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The OPC Stroke Prevention Initiative (SPI): Connecting the Dots Between Health Promotion and Primary Care

I Introduction

This article is about the Ontario Prevention Clearinghouse's (OPC) Stroke Prevention Initiative (SPI) ( As one of the health promotion projects funded through Ontario's Coordinated Stroke Strategy, we thought it was time to share with other health promoters what we are doing and what we have learned.

At least 90,000 Ontario citizens are living with the effects of stroke, which include motor, sensory, cognitive, and communication deficits. The personal and emotional costs of stroke on families can be debilitating. Yet, stroke is highly preventable.

Since 2001, the Ontario Ministry of Health and Long-term Care, Health Promotion and Wellness, Public Health Branch, has funded the SPI through the Coordinated Stroke Strategy. This innovative strategy aims to integrate a system of stroke care in Ontario along a continuum of health promotion, prevention, acute care, rehabilitation, and community re-engagement.

At this time, there are 11 Regional and Enhanced Stroke Centres across Ontario as well as 17 District Stroke Centres and 18 Secondary Prevention Clinics. All of these centres are located inside local hospitals.

Curious about why hospitals would want to dive into health promotion? Health promotion is a mandated part of the strategy and the Regional and District Stroke Centres are ready to learn! Our challenge is to help them find ways to connect to health promotion activities in their local communities that make sense for them and find resources on stroke prevention.

We also partner with provincial health promoters, including members of the Ontario Health Promotion Resource System, the Heart and Stroke Foundation of Canada, and the Ontario Chronic Disease Prevention Alliance.

II Connecting the Dots Between Health Promotion and Primary Care

The task of the SPI team has been to connect the dots across the continuum of stroke care, between primary care providers and health promotion initiatives in the community, through training, consultation, resource dissemination, and networking. Throughout the process, we have learned to listen to the Regional and District Stroke Centres, focus on patients/case studies, and create opportunities to make connections.

Over the past four years, we have helped to make a number of connections.

i Connecting the dots to the language and ideas of health promotion

The Regional and District Stroke Centres were looking for information on health promotion in a primary care setting, including basic terminology on primary and secondary prevention and an introduction to the broader determinants of health.

The SPI team put together a comprehensive, bilingual resource called "Prescribing Prevention: Health Promotion and Stroke Prevention." Now in its second edition, it helps health providers to enlarge their understanding of health promotion and how to apply it effectively in clinical settings.

To illustrate the concepts of primary and secondary prevention, "Prescribing Prevention" explores the case of the Anderson Family (la famille Arsenault in the French version), from southwestern Ontario. Mike Anderson has had a stroke and has been discharged home with serious disabilities. His wife Susan is now his full-time caregiver. Their daughter Janice is at risk for stroke but does not see herself as a potential stroke victim. Janice's son John, in his twenties, is a fairly heavy smoker.

Through the case of the Anderson family, stroke care practitioners are able to make connections between Mike, Susan, Janice, and John and the various physical and social risk factors that can determine whether they have a future stroke or other chronic disease.

"Prescribing Prevention" also features patient risk checklists, a tools section, and a survey on the facts and myths of stroke. It is available for free in print, PDF, and HTML versions at

ii Connecting the dots to programs in the community -- with the click of a mouse

Just as health care practitioners wanted to learn the "what" about health promotion, they also wanted to know about the "where." When a patient is at risk of a first or second stroke and needs to quit smoking, find supportive housing, or access transportation, it is important to know about services and programs in the community.

Over the past two years, the SPI team has developed an online directory of local and provincial programs to reduce the risk of stroke by city and region. We plan to pilot this directory over the next few months. This month, we are beginning to pilot a searchable database of local and provincial programs to reduce the risk of stroke. The database has four ways to search for information and the website includes important links and current resources in health promotion and primary prevention.

The directory will be housed on a new website, We hope that health care providers will find it an easy way to connect with programs for their patients and help them find places to exercise, learn about diabetes, find a healthy restaurant, or join a support group.

Watch for the launch of in June 2005 during Stroke Month!

iii Connecting the dots to the determinants of health

While working with our partners in the stroke centres, we quickly discovered that many clinical staff were unclear about health promotion. Although they appreciated "Prescribing Prevention," we recognized that it was only one way to address their information needs. Offering interactive learning experiences gave us another way to help broaden their understanding of health promotion and how it applies to their hospital caseload.

To help meet this need, the SPI team created a series of workshops. Like "Prescribing Prevention," the workshops focus on patient case studies to illustrate the continuum of stroke prevention and the broader determinants of health.

To help make connections to the determinants of health, we adapted a workshop called "Making Sense of Health Promotion," developed by our colleagues at the OPC Health Promotion Resource Centre. The workshop uses the image of an iceberg to illustrate the determinants of health.

In the stroke workshop, we place Mike Anderson at the top of the iceberg, together with the various factors that lie beneath the surface, such as his limited income and lack of social support. In small groups, we encourage discussion about Mike's physical and social risk factors and what can be done to prevent a second stroke. We also talk about primary prevention for his daughter, Janice, and grandson, John.

All workshops are available free of charge and can be adapted and customized according to individual needs. We have given workshops as long as a full day and as brief as 30 minutes! Some workshops are also available in French. These workshops have served to lay the groundwork and build capacity for further connections to the broader community.

iv Connecting the dots to the broader community

In the early stages of the Coordinated Stroke Strategy, the stroke sites focused their attention on clinical requirements such as setting up emergency protocols and acute hospital requirements. As these practices were put in place, they began to explore their prevention mandate.

An early approach was to connect with community based health promoters, who in most communities included the heart health coalitions. There was confusion and lack of clarity about roles and responsibilities. Although new partnerships were forming, there were a lot of 'dots' that weren't connected at the community level.

"Connecting the Dots. Community-Wide Stroke Prevention and Health Promotion" is a community learning initiative that helps to connects the dots about current practice and engages the community toward collective action. It is an organic, community work-in progress that sets the stage for further collaborative work.

"Connecting the Dots" includes representatives from across the community and throughout the continuum of stroke, including health promotion, public health, hospitals, community services, and long-term care. The goal is to increase awareness and opportunities for collaboration by introducing people to one another and brainstorming new ways of working together.

The first "Connecting the Dots" event was held in Owen Sound in May 2004, co-sponsored by the District Stroke Coordinator and Heart Health Coordinator in Grey-Bruce. This event, planned by a local-provincial committee, included a balance between presentations and group experiences. Participants learned about the demographic and risk factor profiles in their community, the costs of chronic diseases, and the potential benefits of a coordinated chronic disease prevention approach. In small groups, they explored how they could share their expertise, which came from various places along the continuum of care, to address real issues in Grey-Bruce.

The response to the "Connecting the Dots" process has been overwhelming. In 2005, we have already participated in "Connecting the Dots" events in Thunder Bay and Windsor/Essex, with more events in the planning phase in three other communities.

v Connecting the dots to prevent chronic disease

As the "Connecting the Dots" process continues to grow and expand, there is a natural shift in emphasis from stroke prevention toward a broader focus on chronic diseases. Many of the risk factors for stroke are the same risk factors that can cause heart disease, diabetes, osteoporosis, and some cancers.

At the same time, there is a growing trend toward a focus on chronic disease prevention at all levels of government.

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III Conclusions

Over the past four years, the OPC Stroke Prevention Initiative has focused on ways to develop and nurture partnerships between primary care and health promotion. Our effective strategies included actively finding ways to connect to our audience around their issues, listening to our audience, focusing on patients and cases, and creating opportunities to connect the dots.

What began as a small project to bring health promotion information to hospital stroke providers has expanded into a number of exciting and dynamic initiatives involving a variety of community partners. As a small SPI team of three people, we consider our role to be health promotion catalysts helping to connect dots and we look forward to growing more dots in the future.

Many exciting possibilities exist. These include further connections to chronic disease prevention, a train-the-trainer model for health promotion workshops, expanded connections to the Ontario Health Promotion Resource System through the electronic training module HP 101, and more inclusive case studies that reflect the cultural diversity of Ontario.

We look forward to connecting with you!