POP News – June 2012, Volume 2, Issue 3

Table of Contents


Message from the Scientific Director

Nancy Edwards

Over the last few months I have had the opportunity to attend several public and population health conferences in Canada and abroad including the World Congress of Public Health Associations in Ethiopia; the "Diabesity" – A World-Wide Challenge Conference sponsored by the EU Commission in Brussels; the National Health Law Conference on Global Health Challenges and the Role of Law in Toronto; and the International Conference to Advance a Population Health Intervention Research Agenda in Montreal that we co-sponsored with the Centers for Disease Control and Prevention (CDC) and the National Institute on Minority Health and Health Disparities (NIMHD) with the help of the Texas A&M Health Science Centre.

On May 28th, 2012 we hosted a reception at the University of Ottawa in honour of Sir Michael Marmot's visit to Canada for a cross-section of representatives from academia, government, community-based and non-profit organizations. Sir Michael Marmot is past president of the British Medical Association and was Chair of the World Health Organization's Commission on Social Determinants of Health from 2005 until 2008. At the event we also heard from Dr. Richard Massé, Chair, IPPH Institute Advisory Board; Judith Bossé, Assistant Deputy Minister, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada; Denis Prud'homme, Dean, Faculty of Health Sciences, University of Ottawa, Ottawa; and, the Honourable Monique Bégin, Former Commissioner, WHO Commission on Social Determinants of Health. More information about the reception will be posted on our website.

At each of these events, efforts to reorient research towards action on health inequities were described. Promising approaches include taking a systems or whole of government approach, examining ways to implement intersectoral action, identifying what contributes to the scalability of population health interventions and developing approaches for rigorous implementation science. As we look ahead, it will be important for us to continue to forge links between the work of Canadian scientists in these areas with those of colleagues in other settings.

IPPH is also working to insert these approaches within CIHR's Signature Initiatives. We have been collaborating particularly closely with other CIHR Institutes on two of these initiatives for which IPPH is a co-lead: Community-Based Primary Health Care (with IHSPR) and Pathways to Health Equity for Aboriginal Peoples (with IAPH [lead] and IGH [co-lead]). These approaches are also part of our global health efforts, in particular the ongoing work of the Global Health Research Initiative and the Global Alliance on Chronic Diseases. The need for an interdisciplinary approach to advance these fields of research is very apparent.

In addition, we welcome three summer students and a practicum student to IPPH who are sure to bring interdisciplinary perspectives to their work. Andrea Hill is a journalism and biology student at Carleton University with a keen interest in science writing and knowledge translation. Alannah Brown is working towards a double major in Health Studies and Sociology at the University of Toronto. Max Deschner is an Anthropology and Political Science student at McGill University. As a Masters of Public Health Student at the University of Toronto conducting her practicum at the Institute, Rachel MacLean will be applying the knowledge she has acquired through course work, particularly with respect to the application and evaluation of population health intervention research and global health research. We look forward to their contributions.

From all of us at IPPH, we wish you a healthy and productive summer.

Applied Public Health Chair Feature: Dr. Louise Fournier

Dr. Louise Fournier Dr. Louise Fournier

Article by Dr. Louise Fournier, Applied Public Health Chair, Canadian Institutes of Health Research; Ministère de la santé et des services sociaux du Québec, Fonds de la recherche en santé du Québec; Associate Professor, Department of Social and Preventive Medicine, Université de Montréal; Researcher, Centre de recherche du CHUM and Institut national de santé publique du Québec

A mentally healthy population is probably one of the greatest assets that a society can have. But a number of indicators show that the public's mental health is now seriously threatened. Mental health problems rank second in the burden of disease, right after cardiovascular disease and ahead of all forms of cancer combined. In addition, a study that I conducted using a sample of nearly 15,000 clients of general practitioners showed that mental health problems can cause more disabilities than chronic physical diseases do: the risk of having a high degree of disability is two times higher for people who have only chronic physical diseases, six times higher for people who have only a high level of symptoms of depression or anxiety, and 12 times higher for people who have both kinds of problems at once.

My work aims to improve the public's mental health through research and knowledge transfer. This research focuses mainly on the quality of primary care for people with anxiety and depression disorders and on the mental illnesses that are most common in the general population. My team attempts to determine how to improve the quality of this care and how to encourage the adoption of best practices in providing it. Two of our research projects, entitled Dialogue and Trajectoires ("pathways"), examine the impact of contextual and organizational factors on the care process and on changes in the mental health status of people affected by the targeted problems. One of these studies was conducted in the services areas of 15 health and social service centres in Quebec and the other in two isolated regions of Quebec — Nunavik and the Lower North Shore. Two other projects—Cible Qualité ("targeting quality") and Transition Cegep ("college transition") — involve testing knowledge translation programs designed to improve quality of care, the first in a primary care setting and the second in a college setting. This second program includes interventions to promote mental health and prevent mental illness. The hypothesis that we are testing is that teaching best practices and then providing scientific support to the people who implement them will encourage the development of more effective services and interventions. Lastly, to overcome the lack of tools and encourage collaboration among various professionals, I have developed a depression-care protocol for use by primary-care providers in Quebec. Here, the hypothesis is that implementing the recommendations in this protocol will improve the quality of care provided to people with depressive disorders and hence improve their mental health as well.

I conduct all of my research in close collaboration with policy makers, managers, and practitioners. Practitioners are both the source of inspiration for this research and the primary target audience for its results. It was in this context that the Qualaxia network was established. This network is comparable to a community of practice. It includes researchers, students and experts who share their scientific knowledge. The network's website currently offers content on 18 topics in population mental health; a publication, entitled Quintessence, on these same topics; a collection of nearly 900 relevant publications; and nearly 30 blogs. This site also hosts other sites dedicated to individual research projects, so that readers can follow their progress. The Qualaxia network also holds a variety of events, such as luncheon conferences and thematic days. This network has about 150 active members. Its chief goal is to improve the quality of interventions to prevent and cure mental illness and promote mental health. The network is now in its third year of existence. There are plans to conduct an evaluation of this network in the coming year.

Programmatic Grant Feature: How Poverty and Gender Equity Policies Affect Health

Jody Heymann Jody Heymann
Canada Research Chair in Global Health and Social Policy, Professor (joint appointment with the Department of Epidemiology, Biostatistics and Occupational Health and Department of Political Science), McGill University

Article by Andrea Hill, Summer Student, CIHR-IPPH

Though an enormous amount of evidence suggests that poverty, economic and gender inequalities negatively impact health, there has been far less research on how nations can best address this impact. With the support of one of 11 CIHR-IPPH programmatic grants in health and health equity, Dr. Jody Heymann and co-investigators hope to move forward our understanding of effective policy approaches.

Over the next five years, Heymann and her team will systematically examine the relationship between social policies and health outcomes in more than 50 countries worldwide. Specifically, they will examine how policies addressing economic and gender inequality impact three indicators of health central to the Millennium Development Goals (MDGs): morbidity and mortality in children; morbidity and mortality in women of reproductive age; and death from HIV/AIDS, tuberculosis and other diseases.

Research of this type and scale has not been attempted before, in part because appropriate data have not been available. But Heymann has spearheaded the development of a global data centre that contains comprehensive and comparative information on social policies in 193 UN countries. This will be used in tandem with health outcome data collected by surveys including UNICEF'S Multiple Indicator Cluster Survey, the Demographic and Health Surveys and the World Health Survey. Data will be analyzed to examine both average health outcomes and disparities in outcomes as they relate to social policies.

"We'll have very detailed household-level data and far more comprehensive policy data than has ever been available before," Heymann says. "When we only knew what the policy was in one country, it was much harder to know the impact of that policy. You could look at change over time, but other things were changing — the economy was changing over that time period, demographics were changing over that time period. When we're able to look at policies across many countries, it allows us to control much better for factors other than public policies that might be affecting health outcomes."

Heymann's team is made up of researchers from North America, Europe, Africa, Latin America and Asia who are working with knowledge mobilization partners from some of the world's largest nongovernmental (NGO) and intergovernmental organizations (IGO) including UNICEF, Save the Children, CARE and the World Federation of Public Health Associations. Regular meetings between these partners will ensure information is directly shared with the groups involved in designing social policies.

"We will be assessing our ability to develop information that the global NGOs and IGOs can and want to use in their work and that they find important and valuable in what they do," Heymann says.

By the time programmatic grant funding ends, Heymann and her team will also have developed a public use platform to make their findings available to a larger group of governments and policy makers.

"We hope by making available better comparative data across countries that individual countries can learn from the successes and failures, the opportunities and challenges that their neighbours and similar countries face so that every single one doesn't need to reinvent the wheel," Heymann says.

New Brunswick Social Policy Research Network Quietly Changing Public Policy

Andy Scott Andy Scott

Article by Andy Scott, Executive Director, New Brunswick Social Policy Research Network

The New Brunswick Social Policy Research Network (NB-SPRN) was established in 2010. Our mission is to advance an evidence-informed approach to socio-economic policy development. Key to the Network's mandate is identifying occasions for collaboration between government officials and people conducting research relevant to any area of socio-economic policy.

Over the past thirty years, public policy research analysis and development capacity has experienced fiscal restraint within public administrations around the world. There has been a concurrent increase in the amount of public policy research outside of government and an increased interest in the impact of that research, among academics.

These two circumstances have created historic openness on the part of government to receive information and advice, and active participation among those outside of government; academics and community-based organizations. The NBS-SPRN has seized this opportunity to introduce new forms of collaboration between academia, government and community organizations with tremendous response. Specifically, the NB-SPRN played a key role in brokering an arrangement between the University of New Brunswick, the New Brunswick Department of Health and the Regional Development Corporation to establish the New Brunswick Policy Research Institute for the mutual benefit of a data-rich provincial government and interested researchers who now have access to a prolific collection of administrative data.

In the field of health, the NB-SPRN is involved in research projects around childhood obesity, middle-age sedentary lifestyles, Aboriginal health, aging, rural delivery of services, chronic and mental illness, among our eighty-plus on-going projects.

The network is collaborating with the Atlantic Institute on Aging in the development of a research program in New Brunswick. The NB-SPRN identified 98 researchers in the province with an interest in aging and we are actively working on bringing these researchers together, identifying more specific areas of shared interest, introducing those unfamiliar with government and government personnel and also introducing those in government who are unaware of the large numbers of people doing aging-related research in the province.

We are currently playing a key role in knowledge translation by helping the research team of Drs. Stacey Reading (UNB) and Baukje (Bo) Miedema (Dal) expand their CIHR-funded H.E.A.L.T.H. Study and related Take H.E.A.R.T. Program across the province of New Brunswick. These evidence-based programs use inter-professional teams of exercise specialists, dietitians and family physicians to deliver physical activity and nutrition programming to adults in both urban and rural community settings. NB-SPRN was instrumental in bringing the researchers together with provincial government decision makers so that the programs can be developed and delivered in support of a provincial strategy to prevent, delay onset or reduce the severity of chronic illness. NB-SPRN helped the research team project funding grow from $12,000 in 2008 to a current total of over $600,000 in both CIHR and provincial government funds.

Invited Article Review

Jay Kaufman Jay Kaufman

Review of Frank & Haw."Best Practice Guidelines for Monitoring Socioeconomic Inequalities in Health Status: Lessons from Scotland" The Milbank Quarterly 2011; 89(4): 658-693.

Review by Jay Kaufman, Canada Research Chair in Health Disparities, Department of Epidemiology, Biostatistics and Occupational Health, Professor, McGill University

John Frank and Sally Haw provide a thoughtful and timely overview of disparities surveillance at the national level, with a focus on socioeconomic position (SEP) in relation to a suite of outcomes including all-cause mortality, low birthweight and mental health. They first recommend some "critical appraisal criteria" that help evaluate the significance and utility of specific indicators and then apply these criteria to data collected in Scotland over a roughly 10-year period, focusing on the contrast between the extreme deciles of the Scottish Index of Multiple Deprivation.

The criteria delineated by Frank and Haw seem quite reasonable, but at the same time represent an ideal that no indicator can meet unambiguously. Therefore, the summary evaluation the authors present is a subjective assessment of measures that might be close enough to work well, even if not perfectly. For example, Frank and Haw express no hesitations about cancer outcomes with respect to the criterion "epidemiological completeness and accuracy of reporting," giving these all an affirmative checkmark. And yet, cancer incidence and mortality are notoriously sensitive to screening policies, which in turn can show stark socioeconomic gradients. It is challenging to distinguish between men who die from prostate cancer versus those who die with prostate cancer, for example, because aggressive screening increases incidence and prevalence, even for tumors that will never cause death. Similar critiques can beleveled at almost all indicators and, of course, some are inherently more uncertain than others. The indicator "alcohol-related mortality," for example, similarly gets a pass from the authors, despite considerable doubt in causal attribution for most deaths beyond eponymous conditions such as "alcoholic liver disease."

The remaining criteria are likewise sensible in spirit but difficult to apply objectively. For example, the criterion "clarity for non-scientists" is a practical necessity, but judgment of what is deemed accessible to lay people is impossibly fickle. The authors consider healthy life expectancy too obscure on this point, but see no problems with all-cause mortality. However, all-cause mortality must be age-standardized to be meaningfully compared across time or population groups, and this creates ambiguities that can flummox even professionals. For example, when the age standard changed in the US from the 1970 to the 2000 census populations, ratio-measure disparities witnessed an instantaneous decrease.1 Many non-professionals would be hard-pressed to explain this phenomenon. On the other hand, as implied by Frank and Haw, perhaps this means that all ratio comparisons should be avoided. But this, too, would be a controversial suggestion.

Perhaps the most uncomfortable aspect of the paper is that the example data from Scotland are in fact ecologic, with SEP assigned at the level of a postal-code derived areal unit. The authors assure us that with 6505 areal units for a population of roughly 5 million (~750 individuals on average per cluster) these make a good proxy for individual SEP. This is clearly not true, even if the average population was 75 or 7.5.2 The authors themselves embrace this point with their final suggestion, which is that accurate high-quality surveillance ultimately requires anonymous linkage of micro-level data. This may not yet be a reality in Scotland, although some tentative steps in this direction have already been taken in Canada.3 As presciently stated by the authors, the future of disparities monitoring at the national level clearly lies in this direction.

References:

  1. Krieger N, Williams DR. Changing to the 2000 standard million: are declining racial/ethnic and socioeconomic inequalities in health real progress or statistical illusion? Am J Public Health. 2001 Aug;91(8):1209-13.
  2. Geronimus AT, Bound J. Use of census-based aggregate variables to proxy for socioeconomic group: evidence from national samples. Am J Epidemiol. 1998 Sep 1;148(5):475-86.
  3. Wilkins R, Tjepkema M, Mustard C, Choinière R. The Canadian census mortality follow-up study, 1991 through 2001. Statistics Canada, Catalogue no. 82-003-XPE, Health Reports 2008; 19(3): 25-43.

Student Corner

Student Corner: Health Equity Workshop Reflections

Carmen Dell Carmen Dell
Alycia Fridkin Alycia Fridkin
Fareen Karachiwalla Fareen Karachiwalla

Reflection by Carmen Dell (Canadian Nursing Students Association), Alycia Fridkin (Canadian Public Health Association Student Ad Hoc Committee) and Fareen Karachiwalla (National Specialty Society for Community Medicine)

It was a pleasure and honour to be student attendees at the Health Equity Workshop in Toronto hosted by the National Collaborating Centre for Determinants of Health (NCCDH) and CIHR's Institute of Population and Public Health (IPPH). Participating in this two-day event prompted our thinking around the unique perspectives students bring to the broader public health dialogue on health equity. As students, we strive to be meaningfully engaged in these issues and appreciate the need to build on the work of public health organizations such as NCCDH and IPPH to continue the dialogue and move towards action on addressing health equities.

Students across different health disciplines and professions recognize the importance of social and political factors in shaping the distribution of health, and that the current public health landscape is quite different than it was even 10 years ago. "Knowledge," "collaboration," and "leadership" have taken on new meanings and it is our role as students and future public health leaders to continually challenge the historical constructions of these concepts and work to incorporate new understandings of them into ever-changing public health practice. Globalization, capitalism, and information technology are highly influential in shaping peoples' health and if we are to effectively address health inequities in a contemporary context, we must understand how these systems intersect to produce health inequities and apply these understanding to our public health work.

We recognize the unique role of the public health sector in championing intersectoral action to address the root causes of inequities. Students in public health are increasingly being trained in interdisciplinary areas that lie outside of the traditional core public health sciences, such as public policy, critical and cultural studies, applied ethics, and land and food systems. Interdisciplinary perspectives should be included in public health training and public health perspectives should be included in the curricula of other professional health programs, such as medicine, nursing, and dentistry. We need to expand the public health discourse on health equity and learn to speak about health equity in ways that are meaningful to other professional arenas. In doing so we can better collaborate with our partners in economics, education, social work, communications, policy and law, for example, in achieving our common health equity goals. Representatives from other sectors should be invited to engage in public health dialogues on health equity at forums like the one hosted by NCCDH and IPPH.

Finally, in an era where statistics, economics and "hard" sciences dominate the evidence base for policy and decision-making, explicit attention to the underlying ideologies and values that drive our health equity work is being lost in translation. To solicit public support for addressing health inequities, we need to use compelling narratives that point to the implicit values within political agendas and not shy away from using the language of human rights. We need to increasingly engage with the human rights discourses that equity activists have been using for generations and call out injustice as exactly that.

Student Corner: PHIR Conference Reflections

Evan Castle Evan Castel

Reflection by Evan Castel, PhD candidate, Health Geography, Department of Geography, University of Toronto; CIHR Frederick Banting and Charles Best Canada Graduate Scholar

When is a complex intervention truly complex? What does community mean, and to whom? How can we develop and take advantage of emerging methodologies without compromising rigour? These are some of the ambitious questions that were up for discussion at the International Conference to Advance a Population Health Intervention Research (PHIR) Agenda held March 26-27th in Montreal, Quebec.

My own academic interest in each of these questions springs from my doctoral research, which examines health outcomes of social housing redevelopment interventions. Here, many of the common challenges of natural experiments must be addressed. Among these is the issue of randomization into control and intervention groups, which is almost always impossible. Furthermore, redevelopment introduces many overlapping interventions at once, and researchers lack control over the timing, phases, and site conditions. But in the absence of randomized studies, such natural experiments can offer valuable insight into the effectiveness of complex interventions in addressing health and social inequalities, a theme echoed by participants—with no shortage of caveats—using examples from their work across the globe.

Through such discussions, the conference offered a forum for conversations that cut across national, disciplinary and methodological lines, building upon (and sometimes re-examining) ideas that emerged from the 2009 and 2010 PHIR conferences. Student perspectives were encouraged; through my selection for a CIHR-IPPH travel award and acceptance into a poster session, I had the opportunity to contribute to these conversations and to present my work to an international and interdisciplinary audience that offered insightful and generous feedback. I came away with ideas that will strengthen many subsequent steps of my doctoral research. But it was in the breakout sessions that truly intimate exchanges began to happen, as the trials and tribulations of new methodologies were hashed out, tips and commiserations were exchanged, and lessons learned from work with diverse communities were shared. As in all of the best collaborative endeavours, I was reminded that these are the moments that make us excited to be engaged in the research—and research communities—that surround us.

Student Corner: PHIR Conference Reflections

Catherine Jones Catherine Jones

Reflection by Catherine Jones, PhD student in Public Health, Health Promotion option, Chaire Approches communautaires et inégalités de santé, Institute de Recherche en Santé Publique de l'Université de Montréal

Population health intervention research (PHIR) is concerned with developing knowledge on how policy and program interventions impact health at a population level. The international PHIR conference held in Montreal in March 2012 took on the challenge of discussing the nature of interventions, where Penny Hawe confronted the audience with a truism: "the way you think about an intervention determines your research about it." The conceptualisation of interventions as events, or series of events, in complex systems was proposed by Hawe1 as a way to consider "interventions as facilitated evolution." She asked the participants to think about the "boundary" of the intervention with which they were working. However, through which perspectives can PHIR delineate boundaries of interventions within systems? The idea of boundaries seems potentially incompatible with an understanding of complex systems that encompass uncertainty2.

How do I think about an intervention? Conceptualising interventions as events challenges the PHIR language of "policy and program interventions." Any "event" with a possibility of affecting population health pushes PHI researchers to adopt a much broader concept of change. The idea of boundaries presents a conundrum for the nature of interventions. I would argue that the idea of boundaries not only applies to the intervention theory and to the perspective through which we see an intervention, but also applies to what the intervention does and what its outcomes are.

I would suggest an alternative question for PHIR: what kinds of intersections or areas of overlapping boundaries are we working with? This questioning might foster the integration of complexity thinking as part of PHIR. Thinking about the intersections of boundaries calls into question our ideas about how the intervention interacts with its outcomes. While the discussion during the conference was primarily focused on complex interventions and complex systems, PHIR may also need to consider complex effects.

References:

  1. Hawe, P., A. Shiell, et al. "Theorising interventions as events in systems." American Journal of Community Psychology. 2009. 43(3-4): 267-276.
  2. Tremblay, M.-C. and L. Richard. "Complexity: a potential paradigm for a health promotion discipline." Health Promotion International. 2011.

Student Corner: Thinking About Implementation Systems Research for Population Health Interventions 2.0

Rachel MacLean Rachel MacLean

Reflection by Rachel MacLean, MPH candidate, University of Toronto; Practicum Student, CIHR-IPPH

On May 3rd, 2012, IPPH hosted its third webinar on Thinking about Implementation Systems Research for Population Health Interventions. More than 40 participants from across the country heard presentations from three experts in the field: Dr. Louise Potvin from Université de Montréal and le Centre de recherche Léa Roback; Mr. Ted Bruce from Vancouver Coastal Health; and Dr. Marjorie MacDonald from University of Victoria.

Each presenter underscored the necessity of shifting the current research emphasis on identification of the causes of ill-health to an exploration of interventions that contribute to population health, namely population health intervention research (PHIR) or, as coined by Dr. Potvin, "the science of solutions." Implementation systems research — which involves an examination of the organizational, policy and program delivery systems that support, implement, and sustain population health interventions — is an important constituent of PHIR.

Mr. Bruce's discussion of the characteristics of the population health practice and policy environment elucidated some of the challenges associated with PHIR and implementation systems research. Most notably, given the vast array of factors that influence health, there is rarely a direct path between an intervention and a particular outcome and thus it is difficult to define appropriate outcome measures and adequately evaluate a population health intervention. Moreover, a large proportion of health determinants operate outside of the health sector and therefore, as suggested by Drs. Potvin and MacDonald, implementation systems research necessitates a collaborative effort among all relevant stakeholders. Given the broad array of actors that may be involved in implementation systems research, including community groups, Dr. Potvin highlighted the necessity of engaging in a process of reflexivity to address potential power differentials. Lastly, in light of the complexities of conducting implementation systems research, Dr. Potvin also expressed the importance of adopting a range of methodological approaches and moving past the prioritization of evidence generated from randomized controlled trials.

An important goal of implementation systems research is to understand the contextual factors that facilitate the success of population health interventions and thereby a reduction in health inequities. Said research is particularly critical given the current environment whereby population health interventions must compete with other interventions in the health system for limited resources. The current work being conducted by the featured presenters is contributing to the expansion of the field and will assist in the creation of an environment that is conducive to the development, implementation, and sustainability of population health interventions.

Student Corner: Medical Research Council Population Health Methods and Challenges Conference Reflections

Daniel Fuller Daniel Fuller

Reflection by Daniel Fuller, PhD Candidate, Santé Publique, Université de Montréal

The Population Health Methods and Challenges conference brought together approximately 300 delegates for three days of discussion on methods and challenges in population health research in Birmingham, UK from April 24 to 26. From my perspective, the conference met two important purposes: to reflect on the current state of population health research and to learn the practical application of new methods. Reflections on collaborative research to generate and analyze big data, systems approaches and the contribution of history are leading to a focus on new methods for advancing population health research. Top among these methods at the conference was 'causal modeling' which includes propensity score matching, instrumental variables and regression discontinuity among others. New geographical methods and the potential for genome-wide association studies (GWAS) in population health were also discussed.

The main takeaway message from the conference for me was the need for population health researchers to think big and share. Population health researchers need to share data and conduct large scale studies combining multiple 'contexts' (e.g., neighbourhoods, cities, countries) to correctly and precisely estimate the impact of primary outcomes and have the power to detect potential effect heterogeneity by social or other factors. And we need to do this with the best data analysis methods.

Share your ideas, share your methods, share your syntax, and share your data. Population health research and hopefully population health will benefit.

A Framework for the Conduct of Public Health Initiatives

Public Health Ontario (PHO) has developed a framework to guide the ethics review of evidence-generating public health initiatives. The framework interprets the Government of Canada's Tri-Council Policy Statement 2, Ethical Conduct for Research Involving Humans (TCPS 2) through a public health lens and provides ten questions to facilitate the systematic examination of issues, including appropriate consideration of the interests of all stakeholders. The questions emphasize the interrelatedness of the welfare of individuals and communities and the positive obligation to promote equity and reciprocity.

This framework has been developed by a working group of public health and ethics professionals and scholars in consultation with individuals representing a wide range of public health roles. The framework was released broadly as a discussion paper in June 2011, which generated tremendous feedback from public health practitioners and academics from across Ontario, Canada and the U.S. This feedback was used to inform the current version.

Report from the House of Commons' Standing Committee on Health

In December 2011, Institute of Population and Public Health and Institute of Nutrition, Metabolism and Diabetes Scientific Directors Drs. Nancy Edwards and Philip Sherman participated in the House of Commons' Standing Committee on Health study of chronic diseases, health promotion and disease prevention. The Committee recently tabled a report in the House of Commons entitled "Chronic Disease Related to Aging and Health Promotion and Disease Prevention." The Committee heard about CIHR's support for health promotion and disease prevention research, and INMD's support for Obesity and Food and Health research, and made a recommendation that CIHR continue to support research that addresses chronic diseases.

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