Population Health Surveys at STCPrepared for: B.C. Research Data Centre

Date: Nov. 15, 2000

Why Health Information Matters$80 billion a year on health careHow do we improve the health of the populationWhy are some healthier than othersThe most critical contributors to health are not health related -- social status, control over work, education (CPRN)

National Population Health Survey (NPHS)longitudinal survey of 17,276 households and 2,300 residents of institutionsfirst cycle in 1994, continuing every 2 yearsCycle 4, transition to only longitudinal

Self perceived health - a longitudinal and cross sectional analysis. Aged 65 +

Table 2

Self perceived health in 1994/95

% Self perceived health 1998/99

000

%

Excellent, very good,

good

Fair, poor

Total

2,590

100

77

23

Excellent, very good, good

2,030

79

85

15

Fair, poor

560

21

46

54

Percentage of household population aged 65 or older in 1994/95 entering home care by 1996/97, by selected characteristicsChart 7

NPHS: Household Longitudinal Respondents (Full)

Chart 6

NPHS Institutions - results after 3 cycles

Chart1

2287000

14274472195

90971127037

500100166720

resp.inst

resp.hhld

dead

non-resp

NPHS: Residents of Health Institutions

Sheet1

Cycle 1Cycle 2Cycle 3Cycle 4

non-resp0953720

dead072112701667

resp.hhld04471100

resp.inst22871427909500

total2287228722872287

1994/951996/971999 (p.)2001(e.)

resp.inst22871427909500

resp.hhld04471100

dead072112701667

non-resp0953720

total2287228722872287

Sheet1

0000

0000

0000

0000

non-resp

dead

resp.hhld

resp.inst

Sheet2

0000

0000

0000

0000

resp.inst

resp.hhld

dead

non-resp

NPHS: Residents of Health Institutions

Sheet3

HERE SOME RESULTS FROM THE NPHS - INSTITUTIONS SURVEY.

EXPLAIN SLIDE: The purple bar represents persons in institutions. The yellow are persons who died. These are the same 2287 people.We have a lot of transitions in this data set. The first thing to note is that about 1/3 of our respondents die each cycle. On a positive note this allows us to have many records to match to the mortality database to discover the cause of death.

On the other side, the small number of survivors has limited the type of research one can do on the characteristics of people who stay more than 2 years in a long-term care facility, research questions such as: - what kind of social support do Alzheimer patients receive during their stay in an institution?- how does the utilisation of health services change over time for these residents? Which brings us to a kind of fork in the road for the future data collection for seniors in health care institutions.

Opportunities to improve health informationHealth Information Roadmap: a four-year action plan to strengthen Canadas health information system; Creation of Canadian Community Health Survey (CCHS) Person oriented database

NPHS and CCHS - A More Robust Survey Program NPHSlongitudinalsample of 17,276 householdsnational and provincial level estimates

CCHScross-sectional sample of 130,00 respondents national, provincial and sub provincial level estimates

1994-1999

Since 2000

We have a family of surveys covering 3 disctinct populations:

NPHS Households component covers individuals in each of the 10 provinces, both longitudinally and cross-sectionnally over the first 3 cycles, and will continue covering the longitudinal panel starting with cycle 4.

The territories are covered by the NPHS North over the first 3 cycles, and then by the CCHS.The population in long term health care institutions is covered by the NPHS Institutions component.Recently, the Health Information Roadmap has highlighted more areas where policy makers would like more data, specifically for smaller geographical areas (health regions). To address these needs were engaged in doing another survey, the CCHS. This survey is strictly cross-sectional and will replace Households component of the NPHS, as well as cover the North.

The Canadian Community Health SurveyObjectivesEstimates at the community health region level Flexibility to enhance and vary content to meet unique regional and provincial needsregular data collectiontimely data release

Canadian Community Health Survey Cycles and Components

Cycle/

Component

Content

Sample

Collection

1.1

27 Common core + 23 Optional modules

130,000

Sept. 00 - Oct. 01

1.2

Mental disorders, well-being + common core repeated

30,000

Jan. Dec. 2002

2.1

Common core + Optional modules expanded

130,000

Jan. Dec. 2003

2.2

Nutrition, dietary recall, psychosocial determinants, fruit and vegetable consumption, food insecurity + common core

Potential supplement for physical measures

30,000

Jan Dec. 2004

3.1

Common core + Optional modules expanded

130,000

Jan. Dec. 2005

3.2

????

30,000

Jan. Dec. 2006

Canadian Community Health Survey Design 2000/2001Sample size -- 130,000, stratified by health regionQuestionnaire content30 minutes for priority items10 minutes of optional items selected by health regionsstandard socio-economic itemsEstimates for health regions, provinces and Canada2001/2002Sample size -- 30,000Proposed focused study on mental health and well-being

CCHS - Year 1 Survey Sample Frames Area frame (computer-assisted personal interview)94,000 households from the LFS structure78,000 households with 1 person selected16,000 households with 2 persons selected

RDD frame (computer-assisted telephone interview)20,000 households with 1 person selected

these figures will be boosted before going in the field

Common ContentAlcoholAlcohol dependence / abuseBlood pressure checkBreastfeedingChronic conditionContacts with mental health professionalsExposure to second hand smokeFood insecurityFruit & vegetable consumptionGeneral healthHealth care utilizationHealth status - SF36Health Utility Index (HUI)Height / WeightInjuriesMammographyPAP smear testPhysical activitiesPSA testRestriction of activitiesSmoking Tobacco alternatives Two-week disabilityHousehold composition & housingIncomeLabour forceSocio-demographic characteristics Administration

Optional ContentBreast examinationsBreast self examinationsChanges made to improve healthChild & adult stressors (traumas)Dental visitsDepression DistressDriving under influence Drug useEye examinationsFlu shotsHome careMastery MoodOngoing problemsPhysical check-upRecent life events Sedentary activitiesSelf-esteemSexual behavioursSmoking cessation aidsSocial supportSpiritualitySuicidal thoughts and attemptsUse of protective equipmentWork stress

CCHS Cycle 1.1 Preliminary Counts Province Pop. Size No. Health Regions # Records* NFLD 551K 6 4,026 PEI 135K 2 3,617 NS 909K 6 5,226 NB 738K 7 5,039 QUE7,139K 1622,759 ONT 10,714K 3738,910 MAN1,114K 11 8,443 SASK 990K 11 8,062 ALB2,697K 1714,499 BC3,725K 20 18,218 CANADA 29,000K 133 130,917

Pop. Size # Records * Territories: YUK 25,000 791 NWT 36,000 985 NUN 22,000 342 * Preliminary numbers, November 2001

Status of Collection CCHS 1.1Collection completed Nov 3, 2001;National response rate 85%;Projected provincial response rates of at least 80%;Achieved target of more than 130,000 records.

CCHS 1.1 Release Line-upPreliminary Results- Dec. 2001Shared Files - April 2002Official Data Release - May 2002Analytical Results - June 2002Public Use File - August 2002Workshops - Fall 2002

CCHS 1.1 Products & ServicesMicro Data Files for sharing partners and researchers;Analysis that informs the general public;Health Indicators on-line for health region information;Workshops to build capacity.

Canadian Community Health Survey File Outputs

Identifiable information removed from file

Name

Address

Date of Birth

Health Card Number

Etc.

CCHS - Share File

Provided to ministries of health

Only respondents who agree to share information

IDLinkShare

AYesYes

CNoYes

CCHS - Master File

Maintained by Statistics Canada

Record for every respondent

Each assigned random ID

IDLinkShare

AYesYes

BYesNo

CNoYes

DNoNo

CCHS Link File

Provided by request only

Only respondents who agree to link & share

Contains health card and identifiable information

Random ID provides link to share file

IDLinkShare

AYesYes

Microdata Release Committee

Group consisting of Statistics Canada experts on maintaining respondent confidentiality

CCHS Public Use Microdata File

All respondents aggregated to a lower level of detail

All identifying variables removed

Age groups versus single year of age

Health regions combined to meet minimum population thresholds

Other aggregations and suppressions as required

IDLinkShare

AYesYes

BYesNo

CNoYes

DNoNo

Linked Data

Ministry or Statistics Canada must approve all linkage activities

After linkage all identifiable information has been removed

IDLinkShare

AYesYes

Ministry of Health Administrative Data

Data maintained by ministry of health

Contains health card information

IDLinkShare

AYesYes

Organization of Electronic DataCansim IIData Warehouse$ for DownloadCanadian StatisticsFreeCanada Level DetailHealth IndicatorsFreeDetailed Health Region InformationHealth Regioninformationin the CommunityProfileFree, Simple

Linked Sample Data Structure

Mental Health & Well-Being Objectives 1. Determine prevalence rates of selected mental disorders to study adequacy of health care;2. Juxtapose access and utilisation of mental health services with respect to perceived needs;3. Assess the disability associated with mental health problems to individuals and society.

CCHS 1.2 Study MethodologyFace to face interview;Sample of 30,000 individuals, aged 15 years and older;Based on WHO non clinical approach, that profiles disorders depending on symptoms, duration and severity, (ICD10, DSM IV).

Content: Mental Illness & ProblemsDepressionManiaPanic disorderSocial phobiaAgoraphobiaGeneralised anxiety disorderSuicidal thoughts & attemptsEating troubles & behavioursGambling Alcohol dependenceIllicit drugs use & dependence Utilization of mental health servicesMedication Use

Content:General InformationGeneral healthRestriction of activitiesChronic illnessWell-being and satisfaction with lifeSpiritualityDemographicsSmokingSocial SupportDistressStress, Work StressLabour force activityIncome

Surveying ChallengesBalance between individual privacy and informed research;keeping abreast of emerging issues;collecting increasingly sophisticated information e.g. mental health, physical measures, dietary recall

C C H S

Questionnaire Content and Sample Design Information is available on the Statistics Canada Web Site.www.statcan.canphs-ensp@statcancchs-escc@statcan

1 Introduction - Asst director responsible for NPHS and CCHSTwo items on agenda - first talk about the CCHS and secondly accessibility of data from CIHI and CCHS today we want to hear your views on issues surrounding our health care system and the health of Canadiansto get juices flowing, throw our some of the rationale we use in why we have been able to obtain funding to expand the population health studies to include not only a longitudinal study but more recently a cross -sectional study with a large samplea lot of money in being spent on our health care system - more importantly health is a major preoccupation with everyoneinformed decision making is key phrase - better information for better health and health care. Interest in special population ie. aboriginal, youth, elderly -- large sample for CCHS will allow for this indepth studylook beyond health care system to other factors -- work condition, employment, environment, social supportOur very first regular population health survey and one of the most ambitious studies is the National Population Health Survey. This longitudinal study began in 1994 following a panel of approximately 20,000. It has been conducted every 2 years since then. The survey interviews persons aged 12 and over living in private households as well as in institutions. Respondents are asked a broad range of questions that include reported health status and chronic conditions, utilization of health care services, and determinants of health such as alcohol consumption, smoking, exercise, and preventative practices. The set of health related questions are combined with socio-economic and demographic questions in order than one can evaluate the correlate of health to education, income, ethnicity and other such characteristics. A combination of face-to-face and telephone interviewing is used to collect the information and we achieve a response rates of approximately 95%. Longitudinal research can reflect the realities of how one diagnosis of a chronic condition changes an individual. Many move from a state of healthy to unhealthy, and suffer not only physical implications, but often a deterioration of lifestyle as well. Self-perceived health can be a major predictor of a poor or bad health status. In the NPHS, respondents are asked to rate their own health, on a five point scale, as fair, poor, good, very good, or excellent. Although some may find this concept a bit fuzzy and not in keeping with scientific rigor, we have found that it is a good predictor of health problems, use of health services and longevity. We also find it is consistent with the objective ratings made by physicians based on medical and physiological evaluations. This concepts has been verified through linking survey results with administrative health records that can help to confirm the legitimacy of reported chronic conditions, and overall health.

Self perceived health can be argued as being more of a psychological phenomenon than a physical one, but we all know the powerful connection between ones mental well being and healthfulness. This table illustrates how a longitudinal evaluation can identify the dynamics of a longitudinal study versus a cross sectional analyses. In the aged 65 +, if we looked at the historical change from 1994 to 1998, we could say that there was a 2% reduction in the number of individuals who said they were in excellent, very good or good health (79% to 77%). However a more revealing and interesting analysis is that out of those 2,030 individuals who reported excellent or good health in 1994, 15% reported in 1998/99 that their health was now fair or poor.

Who are these individuals who during a period of 4 years experienced a decline in good health? Activity dependence was certainly found to be associated with decline. Seniors in 1994, who became dependent in 1996, had twice the odds of reporting a decline in perceived health status. The only chronic condition associated with a decline was heart disease. Other conditions such as arthritis, high blood pressure, diabetes and cancer were not associated with this decline. Those in lower education levels were twice as likely to report a decline in health status. The better able we are at identifying what makes people remain healthy? and what factors contribute to poor health?, the better able we will be to match health care needs with and effective and efficient delivery of health care services. The offering of home care has been targeted as one means to reduce health care costs. Providing health care and homemaker services in the home can allow patients to be released from hospitals more quickly. There may also be benefits in having most of the recovery period spent in the comfort of their own home surrounded by family. The difficulty is however, this often puts additional stress on the family who are providing informal care.

From the 1994 to the 1996 period, the NPHS identified 7% of household residents 65 and over as entering into a government subsidized home care service. The likelihood of home care entry was higher for older seniors than for those aged 65 to 74. Other predicting factors of those most likely to require these services were having at least one chronic condition, being hospitalized, and living alone.

As well, a significantly higher percentage of lower-income individuals entered home care than did their higher income-income counterparts. This may reflect the poorer health but may also reflect the fact the higher income individuals pay for private services rather than depend government subsidized home care.The NPHS also includes an institutional component. We began in 1994 with approximately 2,287 individuals living in institutions, and after 3 cycles we have about 1,100 remaining. Approximately 1/3 of our respondents living in institutions die in each cycle. Currently 5% of Canadians aged 65+ are institutionalized, and this percentage increases to 18% (185,000) for those aged 80 and over. A major planning feat is to prepare for the increased need, as this number is predicted to rise to anywhere between 565,000 to 746,000 by 2031. The NPHS study results from 1994 to 1997 can help to better understand the circumstances that lead to institutionalization, as we track those respondents as they move from their private residence to institutional care. Two thirds of those who become institutionalized during that period reported a new diagnosis of stroke, Alzheimers or dementia. Becoming ill does not always lead to institutionalization though, as 8% of those who experienced the same condition live in their private homes. Seventy-four percent of those 65 and over living in a long-term care facility had a severe disability, compared to 65.8% of seniors in private households who had not disability. Seniors in the lowest or middle income have twice the odds of being institutionalized compared to middle to high incomes. 73% of the institutional, residents are women. Women with a longer life expectancy than men often find themselves with no spouse to assist them when they become ill. Logically it follows that those seniors who are single, widowed or divorce have higher odds of residing in an institution. Finally those with only a primary school education, had higher odds of being in an institution than those with post secondary schooling. Source: Trottier Helen, Martel Laurent, Houle Christiane, Berthelot Jean-Marie and Legare Jacques. Living at home or in an institution: What makes the difference for seniors? Health Reports, (Catalogue 82-003) 2000: 11(4).

Health information is a major priority with federal and provincial governmentThe Roadmap is a high-level action plan produced jointly by CIHI, Health Canada and Statistics Canada.-- outlines national vision for modernizing the health information system in Canada $95-million was generously provided in the Feb 99 federal budget to support a range of projects, to be led by CIHI and Statistics Canada, in concert with other F/P/T partners across the country over the next four years.-- a response to the needs and priorities identified in consultations, which involved over 550 stakeholders, including health administrators, researchers, caregivers, government officials, health advocacy groups, and consumers.Builds on, complements, and sometimes leads both current and prospective F/P/T, regional, and local initiatives .5In order to meet the health information needs, both a cross sectional and longitudinal survey program will be supported. NPHS will continue as a longitudinal bi-annual survey - plans for addition of cohort in 2004Major objective remains as tracking outcomes over life historyLongitudinal data critical to isolate dynamics (smoking example of not but change in overal trend, however at individual behaviour level one can see much change)

CCHS with sample of 160,000 will provide excellent cross-sectional estimates of health determinants, health status and health system utilization to community health regions or groups of health regions across Canada.

Monthly collection of cross sectional estimates will allow for trend analysis, and flexibility to react in measuring emerging health issuesSurvey designed for collection in year one based on health region needs, year two content will be targeted at provincial level.Plans to over sample target populations ie. heard in consultation need to monitor youth smoking, social support needs for seniors etc.Quarterly estimates will be produced, at end of first 12 months of collection all identified health regions will receive estimates.Health information roadmap initiative identified among other things, the problem of fragmented data -- data we have on health status and determinant remain unconnected to health care services - incomplete data , no data on impact of services, lack of data for vulnerable groups, little data for other areas ie. nutrition, mental health, physical measuresThe major objectives for the first collection cycle are to produce reliable relevant estimates at the subprovincial level in a timely fashion. Operational and content decisions have been based on these two premises - subprovincial data released quickly.

6Sample design optimal to meet major objectives: useful meaningful data to health regions within short period of timeYear two of collection with 30,000 respondents, allows for flexibility to test new content and to benefit from sampling sub-populations. Content for year two will be primarily targeted towards meeting provincial and national level needs.

This sample design raises concerns around unequal distribution of interviewer work load. Although year two will substantially lower numbers of respondents, it will involve more complex and lengthy interviews e.g. mental health maybe 1 hour in length. 7Year one collection will be a combination of RDD and personal interview. For some households, more than one person will be interviewed. A major objective for this is to increase the sample of childrenNova Scotia- The number of HRs has been increased to 6. - An extra 1,000 sample units have been given to Nova Scotia in order to take into consideration those 2 new HRs (500 units per HR).- Half of this extra sample will be taken from other areas in the country>250 from the Toronto HR (new sample size = 3,470)>125 from the Vancouver HR (new sample size = 1,505)>125 from the South Fraser Valley HR (new sample size = 1,505)- The other half of the NS extra sample represents NEW sample.Note: this extra sample for NS will have no impact on cluster listings, a fine balance between RDD sample units and additional starts in the already identified clusters has been achieved.

Qubec- As per Qubec request, only one of their two northern HRs per Cycle will be surveyed. So the Nunavik HR will be out-of-scope for Cycle 1.1,only the Nord-du-Qubec HR will be included. The 1 in 20 respondent burden rule has been relaxed for the Nord-du-Qubec HR, every tenth household will now be selected for CCHS-Cycle 1.1.-As per Qubec request, a new allocation of the provincial sample among their HRs has been performed (see next page)-For miscellaneous reasons, Qubec has now an extra 250 sample units.

The new total sample size for CCHS Cycle 1.1 is 133,300 respondents. Collection began August 2000, and will end October 31, 2001Although 3 weeks left to go, target of 85% will be achieved80% at provincial level -- eastern provinces always higher, Ont. and B.C. lower. Focus is on health region, and last few weeks have been targeting regions (10) for which we had not yet achieved sufficient sample -- hopeful will end up with sufficient cases to publish data for all 136 health regions.Territorial included -- Nunavut at 58%, NWT and Yukon on track. Have processed a six month file, weighted etc. and will release a few highlights from this file. No intention to make this file publicly available, used internally towards data validation, and preliminary analysisSix month release being planned included three analytical short articles -- Unmet health needs in Canada (based on question ever a time when you felt needed care but did not receive it -- why not). Look at trends since 1994; Health Effects of Community Belonging - look at theory that community social ties can protect from onset of illness - based on a new question sense of belonging to community. Winter consumption of fruits and vegetables - patterns across the country, intake by socio demographic characteristics, methodology paper and briefing of study with announcement of spring release.Shared data without identifiers for those respondents agreeing to share (95%) Ministries of Health (ISQ) and Health Canada Daily announcement, aggregate data on Website, community profiles, indicator data - brief summary of resultsAnalytical results -- GaryPublic use files and workshopsShared data will be provided to sharing partners (Health Canada, Prov Minitries of Health, ISQ, Territorial Statistical Agency for respondents agree to share, STC has agreement with shareres to protect confidentiality, restricted use of data etc.Public Use File - microdata screened to ensure confidentiality. Hoping to be able to maintain health regions 70,000 pop and over. File available through DLI to most university libraries, given free to health regions and ministries, minimal cost to other users.Analysis - main publication are quarterly Health Reports and CIHI/STC Annual reports How Health are Canadians, How Health is our Health Care SystemWebsite will contain health region profiles for indicators identified in framework - (handout for specifics): marry with Census information, vital statistics etc. to increase information for each health regionWorkshop - develop workshop on content details ,how to use -- geared to all levels of users. Work with HC on their Skills enhancement for health surveillance developing series of training courses - epidemiology course, using statistical data, eithical and legal issues, analysis. CCHS/NPHS data used in examples, integration of our workshops - GOL initiative for Data Exchange and knowledge sharing environement

New approach to organizing data holdings at Statistics CanadaCANSIM II will be used as the data warehouse from which most electronic data products are producedAs robust as the NPHS data are, other sources of information are essential to not only verify these survey sources but also to better explain the dynamics between population health and health care. Statistics Canada has always relied on administrative data sources such as vital statistics (births, deaths, marriages) and morbidity data. More recently, we have enhanced our research possibilities through greater use of record linkage. NPHS respondents are asked to provide their unique health identification number. This number is then used to link survey provided information with administrative sources such as the hospital morbidity. This allows us to better understand the key risk factors associated with hospitalization. Through this record linkage we have been able to identify those most likely to be hospitalized as older people, and the chronically ill. As well the study has found that men with low income and low education levels and a higher prevalence of risk factors were more likely candidates for hospitalization. NPHS includes a number of questions on risk factors and behavior. Through record linkage we were also able to identify smokers and those who are physically inactive as being admitted to hospitals more often than those who never smoked, and who were physically active. Statistics Canada has recently been mandated and funded to expand their health information program. Population survey work will be extended to collect information at a low geographic level in order to provide better inform at the administrative level responsible for the delivery of health care. We are expanding survey content to include a more detailed study of mental health and mental illness, social support and child health. A nutrition and a physical measures study is being planned for 2003, where dietary recall information could be combined with blood samples to evaluate the biochemical components. Statistics Canada has great opportunity and challenge over the next few years in expanding its health research program. However, as critical as this information is, we always must be cognizant of the need to respect the right of individual privacy and the assurance of complete confidentiality of information. Missing national data on prevalence rates of major disordersappropriate and adequate health care is an issue - number of patients with disorders being institutionalized is decreasing, increase emphasis on treatment in hospitals or community clinicsBarriers to health care include cost, societal stigma, fragmented organization of servicesPrevention - stigma prevents open dialogue, social and cultural context does weigh in causation of depression -- strong families can help Need to look at correlates between socio-economic and demographic characteristics Impact on individual and families - individuals with disorders more likely to work part time, live alone. lifetime essential for a balanced picture of mental health and see determinants-- it is not a dichotomy of those with and without illness, but is represented with periods of problemsvery much like physical health -- cancer, some have brief periods, smaller proportion have chronic problemsFace to face interview in individuals homesWindow for collection planned for April through to December 200230,000 sample 15 years and older will allow for provincial level estimates by age groups and sex -- no Territories sampleIncludes reservists and regular members of Armed Forces - DND contractWHO is a tool with set of questions asking about symptoms (that all experience) - depending on severity, range, prevalence patterns, may lead to a diagnosis of probablity-- is not a diagnosis Example: Initial Screening: e.g. feeling of sad, empty, lose interest.Tests for:Duration: 2 weeks or more.Symptoms: depressed mood, weight loss or gain, insomnia (5 out of 9 ).Severity or Impairment: could not do daily activities, occupational/social impact.Collected data analyized using algorithm Hierarchical approach -- many levels of screeningleft side indicates modules where we are using specific WHO tool, right side, content where we have had some questions in prior surveys, more in depth. Using validated tools. Criteria for disorders are: 12 month prevalence of at least 1%, and that can be measured, common to Canada (eating disorder), and are amenable to intervention (depression) . Schizophrenia although very relevant, cannot be measured in this study, ask for self diagnosis.Previous STC health surveys have included depression, suicidal thoughts and behaviours, stress

majority of respondents will go through these modules -- 80%, approach of a short and long form similar to Census, smaller proportion get short form with just well-being, everyone gets disordersAdded a well-being dimension for a comparable population, as well as general socio-economic and demographic detailsInterest to look at correlations between well-being and disordersBalance of privacy vs need for informationStatistics Canadas success in collecting and disseminating information has largely been due to the fact that Canadians support the need for information and trust us to ensure their information will be kept confidential. We have and will continue to take every precaution towards this end. As we expand on our research program, however we are linking collected survey data with administrative data. For some, however, the thought of combining various sources of information into one databank is seen to be compromising individual privacy. The notion that too much information on someone may jeapordize them in some way. However with heighten awareness around privacy, we need to even more assure respondents of the utility of the information, guarantee data will not mis-used, that is it will only be used for research purposes. We must demonstrate to respondents that their information is being used to improve our heath care system the biggest preoccupation of most. Collecting information will not be sufficient, we need to promote research values, techniques etc. cpacity building, efficient and effective use of information by all health regionsCapacity buildingMore information but is there sufficient expertise availableNeed to close data gaps mental health and mental illness, nutrition, physical measures. There are data gaps and new emerging issues facing health and health care in Canada. Some feel the cancerof the next century will be mental illness. Increased cases of dementia face our elderly, working parents pare plagued by the stress of work and family. Collecting self perceived health and health status as served us well. However there are greater research benefits in going into physical measures, especially if this is combined with dietary recall. We do plan to move towards this, but certainly there are operational, medical and ethical challenges that need to be addressed.Standardization of concepts, questions and processing