Status Report--Retracing the history of the early development of national chronic disease surveillance in Canada and the major role of the Laboratory Centre for Disease Control (LCDC) from 1972 to 2000.

TITRE: Rapport d'étape - Historique des débuts de la surveillance nationale des maladies chroniques au Canada et rôle majeur du Laboratoire de lutte contre la maladie (LLCM) de 1972 à 2000. INTRODUCTION: La surveillance de la santé consiste en l'utilisation systématique et continue de données sur la santé recueillies régulièrement en vue d'orienter les mesures de santé publique en temps opportun. Ce document décrit la création et l'essor des systèmes nationaux de surveillance au Canada et les répercussions de ces systèmes sur la prévention des maladies chroniques et des blessures. En 2008, les auteurs ont commencé à retracer l'historique des débuts de la surveillance nationale des maladies chroniques au Canada, en commençant à 1960, et ils ont poursuivi leur examen jusqu'en 2000. Une publication de 1967 a retracé l'historique de la création du Laboratoire d'hygiène de 1921 à 1967. Notre étude fait suite à cette publication et décrit l'historique de l'établissement de la surveillance nationale des maladies chroniques au Canada, à la fois avant et après la création du Laboratoire de lutte contre la maladie (LCDC).

An intersectoral network for chronic disease prevention: the case of the Alberta healthy living network.

Chronic Diseases (CDs) are the leading causes of death and disability worldwide. CD experts have long promoted the use of integrated and intersectoral approaches to strengthen CD prevention efforts. This qualitative case study examined the perceived benefits and challenges associated with implementing an intersectoral network dedicated to CD prevention. Through interviewing key members of the Alberta Healthy Living Network (AHLN, or the Network), two overarching themes emerged from the data. The first relates to contrasting views on the role of the AHLN in relation to its actions and outcomes, especially concerning policy advocacy. The second focuses on the benefits and contributions of the AHLN and the challenge of demonstrating non-quantifiable outcomes. While the respondents agreed that the AHLN has contributed to intersectoral work in CD prevention in Alberta and to collaboration among Network members, several did not view this achievement as an end in itself and appealed to the Network to engage more in change-oriented activities. Managing contrasting expectations has had a significant impact on the functioning of the Network.

Challenges and opportunities for surveillance data to inform public health policy on chronic non-communicable diseases: Canadian perspectives.

A number of major challenges face surveillance systems in the field of chronic disease. The complex interplay of risk factors and determinants that result in chronic disease is calling into question traditional surveillance systems in terms of what is collected to inform policy decisions. At the same time, the complexity presents an opportunity to broaden the evidence base on which arguments can be based for chronic disease intervention to increase their potential to influence policy makers. This article describes some initiatives in Canada to enhance the capacity and utility of surveillance systems and their associated data to inform policy making in the field of chronic disease.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

The prevalence of hyperlipidemia in women and its association with use of oral contraceptives, sex hormone replacement therapy and nonlipid coronary artery disease risk factors. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To report the prevalence of lipid and nonlipid coronary artery disease risk factors in women classified by use of oral contraceptives or sex hormone replacement therapy. DESIGN, SETTING AND PARTICIPANTS: A population-based cross-sectional survey in nine Canadian provinces (not including Nova Scotia) between 1988 and 1992 invited 13,506 women aged 18 to 74 years to participate. During a clinic visit after a home interview, a blood sample was obtained following a fast of 8 h or more from 8637 women. OUTCOME MEASURES: Fasting plasma total cholesterol, triglycerides, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, blood pressure, smoking status, self-reported diabetes, and self-reported use of oral contraceptive or sex hormone replacement therapy pills. MAIN RESULTS: The prevalence of oral contraceptive use was 41% for women 18 to 24 years old and 20% for women 25 to 34 years old. The prevalence of sex hormone replacement therapy was 4% for women 35 to 44 years old, 20% for women 45 to 64 years old and 11% for women 65 to 74 years old. Users of sex hormone replacement therapy aged 35 to 44 years had slightly higher mean LDL cholesterol than nonusers (3.04 versus 2.89 mmol/L). Users and nonusers aged 45 to 54 years had similar LDL cholesterol levels, and users aged 55 to 64 and 65 to 74 years had lower LDL cholesterol and higher HDL cholesterol levels, respectively, than nonusers. Triglyceride levels were higher in oral contraceptive users and in younger women on sex hormone replacement therapy than in nonusers. In the general population of Canada the use of oral contraceptives in women less than age 35 years had only a marginal effect on the prevalence of lipid and nonlipid risk factors. Women aged 18 to 24 years using oral contraceptives had a higher mean LDL cholesterol level of 2.73 versus 2.35 mmol/L for nonusers. The prevalence of lipid and nonlipid risk factors in women using sex hormone replacement therapy increased slightly for those aged 35 to 54 years and decreased in women aged 55 to 74 years. A lower percentage of women using sex hormone replacement therapy, aged 55 to 74 years, had high risk LDL cholesterol levels (21% versus 36% for nonusers). A larger percentage of women using sex hormone replacement therapy had low risk HDL cholesterol levels (54% versus 29% for nonusers). The nonlipid risk factor profile for women aged 35 to 54 years on sex hormone replacement therapy was less favourable than for nonusers: obesity was more common (36% versus 28%, respectively), hypertension was higher (22% versus 12%, respectively), and the proportion of women with one or more nonlipid risk factors was higher. The nonlipid risk factor profile for women 55 to 74 years of age who were using sex hormone replacement therapy was more favourable than for nonusers: obesity was lower (31% versus 47%, respectively), smoking was lower (7% versus 16%, respectively), sedentary behaviour was lower (28% versus 37%, respectively), and fewer women had two or more of these risk factors (31% versus 52%, respectively). CONCLUSION: The findings suggest that women at higher risk for coronary artery disease tend to have a lower prevalence of use of sex hormone replacement therapy.

Prevalence of high plasma triglyceride combined with low HDL-C levels and its association with smoking, hypertension, obesity, diabetes, sedentariness and LDL-C levels in the Canadian population. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To report the associations of plasma triglyceride, high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) with nonlipid coronary artery disease risk factors. In particular, the associations for persons with high triglyceride and low HDL-C levels were examined. DESIGN: A stratified random probability sample of 29,855 men and women aged 18 to 74 years from the Canadian Heart Health Surveys (1986 to 1992) in 10 provinces. Blood samples were obtained from 18,555 participants who had fasted for 8 h or more. Plasma lipids were determined at the J Alick Little Lipid Research Laboratory, Toronto, Ontario, with standardization of the Centers for Disease Control Lipid Standardization Program, Atlanta. OUTCOME MEASURES: Fasting plasma total cholesterol, triglyceride, LDL-C and HDL-C levels. MAIN RESULTS: The prevalence of men with triglyceride levels above 1.7 mmol/L and HDL-C levels below 0.9 mmol/L was 10%, compared with 3% for men with triglyceride levels below 1.7 mmol/L and HDL-C levels below 0.9 mmol/L. The prevalence of women with triglyceride levels above 1.7 mmol/L and HDL-C levels below 0.9 mmol/L was 3% compared with a prevalence of less than 1% for women with triglyceride levels below 1.7 mmol/L and HDL-C levels below 0.9 mmol/L. Even when plasma LDL-C was low at less than 3.4 mmol/L, there was an age trend for increasing prevalences of the combination of triglyceride levels 2.3 mmol/L or greater and HDL-C levels less than 0.9 mmol/L in both sexes. The prevalence of a triglyceride levels 2.3 mmol/L or greater combined with an HDL-C level below 0.9 mmol/L was increased in groups who were cigarette smokers, diabetic, hypertensive, obese or sedentary, or who had higher LDL-C levels in both sexes, and the increase was even greater in the presence of two or more of these other risk factors. CONCLUSIONS: Among men or women with low HDL-C and high triglyceride levels, smoking, diabetes, sedentariness, hypertension and obesity were much more prevalent than among those at low risk with high HDL-C and low triglyceride levels.

Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening.

BACKGROUND: Currently there are at least 22 countries worldwide where national, regional or pilot population-based breast cancer screening programmes have been established. A collaborative effort has been undertaken by the International Breast Cancer Screening Network (IBSN), an international voluntary collaborative effort administered from the National Cancer Institute in the US for the purposes of producing international data on the policies, funding and administration, and results of population-based breast cancer screening. METHODS: Two surveys conducted by the IBSN in 1990 and 1995 describe the status of population-based breast cancer screening in countries which had or planned to establish breast cancer screening programmes in their countries. The 1990 survey was sent to ten countries in the IBSN and was completed by nine countries. The 1995 survey was sent to and completed by the 13 countries in the organization at that time and an additional nine countries in the European Network. RESULTS: The programmes vary in how they have been organized and have changed from 1990 to 1995. The most notable change is the increase in the number of countries that have established or plan to establish organized breast cancer screening programmes. A second major change is in guidelines for the lower age limit for mammography screening and the use of the clinical breast examination and breast self-examination as additional detection methods. CONCLUSION: As high quality population-based breast cancer screening programmes are implemented in more countries, they will offer an unprecedented opportunity to assess the level of coverage of the population for initial and repeat screening, evaluation of performance, and, in the longer term, outcome of screening in terms of reduction in the incidence of late-stage disease and in mortality.

A dissemination research agenda to strengthen health promotion and disease prevention.

The question of how to enhance the dissemination of knowledge and the use of innovations related to disease prevention and health promotion was posed to an international group of experts at an invitational research conference held in Vancouver, British Columbia in March 1995. The Canadian Conference on Dissemination Research Strengthening Health Promotion and Disease Prevention was co-sponsored by 15 voluntary organizations, government agencies and industries. It examined advances and gaps in the study of diffusion and adoption of preventive knowledge and practices among health professionals and the public. It was the first national conference of its kind devoted to dissemination research and dissemination of research specifically in health promotion and disease prevention. This paper summarizes the major issues raised in the papers presented at this conference. Policies and strategies for strengthening dissemination research and the dissemination of health promotion knowledge and practices are suggested.

The Canadian Heart Health Initiative: dissemination perspectives.

The Canadian Heart Health Initiative is a country-wide strategy for the prevention of cardiovascular disease. Initiated with a 15-year horizon, it has resulted in extensive networks and coalitions involving Health Canada, the 10 provincial departments of health and over 1,000 organizations. There are five phases: policy development through country-wide consultations (1986-88); provincial heart health surveys (1986-91); research demonstration programs (1989-97); and evaluation (1994-97). The dissemination research phase studies the adoption of interventions by communities and health systems. As a paradigm for dissemination of health policy, some key features of the Initiative are translation of the science base in prevention into community programs; consensual policy development; federal and provincial co-funding arrangements; key role played by the public health system; capacity building; organization and management model linking activities at the national, provincial and community levels. The methodologies and capacities developed are applicable to other health promotion and disease prevention areas.

Cervical cancer screening: are the 1989 recommendations still valid? National Workshop on Screening for Cancer of the Cervix.

Although screening for cervical cancer has been shown to be effective in reducing the morbidity and mortality associated with this disease, and despite many attempts to encourage the development of provincial programs, as of 1995 no province had a comprehensive screening program for cervical cancer. Participants at the Interchange '95 workshop, held in Ottawa in November 1995, reviewed the recommendations of the 1989 National Workshop on Screening for Cancer of the Cervix and identified factors that have impeded their implementation. Participants discussed the need for comprehensive information systems, quality control and strategies to increase recruitment of unscreened and underscreened women. They concluded that the formation of a Cervical Cancer Prevention Network involving key stakeholders will facilitate the development and implementation of provincial programs to ensure optimal screening. They agreed that, in the interim, recommendations for practising physicians should remain as they were following the 1989 workshop.

The Canadian Heart Health Initiative: a countrywide cardiovascular disease prevention strategy.

The 1987 Report of the federal/provincial working group on cardiovascular disease prevention entitled "Promoting Heart Health in Canada" was developed about the time the new concepts for health promotion were emerging in government policy. The public health strategy supported in "Promoting Heart Health in Canada" captured the approach advocated in the Ottawa Charter for health promotion: need for environmental, intersectorial approaches and healthy public policy. The implementation of this policy framework had led to the Canadian Heart Health Initiative. It provided a step by step approach to the implementation of the ten provincial heart health programs. Key assets for the Initiative include the development of effective partnerships with over 300 organizations at the provincial, national and international levels; a large database on risk factors and over 40 demonstration communities which should contribute to interventional knowledge in the area of prevention. The heart health model provides an approach to address increasingly complex health issues that we can expect to face in the year 2000.

Self-management teaching programs and morbidity of pediatric asthma: a meta-analysis.

BACKGROUND: Self-management teaching programs are becoming an important asset in the management of pediatric asthma. OBJECTIVE: The study was designed to evaluate the impact of self-management teaching programs on the morbidity of pediatric asthma. METHODS: The meta-analysis included randomized clinical trials, published between 1970 and 1991, addressing the outcome of morbidity. Studies were retrieved from searches of MEDLINE, American Journal of Nursing International Index, and Dissertation Abstracts Online Database. The quality of studies was assessed with the scale of Chalmers. The pooled effect size was calculated by the method of Hedges. RESULTS: The literature search retrieved 23 randomized clinical trials, but 12 studies had to be excluded. Global score of quality of studies (Chalmers' scale) was fair, 51.6% +/- 9.9%. As indicated by the effect size (ES) of the pooled studies, self-management teaching did not reduce school absenteeism (ES: 0.04 +/- 0.08), asthma attacks (ES: 0.09 +/- 0.14), hospitalizations (ES: 0.06 +/- 0.08), hospital days (ES: -0.11 +/- 0.08), or emergency visits (0.14 +/- 0.09). CONCLUSION: Self-management teaching programs do not seem to reduce morbidity, and future programs should focus more on intermediate outcomes such as behavior.

Enhancing preventive practice.

Health professionals can play a major role in prevention. They are perceived as a reliable and credible source of health information and they have contact with a large percentage of the population every year. In Canada, a key development for the integration of prevention in clinical practice was the establishment of the Canadian Task Force on the Periodic Health Examination. The Task Force has provided guidance on effective preventive interventions in the clinical setting over the past 15 years. The challenge lies in the implementation of these guidelines. We need to find innovative ways to disseminate and promote them. In this context, the creation of a National Partnership for Quality in Health is an important avenue for the coordination of practice guideline development and implementation in this country. An emerging concern in the delivery of preventive services is the coordination of activities of health professionals within the public health sector, with those of clinical care. In Canada, such a comprehensive and coordinated approach has been put into practice through the Canadian Heart Health Initiative.

Smoking prevalence and associated risk factors in Canadian adults. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To describe the prevalence and patterns of smoking among Canadian adults, the relation of smoking to other cardiovascular disease risk factors and the awareness of the causes of heart disease. DESIGN: Population-based cross-sectional surveys. SETTING: Nine Canadian provinces, from 1986 to 1990. PARTICIPANTS: A probability sample of 26,293 men and women aged 18 to 74 was selected from the health insurance registries in each province. Of these, 20,585 completed a questionnaire on smoking habits during a home interview. MAIN RESULTS: Approximately 29% of the Canadian population 18 years of age and over were regular cigarette smokers, and over 13% of regular smokers smoked more than 25 cigarettes per day. The proportion of women who had never smoked was higher (37%) than men (24%), except for young women aged 18 to 24. For all participants, there was a lower prevalence of high blood pressure and overweight among smokers than non-smokers. The prevalence of sedentary lifestyle, diabetes and elevated blood cholesterol was positively associated with smoking. The proportion of subjects who identified smoking as a cause of heart disease was higher among smokers, and over 90% believe that heart disease is preventable. CONCLUSION: Because smoking is positively associated with other cardiovascular risk factors, multifactorial and comprehensive approaches are needed in the implementation of cardiovascular disease prevention programs. Knowledge regarding the heart health hazards of smoking is high even among smokers. Motivational approaches that go beyond health risk messages are needed in cessation programs.

Multiple cardiovascular disease risk factors in Canadian adults. Canadian Heart Health Surveys Research Group.

OBJECTIVE: To estimate the prevalence and distribution of the coexistence of major cardiovascular disease (CVD) risk factors among Canadian adults. DESIGN: Population-based cross-sectional surveys. SETTING: Nine Canadian provinces, from 1986 to 1990. PARTICIPANTS: A probability sample of 26,293 men and women, aged 18 to 74 years, was selected from provincial health insurance registries. For 20,582 of these participants, at least two blood pressure (BP) measurements were taken using a standardized technique. At a subsequent visit to a clinic, two additional BP readings, anthropometric measurements and a blood specimen for plasma lipid analysis were obtained. OUTCOME MEASURES: The percentage distribution of subjects by number of major risk factors (smoking, high BP and elevated blood cholesterol level) and by concomitant factors (body mass index [BMI], ratio of waist to hip circumference [WHR], physical activity, diabetes, awareness of CVD risk factors and education). MAIN RESULTS: Sixty-four percent of men and 63% of women had one or more of the major risk factors. Prevalence increased with age to reach 80% in men and 89% in women aged 65 to 74 years. Prevalence of two or three risk factors was highest among men in the 45-54 age group (34%) and in women in the 65-74 age group (37%). The most common associations were between smoking and high blood cholesterol level (10%) and between high BP and high blood cholesterol level (8%). Prevalence of high BP and elevated blood cholesterol, alone or in combination, increased with BMI and WHR. Smoking, elevated blood cholesterol, BMI and prevalence of one or more risk factors increased with lower level of education. Less than 48% of participants mentioned any single major risk factor as a cause of heart disease. Awareness was lowest in the group with fewest years of education. CONCLUSION: The findings of this study call for an approach to reduce CVD that stresses collaboration of the different health sectors to reach both the population as a whole and the individuals at high risk.

Testing various methods of introducing health charts into medical records in family medicine units.

OBJECTIVE: To test three methods of introducing health charts into the medical records of six family medicine units. DESIGN: Quasi-experiment. PARTICIPANTS: The staff physicians and family medicine residents in all six units and the nurses in two units. INTERVENTIONS: Group 1 (minimal intervention): health charts, a user's guide and one training session. Group 2 (intermediate intervention): same intervention as for group 1 plus two feedback sessions at 3 and 6 months. Group 3 (maximum intervention): same intervention as for group 2 plus promotion of the team concept (nurses were included). The intervention phase lasted from September 1987 to August 1988. OUTCOME MEASURES: The frequency with which the health charts were used, the item scores of each preventive care activity and the overall unit scores. Data were gathered through chart audits at baseline and at the end of the intervention phase. RESULTS: The frequency with which the health charts were used varied from 3.9% to 26.9%. The greatest increases in item scores were observed in the use of mammography (20.0%), counselling on lifestyle (19.4%) and breast examination (17.2%). Although the overall improvement in the unit scores was statistically significant (p less than 0.05) the hypothesis of an increasing gradient of effect across the three intervention groups could not be tested because of the variation in scores across the units. CONCLUSION: Health charts and other similar tools are useful; however, they are not sufficient to change practice behaviours. The support of a "champion" on the health care team might well be a determining factor of success for the delivery of preventive services in primary care practice.

Aspirin in transient ischemic attacks and minor stroke: a meta-analysis.

An overview analysis of seven randomized controlled trials testing the effectiveness of aspirin in the treatment of patients with transient ischemic attacks and minor strokes was performed. A total of 6409 patients from the seven trials was entered in the analysis; 2182 patients received only aspirin; 1598 patients received an aspirin-combination regimen with either sulfinpyrazone or dipyridamole; and 2629 subjects received a placebo. Aspirin alone produced an 18% decrease in all strokes and cardiovascular deaths. The pooling of studies examining aspirin-combination regimens and the larger grouping of studies of aspirin and aspirin-combination regimens led to more striking results. Indeed, significant risk reductions were observed for three of the four outcomes, namely, total deaths, total strokes, and total strokes and cardiovascular deaths, with odds ratios ranging from 0.59 to 0.78. Suggestive, albeit more modest, results were obtained when examining the impact of these regimens on total cardiovascular mortality. The same tendencies have also been observed in three previously published meta-analyses.

Congenital malformations as a cause of neonatal and postnatal death in Massachusetts (1970-1980).

Massachusetts birth and death certificate tapes for the years 1970-1980 were linked and analyzed to determine causes of death in the neonatal and postneonatal periods and to identify any related sociodemographic factors. Our analysis suggests that, although the neonatal mortality rate declined by about 43 percent, the postneonatal mortality rate remained relatively unchanged. Perinatal problems remained the principal cause of death during the neonatal period, throughout the decade. In the postneonatal period, congenital malformations became a leading cause of death toward the end of the decade because of a reduction in mortality from infectious diseases and perinatal problems. Infants born to mothers under 18 and over 34 years of age had the highest death rates from congenital birth defects. Higher mortality rates caused by congenital malformations were found in the more industrialized areas of Massachusetts. Further declines in infant mortality rates in Massachusetts will depend on preventive measures to reduce the incidence of congenital malformations.