CARRFS eNews June 2013

CARRFS eNews Volume 3, Issue 3, June 2013

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Canadian Alliance for Regional Risk Factor Surveillance - Quarterly eNewsletter

CARRFS Feature WHO’s Global Action Plan

for Noncommunicable Diseases 2013-2020.

CARRFS eNews talked with

WHO Coordinator Dr. Tim Armstrong

in Geneva.

CARRFS InterviewDr. Cory Neudorf,

Chief Medical Officer of Health, Saskatoon

Health Region, Saskatchewan.

CARRFS ProfileMs. Cristina Ugolini,

Manager, Public Health Observatory,

Saskatoon Health Region, Saskatchewan.


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WHO’s Action Plan for NCDs 2013-20204 The World Health Organization (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 was endorsed in May. By PAUL C. WEBSTER

IUHPE: NCDs and Health Development 8 Ms. Marie-Claude Lamarre, Executive Director for the International Union for Health Promotion and Education, Paris describes the interests in an NCD agenda built on social determinants of health. By JOSTEIN ALGROY

CARRFS Interview 10 Dr. Cory Neudorf, Saskatoon Health Region, Saskatchewan describes how they use surveillance at neighbourhood levels to drive the policy and program making in the health region. By JOSTEIN ALGROY

Surveillance Facts 13 Dr. Bernard Choi, Public Health Agency of Canada outlines Part III of his series about the Past, Present and Future of Public Health Surveillance. By BERNARD CHOI

CARRFS Profile 16 The CARRFS Member Profile in this issue of the CARRFS eNews is with Ms. Cristina Ugolini, Manager, Public Health Observatory, Saskatoon Health Region, Saskatchewan. By JOSTEIN ALGROY

Table of ContentsFrom the Editor ................................................................................. page 3WHO’s Action Plan for NCDs 2013-2020 ....................... page 4Columbia: NCDs in a developing country ......................... page 8IUHPE: NCDs and health development .............................. page 9CARRFS Interview: Dr. Cory Neudorf ................................. page 11Surveillance Facts .............................................................................. page 14Chair’s Message .................................................................................. page 16CARRFS Member Profile ............................................................. page 17Updates from Working Groups ................................................ page 19Events - WARFS ................................................................................. page 20Website Accessibility ....................................................................... page 21Hello & Goodbye ............................................................................. page 22

CONTRIBUTORS

Mr. Jostein Algroy, Editor in ChiefMr. Paul C. Webster, Senior WriterDr. Bernard Choi, Science WriterMs. Mary Lou Decou, Senior WriterMs. Brenda Branchard, Senior WriterMs. Ahalya Mahendra, CARRFS Working Group ChairDr. Gail Butt, Chair, CARRFS

PAN-CANADIAN EDITORIAL ADVISORY BOARD

Mr. Jostein Algroy, Editor in ChiefMr. Paul C. Webster, Health Science WriterMs. Mary Lou Decou, Epidemiologist, Public Health Agency of CanadaDr. Bernard Choi, Senior Research Scientist, Public Health Agency of CanadaDr. Elizabeth Rael, Senior Epidemiologist, Ontario Ministry of Health and Long-Term CareMr. Larry Svenson, Director, Alberta Ministry of HealthDr. Drona Rasali, Director, British Columbia Provincial Health Services Authority

More members to be added to the Board later.

SECRETARIAT SUPPORT

Public Health Agency of CanadaMs. Mary Lou Decou

PUBLICATION DATES

CARRFS eNews is a Quarterly Newsletter for the Canadian Alliance for Regional Risk Factor Surveillance (CARRFS) and is published in the months of March; June; September; and December.

Disclaimer: CARRFS is a pan-Canadian network of public stakeholders across Canada working together to enhance the capacity of Regional Risk Factor Surveillance in Canada. CARRFS is supported by the Public Health Agency of Canada (PHAC). The content in the CARRFS eNews does not necessary reflect the official view of PHAC, Health Canada, the Government of Canada or the employer of its contributors.

CARRFS WEBSITE URL: WWW.CARRFS.ORG

CONTENTS in this Issue...

http://WWW.CARRFS.ORG

http://WWW.CARRFS.ORG


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From the EditorCARRFS Quarterly Newsletter has a new face and a new name: CARRFS eNews. As CARRFS eNews evolves, we’re committed to refining and updating to deliver better insights into the Canadian risk factor surveillance community.

We’re excited to present you with a new version of the newsletter. New visuals. New front page. New name: CARRFS eNews. All to better serve our readers and the community. In this issue, the cover story looks at the World

Health Organization (WHO) Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCD) 2013-2020. This was endorsed at the Sixty-Sixth World Health Assembly in May. It’s big news for the CARRFS community as the WHO decisions about NCD indicators and targets will impact the national agenda for chronic disease risk factor surveillance and trickle down to the regional/local level across the country. CARRFS eNews visited the WHO in Geneva to discuss the NCD Action Plan with Dr. Timothy Armstrong, Coordinator, Surveillance and Population-based Prevention, Department for the Prevention of NCDs. The WHO cover story and associated story are written by the CARRFS eNews Senior Writer, Paul Webster, who covered the 2011 United Nations General Assembly on the NCDs for the Canadian Medical Association Journal. To better understand how this could play out locally and regionally, CARRFS eNews includes an interview with Dr. Cory Neudorf, Chief Medical Officer for the Saskatoon Health Region, in which he describes how Saskatoon has improved the health surveillance at the local level - hence better prepared for future intervention. In the interview, Dr. Neudorf addresses how important it was to incorporate the social determinants of health - the real “causes of the causes”. This groundbreaking work gave Dr. Neudorf and Saskatoon a significant national profile. By focusing on neighbourhoods in Saskatoon, Dr. Neudorf and his team pinpointed information on health conditions needed to design the right interventions - either through widely or locally-targeted interventions. Poverty, says Neudorf, is the single most important issue to tackle in reducing health inequities and health system costs.

Neudorf is convinced that the future of the profession of epidemiology is bright. But he predicts big changes. Epidemiologists need to go beyond simple descriptive analyses and use more complex methods, Neudorf argues: They need to be brave enough to make recommendations for change. In upcoming issues of the CARRFS eNews we will cover more topics that are highly relevant for the CARRFS community. Enjoy the new issue of the CARRFS eNews and stay tuned for the upcoming issue in September.

Jostein AlgroyEditor in Chief

Volunteers to CARRFS eNews

CARRFS eNews needs volunteers to help with specific sections of the newsletter. We need reviewers who are willing to review “Epi” reports and share the information with the network. We are looking for a person who can write up a few blurbs about the news & trends that are taking place in the “Epi” community - nationally and internationally. And we are looking for a copy editor who, with fresh eyes, can go through the text and eliminate the errors that the rest of us have not spotted. If you are interested please contact [email protected].

Send us your Story

We urge all members of CARRFS to send us articles and ideas for upcoming issues. Please submit your story to [email protected].

mailto:[email protected]





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WHO’s Global Action Plan for Noncommunicable Diseases 2013-2020.

CARRFS eNews talked with the Coordinator

Dr. Tim Armstrong in Geneva.

CARRFS Feature...


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WHO: Global Action Plan 2013-2020 for Prevention of Noncommunicable DiseasesMedical journalist Paul C. Webster analyzes the implications of the WHO’s 2013-2020 NCDs Global Action Plan

It was September 2011 and world leaders were at the UN headquarter in New York to confront a vast global health problem. The issue was chronic diseases such as cancer, diabetes, and cardiovascular and respiratory diseases. According to the UN, these non-communicable diseases (NCDs) are associated with 36 million deaths annually. And 80% of these deaths occur in developing nations with limited resources to prevent them, United Nations Secretary General Ban Ki-moon bluntly warned an audience of hundreds of heads of state and senior government leaders, including Canadian Health Minister Leona Aglukkaq. “The prognosis is grim,” Ki-moon continued. Worldwide deaths from NCDs are expected to increase by 17% over the next decade, and by 24% in Africa. As a result of a global shift toward the consumption of processed foods rich in salt, sugars and trans fats, Ki-moon explained, the incidence of NCDs in poor countries is now disproportionately higher than in rich ones. Global obesity levels have doubled since 1980, he added. “This is a slow-motion disaster spreading with stunning speed and sweep,” Ki-moon warned. Noting that the most common NCDs can be largely prevented or controlled by tackling shared risk factors including tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol, as well as through early detection and treatment, Ki-moon had some blame to place: “There is a well-documented and shameful history of certain players in industry who ignored the science — sometimes even their own research — and put public health at risk to protect their own profits,” Ki-moon said before urging “corporations that profit from selling processed foods to act with the utmost integrity.” Spurred on by Ki-moon’s warnings at the 2011 summit, UN member states unanimously voted to task the World Health Organization with expanding global NCD surveillance and developing a set of global targets before the end of 2012 to monitor trends and progress in the battle to reduce NCDs.The WHO followed-up swiftly: In November 2012, it produced a Global Monitoring Framework including 25 indicators and a set of 9 voluntary global targets for prevention and control of NCDs -- including the goal of a 25% relative reduction in overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2025 -- that was approved by 119 member states, the European Union and 17 NGOs. Then, in late May of this year, the WHO’s Global Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 was approved by the World Health Assembly. In September, the Plan will be reported back to the UN General Assembly. Much of the credit for the WHO’s rapid progress in mobilizing global efforts to tackle the rising tsunami of chronic diseases goes to Dr. Tim Armstrong, a soft-spoken Australian who serves as Coordinator for Surveillance and Population-based Prevention in the WHO’s Department for the Prevention of NCDs in Geneva, Switzerland. >>CA

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CARRFS Feature... In a recent interview in Geneva, Armstrong described the WHO’s Global Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020 as an achievement in global health diplomacy that attempts to be of equal utility to all UN member states – rich or poor. It’s a discussion in which money matters loom large, Armstrong notes: according to WHO estimates, the average yearly cost to implement a core set of high-impact NCD prevention treatment interventions for all low- and middle-income countries would be $11.4 billion, while the economic impact of NCDs in these countries is an estimated $500 billion. Over the period 2011-2025, the cumulative lost output in low- and middle-income countries due to NCDs is projected to be $7.28 trillion. But because the WHO is not a funding agency, Armstrong stressed, it will have to raise money to help poor countries – especially those with huge populations and high NCD burdens such as Bangladesh, Indonesia, India and Nigeria – invest in health and social reforms and NCD surveillance tools. “We need support from donors. We are requesting that countries that have the capacity invest in helping those that do not.”

Money isn’t the only thing that is scarce, Armstrong stresses. The WHO process also depends on data, he emphasised – much of it of a sort that simply doesn’t exist in many countries. “What gets measured gets done,” he quipped. But measuring many of the risk factors for NCDs is difficult, he explained, because many are external to healthcare – things like athletics, urban design, transportation, and the amount of time people spend watching television. “The availability of data on a range of NCD outcomes and risk factors and capacities is quite limited. And there are many

high income countries where we don’t have good data whereas in middle income countries where we have been able to get in and do surveys we may have better data.” In Ottawa, Blossom Leung, a spokeswoman for Health Canada, says “Canada intends to work closely with the WHO on a global mechanism to coordinate NCD

action and to share innovative and effective practices.” Canada will also be actively participating in concurrent consultations by the WHO on its engagement with NGOs and business interests, Leung added. >>

“We need support from donors. We are requesting that

countries that have the capacity invest in helping

those that do not.”


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CARRFS Feature (cont’d) As Armstrong acutely knows, the WHO Plan will both please and disappoint many expert observers. Vivian Lin, Chair of Public Health at La Trobe University in Melbourne, Australia, says the WHO’s effort inevitably resulted in a verybroad accommodation of interests and issues – including the business interests of food and beverage and pharmaceutical companies -- that doesn’t “deal with the hard things that have to be done.” She describes the NCD Plan as “workmanlike” compared to earlier WHO global plans such as its “visionary” 1978 Alma Ata declaration on the universal need for access to primary healthcare. And she notes that the WHO’s International Code of Marketing of Breast-Milk Substitutes and Framework Convention on Tobacco Control were much more strident in identifying and confronting industries associated with NCDs. David McQueen, who served as Associate Director for Global Health Promotion at the Centers for Disease Control in Atlanta, U.S.A. until 2011, feels the NCD Plan suffers from a lack of direct guidance on how to achieve NCD control. “It’s not really an action plan,” he worries “it’s a set of guidelines.” He also thinks the WHO’s approach to

NCD surveillance is outdated and overlooks new approaches that include social determinants of health. But he describes the Plan as “impressive” nonetheless. Suzanne Jackson, professor of global health and head of the WHO Collaborating Centre in Health Promotion at the University of Toronto thinks the indicators and targets in the Plan are well chosen. Her main critique is that the WHO has prioritized the need for individuals to change their lifestyles over the need for more sweeping societal changes that will curb NCD risk factors. The biggest drivers of all – trade in food and beverages and drugs, and environmental hazards like air pollution and toxins – are barely hinted at, she notes. For the WHO to succeed reducing the NCDs, Jackson, McQueen, Lin and Armstrong all agree, countries and corporations are going to have to get behind its Plan. But that may not lead to big changes. “They’ve got a set of policy options for member states that are pretty high level,” says Jackson and adds: “But many people may say there’s not a lot here to get people to actually do it.” <>

9 voluntary global NCD targets for 20259 voluntary global NCD targets for 20259 voluntary global NCD targets for 2025

AREA TARGET GOALMortality and Morbidity Premature mortality from NCDs 25% reduction

National Systems ResponseEssential NCD medicines and technologies 80% coverage

National Systems ResponseDrug therapy and counseling 50% coverage

Risk Factors for NCDs

Salt/sodium intake 30% reduction


Tobacco use 30% reduction

Risk Factors for NCDsRaised blood pressure 25% reduction

Risk Factors for NCDsHarmful use of alcohol 10% reduction


Physical inactivity 10% reduction


Diabetes/obesity 0% reduction

Source: World Health Organization


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NCDs in a developing country

With few financial resources, Columbia is using innovative solutions to meet the WHO’s Global Action Plan. Paul C. Webster visited the country and explains the challenges. As many developing countries are discovering, the wave of chronic and noncommunicable diseases that stem from conditions like obesity is posing major challenges for their health care systems. Yet while WHO and other global mandarins mull the options, health care systems like that of Colombia are left to seek on-the-ground solutions. In a country often defined by poverty and war, where it’s been estimated that at least 10% of the population are undernourished, obesity might seem to be a marginal problem. But in 2010, a national nutrition survey indicated that over a five-year period, there had been a 10% increase in the number of overweight and obese Colombians, including children. Some 25% of children aged 5–17 had excess body mass. In some parts of the country, that tally was as high as 31%, roughly equivalent to childhood obesity rates in the United States, which have been labelled epidemic. Precise numbers on chronic disease levels in Colombia are difficult to obtain. But the Center of Development Projects at Pontificia Universidad Javeriana in Bogotá, the Colombian capital, estimates that the total burden of chronic disease increased 40% between 1995 and 2005. Eight of the 10 leading causes of mortality in Colombia are chronic or noncommunicable diseases, according to the Mission of Colombia to the United Nations. In 2002, noncommunicable diseases accounted for 68.1% of 243,747 deaths in Colombia, according to the Pan American Health Organization. Cardiovascular disease was the leading contributor, with age standardized mortality ratio of 239 per 100,000, followed by malignant neoplasms (116 per 100,000), chronic respiratory diseases (54 per 100,000) and diabetes (32 per 100,000). “It’s a problem that Colombia has to tackle immediately,” says Dr. Luis Fernando Gomez, professor of pathology at the Faculty of Medicine at Pontificia Universidad Javeriana in Bogotá. “The biggest change is what is happening to children: We can’t wait until we have problems on the scale of the U.S.A. and Canada. Obesity was at first

concentrated among the wealthiest but we are now on the path where it is also affecting the poorest.” “A reduction in cholesterol levels, blood pressure and obesity is a priority to control the ongoing epidemic of cardiovascular diseases,” which has been estimated to be the cause of 40% of deaths in Colombia, concurs Dr. Leon Bautista, assistant professor of population health services at

the University of Wisconsin in Madison. Gomez and a consortium of nutritionists pressed the government of Colombia into passing an “anti-obesity law” in 2009 that promotes mass physical exercise and regulates school nutrition and food and beverage marketing. But in the face of resistance from the processed food industry, implementation has been an obstacle, Gomez says. “Although the government passed a very progressive law on this issue, it continues to view health promotion mostly as a matter of personal lifestyle choice. That lets them wash their hands of taking further action.” As evidence of government inaction, Gomez cites the gradual whittling of road space allocated to Bogotá’s famous “Ciclovia” program, which closes major

streets in this city of nine million on Sundays to promote walking and biking. Between 1990 and 2002, the city invested $180 million to create 291 kilometres of dedicated bicycle paths and by 2003, the number of trips made by bicycles, as opposed to other forms of transportation, had increased to 4.4% from 0.058%. Some 38 cities in 11 countries have followed Bogota’s lead and a study found that the benefits of Ciclovia programs outweigh the costs (J Urban Health 2011 Dec 15 [Epub ahead of print]). But with automobile ownership exploding in Bogotá, the program was reduced. It’s a retreat that flies in the face of public health, Gomez argues. “As the cities of Colombia and elsewhere in the developing world increasingly mimic the car-oriented settlement patterns of first-world cities, the same kinds of chronic diseases and obesity problems associated with physical inactivity in the United States and other car-based societies will arise.” <>

“While WHO and other global

mandarins mull the options, health care systems like that of Colombia are left to seek on-the-ground

solutions. “


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What is it that IUHPE does?As a membership Organisation, the International Union for Health Promotion and Education (IUHPE) gathers people and institutions from all over the world, working in all the different areas that health promotion encompasses and through a variety of entry points to address and develop health: knowledge development and transferability, capacity building, partnership and alliance building, health promoting environments, social determinants of health, non-communicable diseases prevention and control, health impact assessment of public policies, and risk factor surveillance to cite current priorities. The IUHPE forms a Global network to strengthen dialogue and cooperation that works to meet critical needs for health development in all parts of the world and to contribute to the reduction of inequalities in health. Its programmes solicit the advice of peers to participate in an ongoing dialogue and reflection about public health and more specifically health promotion, and health education. It develops collaborations that lead to active research and practice networks in public health, as well as to contribute to the development of healthy public policy. The IUHPE was established in 1951 as the first international, independent, professional, non-governmental agency in health education by some of the same people who signed the charter for the foundation of the World Health Organization (WHO) and who recognised the practical value of health education, considered both from a social scientific point of view and with regard to the promotion of public health; and the need for an international informal forum to establish closer links between all health workers in the field of health education at that time and the promotion of mutual understanding to advance health for all. The foundation for our work is to view health as a human right that is created when individuals, families, and communities are afforded the income, education and power to control their lives; and their needs and rights are supported by systems, environments, and policies that are enabling and conducive to better health. >>

NCDs and Health DevelopmentThe International Union for Health Promotion and Education (IUHPE) is a worldwide independent, professional network of people and institutions committed to improve health and wellbeing. CARRFS eNews visited Paris to talk with the Executive Director, Ms. Marie-Claude Lamarre.


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IUHPE (cont’d)In order to support its mission, the IUHPE has a family of journals, global and regional conferences on health promotion, forums for discussion electronically or otherwise, specific global working groups on essential issues including competency and workforce development, health literacy, surveillance, social determinants of health, salutogenesis, health impact assessment, healthy settings, research, climate change and health, evidence of health promotion effectiveness and a broad range of partnership organizations at international and national levels, including the Public Health Agency of Canada and the Ministry of Health and Social Services of Quebec.

How can IUHPE provide support for chronic disease risk factor surveillance internationally, including the work of CARRFS?Much of IUHPE’s work concerns developing conceptual frameworks, tools, standards, guidelines to serve health professionals and practitioners across the world. Our niche is our technologic/scientific approach in terms of effectively building learning systems, developing tools and resources into a global, professional network to serve its members as well as the broader health promotion community. Our work in risk factor surveillance is no exception, and the IUHPE, through its Global Working Group on Surveillance WARFS – acronym for World Alliance for Risk Factor Surveillance - has produced a White Paper on Surveillance and Health Promotion to share with a larger audience the knowledge developed so far by WARFS and by its members; to state clearly what we mean by surveillance for health promotion and what it is for ; to provide a better understanding of the role of surveillance in health promotion; and to guide IUHPE members and others willing to participate in the development of effective surveillance systems.

Why does IUHPE support WARFS?The World Alliance for Risk Factor Surveillance (WARFS) is one of our global working groups, which in 2008 adopted the considerable work of an international network of surveillance practitioners and researchers that have met since 1999 to discuss theoretical and practical aspects of risk factors surveillance. This small but active group of renowned experts plays an important role of building tools and to promote the importance of behaviour risk factor surveillance with the purpose of monitoring and evaluating disease prevention and health promotion policies, services and interventions. Furthermore, the Working Group organizes the WARFS Global Conferences every two years (see announcement on page 20), which have been a valuable platform to exchange knowledge among surveillance experts from around the world and is an important mechanism to explore ways to enhance global capacity in risk factor surveillance, to identify

best practices to link risk factor surveillance to health promotion, and to reinforce the capacities in public health and health promotion globally - particularly in developing countries.

What is IUHPE’s response/reaction to the WHO’s draft on Global Action Plan for the Prevention and Control of Non-Communicable Diseases 2013-2020?As we all know, NCDs have become the first cause of mortality and morbidity throughout the world regardless of the level of economic development in individual countries. Thus NCDs and their causes are a global phenomena. It is common sense to see public health surveillance as an approach for all countries regardless of economic development and the level of the health system. In addition, in recent years, global efforts have brought the issues of social determinants of health and health inequities forward for integration into the global health agenda, as they closely relate to NCDs prevention and control. The social determinants of health cut across all sectors and only through embracing multi-sectoral, integrated approaches will we be able to effectively address the social determinants of health in a sustainable manner. However, surveillance has still to reflect, both theoretically and methodologically, on “how to” measure social determinants of health, even with current surveillance systems already offering some information on social determinants of health. Still, the focus on social determinants of health requires more information, particularly moving from the individual level to a social and contextual one. Aspects such as social capital, urbanization and urban development (sidewalks, cycling roads, etc.) should be in some way measured by or, more properly we believe, linked to surveillance systems. The IUHPE is particularly interested in the post-2015 development agenda that is founded upon human development with health and NCDs at the heart of the social development dimension. The recent outcome of the World Health Assembly with the adoption of the Omnibus resolution is encouraging because it highlights the need for integration of NCDs into global development processes; and focuses on multisectoral approaches to the prevention and control of NCDs. <>

By Jostein Algroy


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CARRFS Interview...

CARRFS eNews spoke with Dr.

Cory Neudorf, Medical Officer of Health, Saskatoon

Health Region, about Surveillance and Health Inequity.


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CARRFS Interview...Saskatoon Health Region has been widely credited for the 2008 report Health Disparity in Saskatoon - what was the main reason for this initiative?The background really started with some of the disease monitoring that was going on at that time where the province would put out a report indicating that Saskatoon Health Region had teen pregnancy, diabetes or other rates to be around the provincial average. As the Medical Officer of Health for the Saskatoon Health Region I knew that we had pockets with problems within our region that were large and yet being ignored in these reports. A report in 2006 looked at neighbourhood income combined with a variety of hospitalizations, mortality, physician visits and health status indicators. What we saw was that health disparity by income was a lot higher in various areas around Saskatoon for most of the indicators than what we had expected. And more importantly, it was across many different conditions. Our health board suggested that it was not enough for us to report on this but to give examples of how the health system as well as other sectors of influence on health determinants can respond to improving health equity. So the 2008 Health Disparity in Saskatoon report was a collection of analysis we did with our first CIHR (Canadian Institute for Health Research) grant. It was an attempt to drill down into some of the causes for the health disparity and where these pockets were in the Saskatoon Health Region. The Public Health Observatory has continued with the work. We have developed a few different types of analysis and interventions as well as developed a health equity surveillance system and equity audit tools for the health care system with the purpose of improving health equity. Where we find inequity, whether it is by economic status, gender, age, rural/urban etc. we work with the relevant department(s) to drill down to find out what the driving force for health inequity is and assist them in thinking about ways to improve health equity.

Looking back, are you satisfied with what came out of the work?I am very satisfied with the processes that were put in place. We are starting to see positive outcomes. I am obviously not satisfied with the improvements that have been made up to date, as we have not reduced poverty or reduced the health equity gap to zero. But what we have done is to raise the initiative to a level of importance that is now self-sustaining. There are many different leaders in the community as well as in the health sector that are now integrating a health equity approach into their planning and program delivery, so that has become high priority. Even at the provincial level, within the

provincial health plan, there is a goal of reducing health inequalities. Our health board has measures within their performance monitoring dashboard for improving health equity. And we are starting to see departments within the health system choosing initiatives for improving health equity. I’m satisfied with the momentum it’s gained, but obviously there is still a lot of work to be done to reduce those gaps. The forward thinking for us is to refining the surveillance activities to be able to better inform and prioritize the work. The next report that we are working on will show how health equity has developed over time. We are using a lot more advanced methodologies, looking at 15 years worth of data and doing statistical modeling to be able to look at trends over time to see which of the equity gaps are narrowing or broadening, getting worse or staying the same.

Dealing with determinants of health, going beyond the health sector to get data, you run into “data silos” - various sectors collect the data differently - how did you deal with that?This involves trust and building relationships. When we started looking at teen pregnancy and infant mortality, I tried to build a health status report using publicly available data. What I found was that the data I needed to develop a comprehensive health status report for our region was going beyond health data and into the other determinants areas. But when I went to get publicly available data from education,

social services, justice, police - they were all using different time periods, geography, age breakdowns and publication timeframes. There was never a point in time when everybody’s data was available at the same time. We couldn’t layer the data because it was all too disparate. What we did was to work with the Saskatoon Regional Intersectoral Committee to come up with a shared data infrastructure. Over the years, this has come to be called the Community View Collaboration, which is now a publicly accessible website with a GIS interface, tables and charts and a wide variety of data sets from the contributing partners. We started with a base - the census data that everybody wanted and added on health data, data from municipal governments including police, as well as social services and education. Many other partners have now started to contribute including researchers at the university. Over time, the database has grown - not only the numbers of data sets, but also in years of available data. No agency around the table could have built this on their own. But by pooling resources, we were able to create data sets which everyone could use and we built it in such a way that it had a flexible interface for choosing geography, age groups, gender, socio-economic status etc. >>

“Our health board has measures within their performance monitoring dash-

board for improving health equity.”


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CARRFS Interview (cont’d) When we put reports out we involve the partners if we are using data from other sectors to ask if we have interpreted it right and if we have understood the data limitations. These relationships need constant attention. And the big issue here is having the Regional Intersectoral Committee with the senior members of each of the major partners sitting around the table multiple times a year working collaboratively on projects.

What role do you think public health has in reducing health equity, poverty and social determinants of health?Public health is a relatively small force if you look at the overall health system - less than 2% of the health budget is going to public health. But even that small budget is huge compared to many non-governmental organizations or coalitions that are working in the area of social justice improving social determinants of health. The role that we have played is to coordinate and facilitate. While public health was quite a leader in that area across Canada 100 years ago, it has for decades been relatively absent. We have found that there is a huge need for infrastructure - access to analysts, to data, data sets, and to databases – something that we can do that others don’t have the capacity for. The rigor we have in building infrastructure surveillance can be leveraged for many other groups – taking the data and the reports and building upon them. The other side is the voice that the public health has – especially the Medical Health Officer’s office. We have a legislative mandate to report on what is driving the health status in the region and to make suggestions for improvements. Early on, we decided that the health status reports should not be dry statistical documents left open to the interpretations of others. We needed to analyze the data and put forward potential implications and suggestions for improvements. We now have recommendations in our health status reports. It started out with recommendations from a health perspective but then increasingly using more of a community development approach to work with other sectors and data owners. Our reports are not just us speaking up – input from other sectors gives us a stronger voice. Likewise, there are things we can say that perhaps others groups can’t - so the message about poverty reduction coming from the Medical Health Officers Office, I think, has been a powerful addition to local advocacy efforts. Public Health has a strength in using community development and partnership as the model for improvement of social determinants of health and reducing health inequity - moving away from the lifestyle approach in health promotion and more into the causes of the causes. In addition to our Public Health Observatory work and data analysis, we have taken our health promotion department and reoriented it towards action on the social determinants of health as the prime focus rather

than exclusively a lifestyle approach, and using all elements of the Ottawa Charter for Health Promotion. Even where we do lifestyle interventions it should be through the lens of the social determinants of health.

What role do you see the profession of epidemiology having in the future? We need to think about the rigor we use in building surveillance systems for health equity. We need to systematically build up data sets in a way that we can do stratified analysis by various elements of social determinants for the individuals - something we haven’t done a good job at. The traditional ‘person, place and time’ approach takes us only so far. The details of who that person is in an environmental context are how we need to view

the data. We need to move away from doing one-off equity reports and to systematically apply a surveillance approach to health equity data and beef up our analytical methods. The epidemiologist needs to be conversant in specialized statistics needed for this type of analysis. When was the last time our public health epidemiologists got involved with, for example. the Gini-coefficient or concentration indices? Are we comfortable with Poisson regression and modeling necessary for looking at effects over time and looking at the root cause of some of those differences over time? Getting beyond the simplistic descriptive analysis that we tend to do for basic outbreak analysis and health

status reports into more complex methods are essential. We need to look at the causes of the causes. That is what is needed for the future of chronic disease epidemiologists. The analysis must go beyond the numerical impact to looking at what the clinical implications are. Diversifying the team to include epidemiologists working with, say, medical epidemiologists, medical health officers and staff from various health and human service sector disciplines, in order to bring more life to the analysis and a better understanding of the implications. We also need to be brave enough to go out and make recommendations for change - always taking the practical relevance to our data and starting to look for program or policy implications. If we are going to improve equity, we need to change our methods and approaches. We need to commit to monitoring and evaluating over time to see if we are making a difference. From this perspective, I think the future is very bright for epidemiology. It is far more interesting using a larger range of skills and to actually be able to see program and policy improvements as a result of the work that we are doing. <>

By Jostein Algroy

“We also need to be brave enough to go out and

make recommendations

for change.“


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Surveillance Facts...Part III in a series about the Past, Present and Future of Public Health Surveillance. Written by Dr. Bernard Choi, Senior Research Scientist, Chronic Disease Surveillance, Public Health Agency of Canada and CARRFS eNews science writer.

PastThe concept of systematic ongoing collection of mortality data was first used in 1532 when the town council of London, England started to keep a count of the number of persons dying from the plague. These Bills of Mortality were collected on and off for over 100 years. However, these data were not used for surveillance

purpose until the 1600s, when the clerks of London reported the number of burials and causes of death to the Hall of the Parish Clerk’s Company and released in a weekly Bill of Mortality. In the 1600’s, mortality data (Bills of Mortality, similar to modern day death certificates) were collected using very simple methods. Every night, towards twelve o’clock, a cart goes about with a lantern and a bellman (or sexton), and as he rings the bell, he cries out, “Bring out your dead!” As described by John Graunt, “When any one dies, then, either by tolling, or ringing of a Bell, or by bespeaking of a Grave of the Sexton, the same is known to the Searchers, corresponding with the said Sexton. The Searchers hereupon repair to the place where the dead Corps lies, and by view of the same, and by other enquiries, they examine by what Disease or Casualty the Corps died. Hereupon they make their Report to the Parish Clerk, and he, every Tuesday night, carries in an Accompt of all the Burials and Christnings happening that Week, to the Clerk of the Hall. On Wednesday the general Accompt is made up and printed, and on Thursday published and dispersed to the several Families who will pay four Shillings per Annum for them”.

PresentPublic health surveillance starts with defining the type of data to collect (systematic data framework development), and then the public health surveillance process cycles through three stages: data collection, analysis and interpretation, and the timely dissemination of findings. In

addition, the surveillance system should be able to evaluate public health actions (including the surveillance system itself which is a public health action). The first question when setting up a new surveillance system is what categories of information should be tracked by the surveillance system. There is a need to create a systematic data framework. The data framework is usually defined in terms of indicators. An indicator is a measurable factor that allows decision makers to estimate objectively the size of a health problem and monitor the processes, the products, or the effects of an intervention on the population. The number of potential indicators for tracking is enormous and must be systematically narrowed down. The process of indicator framework development involves several steps: conducting literature review, expert consultation, and Delphi surveys to get a consensus on a list of indicators and evaluating availability and quality of data. Delphi survey is a method that requires experts to answer questionnaires in two or more cycles, with a feedback summary of experts’ opinion after each cycle, in order to converge towards a consensus.

FutureThere is a need in further enhancing the use of computer technology in public health surveillance. New terms like “infodemiology” and “infoveillance” have been coined for the use of informatics methods to analyze queries from the Internet search engines to predict disease outbreaks. Public health informatics is “the systematic application of information and computer science and technology to public health practice, research, and learning”. Public health informatics can introduce new applications to broaden public health perspectives, strengthen prevention in public health, and build healthier communities. Another need is improving methods of epidemic investigations. Rapid technology development in the laboratory will improve diagnostic precision and reduce the time necessary to make a diagnosis. Statisticians will continue to develop new statistical methods that will provide more insights through refined data analysis. <>


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> PROFILE > UPDATE > EVENTS


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Chair’s MessageGail Butt, the Chair for the Canadian Coordinating Committee (CCC) gives a status update on CARRFS achievements over the years in laying the foundation for building a strong organization in the future.This month I will complete my 2-year term as Chair of the Canadian Coordinating Committee (CCC). In this, my last Chair’s message, I share my experiences and hopes for the future for CARRFS.

Over the last several years, we have been busy moving CARRFS forward. We have established a sustainable structure for CARRFS, while at the same time continuing to deliver high quality services for our members. The network continues to grow and be recognized as a valuable and continually evolving entity. This has only been possible through the dedication and commitment of CARRFS members and their belief in the importance of such a network. It has been inspiring to work with member volunteers on both the CCC and its working groups who have consistently delivered on what they identified should be achieved. As I leave, I am confident that CARRFS is in a good position and I look forward to welcoming the new chair at the end of June.

CARRFS has many working groups that lead the direction that the network takes. Without each member of each working group, we would not be where we are today. From the beginning, the educational opportunities have been recognized as a leading reason that members have joined and remained with CARRFS. The virtual structure of the network has provided unrestricted access for the members. The use of the website and the professional

networking that has occurred primarily through the “net” has meant that CARRFS has been able to develop without the need for large administrative support, either for its development or sustainability.

Going into the future, CARRFS is in a good space, but as always in a network like CARRFS, we need more volunteers to continue to thrive and expand. I encourage members to increase their involvement in CARRFS by joining working groups and drive the agenda forward as it will benefit for all of us.

Before I sign off, I would like to express my sincerest thanks to the members of the CCC for all the help I have received in chairing CARRFS. Thank you to the Public Health Agency of Canada (PHAC) for their continuing support. Last but not least, thank you to all the members of the CARRFS community for which it has been a great pleasure to serve.

Gail ButtChair, CARRFS


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CARRFS Profile...To help build our community, the CARRFS eNew profiles a leading member in each issue. In this issue we profile Ms. Cristina Ugolini, Manager, Public Health Observatory, Saskatoon Health Region. What is your background?I have a master degree in Public Administration from Western University (formerly known as the University of Western Ontario) in 1996. Prior to coming to Saskatoon, I worked as a policy analyst for the Ontario Ministry of Health and Long-Term Care and also for the Ministry of Social Services. In early 2000, I came to Saskatoon and worked as a policy analyst as a member of the Kenneth J. Fyke Commission on Medicare in Saskatchewan, which made recommendations for health care reform in the province. Following this, I was fortunate to become part of the Roy J. Romanow Commission on the Future of the Health Care in Canada. Working on both commissions gave me great insight into understanding the broader issues that health care faces both in Saskatchewan and in Canada, as well as the many opportunities for improvement. In 2002, I was hired in Saskatoon Health Region as the Manager for the Strategic Health Information and Planning Services branch. I later joined the Public Health Observatory as manager in late 2007, and have been here ever since.

What do you spend most time on in your current position?As a manager of the Public Health Observatory (PHO), working with a team of 12, I spend a lot of time ensuring the right conditions and resources are in place for the team to excel. I spend time planning and providing feedback and strategic support to my team. We have designed the PHO to provide understandable health information – bringing data and research into the hands of decision makers and public health practitioners. Our aim is to contribute to improved health, and reduced health inequity, through surveillance, applied research and evaluation and knowledge exchange to inform decision-making, policy and service delivery. With this, a big portion of my work is to work with my team to build and nurture partnerships – both within the Health Region and externally. Community partnership include the University of Saskatchewan for research and surveillance projects, school boards, community based organizations, police, First Nations and Metis partners, to name a few. >>


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CARRFS Profile (cont’d)

What inspired you to work with health and health surveillance?I believe that we need a much greater emphasis on improving population health, not only for the benefits to society in general, but so that our publicly funded healthcare system can be sustained. I recognize the tremendous importance of the social determinants of health, and I believe that the work of the PHO contributes to moving that important work forward, particularly at a local level. There are many improvements in social policy that will go a long way to improving health outcomes and the overall health of Canadians. Without the information gathered through surveillance and other activities, we would not be in a good position to make important policy and service decisions.

How do you see CARRFS' current role in Canada today?I appreciate the role that CARRFS plays in bringing a range of organizations and individuals together that are all working toward better information for improved population health. The focus on chronic diseases and risk factors at a regional level fills a previous void in this area. I have appreciated the opportunities to attend conferences and webinars to both learn and share experiences.

You are not currently active involved in CARRFS - what might help you to become involved in CARRFS?More time!

What are the opportunities for CARRFS?I believe CARRFS could become more connected to the National Collaborating Centres (particularly the Health Determinants and Methods and Tools centres). There is some good complimentary work going on.

What knowledge and experience do you think you can bring to CARRFS?I can continue to share what we are learning in Saskatoon to try to improve health outcomes and I can share more about the PHO’s role and contribution toward that work. <>

By Jostein Algroy

Call for Interest

Are you interested in and available to contribute to setting strategy for CARRFS ? Do you have time to volunteer? We are looking for members for the working groups (training, tools & resources, and surveillance innovation) and the coordinating committee. These are two-year terms. Each group has a specific focus. The Training Working Group coordinates opportunities including bi-monthly e-Learning sessions and an e-Forum which will be informed by an updated needs assessment. The Tools and Resources Working Group identifies what tools and resources are out there and how to link those who “have” with those who “need”. They are looking at creative ways to make it easier to connect – including more use of our Twitter account and other networking options. The Surveillance Innovation Working Group is still in its initial stages, and there are opportunities to influence the direction that this group takes. The Coordinating Committee provides advice on the operation of CARRFS, and takes the lead in specific areas including the e-Newsletter and web presence. We have openings and would be pleased to hear from you if you want additional information, would like to nominate a colleague, or volunteer yourself. The strength of CARRFS lies in its membership: We encourage your contributions! <>


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Update...Updates from each CARRFS Working Group Chairs on recent activities. All working groups need members. Please get in touch with the Chair or a member of the working group and join!

Training Working Group

The Training Working Group continues to move forward. Two e-learning sessions have been held and both were positively received. In April, Dr. Flora Matheson presented an “Overview of the Canadian Marginalization Index (CAN-Marg)” which she co-authored.

In May, Dr. M. Nawal Lutfiyya’s presentation posed the question “Is Rural Residency a Social Determinant of Health?” Dr. Lutfiyya provided many references so CARRFS members could get further information on the topic.

Thanks again to the presenters for two excellent sessions and, as always, the webinar is available on the CARRFS website.

The training working group continues with the planning for upcoming bimonthly e-learning series for the fall and another e-forum for the next fiscal year. <>

Surveillance Innovation Working Group

Over the last two months, the Surveillance Innovation Working Group has continued with the ground-work to move targeted projects forward. As previously mentioned, the focus is on the following: o use of the Google search engine as

a chronic disease risk factor surveillance tool often embedded within Google Analytics;

o examine school survey tools from all provinces to determine if similar key/core indicators are being used for surveillance; and

o use of non-traditional data sources for surveillance.

As a result of the last newsletter, we have had valuable contributions which have fed into the projects – keep the emails coming! <>

CARRFS CommitteesCARRFS CommitteesCARRFS CommitteesCARRFS CommitteesCanadian Coordination Committee (CCC)Canadian Coordination Committee (CCC) Tools and Resources Working Group (TRWG)Tools and Resources Working Group (TRWG)

Chair: Gail Butt Chair: Ahalya Mahendra

Co-Chair: Ali Artaman Co-Chair: Vacant

Training Working Group (TWG)Training Working Group (TWG) Surveillance and Innovation Working Group (SIWG)Surveillance and Innovation Working Group (SIWG)

Chair: M. Nawal Lutfiyya Chair: Michelina Mancuso

Co-Chair: Vacant Co-Chair: Vacant

Tools and Resources Working Group

The next major chapter in the work of the Tools and Resources Working Group is the merger with the Member Engagement Working Group. This seemed like a natural fit since the main way in which we would be able to engage with our members is by providing them with the tools and resources they need to do their work!

One way that we are looking into is to connect more with our members is through social media. Twitter, is a nice and easy way in which bite sized pieces of information on new public health developments can quickly be distributed, shared and exchanged by those working in this and related fields.

This is not the only new development that we are working on to ensure that we keep our members engaged and informed, but without spilling the beans on all our plans, why don’t you follow us on twitter and find out as they happen! <>


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Events...

We are pleased to announce that the 8th World Alliance for Risk Factor Surveillance Global Conference (WARFS 2013) will be held from October 29 to November 1, 2013 in Beijing, China.

This conference follows a series of very interesting conferences beginning in USA (Atlanta), 1999; Finland (Tuusula), 2001; Australia (Noosaville), 2003; Uruguay (Montevideo), 2005; Italy (Rome), 2007; Italy (Venice), 2009, and Canada (Toronto), 2011. WARFS 2013 is co-hosted by the Chinese Center for Disease Control and Prevention and the Chinese Preventive Medicine Association.

WARFS is the Global Working Group on Surveillance of the International Union for Health Promotion and Education (IUHPE). It supports the development of behavioural risk factor surveillance (BRFS) as a tool for evidence-based public health, acknowledging the importance of this information source to inform, monitor and evaluate disease prevention and health promotion policies, services and interventions. WARFS aims to (1) integrate surveillance as a tool into the mainstream of health promotion work, (2) finalize the definition and conceptual framework of BRFS that can be shared and discussed globally, (3) serve as a reference for researchers, BRFS practitioners, and countries that are developing BRFS, and (4) share findings, results and experiences with IUHPE community to facilitate the discussion regarding the role of BRFS.

The IUHPE is a global non-profit organization whose mission is to promote global health and to contribute to the achievement of equity in health between and within countries of the world. The WARFS 2013 will continue to pursue the above aims focusing on “Challenges in Developing Behaviour Risk Factors Surveillance Globally for Monitoring Non-Communicable Diseases and Social Determinants of Health”.

An International Scientific Committee (ISC) has been set up to plan the scientific program, and the Local Organizing Committee (LOC) is taking care of the activities of the conference. Dr. Bernard Choi from CARRFS is the Canadian member sitting on the ISC, so please feel free to send him questions and suggestions. His email is: [email protected]. More information about the conference can be found under following URL: http://www.ciccst.org.cn/warfs2013/general%20information.html

The conference venue is Beijing Landmark Hotel, 8 North Dongsanhuan Road, Chaoyang District, Beijing, China. <>

Conference OrganizersDr. David McQueen - [email protected], WARFS; Co-chair, ISCGlobal ConsultantImmediate Past President International Union for Health Promotion and Education (IUHPE)US CDC (Retired)Tucker, Georgia, USA Dr. Stefano Campostrini - [email protected], WARFS; Co-chair, ISCProfessor, University Ca' Foscari of VeniceVenice, Italy Dr. Liang Xiaofeng - [email protected], LOCDeputy DirectorChinese Center for Disease Control and Prevention (China CDC)Beijing, China Dr Cai Jiming - [email protected], LOCSecretary GeneralChinese Preventive Medicine Association (CPMA)Beijing, China



http://www.ciccst.org.cn/warfs2013/general%20information.html













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Web Accessibility...The CARRFS website will be undergoing some exciting changes starting this summer! We will be going through a process of evolving our website to be accessible to everyone, specifically those who are visually or hearing impaired, and are looking to also use this opportunity to make some improvements to the website based on feedback we have received from the membership. The accessibility improvements come from a recent initiative to ensure all Government of Canada websites, including those supported by the Federal Government such as CARRFS, are accessible to visually impaired people. This is based on a Charter challenge brought to the courts by Ms. Donna Jodhan. In 2007, Ms. Jodhan, a visually impaired MBA graduate from McGill University and President of the Alliance for Equity of Blind Canadians, found that many Government of Canada websites, particularly interactive websites such as those that included online job applications, were completely inaccessible to the visually impaired. She felt that this inaccessibility violated her right to equality under the Charter of Rights and Freedoms and brought a Charter challenge to the courts. In May 2012, the Federal Court upheld a ruling that found the Right of Equity, Section 15(1) of the Charter, entitles people with visual impairments equal access to government information and services provided to the public on the internet. The Government of Canada has taken steps to ensure all its websites are accessible through the adoption and implementation of the internationally recognized Web Content Accessibility Guidelines (WCAG). After July 31, 2013, all government or government-supported websites available on the

internet must be WCAG compliant in order to remain online after this deadline. The CARRFS website is supported by the Public Health Agency of Canada (PHAC) and the CARRFS Secretariat and Canadian Coordination Committee have been working together with the IT and eCommunications divisions of PHAC since November 2012 through regular meetings to establish a solution that will ensure the CARRFS website is fully compliant to the new accessibility guidelines. However, this process takes time and it is expected that required changes to the website will not be fully completed by

the July 31st deadline. This will mean some short-term limitations to the website; specifically, the CARRFS Members’ Community portion will not be available for a short time after July 31st as we finish development of a new, improved and accessible version of this portion of the website. Most other areas of the website will still be available and we will use this as well as our member ListServe to keep members informed of CARRFS activities and progress with the website. <>

Public Health Agency of Canada (PHAC) IT Department is working hard to make the CARRFS Website and the CARRFS Members‘ Community compliant with the Federal Government’s Web Accessibility requirements by July 31, 2013. Mary Lou Decou and Brenda Branchard, PHAC Secretariat explain the status and implications for the CARRFS community.


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Hello & Goodbye...This is the place to welcome new members to the CARRFS steering committee - The Canadian Coordinating Committee and honour those who have to leave the committee to pursue or fulfill other commitments.

CARRFS is a network of public health stakeholder interested in

working together to build capacity for regional/local area

chronic disease risk factor surveillance in Canada that will

be used for chronic disease prevention and control.

MANDATE

A sustainable and effective regional/local collection,

analysis, interpretation and use of risk factor data to inform

program and policy decisions in Canada.

VISION

To build and strengthen the capacity for regional/local risk factor surveillance in

Canada.

MISSION

Send us your StoryWe urge all members to send us articles for upcoming editions. Since we are promoting a bilingual newsletter, articles will be published in the language they are submitted - English or French. Please submit your story to the CARRFS eNews Editor in Chief at [email protected].

Brenda Branchard, Public Health Agency of Canada, SecretariatWe wish Brenda Branchard all the best as she begins a one year secondment with Statistics Canada working with the Canadian Cancer Registry. Brenda joined CARRFS just over one year ago and has been a valuable addition to the team. We know that she will take with her all the skills and expertise that she demonstrated with our program and look forward to her return in a year’s time with new skills and experiences. All the best and enjoy your year with Statistics Canada!

Mary Lou Decou, Public Health Agency of Canada



CARRFS eNews June 2013

Documents

health development

health promotion

saskatoon health region

public health observatory

health science writerms

world health organization

social determinants

carrfs enews volume