levels of government, including federal, state/provincial/territorial and local, but most activities remained organised at the state/provincial level or locally in many countries [ 2 , 38 , 39 , 40 , 48 , 58 , 59 , 62 , 63 , 68 , 69 , 70 , 71 ]. Delivery of public health services often rested at the local level but, in some instances, were delivered at the state/provincial level or through separate government or private organisations [ 38 , 48 , 59 , 62 ]. In one United States-based example, although public health and healthcare were largely independent of one another, public health increasingly provided personal health services for pre-identified or vulnerable groups [ 72 ].

By whom are programmes and services provided

Most public health programmes/services were provided by public sector employees as part of a public health unit, as well as faith-based groups, private businesses, social services agencies, schools, workplaces and healthcare providers [ 46 , 73 ]. Healthcare and other sectors support public health in its missions by participating in surveillance, health protection and emergency planning activities [ 37 , 73 , 74 ]. Because of the diversity in the organisations and people involved in providing public health programmes and services, the size of a public health workforce is difficult to determine [ 5 , 57 , 63 , 73 , 75 ].

Where are programmes and services provided

Delivery of public health programmes and services occurs in multiple public and private settings, including schools, homes of private citizens, workplaces, clinics, public health laboratories, local public health agencies and offices, and various indoor and outdoor spaces within the community [ 57 , 61 ]. Partnerships and contracts with non-governmental and community organisations in public and private sectors have often been established to circumvent barriers to service provision (e.g. due to geographical location or size of jurisdictions) [ 40 , 49 , 71 ].

With what supports are programmes and services provided

Support was often referred to as capacity in human health resources [ 2 , 40 , 51 , 57 , 59 ] and information technology [ 62 , 75 ]. A few articles discussed the use of technology as a tool used to deliver and support public health activities and messaging, and included services such as eHealth, web portals, mobile phone applications and social media [ 66 ].

Financial arrangements

It was difficult to estimate the direct and indirect financial contributions by public and private sectors given the diversity in public health activities [ 39 ].

Financing systems

Several sources estimated that, on average, public health systems received between 3% and 8% of the national health budget [ 5 , 32 , 38 , 39 , 44 , 51 , 57 , 72 ]. Like healthcare, public and private funding sources existed in these systems, with many being publicly financed through general taxation, including federal, state/provincial and local taxes such as income, property and sales taxes [ 32 , 39 , 47 , 52 , 57 , 58 , 59 , 62 , 69 , 76 ]. Private sector financing included out-of-pocket service fees and for-profit and non-profit organisations [ 44 , 47 , 52 , 59 ]. A significant part of public health funding is derived from external donors, particularly for disease-specific initiatives, in low-income countries [ 58 ].

Funding organisations

Revenue transfers from national governments to state/provincial or local public health agencies, with funding being distributed to local health agencies to deliver services, were most prevalent. Funding was largely allocated by funding formulas; however, a combination of funding mechanisms, such as activity- and standard-specific funding and reimbursements, per capita allocations, competitive and needs-based grants, and performance-based funding were also reported [ 38 , 46 , 47 , 55 , 58 , 59 ]. Other sources of funding originated from other public sector partners and from collaborations between public and private sectors [ 39 , 47 , 59 , 65 ]. In some instances, external donors allocated funds to community-based organisations to target specific community health needs or provided informal funding for ‘non-essential’ public health programmes [ 4 , 12 , 39 , 47 , 63 , 65 ].

Purchasing products and services

Funding organisations and purchasing products and services were strongly linked. Many federal and state/provincial governments allocated funds for specific public health activities, which influenced the availability of services [ 38 , 46 , 47 , 58 , 59 ]. Generally, there was a trend towards a substantial portion of public health funding directed at individual clinical services (e.g. maternal and child health, mental health, prenatal visits, family planning) [ 12 , 60 ].

Partnerships and communication

Partnerships were identified as an essential way to extend the reach of programmes to target population health issues and to share expertise, information and resources [ 2 , 4 , 39 , 40 , 46 , 56 , 59 , 65 , 66 , 68 , 77 , 78 , 79 , 80 , 81 ]. Partners included other local, national and international government agencies, the healthcare system, academic centres, private sector businesses, faith groups, foundations, service organisations and communities [ 32 , 33 , 34 , 40 , 45 , 46 , 48 , 52 , 54 , 56 , 62 , 63 , 64 , 72 , 79 , 82 , 83 ]. Within governance arrangements, the goal of partnerships was identified as community empowerment and capacity-building for successful interventions [ 4 , 56 , 61 , 74 , 79 , 82 , 84 ]. Engagement within communities reportedly increased stakeholder involvement in policy and decision-making [ 82 , 84 ].

Public health is an information-dependent sector that requires constant information exchange in order to support public health functions, activities and policies, especially in emergency planning and response [ 2 , 58 ]. Communication not only improves surveillance and response systems between all levels of government and internationally but is necessary for effective knowledge translation activities [ 5 , 84 , 85 ]. Clear, consistent and timely communication is essential for delivering messages to the public, preventing mixed messages and encouraging public engagement. Current and evolving technology, such as the internet and other mass media sources, are tools that support this effort by improving health literacy and outreach [ 66 ] but can also spread misinformation.

Public health within health systems

In framing how public health is seen as part of a larger health system, the literature pointed to two related but separate concepts – that of system integration and the role of public health in promoting a population health approach.

Sofaer [ 79 ] states that the best way to judge how effective a health system is, is by how well it can improve the health of individuals and populations. Interest in integrating public health and healthcare systems is not new [ 34 , 48 , 76 ]. While definitions of integration vary, integration in this report is the relationship between public health and healthcare and the extent to which services are provided to promote and achieve health. Integration is believed to bring the two systems closer together to provide a seamless service delivery within the larger health system and better respond to the needs of both individuals and communities [ 33 , 65 ]. Potential benefits of integration include bringing a population health perspective to the healthcare system, increased access to care, and the reduction of direct and indirect healthcare costs [ 4 ]. However, the literature also points to various challenges regarding integration and what it might mean for the future of the public health system. These include the loss of public health authority and expertise, capacity and management of competing priorities, consequently linked to adverse health outcomes [ 58 ]. Over time, the diversion of public health resources to primary care, loss of positions in public health units, and loss of linkages to community partners and communities would hinder public health from being able to extend the reach of its activities and lead to fragmentation in programme delivery and in the services necessary to protect the health of the population such as community health assessments, programme planning, and disease control and surveillance [ 9 , 58 , 86 ].

From the literature, healthcare and public health are separate systems, often with their own aims and functions, governance and financial systems, and ways of delivering services, although significant overlap has been observed, particularly within delivery arrangements. The health system is separate from but influenced by the larger political and social systems. Health, within this health system, is determined by individual factors and access to and use of public health and healthcare services. Yet, the wider determinants of health recognise the importance of social and political factors on health. Figure  2 aims to organise how public health currently fits within a health system. It is important to note that public health is often equated to and touted as a steward of population health. Population health is the driving force behind public health. Its upstream focus, following an ecological model of health, is concerned with how individual, social and environmental determinants influence health outcomes [ 53 , 55 ]. A strength of the population health approach is that it recognises that people are not passive but are active participants in their own health outcomes. Individual health is supported by both public health and healthcare activities and by how individuals interact with these systems and their larger social environments. There is a constant exchange between individuals, healthcare, public health, and the political and social systems they are embedded in, with more resources, programmes and services targeted towards those identified as vulnerable to try and establish a level of equity in health outcomes. It could be argued that, while activities in public health are population based, the ultimate target of public health is still to support individual health within the larger community. For example, although health promotion messages and activities are delivered to the population, the goal of these activities is to encourage individuals within communities towards healthier lifestyles (e.g. tobacco cessation, vaccinations), whose health statistics are then tracked (e.g. surveillance) and regarded as the population’s health.

Conceptual fit of public health systems within current health systems

Population health is conceptualised as extending far beyond the health system to include the political and societal contexts. While policies outside of the public health system may not be implemented to directly impact population health, they often do. For example, taxes on carbon emissions have short- and long-term effects on population-level health outcomes. Similarly, public health systems affect, and are affected by, many sectors. As broader determinants of health are becoming increasingly recognised as influential, there has been an increased emphasis on holistic approaches to healthy public policies [ 9 ]. Recent work has focused on holistic approaches to health such as Health in All Policies and One Health. Health in All Policies refers to the intersectoral aim of integrating health considerations into the actions, interventions and policies outside of the health sector, and One Health refers to the approach that recognises that human health is influenced by both animal and environmental health [ 87 , 88 ]. Figure 2 highlights the gaps that exist between what we currently have, at least in high-income countries, and paradigms of population health, Health in All Policies and, especially, One Health. For example, public health is often separate from healthcare and from the political process (i.e. healthy public policies). Population health spans further than public health’s reach and integration may need to be reconceptualised to align with a broader vision of health.

Main findings

The synthesis suggests that public health systems have not been clearly defined because (1) public health systems have been conceptualised in various ways and (2) there is overlap in terminology with publicly funded healthcare systems. One further potential reason for the lack of clarity regarding definitions and the change in the use of terms over time could be related to funder and publication preferences. No comprehensive public health system frameworks were identified within the literature although there was significant emphasis on defining the essential roles and functions of public health. These are broad and consensus on essential functions is often absent between jurisdictions, which made comparisons challenging. Services not provided by healthcare systems are often taken up by public health, increasing pressures on already limited budgets. In addition, response to health emergencies appears to have largely been adopted by public health systems because they are most likely to possess the capacity and expertise to organise and respond to large-scale events or threats to health. We found that, while many components of public health systems fit under the governance, delivery and financial arrangements of traditional healthcare systems, there are noted differences, specifically related to the role of partnerships and communication within public health. Partnerships provided the structure for multi-sectoral collaboration and facilitated communication and information exchange to accomplish the core functions of public health. A proposed framework for public health systems is presented in this paper.

The argument is made that public health and healthcare share the common goal of supporting the health of individuals within populations. Integration, the intersection of public health and healthcare, is believed to bring the two systems closer together to provide seamless service delivery within the broader health system that better responds to the needs of both individuals and communities [ 33 , 65 ]. The challenge with developing these integrated health systems is determining how to best align financial, governance and delivery arrangements, ensuring both complementarity and positive health outcomes. As population health extends beyond the health system to include the political, environmental and societal contexts, as such, it is important to understand these larger contexts within which health systems operate [ 89 ]. The conceptualisation of the current fit of public health systems within health systems has two important ramifications. The first being that integration of healthcare and public health will be difficult at best given that the aims, governance, finance and service delivery are not often aligned. There would have to be significant incentives for integration to happen and even with that, there may not be a shared vision of health to drive collaboration between these systems. The second ramification is that public health will not be able to inform healthy public policies unless they have a seat at the decision-making table for policies outside of the public health realm. There may be arguments on both sides as to whether this is practical or desired, but the case can be made that population health, encompassing the broader social determinants of health, will not occur within the current paradigm and structures.

Strengths and limitations

The flexibility of the CIS approach allows for a broad sampling frame and iterative filling of conceptual gaps. The BFF approach provides a structured approach to data analysis but also for change if a more applicable model is identified. The combination of these two qualitative approaches allowed for a broad research question in an area that is not well defined and helped bring a lot of data together in an efficient manner. The study was informed by a diverse team of experts in public health, health systems research and qualitative research methodology. The search strategy may not have captured all terms and concepts regarding public health systems. To try and mitigate this, a search string was developed with broad search terms to identify as much relevant literature as possible. Additionally, as the reviewed literature mainly covers the period from 2000 to 2016, the search strategy may not have captured all relevant documents such as recent institutional reports. While literature addressing health systems have origins before 2000, more recent documents were purposively sampled and prioritised in the document selection process as they would expectedly include earlier relevant works. This also presents an opportunity to review works after 2016, such as the 2018 report on the organisation and financing of public health services in Europe, and more recent documents that highlight the importance of improving population health through the Sustainable Development Goals (SDGs) [ 90 , 91 ]. CIS requires constant reflexive analysis by the principal investigator and results may vary if another person were to replicate this study; however, the use of a priori codes was used to increase transparency. Finally, although public health systems from various countries were reviewed, almost all documents were from high-income countries, mostly originating from the United States and Canada. While some of the results may be equally relevant to systems outside of these Western contexts, the findings highlight the need for future research outside of these jurisdictions, for example, in low- and middle-income countries, particularly in light of the SDGs.

Placing this work within the literature

This study is a first attempt at defining a holistic public health systems framework and highlighting the differences and similarities between public health and healthcare system arrangements. We have specifically addressed a priority research theme proposed by Canadian and United States federal agencies, such as the Canadian Institutes of Health Research Institute of Population and Public Health, the Centers for Disease Control and Prevention, and other stakeholders, to describe dimensions of public health systems and conceptualise a framework for public health systems.

Practice and policy implications

This study suggests five considerations for practice and policy. First, defining public health systems solidifies and challenges public health’s role to encourage political interest to secure the investment necessary to improve health system capacity. The COVID-19 pandemic has demonstrated the importance of understanding the role of public health within the larger health system, particularly with respect to the capacity to respond to public health crises efficiently and effectively. As was observed following the 2004 SARS pandemic, it is expected that there will be an increase in renewed calls and discussion around public health systems strengthening. Second, the discourse around establishing essential functions of public health is enhanced. Our synthesis has identified a growing concern that public health is currently filling gaps within the healthcare system by providing clinical services to targeted or vulnerable groups, consuming vast amounts of both human and financial resources from already under-resourced public health systems [ 5 , 60 , 69 ]. Thus, defining public health and the boundaries of public health systems could be an important step towards measuring performance and preventing public health systems from becoming too overburdened from the increasing scope of public health clinical activities [ 48 , 54 ]. Third, this study has reinforced the importance of partnerships in the work of public health. Partnerships have the potential to form and navigate systems in contexts challenged by limited resources. For example, the United Nations Millennium Development Goals, aimed to tackle societal issues influencing health, such as poverty, education, and gender equality and, while substantial progress was made, the state of many health systems revealed barriers to reaching specific targets and delivering services to the most vulnerable, particularly for those in many low- and middle-income countries. The SDGs, whose agenda is broader and more ambitious, explicitly recognise the broader determinants of health, by establishing social, economic and environmental objectives such as climate action, sustainable cities and communities, economic development, and social inclusion [ 92 ]. Defining public health systems serves as a building block for under-developed or transitioning public health systems and services, whereby determining roles and functions of public health systems allows practitioners to identify areas that require strengthening. Fourth, this synthesis suggests that the critical differences between public health and healthcare systems need to be acknowledged and negotiated for integration to be successful. The gaps that exist between the public health and healthcare subsystems have been highlighted. Lastly, the idea that public health is the champion of population health is presented as a challenge. Population health is influenced by political and social factors outside of the public health system. The idea of public health as the steward of population health requires serious consideration, especially if public health continues to be excluded from the decision-making process and its role in protecting and promoting health is relegated to the background.

Research implications

By developing a method that combined the best aspects of two qualitative systematic review methods, CIS and BFF, we were able to bring substantial amounts of data together in a timely manner, while simultaneously testing and refining a well-known framework in a critical way. The use of other frameworks, such as the performance-based conceptual framework by Handler et al. [ 42 ], or an assessment framework identified by Martin-Moreno et al. [ 53 ], provide other ways to examine public health systems and could be a way to validate the findings of this study or illustrate different health system ideas. The performance of public health systems cannot be measured if definitions, functions and key components are not well defined. The numerous variations in terminology make it difficult to perform a comparative analysis of public health systems across jurisdictions. Similarly, the differences in defined functions, or a lack thereof, limits our ability to monitor quality indicators between systems. Furthermore, the lack of research in public health and public health systems hampers both interest and investment in public health and limits the development of recommendations for evidence-based practice. Further research is required to determine what integration might look like and at what systems levels integration might work best. This presents additional opportunities for future research, particularly with respect to the gaps highlighted within financial arrangements such as remunerating providers and incentivising consumers. Lastly, this study is a first attempt at trying to understand how public health systems have been conceptualised. A public health systems framework (Table 1 ) and conceptualisation of how public health currently fits within the larger health system (Fig.  2 ) are proposed and can be applied and tested in real life settings as well as used to guide further research and practice in public health systems.

The aim of this paper was to examine the literature on how public health systems have been defined and classified and to illustrate how current public health systems align within established conceptual frameworks for health systems. Defining the scope of public health systems is crucial to solidify public health’s role as part of the larger health system and the degree to which public health and healthcare systems are different should be understood if public health is to be able to attend to its primary mandate within integrated health systems. While there is increased movement towards health systems focused on population health, specifically the increased focus on Health in All Policies and One Health, many gaps exist to reach those aims.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its additional files.

Abbreviations

Best-fit framework synthesis

Critical interpretive synthesis

Sustainable Development Goals

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Acknowledgements

We would like to acknowledge Dr. Steven J. Hoffman for his input on an earlier version of this manuscript.

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Fran Scott, Fadi El-Jardali and Elizabeth Alvarez contributed equally to this work.

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Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada

Tamika Jarvis, Fran Scott, Fadi El-Jardali & Elizabeth Alvarez

Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

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Contributions

T. Jarvis and E. Alvarez conceived and designed the presented study. E. Alvarez, F. Scott and F. El-Jardali verified the analytical methods. T. Jarvis extracted, analysed and interpreted the data. E. Alvarez supervised the findings of this work. All authors discussed the results and contributed to the final manuscript. The author(s) read and approved the final manuscript.

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This work was completed as part of a Master’s thesis and includes material from a thesis published on MacSphere: http://hdl.handle.net/11375/22170 .

Jarvis, T. (2017). Defining public health systems: A critical interpretive synthesis of how public health systems are defined and classified (Master’s dissertation).

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Correspondence to Tamika Jarvis .

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Supplementary information

Additional file 1..

The initial search strategy and databases. Additional file 1 provides search strings and detailed database search strategy.

Additional file 2.

Characteristics of documents reviewed for this study. Additional file 2 provides a description of the characteristics of the documents included in this study.

Additional file 3.

Definitions of entities and systems. Additional file 3 provides the definitions found within the literature regarding public health and public health systems.

Additional file 4.

Public Health Functions and Purpose. Additional file 4 provides a table as a way of organising what functions were found within the literature across a variety of countries, following the three core public health functions and 10 essential services.

Additional file 5.

Aligning public health systems into the health system arrangements framework. This additional file includes a summary of the coded data sources used to align public health within the health system arrangements framework.

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Jarvis, T., Scott, F., El-Jardali, F. et al. Defining and classifying public health systems: a critical interpretive synthesis. Health Res Policy Sys 18 , 68 (2020). https://doi.org/10.1186/s12961-020-00583-z

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Published : 16 June 2020

DOI : https://doi.org/10.1186/s12961-020-00583-z

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Home > USC Columbia > Public Health, Arnold School of > SPH_HEALTH_SERVICES_POLICY_MANAGEMENT > Health Services Policy and Management Theses and Dissertations

Health Services Policy and Management Theses and Dissertations

Theses/dissertations from 2023 2023.

Examining the Associations of the Kidney Allocation System With Patient Sensitivity, Wait Time to Transplant, and Donor Distance , Shamika Danielle Jones

Female Infertility and Maternal and Infant Outcomes in South Carolina – The Role of Insurance Type , Chelsea Mencio Norregaard

Beyond Vaccination Coverage: A Critical Look At Zero-Dose Children in Sub-Saharan Africa , Chamberline Ekene Ozigbu

Complementary and Integrative Health (CIH) And Opioid Use Among Adults With Chronic Noncancer Pain in the US , Yi-Wen Shih

Patient Experiences and Disparities in Telehealth HIV Care During the COVID-19 Pandemic: Study Results From the Southern United States , Valerie Yelverton

Theses/Dissertations from 2022 2022

Association of Prior Periodontal Disease With Cancer – Exploring Epidemiologic Evidence of Periodontal Exudate-Exposed Site Cancer Risk Versus Remote Gastrointestinal Sites , Asma Alzahrani

Gonorrhea: Core Areas and State Policies , Jessica Purser

Subject Cognitive Decline in Informal Caregivers , Eunika Simons

Identifying Racial Differences in Colorectal Polyp Profile at Screening Colonoscopy Using Traditional Regression and Machine Learning Approaches , Yuqi Wu

Theses/Dissertations from 2021 2021

Examining the Cost and Quality Relationship in Medicare , Alexandria Fleming Delage

Evaluating the Health Impact of CenteringPregnancy Program Versus Traditional Prenatal Care in Midland Obstetric Clinics and Validating Selected Item On Birth Certificate , Oluwatosin A. Momodu

Hear My Voice: Qualitative Studies to Explore What Empowers Patients to Talk With Their Doctor and Participate in Making Health Care Decisions , Alicia Marie Oostdyk

A Cost Effectiveness Analysis Of The Nutritious Eating With Soul Study , Mary Jones Wilson

Theses/Dissertations from 2020 2020

Magnet Recognition (Mr) and Hospital Quality Outcomes in the U.S.A– Analysis Based on 2017 Hospital Data , Abdulmalik Alhammad

Effect of Lifestyle, Medical School Culture and Income on Medical Students' Decision to Pursue a Primary Care Career in Saudi Arabia , Ahmed Abdullah Alhussain

Package Warning Labels for Communicating Relative Risks of Cigarettes, Heated Tobacco Products, and E-Cigarettes , Yoo Jin Cho

Correlates of Maternal Health Service Use and Women’s Experiences Using Antenatal Care in Ghana: A Mixed-Methods Study , Anna Cofie

Examining Parental Perceptions and Decisions to Uptake Child Influenza Immunizations: Assessing Pandemic and Policy Impacts on Vaccination Rates Following the H1N1 Pandemic, and the ACIP LAIV Preferential Recommendation Revocation , Amir H. Mehrabi

The Impact of Financial Incentives on Urban-Rural Disparities in Dental Supply: Evidence From Thailand , Rakchanok Noochpoung

Effectiveness and Experience of an Integrated Maternal Mental Healthcare Intervention in Private Clinics and Public Health Facilities in Pakistan , Syeda Somyyah Owais

Aging With HIV in the United States: Trends and Impact of Hospital Stays on Inpatient Resource Utilization, and Costs of Care, 2003-2015 , Khairul Alam Siddiqi

Maternal Preventive Dental Services Utilization: The Role of Preconception Oral Health Counseling in and the Association With Birth Outcomes: Evidence From South Carolina Prams , Monique Johnette Williams

Effectiveness Among Community Health Center Governing Boards: An Assessment of the Different Governing Board Members’ Perspectives , Brandi L. Wright

Theses/Dissertations from 2019 2019

Factors Associated with Advance Care Plans and End-Of-Life Care Choices Among Elderly Americans: An Analysis of Health and Retirement Study Data , Agha Ajmal

The Association of Reimbursement Methods With the Tendency of Primary Care Physicians to Apply the American Diabetic Association’s Recommendations and Make Referrals to Specialists Among Ambulatory Care Patients in Us Outpatient Settings. , Abdullah Alharbi

Examining Women’s Perceptions of Maternity Care in Public and Private Sectors of National Guard Hospitals in Saudi Arabia: A Qualitative Study , Hanin M. Almahmoud

Effect of Severe Economic Recession on the Psychological Distress: Evidence of Modifying Effect of Risky Behaviors and Insurance Status , Lumi Bakos

Clinically Integrated Networks: The ‘Magic Pill’ for Improving the Quality of Health Care? , Kaitlyn Ann Crosby

Did Medicaid Expansion Under the Affordable Care Act Reduce the Likelihood That People Report Employment Status Changes Due to Health, U.S., 2009-2017 , Songyuan Deng

The Relationship Between the Electronic Health Record Patient Portal and Shared Decision Making , Gloria Esoimeme

HIV Care Location: An Evaluation of Single Versus Multi Facility Utilization of HIV/Aids Care Services and Patient Health Outcomes and Clinical Indicators in South Carolina , Melanie Gwynn

The Intergenerational Effects of Adverse Childhood Experiences on Children’s Emergency Department Utilization and Depression and Anxiety in South Carolina , Eboni E. Haynes

Assessing the Impact of South Carolina’s Medicaid Adult Dental Policy on Dental Emergency Department Visits , Victor Kirksey

The Association of Rural Hospital Closures with In-Hospital and 30-Day Post Hospital Discharge Mortality from Emergency Care Sensitive Conditions , Melinda A. Merrell

Health Insurance Program for the Poor, Out-Of-Pocket Costs, and Catastrophic Health Expenditures in India , Shyamkumar Sriram

The Prescribing Patterns of Gabapentin and Pregabalin in a Medicaid Population Amid the Opioid Epidemic , Sarah Sullivan

The Association of Health Insurance and Prescription Drug Coverage on Cost-Related Non-Adherence and Hospitalization Across Age-Related Groups of Individuals With COPD , Shamika Martin Walls

Theses/Dissertations from 2018 2018

Investigating Drug-Related Violence in Indian Country: The Lumbee Tribe of North Carolina , Asa Alena Revels

The Impact Of The Medicaid Coverage Expansion And The Removal Of Cost-Sharing Under The Affordable Care Act On Mammography And Pap Tests , Abeer Alharbi

Introduction Of Innovative Medical Practices In Mayo Clinic: Effect Of The Interventions On Patient Outcomes , Duaa I. Aljabri

How Do Health System Employees with Established Musculoskeletal Complaints Decide on Their Treatment Pathway? A Qualitative Approach , Noor Alshareef

Patient Characteristics, Discharge Disposition, and Hospital Factors Associated with All cause 30-day Hospital Readmission for Total Joint Arthroplasty in 2014 , Hamad Yahya Alzamanan

Factors Affecting Patient Satisfaction With Healthcare System Of Turkey , Serdar Aydin

The Association of Hospital Practices to Breastfeeding Behaviors in South Carolina: Analysis of 2013-2015 Pregnancy Risk Assessment Monitoring System (PRAMS) Data , Larisa Donnette Bruner

Association Of Insurance And Provider Type With Patients’ Perceived Cost And Ease Of Access To Healthcare Services Among Medicare Beneficiaries Diagnosed With Diabetes , Metria Harris

Residential Mobility And Enrollment Churn In A Medicaid Population , John E. Stewart

Theses/Dissertations from 2017 2017

Association of Freestanding Dialysis Facility Size, Quality Incentive Program Scores and Patient Survival , Fozia Ajmal

Racism Across The American South: The Association Between Racism On Twitter, Rurality, & Black Mortality , Jarrod Bullard

Association of Provider Communication and Inpatient Hospital Readmissions , Jeremy Dean Faulkenburg

Economic Burden of Tuberculosis among Bangladeshi Population and Economic Evaluation of the Current Approaches of Tuberculosis Control in Bangladesh , Mohammad Rifat Haider

The Association between Clinical Recognition of Depression and Unplanned Hospital Readmission among Older Adults , Karen M. Jones

Association between Job Satisfaction and Pay: The Case of the Wage Payment System of Dental Clinics in Korea , Eui Jeong Kim

Feasibility of Introducing Investor-Owned Hospitals in Korea , HongSeok Seo

A Study on Satisfaction of Dental Implant Patients , Jung Su O

Depressive Symptoms Association With Health Outcomes And Treatment In Older Americans With Diabetes , Lashonda Jovon Williams

Internet Speed and the Effect on Health Information Technology Adoption , Matthew W. Yuen

Theses/Dissertations from 2016 2016

Contextualizing Multilayered Sexual Subjectivities of Heterosexual Black Female Undergraduate Students at a Predominantly White Institution in the South , Amarachi Rossana Anakaraonye

Molecular Cues Of Pattern-Recognition-Receptor Pathways In Redox-Toxicity-Driven Environmental NAFLD , Suvarthi Das

Effectiveness Of Community-Based EIBI Treatment: A Longitudinal Analysis Of Adaptive Behavior And Language Outcomes , John Kuntz

Low-Intensity Physical Activity And Cardiometabolic Risk Factors Among Older Adults With Multiple Chronic Conditions , Yueyao Li

Smoking-Related Stigma: A Public Health Tool Or A Damaging Force ? , Paula A. Lozano

Novel Methods for Analyzing Longitudinal Data with Measurement Error in the Time Variable , Caroline Munindi Mulatya

Practice Characteristics That Matter In the Provision of Health Education Services By Primary Care Physicians , George Paul Newby Jr.

Demand And Supply Factors Affecting Maternal Healthcare Utilization Pattern In Nigeria , Dumbiri Joy Powell

Healthcare Utilization And Expenditure Patterns Among Older Adults With Functional And Medical Decline , Ashley Shields Robertson

Frequency of Colonoscopy Surveillance in Average-Risk Adults Relative to Guideline Recommendations , Meng-Han Tsai

Examining The Relationship Among Patient-Centered Communication, Patient Engagement, And Patient’s Perception Of Quality Of Care In The General U.S. Adult Population , Jumee Wang

The Undiagnosed Patient and The Diagnostic Odyssey: Current Genetic Counseling Practices and Perspectives , Amelia Cordell Wardyn

Job Satisfaction And Intent To Quit Outcomes Among Home Health Aides In Home Health Care Industry Of The United States: A Multilevel Study , Seokwon Yoon

Theses/Dissertations from 2015 2015

Relationship Between Job Satisfaction Among Frontline Staff and Patient Satisfaction: Evidence from Community Health Centers in South Carolina , Ashley Lynn Barnes

Association between Electronic Prescribing among Ambulatory Care Providers and Adverse Drug Event Hospitalizations in Older Adults , Grishma Patel Bhavsar

Spatial Analysis and Correlates of Waterpipe Tobacco Smoking among College Students in the United States , Frederick Richard Kates

Community-Level Factors Associated with Health-Related Quality of Life Among Older Adults , Yu-Hsiu Lin

Examination of the Association of Receipt of Opioid Therapy and Lung Cancer Patient Survival Rates among South Carolina Medicaid Recipients , Jametta Sade Magwood

Patient And Provider Characteristics And Practice Patterns of Primary Care Physicians Of Weight-Related Counseling , Kolby T. Redd

Dental Insurance as a Mitigating Factor in Reducing the Risk of Mortality Among Working-Age Adults with Dental Caries and Periodontitis , Naveed Sadiq

Longitudinal Study of the Effectiveness of the South Carolina Medicaid Policy for the Application of Fluoride Varnish for Children Age Three and Under , Christine N. Veschusio

Theses/Dissertations from 2014 2014

Impact of Multi-Hospital System Organizational Structure on Financial Performance and Quality of Care in Rural Hospitals , George Raul Audi

Two Studies of Family-Centered Care Family-Centered Care and Shared Decision Making: Are they the same Construct? and The Association of Family-Centered Care and Shared Decision Making with Receipt of all Needed Prescription Drugs and Emergency Department Visits in Children with Asthma , Barbara Lee Brumbaugh

Women’s HIV Prevention Study (Whips): A Proposal to Pilot Test an HIV Intervention for Older African American Women Living with HIV , Charsey Cherry

Analysis of Risk Factors Contributing to Home–Based Direct Care Workers (DCWS) Occupational Injury in Long–Term Care , Hanadi Y. Hamadi

Mental Disorders, Mental Health Problems, and Treatment Among Army Recruiters and Recruiting Candidates, 2011-2013: An Examination of Current Rates in the Recruiting Population , Chadwick Karl Knight

Theses/Dissertations from 2013 2013

Examining the Role of Electronic Medical Record Generated Provider Reminders On Provider offering of Breast Cancer Screening Services , Charles Beverley, Jr.

An Assessment of Injury Presentation to Determine Elder Abuse Prevalence in South Carolina , Brittani L. Harmon

The Relationship Between Electronic Health Record Implementation and Outcomes of Care For Three Cardiovascular Procedures , Deshia Ann Leonhirth

Assessment of the Effectiveness of an Innovative Screening Colonoscopy Protocol in Producing High Quality Performance and Outcomes by Trained Primary Care Physicians , Yi Jhen Li

Relationship Between the Experience of Perceived and Physician Diagnosed Arthritis and the Presence of DSM-IV Criteria-based Major Depression (MDD) Among Older , Ryan Neil Schmidt

Differential Effects of the Great Recession on Minority Populations , Samuel Towne

Theses/Dissertations from 2012 2012

Assessing Risk Factors, Cost And Mortality Due to Ventilator-Associated Pneumonia (VAP) Using National Inpatient Sample Data , Hasan A. Areabi

Factors Associated With Local Public Health Agency Participation In Obesity Prevention, 2008 , Jeff Hatala

Weathering the Storm Faithfully: African American Women's and Clergy's Perspectives about Natural Disasters and the Role of the Baptist Church In Disaster Preparedness , TaQuesa McClain

A Profile of Diabetes-related Below Knee Amputations Using Nation-wide Patient Discharge Data: Patient, Provider, And Insurance Characteristics , Flora Elisa Melvin

Is Optimum Time to Coronary Artery bypass Surgery Associated With Hospital Teaching Status and Payer Source? A Comparison of Outcomes and Costs Among Non St Segment Elevated Myocardial Infarction Patients and St Segment Elevated Myocardial Infarction Patients , Lamont Andre' Melvin

Association Between Clinical Decision Support System Use and Health Care Disparities in the Treatment and Outcomes of Acute Myocardial Infarction and Pneumonia , Jordan Paul Mitchell

Use of Endoscopic Third Ventriculostomy (ETV) In Treatment of Pediatric Obstructive Hydrocephalus; A Multi-Level Retrospective Analysis of the United States Pediatric Population. , Irene Nancy Okech

Healthcare Cost Implications of Medicaid Managed Care , Margarita Morales Pate

Effectiveness of Medicare's Nonpayment Policy On Hospital-Acquired Conditions , Kristin Schuller

Differences in Interventions for Children With ADHD Their Relationship to Contact with the Juvenile Justice System in SC , Samuel Lee Soltis

Analysis of Hospital-Based Emergency Department Visits for Dental Care Services in the United States in 2008 , Willie A. Walker

Antihyperglycemic Adherence and Risk of Stroke among Type II diabetes mellitus: A Population-based Retrospective Cohort Study , Chuan-Song Wu

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• Attitudes and perceptions of girls in St John's College about the practice of virginity testing  Swaartbooi-Xabadiya, Zolisa Cynthia ( University of Limpopo (Medunsa Campus) , 2010 ) Background Virginity testing is a practice that has stimulated lots of discussions amongst people from various perspectives. Controversies around this practice have necessitated further research in order to bring the voice ...
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• Participation of men attending outpatient services at Qoaling Filter Clinic in family planning  Ralejoana, Ntsoaki ( University of Limpopo (Medunsa Campus) , 2010 ) Introduction The neglect of men with respect to their role in family planning has contributed to a situation in which men remained passive or non-participatory in reproductive health related studies and have generally not ...
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• Accessibility and utilization of the primary health care services in Tshwane Region  Nteta, Thembi Pauline ( University of Limpopo (Medunsa Campus) , 2009 ) Background Primary Health Care is a basic mechanism that brings healthcare as close as possible to the people. In South Africa, it is seen as a cost effective means of improving the health of the population. It is provided ...
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• Compliance of registered health research ethics committees with South African research ethics guidelines  Molebatsi, Thabo Isaac ( University of Limpopo ( Medunsa Campus ) , 2010 ) Background The National Health Research Ethics Council (NHREC) of South Africa (SA) is mandated to oversee health research ethics activities within the country. The oversight role is achieved through registration and ...
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Digital Commons @ USF > College of Public Health > Health Policy and Management > Theses and Dissertations

Health Policy and Management Theses and Dissertations

Theses/dissertations from 2017 2017.

Healthcare Costs of Injured Youth: The Need for Prevention, Policy, and Proper Triage , Jessica Lynn Ryan

Physical Therapy Utilization and Length of Stay among Patients with Low Back Pain in Florida Hospitals , Kyle A. Watterson

Theses/Dissertations from 2013 2013

Predictors of the Incidence and Charges for Lumbar Spinal Fusion Surgery in Florida Hospitals During 2010 , Anna Ialynychev

Theses/Dissertations from 2010 2010

Analysis of Two Strategies for Structuring Medicare Reimbursement to Maximize Profitability in Acute Care General Hospitals , James D. Barrington

Theses/Dissertations from 2009 2009

Predicting the Medical Management Requirements of Large Scale Mass Casualty Events Using Computer Simulation , Scott A. Zuerlein

Theses/Dissertations from 2008 2008

The Association between the Measles, Mumps, and Rubella Vaccine and the Development of Autism: A Meta-Analysis , Rashad Carlton

The Influence of Specialized Cancer Hospitals in Florida on Mortality, Length of Stay, and Charges of Care , Patricia L. Spencer

Theses/Dissertations from 2005 2005

Racial Disparities in Breast Cancer Surgical Treatment and Radiation Therapy Use , Tracey Lynn Koehlmoos

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Home > College of Public Health > Health Services Research & Administration > Theses & Dissertations

Theses & Dissertations: Health Services Research, Administration, and Policy

Theses/dissertations from 2023 2023.

Factors Associated with the Difficulty of Computerized Tasks Among Office-Based Physicians in the United States , Khalid Alshehri

Reducing Oral Health Disparities: Effectiveness of Preventive Dental Care on Treatment Use, Expenditures and Determinants of Service Utilization , Rashmi Lamsal

'The Very Structure of Opportunities Has Collapsed': How Taxation Policies Enhance, Decay, and Otherwise Affect the Distribution of Health & Health Services in the United States , Valerie Pacino

An Exploration of Policies, Equity, and Emerging Threats to the Traffic Safety Environment in the U.S. , Sachi Verma

Theses/Dissertations from 2022 2022

The State of Oral Health in People with Disabilities and the Impact of Family-Centered Care on the Oral Health of Children with Special Health Care Needs , Bedant Chakraborty

Theses/Dissertations from 2021 2021

The Ecology of Mental Health and the Impact of Barriers on Mental Health Service Utilization , Alisha Aggarwal

Health Service Utilization and Expenditure in Cardio-Metabolic Conditions in the United States Adults , Kavita Mosalpuria

Impact of Prescription Drug Monitoring Program on Drug Misuse and Drug-related Fatal Vehicle Crashes , Moosa Tatar

Theses/Dissertations from 2020 2020

Essays on rehospitalization under the Hospital Readmission Reduction Program , Yangyuna Yang

Theses/Dissertations from 2019 2019

Impact of Healthcare Delivery and Policies on Children's Outcomes after the Affordable Care Act of 2010 , Shreya Roy

Examining the Effects of Approaches on Reducing Hospital Utilization: The Patient-Centered Medical Home, Continuity of Care, and the Inpatient Palliative Consultation at the End-of-Life , Xiaoting Sun

Theses/Dissertations from 2018 2018

Essays on the Patient-Centered Medical Home in the United States Military Health System , Glen N. Gilson

A Multi-Level Assessment of Healthcare Facilities Readiness, Willingness, and Ability to Adopt and Sustain Telehealth Services , Jamie Larson

Healthcare Utilization for Behavioral Health Disorders: Policy Implications on Nationwide Readmissions, and Outcomes in the States of Nebraska and New York , Rajvi J. Wani

Theses/Dissertations from 2017 2017

Structural violence and gender-based violence in the United States , Sarbinaz Z. Bekmuratova

Community Benefits Spending by Private Tax-Exempt Hospitals in the U.S. , Wael ElRayes

Patient-Centered Medical Home Adoption in School-Based Health Centers , Abbey Gregg

Meaningful Use of Electronic Health Records for Population Health Management in U.S. Acute Care Hospitals , Niodita Gupta

Hospital Based Emergency Department Visits With Dental Conditions: Outcomes and Policy Implications in the States of California, Nebraska and New York , Sankeerth Rampa

Theses/Dissertations from 2016 2016

Adoption of Medication Management Technologies by U.S. Acute Care Hospitals after the HITECH Act , Aastha Chandak

The Impact of Electronic Health Records on Healthcare Service Delivery, Patient Safety, and Quality , Kate Elizabeth Trout

Essays on Immigration-Related Disparities in Health Behavior and Health Care Utilization , Yang Wang

Theses/Dissertations from 2015 2015

The Impact of Gasoline Prices on Medical Care and Costs of Motor Vehicle Injuries , He Zhu

Theses/Dissertations from 2014 2014

Provision, cost, and quality of robot-assisted radical prostatectomies in the United States , Soumitra Sudip Bhuyan

Organizational factors associated with the implementation of evidence-based public health interventions in local health department settings , Janelle J. Jacobson

Hospital cost shifting in the United States , Tao Li

Patient-centered medical home readiness in the veterans health administration: an organizational perspective , Anh T. Nguyen

Organizational and environmental correlates of electronic health records implementation and performance in acute care hospitals in the United States , Diptee Ojha

Assessing geographic variation and migration behaviors of foreign-born medical graduates in the United States , Samuel Tawiah Yaw Opoku

Theses/Dissertations from 2013 2013

Organizational and environmental correlates of strategic behavior and financial performance in the US hospice industry , Bettye Appiah Apenteng

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UKnowledge > College of Public Health > Public Health M.P.H. Theses & Dr.P.H. Dissertations

Theses and Dissertations--Public Health (M.P.H. & Dr.P.H.)

Theses/dissertations from 2024 2024.

Adverse Outcomes of Co-Occurring Methamphetamine and Opioid Use Among Pregnant and Postpartum Women , Hope Tevis

Theses/Dissertations from 2023 2023

Gender Differences in Barriers to Entering Substance Use Treatment , Casey A. Baker

Maternal Occupation and Pediatric Brain Cancer in Kentucky , Mary Begley

PFAS Clinical Guidance , John Bingham

Evaluation of Facebook Social Media Messages Following the 2022 Eastern Kentucky Floods , Delaney Bonds

Health Management and Policy Capstone: A Case Study in Program Evaluation , Bradford Brewer

Implementing a Mobile Saliva Rinse Screening for P16 Markers for HPV (Human Papillomavirus) Positive Head and Neck Cancers in Central Kentucky , Madeline Brown

Characterizing Region IV State Health Agency - Central Office's Workforce Needs: Results from the 2021 Public Health Workforce Interest and Needs Survey (PH WINS) , Ashley Carroll

Cardinal's Blues: Implementation of a School-based Cognitive Behavioral Therapy Program for Jefferson County Public Schools in Louisville, Kentucky , Loui Chang

Trends in Respirable Coal Mine Dust Concentration (mg/m3) based on Coal Miners’ Occupational Designation: An Analysis of the MSHA Coal Dust Samples Data Set (2000-2022) , Aaron Blake Charles

The PrEPARE Mobile Program for HIV Prevention in Washington D.C. , Gabrielle Cochran

The impact of flooding events in Kentucky counties on preventable asthma hospitalizations , McKaylee Copher

The Relationship Between Maternal Depressive Symptoms and Unsafe Infant Sleep Practices in a Low-Resource Community , Rebecca D. Day, Ketrell L. McWhorter, Hartley C. Feld, and Steven R. Bronwing

Psychosocial Outcomes Post-Concussion of Female Collegiate Athletes , Victoria Farley

Implementation of a School-Based Adolescent Pregnancy Prevention Program in Harlan County, Kentucky , Jaycea Frederick

Health Management and Policy Capstone: A Case Study in Program Evaluation , Kelsey R. Gatton

Epidemiology of Angiosarcomas in Kentucky, 2000-2019 , Emma Gough

The Meals on Wheels-Breathitt: A Health Campaign For Reducing Food Insecurity Among The Older Adults In Breathitt County, Kentucky. , Sarah Haroon

Prevalence of Multimorbidity in the Atherosclerosis Risk in Communities Study at Baseline , Katie Highfill

Physical Inactivity and Single-Female Caregivers , Johanna Hoch, Rachel Hogg-Graham Dr., John Lyons Dr., and Maureen Jones Dr.

Epidemiology of SARS-CoV-2 Breakthrough Infections in Kentucky March 1st 2021 - December 31st, 2022 , Harrison Hynes

CHANGES IN SEVERITY OF DIABETES AT DIAGNOSIS FOLLOWING THE ONSET OF THE SARS-COV-2 PANDEMIC , Annelise King

EFFECT OF MEDICAID EXPANSION ON INFLAMMATORY BOWEL DISEASE AND HEALTHCARE UTILIZATION , Brittany Levy

Rapid Scoping Review of the Epidemiological Evidence for Mercury Exposure and Prevalence of Alzheimer’s Disease , Rebecca Mattingly

Breastfeeding Promotion in the Workplace , Katie C. Nettesheim

Page 1 of 16

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Research Topics & Ideas: Healthcare

100+ Healthcare Research Topic Ideas To Fast-Track Your Project

Finding and choosing a strong research topic is the critical first step when it comes to crafting a high-quality dissertation, thesis or research project. If you’ve landed on this post, chances are you’re looking for a healthcare-related research topic , but aren’t sure where to start. Here, we’ll explore a variety of healthcare-related research ideas and topic thought-starters across a range of healthcare fields, including allopathic and alternative medicine, dentistry, physical therapy, optometry, pharmacology and public health.

NB – This is just the start…

The topic ideation and evaluation process has multiple steps . In this post, we’ll kickstart the process by sharing some research topic ideas within the healthcare domain. This is the starting point, but to develop a well-defined research topic, you’ll need to identify a clear and convincing research gap , along with a well-justified plan of action to fill that gap.

If you’re new to the oftentimes perplexing world of research, or if this is your first time undertaking a formal academic research project, be sure to check out our free dissertation mini-course. In it, we cover the process of writing a dissertation or thesis from start to end. Be sure to also sign up for our free webinar that explores how to find a high-quality research topic.

Overview: Healthcare Research Topics

• Allopathic medicine
• Alternative /complementary medicine
• Veterinary medicine
• Physical therapy/ rehab
• Optometry and ophthalmology
• Pharmacy and pharmacology
• Public health
• Examples of healthcare-related dissertations

Allopathic (Conventional) Medicine

• The effectiveness of telemedicine in remote elderly patient care
• The impact of stress on the immune system of cancer patients
• The effects of a plant-based diet on chronic diseases such as diabetes
• The use of AI in early cancer diagnosis and treatment
• The role of the gut microbiome in mental health conditions such as depression and anxiety
• The efficacy of mindfulness meditation in reducing chronic pain: A systematic review
• The benefits and drawbacks of electronic health records in a developing country
• The effects of environmental pollution on breast milk quality
• The use of personalized medicine in treating genetic disorders
• The impact of social determinants of health on chronic diseases in Asia
• The role of high-intensity interval training in improving cardiovascular health
• The efficacy of using probiotics for gut health in pregnant women
• The impact of poor sleep on the treatment of chronic illnesses
• The role of inflammation in the development of chronic diseases such as lupus
• The effectiveness of physiotherapy in pain control post-surgery

Topics & Ideas: Alternative Medicine

• The benefits of herbal medicine in treating young asthma patients
• The use of acupuncture in treating infertility in women over 40 years of age
• The effectiveness of homoeopathy in treating mental health disorders: A systematic review
• The role of aromatherapy in reducing stress and anxiety post-surgery
• The impact of mindfulness meditation on reducing high blood pressure
• The use of chiropractic therapy in treating back pain of pregnant women
• The efficacy of traditional Chinese medicine such as Shun-Qi-Tong-Xie (SQTX) in treating digestive disorders in China
• The impact of yoga on physical and mental health in adolescents
• The benefits of hydrotherapy in treating musculoskeletal disorders such as tendinitis
• The role of Reiki in promoting healing and relaxation post birth
• The effectiveness of naturopathy in treating skin conditions such as eczema
• The use of deep tissue massage therapy in reducing chronic pain in amputees
• The impact of tai chi on the treatment of anxiety and depression
• The benefits of reflexology in treating stress, anxiety and chronic fatigue
• The role of acupuncture in the prophylactic management of headaches and migraines

Topics & Ideas: Dentistry

• The impact of sugar consumption on the oral health of infants
• The use of digital dentistry in improving patient care: A systematic review
• The efficacy of orthodontic treatments in correcting bite problems in adults
• The role of dental hygiene in preventing gum disease in patients with dental bridges
• The impact of smoking on oral health and tobacco cessation support from UK dentists
• The benefits of dental implants in restoring missing teeth in adolescents
• The use of lasers in dental procedures such as root canals
• The efficacy of root canal treatment using high-frequency electric pulses in saving infected teeth
• The role of fluoride in promoting remineralization and slowing down demineralization
• The impact of stress-induced reflux on oral health
• The benefits of dental crowns in restoring damaged teeth in elderly patients
• The use of sedation dentistry in managing dental anxiety in children
• The efficacy of teeth whitening treatments in improving dental aesthetics in patients with braces
• The role of orthodontic appliances in improving well-being
• The impact of periodontal disease on overall health and chronic illnesses

Tops & Ideas: Veterinary Medicine

• The impact of nutrition on broiler chicken production
• The role of vaccines in disease prevention in horses
• The importance of parasite control in animal health in piggeries
• The impact of animal behaviour on welfare in the dairy industry
• The effects of environmental pollution on the health of cattle
• The role of veterinary technology such as MRI in animal care
• The importance of pain management in post-surgery health outcomes
• The impact of genetics on animal health and disease in layer chickens
• The effectiveness of alternative therapies in veterinary medicine: A systematic review
• The role of veterinary medicine in public health: A case study of the COVID-19 pandemic
• The impact of climate change on animal health and infectious diseases in animals
• The importance of animal welfare in veterinary medicine and sustainable agriculture
• The effects of the human-animal bond on canine health
• The role of veterinary medicine in conservation efforts: A case study of Rhinoceros poaching in Africa
• The impact of veterinary research of new vaccines on animal health

Topics & Ideas: Physical Therapy/Rehab

• The efficacy of aquatic therapy in improving joint mobility and strength in polio patients
• The impact of telerehabilitation on patient outcomes in Germany
• The effect of kinesiotaping on reducing knee pain and improving function in individuals with chronic pain
• A comparison of manual therapy and yoga exercise therapy in the management of low back pain
• The use of wearable technology in physical rehabilitation and the impact on patient adherence to a rehabilitation plan
• The impact of mindfulness-based interventions in physical therapy in adolescents
• The effects of resistance training on individuals with Parkinson’s disease
• The role of hydrotherapy in the management of fibromyalgia
• The impact of cognitive-behavioural therapy in physical rehabilitation for individuals with chronic pain
• The use of virtual reality in physical rehabilitation of sports injuries
• The effects of electrical stimulation on muscle function and strength in athletes
• The role of physical therapy in the management of stroke recovery: A systematic review
• The impact of pilates on mental health in individuals with depression
• The use of thermal modalities in physical therapy and its effectiveness in reducing pain and inflammation
• The effect of strength training on balance and gait in elderly patients

Topics & Ideas: Optometry & Opthalmology

• The impact of screen time on the vision and ocular health of children under the age of 5
• The effects of blue light exposure from digital devices on ocular health
• The role of dietary interventions, such as the intake of whole grains, in the management of age-related macular degeneration
• The use of telemedicine in optometry and ophthalmology in the UK
• The impact of myopia control interventions on African American children’s vision
• The use of contact lenses in the management of dry eye syndrome: different treatment options
• The effects of visual rehabilitation in individuals with traumatic brain injury
• The role of low vision rehabilitation in individuals with age-related vision loss: challenges and solutions
• The impact of environmental air pollution on ocular health
• The effectiveness of orthokeratology in myopia control compared to contact lenses
• The role of dietary supplements, such as omega-3 fatty acids, in ocular health
• The effects of ultraviolet radiation exposure from tanning beds on ocular health
• The impact of computer vision syndrome on long-term visual function
• The use of novel diagnostic tools in optometry and ophthalmology in developing countries
• The effects of virtual reality on visual perception and ocular health: an examination of dry eye syndrome and neurologic symptoms

Topics & Ideas: Pharmacy & Pharmacology

• The impact of medication adherence on patient outcomes in cystic fibrosis
• The use of personalized medicine in the management of chronic diseases such as Alzheimer’s disease
• The effects of pharmacogenomics on drug response and toxicity in cancer patients
• The role of pharmacists in the management of chronic pain in primary care
• The impact of drug-drug interactions on patient mental health outcomes
• The use of telepharmacy in healthcare: Present status and future potential
• The effects of herbal and dietary supplements on drug efficacy and toxicity
• The role of pharmacists in the management of type 1 diabetes
• The impact of medication errors on patient outcomes and satisfaction
• The use of technology in medication management in the USA
• The effects of smoking on drug metabolism and pharmacokinetics: A case study of clozapine
• Leveraging the role of pharmacists in preventing and managing opioid use disorder
• The impact of the opioid epidemic on public health in a developing country
• The use of biosimilars in the management of the skin condition psoriasis
• The effects of the Affordable Care Act on medication utilization and patient outcomes in African Americans

Topics & Ideas: Public Health

• The impact of the built environment and urbanisation on physical activity and obesity
• The effects of food insecurity on health outcomes in Zimbabwe
• The role of community-based participatory research in addressing health disparities
• The impact of social determinants of health, such as racism, on population health
• The effects of heat waves on public health
• The role of telehealth in addressing healthcare access and equity in South America
• The impact of gun violence on public health in South Africa
• The effects of chlorofluorocarbons air pollution on respiratory health
• The role of public health interventions in reducing health disparities in the USA
• The impact of the United States Affordable Care Act on access to healthcare and health outcomes
• The effects of water insecurity on health outcomes in the Middle East
• The role of community health workers in addressing healthcare access and equity in low-income countries
• The impact of mass incarceration on public health and behavioural health of a community
• The effects of floods on public health and healthcare systems
• The role of social media in public health communication and behaviour change in adolescents

Examples: Healthcare Dissertation & Theses

While the ideas we’ve presented above are a decent starting point for finding a healthcare-related research topic, they are fairly generic and non-specific. So, it helps to look at actual dissertations and theses to see how this all comes together.

Below, we’ve included a selection of research projects from various healthcare-related degree programs to help refine your thinking. These are actual dissertations and theses, written as part of Master’s and PhD-level programs, so they can provide some useful insight as to what a research topic looks like in practice.

• Improving Follow-Up Care for Homeless Populations in North County San Diego (Sanchez, 2021)
• On the Incentives of Medicare’s Hospital Reimbursement and an Examination of Exchangeability (Elzinga, 2016)
• Managing the healthcare crisis: the career narratives of nurses (Krueger, 2021)
• Methods for preventing central line-associated bloodstream infection in pediatric haematology-oncology patients: A systematic literature review (Balkan, 2020)
• Farms in Healthcare: Enhancing Knowledge, Sharing, and Collaboration (Garramone, 2019)
• When machine learning meets healthcare: towards knowledge incorporation in multimodal healthcare analytics (Yuan, 2020)
• Integrated behavioural healthcare: The future of rural mental health (Fox, 2019)
• Healthcare service use patterns among autistic adults: A systematic review with narrative synthesis (Gilmore, 2021)
• Mindfulness-Based Interventions: Combatting Burnout and Compassionate Fatigue among Mental Health Caregivers (Lundquist, 2022)
• Transgender and gender-diverse people’s perceptions of gender-inclusive healthcare access and associated hope for the future (Wille, 2021)
• Efficient Neural Network Synthesis and Its Application in Smart Healthcare (Hassantabar, 2022)
• The Experience of Female Veterans and Health-Seeking Behaviors (Switzer, 2022)
• Machine learning applications towards risk prediction and cost forecasting in healthcare (Singh, 2022)
• Does Variation in the Nursing Home Inspection Process Explain Disparity in Regulatory Outcomes? (Fox, 2020)

Looking at these titles, you can probably pick up that the research topics here are quite specific and narrowly-focused , compared to the generic ones presented earlier. This is an important thing to keep in mind as you develop your own research topic. That is to say, to create a top-notch research topic, you must be precise and target a specific context with specific variables of interest . In other words, you need to identify a clear, well-justified research gap.

Need more help?

If you’re still feeling a bit unsure about how to find a research topic for your healthcare dissertation or thesis, check out Topic Kickstarter service below.

You Might Also Like:

15 Comments

I need topics that will match the Msc program am running in healthcare research please

Hello Mabel,

I can help you with a good topic, kindly provide your email let’s have a good discussion on this.

Can you provide some research topics and ideas on Immunology?

Thank you to create new knowledge on research problem verse research topic

Help on problem statement on teen pregnancy

This post might be useful: https://gradcoach.com/research-problem-statement/

can you provide me with a research topic on healthcare related topics to a qqi level 5 student

Please can someone help me with research topics in public health ?

Hello I have requirement of Health related latest research issue/topics for my social media speeches. If possible pls share health issues , diagnosis, treatment.

I would like a topic thought around first-line support for Gender-Based Violence for survivors or one related to prevention of Gender-Based Violence

Please can I be helped with a master’s research topic in either chemical pathology or hematology or immunology? thanks

Can u please provide me with a research topic on occupational health and safety at the health sector

Good day kindly help provide me with Ph.D. Public health topics on Reproductive and Maternal Health, interventional studies on Health Education

may you assist me with a good easy healthcare administration study topic

May you assist me in finding a research topic on nutrition,physical activity and obesity. On the impact on children

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The University of Washington Health Systems and Population Health Master of Science (HSPop M.S.) program is part of the UW School of Public Health, which consistently ranks among the best in the United States . Our curriculum is exceptional in the strength of our required and elective courses, including program evaluation, biostatistics, epidemiology, and health economics.

Our HSPop M.S. degree offers a combination of advanced methods training and the flexibility to customize elective courses to the student’s interest area. The flexibility includes the option to pursue electives across other departments and schools at the University of Washington.

The Master of Science program is an in-residence, two-year graduate degree program for full-time students that offers analytical and practical knowledge and skills in health services research methods. Our students generally have some experience in health fields and want greater responsibility in improving the public’s health and the effectiveness of health care and population health services.

There are two options for students in the program, either a general M.S. degree with a focus on research methods or a concentration in clinical and translational research.

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Stop COVID Cohort: An Observational Study of 3480 Patients Admitted to the Sechenov University Hospital Network in Moscow City for Suspected Coronavirus Disease 2019 (COVID-19) Infection

Collaborators.

• Sechenov StopCOVID Research Team : Anna Berbenyuk ,  Polina Bobkova ,  Semyon Bordyugov ,  Aleksandra Borisenko ,  Ekaterina Bugaiskaya ,  Olesya Druzhkova ,  Dmitry Eliseev ,  Yasmin El-Taravi ,  Natalia Gorbova ,  Elizaveta Gribaleva ,  Rina Grigoryan ,  Shabnam Ibragimova ,  Khadizhat Kabieva ,  Alena Khrapkova ,  Natalia Kogut ,  Karina Kovygina ,  Margaret Kvaratskheliya ,  Maria Lobova ,  Anna Lunicheva ,  Anastasia Maystrenko ,  Daria Nikolaeva ,  Anna Pavlenko ,  Olga Perekosova ,  Olga Romanova ,  Olga Sokova ,  Veronika Solovieva ,  Olga Spasskaya ,  Ekaterina Spiridonova ,  Olga Sukhodolskaya ,  Shakir Suleimanov ,  Nailya Urmantaeva ,  Olga Usalka ,  Margarita Zaikina ,  Anastasia Zorina ,  Nadezhda Khitrina

Affiliations

• 1 Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 2 Inflammation, Repair, and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.
• 3 Soloviev Research and Clinical Center for Neuropsychiatry, Moscow, Russia.
• 4 School of Physics, Astronomy, and Mathematics, University of Hertfordshire, Hatfield, United Kingdom.
• 5 Biobank, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 6 Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 7 Chemistry Department, Lomonosov Moscow State University, Moscow, Russia.
• 8 Department of Polymers and Composites, N. N. Semenov Institute of Chemical Physics, Moscow, Russia.
• 9 Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy.
• 10 Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany.
• 11 Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 12 Department of Intensive Care, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 13 Clinic of Pulmonology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 14 Department of Internal Medicine No. 1, Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 15 Department of Forensic Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 16 Department of Statistics, University of Oxford, Oxford, United Kingdom.
• 17 Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
• 18 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
• 19 Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
• 20 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• PMID: 33035307
• PMCID: PMC7665333
• DOI: 10.1093/cid/ciaa1535

Background: The epidemiology, clinical course, and outcomes of patients with coronavirus disease 2019 (COVID-19) in the Russian population are unknown. Information on the differences between laboratory-confirmed and clinically diagnosed COVID-19 in real-life settings is lacking.

Methods: We extracted data from the medical records of adult patients who were consecutively admitted for suspected COVID-19 infection in Moscow between 8 April and 28 May 2020.

Results: Of the 4261 patients hospitalized for suspected COVID-19, outcomes were available for 3480 patients (median age, 56 years; interquartile range, 45-66). The most common comorbidities were hypertension, obesity, chronic cardiovascular disease, and diabetes. Half of the patients (n = 1728) had a positive reverse transcriptase-polymerase chain reaction (RT-PCR), while 1748 had a negative RT-PCR but had clinical symptoms and characteristic computed tomography signs suggestive of COVID-19. No significant differences in frequency of symptoms, laboratory test results, and risk factors for in-hospital mortality were found between those exclusively clinically diagnosed or with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR. In a multivariable logistic regression model the following were associated with in-hospital mortality: older age (per 1-year increase; odds ratio, 1.05; 95% confidence interval, 1.03-1.06), male sex (1.71; 1.24-2.37), chronic kidney disease (2.99; 1.89-4.64), diabetes (2.1; 1.46-2.99), chronic cardiovascular disease (1.78; 1.24-2.57), and dementia (2.73; 1.34-5.47).

Conclusions: Age, male sex, and chronic comorbidities were risk factors for in-hospital mortality. The combination of clinical features was sufficient to diagnose COVID-19 infection, indicating that laboratory testing is not critical in real-life clinical practice.

Keywords: COVID-19; Russia; SARS-CoV-2; cohort; mortality risk factors.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected].

Publication types

• Observational Study
• Research Support, Non-U.S. Gov't
• Hospitalization
• Middle Aged

Grants and funding

• 20-04-60063/Russian Foundation for Basic Research