Dr. Heather Manson, Public Health Ontario

Public Health Ontario recently released its report “Taking Action to Prevent Chronic Disease”. CARRFS eNews spoke with Dr. Heather Manson, Director, Health Promotion, Chronic Disease and Injury Prevention about the report and its development.

This article was published in May 2012.

Dr. Heather Manson, Director, Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario.

Dr. Heather Manson, Director, Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario.

What was the purpose of developing the report Taking Action to Prevent Chronic Disease?

The purpose of the report was to provide the Government of Ontario with evidence to guide action to reduce the burden of Chronic Diseases. The report provides evidence-informed recommendations focused on population level interventions addressing key risk factors for chronic disease such as alcohol, tobacco, physical inactivity and unhealthy eating. The report also includes recommendations on the key system enabling capacities required to reduce the burden of chronic disease and to improve health equity in Ontario.

How was the report developed - what methodologies did you use? 

The report was produced in partnership between Public Health Ontario (PHO) and the Cancer Care Ontario (CCO) combining our mandates to provide scientific and technical advice to the government of Ontario. Organizationally, we formed a collaborative Prevention Working Group and identified key risk factor leads - one for each of the four risk factor areas and one to identify over-arching chronic disease prevention recommendations. Our epidemiologists formed the risk factor and disease group (RF&DG) to examine the evidence linking risk factors with chronic diseases. The RF&DG estimated the prevalence of risk factors using Canadian Community Health Survey accessed through the Public Health Agency of Canada’s InfoBase. They examined the evidence on causal linkages between those risk factors and chronic diseases using monographs available through IARC [International Agency for Research on Cancer], the US Surgeon General and other reports. The RF&DG also undertook a systematic review of the literature – looking for any evidence of causal relationships. 

In terms of identifying intervention to address the four risk factors we engaged with experts - each of the four risk factors had an expert working group or an expert panel. We also undertook a jurisdictional scan looking for reports from Canadian and other jurisdictions to identify the key recommendations - for example the UN Summit of Non-communicable Diseases and the Beaglehole article “Priority actions for the non-communicable disease crisis” in the Lancet. We also undertook literature reviews examining the evidence in support of key recommendations emerging from each of these documents and other reports.

Why did you focus on the four risk factors - alcohol, tobacco, physical inactivity and unhealthy eating?

There were two main reasons. First, these four risk factors account for a sizeable burden of all-cause mortality here in Ontario. These are the big ones to go after if we want to systematically address the burden of chronic disease in Ontario. Second, addressing these four risk factors was aligned with the UN Summit on the prevention and control of non-communicative diseases, held in New York City on September 19-20, 2011. To address non-communicative or chronic diseases internationally, nationally and provincially, it is useful to have alignment of strategies addressing key risk factors.

How did you arrive at the 22 recommendations - what criteria did you use and how did the recommendations emerge?

We developed a set of criteria to choose the recommendations; for example, they needed to be within the Government of Ontario’s scope of control. The primary audience for the report was intended to be the Government of Ontario so we asked the question: What can a provincial government do that is directed at these four risk factors? The interventions also needed to be supported by the strength of evidence, and, given the tight timelines on the report and the wealth of earlier work in this area, we privileged interventions that had already been identified in previous reports.

Throughout the process you have consulted a range of stakeholders - what role did they play in the research process and in the selection of the recommendations?

The stakeholders were engaged in multiple points throughout the process of developing the report. To a certain extent our expert panel represented a particular type of stakeholder - they were people with research, policy and/or administrative experience, who added their knowledge and expertise. Beyond that, we engaged the Ontario Collaborative Group for Food, Nutrition and Physical Activity; the Ontario Chronic Disease Prevention Alliance, the Ontario Vascular Group, and others. Each group provided their advice early on and repeatedly throughout the process. Importantly, the Cancer Quality Council of Ontario [CQCO] held a signature event held on December 5, 2011 which included over100 participants across Ontario and other jurisdictions. The day was devoted to discussing the recommendations in the draft report and reviewing presentations by experts. Others who were engaged included the Ontario Public Health Association and the COMOH [Council of Medical Officers of Health of Ontario]. Also, we received a wealth of written feedback. All of this helped to enhance the report. Prior to the release of the report, the leadership from Public Health Ontario and Cancer Care of Ontario also met with folks from key ministries who would need to take action to address these risk factors.

What do you envision as the next steps?

The report describes recommendations for action at the provincial level to address these four risk factors. It also recommends a whole-of-government approach, which includes alignment of effort horizontally across government’s ministries and vertically from local, provincial to national levels. The report aligns with several of the recommendations in the Ministry of Health and Long-Term Care’s Action Plan for Health Care as well as the recommendations of the Drummond Commission on the Reform of Ontario’s Public Services. If we want to promote the health of Ontarians and reduce the burden of chronic disease, this report provides evidence on what we need to do – especially what leaders need to do. We expect that recommendations will be taken up over time. In the near term, we know that the Government of Ontario is renewing the Tobacco Strategy and these recommendations are supportive of that strategy. The government has also a goal to reduce childhood obesity by 20 percent in five years, and there are recommendations in the physical activity and healthy eating section of the report that speak to this ambitious target. Beyond government action, we are hopeful that private businesses will adopt the recommendations regarding workplace physical activity policies and workplace food and nutrition policies.  We are hopeful for local action on built environment and active transportation. 

What is the lesson learned from this report?

There are many lessons learned. First, we always need to define scope and audience, and it worked well to define our audience as the Government of Ontario, because this led us to be more creative in our recommendations. For example, food reformulation or labeling is largely a federal responsibility. However, by focusing on the Government of Ontario, we were able to ask: What can the Government of Ontario do? Can the government create momentum on product reformulation through the setting of food and nutrition standards for publicly funded institutions? The second lesson learned was the value of partnership. It was critical to have partnership between Public Health Ontario and Cancer Care Ontario. For us, the partnership helped us to deliver a report which addressed multiple risk factors and multiple chronic diseases simultaneously - including cancer. Third, engagement was critical for success, including engagement with a broad set of experts for each of the four risk factors and overarching chronic disease; this was critical for the success of the report. Finally, the engagement with the broader group of stakeholders, NGOs, public health professional, the Ontario Medical Association and others helped to point out gaps, strengthen improve and further refine the report.

"CARRFS could pay attention to this recommendation and talk about what that could look like at a Canadian level."

Given the CARRFS’ national network, what role could CARRFS potentially play in the next steps?

One of the things I would like to let CARRFS members to know is that the WARFS [World Alliance for Risk Factor Surveillance] White Paper was very helpful to inform our thinking for this report. Further, there is an important recommendation in the report that I would like CARRFS members to be aware of: No. 18 “Improved measurement, increased accountability” on page 54 in the report. As we were going through the report, we were astounded by our inability to provide a full picture of the burden of chronic diseases and related risk factors in Ontario. For example, we lacked incidence data for some of the diseases, although we did have this for cancer because of the cancer registry and for diabetes. In terms of risk factors surveillance, we were concerned about the validity of some of the indicators (e.g. physical activity).  In the recommendation in the report, we provide detail on the elements of a surveillance system for chronic disease and related risk factors. I would appreciate if CARRFS members could pay attention to this recommendation and talk about what that could look like at a Canadian level and in the provinces.  <>

    By Jostein Algroy