moving risk and behaviour surveillance forward in ontario ... · medical officer of health, leeds,...

Moving Risk and Behaviour Surveillance Forward

in Ontario:

A Proposal and Recommendations

Prepared by the Ontario Risk and Behaviour Surveillance System (ORBSS)

Advisory Committee

May 30, 2011

Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations i

How to cite this publication

Material appearing in this report may be reproduced or used without permission for educational purposes only.

Please use the following citation to acknowledge the source:

Ontario Risk and Behaviour Surveillance System Advisory Committee; Ontario Agency for Health Protection and

Promotion. Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations.

Toronto: Queen’s Printer for Ontario; 2011.

Publication Information

ISBN 978-1-4435-6772-5

Published by the Ontario Agency for Health Protection and Promotion.

©Queen’s Printer for Ontario, 2011

Ontario Agency for Health Promotion and Protection

480 University Avenue, Suite 300

Toronto, ON M5G 1V2

Telephone: 647-260-7100

www.oahpp.ca

The opinions, results and conclusions reported in this paper are those of the Ontario Risk and Behaviour

Surveillance System Advisory Committee. No endorsement by the Ontario Agency for Health Protection and

Promotion is intended or should be inferred.

http://www.oahpp.ca/

Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations ii

Table of Contents

Acknowledgements ..................................................................................................................................................... iii

ORBSS advisory committee .......................................................................................................................................... iii

Executive Summary ...................................................................................................................................................... 1

1.0 Introduction ............................................................................................................................................................ 4

2.0 Background ............................................................................................................................................................. 5

3.0 Priority Setting ........................................................................................................................................................ 9

4.0 Vision, Mission, Goals and Values ........................................................................................................................ 10

5.0 Environmental Scan Review.................................................................................................................................. 13

6.0 Achieving the Vision .............................................................................................................................................. 13

7.0 Recommendations ................................................................................................................................................ 20

7.1 Coordination ..................................................................................................................................................... 20

7.2 Central analytics................................................................................................................................................ 24

7.3 Funding ............................................................................................................................................................. 25

8.0 Conclusion ............................................................................................................................................................. 27

Appendix A: Ontario environmental scan summary of key systems for ORBSS by ORBSS values ............................. 28

Appendix B: Draft terms of reference for the ORBS partnership ............................................................................... 40

References .................................................................................................................................................................. 45

Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations iii

Acknowledgements Many individuals and organizations have contributed to the development of this report. First we would like to thank the Ontario public health community which provided valuable feedback during the conceptualization of an Ontario risk and behaviour surveillance system.We would also like to acknowledge the members of the Ontario Risk and Behaviour Surveillance System (ORBSS) advisory committee for their dedication to creating a vision for risk and behaviour surveillance in Ontario.

ORBSS advisory committee Ian Johnson (chair) Scientific Advisor, Ontario Agency for Health Protection and Promotion (OAHPP)

Natasha Crowcroft Director, Surveillance and Epidemiology, OAHPP (ex-officio)

Paul Fleiszer Manager, Surveillance and Epidemiology, Toronto Public Health

Liz Haugh Director, Health Promotion, Windsor-Essex County Health Unit

Michael King Epidemiologist, Sudbury & District Health Unit

Robert Kyle Commissioner & Medical Officer of Health, Durham Region Health Department

Carol Paul Senior Health Analyst, Ontario Ministry of Health and Long-Term Care (MOHLTC)

Rosana Pellizzari Medical Officer of Health, Peterborough County-City Health Unit

Elizabeth Rael Senior Epidemiologist, Ontario Ministry of Health Promotion and Sport

Ruth Sanderson Chronic Disease Epidemiologist, OAHPP

Linda Stewart Executive Director, Association of Local Public Health Agencies

Paula Stewart Medical Officer of Health, Leeds, Grenville, & Lanark District Health Unit (as of May 25, 2010) (Former Director, Chronic Disease Surveillance, Public Health Agency of Canada)

Joanne Thanos Senior Epidemiologist, MOHLTC

Carol Woods Program Director/Epidemiologist, Algoma Public Health

Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations 1

Executive Summary

The Ontario Risk and Behaviour Surveillance System (ORBSS) Advisory Committee formed in 2010 with the

purpose of providing guidance to the Ontario Agency for Health Protection and Promotion (OAHPP) on:

Potential models and approach to develop a provincial risk factor and behaviour surveillance system that

covers all geographic areas of Ontario and builds on existing infrastructure and systems within Ontario.

Governance and coordination mechanisms to support the models.

Stakeholder engagement process to test and evaluate proposed models.

An initial environmental scan and consultation with the field confirmed the lack of a comprehensive risk and behaviour surveillance system in Ontario. To support a common understanding of how risk and behaviour surveillance should move forward in Ontario, the ORBSS advisory committee developed a vision, mission, goals and values which was confirmed through consultation with the field. These were:

Vision Public health priorities and decisions are informed by a province-wide risk and behaviour surveillance system.

Mission

To coordinate a province-wide surveillance system that provides timely and accurate provincial and local health unit-level estimates of health behaviours, attitudes and other risk factors to support public health decision-making.

Goals

Inform program planning by providing data and information so that programs and services can be tailored

to address current and emerging public health needs at the provincial and local health unit level.

Enhance policy development by allowing policy-makers to have the information required to enable them

to develop new policies or amend existing policies that positively impact the public’s health.

Enable the identification of priority groups for public health action.

Inform program performance management by contributing information for key performance indicators.

Use resources efficiently by using existing data, generating province-wide estimates, and providing

infrastructure support to eliminate duplication of work in order to maximize access to information in a

timely fashion.


Values

Equitable

Responsive

Sustainable

Collaborative

Accomplishing this vision is a complex undertaking, requiring support from multiple stakeholders made even more

challenging in this time of fiscal constraint. To focus our efforts, this report outlines specific recommendations for

moving risk and behaviour surveillance forward in Ontario. The recommendations are directed to OAHPP as the

ORBSS advisory committee felt that OAHPP was in the best position to receive these recommendations and

promote change across the public health system. The final recommendations comprise 15 recommendations in

three groupings: coordination, central analytics and funding.

Recommendation 1 - Coordination

a) OAHPP establishes and provides secretariat support for an Ontario Risk and Behaviour Surveillance (ORBS)

partnership, to facilitate relationships among data users, suppliers and funders.

b) OAHPP establishes and supports the creation of an ORBS coordinating committee, to facilitate joint

planning and integration.

c) ORBS partnership identifies existing datasets pertinent to the Ontario Public Health Standards (OPHS).

d) ORBS partnership identifies opportunities to gain access to these datasets or tabulated results.

e) ORBS partnership investigates the potential to develop new datasets or expand the use of existing ones

including the linkages between datasets.

f) OAHPP and relevant ministries within the Ontario Government consult with the ORBS coordinating

committee/partnership for their collective advice on areas where:

collaboration across existing surveillance systems is possible and beneficial

new investments in risk and behaviour surveillance would be most efficient.

g) OAHPP consults with Aboriginal organizations and the First Nations and Inuit Health Branch of Health

Canada on collaborative risk and behaviour surveillance activities for Aboriginal Peoples.


Recommendation 2 - Central analytics

a) OAHPP establishes and supports a Central Analytics Advisory Committee (including members from public

health units, government, resource centres, and the Association of Public Health Epidemiologists in

Ontario (APHEO)).

b) OAHPP assumes the role of developing a central analytics program including an electronic platform for

risk factor and behaviour surveillance in Ontario.

c) OAHPP supports APHEO Core Indicators for Public Health Work Group to define the core indicators for

central analytics.

d) OAHPP assumes the role of producing the results for a key set of indicators.

e) OAHPP examines ways to enhance education and training on the production and interpretation of

indicators.

Recommendation 3 - Funding

a) OAHPP seeks support from Ontario Ministries of Health and Long-Term Care, Health Promotion and Sport

and Children and Youth Services for the development of the central analytics program, key indicators and

ORBS coordinating committee.

b) OAHPP continues their current support of Rapid Risk Factor Surveillance System (RRFSS) including the

scientific and technical advice for the development of modules of mutual interest.

c) OAHPP works with the ORBS partnership to enhance funding to expand data collection in order to answer

provincial time-sensitive/emerging questions.

While the ORBSS advisory committee has made recommendations on the major issues, identified gaps remain, particulary in the surveillance systems related to child health and other priority populations. Furthermore, comprehensive province-wide coverage in RRFSS for all health units has not yet been achieved and continues to raise considerable discussion in the public health community. The ORBSS advisory committee encourages others to address these issues while the initial recommendations are acted upon.


1.0 Introduction

In Ontario, the public health system is informed by a number of risk and behaviour monitoring systems. Some of

these systems provide information on health determinants and status for the general population (e.g., the

Canadian Community Health Survey (CCHS) and the Rapid Risk Factor Surveillance System (RRFSS)), while other

systems focus on a specific population or behaviour (e.g., Aboriginal Peoples Survey (APS), Ontario Student Drug

Use and Health Survey (OSDUHS) and the Infant Feeding Survey). The existing monitoring systems provide

needed and relevant data and information for program development and evaluation. However, each system

operates independently, guided by its own mandate. With the notable exception of the CCHS, most of the

systems are not designed to provide both provincial and local level estimates or produce trends over time.

Furthermore, despite Ontario’s many sources of information, key information gaps continue to exist.

The monitoring of behaviour and risk plays a key role in managing public health. Since the second half of the 20th

century, behaviour and social factors have been recognized as major contributors to health. 1,2,3 Within Ontario

and more broadly within Canada, public health monitoring or surveillance has been recognized at all levels as a

core function of public health.4 Surveillance is the systematic and continuous collection, collation and analysis of

health-related data that is disseminated so appropriate action can be taken.5 Federal, provincial and territorial

ministers of health are committed to enhancing capacity for surveillance of chronic disease risk factors and

determinants. To address the gaps in chronic disease surveillance, they endorsed four strategiesa to address the

gaps in surveillance in Canada.6

Risk and behaviour surveillance plays an essential role in public health planning, interventions and evaluation. It

allows for observing, predicting and minimizing the harm of emerging health threats, and assists with establishing

effective public health programs and services. Public health programs should be evidence-informed, using both

effective approaches to help reduce risk and behavioural factors for disease, and surveillance to identify the

optimal design and evaluation of such programs.

The need for a province-wide risk and behaviour surveillance system was articulated in the Agency

Implementation Task Force’s “From Vision to Action: A Plan for the Ontario Agency for Health Protection and

Promotion”7 and echoed in “Strategic Plan for Action,”8 a document commissioned by the RRFSS steering

committee. The strategic plan for action identified the need for representative sampling and analysis at both the

provincial and local level, as well as sustainable base funding for surveillance activities.

The Agency Implementation Task Force also recommended that the Ontario Agency for Health Protection and

Promotion (OAHPP) lead the enhancement of RRFSS and provide a vehicle for addressing pressing surveillance

needs in Ontario. The recommendation to establish a province-wide risk and behaviour surveillance system was

a The four strategies to enhance capacity are: 1. Enhance federal, provincial, territorial and local/regional capacity to analyze,

interpret and use surveillance data; 2. Expand data sources to fill gaps in surveillance knowledge; 3. Enhance collaboration,

planning and evaluation for surveillance among all the stakeholders; 4. Build capacity across jurisdictions for congruent public

health legislation supportive of chronic disease surveillance.


supported by the understanding that provincial funding had been designated for the purpose. However, in

September 2009, the Ministry of Health and Long-Term Care and the then Ministry of Health Promotion (now

Ministry of Health Promotion and Sport) identified that funds for this system were not available. As such, a new

approach was required.

An Advisory Committee, led and centrally supported by OAHPP, was established to propose a plan for the Ontario

Risk and Behaviour Surveillance System (ORBSS). Recognizing the constraints of the current funding environment

within Ontario, the ORBSS advisory committee abandoned the notion of creating a new surveillance system and

instead considered ways to better align and build on Ontario’s existing surveillance infrastructure and systems to

move risk and behaviour surveillance forward in Ontario.

The ORBSS advisory committee has, through consultation, identified risk and behaviour surveillance needs and

priorities of the public health community, and articulated a vision, mission, goals and values for how to move risk

and behaviour surveillance forward in Ontario. This document includes this information and specific sets of

recommended actions and approaches for OAHPP in three key areas: coordination, central analytics and funding

designed to advance the vision of ORBSS. It is recognized that advancing this vision of ORBSS is a complex

undertaking and goes beyond the work of OAHPP itself, requiring multiple stakeholder participation.

2.0 Background

Environmental scan

The first job of the ORBSS advisory committee was to conduct an environmental scan in order to understand the

current status of risk and behaviour surveillance systems in Ontario. The scan included a review and assessment

of the strengths and limitations of:

Aboriginal Children’s Survey (ACS)

Aboriginal Peoples Survey (APS)

Better Outcomes Registry and Network Ontario (BORN-Ontario)

Canadian Community Health Survey (CCHS)

Canadian Health Measures Survey (CHMS)

First Nations Regional Longitudinal Health Survey (RHS)

Infant Feeding Surveys

Integrated Services for Children Information System (ISCIS) of the Health Babies Healthy Children (HBHC)

program

Ontario Student Drug Use and Health Survey (OSDUHS)

Rapid Risk Factor Surveillance System (RRFSS)

School Health Action Planning and Evaluation System Ontario (SHAPES-Ontario)

School Health Environment Survey (SHES).


Appendix A provides a summary of the strengths and limitations of these key systems. The detailed report,

including the environmental scan entitled, “Discussion paper: Developing the foundations for an Ontario Risk and

Behaviour Surveillance System (ORBSS),” is available on the ORBSS website. The ORBSS advisory committee also

considered other scans and overview documents, including an environmental scan of regional risk factor

surveillance9, an international scan of local-level chronic disease risk factor surveillance systems10 conducted by

the Canadian Alliance for Regional Risk Factor Surveillance, a recently released “’White Paper on Surveillance and

Health Promotion”11 by the International Union for Health Promotion and Education Global Working Group of the

World Alliance for Risk Factor Surveillance, and the Centers for Disease Control and Prevention’s Behavioural Risk

Factor Surveillance System12 (which operates throughout the United States of America). A number of additional

systems, surveys and organizations were considered, but were not included in this summary since they did not

focus on the surveillance of risks or behaviours. Specifically these were:

intelliHEALTH ONTARIO

Ontario Health Study

SMARTRISK.

From a review of the environmental scan, the ORBSS advisory committee confirmed that Ontario lacks a

centralized and comprehensive province-wide risk and behaviour surveillance system. While there are many

existing risk and behaviour surveillance systems in Ontario conducting excellent work, there is minimal to no

coordination among the various systems. The cultivation of partnerships among these systems and centralized

support for others may augment the ability of each system and the systems as a whole.

Gaps and challenges within the existing systems

Despite the number of available surveys and surveillance systems that capture ongoing population-level risk and

behaviour information for Ontario, the ORBSS advisory committee identified a number of gaps in surveillance

capacity which exist along a range of dimensions. The following is a summary of these dimensions, including

examples or explanations of gaps in Ontario’s risk and behaviour surveillance capacity.

Framework

Current surveillance systems for risk and behavioural factors have developed without an overall conceptual

framework. A conceptual model of health would assist with determining the areas of greatest priority and how

the indicators would fit together to create a more complete picture of the public health need. Ideally, the

framework would be linked to one used for program development and evaluation so the indicators will support

such decision-making.

Supportive infrastructure

The overall development of risk factor surveillance for health promotion and disease prevention for public health

in Ontario is driven by the requirements of the Ontario Public Health Standards (OPHS) which include assessment

and surveillance. The OPHS outline the expectations for boards of health, which are responsible for providing

public health programs and services but does not include consideration of the overall management and


coordination of provincial risk factor surveillance. Ideally, other considerations (such as the need for supportive

legislation that balances the needs of the public health practice, policy and research) would help embed the use of

the information gathered from surveillance into the decision-making process.

Coverage

Gaps exist geographically, for specific topics, and subpopulations (e.g., children and vulnerable populations). Gaps

which exist over time make it difficult to assess changing trends.

Some systems, like CCHS and OSDUHS, provide precise estimates at the provincial and regional level. Other

systems, like RRFSS, have not yet achieved full provincial coverage, but provide participating public health units

with the flexibility to achieve more precise estimates and drill down to information for lower geographic levels.

Specific subpopulations and potential priority populations for public health interventions, such as young children

and Aboriginal Peoples, are not well served by general population surveys such as CCHS, RRFSS and OSDUHS.

Separate targeted surveys, such as ACS, APS and RHS, do exist, but health unit-level estimates for these

subpopulations do not.

One specific challenge for most survey-based behavioural and risk factor surveillance is the declining response

rates. These are now at critical levels (below 60 per cent) which in turn increase the potential response bias.

Addressing these declining rates requires innovation in survey methods to ensure the inclusion of subpopulations

and validity of the estimates.

Content

Surveillance systems must be both flexible, to accommodate emerging issues, and consistent, to support trend

analysis. Most systems are created with their own specific balance of these two competing parameters. For

example, RRFSS is more flexible than other systems such as the CCHS or OSDUHS. RRFSS has the potential to

develop, test and implement survey modules or content on particular topics, or to initiate surveys in new

geographic areas in a much more timely fashion that these other two surveys. On the other hand, CCHS and

OSDUHS have stable estimates that go back over years, allowing for the accurate assessment of trends.

Most systems focus on individual risk factor surveillance. With a few notable exceptions13, systems that monitor a

multiple set of community risk factors (such as work, school and built environments, or monitor environmental

risks (e.g., noise pollution, contaminants)) remain largely underdeveloped and/or underutilized.

Linkages between systems

Few opportunities exist for formal linkage between datasets at the individual level and widespread examples of

group (ecological) level analysis within Ontario are still rare. Some systems, such as RRFSS, provide postal codes

that may permit geographic visualization or neighbourhood-level (including ecological) analysis. Some, like CCHS,

permit individual record-level linkage (e.g., using the health card number) for specified users (such as the Institute

for Clinical Evaluative Sciences (ICES)), purposes and research projects. No systematic approach exists to link risk

factor surveillance data in Ontario and while record linkage is employed by some surveillance systems such as


cancer or diabetes, methodologies for record linkage for the purpose of risk factor surveillance remains largely

underdeveloped. Development of plans, principles or an orchestrated approach for linkage or ecological analysis

could contribute to evaluation of programs and policies, and to answering in-depth research questions they would

enhance public health and health promotion practice in Ontario by making better use of available data.

Link to a public health action

Ontario’s risk and behaviour surveillance systems have historically focused on data collection with a smaller

investment in other aspects of surveillance such as the analysis, interpretation and dissemination of the results so

as to achieve action. While the ORBSS advisory committee focused solely on surveillance systems that went

beyond data collection, it was generally difficult to determine if the data or information were used in decision-

making.

The ORBSS advisory committee noted that there are a growing number of analysis interfaces available on the

Internet that aim to add value to data. For example, the CCHS provides a range of data products through the web,

OSDUHS provides standard reports with trend analyses using their survey data (also on the web), the Ontario

Tobacco Research Unit accesses a variety of data sources for the Tobacco Informatics Monitoring System (TIMS)

as well as the Chronic Disease Informatics Monitoring System currently in the development stages14. In most

cases, the ability to analyze, interpret and link to action is determined by the individual public health unit. While

centrally RRFSS provides results for a core set of indicators on the web, some public health units produce

extensive tailored analyses of RRFSS data, with the result being a documented impact on local decision-making.

This means that the onus is on the public health unit to produce detailed results and not all public health units

have the same capacity to analyze such data, process the information and interpret it to create public health

intelligence and ultimately inform decision-making.

Sustainability

By their very nature, surveillance systems require long-term stable funding. Cuts to the systems are often

accommodated by decreasing the sample size (which leads to unstable rates) or decreasing the number of

indicators (which leads to data gaps and an inability to do trend analyses). Other cuts may reduce the ability to

produce or interpret the results and sustain the quality of the data collection or the system as a whole which will

in turn affect decision-making. This does not even consider the capacity to respond to emerging issues where

new funds have to be found or existing ones redeployed.

Some systems, such as SHAPES-Ontario, SHES and the IFS, are transient and rely on project-based funding. Other

systems, such as RRFSS, rely on decentralized funding by participating health units on a year-to-year basis. As

indicated above, secure funding is preferred in order to generate meaningful and useful surveillance products.

Developing the plan

With all these options and issues in mind, the ORBSS advisory committee made two decisions:

1. Proceed by assessing the priorities of the field and initiating a strategic planning approach to risk and

behaviour surveillance.


The Committee produced a discussion paper which included a draft vision, mission, goals and values.

This paper was shared with the public health community and other stakeholders for consultation and

comment.

2. Focus surveillance activities for two main audiences: the local public health units and the provincial public

health system as a whole.

This meant that the needs of other interested public health partners such as Local Health Integration

Networks (LHINs) would be considered but the needs of the public health system (both local and

provincial) would take priority.

3.0 Priority Setting

To help to establish the needs and priorities for risk and behaviour surveillance, the ORBSS advisory committee

conducted an online survey in August 2010, which helped to inform the development of this proposal for ORBSS.

The online survey was designed to collect feedback on the preliminary vision, mission, goals and values of ORBSS,

and to gather the key priorities for risk and behaviour surveillance in Ontario. The invitation to participate in the

online survey was distributed to public health units and interested persons/groups who had indicated an interest

in ORBSS by signing up to receive updates from the ORBSS email list. A total of 25 out of 36 public health units (69

per cent) submitted a formal response on behalf of their public health unit. An additional 42 respondents

completed the general stakeholder survey for an estimated response rate of 55 per cent. A full report of the

online consultation is available on the ORBSS website15.

The main results of the online consultation indicated:

• Strong support for the vision, mission and values as stated. Some areas were identified as requiring

changes to word choice. Subsequently, the term “province-wide” was clarified to mean covering and

available to the whole province, both at the health unit and at the provincial level.

• Strong agreement that the primary audience should be health units and provincial government ministries.

• Existing data gaps and data needs for key populations are not covered by the current surveillance

systems. In particular, surveillance systems for children and youth as well as priority populations (such as

new immigrants and Aboriginal Peoples) were identified. In addition, information on policies and

programs in specific settings, and specific environmental factors or organizational environments were

identified.

• Population health assessment could be improved by making more datasets available to public health units

and by using existing datasets to provide detailed reports on selected topics that relate to the OPHS. A

final suggestion was to develop online tools to facilitate data analysis at the local level.


Based on the online consultation the ORBSS advisory committee amended the vision, mission, goals and values

and identified three key proposed directions for ORBSS related activities, specifically:

1. Central analytics

2. New data or information acquisition

3. Support for the Rapid Risk Factor Surveillance System (RRFSS).

These three directions were shared in subsequent focused discussions with APHEO and government stakeholders.

Two additional consultations augmented the results from the online consultation. The first, with APHEO, was held

on September 21,2 010, and involved approximately 50 to 60 public health epidemiologists and others interested

in public health epidemiology. The themes from this consultation were similar to those expressed in the online

survey but some additional themes arose. These themes included:

• Continue to clarify that ORBSS is a planning project for a comprehensive surveillance strategy in Ontario

and not meant to replace RRFSS by creating a new data collection system.

• Seek to align efforts with APHEO’s Core Indicators for Public Health in Ontario project.

• Focus on efforts which raise the capacity of all health units to meet the OPHS.

The third consultation was held on October 13, 2010, with representatives from the Ontario Ministries of Health

and Long-Term Care, Health Promotion and Sport, and Children and Youth Services. Participants, who included

senior management, suggested that, in addition to health units and government, ORBSS would also be of interest

to Local Health Integration Networks. The participants indicated that there is a need for an overall coordinated

approach to risk factor surveillance in Ontario and that they are looking forward to receiving a detailed proposal

to which they could respond.

4.0 Vision, Mission, Goals and Values

The environmental scan and consultation with the field confirmed the lack of a comprehensive risk and behaviour

surveillance system in Ontario. In addition, despite informal and sporadic communication between systems, there

was a notable absence of any formal coordination among existing systems. To come to a common understanding

of how risk and behaviour surveillance should move forward in Ontario, the ORBSS advisory committee developed

a vision, mission, goals and values which were modified to reflect feedback from the public health community

during the first consultation. Figure 1 provides an overview of the vision, mission, goals and values of ORBSS.


Figure 1: Overview of ORBSS vision, mission, goals and values

Vision Public health priorities and decisions are informed by a province-wideb risk and behaviour surveillance systemc

The vision affirms that establishing and maintaining effective public health programs and services depends on the

availability and use of timely, valid and reliable information. Public health programs and services are a vital

component of the health system. They help people stay healthy through the protection and promotion of health

and the prevention of illness. The need for a comprehensive risk and behavioural surveillance system in Ontario is

b Province-wide refers to having data available at both the local and provincial level.

c Surveillance includes not only data collection and analysis, but also data integration, interpretation, preparation of reports,

dissemination of reports, management and coordination, and supportive legislation.

Enable the

identification

of priority

groups

Enhance

policy

development

Inform

program

performance

management

Inform

program

planning

Equitable Responsive Sustainable Collaborative

Mis

sio

n

Go

als

Val

ue

s

Use

resources

efficiently

A coordinated province-wide surveillance system that provides timely

and accurate provincial and local public health unit-level estimates of

health behaviours, attitudes and other risk factors to support public

health decision-making

Public health priorities and decisions are informed by a province-wide risk and behaviour surveillance system

Vis

ion


shaped by the need of local health units, OAHPP, the Government of Ontario and others to have accurate and up-

to-date information on behaviour and risk factors in Ontario to allow for informed public health practices and

decisions.

Mission A coordinated province-wide surveillance system that provides timely and accurate provincial and local public health unit-level estimates of health behaviours, attitudes and other risk factors to support public health decision-making. To achieve the vision that public health practices and decisions are informed by a province-wide risk and behaviour surveillance system, a comprehensive risk and behavioural surveillance system will help public health units, OAHPP, the Government of Ontario and others plan and implement programs and services that meet the OPHS requirements by providing relevant evidence.

Goals

The ORBSS advisory committee identified the following primary goals for a comprehensive risk and behavioural

surveillance system in Ontario:

Inform program planning by providing data and information so that programs and services can be tailored to address current and emerging public health needs at the provincial and local health unit level.

Enhance policy development by allowing policy-makers to have the information required to enable them to develop new policies or amend existing policies that positively impact the public’s health.



Use resources efficiently by using existing data, generating province-wide estimates, and providing infrastructure support to eliminate duplication of work in order to maximize access to information in a timely fashion.

Values

Equitable, responsive, sustainable and collaborative have been identified as the four values of moving risk and

behavioural surveillance forward in Ontario. As the key, underlying qualities that will guide the ORBSS advisory

committee in developing a proposal and recommendations, these values support criteria for decision-making,

particularly when resources are scarce.


Equitable

Ensure that the all public health units in Ontario are represented in the surveillance system and that all public

health units have access to surveillance information and related products in order to address the public health

needs of Ontario’s diverse and vast population.

Responsive

Respond to current and emerging public health events and the needs of health units by providing high-quality

data in a flexible manner.

Sustainable

Build the foundation for a surveillance system that can continue to meet the needs of public health units and the

Government of Ontario.

Collaborative

Work effectively and efficiently with other surveillance systems, and to mutually build on existing sources.

5.0 Environmental Scan Review The ORBSS advisory committee returned to the surveillance systems and surveys considered in their

environmental scan and reviewed them in the context of stated values - responsive, equitable, sustainable and

collaborative (see Appendix A). The review highlighted that no individual system or survey exhibits strength in all

four value areas, but that each system possesses individual strengths and limitations. When considered

collectively, the overall system presents strengths across all areas.

6.0 Achieving the Vision With the overall strategic vision set, the ORBSS advisory committee moved on to the methods of achieving this

vision. The following steps were taken:

Creation of an overall conceptual model for health on which to base the surveillance system.

Examination of the flow of data to intelligence within a surveillance system and application of this

approach to identify areas where investments in the system may be most effective and efficient.

Review of the options where investments would have the most effect so as to map out a plan of action.

At the same time as ORBSS was exploring an approach to achieving its vision, RRFSS was also moving forward

independently with some major changes including:

Examination of the feasibility of creating a provincial sample for RRFSS through a one year pilot study.


Reduction of the number of questions in the survey’s core content (those questions common to all public

health units).

Studying the use of multimodal data collection methods to improve response rates and move away from

only using telephone interviewing.

To accomplish these changes RRFSS participating public health units agreed to jointly fund a 2011 pilot project of

provincial data collection.

Conceptual model of health

Having a theoretical basis or conceptual model about health and its determinants is important for ORBSS, since it

underpins the development of the content and scope of the surveillance system.16 The conceptual model helps

define the underlying assumptions of causation and relationship, which in turn indicate what information would

be required. The model can also guide how the indicators will be assembled into the final reports. The ORBSS

advisory committee chose a conceptual model of health first proposed by Dahlgren and Whitehead (Figure 2) and

described in a paper by the World Health Organization (WHO) 17. An advantage of this model is that it is linked to

action since the authors focus on policy options for the WHO that could reduce inequity and promote health. The

model is also supported by the chief public health officer of Canada who used it in his 2008 report on the state of

public health in Canada18 and it has been used by many other public health jurisdictions within Ontario and

around the world.

The implications of the adoption of this model include the following:

Inclusion of a broad range of risk factors and determinants of health that impact on those risk factors.

Factors such as income, culture and ethnic origin are all envisioned to contribute to the populations

health and are included as part of ORBSS. In addition, the model opens the door to non-traditional

sources of information, such as measures of agriculture and food production, since these factors do

impact on health. The broader conceptual model is therefore permissive, in the sense of allowing for a

broader scope of contributing factors to be included in the surveillance system.

Inclusion of a continuum of individual-based measures (such as traditional risk factor surveys) to more

community-based and environmental measures such as housing, food production, physical environment

and employment.

Many of these factors may be available at an ecological level and imply the use of more recent analytic

techniques such as geographic information systems (GIS) and analyses over time and space. One

example of such an application is the work by Glazier and Booth19 on the availability of transportation and

grocery store access on diabetes rates in Toronto neighbourhoods. New data sources that will assist in

providing ecological analyses should thus be considered.


Applicability of the model to public health planning and evaluation.

Many of public health programs and particularly those with health promotion requirements acknowledge

social and environmental factors. Including these factors in the surveillance system should support better

overall public health planning, delivery and evaluation.

Figure 2: Conceptual model of risk factors for health

Source: Adapted from Dahlgren & Whitehead (1991)

It should be noted that the conditions provided in the figure are examples and not meant to be an exhaustive list.

It is also acknowledged that some factors may interact directly. For example, exposures in the work environment

(second outermost shell) may have a direct impact on health and are not mediated by social and community

networks (third outermost shell). Indeed the list of determinants included originally by Dahlgren and Whitehead

is slightly different and may be considered more inclusive than those listed by the 2008 report by the chief public

health officer in Canada. Examples of the indicators in the different levels of the conceptual model are

summarized in Table 1.


Table 1: Conceptual model factors and examples

Conceptual model risk factor Examples

Age, sex, hereditary/constitutional

factors

Age, sex, ethnic origin

Individual lifestyle factors Diet, exercise, sexual practices, environmental exposure

(e.g., suntanning), etc. as experienced by the individual

Social and community networks Lifestyle factors of friends (e.g., proportion of friends who

smoke or binge drink alcohol), social support, etc.

Living and working conditions

o Income

o Education

o Unemployment

o Work environment

o Housing

o Health services

o Agriculture and food production

Many of these are interrelated (e.g., income and education,

income and unemployment)

Relative and absolute income

Education (> grade nine, professional training, etc.)

Short-term, long-term unemployment

Work exposures, stress, etc.

Housing, type of housing, or lack thereof

Access to health services (both treatment and preventive)

Measures of local versus imported food production, levels of fat in diet, etc.

General socio-economic, cultural and

environmental conditions

Distinct from the examples above, these refer to the overall

economic conditions of the state (i.e., economic status of

the community as a whole) and cultural norms of particular

groups. The environmental conditions can refer to

increased environmental exposures in one area versus

another (e.g., increased heat in a city due to the “canyon

effect”).


Conceptual model of data, information and intelligence

Most surveillance systems start with the collection of raw “data” (Figure 3). These data points typically include

individual attributes (such as age or sex), dates of events or practices, and descriptions of the outcomes of

interest. These data points by themselves must be aggregated or summarized as “indicators” and turned into

“information” through the use of analytical techniques. An example of the latter is the calculation of rates and

presentation of rates over time, age, or other analytical dimension. The information is then interpreted in the

context of what is known from the scientific literature and local characteristics to create “intelligence.” The

vision of ORBSS is to support the creation of this intelligence and thereby improve decision-making so that it will

ultimately lead to actions that improve health outcomes.

Figure 3: Conceptual model of data to information to intelligence

Intelligence

Information

Raw

data

files

Pre-set analysis

e.g. dashboard

Epidemiologists and

analysts

Epidemiologists and

analysts

Epidemiologists, analysts, and

other specialists

Public

reports

Indicators

Admin

data Vital

stats

Surveys

e.g.

RRFSS

CCHS

Census

Epidemiologists, program managers, directors, and staff

Information and interpretation

Aggregated

datasets

Audiences/ Users

Policy-makers, decision-makers, health professionals and public

Synthesis level

Users


Although this data-information-intelligence model describes the output, there are approximately nine main

components to the surveillance process. These are:

1. System design (decisions on the overall structure of the surveillance system)

2. Content selection (what measures or data will be collected)

3. Data collection (how the data is collected in a complete and unbiased fashion)

4. Data collation (how the data is stored and brought together in an appropriate manner)

5. Data analysis (how the data is turned into indicators and information)

6. Report writing (the creation of intelligence relative to the questions that need to be addressed/decisions

that need to be made)

7. Dissemination of results (how the reports are distributed to those who need to know)

8. Quality assurance (assuring that the processes described above are appropriate and done well)

9. Training and education (enhancing the skills of persons involved in risk and behavioural surveillance).

Underlying these, and implicit in them, was the recognized need for management and coordination. The ORBSS

advisory committee examined these nine components relative to the existing risk factor surveillance systems

(listed in the environmental scan) and tried to assess the relative needs for investment as well as return on

investment of new resources. The results were as follows:

Content selection

Existing surveillance system should realign their content selection so as to maximize coverage and

minimize duplication. As an example, some of the content that is routinely collected by RRFSS is identical

to that collected by the CCHS. While duplication of selected demographic data is required, the degree of

duplication should be minimal so that greater efficiencies can be found.

Data collection

Many public health units indicated that the priority area for new or additional data collection was child

health (aged 0 to 11 years) since public health is responsible for significant programming in this area but

have fewer systems collecting data about this population. However, creating a new surveillance system

or building on those that already exist in order to better understand the risk and behaviours of children

would require significant investments. There was agreement that this is an overall priority for Ontario

and it would require significant work to create such a system.

Data collation

There was widespread support for the creation of a “data warehouse” for risk factor data, similar to that

of intelliHEALTH ONTARIO. There was recognition that, in comparison to this extensive collection of

clinical administrative records of health service delivery, there is no similar approach for the collation of


risk factor, chronic disease, and environmental health surveillance data. The creation of such a

“warehouse” or repository would support an overall system. However, the logistics of doing so were

considered beyond the scope of the ORBSS advisory committee.

As indicated earlier, the exploration of new data sources and their application to geographic and

community level analysis was considered as a potential area for improvement in risk factor surveillance.

Data analysis

The idea of centralized analysis of CCHS, RRFSS and other datasets by one central provincial agency was

seen as both efficient and effective. Such reports would standardize the outputs and ease the workload

on public health epidemiologists particularly in smaller health units. It would allow epidemiologists to take

on other types of work, such as interpreting and applying the results. APHEO’s Core Indicators for Public

Health in Ontario Working Group indicated their strong interest in OAHPP supporting their development

of indicators to assist with this aspect of ORBSS. One of the emerging areas identified where central

analysis may be helpful was the use of geographic information systems (GIS) and spatial analysis.

Report writing

While the ORBSS advisory committee believed that the writing of detailed surveillance reports should be

left to the appropriate local and provincial authorities, there was agreement that ORBSS should explore

the creation of a “dashboard” or other similar format for creating a standard report with a small set of key

indicators. These indicators would need to be chosen relative to the requirements of the OPHS, and then

made operational in the form of standard reports. Guides to aid in the interpretation of these reports

(including documentation on the data sources and methods used) should also be produced.

Dissemination and quality assurance

The ORBSS advisory committee recognized that through dissemination, feedback to data funders and

suppliers would be gained and changes could be made in the development process. In turn, more

purposeful, multi-directional, knowledge exchange processes should be fostered.

Training and education

There was general agreement that ORBSS had to include training and education components at all levels.

This would include education or resources on the advantages and disadvantages of each source of data,

methods of analysis and the limitations of interpretations. Training on new forms of analysis such as

geographic information systems (GIS) should also be included.


7.0 Recommendations

A draft set of recommendations for ORBSS was developed and reviewed by the ORBSS advisory committee. The

ORBSS advisory committee chose to direct the recommendations to OAHPP as they felt that OAHPP was in the

best position to receive these recommendations and promote change across the public health system.

To garner feedback on the draft recommendations a second stakeholder consultation was undertaken including a

series of focused discussions and an opportunity for email feedback. A PowerPoint presentation including

background on ORBSS and the draft recommendations was created for use during the second round of

consultations and later posted on the ORBSS website for feedback. Four different consultation meetings were

held, one for each key group of stakeholders, including the Council of Ontario Medical Officers of Health

(COMOH), RRFSS, APHEO, and the Ontario Ministries of Health and Long-Term Care, Health Promotion and Sport

and Children and Youth Services. An email was sent to all persons who had signed up to the ORBSS email list

inviting them to review the presentation and submit comments directly to a designated project email address.

The results of these consultations can be grouped into three main areas. These are:

1. Coordination of existing surveillance systems

2. Provision of central analytical support

3. Funding including support for RRFSS.

Each of these sets of recommendations will be discussed and presented below. Results of the consultation will be

presented after each of the recommendations.

7.1 Coordination

ORBSS as a “system” of systems - Coordination of existing surveillance systems: Integration and joint planning

At many points during the initial and second round of consultations, there were instances when participants

requested clarification of the meaning and use of the term “system” within the name ORBSS. From their

perspective, a surveillance system was one that went through all the steps from data collection to analysis,

interpretation, preparation and dissemination of reports. In contrast, other respondents agreed with the concept

of ORBSS as a “system” that would provide better integration of the existing surveys and smaller systems. As the

ORBSS advisory committee reflected on the existing political context and fiscal environment, the members shifted

away from the idea of ORBSS replacing existing surveys or systems. A more pragmatic view emerged, that of a

partnership and coordinating committee. Figure 4 shows a schematic view of the Ontario Risk and Behavioural

Surveillance (ORBS) partnership including the coordinating committee.


In this proposed partnership, the membership included four overlapping groups:

1. Funders - those who fund surveillance systems such as governments and interested non-government

organizations.

2. Suppliers - those who collect and/or supply data such as RRFSS, CCHS and others.

3. Users - those who use the data such as epidemiologists in health units and ultimately public health

decision-makers.

4. Other Stakeholders - those who are interested in risk and behaviour surveillance but have yet to define

clearly their role in provincial or local surveillance.

Figure 4: Schematic view of ORBS partnership and coordinating committee

The ORBSS advisory committee proposes that these groups be brought together to create a forum where

interested members would agree to work together with a view to advance risk factor and behaviour surveillance

in Ontario. Participation would be voluntary. The main concept is to have members share information and

discuss how best to advance risk and behaviour surveillance through regular meetings. Interested parties would

form the ORBS partnership. Opportunities would be pursued, either through the ORBS partnership as a whole,

through subgroups or through individual organizations’ actions as warranted.

Suppliers

Users

Funders

C o o r d i n a t i n gC o m m i t t e e


The ORBSS advisory committee had considerable discussions about how this group would be governed and this

was also discussed in the consultation process. Some such as those committee members that work at

government ministries believed that the ORBS partnership needs to be accountable to an agency such as OAHPP,

while the majority felt that it should be reporting to the individual member’s agencies. After careful discussion of

the pros and cons, the latter view is proposed. The role of the ORBS partnership is seen as providing a forum for

enhancing collaboration and for coordinating risk factor and behaviour surveillance in Ontario through facilitating

discussion, collaboration and coordination of the existing surveillance systems and risk and behaviour surveillance

networks to make best use of Ontario’s resources.

While the ORBS partnership would be relatively unstructured and provide a forum for discussion and voluntary

collaboration, the ORBSS advisory committee also recognize the need for a more formally defined ORBS

coordinating committee. While this committee is called a “coordinating committee,” its main role will be to

collectively work towards creating more coordination among the core members of the risk and behaviour

surveillance systems in Ontario. Membership would be drawn from the ORBS partnership and would consist of

three main groups: key data providers who provide surveillance data on a provincial or near provincial level

(examples would be RRFSS, CCHS, and OSDUHS), key data users such as APHEO and other epidemiological groups,

and data funders such as the Ontario Ministries of Health and Long-Term Care, Health Promotion and Sport, and

Children and Youth Services.

As with the partnership, governance of this coordinating committee was actively discussed and, after considerable

debate, the ORBSS advisory committee proposed that the coordinating committee be independent of any

individual organization and be self-organized to collectively support the member organizations as was

recommended for the ORBS partnership. The key roles of the ORBS coordinating committee are to:

Facilitate discussion, collaboration and coordination between users, suppliers and funders of surveillance systems.

Facilitate the evolution of the existing surveillance systems so they can collectively address emerging surveillance needs.

Provide advice on new and existing provincial investments in risk and behaviour surveillance.

Support the evaluation and incorporation of new or existing data sources, particularly those that would fill identified gaps.

Recommend and support education and training programs related to risk and behaviour surveillance and, in particular, ORBSS products and processes.

Draft terms of reference for the ORBS partnership are attached in Appendix B.


Recommendation 1 - Coordination

The ORBSS advisory committee recommends that:

a) OAHPP establishes and provides secretariat support for an Ontario Risk and Behaviour Surveillance

(ORBS) partnership, to facilitate relationships among data users, suppliers and funders.

b) OAHPP establishes and supports the creation of an ORBS coordinating committee, to facilitate joint

planning and integration.

c) ORBS partnership identifies existing datasets pertinent to the Ontario Public Health Standards (OPHS).

d) ORBS partnership identifies opportunities to gain access to these datasets or tabulated results.

e) ORBS partnership investigates the potential to develop new datasets or expand the use of existing ones

including the linkages between datasets.

f) OAHPP and relevant ministries within the Ontario Government consult with the ORBS coordinating

committee/partnership for their collective advice on areas where:

collaboration across existing surveillance systems is possible and beneficial, and

new investments in risk and behaviour surveillance would be most efficient.

g) OAHPP consults with Aboriginal organizations and the First Nations and Inuit Health Branch of Health

Canada on collaborative risk and behaviour surveillance activities for Aboriginal Peoples d.

Results of the consultation:

There was near uniform support for the need for more coordination and collaboration among the existing

systems, however, there continued to be a divergence of opinion relative to the proposed governance

model. As indicated earlier, some, including ministry representatives, felt that the ORBS partnership and

ORBS coordinating committee needed to be accountable to an agency or body for their actions. However,

as one participant identified, apart from funding, there are no “levers” to drive change among the

partnership or coordination committee. The majority of the ORBSS advisory committee supported this

voluntary approach.

One additional observation of note was that there was no mention of Aboriginal Peoples and how

collaboration might be sought to best include and serve this population. Given that half of public health

units border on First Nations, the ORBSS advisory committee agreed with the need to include a

recommendation that OAHPP consult with Aboriginal organizations and the First Nations and Inuit Health

Branch of Health Canada on collaborative risk and behaviour surveillance activities for Aboriginal Peoples.

d Recommendation added as a result of consultations.


7.2 Central analytics

The need for central analytics for the existing risk and behaviour surveillance systems was identified as a priority.

The creation of such standardized reports, linked to the Ontario Public Health Standards (OPHS) would improve

the ability of all public health units to meet the Foundational Standard and the related Population Health

Assessment and Surveillance Protocol. It would improve the quality, consistency and efficiency of reporting for

both public health units and the Ontario Government and its agencies. The ORBSS advisory committee

recommended that OAHPP take on this role. The recommended approach would be to start with the CCHS

datasets and use the core indicators as developed by the APHEO Core Indicators Work Group that relate to the

OPHS. With advice from an advisory committee (consisting of representatives from APHEO, public health units

units, and government), standard output products could be developed and distributed electronically to all public

health units and the relevant ministries within the Ontario Government. Over time, it is anticipated that the

scope and frequency of the release or updating of surveillance products will increase to provide improved

coverage of the OPHS and to support additional public health reporting needs (accountability indicators etc.).

The second part of the central analytics role, which must precede the actual preparation of reports, is the

agreement on a small set of key indicators for monitoring progress towards stated public health goals and

objectives. These indicators should help managers and directors monitor their population’s health and contribute

to documenting program needs. This set of indicators, presented in a summary, visual format that is often called

a “dashboard,” would provide a population health assessment “bridge.” It needs to be developed, pilot tested

and evaluated. Given the role of OAHPP in applied public health research and its role in central analytics, it is

recommended that OAHPP assume leadership on this initiative.

As the products are disseminated and used, and the audience becomes more familiar with surveillance and its

potential, it is likely that additional gaps in indicators and data sources will be identified. This feedback will, in

turn, help refine future plans to improve population health assessment and surveillance activities.

Recommendation 2 - Central analytics


a) OAHPP establishes and supports a central analytics advisory committee (including members from

boards of health, government, resource centres and the Association of Public Health Epidemiologists in

Ontario (APHEO)).

b) OAHPP assumes the role of developing a central analytics program including an electronic platform for

risk factor and behaviour surveillance in Ontario.

c) OAHPP supports APHEO Core Indicators for Public Health Work Group to define the core indicators for

central analytics.

d) OAHPP assumes the role of producing the results for a key set of indicators.


e) OAHPP examines ways to enhance education and training on the production and interpretation of

indicators.e


Overall, there was strong support for the need for central analytics. Respondents were happy to see that

support for the development of indicators was included in the recommendations. There was a general

suggestion to increase the level of education and training on use of the reports as well as provision of

advanced statistical help.

One suggestion was to create a “hotline” or designated person to help answer technical questions on the

calculation of indicators and interpretation of statistics. The latter raised questions about creating a

“community of practice” around these indicators and reports. The ORBSS advisory committee agreed

with this recommendation and thus added the recommendation that OAHPP examine ways to enhance

education and training on the calculation and interpretation of indicators.

7.3 Funding

While the ORBSS advisory committee recognized the nature of the provincial debt and financial constraints on the

Ontario Government, they also believe that changes to surveillance systems will require an infusion of new

resources. The ORBSS advisory committee believes that the current amount of resources will not be sufficient. As

a result, they call on the Ontario ministries of Health and Long-Term Care, Health Promotion and Sport, and

Children and Youth Services to provide additional support as necessary. It is noted that this statement was not

supported by all members of the ORBSS advisory committee due to a conflict of interest. Members of the

committee who work in these ministries did not support the inclusion of this recommendation.

The ORBSS advisory committee recognized that RRFSS plays an extremely important role in risk and behaviour

surveillance, particularly with respect to providing timely information on emerging public health issues that are

not covered by existing systems. Examples include the rapid collection of data on public perceptions of risk for

pH1N1 and use of artificial tanning salons. This flexibility is one of the key strengths of RRFSS. The challenge is that

RRFSS does not currently include all Ontario health units or have provincial coverage. The ORBSS advisory

committee foresees such provision of information important for public health programming both locally and at

the provincial level.

During the initial planning for ORBSS, many of the discussions focussed on how ORBSS might assist RRFSS to

achieve full provincial coverage. Prior to ORBSS, efforts to secure provincial funding for RRFSS enhancements

were unsuccessful. During the deliberations of the ORBSS advisory committee, two major issues were recognized.

First, the consultation underscored the fact that many of the public health units are not currently participating in

RRFSS because they lack the necessary epidemiological infrastructure. Simply providing funding for additional

e Recommendation added as a result of consultations.


survey sampling for these non-participating public health units would be insufficient since additional

epidemiological support also needs to be made available. Second, the RRFSS partnership values their autonomy

and wished to continue to operate as an independent surveillance system.

Recognizing the need to have a flexible and responsive surveillance system and the above constraints, the ORBSS

advisory committee recommended that the current level of support provided by OAHPP to RRFSS be continued

and potentially expanded in terms of providing scientific and technical support for the development of new

questions and modules to address novel and emerging issues. Presently, OAHPP supports RRFSS by hosting its

website and providing support for conference calls. In terms of funding provincial samples for RRFSS, the ORBSS

advisory committee recommended that additional funding of RRFSS should be determined once the results of the

pilot study are complete.

Recommendation 3 - Funding


a) OAHPP seeks support from Ontario Ministries of Health and Long-Term Care, Health Promotion and

Sport, and Children and Youth Services for the development of the central analytics program, key

indicators and ORBS coordinating committee.

b) OAHPP continues their current support of RRFSS including the scientific and technical advice for the

development of modules of mutual interest.

c) OAHPP works with the ORBS partnership to enhance funding and expand data collection in order to

answer provincial time-sensitive/emerging questions.


The main discussion focused on where RRFSS fits within the vision of the ORBSS advisory committee.

While there was no clear consensus on the best approach, the following comments were made:

During the consultation with the medical officers of health, there was a suggestion that RRFSS

should be aligned with the directions outlined in this report.

During the consultation with RRFSS, there was general support for the recommendations and a

suggestion that the enhanced collaboration of module development could start now and not wait

for the development of the ORBS partnership.


While the need for additional funding was recognized to support the ORBS partnership and the

recommendations in this report, it remains unclear where the responsibility for funding lies.

Based on the above, the funding recommendations were not changed by the consultation process.

8.0 Conclusion

The ORBSS advisory committee completed a review of the existing risk and behaviour surveillance systems that

support public health practice and decision-making in Ontario. Based on the gaps and challenges in the existing

system, the committee undertook a strategic planning process, including the creation of a vision, mission, goals

and values which was reviewed and modified by an initial stakeholder consultation process.

Accomplishing this vision will be a complex undertaking, requiring multiple stakeholder participation. The task is

even more challenging given the current environment of fiscal constraint. While the ORBSS advisory committee

has made recommendations on the major issues, identified gaps remain, in particular, the need for surveillance

systems related to child health and other priority populations. Furthermore, comprehensive province-wide

coverage in RRFSS for all health units has not yet been achieved and continues to raise considerable discussion in

the public health community. The ORBSS advisory committee encourages others to continue to address these

issues while the the recommendated priorities are acted upon.

Using an incremental, evolutionary approach, the ORBSS advisory committee is making recommendations to

OAHPP in three major areas of change. These recommendations have been modified through a second

consultation including focused discussions with key stakeholders and targeted email responses. The first set of

recommendations involve increasing collaboration among the existing systems through the creation of an ORBS

partnership and coordinating committee consisting of data suppliers, data users and funders. The second set of

recommendations involve central analytics and specifically creating a central analytics “bridge” at OAHPP which

will provide timely, consistent results for public health indicators for all health units and thereby freeup resources

(particularly for under-resourced health units) to interpret these findings. The third set of recommendations

focuses on funding and the need for financial support for the infrastructure for the first two sets of

recommendations as well as efforts to enhance RRFSS, particularly as it relates to its role as a flexible surveillance

system to rapidly obtain information not covered by other surveillance systems.


Appendix A: Ontario environmental scan summary of key systems for ORBSS by ORBSS values

Surveillance system Overview ORBSS values

Responsive Equitable Sustainable Collaborative

Aboriginal Children’s

Survey (ACS)

Assesses early development of aboriginal children (North American Indian, Métis, Inuit and off-reserve First Nations) on a wide range of topics, including breastfeeding, physical activity, height and weight, fruit and vegetable consumption, and chronic conditions.

Administered by Statistics Canada.

Conducted in 2001 (for children zero to 14 years of age) and 2006 (for children zero to five years of age).

Large, cross-sectional, parent-reported survey by telephone or personal interview in remote regions.

Survey was designed to address the data gap on aboriginal children, and provide information on the motor, social and cognitive development of young aboriginal children.

Questions were translated into seven aboriginal languages.

Documentation and summary results for common health indicators are available on the Statistics Canada website for national, provincial and territorial level.

Sample is too small to have health unit-level estimates. Some community-level data will be available for those areas with large aboriginal populations. Data will be available for each of the four Inuit Land Claim regions. Data will also be available for certain census metropolitan areas in Canada.

Record-level data not routinely sought by or shared with health units.

Developed by Statistics Canada and aboriginal advisors from across the country. Conducted in partnership with Human Resources and Social Development Canada.

Anticipated to be repeated by Statistics Canada every five years.

Survey development included direct participation of parents, front line workers, early childhood educators, researchers, various aboriginal organizations and others.

A Technical Advisory Group, consisting of specialists in aboriginal early childhood development, was established to provide guidance on survey development.

Aboriginal Peoples have been hired and trained as interviewers and for other survey-related positions.

Overall assessment STRENGTH LIMITATION STRENGTH STRENGTH




Aboriginal Peoples

Survey (APS)

General social survey of Aboriginal Peoples (North American Indian, Métis, Inuit and off-reserve First Nations) on a wide range of topics, including health-specific issues such as physical activity, height and weight, smoking and drinking.

Administered by Statistics Canada every five years (1991, 2001 and 2006).

Includes aboriginal children and youth (six to 14 years of age) and aboriginal people (15 or more years of age).

Large, cross-sectional, self-reported (or parent-reported for children six to 14 years of age) survey by telephone or personal interview in remote regions.

2006 sample: Canada 48,921; Ontario 7,808.

Aboriginal Peoples are involved in all aspects of the survey, including content design.

Translated into 20 aboriginal languages and additional interpreters available.

Regional supplements incorporated.

All provinces and

territories included.

Documentation and summary results for common health indicators available on Statistics Canada website.

Sample is too small for health unit-level estimates.

Record-level data not routinely sought by or shared with health units.

Funded by a consortium of federal departments, including Indian and Northern Affairs Canada, Human Resources and Social Development Canada, Health Canada, the Canada Mortgage and Housing Corporation and Canadian Heritage.

Anticipated to be repeated every five years.

Developed by Statistics Canada in collaboration with national aboriginal organizations.

A representative from each of the five national aboriginal organizations is part of the survey’s implementation committee.

Aboriginal Peoples are involved in all aspects of the survey. Many were hired and trained as interviewers or for other survey-related positions.





Better Outcomes

Registry and Network

Ontario (BORN-Ontario)

(formerly the Ontario

Perinatal Surveillance

System)

Integrates data from five maternal and infant-related databases to provide information that helps monitor, evaluate and plan maternal, child and youth health services across the provincial health care system.

Prescribed Registry under Ontario’s Personal Health Information Protection Act, using its legacy name the Ontario Perinatal Surveillance System.

Ability to respond to public health needs, such as enhanced socio-demographics, has not yet been tested.

Collects information on all hospital and most non-hospital births across the province, including some maternal/child risk factors.

Hospital birth capture reached 100 per cent in November 2009, which will allow for analysis within and between health units.

Completed summary report for 2008 data and continue to align indicators with OPHS.

Children’s Hospital of Eastern Ontario provided founding support and sponsorship, while ongoing funding is provided by the Ministry of Health and Long-Term Care.

Governance structure includes a scientific advisory committee with one public health representative.

Privacy concerns may limit health unit access to “real-time” record-level data. BORN-Ontario proposing that all public health units be provided with a modified standard dataset.

Overall assessment LIMITATION STRENGTH STRENGTH LIMITATION




Canadian Community

Health Survey (CCHS)

Designed to collect information related to health status, health-care utilization and health determinants.

Administered by

Statistics Canada.

Includes Canadian household population 12 years and older.

Large, cross-sectional, self-reported survey at the health unit level.

Complex sample design, stratified by province and health unit.

Repeated cross-sectional survey every two years. Changed to continuous data collection in 2007.

Content is relatively fixed, limiting health unit-specific content.

Balances ongoing core surveillance needs with episodic population health assessment of areas of interest through four types of content: Core, Theme, Optional and Rapid Response.

Optional content: Can vary

each year. Content is

common across Ontario to

accommodate differences

in health unit and Local

Health Integration Network

boundaries.

Rapid response content:

Designed for national

estimates on emerging

population health issues.

Strengthens overall

responsiveness. Can be

included in any two-month

survey collection period

(e.g. Osteoporosis –

March/April 2009).

Full provincial coverage by health unit.

Excludes some subpopulations (i.e. children younger than 12 years of age, on-reserve, institutionalized, military and some remote populations).

Sample allocation starts

with minimum of 500 per

health unit (over two

years of collection).

Each health unit receives Ontario’s record-level data (Ontario Share File) annually through the Ministry of Health and Long-Term Care.

Summary results for common health indicators available on Statistics Canada website.

Limited central analysis of

Ontario’s optional

content.

Primarily funded by Statistics Canada with no additional cost to health unit.

Additional sample for

Ontario purchased by

Ministry of Health and

Long-Term Care,

specifically for Toronto

Local Health Integration

Network area.

Collection began in 2000-01 and is anticipated to continue.

Statistics Canada periodically seeks input for content and product development through an advisory committee or consultation processes.

Ontario has three representatives, including one health unit representative on the Population Health Surveys Advisory Committee who provides advice on survey needs, priorities, content, dissemination, products and tools.

Survey documentation and bootstrap analysis files widely available to facilitate data use at health unit level.

Collection of health card number can facilitate record linkage with other data systems.





Canadian Health

Measures Survey

(CHMS)

Designed to provide reliable estimates at the national level and by age group for selected health conditions (e.g. obesity), characteristics and environmental exposures based on direct health measures; ascertain relationships among risk factors, health promotion and protection behaviours, and health status; and establish a biorepository of biospecimens (urine, blood, DNA) from a representative sample of Canadians to be used for future research and surveillance.

Includes Canadian household population six to 79 years of age.

Survey includes personal interviews and physical health measures. One of a few surveys in Canada that collects direct measures, thus providing more reliable estimates.

Includes environmental exposure data that is largely unobtainable on a population level.

Sample size (approximately 5,000 for all of Canada) is too small to report on the health unit level.

Sample excludes some subpopulations (i.e. children younger than six years of age, on-reserve, institutionalized, military and some remote populations).

Summary results for common health indicators available on Statistics Canada website at the national level.

Primarily funded by

Statistics Canada, with no

additional cost to health

unit.

Collection began in 2007

and is anticipated to

continue.

Minimal local public health involvement in survey development.

Survey documentation is widely available on the Statistics Canada website.

Collection of postal code

and health card number can

facilitate record linkage

with other data systems.

Overall assessment STRENGTH LIMITATION STRENGTH LIMITATION




First Nations Regional

Longitudinal Health

Survey (RHS)

Collects information based on Western and traditional understandings to explore factors affecting the health and well-being of First Nations peoples. Includes health-specific issues such as physical activity, height and weight, smoking and nutrition.

Completed two phases in 2002-03 and 2007-08.

Includes First Nations peoples living on-reserve (all ages) across Canada. In Ontario, 35 of 134 communities participated (2.9 per cent of population).

Longitudinal, self-

reported (or

knowledgeable person

for children zero to 11

years of age) survey by

personal interview.

Fully directed and controlled by First Nations peoples.

Developed to fill information gap, as First Nations peoples living on-reserve were excluded from major national health surveys, such as CCHS.

National questions included in all participating communities. Additional questions may be incorporated at the regional level.

Does not yet represent all First Nations communities.

Documentation and summary results on national level available on website.

Each region is responsible for reporting independently. No Ontario region results currently posted on website.

Record-level data not generally shared outside of First Nations or with health units.

Primary funding contributor is First Nations Inuit Health Branch of Health Canada.

Anticipated to be repeated every four years, with next phases in 2011 and 2015.

The Assembly of First Nations Chiefs Committee on Health appointed the First Nations information governance committee to provide oversight and governance over the administration of the survey. Ten independent regional partners coordinate the survey in their respective regions.





Infant Feeding Survey

No consistent or overall approach in Ontario health units to capture breastfeeding initiation, duration and exclusivity of breastfeeding.

A 2009 Ministry of Health Promotion review showed that 28 of 36 health units had completed an infant feeding survey, with four additional health units anticipating the completion of a survey in 2009.

Each health unit able to develop its own approach to infant feeding surveillance.

Due to the size of the subpopulation, precise health unit estimates are only available for those that can launch their own surveys.

Infant feeding surveillance within health units relies on project-based funding or internal resources and expertise.

Infant feeding surveys

were done in the majority

of health units around

2002-03 due to an

availability of funding for

Early Child Development,

but many have not been

repeated and do not have

any trend data.

Currently, no standard approach to infant feeding surveys across health units.

A collaborative health unit initiative began in 2007 to develop survey questions that all health units could potentially use for measuring breastfeeding in their area, promoting a standard approach.

Overall assessment STRENGTH LIMITATION LIMITATION STRENGTH




Integrated Services

for Children (ISCIS) -

Healthy Babies

Healthy Children

(HBHC)

ISCIS is a real-time

administrative system

used by all health units in

Ontario to manage service

delivery related to HBHC

program. It is accessed

through HBHC-ISCIS

Reporting Sub-System

(IRSS) and IRSS has a one

day reporting delay from

date of entry.

Primarily designed for case

management but also

includes some

family/parent risk factors

for children such as

smoking, poverty etc. and

risk factors at birth such as

birthweight, and other

assessment tool results.

Entry screens have been

modified on the advice of

service providers to include

additional information.

Full provincial coverage by health unit for mandatory data elements.

Ongoing funding is provided by the Ministry of Children and Youth Services.

Data marts/data reports are

created by MCYS with input

from service providers.





Ontario Student Drug

Use and Health

Survey (OSDUHS)

Supports regional and provincial-level planning in Ontario through the collection of information about health and risk behaviour, attitudes and beliefs of Ontario children and youth, primarily related to alcohol, tobacco and other drug use, as well as indicators of mental and physical health.

Includes students in publicly funded schools, grades seven to 12.

Paper-based survey collected every two years within schools. Self-administered, repeated and cross-sectional.

Survey administered by

Institute of Social

Research, York University,

on behalf of the Centre for

Addiction and Mental

Health.

Balances ongoing surveillance needs with areas of interest through two questionnaire forms.

Each form includes core

content, but one form

includes specific content,

thus reducing the sample

size by half for some

content areas.

In 2008-09, six health units

added public health-

specific content and

purchased oversample in

order to have health unit-

level estimates. Anticipated

that four health units will

purchase oversample in

2010-11.

Designed and funded for

provincial and grade-level

estimates. Regional

estimates produced. No

health unit-level

estimates (excluding

those oversampled).

Excluded are youth that have dropped out of school, are institutionalized or enrolled in private schools, or are living on reserves, military bases or in far northern regions.

Survey available in English

and French only.

Schools given a report in which provincial data is provided as a comparison. One year after, record-level data is available for public use.

Central analysis is conducted by Centre for Addiction and Mental Health and summary reports are posted to their website.

Trend analysis available. A cycle is completed every two years. 17 cycles have been conducted since 1977.

Lack of health unit-level estimates limits ability to meet health unit needs.

Funded by Centre for

Addiction and Mental

Health (indirectly by

Ministry of Health and

Long-Term Care).

Most of questionnaire based on valid and reliable scales from other student surveys.

Response rate is still high

(65 per cent). Attributed to

school-based collection.

Centralized decision-making processes through Centre for Addiction and Mental Health.

Survey content and documentation is posted on Centre for Addiction and Mental Health website.

Well developed relationship with schools and school boards enables ongoing collection within school systems.

Linkage with other datasets

is limited by the absence of

any linking variable.

Overall assessment LIMITATION LIMITATION STRENGTH STRENGTH




Rapid Risk Factor

Surveillance System

(RRFSS)

Supports health unit-level public health planning through the collection of information on health-related conditions, behavioural risk factors, attitudes, awareness, perceptions and knowledge.

Includes household population 18 years of age and older.

20-minute household telephone survey, self-reported, cross-sectional, at the health unit health unit level.

Survey conducted by Institute of Social Research, York University, on behalf of each participating health unit.

Ongoing monthly data

collection changed to four

month cycles (three per

year) in 2009.

Health unit-specific content that is flexible and relevant for local public health planning.

Any participating health unit can develop a module on a topic of interest.

Rapid development of content permitted during emergencies.

Dataset every four months.

Balances ongoing core surveillance needs with areas of interest to specific health unit through two types of content: Core/Rotating Core and Optional.

Core/Rotating Core:

selected every two years.

Approximately 60

questions, common for all

participating health units,

typically for full year.

Optional content:

Approximately 40

questions selected by

individual health unit. Can

be changed each cycle

(every four months).

Incomplete provincial

coverage. 19 of 36

Ontario health units

participate, or

approximately 80 per

cent of Ontario’s

population.

Range of sample size available per health unit depends on health unit’s ability to fund. Typical sample 1,200 per year.

Survey available English

and French only.

Each participating health unit receives record-level data, including all other health units’ data.

Central analysis funded equally by participating health units and summary results for core content posted on RRFSS website.

Analysis of optional content completed by health unit, with limited comparisons between jurisdictions.

Health unit participation has varied by year since initial pilot in 1999.

Lack of provincial sample limits ability to meet provincial needs.

Funded by participating health units, with equal contributions for central support, including the RRFSS coordinator.

Many health units challenged by resource needs for collection costs, as well as the time and effort required to complete analysis and sustain collaborative processes.

Declining telephone response rates and cell phone usage indicate need for multi-modal approaches.

Process for ongoing

validation and reliability

testing of modules

required.

Decentralized, collaborative processes facilitate shared decision-making among participating health units, as well as local autonomy.

Survey content and documentation (i.e. data dictionaries) is collaboratively developed and posted on RRFSS website.

Innovation is informally shared by health unit representatives at regional group meetings, and more formally shared at workshops and conferences.

Collection of three digit

postal codes can facilitate

linking with other data, as

well as mapping and spatial

analysis.



ORBSS values

Surveillance system Overview Responsive Equitable Sustainable Collaborative

School Health Action

Planning and

Evaluation System

Ontario (SHAPES-

Ontario)

Designed to provide evidence for population-based intervention planning, evaluation and field research on youth.

Modules focus on smoking, physical activity, healthy eating, mental fitness and school environment.

Includes individual, machine-readable questionnaire validated for grades five to 12 and some organizational-level data through a school administrator survey to assess school policies and programs.

May include students and their schools, grades five to 12. Specific grades may vary.

Created by the Propel Centre for Population Health Impact at the University of Waterloo.

Open to the creation of new modules that deal with other areas of interest (e.g. bullying).

Conducted in only a small number of health units in Ontario. No overall provincial estimates generated.

A school-specific, computer-generated feedback report is provided to each participating school. Health units can access reports and data for schools within their districts. Aggregated data is disseminated with all identifying information (student and school level is removed).

Central analysis is

conducted by University

of Waterloo.

Funding was project-specific and time-limited. Project is not currently funded in Ontario.

Funded by Canadian Institutes of Health Research and the Sociobehavioural Cancer Research Network.

Little trend analysis

available.

Incorporated a number of knowledge exchange activities with health units and schools.





School Health

Environment Survey

(SHES)

Designed to assist schools in further promoting healthy eating and physical activity, as well as to support Ontario’s Action Plan for Healthy Eating and Active Living.

Assesses aspects of the school environment, including promotion of healthy eating and physical activity, as important aspects of health promotion in schools.

Developed in collaboration with health units and in consultation with other public health professionals.

Intended to represent

sample of 500 elementary

and secondary schools

across Ontario during the

2007-08 school year.

Included a feedback report to support continuous improvement in the school community.

Central analysis is

conducted by University

of Waterloo.

Survey content, documentation and overall results are posted on University of Waterloo SHES website.

Funding was project-specific and time-limited. Project is not currently funded in Ontario.

No trend analysis available.

Survey designed to facilitate a partnership between schools and public health units. Incorporated a number of knowledge exchange activities with health units and schools.

Developed by the Public

Health Research, Education

and Development (PHRED)

Program (Sudbury & District

Public Health) and the

Centre for Behavioural

Research and Program

Evaluation at the University

of Waterloo, with one-time

funding from the Ministry

of Health Promotion.

Overall assessment STRENGTH STRENGTH LIMITATION STRENGTH

Moving Risk and Behaviour Surveillance Forward in Ontario: A Proposal and Recommendations

40

Appendix B: Draft terms of reference for the ORBS partnership

Discussion Draft- May 2011

1.0 FOUNDATIONS

Background

Attitude, risk factor and behaviour surveillance knowledge and expertise are dispersed throughout Ontario’s public health system. To make this information and expertise readily accessible to all stakeholders, the Ontario Risk and Behaviour Surveillance (ORBS) partnership was established. The ORBS partnership is an inclusive and voluntary group of stakeholders interested in working together to strengthen the surveillance of attitudes, risk factors and behaviours in Ontario to better inform public health decision-making. The ORBS partnership is a broad-based group of multiple communities of practice and includes both data providers and data users. Participation on the partnership does not preclude the independent efforts and actions of partner entities or individuals.

Mandate

To work toward the vision, mission, goals and values as laid out for an Ontario Risk and Behaviour Surveillance System:

Vision:

Public health priorities and decisions are informed by a province-wide* risk factor and behaviour surveillance system.

* province-wide is defined as covering and available to the whole province, both the health unit and the provincial level.

Mission

To coordinate a province-wide surveillance system that provides timely and accurate provincial and local health unit-level estimates of health behaviours, attitudes and other risk factors to support public health decision-making.

Goals

Inform program planning by providing data and information so that programs and services can be tailored to address current and emerging public health needs at the provincial and local health unit level.

Enhance policy development by allowing policy-makers to have the information required to enable them to develop new policies or amend existing policies that positively impact the public’s health.



41


Use resources efficiently by using existing data, generating province-wide estimates, and providing infrastructure support to eliminate duplication of work in order to maximize access to information in a timely fashion.

Values

Equitable

Responsive

Sustainable

Collaborative

Scope in and out of the partnership per se

In:

exchanging information and literature on best practices, methods and tools on risk and behaviour population health assessment and surveillance

providing input into the development and validation of collection tools and methods

providing advice on and promoting optimal implementation strategies for alignment and integration of surveillance activities (e.g. promoting collaborative data collection, optimally leveraging existing resources for surveillance activities and products and recommending strategic directions for surveillance in Ontario)

identifying surveillance system gaps and recommending approaches to fill these gaps.

Out (note that the following does not preclude individual member organizations or groups of any of them undertaking or participating in any of these):

managing individual organizations’ surveillance work

managing or conducting research (e.g. hypothesis testing)

conducting public health hazard/cluster investigations

advocating on public health policy and practice priorities

providing individual or organizational job references/endorsements

funding research and/or surveillance initiatives.

Partnership membership and relations

The partnership includes entities and individuals with an interest and/or responsibility for a range of public health surveillance activities including:

data collection

data integration/holding/stewardship


42

analysis

interpretation

preparation of reports

dissemination of reports

development of responses to results.

The members of the partnership relate to each other by:

informing, gathering, information/listening, discussing, engaging/influencing

openly exploring opportunities for collaboration including identifying potential synergies for action

enabling interdependence, through harnessing support and providing resources (we look to each other for help)

acting to align the initiatives back with the partner’s home organization, and seeking endorsement/adoption of initiatives.

What we do:

remove obstacles, manage critical success factors and remediate problems/shortfalls

control scope/resources

monitor/measure overall system advancement and accomplishments as well as initiative progress

monitor the stakeholders’ commitment/partnership status

build the partnership’s ability to develop and implement more complex and challenging elements of, and enhancements to the overall system.

2.0 GOVERNANCE AND MANAGEMENT

Partnership governance

As a partnership, the group will be accountable to itself and supported by a coordinating committee.

Membership of coordinating committee

The coordinating committee will be include approximately 10 to 12 self-identified partnership members including representation from each of the the identified groups.

Term


43

Partnership members will continue to be members until such time as they elect to withdraw from the partnership. Coordinating committee members will represent the partnership for two years with option of renewal for one term.

Frequency/Timing of meetings (for further development)

Bimonthly on a set day of a set week (offering both teleconference and in-person options for each meeting, with a minimum of one in-person meeting per year)

Role of the coordinating committee co-chairs:

The coordinating committee will be chaired by two identified members from within the coordinating committee. The co-chairs are responsible for:

developing meeting agendas

facilitating meetings

approving the draft agenda, minutes, notices and correspondence

ensuring that committee terms of reference are reviewed and updated biannually.

Role of members (to be further developed)

Partnership members are responsible for:

participating in the decision-making processes of the partnership

providing feedback on draft materials

identifying and facilitating the resolution of issues

providing updates on partnership work to their respective section areas.

Duration/ Sunset Review (to be developed)

Quorum (to be further developed)

The partnership shall have a quorum of 60 per cent of members in order to make decisions that bind the partnership. A co-chair must be present.

Role of Secretariat

Secretariat functions for the partnership will be assumed by OAHPP, which is responsible for:

preparing and distributing the agenda and related information prior to each meeting

preparing and revising all background materials for the partnership

facilitating knowledge and literature exchange

preparing brief decision minutes of the meeting and distributing to partnership members

revising minutes based on the feedback from partnership members


44

preparing and maintaining meeting schedules and room bookings

taking on assignments and duties as capacities permit.

Minutes and reports

Minutes and reports will be made public once approved by posting them online.

Review of terms of reference

Terms of reference will be reviewed on an annual basis and will consider areas for future growth including these possible additions to the scope:

monitoring the literature

developing/endorsing components for common datasets

collaborating within member organizations to complete surveillance functions (e.g., using data collected by one organization to generate reports in another organization), sharing of datasets, joint analyses/projects

recommending priorities for surveillance research

endorsing grant applications

submitting joint grant proposals.


45

References

1 Framingham Heart Study. (2011). Research Milestones. Retrieved April 21, 2011, from

http://www.framinghamheartstudy.org/about/milestones.html 2 Puska P. (2002). Successful prevention of non-communicable diseases: 25 year experiences

with North Karelia Project in Finland. Publ Health Med, 4(1), 5-7. Also available at

http://www.who.int/chp/media/en/north_karelia_successful_ncd_prevention.pdf

3 Farquhar, J.W., Fortmann, S.P., Flora, J.A., Taylor, C.B., Haskell, W.L., Williams, P.T., Maccoby,

N., & Wood, P.D. (1990). Effects of communitywide education on cardiovascular disease risk

factors: The Stanford Five-City Project. JAMA, 264(3), 359–365.

4 Public Health Agency of Canada. (2007). Core competencies for public health in Canada:

Release 1.0. Retrieved from http://www.phac-aspc.gc.ca/ccph-cesp/pdfs/cc-manual-eng090407.pdf 5 Ontario. Ministry of Health and Long-Term Care. (2008). Ontario public health standards. Retrieved from http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/progstds/pdfs/ophs_2008.pdf 6 Advisory Committee on Population Health and Health Security Surveillance Systems for Chronic Disease Risk Factors Task Group. Enhancing capacity for surveillance of chronic disease risk factors and determinants. (Jun 2005). Retrieved from http://www.rrfss.ca/resources/Report-%20Enhancing%20Capacity%20for%20Surveillance%20of%20Chronic%20Disease%20Risk%20Factors%20in%20Canada.pdf 7 Agency Implementation Task Force. (2006). From vision to action: a plan for the Ontario Agency for Health Protection and Promotion. Retrieved from http://www.health.gov.on.ca/english/public/pub/ministry_reports/agency_06/agency_06.pdf 8 Dubois, N. & Wilkerson, T. (2005). Rapid Risk Factor Surveillance System: strategic plan for action. Rev ed. Retrieved from http://www.rrfss.on.ca/resources/RRFSS%20Strategic%20Plan%20Report%202005%20final,%20April%2005.pdf 9 CARFSS ESI-WG. (October 2009). Environmental scan of regional risk factor surveillance phase 1 final report.

http://www.framinghamheartstudy.org/about/milestones.html

http://www.who.int/chp/media/en/north_karelia_successful_ncd_prevention.pdf

http://www.phac-aspc.gc.ca/ccph-cesp/pdfs/cc-manual-eng090407.pdf

http://www.phac-aspc.gc.ca/ccph-cesp/pdfs/cc-manual-eng090407.pdf

http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/progstds/pdfs/ophs_2008.pdf

http://www.health.gov.on.ca/english/providers/program/pubhealth/oph_standards/ophs/progstds/pdfs/ophs_2008.pdf

http://www.rrfss.ca/resources/Report-%20Enhancing%20Capacity%20for%20Surveillance%20of%20Chronic%20Disease%20Risk%20Factors%20in%20Canada.pdf



http://www.health.gov.on.ca/english/public/pub/ministry_reports/agency_06/agency_06.pdf

http://www.rrfss.on.ca/resources/RRFSS%20Strategic%20Plan%20Report%202005%20final,%20April%2005.pdf

http://www.rrfss.on.ca/resources/RRFSS%20Strategic%20Plan%20Report%202005%20final,%20April%2005.pdf


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10 CARFSS ESI-WG. (August 2009). International scan of local-level chronic disease risk factor surveillance systems. 11 IUHPE WARFS GWG. (July 2010). “White paper” on surveillance and health promotion DRAFT for IUHPE Geneva Conference. 12 Centers for Disease Control and Prevention. (2011). Behavioral Risk Factor Surveillance System (BRFSS). Retrieved April 20, 2011, from http://www.cdc.gov/BRFSS/ 13 Propel Centre for Population Health Impact. (2011). School Health Environment System (SHES). Retrieved April 20, 2011, from http://www.shapes.uwaterloo.ca/shes/ 14 Ontario Tobacco Research Unit. (2011). Tobacco Informatics Monitoring System. Retrieved April 20, 2011, from http://tims.otru.org/ 15 ORBSS advisory committee. (1 September 2010). Ontario Risk and Behaviour Surveillance System (ORBSS) initial consultation results. Retrieved from http://www.oahpp.ca/resources/projects/orbss/documents/Summary_Report_ORBSS_Initial_Consultation_Dec6.pdf 16 IUHPE WARFS GWG. (July 2010). “White paper” on surveillance and health promotion DRAFT for IUHPE Geneva Conference. 17 Dahlgren, G. & Whitehead, M. (1991). Policies and strategies to promote social equity in health: background document to WHO strategy paper for Europe. Stockholm: Institute for Futures Studies. 18 Public Health Agency of Canada. (2008). The Chief Public Health Officer's report on the state of public health in Canada 2008. Cat.: HP2-10/2008E. Ottawa, ON: Minister of Health. 19 Glazier, R. & Booth, G. (2007). Neighbourhood environments and resources for healthy living - A focus on diabetes in Toronto. Available from http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=4406&type=atlas

http://www.cdc.gov/BRFSS/

http://www.shapes.uwaterloo.ca/shes/

http://tims.otru.org/

http://www.oahpp.ca/resources/projects/orbss/documents/Summary_Report_ORBSS_Initial_Consultation_Dec6.pdf

http://www.oahpp.ca/resources/projects/orbss/documents/Summary_Report_ORBSS_Initial_Consultation_Dec6.pdf

http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=4406&type=atlas

http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=4406&type=atlas

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