A Systemic Approach to Address Population Health, with a Focus on Underserved Communities
Main Article Content
Mohan R. Tanniru, PhD
http://orcid.org/0000-0002-9584-0090
http://orcid.org/0000-0002-9584-0090
Abstract
Background: Hospitals and public health agencies are increasingly asked to improve the health outcomes of underserved populations by addressing social determinants of health and long-term health goals, including those with chronic care conditions. There have been calls for systemic action and cross-sector collaboration to support these goals.
Methods: The paper uses research on service-dominant logic, inter-organizational dynamic capabilities (IDC), and social diagnosis to propose a four-step methodology: structuring the patient care journey into patient value networks, defining community model (CM) capabilities to support inter-sector collaboration, modeling the patient journey to understand challenges and competencies of patient populations, structuring a "meta-community model" (meta-CM) network to support patient transitions to address their long-term health goals. The methodology is illustrated using three use cases of underserved populations.
Results: The paper illustrates the use of a three-level strategy (micro-, meso- and macro-level) to operationalize healthcare transformation using cross-sector collaboration to help patients reach their long-term goals. It highlights specific areas for future research and discusses the implication of how organizational leadership can build agility to their community strategy in a constantly evolving patient and technology environment.
Conclusions: The methodology proposed and illustrated using three different case scenarios highlights the need for community model actors to deepen their understanding of the life experiences of patient populations with both challenges and competencies and broaden their strategies using both a social and technology platform.
Article Details
How to Cite
TANNIRU, Mohan R..
A Systemic Approach to Address Population Health, with a Focus on Underserved Communities.
Medical Research Archives, [S.l.], v. 14, n. 6, july 2026.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/7624>. Date accessed: 10 july 2026.
doi: https://doi.org/10.18103/mra.v14i6.7624.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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30. Gaviano L, Pili R, Petretto AD, Berti R, Carrogu GP, Pinna M, et al. (2024) Definitions of ageing according to the perspective of the psychology of ageing: A scoping review. Geriatrics; 9: 107.
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32. Elder GH, Shanahan MJ, Jennings JA. (2015) Human development in time and place. In: Handbook of child psychology and developmental science: Ecological settings and processes in developmental systems. Hoboken, NJ: John Wiley & Sons, Inc. pp. 6-54.
33. Chapin RK. (2017) Social policy for effective practice: A strengths approach. 4th ed. New York, NY: Routledge.
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38. Tanniru, M. and M. Martz (2026a) Reenvisioning Population Health using Surgical Lens, Vol. 9, No.2, Kosovo Journal of Surgery, 2026
39. Dawson, A., M. Hirt, J. Scanlan (2016) The economic essentials of digital strategy, McKinsey Quarterly, March
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41. Uhl-Bien, M., M. Arena (2018) Leadership for organizational adaptability: A theoretical synthesis and integrative framework, The Leadership Quarterly, Volume 29, Issue 1, 2018, Pages 89-104.
42. Tanniru M. and M. Martz (2020), An Analysis of Health Intermediary and a Proposal to Sustain Public-Private Partnership- The Case of the Arizona Smokers’ Helpline (ASHLine) in Theory and Practice of Business Intelligence in Healthcare, Khuntia J, Ning X, Tanniru M (editors), Edition, IGI Global, Hershey, PA, USA, 185-199.
43. Tanniru, M. and S. Kazziha (2025) Digital Leadership and Strategies to Transform Post-Surgical Transition of Care (TOC), Kosovo Journal of Surgery, Vol.9, No.1, June. https://kosovajournalofsurgery.net/kosova-journal-of-surgery-volume-9-issue-1-2/
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47. Akofio-Sowah, L., Agbavitoh, J.K., Oppong, S., Owusu, P.G., & Sakyi, K.S. (2023). Building Organizational Capacity Using Partners and Technology to Support Caregivers of Children with Disabilities. e-Service Journal 15(2), 92-112. https://dx.doi.org/10.2979/esj.00007
48. Tanniru M, Sokan A. (2025) Transforming Community Strategy from Population Health to Quality Aging — The Role of Digital Technologies. OBM Geriatrics 2025; 9(3): 321; https://www.lidsen.com/journals/geriatrics/geriatrics-09-03-321
49. Horvat A., J. Filipovic (2018) Service quality and maturity of health care organizations through the lens of Complexity Leadership Theory. J Eval Clin Pract., Feb;24(1):301-307
50. Khine, P.K., J. Mi, R. Shahid (2021) A Comparative Analysis of Co-Production in Public Services. Sustainability 2021, 13, 6730.
51. Amakobe, D.M., E. Kansiime, D.M. Uwayo (2021) Employing decentralized blockchain technology to centralize Africa’s health systems. Academia Letters, Article 2264
52. Ray, R., Lantz, P. M., & Williams, D. (2023). Upstream policy changes to improve population health and health equity: a priority agenda. The Milbank Quarterly, 101(Suppl 1),
2. Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of health and social behavior, 80-94.
3. Frank, J. W. (1995). Why" population health”? Canadian Journal of Public Health, 86(3), 162-164.
4. Braveman, P. A., Egerter, S. A., Woolf, S. H., & Marks, J. S. (2011). When do we know enough to recommend action on the social determinants of health? American journal of preventive medicine, 40(1), S58-S66.
5. Kreuter, M., & Lezin, N. (2001). Improving everyone’s quality of life: a primer on population health. Seattle: Group Health Community Foundation.
6. Galea, S., & Vaughan, R. (2021) Embedding prevention at the heart of the US health conversation. American Journal of Public Health, 111(1), 17-19.
7. DeSalvo, K. B., O’Carroll, P. W., Koo, D., Auerbach, J. M., & Monroe, J. A. (2016). Public health 3.0: time for an upgrade. American journal of public health, 106(4), 621.
8. Vargo, S. L., & Lusch, R. F. (2008). Why “service”? Journal of the Academy of marketing Science, 36(1), 25-38.
9. Lusch, R. F., & Nambisan, S. (2015). Service innovation. MIS quarterly, 39(1), 155-176.
10. Plum, A., M. Tanniru and J. Khuntia (2020) An Innovation Platform for Diffusing Public Health Practices across a Global Network, Health Policy and Technology, Feb, https://doi.org/10.1016/j.hlpt.2020.02.008
11. Saini, V., M. Tanniru, TP Liang, E. Yoder, Y. Yang (2022) E-Relationship Through a Value Lens—Implications for Organizational Capability, e-Service Journal, Volume 14, Number 1, Fall, pp. 1-31
12. Soto S, Cordova RV, Khambekar P (2023) Leadership of mobile health units for preventative health-using networks and distributed digital platform. e-Service J. 15: 46-71.
13. St Joseph Care Group, https://sjcg.net/
14. NorWest Community Health Centers, https://norwestchc.org/programs-services/mobile-services/
15. Dilico, https://www.dilico.com/
16. MisinfoRx https://misinforx.com/about/
17. Finkelman EM, McGinnis JM, McClellan MB, et al. (2017) editors. Vital Directions for Health & Health Care: An Initiative of the National Academy of Medicine. Washington (DC): National Academies Press (US); 14, The Democratization of Health Care, Available from: https://www.ncbi.nlm.nih.gov/books/NBK595179/
18. Harfield, S, C. Davy, E. Kite, A. McArthur, Z. Munn, N. Brown (2018) A. Characteristics of Indigenous primary health care models of service delivery: a scoping review protocol. JBI Database System Rev Implement Rep., Nov;13(11):43-51.
19. Tanniru, M. (2023) Digital Leadership and Community Strategies to Transform Population Health, Research Handbook on Leadership in Healthcare, editors: Naomi Chambers, 2023. Edward Elgar Publishing, publisher.
20. Pucher, K.K, MJJM. Candel, A. Krumeich, NMWM. Boot, N.K. de Vries (2015) Effectiveness of a systematic approach to promote intersectoral collaboration in comprehensive school health promotion-a multiple-case study using quantitative and qualitative data, BMC Public Health, 15:613
21. Teece, D. (2007) Explicating dynamic capabilities: The nature and microfoundations of (sustainable) enterprise performance. Strategic Management Journal, 28(13), 1319–1350. https://doi.org/10.1002/smj.640
22. Sandberg, E., D. Kindström, L. Haag (2021) Delineating inter-organizational dynamic capabilities: A literature review and a conceptual framework, Journal of Inter-Organizational Relationships, DOI: 10.1080/26943980.2021.1939224
23. Bobryk D, Collins E, Tanniru M. (2024) Implementing Digital Solutions for Improved Healthcare Delivery. In: Wickramasinghe N. editor. Impact of Digital Solutions for Improved Healthcare Delivery. Hershey, PA, USA: IGI Global
24. Tanniru, M. and C. Fedel, (2026b) Patient Value Networks as Inter-Organizational Models to Transform Population Health, Forthcoming in Journal of Hospital Management and Health Policy
25. Håkansson, H., & Ford, D. (2002). How should companies interact in business networks? Journal of business research, 55(2), 133-139.
26. Haug, C. (2013) Organizing spaces: Meeting arenas as a social movement infrastructure between organization, network, and institution. Organization Studies, 34, 705–732
27. Nadler, D. A., and M. Tushman (1999) The Organization of the Future: Strategic Imperatives and Core Competencies for the 21st Century, Organizational Dynamics, vol. 27, no. 1, July, p. 45.
28. Aminzade, M., (2018) Confidentiality, integrity, and availability – finding a balanced IT framework, Network Security, Volume Issue 5, Pages 9-11, ISSN 1353-4858
29. Doremus, B.L. (1976) The Four R’s: Social Diagnosis in Health Care, Health and Social Work, Vol. 1, No.4., pp: 120-139
30. Gaviano L, Pili R, Petretto AD, Berti R, Carrogu GP, Pinna M, et al. (2024) Definitions of ageing according to the perspective of the psychology of ageing: A scoping review. Geriatrics; 9: 107.
31. World Health Organization. Social determinants of health (2025) [Internet]. Geneva, Switzerland: World Health Organization; Available from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
32. Elder GH, Shanahan MJ, Jennings JA. (2015) Human development in time and place. In: Handbook of child psychology and developmental science: Ecological settings and processes in developmental systems. Hoboken, NJ: John Wiley & Sons, Inc. pp. 6-54.
33. Chapin RK. (2017) Social policy for effective practice: A strengths approach. 4th ed. New York, NY: Routledge.
34. Beedie CJ, Lane AM, Udberg R, Terry PC (2022) The 4R model of mood and emotion for sustainable mental health in organisational settings. Sustainability. 14: 11670.
35. McLaughlin J (2005) Exploring diagnostic processes: Social science perspectives. Arch Dis Child, 90: 284-287.
36. Robbins S, Chatterjee P, Canda E, Leibowitz G. (2019) Contemporary human behavior theory: A critical perspective for social work. 4th ed. New York, NY: Pearson.
37. Sloan-Aagard C, Helgesen W, Nañez J, Law J, Currey JC, Meils J, Bishop J, Hartmann E. (2022) The value of community-integrated health information exchanges: three recent examples from El Paso, Texas. J Am Med Inform Assoc. 2022 Nov 14;29(12):2201-2205.
38. Tanniru, M. and M. Martz (2026a) Reenvisioning Population Health using Surgical Lens, Vol. 9, No.2, Kosovo Journal of Surgery, 2026
39. Dawson, A., M. Hirt, J. Scanlan (2016) The economic essentials of digital strategy, McKinsey Quarterly, March
40. Nambisan, S., K. Lyytinen, A. Majchrzak, M. Song (2017) Digital Innovation Management: Reinventing Innovation Management Research in a Digital World, MIS Quarterly, (41: 1) pp.223-238.
41. Uhl-Bien, M., M. Arena (2018) Leadership for organizational adaptability: A theoretical synthesis and integrative framework, The Leadership Quarterly, Volume 29, Issue 1, 2018, Pages 89-104.
42. Tanniru M. and M. Martz (2020), An Analysis of Health Intermediary and a Proposal to Sustain Public-Private Partnership- The Case of the Arizona Smokers’ Helpline (ASHLine) in Theory and Practice of Business Intelligence in Healthcare, Khuntia J, Ning X, Tanniru M (editors), Edition, IGI Global, Hershey, PA, USA, 185-199.
43. Tanniru, M. and S. Kazziha (2025) Digital Leadership and Strategies to Transform Post-Surgical Transition of Care (TOC), Kosovo Journal of Surgery, Vol.9, No.1, June. https://kosovajournalofsurgery.net/kosova-journal-of-surgery-volume-9-issue-1-2/
44. Deng, Xiadong; Khuntia, Jiban; and Ghosh, Kaushik (2013) Psychological Empowerment of Patients with Chronic Diseases: The Role of Digital Integration" (2013). ICIS Proceedings. 4. https://aisel.aisnet.org/icis2013/proceedings/HealthcareIS/4
45. Find Help, FindHelp.org
46. Ruprecht, M.T., Kaljee, L., Zervos, J., Gleason, J., Lorenz-Goings, K., & Ashlock, G. (2023). Engaging Caregivers through mHealth to Support Chronic Care Patients. e-Service Journal 15(2), 72-91. https://dx.doi.org/10.2979/esj.00006.
47. Akofio-Sowah, L., Agbavitoh, J.K., Oppong, S., Owusu, P.G., & Sakyi, K.S. (2023). Building Organizational Capacity Using Partners and Technology to Support Caregivers of Children with Disabilities. e-Service Journal 15(2), 92-112. https://dx.doi.org/10.2979/esj.00007
48. Tanniru M, Sokan A. (2025) Transforming Community Strategy from Population Health to Quality Aging — The Role of Digital Technologies. OBM Geriatrics 2025; 9(3): 321; https://www.lidsen.com/journals/geriatrics/geriatrics-09-03-321
49. Horvat A., J. Filipovic (2018) Service quality and maturity of health care organizations through the lens of Complexity Leadership Theory. J Eval Clin Pract., Feb;24(1):301-307
50. Khine, P.K., J. Mi, R. Shahid (2021) A Comparative Analysis of Co-Production in Public Services. Sustainability 2021, 13, 6730.
51. Amakobe, D.M., E. Kansiime, D.M. Uwayo (2021) Employing decentralized blockchain technology to centralize Africa’s health systems. Academia Letters, Article 2264
52. Ray, R., Lantz, P. M., & Williams, D. (2023). Upstream policy changes to improve population health and health equity: a priority agenda. The Milbank Quarterly, 101(Suppl 1),