POP News - Issue 19

June 2009 

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Inside this Issue

Message from the Scientific Director

In some ways it seems fitting that daily reminders of the H1N1 flu virus have formed part of the backdrop for the final stages of our strategic planning process. It is fitting for several reasons. Daily communications about this health threat have kept public health in the foreground rather than in the background of our news coverage. The dynamic nature of this outbreak further reminds us that our scientific methodologies need to match the complexity inherent in public health problems, and finally all of the pandemic preparedness planning work that has gone on behind the scenes over the past five years is now making a visible difference. This backdrop reminds us that successfully responding to public health threats requires the combined expertise of scientists, front-line workers, community leaders and policy-makers. It points to the critical involvement of partners in our future research endeavours.

We want to thank those of you who responded to our request for input on our draft strategic priorities. The feedback was carefully considered as we made further adjustments to the priorities. In April, our Institute Advisory Board (IAB) members indicated their unanimous support for our strategic priorities. Since that time, we have been finalizing the strategic plan and will be launching it at the upcoming Canadian Public Health Association (CPHA) Conference.

I would like to thank our Institute Advisory Board members, who provided valuable input on development of the strategic priorities. They have consistently provided outstanding guidance for the work of our Institute. In particular I want to acknowledge the contributions of our IAB members who will finish their terms at the end of August. Gilles Paradis has skilfully served as the Chair of our advisory board. Gilles' contributions to our board and to the public health community have been outstanding. At our last board meeting, he and his colleagues shared the impressive work of their Quebec Population Health Research Network and Gilles never leaves an IAB meeting without reminding us of the opportunity to publish in the Canadian Journal of Public Health. Pat Martens will complete her term as Vice Chair. We are pleased to present a featured interview with Pat in this issue.

Pat, like Gilles, holds an Applied Public Health Chair award from our institute and the Public Health Agency of Canada (PHAC). She is also this year's scientific cochair of the CPHA conference steering committee. She is wise, yet pragmatic and probably has the best collection of deer crossing road signs of anyone in Canada! Pat really understands how to work with decision-makers; as she so aptly states in her featured interview – "I'm here to bring my toolkit, and they (policy-makers and planners) are there to bring the context". David Mowat is one of those decision-makers. His insights from the policy arena and more recently from the front lines of public health in his role as Medical Officer of Health, Peel Region, have been enormously helpful. Elinor Wilson has skilfully contributed to our board, as she herself has taken on new roles, first as CEO of the CPHA and more recently, as President, Assisted Human Reproduction Canada. She too, has provided critical guidance for the Institute on how our scientific community might best interface with the policy realm.

Jason Robert has served as our ethics designate, always bringing an interesting angle for us to consider in relation to complex population health questions and thereby enriching our board discussions. Finally, we bid adieu to Michael Wolfson, our longest standing IAB member. It is difficult for us to imagine what an IAB meeting will be like without Michael's input. He is truly an outside-the-box thinker who consistently urges us to think big and to think differently. Once again, we thank all of our outgoing board members for their outstanding contributions. Your combined vision, wisdom and expertise have helped to shape the field of population and public health science in Canada and beyond.

In September, we will welcome new board members. We look forward to meeting them in Halifax, where we will be holding a joint IAB meeting with the Institute of Gender and Health. In the meantime, we look forward to seeing many of you at the upcoming conference in Winnipeg. There is an excellent scientific program lined up for this event. It is sure to be an exciting conference.


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Canadian Literacy and Health

Judith Maxwell
Past President and Senior
Fellow of Canadian Policy
Research Networks

On the face of it, the global recession appears to tip the balance in labour market policy from labour shortages to job shortages. In fact, the problem is far more complex and threatening to the health of Canadians. The jobs that are being lost are primarily in manufacturing and construction. Most require relatively low literacy skill. In contrast, jobs requiring high literacy skills are more stable and, in some occupations, are still rising. Thus we have the paradox that labour shortages may well continue in some occupations even as unemployment shatters the lives of people with low literacy skills.

With income inequality accelerating, we know that the health of the Canadian population will deteriorate. You will see it first on the frontlines in the communities you serve, as growing food insecurity, homelessness, and family stress affect the well -being of adults and their children.

What is scary about this situation is that the billions of dollars in economic stimulus announced since January do not address the underlying issue – that 42% of working age adults in Canada lack the literacy skills required to qualify for a good, steady job. Most of these people can read, but they cannot integrate information from dense texts in order to solve problems, which is what they need for Level 3 literacy.

Yet, the Canadian Council on Learning (CCL) estimates that there are about 4.4 million Canadians who could reach Level 3 if they had access to 40 hours of instruction.1 Imagine what a difference this training could make to their capacity to qualify for a better job!

The problem is that Canada does not have a wellfunctioning literacy training system at any stage of the life course from child care to adult education2.

The federal government has never come to grips with the importance of literacy for competitiveness and the provinces do their best to keep Ottawa out of their turf. The result is that community-based literacy programs in Canada are fragmented, under-funded, and lacking in basic infrastructure such as curriculum and professional development standards.

This is not just a recession issue. It is slated to get worse. The CCL also forecasts that the number of people with low literacy skill in Ontario, Alberta and British Columbia will grow by about 40% between 2001 and 20313.

Given this outlook, a country with any economic ambition would make literacy a national project. We can and should lobby for this. But don't hold your breath.

The good news is that some provinces (Saskatchewan and Nova Scotia, to name only two) have begun to focus more seriously on literacy in recent years, and there are examples of superb community projects (such as Pathways to Education) which are changing the trajectory of people's lives.

The most powerful mobilization against poverty and inequality in Canada at this time is happening at the local level – through the Vibrant Communities network, for example. So let's just think for a few minutes about what could be achieved at the local level, in the poor neighbourhoods where people with low literacy skills tend to be concentrated4.

The Canadian Public Health Association and its Health Partners have had a long-standing interest in promoting health literacy. But you can also be catalysts to raise literacy skills for vulnerable workers, by mobilizing business, labour, local government, educators, philanthropists and front-line social agencies in your community.

Be warned that the people who need help face personal barriers to success. Most do not perceive they have a literacy problem and they tend to have negative attitudes toward computers5. But they do want to find a job, and they know they need help. Their literacy skills can be assessed in the context of offering job counselling and job search supports.

To draw these people into learning mode, you will need well-trained counsellors to assess needs, identify the right training, and give wary students the confidence to commit. Some will also need financial or other kinds of support like child care or transportation.

Literacy gains can change people's lives, bringing hope where there is only despair. Believe me, it will be the best investment your community could make.

Yes we can!

  1. Canadian Council on Learning, Reading the Future: Planning to meet Canada's Future Literacy Needs, June 2008
  2. Judith Maxwell and Tatyana Teplova, Canada's Hidden Deficit: The Social Cost of Low Literacy Skills, Canadian Language and Literacy Research Network, National Strategy for Early Literacy, July, 2007 
  3. CCL, Reading the Future.
  4. Judith Maxwell, Strategies for Social Justice: Place, People and Policy, Community Foundations of Canada, September, 2006 5. CCL, Reading the Future.
  5. CCL, Reading the Future.

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Canadian Public Health Association Conference 2009

Debra Lynkowski
Chief Executive Officer
Canadian Public Health
Association

Since the 1800s, public health in Canada has been helping individuals take care of themselves, their families and their communities. "Since 1900, the average life expectancy for North Americans has increased by about 30 years. Over 25 of the 30 years can be accredited to public health initiatives, while medical advances account for less than four years." (B. J. Turnock, "Public Health: What it is and How it Works")

Research has been at the foundation of those advances and, research plays a pivotal role at the Canadian Public Health Association's (CPHA) Annual Conference.

The CPHA Annual Conference is Canada's largest national gathering of public health researchers, practitioners, policymakers, academics, students, and stakeholders from a range of disciplines and sectors. During the past several years, CPHA has hosted the conference in collaboration with the Canadian Institutes of Health Research – Institute of Population and Public Health, the Canadian Institute for Health Information – Canadian Population Health Initiative, and the Public Health Agency of Canada: The conference is also held in association with the local Public Health Association (this year, the Manitoba Public Health Association) and, most recently, the National Collaborating Centres for Public Health. This ongoing collaboration has created a unique knowledge exchange opportunity, grounded in a high-calibre scientific program.

A primary objective of the conference is to provide a forum to showcase and learn from innovative research, policies and practices. It is also an opportunity to profile strategies and programs that build the capacity of population and public health at all levels, and to leverage the potential of intersectoral partnerships and collaboration.

From a researcher's perspective, the Conference is an ideal venue for instructive dialogue. Policy makers and practitioners are eager to hear of the latest research advancements, and the evidence that supports their efforts in policy development or actual interventions in the field. At the same time, it is a unique opportunity for researchers to learn of the challenges and successes in current practice and policy, thereby helping to illuminate and inform future research.

At the foundation of its success, the public health response in Canada has created and strengthened numerous partnerships with the health sector and beyond. At its best, public health bridges gaps in communication and action. The Annual Conference is an ideal forum to quash the silos that can prevent an integrated, coordinated, and informed response to today's critical public health challenges. Just as important, the Conference is a meeting place for friends, old and new, to share successes and struggles.

It is an opportunity to reflect and renew. In further strengthening the connections between research, policy and practice, clinical care and public health, we will create a mosaic approach to population health and wellbeing, for the betterment of all Canadians. This is what public health has always been about and it is what we do best.


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Public Health Chair Feature: Dr. Pat Martens

Dr. Pat Martens (PM) is the recipient of one of fifteen Ap-plied Public Health Chairs funded by the CIHR-Institute of Population and Public Health, the Public Health Agency of Canada and other partners. She is also the Director of the Manitoba Centre for Health Policy (MCHP), Senior Research Scientist and Associate Professor, University of Manitoba. Steven Lewis (SL) interviewed Dr. Martens about her research and knowledge translation activities.

SL: The Manitoba Centre for Health Policy is widely known for its health services research. What drew you to apply for an Applied Public Health Chair?

PM: The Manitoba Centre has been misconstrued as only ad-dressing health services and policy (HSP) research, but it also deals with questions of population and public health (PPH) including an important focus on social determinants of health. This 'hybrid' focus characterizes my work with regional health authorities and other stakeholders. I see myself as a boundary spanner between HSP and PPH. The data we have available at the centre allow for analyses across the spectrum.

I was also drawn to the "applied" focus meaning that it has direct implications for public health policy and practice. It is embedded in my consciousness and part of my personal mission as a researcher. I think this is a focus that is shared by all public health chairs. There must have been a self-selection process to apply to this competition as many of my colleagues who hold such a chair were already naturally connecting to decision-makers. Our centre has also had a long-standing history working with regional health authorities and integrating knowledge translation (KT) into what we do. The Need to Know Team is a case in point. We consider the needs of decision-makers when framing our research questions and analyzing and interpreting the data we collect.

SL: You are one of fifteen chairs. Tell me about this net-work and how you have benefited from it thus far.

PM: I was fortunate to already know about half of the chairs through connections fostered by the Institute of Population and Public Health, including its advisory board and past summer institutes. It's a small country and a number of us have already informally collaborated and continue to do so. For instance, I will probably be working with Jim Dunn once MCHP has validated our newly acquired public housing data. There will be lots of opportunity to investigate the role of housing and health, and to develop methodologies to be able to answer a diversity of questions. Why do we see resiliency in some regions and not in others? What can we tease out from longitudinal data to study the effects of housing interventions on long-term and short-term outcomes in health, or education?

SL: What has surprised you most in your work so far?

PM: I have been surprised by the importance of drawing the differences between population vs. individual level effects and the need to improve literacy in this regard. Of note, we shouldn't discard small effects if they can create a population shift à la [renowned researcher Geoffrey] Rose. However, since most effects are measured at the individual level, the focus tends to be there. While relative risks and odds ratios at the individual level may appear modest, they can be dramatic at the population level. The Applied Public Health Chair gives me the credibility to speak to such issues to a wide variety of audiences in research and policy circles.

SL: Over the last 20 years, numerous reports have called for a shift from downstream health care issues - a clear focus in your 'day job' - to the up-stream factors that affect health. How do you balance these roles to help shift the discourse more upstream?

PM: I am the face who negotiates the deliverables for MCHP and I can confirm that Manitoba Health & Healthy Living is interested in upstream matters. After the public housing data was brought into the repository, the ministry was very interested in asking questions about what impact different types of housing are having on those with mental illness. Centre researchers like Marni Brownell and Noralou Roos have pioneered leading edge research on the health effects of education in childhood and adolescence.

SL: When do you think our understanding of the social determinants of health will translate into meaningful action?

PM: I see as part of my role as public health chair to be very visible in other sectors outside of health and to also ask questions about the health and economic impacts of public health interventions. Politicians are ultimately affected by public opinion. So what population health messages resonate with the public? How do we get the public to understand that taking an upstream lens is critical to reducing inequities? Unfortunately, governments are often more comfortable with using midstream approaches, like education (pamphlets, ads, etc.) which focuses on individual behaviour change. We need to encourage public comfort, through sharing research, that shows how tackling the big policy changes (like legislating no smoking policies in public places, not just telling people that smoking is bad) is really necessary to create healthy populations.

I recently read Nudge: Improving decisions about health, wealth and happiness (Thaler and Sunstein, 2008), outlining a USA approach to libertarian paternalism. It suggests that we need to build nudges into the system. This is a great book for helping more conservatively oriented people understand what public health people have known for a long time – up-stream is where it's at, and we need to build into our systems the things that make the right choice the easy choice for people and society. We need to stop looking at our noses, be creative and we need good data to support such action.

SL: This may be so but there is a steep discount value for future benefits. We seem to be more interested in a reassuring MRI than interventions with the potential for population level benefits later on. How would you respond?

PM: This is why we need to do good health services research to show the population picture of what the socioeconomic drivers are. We showed in our 2002 First Nations study that average household income had a real relationship with diabetes rates, but access to health care ser-vices best predicted an adverse outcome of diabetes – lower limb amputation. I am presently working with the Manitoba Métis Federation (MMF) to produce a similar "atlas" to depict differences at a population level. This work is revealing some non-intuitive results about geographical hot spots, and places of resilience. MMF is doing community consultations to plan interventions tailored to different social con-texts. This example helps illustrate the power of using epidemiological data in tandem with intervention planning.

SL: Which population health expert would you most like to have dinner with?

PM: It would have to be Geoffrey Rose, and also John McKinlay who so eloquently wrote about the work of Rose. Both have profoundly influenced my thinking. In terms of other luminaries, I actually had the pleasure of having dinner with Professor Sir Michael Marmot and we might collaborate on health inequities re-search. I'd love to talk with all these people about the double-edged sword of trying to shift populations, to be wary of some parts of the population improving faster and actually creating a bimodal distribution where some are "left behind".

SL: Why would we bother with those in the top quintile? Shouldn't we focus our efforts on those in the two bottom quintiles through targeted pro-grams? Isn't it all about redistribution of wealth?

PM: It's all about buy-in and the wealthy need to buy-in too. It's also about what strategies we employ for achieving societal benefits. In the case of non-smoking in public places, it was aimed at all citizens. We also know that increases in taxation led to greater population effects compared to mass education campaigns. I don't pretend to have all of the answers to the big policy questions though.

For example, we just finished a study that we call "What Works". In one chapter, we looked at breast-feeding initiation rates, to see what really influenced the shrinking inequities in the city of Winnipeg. Interestingly enough, we found that the introduction of the national and provincial intervention for low income women (e.g. Canadian Prenatal Nutrition Program in the inner city) actually showed a significant upward shift that reduced inequities in initiation rates. We also analyzed breast-feeding rates using regression modeling to control for individual risk factors, to see if there was a regional or hospital effect. In two regional health authorities, and in three hospitals, we saw an impact on breastfeeding rates (and it turns out that these regions and hospitals were the most proactive in activities to promote, support and protect breastfeeding in alignment with WHO/UNICEF and their Baby Friendly initiatives). Policy can make a difference at the population level!

Sometimes I wonder what area of expertise I represent. And I've decided that I am a generalist who brings the tool box of epidemiology to decision-making. You can bring the tools of epidemiology, population health perspectives and a keen interest in listening to policy makers and planners to decide what important questions need to be addressed (like we do with the provincial government and MCHP, or the regional health authorities in The Need to Know Team). I'm there to bring my toolkit, and they're there to bring the con-text. It's a great collaboration model.

SL: If you were to look around the world, what would you consider as population and pub-lic health heaven?

PM: Manitoba

SL: Seriously, which countries are leading the world to address inequities? How about the Scandinavian countries?

PM: Yes, I agree but only partially in the case of breastfeeding initiatives. I have been very impressed by the work on health inequities in the UK. In Canada, we are good at starting initiatives but we don't seem to follow-through. Through this chair, I think that we can, how-ever, put more emphasis on evidence-informed solutions at a population level.

SL: But don't we know enough to make good social policy?

PM: Well, perhaps but we each have a job to do. My job as researcher is to not only generate evidence, but ensure that this evidence is around the policy-making or planning table. And to do that, I need to make sure that our research is understandable and relevant, and that the people sitting around the table are capacitated to use it. We all need to consistently advocate for evidence-informed policy.

SL: Do academic institutions reward this kind of research?

PM: I can't speak for all institutions across the country but at the University of Manitoba, we are seeing changes where a focus on interdisciplinarity and integrated knowledge translation are being recognized as important. Of course, I'm in a great department (Community Health Sciences) which has understood this for a long time; so it is definitely rewarded within our Faculty of Medicine.

SL: What's on the immediate horizon for you?

PM: I am awaiting word on a Canadian Foundation for Innovation grant application, which will help us get justice data into the repository and offer interesting opportunities for social determinants of health research. I am also very committed to improving access to the repository housed at Manitoba Centre for Health Policy data repository.


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The National Collaborating Centre for Infectious Diseases

Dr. Margaret Fast
Scientific Director
The staff of NCCID

When the federal government created the Public Health Agency of Canada (PHAC) in 2004, it also established six National Collaborating Centres for Public Health (NCCPH). The primary function of the NCCPH was to promote and support the use of knowledge and evidence by public health practitioners across Canada through the development of collaboration across and between institutions, disciplines and jurisdictions, as part of an overarching strategy to build public health capacity in the country.

The National Collaborating Centre for Infectious Diseases (NCCID) is located in Winnipeg and is hosted by the Inter-national Centre for Infectious Diseases. Canada has a number of individuals, organizations and agencies involved in various aspects of infectious diseases and a wealth of experience and expertise in this discipline. NCCID's unique contribution is a public health approach to infectious diseases within a knowledge synthesis and translation context. NCCID draws on regional, national and international expertise and complements the contributions of the many other individuals and organizations in the public health system including PHAC, the provincial/territorial governments, academia, non-government organizations and public health professionals.

Linkages with and support from the five other NCCs – Determinants of Health, Aboriginal Health, Healthy Public Policy, Environmental Health, and Methods and Tools - and the NCCPH also provide unique opportunities for innovative approaches to prevention and control of communicable diseases.

The process for defining and selecting knowledge translation topics includes environmental scans, consultation with public health leaders and practitioners, and discussions with the NCCID Advisory Board. Key considerations are topical importance for public health, gaps in knowledge and knowledge translation and scope for value addition by the NCCID.

Main Knowledge Translation Topics:

  1. Prevention of sexually transmitted and blood-borne infections (STBBIs) with a specific focus on HIV/AIDS
  2. Reducing the burden of community-associated antimicrobial resistance
  3. Supporting public health capacity in northern and remote regions
  4. Integrating new technologies into public health

NCCID also recognizes that emerging and re-emerging pathogens (e.g. zoonoses, tuberculosis) are important disease threats in Canada and is exploring if and how the Centre might play a role in addressing these diseases.

The knowledge translation model utilized by NCCID focuses on knowledge synthesis which includes review of evidence – both explicit and tacit – and consultation with experts; knowledge exchange which includes NCCID-hosted forums and networks; and capacity-building which currently includes an NCCID Learning Site. The strategic approaches considered within this model are policy, program, practice and partnership.

Recent initiatives include:

  • Knowledge products generated by NCCID include eight Evidence Reviews summarizing the latest available evidence on specific HIV prevention topics. Additional Evidence Reviews are under development. In response to a Forum recommendation and in partnership with a nationally representative advisory committee, NCCID is developing an Outreach Guide for HIV and STBBI prevention in vulnerable populations. The Centre is also facilitating the development of three commissioned comprehensive reviews related to population-level interventions relevant to both human and veterinary public health to reduce ca-AMR in Canada.
  • Four national forums have been conducted with partners and stakeholders on a range of issues related to HIV/AIDS and STBBI and with an emphasis on prevention programs. NCCID has also hosted a consultation and a forum in the Territories to facilitate knowledge exchange related to communicable disease priorities and novel program strategies for northern and remote communities. Several on-line networks have been established as a result of these meetings and are being evaluated.
  • Another outcome of the forums is the Learning Site for HIV and STBBI prevention which was established in collaboration with staff at the Boyle McCauley Public Health Office in Edmonton. On-going evaluation and enhancements at this site will foster knowledge synthesis and ex-change for improving HIV and STBBI prevention programs across Canada. NCCID supports several initiatives of PHAC, particularly in the area of STBBI prevention and a national approach to antimicrobial resistance. NCCID also continues to participate in the annual NCCPH Summer Institute and all NCCs will be collaborating on a project related to small water systems in Canada.

Finally, although the focus of NCCID is on infectious diseases, we recognize that we need to concern ourselves with those social, cultural and economic forces which contribute to steep societal gradients in health status by undermining the health of vulnerable sub-populations. This remains arguably the most important challenge for all of us concerned with the health of the population.


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Call for Proposals

The Global Health Research Initiative (GHRI) promotes the conduct of health research and the use of its results in low- and middle-income countries (LMICs). The CIII2-Haiti program supports operations research activities to inform the decision-making process, generate scientific evidence, promote a better understanding of immunization-related issues, encourage and support new approaches to immunize hard-to-reach groups, strengthen research partnerships and develop research capacities. The aim of this call for proposals is to provide operations research grants on the following themes:

  • Issues Related to Service Provision
  • Issues Related to Demand for Services
  • Economic modeling / Epidemiology / Statistics

Gender, equity and ethics are integral aspects of these grants and must be addressed by all applications to this competition. Letters of intent due: June 29, 2009

Please visit the website for information about the Program.


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PPH Student Award Winners

The IPPH, in partnership with the Canadian Public Health Association (CPHA), the Canadian Population Health Initiative (CPHI) and the Public Health Agency of Canada (PHAC) are pleased to announce the results of the 2009 Dr. John Hastings CPHA Stu-dent Award Program, the Population and Public Health (PPH) Student Award Program and the Student Travel Bursary Program. The award winning research abstracts represent diverse topics in PPH research, policy and practice, particularly as they relate to the conference theme, "Strengthening Connections".

Dr. John Hastings CPHA Student Award: Ms. Marianne Paquet, a PhD student at the Université de Montréal. The Dr. John Hastings CPHA Student Award is presented to one successful applicant for the best abstract.

PhD Level PPH Student Awards: Ms. Amanda Ritchie, University of Toronto and Ms. Jennifer Cushon, University of Saskatchewan.

Master's Level PPH Student Awards: Ms. Ashley Heaslip, University of Toronto and Ms. Tamara Cohen, McGill University.

This is the sixth year of the awards program, which is in-tended to recognize excellence in Masters and PhD level PPH research in Canada. In addition to a cash prize, the awards pro-vide an opportunity for students to present their research at the annual CPHA Conference, and to have their research published in a special insert of the Canadian Journal of Public Health.

2009 CPHA Conference Student Travel Bursaries: For the third year, IPPH and PHAC have co-sponsored the Student Travel Bursary Pro-gram at the CPHA Conference. A total of 15 travel bursaries were offered this year.


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Funding Opportunities

Please visit the IPPH website in June for a list of new funding opportunities being offered by the Institute.

National Collaborating Centres for Public Health Summer Institute 2009

Knowledge for a Change July 7 to 9, 2009 - Château Mont-Sainte-Anne, Quebec The 2009 Summer Institute offers a program of practical sessions, networking opportunities, and accomplished speakers. You will find knowledge and tools for public health practitioners, policy-makers, re-searchers and community-based practitioners.

Speakers will include Marleen Bekker, Jacques Bourgault, Roz Lasker, Brint Milward, Mathieu Ouimet, André Picard, Janice Popp, Louise Potvin, and Kelly Skinner, as well as re-source people from across Can-ada affiliated with the National Collaborating Centres. They will share expertise in using networks, making re-search available to the public, understanding research-policy-practice interactions, and more.

Registration is now open online. We encourage you to act now as the registration deadline for pre-conference sessions is June 1. The Summer Institute will be a bilingual event, with simultaneous translation provided for all workshops and plenary sessions. For more information please visit their website.