Chronicling changes to the chronic disease prevention landscape in Canada's public health system 2004-2010.

The collective impact of major shifts in public health infrastructure and numerous new chronic disease prevention (CDP) capacity-building initiatives that have taken place in Canada over the last decade is unknown. The objective of this study was to determine if CDP capacity (i.e., skills and resources) and involvement in CDP programming improved in public health organizations in Canada from 2004 to 2010. Data for this repeated cross-sectional study were drawn from two waves of a national census of organizations mandated to carry out primary prevention of chronic disease and/or promotion of healthy eating, physical activity and tobacco control. Medians for continuous variables and frequencies for categorical variables were compared across time. Neither resources nor level of priority for CDP increased over time. There was little difference in the proportion of organizations with high levels of skills and involvement in core CDP practices (i.e., needs assessment, identification of relevant practices, planning, evaluation). Skills and involvement in CDP risk factor programming showed some gains, some steady states and some losses. Specifically, skill and involvement in tobacco control programming declined markedly while the proportion of organizations involved in healthy eating and physical activity programming increased. Skills to address and involvement in programming related to social determinants of health remained low over time as did involvement in programming addressing multiple risk factors concurrently. The lack of marked improvement in CDP capacity between 2004 and 2010 against a backdrop of initiatives favourable to strengthening the preventive health system in Canada suggests that efforts may have fallen short.

Reporting of ethnicity in research on chronic disease: update.

This paper examines the inclusion of ethnicity and race as variables in current, leading edge research on chronic disease and its risk factors. Of 100 randomly selected original research articles published in high-impact journals in 2005, 85% did not report either a definition of ethnicity or its conceptualisation in terms of theoretical reasoning, and 98% did not report an actual measurement item. Ethnicity and race remain non-standardised and largely underdescribed variables in research on chronic disease. This represents an important loss of opportunity to articulate and test hypotheses about the mechanisms underlying ethnic group differences in chronic disease.

Organizational and professional characteristics predicting external communications in Canadian public health units.

This study is a survey of administrative divisions involved in tobacco programs in Canadian public health units. It aims to identify correlates of public health units' contacts and collaborations with external agencies, as predisposing factors in their capacity to innovate. Heads of 124 divisions involved in tobacco control completed a questionnaire about their budgets, staff, and management practices. In each of these divisions, professionals involved in tobacco programs also completed a questionnaire about their characteristics and experience. Results showed a high level of contacts and collaborations with external agencies. Four variables emerged as correlates of external communications: professionals' degree of access to public health information sources, the diversity of disciplines within the administrative division, the decentralization of authority, and the level of professionals' participation in decision-making. Because of the potential relationship between innovation and external communication, public health units should consider fostering external communication by management practices and policies, such as favouring professional diversity, increasing access to sources of information, and adopting more decentralized, participatory management.

Screening mammography referral rates for women ages 50 to 69 years by recently-licensed family physicians: physician and practice environment correlates.

BACKGROUND: Physician mammography referral remains below optimal levels despite a long-standing recommendation that all women ages 50 to 69 years receive screening mammography every 1 to 2 years. The purpose of this study was to determine physician and practice environment predictors of family physicians' screening mammography referral rates to women ages 50-69 years. METHOD: A cohort of 498 recently-licensed family physicians was followed for 18-months of incipient medical practice. The referral rate was the percentage of new clinically eligible women patients seen in a primary care context who had a screening mammogram ordered by the study physician. Mammograms and independent variables were identified from physician claims to a Canadian universal health insurance agency. The effects of factors in a conceptual framework were assessed using multivariable linear regression. RESULTS: Correlates of higher mammography referral rates were female gender, better general prevention knowledge, the combination of comprehensive inquiry and continuity care, lower patient volume, and lower shared primary care (multivariable model R(2) = 0.47). Factors belonging to practice environment explained more of the observed variance than did physician characteristics. CONCLUSIONS: Mammography referral varies enormously and almost half of the variance is explained by physician characteristics and practice preferences. Higher mammography referral is observed in practices with more comprehensive and continuity care.

Prevalence and correlates of physical activity behaviors among elementary schoolchildren in multiethnic, low income, inner-city neighborhoods in Montreal, Canada.

PURPOSE: To describe the prevalence and correlates of physical inactivity and of participation in organized sports at and outside school among elementary schoolchildren in multiethnic, low income, urban neighborhoods in Montreal, Canada. METHODS: As part of the evaluation of a school-based heart health promotion program, baseline data on physical activity behaviors and potential correlates of these behaviors, were collected from 2285 students aged 9-13 in all 130 grade 4 to 6 classes in 24 inner-city elementary schools from May to June 1993. RESULTS: One-fifth of boys (20.5%) and 24.4% of girls were inactive; 40.0% and 33.3% of boys and girls respectively, participated in school sports teams; 82.5% and 74.7% participated in organized sports outside school. Declines in activity levels with age were apparent in both genders. Children who participated in organized sports programs at and outside school, those with higher perceived self-efficacy for physical activity, and those with more parental support for engaging in physical activity were more active. Children of Asian family origin were less active. Socioeconomic status was related to participation in organized sports outside school. CONCLUSIONS: To reach children in socio-economically disadvantaged areas and to prevent age-related declines in activity levels, interventions promoting physical activity should focus on increasing availability and access to community-based organized sports programs at and outside school. Also they should include components to increase parental support and to improve perceived self-efficacy for physical activity.

Evaluation of an 8-week mailed healthy-weight intervention.

BACKGROUND: This study investigated the impact of a low-intensity, healthy-weight intervention among adult volunteers in a low-income, inner-city neighborhood. The intervention, which comprised 18 pamphlets mailed to participants' homes over 8 weeks, focused on increasing awareness of healthy weight ranges, increasing self-acceptance and satisfaction with weight, and improving eating habits, while downplaying dieting and weight loss. METHODS: Subjects were recruited from households randomly selected from residential telephone subscriber lists. The 188 volunteers (23.0% of 816 persons contacted) were randomly assigned to intervention or control status. Psychosocial and behavioral measures were administered by telephone 1 week before and 2 weeks after the intervention. RESULTS: After exposure to the pamphlets, intervention subjects were more likely than controls to know how to control their weight. They were more satisfied with their weight and less likely to report they were too heavy. They reported less high-fat/junk food consumption, more improvements in their eating habits, and more frequent exercise. CONCLUSION: This inexpensive, low-intensity intervention was effective in supporting change processes among volunteers who wanted to learn about weight control, to improve eating habits, and to improve health.

Estimation of breast cancer risk by women aged 40 and over: a population-based study.

OBJECTIVE: Identify factors associated with knowledge of breast cancer and estimation of risk. METHODS: Telephone survey of 412 women aged 40 and over, living in Montreal and selected by random digit dialing. RESULTS: The majority of the respondents had recently been exposed to some information on breast cancer, but only a third quoted the average lifetime probability estimate of about 1 in 10. Older individuals systematically considered themselves at low risk (odds ratio (OR) of perceiving risk as lower than average for women aged 50 or over versus under 50: 2.6, 95% confidence interval: (1.5, 4.6)). In addition, both a first-degree family history of breast cancer (OR: 5.3 (1.7, 17.0)) and a recent mammogram (OR: 3.0 (1.4, 6.2)) were strongly associated with a woman's probability of perceiving herself at high risk. CONCLUSIONS: Information campaigns should emphasize the frequency of breast cancer in different age groups and the strength of the established associations with specific risk factors. Better knowledge of risk could promote sustained participation in breast screening programs.

When anthropology meets epidemiology: using social representations to predict drinking patterns.

Based on a sample of 2,015 adult drinkers from the Montreal metropolitan area (Quebec, Canada), this study investigates the relationship between eight social representations of drinking (i.e., compensatory, convivial, relaxing, disinhibitory, harmful, sexually enhancing, conventional, socially enabling) and drinking measures (QF Index, drinking frequency, and maximum number of drinks on one occasion) according to age and sex. The representations explain up to 34% of the variance in drinking measures. Representations differed in the strength of their relation to drinking measures and in population prevalence. Strength of relation to drinking and prevalence rates were relatively independent. Representations were generally more strongly endorsed by men than women, although they were related in the same way to drinking behaviors. Representations were also more strongly endorsed by younger than by older respondents, and they related differently to drinking in each age group. The implications of these results for prevention are discussed.

Assessment of the integration of the ecological approach in health promotion programs.

PURPOSE: This article proposes a model of the ecological approach in health promotion programs. Based on system theory, the model identifies intervention settings and targets as two independent dimensions for assessing the integration of this approach in programs. Additional objectives are to present and pretest an analytical procedure that allows the assessment of integration of the ecological approach in programs. DESIGN: This was a descriptive study of the integration of the ecological approach in a sample of health promotion programs. SUBJECTS: Subjects were 44 health promotion programs drawn from the population of Canadian federally funded programs. MEASURES: Descriptions of programs were obtained by telephone interviews. A coding scheme was applied to the data to identify intervention settings and targets for each program. Using this information, a summative score of the integration of the ecological approach was estimated for each program. RESULTS: Single-setting programs were the dominant pattern in the sample. Individuals whose health was of concern were very frequently the direct targets of the programs. However, organizational and interpersonal environments were also often directly targeted. Single-setting or single-intervention strategy programs outnumbered ecological programs. CONCLUSION: The proposed model and analytical procedure is a useful framework for the assessment of integration of the ecological approach in health promotion programs. The pilot test having been conducted on a convenience sample, future work should replicate the study in a representative sample of programs.

Coeur en santé St-Henri--a heart health promotion programme in Montreal, Canada: design and methods for evaluation.

STUDY OBJECTIVE: This paper describes the objectives, design, and methods of evaluation of the impact of the coeur en santé St-Henri programme, as well as selected results from the evaluation to date. It discusses the possible effects of study design choices made to maintain the impact evaluation within budget. DESIGN: The impact of the programme is evaluated in a community trial which compares the prevalence of cardiovascular disease behavioural risk factors before and after programme implementation in the intervention and a matched comparison community, in both longitudinal cohort and independent sample surveys. In addition, repeated independent sample surveys are conducted in the intervention community to monitor awareness of and participation in the programme. PARTICIPANTS: The baseline sample for both the longitudinal cohort and independent sample surveys included 849 subjects from the intervention community (79.3% of 1071 eligible subjects--8.0% could not be contacted and 12.6% refused) and 825 subjects from the comparison community (77.8% of 1066 eligible subjects--6.6% could not be contacted and 15.6% refused). The two surveys on awareness and participation conducted to date, included 461 (71.0% of 649 eligible subjects) and 387 (67.9% of 570 eligible subjects) subjects respectively from the intervention community. MEASUREMENTS: Baseline data for the longitudinal cohort and independent sample surveys on behavioural risk factor outcomes including use of tobacco, physical activity behaviour, high fat diet, and behaviours related to blood pressure and cholesterol control were collected in 35 minute telephone interviews in both the intervention and comparison communities. Data on awareness of and participation in the programme were collected in 10 minute interviews in the intervention community only in two independent sample surveys conducted seven and 22 months respectively after the baseline survey. RESULTS: With the exception of smoking, the intervention and comparison communities were similar at baseline with regard to the prevalence of behavioural risk factors studied. Awareness of the coeur en santé programme increased from 64.1% in January 1993 to 72.9% 15 months later. Participation in the programme increased from 21.3% to 33.7%. CONCLUSIONS: This paper presents background information on the evaluation of the impact of the coeur en santé programme, as a reference for future publications.

Parental support: effects of a mass-media intervention.

Although face-to-face parental support programs have been shown to improve parents' knowledge, attitudes and behaviour, such interventions are relatively costly to administer. This article reports the findings of a quasi-experimental evaluation of a relatively less costly, mass-media intervention: an age-paced newsletter for new parents. Readership and effectiveness of the newsletter were assessed after three years of distribution. Evaluation participants were 453 randomly selected fathers and mothers of three-year-olds, of which 193 were newsletter recipients and 260 were nonrecipients. Results showed that readership and satisfaction were high. Modest effects were found among mothers in the experimental group on knowledge and perception of existing community resources. Experimental mothers also tended to display greater knowledge of child development. No significant effects of the newsletter were found for fathers. The discussion centres on the potential for this type of intervention strategy to optimize existing investment in public family support programs.

A qualitative investigation of organizational issues in an alcohol awareness program for blue-collar workers.

PURPOSE: To explore sociopolitical and organizational issues in worksite alcohol health promotion. Few such programs are reported in the literature. DESIGN: Qualitative data were gathered during the development and implementation phases of a program through focus groups, key informant interviews, and observations made by the research team. SETTINGS AND SUBJECTS: One hundred and ninety-nine blue-collar workers from a private company (a group which was also involved in a randomized controlled trial) and 123 workers from four other organizations (nontrial groups) received the intervention. The nontrial groups were used to pilot-test the intervention and in a post-trial assessment. All companies were located in Montreal, Quebec, Canada. INTERVENTION: Two worksite health promotion sessions on responsible drinking were given to small groups of workers. MEASURES: The reactions of workers, unions, and employers to the program and to the evaluation trial were observed. The viewpoints of key informants were solicited through semi-structured interviews. Analysis was accomplished through several cycles of memo writing. RESULTS: Alcohol is a sensitive subject when discussed in worksite group settings. Our data suggest that there are alcohol problems in the workplace of which coworkers are clearly cognizant. In one setting the intervention led to the development of organizational rules regarding workers who reported to work inebriated, where this behavior had been previously tolerated. The sessions were better received when disease concepts were avoided. Evaluation research on alcohol requires particular care with confidentiality and ongoing communication with all stakeholders, especially unions. CONCLUSIONS: Worksite health promotion regarding alcohol is feasible.(ABSTRACT TRUNCATED AT 250 WORDS)

Formative and effectiveness evaluation of a worksite program promoting healthy alcohol consumption.

PURPOSE: This project involved the formative and effectiveness evaluation of a program aiming to enable working, nondependent drinkers to consume alcohol in a healthy and socially responsible fashion. DESIGN: A baseline survey (n=387) of employee needs and interests was followed by a formative evaluation testing accessibility, interest/resistance, and potential effectiveness. The formative evaluation used successive iterations of focus groups. The subsequent effectiveness evaluation (n=268) used a randomized pre-post design with three conditions: alcohol program, placebo (nutrition) program, or no program. SETTINGS AND SUBJECTS: The program was implemented in a multi-branch, blue-collar, shiftworking organization (n=813) in four Quebec cities with many mobile workers. INTERVENTION: The worksite alcohol program consisted of two, half-hour sessions delivered one week apart by a health professional during paid time. The program provided information on the social and personal costs of alcohol, on strategies for promoting socially responsible drinking, and for the prevention of negative consequences of intoxication for oneself and one's family and friends. MEASURES: Constructs measured using self-administered questionnaires were: alcohol knowledge, socially responsible attitudes, perceived self-efficacy for drinking management, and self-reported drinking behavior. RESULTS: Despite the lack of interest in the topic (as found in the needs and interests survey), the program was effective in promoting socially responsible attitudes and reducing self-reported weekly consumption among participants. Some placebo effects were also present. Participants were not completely representative of all employees. CONCLUSION: Worksite alcohol health promotion programs can be effective especially when promoting socially responsible attitudes.

[The interdiction of tobacco sales to minors: a concerted effort is necessary]. / L'interdiction de la vente de tabac aux mineurs: une concertation est nécessaire.

We discuss the feasibility of an intervention involving retailers of over-the-counter tobacco sales to minors in a multi-ethnic Montreal neighbourhood. An overview of the literature on the efficacy of such interventions and an analysis of the present sociopolitical situation have influenced our decision to delay this intervention. The community should be made aware of this problem prior to intervention.

{Evaluation after three years of early intervention for parental support}. / Evaluation après trois ans d'une intervention précoce de soutien au rôle parental.

This article reports the findings of a quasi-experimental evaluation of a newsletter for new parents which was adapted to the age of their children. Satisfaction with and the effectiveness of the intervention after three years of distribution were assessed. As in a previous evaluation undertaken after one year, the newsletter enjoyed widespread readership in the experimental families and among their friends and relatives. Compared to this previous evaluation, similar but stronger effects on aspects of the parental role were found, although these were confined to mothers. Mothers in the experimental group displayed greater knowledge of family support resources and had more favourable attitudes toward them than mothers in the comparison group. They also tended to display greater knowledge of child development. The discussion centres on the study's implications for research and the advisability of broadening this form of intervention.

Efficiency of printed materials in worksite health promotion.

BACKGROUND: Printed health promotion materials are widely believed to be an efficient means of achieving basic health promotion objectives, such as increasing knowledge of risk factors. This study examined the efficiency of cardiovascular health promotion leaflets in reaching employees in a heterogeneous sample of worksites. METHODS: Two types of distribution were used: copies of the leaflets were either made available centrally or distributed to each individual employee. Interviews were conducted with 272 employees in six worksites. Respondents were asked whether they recognized, had read, and had learned something from the leaflets. RESULTS: Only one-quarter of respondents recognized the leaflets and only 14% stated that they had learned something. The efficiency of the leaflets was therefore much lower than expected. Z-tests for proportions showed that recognition, reading, and learning were significantly greater among those employees who had been given individual copies of the material. Among those who had been given individual copies, 45% reported recognizing the leaflet, 36% reading it, and 23% learning something from it. Among those who had only central access, the respective scores were 11%, 7% and 6%. DISCUSSION: These results suggest that the potential cost-effectiveness of printed materials such as leaflets and brochures should be weighed against alternative forms of intervention, given specific program objectives and characteristics of the target population. They also suggest that the cost and effort required in organizing the distribution of individual copies may be recouped in greater penetration.

Evaluation of an early, mass media parental support intervention.

This article reports on the evaluation of Parents Magazine, an age-paced newsletter distributed to parents starting with the birth of their children. The evaluation was carried out after the newsletter's first year of circulation. Measures were taken of reader satisfaction as well as impact on parents' knowledge, attitudes and behavior toward education and use of community resources. Findings indicated that the newsletter's penetration of families and their natural milieu was strong but that it had a limited impact. However, the parents who received the newsletter developed more positive attitudes toward community resources. The articles discusses the implication of these findings for future research.

Illuminating negative results in evaluation of smoking prevention programs.

Evaluation of program implementation can help illuminate negative results of school-based smoking prevention programs. In three conventional quasiexperimental evaluations, no statistically significant impacts of smoking prevention programs on children's knowledge, attitudes, intentions, or behavior were detected. Complementary evaluations of program implementation along several dimensions using naturalistic methods suggested reasons for null effects were different at each site. These data were used to form hypotheses and recommendations for future interventions.