John is an overweight, 46 year old smoker with a sedentary lifestyle. For years, his family doctor has been trying to get him to quit smoking, eat better and get more exercise. Unfortunately, John’s more immediate health needs have tended to absorb the bulk of his doctor’s available time. As a result, despite his doctor’s best efforts, John is not fully aware of the chronic disease risks he faces or the steps he should take to address his smoking and lack of physical activity, leaving him increasingly discouraged about making improvements to his health.
But on his next visit, John’s doctor invites him to participate in a new program at the clinic. John is introduced to a new member of the practice, a ‘Prevention Practitioner’, who works with John to develop a Personal Plan that incorporates research-proven chronic disease prevention and screening techniques. Given John’s background, his Personal Plan includes a referral for colorectal cancer screening and a lipid profile for heart disease screening, as well as steps to increase exercise and reduce smoking. The Prevention Practitioner arranges a follow-up.
After a few months, John begins to notice he has more energy and that he is better able to manage his nicotine cravings. At his six-month follow up meeting to review and discuss his progress, John comments that friends and family have begun asking if he has lost weight, which has given him the confidence and drive to keep moving forward. He then asks the Prevention Practitioner what the next step is in his personal plan to accomplish his new goals.
The BETTER 2 Program: Building on Existing Tools to Improve Chronic Disease Prevention & Screening in Family Practice
The BETTER 2 Program was designed to help patients like John by working with the physician’s practice and individual patients to improve screening for, and prevention of, chronic diseases. The project involved clinicians, researchers and policy experts exploring new ways to work together so as to establish and test consistent techniques and tools that can be applied in a family practice to improve chronic disease prevention and screening outcomes.
Chronic diseases are exacting a heavy toll in Canada, with 1/3rd of Canadians suffering from at least one chronic disease. Better chronic disease prevention and screening in the family practice setting represents a critical opportunity to improve patient care.
However, most family physicians simply don’t have the time or resources to address all screening and prevention methods during a regular scheduled 10-15 minute visit. In fact, a recent study concluded that to adequately address prevention, the average physician would need to add 7.4 hours to his or her day.
Moreover, there are many different, and sometimes conflicting, guidelines for chronic disease prevention and screening. What’s needed is an established set of proven prevention and screening tools that can be applied by most family practices. In addition, family practices must have the capacity, information and resources to implement those tools on a consistent basis to help patients address their concerns.
The BETTER 2 Program was formed out of a desire among clinicians and researchers to figure out what works best for different patients and family practices alike. Before the project started, existing chronic disease prevention and screening programs tended to focus on individual chronic diseases. With CLASP funding, the BETTER 2 Program was able to take a holistic approach that is more consistent with how family practices operate and how individuals think about their health. Through the BETTER 2 Program, researchers and clinicians in both Ontario and Alberta were able to collaborate on the development of a set of chronic disease prevention and screening tools that are now being tested. Patients from four family practices in Ontario and four family practices in Alberta participated in the project. The overall program combined Practice Facilitators, Prevention Practitioners, a standardized screening tool, and a comprehensive evaluation.
Practice facilitators: To aid family physician practices in their chronic disease prevention and screening efforts, the BETTER 2 Program assigned a Practice Facilitator in each region. The role of the Practice Facilitator is to assess the practice’s current and potential use of its electronic medical record as a tool for chronic disease prevention and screening. Based on that assessment, the Practice Facilitator then works with the physician to plan and implement any desired changes at the practice level.
Prevention practitioners: Each participating practice also identified a practitioner from within their group to receive training in prevention and screening manoeuvres and act as their Prevention Practitioner. The Prevention Practitioner is trained to screen patients using tools developed by the BETTER 2 Program and then work with patients on the development of personal prevention plans based on research proven prevention methods. Essentially, the Prevention Practitioner’s role is to address the prevention needs of patients without taking time away from the physician’s interaction with patients with respect to their more acute needs.
Standardized screening tools: The BETTER 2 Program also developed a sophisticated screening tool that could serve as a consistent standard for most family practices. This tool was developed by a clinical working group made up of 15 clinicians who studied a range of different guidelines to determine the best set of prevention and screening protocols for use in the family practice.
Evaluation: The BETTER 2 Program conducted a rigorous evaluation to determine which prevention techniques work best. The evaluation design supported comparisons among interventions at the practice level, patient level and both levels – as well as comparisons against no interventions at either level. The results of this project will be used to inform policy decisions and support family practices and patients alike.
Jordan is a grade 5 student. He and his three best friends spend most of their time playing video games, watching TV and hanging out at Jordan’s house after school. Over the past year, Jordan’s teacher has noticed that he and his friends are becoming less focused in class and often seem either tired or distracted. His teacher has also noticed Jordan’s weight gain and is concerned about how it seems to be affecting his self-esteem.
One day in school, Jordan and his friends are introduced to a new program developed by Collaborative Action on Childhood Obesity (CACO) called Screen Smart, which informs them about the links between screen time and their health. Later, during the school’s “Drop the Pop” campaign, Jordan and his friends are introduced to another program called Sip Smart that was created by the Heart and Stroke Foundation of British Columbia and Yukon, and the British Columbia Paediatric Society. The Sip Smart program gets them talking with each other about the amount of sugar-sweetened beverages they consume.
As part of these programs, Jordan and his classmates begin tracking their screen time and sugary beverage consumption. Jordan is able to cut back significantly in both areas. He and his friends also become more aware, and more critical, of the junk food marketing they see on TV. One of Jordan’s friends even decides he’s tired of spending so much time playing video games and starts spending more time playing outdoors. This gets Jordan thinking about the games he likes to play outdoors as well.
At the same time, through CACO’s work with researchers, policy makers and practitioners, new policies are being considered in Jordan’s community and elsewhere that limit the marketing of, access to, and consumption of products that contribute to childhood obesity. These collaborative efforts help to eventually change social norms related to reduced screen-time and sugar sweetened beverage consumption.
CACO helped address childhood obesity by addressing underlying causes such as unhealthy eating habits, not enough physical activity, and difficulty accessing healthy foods in remote communities. Ultimately, CACO’s goal was to make it easier for children, their families, and communities to make healthier choices. While childhood obesity is a complex and multi-faceted issue, CACO set out to demonstrate that with the right approach and collaboration among key stakeholders in youth health and education, it is possible to make a difference. The CACO approach included ensuring that individuals have the knowledge and skills to make healthy decisions, that remote populations, like many First Nations communities, have access to healthy food choices, and that effective policies are put in place to reduce the appeal of unhealthy options through such things as marketing restrictions, taxes and zoning laws.
Childhood obesity is a global issue that has reached epidemic proportions. In Canada, childhood obesity rates are rising, and the problem is particularly acute among Canada’s First Nations, Inuit, and Métis populations.
Along with the social, economic and mental health impacts of childhood obesity, overweight and obese children are also at greater immediate risk for developing asthma and type-2 diabetes. Childhood obesity usually persists and worsens into adulthood leaving children at an increased risk for cancer, type 2 diabetes and other chronic diseases as they grow older.
The challenge of addressing childhood obesity is underscored by the complex and interacting system of factors that contribute to the problem, from our built environments, to food security issues, to commercial interests. For some remote populations in Canada, the challenge is compounded by the fact that many remote First Nations, Inuit, and Métis communities lack access to affordable healthy foods.
The good news is that childhood obesity is preventable. What’s needed is concurrent and coordinated actions at the policy, community and individual levels.
CACO brought together six National, Provincial, and Territorial partners with expertise in program design, policy development, research and evaluation, prevention/promotion, and clinical practice. CACO worked with policy makers, teachers, health professionals, NGO’s, communities, and kids to build capacity and encourage the implementation of evidence-based obesity and chronic disease prevention initiatives. This work was supported by a range of inter-jurisdictional networking, evaluation and knowledge exchange initiatives specific to CACO’s work at three different levels: the policy level, the community level, and the individual level.
Policy level: CACO was identified ways in which policy can promote and support healthy weights. This work includes studying and supporting the introduction of policies that decrease the appeal of, and access to, unhealthy food and beverage options while simultaneously increasing the appeal of locally harvested, healthy foods. For example, policies that restrict the marketing of high-fat or high sugar foods to kids, along with new taxation policies, can help to reduce the purchase of unhealthy options and increase the consumption of healthier ones. Policies that limit where fast food outlets are built, for example near schools, are also being supported.
Community level: Not all communities have access to locally harvested, culturally relevant and nutritious foods. This problem is particularly acute in Canada’s remote First Nations communities. For this reason, CACO worked with First Nations communities to increase local production and distribution of healthy, culturally relevant foods. For example, one initiative involved education, training and support with respect to the development of community gardens aimed at increasing the availability of fresh vegetables and reducing reliance many remote communities have on low-cost processed foods that are typically flown into the community. CACO also worked to build traditional and contemporary skills and knowledge with respect to how food is secured, distributed and prepared in order to help support healthier communities.
Individual level: CACO worked with schools to implement two classroom-based education modules, Sip Smart and Screen Smart. The modules were designed to help youth reduce both their sugar sweetened beverage consumption and daily screen time. By educating children about the benefits of reducing sugar-sweetened beverage consumption and screen time, and by having children track their progress, the program helps to educate while simultaneously tracking actual behavioural change. The Screen Smart program is the first of its kind in Canada.
CACO worked to prove that despite the number and complexity of factors that are contributing to the rise in childhood obesity, it is possible to make a tangible difference through focused, concurrent action at the policy, community and individual levels. The Sip Smart and Screen Smart programs are already showing increased health literacy and healthy behaviours impacting not only children, but their parents and teachers as well. Teachers have noted the visceral reaction of their students upon learning how much sugar is in their drinks. One teacher reported, “the students wanted to issue a challenge to the parents after being revolted by the amounts of sugar they were taking in.” Teachers have also indicated their intent to share the programs with teachers in other classrooms.
In the First Nations communities of Wawakapewin, Wapekeka and Kasabonika, community food programs have helped to decrease reliance on the predominantly high-sugar, high-sodium processed non-perishable foods that are available in the community stores. In the words of a former economic development officer in Wawakapewin, “I’m really excited with all the developments we’ve seen this year. It’s expanding the diet into things we have not previously had available to us.”
CACO also explored and learned how different policy options can contribute to healthy weights. By collaborating with other stakeholders, the CACO project was able to grow in both reach and impact.
Raj works as a planner for his local municipality. He has noticed that it’s becoming harder and harder for community members to walk to work or shop for fresh fruits and vegetables, while at the same time people have less and less time for recreational physical activity and must drive longer distances to access healthy foods. Based on these observations, Raj is concerned that rapid and sprawling development in his community may be having negative health impacts, such as contributing to growing obesity rates, because these new developments put more emphasis on moving cars than on moving people.
At the same time, Jane, one of Raj’s colleagues in the health department, has been working with Healthy Canada by Design to learn how public health can work more closely with community planners, developers and other stakeholders to ensure that planning and development issues – which determine the physical layout and feel of our communities – are also looked at through a health lens. One day, Jane contacts Raj to discuss how Public Health and the Planning Department can work together to foster collaboration among stakeholders in public health and community planning. With the support of tools and processes provided through Healthy Canada by Design, Jane and Raj begin a collaboration that snowballs to involve transportation planners, developers, engineers, architects, local businesses, community groups, and NGOs.
Raj is excited to learn that he was not alone in his concerns and that there is a growing and diverse community of individuals committed to creating communities that are built to make ‘healthy choices, easy choices’ for all. Before long, he and Jane are proud to see policies and processes in place in their community aiming to ensure that planning and development account for public health and chronic disease prevention.
Healthy Canada by Design helped to ensure that the physical layout and design of our neighbourhoods, towns, cities and regions promote a wide range of positive health outcomes such as physical activity, healthy eating, community spirit, clean air and high quality water. To this end, Healthy Canada by Design worked from the latest research to develop state-of-the-art tools to help community planners, public health officials, developers, policy makers and the public realize the many opportunities and benefits of healthy built environments.
In Canada, most communities continue to be built the same way they were in the 1950’s when the automobile began to dominate the way we looked at moving through our neighbourhoods. Wide roads, limited public transit, and suburban sprawl are just some of the outcomes of decades of planning and development that has placed more emphasis on the role and use of cars. The result is that many of our communities are unable to support the underlying conditions that contribute to chronic disease prevention such as access to recreational opportunities, pedestrian friendly neighbourhoods, easy access to fresh foods, community cohesion, and civic engagement.
Moreover, the number and complexity of factors and stakeholders that influence the shape of our communities make it difficult to coordinate and drive positive change. Finally, many people are fearful of, or resistant to, change simply because they have grown comfortable with what they already know.
Fortunately, it is possible to introduce changes to our built environments that can create a better balance between our reliance on cars and the importance of pedestrian walking areas and access to fresh foods that contribute to chronic disease prevention. These changes include such things as increasing population density while maintaining high livability standards through good design and green spaces, narrowing roads, introducing more mixed housing, creating and enhancing access to parks and trails, and defining containment boundaries for development areas.
Healthy Canada by Design worked to enhance the capacity of health stakeholders to engage in land use planning, improve the way in which key organizations and stakeholders collaborate, and, ultimately, increase awareness across Canada of issues related to how health is impacted by the design and physical layout of our communities.
To achieve these goals, Healthy Canada by Design collaborated with health authorities, researchers, community groups, planners and policy experts across Canada to review research, develop effective planning tools, and promote action for change.
Reviewing research: The Healthy Canada by Design team conducted a number of literature reviews in order to inform their practice and tool development. They also collaborated with researchers and health agencies Canada-wide to collate findings from Canadian health and built environment research conducted between 2007 and 2011 under a coordinated set of fact sheets. These were in turn made available to community planners, health officials and policy-makers Canada-wide with the purpose of informing them of the latest Canadian research in this field – an initiative that was the first of its kind in Canada.
Healthy Canada by Design also collected data and studied best practices stemming from its work with Health Authorities in Montreal, Toronto, Peel Region, and British Columbia. This work involved developing and evaluating planning tools and processes that are tailored to the unique characteristics of each health authority and the communities they represent. Data from these projects contributed to a growing body of knowledge on approaches that can be adapted to a diverse range of communities across Canada.
Developing tools: Based on research and the experience of working directly with communities, Healthy Canada by Design developed various tools to facilitate collaboration among the many agents of influence involved in community design and development. For example, communication tools such as briefing sheets, PowerPoint templates and sample Op-Ed pieces were developed to support stakeholder engagement. Tools to help guide planning and development decisions were produced. These include a health impact assessment framework that helps planners and developers evaluate the extent to which proposed developments will promote or hinder health. Healthy Canada by Design also developed an index that outlines healthy development ranges and targets such as optimal neighbourhood density in order to guide planning and development.
Promoting action: Building and shaping healthy built environments requires the support and coordinated effort of a broad range of influencers and decision makers. To this end, Healthy Canada by Design worked to increase the profile, awareness and reach of this issue through workshops, conferences and a range of ongoing efforts to unify stakeholders in health and the built environment across the country. By documenting case studies from projects across Canada, Healthy Canada by Design also demonstrated how health authorities, planners and developers can work together, while simultaneously creating a manual for planners and designers to guide their practice and assist them in collaborating more effectively with the health sector.
Healthy Canada by Design acted as a catalyst for change by influencing policy and helping those committed to change achieve their goals as efficiently and effectively as possible.
Policy changes have already started happen. For example, in Peel Region, wording was incorporated into the Official Plans for the Region and the local municipalities that would allow municipalities to request a health impact study as part of a complete development application. The Region also developed tools such as the Terms of Reference Framework for Health Background Studies to evaluate the health impacts of developments.
In Metro Vancouver’s Regional Growth Strategy, health related policies include a commitment to collaborate with health authorities to advance measures to promote healthy living through land use policies. The Strategy includes specific performance measures to assess progress regionally towards the development of healthy and complete communities with access to a range of services and amenities. These include monitoring the number of residents living within walking distance of a dedicated park or trail, the number and percent of residents living within walking distance of a recreation facility or community centre, and the number and percent of residents living within walking distance of a grocery store. In the City of Toronto, the incorporation of and equity considerations into major urban policies, such as those related to the Official Plan and Parks Plan, are facilitated through the Board of Health’s recent adoption of the Healthy Toronto by Design report. Creation of a health impact assessment software tool has provided, and will continue to provide a decision-support tool for health staff, planners and other city officials to determine and visualize health outcomes associated with diverse land use and transportation options.
The Island of Montreal now has an interactive atlas that maps and catalogues all of the region’s 180+ community organizing efforts to create greener, more walkable neighbourhoods. This new tool is positioning these Montreal-based groups to work more closely together and in new ways. Finally, word is getting out about healthy built environments through three major new websites from the Canadian Institute of Planners, Urban Public Health Network, the Heart and Stroke Foundation, and more.
This CLASP1 project, which also received funding from the Public Health Agency of Canada, focused on enhancing health programming to better prevent cancer and chronic disease, and monitor and reduce the growing burden of these diseases, among First Nations populations. This work included raising awareness of the critical risk factors for cancer and chronic disease, implementing primary and secondary prevention and screening programs, and creating culturally relevant educational materials and expertise to address the knowledge gap among Aboriginal people. – Link
This CLASP1 project, which was also supported by funding from the Public Health Agency of Canada, focused on increasing the number of children doing daily physical activity. The program did this by promoting active transportation as an alternative way for elementary schoolchildren to get to school. – Link
The Healthy Community movement was a dynamic force in many communities across Canada that brought together groups from many sectors to plan and implement strategies to enhance community well-being and address complex community issues. This CLASP1 project aimed to demonstrate that the Healthy Community approach is an effective way to address chronic disease prevention. – Link
This CLASP1 project sought to improve the health of Canada’s youth by creating collaboration opportunities among researchers, policy-makers, practitioners and communities in an effort to assess, and guide policies and programs focused on physical activity, tobacco use and healthy eating. The project team developed methods to rapidly gather and share evidence across jurisdictions to create environments that helped make healthy choices easier choices for young people. – Link