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Reducing Gaps in Health: KnowledgeSynthesis, Translation and Exchange

Halifax, Nova Scotia

March 9, 2007

P R O C E E D I N G S R E P O R T

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How to cite this document:

Canadian Institute for Health Information, Proceedings Report—Reducing Gaps

in Health: Knowledge Synthesis, Translation and Exchange (Ottawa: CIHI, 2007).

Cette publication est aussi disponible en français sous le titre Compte rendu —

Réduction des écarts en matière de santé : Synthèse, application et échange

des connaissances.

ISBN 978-1-55465-154-2

Proceedings Report

Reducing Gaps in Health:Knowledge Synthesis, Translation and Exchange

March 9, 2007Halifax, Nova Scotia

Canadian Population Health Initiative National Collaborating Centre for the Determinants of Health

Reducing Gaps in Health: Knowledge Synthesis,Translation and Exchange March 2007

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Contents

About the Canadian Population Health Initiative . . . . . . . . . . . . . . . . . .5

About the National Collaborating Centre for Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

From Disease to Determinants: Reducing Gaps in Health at the Regional Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Reducing Gaps in Health: Knowledge Synthesis, Translation and Exchange . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

“The Determinants of Human Health Revisited—12 Years After Why Are Some People Healthy and Others Not?” . . . . . . . . . . . . . . . .10

In Our Own Backyards: Local Evidence as a Platform to InformSystematic Approaches on the Determinants of Health . . . . . . . . . . . .12

Health Disparity in Saskatoon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Expectations Versus Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Health Status Disparities by Income in Saskatoon . . . . . . . . . . . . . . .13

Community Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Building Health Equity: Community Interventions and Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

“Understanding Our Health” at the Community Level . . . . . . . . . . . . . . . .15

A History of Collaboration on Health Determinants . . . . . . . . . . . . .15

Mandating Community Involvement in Health . . . . . . . . . . . . . . . . .15

Local Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Learning at the Regional Level: Priorities, Needs, Challenges and Next Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Priorities: What’s on Regional Agendas? . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Strategic Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Intersectoral Work and Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Action and Strategies on Specific Populations/Behaviours . . . . . . . . . . . . .19

Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

Information Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20


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Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Implications for Action: Possible Next Steps . . . . . . . . . . . . . . . . . . . . . . . . .22

Addressing Population Health in Health Regions . . . . . . . . . . . . . . . . . . . .23

Reducing Gaps Through Knowledge Synthesis, Translation andExchange: Roles for CPHI and the NCC-DH . . . . . . . . . . . . . . . . . . . . .25

Facilitating Access to Data in Formats Useful to Regions . . . . . . . . . . . . . .25

Acting as a Clearinghouse/Information Steward for Success Stories, Resource Inventories, Data Sources, Best Practices . . . . . . . . . . . . . . . . . . . .26

Providing Expertise at Regional Levels Across the Country . . . . . . . . . . . .26

Knowledge Synthesis, Translation and Exchange . . . . . . . . . . . . . . . . . . . . .27

“The Start of a Great Relationship”: Where do We Go From Here? . .28

Appendix A. List of Workshop Participants . . . . . . . . . . . . . . . . . . . . . .29

Appendix B. Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

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About CPHI

The Canadian Population Health Initiative (CPHI), a part of the CanadianInstitute for Health Information (CIHI), was created in 1999. CPHI’s missionis twofold:

• To foster a better understanding of factors that affect the health ofindividuals and communities; and

• To contribute to the development of policies that reduce inequities andimprove the health and well-being of Canadians.

As a key actor in population health, CPHI:

• Provides analysis of Canadian and international population health evidenceto inform policies that improve the health of Canadians;

• Commissions research and builds research partnerships to enhanceunderstanding of research findings and to promote analysis of strategiesthat improve population health;

• Synthesizes evidence about policy experiences, analyzes evidence on theeffectiveness of policy initiatives and develops policy options;

• Works to improve public knowledge and understanding of the determinantsthat affect individual and community health and well-being; and

• Works within CIHI to contribute to improvements in Canada’s healthsystem and the health of Canadians.

For more information and to download CPHI reports, please visitwww.cihi.ca/cphi.


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About NCC-DH

The National Collaborating Centre for Determinants of Health (NCC-DH) ishosted by St. Francis Xavier University, located in Antigonish, Nova Scotia. TheNCC-DH partners with researchers, academics, the public health community,government and non-governmental organizations.

The NCC-DH focuses on the social and economic factors that influence thehealth of Canadians. It is currently examining literacy as a determinant of health,and in particular how health literacy impacts the health of the population. It isexploring how public health interventions in Canada address literacy as adeterminant of health and the implications of these interventions for healthliteracy practice and policy.

The NCC-DH will develop and implement strategies to advance public healthpractice and policy. These strategies include:

• Knowledge synthesis, translation and exchange;

• Identifying knowledge gaps; and

• Network development.

For more information, please visit www.nccdh.stfx.ca.

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From Disease to Determinants: Reducing Gaps inHealth at the Regional Level

In Canada and internationally, it is increasingly accepted that “health” is apersonal and collective resource determined by a complex set of factors andinteractions that extends far beyond the health care system. “Non-medicaldeterminants of health” (NMDH) include such factors as gender, education,culture, income/wealth and social and physical environments.

A population health approach takes as a starting point these complex factorsand interactions in order to understand and improve health outcomes. It isbased on evidence that population-wide interventions have greater impactson overall health status than does an individual focus. Therefore, actions toimprove population health are targeted more at the community, societal orsystem levels than at the level of individuals. A focus on NMDH involvesreducing health inequalities between population groups with different socialconditions, status or advantages, and addressing the social and environmentalconditions that produce poorer or unequal health outcomes.

At the same time as focus shifted to population health and a broaderunderstanding of the determinants of health, Canadian provinces also begana process—beginning in the 1990s—of “regionalizing” the management andprovision of health services. Today, regions are the core organizing structuresfor most health service delivery in the country.1 As such, they are in a positionto take lead or partnering roles in action(s) related to NMDH—actions thatoften move beyond traditional health care boundaries to span intersectoralresponsibilities.

Despite a widespread commitment to an intersectoral approach that focuseson NMDH, however, it can be difficult to assess needs and implement programsand initiatives to address the determinants. Frankish et al. note that “manydecision-makers are struggling to address health determinants beyond a narrowscope of illness-related causes,” and that “most decision-makers and resourcesin the health sector are understandably focused on illness and disability-relatedissues.”1 Regions and decision-makers—at all levels and across sectors andgeographic boundaries—may have much to share in terms of success storiesand collaborating to address barriers to a population health approach andreducing gaps in health.

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Reducing Gaps in Health: Knowledge Synthesis,Translation and Exchange

On March 9, 2007, approximately 25 representatives from health regionsacross Canada gathered in Halifax, Nova Scotia, for a one-day workshopcalled “Reducing Gaps in Health: Knowledge Synthesis, Translation andExchange.” The program was sponsored by the Canadian Population HealthInitiative (CPHI) and the National Collaborating Centre for the Determinantsof Health (NCC-DH). The workshop objectives were:

• To share current research on factors associated with health gaps in Canada;

• To facilitate knowledge exchange and transfer;2 and

• To discuss concrete policy and program development directions that couldreduce health gaps at the regional level.

This workshop was an opportunity to encourage discussion and to facilitatereflective practice on population health approaches at the regional level.

Throughout the workshop, regional health professionals shared ideas aboutchallenges, successes and next steps. Participants repeatedly brought up theideas of sharing data, resources and success stories, and of finding ways tocollaborate and build on each other’s expertise and experiences. They welcomedopportunities to continue the conversation via future workshops or onlinedatabases or discussion groups.

This report summarizes the day’s discussion, learning, conclusions and next steps.


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“The Determinants of Human Health Revisited—12 Years After. Why Are Some People Healthy andOthers Not?”Keynote address: Dr. John Frank, Scientific Director, Canadian Institutes ofHealth Research

The day began with Dr. John Frank’s keynote presentation, which situatedCanada’s current population health approach in national, international andhistorical contexts.

In the first part of his talk, Dr. Frank described the limits to medical care as adeterminant of population health status, despite the fact that the vast majorityof Canada’s health budget is spent on clinical care.

Medical care, he said, is not necessarily a driver of population health. A rangeof assumptions, he noted, hamper our understanding of the role of medicalcare in relation to population health. Such assumptions include:

• A focus on wait times as opposed to which groups may be over-represented in line;

• A focus on the inequitable distribution of specialty as opposed to primary care;

• The “thermostatic model” of health: that is, the idea that health care servicescan be “cranked up”—like the heat—to solve health problems, many of whichcannot be “cured” but at best managed, especially for those over age 50;

• An under-appreciation of the links between economic disparity and gapsin health; and

• A misperception that increased access to universal medical care reducesmortality (although there is some new Canadian evidence that it did reducesocio-economic mortality inequalities between 1971 and 1996 and that it doesimprove quality of life).

Dr. Frank then focused on “macro socio-economic and cultural factors, at thesocietal level,” as the key class of determinants of health. Education, he noted,“is a primary lever,” as is literacy. Infant mortality in Japan, for example,“dropped like a stone” in the early part of the century, approximately 15 yearsafter the Japanese government introduced universal primary education forboys and greatly increased enrolment for girls.


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He spent some time clarifying some misperceptions that surround thepopulation health approach. For example:

• The heightened role of individual behaviours and personal risk factors:Personal risks factors—such as weight, exercise, consumption of fruit andvegetables, smoking, hypertension—are thought to have a big impact onpopulation health. In reality, said Dr. Frank, those risk factors do not createmuch of an actual disease or death gradient until ages 50 plus. “We haveto resist the argument that it’s all about lifestyle risk factors,” he observed.

• Income equality as a major determinant of health: Income inequality, henoted, is important socially and should be addressed for social justice reasons,but it is not magically linked to mortality. The distribution of wealth is moreuneven than the distribution of income, he explained: rather than incomeequity, we need to focus on doing a better job of equitably (re)distributingthe benefits of public (social) goods and services.

• The problem of researchers assuming that local findings hold internationally:For example, researchers in the United States assumed that because socialtrust played an important role in mediating the influence of income inequalityon mortality among U.S. citizens, it played an important role in populationhealth internationally—which it may not.

Dr. Frank noted “the long reach of early life”: the social class of parents at birthis linked to health gradients by socio-economic status in adulthood. That link,however, can be mitigated through wealth redistribution, education and otherprograms. He cited Japan as a country that has done a good job of basingeducation and training “on individuals as opposed to their parents;” in otherwords, social and education programs in that country create the opportunityfor all children to succeed, regardless of social class or parental income.

He suggested that Canada may improve health status by focusing on earlychildhood. We have already successfully reduced low income among seniors inCanada. Through wealth transfers, low income among seniors has been reducedfrom approximately 60% to approximately 8%. For children, we have been lesssuccessful: low income has been reduced from approximately 23% to 15%.

Part of the problem, suggested Dr. Frank, is that data on redistribution of wealthare not readily available to Canadians—we simply do not know the extent ofthe problem; nor do we know of our ability to address it. “We’re not monitoringinequalities in a systematic way in Canada. Therefore, it is perhaps not surprisingthat there have been no improvements on the equalization of national wealth.”

Dr. Frank concluded with a challenge for Canadian policy-makers to increasehealth by optimizing every individual’s potential, starting in childhood.

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In Our Own Backyards: Local Evidence as aPlatform to Inform Systematic Approacheson the Determinants of Health

“A city, a health region, can find . . . where disparity lies so that we can devote moreresources to those neighbourhoods. From an absolute point of view, we can find outwhere our interventions should be.”

—Dr. Mark Lemstra, Senior Epidemiologist, Saskatoon Health Region

In order to get regional populations to think about and begin to address healthdisparities, regions need to have data from the populations they serve.

That was the premise of two projects described by speakers during theworkshop’s morning panel discussion. Dr. Mark Lemstra (Senior Epidemiologist,Saskatoon Health Region) and Eileen Woodford (Director, Public Health Services,Eastern Health Region) provided perspectives on how two Canadian healthregions—one in the Prairies, the other in the Maritimes—have begun to identifylocal determinants and gaps in health in order to intervene and address thesegaps more effectively.

This approach was particularly relevant to workshop participants, whoare struggling with issues of access to local, relevant data on which tobase population health recommendations and interventions.

Health Disparity in SaskatoonDr. Mark Lemstra, Senior Epidemiologist, Saskatoon Health Region

Dr. Lemstra described the Saskatoon Health Region’s “health disparityassessment” of the city’s low-income, middle-income and affluent residentialneighbourhoods. Researchers compared health indicators for the low-incomeareas to those of the more affluent areas. The assessment was the basis forcommunity consultations and interventions.

Expectations Versus Reality

In individual meetings with various government workers (front-line, middleand senior) in the health and policy sectors, as well as the Saskatoon TribalCouncil and various community groups, Dr. Lemstra asked, “What level ofhealth disparity would you expect between income classes?” Most respondents,he remarked, believed that health indicators would vary between 10% to 20%—maybe 30%—between low-income and wealthier groups.


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In fact, the variations ranged from 110% to 3,460%—illustrating both theassociations of low income with health status and a general tendency tounderestimate those associations, even in decision-making contexts. (Healthdisparities in Regina were similar.) Dr. Lemstra used the disparity betweenexpectation and reality as a way to call attention to the need to address healthdisparities according to income.

Health Status Disparities by Income in Saskatoon

• According to hospital separation data, the low-income population wasnearly 4 times more likely to attempt suicide than the middle-incomepopulation, and almost 16 times more likely to attempt suicide than theaffluent population.

• The low-income population had chlamydia rates 4 times that of the middle-income population and nearly 15 times that of the affluent population.

• Low-income teens were more than 4 times as likely as their middle-incomepeers and more than 16 times as likely as their affluent peers to give birth.Babies born in low-income communities were more than 110% more likelyto have a low birth weight, and infant mortality rates for low-incomecommunities were over five times those of middle-income and three timesthose of affluent communities.

• Low-income populations were hospitalized much more frequently forconditions such as diabetes (398% and 1,286% more than middle-incomeand affluent populations, respectively), chronic obstructive pulmonarydisease (COPD) (138% and 153% more than middle-income and affluentpopulations, respectively) and coronary heart disease (134% and 170% morethan middle-income and affluent populations, respectively).

• Affluent children were much more likely to be immunized than their low-income peers (94% versus 46%).

Community Consultation

In order to transfer knowledge of the disparities—and to mobilize communityresearch into action—the research team organized approximately 200 individualmeetings with government workers, the Tribal Council and others. Communityconsultation involved meeting with 40 different community groups in coreneighbourhoods and five team meetings with 10 government agencies and40 community organizations.

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A phone survey, with 5,000 respondents, gauged community knowledge ofand attitude toward health disparities and possible approaches to addressthem. The survey revealed a general lack of public awareness about healthstatus differences between low- and high-income families. Most thought thatindividual choices were more linked to health status than socio-economic statusindicators. While a significant majority supported work earning supplements,early intervention and health prevention efforts, there was little support forAboriginal self determination, and only 40% supported transferring moneyfrom treatment to prevention or health-creating services (that is, education,low-income housing).

Building Health Equity: Community Interventions and Evaluation

The region’s first action was a school-based project in six core neighbourhoodmiddle-year schools (grades 5 to 8). Interventions focused on the following:

• Increasing access to on-site health and social practitioners, and makingpractitioners part of the community;

• Focusing on prevention and treatment. Interventions were designed withthe input of the audience to be interactive, multidisciplinary, peer-led andculturally appropriate. For example, instead of a lecture, students askedpractitioners to write a play and cast students;

• Daily after-school programs, with a focus on reading and writing—suggested by students as a way to improve health—as well as recreation,music, arts and culture; and

• Engaging the Aboriginal community as full partners.

Other interventions included:

• Changing strategic goals for the health region (health disparity andAboriginal health are now two of five goals);

• Allocating $100 million for low-income housing (Regina and Saskatoon);

• Allocating $8 million for a primary care clinic;

• Redistributing the police force;

• Creating the Saskatoon Tribal Council immunization clinic; and

• Harnessing United Way support for after-school programs.

Evaluation components include vehicles such as a school health survey andfurther examination of health administrative data and population surveys(for example, the Canadian Community Health Survey [CCHS]).


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“Understanding Our Health” at the Community Level Eileen Woodford, Director, Public Health Services, Eastern Health Region,Nova Scotia

A History of Collaboration on Health Determinants

Ms. Woodford began by situating her region in light of its historical approachto health determinants. Eastern Nova Scotia has a strong community and regionalhistory of local action, community development and cooperative, labour andsocial justice movements, she noted. Historically, local initiatives have sprungup between communities to address gaps in determinants of health. Schoolbreakfast programs, community gardens and kitchens, women’s resources,child care programs and other prevention-focused activities are the resultsof broad-based buy-in at community and administrative levels, with keystakeholders from education, police, justice and health.

At the same time, she said, many such efforts have flown under the radar ofthe health system. Although its focus has broadened beyond acute care, thesystem remains inconsistent in its framing, vision and legitimization of publichealth and what counts as “real” work in the health care sector.

Mandating Community Involvement in Health

Nova Scotia general health services legislation outlines at a very high level theroles of its district health authorities (DHAs) in providing health services toresidents, explained Ms. Woodford. Act 34, the Community Health Board Mandate,provides clear responsibilities for community participation in health decisions.

When the health region wanted to develop strategies to address determinantsof health, local buy-in and collaboration between DHAs, community healthboards (CHBs) and public health services (PHS) were essential. The regiondrafted a high-level agreement of collaboration and support, based on CHBs’legislated responsibilities and PHS functions. This agreement was presented toeach CHB individually; over time, each board signed on. The result was a truepartnership between agencies, full support of a collaborative effort to completea community health assessment and the articulation of a shared vision:

PHS and the CHB understand that knowledge of the factors (determinants) that affectthe health of the community (population) is essential for responsive and effectiveplanning and service delivery.

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As part of the community health assessment, the region undertook the“Understanding Our Health” telephone survey (adapted from the CCHS),designed collaboratively by CHBs and PHS and coordinated by the CommunityHealth Assessment Advisory Committee. More than 3,500 people in the sixCHB areas in Cape Breton and the three CHB areas in Guysborough AntigonishStrait were surveyed—in English, French and Mi’kmaq—in 2005–2006.“Understanding Our Health,” said Woodford, was a way to put the legalmandate of the community health boards into action.

Local Data

Previously, most local health-related decisions were based on informationcollected at either the provincial or federal levels. “Understanding OurHealth” was an opportunity for the region’s CHBs to collect scientificallysound data on determinants at the population level that reflected theirdistinct demographic make-up and unique community health concerns,while increasing community participation in health planning.

Survey results provide a rich source of locally produced data to meetinformation needs. Results will be made available to local universities,health care facilities, the provincial department of health, various communityagencies and organizations and the general public. These results will guidehealth-related research, policy, program development and evaluation at thecommunity and DHA levels. They will also be used to better understandcommunity health care expectations; raise public awareness of local health/illness issues; and identify opportunities for local disease/injury prevention,health promotion and health protection efforts.

Discussion

The two presentations sparked several comments from workshop participants:

• Is there a difference between “targeted” and “population” approaches tointerventions? How do we “walk the fine line” between serving individualcommunities versus entire populations?

Dr. Lemstra suggested that while a traditional population health approachwould focus on equal resources for all neighbourhoods, a targeted approachwould be more appropriate in a situation where specific areas of populationsobviously need more resources: For example, should 9% of the populationget 9% of HIV resources, or should the 9% of the population with 50% of theHIV cases get 50% of the resources? In some cases, he suggested, a targetedapproach is a population health approach.


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• The importance of framing differences as income-based, rather thanculturally based, especially in reference to Aboriginal populations

After controlling for socio-economic status, Aboriginal status is not a predictorof health status, Dr. Lemstra found. In fact, the greatest predictors of healthoutcomes are individual effect of income, neighbourhood and individualeducation, after controlling for other covariates.

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Learning at the Regional Level: Priorities, Needs,Challenges and Next StepsThe first of the day’s two small-group dialogue and feedback sessions focused onsharing regional learning on the determinants of health and closing health gaps.

Priorities: What’s on Regional Agendas?

Discussion and pre-work responses3 yielded several areas where regions aretaking action on determinants and gaps in health.

Strategic Planning

Regions play a role—and have a stake in—strategic planning.

Development of Ontario’s 10-year strategic plan for the health care system isunderway with:

• Public consultations and web feedback . . .

• Planning and engagement emerging from each of the 14 Ontario LHINs has beenintegrated.

• Draft strategic directions released by the province in 2006 included: “improvedhealth status of all Ontarians especially groups with the poorest health status”;“reduced barriers to access”; and “equitable allocation of health resources accordingto the health needs of the population including disease management.”

• The consultation process includes a research summary on equity that recommendsthe use of health equity audits.

• The Ontario provincial and local health system scorecard includes indicators andperformance objectives for “improving access to the appropriate services”; “influencingbroader determinants of health”; and “increasing equity of the health system.”

—Toronto Central Local Health Integration Networki

Intersectoral Work and Agreements

• Several regions are partnering with other community groups, governmentagencies and departments and universities on wellness and preventioninitiatives, education and research. Such partnerships can identify strengths,address challenges and leverage resources and expertise to address issues.

• Partnerships have also developed to advocate for a public health/populationhealth/NMDH approach in government.

i. Quoted response to pre-workshop handouts.

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The organization has signed a working agreement with the University of Alberta andthe City of Edmonton. We are hopeful that this will facilitate the multi-player workthat is necessary to make progress on the social determinants of health.

—Capital Health Edmontonii

[We are] building partnerships/community capacity to address issues.Examples include:

• A [Crisis Assistance Network] that is working collaboratively to identify the needsof those living in poverty and addressing these needs.

• A Newcomer Liaison Coordinating Committee . . . to address the health and socialservice needs of immigrants who move to our region.

• Moving and Choosing to be Healthy[,] a school-based program . . . plannedand delivered by a Steering Committee including the health region and schoolrepresentatives with a goal of improving the health of students and teachers throughpolicy development and activities that promote active living and healthy eating.

• Early Childhood Development[,] a program of in-home visitation to help familiespromote health and social development of children from birth to 6 years. A multi-agency committee oversees the operation of this program in the region.

• Injury Prevention activities, [involving partnerships] with related non-profitsocieties to address needs and identify activities ranging from school basededucation, senior’s falls prevention, suicide awareness and prevention, motorvehicle injury prevention, etc.

—Palliser Health Region, Medicine Hat, Alta.ii

Action and Strategies on Specific Populations/Behaviours

Several regions have developed strategies targeting specific populations (forexample, Aboriginal, Kanadier Mennonites, smokers, diabetics, children andyouth and seniors) or behaviours/risks (diabetes, physical activity, tobaccocessation, nutrition and injury preventions).

Surveillance

Many regions are working on surveillance activities—for example of elementaryschool students, injury tracking and chronic disease—in order to improve theplanning and coordination of initiatives.

ii. Based on responses to pre-workshop handout.

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Information Needs

The need for data—local, population-specific, accessible, affordable, applicableand/or accurate data—emerged as a key issue for participants looking to takeaction on determinants at the regional level. This issue came up repeatedly bothin the day’s discussion and in comments generated in advance of the workshop.

Participants expressed a strong desire for data that could be broken down atthe regional/local level, and for more precise indicators specific to programneeds, particularly about at-risk populations:

• Participants noted that understanding of health status and disparities—aswell as the ability to assess the impact of interventions—for smaller, minorityor localized groups are limited by the fact that sample sizes are often notlarge enough. Understanding is also limited by a lack of variables related tolocation or culture and language.

• Such concerns are especially common among northern and rural populations,as well as Aboriginal and Francophone groups. Many regions serving FirstNations, Inuit and Métis populations noted that there is little populationhealth data on these groups. “Tri-partite agreements (provincial/territorialand federal levels with Inuit) are needed, along with inter-governmentalagreements [that is, between health, housing, education] to effectivelyacquire information needed for a population health approach with Inuitcommunities,” noted one participant.

• In the urban context, one participant suggested, larger survey samplesizes are needed, “to identify prevalence and risk rates for the diversepopulation groups, [which] are masked by the overall average rates.” Thisproblem can be addressed in part, she noted, by combining years of surveyresults, a complicated procedure requiring Statistics Canada–approvedweighting methods.

In a similar vein, access to information (getting data from other jurisdictionsor from government departments and agencies) emerged as a strong concern:

• It can be difficult and costly to adapt large survey data to regional populations,said participants. Some health units do not have the capacity to analyze andutilize data from surveys. For example, noted one participant, “if a regionwants more timely information and detail to determine the pockets of highand low income in a region or community, we need to pay for a tax filerdata run through Canada Revenue Agency. This is tough for smaller healthregions financially, and often region size makes it difficult to apply sub-regional data.”


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• Current surveys and data sources provide some information, but also havelimitations. Census data are released at least a year after the survey, whichis conducted only every five years.

• The CCHS is a primary source of public health data for many regions. Thethemes and optional content sections of the survey often focus on acute carepriorities, such as wait times, detracting from content of interest to publichealth. It is critical, said another participant, “to maintain and enhance . . .CCHS data related to determinants of health and . . . public and populationhealth topics. Public health input into the content of CCHS is also critical.”

• In addition, many regions do not have the capacity to use the NationalPopulation Health Survey (NPHS)—a longitudinal survey—which is apotentially important data source.

• Large surveys and other data sources do not necessarily address many ofthe social determinants of health, including personal resources, social andphysical environments, living and working conditions, culture and gender.As one person noted, regions need “additional collection of populationsocio-demographic variables (education, income, gender, ethno-racialidentity, period of immigration, employment status, etc.) on administrativeand service databases, along with regular analysis and reporting accordingto these variables.”

• Access to and sharing of data are also limited by a lack of standardmeasures and of varying definitions of determinants of health. Further,agreed-upon (provincially, nationally) targets or goals related to reducingsocial inequities would be extremely helpful.

Regions need to resolve these data issues in order to plan community-appropriate interventions. In summary, as one participant suggested, “Weneed information at a health region level where possible. Then we need thecapacity and willingness at the health region level to act upon this information.”

Challenges

“Public health practitioners feel challenged by the diversity of their regional-levelorganizations, structures and practices; moving from principles to practice; andidentifying the greatest potential for breakthroughs and successes.”

—Workshop participantiii

iii. Based on responses to pre-workshop handout.

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Other challenges identified in implementing a population health approachat the regional level include:

• Overcoming jurisdictional and sectoral boundaries to encourage healthor “healthy public policy” in all government department policies. Someregions have begun to collaborate between jurisdictions;

• Difficulty recruiting the academic community to the public sector, and inknowing about pertinent academic research;

• Overcoming established organizational cultures, including the following:

• Demographics of staff members of public health agencies do not alwaysor rarely reflect the demographics of the communities being served.

• Front-line staff may not have the time, resources or skills needed toimplement new programs.

• Staff may not be trained to act in areas related to social inequalities andhealth. Organizations may not be mandated to do this kind of work.

• The issues are often framed as moral and political:

• It is difficult to convince policy- and decision-makers (and the public)to redistribute resources: How can we take from one area (acute care)and give to another (determinants of health)?

• It is difficult to convince the public (and decision-makers) that healthis not only about lifestyle and personal choices.

• It can be difficult to articulate and/or model the potential impact or benefitof interventions in order to convince decision-makers.

Implications for Action: Possible Next Steps

• Increase awareness—of board members, staff, the general public, decision-makers, politicians, the well-off, the business world—about the determinantsof health and gaps in health:

• Take advantage of innovative popular media (for example, YouTube),viral marketing strategies and technology to reach population groups.

• Boards and senior administration need to understand the potentialimpact of not addressing determinants of health and not usingpopulation health approaches—financially and in the broader contexts.

• Pay attention to language: for example, using terms like “sustainability”as it relates to health can help relate population health issues to widerenvironmental and economic concerns and jurisdictions.


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• As awareness and policy discussion of health inequalities becomemore “mainstream,” according to one participant, “There is a need fororganizations long advocating for reporting and identifying inequitiesto shift focus to demonstrating how to reduce them.”

• Find ways to expand the focus on wait times and/or personal healthpractices to include disparities.

• Improve equitable distribution of health services and resources.

• Focus on healthy public policy and intersectoral collaboration in theeconomic, education, social services, transportation, housing and otherpublic sectors of crucial importance to health; for example, adopting a“health in all policy” approach, or health impact assessments for all policy(for example, as recently mandated in Quebec).

• Increase focus on children and youth: develop school programs, an “equity‘til 18” policy focus.

• Continue to generate and transfer knowledge on planning andimplementation of population/public health programming; establish aclearinghouse of “success—and less successful—stories,” in order to reviewand critically evaluate current programs; share best practices and policies.

• Develop a user-friendly needs assessment tool kit for the determinants of health.

Addressing Population Health in Health Regions

In June 2006, the Canadian Population Health Initiative (CPHI) commissioneda survey of Canadian health regions in order to determine their roles and needsrelated to population health planning and decision-making. The survey asked27 individuals from 17 organizations (mainly health regions) to provide inputon planning and performance assessment activities in population health atprovincial and regional levels.

Keith Denny, Program Consultant at CPHI, summarized the survey’s keyfindings in terms of options for CPHI to consider:

CPHI could provide pan-Canadian leadership to:

• Frame or conceptualize population health (as distinct from public health);

• Facilitate connections, drawing on national and international expertise;

• Act as a conduit for resources; and

• Legitimize a population health approach (act as an “honest broker”).

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Activities—CPHI could:

• Target sectors beyond those already working—or attempting to work—with a population health perspective; and

• Hold more workshops on planning from a population health perspective.

Research—CPHI could:

• Support research in high-priority areas (for example, “what works”);

• Collect and share best practices;

• Support long-term research networks; and

• Make the case for community-based research.

Performance assessment—CPHI could:

• Support development of better population health indicators;

• Support the effective use of indicators; and

• Help make population health real—not abstract—at the community level.


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Reducing Gaps Through Knowledge Synthesis,Translation And Exchange: Roles for CPHI andthe NCC-DH

The day’s second round-table discussion focused on how CPHI and the NCC-DH might help regions and others reduce gaps through knowledge synthesis,translation and exchange.

Participants noted that support from CPHI and the NCC-DH can give acredible voice to those trying to implement change and conduct researchat the regional and community levels. Both organizations have strongrelationships with academic institutions and can act as knowledge brokersand bridges between research and policy worlds. Many participants wantedto see more such information-sharing.

Participants suggested that CPHI and the NCC-DH needed to establish clearlydefined roles and responsibilities in order to avoid duplication. The two canleverage each other by continuing to collaborate on networking events suchas the current workshop, and establishing and agreeing on roles and priorities(for example, an “equity lens”).

As a new entity, participants said, the NCC-DH needs to clearly defineits approach and role in relation not only to CPHI but also to governmentorganizations such as the Public Health Agency of Canada. Which topics willNCC-DH cover? What is its national mandate? What will happen to the NCC-DH after the research dollars run out?

Participants identified several areas in which the two organizations couldplay a role:

Facilitating Access to Data in Formats Useful to Regions

• “Data liberation,” especially from Statistics Canada, CCHS and NPHS:CPHI or the NCC-DH could broker/advocate for data and help buildcollaboration and sharing agreements into Statistics Canada contracts;

• Providing expertise in data use and modelling at the regional level;

• Providing an inventory of data lists, beyond health, to match thebroader set of social determinants (for example, water, education,medical practitioners);

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• Analyzing and breaking down data at the health region or smallergeographic level, as well as by social determinants such as education,income, gender, age, urban/rural, etc.;

• Providing a mechanism to identify outstanding research and evaluationquestions; and

• Facilitating or providing sophisticated trend analysis to:

• Provide foresight into future health impacts (for example, the impactof aging on the economy and on society, the impact of changingweather patterns in a region); and

• Assess changes over time to know whether an intervention is makinga difference.

Acting as a Clearinghouse/Information Steward for Success Stories,Resource Inventories, Data Sources, Best Practices

• CPHI can synthesize and provide syntheses of its completed fundedstudies and those currently underway;

• Providing expertise on conducting and analyzing outcome evaluation;

• Providing expertise on understanding and accessing “best practice”information: evidence of effective or promising practices to reduce socialinequities in health; and

• Providing access to health determinants, education, social services andother data.

Providing Expertise at Regional Levels Across the Country

• Training for future population health workers, establishing competenciesfor human resources, technology training;

• Helping regions build population health frameworks into planning andeveryday work;

• Helping the health care system reallocate its own resources; and

• CPHI can establish a stronger presence at the local level, via CIHI’s regional offices.


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Knowledge Synthesis, Translation and Exchange

• Funding prospective studies (“What would happen if . . . ?”); focus onfuture implications rather than past;

• Funding and evaluating intervention research;

• Disseminating research horizontally and vertically;

• Fostering intersectoral communication and collaboration to reduce oreliminate redundancies, duplication of roles; bridging gaps betweenresearchers, regional workers, and policy-makers;

• Engaging practitioners in population health knowledge transfer; bringingtogether representatives from ministries and departments beyond healthto collaborate;

• Providing media strategies: how to package messages to government orto caucus; how to hitch social determinants/population health issues tothe “hot” issues of the day; and

• Using technology to build and maintain networks.

Participants identified several challenges to furthering a population healthapproach at the regional level, including:

• Too broad a focus on social determinants: do we need to focus on areaswhere we have really good research or evidence (for example, educationand income)? There are advantages to choosing a pan-Canadian, limitedlist of “action” determinants and priorities.

• A lack of clarity in terms of federal, provincial and regional roles inrelation to social determinants of health.

• Vague terms: perhaps we need to move away from the term “populationhealth” to something more descriptive/specific/dynamic.

• Different structures of regions.

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“The Start of a Great Relationship”: Where Do We Go From Here?

In his closing comments, Dr. Frank remarked on the productivity of the day,due in large part to the enthusiasm, diversity and collective wisdom of thepractitioners in the room. “Knowledge synthesis and transfer to application isthe work of practitioners, not just researchers,” he noted. Dr. Frank suggestedthat we should keep collaborating and perhaps meet again, next time focusingon an agreed-upon, fairly narrow set of determinants.

The day’s discussion made it clear that population health practitioners aresearching for an accessible inventory of data and “work to date” in orderto benefit from the group’s collective experience and to avoid reinventingthe wheel.

We still have tough questions to answer, noted Frank:

• Which social determinants of health are really going to become feasibleparts of population/public health? of health policy?

• What about determinants that have to do with other sectors, such astransportation and education? The “silo-ism” in Western democraticsystems doesn’t necessarily foster a population health approach.

He suggested that we might look to the impact of recent Health ImpactAssessment (HIA) legislation in Quebec (and similar laws in EuropeanUnion countries). What would it mean to have HIA applied across Canada?

“The good news,” noted Frank, “is that there is plenty to do in knowledgesynthesis and transfer around the determinants of health, not for researchersso much as for practitioners: we need to transfer this knowledge from academicsto practical decision-making needs and contexts. I think this is the start of thegreat relationship, between the two hosts, and between the people in this field—such a diverse representation from such diverse corners of the country.”


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Appendix A. List of Workshop ParticipantsLori Benning, Vancouver Coastal Health Authority

Janice Blair, Palliser Health Region

Fiona Chin-Yee, Public Health Agency of Canada

Connie Clement, Ontario Prevention Clearinghouse

Jeanny Dhaliwal, Vancouver Coastal Health Authority

Lesley Dyck, Interior Health Authority

Tannis Erickson, Interlake Regional Health Authority

Anna Fowler, Inuit Tapiriit Kanatami

John Frank, Canadian Institutes of Health Research

François Gagnon, Centre de collaboration nationale sur les politiquespubliques et la santé

Debra Godlewski, Atlantic Health Sciences Corporation

Verlé Harrop, Bell Island Health and Wellness Advisory Council

Teresa Hennebery, Prince Edward Island Health Department

Faye Hofer, Heartland Health Region

Michelle Hopkins, South-East Regional Health Authority

Catherine Hynes, Nor-Man Regional Health Authority

Bob Layne, Regina Qu’Appelle Health Region

Mark Lemstra, Saskatoon Health Region

Penny Lightfoot, Capital Health

Anne Lynch, Western Health

Madonna MacDonald, Guysborough Antigonish Strait Health Authority

David McKeown, Toronto Public Health

Moira O’Regan-Hogan, Eastern Health Services

Dianne Patychuk, Toronto Central Local Health Integration Network

Karoline Philipp, Chinook Health

Susan Scrivens, Vancouver Coastal Health Authority

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David Strong, Calgary Health Region

Penny Sutcliffe, Sudbury and District Health Unit

Eileen Woodford, Guysborough Antigonish Strait Health Authority and Cape Breton District Health Authority

NCC-DH staff

Lesley PoirierRyan McCarthy

CPHI staff

Elizabeth Gyorfi-Dyke Keith DennySusan Charron

Wayne Marsh (Facilitator)

Susan Goldberg (Writer)

Pamela Chappell (Note-taker)Pamela Rizzotti (Note-taker)Angela Peckham (Note-taker)Heather MacDonald (Note-taker)


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Appendix B. AgendaReducing Gaps in Health Knowledge Synthesis, Translation and Exchange

Workshop Objectives

To share currentresearch on factorsassociated with healthgaps in Canada

To facilitate knowledgeexchange and transfer

To discuss concretepolicy and programdevelopment directionsthat could reduce healthgaps at the regional level

Workshop Outline

REGISTRATION AND HOT BUFFET BREAKFAST AVAILABLE 7:45 a.m.

1. Welcome, Brief Intro and Context Setting 8:30 a.m.

— Elizabeth Gyorfi-Dyke, CPHI

— Lesley Poirier, NCC-DH

PART ONEGaps in Health: What Do We Know About Determinants?

2. Keynote Address 8:45 a.m.• What have we learned about improving

population health?• Key messages for action on gaps• Q&A

— John Frank

3. Panel-Based Dialogue: The Determinants and Gaps 9:30 a.m.• What’s been tried at the regional level,

what’s worked and outstanding challenges • Q&A

— Mark Lemstra— Eileen Woodford

BREAK 10:15 a.m.

4. Round-table Dialogue; Group Reports Back 10:45 a.m.• Small-group dialogue and feedback

regarding learning at the regional level and key messages for action on gaps

• Reports back

LUNCH 12:00 noon

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1 C.J. Frankish, G.E. Moulton, D. Quantz, A.J. Carson, A.L. Casebeer, J.D. Eyles, R. Labonte andB.E. Evoy. Addressing the non-medical determinants of health: a survey of Canada's health regions.Can J Public Health. 98, 1 (Jan-Feb 2007): pp. 41–7.

2 Knowledge translation in this context has been defined by the Canadian Institutes of HealthResearch as the “exchange, synthesis and ethically sound application of knowledge—within acomplex system of interactions among researchers and users—to accelerate the capture of thebenefits of research for Canadians through improved health, more effective services and products,and a strengthened health care system.”

3 Wayne Marsh, Ed. “Reducing Gaps in Health: Knowledge Synthesis, Translation & Exchange. ThePre-Work.” (Handout; synthesis of participants’ responses to two pre-workshop questions: 1. Whatis on your region’s agenda regarding determinants of health and reducing gaps in health?; 2. Whatinformation do you need to apply a population health approach at the regional level?) March 9, 2007.

PART TWOReducing Gaps Through Knowledge Synthesis,Translation and Exchange

6. Introduction to the Knowledge Brokers 1:00 p.m.• Mini-briefings to frame the afternoon’s dialogue

— Elizabeth Gyorfi-Dyke and Keith Denny, CPHI— Lesley Poirier and Ryan McCarthy, NCC-DH

7. Round-Table Dialogue 1:30 p.m.• Small-group dialogue and feedback

regarding how NCC and CPHI could help others reduce gaps through knowledgesynthesis, translation and exchange

BREAK 2:30 p.m.

Round-Table Group Reports Back 2:50 p.m.

8. Synthesis of the Afternoon’s Dialogue and Reflections on the Day 3:10 p.m.

— John Frank

9. Wrapping Up 3:30 p.m.• Revisiting the work we’ve done,

acknowledging points of consensus and unresolved challenges

• Tying off loose ends• Completing the formal evaluation

ADJOURNMENT 4:00 p.m.

Taking health information further

À l’avant-garde de l’information sur la santé

www.cihi.ca

www.icis.ca

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