Chronic Diseases and Injuries in Canada Inside this issue

Chronic Diseases and Injuries in Canada Inside this issue
Chronic Diseases and
Injuries in Canada
Volume 34 · Number 1 · February 2014
Inside this issue
1
Cyclist head and facial injury risk in relation to helmet fit: a
case-control study
8
Canadian parents’ attitudes and beliefs about bicycle helmet
legislation in provinces with and without legislation
12
Validation of a deprivation index for public health: a complex
exercise illustrated by the Quebec index
23
Coroners’ records on suicide mortality in Montréal: limitations
and implications in suicide prevention strategies
30
Prevalence of self-reported hysterectomy among Canadian
women, 2000/2001–2008
36
Metabolic syndrome and chronic disease
46
Impact of individual and ecological characteristics on small for
gestational age births: an observational study in Quebec
55
An environmental scan of policies in support of chronic disease
self-management in Canada
64
Cancer in Canada Fact Sheet Series #1 – Thyroid cancer in
Canada
69
Book review – Community-based Prevention: Reducing the Risk
of Cancer and Chronic Disease
Chronic Diseases and Injuries in Canada
a publication of the Public Health Agency
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Howard Morrison, PhD
Editor-in-Chief
CDIC Editorial Board
Robert Geneau, PhD
International Development Research Centre
Anne-Marie Ugnat, PhD
Brent Hagel, PhD
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University of Calgary
Claire Infante-Rivard, MD, PhD, FRCPC
Associate Scientific Editor
Public Health Agency of Canada
Barry Pless, CM, MD, FRCPC
Associate Scientific Editor
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Associate Scientific Editor
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Valerie Leinan
Isra Levy, MB, FRCPC, FACPM
Ottawa Public Health
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Centers for Disease Control and Prevention
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University of Calgary
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Public Health Agency of Canada
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University of Ottawa
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Freelance Copyeditor
Vancouver Island Health Authority
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McGill University
Andreas T. Wielgosz, MD, PhD, FRCPC
Chronic Diseases and Injuries in Canada (CDIC)
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ISSN 1925-6523
Pub. 130369
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Également disponible en français sous le titre : Maladies chroniques et blessures au Canada
Cyclist head and facial injury risk in relation to helmet fit: a
case-control study
N. R. Romanow, MSc (1); B. E. Hagel, PhD (1, 2, 3); J. Williamson, BHSc (4); B. H. Rowe, MD (5)
This article has been peer reviewed.
Abstract
Introduction: We examined the effect of bicycle helmet fit and position on head and
facial injuries.
Methods: Cases were helmeted cyclists with a head (n = 297) or facial (n = 289) injury.
Controls were helmeted cyclists with other injuries, excluding the neck. Participants
were interviewed in seven Alberta emergency departments or by telephone; injury data
were collected from charts. Missing values were imputed using chained equations and
custom prediction imputation models.
Results: Compared with excellent helmet fit, those with poor fit had increased odds of
head injury (odds ratio [OR] = 3.38, 95% confidence interval [CI]: 1.06–10.74).
Compared with a helmet that stayed centred, those whose helmet tilted back
(OR = 2.90, 95% CI: 1.54–5.47), shifted (OR = 1.91, 95% CI: 1.01–3.63) or came off
(OR = 6.72, 95% CI: 2.86–15.82) had higher odds of head injury. A helmet that tilted
back (OR = 4.81, 95% CI: 2.74–8.46), shifted (OR = 1.83, 95% CI: 1.04–3.19) or came
off (OR = 3.31, 95% CI: 1.24–8.85) also increased the odds of facial injury.
Conclusion: Our findings have implications for consumer and retail education
programs.
Keywords: head protective devices, bicycling, injuries
Introduction
Helmets reduce the risk of head and
facial injury in cycling crashes.1
However, many cyclists do not wear
their helmets correctly.2 Bicycle helmet
design and certification have changed
during the past two decades.3 While
mandated use of bicycle helmets is
increasing worldwide, a variety of types
of legislation exist; some are restricted to
youth, others apply to all ages.4,5
Comparative studies in regions that have
implemented helmet legislation have
shown an overall decrease in reported
traumatic brain injuries.4,6,7 While this
lends strength to arguments supporting
helmet legislation, efforts to increase
helmet use could fail to achieve the
expected benefits to health outcomes if
helmets are worn incorrectly.
Safety certification testing is typically
based on drop tests, ensuring that the
impact is delivered centred on the top of
the helmet. In this setting, helmet effectiveness is based on ideal conditions, and
a helmet’s maximum protection is
achieved when the helmet is correctly
positioned. Proper fit is important in cases
where the rider receives multiple hits to
the head. Ensuring the helmet remains in
place after the first blow protects against
subsequent blows.8
Most of the literature on correct bicycle
helmet use refers to the prevalence of
correct use,9 but reports vary largely due
to the inconsistent criteria used to assess
helmet fit. A 2010 study found that 20%
of children aged under 13 years and
16.7% of 13- to 17-year-olds wore their
helmets incorrectly.10 The most frequently
observed error was the helmet sitting too
far back on the head. The upper rim of the
helmet has been shown to protect the
upper face from injury in a frontal
collision,1,11 and helmeted cyclists have a
significantly lower risk of facial injury,1,12
though it seems necessary that their
helmets stay in place to do this. Only
one study has investigated the relationship
between bicycle helmet fit and the risk of
head injury.13 The authors found double
the risk of head injury with a poorly fitting
helmet compared with an excellently
fitting helmet, triple the risk of head injury
with a helmet that came off during the
incident compared with one that stayed
centred, and a 52% increase in risk of
head injury in those with a helmet that
tipped back compared with a helmet that
stayed centred.13 Though methodologically sound, this study used data captured
nearly two decades ago, making it necessary to re-examine this issue with newer
helmet designs. In addition, no studies
have reported how proper helmet use and
correct fit affect facial injuries among
cyclists.
Author references:
1.
2.
3.
4.
5.
Department of Paediatrics, Faculty of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada
Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta Children’s Hospital, Calgary, Alberta, Canada
Alberta Children’s Hospital Research Institute for Child and Maternal Health, University of Calgary, Calgary, Alberta, Canada
Bachelor of Health Sciences Program, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
Correspondence: Brent E. Hagel, Departments of Paediatrics and Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta Children’s Hospital Research Institute for
Child and Maternal Health, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, C4-434, Calgary, AB T3B 6A8; Tel.: 403-955-7403; Fax: 403-955-3055;
Email: brent.hagel@albertahealthservices.ca
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1
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
The purpose of our study was to determine the relation between the risk of head
or facial injury and self-reported bicycle
helmet fit and position.
Methods
Data collection
Injured cyclists were recruited from seven
emergency departments (EDs) in Calgary
(Alberta Children’s Hospital, Foothills
Medical Centre, Rockyview General
Hospital, Peter Lougheed Centre) and
Edmonton (Stollery Children’s Hospital,
University of Alberta Hospital, Northeast
Community Health Centre), Alberta, over
three years (May 2008 to October 2010).
We identified the cyclists by scanning
the Regional Emergency Department
Information System and reviewing ED
charts daily, with the co-operation of the
ED staff. Eligible injured cyclists (or parents of those aged less than 14 years) were
approached and asked to participate by
research staff or, in some cases, the ED
physician or nurse.
After giving consent, patients were interviewed in the ED or, if they did not wish to
complete the interview immediately, by
telephone. If an eligible patient was
missed in the ED, they were mailed a
study information package including a
consent form and were contacted by
telephone and asked to participate. If a
patient was admitted to the hospital after
their ED visit, the research staff made
arrangements to inform the patient about
the study and interview them in hospital if
they were willing. If the patient was too
young to answer the questions, research
staff interviewed the patient’s parent or
guardian. If the parent did not know the
details of the event or could not respond to
a question, responses were filled out as
‘‘don’t know’’ or ‘‘missing,’’ as appropriate. For telephone interviews, we
requested the participation of the child;
however, if the parent did not allow the
child to respond on their own, responses
from the parent were accepted instead.
We collected injury information from the
patient’s medical chart. Excluded from the
study were injured cyclists who did not
speak English, those missed in the ED who
did not have a telephone or who could not
be reached after a maximum of six call
attempts, and those who were injured
while riding indoors or while using a
stationary bicycle. We also did not include
cyclists who received a neck injury as the
relationship between helmet use and neck
injury risk is less clear or well-accepted.7
good, (3) fair and (4) poor. Helmet
position response choices were (1) stayed
centred, (2) tilted back, (3) shifted to the
side and (4) came off. For both variables
participants could also respond ‘‘don’t
know’’ or ‘‘refuse to answer,’’ both of
which were treated as missing values for
the primary analysis.
From within this arm of the study focusing
on helmet fit, we identified two separate
case groups. The first consisted of helmeted cyclists who had received a head
injury, regardless of the severity of any
other injuries. A head injury was defined
as any injury to the scalp, skull or brain
and did not include injuries to the cervical
vertebrae or spinal cord, injuries to the
point where the skull meets the spine or
injuries to the neck regions or the face.
The boundaries of the skull were defined
as an imaginary line from normal eyebrow
position laterally to the normal hairline,
descending posterior to and not including
the ears, and to and around the base of the
occipital bone.
Follow-up interviews were conducted
with a subsample of participants to measure the reliability of the initial interview.
The same questionnaire was used and the
initial respondent was asked to complete
the follow-up interview (e.g. the parent if
they responded initially). The results of
the two time-separated interviews were
compared using kappa (k) statistics16 with
95% confidence intervals (CIs). The follow-up interviews were conducted at least
two weeks after the initial interview with
those patients who had agreed to be
contacted for follow-up during the initial
interview.
Since there is some evidence that bicycle
helmets prevent facial injuries,1 our second case group consisted of helmeted
cyclists who had received any injury to
the face, regardless of the severity of any
other injuries. A facial injury was defined
as any injury below the normal hairline,
anterior to and including the ears, and
superior to and including the mandible.
Cyclists with both head and facial injuries
were included in both case groups.
Controls, obtained from the same EDs as
the cases, were helmeted cyclists who had
received injuries below the neck and had
no head, brain or face injuries.
We interviewed bicyclists in the ED using
a structured questionnaire (available on
request) based on previous work14,15 that
was pilot tested with a convenience
sample of respondents. Survey information was captured on the cyclist and the
circumstances of the crash. For this
analysis, we focused on information that
related to helmet use and helmet fit. The
two main variables of interest, helmet fit
and helmet position/movement during the
crash, were self-reported using fixedresponse choices. For helmet fit, the
response choices were (1) excellent, (2)
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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2
The study was approved by the Conjoint
Health Research Ethics Board at the
University of Calgary and the Health
Research Ethics Board at the University
of Alberta.
Data analysis
We calculated crude odds ratios (ORs,
with 95% CIs) for the association between
helmet fit and head or facial injury. We
also examined the relation between helmet position during the crash and head or
facial injury. Multiple logistic regression
analyses were conducted to adjust for
potential confounders (i.e. variables
potentially related to helmet fit/position
and independent risk factors for head or
facial injury) including age, sex, body
mass index (BMI), cycling frequency,
presence of a cycling companion and
cyclist self-reported estimated speed. Age
was categorized as less than 13 years, 13
to 17 years, 18 to 39 years or 40 years and
older. BMI categories were based on the
World Health Organization classifications
for underweight (< 18.50 kg/m2), normal
weight (18.50–24.99 kg/m2), overweight
(25.00–29.99 kg/m2) and obese (§ 30 kg/
m2).17 Cycling frequency was classified as
at least once per week, at least once per
month or at least once per year.18 Cyclists
were grouped as cycling alone, with
children, with adults or with others (e.g.
camp leaders). Cyclist speed was dichotomized into less than 25 km/h and greater
than or equal to 25 km/h. A forward
selection modelling strategy was used
where each co-variate was added to the
model containing outcome (head or facial
injury) and exposure (helmet fit or helmet
position) individually. Separate models
were developed for helmet fit and helmet
position to avoid potential collinearity of
the two variables. If a co-variate produced
a change in helmet fit or position estimates of greater than or equal to 10%, it
was retained in the model. This process
was repeated until no more changes were
observed or until the number of variables
in the model reached 10% of the number
of cases.19
Multiple imputation analysis
We imputed missing values for exposure
variables and potential confounders using
chained equations and custom prediction
imputation models.20 In the imputation
model, variables were imputed in order of
least missing to most missing using predictive mean matching for continuous
variables and multinomial logistic or
ordered logistic regression for categorical
variables as appropriate. Non-missing predictors were also included. Logistic regression models including all co-variates (age,
sex, BMI, cyclist speed, cycling frequency
and cycling companions) were used to
calculate OR estimates and 95% CIs from
the imputed data. All data analyses were
conducted using STATA version 11.0
(StataCorp LP, College Station, TX, US).
Results
Characteristics of the study sample
In total, 4960 injured cyclists were screened
for eligibility and 3111 (63%) agreed to
participate and were enrolled into the
study. Of these, 2336 (75%) were wearing
a helmet at the time of the crash. For this
analysis, there were 297 cyclists with a
head injury, 289 facial injury cases and
1694 controls. There were 64 participants
who had both head and facial injuries;
these were included in both case groups.
Table 1 shows the characteristics of
the groups of cyclists with head and
facial injuries. Compared with controls,
the cyclists with head injuries tended to be
biking faster and were more likely to be
biking alone, while those with facial
injuries were younger, had a lower BMI,
were cycling alone or with adults and
rarely used a full-face helmet.
Helmet fit and position and risk of head
injury
Based on the crude estimates, poor
helmet fit significantly increased the odds
of head injury relative to the excellent fit
category (OR = 3.26, 95% CI: 1.08–9.83)
(Table 2). If the helmet tilted back (OR =
2.76, 95% CI: 1.47–5.18), shifted to the
side (OR = 1.87, 95% CI: 1.03–3.42), or
came off (OR = 6.77, 95% CI: 3.08–
14.86), the odds of head injury increased
significantly relative to the ‘‘stayed
centred’’ group.
The adjusted ORs for good, fair and poor
helmet fit were 0.96 (95% CI: 0.69–1.36),
1.93 (95% CI: 1.04–3.57), and 3.23 (95%
CI: 0.78–13.41), respectively, compared
with excellent helmet fit. Cyclists who
reported a fair helmet fit had nearly twice
the odds of incurring a head injury
compared with those who reported an
excellent helmet fit. After conducting the
imputation, only those who reported
poor helmet fit (OR = 3.38, 95% CI:
1.06–10.74) had significantly increased
odds of head injury relative to those with
excellent helmet fit.
After adjustment for co-variates, cyclists
with a helmet that came off during the
crash had a 7-fold increase in the odds of
head injury compared with those whose
helmet stayed centred (OR = 7.13, 95%
CI: 2.94–17.29). Those with a helmet that
tilted back had more than a three-fold
increase in the odds of a head injury
(OR = 3.54, 95% CI: 1.70–7.40). The
adjusted estimates based on the imputed
data were similar; the OR estimate for a
helmet that tilted back was 2.90 (95% CI:
1.54–5.47) and the estimate for a helmet that
came off was 6.72 (95% CI: 2.86–15.82).
The result for a helmet that shifted to the
side was also significant after imputation
(OR = 1.91, 95% CI: 1.01–3.62).
$
3
Helmet fit and position and risk of facial
injury
Crude estimates showed increased odds of
facial injury with a helmet that tilted back
(OR = 4.19, 95% CI: 2.46–7.15), shifted to
the side (OR = 1.98, 95% CI: 1.11–3.50) or
came off (OR = 3.12, 95% CI: 1.19–8.22)
(Table 3). However, when adjusted for
BMI, cycling frequency and cycling speed,
only those helmets that tilted back were
associated with an increase in the odds of
facial injury (OR = 4.49, 95% CI: 2.30–
8.77). Poor fit was indicative of a harmful
effect but was not statistically significant
(OR = 3.10, 95% CI: 0.76–12.69).
Compared with the adjusted estimates
from the original data, the imputed ORs
for facial injury risk tended to be further
from 1.00. The odds of facial injury
increased significantly if the helmet tilted
back (OR = 4.81, 95% CI: 2.74–8.46),
shifted to the side (OR = 1.83, 95% CI:
1.04–3.19) or came off (OR = 3.31, 95%
CI: 1.24–8.85).
Data quality and reliability
For helmet fit, overall observed agreement
was 87.5% and expected agreement was
81.0% (Table 4). Weighted kappa was
calculated since the responses were
ordered, and kappa was 0.34 (95% CI:
0.16–0.64), which represents fair agreement.14 For head and face injury cases
(n = 24), observed agreement was 91.7%
and expected agreement was 79.8%,
resulting in a kappa of 0.59 (95% CI:
0.28–1.00), representing moderate agreement. For controls, kappa was 0.22 (95%
CI: 0.00–0.44).
An un-weighted kappa score was calculated for helmet position. For head and
face injury cases, observed agreement was
62.5%, expected agreement was 49.3%
and kappa was 0.26 (95% CI: 0.00–0.54)
or fair agreement. For controls, observed
agreement was 90.6%, expected was
85.6%, and kappa was 0.35 (95% CI:
0.19–0.71), fair agreement.
Discussion
This study provides updated evidence on
the relationship between correct bicycle
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 1
Cyclist and crash characteristics by case-control status for cyclists injured in Calgary and Edmonton, Alberta
Controls
(n = 1694)
n
Head injury
(n = 297)
(%)
n
Chi2 (x2)
p value
(%)
Facial injury
(n = 289)
n
(%)
78
(27.0)
211
(73.0)
.70
Sex
Female
Male
450
(26.6)
76
(25.6)
1244
(73.4)
221
(74.4)
.88
.14
Age, years
ƒ .001
< 13
695
(41.0)
101
(34.0)
154
(53.3)
13–17
394
(23.3)
77
(25.9)
41
(14.2)
18–39
308
(18.2)
56
(18.9)
53
(8.0)
§ 40
297
(17.5)
63
(21.2)
41
(14.2)
BMI, kg/m2
.34
.03
< 18.50 (underweight)
407
(24.0)
69
(23.2)
89
(30.8)
18.50–24.99 (normal)
783
(46.2)
154
(51.9)
125
(43.3)
25.00–29.99 (overweight)
279
(16.5)
40
(13.5)
41
(14.2)
> 30.00 (obese)
Unknowna
56
(3.3)
6
(2.0)
4
(1.4)
169
(10.0)
28
(9.4)
30
(10.4)
1240
(73.2)
183
(61.6)
199
(68.9)
181
(10.7)
42
(14.1)
33
(11.4)
273
(16.1)
72
(24.2)
57
(19.7)
< .001
Cyclist speed, km/h
< 25
§ 25
a
Unknown
.20
.14
Cycling frequency
At least once per week
At least once per month
.89
1476
(87.1)
257
(86.5)
253
(87.5)
102
(6.0)
13
(4.4)
12
(4.2)
57
(3.4)
10
(3.4)
12
(4.2)
59
(3.5)
17
(5.7)
12
(4.2)
(42.8)
103
(35.6)
At least once per year
a
Unknown
< .001
Cycling with others
Cycling alone
545
(32.2)
127
.02
With adults
643
(38.0)
95
(32.0)
124
(42.9)
With children only
493
(29.1)
74
(24.9)
59
(20.4)
12
(0.7)
0
(0.0)
3
(1.0)
1
(0.1)
1
(0.3)
0
(0.0)
With someone else
b
Unknowna
.23
Helmet type
Full-face helmet
No face guard
ƒ .001
258
(15.2)
34
(11.5)
17
(5.9)
1405
(82.9)
257
(86.5)
269
(93.1)
26
(1.5)
4
(1.4)
2
(0.7)
5
(0.3)
2
(0.7)
1
(0.4)
Don’t know about face guardc
Unknowna
Chi2 (x2)
p value
Abbreviation: BMI, body mass index.
a
The ‘‘unknown’’ category includes the responses ‘‘don’t know,’’ ‘‘refused to answer’’ and where the data were missing. This category was not included in the tests of significance.
b
Includes responses that were not possible to categorize as ‘‘adult’’ or ‘‘child’’ companions (e.g. cycling with an instructor or a baby-sitter).
c
The question about type of helmet was added in year two (2009) of data collection and so information on the use of a face guard was not available for participant interviews in year one
(2008).
helmet fit and risk of head or facial
injuries. While the overall protective effect
of bicycle helmets has been well documented, specific information on helmet fit
and position increases our understanding
of their impact and provides evidence
that can be used by cyclists, helmet
manufacturers and those promoting
injury prevention.
Rivara et al.13 reported an increase in head
injury risk as a result of cyclists’ helmets
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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4
shifting back or coming off. Our results
were approximately twice as high as those
previously reported. We also found a
relationship between head injury and a
helmet that shifted to the side, an observation that had not been previously
TABLE 2
Odds ratio estimates for the relationship between helmet fit and head injury among cyclists injured in Calgary and Edmonton, Alberta
Controls
(n = 1694)
Cases
(n = 297)
n
(%)
n
(%)
1014
(59.9)
173
(58.1)
Crude OR (95% CI)
Adjusted OR (95% CI)
Imputed adjusted ORa
(95% CI)
1.00
1.00
Helmet fitb
Excellent
Good
Fair
(reference)
(reference)
1.00
(reference)
c
579
(34.2)
92
(30.9)
0.93
(0.71–1.22)
0.96
(0.69–1.36)
0.97
(0.73–1.29)
81
(4.8)
22
(7.4)
1.59
(0.97–2.62)
1.93
(1.04–3.57)c
1.60
(0.96–2.66)
3.38
(1.06–10.74)
Poor
9
(0.5)
5
(1.7)
3.26
(1.08–9.83)
3.23
(0.78–13.41)
1421
(83.9)
180
(60.4)
1.00
(reference)
1.00
(reference)
c
What happened to your helmet?d
Stayed centred
1.00
(reference)
e
Tilted back
40
(2.4)
14
(4.7)
2.76
(1.47–5.18)
3.54
(1.70–7.40)
2.90
(1.54–5.47)
Shifted to side
59
(3.5)
14
(4.7)
1.87
(1.03–3.42)
1.84
(0.90–3.77)e
1.91
(1.01–3.63)
e
6.72
(2.86–15.82)
1.52
(0.32–7.19)
Came off
14
(0.8)
12
(4.0)
6.77
(3.08–14.86)
7.13
(2.94–17.29)
Tilted forward
10
(0.6)
2
(0.7)
1.58
(0.34–7.26)
1.39
(0.17–11.61)e
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio.
Note: Missing values in original data: age (n = 7), height (n = 159), weight (n = 82), helmet fit (n = 16), cyclist speed (n = 345), helmet position (n = 225), cycling frequency (n = 76) and
cycling companion (n = 2).
a
Estimates adjusted for cycling frequency, presence of cycling companion, speed, BMI, sex and age.
b
Adjusted analysis includes 198 cases and 1244 controls before imputation.
c
Estimates adjusted for cycling frequency, speed, BMI and age.
d
Adjusted analysis includes 166 cases and 1178 controls before imputation.
e
Estimates adjusted for speed, cycling companion and BMI.
TABLE 3
Odds ratio estimates for the relationship between helmet fit and facial injury among cyclists injured in Calgary and Edmonton, Alberta
Controls
(n = 1694)
Helmet fit
Cases
(n = 289)
Crude OR (95% CI)
Adjusted ORa (95% CI)
Imputed adjusted ORb
(95% CI)
n
(%)
n
(%)
1014
(59.9)
165
(57.1)
1.00
(reference)
1.00
(reference)
1.00
(reference)
(0.85–1.46)
c
Excellent
Good
579
(34.2)
106
(36.7)
1.13
(0.86–1.47)
0.95
(0.69–1.32)
1.11
Fair
81
(4.8)
14
(4.8)
1.06
(0.59–1.92)
0.91
(0.42–1.98)
1.05
(0.58–1.93)
Poor
9
(0.5)
3
(1.0)
2.05
(0.55–7.65)
3.10
(0.76–12.69)
2.08
(0.54–8.02)
What happened to your helmet?d
Stayed centred
1421
(83.9)
195
(67.5)
1.00
(reference)
1.00
(reference)
1.00
(reference)
Tilted back
40
(2.4)
23
(8.0)
4.19
(2.46–7.15)
4.49
(2.30–8.77)
4.81
(2.74–8.46)
Shifted to side
59
(3.5)
16
(5.5)
1.98
(1.11–3.50)
1.51
(0.72–3.17)
1.83
(1.04–3.19)
Came off
14
(0.8)
6
(2.1)
3.12
(1.19–8.22)
3.08
(0.95–9.93)
3.31
(1.24–8.85)
Tilted forward
10
(0.6)
2
(0.7)
1.46
(0.32–6.70)
2.02
(0.41–9.99)
1.54
(0.35–6.85)
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio.
Note: Missing values in original data: age (n = 6), height (n = 163), weight (n = 71), helmet fit (n = 12), cyclist speed (n = 330), helmet position (n = 194), cycling frequency (n = 71) and
cycling companion (n = 1).
a
Estimates adjusted for BMI, cycling frequency and cycling speed.
b
Estimates adjusted for cycling frequency, cycling companion, speed, BMI, sex and age.
c
Adjusted analysis includes 198 cases and 1244 controls before imputation.
d
Adjusted analysis includes 170 cases and 1318 controls before imputation.
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 4
Agreement and kappa for helmet fit and position by cases and controls for cyclists injured in Calgary and Edmonton, Alberta
Observed agreement, %
Expected agreement, %
k
95% CI
Cases (n = 24)
Helmet fit
91.7
79.8
0.59
(0.28–1.00)
Helmet position
62.5
49.3
0.26
(0.00–0.54)
Controls (n = 53)
Helmet fit
85.5
81.6
0.22
(0.00–0.44)
Helmet position
90.6
85.6
0.35
(0.19–0.71)
Overall (n = 77)
Helmet fit
87.5
81.0
0.34
(0.16–0.64)
Helmet position
81.8
72.0
0.35
(0.20–0.74)
Abbreviations: CI, confidence interval; k, kappa.
reported. We did not find that selfreported helmet fit influenced the odds of
a facial injury, but a helmet that came off
during a crash increased the odds of facial
injury 3-fold and a helmet that tilted back
increased the odds of facial injury almost
5-fold.
Foss and Beirness21 reported that incorrect
helmet use is more prevalent in 1- to 5year-olds and 6- to 15-year-olds compared
with older cyclists and that those aged
6 to 15 years have a higher risk of head
injury.21 Their definition of incorrect
helmet use included an unfastened chin
strap or a helmet that was tipped back.21
We also found that the youngest age group
(< 13 years old) suffered a high proportion of head and facial injuries compared
with older age groups, which may be
related to having a helmet that tilted back
in the crash.
Another Canadian study found that 4.3%
of helmet users wore their helmet incorrectly, either tipped back, with the chin
strap unfastened or with a baseball cap
worn underneath.22 A 2010 observational
study in Alberta10 showed that 16.6% of
cyclists—and 21% of children aged under
13 years—used a helmet incorrectly. In
our study, approximately 9% of those
with head injuries and 6% of those with
facial injuries reported fair or poor helmet
fit compared with 5.3% of controls. These
are likely underestimates, as Lee et al.9
reported that the prevalence of correct
helmet use varied from 46% to 100%
among recent studies, noting inconsistencies in the definition of correct use.
Our findings on the importance of helmet
fit provide a better understanding of the
potential protective effect of bicycle helmets. Previous studies that documented
that helmet use (vs. non-use) reduces the
risk of a head or brain injury1 may in fact
underestimate the protective effect of helmets given that it is likely that a number of
the participants in these studies were
wearing a poorly fitting helmet or using
the helmet incorrectly (e.g. strap not
fastened). If so, this has implications for
the promotion of helmet use, which should
include a focus on how to wear helmets
correctly in order to achieve the maximum
protective benefit.
Limitations
If cyclists who did not participate differed
in their helmet use compared with the
study sample, there is potential for selection bias. Unfortunately, in addition to
lack of information on helmet use for
these patients, the nature of the data
collection process made it impossible for
us to determine whether or not those we
could not reach or who refused to participate would have been cases or controls.
If those who refused were more likely to
wear their helmet incorrectly and this
resulted in more severe injuries involving
the head or face, then we would have
underestimated the protective effect of a
helmet that fit correctly or stayed centred.
Helmet fit was self-reported, and therefore
may be prone to misclassification if
cyclists were more likely to indicate that
the helmet fit better than it actually did. It
may be that those without a head injury
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
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would over-report excellent helmet fit and
those with a head injury under-report
excellent fit. If so, this would have
resulted in an inflated estimate of the
effect of poor helmet fit. Lee et al.9 found
that self-perceived helmet fit was often
over-estimated compared with expert evaluation, meaning that the helmet fit risk
estimates in our study could be biased. We
had high observed agreement between the
initial and follow-up reported helmet fit
for cases (91.7%) and controls (85.5%);
though kappa values were lower for controls and could potentially reflect misclassification bias of the odds ratios toward or
away from the null. The poorer reliability
estimates for helmet position were similar
for cases and controls and may indicate
misclassification that would push the odds
ratios to the null.
We included several potential confounders that have been shown to relate to
bicycling injury. These included cycling
frequency, presence of a companion,
speed, BMI, sex and age. In their study,
Rivara et al.13 presented unadjusted
results after determining that crash severity did not influence the effect estimates
for the relationship between head injury
risk and helmet fit or position. Therefore,
it is unlikely that other factors related to
both bicycling head and facial injury and
helmet fit could account for the effects we
have identified.
Conclusion
Helmet fit and position during a crash can
significantly affect the risk of head and
face injuries. Correct helmet use may be
increased as a result of educational programs informing cyclists that wearing a
helmet is not enough to provide full
protection without considering proper fit.
Manufacturers should continue to try to
design easy-to-use helmets in many different shapes and sizes that stay in place to
best protect the cyclist. Retail employees
selling helmets must be trained in the
principles of correct helmet use to convey
this important information to consumers.
Acknowledgements
The authors would like to thank the
clinical and research staff at the Alberta
Children’s Hospital, Foothills Medical
Centre, Rockyview General Hospital and
Peter Lougheed Centre in Calgary and the
Stollery Children’s Hospital, University of
Alberta Hospital and Northeast Community Health Centre in Edmonton. A special
acknowledgment is due to the study
research staff and students in Edmonton
and Calgary, the Paediatric Emergency
Research Team (PERT), the volunteers
from the Paediatric Emergency Medicine
Research Associates Program (PEMRAP)
at the Alberta Children’s Hospital and the
emergency medicine research assistants at
the Foothills Medical Centre.
Dr. Brent Hagel holds the Alberta Children’s
Hospital Foundation Professorship in Child
Health and Wellness, funded through the
support of an anonymous donor and the
Canadian National Railway Company, as
well as the Alberta Heritage Foundation for
Medical Research (AHFMR – now Alberta
Innovates-Health Solutions) Population
Health Investigator Award. This work was
made possible by Dr. Hagel’s Establishment
Grant from AHFMR. Dr. Rowe is supported
as a Tier I Canada Research Chair in
Evidence-Based Emergency Medicine from
the Canadian Institutes of Health Research
(CIHR) through the Government of Canada.
Jacqueline Williamson was supported by a
summer studentship from the University of
Calgary O’Brien Centre for the Bachelor of
Health Sciences program. Nicole Romanow
was supported by a studentship from the
Alberta Children’s Hospital Research
Institute CIHR Training Program.
References
1.
2.
3.
4.
Thompson DC, Rivara FP, Thompson RS.
Helmets for preventing head and facial
injuries in bicyclists. Cochrane Database
of Systematic Reviews.1999;(4):CD001855.
Hagel BE, Rizkallah JW, Lamy A, et al.
Bicycle helmet prevalence two years after
the introduction of mandatory use legislation for under 18 year olds in Alberta,
Canada. Inj Prev. 2006;12:262-5.
Swart R. The history of bicycle helmets.
Arlington (VA): Bicycle Helmet Safety
Institute; 2010 [updated 2010 Sep 9; cited
2012 Oct 25]. Available from: http://www
.helmets.org/history.htm
Ichikawa M, Nakahara S. School regulations governing bicycle helmet use and
head injuries among Japanese junior high
school students. Accid Anal Prev.
2007;39:469-74.
5.
Robinson DL. Bicycle helmet legislation:
can we reach a consensus? Accid Anal
Prev. 2007;39:86-93.
6.
Karkhaneh M, Rowe BH, Saunders LD,
Voaklander DC, Hagel BE. Bicycle helmet
use four years after the introduction of
helmet legislation in Alberta, Canada. Accid
Anal Prev. 2011;43:788-96.
7.
Attewell RG, Glase K, McFaden M. Bicycle
helmet efficacy: a meta-analysis. Accid
Anal Prev. 2001;33:345-52.
8.
Strohm PC, Sudkamp NP, Zwingmann J,
El Saman A, Kostler W. Polytrauma in
cyclists. Incidence, etiology, and injury
patterns. Unfallchirurg. 2005;108:1022-4.
9.
Lee RS, Hagel BE, Karkhaneh M, Rowe BH.
A systematic review of correct bicycle
helmet use: how varying definitions and
study quality influence the results. Inj Prev.
2009;15:125-31.
10. Hagel BE, Lee RS, Karkhaneh M,
Voaklander D, Rowe BH. Factors associated
with incorrect bicycle helmet use. Inj Prev.
2010;16:178-84.
11. Hansen KS. Protective effect of different
types of bicycle helmets. Traffic Inj Prev.
2003;4:285-90.
$
7
12. Amoros E, Chiron M, Martin JL, Thélot B,
Laumon B. Bicycle helmet wearing and the
risk of head, face, and neck injury: a French
case-control study based on a road trauma
registry. Inj Prev. 2012;18:27-32.
13. Rivara FP, Astley S, Clarren S, Thompson
DC, Thompson RS. Fit of bicycle safety
helmets and risk of head injuries in
children. Inj Prev. 1999;5:195-7.
14. Rivara FP, Thompson DC, Thompson RS.
Epidemiology of bicycle injuries and risk
factors for serious injury. Inj Prev.
1997;3:110-4.
15. Wells S, Mullin B, Norton R, et al.
Motorcycle rider conspicuity and crash
related injury: case-control study. BMJ.
2004;328(7444):857-62.
16. Landis JR, Koch GG. The measurement of
observer agreement for categorical data.
Biometrics. 1977;33:159-74.
17. World Health Organization. BMI classification. Geneva (CH): World Health
Organization; 2006 [cited 2012 Sep 4].
Available from: http://apps.who.int/bmi
/index.jsp?introPage=intro_3.html
18. Winters M, Davidson G, Kao D, Teschke K.
Motivators and deterrents of bicycling:
comparing influences on decisions to ride.
Transportation. 2011;38:153-68.
19. Mickey RM, Greenland S. The impact of
confounder selection criteria on effect
estimation. Am J Epidemiol. 1989;129:
125-37.
20. White IR, Royston P, Wood AM. Multiple
imputation using chained equations: issues
and guidance for practice. Stat Med.
2010;30:377-99.
21. Foss RD, Beirness DJ. Bicycle helmet use in
British Columbia: effects of the helmet use
law. Chapel Hill (NC): UNC Highway Safety
Research Center, University of North
Carolina; 2000. Joint publication of the
Traffic Injury Research Foundation.
22. Page JL, Macpherson AK, MiddaughBonney T, Tator CH. Prevalence of helmet
use by users of bicycles, push scooters,
inline skate and skateboards in Toronto
and the surrounding area in the absence of
comprehensive legislation: an observational study. Inj Prev. 2012;18:94-7.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Canadian parents’ attitudes and beliefs about bicycle helmet
legislation in provinces with and without legislation
P. C. Parkin, MD (1, 2, 3); J. DeGroot, MSc (1, 2); A. Macpherson, PhD (4); P. Fuselli, MSc (5);
C. Macarthur, MBChB (1, 2, 3)
This article has been peer reviewed.
Abstract
Methods
Introduction: The objective of this study was to survey Canadian parents on their
attitudes and beliefs about bicycle helmet legislation and to compare responses from
parents living in provinces with and without legislation.
We designed our survey to examine
several currently debated issues from the
perspective of Canadian parents. The
questions related to parents’ perceptions
of the effectiveness of bicycle helmets,
their support for bicycle helmet legislation
and enforcement and their perceptions
of the effect of legislation on bicycle
use. Additional demographic questions
included age and sex of their child, age
and education of the responding parent,
family income and the province where the
family lived. The survey was conducted
from 1 February 2010 to 5 February 2010.
The sampling frame was Canadian adults
aged 18 years and over who were members of the LegerWeb online panel.* This
national online panel, which is used to
conduct over 1000 surveys per year in
Canada, consists of about 345 000 members, with between 10 000 and 20 000
new members added each month and a
retention rate of 90%. Invitations to new
panelists are made to ensure representativeness of the entire adult population in
Canada by sex, age, income and region.
To enhance participation, respondents are
entered into monthly draws for prizes. For
this study, panel members with children
under the age of 18 years were randomly
selected to receive an email invitation to
the survey.
Methods: A national survey of 1002 parents of children aged under 18 years was
conducted. Chi-square tests were used to compare responses from the surveyed parents
in the different jurisdictions.
Results: Responses from parents living in provinces with legislation (n = 640) and
without legislation (n = 362) were as follows: concern for injury (63% vs. 68%,
nonsignificant [NS]); believe helmets are effective (98% vs. 98%, NS); child always
wears a helmet (74% vs. 69%, NS); support legislation for children (95% vs. 83%,
p < .001); support legislation for all ages (85% vs. 75%, p < .001); support police
enforcement (83% vs. 76%, p = .003); believe legislation decreases the amount of time
their child bicycles (5% vs. 8%, NS).
Conclusion: Parents are highly supportive of bicycle helmet legislation in Canada. They
believe that bicycle helmets are effective and that legislation does not decrease the
amount of time a child spends bicycling. There was also a high level of support for
legislation across all ages, and for police enforcement.
Keywords: helmets, legislation, surveys, child, attitude, public health, head protective
devices, bicycle
Introduction
Systematic reviews have shown that wearing bicycle helmets reduces the risk of
head, brain and facial injuries and that
helmet legislation increases helmet use
and decreases head injury rates.1-3 Many
jurisdictions in Canada (6 out of 10
provinces) have legislated helmet use,
and some municipalities have adopted
more rigorous and universal legislation.4
Despite the supporting evidence, debate
about the advantages of helmet use and
helmet legislation continues.5,6 This
debate has not, however, included a
societal perspective.
The objective of our study was to survey
Canadian parents about their attitudes and
beliefs towards bicycle helmet legislation and
to compare responses from parents living in
provinces with and without legislation.
A sample size of 1000 was sufficient to
determine the single proportion of all
respondents supporting legislation with a
* http://www.legermarketing.com
Author references:
1.
2.
3.
4.
5.
Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Hospital for Sick Children, Toronto, Ontario, Canada
Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Ontario, Canada
Department of Pediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
Safe Kids Canada, Toronto, Ontario, Canada
Correspondence: Patricia Parkin, Division of Pediatric Medicine and the Pediatric Outcomes Research Team, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8;
Tel.: 416-813-6933; Fax: 416-813-5663; Email: patricia.parkin@sickkids.ca
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
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margin of error of ¡ 3% with 95%
confidence and to provide 90% power to
detect a difference of 10% between
respondents living in provinces with and
without legislation. We used descriptive
statistics to describe responses from the
entire survey population and chi-square
tests to compare responses from those
living in provinces with and without
legislation. We used Bonferroni correction
to account for multiple comparisons
(adjusted p < .004 considered significant). We also conducted an exploratory
analysis of the responses of those living in
provinces with all-ages bicycle helmet
legislation and those living in provinces
with child-only legislation.
TABLE 1
Survey participant characteristics (N = 1002)
Demographics
(%)
< 35
375
(37.4)
35–44
467
(46.6)
§ 45
160
(16.0)
465
(46.4)
High school / college
492
(49.1)
University
500
(49.9)
10
(1.0)
< 50 000
178
(17.8)
50 000–124 999
528
(52.7)
§ 125 000
160
(16.0)
136
(13.6)
<1
138
(6.8)
1–4
829
(40.8)
5–9
777
(38.2)
10–14
217
(10.7)
15–17
72
(3.5)
Sex of surveyed parent
Male
Parent education attained
Prefer not to answer
Household income, $
Ethics approval for the study was given by
the Hospital for Sick Children Research
Ethics Board.
Don’t know / prefer not to answer
a
Child age, years
Results
Of 1128 parents invited to join the survey,
1002 responded (89% response rate), 640
from provinces with legislation (155 with
all-ages legislation and 485 with child-only
legislation) and 362 from provinces without. Only 3.6% of respondents indicated
that their child or children had ever had a
bicycle injury requiring medical attention.
The characteristics of the parent respondents and their children are shown in
Table 1. The proportion of respondents
with a household income between
$50 000 and $125 000 (53%, 95% confidence interval [CI]: 50%–56%) is similar
to the national census for family income
(51%).7 The proportion of respondents
who attained a university education (50%,
95% CI: 47%–53%) is higher than the
national census for adults aged 25 to 64
years (23%).8 The proportion of respondents by province was similar to population density by province according to
national census data.9
Responses to various issues from parents
living in provinces with and without
legislation, respectively, were as follows:
concern about injury (63% vs. 68%, nonsignificant [NS]); believe helmets are effective (98% vs. 98%, NS); child always wears
a helmet (74% vs. 69%, NS); support childonly legislation (95% vs. 83%, p < .001);
support all-ages legislation (85% vs. 75%,
n
Parent age, years
Sex of children
Male only
292
(29.1)
Female only
286
(28.5)
Both male and female
414
(41.3)
10
(1.0)
100
(10.0)
Prefer not to answer
Province
British Columbia
Alberta
85
(8.5)
Saskatchewan
28
(2.8)
Manitoba
57
(5.7)
Ontario
400
(39.9)
Quebec
267
(26.7)
New Brunswick
Prince Edward Island
31
(3.1)
1
(0.1)
Nova Scotia
23
(2.3)
Newfoundland and Labrador
10
(1.0)
Child has had bicycle injury requiring medical attention
Yes
36
(3.6)
No
957
(95.5)
9
(0.9)
Don’t know / prefer not to answer
a
The total number of children is greater than the number of participants because there are multiple children in families
(n = 2033).
p < .001); support police enforcement
(83% vs. 76%, p = .003); believe legislation decreases the amount of time their
child bicycles (5% vs. 8%, NS).
$
9
Responses from parents living in provinces with all-ages legislation and childonly legislation, respectively, were as
follows: concern about injury (68% vs.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
61%); believe helmets are effective (96%
vs. 99%); child always wears a helmet
(77% vs. 73%); support child-only legislation (97% vs. 94%); support all-ages
legislation (91% vs. 84%); support police
enforcement (89% vs. 82%); believe
legislation decreases the amount of time
their child bicycles (6% vs. 5%). None of
these comparisons were statistically significant (at the p < .004 level).
Discussion
This national sample of Canadian parents
living in provinces with and without
bicycle helmet legislation has shown that
many parents believe that bicycle helmets
are effective and that legislation does not
decrease the amount of time a child
spends bicycling; there was also a high
level of support for legislation across all
ages and for police enforcement of this
legislation.
An earlier survey, conducted in a Canadian
city in 1991 prior to legislation, demonstrated 80% support for legislation.10 This
is similar to the rate of support that we
found among parents living in provinces
without legislation. The current 93% rate
of support from parents living in provinces
with legislation indicates a substantial
increase over the past two decades.
Four of the 10 Canadian provinces (British
Columbia, New Brunswick, Prince Edward
Island and Nova Scotia) have all-ages
helmet legislation; Alberta and Ontario
have legislation for bicyclists aged less
than 18 years; and the remaining provinces (Saskatchewan, Manitoba, Quebec,
Newfoundland and Labrador) and the three
territories (Yukon, Northwest Territories
and Nunavut) have no legislation. This
variety provides information for a natural
experiment examining helmet use and
beliefs. A recent analysis of data from the
Canadian Community Health Survey found
that self-reported bicycle helmet use in
youth (12–18 years) increases as helmet
legislation becomes more comprehensive:
33% in provinces with no legislation; 47%
in provinces with child-only legislation; and
78% in provinces with all-ages legislation.11 In our predominately pre-adolescent
age group (86% were under the age of 10
years), comprehensiveness of the legisla-
tion was associated with parent-reported
support of legislation (both child-only and
all-ages) and police enforcement, but not
with parent-reported child helmet use rates.
Ontario, one of the two provinces with
child-only legislation, has debated
whether to introduce all-ages legislation.
In June 2012, the Office of the Chief
Coroner12 reported on their review of all
129 cycling deaths in Ontario between
2006 and 2010. Of these, 15% were aged
19 years or less and only 27% were
wearing a helmet. The report recommended amending the Highway Traffic
Act to make helmets mandatory for
cyclists of all ages.12 The results of our
survey suggest that parents would
strongly support this recommendation.
The ongoing debate about the potential
benefit and harm of bicycle helmet legislation includes a concern that ‘‘…enforced
laws discourage cycling, increasing the
costs to society of obesity and lack of
exercise and reducing overall safety of
cycling…’’13,p86 However, direct observations of bicycling children in one Canadian
city yearly between 1993 and 1999 found
that the introduction of helmet legislation
did not significantly affect the numbers of
hours that children cycled.14 In addition,
our survey found that only 5% of parents
who lived in a province with bicycle
helmet legislation reported that this legislation decreased the amount of time their
child cycled. Together, these studies of
directly observed and parent-reported
child behaviours suggest that legislation
has promoted safety without reducing
physical activity.
Limitations
A limitation of this survey is the higher
educational attainment of the parent
respondents as compared with the
national census. Nevertheless, that 70%
of the parents surveyed reported that their
child(ren) always wore a helmet is consistent with direct observational studies of
bicyclists in Canadian provinces before
and after the introduction of legislation.3,15,16 For example, several years after
the introduction of legislation in Alberta
and Nova Scotia, 63% to 90% of children
and adolescents were observed wearing a
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
10
helmet while cycling. Although these
surveys, which used direct observation,
are not able to assess the educational
attainment of the parents, observation
sites were selected randomly and the
analysis controlled for neighborhood
income quintile. In contrast, direct observations of children’s helmet use six years
after the introduction of legislation in
Ontario found variation by the level of
neighborhood income.17 Therefore, it
remains possible that parents’ attitudes
and beliefs about bicycle helmet legislation are influenced by their level of
educational attainment and income.
There are several other potential limitations to this study. For example, data were
collected in February, a month when few
children cycle. Parental perception of
children’s helmet use, concern for injury
and support for legislation may be higher
during the seasons when children typically cycle. If true, then the estimates in
this study would be considered conservative. In addition, although the response
rate was high, there were no data available on non-responders for comparison.
Finally, we acknowledge that only parents
completed this survey. Other members of
society should have an opportunity to
participate in this debate, particularly
when considering whether legislation
should be restricted to children or encompass all ages.
Conclusions
Parents of Canadian children are highly
supportive of bicycle helmet legislation.
This information provides a societal perspective, which may inform the current
debate and may be useful for public
health, knowledge translation professionals and policy makers in Canada and
other countries.
References
1.
Ivers R. Systematic reviews of bicycle
helmet research. Inj Prev. 2007;13:190.
2.
Thompson DC, Rivara FP, Thompson R.
Helmets for preventing head and facial
injuries in bicyclists. Cochrane Database
Syst Rev. 1999;4:CD001855.
3.
Macpherson A, Spinks A. Bicycle helmet
legislation for the uptake of helmet use and
prevention of head injuries. Cochrane
Database Syst Rev. 2007;2:CD005401.
4.
Karkhaneh M, Rowe BH, Saunders LD,
Voaklander DC, Hagel BE. Bicycle helmet
use after the introduction of all ages helmet
legislation in an urban community in
Alberta, Canada. Can J Public Health.
2011;102:134-8.
5.
6.
7.
Robinson DL. No clear evidence from
countries that have enforced the wearing
of helmets. BMJ. 2006;332:722-5.
Hagel B, Macpherson A, Rivara FP, Pless B.
Arguments against helmet legislation are
flawed. BMJ. 2006;332:725-6.
Table 2 Number and proportion of persons
aged 25 to 64 by level of educational
attainment and age groups, Canada, 2006
[Internet]. Ottawa (ON): Statistics Canada;
[modified 2009 Nov 20; cited 2013 Feb 7].
Available from: http://www12.statcan.gc
.ca/census-recensement/2006/as-sa/97-560
/table/t2-eng.cfm
8.
Family income, by family type (couple
families), 2009 [Internet]. Ottawa (ON):
Statistics Canada; [cited 2013 Feb 7].
Available from: http://www.statcan.gc.ca
/tables-tableaux/sum-som/l01/cst01/famil106a
-eng.htm
9.
Population and dwelling counts, for
Canada, provinces and territories, 2011
and 2006 censuses [Internet]. Ottawa
(ON): Statistics Canada; [modified 2013
Jan 30; cited 2013 Feb 7]. Available from:
http://www12.statcan.gc.ca/census-recen
sement/2011/dp-pd/hlt-fst/pd-pl/Table-Tableau
.cfm?LANG=Eng&T=101&S=50&O=A
12. Cycling death review: a review of all
accidental cycling deaths in Ontario from
January 1st, 2006 to December 31st, 2010.
Toronto (ON): Office of the Chief Coroner
for Ontario; 2012 Jun [cited 2012 Jun 21].
Available from: http://www.mcscs.jus.gov
.on.ca/stellent/groups/public/@mcscs
/@www/@com/documents/webasset
/ec159773.pdf
13. Robinson DL. Bicycle helmet legislation:
can we reach a consensus? Accid Anal
Prev. 2007;9:86-93.
14. Macpherson AK, Parkin PC, To TM.
Mandatory helmet legislation and children’s exposure to cycling. Inj Prev.
2001;7:228-30.
15. Karkhaneh M, Rowe BH, Saunders LD,
Voaklander DC, Hagel BE. Bicycle helmet
use four years after the introduction of
helmet legislation in Alberta, Canada. Accid
Anal Prev. 2011;43:788-96.
16. LeBlanc JC, Beattie TL, Culligan C. Effect of
legislation on the use of bicycle helmets.
CMAJ. 2002;166:592-5.
17. Macpherson AK, Macarthur C, To TM,
Chipman ML, Wright JG, Parkin PC.
Economic disparity in bicycle helmet use
by children six years after the introduction
of legislation. Inj Prev. 2006;12:231-5.
10. Hu X, Wesson DE, Parkin PC, Chipman ML,
Spence LJ. Parental attitudes toward legislation for helmet use by child cyclists. Can J
Public Health. 1993;84:163-5.
11. Dennis J, Potter B, Ramsay T, Zarychanski
R. The effects of provincial bicycle helmet
legislation on helmet use and bicycle ridership in Canada. Inj Prev. 2010;16:219-24.
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Validation of a deprivation index for public health: a complex
exercise illustrated by the Quebec index
R. Pampalon, PhD; D. Hamel, MSc; P. Gamache, BSc; A. Simpson, MSc; M. D. Philibert, PhD
This article has been peer reviewed.
Abstract
Introduction: Despite the widespread use of deprivation indices in public health, they
are rarely explicitly or extensively validated, owing to the complex nature of the
exercise.
Methods: Based on the proposals of British researchers, we sought to validate Quebec’s
material and social deprivation index using criteria of validity (content, criterion and
construct validity), reliability and responsiveness, as well as other properties relevant to
public health (comprehensibility, objectivity and practicality).
Results: We reviewed the international literature on deprivation indices, as well as
publications and uses of the Quebec index, to which we added factual data.
Conclusion: Based on the review, it appears that the Quebec index responds favourably
to the proposed validation criteria and properties. However, additional validations are
required to better identify the contextual factors associated with the index.
Keywords: deprivation, social inequalities in health, index, validity, reliability, Quebec
Introduction
Deprivation and other area-based socioeconomic indices are used extensively in
public health in a number of countries1-18
including Canada.19-23 Despite their widespread use, they have seldom been explicitly validated, except in a few mainly
British studies.7,24-27 Validating a deprivation index means verifying whether it
adequately reflects the reality being measured. Validation is a complex exercise
because the index must respond to a
number of criteria and have certain
properties that are useful in its field of
application (in this case, public health).
The purpose of this study is to subject
Quebec’s material and social deprivation
index23 to these validation criteria and
properties. The Quebec index was developed at the end of the 1990s and has since
been used in Quebec and Canada in
various contexts. In this paper, we first
describe the index and then present the
validation criteria and properties, first
with reference to the international literature, then to the Quebec index. Finally, we
discuss the nature of the Quebec index and
make proposals for additional validations.
Quebec material and social
deprivation index
The Quebec deprivation index was
designed to illustrate social inequalities
in health and in the use of health services.
Its objectives are primarily exploratory
and descriptive in nature. It applies to the
entire Quebec population, by place of
residence.
The design and creation of the index is
based on Peter Townsend’s ideas on
deprivation and the international literature on social determinants of health. The
index has two dimensions, material deprivation and social deprivation. The index is
also geographical: it is based on the
smallest standardized Canadian census
unit, composed of one or more blocks of
neighbouring houses with a population of
400 to 700 persons. This unit is the
enumeration area (EA) for the 1991 and
1996 censuses and the dissemination area
(DA) for the 2001 and 2006 censuses.28
The Quebec deprivation index is made up
of six socioeconomic indicators by EA or
DA: the proportion of people 15 years and
older with no high school diploma or
certificate; the employment:population
ratio of people aged 15 years and older;
the average income of people aged 15
years and older; the proportion of people
aged 15 years and older living alone; the
proportion of people aged 15 years and
older who are either separated, divorced
or widowed; and the proportion of singleparent families. All but the last are
adjusted according to the age and sex of
the Quebec population.
We extracted two components from these
indicators using principal component analysis (PCA): the material component, which
is associated with employment, education
and income, and the social component,
which is associated with marital status,
living alone and single-parent families. For
each component, the PCA produces a factor
score by EA or DA, indicating its relative
level of deprivation. Depending on this
score, Quebec EAs or DAs are grouped into
quintiles (population groups of 20%) from
the most privileged (quintile 1, Q1) to the
least (quintile 5, Q5). Thus, it is possible to
Author references:
Institut national de santé publique du Québec, Québec, Quebec, Canada
Correspondence: Robert Pampalon, Institut national de santé publique du Québec, 945 Wolfe Avenue, Quebec City, QC G1V 5B3; Tel.: 418-650-5115 ext. 5719; Fax: 418-654-3136;
Email: robert.pampalon@inspq.qc.ca
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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follow variations in deprivation for each
dimension separately (Q1 to Q5) and for
both dimensions simultaneously (Q1Q1 to
Q5Q5).
The validation of deprivation
indices
Validation of deprivation indices, including the Quebec material and social deprivation index, is based on proposals in the
literature7,24-27 and, more specifically, on
work focused on the surveillance and
measurement of deprivation and social
inequalities in health.24 After reviewing
the deprivation indices used in the United
Kingdom, Carr-Hill and Chalmers-Dixon24
suggested using three criteria to evaluate
this type of index (validity, reliability and
responsiveness) and also suggested considering other properties useful for health
policies. While recognizing that the scientific community identify other criteria and
properties,29 we used the definition proposed by Carr-Hill and Chalmers-Dixon.24
We used three approaches to measure the
validity of the deprivation indices. These
three approaches are usually referred to as
content validity, criterion validity and
construct validity.
ment and work. The second, social deprivation, which according to Townsend, is
more difficult to define, refers to the
fragility of social ties. This fragility may
occur within the family unit or it may
extend to close relationships, friends,
confidants, neighbours and others who
provide emotional and material support
(social support). It can also reflect the
difficulties associated with integration and
participation in social relationships and
other common activities within the local
community, such as recreational or educational activities.
with those of measurements involving
individuals, even though they are different
realities.1,16,26 Moreover, certain authors
have compared the area-based variations
of a new index to indices already in use,
such as Townsend’s.6,7,15,16
This brief definition of deprivation forms
the basis for a number of deprivation
indices.7,9,20,25,26,31-33 The authors of these
indices highlighted the relative character
of deprivation, its subjective and objective
aspects, and its material and social dimensions. The analysis of deprivation can,
however, involve more than two dimensions or different fields13 and overlap
with other concepts, such as poverty,
disadvantage, socio-economic status or
position,1,6,10,15,16,26 marginalization,22 or
social isolation or fragmentation.34,35 In
all cases, the concepts beneath these
area-based deprivation indices and
other socio-economic indicators remain
underdeveloped.25-27
Construct validity of a deprivation index in
the health sector can take on a number of
forms.24,29 Above all, it aims to determine
whether the construction is consistent with
the concept of deprivation. Construct
validity is also expressed through consistent relationships between the index and
other measurements related to the concept
of deprivation, on the one hand, and
various health measures and the use of
health services, on the other. These forms
of validity will be more specifically
addressed through convergence validity
and predictive validity, respectively.
Content validity
Content validity refers to the agreement
between the general concept of deprivation, its main dimensions and the indicators selected to illustrate them:24 Are the
dimensions and indicators appropriate?
Do they represent all the facets of
deprivation that the index is attempting
to reflect?
The conceptual foundations of the Quebec
material and social deprivation index are
mainly based on the proposals set forth by
Peter Townsend,30 for whom deprivation
is a ‘‘state of observable and demonstrable
disadvantage, relative to the local community or the wider society or nation to
which an individual, family or group
belongs.’’ The author distinguished
between two forms of deprivation: material and social. The first, material deprivation, refers to the lack of the normal goods
and amenities of modern living in various
areas, such as food, housing, the environ-
The area-based scale is, however, a
fundamental element of deprivation indicators that distinguishes them from
indicators related to individuals, even
though they often serve as a substitute or
proxy for each other and are sometimes
compared.1,5,11,16,26,27 An area-based
indicator reflects a specific reality6,13,36
that varies according to the scale
considered.36,37
Criterion validity
Criterion validity is used to verify whether
the variations in a deprivation index
correlate highly with those of an external
measurement of deprivation.24 Criterion
validity is not used extensively because it
is commonly accepted that there is no gold
or reference standard for deprivation.
Nevertheless, certain practices are similar.
For example, some authors have compared
the area-based variations of different deprivation indices with one another25,27,37 or
$
13
Because there is no standard or reference
measure for deprivation, we preferred to
discuss the Quebec index in terms of
convergence validity, as will be discussed
later.
Construct validity
To operationalize his vision of deprivation, Townsend reviewed various indicators used in Great Britain, some from
administrative bases and others from
health surveys,30 and proposed a material
deprivation index combining four indicators.24 Other authors added a social
dimension by creating a separate social
deprivation index,26 or social isolation
index,34 combining a number of indicators, all from censuses.
To construct the Quebec index, we took
into consideration these indicators and
also conducted a literature review on the
social environment and social inequalities
in health.34,38-41 We then selected our
indicators on the basis of theoretical and
practical criteria: affinity with one of the
two forms of deprivation, known link with
health, availability at a fine geographical
scale in the census28 and a limited number
of indicators in the composition of the
index (parsimony) to simplify comprehension. We selected six indicators through
this process.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
The integration of these indicators in the
form of an index was not the subject of
any explicit hypothesis. The intention was
to let the ‘‘natural’’ area-based variations
of the indicators express themselves without a priori grouping. For this, we used
principal component analysis (PCA), an
exploratory synthesis method widely used
in the creation of geographically based
indices,3,6,7,13,16,18,20,22,32,33 while recognizing the relevance of using groups of
experts8,19 or equally weighted sums5,25,27
for the integration of indicators related to
certain indices.
The PCA revealed the presence of two
components. In the 2006 census, the first
component reflected the variations in
education, employment and personal
income42 (see Table 1). The second component reflected the variations in the
proportion of individuals who were living
alone, separated, divorced, widowed or
living in single-parent families. These
results are similar to Townsend’s proposals concerning the two dimensions
(material and social) of deprivation.
However, they differ in terms of education, which according to Townsend, is
associated with social deprivation.
Moreover, these two components do not
appear to be very explicit with respect to
the forms of deprivation.
Work connecting the two dimensions of
the Quebec index with other indicators
from censuses by EA or DA makes it
possible to clarify these dimensions.43,44
For example, social deprivation is closely
associated with residential mobility (frequent moves) and the proportion of
renters, two indicators used in the construction of social fragmentation and
isolation indices.34,35 The fact remains
that the census is a limited source of data
for reporting on the fragility of social
networks.
Convergence validity
It is therefore necessary to compare the
index to external measures (not from
censuses) that reflect deprivation and its
various dimensions. We conducted three
exercises of this kind.
We first compared the spatial variations in
the deprivation index to those in the
proportion of children living with families
receiving last-resort financial assistance
from the Government of Quebec (see
Table 2). Such assistance is given to
families whose liquid assets (cash, etc.)
are less than a particular amount that
corresponds to the size and needs of the
family. It is the only source of income the
family has to meet its basic needs (e.g.
housing and food). Two-thirds of the
families receiving this assistance are
single-parent families.45 Therefore, we
expected material and social deprivation
to increase with the proportion of children
living with families receiving this assis-
TABLE 1
Indicators and components of the index of material and social deprivation, Quebec, 2006
Indicator
Component
Material
a
No high school diploma or certificate
a
Employment:population ratio
a
Social
20.85
+0.04
+0.75
20.18
+0.83
20.28
20.12
+0.82
Separated, divorced or widowed
20.12
+0.85
Single-parent families
20.21
+0.68
Average personal income
a
Living alone
a
Explained variance, %
34
33
Cumulated variance, %
34
67
Source: Canadian Census, 2006.
Note: These values are factor loadings and can be interpreted as coefficients of correlation between indicators and
components. The sign (+ or 2) of the indicators on the material dimension should be reversed to be interpreted in terms of
deprivation.
a
Proportion of people among those aged 15 years and older, adjusted according to the age and sex of the Quebec
population.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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tance, which is the case according to the
statistics provided by Quebec’s Department
of Employment and Social Solidarity.45
The other two exercises made it possible
to better define the social dimension of the
deprivation index.
One linked the variations in the Quebec
index with those observed in an in-depth
study of three areas in the Quebec City
region.46-48 Two of the areas had different
health reports. The material deprivation
index was similar in these areas, whereas
the social deprivation index differed significantly. A telephone survey of 600
respondents in each area collected data
on health and perceptions of the local
environment. The use of a social cohesion
index,49 addressing the appeal of the local
environment and sense of neighbourhood
and community, produced coherent
results with those obtained from the social
deprivation indices. Where social deprivation was high, social cohesion was low,
and vice versa. Qualitative interviews with
residents revealed that being born in the
area and having family members in the
area were cohesive factors.
The last exercise was based on an analysis
of a number of cycles of the Canadian
Community Health Survey50 and explored
the links between certain social support
measures at the individual level51 and the
social deprivation index in urban
Quebec.52 The exercise revealed that an
increase in social deprivation went hand
in hand with a decrease in three social
support measures, that is, affection, positive social interactions, and emotional or
informational support. These associations
are independent from the age, gender,
lifestyle, education and household income
of the survey respondents.
In summary, not only do the indicators
used in the construction of the social
dimension of the index reflect family
structure and marital status, the dimension also captures a broader reality. At the
individual level, this reflects the fragility
of social support for single-parent families
and those who are living alone or who are
separated, widowed or divorced. At the
local scale, it reflects residential instability
(very frequent moves34,35), which does
TABLE 2
Percentage of children living in families receiving last-resort financial assistance, by quintilea of material and social deprivation, Quebec, 2001
Social deprivation
Material deprivation
Q1
Q2
Q3
Q4
Q5
Total material deprivation
Q1
0.6
1.1
2.1
3.9
8.2
2.7
Q2
1.6
2.9
4.2
7.6
13.5
5.2
Q3
2.7
4.0
6.4
10.7
20.0
7.7
Q4
4.3
5.6
9.2
15.5
26.0
11.3
Q5
8.4
11.0
16.6
23.3
38.1
18.8
Total social deprivation
3.6
4.9
7.2
12.3
22.7
9.2
Source: Ministère de l’Emploi et de la Solidarité sociale.
a
From Q1, the most privileged quintile, to Q5, the least privileged quintile.
not foster the establishment of roots,
neighbourhood ties, or the development
or knowledge of and access to local
resources and assistance networks, which
some associate with social cohesion and
social capital.53
Predictive validity
As we have seen, the primary objective of
a deprivation index is to identify social
inequalities in health and, therefore, the
associations between deprivation and
health.24 These associations must be
plausible, corroborate observations made
in the literature, or be supported by
credible explanations or hypotheses.
Predictive validity is by far the most
widely used approach to demonstrate the
quality of a deprivation index.24 It is seen
as ‘‘proof’’ of its performance. For example, links have been made with overall
mortality,10,12,14,27 premature mortality
(0–64 years),4,18 cause of death,3,18 the
incidence of cancer10 (including lung
cancer14), long-term disability,25-27 perceived health,1,37 smoking and nutrition,5
low birth-weight, immunization status
and lead poisoning among children,11,14
sexually transmitted infections, tuberculosis and violence,54 myocardial infarction,7
hospitalization,14,27 and use of medical8
and psychiatric services.16 Moreover, the
strength of the relationship between deprivation and health varies according to the
size of the basic spatial unit of the index.
The smaller the spatial unit, the stronger
the relationship.1,10,11,26,54
The Quebec deprivation index accounts
for various health and social situations. It
is linked to global health indicators,
namely, life expectancy and health expectancy at birth and different ages23,44,55,56
and mortality, including overall mortality,
mortality by medical cause (e.g. cancer,
circulatory disease, trauma and stroke),
mortality related to lifestyle (e.g. smoking), premature death (less than 75 years),
death among young people (18 years or
less) and survival.23,55-69 For example, an
increase in the rate of premature deaths
was observed both in the early 1990s and
the mid-2000s as a function of material
and social deprivation (Figure 1). The
same is true for other indicators, such as
disability,56,64,70-72 the incidence or prevalence of diabetes and high blood pressure,72-74 self-reported health,70 and protective and risk factors for health: flu
vaccination, premature birth or low birth
weight, smoking and exposure to secondhand smoke, obesity, food insecurity
and physical inactivity.23,61,70,75-78 Social
issues, such as teenage pregnancy and
cases of abuse, neglect and behavioural
problems among young people, are also
associated with deprivation.23,44,61
Such relationships were also observed in
use of health services. An increase in visits
to general practitioners was noted with
increased deprivation, but an opposing
trend was sometimes found for certain
medical specialties.44,61 This opposing
trend was also true for certain free
services available for young people aged
under 18 years (eye exams) and under 10
years (dental appointments) (Figure 2).
However, the use of local community
service centres (CLSCs), as well as hospitalization, day surgery and stays in long-
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15
term care facilities increased with material
and social deprivation.44,61,70,79 A recent
example is the rate of hospitalization
following influenza A(H1N1) infection
(Figure 3).
In summary, the Quebec deprivation index
accounts for significant inequalities in
health, even though their magnitude may
vary depending on the theme under
consideration. The two forms of deprivation (material and social) usually act
independently.23,44,56-61,63-69,71-76,78,79
Reliability
The reliability of a measurement tool is
defined as its ability to produce the same
result under the same circumstances.24
For deprivation indices, this ability can be
expressed through strong correlations
between the indicators that form the
index. These correlations are often tested
using Cronbach’s alpha. Some authors
refer to an index’s internal consistency.6,7,26 This internal consistency, however, is not relevant when the index has
more than one dimension.24 The reliability
of a deprivation index can also be
expressed through correlation structure
stability in time and space. The goal is to
verify whether the correlation structure
remains, regardless of the period and
environment being considered.
The reliability of the Quebec deprivation
index can be seen from the perspective of
internal coherence for each dimension of
deprivation. As seen in Table 1, close
correlations exist between the indicators
that make up each of the two dimensions
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
FIGURE 1
Premature mortality rate by quintilea of material and social deprivation, Quebec, 1989–1993 and 2004–2008
1989-1993
2004-2008
Rate per 100 000 population
700
600
500
400
300
200
100
0
Q1
Q2
Q3
Q4
Q5
Q1
Q3
Q2
Q4
Q5
Q1Q1 Q5Q5
Material and
social
deprivation
Social deprivation
Material deprivation
Source: 1991 and 2006 censuses; Quebec death records, 1989–1993 and 2004–2008.
Note: Death rates are adjusted by age, gender, geographical area and other form of deprivation.
a
From Q1, the most privileged quintile, to Q5, the least privileged quintile.
FIGURE 2
Percentage of young people aged less than 10 years who have visited a dentist and of young people aged less than 18 years who have had an
eye exam, by quintilea of material and social deprivation, Quebec, 2000–2002
Dental visit
Percentage (%)
60
55
50
45
40
Q1
Q2
Q3
Q4
Material deprivation
Q5
Q1
Q2
Q3
Q4
Social deprivation
Q5
Q2
Q5
Q1Q1
Q5Q5
Material and social
deprivation
Eye exam
Percentage (%)
30
25
20
15
10
Q1
Q2
Q3
Q4
Q5
Q1
Material deprivation
Q3
Q4
Social deprivation
Q1Q1
Source: Calculations by the Institut national de santé publique du Québec based on data provided by the Régie de l’assurance maladie du Québec.
a
From Q1, the most privileged quintile, to Q5, the least privileged quintile.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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Q5Q5
Material and social
deprivation
FIGURE 3
Relative risk of hospitalization following an A(H1N1) infection by quintilea of material and social deprivation, Quebec, April–December 2009
Relative risk
3
2
1
0
Q1
Q2
Q3
Q4
Q5
Q1
Q2
Material deprivation
Q3
Q4
Q5
Social deprivation
Q1Q1 Q5Q5
Material and
social
deprivation
Source: A(H1N1) surveillance record, MED-ÉCHO hospitalization records, Ministère de la santé et des services sociaux du Québec.
Note: The relative risk is adjusted by age, gender, geographical area and other form of deprivation.
a
From Q1, the most privileged quintile, to Q5, the least privileged quintile.
(material and social) of the index. This
fundamental structure of the index can be
seen throughout Quebec and Canada42,68
at various levels: regional, census metropolitan areas, cities of varying sizes and
rural environments. It is also present for
each census year between 1991 and 2006.
Although the correlations between the
indicators may vary slightly according to
the location and period considered, the
two-dimensional structure of the Quebec
index is maintained.42 This fundamental
structure seems to be permanent, an
essential quality for monitoring the social
inequalities in health in time and space.
Responsiveness
Responsiveness reflects the ability of a
measurement tool to detect differences or
changes according to the location, time and
individual characteristics.24 Variations in
the deprivation index are observable at the
national, regional and local levels, through
the use of maps, for example.2,7,8,26,37 They
are also observable in relation to various
health characteristics. The relationships
vary according to the age and gender of
the population,3,4,18,27 with adults (aged
25–64 years) usually showing the highest
inequalities in health. The inequalities
change over the years (reducing or increasing) or with the area3,4,11,16 and fluctuate
according to the health issue under study
(e.g. cause of death).10,16,27
The Quebec deprivation index was used to
create an interactive atlas44,80 that shows
wide variations in deprivation at the
provincial level and at a smaller level, in
both urban and rural environments. These
variations in the Quebec index are also
associated with inequalities in health that
relate to gender and age, with adults
having the highest mortality ratios
between groups at the extreme ends of
material and social deprivation (Figure 4).
Moreover, as is the case elsewhere,18,81-84
the Quebec index has identified an
increase in relative health differences in
Quebec. According to the data presented
(Figure 1), the premature mortality ratio
between groups at the extreme ends of
deprivation increased from 1.8 in 1989–
1993 to 2.4 in 2004–2008. The Quebec
index identified health inequalities of
varying magnitude according to geographical area and fluctuating over
time.62,64,66 Thus, inequalities are growing
throughout Quebec, except in the
Montreal area, where they are actually
bigger than in the rest of the province.
Such health differences have also been
demonstrated elsewhere in Canada.63,67,68
Other properties
In the context of the development of
public health policies or programs, deprivation indices must respond to requirements beyond those that are purely
$
17
technical or statistical.24 This is the case
for the comprehensibility of the index for
an audience made up of decision makers
and stakeholders in the field. The index
must be easy to understand, appeal to
common sense and be conducive to
reasonable, unambiguous explanations.
Thus, the contribution of the indicators
to the index must be precise, clear and, if
possible, quantified. The index must also
be objective (cannot be manipulated) and
be applicable to every part of the area
being considered, at the national, regional
and local levels. Finally, the index must
respond to practical requirements. It must
be possible to update it regularly, using
the same method, and be manageable
in terms of time and cost; it should also
be possible to introduce it into health
databases.
As we have seen, the Quebec deprivation
index remains a simple measure, made up
of two components and six indicators that
are well known as being connected to
health. Its structure is clear, and the
weighting of the indicators in the index
reflects their correlation with the components (Table 1). Its use demonstrates its
comprehensibility for an audience made
up of stakeholders and decision makers in
the health and social service sectors in
Quebec. Local variations in the index
corroborated the perception of CLSC stakeholders,79,85 and, at a provincial level,
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
FIGURE 4
Ratio of death rates between extreme quintiles of material and social deprivation (Q5Q5/Q1Q1) by age group, Quebec, 2000–2004
5.0
Ratio
4.0
3.0
2.0
1.0
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Age (years)
65-69
70-74
75-79
80-84
85
years
and
over
Source: Institut national de santé publique du Québec, 2008; http://www.inspq.qc.ca/Santescope/element.asp?NoEle=740
these variations were used to develop
departmental policies61 and to allocate
health resources among regions.86 A
recent compilation indicates that most of
Quebec’s regional health and social services agencies use the deprivation index to
identify variations in their areas and the
connections with various health and social
issues.87
Although groups of experts were not
involved in the design or initial construction of the deprivation index, many health
experts (stakeholders and managers) at all
geographical levels have since commented
on, used and adapted the index to their
needs and work contexts, contributing to
its validation and evolution. For example,
a local version of the index and an
interpretation grid of the inequalities in
the use of services were developed jointly
with local CLSC stakeholders.79,85 The
grid compares the variations in the index
and the knowledge of stakeholders regarding their organization directions and practices (e.g. target clientele, service access
criteria), resources available locally (e.g.
medical clinics, self-help groups and associations) and hard-to-reach populations
(e.g. the homeless or individuals with
mental health issues).
Finally, the relevance of the Quebec index
depends on its availability over time and
space. We have seen that the index exists
for 1991, 1996, 2001 and 2006, and that it
covers all of Quebec (and Canada) in
different versions: national, regional and
local. There are supporting products (e.g.
interactive maps, population tables, index
assignment programs), which are all free
and available online.80,88 Tables and
figures illustrating the health inequalities
in Quebec using the deprivation index are
regularly produced and posted online.89
Conclusion
Despite the widespread use of deprivation
indices, there have been few formal
validation exercises. On the basis of the
validation criteria proposed by Carr-Hill
and Chalmers-Dixon,24 it can be concluded that the Quebec material and social
deprivation index responds favourably to
various requirements for validity, reliability, responsiveness and use in public
health.
However, there are limitations related to the
geographical nature of the index. The index
characterizes the socio-economic attributes
of all residents of small areas. Although it is
often used as a substitute for measurements
related to individuals, the index is a
measurement linked to an area. Studies,
some of which are from Quebec and
Canada,56,64,67,90 show that the magnitude
of health inequalities is underestimated
through geographical measurement, espe-
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
18
cially in small cities and rural environments.
They also reveal that health inequalities are
associated with both types of measurements
(those related to area and those related to
individuals), independently, which signifies
that they result from both geographical and
individual realities.56,64,67,91-97
A better understanding of these geographical realities is therefore necessary to
identify all the content and construct
elements associated with a deprivation
index. To achieve this, a research strategy
at the local level combining theories,
concepts, methods and indicators is necessary.98-101 Reference frameworks on ‘‘contextual’’ factors associated with health
must be used.53,98,102,103 The social
dimension of the index would particularly
benefit from being associated with concepts and measurements of social cohesion and capital as well as their
components (e.g. values, social support,
informal social control and community
participation). The material dimension
would benefit from being associated with
various fields, such as the physical environment (e.g. water and air), the built
environment (e.g. housing and access to
services), and public (e.g. schools, green
space and public transportation) and
private (e.g. food stores) infrastructure.
This roadmap should be followed for
future validation exercises of the Quebec
index.
Finally, it should be noted that this index
was designed to illustrate the existence of
social health inequalities and that its
purposes are exploratory and descriptive.
The index is not an explanatory framework
for these inequalities. For example, it does
not consider dimensions related to health,
such as immigration or Aboriginal status,
even though these dimensions can be
accounted for.63,66 Rather, the Quebec
index constitutes more of a marker of
social and health inequalities and, as a
result, is a relevant starting point toward
more in-depth studies and increased understanding of these inequalities.
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$
22
Coroners’ records on suicide mortality in Montréal: limitations
and implications in suicide prevention strategies
J. Houle, PhD; C. Guillou-Ouellette, BSc
This article has been peer reviewed.
Abstract
Introduction: In Montréal, the characteristics of suicide cases may vary between
different areas. The information collected by coroners during their investigations of
suicides could be used to support local suicide-prevention planning actions.
Methods: This study analyzes all coroners’ records on suicide in Montréal from 2007 to
2009 to (1) determine the usefulness of the data available; (2) develop a profile of cases;
(3) examine local differences by comparing two areas, one with the highest suicide rate
and the other with the lowest.
(e.g. means restriction) are effective,4
experts generally agree that it is necessary
to implement selective suicide-prevention
strategies that target specific populations
at risk and take into account factors such
as age, socioeconomic status, cultural
norms and the social environment.5-8
Tailored interventions have proven effective at reducing suicide rates in older
adults,5,9 police officers10 and the United
States air force.11,12
Montréal’s health and social services
agency (Agence de la santé et des services
sociaux de Montréal, ASSS) provides the
HSSCs with general statistics on suicide
rates in their areas and on the links
between these rates and other indicators.16 These statistics reveal considerable
differences in the suicide rates in the
different health service areas. For the
period 2005 to 2009, the adjusted rate of
death by suicide for an HSSC in the centre
of Montréal was 17.4 per 100 000, while
that of an HSSC at in the west of the city
was 5.1 per 100 000.14 Although these
statistics are useful, they are insufficient to
prepare even a summary profile of suicide
cases in each area as they do not allow for
the sociodemographic characteristics of
the deceased or the circumstances surrounding the deaths to be known.
Furthermore, such a profile would probably vary from one HSSC area to another,
implying that the preventative actions
taken need to be adjusted at the local
level.
Suicide rates in rural settings differ from
those in urban settings.13 The densely
populated areas of Laval and Montréal
have the lowest suicide rates in the
province of Quebec. In 2009, the suicide
rate in the Montréal metropolitan area was
In Quebec, in accordance with An Act
Respecting the Determination of the Causes
and Circumstances of Death,17 a coroner
must identify the causes of all uncertain or
violent deaths, including all cases of
suicide. Each suicide is therefore subject
Results: The data collected revealed the lack of a systematic, standardized procedure for
recording information about deaths by suicide. The rates of missing data varied, but
were very high for antecedents of suicide attempts and recent events that could have
precipitated the suicide. We observed differences in the characteristics of suicide cases
according to area of residence.
Conclusion: By adopting a standardized procedure for collecting information on cases of
suicide, coroners could provide local decision makers with a more accurate portrait of
the people who die by suicide in their area. Local adjustments may improve suicideprevention strategies.
Keywords: suicide, coroner, prevention, surveillance
Introduction
Between 2000 and 2009, the suicide rate in
Quebec fell significantly, from 16.8 per
100 000 to 12.5 per 100 000, while the
Canadian rate remained relatively stable,
decreasing from 11.4 to 10.7 per
100 000.1,2 This decrease was not uniform
in all population sub-groups.3 For example, the decrease in the suicide rate in
youth aged 15 to 19 years was notable
(10% in males and 14% in females), but
in those aged 50 years plus, the suicide
rate has remained relatively stable for
both sexes. This suggests that existing
suicide-prevention strategies targeting
older adults need to be improved. Even
if universal suicide-prevention strategies
10.1 per 100 000.2,14 The Montréal metropolitan area is divided into 12 areas, each
managed by a different health and social
services centre (HSSC) with its own
structure and set of services. With their
community-based partners, for example,
nongovernmental organizations and physicians, the HSSCs are responsible for
implementing the most effective suicideprevention strategies.15
Author references:
Department of Psychology, Centre for Research and Intervention on Suicide and Euthanasia (CRISE), Université du Québec à Montréal, Montréal, Quebec, Canada
Correspondence: Janie Houle, Department of Psychology, Centre for Research and Intervention on Suicide and Euthanasia (CRISE), Université du Québec à Montréal, PO Box 8888, Centreville Branch, Montréal, QC H3C 3P8; Tel.: 514-987-3000 ext. 4751; Fax: 514-987-0350; Email: houle.janie@uqam.ca
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
to an investigation conducted by one of
the province’s 85 coroners. Coroners are
physicians, lawyers or notaries who must
have a minimum of four years of professional experience to be part-time coroners
and eight to be full-time. Coroners are
appointed by the Quebec government after
an extensive interview process and on
being recommended by the Ministry of
Public Security. The Montréal metropolitan area has 13 coroners, mostly part-time
physicians (n = 9).
When investigating a death by suicide,
coroners need to produce an investigation
report but are not provided with a
template or any guidelines. Police officers
often help in the investigation, and friends
and family are almost always consulted.
Coroners rarely conclude the cause of
death as undetermined (less than 2% of
investigations in 2009). The rate of underreported suicides is also believed to be so
low that it does not affect the conclusions
reached from analyzing coroners’ reports.18
As sources of information, coroners’
records are therefore crucial for developing
a profile of suicide cases, though the
Coroner’s Office has never provided anything beyond a minimal analysis based on
sex, age and methods of suicide for the
cases in each area.
The purpose of this study is to explore the
information on deaths by suicide in
Montréal-area coroners’ records to: (1)
determine whether these data can be used
at the local level to monitor suicide trends
and support the development of suicideprevention strategies; (2) establish a comprehensive profile of suicide cases in 2007
through 2009; (3) examine local differences in the profile of suicide cases by
comparing the two health service areas
with the highest and lowest suicide rates.
The Chief Coroner’s Office and Quebec’s
Ministry of Justice (Ministère de la Justice)
reviewed and approved this research project
before we began collecting our data.
Methods
Population
We included all residents of Montréal
who, based on coroners’ records, died in
2007, 2008 or 2009, and whose stated
cause of death was death by suicide.
Montréal is Quebec’s economic hub, with
close to 2 million inhabitants of diverse
ethnicity and socioeconomic status. The
HSSC area with the highest suicide rate
(Area A) is in the downtown core and is
one of the most populated neighbourhoods in Canada, with about 138 500
residents. Area A is also very socially
diverse and includes marginal populations, such as homeless people, prostitutes
and drug addicts, as well as young
professionals and families.19 The HSSC
area with the lowest suicide rate (Area B)
has about 217 000 residents and some of
the best living conditions in Montréal
(based on socioeconomic status). The
population from this area consists mostly
of English-speaking families with high
annual incomes compared to the average
in Montréal.20
Data sources
Data for our study came from the complete
records prepared for each suicide case and
kept in the office of Quebec’s Chief
Coroner. A single researcher examined
the coroner’s investigative report, the
official report on the police investigation
and, where applicable, the suicide note,
results of toxicological tests, medical
records and any other relevant information. These records, which must be consulted on site, were subsequently verified
by another researcher.
Data collection form and variables
Following an initial analysis of the coroners’ investigative reports on deaths by
suicide in 2009, we developed a data
collection form. A researcher with many
years’ experience of collecting data from
the Coroner’s records subsequently
revised this form. The final data collection
form targeted the following information:
N Sociodemographic profile: Sex, age,
marital status (single or cohabiting),
parental status, employment status,
household status (living alone or with
others), the existence of financial problems or a criminal record, and postal
code at the place of residence (HSSC
area).
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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24
N
N
N
N
N
Mental disorders: Psychiatric pathology
(depression, substance abuse, schizophrenia, bipolar disorder, etc.).
Recent life events: Conjugal separation
or loss of employment in the year
before death.
Suicidal behaviour: Any previous suicide attempts and the time between the
previous attempt and the suicide death;
suicidal verbalizations or behavioural
changes suggesting a suicidal intent
before the suicide death.
Recent health services utilization:
Professional assistance (physician, psychologist, HSSC, etc.) consulted in the
year before death.
Circumstances of death: Place (at
home, in the workplace, etc.), the
means used, whether a suicide note
was found and signs of planning.
Statistical analyses
We used the statistical software SPSS
version X for Windows (IBM, Chicago,
IL, US). Data not mentioned in the
coroner’s file for a case were identified
as missing. The frequency of missing data
was calculated for each variable. We then
established a profile of the suicide cases
through a descriptive analysis (frequency,
percentage) of the available data, excluding the missing data. For example, we
calculated the percentage of suicide cases
who were employed at the time of their
death by dividing the number of cases
employed at time of death by the total
number of cases whose files indicated an
employment status. Differences in sex
were examined using Student’s t-test for
age and chi-square tests for the other
variables. Finally, we used chi-square
tests to determine the differences between
the two HSSC areas, Area A and Area B.
Results
Data available in the Coroner’s records
The data collected from the coroner’s
records revealed that there was no standard investigative procedure used for
deaths by suicide. The rate of missing
data varied considerably from one variable to the next (Table 1). Besides basic
information such as sex, age, place of
TABLE 1
Data on death by suicide missing from coroners’ records, Montréal, Quebec, 2007–2009
Variable
Missing data
(N = 566)
n (%)
Sex
0 (0.0)
Age
0 (0.0)
Place of residence by postal code
4 (0.7)
Sociodemographic profile
Not cohabiting
16 (2.8)
Unemployed
71 (12.5)
Childless
54 (9.5)
Living alone
0 (0.0)
Financial problems
250 (44.2)
Criminal record
1 (0.2)
Mental disorders
3 (0.5)
Physical illnesses
3 (0.5)
among men, while poisoning was more
common among women (see Table 2).
Comparison of HSSC areas with the lowest
and highest suicide rates
Compared with Area A, suicide cases in
Area B experienced less social isolation:
they were less likely to be living alone and
more likely to be married or cohabiting
and to have children (see Table 3). They
were also less likely to have had a criminal
record or recent financial problems or to
have previously attempted suicide. The
means used also differed: cases in Area A
tended to use poisoning while cases in
Area B tended to use strangulation.
Discussion
Recent life events (ƒ 1 year)
Job loss
139 (24.6)
Conjugal separation
277 (48.9)
Suicidal behaviours
Previous attempt(s)
243 (42.9)
Previous attempt(s) within past year
284 (50.2)
Suicidal verbalizations
84 (14.8)
Changes in behaviour
178 (31.4)
Recent health services utilization (ƒ 1 year)
0 (0.0)
Death circumstances
Suicide note found
23 (4.1)
Signs of planning
429 (75.8)
Death at home
1 (0.2)
Method of suicide
0 (0.0)
suicide and means used—which were
consistently noted in the records—other
relevant information was not systematically recorded. For example, information
on prior suicide attempts was missing
from over 40% of the records.
Profile of suicide cases in Montréal
A total of 566 Montréal residents died by
suicide in the years 2007, 2008 and 2009.
The results show that 74.4% of the suicide
deaths were among men and that over half
(52.3%) were aged 40 to 64 years
(Table 2). Signs of social isolation—not
cohabiting, unemployment, no children or
living alone—were common. These signs
tended to be cumulative: 55.0% of our
subjects had three signs of social isolation
while only 4.1% had none (data not
shown). Many had at least one mental
disorder (63.1%), in particular depression
(32.3%) and substance abuse (30.0%).
Conjugal separation was the most commonly reported recent life event in the
coroners’ records (13.6%). Three out of
five cases (59.9%) had consulted at least
one source of professional assistance in
the year before death, with family physicians (35.7%) and psychiatrists (27.7%)
consulted most often.
Financial problems and criminal records
were reported more often among men
than among women. Women were more
likely to have consulted professional
assistance in the year before their deaths.
Women were also more likely to die by
suicide at home. The means of suicide also
varied by sex: hanging was more common
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25
In this study we analyzed all the coroner’s
records of death by suicide in Montréal
from 2007 to 2009. Using a data extraction
form, we combed through 566 files for
information on suicide. In addition to
establishing a profile of all the people
who died by suicide, this process revealed
the absence of a systematic, standardized
procedure that coroners can use to collect
information on death by suicide. The goal
of our study was to examine the potential
of coroners’ files as a source of valid and
useful information for local surveillance of
suicide and planning of suicide-prevention
actions. Given such a high rate of missing
data and the lack of standardization in the
coroners’ practices, we cannot recommend that they be used for this purpose.
Many other
studies—in
Quebec,21
22
Canada and the United States23— have
described the incomplete nature of the
information collected by coroners. Many
factors may explain the extent of the
missing data. First, there is no standard
method for drafting reports and collecting
data for the official record. As a result,
some coroners focus on looking for the
causes of suicide, while others stop the
investigation as soon as they have determined whether the cause of death was
intentional, accidental or due to homicide.
Finally, the absence of electronic health
records in Quebec makes access to important medical data—such as a diagnosis of
mental disorders or hospitalizations for
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
attempted suicide—difficult for coroners
to obtain.
TABLE 2
Profile of suicide cases, Montréal, Quebec, 2007–2009
Characteristic
Total
Female
(n = 145)
Male
(n = 421)
p value
n (%)
n (%)
n (%)
15–19
18 (3.2)
5 (3.4)
13 (3.1)
.831
20–29
79 (13.9)
19 (13.1)
60 (14.3)
.731
30–39
95 (16.8)
22 (15.3)
73 (17.3)
.547
40–49
142 (25.1)
35 (24.1)
107 (25.4)
.760
50–64
154 (27.2)
42 (28.9)
112 (26.6)
.581
§ 65
78 (13.8)
22 (15.2)
56 (13.3)
.573
398 (70.3)
102 (70.3)
296 (70.3)
.994
Unemployed
334 (59.0)
91 (62.8)
243 (57.7)
.900
Childless
296 (52.3)
63 (43.4)
233 (55.3)
.001
Living alone
279 (49.3)
71 (48.9)
208 (49.4)
.927
Financial problems
202 (35.7)
37 (25.5)
165 (39.2)
.001
Criminal record
112 (19.8)
14 (9.7)
98 (23.3)
.000
At least one disorder
357 (63.1)
101 (69.7)
256 (60.1)
.038
Depression
183 (32.3)
56 (38.6)
127 (30.2)
.058
Substance abuse
170 (30.0)
40 (27.6)
130 (30.9)
.464
Bipolar disorder
51 (9.0)
22 (15.2)
29 (6.9)
.003
Schizophrenia
48 (8.5)
13 (9.0)
35 (8.3)
.803
Conjugal separation
77 (13.6)
16 (11.0)
61 (14.5)
.147
Job loss
51 (9.0)
8 (5.5)
43 (10.2)
.082
208 (36.7)
72 (49.7)
136 (32.3)
.081
Age, years
Sociodemographic profile
Not cohabiting
Mental disorders
Recent life events (ƒ 1 year)
Suicidal behaviours
Previous suicide attempt
Previous suicide attempt within past year
91 (16.1)
31 (21.4)
60 (14.3)
.583
Suicidal verbalizations
304 (53.7)
85 (58.6)
219 (52.0)
.185
Behavioural changes
271 (47.8)
67 (46.2)
204 (48.5)
.081
At least 1 service
339 (59.9)
105 (72.4)
234 (55.6)
.000
Family physician
202 (35.7)
63 (43.4)
139 (33.0)
.024
Psychiatrist
157 (27.7)
59 (40.7)
98 (23.3)
.000
Psychologist
23 (4.1)
10 (6.9)
13 (3.1)
.045
Suicide note
246 (43.5)
72 (49.7)
174 (41.3)
.110
Signs of planning
117 (20.7)
39 (26.9)
78 (18.5)
.461
Death at home
381 (67.3)
110 (75.9)
271 (64.4)
.012
Strangulation
259 (45.7)
41 (28.3)
218 (51.8)
.000
Poisoning
130 (22.9)
61 (42.1)
69 (16.4)
.000
Fall
44 (7.8)
13 (9.0)
31 (7.4)
.534
Firearm
26 (4.6)
6 (4.1)
20 (4.8)
.761
Drowning
20 (3.6)
6 (4.1)
14 (3.3)
.648
Recent health services utilization (ƒ 1 year)
Death circumstances
Means of death
Subway
19 (3.4)
4 (2.8)
15 (3.6)
.643
Other
68 (12.0)
14 (9.6)
54 (12.7)
.311
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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The data collected by coroners in their
investigations could prove highly useful in
suicide prevention. Coroners have direct
and privileged access to the family of the
deceased and to additional sources of
information, such as the police report,
the toxicology report and the medical
record. All these sources of information
could help us better understand the
circumstances surrounding deaths by suicide and develop a profile of suicide cases
that could inform decision making around
suicide prevention. Unfortunately, coroners’ records are often incomplete
sources of information. In almost half of
the files, there is no information on prior
suicide attempts or on recent events that
may have precipitated the suicide, such as
a conjugal separation or job loss. In
contrast, diagnoses of mental disorders
and a history of health services utilization
are always available in coroner’s files. One
explanation may be that coroners adhere
to a biomedical model in which suicide
is seen as a medical complication of a
mental illness.24 As previously mentioned,
Montréal’s coroners are mostly physicians. However, even if the coroners
always investigate mental disorders, they
seem to underestimate their prevalence.
Almost two-thirds (63.1%) of the files
mentioned at least one disorder while this
proportion ranged from 80% to 96% in
psychological autopsies.25,26 The same
can be said of health service use in the
year before the suicide: according to the
coroners’ records, 36% of the cases consulted a general practitioner in the year
preceding their death, whereas this figure
is between 76% and 86% in rigorous
studies of the issue.27,28 A standardized
data collection form that covers all the
parameters relevant to preventing suicide
would help to reduce the amount of
missing data in coroners’ records.
In the United States, the Centers for
Disease Control and Prevention (CDC)
have sponsored the development of a
National Violent Death Reporting System
(NVDRS).29,30 This active, state-based
surveillance system collects risk factor
data on all violent deaths, including
homicides, suicides and unintentional fire-
TABLE 3
Profiles of suicide cases in HSSC Area A and Area B, Montréal, Quebec, 2007–2009
Characteristic
Area A
(n = 85)
Area B
(n = 32)
p value
n (%)
n (%)
64 (75)
23 (72)
.706
15–64
74 (87)
24 (75)
.115
§ 65
11 (13)
8 (25)
.113
Not cohabiting
70 (82)
15 (47)
.000
Unemployed
48 (57)
18 (56)
.956
Childless
61 (72)
13 (41)
.001
Living alone
53 (62)
9 (28)
.001
Financial problems
35 (41)
4 (13)
.005
Criminal record
20 (24)
2 (6)
.033
At least 1 disorder
55 (65)
16 (50)
.145
Depression
27 (32)
12 (38)
.557
Substance abuse
31 (37)
2 (6)
.001
Bipolar disorder
5 (6)
1 (3)
.547
12 (14)
1 (3)
.092
Sex (male)
Age, years
Sociodemographic profile
Mental disorders
Schizophrenia
Suicidal manifestations
Previous suicide attempt
44 (52)
8 (25)
.001
Previous suicide attempt within past year
20 (24)
2 (6)
.085
Suicidal verbalizations
49 (58)
21 (66)
.667
Behavioural changes
35 (41)
16 (19)
.874
Recent health services utilization (within past year)
At least 1 service
53 (62)
17 (53)
.364
Family physician
30 (35)
11 (34)
.926
Psychiatrist
22 (26)
8 (25)
.922
Psychologist
6 (7)
3 (9)
.675
Suicide note
40 (47)
11 (34)
.181
Signs of planning
12 (14)
9 (28)
.754
Death at home
63 (74)
21 (66)
.363
Strangulation
32 (38)
15 (47)
.364
Poisoning
32 (38)
4 (13)
.009
Fall
12 (14)
0 (0)
.025
Firearm
2 (2)
3 (9)
.094
Drowning
0 (0)
2 (6)
.020
Death circumstances
Suicide method
Abbreviation: HSSC, Health and social services centre.
arms deaths. The detailed information
stored in the system is used to help
develop, implement and evaluate strategies designed to reduce and prevent
violence-related deaths. Precipitating circumstances are particularly carefully
investigated (e.g. mental health diagnoses
and treatment, substance abuse problems,
interpersonal problems involving intimate
partners, recent deaths in the family or
among friends, financial problems, interpersonal violence, etc.).31 This tool could
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27
also prove highly useful in developing
more comprehensive and structured
investigation forms for use by coroners
in Quebec.
Improving the quality of the data collected
by coroners and making it more complete
will not, however, guarantee its use by
local decision makers, who do not currently have access to this information. To
alleviate this problem, work has begun
on a regional observatory of attempted
and completed suicide in Montréal.
Suicide Action Montréal and the Centre
for Research and Intervention on Suicide
and Euthanasia (CRISE) of the Université
du Québec à Montréal will be jointly
responsible for the observatory. The
observatory will access all available data
on people who died by suicide (including
data from the Coroner’s Office and administrative data about physician claims and
hospitalization). This data will be anonymized and securely stored to protect
personal information. A team of researchers will have a mandate to regularly
produce useful local profiles for the
program’s decision makers and planners.
With infrastructure in place dedicated to
making use of the data collected by
coroners, we can expect this information
to lead to improvements in targeted
suicide-prevention strategies.
The large variance in suicide rates in the
12 HSSC areas in Montréal is undoubtedly
due in part to the great social diversity of
this city. This study is unique in that we
were able to develop different profiles of
the suicide cases in two HSSC areas: in
Area A, with the highest suicide rate,
suicide cases are often socially isolated
and have a substance abuse problem,
while in Area B, with the lowest suicide
rate, a higher number of suicide cases
appear to be socially well integrated and
their rate of substance abuse is low.
However, these data should be interpreted
with caution because of the low number of
cases (n = 117), particularly in the area
with the lowest suicide rate (n = 32). The
findings nonetheless suggest that distinct
preventive actions could be taken with
these two subpopulations to improve the
effectiveness of suicide-prevention strategies. If HSSC mental health teams had
better knowledge of the characteristics of
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
suicide cases in their area, they could
adjust their interventions accordingly, for
example, by monitoring people more
closely when they present a specific risk
profile.
Strengths and limitations
By analyzing coroners’ records, we have
expanded our knowledge of suicide cases
in Montreal from 2007 to 2009. However,
the originality of the study lies not only in
the fact that we have revealed shortcomings in the process used to investigate
deaths by suicide, but also in that we have
shown the potential positive implications
of being able to have detailed and valid
local data.
However, several factors limit the conclusions that can be drawn from this study.
First, by using coroners’ files as our only
source of data, the results are limited by
the uneven quality of the compiled information and the absence of some important
information. In order to obtain a fuller and
more accurate profile, it would have been
necessary to perform psychological autopsies. This research procedure consists of
conducting structured interviews with the
family and friends of suicide cases to
accurately establish the person’s physical
and mental state at time of death and
investigate the circumstances leading up
to their death. Had we used the administrative databases of Quebec’s health insurance authority (the Régie de l’Assurance
maladie du Québec), we could have also
described with certainty the person’s use
of medical resources in the year leading up
to their death. We could have also
confirmed or added certain diagnoses of
mental health problems. For reasons of
feasibility and due to the exploratory
nature of this study, we limited our
analysis to a three-year period. Great care
should be exercised when interpreting the
results from areas that had few suicides
during this period.
Conclusion
Almost all decisions to do with implementing suicide-prevention actions are
made at the local level. HSSCs play a key
role by developing services for their client
base and ensuring that their actions are
co-ordinated with those of all their community-based partners. In order to be
effective in this role, HSSCs need detailed
data on suicide cases in their areas. With
its 12 HSSCs, Montreal has a very heterogeneous population. Our study has shown
that this diversity can also be seen in
geographic variations in local profiles of
suicide cases. General profiles of the entire
population of Montreal are of limited use
to decision makers. We need to go beyond
general findings and provide them with
more detailed information.
The scale of suicide and its tragic consequences for thousands of Canadians
each year requires the strongest possible
actions, and coroners have an important
role to play in reducing suicide rates by
helping us better understand the causes of
suicide. They can help greatly advance
knowledge in this area by applying a
systematic, standardized data collection
procedure to suicide cases. Such knowledge may lead to better targeted and more
effective actions in at-risk individuals.
2.
Statistics Canada. Mortality, summary list
of causes: 2009. Ottawa (ON): Statistics
Canada, Health Statistics Division; 2012
[Statistics
Canada,
Catalogue
No.:
84F0209X].
3.
Gagné M, Saint-Laurent D. La mortalité par
suicide au Québec: tendances et données
récentes, 1981 à 2008. Direction, recherche,
formation et développement. Québec (QC):
Institut national de santé publique; 2012.
19 p. [INSPQ, Publication No.: 890].
4.
Mann JJ, Apter A, Bertolote J, et al. Suicide
prevention strategies: a systematic review.
JAMA. 2005 Oct;294(16):2064-74.
5.
Erlangsen A, Nordentoft M, Conwell Y,
et al. Key considerations for preventing
suicide in older adults. Crisis. 2011;32(2):
106-9.
6.
Davis SP, Arnette NC, Bethea KS, et al. The
Grady Nia Project: A culturally competent
intervention for low-income, abused, and
suicidal African American women. Prof
Psychol Res Pr. 2009:40(2):141-7.
7.
Nordentoft M. Crucial elements in suicide
prevention strategies. Prog Neuropsychopharmacol Biol Psychiatry. 2011;35(4):
848-53.
8.
Schwartz-Lifshitz M, Zalsman G and Giner
L. Can we really prevent suicide? Curr
Psychiatry Rep. 2012;14(6):624-33.
9.
De Leo D, Dello Buono MD, Dwyer J.
Suicide among the elderly: the long-term
impact of a telephone support and assessment intervention in northern Italy. Br J
Psychiatry. 2002;181:226-9.
Acknowledgements
This study has been made possible by
financial support from Suicide Action
Montréal and the Centre for Research and
Intervention on Suicide and Euthanasia
(CRISE). The authors would like to thank
Carole Renaud, who collected data at
Quebec’s Coroner’s Office, and Francis
Allard, who verified all the results. PaulAndré Perron of the Chief Coroner’s Office
as well as Philippe Angers and Véronique
Landry of Suicide Action Montréal read the
report and provided their comments. We
would also like to thank Charles Cardinal,
librarian at the Centre for Research and
Intervention on Suicide and Euthanasia, for
his invaluable support in the literature
review.
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Statistics Canada. Mortality, summary list
of causes: 2000. Ottawa (ON): Statistics
Canada, Health Statistics Division; 2006
[Statistics
Canada,
Catalogue
No.:
84F0209XIE].
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10. Mishara BL, Martin N. Effects of a comprehensive police suicide prevention program.
Crisis. 2012;33(3):162-8.
11. Knox KL, Litts DA, Talcott GW, Feig JC,
Caine ED. Risk of suicide and related
adverse outcomes after exposure to a
suicide prevention programme in the US
Air Force: cohort study. BMJ. 2003;
327:1376.
12. Knox KL, Pflanz S, Talcott GW, et al. The
Air Force suicide prevention program:
implications for public health policy. Am J
Public Health. 2010;100(12):2457-63.
13. Ostry AS. The mortality gap between urban
and rural Canadians: a gendered analysis.
Rural Remote Health. 2009;9(4):1286.
14. Taux de mortalité par suicide, Montréal, CSSS
et CLSC, 2005-2009. Montreal (QC): Direction
de santé publique de Montréal; 2009.
15. Lane J, Archambault J, Collins-Poulette M,
Camirand R. Prévention du suicide: guide
des bonnes pratiques à l’intention des
intervenants des centres de santé et de
services sociaux. Québec (QC): Direction
des communications, Ministère de la santé
et des services sociaux; 2010.
16. Agence de la santé et des services sociaux
de Montréal. Regard local sur la défavorisation et le suicide. Présentation dans le cadre
des ateliers de gestionnaires sur l’implantation du Guide de bonnes pratiques en
prévention du suicide à l’intention des
gestionnaires des Centres de santé et de
services sociaux et des réseaux locaux de
services. Montréal (QC): Agence de la santé
et des services sociaux de Montréal; 2012.
17. Act respecting the determination of the
causes and circumstances of death. LRQ,
1983. c.4, a.2.
18. St-Laurent D, Bouchard C. L’épidémiologie
du suicide au Québec: que savons-nous de
la situation récente? [Internet]. Québec
(QC): Institut national de santé publique
du Québec; 2004 [cited 2013 Dec 9]. 24 p.
Available from: http://www.inspq.qc.ca
19. Guindon M. Quartiers à la loupe: un
portrait pour l’action. Portrait de la population du territoire du CSSS Jeanne-Mance.
Montréal (QC): Centre de santé et de
services sociaux; 2009, 24 p.
20. Centre de santé et de services sociaux de
l’Ouest-de-l’Île. Snapshot of the West Island
HSSC. Pointe-Claire (QC): West Island
Health and Social Services Centre; 2010.
Available from: http://www.csssouestdelile
.qc.ca/fileadmin/csss_odi/publications
/Portrait_du_CSSS/brochureMars2010_
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21. Boileau JC, Corriveau-Durand S, Grondines
L, Lamoureux-Auclair A, Morin-Ben
Abdallah S. Analyse des rapports des
coroners des décès par suicide en Estrie:
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Sherbrooke (QC); 2011. 61pp.
22. Campbell LA, Jackson L, Bassett R, et al.
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for suicide surveillance and prevention
research in Nova Scotia? Chronic Dis Inj
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23. Powell V, Barber CW, Hedegaard H, et al.
Using NVDRS data for suicide prevention:
promising practices in seven states. Inj
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24. Mishara BL, Chagnon F. Understanding the
relationship between mental illness and
suicide and the implications for suicide
prevention. In: O’Connor RC, Platt S,
Gordon J, editors. International handbook
of suicide prevention: research, policy and
practice. Chichester (UK): John Wiley &
Sons Ltd; 2011. p. 609-623.
25. Canavagh JT, Carson AJ, Sharpe M, Lawrie
SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med.
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26. Arsenault-Lapierre G, Kim C, Turecki G.
Psychiatric diagnoses in 3275 suicides:
a meta-analysis. BMC Psychiatry. 2004;
4:37.
27. Luoma JB, Martin CE, Pearson JL. Contact
with mental health and primary care
providers before suicide: a review of
the evidence. Am J Psychiatry. 2002;
159(6):909-16.
28. Morrison KB, Laing L. Adults’ use of health
services in the year before death by suicide
in Alberta. Health Rep. 2011 Sep;22(3):1522. [Statistics Canada, Catalogue No.: 82003-XIE].
29. Paulozzi LJ, Mercy J, Frazier L Jr, Annest
JL. CDC’s National Violent Death Reporting
System: background and methodology. Inj
Prev. 2004;10(1):47-52.
30. Steencamp M, Frazier L, Lipskiy N, et al.
The National Violent Death Reporting
System: an exciting new tool for public
health surveillance. Inj Prev. 2006;
12(Suppl 2):ii3-5.
31. CDC. National Violent Death Reporting
System (NVDRS) Coding Manual Version
3 [Internet]. National Center for Injury
Prevention and Control, Centers for
Disease Control and Prevention; 2008 [cited
2013 Dec 9]. Available from: http://
www.cdc.gov/ncipc/pub-res/nvdrs-coding
/vs3/nvdrs_coding_manual_version_3-a.pdf
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Prevalence of self-reported hysterectomy among Canadian
women, 2000/2001–2008
A. Stankiewicz, MPH (1); L. Pogany, MSc (1); C. Popadiuk, MD, FRCS (2)
This article has been peer reviewed.
Abstract
Background: Hysterectomy is one of the most frequently performed surgical procedures
among Canadian women. The consequence is a population that no longer requires
cervical cancer screening. The objective of our analysis was to provide more accurate
estimates of eligible participation in cervical screening by estimating the age-specific
prevalence of hysterectomy among Canadian women aged 20 to 69 by province and
territory between 2000/2001 and 2008.
Methods: Self-reported hysterectomy prevalence was obtained from the 2000/2001,
2003 and 2008 Canadian Community Health Survey. Age-specific prevalence and 95%
confidence intervals (CIs) were estimated for Canada and provinces and territories for
the three time periods.
Results: Interprovincial variations in hysterectomy prevalence were observed among
women in each age group and time period. Among women aged 50 to 59, prevalence
was as high as 35.1% (95% CI: 25.8–44.3) (p < .01) in 2008 and appeared to decrease in
all provinces from 2000/2001 to 2008.
Conclusion: Interprovincial and time period variation suggest that using hysterectomy
prevalence to adjust the population eligible for cervical cancer screening may be helpful
to inform more comparable screening participation rates. In addition, both cervical
cancer incidence and mortality rates can be adjusted by hysterectomy to ensure
estimates across time and provinces and territories are also comparable.
Keywords: hysterectomy prevalence, cervical cancer screening participation rates,
hysterectomy epidemiology
Introduction
With nearly 47 000 procedures performed
in 2008 to 2009 in Canada,1 hysterectomy
is second only to Caesarean section as the
most frequently performed surgical procedure in Canadian women. Complete hysterectomy involves the removal of the
uterus and cervix; partial supra-cervical
hysterectomy, which is less frequently
performed, involves the removal of the
uterine fundus. Hysterectomy can be elective, for benign gynecologic conditions, or
emergent, for uncontrollable hemorrhage,
to treat various malignant conditions, and
to prevent cancer in pre-cancerous cervical
conditions and in carriers of the hereditary
non-polyposis colorectal cancer genes who
are predisposed to endometrial and ovarian
cancers. The indications for hysterectomy
are becoming more rigorous with respect to
its necessity and frequency, resulting in
changes in the annual incidence of hysterectomy and therefore the number of
women living without a cervix.2-4
Pap smear screening is recommended for
all women who have ever been sexually
active, but is generally not required
among women who no longer have a
cervix. The exception to this is among
women with a history of treatment for
carcinoma in situ (severe cervical dysplasia). As a result, women who have had a
hysterectomy and have never been treated
for cervical dysplasia should neither be
targeted for population-based cervical
cancer screening nor included in summary
participation screening statistics. When
estimates of screening participation have
been corrected for history of hysterectomy, the result has been a stabilization of
participation across age groups. However,
this approach has not been used across all
provinces.5 This is increasingly important
in Canada, where participation in cervical
cancer screening is used as a benchmark
for assessing the performance of national
and provincial cancer control and health
care delivery systems.6 An accurate
assessment of the target population and
screening participation can only be made
if women living without a cervix are
removed from the denominator. Recognizing the need to correct for history
of hysterectomy is in alignment with the
Canadian Task Force Guidelines that state
that the guidelines do not apply to women
who do not have a cervix as a result of
hysterectomy.7
Canadian health care professionals do not
agree on the standard for the use of
hysterectomy in treating benign uterine
conditions.8 The incidence of hysterectomy varies over time and across
regions, 9-12 suggesting that the prevalence
of women living without a cervix also
varies. This variance is a result of regional
differences in incidence of uterine pathology and physician and patient fac-
Author references:
1. Public Health Agency of Canada, Ottawa, Ontario, Canada
2. Department of Women’s Health, Memorial University, St John’s, Newfoundland and Labrador, Canada
Correspondence: Agata Stankiewicz, Public Health Agency of Canada, 785 Carling Ave., Ottawa, ON K2T 0A5; Tel.: 613-954-8604; Fax: 613-941-2633; Email: agata.stankiewicz@phac-aspc.gc.ca
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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30
tors.9,13,14
Physician-related
factors
include disagreement on indications for
hysterectomy, differences in training and
variation in regional practices;2,9,10,13,14
patient factors relate to personal preference and beliefs or attitudes towards
hysterectomy.10,13
The objective of our analysis was to
estimate the prevalence of hysterectomy
among Canadian women aged 20 to 69
years, by province and territory and over
time.
Methods
Data sources
We used data from the Canadian
Community Health Survey (CCHS) cycles
1.1 (2000/2001) and 2.1 (2003) and the
CCHS Annual Component (2008) to estimate prevalence of hysterectomy. In all
three time periods, CCHS data were
collected over a 12-month period. Data
were unavailable for CCHS cycle 3.1
(2005), the 2007 Annual Component or
CCHS 2007–2008.15-17
The CCHS is a cross-sectional population
health survey targeting Canadians aged 12
years and older living in private dwellings
in all provinces and territories. Excluded
are full-time members of the Canadian
Forces and residents of institutions, certain remote areas and Indian Reserves and
Crown Lands.15-17 Until (and including)
2005, CCHS data were collected every two
years; since 2007, data have been collected annually.17
Respondents 18 years or older were asked,
‘‘Have you had a hysterectomy (in other
words, has your uterus been removed),’’
to which they could answer yes or no.18-20
This question can be found in the mammography modules of the CCHS cycles 1.1
(2000/2001) and 2.1 (2003) and in the
Annual component, 2008.18-20
Data analysis
Frequency estimates were produced to
estimate hysterectomy prevalence. We
analyzed hysterectomy prevalence for
women aged 20 to 69 years by 10-year
age groups, nationally and by each pro-
vince and territory, and differences
between provincial hysterectomy estimates in a given time period using
Ontario as the reference.21 Weight adjustments, coefficients of variation, standard
errors and 95% confidence intervals (CIs)
were analyzed using the bootstrap
method.16 Prevalence estimates with
fewer than 30 sampled respondents and/
or coefficients of variation (CV) higher
than 33.3% were suppressed, and prevalence estimates with CV between 16.6%
and 33.3% were identified as needing to
be interpreted with caution.15-17 CV is
commonly used by Statistics Canada to
determine the quality of an estimate
obtained from survey samples when
applying the bootstrap method.15-17
Statistical significance (p < .05 and
p < .01) was determined using variance
estimates for difference between ratios
analysis (t test) available through the
bootstrap method.21
Results
We observed interprovincial variations in
hysterectomy prevalence among women
in each age group and time period.
Hysterectomy prevalence among 20- to
29-year olds and 30- to 39-year olds in the
majority of regions was suppressed due to
small sample sizes and/or higher CV
(> 33.3%). For the same reasons, hysterectomy prevalence was suppressed for
Yukon, Northwest Territories and Nunavut
in all age groups in all three time periods.
In 2008, the prevalence of hysterectomy
ranged from 9.6% to 21.2% in women
aged 40 to 49 years. The differences were
statistically significant only between Nova
Scotia (21.2%, 95% CI: 13.1–29.3) and
New Brunswick (19.5%, 95% CI: 12.6–
26.5) when compared to Ontario (9.6%,
95% CI: 7.1–12.1) (p < .05) (Figure 1).
Between 2000/2001 and 2008, the prevalence appeared to increase in three provinces, decrease in three and remain
stable in one; however, all estimates were
characterized by wide and overlapping
confidence intervals (Table 1). In women
aged 50 to 59 years, prevalence was as
high as 35.1% (95% CI: 25.8–44.3) (p <
.01) in 2008 (in Newfoundland and
Labrador) and appeared to decrease in
all provinces from 2000/2001 to 2008
$
31
(Figure 1; Table 1), although estimates
were characterized by wide and overlapping CIs in all provinces apart from
Nova Scotia, Quebec and Ontario. In
women aged 60 to 69 years, the prevalence of hysterectomy ranged from 30.7%
to 43.1% in 2008. When compared to
Ontario (30.7%, 95% CI: 27.2–34.2), the
differences were statistically significant for
Nova Scotia (43.1%, 95% CI: 35.2–51.1),
New Brunswick (41.4%, 95% CI: 33.8–
49.0), Quebec (36.5%, 95% CI: 32.2–40.8)
and Alberta (39.4%, 95% CI: 31.9–47.0)
(Figure 1). In this age group, prevalence
appeared to decrease between 2000/2001
and 2008 in all provinces but one, where it
remained stable (Table 1).
Discussion
The prevalence of hysterectomy in Canada
declined from 2000/2001 to 2008 and
varied by province, with over half showing gradual decline over time in the 50- to
59- and 60- to 69-year age groups. We did
not report patterns for the youngest age
groups (20- to 29- and 30- to 39-year) due
to the relative rarity of the procedure.
Provincial variation in the incidence of
hysterectomy in this time period has been
previously demonstrated and shows similar trends to that of the prevalence data.11
The variations observed across the provinces demonstrate how important it is to
accurately report provincial prevalence
since these will affect participation in
cervical cancer screening rates and adjustment for cervical cancer incidence and
mortality rates.22
Direct comparison of our analysis of
hysterectomy prevalence to international
estimates is difficult, primarily because of
the different analysis periods and age
ranges used.13,23-25 However, most developed countries appear to have experienced
a decline in new cases of women undergoing hysterectomy.26,27 Within Canada,
the lower prevalence seen in certain
provinces may reflect a variation in the
practice of limiting hysterectomy and a
shift to conservative treatments for discretionary conditions. Among women aged
60 to 69 years, the smaller reductions in
prevalence over time are likely because
this cohort underwent hysterectomy
before more conservative treatments
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
FIGURE 1
Self-reported hysterectomy prevalence rates in Canada among women aged 40 to 49, 50 to 59 and 60 to 69 in 2008
60
40
30
CDN: 34.0
BC: 31.4
AB: 39.4 *
SK: 37.2
MB: 32.5
ON: 30.7
QC: 36.5 *
NB: 41.4 *
NS: 43.1 **
50-59
60-69
40-49
NL: 36.8
CDN: 21.2
BC: 19.3
AB: 24.0
SK: 21.2
MB: 19.6
ON: 20.4
QC: 20.0
NB: 30.5 *
NS: 25.6
PEI: 27.7 E
NL: 35.1 **
0
ON: 9.6
QC: 13.7
NB: 19.5 E *
NS: 21.2 E *
10
MB: 14.2 E
20
CDN: 12.4
BC: 13.7
AB: 15.3 E
Hysterectomy prevalence (%)
50
Abbreviations: AB, Alberta; BC, British Columbia; CDN, Canada; CV, coefficients of variation; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia;
ON, Ontario; PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.
Note: Data for 40-49 year olds in NL, PEI, SK and 60-69 year olds in PEI is too unreliable to be published.
E
Use with caution (CV: 16.6-33.3%).
* p < .05
** p < .01
became more common. Treatments such
as the progesterone intrauterine device
and endometrial ablation did not become
widely available until the last decade.28
Reduced prevalence of Canadian women
living with a history of hysterectomy will
probably continue to be observed until a
minimum level is reached when its use
will be limited to non-elective treatment
for hemorrhagic emergencies and malignancies.29
The consequence of including in the
denominator women who have had hysterectomies results in overestimating the
target population and underestimating cervical cancer screening participation. A
significant proportion of invasive cervical
cancer cases in Canada, 40% to 50%, occur
in the under-screened and never-screened
population; while some provinces achieve
almost 80% screening coverage for the
population at risk once in three years, half
the women presenting with invasive cervical
cancer had not been screened.5 In addition,
failure to remove women without a cervix
from the denominator calculations results in
less accurate comparisons of target populations and screening participation across
programs and age groups: a recent Canadian report estimated overall participation at
70.2% (uncorrected for hysterectomy) and
74.1% (corrected).5 More importantly, these
results demonstrated the stabilizing effect of
correction resulting in more uniform participation across age groups.5
Limitations
Our estimates of prevalence are limited by
the nature of self-reported responses to
CCHS questions including those about
hysterectomy. There is also no indication
of hysterectomy type, resulting in an
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
32
overestimate of total hysterectomy.
However, partial supra-cervical hysterectomy is uncommon (less than 10%) in
Canada, and thus it is not likely to
contribute significantly to the numbers.30
Removal of the cervix only, trachelectomy, is also a very uncommon procedure
used to treat early stage cervical cancer. It,
too, will not significantly affect the numbers.31,32 Other limitations include data
unavailability in certain years.
Conclusion
Our analysis contributes to the current
knowledge of hysterectomy epidemiology
in Canada. Given provincial and age
variations, up-to-date knowledge of hysterectomy prevalence will contribute to
more accurate population denominators
for post-hoc calculation of cervical cancer
screening participation rates.
TABLE 1
Prevalence of hysterectomy rates in 2000/2001, 2003 and 2008, Canada and provinces, by age group
Age group, years
Province
Year
2000/2001
40–49
NL
PEI
50–59
60–69
2003
%
(95% CI)
%
18.9
(15.0–22.9)
15.1
18.6
(13.1–24.0)
E
E
25.6
2008
(95% CI)
%
(9.7–20.5)
—
(16.0–35.1)
—
(95% CI)
F
F
—
F
F
—
E
Difference between
2000/2001 and 2008
—
—
NS
18.2
(14.4–22.1)
25.6
(18.2–33.1)
21.2
(13.1–29.3)
3.0
NB
21.2
(17.1–25.3)
20.9
(15.6–26.2)
19.5
(12.6–26.5)
21.7
E
QC
14.7
(12.6–16.7)
13.4
(11.3–15.6)
13.7
(10.0–17.3)
21.0
ON
12.4
(11.0–13.8)
10.6
(9.3–11.9)
9.6
(7.1–12.1)
22.7
MB
9.2
(6.1–12.3)
11.6
(8.0–15.1)
14.2
(6.2–22.2)
5.0
E
E
E
F
F
SK
16.2
(12.5–19.8)
16.7
(11.1–22.3)
—
AB
14.3
(11.6–17.1)
13.7
(10.7–16.7)
15.3
—
E
(10.2–20.4)
—
1.0
BC
13.6
(11.5–15.6)
13.8
(11.3–16.4)
13.7
(9.8–17.6)
0.1
Canada
13.9
(13.0–14.8)
13.0
(12.1–13.9)
12.4
(10.9–13.9)
21.5
NL
35.4
(29.4–41.3)
34.8
(28.7–40.9)
35.1
(25.8–44.3)
20.3
E
PEI
29.7
(22.8–36.7)
34.2
(24.3–44.2)
27.7
(17.6–37.8)
22.0
NS
39.8
(34.5–45.1)
36.8
(30.9–42.6)
25.6
(18.1–33.0)
214.2
NB
38.6
(33.0–44.3)
36.9
(31.3–42.4)
30.5
(23.8–37.2)
28.2
QC
31.3
(28.2–34.4)
31.0
(28.0–34.1)
20.0
(16.9–23.1)
211.3
ON
26.9
(24.5–29.3)
24.8
(22.8–26.7)
20.4
(17.4–23.4)
26.5
MB
24.4
(19.4–29.5)
17.3
(13.1–21.6)
19.6
(13.3–25.9)
24.8
SK
30.3
(25.0–35.6)
24.5
(20.0–29.1)
21.2
(15.1–27.4)
29.0
AB
33.4
(29.0–37.8)
24.5
(20.6–28.4)
24.0
(18.0–30.1)
29.4
BC
25.8
(22.8–28.9)
25.8
(22.5–29.0)
19.3
(15.0–23.7)
26.5
Canada
29.4
(28.0–30.8)
27.2
(25.9–28.4)
21.2
(19.4–23.0)
28.2
(28.1–45.6)
20.9
NL
37.7
(30.0–45.4)
38.1
(31.2–45.0)
36.8
PEI
43.6
(36.6–50.6)
36.6
(26.2–46.9)
—
NS
42.4
(35.2–49.5)
49.7
(42.4–57.0)
43.1
(35.2–51.1)
0.8
F
F
—
—
NB
42.8
(36.2–49.4)
47.0
(39.9–54.1)
41.4
(33.8–49.0)
21.4
QC
42.8
(38.8–46.9)
37.7
(34.6–40.8)
36.5
(32.2–40.8)
26.3
ON
34.2
(31.3–37.1)
32.7
(30.3–35.1)
30.7
(27.2–34.2)
23.5
MB
40.8
(34.1–47.6)
38.5
(31.6–45.3)
32.5
(24.5–40.5)
28.3
SK
41.1
(35.3–46.8)
34.4
(28.5–40.3)
37.2
(29.4–44.9)
23.9
AB
40.3
(35.2–45.4)
40.5
(35.6–45.3)
39.4
(31.9–47.0)
20.8
BC
35.3
(31.5–39.1)
36.2
(32.3–40.2)
31.4
(26.4–36.3)
23.9
Canada
38.1
(36.4–39.8)
36.4
(35.0–37.9)
34.0
(31.8–36.1)
24.1
Abbreviations: AB, Alberta; BC, British Columbia; CV, coefficients of variation; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador; NS, Nova Scotia; ON, Ontario;
PEI, Prince Edward Island; QC, Quebec; SK, Saskatchewan.
E
Use with caution (CV = 16.6%–33.3%).
F
Too unreliable to be published (n < 30 and/or CV > 33.3%).
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Canadian Institute for Health Information.
In focus: measuring disparities in the health
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Canadian Partnership Against Cancer
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Canadian Partnership Against Cancer;
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_cs_report.pdf
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Cancer System Performance Working
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Canadian Institute for Health Information.
Health care in Canada 2010: evidence of
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Hall RE, Cohen MM. Variations in hysterectomy rates in Ontario: does the indication
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10. Allard P, Rochette L. The descriptive
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/internet/en/applicationfull/health+system
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12. Stewart D, Evans M, Henderson G, et al.
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14. Mulholland C, Harding N, Bradley S,
Stevenson M. Regional variations in the
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&SurvVer=0&InstaId=15282&InstaVer=1
&SDDS=3226&lang=en&db=imdb&adm
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&SurvId=3226&SurvVer=0&SDDS=3226
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17. Canadian Community Health Survey –
annual component (CCHS). Detailed information for 2008 [Internet]. Ottawa (ON):
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&SurvVer=1&InstaId=15282&InstaVer=5
&SDDS=3226&lang=en&db=imdb&adm
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Statistics Canada; [cited 2013 May 15].
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November 2003. Revised version – July
2005 [Internet]. Ottawa (ON): Statistics
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/instrument/3226_Q1_V2-eng.pdf
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21. BOOTVAR: user guide (BOOTVAR 3.1 –
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22. Taylor R, Rushworth RL. Hysterectomy
fractions in New South Wales, 1971-2006.
Aust N Z J Public Health. 1998;22(7):
759-64.
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prevalence and adjusted cervical and uterine cancer rates in England and Wales.
BJOG. 2001;108(4):388-95.
24. Nolan TF, Ory HW, Layde PM, Hughes JM,
Greenspan JR. Cumulative prevalence rates
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the United States, 2000-2004. Am J Obstet
Gynecol. 2008;198(1):34.e1-7.
27. Hill EL, Graham ML, Shelley JM.
Hysterectomy trends in Australia - between
2000/01 and 2004/05. Aust N Z J Obstet
Gynaecol. 2010;50(2):153-8.
28. Van Dongen H, van de Merwe AG, de
Kroon CD, Jansen FW. The impact of
alternative treatment for abnormal uterine
bleeding on hysterectomy rates in a tertiary
referral center. J Minim Invasive Gynecol.
2009;16(1):47-51.
29. Kramer MG, Reiter RC. Hysterectomy:
indications, alternatives and predictors.
Am Fam Physician. 1997;55(3):827-34.
30. Cohen MM, Young W. Costs of hysterectomy: does surgical approach make a
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885-92.
31. Beiner ME, Hauspy J, Rosen B, et al.
Radical vaginal trachelectomy vs. radical
hysterectomy for small early stage cervical
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Gynecol Oncol. 2008;110(2):168-71.
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update of a series of 125 cases and 106
pregnancies. Gynecol Oncol. 2011;121(2):
290-7.
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Metabolic syndrome and chronic disease
D. P. Rao, MSc (1, 2); S. Dai, MD (2); C. Lagacé, MSc (2); D. Krewski, PhD (1, 3)
This article has been peer reviewed.
Abstract
Introduction: Metabolic syndrome (MetS) is a combination of risk markers that appear
to promote the development of chronic disease. We examined the burden of MetS in
Canada through its current and projected association with chronic disease.
Methods: We used measures from the Canadian Health Measures Survey 2007–2009 to
identify the prevalence of MetS in Canadian adults and examine associations between
sociodemographic factors and major chronic diseases. We estimated the projected
cumulative incidence of diabetes and percent risk of a fatal cardiovascular event using
the Diabetes Population Risk Tool (DPoRT) and Framingham algorithms.
Results: After adjusting for age, we found that 14.9% of Canadian adults had MetS.
Rates were similar in both sexes, but higher in those who are non-Caucasian or
overweight or obese (p < .001 for all three). The importance of MetS for public health
was demonstrated by its significant association with chronic disease relative to the
general population, particularly for diagnosed (11.2% vs. 3.4%) and undiagnosed (6.0%
vs. 1.1%) type 2 diabetes. The ten-year incidence estimate for diabetes and mean percent
risk of a fatal cardiovascular disease (CVD) event were higher in those with MetS
compared to those without (18.0% vs. 7.1% for diabetes, and 4.1% vs. 0.8% for CVD).
Conclusion: MetS is prevalent in Canadian adults and a high proportion of individuals
with MetS have diagnosed or undiagnosed chronic conditions. Projection estimates for
the incidence of chronic disease associated with MetS demonstrate higher rates in
individuals with this condition. Thus, MetS may be a relevant risk factor in the
development of chronic disease.
Introduction
The vast majority of patients in the
Canadian healthcare system are living
with one or more chronic diseases.1
Cardiovascular disease, chronic obstructive pulmonary disease, cancer and diabetes are the most common causes of
hospitalization and premature death in
Canada, accounting for almost threequarters of all deaths.2 Together, these
chronic diseases account for 80% of
primary care visits and more than twothirds of medical costs.1,3 Knowing more
about the risk factors and indicators for
chronic disease may, therefore, help
public health efforts aimed at addressing
this growing concern.
Metabolic syndrome (MetS) is a condition
that describes the clustering of risk markers that increase an individual’s likelihood of developing chronic disease.4 A
number of leading chronic conditions
have been shown to be associated with
MetS. These include cardiovascular disease (CVD)5, type 2 diabetes,6 cancers,7
and chronic kidney disease (CKD)8.
The growing prevalence of obesity and
sedentary lifestyles contributes to the
prevalence of MetS.9-11 While the patho-
genesis of MetS may be attributed to
obesity and metabolic susceptibility,12 a
variety of socioeconomic factors have also
been shown to influence the prevalence of
MetS. For example, Canadian adults with
a postgraduate degree had half the odds of
acquiring MetS compared with those who
have completed high school (odds ratio
[OR] = 0.45, 95% confidence interval
[CI]: 0.25–0.81).13 Ethnicity also affects
observed prevalence rates (OR = 0.54,
95% CI: 0.4–0.73 in non-Hispanic Blacks
relative to non-Hispanic Whites).14 Considering differences based on ethnicity has
resulted in a variety of official MetS
definitions being sanctioned by international health authorities.4,15,16 MetS has
also been described as a progressive
disorder; the several components of MetS
tend to worsen over time and collectively
contribute to an increased risk for chronic
disease.17
Hivert et al.18 demonstrated the utility of
MetS as a relevant public health tool.
Using electronic health records to identify
and track patients with MetS for future
development of CVD and diabetes, they
showed that patients with MetS had a
higher incidence of these chronic conditions and incurred higher healthcare costs
than did those patients without MetS.18
This signifies an important role for MetS
as a chronic disease indicator that could
benefit individual health as well as
healthcare costs and resources.18 The
limited availability of prevalence estimates derived from Canadian data to date
has meant that international estimates are
often used instead. It is therefore important to develop Canadian findings on
MetS and its association with chronic
conditions.
Author references:
1. Institute of Population Health, University of Ottawa, Ontario, Canada
2. Public Health Agency of Canada, Ottawa, Ontario, Canada
3. Risk Sciences International, Ottawa, Ontario, Canada
Correspondence: Deepa Rao, Institute of Population Health, University of Ottawa, 1 Stewart Street, Room 300, Ottawa, ON K1N 6N5; Tel.: 613-897-8111; Fax: 613-562-5380;
Email: Deepa.Rao@uottawa.ca
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In this study, our aim was to (1) estimate
the prevalence of MetS in the Canadian
adult population; (2) examine the relationship between MetS, risk factors and
chronic disease; and (3) characterize the
future risk of chronic diseases associated
with MetS through measures of undiagnosed disease, as well as through 10-year
projections for diabetes and CVD, using
established prediction tools.
Methods
tive of the entire Canadian population.
These weighting factors account for nonresponse and for the demographic distribution of the country. Missing values were
removed prior to analyses.
To test for potential selection bias as a
result of various exclusion criteria, we
performed a sensitivity analysis to compare the baseline demographic status of
our study population with national-level
estimates. Comparing our study popula-
tion with recent Canadian estimates, we
found that our study population (Table 1)
showed similar estimates for age,23 education,24 gender,25 ethnicity26 and income,27
indicating that it is representative of the
general Canadian population.
Key definitions
Metabolic syndrome
We used the revised National Cholesterol
Education
Program
(rNCEP)
Adult
TABLE 1
Characteristics of the study population (N = 1693)
Data source
We used data from the 2007–2009
Canadian Health Measures Survey
(CHMS).19 This cross-sectional survey,
conducted by Statistics Canada, recruited
a representative sample of 5600 Canadians
aged 6 to 79 years, which covers about
96.3% of the Canadian population. The
survey used a mobile examination clinic to
measure, for example, participants’ blood
pressure (BP) and serum factors.
Information about current health status,
socioeconomic variables, etc., was gathered through a general household interview.19 Statistics Canada provides weights
for each participant that capture the
number of people represented by that
participant in the population and account
for non-response and the demographic
distribution of the population. Additional
information on sampling and estimations
is described elsewhere.20,21
Characteristics
N
%
95% CI
Women
886
50.4
49.8–50.9
Men
807
49.6
49.1–50.2
20–39
536
37.8
37.1–38.4
40–59
603
41.3
40.8–41.8
554
20.9
20.6–21.2
1441
84.3
74.2–94.4
205
15.7E
5.6–25.8
Sex
Age, years
60–80
Mean age (SE), years
45.3 (0.2)
Cultural / ethnic background
Caucasian
Non-Caucasian
Total household income, $
ƒ 29 999
290
14.6
11.6–17.7
30 000–49 999
324
18.4
16.3–20.5
50 000–79 999
400
26.4
22.5–30.3
§ 80 000
583
40.6
33.6–42.9
Less than secondary
206
11.4
7.6–15.2
Secondary graduate
289
18.8
13.1–24.5
1178
69.8
61.5–78.2
810
45.7
41.8–49.5
Highest level of education
Study population
Some post-secondary / post-secondary graduate
Some of the CHMS study participants
(n = 2634) were asked to fast before the
tests at the mobile examination clinic; we
used data from this subsample in this
study. The response rate for this subsample was 85.2%, which when combined
with the overall response rate for the
CHMS, makes the overall fasting subsample response rate 46.3%.19,20,22 Pregnant
women (n = 8) and individuals aged
under 20 years (n = 933) were excluded
from the analysis, leaving a study population of 1693 participants. For analyses
using this subsample, Statistics Canada
provided separate weights, based on the
2006 Census, for fasting participants, to
ensure that analyses in this restricted
subpopulation would remain representa-
Smoking status
Never smoked
Former smoker
553
31.2
27.9–34.5
Current smoker – daily or occasional
325
23.1
20.6–25.6
Active / moderately active
800
44.3
37.2–51.5
Inactive
893
55.7
48.5–62.8
< 25
676
43.5
37.8–49.2
25–29
638
37.8
33.8–41.8
§ 30
351
18.7
15.6–21.2
Leisure time physical activity
2
BMI, kg/m
Source: Canadian Health Measures Survey, 2007–2009, clinic dataset.
Abbreviations: BMI, body mass index; CI, confidence interval; SE, standard error.
Notes: Missing data (not applicable, not stated, don’t know) not included in calculation of proportions.
Percentages have been weighted using CHMS survey weights.
E
Interpret with caution (coefficient of variation: 16.6%–33.3%).
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Treatment Panel III definition for MetS,
which uses revised waist circumference
criteria.4 We also examined prevalence
rates of MetS using the International
Diabetes Federation (IDF) and Harmonized
definitions.15,16
Undiagnosed and diagnosed chronic
conditions
In the absence of any longitudinal data to
determine whether individuals with MetS
may develop chronic diseases with time,
we determined whether participants may
have had an undiagnosed condition. This
is treated as a proxy measure for future
chronic disease risk. Participants were
deemed to have a particular condition
undiagnosed if they said that they did not
have the condition but had measurable
physical attributes of the condition.
Diagnosed hypertension was based on a
positive response to the question ‘‘Do you
have high blood pressure?’’ or from selfreported use of specific medications (list
available from the authors on request).
Average systolic BP and diastolic BP were
derived from an average of six blood
pressure measurements.22,28,29 We determined that individuals had undiagnosed
hypertension if they reported no diagnosed hypertension but had BP readings
above 140/90 mmHg (for either reading).
Diagnosed diabetes (type 2) was based on
positive responses to the questions, ‘‘Do
you have diabetes?’’ and ‘‘Were you
diagnosed with non-insulin dependent
diabetes (type 2)?’’ or from self-reported
use of specific medications (list available
from the authors on request).22 As with
BP, we determined that individuals had
undiagnosed diabetes if they gave a
negative response to questions about
having physician-diagnosed diabetes but
their fasting plasma glucose levels measured at 7.0 mmol/L or more. Individuals
with type 1 diabetes were not included in
the analysis.
Diagnosed CKD was based on a positive
response to the question ‘‘Do you suffer
from kidney dysfunction or disease?’’22
Undiagnosed CKD was based on a negative response to this question plus either a
low measured glomerular filtration rate
(ƒ 60 mL/min using the Modification of
Diet and Renal Disease Study equation30)
or a high measured microalbumin to
creatinine ratio (> 2.65 mg/mmol).
Diagnosed dyslipidemia was based on a
positive response to the question ‘‘Have
you ever been told by a health professional that your blood cholesterol was
high?’’22 Undiagnosed dyslipidemia was
based on a negative response to this
question plus the participant either meeting both the total cholesterol to high
density lipoprotein (HDL) ratio (§ 5.5 in
men, § 4.5 in women) and low density
lipoprotein (LDL) criteria (§ 3.5 mmol/L)
or using appropriate medications (list
available from the authors on request).
Descriptive variables
Analyses are described by sex, age (at
clinic visit), education, ethnicity (selfreported cultural or racial group, not
including Aboriginal populations) and
total household income. Lifestyle factors
include measured body mass index (BMI)
and self-reported leisure time physical
activity and smoking status.19
Analysis
We undertook multivariate analyses using
statistical software SAS Enterprise Guide
4.1 (Cary, NC, US).31 National estimates
were calculated with the CHMS weights
for the subsample of the population
who had fasted and were age-adjusted
using Canadian Census data. We calculated variance estimates using Statistics Canada Bootvar software (Statistics
Canada, Ottawa, ON) and followed their
reporting guidelines. Horvitz-Thompson
estimation was used to analyze statistical
significance following a t distribution with
11 degrees of freedom.
We examined prevalence estimates using
the frequency procedure on SAS
Enterprise Guide 4.1, and adjusted for
these as described for individual reported
estimates in the Results section. OR
estimates were calculated from logistic
regression models and adjusted for age
and sex, where mentioned. Ten-year
cumulative incidence projections for type
2 diabetes were estimated using the
Diabetes Population Risk Tool (DPoRT).32
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Originally developed using the National
Population Health Survey, this prediction
tool uses commonly collected survey data,
such as self-reported estimates for health
behaviours and sociodemographic factors,
to predict the risk of developing incident
physician-diagnosed diabetes. Sex-specific
Weibull survival models were used to
create DPoRT for individuals without
diabetes mellitus, who are not pregnant
and who are aged over 20 years. Predictive
variables used in the model include age,
sex, self-reported ethnicity, self-reported
BMI, immigrant status (for women), education, smoking status and history of
hypertension and heart disease, all of
which were available for our analysis.32
We used the lipid-based Framingham
10-year risk calculator to estimate the
risk of a fatal general CVD event, defined
as either coronary death, myocardial
infarction, coronary insufficiency, angina,
ischemic stroke, hemorrhagic stroke, transient ischemic attack, peripheral artery
disease or heart failure. This risk prediction tool was originally created using data
from the Framingham Heart Study and
Framingham Offspring Study. Sex-specific
Cox proportional hazards regressions
were used to relate various risk factors to
the incidence of fatal general CVD events.
Mathematical CVD risk functions derived
from this were then used in the development of the Framingham Risk Tool. Results
are presented as high risk (§ 20%) or
intermediate and high risk (§ 10%). The
population subset for CVD projections was
restricted to individuals aged 30 to 74 years
who had no previous history of a CVD
event.33
Ethics approval
Approval to conduct our study was
obtained from the Ottawa Hospital
Research Ethics Board (Protocol #
20120767-01H) prior to commencement.
Results
The majority of the survey participants
were Caucasian, physically inactive and
former or current smokers. Most had at
least some post-secondary education and
an annual household income of more than
$50 000. The mean age of the study
population was 45 years, and the population was equally represented by each sex
(Table 1).
Participants were deemed to have MetS
when they met three or more rNCEP MetS
criteria, resulting in a crude prevalence of
15.5% and an age-adjusted prevalence of
14.9%. In the overall population, 34.9%
had no MetS risk markers, whereas 29.5%
had one and 20.2% had two. The most
prevalent MetS risk markers among those
identified as having MetS were waist circumference (89.2%), hypertriglyceridemia
(82.3%), low HDL cholesterol (75.4%),
high fasting plasma glucose (53.3%) and
high systolic or diastolic BP (40.3%)
(Figure 1).
The rNCEP estimates were compared to
prevalence estimates based on the IDF and
Harmonized definitions, both of which
resulted in significantly larger prevalence
estimates (crude prevalence: IDF = 23.1%,
Harmonized = 19.6%; age-adjusted
prevalence estimates: IDF = 22.3%,
Harmonized = 19.1%) (Table 2).
The prevalence of MetS varied by age
group, but the difference by sex for each
age group was not statistically significant
(Figure 2). Variation occurred according to
smoking status as well, although these
patterns varied by sex (Table 2). On the
other hand, ethnic background significantly
influenced prevalence rates, with people of
non-Caucasian origin having a higher prevalence than those of Caucasian origin. For
both sexes, a high BMI and being physically
inactive were significantly associated with a
higher prevalence of MetS.
The odds of MetS varied according to
participant characteristics, and was significantly associated with being nonCaucasian and older (Table 2). Other
characteristics were also significant,
although this varied based on sex. For
example, the odds of MetS was significantly associated with being a current
smoker in women but not in men.
We examined the prevalence of chronic
conditions across three population groups:
the overall population, individuals with
obesity (BMI § 30 kg/m2) and individuals
with MetS. Undiagnosed disease was more
prevalent in those with MetS compared
with those with obesity or the overall
study population for all conditions examined, and was most prominent for dyslipidemia (28.3% vs. 18.5% and 10.0%,
respectively) (Table 3). Note that the rate
of undiagnosed diabetes was more than
five times higher in those with MetS than
in the overall population (6.0% vs. 1.1%,
p = .009; interpret with caution).
We estimated the future burden of type 2
diabetes and CVD that can be attributed to
MetS using existing algorithms. The mean
10-year predicted risk of diabetes in
individuals with MetS, as opposed to those
without, is 18.0% (95% CI: 15.3–20.7)
versus 7.1% (95% CI: 6.2–8.1). The
proportion of Canadian adults anticipated
to develop diabetes between 2007 and
2017 is thus 8.7% (95% CI: 7.5–9.9)
(Figure 3). Similarly, the mean predicted
risks for fatal CVD are 4.1% (95% CI: 2.3–
6.0; interpret with caution) vs. 0.8% (95%
CI: 0.6–1.0). The risk of CVD can be
further analyzed as being high, that is, a
20% or higher risk of a CVD event in 10
years, or as intermediate to high, a 10% to
20% CVD risk in 10 years. The proportion
of Canadian adults with MetS with a high
risk of a CVD event is 6.81% (95% CI:
3.2–10.4, p = .004 relative to those
without MetS; interpret with caution).
Furthermore, the proportion of Canadian
adults at intermediate to high risk of a
CVD event is 8.9% (95% CI: 4.3–13.6;
interpret with caution) in those with MetS,
compared with 2.0% (95% CI: 1.3–2.7,
p = .008) in those without MetS.
FIGURE 1
Prevalence of different metabolic syndrome risk markers in individuals with metbolic syndrome, CHMS 2007–2009
100
89.2
82.3
75.4
Prevalence, %
80
53.3
60
40.3
40
20
0
Waist
Circumference
Hypertriglyceridemia
Low HDL
cholesterol
High Fasting Plasma
Glucose
Hypertension
Abbreviation: HDL, high density lipoprotein.
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 2
Metabolic syndrome prevalence and odds ratios according to population characteristics,
CHMS 2007–2009
Definitions
Prevalence
95% CI
p value
Crude
15.5
12.0–19.0
—
Adjusted
14.9
13.3–16.6
OR
95% CI
rNCEP ATP III
IDF
23.1
20.4–25.8
Adjusted
22.3
20.4–24.3
< .001
Harmonized
Crude
19.6
15.9–23.2
Adjusted
19.1
17.3–20.9
< .001
Men (ref)
14.5
10.4–18.6
—
1
Women
16.5
12.6–20.3
.25
1.12
Caucasian (ref)
15.5
12.1–18.8
—
1
Non-Caucasian
16.6E
5.4–27.7
< .001
8.0E
4.4–11.5
—
Characteristics
Overall population
Sexa,b
2.66
—
1.29–5.45
Men
Ageb
E
1
—
40–59
14.5
6.7–22.4
.05
1.48
0.67–3.26
60–80
26.9
21.3–32.5
.012
3.33
2.07–5.34
Smoking statusa,b
6.6E
Current
Comparing prevalence for MetS using the
same rNCEP definition, the age-adjusted
rate in Canada is less than half that
reported in the United States (14.9% vs.
34.4%),14 but similar to previously published findings for the Canadian population.34 Using newly suggested IDF
definitions, which take into account variations in waist circumference for different
ethnic groups, or the Harmonized definition, the age-adjusted prevalence of MetS
in Canada is higher than with the rNCEP
(22.3% and 19.1%, respectively), showing that the choice of definition for MetS
does appear to matter.
—
0.87–1.42
Ethnicitya,b,c
20–39 (ref)
Prevalence of metabolic syndrome
Odds Ratios
%
Crude
Discussion
2.0–11.1
.01
0.65
0.23–1.86
Former
24.1
15.5–32.7
.12
1.54
0.66–3.61
Never (ref)
11.4E
5.6–17.3
—
1
We chose to use the rNCEP definition for
MetS in our study to facilitate comparisons
with previously published epidemiological
data.14 The rNCEP definition was reasonably accurate in representing the ethnic
composition of our study population (84%
Caucasian; Table 1). While sample size
limitations did not allow us to explore
variations in MetS prevalence based on
self-reported ethnic origin, when this
information was used to apply the IDF
definition of MetS, it appears as though
more people are being included as having
MetS.15
—
a,b
Risk factors and metabolic syndrome
LTPA
Active (ref)
12.0
8.5–15.6
Inactive
16.9E
10.0–23.9
—
1
.001
1.39
—
0.69–2.78
2 a
BMI, kg/m
—F
—
—
1
—
25–29
15.8
10.4–21.2
< .001
—F
—
§ 30
38.6
25.5–51.8
< .001
—F
—
—F
—
—
1
18.7E
11.7–25.7
.003
3.67
1.20–11.17
31.5
24.3–38.6
< .001
7.43
2.62–21.05
21.1
13.6–28.5
.71
3.15
1.63–6.07
0.93–4.59
< 25 (ref)
Women
Ageb
20–39 (ref)
40–59
60–80
—
a,b
Smoking status
Current
E
Former
21.3
10.8–31.8
.38
2.06
Never (ref)
11.0
8.7–13.3
—
1
—
Continued
Continued on
on the
the following
following pages
page
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
40
Our findings indicate that the prevalence
of MetS in Canada is associated with age,
ethnicity, BMI and leisure time physical
activity. Older age was significantly associated with MetS, but the patterns of
prevalence varied by age and sex.
Prevalence was higher in men than in
women in the 30- to 39-year age group.
Thereafter, the prevalence of MetS
increases steadily in women, exceeding
the prevalence of MetS in men, from age
40 through 60 to 74 years, after which
time it levels off. In men, the steady
increase in prevalence seems to occur
after the age of 40. Tjepkema35 suggested
that this transition reflects the marked
increase in rates of obesity in men after
age 45 years. In the same study,
Tjepkema35 also showed that obesity rates
increase steadily in women until age 65
TABLE 2 (continued)
Metabolic syndrome prevalence and odds ratios according to population characteristics,
CHMS 2007–2009
Characteristics
Definitions
Prevalence
%
95% CI
Odds Ratios
p value
OR
95% CI
LTPAa,b
Active (ref)
10.5E
6.6–14.5
—
Inactive
20.2
15.4–25.0
< .001
BMI, kg/m2
1
—
1.76
1.13–2.73
a
—F
—
—
1
—
25–29
22.9
16.1–30.0
< .001
—F
—
§ 30
43.2
34.2–52.2
< .001
—F
—
< 25 (ref)
in Mexican American and non-Hispanic
white individuals in the United States.14
In addition to Hispanic and African
Canadians, we included Filipino, Chinese,
South Asian, Arab and other populations
in our study. It is possible that the
inclusion of these additional groups may
account for the difference in the odds
of MetS by ethnicity between the two
studies. Previous findings using the rNCEP
definition also showed higher prevalence
rates in some of the ethnic groups
included in our study relative to our
overall population.37,38
Source: Canadian Health Measures Survey, 2007–2009, clinic dataset.
Abbreviations: BMI, Body Mass Index; CHMS, Canadian Health Measures Survey; CI, confidence interval; IDF, International
Diabetes Federation; LTPA, leisure time physical activity; ref, reference; rNCEP ATP, revised National Cholesterol Education
Program Adult Treatment Panel III.
Note: The adjusted prevalence estimate is age-adjusted to the Canadian Census information.
a
Odds ratio adjusted for age.
b
Odds ratio adjusted for BMI.
c
Odds ratio adjusted for sex.
E
Interpret with caution (coefficient of variation: 16.6%–33.3%).
F
Cannot be reported (coefficient of variation: > 33.3%).
years. The changes in prevalence that we
observed align with reported increased
rates of MetS in peri- and post-menopausal
women.36
The odds of MetS were significantly higher
in non-Caucasian individuals, and we
found greater risk of MetS in nonCaucasian Canadians than was found
Our results indicate that being physically
active lowers the odds of MetS compared
with being inactive, although this lower
risk is only statistically significant in
women. Our analysis clearly shows that
rates of overweight and obesity are high in
adults, with a prevalence of almost 57%.
This is of concern given the close association of obesity with MetS, as well as with
pre-diabetes.39
MetS is commonly associated with prediabetes, wherein individuals have elevated plasma glucose levels as well as
FIGURE 2
Prevalence of metabolic syndrome by gender and by age group, CHMS 2007–2009
35
Both
Males
30
Females
Prevalence, %
25
20
15
10
5
0
30–39
40–49
50–59
60–74
75+
Age, years
Source: Canadian Health Measures Survey, 2007–2009, clinic dataset.
Abbreviation: CHMS, Canadian Health Measures Survey.
Note: For all reported age groups, except for ages 60–74 years, estimates should be interpreted with caution (coefficient of variation: 16.6%–33.3%). Estimates that could not be reported
(coefficient of variation: > 33.3%) were not included in the figure.
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41
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 3
Prevalence of diagnosed and undiagnosed chronic conditions in the overall population and in individuals with obesity and with metabolic
syndrome, CHMS 2007–2009
Overall
%
Obesity
p valueb
Metabolic Syndrome
95% CI
%
95% CI
p valuea
%
95% CI
p valuea
14.2–20.1
33.6
25.2–41.9
.001
36.1
29.0–43.1
< .001
.61
—
—
Hypertension
Diagnosed
Undiagnosed
17.2
E
F
0.7
0.2–1.1
—
3.4
2.4–4.5
8.0
F
—
—
—
—
5.2–10.8
.003
11.2E
6.7–15.6
.003
.07
2.2–9.8
.009
.27
1.2–6.8
.13
—
14.9–29.5
.002
.10
Diabetes
Diagnosed
Undiagnosed
E
E
1.1
0.6–1.7
4.4
1.5–7.2
.02
6.0E
1.9
1.4–2.4
—F
—
—
4.0E
9.0–21.5
.11
Chronic Kidney Disease
Diagnosed
Undiagnosed
E
10.0
8.1–11.9
15.2
Diagnosed
29.4
26.5–32.3
37.0
31.3–42.6
.02
50.8
46.6–55.1
< .001
< .001
Undiagnosed
10.0
6.9–13.1
18.5
12.3–24.7
.006
28.3
22.5–34.1
< .001
.006
22.2
Dyslipidemia
Source: Canadian Health Measures Survey, 2007–2009, clinic dataset.
Abbreviations: CHMS, Canadian Health Measures Survey; CI, confidence interval.
a
These p values represent the significance of the difference between population subgroups and the overall population.
b
This p value represents the significance of the difference between population subgroups.
E
Interpret with caution (coefficient of variation: 16.6%–33.3%).
F
Cannot be reported (coefficient of variation: > 33.3%).
systemic inflammation. It is also associated with characteristics such as prothrombotic state and dyslipidemia, which
may account for its link to cardiovascular
risk.40 The increased risk of type 2
diabetes and of a fatal CVD event in
individuals with MetS is thus not surprising, given the research demonstrating
these associations.5,41 The proportion of
individuals identified as being at risk of
developing diabetes in the next 10 years,
relative to those without MetS, indicates
the role of MetS as a potential chronic
disease indicator. These findings are corroborated by a 2010 study that estimated
risk of diabetes for Canadians at 8.9%.42
When considering the projections for
CVD, which estimate the risk of a fatal
event, the concern is clear.
We need to be aware of a possible overlap
in definitions for chronic disease risk
factors and for MetS. In the case of
dyslipidemia, this overlap may contribute
to the high rates of abnormal lipid levels in
those with MetS. The risk marker of low
HDL cholesterol was prevalent in 75% of
the population with MetS, but it is worth
noting that the definition of dyslipidemia
was based on a high total cholesterol to
HDL cholesterol ratio combined with
elevated LDL levels. Similarly, MetS is
defined based on waist circumference, not
BMI, which makes both populations distinct but potentially related.
Public health impact of metabolic
syndrome
previous study has described MetS as
more predictive of future disease than
obesity alone.44 The greater association
between chronic disease and MetS in our
study may, therefore, further signify a
public health utility for MetS as a key
indicator of disease risk.
Limitations
Independent of race/ethnicity, age, sex
and health status, evidence shows an
increased risk of developing certain
chronic diseases with each additional
MetS risk marker.41 Reaven43 suggests
that even though an individual may not
meet the number of risk markers (3 or
more) necessary to be diagnosed with
MetS, they may still be at risk of future
disease and should therefore not be overlooked. We found that 50% the study
population had one or two MetS risk
markers, by no means a small proportion.
We compared MetS with a well-studied
chronic disease risk factor, obesity. Our
findings demonstrated a higher prevalence
of chronic disease in individuals with
MetS compared with those with obesity
(shown in Table 3), although the differences were not statistically significant. A
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
42
Working with the CHMS data, sample size
proved to be a limiting factor in providing
reportable estimates for key covariates,
such as for sociodemographic characteristics, and limited the scope of the study to
a national viewpoint, since it is not built to
produce regional estimates. Further, the
use of self-reported information for activities such as smoking or leisure time
physical activity may have proven to be
a limitation. Due to the lack of pertinent
variables to measure undiagnosed diabetes, our definition is limited in scope
and interpretations should be made with
caution. To limit the effects of confounders, BMI, age and sex were all controlled
for in multivariate analyses. The removal
of missing values may have contributed to
a downward bias in our diabetes risk
projections since the proportion of missing
Ten‐year projections,
% FIGURE 3
Ten-year projections for the cumulative
incidence of diabetesa and mean percent risk of
a fatal CVDb event in individuals with or
without MetS,c CHMS 2007–2009
10
9
8
7
6
5
4
3
2
1
0
MetS
No MetS CVD c
future chronic disease, it may be of value
for clinicians to include MetS, in addition to
obesity, as an indicator for chronic disease
and useful for public health policy-makers
to consider MetS when directing preventive
population health efforts.
4.
National Cholesterol Education Program
(NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood
Cholesterol in Adults (Adult Treatment
Panel III). Third Report of the National
Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation,
and Treatment of High Blood Cholesterol
in Adults (Adult Treatment Panel III) final
report. Circulation. 2002;106:3143-421.
5.
Mottillo S, Filion KB, Genest J, et al. The
metabolic syndrome and cardiovascular
risk a systematic review and meta-analysis.
J Am Coll Cardiol. 2010;56:1113-32.
6.
Ford ES, Li C, Sattar N. Metabolic syndrome and incident diabetes: current state
of the evidence. Diabetes Care. 2008;31:
1898-904.
7.
Esposito K, Chiodini P, Colao A, Lenzi A,
Giugliano D. Metabolic syndrome and risk
of cancer: a systematic review and metaanalysis. Diabetes Care. 2012;35:2402-11.
8.
Chen J, Muntner P, Hamm LL, et al. The
metabolic syndrome and chronic kidney
disease in US adults. Ann Intern Med. 2004;
140: 167-174.
9.
Bonora E, Targher G, Formentini G, et al.
The metabolic syndrome is an independent
predictor of cardiovascular disease in type
2 diabetic subjects. Prospective data from
the Verona Diabetes Complications Study.
Diabet Med. 2004;21:52-8.
Acknowledgements
Diabetes d
Source: Canadian Health Measures Survey, 2007–2009,
clinic dataset.
Abbreviations: CVD, cardiovascular disease; CHMS,
Canadian Health Measures Survey; CI, confidence interval;
MetS, metabolic syndrome.
Note: Given the identified population prevalence of MetS
among Canadian adults (85.1% without MetS, 14.9% with
MetS), this suggests a projected 10-year risk of a fatal CVD
event as 1.29%, and a projected 10-year cumulative
incidence of diabetes as 8.7% (95% CI: 7.5–9.9).
a
Estimated using the Diabetes Population Risk Tool
(DPoRT).32
b
Calculated using the lipid-based Framingham 10-year risk
calculator.33 The population subset for CVD projections was
restricted to adults aged 30–74 years who have no previous
history of a CVD event.
c
Projections: With MetS = 4.1% (95% CI: 2.3–6.0), p < .01;
without MetS = 0.8% (95% CI: 0.6–1.0), p < .01.
d
Projections: With MetS = 18.0% (95% CI: 15.3–20.7),
p < .01; without MetS = 7.1% (95% CI: 6.2–8.1), p < .01.
Deepa P. Rao is supported by a Frederick
Banting and Charles Best Doctoral
Research Award from the EvidenceInformed Healthcare Renewal Initiative
of the Canadian Institutes of Health
Research (CIHR) Knowledge Translation
Branch. Dr. D. Krewski holds a Natural
Sciences and Engineering Research
Council of Canada (NSERC) Industrial
Research Chair in Risk Science.
The Canadian Health Measures Survey
was conducted by Statistics Canada in
partnership with Health Canada and the
Public Health Agency of Canada with
funding from the Canadian Federal
Government.
We thank Dr. Michael J. Pencina, of
Boston University, for providing us with
the SAS-based macro to calculate the CVD
risk projections and Dr. Laura Rosella and
Mr. Michael Lebenbaum, of Public Health
Ontario, for helping us use the DPoRT
algorithm for diabetes risk projections.
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values for BMI tends to be higher among
females. However, since missing values
for women only represent a small proportion of all responses for BMI among
females, their removal should not skew
our results.
Conclusion
MetS represents a condition that is strongly
associated with factors such as obesity,
ethnicity and leisure time physical activity.
Our study demonstrates the differential
pattern by which MetS affects specific
subpopulations and indicates an association between MetS and major chronic
conditions.45 Since Canadians with MetS
have significantly higher rates of undiagnosed chronic diseases than the overall
population and higher predicted rates of
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al. General cardiovascular risk profile for
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34. Ardern CI, Katzmarzyk PT. Geographic and
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Impact of individual and ecological characteristics on small for
gestational age births: an observational study in Quebec
N. Savard, MSc (1, 2); P. Levallois, MD (1, 2, 3); L. P. Rivest, PhD (4); S. Gingras, MSc (2)
This article has been peer reviewed.
Abstract
Introduction: We evaluated associations between ecological variables and the risk of
very small for gestational age (VSGA) birth in Quebec in 2000–2008.
Methods: Ecological variables came from the Canadian Community Health Survey, the
Canadian census and Quebec’s birth registry; individual variables also came from
Quebec’s birth registry. Odds ratios (ORs) adjusted for mother’s age, academic
qualification, parity, marital status and country of birth were estimated using
multilevel logistic regression (generalized estimating equations method).
Results: Births in neighbourhoods with a high proportion of people leading a sedentary
lifestyle (OR: 1.07, 95% confidence interval [CI]: 1.01–1.11) and those with a high/
middle proportion of residents with food insecurity (OR: 1.09, 95% CI: 1.05–1.15; OR:
1.05, 95% CI: 1.01–1.11) had higher odds of VSGA birth. Those with middle proportion
of married residents had lower odds of VSGA birth (OR: 0.94, 95% CI: 0.90–0.98).
Keywords: birth weight, fetal health, reproductive health, social epidemiology, health
behaviour, sedentary lifestyle, food insecurity
Introduction
Individuals with sub-optimal fetal development that results in small for gestational
age (SGA) or very small for gestational age
(VSGA) birth are at an increased risk of
neonatal illness and are more likely to
develop type 2 diabetes, hypertension,
metabolic syndrome and coronary diseases in adulthood.1
Risk factors for sub-optimal fetal development include characteristics of maternal
age, race, parity, partnership status, education and smoking.1-3 Neighbourhood deprivation is also associated with health4
and with a number of modifiable individual risk factors such as smoking and
alcohol consumption during pregnancy.5
Unfortunately, past ecological analyses
were often mostly based on available data
rather than on plausible social pathways.4,6
In Canada and in the United States, this
yielded a set of widely explored neighbourhood census-derived features, including
economic deprivation,7-22 race,10,11,15,17,19
crime,15,23 and single-headed households.19
A few studies used data from large specific
surveys on features of the built and social
environment.8,11,16,24,25 The researchers
observed that social support24 and availability or use of neighbourhood services11,16 were associated with the risk of
adverse birth outcomes, while built environment16 and availability of restaurants
and supermarkets8 were not. Residents’
sedentary lifestyles were previously asso-
ciated with a higher risk of SGA in a model
that was built only from ecological variables for public health purposes.25 To our
knowledge, residents’ food consumption
was not included in previous ecological
analyses of SGA or VSGA.
We had access to information on singleton
births through Quebec’s birth registration
forms. We collected information about
Quebec’s local community services centres (CLSC) from three sources: Quebec’s
birth registration forms, a survey on
Canadian residents and the Canadian
census. While hypothesizing the model
shown in Figure 1 to identify program
levers for intervention, we evaluated
associations between individual variables
and the outcome of VSGA. We also
evaluated associations between single
and aggregated CLSC territory variables
and VSGA.
Methods
Study population and setting
The population of this observational study
consisted of singleton live births that took
place between 2000 and 2008 and their
mothers, in Quebec, Canada. Because the
survey data from the northern regions of
Nord-du-Québec, Terres-Cries-de-la-BaieJames and Nunavik were not methodologically comparable to other provincial
regions, we did not include them.
Neonates with missing weight or gestational age, those born at less than 22
weeks or more than 43 weeks gestation
Author references:
1.
2.
3.
4.
Department of Social and Preventive Medicine, Université Laval, Québec, Quebec, Canada
Institut national de santé publique du Québec, Québec, Quebec, Canada
Centre hospitalier universitaire du Québec, Québec, Quebec, Canada
Department of Mathematics and Statistics, Université Laval, Québec, Quebec, Canada
Correspondence: Nathalie Savard, INSPQ, 1000 Route de l’Église, Québec, QC G1V 3V9; Tel.: 418-654-3010 ext. 5741; Fax: 418-654-3032; Email: nathalie.savard.8@ulaval.ca
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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FIGURE 1
Mother and neonate’s individual explanatory variables from the birth registry, Quebec, Canada, 2000–2008
Social environment
Material deprivation
Mean income, $
% population without high school diploma
% mothers without high school diploma
% population smoking cigarettes daily
Social isolation
% of unmarried people
% of unmarried mothers
% of single-headed households
% of workers walking or biking to work
Race
% of immigrants
% of people speaking a non-official language at home
% mothers born outside of Canada
Other environment variables
Neighbourhood is urban, semi-urban or rural
% people having ≥ 5 alcohol drinks on ≥ 1 occasion/week
% of people eating fruit/vegetables less than 5 times/day
% of people with low tangible social support
% of sedentary people (physically inactive)
% people with food insecurity
Mean age, years
Individual characteristics of mother and neonate
Mother’s age
Mother’s marital status
Mother’s material deprivation (education)
Mother being Canadian-born
Mother’s parity
Premature birth of neonate
VSGA neonate
Abbreviation: VSGA, very small for gestational age.
Note: Accounting for associations of contextual variables through individual variables (dashed arrows) enabled the study of contextual associations above and beyond association through
individual variables (full arrow).
and those with implausible weight for
gestational age were also excluded.26
Territory definition
Territories were the 143 CLSCs, the first
level of organization of the Quebec health
care system. CLSCs had an average of
46 727 residents and 4666 singleton live
births from 2000 to 2008.
Variables
Outcome
Neonates with a weight for gestational age
below the 5th percentile on the Canadian
sex-specific standardized scale were identified as VSGA.27
Individual variables
We categorized individual characteristics
gathered from birth registration forms.
These included maternal age at delivery
(< 20, 20–24, 25–29, 30–34, § 35 years);
marital status (married in a civil or
religious ceremony vs. unmarried); highest academic qualification (less than high
school, high school diploma, college,
university and higher); mother’s place of
birth (Canada vs. not Canada) and parity
(primiparous vs. multiparous).
Aggregated ecological variables
Aggregated ecological variables for births
and the whole population of the CLSC
(men, other women, youth and the elderly)
summarize the average level of a characteristic within the CLSC territory population
(Table 1). We calculated birth-oriented
variables over CLSC territories by pooling
individual data. Population-oriented variables were obtained both by producing
proportion-like values from the responses
of individuals surveyed in the Canadian
$
47
Community Health Survey (CCHS)25,28 and
by pooling census profiles of sub-territories.
The proportions were coded into first,
second and third tertiles (for the lowest,
middle and upper-most parts of the distribution). The first tertile was the reference
for all variables except for mean income,
where the third tertile was the reference.
We imputed missing values using the SAS
multiple imputation (MI) procedure, with
the MCMC method for categorical individual variables and the EM algorithm with
the logit transform for proportions.29
Data sources
Birth registration forms from 2000 to 2008
are part of Quebec’s registry of demographic events.30 The forms include information on all live births (weight at birth,
maternal age at delivery, marital status,
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 1
Explanatory ecological variables at the local community services centre (CLSC) level, Quebec, Canada, 2000–2008
Target population and data source
Ecological variable
Birth registry information (2000–2008)
Births
Mothers without high school diploma, %
Births
Mothers born outside of Canada, %
Births
Unmarried mothers, %
Canadian Community Health Survey (2000–2001; 2003; 2005; 2007–2008)
Population of § 12 years
a
People smoking cigarettes daily, %
b
Population of § 12 years
a
People drinking § five alcohol drinks at each occasion § 1 per week, %
Population of § 12 years
a
People eating fruit and vegetables < 5 times per day, %
Population of § 12 years
a
People with low tangible social support, %
Population of § 12 years
a
Sedentary (physically inactive) people in the past 3 months, %
Population of § 12 years
a
b
b
b,c
People with food insecurity in the past 12 months, %
b
b
Census profiles (2000 and 2006)
Total population
a
Urban/rural continuum (local community services centre combines only urban sub-territories,
rural and urban sub-territories or only rural sub-territories)
Population 25–64 years (2006) and § 20 years (2001)
People without high school diploma, %
Total population
Mean age, years
Total population
Immigrants, %
Total population
People speaking a non-official language at home, %
Population § 15 years old with income
Mean income, $
Population § 15 years old
Unmarried people, %
Households (private)
Single-headed households, %
Workers § 15 years old
Workers walking or biking to work, %
Includes only individuals living at home.
b
Proportion-like value that excludes year-cycle and data collection method effects of the survey.
c
< 15 out of 95 on the Social Support Survey subscale of the Medical Outcome Study.
of residence. Odds ratios (OR) were used
to estimate relative risks.
unexplained variation resulting from the
individual model with interaction terms.
Statistical analysis
Regression
We estimated adjusted ORs for individual
variables (ORIAdjusted) using a multilevel
logistic regression fitted through generalized estimating equations (GEE). We
chose the mother as the first level and
the CLSC as the second.33 The GEE
method provides consistent OR estimates
for the population even though the
correlation between mothers from the
same CLSC is unknown. We assumed
this correlation to be small; hence the
‘‘independence working correlation’’
structure was provided as a starting point
for the computations. We obtained
empirical standard error estimates and
thus avoided problems with correlation
misspecification.34
We obtained crude ORs (ORECrude) and
ORs adjusted for individual variables and
interaction terms (OREAdjusted I) using the
GEE method for each ecological variable.
Interactions between individual variables
were selected using the stepwise method
with the option ‘‘hierarchy = multiple’’ of
the logistic procedure (entry/stay p values
< .001). A final model was built using
variables with significant OREAdjusted I values
as candidates in a stepwise method and
by forcing inclusion of individual variables as well as interaction terms (entry/
stay p values of .25/.05). GEE parameter
estimates adjusted for individual variables and for other ecological variables
(OREAdjusted IE) were produced for every
ecological variable.
CLSC values were linked to individual
births based on the mothers’ postal code
A deviance test determined whether
CLSCs explained a significant part of the
Ecological results were restricted to showing those variables with differences in
mother’s highest academic qualification,
mother’s place of birth, parity) and the
postal code of the mothers’ residence at
time of giving birth.
The CCHS is a cross-sectional survey that
has, to date, been conducted in four yearlong cycles (2000–2001, 2003, 2005 and
2007–2008).28 To increase statistical power,
we pooled the four survey year-cycles.31
The 2001 and 2006 census profiles are
available at two sub-territory levels: census
tracts and census subdivisions.32 Tracts
were used in metropolitan areas and
subdivisions elsewhere. Hence, sub-territories had similar population sizes. Subterritory profiles were aggregated by CLSC
regardless of the year of data collection.
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crude ORs. We presented a maximum of
one material deprivation, racial and social
isolation variable (Figure 1) by dataset (all
data available from the authors on
request).
research project. Analysis was carried
out using SAS version 9.2 (MI, LOGISTIC
and GENMOD procedures).29 Regression
results were considered statistically significant if p values were less than .05.
The adjusted OR values (ORIAdjusted,
OREAdjusted I and OREAdjusted IE) were validated by two sensitivity analyses, first,
with non-imputed data, and second, by
incorporating variables at the smallest
possible territory level, that is, census
and birth data at the sub-territory level
(there are 2368 sub-territories) plus CCHS
data at the CLSC level.
Results
The Commission d’accès à l’information
du Québec and the Ethics Committee of
the Université Laval approved this
Descriptive analysis
Of the 676 165 singleton births recorded
in all of Quebec’s regions between 2000
and 2008, 7379 were to mothers from
northern regions, 850 could not be linked
to CLSCs, 67 had no SGA status (missing
weight or gestational age), 452 had less
than 22 weeks or more than 43 weeks
gestation and 163 had implausible weights
for gestational age. Thus, our population
consisted of a total of 667 254 births in 143
CLSCs.
Regression
Every individual variable was significantly
associated with VSGA (Table 2). Mothers
without and with a high school diploma
and with a college diploma were at a
higher risk (ORIAdjusted = 2.08, 1.53 and
1.14, respectfully) of VSGA compared with
mothers with a university degree; firsttime mothers were also at a higher risk
(ORIAdjusted = 1.96) than other women, all
other individual variables being equal.
CLSCs represented a significant part of the
unexplained variation that resulted from
the individual model with interactions
TABLE 2
Adjusted odds ratios for VSGA singleton live births according to maternal individual explanatory variables, Quebec, Canada, 2000–2008
Variable
% imputed
a
N
ORIAdjusted
%
Estimate
Age, years
0.0
100.0
b
95% CI
c
< .001
d
< 20
21 566
3.2
0.90
0.83–0.98
20–24
114 780
17.2
1.00
0.96–1.04
25–29e
235 120
35.2
1.00
—
30–34
198 985
29.8
1.08
1.03–1.12
§ 35
96 803
14.5
1.39
1.31–1.47
Marital status
0.0
100.0
e
< .001
d
Married
268 130
40.2
1.00
—
Unmarried
399 124
59.8
1.18
1.13–1.23
Highest academic qualification
8.7
10.1
e
University degree
229 122
34.3
< .001
1.00
d
—
College degree
173 265
26.0
1.14
1.10–1.19
High school diploma
197 485
29.6
1.53
1.47–1.60
67 382
10.1
2.08
1.96–2.21
< High school
Mother’s country of birth
Canada
1.2
100.0
e
Other
Parity
< .001
540 272
81.0
1.00
—
126 982
19.0
1.28
1.20–1.36
0.0
47.3
d
d
< .001
d
Multiparous
351 539
52.7
1.00
—
Primiparous
315 715
47.3
1.96
1.90–2.03
Abbreviations: CI, confidence interval; OR, odds ratio; VSGA, very small for gestational age.
a
Percentage of births with imputed values.
b
Odds ratio adjusted for individual variables (mother’s age, mother’s marital status, mother’s academic degree, mother’s country of birth and mother’s parity).
c
Confidence intervals built using robust variance estimates resulting from a multilevel model fitted using generalized estimating equations (GEE).
d
p value of test of global difference.
e
Reference category.
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(chi-square statistic = 497.3 p < .001;
df = 142). For this reason, it was
appropriate to include aggregated CLSC
variables in the model.
There were significant crude associations
between VSGA and every ecological variable presented except for ‘‘people eating
fruit and vegetables less than five times
a day’’ and ‘‘urban/rural continuum’’
(Table 3; additional data are available from
the authors on request). Adjusted ORs
(OREAdjusted I) were slightly lower than crude
values (ORECrude), though confidence intervals did not indicate significant differences.
When accounting for individual variables,
births in CLSCs with lowest mean income
(OREAdjusted I = 1.12) and variables ranking
in the third tertile of the following categories
had higher risks of VSGA: mothers without
high school diploma (OREAdjusted I = 1.12);
immigrants (OREAdjusted I = 1.06); mothers
born outside of Canada (OREAdjusted I =
1.08); people speaking a non-official language at home (OREAdjusted I = 1.08) and
single-headed households (OREAdjusted I =
1.11) (Table 3). Births in CLSCs ranking in
second or third tertiles of food insecurity
(OREAdjusted I = 1.08; 1.14) and sedentariness (OREAdjusted I = 1.06; 1.11) also had
higher risks of VSGA, while those in CLSCs
ranking in the second tertile with respect to
unmarried residents (OREAdjusted I = 0.93)
had lower risks.
The final model incorporated ecological
variables of food insecurity, sedentariness
and partnership status. Births in CLSCs
ranking in the second or third tertile of
people with food insecurity had higher risks
of VSGA (OREAdjusted IE = 1.05; 1.09) when
adjusted for all individual variables, unmarried residents and sedentariness. Births in
CLSCs ranking in the third tertile of sedentariness also had higher risks of VSGA
(OREAdjusted IE = 1.07) when adjusting for
these same variables. In a similar manner,
births in CLSCs with middle proportion of
unmarried residents had lower risks of
VSGA (OREAdjusted IE = 0.94) (Table 3).
Adjusted ORs (ORIAdjusted, OREAdjusted I and
OREAdjusted IE) would have been similar
had we used non-imputed data. Some
ORIAdjusted values (for mothers § 35
years, for mothers with high school
diploma, for those with less than high
school, as well as for primiparous
mothers) would have been smaller and
OREAdjusted I and OREAdjusted IE would have
been similar had we studied 5th to 10th
percentile of neonatal weights. Likewise,
OREAdjusted I and OREAdjusted IE would have
been similar had they been assessed with
a logistic model incorporating variables at
the smallest possible territory level.
Exceptions apply to third tertile mothers
without a high school diploma and second
tertile single-headed households that had
higher OREAdjusted I values in the latter
analysis.
Discussion
We adopted a comprehensive approach to
understanding the determinants of fetal
health in Quebec, Canada, by using
ecological information from a separate
survey, birth data and the census in a
context in which individual data were
available. We found associations between
VSGA and ecological variables from each
source of data independent of individual
variables. Neither census data, survey
data nor Quebec’s birth data contained
such a wide spectrum of relevant area
variables. The ecological variables of food
insecurity and sedentariness were pertinent for inclusion in a model with several
ecological variables. Both were significantly associated with VSGA. Those
ecological variables are not necessarily
proxies for individual food insecurity and
sedentariness. For example, in previous
analyses an income below the lowincome cut-off in the CLSC reflected both
social isolation and race, whereas mean
income reflected material deprivation.25
Some of the ecological variables we
investigated in this research have also
been examined in Canadian and American
studies.7,9,13,14,19 When individual variables and a few ecological variables were
available and accounted for, significant
associations were found between SGA and
the low-income cut-off both among the
births in Quebec from 1991 to 200014 and
among births in Montréal from 1997 to
2001.9 There was also a significant association between SGA and material deprivation measured by area income in
Ontario from 2004 to 2006.13
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When individual variables and several
ecological variables were accounted for,
social isolation and race (measured by
single-headed households, low income
and ethnicity) were no longer significantly
associated with low birth weight among
South Carolina births from 2000 to 2003.19
These variables were not included in our
final model with several ecological variables.
Limitations
There are a few limitations worth highlighting. First, we were interested in suboptimal fetal development as measured by
the VSGA indicator. Some constitutionally
small births may not have been a result of
sub-optimal fetal development but, being
classified as VSGA, contributed to a nondifferential misclassification bias of the
outcome. Such misclassification was minimized using the VSGA instead of the SGA
indicator.
CLSC exposure was potentially misclassified. By pooling data, we implicitly postulated that CLSC tertiles remained the same
throughout the years. Moreover, information about relocated mothers was unavailable. According to 2006 census data,35
about 3.5% of women were incorrectly
assigned to the CLSC tertile we had
attributed to them. These misclassifications contributed to a small bias toward
the null value.
Our results might have been subject to
confounding of unmeasured individual
factors such as maternal characteristics
of social isolation, lifestyle (smoking,
caffeine, high alcohol consumption, abuse
or sedentariness) and health status (daily
caloric intake, maternal body mass index
[BMI], maternal hypertension or diabetes
in pregnancy).
Our pooled data did not allow us to
distinguish the effect of ecological exposure during pregnancy from prior exposure and to note whether the association
of deprivation with VSGA has changed
over time.
Finally, we were limited by the relatively
little knowledge available on the spatial
scale that is likely to be relevant to this
TABLE 3
Crude and adjusted odds ratios for VSGA singleton live births according to ecological variables, Quebec, Canada, 2000–2008
Variable
a
Mean income, $
Percent
imputed b
%
Population
N
(%)
ORECrude
Estimate
c
OREAdjustedI
95% CI
Estimate
.001f
0.0
d
OREAdjustedIEe
95% CI
Estimate
95% CI
.012f
Highest tertile (28 798–56 036) (reference)
331 133
(49.6)
1.00
—
1.00
—
—
—
Middle tertile (25 269–28 797)
223 233
(33.5)
1.07
1.00–1.15
1.03
0.98–1.09
—
—
Lowest tertile (16 144–25 268)
112 888
(16.9)
1.22
1.13–1.33
1.12
1.02–1.15
—
—
Mother without high school diploma, %
f
0.0
f
< .001
.01
Lowest tertile (1.9–9.3) (reference)
309 090
(41.3)
1.00
—
1.00
—
Middle tertile (9.3–13.1)
229 173
(34.3)
1.13
1.06–1.21
1.05
1.00–1.11
—
—
Highest tertile (13.1–41.6)
128 991
(19.3)
1.25
1.15–1.37
1.12
1.04–1.20
—
—
Smoking cigarettes daily, %
.04f
1.4
NSf
Lowest tertile (0.5–20.4) (reference)
275 503
(41.3)
1.00
—
1.00
—
—
—
Middle tertile (20.5–25.8)
218 642
(32.8)
1.05
0.97–1.14
1.02
0.97–1.08
—
—
Highest tertile (25.9–47.1)
173 109
(25.9)
1.13
1.03–1.23
1.06
0.99–1.13
—
—
Immigrants, %
f
0.1
f
.01
.01
Lowest tertile (0.2–1.3) (reference)
106 403
(15.9)
1.00
—
1.00
—
—
—
Middle tertile (1.3–4.8)
234 675
(35.2)
0.96
0.89–1.04
0.98
0.92–1.05
—
—
Highest tertile (4.9–61.8)
326 176
(48.9)
1.09
1.01–1.17
1.06
1.00–1.13
—
—
Mother born in another country, %
.02f
0.0
.03f
Lowest tertile (0.0–1.9) (reference)
111 383
(16.7)
1.00
—
1.00
—
—
—
Middle tertile (2.0–8.1)
216 916
(32.5)
1.00
0.92–1.09
1.01
0.94–1.09
—
—
338 955
(50.8)
1.11
1.01–1.21
1.08
1.00–1.16
—
—
Highest tertile (8.2–88.1)
Unmarried mothers, %
.01f
0.0
NSf
Lowest tertile (14.9–64.9) (reference)
315 619
(47.3)
1.00
—
1.00
—
—
—
Middle tertile (65.0–75.8)
230 812
(34.6)
0.90
0.84–0.97
0.94
0.90–0.99
—
—
Highest tertile (75.8–90.4)
120 823
(18.1)
1.01
0.94–1.09
0.99
0.94–1.05
—
Unmarried residents, %
.005f
0.0
.03f
—
.04f
Lowest tertile (43.9–58.2) (reference)
203 717
(30.5)
1.00
—
1.00
—
1.00
—
Middle tertile (58.3–61.6)
219 668
(32.9)
0.93
0.85–1.02
0.93
0.87–0.99
0.94
0.90–0.98
Highest tertile (61.7–86.0)
243 869
(36.5)
1.05
0.96–1.15
0.98
0.93–1.05
0.95
0.91–1.00g
Walking or biking to work, %
f
0.0
f
.008
NS
Lowest tertile (2.4–6.8) (reference)
323 121
(48.4)
1.00
—
1.00
—
—
—
Middle tertile (6.8–10.2)
202 876
(30.4)
1.08
1.01–1.15
1.02
0.97–1.07
—
—
Highest tertile (10.3–64.0)
141 257
(21.2)
1.17
1.07–1.27
1.08
1.01–1.16
—
—
People with food insecurity, %
f
5.6
f
< .001
.001f
< .001
Lowest tertile (2.5–10.5) (reference)
222 636
(33.4)
1.00
—
1.00
—
1.00
—
Middle tertile (10.6–15.1)
238 685
(35.8)
1.13
1.05–1.22
1.08
1.01–1.15
1.05
1.01–1.11
205 933
(30.9)
1.25
1.16–1.34
1.14
1.07–1.21
1.09
1.05–1.15
Highest tertile (15.2–36.4)
Sedentariness, %
.001f
1.4
.005f
.05f
Lowest tertile (1.7–9.9) (reference)
215 997
(32.4)
1.00
—
1.00
—
1.00
—
Middle tertile (9.9–14.4)
209 287
(31.4)
1.10
1.03–1.18
1.06
1.01–1.12
1.03
0.98–1.07
Highest tertile (14.4–75.3)
241 970
(36.3)
1.20
1.11–1.29
1.11
1.05–1.18
1.07
1.01–1.11
§ 5 alcohol drinks § once per week, %
f
2.1
f
.01
NS
Lowest tertile (0.0–6.9) (reference)
256 571
(38.5)
1.00
—
1.00
—
—
—
Middle tertile (6.9–9.7)
260 022
(39.0)
0.91
0.85–0.98
0.94
0.90–0.99
—
—
Highest tertile (9.7–20.9)
150 661
(22.6)
1.04
0.95–1.13
1.00
0.94–1.07
—
—
Continued on the following pages
page
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
TABLE 3 (continued)
Crude and adjusted odds ratios for VSGA singleton live births according to ecological variables, Quebec, Canada, 2000–2008
Variable
a
Percent
imputed b
%
Mean age, years
Population
N
(%)
ORECrude
Estimate
c
OREAdjustedI
95% CI
Estimate
95% CI
.003f
0.0
d
OREAdjustedIEe
Estimate
95% CI
.04f
Lowest tertile (25.9–38.3) (reference)
264 998
(39.7)
1.00
—
1.00
—
—
—
Middle tertile (38.3–40.5)
246 054
(36.9)
0.99
0.91–1.07
0.98
0.93–1.04
—
—
Highest tertile (40.5–51.8)
156 202
(23.4)
1.10
1.02–1.20
1.05
0.98–1.12
—
—
Abbreviations: CI, confidence interval; NS, non significant; OR, odds ratio; VSGA, very small for gestational age.
Note: Confidence interval built using robust variance estimates resulting from a multilevel model fitted through generalized estimating equations.
a
The interpretation of an ecological portrait as a proxy of the corresponding individual variable could be inappropriate.
b
Percentage of local community services centres with imputed value.
c
Crude odds ratio.
d
Odds ratio adjusted for individual variables including interaction terms (mother’s age, mother’s marital status, mother’s academic degree, mother’s country of birth, mother’s parity,
academic degree 6 marital status, country of birth 6 age, country of birth 6 marital status, academic degree 6 country of birth, age 6 parity and academic degree 6 parity).
e
Odds ratio adjusted for contextual variables (people with food insecurity and inactive people) and for individual variables including interaction terms.
f
p value for test for global difference.
g
Value < 1.0.
specific health outcome.36 For this reason,
sensitivity analyses were done on data
pooled by sub-territories.
Mechanisms through which CLSC food
insecurity could be associated with lower
birth weight for gestational age include
interpersonal factors, which have been
shown to be consistently related to dietary
behaviours in young people.37 Higher prepregnancy weight in mothers, an unmeasured factor, could also lead to gestational
diabetes.38
Residents from CLSCs with less sedentariness or inactivity are certainly globally
healthier and have a lower incidence of
chronic diseases and disabilities.39
Mothers from these CLSCs have a better
chance of being physically active themselves. Inactivity of residents might be as a
result of the built environment encouraging (or otherwise) activity,37,39,40 rather
than the social environment doing so.37 In
addition, activity also reflects the global
understanding of public health messages
(people eating well, exercising, not smoking, etc.).37 Results appear relevant for
other countries with similar social welfare
systems.
sophisticated Canadian survey with census and birth data to build diversified
community-defined portraits. The use of
portraits derived from a broad range of
variables allowed for the identification of
ecological associations between VSGA and
marital status, food insecurity and sedentariness of residents. These ecological
associations were not identified as ‘‘contextual associations’’ as mothers’ food
insecurity and sedentariness were not
adjusted for in the analyses even though
many other individual characteristics
were.
Results of this study add to the growing
body of evidence suggesting that ecological social processes affect fetal health.
Future Canadian studies could benefit
from the inclusion of information gathered
by large surveys such as the CCHS to the
narrow set of census data to depict and
use details of neighbourhood contexts in a
comprehensive approach.
2.
Henrichs J, Schenk JJ, Roza SJ, et al.
Maternal psychological distress and fetal
growth trajectories: the Generation R
Study. Psychol Med. 2010;40:633-43.
3.
Blumenshine P, Egerter S, Barclay CJ,
Cubbin C, Braveman PA. Socioeconomic
disparities in adverse birth outcomes: a
systematic review. Am J Prev Med.
2010;39:263-72.
4.
Berkman
LF,
Kawachi
I.
Social
Epidemiology. New York (NY): Oxford
University Press; 2000.
5.
Timmermans S, Bonsel GJ, SteegersTheunissen RP, et al. Individual accumulation of heterogeneous risks explains perinatal
inequalities within deprived neighbourhoods. Eur J Epidemiol. 2010;26:165-80.
6.
Riva M, Gauvin L, Barnett TA. Toward the
next generation of research into small area
effects on health: a synthesis of multilevel
investigations published since July 1998. J
Epidemiol Community Health. 2007;61:
853-61.
7.
Auger N, Giraud J, Daniel M. The joint
influence of area income, income inequality, and immigrant density on adverse birth
outcomes: a population-based study. BMC
Public Health. 2009;9:237.
References
1.
World Health Organization. Promoting
optimal fetal development: report of a
technical consultation. Geneva (CH): WHO
Press; 2006.
In this effort to enlarge the set of
ecological determinants of fetal health,
we incorporated data aggregated from a
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8.
Farley TA, Mason K, Rice J, Habel JD,
Scribner R, Cohen DA. The relationship
between the neighbourhood environment
and adverse birth outcomes. Paediatr
Perinat Epidemiol. 2006;20:188-200.
9.
Généreux M, Auger N, Goneau M, Daniel
M. Neighbourhood socioeconomic status,
maternal education and adverse birth outcomes among mothers living near highways. J Epidemiol Community Health.
2008;62:695-700.
10. Gorman BK. Racial and ethnic variation in
low birthweight in the United States:
individual and contextual determinants.
Health Place. 1999;5:195-207.
11. Jaffee KD, Perloff JD. An ecological analysis
of racial differences in low birthweight:
implications for maternal and child health
social work. Health Soc Work. 2003;28:9-22.
12. Krieger N, Chen JT, Waterman PD, Rehkopf
DH, Subramanian SV. Painting a truer
picture of US socioeconomic and racial/
ethnic health inequalities: the Public Health
Disparities Geocoding Project. Am J Public
Health. 2005;95:312-23.
13. Liu N, Wen SW, Katherine W, Bottomley J,
Yang Q, Walker MC. Neighbourhood family
income and adverse birth outcomes among
singleton deliveries. J Obstet Gynaecol Can.
2010;32:1042-8.
14. Luo ZC, Wilkins R, Kramer MS. Effect of
neighbourhood income and maternal education on birth outcomes: a populationbased study. CMAJ. 2006;174:1415-20.
15. Masi CM, Hawkley LC, Piotrowski ZH,
Pickett KE. Neighborhood economic disadvantage, violent crime, group density, and
pregnancy outcomes in a diverse, urban
population. Soc Sci Med. 2007;65:2440-57.
16. Muhajarine N, Vu LT. Neighbourhood
contexts and low birthweight: social disconnection heightens single parents risks
in Saskatoon. Can J Public Health. 2009;
100:130-4.
17. Nkansah-Amankra S, Luchok KJ, Hussey
JR, Watkins K, Liu X. Effects of maternal
stress on low birth weight and preterm
birth outcomes across neighborhoods of
South Carolina, 2000-2003. Matern Child
Health J. 2010;14:215-26.
18. Nkansah-Amankra S, Dhawain A, Hussey
JR, Luchok KJ. Maternal social support and
neighborhood income inequality as predictors of low birth weight and preterm birth
outcome disparities: analysis of South
Carolina pregnancy risk assessment and
monitoring system survey, 2000-2003.
Matern Child Health J. 2010;14:774-85.
27. Kramer MS, Platt RW, Wen SW, et al. A new
and improved population-based Canadian
reference for birth weight for gestational
age. Pediatrics. 2001;108(2):E35.
19. Nkansah-Amankra S. Neighborhood contextual factors, maternal smoking, and
birth outcomes: multilevel analysis of the
South Carolina PRAMS survey, 2000-2003.
J Womens Health (Larchmt). 2010;19:
1543-52.
29. SAS Institute Inc. SAS/STAT 9.2 user’s
guide: the MI procedure. 2nd ed. Cary
(NC): SAS Institute Inc; 2009.
20. Pearl M, Braveman P, Abrams B. The
relationship of neighborhood socioeconomic characteristics to birthweight among
5 ethnic groups in California. Am J Public
Health. 2001;91:1808-14.
21. Rich-Edwards JW, Buka SL, Brennan RT,
Earls F. Diverging associations of maternal
age with low birthweight for black and
white mothers. Int J Epidemiol. 2003;32:
83-90.
22. Subramanian SV, Chen JT, Rehkopf DH,
Waterman PD, Krieger N. Comparing individual- and area-based socioeconomic measures for the surveillance of health
disparities: a multilevel analysis of
Massachusetts births, 1989-1991. Am J
Epidemiol. 2006;164:823-34.
23. Messer LC, Kaufman JS, Dole N, Herring A,
Laraia BA. Violent crime exposure classification and adverse birth outcomes: a
geographically-defined cohort study. Int J
Health Geogr. 2006;5:22.
24. Buka SL, Brennan RT, Rich-Edwards JW,
Raudenbush SW, Earls F. Neighborhood
support and the birth weight of urban
infants. Am J Epidemiol. 2003;157:1-8.
25. Savard N, Levallois P, Rivest LP, Gingras S.
A study of the association between characteristics of the CLSCs and the risk of
small for gestational age births among term
and preterm births in Quebec, Canada. Can
J Public Health. 2012;103:152-7.
26. Alexander GR, Himes JH, Kaufman RB, et
al. A United States national reference
for fetal growth. Obstet Gynecol. 1996;87:
163-8.
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53
28. Béland Y. Canadian community health
survey—methodological overview. Health
Rep. 2002;13:9-14.
30. Ministère de la Santé et des services sociaux.
Registre des événements démographiques Fichier des naissances vivantes (RED/naissances vivantes (K29)) [Internet]. Québec
(QC): Government of Quebec; [cited 2011
Feb 10]. Available from: http://www.informa
.msss.gouv.qc.ca/Details.aspx?Id=pDH1q4
exKSc=&Source=/dlVmYIVYBQ=
31. Thomas S, Wannell B. Combining cycles of
the Canadian Community Health Survey.
Health Rep. 2009;20:53-8.
32. Statistics Canada. Profile for Canada, provinces, territories, census divisions, census
subdivisions and dissemination areas, 2006
Census [Internet]. Ottawa (ON): Statistics
Canada; [cited 2011 Feb 10]. http://www5
.statcan.gc.ca/bsolc/olc-cel/olc-cel?catno=94
-581-X2006001&lang=eng
33. Rothman KJ, Greenland S, Lash TL. Modern
epidemiology. 3rd ed. Philadelphia (PA):
Wolters Kluwer Health/Lippincott Williams
& Wilkins; 2008.
34. Hardin JW, Hilbe JM. Generalized estimating equations. Boca Raton (FL): Chapman
& Hall/CRC; 2002.
35. Statistics Canada. Institut national de santé
publique du Québec. Population 5 years
and over by mobility status, by province
and territory (2006 Census) [Internet].
Ottawa (ON) : Statistics Canada; [cited
2013 July 31]. http://www.statcan.gc.ca
/tables-tableaux/sum-som/l01/cst01/demo56b
-eng.htm
36. Diez Roux AV. Neighborhoods and health:
where are we and where do we go from
here? Rev Epidemiol Sante Publique.
2007;55:13-21.
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37. De Vet E, de Ridder DT, de Wit JB.
Environmental correlates of physical activity and dietary behaviours among young
people: a systematic review of reviews.
Obes Rev. 2011;12:e130-42.
38. Janevic T, Borrell LN, Savitz DA, Herring
AH, Rundle A. Neighbourhood food environment and gestational diabetes in New
York City. Paediatr Perinat Epidemiol.
2010;24:249-54.
39. Haskell WL, Blair SN, Hill JO. Physical
activity: health outcomes and importance
for public health policy. Prev Med.
2009;49:280-2.
40. Durand CP, Andalib M, Dunton GF, Wolch
J, Pentz MA. A systematic review of built
environment factors related to physical
activity and obesity risk: implications for
smart growth urban planning. Obes Rev.
2011;12:e173-82.
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An environmental scan of policies in support of chronic disease
self-management in Canada
C. Liddy, MD (1, 2); K. Mill, BSc (1)
This article has been peer reviewed.
Abstract
Introduction: The evidence supporting chronic disease self-management warrants
further attention. Our aim was to identify existing policies, strategies and frameworks
that support self-management initiatives.
Methods: This descriptive study was conducted as an environmental scan, consisting of
an Internet search of government and other publicly available websites, and interviews
with jurisdictional representatives identified through the Health Council of Canada and
academic networking.
Results: We interviewed 16 representatives from all provinces and territories in Canada
and found 30 publicly available and relevant provincial and national documents. Most
provinces and territories have policies that incorporate aspects of chronic disease selfmanagement. Alberta and British Columbia have the most detailed policies. Both feature
primary care prominently and are not disease specific. Both also have provincial level
implementation of chronic disease self-management programming. Canada’s northern
territories all lacked specific policies supporting chronic disease self-management
despite a significant burden of disease.
Conclusion: Engaging patients in self-management of their chronic diseases is important
and effective. Although most provinces and territories have policies that incorporate
aspects of chronic disease self-management, they were often embedded within other
initiatives and/or policy documents framed around specific diseases or populations. This
approach could limit the potential reach and effect of self-management.
Keywords: chronic disease self-management, self-management support, health policy,
primary care, environmental scan
Introduction
Chronic disease is Canada’s most prominent
health care problem, costing more than $80
billion each year1,2 and causing increased
use of emergency departments, extended
hospital stays, reduced quality of life and
increased mortality rates.3-10 Improving the
quality of care for people with chronic
diseases is complex,11 requiring timely
diagnosis and treatment, access to primary
and specialist care and a focus on selfmanagement tasks and decisions.12,13
Supporting people in self-management has
been shown to be effective at improving
outcomes and has been promoted across
the widest array of conditions and populations.14-20 Self-management support (SMS)
focuses on the individuals and their
families by using collaborative goal setting
and a variety of self-efficacy strategies.16
These strategies enable patients, together
with their health care providers, to medically manage their illnesses more effectively, carry out normal roles and activities
and manage the emotional impact of their
illnesses.15 Adams et al.21 further this
definition by highlighting what health care
providers can do through ‘‘the systematic
provision of education and supportive
interventions by health care staff’’21,p57 to
increase patients’ skills and confidence in
managing their health problems, including
regular assessment of progress and problems, goal setting and support in problemsolving.
There is much interest in implementing
SMS programs in Canada. However, many
programs are being implemented in isolation, often by disease-specific organizations or local public health or communitybased organizations.22 But while the
patients and their communities, health
providers and the health care delivery
system are certainly linchpins in the
success of chronic disease support and
care, federal, provincial and territorial
governments have major roles to play
because they set and implement public
policy for health and health care across
Canada.
While there is some mention of the
importance of self-care and self-management in national strategies, such as
healthy aging23 and the Canadian
Diabetes strategy,24 little is known about
provincial and territorial government policy directions associated with SMS, despite
that these governments are responsible for
health and health care within their jurisdictions.
As part of a broader project on chronic
disease care and self-management conducted with the Health Council of Canada
(HCC),25 we performed an environmental
scan to identify provincial and territorial
Author references:
1. Bruyère Research Institute, C.T. Lamont Primary Health Care Research Centre, Ottawa, Ontario, Canada
2. University of Ottawa, Department of Family Medicine, Ottawa, Ontario, Canada
Correspondence: Clare Liddy, Bruyère Research Institute, 43 Bruyère St., Ottawa, ON K1N 5C8; Tel.: 613-562-6262 ext. 1326; Fax: 613-562-6099; Email: cliddy@bruyere.org
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
government strategic policy documents
that support patient self-management.26
The HCC is an independent, not-for-profit
organization established by the country’s
first ministers in 2003 to monitor the
health care system within the context of
the Health Accords. The HCC has focused
some of its attention on the prevention
and management of chronic conditions to
encourage discussion of the changes to
public policy, health care management
and health services delivery required to
improve health outcomes for all
Canadians.27
The intent of this report is to increase
awareness of provincial activities and
policy directions to allow jurisdictions to
build on emerging trends across the
country.
Methods
We conducted the environmental scan of
SMS and chronic disease care in three
phases: (1) an online scan using the
Google search engine to identify publicly
available policies that support or influence
SMS initiatives; (2) interviews with jurisdictional representatives of the HCC to
gain an inside perspective on existing
policies and strategies and future plans
related to SMS; (3) a second online scan
based on interview findings.
The aim of the first online scan was to
identify publicly available policy documents at the provincial and territorial
level. We defined policy as any course of
action or broad direction endorsed by a
body of authority in government and
included frameworks, strategies, action
plans and official priority documents.28
Three people from our research team
scanned online literature and websites
from each of the provinces and territories
in September 2011 to identify policies,
legislation, strategies and frameworks that
discussed or focused on SMS and programs or their implementation. Keywords
used in the search were ‘‘self-management,’’ ‘‘self-care,’’ ‘‘self-management
support,’’ ‘‘chronic conditions,’’ ‘‘policy,’’
‘‘action plan,’’ ‘‘framework,’’ ‘‘strategy’’
and ‘‘initiative.’’ Relevant findings were
organized in a database using Microsoft
Excel version 12 (2007; Redmond, WA,
US), tracking the year and details of each
initiative.
Next, for a more in-depth and accurate
view of existing policies, we interviewed
individuals involved in policy in the
ministries of health. Jurisdictional representatives from all provinces and territories, with the exception of Quebec,
were identified and invited by email to
participate in a 30-minute telephone
interview through the network of the
HCC. At the time, Quebec was not in a
formal partnership with the HCC so we
identified our Quebec participant through
academic networking. All the jurisdictional representatives invited agreed to
participate and granted informed consent. The interview process was
approved by the Ottawa Hospital
Research Ethics Board.
The interview guide used for these semistructured interviews is available from
the authors on request. The principal
investigator (CL) or the research assistant
(KM) conducted the interviews between
September and October 2011, with the
Quebec interview conducted in May
2012. Interviews were recorded and
transcribed by the research assistant.
Copies of the interview transcripts were
sent to each interviewee for approval
to increase the trustworthiness of the
results.
The third step of the study, which took
place in July 2012, consisted of a focused
online scan to identify newly released or
updated policy documents that had been
identified by the interviewees as forthcoming. The iterative analysis used examples of other policy scans for guidance.29-31
Based on the work by Dixon-Woods
et al.32 we used a descriptive narrative
approach with thematic analysis. This
approach has been identified as appropriate for reviews that focus on policy.32
Two members of the research team
reviewed the policy documents and the
interview transcripts to identify themes.
Several team meetings were held during
the analysis phase to discuss findings
and come to an agreement upon key
themes.32
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Results
Through our Internet scan and interviews
with 16 representatives from all provinces
and territories in Canada, we learned that
most provinces and territories have a
policy, framework or strategy that incorporates aspects of chronic disease management. However, they vary significantly
in terms of number of available policy
documents that explicitly acknowledge the
role of self-management (see Table 1).
Our online scan to identify policies that
support or influence SMS initiatives found
30 publicly available and relevant provincial and national documents.
Most provinces have implemented SMS
programs, the most common one being
the Stanford Chronic Disease SelfManagement Program (see Table 2),
although these are often run through
small-scale community organizations or
the local health regions. Of all the provinces, Alberta and British Columbia have
the most detailed policies supporting
patient self-management. They offer their
widely available self-management programs mainly through provincial health
organizations (as opposed to diseasespecific and or grassroots community
groups). These programs focus on
patient-centred care and include primary
health care and primary care.
For example, Alberta has an overarching
vision for the future of health care, called
Vision 2020,33 that focuses on the needs of
the patient. In addition, the development
of its model of chronic disease management care and the launch of integrated
community-based programming across
the province promotes a well-rounded
approach to supporting patients with
chronic conditions. SMS is one of the
main pillars of the model and programming. The Stanford Chronic Disease SelfManagement Program is now offered
across the province through Alberta
Health Services as the Better Choices,
Better Health program. The program is
a component of integrated communitybased programming, and patients can be
referred to it by their physicians or staff
from one of the other integrated programs.
Other programs offered under the
umbrella of integrated community-based
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Federal
Yukon
Strategy
Strategy
Canadian Diabetes Strategy (2005)
Strategy
Chronic Disease Prevention and Management Strategy (under development)
Legislation
Tobacco cessation legislation
Aging Well Strategy (under development)
Action Plan
Strategy and
Action Plan
Stratégie de prévention et de gestion des maladies chroniques et Plan
d’action 2008-2013 (2008)
Strategy
Framework
Cadre de référence pour la prévention et la gestion des maladies
chroniques physiques en première ligne [French Only] (2012)
Quebec
The Diabetes Provincial Plan (2004)
Strategy
Prince Edward Island Prince Edward Island Strategy for Healthy Living (2008)
Self-Management Support Action Plan (2006)
Strategy
Saskatchewan
Framework
Preventing and Managing Chronic Disease: Ontario’s Framework (2007)
Strategy
Action Plan
Action Plan for the Organization and Delivery of Chronic Pain
Services in Nova Scotia (2006)
Strategy
Action Plan
Chronic Disease Management Action Plan (2011)
Public Health Strategy (2008)
Strategy
Chronic Disease Prevention Strategy
Strategy
Strategy for Positive Aging in Nova Scotia (2005)
Strategy
Strategy
Nova Scotia Chronic Disease Prevention Strategy (2003)
Chronic Disease Prevention and Management Strategy, based on
the Expanded Chronic Care Model (under development)
Chronic Disease Management Strategy (under development, in
partnership with the Canadian Health Services Research Foundation)
Framework
Chronic Disease Policy Framework (under development)
Ontario Diabetes Strategy (2008)
Ontario
Nunavut
Nova Scotia
Northwest
Territories
Framework
Strategy
Improving Health Together: A Policy Framework for Chronic Disease
Prevention and Management in Newfound Land and Labrador (2011)
Comprehensive Diabetes Strategy for New Brunswickers (2011)
Newfoundland
and Labrador
Framework
Discussion Paper
Self-Management in Primary Care in Manitoba: The Way Forward (2011)
Initiative
Patients as Partners (2007)
A Chronic Disease Prevention and Management Framework for New
Brunswick (2010)
Strategy
Primary Health Care Charter: A Collaborative Approach (2007)
New Brunswick
Framework
Action Plan
Becoming the Best: Alberta’s 5-Year Health Action Plan, 2010-2015 (2007)
Expanded Chronic Care Model (2003)
Strategy
Vision 2020 (2008)
Document type
Framework
Document title
Alberta’s model for chronic disease management care (2008)
Manitoba
British Columbia
Alberta
Jurisdiction
Link
http://www.hc-sc.gc.ca/ahc-asc/activit/strateg/diabete-eng.php
Not available online
Not available online. For more information, see www.hss.gov.yk.ca/news/10-025.php
http://www.health.gov.sk.ca/quitting-smoking
Not available online
http://www.health.gov.sk.ca/provincial-diabetes-plan
http://www.frsq.gouv.qc.ca/fr/financement/pdf_2010_2011/Strategie_maladies
_chroniques.pdf
msssa4.msss.gouv.qc.ca/fr/document/publication.nsf/4b1768b3f849519c
852568fd0061480d/0c9fcebe57c4d7ce85257a8500766b62?OpenDocument
http://www.gov.pe.ca/health/index.php3?number=1020884&lang=E
http://www.health.gov.on.ca/en/ms/diabetes/en/about_diabetes_strategy.html
http://www.health.gov.on.ca/english/providers/program/cdpm/index.html
http://www.hss.gov.nu.ca/en/Public%20Health%20Strategy.aspx
Not available online
http://www.gov.ns.ca/health/reports/pubs/Action_Plan_Chronic_Pain.pdf
Not available online
http://www.gov.ns.ca/seniors/pub/2005_StrategyPositiveAging.pdf
http://www.gov.ns.ca/hpp/publications/CDP_Strategy_Report_Final_October30.pdf
Not available online
Not available online. For more information, see: Leith E, Kirvan C, Verma JY, Lewis
K, Robertson S. Re-imagining healthcare: the Northwest Territories transitions to
an integrated chronic disease management strategy. Healthc Quarterly. 2012:15(1);19–21.
Not available online
http://www.health.gov.nl.ca/health/chronicdisease/Improving_Health_Together.pdf
http://www.gnb.ca/0053/phc/pdf/2011/8023-e.pdf
http://www.gnb.ca/0051/pub/pdf/2010/6960e-final.pdf
http://www.gov.mb.ca/health/primarycare/self_management.html
http://www.impactbc.ca/patients-as-partners
http://www.primaryhealthcarebc.ca/
http://www.primaryhealthcarebc.ca/resource_eccm.html
Not available online
http://www.health.alberta.ca/initiatives/vision-2020.html
http://www.albertahealthservices.ca/4058.asp
TABLE 1
Examples of policy documents relevant to self-management of chronic diseases
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Living a Healthy Life with
Chronic Conditions (CDSMP/CPSMP):
‘‘My tool Box’’/‘‘L’atelier’’
‘‘Chronic Conditions Support Program’’
Quebec
Yukon
http://www.hss.gov.yk.ca/ccsp.php
http://mytoolbox.mcgill.ca/en/
http://www.saskatoonhealthregion.ca/your
_health/ps_cdm_about_livewell.htm
http://patienteducation.stanford.edu
/programs/cdsmp.html
https://www.healthylifeworkshop.ca/
http://www.livinghealthychamplain.ca
http://patienteducation.stanford.edu
/programs/cdsmp.html
http://www.gnb.ca/0053/phc/workshop-e.asp
Abbreviations: CDSMP, chronic disease self-management program; CPSMP, chronic pain self-management program.
CDSMP ‘‘LiveWell Chronic
Disease Management’’
Saskatchewan
‘‘You’re in Charge’’
Stanford CDSMP
CPSMP ‘‘The Chronic Pain
Self Management Program’’
Prince Edward Island
http://www.caot.ca/otnow/sept%2011/youre.pdf
http://www.iwk.nshealth.ca/index.cfm?objectid
=924CF1E6-AF34-AF7E-2E6D746123614962
CDSMP ‘‘Your Way to Wellness’’
Nova Scotia
Many different titles, e.g.
Stanford CDSMP ‘‘Living a Healthy
Life with Chronic Conditions’’
http://www.southshorehealth.ca/education
-programs/bone-health.html
Stanford CDSMP
Newfoundland and
Labrador
Ontario
https://yourway2wellness.gov.ns.ca/
CDSMP ‘‘My Choices – My Health’’
New Brunswick
http://www.gov.mb.ca/health/chronicdisease
/cden/docs/2007/thursday/keyzer.pdf
CDSMP ‘‘Get Better Together:
Building Capacity for Chronic
Disease Self-Management’’
Link/source
http://www.albertahealthservices.ca/services
.asp?pid=service&rid=1054851
Manitoba
Program
Stanford Chronic Disease
Self-Management Program (CDSMP)
‘‘Better Choices, Better Health’’
Alberta
Province/territory
Additional information
The Yukon Department of Health and Social Services no longer offers a Stanford CDSMP,
in large part due to the difficulties in finding a sufficient number of interested participants.
The currently available Chronic Conditions Support Program is offered to both patients
with chronic conditions and health professionals engaged in their care. The program is
not primarily a self-management program, but does contain a few components that are
related to self-management. It is offered in both French and English
A CDSMP and a CPSMP are offered in both French and English. Both follow the
Stanford CDSMP course
Saskatchewan has a central hub for several programs and services across the province
called the LiveWell Chronic Disease Management Programs and Services. These programs
and services target both patients with chronic conditions and their caregivers
Prince Edward Island offers the standard Stanford CDSMP course throughout the
province
Many different programs, which are often in collaboration with academic health centres,
offer self-management programs to patients with different chronic diseases. These
programs are mainly based on the Stanford model with many specifically targeting
people with diabetes.
A weekend-long self-management workshop specifically designed for youth with
chronic conditions, sometimes including family members
A program offered in Nova Scotia’s chronic pain clinics that follows the Stanford
CPSMP model
A self-management program for people living with or supporting someone with a
chronic health condition
This Stanford program is not offered province-wide yet. Only three out of four regional
health authorities have run sessions, but all health authorities have master trainers
available to lead the program
This permanent program is based on the Stanford CDSMP and is offered in both
official languages
A modified Stanford model that is co-ordinated provincially by the Wellness Institute
within the Winnipeg Regional Health Authority. It offers self-management programs
across the province and is open to all patients with chronic diseases. These programs are
led by both professional and peer leaders
This Stanford program runs province-wide and is a component of the integrated
community-based programming. Patients can be referred to it by their physicians or staff
from one of the other integrated programs
TABLE 2
Examples of Chronic Disease Self-Management Programs across Canada
programming include supervised exercise
programs and nutrition information
through either a dietician or a group
workshop. Primary Care Networks in
Alberta also strongly encourages selfmanagement. The networks play a large
role in the integrated community-based
programming because of their ability to
enhance care co-ordination and collaboration through shared care among the
appropriate providers.
Similarly, self-management is identified in
the mission, vision and goals of the British
Columbia Ministry of Health. The ministry
initiative, Patients as Partners, part of the
2007 Primary Health Charter,34 specifically addresses self-management implementation and evaluation in asking
primary health care providers and organizations to develop additional ways to
support the central role of patients as
partners in their own care. The province
offers many SMS programs, including
Chronic Disease Self-Management; Online Chronic Disease Self-Management;
Arthritis/Fibromyalgia Self-Management;
Chronic Pain Self-Management; Diabetes
Self-Management; Active Choices; A
Matter of Balance: Managing Concerns
about Falls; Bounce Back: Reclaim Your
Health; InterCultural Online Health
Network; Patient Voices Network’s Peer
Coaching; Dietician Services at HealthLink
BC; and QuitNow Services.
Manitoba has also recently released a
discussion paper specifically targeting
self-management in primary care.
Frameworks
Many of the other provinces have chronic
disease management and prevention frameworks that include self-management as
a core component. For example, Ontario,
New Brunswick and Quebec have aligned
their Chronic Disease Management and
Prevention (CDMP) Frameworks, based
on the Expanded Chronic Care Model,34,35
to build future strategies and policies for
the prevention and management of
chronic diseases. The Expanded Chronic
Care Model itself builds on the wellknown Chronic Care Model (CCM),36
which has been shown to enhance the
delivery and quality of care and control
health care costs.14,19,37 The Expanded
Chronic Care Model is more suited to the
Canadian health care environment
because it more effectively integrates
health promotion and prevention in both
the health system and communities.
Newfoundland and Labrador has also
adopted a Chronic Disease Policy
Framework that includes six policy statements, one which focuses on self-management.38 It has eight priority areas:
arthritis, cancer, chronic pain, diabetes,
heart disease, lung disease, kidney disease
and stroke. It covers all four regional
health authorities in the province.
Strategies
The Unit for Population Health and
Chronic Disease Prevention at Dalhousie
University, in collaboration with the Nova
Scotia Department of Health, developed
the Nova Scotia Chronic Disease
Prevention Strategy in 2003; however, it
does not explicitly emphasize self-management. The Strategy for Positive Aging
in Nova Scotia, published in 2005, does
speak of the importance of self-management for seniors.
Disease-specific policies with a focus on
self-management
Many of the provinces have policies that
focus on disease-specific conditions, such
as diabetes, arthritis, stroke and chronic
obstructive pulmonary disease. For example, The Ontario Diabetes Strategy,
launched in 2008, emphasizes patients’
self-management as an important component. Under this strategy, funding was
allocated to cover a four-year plan to
execute a multidimensional approach to
diabetes care that addresses the growing
needs of the Ontario population. The
Ontario Diabetes Strategy appears to be
the leading strategy in Ontario in terms of
incorporating self-management. However,
the interviewed experts in the field
expressed the belief that there is a need
to go beyond a disease-specific strategy
toward a general policy that addresses
self-management of chronic diseases as a
whole, especially in patients with multimorbidities.
$
59
Saskatchewan’s
Provincial
Diabetes
Plan, released in February 2004, emphasizes the role of self-management. The
Saskatchewan Ministry of Health and local
health authorities have also set in place
guidelines that mandate the delivery of
SMS.
In Prince Edward Island, self-management
of specific chronic diseases is also
addressed in some programs, such as
those for diabetes and arthritis. The
province has also been piloting programs
for chronic obstructive pulmonary disease, hypertension and weight management that include self-management
components. Prince Edward Island does
not have a specific policy document
to support self-management of chronic
diseases in general. Instead, it offers
education and training for health care
providers that incorporates self-management principles.
Lack of policies, frameworks, strategies in
the North
Nunavut
Our policy scan, further supported by our
interview with a local expert in Nunavut,
revealed that the territory does not have
policy documents or strategies that specifically address the issue of self-management for patients with chronic diseases. In
addition, there are currently no active selfmanagement programs to support either
patients or health professionals in
Nunavut.
Northwest Territories
There are no policies in place in the
Northwest Territories that specifically
support the design and implementation
of self-management programs for patients
with chronic diseases, although a chronic
disease management strategy is being
developed by the Department of Health
and Social Services, and a first draft of the
document had been developed and was
under review. SMS is recognized as an
important component of the chronic disease management strategy and was
included in the draft. The number of
programs that fully integrate self-management is limited in the region; some
diabetes education programs and a small
number of other disease-specific pro-
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
grams, such as mental health programs,
have incorporated elements of self-management. A chronic disease management
strategy will provide opportunities to
enhance the role of self-management in
these programs and design new programs
that better address the need for SMS in the
Northwest Territories.
Yukon
The Department of Health and Social
Services has applied for funding to begin
developing a chronic disease prevention
and management strategy. According to the
experts we interviewed, the aim is to
include self-management in this strategy.
The Stanford Chronic Disease SelfManagement Program is no longer being
offered by the Department of Health and
Social Services, largely due to difficulties in
finding a sufficient number of interested
patients. The Chronic Conditions Support
Program is offered to both patients with
chronic conditions and health professionals
engaged in their care. The program is not
primarily a self-management program, but
does contain a few related components.
Discussion
Through our scan of environmental policies, we found that although most provinces and territories have policies that
incorporate aspects of chronic disease selfmanagement, these policies were often
embedded within other initiatives and/or
policy documents framed around specific
populations or diseases. The lack of specific
self-management policies in all of Canada’s
North was surprising given that these
regions have the highest burden of chronic
diseases in the country.39,40 Residents also
have many challenges in accessing care.
Other competing health priorities, combined with the geographical spread of the
population, may be reasons for self-management being under-developed here.
Great potential for improving health does
exist in the North given that the most
common and effective chronic disease selfmanagement programs15,41 are based on
the peer support model that does not rely
on access to trained health care professionals. In addition, many of the programs
have already been adapted and success-
fully implemented for many cultures and
into different languages.42-44
Canada has many disease-focused strategies that incorporate self-management as a
theme. For example, SMS programs in
Ontario are mainly funded as part of the
Ontario Diabetes Strategy. This diminishes
the ability to integrate care on a programmatic level as performance measures are
then often linked to specific diseases and
not to the population. Although diabetes
care is often framed as a first step or
template in tackling chronic diseases, the
self-management approaches in diabetes
remain tethered to disease-specific medical management, such as content knowledge on diabetes and learning medical
tasks (i.e. managing insulin). In addition,
the population that is targeted by these
SMS programs are people with diabetes,
which tends to exclude groups of people
with other chronic diseases.
It is critical to maintain focus on a more
generic approach (dealing with fatigue,
action planning for a healthy lifestyle,
etc.) that addresses all three dimensions
of self-management: patients medically
managing their illness; carrying out normal roles and activities; and managing the
emotional impact.15 Focusing on common
risk factors across all chronic diseases is
a basic principle of the Chronic Care
Model approach.36 The World Health
Organization recommends that ‘‘sound
and explicit government policy is the key
to effective prevention and control of
chronic diseases.’’45,p2 A generic strategy
that takes a life course perspective and is
co-ordinated among decision makers
across sectors is recommended.45
Alberta and British Columbia, the provinces that seem to have the most comprehensive self-management approaches, are
also the ones with the most detailed
policies/strategies that are not disease
specific. Both feature primary health care
and primary care prominently. The role of
the primary care provider can be seen as
foundational in supporting patient selfmanagement. The nature of primary care
and its position within the health care
system makes it a perfect target for such
interventions. Primary care not only has
access to most patients with chronic con-
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
60
ditions but can also address different
medical conditions beyond one specific
disease. Primary care providers are in an
ideal position to play a central role in
preventing and managing chronic conditions, as 95% of Canadians with a chronic
disease report having a regular family
physician.46 Primary care visits provide a
unique opportunity to monitor patients’
health and to encourage self-management,47-49 as the majority of Canadians
perceive their family physician to be a
credible resource of health information and
value their advice.50,51 As these provinces
move forward with strategies grounded
more in the primary health care community rather than disease areas, it will be
important to evaluate the impact the
different provincial policies have on program reach and overall effectiveness. To
date, there is still very little published
evidence that describes the overall reach
of SMS programs in all provinces.52
Future research examining the association
of policy and program reach and effect in
self-management of chronic diseases is
needed.
Limitations
The findings of this study are limited by
several factors including participation bias
and issues related to timing. We relied
mainly on the initial contact list of
jurisdictional representatives provided by
the HCC. Although we did speak to
representatives from all the provinces
and territories and we did follow up for
verification and/or clarification as needed,
individual depth of knowledge varied,
probably as a result of how much time
they had spent in that position and their
overall knowledge of the governmental
system. These aspects were not specifically assessed.
In addition, a common limitation of policy
scans relates to much of the material being
time sensitive and linked to political
agendas and public statements; thus,
material was not necessarily publicly
available when we were conducting our
research. We attempted to minimize this
limitation through interviewing the
experts in the field as well as by conduct-
ing an updated online scan after the
interviews, in July 2012.
3.
Fortin M, Bravo G, Hudon C, et al.
Relationship between multimorbidity and
health-related quality of life of patients in
primary care. Qual Life Res. 2006;15(1):
83-91.
4.
Fortin M, Bravo G, Hudon C, Lapointe L,
Dubois MF, Almirall J. Psychological distress and multimorbidity in primary care.
Ann Fam Med. 2006;4(5):417-22.
5.
Fortin M, Soubhi H, Hudon C, Bayliss EA,
van den Akker M. Multimorbidity’s many
challenges. BMJ. 2007;334(7602):1016-7.
6.
Hansagi H, Olsson M, Sjoberg S, Tomson Y,
Goransson S. Frequent use of the hospital
emergency department is indicative of high
use of other health care services. Ann
Emerg Med. 2001;37(6):561-7.
Conclusion
Evidence suggests that engaging patients
in self-management of their chronic diseases is important and effective. Although
most provinces and territories have policies that incorporate aspects of chronic
disease self-management, these policies
are often embedded within other initiatives and/or policy documents framed
around specific diseases or populations.
This approach could limit the potential
reach and effect of self-management.
Creating policies that identify self-management as a key element in a total population approach could lead to improved
care for Canadians living with chronic
diseases.
7.
Acknowledgements
Funding for this report was provided by
the Health Council of Canada as part of the
development of a technical paper on
chronic disease self-management. The
authors would like to acknowledge the
contributions of Mary Byrnes from the
Health Council of Canada, who liaised
with the jurisdictional representatives for
the interviews, and Ottawa-based medical
editor Joan Ramsay, who helped with the
editorial development of this article.
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
Cancer in Canada Fact Sheet Series #1
Thyroid cancer in Canada
A. Shaw, MSc; R. Semenciw, MSc; L. Mery, MSc
This article has been peer reviewed.
N
N
N
Thyroid cancer is a cancer that forms in
the thyroid gland (an organ at the base of
the throat that makes hormones that help
control heart rate, blood pressure, body
temperature and weight).* Although thyroid cancer is a relatively rare tumour, it is
the most common endocrine malignancy
worldwide1 and the tenth most common
cancer in Canada.2
More than 4000 Canadians were diagnosed
with thyroid cancer in 2007, or nearly 12
per 100 000, accounting for approximately
2.5% of all malignant tumours.{ Unlike
most cancers, thyroid cancer is three times
more common in females than males and is
generally diagnosed at a younger age2,3
(Figure 1). Nearly 40% of all thyroid
cancers are diagnosed before 45 years of
age and three-quarters before age 60.
Thyroid cancer ranks second in Canadians
aged 15 to 44 years (Figure 2) and is the
most common cancer diagnosis in those
aged 15 to 29 years (Figure 3). The large
majority of thyroid cancers are papillary
carcinomas (86%), while others include
follicular (6%), medullary (2%), anaplastic
(1%) and other/unknown (5%).
Trends in incidence and mortality
The incidence rate of thyroid cancer is
increasing more rapidly than any other
cancer in Canada.2,4,5 Between 1992 and
2007, the age-standardized incidence rate
(ASIR) increased 5.7% per year in males,
The ASIR of thyroid cancer has increased
in every province and territory in Canada
over the last 16 years, but percent change
FIGURE 1
New thyroid cancer cases and incidence rates, by age and sex, Canada, 2007
1200
35
1000
30
25
800
20
600
15
400
10
200
5
0
Incidence rate (per 100 000)
N
The incidence of thyroid cancer is increasing more rapidly than that of any
other cancer in Canada, while mortality has remained low and stable
In the last 10 years the number of thyroid cancer cases has increased 144%
from 1709 to 4172 cases per year
Thyroid cancer is three times more common in females than males
40% of thyroid cancers are diagnosed in Canadians under 45 years of age
Some of the apparent increase in incidence is likely due to improved and more
widely available diagnostic techniques
New cases
N
from 2.0 to 5.2 per 100 000, and 7.3% per
year in females, from 6.8 to 17.9 per
100 000 (Figure 4). The highest increase,
8.2% per year, was found in women aged
30 to 59 years. The increase in thyroid
cancers has been particularly rapid in the
last 10 years as the number of new cases
diagnosed in Canada increased by 144%,
from 1709 in 1998 to 4172 in 2007. Similar
increases took place in Europe, North and
South America, Oceania and parts of
Asia.1,3,6-8 However, rates vary considerably between and within continents and
are not consistently higher or lower in any
region of the world except in Africa where
rates are generally low.
0
0 to 14
15 to 29
Male Count
30 to 44 45 to 59 60 to 74
Age at diagnosis (years)
Female Count
Male Rate
75+
Female Rate
Source: The Canadian Cancer Registry database at Statistics Canada;23 Canadian population estimates provided by Statistics
Canada.24
* See The Canadian Cancer Society (www.cancer.ca) for more details on thyroid cancer biology and clinical treatment.
{
Data definitions and statistical methods used in this analysis are outlined in the Canadian Cancer Statistics Annual Report.
2
Author references:
Chronic Disease Surveillance and Monitoring Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada
Correspondence: Amanda Shaw, Chronic Disease Surveillance and Monitoring Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada, 785 Carling Avenue, Ottawa,
ON K1A 0K9; Tel.: 613-941-6464; Fax: 613-941-2057; Email: amanda.shaw@phac-aspc.gc.ca
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
$
64
FIGURE 2
Distribution of new cancer cases, aged 15–44 years, males and females, Canada,
2007 (N = 11 746)
Breast
19%
Other
38%
Thyroid
14%
Risk factors
Melanoma
Cervix
7%
5%
Testis
Non-Hodgkin
Colorectal
Colorectal
Testis
Lymphoma 6%
6%
5%
Source: The Canadian Cancer Registry database at Statistics Canada.23
and rates vary widely across the country
(Figure 5). In 2007, ASIR were highest in
the most populous province, Ontario, at
15.2 per 100 000, and lowest in
Saskatchewan (5.2), British Columbia
(5.8) and Manitoba (8.5). These rates were
significantly different (p < .05) than the
average Canadian ASIR of 11.6 per 100 000.
FIGURE 3
Distribution of new cancer cases, aged 15–29 years, males and females, Canada,
2007 (N = 2265)
Thyroid
17%
Other
32%
Testis
13%
Non-Hodgkin Lymphoma
6%
Leukemia
6%
Hodgkin Lymphoma
13%
Brain
6%
In contrast to incidence, mortality from
thyroid cancer has remained exceptionally
low and stable. Between 1992 and 2007
there was an average 142 deaths due
to thyroid cancer each year in Canada
and the age-standardized mortality rate
(ASMR) decreased, on average, by less
than 1% per year from 0.5 per 100 000 in
1992 to 0.4 per 100 000 in 2007 (Figure 6).
The low and stable rate of thyroid cancer
mortality in Canada is consistent with
rates found in the US, Europe, Oceania
and Asia.1,3 Accordingly, thyroid cancer
has the highest five-year relative survival
rate of all cancers in Canada, at 97% for
the period 2001 to 2003.9
Melanoma
7%
Source: The Canadian Cancer Registry database at Statistics Canada.23
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The most well-established risk factor for
thyroid cancer is ionizing radiation from
therapeutic radiation treatment or nuclear
accidents/fallout.10 However, at a population level, this accounts for very few cases.
The risk of developing thyroid cancer is
also increased in those with benign
thyroid conditions, such as goitre and
thyroid nodules, and in those with a
family history of thyroid cancer or some
genetic conditions.10 Female reproductive
factors, body mass index and iodine
consumption have shown some association with thyroid cancer but results
are inconsistent.11-13 The association
between thyroid cancer risk and exposure
to endocrine-disrupting chemicals is
inconclusive, although research is
limited.14-17
Some of the increase in incidence of
thyroid cancer is likely due to better
detection as a result of improved and
more widely available diagnostic techniques (primarily ultrasound and fine
needle aspiration).4,6 A number of studies
have shown the increase to be primarily
restricted to small, asymptomatic tumours
that may have had little clinical significance.4,6,7,18 which is supported by the
fact that mortality from thyroid cancer has
remained low and stable. However, other
studies have found increased rates in all
tumour sizes and across sex and racial/
ethnic groups, suggesting a true increase
in incidence.19-22 In addition, rates have
not plateaued, which is what would be
expected after new or improved diagnostic
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
FIGURE 4
New thyroid cancer cases, age-standardized incidence rates and annual percent change, Canada, 1992–2007
20
4500
18
4000
16
3500
73% *
7.3%*
3000
12
2500
10
6.9%*
2000
8
1500
6
1000
4
5.7%*
07
06
Male Rate
20
05
20
04
20
03
20
02
Both Sexes Rate
20
01
20
00
20
99
20
98
19
97
Both Sexes Count
19
96
19
19
19
19
19
19
95
0
94
0
93
500
92
2
APC
New cases
ASIR (per 100 000)
14
Female Rate
Source: The Canadian Cancer Registry database at Statistics Canada.23
Abbreviations: APC, annual percent change; ASIR, age-standardized incidence rates.
Note: Rates are age-standardized to the 1991 Canadian population estimates provided by Statistics Canada.
*p < .01
FIGURE 5
Thyroid cancer age-standardized incidence rates,a 95% confidence intervalsb and annual percent change, by province, 1992 and 2007, Canada
20
7.1%
18
7.9%**
9.3%**
ASIR (per 100 000)
16
14
3.5%
4.4%*
7.6%**
7.3%**
12
10
6.9%**
6.1%**
3.2%**
2.5%**
2.6%**
8
6
4
2
0
NL
PE
NS
NB
QC
ON
MB
SK
AB
BC
TR
Canada
Province at diagnosis
APC
1992
2007
Source: The Canadian Cancer Registry database at Statistics Canada.23
Abbreviations: AB, Alberta; APC, annual percent change; ASIR, age-standardized incidence rates; BC, British Columbia; MB, Manitoba; NB, New Brunswick; NL, Newfoundland and Labrador;
NS, Nova Scotia; ON, Ontario; PE, Prince Edward Island; QC, Quebec; SK, Saskatchewan; TR, territories i.e. Yukon, North West Territory and Nunavut.
Note: Rates are age-standardized to the 1991 Canadian population estimates provided by Statistics Canada.
a
ASIR for PE and TR suppressed for 1992 due to small numbers.
b
95% confidence intervals calculated using bootstrap variance estimates.
*p < .05
**p < .01
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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66
FIGURE 6
Thyroid cancer deaths, age-standardized mortality rates and annual percent change, 1992–2007, Canada
0.7
200
180
0.6
–2.1%*
140
120
0.4
100
0.3
–1.0%
0.8%
80
60
0.2
Number of
deaths
ASMR (per 100 000)
160
0.5
40
0.1
20
0
0
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
APC
Both Sexes Count
Male Rate
Female Rate
Both Sexes Rate
Source: Canadian Vital Statistics Death database at Statistics Canada.25
Abbreviations: APC, annual percent change; ASMR, age-standardized mortality rates.
Note: Rates are age-standardized to the 1991 Canadian population estimates provided by Statistics Canada.
*p < .05
techniques have identified the prevalent
cases in the population.
2.
Canadian Cancer Society’s Steering
Committee on Cancer Statistics. Canadian
Cancer Statistics 2012. Toronto (ON):
Canadian Cancer Society; 2012
3.
Kilfoy BA, Zheng T, Holford TR, et al.
International patterns and trends in thyroid
cancer incidence, 1973-2002. Cancer
Causes Control. 2009;20:525-31.
Summary
The incidence of thyroid cancer is increasing more rapidly than that of any other in
Canada. The number of Canadians diagnosed with thyroid cancer has more than
doubled over the past 10 years, particularly in young to middle-aged females.
Part of the increase may be due to
improved detection of small, indolent
tumours, which is leading to the treatment
of previously untreated or undiagnosed
cases. Other potential risk factors, or a
combination of factors, may also be
associated with the rising rates. Further
in-depth investigations are needed to
elucidate the causes of this rapidly
increasing cancer.
4.
5.
Curado MP, Edwards B, Shin HR, et al,
editors. Cancer Incidence in Five
Continents, Vol IX. Lyon (FR): IARC
Scientific Publications 160; 2007.
Liu S, Semenciw R, Ugnat AM, Mao Y.
Increasing thyroid cancer incidence in
Canada, 1970-1996: time trends and ageperiod-cohort effects. Br J Cancer. 2001;
85(9):1335-9.
6.
Davis L, Welch HG. Increasing incidence of
thyroid cancer in the United States, 19732002. JAMA. 2006;295(18):2164-7.
7.
Colonna M, Grosclaude P, Remontet L, et
al. Incidence of thyroid cancer in adults
recorded by French cancer registries (19781997). Eur J Cancer. 2002;38:1762-8.
References
1.
Kent WD, Hall SF, Isotalo PA, Houlden RL,
George RL, Groome PA. Increased incidence of differentiated thyroid carcinoma
and detection of subclinical disease. CMAJ.
2007;177(11): 1357-61.
$
67
8.
Montanaro F, Pury P, Bordoni A, Lutz JM.
Unexpected additional increase in the
incidence of thyroid cancer among a recent
birth cohort in Switzerland. Eur J Cancer
Prev. 2006;15:178-86.
9.
Statistics Canada. Cancer survival statistics.
Statistical tables. Ottawa (ON): Statistics
Canada; [modified 2012 Dec 12; cited 2012
Oct 3]. [Statistics Canada, Catalogue no.:
82-226-XWE]. Available from: http://www
.statcan.gc.ca/pub/82-226-x/2012001
/tablesectlist-listetableauxsect-eng.htm
10. Ron E, Schneider A. Thyroid cancer. In:
Schottenfeld D, Fraumeni JF, editors.
Cancer epidemiology and prevention.
New York: Oxford University Press; 2006.
p. 975-994.
11. Peterson E, De P, Nuttal R. BMI, diet and
female reproductive factors as risks for
thyroid cancer: a systematic review. Plos
One. 2012;7(1):e29177.
12. Cléro É, Doyon F, Chungue V, et al. Dietary
iodine and thyroid cancer risk in French
Polynesia: a case-control study. Thyroid.
2012;22(4):422-9.
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
13. Navarro Silvera SA, Miller AB, Rohan TE.
Risk factors for thyroid cancer: a prospective cohort study. Int J Cancer. 2005;
116:433-8.
14. Boas M, Main KM, Feldt-Rasmussen U.
Environmental chemicals and thyroid function: an update. Curr Opin Endrocrinol
Diabetes Obes. 2009;16:385-91.
15. Kohrle J. Environmental and endocrinology: the case for thyroidology. Ann
Endocrinol. 2008;69:116-22.
16. Zhang Y, Guo G, Han X, et al. Do
polybrominated diphenyl ethers (PBDEs)
increase the risk of thyroid cancer? Biosci
Hypothesis. 2008;1:195-9.
24. Statistics Canada. Annual demographic
estimates: Canada, provinces and territories [Internet]. Ottawa (ON): Minister of
Industry; 2012 [cited 2013 May 21].
[Statistics Canada, Catalogue no. 91-215XWE]. Available from: http://www5.statcan
.gc.ca/bsolc/olc-cel/olc-cel?catno=91-215-X
&lang=eng
25. Statistics Canada. Causes of death, 2009
[Internet]. Ottawa (ON): Minister of
Industry; 2012 [cited 2013 May 21].
[Statistics Canada, Catalogue no. 84-208XIE]. Available from: http://www5.statcan
.gc.ca/bsolc/olc-cel/olc-cel?catno=84-208
-XIE&lang=eng
17. Zhu C, Zheng T, Kilfoy BA, et al. A birth
cohort analysis of the incidence of papillary
thyroid cancer in the United States, 19732004. Thyroid. 2009;19(10):1061-6.
18. Cramer JD, Fu P, Harth KC, Margevicius S,
Wilhelm SM. Analysis of the rising incidence of thyroid cancer using the
Surveillance, Epidemiology and End
Results national cancer data registry.
Surgery. 2010;148:1147-53.
19. Simard EP, Ward EM, Siegel R, Jemal A.
Cancers with increasing incidence trends in
the United States: 1999 through 2008. CA
Cancer J Clin. 2012;62:118-28.
20. Chen AY, Jemal A, Ward EM. Increasing
incidence of differentiated thyroid cancer in
the United States, 1988-2005. Cancer.
2009;115:3801-7.
21. Aschebrook-Kilfoy B, Ward MH, Sabra
MM, Devesa SS. Thyroid cancer incidence
patterns in the United States by histologic
type, 1992-2006. Thyroid. 2011;21:125-34.
22. Enewold L, Zhu K, Ron E, et al. Rising
thyroid cancer incidence in the United
States by demographic and tumor characteristics, 1980-2005. Cancer Epidemiol
Biomarkers Prev. 2009;18:784-91.
23. Statistics Canada. Cancer incidence in
Canada, 2007 and 2008 [Internet]. Ottawa
(ON): Minister of Industry; 2010 [cited 2013
May 21]. [Statistics Canada, Catalogue no.: 82231-X]. Available from: http://www.statcan
.gc.ca/pub/82-231-x/82-231-x2009001-eng
.htm
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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Book review
Community-based Prevention: Reducing the Risk of Cancer and
Chronic Disease
D. P. Rao, MSc
Authors: David McLean, Dan Williams, Sonia Lamont, Hans Krueger
Publisher: University of Toronto Press, Scholarly Publishing Division
Publication date: April 1, 2013
Number of pages: 232
Format: Hardcover
ISBN (2013) – 978-1442645301
ISBN (2010) – 144264530X
The escalating impact of cancer and
chronic disease on morbidity and mortality affect quality of life, and their impact
on health care expenditures highlight the
need for long-term and sustainable solutions. In ‘‘Community-based Prevention:
Reducing the Risk of Cancer and Chronic
Disease,’’ the authors explore health promotion-based programs as a solution for
individual- and population-level improvements in health. Using as a template the
community-based prevention educator
(CPE)-led program delivered by the
British Columbia Cancer Agency (BCCA),
the authors analyze and compare six
programs identified as having community
engagement, professional leadership,
regional deployment and a generalist
prevention agenda at their foundation.
To convince public health policy planners
to consider a prevention strategy similar to
the CPE program, the authors discuss the
need for upstream investments in the
context of current chronic disease management requirements in Part A of the
book. They then explain BCCA’s CPE-led
program so that readers can understand
the concepts that guided its development
and implementation. Following a review
of the program’s vision and purpose,
organizational structure, key roles and
responsibilities and approach towards
secondary prevention and special populations, the authors shows how this CPE
program fosters supportive environments
to help individuals and populations make
healthy life choices. While this bottom-up
program was designed with the goal of
preventing cancer, the authors recognize
that cancer prevention efforts correspond
with those required for broader chronic
disease by virtue of their similar modifiable risk factors.
To consider which components of the
BCCA program have contributed to its
success and to gain insight from the
achievements of similar models globally,
the authors undertake case study research
in Part B of their book. They analyzed six
programs from five jurisdictions—two
European countries, two American states
and one Canadian province—starting with
Finland’s North Karelia project, which was
ahead of its time when implemented in the
1970s. Poverty, social and political issues,
and an unhealthy diet all contributed to the
region having one of the highest coronary
heart disease mortality rates in the world.
This robust project achieved great success
and has since served as an important
example for health planners.
The Health Promotion Officers from
Northern Ireland’s Action Cancer charity
is the next CPE-type program the authors
describe in their book. In addition to early
detection initiatives and mobile screening
activities, this private charity has the freedom to endorse and fundraise for initiatives, opportunities that may not always be
available to public organizations.
Kentucky’s Health Education through
Extension Leadership (HEEL) program
and the Kentucky Cancer Program both
profited from a close collaboration with
the University of Kentucky. The authors
observe that this allowed for two-way
communication about up-to-date knowledge and evidence-informed interventions
between researchers and community
workers. The HEEL program’s acknowledgment of the roles that social determinants of health and sustained community
ownership play in health promotion
underscores the socioecological underpinnings of many health promotion programs
as well as the application of diffusion and
innovations theory to achieve positive
outcomes. This commitment to action on
the social determinants of health is paralleled in North Carolina’s Community
Health Ambassador Program (CHAP),
which was developed to eliminate health
disparities. By recruiting community leaders to serve as health ambassadors, the
program’s message is shared through
Author references:
Institute of Population Health, University of Ottawa, Ottawa, ON, Canada
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Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
established and trusted relationships
within the community. The authors lastly
discuss Health Promotion Co-ordinators
from
Manitoba’s
Chronic
Disease
Prevention Initiative. Given the geopolitical barriers in this province, this project
was a testament to the value of teamwork
between regional health authorities and
communities to, for example, provide
locally adapted risk factor prevention
support for First Nations communities.
Throughout Parts A and B of the book, the
authors draw readers in to make them feel
connected with the message of health
promotion and how it can be applied in
various contexts. Part B specifically
focuses on the parallels and contrasts of
each case study with BCCA’s program and
highlights any insights that may be
gained. Part C then expands upon these
lessons to further encourage the reader to
consider the value of each insight. This
section also offers a synopsis of various
lessons learned and serves as a powerful
resource for health planners seeking to be
comprehensive in the design of their
health promotion efforts. The importance
of local knowledge and connections,
intensive staff-to-population ratios, scalability, primary and secondary prevention
efforts, university affiliation, and more are
all discussed in compelling detail.
effects of secular trends, are all discussed
in substantial detail.
‘‘Community-based Prevention: Reducing
the Risk of Cancer and Chronic Disease’’ is
persuasive in its argument for CPE-type
programs and provides the reader with
ample opportunity to learn from various
insights and extrapolate to their own
planning. While the authors do present
several alternate routes a planner might
take, they reinforce the benefits of their
approach by illustrating how disease
latency and the slow onset of chronic
disease make CPE-type programs a longterm investment that can leverage often
modest health promotion budgets to effect
far-reaching success.
This book may have a much wider
audience than the public health planners
the authors identify. The book’s message
is relevant to public health practitioners,
primary care physicians, policy experts,
social workers and others. This book
reinforces many of the lessons taught in
population health, reinforcing the scientific foundations in an appealing format. For
example, the book is very clear about the
value of theory and conceptual frameworks in helping organize thinking about
programs so that they may be developed
in a systematic way. On the other end of
the program cycle is the role of evaluation
and dissemination, which are also both
discussed in great detail. The authors
advise for ongoing evaluation and collection of both qualitative and quantitative
metrics so as to guide program delivery
and assess their outcomes. The utility of
evaluation in assessing efficacy, as well as
in considering possible confounding
Vol 34, No 1, February 2014 – Chronic Diseases and Injuries in Canada
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CDIC: Information for authors
Our Journal
CDIC Mandate
Chronic Diseases and Injuries in Canada (CDIC) is a
quarterly scientific journal focussing on the prevention
and control of non-communicable diseases and
injuries in Canada. Its feature articles are peer
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CDIC fosters communication on chronic diseases
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and an abstract may be required at the request of
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