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Looking Forward and Looking Back Part I--Reflecting on the Past and Coming Years In Health Promotion


I Introduction
II Association of Public Health Epidemiologists in Ontario
III Did Health Promotion Die in 2012?
IV An Annotated Scrooge for 2012
V The Economics of Prevention and Health Promotion Interventions
VI 2012 Year in Review: Health Promotion, Chronic Disease and Injury Prevention Program Area at Public Health Ontario – Taking Action to Prevent Chronic Disease
VII The Chronic Disease Prevention Alliance of Canada (CDPAC) 2012 Year in Review

I Introduction

Each year the OHPE invites organizations and individuals working in health promotion in Ontario and across the country to reflect on milestones and events of significance over the past year and provide insight on what might lie ahead in the coming 12 months. This is the first part of the reflections piece and the final OHPE feature for 2012. The second half of the reflections will ring in the OHPE for 2013 and run on January 4, 2013. Thanks to everyone who contributed to this as well as the other features that ran throughout the year.

II Association of Public Health Epidemiologists in Ontario (APHEO)
Submitted by Patrick Seliske Ph.D., APHEO President

This has been a year of ongoing growth and development for APHEO. Since 2010 we have seen our membership grow at a rate of 20% per year.  At our current level of 327 members we are three times larger as a professional association than we were 10 years ago.  This exceptional growth has created diversity and increased our capacity.  Members are actively involved in many important provincial projects and committees.  In this way we improve population health by supporting excellence in professional practice and promoting the integration of epidemiology within public health decision making in Ontario.

Throughout 2012, APHEO has continued to embrace collaboration and partnership and sought opportunities to facilitate learning and the sharing of knowledge and expertise.  At the inaugural session of “PHO Rounds: Epidemiology” on October 18th, APHEO members joined with Public Health Ontario staff to learn more about sample size and power.  This successful session was followed by Alternatives to Logistic Regression on November 15th.  During the education portion of its November General Meeting APHEO members received a progress report on Ontario's new health information management system Panorama, from Karen Hay of the Ministry of Health and Long Term Care, heard about recent advances in Cancer Surveillance (SEERSTAT) from Diane Nishri of Cancer Care Ontario, listened to an update on Ontario's Rapid Risk Factor Surveillance System (RRFSS) from Lynne Russell, and received insight from an epidemiologist, John Cunningham, on his health unit's use of Geographic Information System (GIS) technology.  These and many other useful resources can be found on our website at:

This has also been a busy year for the APHEO Executive Committee.  In the interest of maintaining strong governance and operations we have made significant steps forward in our incorporation and constitutional review process and extensively reviewed and standardized all APHEO policies and procedures.  Notable among our many ongoing activities, we hosted a workshop on social media, developed a new strategic plan to guide us through the next three years, and launched the planning process for our 2013 conference that will focus on the social determinants of health and accountability and performance evaluation. This conference is scheduled for June 9–11in Niagara.  Please join us for this stimulating and fun event.

We are proud of our contributions and wish to thank our members and partners for their investment in another successful year of serving the population of Ontario.  All the best to you and those close to you for a happy and productive new year.

III Did Health Promotion Die in 2012?
Submitted by Dr. Irv Rootman

At the end of my reflections on 2011 last year I raised the question of whether or not health promotion in Canada was going to die when the “Year of the Ottawa Charter” ended.  I answered the question with a “no” and supported that prediction with several arguments: enough infrastructure to “carry the torch of the Ottawa Charter” still exists; new schools of public health feature health promotion in their curriculum; it is gathering momentum with its acceptance as a cross-cutting issue by the Public Health Agency of Canada (PHAC)  and by the possible launch of a National Health Literacy Council; the launch of the third edition of Health Promotion in Canada; and the spread of health promotion values, approaches and strategies as expressed in the Ottawa Charter to other components of the health system including health care.

As it turned out, most of my predictions were accurate, with the possible exception of the establishment of a National Health Literacy Council, which didn’t happen, perhaps because PHAC was distracted by the need to cut costs, reorganize and cope with other difficult issues. Nevertheless, the Agency was able to support a pre-Canadian Pubic Health Association (CPHA) conference workshop on the “Future of Health Promotion,” some consultations on the development of a new Framework on Health Promotion, and a “Think Tank” on health literacy which produced a discussion paper on health literacy that is available for use across the country in both official languages. (

The pre-conference workshop was especially encouraging in relation to the future of health promotion in Canada. It was attended by about 50 people including researchers, policymakers, practitioners and students who reviewed a SWOT Analysis on Health Promotion in Canada based on a review of the many presentations and publications on health promotion that were made or produced during 2011 to celebrate or recognize the 25th Anniversary year of the Ottawa Charter. The organizers, which included myself and the other editors of the third edition of Health Promotion in Canada which we launched at the workshop, were impressed with the level of enthusiasm of the participants as well as the fact that they added much more to the lists of “strengths” and “opportunities” for the field than to the lists of “weaknesses” and “threats.” Moreover, most filled out postcards specifying what they were going to do to “strengthen” health promotion in the coming year. Particularly encouraging was the palpable commitment to the field and the principles of the Ottawa Charter of the students who attended.

Based on the experience of the workshop and other experiences I have had in the last year related to health promotion including the favorable reception of the third edition of Health Promotion in Canada, I remain optimistic about its future, both in Canada and internationally and am personally committed to doing what I can do to enable this to happen. This includes proposing a workshop at the CPHA Conference in June 2013 to follow-up on the 2012 workshop and provide an opportunity for those who were not able to attend the latter to express their views and indicate their commitment to the values and principles of the Ottawa Charter for Health Promotion. In the meantime, I hope all of you will read the report on the 2012 workshop which is posted in both official languages on the website of the Public Health Association of British Columbia (

IV An Annotated Scrooge for 2012
By Michael Shapcott

Charles Dickens, in his famous novel A Christmas Carol, writes of a visit by two charity-minded men to the office of Ebenezer Scrooge. The words of Dickens follow, with notes from Toronto, Ontario and Canada in 2012 in italics.

"At this festive season of the year, Mr. Scrooge," said the gentleman, taking up a pen, "it is more than usually desirable that we should make some slight provision for the Poor and Destitute, who suffer greatly at the present time.  Many thousands are in want of common necessaries; hundreds of thousands are in want of common comforts, sir."

Toronto's Daily Bread Food Bank reports a total of 1,123,500 visits to food charities in the Greater Toronto area in 2012 – up 18% from the recession of 2008. The Ontario Association of Food Banks reports 412,998 individuals lined up at food banks in March of 2012, with Food Banks Canada reporting 882,188 people used food banks across the country in that same month.

Toronto Housing Connections reports that there are 87,638 households on the city's affordable housing wait list as of November 2012. That's an all-time record. In fact, the wait list has set a new record every month since the recession of 2008. Those households include a total of 161,886 women, men and children.

"Are there no prisons?" asked Scrooge.

"Plenty of prisons," said the gentleman, laying down the pen again.

There were about 38,000 adults in Canada's prisons in 2010/11, the latest year for which numbers are available from Statistics Canada. The prison population is growing, even though Canada's crime rate has been dropping since the early 1990s.

"And the Union workhouses?"  demanded Scrooge.  "Are they still in operation?"

"They are.  Still," returned the gentleman, "I wish I could say they were not."

Toronto's homeless shelter system is projected to have 1,416,766 bednights (one woman, man or child in one bed for one night) during 2012 – an increase of 61,490 bednights from 2011 (that's a 4.5% increase in one year).

"The Treadmill and the Poor Law are in full vigour, then?"  said Scrooge.

"Both very busy, sir."

Toronto police issued 15,324 panhandling tickets under the Safe Streets Act to homeless people in 2010 – an increase of more than 2000% since the year 2000. York University Prof Stephen Gaetz estimates that police have spent more than $1 million issuing the tickets.

"Oh!  I was afraid, from what you said at first, that something had occurred to stop them in their useful course," said Scrooge.  "I'm very glad to hear it."

"Under the impression that they scarcely furnish Christian cheer of mind or body to the multitude," returned the gentleman, "a few of us are endeavouring to raise a fund to buy the Poor some meat and drink and means of warmth.  We choose this time, because it is a time, of all others, when Want is keenly felt, and Abundance rejoices.  What shall I put you down for?"

Poverty and income inequality have been on the rise in Canada since the mid-1990s, according to the Organisation for Economic Co-operation and Development. It notes that Canada cut poverty in half from the mid-1970s to the mid-1990s, but the positive trend has been reversed as governments in Canada have steadily cut social expenditures, including income transfers, and public services, such as housing. The Conference Board of Canada in its global inequality survey also confirms that inequality is growing rapidly in Canada in recent years.

"Nothing!" Scrooge replied.

"You wish to be anonymous?"

"I wish to be left alone," said Scrooge.  "Since you ask me what I wish, gentlemen, that is my answer.  I don't make merry myself at Christmas and I can't afford to make idle people merry.  I help to support the establishments I have mentioned – they cost enough; and those who are badly off must go there."

Government investments in affordable housing have been on a steady downward slide since the early 1990s. The erosion in federal housing investments reversed with a $2 billion investment in affordable housing in the 2009 federal stimulus budget, but that funding was 'terminated' in 2011, when the federal government made a 39% cut in housing investments in one year. The federal affordable housing initiative (which funds new homes) and the federal homelessness strategy (which funds transitional housing and supports for the homeless) are both scheduled to expire in 2014.

When it comes to public social expenditures (cash benefits and public services) Canada ranks towards the bottom of the league of the richest countries of the world, and below the average among OECD countries. Canada is tied with the US at 25th among 35 OECD countries for overall public social expenditures. When it comes to family benefits, Canada is tied with US in 32nd spot among 34 OECD countries.

"Many can't go there; and many would rather die."

"If they would rather die," said Scrooge, "they had better do it, and decrease the surplus population."

The research evidence is clear and compelling – low income, poor housing and social exclusion are all strongly linked to poor health and premature death. The Wellesley Institute's Street Health Report provides the evidence that homeless people have a heavier burden of poor health that those who are housed. Toronto Public Health's Unequal City report provides a chilling catalogue of the devastating health burden of poverty. It notes that health inequalities are responsible for almost 1,100 premature deaths annually in Toronto.

The austerity agenda continues to grip the federal, provincial and municipal governments when it comes to necessary spending on health, housing, incomes, education and other social priorities. The lingering impact of the 2008 recession continues to put pressure on the diminishing social expenditures. The cost of the austerity agenda is measured in the growing burden of poverty, inequality poor health and premature death.

Individual acts of kindness and charity are always appreciated, but unless the root causes of poverty and inequality are tackled, and funding for social expenditures is raised to adequate levels, the horrors of Victorian England will continue to play out in Toronto of 2013.  

V The Economics of Prevention and Health Promotion Interventions
Submitted by Jon Kerner and Deb Keen

Looking Back on 2012

This past year was a time of fiscal restraint at both the federal and provincial level in Ontario with a focus on decreasing the debt and balancing the budget.  In Ontario, healthcare spending continued to be a focus with a commitment to transforming health care to reduce the rate of growth of spending to an average of 2.1 per cent annually over the next three years. [1] In February, 2012, the Commission on the Reform of the Public Service chaired by Don Drummond released the report entitled, Public Service for Ontarians, A Path to Sustainability and Excellence. [2] The report suggested that an ideal health system would put more emphasize on preventing poor health, a shift towards health promotion instead of after the problem required diagnosis and treatment.

Evidence continues to be developed about what works in prevention and health promotion. Many Canadian on-line sources for what works exist including the Canadian Best Practices Portal, [3], [4] The Canadian Cochrane Centre, [5] and Steps 3 & 4 of Cancer Control P.L.A.N.E.T. Canada [6] which integrates many of the aforementioned Canadian evidence resources with equally relevant evidence resources from the U.S.  However, what is often missing from these “what works” resources is information about what it costs to implement these public health approaches in order to make them work in different contexts. Such cost data and cost utility analyses of programs and policies are needed to help better inform policy makers about what’s feasible where in these difficult financial times.

Looking Forward to 2013 and Beyond

In a recently published letter to the editor of the Canadian Journal of Public Health (CJPH), [7] authors from Cancer Care Ontario and the Canadian Partnership Against Cancer noted that out of 45 published cost utility analysis from Canada published between 1976 and 2011, focused on cancer control, only four focused on cancer prevention.  Even within the few studies that have evaluated the cost effectiveness of specific prevention interventions in Canada, not all prevention strategies are cost-effective. For example, within the single study of a hepatitis B screening program, the cost per Quality Adjusted Life Year (QALY) was $69,000 using one strategy versus cost $3.6 million per QALY using another.

Recently the Canadian Cancer Research Alliance published a strategic framework report for prevention research which specifically recommended that health economics research and the routine collection of cost data should be considered a very high priority in all future intervention development and service delivery research strategic investments. [8] If public health practitioners and policy makers in the future will increase the demand for prevention intervention cost data and cost effectiveness/cost utility analyses, this may help to increase the likelihood that researchers and research funding agencies will address this important need in 2013 and beyond.


1. Ontario Ministry of Finance, 2012 Ontario Budget Highlights, March 27, 2012
7. Young J, Kerner J, Hoch, J. The need for economic evaluation in primary prevention of cancer. Canadian Journal Of Public Health, September/October 2012: 395.

VI 2012 Year in Review: Health Promotion, Chronic Disease and Injury Prevention Program Area at Public Health Ontario – Taking Action to Prevent Chronic Disease
Submitted by the HPCDIP team

Public Health Ontario (PHO) released several major chronic disease reports in the past year. In March, PHO in partnership with Cancer Care Ontario released Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario ( at the Toronto Board of Trade. This report outlines 22 evidence-informed recommendations to address the four major risk factors responsible for the majority of chronic disease in Ontario: physical inactivity, alcohol use, unhealthy eating, and tobacco use. Recommendations also addressed capacity building requirements and reducing health inequities.

In April, Seven more years: The impact of smoking, alcohol, diet, physical activity and stress on health and life expectancy in Ontario ( was released at The Ontario Public Health Convention (TOPHC) ( This project, completed in partnership with the Institute for Clinical Evaluative Sciences (ICES), quantifies the impact of the four major health risks above (plus stress) on Ontarians’ life expectancy and health-adjusted life expectancy. The Life Expectancy Calculator ( was developed as a related product to help individuals understand the impact of these risks on their own life expectancy. This is posted on the Population Health Improvement Research Network (PHIRN) website.

Mental illness and addictions: a significant burden in Ontario

In October, Public Health Ontario and the Institute for Clinical Evaluative Sciences (ICES) released Opening Eyes, Opening Minds: The Ontario Burden of Mental Illness Report ( ). Building on previous studies, this report provides the most complete assessment of the burden of mental illness and addictions in Ontario. The findings show that the burden of mental illness and addictions is 1.5 times more than all cancers and seven times more than all infectious diseases. Dr. Heather Manson, a co-author, has also received a CIHR Dissemination Events grant to increase the reach and uptake of Opening Eyes, Opening Minds. This innovative project will use composite narratives and input from a knowledge exchange event to contextualize the burden of mental illness and addiction from the perspectives of those with lived experience.

Health Promotion Capacity Building Services and Resources

These services are provided by field support specialists ( )who focus on health promotion planning, evaluation, policy, health communication and alcohol policy as well as our partner resource centres with a risk factor focus on injury prevention at the Ontario Injury Prevention Resource Centre (OIPRC) (; and comprehensive tobacco control at the Program Training and Consultation Centre (PTCC) ( Some highlights from this year include:

  • In March, the 3rd annual Injury Prevention Forum was held, as well as the 9th annual Alcohol Policy Forum: Alcohol, No Ordinary Commodity, which focused on working with media to influence alcohol policy-related news coverage.
  • In March, the Ontario Injury Data Report was released by OIPRC, which is a statistical overview of injury related emergency department visits, hospitalizations and deaths by cause of injury in Ontario and by health unit.
  • In April, the former Alcohol Policy Network housed at OPHA was successfully transitioned to PHO.
  • In July, Tools for supporting local action to reduce alcohol-related harms: Policy options and a resource inventory to support alcohol policy in Ontario ( )was released, as a collaborative effort with the Centre for Addiction and Mental Health. This resource is intended to assist community partnerships and public health stakeholders with the prevention of alcohol-related harms through the development and implementation of healthy public policies at the local level.
  • PHO has continued to expand the Online Health Program Planner 2.0 ( a joint collaboration with the National Collaborating Centre for Methods and Tools.

Other highlights from 2012

  • In February, Public Health Ontario and a number of partners hosted the Ontario Sodium Summit to identify provincial actions towards the implementation of the Sodium Reduction Strategy for Canada. The proceedings are available at
  • HPCDIP co-authored Chapter 12 ( ) of the Project for an Ontario Women’s Health Evidence-Based Report (POWER) study. This chapter describes the health inequities associated with income, education, race/ethnicity, place of residence, and gender.
  • PHO, in collaboration with provincial stakeholders, is identifying and assessing existing indicators of infant, child and youth health, including identifying indicator gaps. A report will be released in early 2013 that will help to provide a foundation for population-level health assessment and monitoring in this area.
  • HPCDIP is developing a research plan to outline strategic priorities in population health intervention research, public health capacity-building research, and additional areas of focus.
  • Dr. Jennifer Robertson, senior evaluator, is supporting Niagara Region Public Health in their evaluation of the Sparking Life Niagara (SLN) program ( SLN aims to help students live healthier and perform better in school through daily aerobic physical activity.
  • Dr. Ken Allison, senior scientist, is leading a series of studies to examine the development, implementation, and status of the provincial daily physical activity policy initiative.

The coming year at HPCDIP

In 2013, we will continue to provide scientific and technical products on important public health issues, respond to emerging priorities, and pursue innovative and original research. Some key initiatives of capacity building services and resources for the year ahead include:

  • 10th annual Alcohol No Ordinary Commodity Forum in April 2013
  • PTCC in collaboration with PHO and the Ontario Tobacco Research Unit will host the Knowledge Exchange Forum entitled Leadership in Tobacco Control: Policy Initiatives at the Local Level on February 12th and 13th, 2013 in Toronto. 
  • The 4th annual Injury Prevention Forum in February 2013
  • We look forward to strengthening our existing relationships, developing new partnerships, and engaging additional public health stakeholders.

Building the HPCDIP team to meet the needs of public health

The past year saw significant growth in our capacity to conduct original research, carry-out our health promotion capacity building mandate, and extend our engagement of public health partners. We increased our complement of staff related to research coordination and health promotion capacity building. Notably, we have brought on additional scientific and public health expertise that will drive the generation of new evidence and innovative approaches to support the needs of public health.

  • Dr. Maria Chiu is a CIHR-funded, post-doctoral fellow in HPCDIP and brings expertise in examining the effects of the built environment and ethno-racial differences in chronic disease risk. She was awarded the CIHR Institute of Health Services and Policy Research’s Rising Star Award in recognition of her article, Deriving ethnic-specific BMI cutoff points for assessing diabetes risk. Maria is studying the population impact of neighbourhood walkability and cardiovascular risk factors.
  • Dr. Erin Hobin joined HPCDIP as a scientist in September. She recently completed a post-doctoral fellowship, co-sponsored by the University of Waterloo and Public Health Ontario. Erin’s research is focused on identifying environmental factors associated with physical activity and healthy eating and examining how interventions impact health behaviours and conditions (e.g., obesity). She is leading a Canadian Foundation for Dietetic Research funded study on nutrition labelling and how youth compare and choose food.
  • Dr. Chris Mackie is a public health and preventive medicine physician seconded from Hamilton Public Health Services. He has interest and experience in many areas, but, particularly in mental health and early childhood development. Chris is leading an outreach initiative with medical and associate medical officers of health and a research partnership with the Centre for Addiction and Mental Health and Toronto Public Health on child/youth mental health.
  • Mary Fodor O’Brien is a public health nutritionist seconded from the Halton Region Public Health Department. She co-led the development of the nutrition recommendations in Taking Action to Prevent Chronic Disease: Recommendations for a Healthier Ontario and has provided nutrition expertise to many other HPCDIP projects.

VII The Chronic Disease Prevention Alliance of Canada (CDPAC) 2012 Year in Review
Submitted by Bill Callery

The Chronic Disease Prevention Alliance of Canada (CDPAC) is an alliance of national organizations sharing a common vision for an integrated system of research, surveillance, policies, and programs for maintaining health and prevention of chronic disease in Canada. In our 2012 reflection we provide an update on progress over the year, and review CDPAC’s major initiatives for 2013.

As we reflect on 2012, it is clear that interest and momentum in CDP is increasing. Still, we know that chronic diseases are the leading causes of death and disability worldwide, and in Canada. About two thirds of total deaths in Canada are due to chronic diseases, and three out of five Canadians over age 20 are living with a chronic disease. In total, chronic diseases are estimated to cost the Canadian economy at least $190 billion a year (2010) ( At the same time, we know that a large portion of these diseases are preventable.

To start off the year in 2012, CDPAC convened over 500 delegates from across Canada for our fourth pan-Canadian conference entitled “Integrated Chronic Disease Prevention: It Works!” The emphasis was on ‘what works’, and how sectors are coming together for collaborative action on CDP. We are excited to announce that our next pan-Canadian conference will take place in Ottawa in Spring 2014. We surveyed past delegates, and based on their feedback we aim to be increasingly cutting edge and include an even greater focus on dialogue and networking in 2014. More information will be available in early 2013.To view the 2012 conference proceedings report, containing summaries and highlights of sessions, as well as slide and video presentations from the conference, please see our website at

In our 2011 year in review we noted that our CDP webinar series, delivered in collaboration with the Public Health Agency of Canada’s (PHAC) Canadian Best Practices Initiative, was becoming an ever more popular learning tool and best-practices resource. In 2012, this momentum has continued with exciting webinars addressing Food Security, the linkages between mental health and chronic disease, and suicide prevention.

At the end of 2012, we are well into our third series of CDPAC/PHAC webinars. CDPAC is delighted to continue offering these webinars, and we hope to continue to grow and improve upon the series in 2013. Archived webinars, including podcast recordings and streaming video presentations, can be found on the CDPAC website at

In October 2012, we began phase two of our Collaborative Action on Childhood Obesity initiative (CACO). In CACO phase two we are working in collaboration with six partner agencies and nine rural remote First Nations communities across Canada to prevent chronic disease by intervening upstream to promote health and healthy weights. The CACO coalition is one of three Canadian Coalitions Linking Action and Science for Prevention (CLASP) renewal initiatives funded by the Canadian Partnership Against Cancer (CPAC) (see For more information about CACO please visit our website at

In September 2011, Canada as well as nations worldwide showed an increased interest and engagement in addressing the heavy health, social, and economic burdens of chronic diseases, through the United Nations high-level Meeting on Non-Communicable diseases (UN NCD). CDPAC was honoured to be invited to attend the UN NCD summit as part of the Federal Minister of Health’s core delegation. Since the Summit, Canada has been working with other UN member states on the development of a suite of specific targets and indicators by which progress can be assessed.

In November 2012, UN member states agreed on a set of 9 targets and 25 indicators to be included in the Global Monitoring Framework for the prevention and control of NCDs, or chronic diseases. We commend the Government of Canada on its involvement and support, and have offered to work more closely with them in 2013 on this important global process with significant implications for CDP in Canada.

Finally, in 2012 we are also proud to have made strides into the social media world. In late 2011 we cautiously waded in, first with our YouTube (, and then with our Twitter (@theCDPAC) and Facebook ( The experience has been positive, and thanks to the guidance of social media gurus at a number of our partner organizations we are increasingly connecting with our stakeholders in new and innovative ways. At the time of writing this article we have nearly 300 Twitter followers, 40 YouTube videos, and 6 likes on Facebook.

As we wrap up the year, CDPAC wishes everyone a safe and happy holiday season and a wonderful new year.