the Canadian Heart Health Initiative

Building Block towards a

Countrywide Integrated

Chronic Disease Prevention

Action

NON COMMUNICABLE DISEASE SEMINAR, THL, Helsinki, FinlandN

Sylvie Stachenko

About Canada

A Federated System

• 10 Provinces, 3 Territories and Federal

Government

• Provinces and territories primary

responsibility for health services– Adherence to Canada Health Act

– Federal transfers support provincial/territorial services

– Shared decision-making

• Universal health insurance: medical and

hospital care

The Burden of Chronic Disease in

Canada

Individuals and families

18,000,000 live with chronic illness

Chronic disease accounts for 87% of disability

High risk groups

Increased prevalence in vulnerable communities (e.g. Aboriginals) and in socio-economically disadvantaged groups.

Economy

Direct health care costs: 67% of total direct costs are expended on chronic diseases

Indirect costs: 60% of total indirect costs), e.g, loss of productivity and foregone income

All these numbers are increasing

Aging, increased prevalence of some risk factors, e.g. obesity

A rich history in health

promotion

Incremental Investment in Chronic

Disease Prevention

• Single diseases

• Single risk factors

• Specific population groups

Towards an integrated

approach to NCD prevention…

at the core of the CINDI concept...

Commonality of risk factors for major NCD’s

Systems approach to delivery

Partnerships

National Disease / Risk Factor

Strategies

Partnership models

Good foundation for integrated

chronic disease policies / programs

Canadian Strategy for Tobacco

Control

Governance

- Multisectoral Partnerships

Multi-pronged Strategy

- Access

- Advertising and Promotion

- Packaging and Labelling

- Product Regulations

- Taxes

- Smuggling

- Enforcement and Education

Sustained over time

Some successes...

Trends in Smoking Current Smokers,

12+ years, 2001-2009, Canada

Source::Canadian Community Health Survey

Age-Standardized Mortality Rates for

Cardiovascular Diseases

Canadian Males and Females,

1950-2005

Source: Public Health Agency, 2007. Age-standardized to the 1991 Canadian population.

Some Emerging Trends

Source: Why Health Care Renewal Matters: Lessons from Diabetes,

The Health Council of Canada, March 2007

More and More

Canadians are Obese

CANADA overall*

23% obese in 2007

15% obese in 1992*No data available for the Territories

YUKON*

NORTHWEST

TERRITORIES*NUNAVUT*

BRITISH

COLUMBIA

19%

14%ALBERTA

25%

15% SASKATCHEWAN

31%

16%

MANITOBA

28%

17%ONTARIO

23%

13%

QUÉBEC

22%

13%

NEWFOUNDLAND

and LABRADOR

34%

22%

NEW

BRUNSWICK

29%

18%

NOVA

SCOTIA

25%

19%

PRINCE

EDWARD

ISLAND

26%

16%

Self-Reported Risk Factor Prevalence,

2007

Source: Source: Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, 2007 using

Statistics Canada, Canadian Community Health Survey Data.

Copyright ©2009 Canadian Medical Association or its licensors

The Canadian Heart Health Initiative

Entry point for an

integrated approach to

chronic disease

prevention

Common Risk Factor Approach

Canadian Heart Health Initiative

Co funded by theNational Health Research Development

Programand National Department of Health

Provide practical and evidence based know how on integrated action

Conceived in 1987 as per the Ottawa Charter

to strengthen public health capacity in health

promotion and implement integrated approaches

interventions to address CVD

To apply the existing available knowledge on CVD

prevention in diverse systems across Canada

Uses heart health as entry point with a view to expand

to other NCDs that share common risk factors

Canadian Heart Health Initiative

backbone of CINDI

Integration as a Principle of

Program Design

• Organizing Principle• Working together to address risk factors and their

underlying determinants

• Maximizing the preventive dose

• In Practice – Partnership approaches and

modern governance arrangements• Concerted and coordinated action around:

• Policy and program

• Surveillance and evaluation

• Funding systems

• Research agenda

• Dissemination

CHINESECOMMUNITIES

SOUTH ASIA

FOUNDATIONS

CANADIAN

COPI

CANADA

HEALTHHEALTH

SCIENTIFIC COMMUNITY

INTERNATIONALINTERNATIONAL

WHO

CINDI

PROVINCIAL

PROVINCIAL

VICTORIA

IMPLEMENTATIONGROUP

CANCER FOUNDATIONS

RÉSEAUINTERNATIONAL

FRANCOPHONE

The Canadian

Heart Health Initiative

A Partnership

ModelPROVINCIALHEART HEALTH

PROGRAMS

COORDINATINGCOMMITTEES

HEART HEALTHPROGRAMS

HEART HEALTHNETWORKS

PROFESSIONALASSOCIATIONS

GOVERNMENTDEPARTMENTS

HEART HEALTHCONFERENCE

HEART HEALTHNETWORK

HEART HEALTHNETWORK

HEART HEALTHNETWORK

INTERNATIONALNETWORKS

PRIVATESECTOR

HEART &STROKE

Canadian Heart Health Initiative

A phased approach

Policy Development

(1986-88)

• Federal / Provincial working group

recommendations

• Consultations with stakeholders

• Consensus approach to Policy

Framework

• “Promoting Heart Health in Canada”

(1987)

Provincial Heart Health Surveys

(1986-92)

• 10 provincially-based surveys were

conducted

• Built provincial capacity

• Risk factor data and physical

measurement

• Media / Marketing for visibility

• Consolidated into one national database

– The Canadian Heart Health Database

Demonstration Phase

(1989-97)

• To determine feasibility of implementing

a comprehensive approach to CVD

prevention at the community level

• 311 community-based provincial heart

health multifactorial demonstration

programs in 10 provinces

• Common risk factor focus: tobacco,

physical activity, nutrition eg fat intake

A focus on evaluation

• Outcome evaluation on a focused set of risk factors through risk factor surveys

• Process evaluation guidelines developed• common process indicators for

heart health strategies

• increased capacity of public health departments to monitor and implement prevention programs

• Canadian Heart Health Evaluation Database

• CHHI - Process Evaluation of the Demonstration Phase

• Rich experience on integrated action at the

community level across the country

• Broadened experience on community

mobilization and participation in Canada

… coalition building, partnership approaches

Canadian Heart Health InitiativeKey Achievements

• New skills for public health practitioners:

• Organizational development

• Leadership development

• Conflict resolution

• Marketing

• Political process

• Advocacy and communication

• Capacity was transferable to other issues

Canadian Heart Health Initiative

Other Achievements

• First national database on behavioural and physical risk factors which is ongoing

• Linkage to mortality and morbidity data

• Flexible network management model for pan-Canadian initiatives in a decentralized environment

• Knowledgeable trained teams at all levels

with skills in planning and evaluation in the

delivery of integrated approaches

• Link to international efforts such as WHO CINDI/CARMEN

Learnings from the

Demonstration Phase

• Combination of science and practice powerful

force to advance the prevention agenda –visible

results are critical to secure political

commitment

• Focused mainly on community mobilization and

formal public health infrastructure – health care

system not fully mobilized…..insufficient

supportive policy changes in other sectors

• Need to link up with other targeted prevention

initiatives and combine strategies whenever

possible (CHHI, Diabetes, Canadian Strategy on

Cancer Control…)

Dissemination Phase

• Research dissemination projects

• Building on the learnings of the CHHI

– Towards an integrated approach to

chronic disease prevention

Canadian Heart Health

Dissemination Project

• Description

and synthesis

of 9 provincial

dissemination

projects

- published

http://www.science.mcmaster.ca/chhdp/CHHDP_IE.html

Partnership and Linkage ModelTo Facilitate Dissemination

Dissemination PhaseTowards an Integrated Approach to

Chronic Disease Prevention

• Expanding existing heart health coalitions

to chronic disease alliances at national,

provincial and community levels

– Chronic Disease Prevention Alliance

of Canada

. . . . . . . . .

– Provincial alliances

– … Important role of civil society

Building on the

Heart Health Platforms to

Guide Integrated Action

• Knowledge Synthesis

and exchange

• Surveillance

• New National Governance

Mechanisms

Knowledge Synthesis and

Exchange

• Comprehensive learning system• National Best Practice Consortium for Integrated Chronic

Disease Prevention and Control • www.phac.gc.ca/cbpp

• Observatory of Chronic Disease Policy • www.phac-aspc.gc.ca/ccdpc-cpcmc

• Supportive infrastructure for NCD preventive

research• Canadian Institutes for Health Research

• Health Promotion Research Consortium

• Knowledge networks

• New “demonstration sites” to evaluate and monitor

intersectoral NCD prevention approaches• Alberta WHO CINDI demonstration site

… … …

Surveillance

• Towards a comprehensive surveillance

system for chronic diseases

• Accommodates existing initiatives building on

disease and risk factor surveillance but focus on

coordination among different levels and

jurisdictions

• Stronger emphasis on data analysis, interpretation

and dissemination

• National ongoing risk factor surveys extended to

capture information on determinants

… … …

New Governance Mechanisms

to support

integrated Chronic Disease

Prevention• Centre for Chronic disease Prevention and

Control (PHAC)

• Public Health Network (cross jurisdictional)• Expert group on chronic diseases

• Intersectoral Healthy Living Network… Moving towards “Whole of Government

Approaches” at the national level

• Chronic Disease Prevention Alliance of Canada

Federal Integrated Chronic

Disease Prevention Strategy

• Combines:• Inter-sectoral action on diet and physical activity

with disease-specific actions related to cancer,

diabetes and cardiovascular disease

• Three pronged:• Promote health through inter-sectoral action

• Minimize risk of chronic disease and injury

• Detect early and effectively manage

chronic health problems and injuries

• Implemented by:• Combining actions of public health and

primary health care

• Involving multiple sectors and acting in

multiple settings

Provincial Territorial Chronic

Disease EffortsMoving towards … Whole of government approaches

Some reflections on moving

knowledge into NCD action

Value Added of a Policy Framework

• Articulation of policy principles, issues, strategies

• Informed/focused debate

• Make complexity clear

• Additional information research needs?

• Link various levels: national, regional, community

• Identify stakeholders: health and non-health sectors

basis for partnerships

political support

towards an action plan

The importance of building

capacity• Demonstration projects, evaluation,

tools and resources, surveillance

Role of Knowledge Brokers

• Knowledge brokering links

researchers and decision

makers, facilitating their

interaction so that they are

able to:

• better understand each other's

goals and professional culture,

• influence each other's work,

• forge new partnerships, and

• use evidence into decision

making.

• Individuals or organizations

can be knowledge brokers

adapted from Murphy, 2006

Role of Credible champions and

leaders• People and their interactions

matter more than the message

• On-going liaison and institution

inter-connections

• Personal contact and trust-

building through quality

relationships over time can

offer systems change potential

• Necessary for:

– Access to decision-making

settings

– Credibility

In memoriam Dr. Andrés PetrasovitsFebruary 11, 1937 – July 24, 2001

• Engage the media

• Use of local case studies– “Stories” make issues real

• Use of visuals

– Geographic Information Systems (GIS)

• Visuals and Colors (rather than stats)

to communicate urgency

Use Effective Communication Strategies

Effective Communication Strategies

• Customise the message

– Politicians and policy makers:

key points, implications, policy direction

and costs

– Informed user:

access to data for manipulation e.g.

Chronic Disease Infobase on Web

– General public:

packaged information

Create public demand but takes

time, reliable

information

Gosmokefree!

Partnerships with nongovernmental

organizations

• Chronic Disease Prevention

Alliance of Canada

Involve the End Users

• Meaningful engagement of stakeholders

that will use the data

e.g. risk factor surveys

Address Concerns of

Decision Makers

• Focused on solutions and cost of policies

• Need to supplement data with cost

effectiveness studies,consumer research,etc

• Timing and policy window

– Include short term objectives

Make the economic argument

• Work with economists to assess

economic impact of trends – important

for government

• Projections to make the case for status

quo

Use of projections and

economic modeling

The Business Case: British Columbia

100

90

80

70

60

50

40

30

20

10

0

-10

Revenue Growth – 3%

Education Growth 3%

Health Growth 8%

Balanced Budget

–

–

Other spending reaches zero by 17/18

Percent

TOTAL 100.0%

71.3%

27.0%

-0.6%

41.6%

28.4%

27.0%

53.6%

27.0%

16.6%

Health

Education

Other

04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 15/16 16/17 17/18

Year

Document innovation and learn

from a variety

of models• ActNow! BC

• Quebec Public Health Act

• Intersectoral community initiatives

Develop mechanisms for

sharing and

disseminating innovation

Thank you

Kiitos