POP News - Issue 21

February 2010

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Inside this Issue

 

Message from the Scientific Director: Dr. Nancy Edwards

Dr. Nancy EdwardsThe fall of 2009 will long be remembered as a period of unprecedented efforts by public health practitioners to get the H1N1 vaccine to Canadians. The pandemic reminded all of us of the essential role of those who deliver public health services. We thank them for their ongoing contributions to the health of Canadians.

The past few months have been a busy period for our Institute. We have been steaming ahead on several fronts to address our new strategic priorities. Working with a number of internal and external partners, we have developed several new requests for applications (RFAs) including a rapid response RFA for the H1N1 outbreak, a rapid response intervention research RFA and a soon to be launched programmatic research RFA. These RFAs focus on our priority objectives to further our understanding of pathways to health equity, to examine the impact of complex population health interventions on health and health equity, and to examine how implementation systems for population health interventions may strengthen or weaken the impact of population health interventions.

In an effort to increase the reach to our community of scientists, we have started to use more distance technology. We have held two virtual sessions on our strategic priorities and funding opportunities, and our virtual population health ethics journal club commenced on February 22nd. Additional virtual sessions are planned on programmatic research following the launch of the RFA. Registration information for the latter will be available on our CHNET-Works! partner website. We welcome your feedback on these sessions and on ways in which we may continue to extend our reach across Canada.

Preparations for the CIHR 10-year international review have begun in earnest and we are evaluating a number of IPPH-funded initiatives. We are pleased to welcome Sarah Viehbeck who will join us as a Senior Evaluation Analyst in March. Ghisline Bourque has also joined our team, replacing Julie Senécal as Assistant Director during her maternity leave. As part of our preparations for the international review, two new casebooks are planned for this year. The Population Health Interventions Casebook will be prepared in partnership with the Canadian Population Health Initiative and CIHR's Knowledge Translation Branch, while the Global Health Casebook will be jointly sponsored by the Global Health Research Initiative. These casebooks will highlight significant accomplishments in the field and will identify important research gaps. An announcement about contributions to both casebooks will be issued in the next couple of months.

We have been involved in planning for the upcoming Canadian Public Health Association (CPHA) Centennial Conference (June 13-16, 2010). This event will provide an opportunity to celebrate a century of public health accomplishments. We are pleased to join CPHA in a call for the top research contributions in the field of public and population health. The research nomination process will be announced shortly.

In closing, we hope to see many of you at the CPHA Conference in Toronto. It will be an important time to reflect on accomplishments and to think about the many challenges that lie ahead.


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Invited Book Review - Textbook of International Health: Global Health in a Dynamic World (3rd edition)

Textbook of International Health: Global Health in a Dynamic World (3rd edition)
Anne-Emanuelle Birn, Yogan Pillay and Timothy M. Holtz
New York and Oxford: Oxford University Press, 2009

By Ted Schrecker
Scientist/Associate Professor
Department of Epidemiology and Community Medicine
Institute of Population Health, University of Ottawa

Sir Michael Marmot, who chaired the WHO Commission on Social Determinants of Health, defined the imperative of seeking "public policy based on a vision of the world where people matter and social justice is paramount." In this third edition of a well known text the authors have produced a compelling case for such an approach to global health. This book will be a valuable resource for teaching, for global health professionals and a reference for researchers outside the field seeking a map of key concepts and methodological debates.

Opening chapters cover the history of international health, and the many international organizations that are now involved. The World Health Organization and various other UN system agencies are often less influential than the World Bank, the International Monetary Fund, and a range of private philanthropies (of which the Bill and Melinda Gates Foundation is the largest) and public-private partnerships, or PPPs. In Chapter 4, the conceptual core of the book, the authors distinguish among "biomedical," "behavioural" and "political economy of health" approaches to understanding health and disease and describe the historical background to these understandings. Biomedical and behavioural approaches today dominate research and professional practice; while emphasizing that each approach has explanatory value and they are not mutually exclusive, the authors are clearly committed to the political economy of health. Here and throughout the book, they advance this perspective with extensive citation of the relevant scientific literature; the references, useful in themselves, also add transparency for readers who may not share the authors' analysis.

The thorough description in Chapter 6 of the global distribution of illness and death will be especially valuable for readers without a previous background in epidemiology or the health sciences. The authors emphasize the limits of the epidemiological transition model, and indeed suggest that the conventional division between communicable and non-communicable disease is less useful than a threefold typology: diseases of marginalization and deprivation (diarrhea, neglected tropical diseases, malaria, respiratory infections); diseases of modernization and work (cardiovascular disease, cancer, road traffic injuries); and diseases of marginalization and modernization (diabetes, chronic obstructive pulmonary disease, tuberculosis, and HIV/AIDS).

Chapter 7 is devoted to the societal determinants of health that contribute to health inequalities in countries rich and poor alike, and to a succinct comparison of models (once again, not mutually exclusive) that seek to explain those disparities. Both chapters demonstrate the indispensability of theory, and theoretical self-consciousness: scientific explanations are always constructed within a theoretical framework, and too often the presumptions that constitute that framework remain unexamined.

Against this background, Chapter 5 describes the availability of health data and the many relevant uncertainties, emphasizing the incompleteness of data on social inequalities in health; the problematic nature of the Disability Adjusted Life-Years (DALYs) used in studies of the global burden of disease; and the need for attention to intra-national variations in health indicators. Chapter 8 focuses on health in crises, both 'natural' and human-made. The effects of 'natural' disasters like Hurricane Katrina must be understood as consequences of how societies organize to respond to such events. The authors succinctly describe major health consequences of war and militarism, with the war in Iraq and the conflict in the Democratic Republic of Congo (the deadliest since World War II) among the case studies. Among these consequences, the forced displacement of human populations both within and across national borders creates formidable obstacles to providing even minimal standards of care for the world's growing numbers of refugees.

Then, in Chapter 9, the authors situate many of the influences on societal determinants of health with reference to "neoliberal globalization": the emergence of a global marketplace. (Full disclosure: the analytical framework they use to identify pathways through which globalization affects health is drawn from an article I co-authored.) They argue that the current multilateral trade regime, the activities of transnational corporations, the ways in which the World Bank and IMF have addressed the problems of developing country debt, and financial liberalization all have often had negative consequences for health. A particular focus is on hazardous working conditions (including child labour) and the export of hazardous industrial processes and industrial wastes. In the following chapter, the authors expand this analysis with reference to the political economy of environmental health.

Chapters 11 and 12 cover health economics and the organization of health systems. The authors explore such issues as the equity implications of user fees, the growing role of international aid agencies in financing health services in low-income countries, and the expanded emphasis on cost-benefit and cost-effectiveness analysis. A thorough comparison of health care systems in Germany, the United Kingdom, the former Soviet Union and the United States is followed by a comparably detailed description of health 'reform' initiatives in rich and poor regions, emphasizing that health systems reflect political choices and underlying, sometimes competing, sets of values. Thus, health system design – like other areas of international health - emerges as far more than a technical question.

Chapter 13 recapitulates earlier discussions of the successes and limitations of technical approaches to international health, offering case studies of societies that have achieved widespread improvements in health and a powerful critique of current perspectives on health promotion. The concluding chapter, on "doing international health," offers useful advice for those planning a career in the field as well as a strong statement that such a career must combine political engagement with a firm command of the necessary scientific knowledge.

Special care has been taken to ensure the book's suitability for the classroom. Numerous case studies are included, clarifying conceptual issues while also offering starting points for assignment topics. Tables and lists of terms and concepts make the material accessible for newcomers to the field. However, this is more than a first-rate textbook; it belongs in the libraries of all researchers, practitioners, and serious students of global health.


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Engaging citizens about the social determinants of health: a snapshot of IPPH-PHAC Cafés Scientifiques

By Emma Cohen
IPPH Knowledge Translation and Communications Officer

A café scientifique is an opportunity for two-way knowledge exchange between researchers and other professionals and the public on a topic of mutual interest in an informal, intimate setting. Typically, the format consists of three invited speakers presenting different perspectives on a predetermined topic followed by a moderated question and answer period.

The Institute of Population and Public Health (IPPH) and the Public Health Agency of Canada (PHAC) are jointly hosting cafés scientifiques with the objectives of sharing knowledge, raising awareness, and engaging citizens on the social determinants of health.

In October 2009 we hosted a café as part of CIHR's Mental Health Café Scientifique Series in partnership with the Mental Health Commission of Canada (MHCC). Given the café was taking place in Toronto, the Canadian city with the highest proportion of immigrants, we chose the theme of immigration and mental health: "Stranger in a Strange Land: How does Immigration Impact on Mental Health?"

Glenn Thompson of the MHCC commented, "We have something going here that creates an opportunity for the Commission. The Mental Health Café Scientifique Series gives an opportunity to speak to the audience about the MHCC and share its mandate but also to listen to comments and questions from the public."

Peter Smith, Institute for Work and Health and the University of Toronto, underscored that "immigrants" are not a homogeneous group. In his research, he has observed a cycle of financial and job insecurity among recent immigrants to Canada. Immigrants are often employed in temporary work and night shift positions, their work tends to be physically demanding, and they are traditionally over-qualified for their jobs. This job insecurity is closely tied to financial insecurity, which are both linked to poor mental health.

Laura Simich, Centre for Addiction and Mental Health, University of Toronto, shared her insights from qualitative research with new Canadians, particularly Tamil refugees. Gainful employment is perhaps one of the most important determinants to help refugees recover from trauma experienced in their native country. Unfortunately, their mental health may deteriorate over time when discrimination and other stresses are experienced. A research participant commented, "I didn't know the meaning of 'stress' until I came to Canada." Laura emphasized that mental health is not just an issue for the Canadian health systems to address; it requires a societal response.

Martha Ocampo offered a community perspective and shared information about programs and services available to racialized communities in Toronto through Across Boundaries mental health centre where she works as the Manager of Education and Resources. She painted a dire picture of immigrants' mental health as a result of discrimination, lack of social support, and homelessness but ended on a hopeful note by sharing the diverse strategies adopted by Across Boundaries to promote health. These include community outreach and mobilization, hiring staff with lived experience, honouring culture, and working with community leaders.

Following the Global Forum on Health Research, the Canadian Conference on International Health and other global health events in November 2009, we held a café scientifique in Ottawa on violence as a global public health issue: "In Conflict and in Peace: Supporting the Health of Global Populations."

Valerie Percival, International Affairs, Carleton University, gave a general account of the relationship between health and violent conflict emphasizing the political nature of health and health interventions. Later Valerie mentioned that she was surprised there was not more critical reflection from the audience on the potential risk of implementing health interventions in conflict zones, for example, the unintended consequence of these interventions to worsen health outcomes.

Janet Hatcher-Roberts, Canadian Society for International Health, shared stark evidence that ultimately led to a CIDA-funded health project with Balkan youths dealing with the aftermath of armed conflict. With an average person's salary decreasing by almost 75% from pre-war levels it is not surprising that Balkan youth experience high and increasing rates of depression, lack youth-friendly health services, and are under-employed. By engaging youth through theatre and stories the project helped to inform them of their right to health.

Chris Rosene, Canadian Red Cross Society, discussed the international work of the Red Cross societies with a focus on the Sri Lanka conflict (a civil war fought in Sri Lanka from 1983 to 2009). The Red Cross was active in Sri Lanka prior to, during, and after the conflict. Health services provided pre-conflict can help to build trust between the Red Cross and national leaders. Health services provided during a conflict can help create opportunities for rapprochement between parties and communities and can occasionally lead to ceasefires. Support is still needed after a conflict because of the long-term health effects of war including internally displaced people. But "even wars have limits" and Chris remarked it is always possible to sow seeds for peace.

There was at least an hour of audience discussion following the presentations at each of the cafés. At the mental health café, this was centered on what can be done to improve the situation. Discussion at the global health café was around the characteristics and training needs of people working internationally in conflict zones. A few people noted in their evaluations that the cafés are a "great initiative to start dialogue" and that "people from a variety of backgrounds" can participate.

The diverse audiences at both cafés necessitated skilled moderators to keep discussion on topic and to raise new issues. Evaluation comments and the speakers themselves noted Kwame McKenzie's excellent ability to moderate the discussion at the mental health café. Jim Chauvin, moderator of the global health café, left us with questions concerning Canada's role as a peace-building nation and whether our elected officials and general public are doing enough to promote peace internationally.

We are always open to your suggestions for future café scientifique themes. Please email Emma Cohen to offer suggestions. Please check the calendar on the IPPH Website for future café listings.

Upcoming Café: Child Poverty and Health. Montreal, Quebec. April 2010.


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Applied Public Health Chair Feature: Dr. Carolyn Dewa

Carolyn S. DewaCarolyn S. Dewa, MPH, PhD is a health economist and the recipient of an Applied Public Health Chair funded by the CIHR Institute of Population and Public Health and the Public Health Agency of Canada. Dr. Dewa is an expert on mental health and the workplace. Dr. Dewa leads the Centre for Addiction and Mental Health's Work and Well-being Research and Evaluation Program (WWREP) and is an Associate Professor at the University of Toronto.

Although many stakeholders work toward the same goal of improving workers' mental health, they rarely have opportunities to interact. The goal of Dr. Dewa's program of research is to conduct studies and encourage knowledge exchange that builds meaningful bridges between all the stakeholder groups required to transform mental heath in the workplace. The planning and development of the program for the 2009 Annual Canadian Congress for Research on Mental Health and Addiction in the Workplace is just one example of the approach used in Dr. Dewa's research program.

This recent Congress provided delegates an opportunity to share information on the latest research and evidence-based interventions (see, for example, the article by Mahée Gilbert-Ouimet et al. in this issue of POP News). In addition, it introduced a broader public health perspective to research in this area by facilitating discussions about the roles of the physical environment, policy, law as well as biological and psychosocial risk factors to mental health with the goal of breaking down disciplinary silos. It also provided forums for the media, labor unions, employers, research funders and policy makers to offer their perspectives about their contributions to mental health for workers.

Emma Cohen (CIHR-IPPH): What motivated you to Chair the 2009 Annual Canadian Congress for Research on Mental Health and Addiction in the Workplace?

Dr. Dewa: The Congress is the leading Canadian forum of its kind dedicated to improving the working environment and the mental health of employees. I wanted to create a forum for people to hear other perspectives and interact in a meaningful way with different stakeholders.

EC: Who attended the Congress?

Dr. Dewa: Of the almost 200 Canadian and international delegates, most were researchers, administrators, clinicians, students or policy makers. The meeting also provided opportunities for the media, labor unions, employers, research funders and policy makers to offer their perspectives.

EC: Did you receive any feedback from Congress attendees?

Dr. Dewa: The Congress was a great success. Evaluations indicated that 96% of respondents found the topics covered at the Congress were informative and 87% thought they were useful. Moreover, 90% of delegates reported they gained new knowledge that could be applied to their own workplace or research.

EC: How can people who missed the Congress find out more about it?

Dr. Dewa: Based on the Congress program, a special issue of HealthcarePapers will appear in Summer 2010.


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2009-2010 CIHR Grants and Awards Guide

CIHR announces the launch of the revised Grants and Awards Guide. The guide has been significantly restructured and many changes have been made to the policies. The scientists are strongly encouraged to read the entire document to familiarize themselves with the revised guide.

Public Consultation on Population Health Intervention Research FAQs

The Population Health Intervention Research Initiative for Canada (PHIRIC) aims to increase the quantity, quality and use of population health intervention research in Canada through a strategic and deliberate alignment of initiatives by key organizations responsible for public health research, policy and practice.

The PHIRIC Communications Committee developed a list of Frequently Asked Questions (FAQs) and this related survey for public consultation. The purpose of the FAQs is to ensure consistent descriptions of population health intervention research terms and concepts.

Here are some examples:

What's the intervention?

It can be a range of things. What automatically often comes to mind is programs or policies designed and delivered to improve health or health equity or to address a given health behaviour – so a new school-based intervention to reduce obesity, or a policy to ban trans fat, or a tax hike on cigarettes.

But "the intervention" can also be policy or program designed for another purpose, like money injected into the economy to increase employment that is investigated for its impact on health because the investigator makes a cogent theoretical argument for why the phenomena might be linked. By calling this "intervention research" we are drawing attention to the human agency in the design of these policies, with the aim that good research on the policy impact might influence the decisions people take about these policies in future.

By this definition, PHIR includes fields like health promotion research, program evaluation, policy analysis and health impact assessment to name but a few.

Does the focus have to be on the effects of the intervention, for it to be called intervention research?

No. Intervention research is also about all parts of the process of designing and testing solutions to problems and getting solutions into place – or any one piece of this. It can involve process evaluation of interventions (assessing reach, implementation, satisfaction of participants, quality). It can involve assessment of the contribution of context and how interventions adjust to different contexts. It extends to an assessment of how interventions are sustained over time or become embedded in the host institutions. It also includes diffusion research- or understanding how interventions are spread to new sites or taken up differently by different groups. It therefore identifies a specific population health intervention as its object of investigation either as an independent or as a dependent variable. PHIR can also be focused on refining and further developing PHIR methods.

Click here to take the survey. Thank you.


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Summary and Key Findings of a Study Assessing the Effects of an Organizational Intervention in the Workplace on Health

Mahée Gilbert-Ouimet, MSc; Chantal Brisson, PhD; Michel Vézina, PhD; Alain Vinet, PhD; Louis Trudel, PhD; Renée Bourbonnais, PhD; Benoît Masse, PhD; Geneviève Baril-Gingras, PhD.

From 2000 to 2007, the Interdisciplinary Research Group on Workplace Organization and Health (GIROST) conducted a study in partnership with a Quebec public organization in the insurance sector with over 1,300 employees. The study's objective was to assess the effects of an organizational intervention in the workplace on the health of employees.

The intervention was defined as being the organizational changes undertaken to reduce one or more stressors of the work environment. Four stressors were targeted: psychological demands, decision latitude, social support, and recognition. These are defined as follows:

  1. psychological demands: excessive work load, having to work very hard or very fast, conflicting demands and interruptions;
  2. decision latitude: not making one's own decision or taking part in decisions affecting oneself, as well as in opportunities to develop skills and learning new things;
  3. social support: lack of help and cooperation of colleagues and superiors;
  4. recognition (as defined by three dimensions): a social dimension referring to respect and esteem, an organizational dimension related to promotion prospects and job security, and a financial dimension (income).

The health indicators evaluated were: symptoms of psychological distress, blood pressure and musculoskeletal symptoms (pain in the back, shoulders, neck, wrists, hands).

A first measurement consisted in painting an initial picture of the stressors and health indicators in each of the participating organization's departments. This provided an opportunity to identify priority targets for intervention. In a given department, the priority targets corresponded to stressors for which the percentage of exposed employees was higher than in the rest of the organization or in two external reference groups of workers.

Between 2002 and 2004, management implemented various organizational changes designed to improve the work environment. A second measurement was taken six months after the intervention period to determine short-term effects. This measurement allowed us to observe that the majority of changes implemented corresponded to the initially identified targets for intervention.

A third measurement, taken 36 months after the intervention, made it possible to assess observed effects over the medium term. Following the implementation of changes, three stressors of the work environment had significantly decreased: high psychological demands, low social support between colleagues, and low social recognition (respect and esteem). In addition, employees showed fewer symptoms of psychological distress, had improved blood pressure levels and experienced less neck and shoulder pain as well as less lower back pain than at the beginning of the study.

Mental health problems, cardiovascular diseases and musculoskeletal disorders are the three most frequent, costly and disabling groups of health problems in the working-age population. This study has demonstrated that changes designed to improve specific stressors in the work environment can contribute to preventing these problems.


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Mental Health and Resilience-A Key Theme for CPHI

Jean Harvey, Director and Andrew Taylor, Senior Analyst, CPHI

The Canadian Institute for Health Information (CIHI) collects and analyzes information on health and health care in Canada. The Canadian Population Health Initiative (CPHI), a part of CIHI, focuses specifically on population health issues to foster a better understanding of factors that affect the health of individuals and communities and to contribute to the development of policies that reduce inequities and improve the health and well-being of Canadians.

Since 2007, CPHI has produced a series of three reports in the area of mental health and resilience. The reports synthesize key research findings, present new data analyses and share evidence of what works and does not work from a policy and programming perspective.

Exploring the links between individual, social, economic, and cultural factors and mental health- the first two reports focused on at-risk groups – those at-risk of or experiencing homelessness, and those at-risk of committing criminal acts or who are involved with Canada's criminal justice system.

Mental Health and Homelessness (released August 2007) provides an overview of the latest research, surveys and policy initiatives related to mental health, homelessness and various determinants of health, as well as information on hospital use by homeless Canadians.

Mental Health, Delinquency and Criminal Activity (released April 2008) examines what factors related to mental health are protective against or increase the risk for youth delinquency. It also looks at the characteristics of people hospitalized with mental illness who have a criminal history, and issues specific to mental illness and the justice system.

A third report, Exploring Positive Mental Health (released March 2009) looks more closely at the determinants of mental health, specifically what makes people mentally healthy. It moves away from mental illness issues and toward the concept of positive mental health; how it's measured, characteristics associated with it, and key components for the promotion of positive mental health.

Several themes emerged across the reports:

  1. To better understand and address issues related to mental health, mental illness, homelessness, and criminal activity there is a role for all levels of government and sectors within and beyond the health care sector.
  2. Addressing the larger contextual needs of at-risk groups in addition to treating individual symptoms or factors has value.
  3. Within the individual, family, school/peer and community contexts, various factors may protect against or increase one's risk of homelessness and criminal activity as well as promote or hinder the development of positive mental health
  4. Programming that targets multiple risk and protective factors is key
  5. Upstream approaches that promote positive and protective aspects are often as necessary as strategies to address and prevent the consequences of risk factors for mental illness.
  6. Aspects of our social environment including social support, community belonging and "connectedness" are most consistently associated with mental health.

Related to the theme of mental health and resilience, CPHI also commissioned a number of papers on what makes communities mentally healthy and produced a range of activities and products such as facilitated workshops and online learning resources. Please visit our Website for more information.


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Announcements

The 9th Annual CIHR IHSPR-IPPH Summer Institute 2010: Revisiting the Foundations of Primary Healthcare Research
Nottawasaga Inn, Alliston, Ontario
June 20-23, 2010

A strong primary healthcare system is the foundation of any high-performing, sustainable, and accessible healthcare system and is associated with advantages such as better health outcomes, lower cost of care, and reduced inequities in health and health services across populations. Despite these recognized benefits, Canada continues to grapple with access to coordinated care, universal coverage, person-centered care systems, healthy public policies, leadership and effective governance.

Health decision makers and researchers in Canada are increasingly recognizing the need for primary healthcare transformation and wide-scale innovation, which must be supported by timely, relevant, and high-quality primary research.

The 2010 Summer Institute will focus on the next frontiers in primary healthcare research, including pressing questions, methodological gaps, and issues in knowledge translation. Topics covered may include primary healthcare policy, quality and safety in primary healthcare delivery, the interface between primary healthcare and public health in Canada, ethical issues in the conduct of primary healthcare research, comparative and population-based research, knowledge translation for practice and policy, and other emerging issues in primary healthcare research.

The call for applications will be launched in March, 2010. Please join the IPPH or IHSPR electronic mailing lists to receive notice of this training opportunity.

To join the IHSPR mailing list, visit the IHSPR Website.
To join the IPPH mailing list, please email Ashley Page.

Funding Opportunities

Please visit the CIHR Website for a list of current funding opportunities being offered by the Institute

Communications

Please let us know about your recent publications. We would like to profile some of these in future newsletters. Please email Emma Cohen, IPPH Knowledge Translation and Communications Officer. Thank you.

Featured articles:
Hanusaik N, O'Loughlin JL, Kishchuk N, Paradis G, Cameron R. (2009). Organizational capacity for chronic disease prevention: A survey of Canadian public health organizations. Euro J Public Health. [Epub ahead of print].
Hwang SW, Wilkins R, Tjepkema M, O'Campo PJ, Dunn JR. (2009). Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. Bmj. 26;339-47.
Fang R, Kmetic A, Millar J, Drasic L. (2009). Disparities in chronic disease among Canada's low-income populations. Prev Chronic Dis. 6(4):a115.

Canadian Public Health Association Centenary Conference

Public Health in Canada: Shaping the Future Together
June 13-16, 2010, Sheraton Centre Toronto, Toronto, Ontario
IPPH session on Intersectoral Action: Wednesday, June 16th, from 9:00 – 10:30 am