I Chronic Diseases in Canada n this issue

Health
Canada
Santé
Canada
Chronic Diseases
in Canada
Volume 21, No 1
2000
In this issue
New Associate Scientific Editor
1
Agreement in Measuring Socio-economic Status: Area-based Versus
Individual Measures
Kitaw Demissie, James A Hanley, Dick Menzies, Lawrence Joseph and Pierre Ernst
8
An Assessment of the Validity of a Computer System for Probabilistic
Record Linkage of Birth and Infant Death Records in Canada
Martha Fair, Margaret Cyr, Alexander C Allen, Shi Wu Wen, Grace Guyon and Ralph C MacDonald,
for the Fetal and Infant Health Study Group
14
Infant Mortality by Gestational Age and Birth Weight in Canadian
Provinces and Territories, 1990–1994 Births
Shi Wu Wen, Michael S Kramer, Shiliang Liu, Susie Dzakpasu and Reg Sauvé, for the Fetal and Infant
Health Study Group
Status Reports
23
Canadian Strategy for Cancer Control
Silvana Luciani and Neil J Berman
26
Canadian Coalition on Cancer Surveillance
Barbara Foster and Anna Maria Boscaino, for the CCOCS Management Committee
30
Canadian Association of Provincial Cancer Agencies
Donald R Carlow
34
National Enhanced Cancer Surveillance System: A Federal–Provincial
Collaboration to Examine Environmental Cancer Risks
Kenneth C Johnson
(continued on reverse)
Our mission is to help the people of Canada
maintain and improve their health.
Health Canada
(Contents continued)
35
Announcement: Formation of the Canadian Prostate Cancer Research
Initiative
36
Book Reviews
Health Promotion Planning: An Educational and Ecological Approach (third edition)
Reviewed by Paula J Stewart
Quantitative Estimation and Prediction of Human Cancer Risks
Reviewed by Ian B MacNeill
Epidemiology of Childhood Cancer
Reviewed by Amanda Shaw
40
New Resources
41
Calendar of Events
43
1999 Peer Reviewers
44
Indexes for Volume 20, 1999
Information for Authors (on inside back cover)
New Associate Scientific Editor
We are very pleased to announce and welcome a new
Associate Scientific Editor to the editorial staff of Chronic
Diseases in Canada, Dr Robert A Spasoff. He is a
full-time Professor at the University of Ottawa’s
Department of Epidemiology and Community Medicine.
Published by authority of the Minister of Health
© Minister of Public Works and Government Services Canada 2000
ISSN 0228-8699
Aussi disponible en français sous le titre Maladies chroniques au Canada
Agreement in Measuring Socio-economic Status: Area-based
Versus Individual Measures
Kitaw Demissie, James A Hanley, Dick Menzies, Lawrence Joseph and Pierre Ernst
Abstract
Area-based socio-economic status (SES) measures are frequently used in epidemiology. Such
an approach assumes socio-economic homogeneity within an area. To quantify the agreement
between area-based SES measures and SES assessed at the individual level, we conducted a
cross-sectional study of 943 children who resided in 155 small enumeration areas and 117
census tracts from 18 schools in Montreal, Quebec. We used street address information
together with 1986 census data and parental occupation to establish area-based and
individual level SES indicators, respectively. As compared with the SES score determined at
the level of the individual, 13 different area-based SES indices classified the children within
the same quintile 28.7% (± 2.8%) of the time. The discrepancy was within one quintile in
35.3% (± 2.3%) of cases, two quintiles in 20.6% (± 3.6%), three quintiles in 11.3% (± 4.2%)
and four quintiles in 4.1% (± 0.2%). In conclusion, we observed a substantial discrepancy
between area-based SES measures and SES assessed at the individual level. Caution should
therefore be used in designing or interpreting the results of studies in which area-based SES
measures are used to test hypotheses or control for confounding.
Key words: contextual variables; cross-level bias; ecological variables; etiologic research;
small area; socio-economic status
Introduction
Individual health outcomes may have individual and
aggregate (environmental) level determinants. Crosslevel bias is a phenomenon whereby inference about one
level of analysis is made on the basis of associations
observed at a different level.1 The most commonly
discussed cross-level bias in epidemiology is “ecological
fallacy,” which is the result of improper interpretation
and inference about individual level associations based
on associations at the aggregate level.2,3 Analyses that
relate aggregate characteristics to individual outcomes
do not necessarily result in ecological bias.1
In surveys, socio-economic status (SES) may be a
sensitive issue for an individual, and this may impair the
practicality and validity of direct questions concerning
various attributes of SES.4 An alternative approach is to
use indirect information based on average values of
social and economic conditions for geographic areas of
residence. In addition to the advantage of limiting
non-response, this area-based approach is relatively
inexpensive, and information is readily accessible.
In etiologic research, the health outcome may be
collected at the level of the individual, while the
exposure characteristics, such as SES attributes, are
collected at the level of geographic area to test the
hypothesis that SES is associated with a particular health
outcome or to control for confounding by SES.5S13
Various area-based attributes of SES have been
used—for example, average house value, median
monthly rental value of dwellings and the proportion of
university-educated subjects, single-parent families or
unemployed people as well as composite scales formed
by combining these variables.7,8 This approach is based
on an assumption that the characteristics are stable and
homogeneous within the geographic area. However, in
urban areas the population can be heterogeneous in terms
of social and economic conditions,9 even in small areas
(e.g. one city block), and can change over time.
Author References
Kitaw Demissie, Dick Menzies and Pierre Ernst, Respiratory Epidemiology Unit, Department of Epidemiology and Biostatistics, McGill University,
Montreal, Quebec
James A Hanley and Lawrence Joseph, Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec
Correspondence: Kitaw Demissie, Department of Environmental and Community Medicine, University of Medicine and Dentistry of New Jersey, Robert
Wood Johnson Medical School, 675 Hoes Lane, Piscataway, New Jersey, USA, 08854-5635; Fax: (732) 235-4569; E-mail: [email protected]
2000
1
We therefore studied the degree of agreement between
area-based SES measures and SES assessed at the individual level, rating the various area-based SES variables
as to their proximity to the individual SES measure.
Other proxy SES measures obtained at the individual
level were number of people per room in the home
(crowding index), single-parent family status and
maximal level of education attained by either parent.
Materials and Methods
Assessment of Socio-economic Status at the Area Level
By this method, socio-economic status for the individual (family of the child in this case) is inferred from the
place of residence. In Canada, information on demographic
factors, housing, income, education, quality of housing
and other household characteristics is summarized at the
level of enumeration area by Statistics Canada. Enumeration areas (EAs) represent census geostatistical neighbourhoods that contain up to a maximum of 375 households
with relatively homogeneous economic and social living
conditions. Census tracts (CTs) represent the next level
of geostatistical area, containing between 2,500 and
8,000 (average of 4,000) residents. The boundaries of
these areas have been drawn along recognizable
divisions between neighbourhoods to create units that are
as homogeneous as possible in socio-economic terms.14
The street address and postal code of the child’s usual
place of residence together with the Statistics Canada
Postal Code Conversion File18 were used to identify the
enumeration area and census tract. The Canada Postal
Code Directory19 in hard copy was used to verify postal
codes when the correct spelling of a street was in doubt.
The validity of the Statistics Canada Postal Code
Conversion file has been indirectly evaluated. The SES
rankings of small geographic areas obtained using this
conversion file have been found to accurately predict
numerous health outcomes.20
The 1986 Census Dictionary21 and the code books of
the 1986 census tape files prepared by Statistics Canada
were used to select variables that were thought to reflect
a neighbourhood’s SES. Variables used in our analysis
for both CTs and EAs were selected from the literature22S28
on the basis of their frequency of use as social inequality
indicators for small areas and were defined as follows.
· Net educational level: the proportion of people aged
15 and over without a high school certificate or
diploma subtracted from the proportion of people
aged 15 and over with a university degree or
post-secondary diploma for each small area (This
variable is believed to be the most sensitive indicator
of educational attainment.16)
· Proportion university educated: the proportion of
people aged 15 and over with a university degree or
post-secondary diploma
· Median income: median income of census families
· Income adequacy: median income divided by family
size of census families
· Average house value: average house value of
occupied private dwellings
Study Population
This study was part of a larger study designed to
investigate the indoor risk factors for airway hyperresponsiveness in Montreal school children. In order to
represent a broad range of SES, all schools belonging to
five school boards in central Montreal, Quebec, were
ranked according to neighbourhood average house value14
and, within each school board, schools were randomly
selected from the upper, middle and lower ranks. One
class was selected from each of the 18 schools from each
of grades one (ages 6 and 7), three (ages 8 and 9) and
five (ages 10 and 11).
Comparison of selected and non-selected schools
showed no difference with respect to neighbourhood
poverty, income or educational attainment level.14 For
example, for schools selected and not selected in the
upper stratum (>$95,000 neighbourhood average house
value), the respective proportions of subjects living in
poverty (as defined by Statistics Canada) were 6.1%
(n = 6) versus 5.4% (n = 115), p = 0. 83; in the middle
stratum ($70,000–$95,000 average house value) the
respective values were 12.2% (n = 6) versus 12.2%
(n = 124), p = 0.98; and in the lower stratum (<$70,000
average house value), they were 45.1% (n = 6) versus
35.9% (n = 52), p = 0.21.
Assessment of Socio-economic Status at the
Individual Level
At the individual (family) level, one parent’s most
recent occupation was used to assess the SES of the
child. A trained person interviewed both parents at home
in order to obtain a detailed employment history: the
name of the company, type of industry, department
within a company, job title, short job description, and
year job began and ended. This information was collected
for current and all preceding jobs. Information on the
most recent occupation of the parent was used to identify
the corresponding codes of the Canadian Classification
and Dictionary of Occupations.15 The codes were then
converted into SES scores for the child, based on income
and educational level for each occupation from the tables
developed by Blishen and colleagues.16 The highest
score from either parent was retained for analysis
(individual level SES index).
The validity of self-reported employment history is
well established.17 The correlations between the SES
score derived from the most recent and from the previous
three jobs respectively were r = 0.86, r = 0.84 and
r = 0.62 for the mothers’ jobs and r = 0.87, r = 0.84 and
r = 0.81 for the fathers’ jobs. The correlation between
the fathers’ and mothers’ current jobs was r = 0.89.
2
Chronic Diseases in Canada
Vol 21, No 1
Proportion unemployed: unemployed people aged 15
and over as a percentage of people aged 15 and over
who were in the labour force
·
Proportion of owned dwellings: total owner-occupied
private dwellings as a percentage of total occupied
private dwellings
·
Proportion of male parents: the number of census
families with a male parent as a percentage of total
census families
·
Proportion of female parents: the number of census
families with a female parent as a percentage of total
census families
·
·
Proportion of single parents: the number of singleparent census families as a percentage of total census
families
In addition to the above variables, the socio-economic
status score for each occupation developed by Blishen and
his colleagues16 was weighted according to the proportion
of people in each occupation category and summed, in
order to get one SES score for each small area, the neighbourhood SES index-I; the z scores of net educational
level, median income and proportion unemployed were
summed to create the neighbourhood SES index-II; and
the z scores of net educational level, median income,
average house value, proportion of owned dwellings and
proportion of single parents were also summed to
calculate the neighbourhood SES index-III.
These area-based SES variables were abstracted for
each child in our sample at the EA level. To abstract the
variables for the corresponding CTs, raw data were
summed whenever possible before averages and
proportions were calculated. If means and proportions of
enumeration areas were used to derive variables at the
CT level, appropriate weighting was used.
Statistical Methods
Agreement between the various area-based SES
indices (at both CT and EA levels) and the individual
level SES index was assessed in four ways. First, we
used both the area-based and individual level SES scores
to group the children into quintiles (quintile I having the
most deprived and quintile V the least deprived), and we
calculated the amount of agreement in classifying the
child into the same or a close quintile by the two
methods. Second, we ranked children according to the
scores obtained from the two methods and used the ranks
to plot the data and draw the median trace (Figure 1).
FIGURE 1
Neighbourhood SES index-I (at census tract level)
versus the individual SES score ranks
2000
3
Third, we calculated
Spearman’s rank correlations
of the various area-based
SES indices with the
individual-based SES
indices. Finally, we used
the ranks to calculate the
intra-class correlation
coefficient.29
Statistical analysis was
carried out using SAS
statistical software.30
Results
TABLE 1
Discrepancy between area-based measures of SES and
SES assessed individually
Area-based SES
measures in quintiles
Level
None
One
Two
Three
Net educational level
EA
CT
30.7
30.4
32.0
33.9
21.8
20.8
11.3
10.8
4.3
4.1
Proportion university
educated
EA
CT
29.2
29.6
32.3
32.4
22.9
19.9
11.1
13.8
4.5
4.3
Median income
EA
CT
30.5
34.2
37.4
34.9
19.4
17.7
8.5
8.9
4.3
4.3
Income adequacy
EA
CT
29.7
29.5
36.3
39.6
21.4
18.2
9.0
9.0
3.6
3.8
EA
CT
25.1
25.9
33.3
33.6
24.7
23.4
13.0
12.7
3.9
4.3
EA
CT
29.8
29.0
34.7
39.9
20.6
18.6
10.7
9.2
4.3
3.3
EA
CT
29.6
28.8
36.4
37.2
19.5
19.8
11.0
9.6
3.6
4.5
EA
CT
23.8
22.4
31.1
33.2
22.8
24.4
15.4
15.2
6.9
4.9
EA
CT
26.6
27.2
34.7
34.8
22.4
20.4
13.1
13.5
3.3
4.1
EA
CT
27.6
26.6
33.0
35.4
23.6
21.5
12.4
12.3
3.4
4.2
EA
CT
28.5
30.4
33.6
33.9
22.7
20.8
11.2
11.1
4.0
3.8
EA
CT
26.3
29.1
34.4
35.9
23.1
20.8
11.6
10.0
4.6
4.3
EA
CT
28.2
29.3
36.6
34.5
20.1
21.6
11.6
10.8
3.6
3.8
From the 18 Montreal
schools selected, 1,274
Average house value
eligible children were
identified, of whom 989
Proportion unemployed
(77.6%) participated in the
study; parental occupation
Proportion of owned
dwellings
could be coded into an SES
score for 934 (94.4%) of
Proportion of male parents
these children. The postal
codes for the addresses of
Proportion of female parents
952 (96.3%) children could be
linked to 117 corresponding
Proportion of single parents
census tract identifiers and
155 smaller enumeration
area identifiers to determine
Neighbourhood SES index-I
area-based SES.
Neighbourhood SES index-II
The 13 different
area-based SES indices
classified children as being
Neighbourhood SES index-III
within the same quintile as
EA = Enumeration area
that determined by the
CT = Census tract
individual level SES score
28.7% (± 2.8%) of the time.
There was a discrepancy of
one quintile in 35.3% (± 2.3%) of cases, two quintiles in
20.6% (± 3.6%), three quintiles in 11.3% (± 4.2%) and
four quintiles in 4.1% (± 0.2%) of cases (Table 1). The
degree of discrepancy was similar for area-based SES
measures obtained at both the CT and EA level.
Similarly, Spearman’s rank correlations and the
intra-class correlation coefficients between the
area-based and individual level SES measures were
always less than 0.40 (Table 2), suggesting little
agreement. Figure 1 shows a scatter diagram with a
median trace of the relation between occupation-derived,
area-based SES measure (neighbourhood SES index-I)
and the individual level SES. A wide variability around
the median trace is evident.
Agreement of the various area-based SES indices with
parental education, single-parent family status and
crowding index obtained at an individual level was also
poor and did not differ from that obtained for the
individual level SES index (data not shown).
4
Chronic Diseases in Canada
Discrepancy by quintile (%)
Four
Discussion
We found poor agreement between the area-based and
the individual level SES measures even when we used
them to classify children into broad SES categories. The
lack of agreement appeared across a wide distribution of
both individual and neighbourhood indicators of SES,
and a large number of small areas contained in various
neighbourhoods were included. Furthermore, there were
no important differences in terms of neighbourhood
indicators of poverty between selected and non-selected
schools, thus limiting selection bias.
Various methods and information have been used in
forming area-based SES indices. In a British study,
Campbell et al.22 used unemployment rates in different
areas. Wegner combined (with equal weighting) the
z scores of mean years of education and mean income
of subjects residing in a given census tract.23 From
examining determinants of mortality in Connecticut and
Rhode Island, Stockwell24 obtained the mean of the
Vol 21, No 1
TABLE 2
Spearmans’s rank correlation and intra-class
correlation coefficients for the association
of area-based SES measures with SES
assessed individually
Area-based SES
measures
Census tract
Enumeration area
rs
ICC
rs
ICC
Net educational level
0.31
0.32
0.34
0.34
Proportion university educated
0.29
0.29
0.30
0.30
Median income
0.39
0.39
0.39
0.38
Income adequacy
0.39
0.39
0.37
0.37
Average house value
0.26
0.26
0.25
0.24
Proportion unemployed
0.38
0.38
0.31
0.31
Proportion of owned dwellings
0.34
0.34
0.34
0.35
Proportion of male parents
0.19
0.18
0.09
0.08
Proportion of female parents
0.30
0.30
0.30
0.29
Proportion of single parents
0.27
0.27
0.30
0.29
Neighbourhood SES index-I
0.31
0.31
0.31
0.31
Neighbourhood SES index-II
0.33
0.34
0.25
0.25
Neighbourhood SES index-III
0.33
0.33
0.33
0.32
ICC = Intra-class correlation coefficient
rs = Spearman’s rank correlation
percentile scores for occupation, education and median
income by census tract and subsequently modified this
by adding the rental value of housing and the extent of
overcrowding in dwelling units within each census tract.
There is no standard way of constructing area-based
indices, and the various methods used in the literature
have not been compared with or rated on their relative
proximity to information on SES that is specific to the
individual.
In this study we compared and rated 13 different
variables thought to be related to SES that could be
derived from area-based information, and all correlated
poorly with the individual SES measure. Furthermore,
there were no substantial differences among them as to
their proximity to SES assessed individually.
The strength of association between SES and disease
outcome has been reported to vary according to the level
of small area used in the analysis. For instance, in a
study in which census tract was used as a small area of
analysis, median rental values of residences were not
found to be associated with endometrial cancer;7
however, the same variable was associated with
endometrial cancer when the unit of analysis was a
residential block.8
2000
In the present study, there was no substantial
improvement when the smaller and potentially more
homogeneous enumeration areas were used as opposed
to the larger census tracts. This may have been the result
of a close correspondence between enumeration areas
and census tracts in our study sample, given that many
more than 155 enumeration areas would be expected
from 117 census tracts. One possible explanation for the
small number of enumeration areas is that the school
catchment areas were fairly small and may have included
only a few enumeration areas from each census tract.
Individual level SES was used as a standard of
reference with which area-based SES measures were
compared. We used Blishen’s SES index to measure
individual level SES.16 Parents were directly interviewed
to obtain detailed employment histories, and this
information was used to discriminate between the
various occupations with similar job titles. The SES
score assigned for each occupation has been developed
after substantial research and is based on objective
measures of educational level and income for each
occupation. Blishen’s SES index, developed for
occupations in Canada, and its US counterpart (Duncan’s
SES index) are considered to be the most appropriate
measures of ranking North American societies in terms
of social and economic conditions. These composite
measures are the most frequently used in social science
research,31 although they may not represent a true gold
standard, given the complexities involved in the
assessment of socio-economic status.
The poor agreement between the various area-based
and individual SES measures is unlikely to have been
due to intrinsic problems of the individual level Blishen
ratings, because the area-based Blishen index
(neighbourhood SES index-I) was found to have a
similarly low agreement with the individual measures as
the other area-based indices.
Persons of low and high SES tend to reside in certain
areas within cities. Area-based measures of low SES
appear to reflect a similar construct to that of low SES
measured at the individual level, as shown in studies
linking both levels of SES measures to various health
indicators.4 Area-based SES scores have been shown to
be inversely related to all-cause mortality.24 Among
women, strong correlations have been found between
standardized mortality ratios and area-based socioeconomic variables.32 Area-based SES variables have
been linked to low birth weight, proportion of teenage
mothers, non-immunized children and height as well
as other potential markers of poor health.23,33
At issue in this type of analysis is the extent of
measurement error that results when area-based SES
measures are used. We expect the misclassification
associated with area-based SES measures to be
non-differential (i.e. the probabilities of exposure
misclassification are the same in all groups being
compared and unrelated to disease status). The effect of
unreliable measurements, therefore, is to attenuate
5
exposure–outcome correlation or regression coefficients.29
One consequence of attenuation is that a sample estimate
of the observable correlation may fail to reach statistical
significance, whereas a sample estimate of the correlation
using more precise scores might be significant. The use
of area-based SES measures may therefore involve use
of larger sample sizes and incur additional costs.
A recent report from the US used a national sample to
examine the use of census-based aggregate variables as a
proxy for SES, concluding that associations of health
outcomes with aggregate SES measures were
substantially weaker than with micro-level measures.13
From the intra-class correlation coefficients presented in
Table 2, one can calculate a correction factor for the
attenuated correlations.29
We used the 1986 Canadian census data to construct
the area-based SES measures, whereas we obtained
parental occupation for the period from April 1990 to
November 1992. This time difference may have
contributed to the lack of correlation between the
individual and area-based measures of SES. Census data
are collected only every 5 or 10 years in most countries,
so that similar time differences are a regular feature of
using area-based measures of SES. Geronimus and
Bound13 reported that the time lag between the primary
data set being analyzed and collection of the census data
makes little difference to area-based SES measures in
predicting health outcomes.
In conclusion, we observed a substantial discrepancy
between area-based SES measures and SES assessed on
the basis of individually obtained information. Caution
should therefore be used in designing or interpreting the
results of studies in which area-based SES measures are
used to test hypotheses or control for confounding.
Acknowledgements
The study was approved by the Ethics Committee of the
Department of Epidemiology and Biostatistics, McGill
University, and was supported financially by the Medical
Research Council of Canada and the Respiratory Health
Network of Centres of Excellence (Canada).
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J Epidemiol Community Health 1978;32:28–33.
Vol 21, No 1
27. Sargent JD, Bailey A, Simon P, Blake M, Dalton MA.
Census tract analysis of lead exposure in Rhode Island
children. Environmental Research 1997;74:159–68.
28. Crosse EA, Alder RJ, Ostbye T, Campbell MK. Small area
variation in low birthweight: looking beyond
socioeconomic predictors. Can J Public Health
1997;88:57–61.
29. Fleiss JL. The reliability of measurement. In: Fleiss JL.
The design and analysis of clinical experiments.
New York: John Wiley & Sons, 1986:1–32.
30. SAS Institute Inc. Statistical Analysis System, Version 6.
Cary (NC): SAS Institute Inc., 1989.
2000
31. Powers MG. Measures of socioeconomic status: an
introduction. In: Powers MG, ed. Measures of
socioeconomic status: current issues. Boulder (CO):
Westview Press, 1982.
32. Alexander FE, O’Brien F, Hepburn W, Miller M.
Association between mortality among women and
socioeconomic factors in general practices in Edinburgh:
an application of small area statistics. BMJ
1987;295:754–6.
33. Reading R, Jarvis S, Openshaw S. Measurement of social
inequalities in health and use of health services among
children in Northumberland. Arch Dis Child
1993;68:626–31. O
7
An Assessment of the Validity of a Computer System for
Probabilistic Record Linkage of Birth and Infant Death
Records in Canada
Martha Fair, Margaret Cyr, Alexander C Allen, Shi Wu Wen, Grace Guyon and Ralph C MacDonald,
for the Fetal and Infant Health Study Groupa
Abstract
Studies on the validity of probabilistic record linkage are sparse. We performed a
probabilistic linkage to link the 1984S1994 birth records (obtained from the Canadian Birth
Data Base) with 1984S1995 infant death records (from the Canadian Mortality Data Base) in
Canada. We extracted the linked birthSdeath records for Nova Scotia and Alberta (from
January 1990 to December 1991) obtained from Statistics Canada’s vital registration data
and compared them with corresponding records from provincial data (primarily hospital
records). The results showed that over 99% of infant deaths (153/155) in the Nova Scotia
provincial data were successfully located in the linked Statistics Canada file; the
corresponding figure for Alberta neonatal deaths was also 99% (365/367). The distributions
of gestational age and birth weight in matched cases demonstrated high agreement between
the two data sources. We conclude that the computer system for probabilistic linkage
developed by Statistics Canada using the available personal identifying variables in the
Canadian Birth Data Base and the Canadian Mortality Data Base is valid.
Key words: births; deaths; epidemiologic methods; infant; medical record linkage; validity
Introduction
Existing databases such as the Canadian Birth Data
Base (CBDB)1 and the Canadian Mortality Data Base
(CMDB)2 are attractive to health and health care analysts
because they permit detailed studies of large populations.
However, a single database may lack information that is
crucial to the analysis. For example, information on birth
weight and gestational age is usually recorded on birth
registrations, whereas information on infant mortality is
recorded on death registrations. Thus, an analysis of
birth weight-specific or gestational age-specific infant
mortality is impossible using separately registered data.
In recent years, developments in computerized record
linkage methodology have made it possible to bring such
databases together.3S6 To facilitate the surveillance of
fetal and infant health, the Canadian Perinatal
Surveillance System (CPSS) funded a record linkage of
the Canadian Birth Data Base for 1985S1994 with infant
deaths from the Canadian Mortality Data Base for
1985S1995 at Statistics Canada. A probabilistic linkage
(or maximum likelihood linkage) was performed of
infant death records with corresponding birth records
using the Generalized Record Linkage System developed
by Statistics Canada6,7 and a calculated statistical
probability based on relevant identifying variables
(e.g. name, date of birth).
To assess the validity of this record linkage
procedure, the records located in the Statistics Canada
Author References
Martha Fair, Margaret Cyr and Ralph C MacDonald, Statistics Canada, Ottawa, Ontario
Alexander C Allen, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia
Shi Wu Wen, Bureau of Reproductive and Child Health, Laboratory Centre for Disease Control, Health Protection Branch, Health Canada, Ottawa,
Ontario
Grace Guyon, Alberta Medical Association, Edmonton, Alberta
Correspondence: Shi Wu Wen, Bureau of Reproductive and Child Health, Laboratory Centre for Disease Control, Tunney’s Pasture, Address Locator:
0701D, Ottawa, Ontario K1A 0L2
a
Contributing members of the Fetal and Infant Health Study Group: Linda Bartlett (Centers for Disease Control and Prevention), KS Joseph (Dalhousie
University), Michael S Kramer (McGill University), Robert M Liston (University of British Columbia), Sylvie Marcoux (Université Laval), Brian
McCarthy (Centers for Disease Control and Prevention), Douglas D McMillan (University of Calgary), Arne Ohlsson (University of Toronto), Reg
Sauvé (University of Calgary) and Russell Wilkins (Statistics Canada)
8
Chronic Diseases in Canada
Vol 21, No 1
linked file were compared with information on the
corresponding births and deaths collected independently
by the provincial perinatal surveillance programs in
Nova Scotia and Alberta. A full account of this
validation study has been published by Statistics Canada
as a technical report.8 Studies on the validity of
probabilistic linkage are sparse in the published
literature, despite widespread use of this methodology in
public health surveillance and epidemiologic research
activities. We felt it important to disseminate the main
results of this validation study to a broad audience
through a peer-reviewed publication.
Methods
The Linked Statistics Canada Birth and Death Files
Statistics Canada’s vital registration data are primarily
collected through parental reporting at registration. The
registrars of the 10 provinces and 2 territories collect
data on live births, fetal deaths and other deaths. Paper
and electronic (if available) copies of the registration
documents are submitted to Statistics Canada under
agreements between federal and provincial governments.
The data are reformatted, edited, verified and stored in
Statistics Canada’s Integrated Vital Statistics files.
Statistics Canada’s files were preprocessed into a
format suitable for record linkage. A phonetic code from
the New York State Individual and Intelligence System9
was generated to encode the surname values so that,
during the linkage process, records could be compared
that had similar sounding surnames in order to check
for misspelling or key entry errors. Data items from
other sources, such as postal codes, were added, and
alternative records were created using other surname
fields (e.g. parental surnames). The 1990S1991 live
birth events recorded in the CBDB were linked to the
1990S1992 deaths recorded in the CMDB. A probabilistic
record linkage was performed using the Generalized
Record Linkage System,6,7 which compares fields
common to the two files, assigns weights to the resulting
links and calculates a total weight. A weight of less than
-90 would be automatically rejected, and a weight
greater than +300 would be automatically accepted as a
match. Manual resolution was carried out to confirm all
linked records with a total weight ranging from -90 to
300, and to confirm all links to multiple births. Updates
were made to the computer decisions where necessary, to
create the linked Statistics Canada birthSinfant death file.
Two subsets of the linked birthSdeath file were extracted
for the validation comparison: (1) all 1990S1991 live
birthSdeath linkages for which the province of birth
was Nova Scotia and the age at death was 0S364 days
(158 infant deaths); and (2) all 1990S1991 live birthS
death linkages for which the province of birth and death
was Alberta and the age at death was 0S< 28 days
(371 neonatal deaths). These two provinces were chosen
because they were the only ones with a perinatal data
system that would allow an independent assessment of
Statistic Canada’s vital registration data.
2000
The Nova Scotia and Alberta Provincial Data Files
In contrast to Statistics Canada’s vital registration
data, the provincial perinatal data were obtained
primarily from hospital discharge records.
The Reproductive Care Program of Nova Scotia
supports the Nova Scotia Atlee Perinatal Database,
which collects data on obstetric and neonatal events from
hospital records in the province, including information
on birth weight and gestational age.10 To ensure that all
cases are received by the Reproductive Care Program,
these records are matched with Nova Scotia’s vital
statistics. Birth and death registration numbers are
entered in the database. Records of infant deaths
occurring after discharge from hospital are captured from
Nova Scotia’s vital statistics. Nova Scotia supplied the
data for this validation study for births that took place
only in Nova Scotia: babies born out of province and
transferred to Nova Scotia were not included, nor were
babies born out of province to Nova Scotia residents.
The Nova Scotia file contains data for infant deaths
occurring from 0 to 364 days after birth and includes
birth weight and gestational age.
The Alberta Medical Association’s Committee on
Reproductive Care obtains mortality data from Alberta’s
hospital records for case review of fetal, neonatal and
maternal deaths. Data are also collected from hospital
birth records, including delivery, prenatal and newborn
records as well as autopsy reports. Patient records are
verified with Alberta’s vital statistics (no information is
extracted) to ensure that all cases have been received.11
The cases reviewed were those for which the province of
birth and death was Alberta: babies born out of province
and transferred to Alberta were not included, nor were
babies born out of province to Alberta residents. The
Alberta file contains data for neonatal deaths occurring
less than 28 days after birth and includes birth weight
and gestational age.
In order for the records of deaths to be matched, each
province was asked to provide Statistics Canada with a
special file containing all infant (Nova Scotia) and
neonatal (Alberta) deaths in 1990S1991.
Assessment Technique
The Nova Scotia and Alberta files were processed at
Statistics Canada to facilitate the match to the Statistics
Canada files. Name fields were standardized, geographic
fields were recoded and infant (neonatal) death records
were grouped. Agreement (matching rate) between
provincial records and Statistics Canada’s records was
used as the indicator of validity.
For data from Nova Scotia, the infant deaths on the
provincial file were matched to the linked Statistics
Canada file by the death registration and birth
registration numbers supplied by the province. An exact
match technique was employed using the SAS software
package.12 For data from Alberta, registration numbers
were not available on the provincial fetal and neonatal
death records. Therefore, they were matched using
9
Results
common personal identifiers and processed together to
maximize the number of individual matches.
Because there was no “type of event” field (i.e. live
birth or stillbirth) on the Alberta file, this variable was
imputed using “age at death” and “time of death”
variables. When there were discrepancies in “type of
event” between the Statistics Canada and Alberta files,
the Alberta database administrator was contacted. There
were 22 cases with such anomalies, 19 of which were
corrected to agree with the Statistics Canada file; 3 of the
22 were not reconciled. In 2 of these cases, the records
were coded as fetal death on the Alberta file and infant
death on the linked Statistics Canada file. In the
remaining case, the event was coded as neonatal death
on the Alberta file and fetal death on the Statistics
Canada file. For the 3 cases, Statistics Canada’s “type of
event” code was used in the presentation of the results.
Three passes were executed to maximize the number
of potential matches. The selected fields for matching in
the first pass were sex, the first four bytes of the surname
(equivalent to first four letters) and date of birth (year,
month, day). The second pass used sex, the first four
bytes of the surname field and birth weight. The third
pass used sex and date of birth. All matches were
manually verified.
Birth weight and gestational age in the two provincial
files were compared with the Statistics Canada file if the
records referred to the same individual.
Nova Scotia
All but 2 (153/155, or 99%) of the infant deaths in the
Nova Scotia file matched the corresponding Statistics
Canada file. When gestational age was grouped by
important analytic categories, agreement was found on
105 of 153 (70%) infant deaths (Table 1). Most of the
disagreements were out by just plus or minus one
category. When birth weight was grouped by important
analytic categories, agreement was reached on 147 of
153 (96%) (Table 2).
Alberta
All but 2 (365/367, or 99%) of the neonatal deaths in
the Alberta file matched the corresponding Statistics
Canada file. When gestational age was grouped by
important analytic categories, there was agreement on
317 of 365 (87%) neonatal deaths (Table 3). When birth
weight was grouped by important analytic categories,
there was agreement on 354 of 365 (97%) (Table 4).
Discussion
Probabilistic linkage is considered the preferable
linkage method because the calculation of the probability
can be refined in various respects to accommodate
weights associated with identifier values and coding
errors, and can thus maximize the available information.
As a result, computer systems used for probabilistic
TABLE 1
Comparison of gestational age on Statistics Canada’s records with gestational age
on Nova Scotia’s records—infant deaths, for birth years 1990–1991
Gestational age
(weeks)
20–21
STATISTICS CANADA
20–21
22
1
3
22
S
C
O
T
I
A
4
25–26
27–28
29–31
32–33
34–36
12
1
17
(11.11)
3
7
2
12
(7.84)
2
8
10
(6.54)
1
1
1
34–36
1
37–41
1
14
(9.15)
3
2
6
(3.92)
1
13
4
3
43
4
51
(33.33)
2
5
7
(4.58)
10
1
1
$42
Column total
(%)
10
1
2
(1.31)
Chronic Diseases in Canada
10
(6.54)
$42
4
(2.61)
32–33
N/A
37–41
1
27–28
29–31
25–26
4
(2.61)
3
23–24
N
O
V
A
23–24
Row total
(%)
1
1
17
(11.11)
14
(9.15)
11
(7.19)
12
(7.84)
4
(2.61)
1
5
20
(13.07)
54
(35.29)
19
(12.42)
9
(5.88)
9
(5.88)
153
(100.00)
Vol 21, No 1
TABLE 2
Comparison of birth weight on Statistics Canada’s records with birth weight
on Nova Scotia’s records—infant deaths, for birth years 1990–1991
Birth weight
(grams)
STATISTICS CANADA
#399
#399
N
O
V
A
S
C
O
T
I
A
400–499
500–749
750–999
1000–1499
1500–2499
2500–4499
$4500
N/A
4
(2.61)
4
400–499
9
500–749
10
(6.54)
1
2
750–999
20
1
23
(15.03)
1
14
15
(9.80)
1000–1499
11
(7.19)
11
1500–2499
26
(16.99)
26
2500–4499
60
61
(39.87)
1
$4500
Column total
(%)
Row total
(%)
3
(1.96)
3
4
(2.61)
11
(7.19)
21
(13.73)
15
(9.80)
11
(7.19)
26
(16.99)
61
(39.87)
3
(1.96)
1
(0.65)
153
(100.00)
TABLE 3
Comparison of gestational age on Statistics Canada’s records with gestational age
on Alberta’s records—neonatal deaths, for birth years 1990–1991
Gestational age
(weeks)
STATISTICS CANADA
#20
#20
20–21
A
L
B
E
R
T
A
22
23–24
25–26
27–28
29–31
32–33
34–36
37–41
3
1
(0.27)
1
33
(9.04)
27
3
3
26
2
2
4
55
4
1
1
3
32
4
1
2
27
2
32
(8.77)
2
22
24
(6.58)
25–26
27–28
31
(8.49)
29–31
67
(18.36)
12
34–36
37–41
14
(3.84)
2
38
3
2
72
$42
2000
4
(1.10)
33
(9.04)
34
(9.32)
61
(16.71)
38
(10.41)
34
(9.32)
41
(11.23)
1
32–33
Column total
(%)
$42
1
22
23–24
20–21
Row total
(%)
24
(6.58)
12
(3.29)
42
(11.51)
76
(20.82)
41
(11.23)
1
75
(20.55)
6
6
(1.64)
7
(1.92)
365
(100.00)
11
TABLE 4
Comparison of birth weight on Statistics Canada’s records with birth weight
on Alberta’s records—neonatal deaths, for birth years 1990–1991
Birth weight
(grams)
#399
400–499
STATISTICS CANADA
#399
400–499
750–999
1000–1499
1500–2499
1
N/A
41
(11.23)
40
81
1
1
1000–1499
1
1
47
(12.88)
45
1500–2499
44
(12.05)
44
2500–4499
1
85
(23.29)
84
4
N/A
5
(1.37)
1
1
(0.27)
1
30
(8.22)
40
(10.96)
82
(22.47)
33
(9.04)
linkage, including the one developed by Statistics
Canada, have become popular tools in large
population-based studies.3S6 However, before applying
the methodology to different data sets, it is important to
assess the validity of the linked records, that is, whether
and to what extent the linked records are accurate.
The matching rate between provincial records and
Statistics Canada’s records is high: for the Nova Scotia
file, 99% of the infant deaths were successfully located
on the linked Statistics Canada file, and for Alberta
neonatal deaths, the agreement was over 99%. The high
agreement was demonstrated not only in the matching
percentage of the study records but also in the agreement
of birth weights obtained from these records. The
agreement for gestational age, a variable that is more
vulnerable to misclassification, was still quite
satisfactory. The robustness of Statistics Canada’s
computer system is further documented by the
consistently high agreement in data collected in this
study from different jurisdictions through different data
collection mechanisms and with different available
personal identifying variables. Furthermore, a matching
rate of 84S98% has been observed in a few earlier
studies using similar methods.13S17
We acknowledge that there is no “gold standard” for
the current study. Nova Scotia’s and Alberta’s provincial
surveillance data may not necessarily be superior to
Statistics Canada’s registry data, and the reverse is also
true. However, if we can assume that a high degree of
agreement between records collected from two different
Chronic Diseases in Canada
83
(22.74)
30
(8.22)
30
$4500
12
$4500
29
(7.95)
750–999
Column total
(%)
2500–4499
29
500–749
A
L
B
E
R
T
A
500–749
Row total
(%)
45
(12.33)
45
(12.33)
88
(24.11)
1
(0.27)
1
(0.27)
365
(100.00)
systems suggests a high degree of validity, then these
results indicate that Statistic Canada’s computer system
for probabilistic linkage using the available personal
identifying variables in the CBDB and the CMDB is
valid.
Record linkage also provides an opportunity to
improve the data quality of participating databases. In
this case, the linkage study located three infants born in
Nova Scotia who had died in another province and who
had not been identified on the Nova Scotia file. The
linkage also located 22 events in Alberta (i.e. fetal or
neonatal deaths) that had been incorrectly identified in
the Alberta file.
This validation study examines the linkage results and
analytic variables in only two provinces over a two-year
period. Whether the results are applicable to other
jurisdictions or other periods of time needs
consideration. There may be variations in coding and
recording practices over time and across jurisdictions.
For example, some provinces have historically recorded
birth weight in pounds and ounces whereas other
provinces have used grams. Standard definitions and
coding schemes are required in all jurisdictions in order
to carry out a comprehensive comparison. Also noted
within the Alberta file were inconsistencies between the
type of death and the age of death. To improve record
linkage, definitions should be followed precisely and the
personal identifiers necessary for record linkage and
grouping of analytic variables should be as complete as
possible.
Vol 21, No 1
Acknowledgements
We thank the Vital Statistics Registrars of the provinces and
territories who gave us access to their files. This study was
conducted under the auspices of the Canadian Perinatal
Surveillance System. The study’s participants would like to
thank Monique Atkinson and Ernesto Delgado for their
assistance in preparing the text and tables.
References
1. Fair M, Cyr M. The Canadian Birth Data Base: a new
research tool to study reproductive outcomes. Health Rep
1993;5(3):281–90.
2. Smith ME, Newcombe HB. Use of the Canadian Mortality
Data Base for epidemiological follow-up. Can J Public
Health 1982;73:39–44.
3. Newcombe HB, Kennedy JM, Axford SJ. Automatic
linkage of vital records. Science 1959;130:954S9.
4. Newcombe HB. Handbook of record linkage: methods for
health and statistical studies, administration, and
business. Oxford (England): Oxford University Press,
1988.
5. Howe GR. Use of computerized record linkage in cohort
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6. Howe GR, Lindsay J. A generalized iterative record
linkage computer system for use in medical follow-up
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7. Smith ME, Silins J. Generalized iterative record linkage
system. In: Proceedings of the American Statistical
Association, Social Statistics Section. 1981:128S37.
8. Fair M, Cyr M, Allen AC, Wen SW, Guyon G,
MacDonald RC and the Fetal-Infant Mortality Study
Group of the Canadian Perinatal Surveillance System.
Validation study for a record linkage of births and infant
2000
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Lynch BT, Arends WL. Selection of surname coding
procedure for the SRS record linkage system. Washington
(DC): US Department of Agriculture, 1977 Feb.
Allen A, Attenborough R, Dodds L, Luther E, Pole J.
Perinatal care in Nova Scotia, 1988–1995. Halifax: The
Reproductive Care Program, 1996.
The Alberta Medical Association Committee on
Reproductive Care. 1995 Alberta perinatal and neonatal
statistics and maternal mortality annual report.
Edmonton: Alberta Medical Association, 1997.
SAS Institute Inc. Statistical Analysis System, Version 6.
Cary (NC): SAS Institute Inc., 1989.
Kusiak RA, Springer J, Ritchie AC, Muller J. Carcinoma
of the lung in Ontario gold miners: possible etiological
factors. Br J Ind Med 1991;48:808S17.
Goldberg MS, Carpenter M, Thériault G, Fair ME. The
accuracy of ascertaining vital status in a historical cohort
study of synthetic textiles workers using computerized
record linkage to the Canadian Mortality Data Base. Can J
Public Health 1993;84(3):201S4.
Shannon HS, Jamieson E, Walsh C, Julian JA, Fair ME,
Buffet A. Comparison of individual follow-up and
computerized record linkage using the Canadian Mortality
Data Base. Can J Public Health 1989;80:54S7.
Newcombe HB, Smith ME, Howe GR, Mingay J,
Strugnell, Abatt A. Reliability of computerized versus
manual death searches in a study of the health of Eldorado
uranium workers. Comput Biol Med 1983;13:111S23.
Schnatter AR, Thériault G, Katz AM, Thompson FS,
Donaleski D, Murray N. A retrospective mortality study
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Ind Med 1992;22:209S29. O
13
Infant Mortality by Gestational Age and Birth Weight in
Canadian Provinces and Territories, 1990S1994 Births
Shi Wu Wen, Michael S Kramer, Shiliang Liu, Susie Dzakpasu and Reg Sauvé,
for the Fetal and Infant Health Study Groupa
Abstract
We compared gestational age-specific and birth weight-specific infant mortality in the
Canadian provinces (excluding Ontario) and territories using the linked birth and death
records for 1990–1994 births. Compared with Quebec, early neonatal mortality rates were
higher in Saskatchewan, Alberta and Newfoundland among extremely small and preterm
infants and among infants with no information on gestational age and birth weight on their
records. Post-neonatal mortality rates were higher in Prince Edward Island, Manitoba,
Saskatchewan, Alberta, British Columbia and the Northwest Territories among preterm
(and low birth weight) and term (and normal birth weight) infants. We suggest that
differences in registration practices probably explain the substantial interprovincial
variations in early neonatal mortality rates among extremely small and preterm infants,
whereas differences in demographic profile and the quality of obstetric, neonatal and infant
care probably explain interprovincial variations in infant mortality rates among less
extremely small and preterm infants.
Key words: birth weight; gestational age; infant mortality
Introduction
In almost all countries throughout the world, infant
mortality has dropped markedly over the last century
with improvements in sanitation, nutrition, infant
feeding, and maternal and child health care,1 although
the decline has been slower in recent years.2 Disparities
in the risk of infant death remain, however, even in
countries like Canada, where universal health care has
been in place since 1970.3 For example, according to
Statistics Canada figures, infant mortality for the
combined years of 1991–1995 was 5.63 per 1,000 live
births in Quebec but 13.22 per 1,000 live births in the
Northwest Territories.4,5
Why should such disparities remain in Canada despite
the availability of universal health care for three decades?
Analysis of infant mortality rates in Canadian provinces
and territories by gestational age and birth weight groups
may provide some hints. Improvements in, and access to,
high-risk obstetric and neonatal care have led not only to
markedly increased survival among extremely preterm
newborns but to changes in registration practices of
extremely small, immature newborns as well. Thus,
births that were previously registered as spontaneous
abortions (if they were registered at all) are now being
registered as births, and births that were previously
registered as stillbirths are now being registered as
live births.6S10
If there were substantial regional differences in
registration practices, it should primarily affect the
calculated infant mortality rates in groups with extremely
low gestational age and birth weight, rather than other
gestational age and birth weight groups. On the other
hand, if substantial differences in infant mortality rates
were observed in less extremely small or preterm infants,
Author References
Shi Wu Wen, Shiliang Liu and Susie Dzakpasu, Bureau of Reproductive and Child Health, Laboratory Centre for Disease Control, Health Protection
Branch, Health Canada, Ottawa, Ontario
Michael S Kramer, Departments of Epidemiology and Biostatistics and of Pediatrics, Faculty of Medicine, McGill University, Montreal, Quebec
Reg Sauvé, Department of Pediatrics, University of Calgary, Calgary, Alberta
Correspondence: Shi Wu Wen, Bureau of Reproductive and Child Health, Laboratory Centre for Disease Control, Tunney’s Pasture, Address Locator:
0701D, Ottawa, Ontario K1A 0L2
a
Contributing members of the Fetal and Infant Health Study Group: Alexander C Allen (Chair, Dalhousie University), Margaret Cyr and Martha Fair
(Statistics Canada), KS Joseph (Dalhousie University), Robert M Liston (University of British Columbia), Sylvie Marcoux (Université Laval), Brian
McCarthy (Centers for Disease Control and Prevention), Douglas D McMillan (University of Calgary), Arne Ohlsson (University of Toronto) and
Russell Wilkins (Statistics Canada)
14
Chronic Diseases in Canada
Vol 21, No 1
disparities in factors related to maternal health and
maternal, neonatal and infant care should be considered.
To examine such potential disparities, we analyzed
gestational age-specific and birth weight-specific infant
mortality rates among Canadian provinces and territories.
Methods
We used the linked birth and death records in Canada
for births occurring from 1990 to 1994. Data processing
and linkage procedures have been described elsewhere.11
In brief, information on live births and deaths in Canada
is collected by the registrars of the 10 provinces and
2 territories. Paper and electronic copies of the registration documents are submitted to Statistics Canada. Live
birth data are stored in the Canadian Birth Data Base, and
death data are stored in the Canadian Mortality Data Base.
To allow analysis of the relation between birth
characteristics and death outcomes, Statistics Canada
created a linked Canadian birthSdeath file for 1985S1994
birth records and 1985S1995 death records through the
Canadian Perinatal Surveillance System. This linkage
was based on a probabilistic procedure, using the
Generalized Record Linkage System.12,13 The Generalized
Record Linkage System compares common fields in the
two files, assigns weights to the resulting links and
calculates a total weight. A weight of less than -90 would
be automatically rejected and a weight of greater than
+300 would be automatically accepted as a match.
Manual resolution is carried out to confirm all linked
records with a total weight ranging from -90 to +300 and
all links to multiple births.
To reduce potential bias caused by secular trends in
mortality and its determinants, we restricted our analysis
to infants born between 1990 and 1994. Ontario data
were excluded because of concerns about data quality.14
Newfoundland data were restricted to births between
1991 and 1994, because data from this province were
not available to Statistics Canada before 1991. In the
provinces and territories studied, nine live births
occurring between 1990 and 1994 with a gestational age
of less than 22 weeks and a birth weight of less than
500 g appeared to have survived infancy. Because the
probability of survival at these birth weights and
gestational ages is negligible, the survival designation
in these cases could have been due to missing death
certificates. The vital status of such births was
reclassified as death on the first day of life; this
reclassification is identified in all analyses.
We calculated province-specific rates for early neonatal
(0–6 days after birth), late neonatal (7– 27 days after birth)
and post-neonatal (28–365 days after birth) deaths, using
all live births, survivors to the 7th day after birth and
survivors to the 28th day after birth, respectively, as the
denominators. Province-specific mortality rates were
further calculated for the following gestational age
and birth weight groups: <22 weeks, 22S23 weeks,
24S25 weeks, 26S27 weeks, 28S31 weeks, 32S33 weeks,
34S36 weeks, 37S41 weeks, 42 weeks and over, and not
2000
available (missing) for gestational age; and <500 g,
500S749 g, 750S999 g, 1,000S1,249 g, 1,250S1,499 g,
1,500S1,999 g, 2,000S2,499 g, 2,500S3,999 g, 4,000 g
and over, and not available for birth weight. Relative
risks and 95% confidence intervals were estimated for
each province. Quebec was used as the reference for
the estimates because Quebec had both the largest
population and the lowest infant mortality rate14 among
the provinces and territories studied.
To further explore the reasons for interprovincial
variations in infant mortality, we also compared the
distribution of important characteristics recorded on the
birth certificate. We used mother’s province of residence
at delivery to calculate the province-specific rates and
relative risks; nine births could not be assigned to a
province or territory according to this variable and were
excluded from these calculations.
Finally, to assess the potential impact of unlinked
deaths and misclassification of birth weight and
especially gestational age on the comparison of
gestational age-specific and birth weight-specific
mortality rates, we conducted supplementary analyses.
In these, unlinked infant deaths were included in the
calculation of overall early neonatal, late neonatal and
post-neonatal mortality rates, and for those infants with
a birth weight that deviated from the mean for a given
gestational age by more than 5 standard deviations
(based on the standard deviation for 1992–1994 live
births), gestational age and birth weight were reclassified
as “not available.”
Results
A total of 1,230,938 births were registered by
Statistics Canada for the nine provinces and two
territories during the five-year study period. Among
these, 1,223,895 were live births, 1,219,788 were live
births surviving to the 7th day after birth and 1,218,928
were live births surviving to the 28th day after birth.
Overall early neonatal, late neonatal and post-neonatal
death rates were respectively 3.4, 0.7 and 2.3 per 1,000
live births. Of the 7,847 infant deaths, 199 could not be
linked to birth records (i.e. the matching rate was 97.6%).
The majority of infants born before 22 weeks of
gestation and a large proportion of those born before
24 weeks of gestation died soon after birth. Mortality
rates were very high among infants born before 28 weeks
and declined rapidly at higher gestational ages. Mortality
rates reached their lowest level at term and increased
slightly post-term. This “U”-shaped distribution in
mortality rates was consistently observed in all provinces
and territories studied, although some fluctuations did
occur because of small samples in certain provinces and
territories. Birth weight-specific mortality rates showed a
similar pattern, with very high mortality in extremely
low birth weight groups and a steep reduction at higher
birth weights. However, unlike the situation for post-term
infants, infants with large birth weight ($4,000 g) were
not at increased risk of infant mortality as compared with
15
TABLE 1
Relative risk of early neonatal (0–6 days) death in Canadian provinces/territoriesa
by gestational age group, 1990–1994 births
Gestational
age
(weeks)
Deaths per
1,000 live
births
Relative risk
(and 95% confidence interval)
NFLD
PEI
NS
NB
MAN
YUK
NWT
QUEb
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
1.01c
1.02c
0.91c
(0.77–1.08) (0.96–1.07) (0.96–1.09)
NE
(NE)
NE
NE
944.8
22–23
0.78
(0.59–1.03)
NE
(NE)
0.91
0.98
1.05
0.97
0.84
1.11c
(0.84–1.11) (0.66–1.06) (1.05–1.19) (0.79–1.04) (0.90–1.05) (0.98–1.12)
NE
(NE)
0.82c
(0.51–1.31)
870.8
24–25
1.03
0.89
0.89
0.97
0.73
1.03
0.93
0.46c
(0.66–1.31) (0.13–1.56) (0.81–1.30) (0.66–1.21) (0.69–1.16) (0.77–1.23) (0.61–0.88) (0.88–1.21)
NE
(NE)
0.34c
(0.06–2.06)
486.1
26–27
1.38
(0.78–2.44)
2.28
0.75
0.98
1.15
1.48
0.91
0.99
0.55c
(0.45–1.27) (0.56–1.73) (0.80–1.67) (1.02–2.15) (0.66–1.24) (0.74–1.32) (0.08–3.61) (1.18–4.39)
164.5
28–31
1.35
2.14
1.37
0.87
0.77
1.53
1.12
1.09
(0.81–2.26) (0.99–4.63) (0.93–2.03) (0.50–1.51) (0.50–1.18) (1.08–2.18) (0.85–1.47) (0.83–1.43)
NE
(NE)
0.98c
(0.37–2.59)
52.9
32–33
0.25c
1.48
0.55
1.11
0.96
0.84
1.70
1.86c
(0.92–3.14) (0.47–7.29) (0.08–0.75) (0.87–2.53) (0.29–1.05) (0.65–1.87) (0.67–1.39) (0.58–1.23)
NE
(NE)
0.99c
(0.25–3.94)
25.6
34–36
0.90
1.27
1.08
1.31
1.00
0.88
0.98c
0.88c
1.19
1.49c
(0.63–2.25) (0.55–3.99) (0.57–1.44) (0.80–2.02) (0.92–1.53) (0.90–1.93) (0.76–1.32) (0.66–1.18) (0.14–6.99) (0.28–2.73)
6.9
37–41
1.06
1.22
1.18
1.02
0.97
0.95
1.12c
1.59c
1.32
0.44c
(0.89–1.97) (0.14–1.36) (0.77–1.45) (0.88–1.69) (0.92–1.53) (0.77–1.36) (0.80–1.18) (0.79–1.15) (0.28–4.51) (0.82–3.08)
0.8
42–47
1.71
(0.39–7.44)
NE
(NE)
43.24c
(6.48–288.70)
NE
(NE)
<22
Not available
NE
(NE)
SASK
ALTA
BC
1.34
0.97
0.78
1.23
1.39
0.70
3.47c
(0.59–3.03) (0.28–3.33) (0.31–2.00) (0.48–3.15) (0.66–2.93) (0.32–1.50) (0.46–26.01)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
6.20
(2.39–16.04)
NE
(NE)
NE
(NE)
1.4
NE
(NE)
2.3
TOTALd
1.42
0.83
1.10
1.08
1.15
1.20
1.11
1.05
1.35
1.25
(1.18–1.71) (0.55–1.24) (0.95–1.27) (0.91–1.27) (1.02–1.30) (1.06–1.36) (1.02–1.22) (0.96–1.15) (0.75–2.44) (0.88–1.78)
3.1
TOTALe
1.38
0.79
1.06
1.03
1.13
1.14
1.06
1.06
1.28
1.38
(1.14–1.67) (0.53–1.18) (0.92–1.22) (0.88–1.22) (1.00–1.27) (1.01–1.30) (0.97–1.16) (0.98–1.16) (0.71–2.32) (0.99–1.92)
3.3
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
normal birth weight (2,500S3,999 g) infants (for detailed
numbers and rates by province and territory see the
perinatal health report from the Bureau of Reproductive
and Child Health, Health Canada).
Compared with the province of Quebec, risks of early
neonatal death, late neonatal death and post-neonatal
death were substantially higher in most of the provinces
and territories for most of the gestational age and birth
weight groups (Tables 1S6), although we observed
marked fluctuations due to small samples in several
small provinces and territories.
Relatively large (relative risk >2.00) and statistically
significant increases in risk were observed for early
neonatal death at 26S27 weeks in the Northwest
Territories; for late neonatal death at 24S25 weeks in
Saskatchewan, and at 26S27 and 34S36 weeks in New
16
Chronic Diseases in Canada
Brunswick; and for post-neonatal death at 24S25 weeks
in Saskatchewan, at 32S41 weeks in the Northwest
Territories and at 37S41 weeks in Prince Edward Island
and Saskatchewan (Tables 1–3).
Relatively large and statistically significant increases
in risk were also observed for early neonatal death at
1,250S1,499 g in Saskatchewan, at 1,500S1,999 g in
Prince Edward Island and at $4,000 g in Newfoundland;
for late neonatal death at <500 g in New Brunswick,
Manitoba and Saskatchewan, at 500S749 g in Nova Scotia
and Saskatchewan, at 750S999 g and 1,500S1,999 g in
Newfoundland, and at 1,500S1,999 g in New Brunswick
and Manitoba; and for post-neonatal death at <500 g in
New Brunswick, at 750S999 g in Prince Edward Island,
at all birth weights $1,250 g in the Northwest Territories,
at 1,500S1,999 g, 2,500S3,999 g and 4,000 g and over in
Vol 21, No 1
TABLE 2
Relative risk of late neonatal (7–27 days) death in Canadian provinces/territoriesa
by gestational age group, 1990–1994 births
Gestational
age
(weeks)
Deaths
per 1,000
live births
surviving
at 7th day
of life
Relative risk
(and 95% confidence interval)
NFLD
PEI
NS
NB
MAN
SASK
ALTA
BC
YUK
NWT
QUEb
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
0.0
22–23
1.75c
(0.41–7.45)
NE
(NE)
2.00c
3.00c
3.50c
2.15c
1.35
1.31c
(0.48–8.32) (0.92–9.75) (0.70–17.44) (0.68–6.81) (0.43–4.17) (0.36–4.83)
NE
(NE)
NE
(NE)
142.9
24–25
1.61c
(0.62–4.22)
NE
(NE)
1.39
1.09c
0.79c
2.51
1.26
0.93
(0.61–3.16) (0.41–2.93) (0.29–2.16) (1.39–4.53) (0.75–2.13) (0.48–1.77)
NE
(NE)
NE
(NE)
107.9
26–27
2.39c
1.21
2.52
1.35
1.48
1.16
1.01
1.41c
(0.35–5.71) (0.36–15.99) (0.47–3.09) (1.07–5.90) (0.60–3.06) (0.58–3.76) (0.60–2.24) (0.52–1.95)
NE
(NE)
2.39c
(0.36–15.99)
41.8
28–31
1.23c
(0.38–3.98)
NE
(NE)
NE
(NE)
NE
(NE)
12.5
32–33
1.75c
(0.41–7.58)
NE
(NE)
0.56c
0.61c
1.16
0.78
0.62
(0.07–4.18) (0.14–2.63) (0.34–3.96) (0.31–2.00) (0.23–1.68)
NE
(NE)
NE
(NE)
4.7
34–36
3.71
0.90c
3.80
0.17c
1.27
1.54
0.93
1.78c
(0.55–5.78) (0.89–15.41) (0.32–2.53) (1.97–7.35) (0.02–1.23) (0.53–3.02) (0.90–2.64) (0.49–1.77)
NE
(NE)
1.45c
(0.20–10.58)
1.4
37–41
1.50c
0.65
1.86
0.52
1.08
1.37
1.15
1.15
0.82
1.20c
(0.29–1.47) (0.82–4.20) (0.28–0.99) (0.66–1.78) (0.96–1.95) (0.77–1.70) (0.88–1.50) (0.62–1.10) (0.17–8.56) (0.56–4.06)
0.4
<22
42–47
NE
(NE)
NE
(NE)
Not available
NE
(NE)
NE
(NE)
1.34
1.48
0.73
1.37
1.22
0.57
(0.56–3.18) (0.58–3.77) (0.29–1.88) (0.61–3.09) (0.69–2.17) (0.27–1.28)
NE
(NE)
0.74c
0.68c
(0.14–3.28) (0.09–6.01)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
0.47
1.59
1.01
(0.06–3.82) (0.53–4.71) (0.35–2.88)
NE
(NE)
467.40c
(71.6–3052.1)
NE
(NE)
NE
(NE)
NE
(NE)
0.6
NE
(NE)
NE
(NE)
0.5
TOTALd
1.26
1.50
0.99
1.62
1.16
1.42
1.30
0.84
0.59
1.17
(0.82–1.95) (0.77–2.92) (0.44–2.23) (1.20–2.18) (0.53–2.54) (1.10–1.85) (1.08–1.57) (0.69–1.04) (0.08–4.22) (0.52–2.63)
0.7
TOTALe
1.24
1.47
0.89
1.58
1.06
1.25
1.29
0.86
0.58
1.53
(0.80–1.91) (0.76–2.86) (0.63–1.26) (1.17–2.14) (0.80–1.40) (0.97–1.63) (1.07–1.55) (0.70–1.06) (0.08–4.14) (0.76–3.03)
0.7
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
Saskatchewan, and at 4,000 g and over in Newfoundland
(Tables 4–6).
Quebec had the lowest rate of teenage (<20 years)
mothers, and the Northwest Territories had the highest
rate (Table 7). Noticeable interprovincial variations were
also observed in the proportions of mothers aged 35 and
over and of primiparae. On the other hand, proportions
of male sex and multi-fetal pregnancies were quite
similar across the provinces and territories (Table 7).
Similar results were obtained after including unlinked
infant deaths in the calculation of overall early neonatal,
late neonatal and post-neonatal mortality (bottom row of
Tables 1S6) and after reclassifying gestational age and
2000
birth weight as “not available” for those infants with a
birth weight that deviated from the mean for a given
gestational age (week) by more than 5 standard
deviations (data not shown).
Discussion
An understanding of data quality and comparability is
crucial for interpreting regional variations in infant
mortality rates. Close scrutiny of Canada’s vital statistics
data has identified errors in birth and death registries in
the province of Ontario.14 To ensure high data quality,
we therefore excluded Ontario from our study.
17
TABLE 3
Relative risk of post-neonatal (28–365 days) death in Canadian provinces/territoriesa
by gestational age group, 1990–1994 births
Gestational
age
(weeks)
Deaths per
1,000 live
births
surviving
at 28th day
of life
Relative risk
(and 95% confidence interval)
NFLD
PEI
NS
NB
MAN
SASK
ALTA
BC
YUK
NWT
QUEb
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
0.0
22–23
1.00c
(0.14–7.10)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
0.67c
1.14c
0.46
(0.09–4.99) (0.35–3.76) (0.06–3.57)
NE
(NE)
3.00c
(0.61–14.86)
166.7
24–25
0.81c
(0.11–5.82)
NE
(NE)
1.36c
2.05c
2.14
2.63
1.47
1.56
(0.41–4.47) (0.72–5.81) (0.87–5.26) (1.08–6.39) (0.72–3.00) (0.74–3.33)
NE
(NE)
NE
(NE)
65.1
26–27
1.84c
(0.05–2.36)
NE
(NE)
1.67
1.16c
0.34c
0.78c
1.00
1.20
(0.79–3.56) (0.36–3.67) (0.08–1.39) (0.24–2.49) (0.53–1.90) (0.67–2.13)
NE
(NE)
2.18c
(0.33–14.34)
50.9
28–31
2.18c
0.18c
0.95c
1.28
1.41
1.62
1.31
0.33c
(0.05–2.36) (0.33–14.34) (0.02–1.29) (0.34–2.62) (0.66–2.48) (0.69–2.88) (1.01–2.60) (0.80–2.13)
NE
(NE)
2.57c
(0.81–8.14)
16.0
32–33
1.23
0.51c
1.38
1.41
1.37
1.24
2.01
1.33c
(0.80–5.09) (0.19–9.49) (0.52–2.91) (0.12–2.10) (0.69–2.78) (0.66–3.03) (0.81–2.31) (0.73–2.10)
NE
(NE)
3.75c
(1.18–11.92)
10.4
34–36
0.98
1.38
1.77
1.69
1.86
1.48
1.72
2.40c
(0.84–3.53) (0.34–17.12) (0.54–1.78) (0.76–2.52) (1.17–2.68) (1.06–2.68) (1.37–2.52) (1.06–2.06)
NE
(NE)
4.73
(2.40–9.33)
3.9
37–41
4.48
1.23
3.38
1.14
1.14
1.47
2.09
1.53
1.34
0.97c
(0.90–1.69) (1.38–8.26) (0.90–1.43) (0.88–1.46) (1.23–1.76) (1.78–2.45) (1.35–1.74) (1.18–1.52) (0.31–3.03) (3.30–6.08)
1.4
42–47
1.96c
1.17
1.02
1.11c
1.34
1.64
0.92
1.44
3.97c
(0.45–8.61) (0.69–1.99) (0.39–2.66) (0.32–3.86) (0.58–3.10) (0.66–4.07) (0.37–2.29) (0.73–2.86) (0.52–30.07)
NE
(NE)
1.2
NE
(NE)
2.1
<22
Not available
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
1.42
(0.19–10.46)
NE
(NE)
TOTALd
1.33
1.35
1.10
1.14
1.46
1.90
1.54
1.33
0.87
4.36
(1.03–1.71) (0.88–2.06) (0.91–1.34) (0.92–1.41) (1.26–1.70) (1.65–2.19) (1.39–1.72) (1.19–1.48) (0.33–2.32) (3.37–5.65)
1.8
TOTALe
1.37
1.31
1.09
1.12
1.42
1.89
1.51
1.31
0.85
4.58
(1.07–1.76) (0.86–2.01) (0.90–1.33) (0.91–1.38) (1.23–1.65) (1.64–2.17) (1.36–1.68) (1.18–1.46) (0.32–2.26) (3.57–5.87)
1.8
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
The Generalized Record Linkage System used by
Statistics Canada for the birth and death record linkage
is a well-established system.11S13 The matching rate was
more than 97% for the provinces and territories studied,
and the calculated overall mortality rates were similar
when unlinked infant death cases were included. The
quality of the linked birth and death records has been
assessed by comparing the agreements for variables
collected by two independent systems run in parallel in
the provinces of Nova Scotia and Alberta.11 This
assessment demonstrated close agreement not only in the
survival status of the linked records, but in gestational
age and birth weight information as well.
18
Chronic Diseases in Canada
Misclassification of birth weight and especially
gestational age can occur in birth registry data,15 which
may affect comparisons of gestational age-specific and
birth weight-specific mortality rates. However, results
obtained after reclassifying gestational age and birth
weight as not available for those infants with a birth
weight for gestational age that deviated from the mean
by more than 5 standard deviations did not differ from
the original results. Misclassification appears to have had
no major impact on our overall results.
Because of the profound effect on infant mortality of
low birth weight, in general, and of extremely preterm
birth, in particular,16S20 differences in registration of
Vol 21, No 1
TABLE 4
Relative risk of early neonatal (0–6 days) death in Canadian provinces/territoriesa
by birth weight group, 1990–1994 births
Deaths
per 1,000
live births
Relative risk
(and 95% confidence interval)
Birth weight
(grams)
NFLD
PEI
<500
0.94
(0.76–1.17)
NE
(NE)
500–749
0.92
1.24
0.90
0.84
(0.71–1.20) (0.82–1.87) (0.72–1.12) (0.67–1.17)
750–999
0.74
1.08
0.74
0.91
0.84
0.91
1.34
0.46c
(0.84–2.14) (0.07–3.00) (0.48–1.15) (0.71–1.65) (0.51–1.18) (0.61–1.34) (0.64–1.11) (0.70–1.19)
1,000–1,249
0.54c
(0.18–1.67)
1,250–1,499
1.67
1.51
1.23
2.01
1.65
1.07
1.45
1.16c
(0.59–3.53) (0.17–8.00) (0.89–3.14) (0.73–3.11) (0.68–2.23) (1.17–3.45) (1.10–2.49) (0.68–1.70)
NE
(NE)
0.74c
(0.11–5.18)
41.1
1,500–1,999
1.41
3.90
0.62
1.90
0.76
1.66
1.04
0.98
(0.75–2.66) (1.88–8.10) (0.33–1.19) (1.22–2.98) (0.45–1.30) (1.10–2.49) (0.76–1.46) (0.70–1.36)
NE
(NE)
1.21c
(0.39–3.76)
22.7
2,000–2,499
0.98
0.98
1.04
1.53
1.05
1.30
1.65
0.51c
(0.87–3.15) (0.07–3.62) (0.55–1.73) (0.51–1.87) (0.63–1.70) (0.98–2.39) (0.76–1.46) (0.96–1.78)
NE
(NE)
1.17c
(0.29–4.71)
6.3
2,500–3,999
1.95c
1.29
0.86
1.23
1.36
1.30
1.14
1.03
0.91
1.76c
(0.84–1.99) (0.35–2.08) (0.91–1.68) (0.99–1.89) (1.01–1.68) (0.86–1.51) (0.84–1.25) (0.75–1.12) (0.57–5.48) (1.04–3.66)
0.8
4,000–6,999
3.56
(1.52–8.33)
Not available
2.26
3.86c
16.47c
(6.87–38.45) (0.57–26.15) (0.72–7.04)
NE
(NE)
NE
(NE)
NS
NB
MAN
SASK
ALTA
BC
YUK
NWT
QUEb
NE
(NE)
0.39c
(0.08–1.92)
860.0
0.83
1.04
0.86
1.08
1.06c
(0.88–1.24) (0.75–0.98) (0.97–1.21) (0.52–2.19) (0.48–1.43)
563.5
1.09
0.91
0.95
1.12
1.08
1.15c
(0.66–10.20) (0.75–1.12) (0.85–1.06) (1.03–1.20) (1.02–1.15) (1.09–1.22)
0.98
0.83–1.17
1.09c
(0.39–2.99)
197.5
1.00
0.96
1.16
1.26
1.01
1.45
1.49c
1.18c
(0.56–1.78) (0.50–1.85) (0.73–1.84) (0.76–2.09) (0.77–1.58) (1.06–1.99) (0.24–9.42) (0.65–5.42)
83.9
0.73
1.23
1.56
1.50
1.75
1.37
(0.22–2.45) (0.42–3.57) (0.72–3.39) (0.64–3.50) (0.95–3.22) (0.75–2.51)
NE
(NE)
NE
(NE)
NE
(NE)
0.5
NE
(NE)
3.86c
(0.57–26.15)
16.2
TOTALd
1.42
0.83
1.10
1.08
1.15
1.20
1.11
1.05
1.35
1.25
(1.18–1.71) (0.55–1.24) (0.95–1.27) (0.92–1.27) (1.02–1.30) (1.06–1.36) (1.02–1.22) (0.96–1.15) (0.75–2.44) (0.88–1.78)
3.1
TOTALe
1.38
0.79
1.06
1.03
1.13
1.14
1.06
1.06
1.28
1.38
(1.14–1.67) (0.53–1.18) (0.92–1.22) (0.88–1.22) (1.00–1.27) (1.01–1.30) (0.97–1.16) (0.98–1.16) (0.71–2.32) (0.99–1.92)
3.3
NE
(NE)
NE
(NE)
NE
(NE)
12.35c
4.62
(2.10–72.49) (2.98–7.15)
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
extremely small and immature infants (i.e. <500 g) as
live births can severely compromise the comparison of
infant mortality.14,20 Regional variations may also exist
in the registration of spontaneous or therapeutic
abortions as births.6S10 The substantial interprovincial
variations in fetal and early neonatal mortality rates in
infants of extremely preterm (<22 weeks of gestation) or
low birth weight (<500 g) infants observed in our data
(Tables 1S6) may have been caused, at least in part, by
such differences in registration practices among
Canadian provinces and territories. A similar inference
can probably be made for births with no available
gestational age or birth weight, since it is reasonable to
assume that gestational age and birth weight were less
likely to be recorded when extreme immaturity rendered
viability unlikely.
2000
Interprovincial variations in such factors as maternal
health risks (e.g. genitourinary tract infection, cigarette
smoking and substance abuse), quality of and access to
both obstetric care (e.g. timely access to cesarean
section) and neonatal intensive care, and quality of infant
care (e.g. infant feeding, sleep positioning and injury
prevention) may have played an important role in the
observed interprovincial differences in mortality rates
among less extremely small and preterm infants.
The provinces and territories with substantially higher
rates in post-neonatal mortality, such as Manitoba,
Saskatchewan, Alberta and the Northwest Territories,
have proportionally larger native populations. It is
widely recognized that post-neonatal mortality is much
higher among native populations.21,22 However, it seems
difficult to attribute all of the increased post-neonatal
19
TABLE 5
Relative risk of late neonatal (7–27 days) death in Canadian provinces/territoriesa
by birth weight group, 1990–1994 births
Deaths per
1,000 live
births
surviving
at 7th day
of life
Relative risk
(and 95% confidence interval)
Birth weight
(grams)
NFLD
PEI
NS
NE
(NE)
NE
(NE)
NE
(NE)
500–749
1.72c
(0.65–4.57)
NE
(NE)
750–999
3.23
(1.31–7.98)
NE
(NE)
1,000–1,249
<500
NB
MAN
SASK
ALTA
BC
YUK
NWT
QUEb
NE
(NE)
NE
(NE)
NE
(NE)
85.7
2.13
1.67
1.67
3.72
1.80
1.27
(1.02–4.42) (0.73–3.84) (0.73–3.84) (2.12–6.53) (1.08–2.99) (0.69–2.34)
NE
(NE)
NE
(NE)
89.6
0.72c
1.83
1.35
1.20
0.91
0.72c
(0.32–2.56) (0.17–2.98) (0.17–2.98) (0.85–3.96) (0.72–2.51) (0.62–2.31)
NE
(NE)
1.40c
(0.21–9.08)
39.7
3.31c
0.71
1.35c
1.35c
1.37c
0.59
0.66
0.74c
(0.10–5.40) (0.48–23.01) (0.17–3.00) (0.41–4.47) (0.41–4.47) (0.48–3.96) (0.22–1.57) (0.27–1.64)
NE
(NE)
NE
(NE)
21.6
2.62c
2.62c
0.89c
1.72
0.56c
(0.88–7.78) (0.88–7.78) (0.21–3.87) (0.79–3.71) (0.19–1.69)
NE
(NE)
NE
(NE)
12.6
7.78c
5.83c
2.92c
7.78c
(2.29–26.37) (2.29–26.37) (1.01–33.85) (0.68–12.56)
1,250–1,499
NE
(NE)
3.97c
(0.55–28.60)
1,500–1,999
3.81c
(1.29–11.26)
NE
(NE)
3.56
3.56
2.01
1.46
0.53c
0.83c
(0.19–3.59) (1.41–8.98) (1.41–8.98) (0.75–5.44) (0.68–3.10) (0.18–1.59)
NE
(NE)
NE
(NE)
3.5
2,000–2,499
1.68c
0.75c
1.95
1.95
1.33
0.81
1.08
1.10c
(0.27–4.57) (0.23–12.20) (0.23–2.43) (0.82–4.63) (0.82–4.63) (0.56–3.16) (0.42–1.55) (0.59–1.98)
NE
(NE)
NE
(NE)
1.9
2,500–3,999
0.77
1.88
0.75
1.31
1.31
1.16
1.32
0.89
(0.34–1.75) (0.77–4.59) (0.42–1.32) (0.80–2.64) (0.80–2.14) (0.76–1.76) (1.01–1.73) (0.66–1.19)
NE
(NE)
1.94c
(0.27–14.13)
0.4
0.59c
0.76
0.57
8.60c
1.28c
(0.14–2.56) (0.30–1.94) (0.22–1.44) (1.14–64.68) (0.41–4.03)
0.3
NE
(NE)
4,000–6,999
NE
(NE)
1.91c
(0.25–14.42)
NE
(NE)
NE
(NE)
NE
(NE)
Not available
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
2.73c
(0.36–20.55)
1.8
TOTALd
1.26
1.50
0.99
1.62
1.16
1.42
1.30
0.84
0.59
1.17
(0.82–1.95) (0.77–2.92) (0.44–2.23) (1.20–2.18) (0.53–2.54) (1.10–1.85) (1.08–1.57) (0.69–1.04) (0.08–4.22) (0.52–2.63)
0.7
TOTALe
1.24
1.47
0.89
1.58
1.06
1.25
1.29
0.86
0.58
1.53
(0.80–1.91) (0.76–2.86) (0.63–1.26) (1.17–2.14) (0.80–1.40) (0.97–1.63) (1.07–1.55) (0.70–1.06) (0.08–4.14) (0.76–3.03)
0.7
NE
(NE)
1.66
138.86c
(21.80–884.70) (0.21–13.48)
NE
(NE)
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
mortality to this factor. We speculate that interprovincial
differences in other aspects of infant health and health
care may have also played a role. For example, the
proportion of infants born to teenage mothers, a known risk
factor for post-neonatal mortality,23,24 is lowest in the
province of Quebec (Table 7).
In summary, our analysis of linked birth and death
records in Canada revealed substantial interprovincial
variation both in early neonatal mortality rates for
extremely small and preterm infants and in infant
mortality rates for less extremely small and preterm
infants. These findings emphasize that, when comparing
infant mortality among regions, it is important to assess
20
Chronic Diseases in Canada
the regional differences in registration practices; as well,
there remain major gaps among Canadian provinces and
territories in terms of infant health and health care,
despite a universal health care system that has been in
place for three decades.
Acknowledgements
We thank the Vital Statistics Registrars of the provinces and
territories who gave us access to their data files. This study
was conducted under the auspices of the Canadian Perinatal
Surveillance System. Dr. Kramer is a Distinguished Scientist
of the Medical Council of Canada.
Vol 21, No 1
TABLE 6
Relative risk of post-neonatal (28–365 days) death in Canadian provinces/territoriesa
by birth weight group, 1990–1994 births
Deaths per
1,000 live
births
surviving
at 28th day
of life
Relative risk
(and 95% confidence interval)
Birth
weight
(grams)
NFLD
PEI
NS
NE
(NE)
NE
(NE)
NE
(NE)
500–749
2.05
(0.88–4.80)
NE
(NE)
1.33
(0.55–3.22)
1.06c
(0.40–2.85)
750–999
NE
(NE)
4.03c
1.13
(1.11–14.62) (0.48–2.65)
<500
NB
MAN
SASK
ALTA
BC
YUK
NWT
QUEb
NE
(NE)
3.56c
(0.25–51.41)
NE
(NE)
NE
(NE)
NE
(NE)
31.3
1.20
(0.53–2.75)
1.20c
(0.45–3.21)
1.73
(1.06–2.82)
0.85
(0.44–1.65)
NE
(NE)
2.58c
(0.76–8.78)
110.7
0.89c
(0.28–2.84)
0.43c
(0.13–1.39)
1.38
(0.62–3.07)
0.76
(0.38–1.53)
1.09
(0.59–2.01)
NE
(NE)
NE
(NE)
49.6
2.29c
16.00c
(1.49–172.08) (0.15–34.00)
1,000–1,249
1.27c
(0.31–5.28)
NE
(NE)
0.61
(0.15–2.57)
0.79c
(0.19–3.30)
0.87c
(0.30–2.48)
1.51
(0.58–3.89)
1.43
(0.74–2.75)
1.05
(0.52–2.14)
NE
(NE)
2.47c
(0.35–17.17)
25.3
1,250–1,499
0.87c
(0.12–6.49)
NE
(NE)
NE
(NE)
1.18c
(0.28–5.05)
1.13c
(0.38–3.34)
1.57c
(0.53–4.61)
1.65
(0.80–3.47)
1.48
(0.71–3.08)
NE
(NE)
4.32c
(1.04–17.92)
14.5
1,500–1,999
3.16c
1.48
0.76c
(0.19–3.13) (0.78–12.88) (0.72–3.02)
0.95c
(0.34–2.62)
1.60
(0.85–3.03)
2.24
(1.23–4.07)
1.73
(1.10–2.71)
1.79
(1.15–2.81)
NE
(NE)
4.29c
(1.57–11.74)
8.8
2,000–2,499
1.08
(0.48–2.45)
0.55c
(0.08–3.92)
1.06
(0.60–1.88)
0.75
(0.35–1.60)
1.69
(1.11–2.57)
1.74
(1.12–2.71)
1.40
(1.03–1.91)
1.20
(0.86–1.68)
NE
(NE)
3.82
(1.69–8.61)
5.8
2,500–3,999
1.36
(0.98–1.88)
1.53
(0.91–2.55)
1.12
(0.88–1.43)
1.28
(0.99–1.66)
1.55
(1.29–1.87)
2.02
(1.70–2.41)
1.56
(1.36–1.78)
1.45
(1.27–1.66)
1.39c
(0.52–3.72)
4.75
(3.46–6.52)
1.4
4,000–6,999
2.18
(1.02–4.66)
1.49c
(0.36–6.17)
1.18
(0.57–2.42)
0.99
(0.42–2.33)
1.67
(0.96–2.91)
2.87
(1.74–4.71)
1.92
(1.24–2.98)
1.45
(1.27–1.66)
NE
(NE)
5.33
(2.11–13.45)
0.9
Not available
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
NE
(NE)
1.25
57.00c
(10.36–313.69) (0.79–1.97)
NE
(NE)
NE
(NE)
2.8
TOTALd
1.33
(1.03–1.71)
1.35
(0.88–2.06)
1.10
(0.91–1.34)
1.14
(0.92–1.41)
1.46
(1.26–1.70)
1.90
(1.65–2.19)
1.54
(1.39–1.72)
1.33
(1.19–1.48)
0.87
(0.33–2.32)
4.36
(3.37–5.65)
1.8
TOTALe
1.37
(1.07–1.76)
1.31
(0.86–2.01)
1.09
(0.90–1.33)
1.12
(0.91–1.38)
1.42
(1.23–1.65)
1.89
(1.64–2.17)
1.51
(1.36–1.68)
1.31
(1.18–1.46)
0.85
(0.32–2.26)
4.58
(3.57–5.87)
1.8
Numbers in bold are statistically significant.; NE = Not estimable because of cell(s) with value of 0; a Excluding Ontario; b Quebec is the reference for the relative risks.; c Small sample with
cell(s) <5; d Not including unlinked cases; e Including unlinked cases
TABLE 7
Comparison of birth characteristics in Canadian provinces/territories, 1990–1994 births
Characteristic
NFLD
% mothers <20 years
10.72
% mothers >35 years
% male infants
% multiple births
% primiparae
2000
PEI
8.52
NS
8.54
NB
9.76
QUE
MAN
SASK
ALTA
4.39
10.16
11.26
7.81
BC
5.69
YUK
8.35
NWT
16.48
4.27
6.12
5.87
4.25
6.14
6.04
4.92
6.64
8.58
9.19
4.53
51.45
51.14
51.23
51.17
51.38
51.22
51.49
51.32
51.35
51.84
52.03
2.46
2.26
2.24
2.11
2.15
2.12
2.08
2.20
2.10
2.26
2.14
45.26
38.22
44.49
45.29
44.33
40.90
36.09
39.70
43.66
42.19
32.70
21
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Vol 21, No 1
Status Report
Canadian Strategy for Cancer Control
Silvana Luciani and Neil J Berman
Abstract
The Canadian Strategy for Cancer Control is a stakeholder-driven initiative, led by a
partnership between the Canadian Cancer Society, National Cancer Institute of Canada,
Canadian Association of Provincial Cancer Agencies and Health Canada. The planning
process began in January 1999 and currently involves more than 130 health professionals
and community representatives who are volunteering their time, experience and expertise. A
crucial aspect of the strategy’s successful implementation is early participation of the
provincial/territorial ministries of health in the planning process. Working groups are
addressing 11 areas of the cancer continuum: prevention, screening, diagnosis, treatment,
supportive care/rehabilitation, palliative care, pediatric cancer, research, human resource
planning, surveillance and informatics/technology. Two stakeholder conferences will engage
all cancer stakeholders in helping develop recommendations and establishing priorities for
cancer control in Canada.
Key words: cancer control strategy; health care; health policy
The concept of a coordinated strategic approach to
cancer control is not new1 or unique to Canada.2 What is
new is the growing consensus that now may be the last
opportunity to plan for the looming, demographically
induced burden of cancer, before our health care system
becomes inundated by the rising prevalence and
incidence of cancer in Canada. The imperative to deal
with the coming crisis is driven not only by the
economic costs that will be imposed on our health care
system but also by the significant impact of human
suffering on individuals, families and communities. The
challenge is being faced by all groups, individuals and
organizations that make up the cancer control mosaic in
Canada, and indeed no single organization or institution
has the resources or jurisdiction to address the problem
alone. In recognition of this axiom, the Canadian Cancer
Society (CCS), the National Cancer Institute of Canada
(NCIC), the Canadian Association of Provincial Cancer
Agencies (CAPCA) and Health Canada (HC) are leading
a participatory process to develop the Canadian Strategy
for Cancer Control.
The following definition of cancer control was
adapted from a definition developed by the Advisory
Committee on Cancer Control, National Cancer Institute
of Canada.3
What Is Cancer Control?
·
Cancer control aims to prevent cancer, cure cancer,
and increase survival and quality of life for those who
develop cancer, by converting the knowledge gained
through research, surveillance and outcome evaluation
into strategies and actions.
How Do We Control Cancer?
·
Conduct research relevant to the biology of cancer,
the underlying causes of cancer and methods for
preventing, detecting and treating cancer
·
Develop consensus on the significance and
implications of the results of cancer research,
surveillance and outcome evaluation
·
Implement strategies based on scientific evidence to
prevent cancer and to reduce its impact
·
Conduct surveillance to monitor and evaluate
progress in cancer control
Starting in January 1999, a steering committee with
representatives from the four leading organizations
prepared a work plan for the strategy development
process. The objective of the two-year process is to
Author References
Silvana Luciani and Neil J Berman, Cancer Control Secretariat, Health Promotion and Programs Branch, Health Canada
Correspondence: Silvana Luciani, Cancer Control Secretariat, Health Canada, Tunney’s Pasture, Jeanne Mance Building, Address Locator: 1909A2,
Ottawa, Ontario K1A 0K9
2000
23
create, with the support of all the stakeholders in cancer
control in Canada, a coordinated strategy with common
goals aimed at reducing and dealing effectively with the
cancer burden.
Participation by provincial/territorial ministries of
health at all stages of this initiative is paramount, since
ultimately they will be the ones to set policies and
program priorities for the implementation of most of the
strategy recommendations. The complexity and diversity
of the way the provincial/territorial ministries organize
cancer care require multiple and mutually reinforcing
methods to ensure appropriate participation in this
process. To date, the federal/provincial/territorial
advisory committees (Advisory Committee on
Population Health [ACPH], Advisory Committee on
Health Services, Advisory Committee on Human Health
Resources and Advisory Committee on Health
Information) have been invited to indicate how actively
their jurisdictions wish to participate in the development
of the strategy. Representatives from provincial/territorial
ministries are participating in the main planning bodies
(see next section).
The strategy will apply current knowledge on cancer
causes, diagnosis, treatment, survival and quality-of-life
issues to actions that will prevent, cure and manage
cancer. The focus will be on the following activities.
·
Achieving consensus on goals and priorities that will
reduce the premature mortality and morbidity caused
by cancer, encouraging health-promoting behaviours,
reducing exposure to cancer risk factors and
improving the quality of life of those affected by
cancer
·
Linking existing cancer
strategies (such as the Canadian
Breast Cancer Initiative, the
Prostate Cancer Research
Initiative and the Canadian
Coalition on Cancer
Surveillance) to a
comprehensive framework that
addresses current and emerging
cancer issues
·
Denoting clear roles and
responsibilities among the
jurisdictions involved in cancer
control
·
Creating enduring mechanisms
for national cooperation and
partnerships among various
stakeholders
Broad Support and Expert Input
The strategy planning process has generated
tremendous support and momentum among the
organizations and health professionals working in the
field of cancer control. This commitment is reflected in
the structure and organization of the initiative (see
Figure 1) and the more than 130 professionals and
community representatives engaged in this planning
process.
Eleven topic and theme working groups of volunteer
professionals and community representatives have been
established to examine issues of priority and the
evidence and opportunities for intervention, and to make
recommendations for the subject area (see Table 1).
Chairs have been appointed by the Steering Committee.
The working groups’ recommendations will be presented
to an oversight committee, named the Integration Group.
This group is coordinating the strategy’s content by
directing the working groups, reviewing their
recommendations and promoting integration across topic
and theme areas. It is composed of the chairs of each
working group, representatives of national health
organizations, community representatives and experts in
cancer control (see Table 2). All stages of the strategy
planning process are being led by the Steering
Committee, which comprises senior executives of the
four partner organizations. A cancer control secretariat at
Health Canada has been established to coordinate and
facilitate the planning process.
A broad range of representatives of cancer control
stakeholders will be invited to attend two national
conferences: one will be held at the midpoint of the
FIGURE 1
Organization and structure of the planning process for the
Canadian Strategy for Cancer Control
Steering Committee
(HC, CAPCA, NCIC, CCS, ACPH)
Provincial/
territorial
ministries
Topic
working
groups
Integration Group
(Organization representatives, working
group chairs, Steering Committee,
provincial/territorial representatives)
Prevention
Supportive
care
Human
resources
Screening
Palliative
care
Informatics/
technology
Diagnosis
Pediatric
cancer
Research
Treatment
24
Chronic Diseases in Canada
Consumers,
other cancer
stakeholders
Theme
working
groups
Surveillance
Vol 21, No 1
TABLE 1
Issues being examined by the topic and theme working
groups of the Canadian Strategy for Cancer Control
Issues
Topic working group
(Chair)
Prevention
(Ellen Murphy, Alberta Cancer Board)
Screening
(Richard Schabas, Cancer Care Ontario)
Diagnosis
(Eva Grunfeld, Ottawa Regional Cancer
Centre)
Treatment
(Simon Sutcliffe, BC Cancer Agency)
Supportive care
(Richard Doll, BC Cancer Agency)
Palliative care
(Neil Hagen, University of Calgary)
Pediatric cancer
(Mark Bernstein, Ste-Justine Hospital)
Recommendations for a cancer prevention system
that could be integrated into the formal care system
A conceptual framework, process for program
guideline review and evaluation, organizational
elements for programs/guidelines. Propose
Canadian Cancer Research and Evaluation
Network, National Cancer Screening Committee
Diagnostic assessment, delay, staging assessment,
psychosocial outcomes, clinical outcomes,
education, patient–physician communication,
diagnostic assessment units
System capacity and service delivery: radiation
therapy, systemic therapy, surgical oncology;
integrated case management; relation between
conventional medicine and complementary and
alternative medicine; clinical trials/research; clinical
practice guidelines
Identifying needs and gaps in supportive care
services, including emotional/cognitive, information,
spiritual, physical and practical needs
Research, education, program delivery, cancer
control
Basic scientific infrastructure, human resources,
delivery of care in large and small institutions,
surveillance, supportive and palliative care
Theme working group
(Chair)
Research
(Victor Ling, BC Cancer Research Centre)
Surveillance
(Roy West, University of Newfoundland)
Emphasis on research needs for service delivery,
prevention, screening, supportive and palliative care
Integration of the needs of the strategy with the
activities of the Canadian Coalition on Cancer
Surveillance
(Andrew Padmos, Cancer Care Nova
Scotia)
National Cancer Work Force Strategy: national
database on human resources supply and demand;
Saskatchewan: workforce training programs,
immigration, emigration; Ontario: database on
cancer professionals; British Columbia:
compensation and benefits
Informatics and technology
Information management model, public access to
information, electronic patient records
Human resource planning
(Kathryn Hannah, University of Calgary)
TABLE 2
Members of the Integration Group
• Association of Canadian Medical Colleges
• Canadian Association of Nurses in Oncology
• Canadian Association of Psychosocial Oncology
• Canadian Association of Radiation Oncology
• Canadian Coalition on Cancer Surveillance
• Canadian Oncology Society
• Canadian Public Health Association
• Chairs of working groups
• College of Family Physicians of Canada
• Community representatives
• Consumers’ Association of Canada
• Provincial/territorial representation
• Steering Committee
2000
strategy’s planning process to provide
input and feedback on the preliminary
recommendations from each working
group, and the other will take place toward
the end of the planning process to establish
priorities for action. The participation of
the broader cancer control community,
such as site-specific cancer support groups
and allied health professionals, is required
to provide the basis of support on which a
coordinated strategy can be built.
Implementation of a coordinated strategy
will necessarily require broad agreement
on national strategic priorities. It is
anticipated that such input will be obtained
not only by means of the stakeholder
conferences but also through participation
in the partnerships and mechanisms
required to implement the strategy.
Opportunities
The successful creation of a national
strategy with agreed-upon goals will create
opportunities for a coordinated,
collaborative effort on a major public
health issue, sharing of responsibility
across a number of organizations, specific
interventions that would otherwise be
impractical and structures with broad
support that could address emerging issues
in cancer control.
Specific opportunities that may be
achievable within the context of a
coordinated strategic framework could
include a national mechanism for the
evaluation and clarification of cancer
screening programs and guidelines, a
national mechanism for the monitoring and
coordination of human resource supply and
demand in cancer care and treatment, and
establishment of research networks that
target topics in cancer control deemed to
be of national priority.
References
1. The proceedings of Cancer 2000: a report on the work of
a national task force. Cancer 2000: strategies for cancer
control in Canada. Toronto: Cancer 2000 Task Force,
1992.
2. World Health Organization. National cancer control
programmes: policies and managerial guidelines. Geneva:
World Health Organization, 1995.
3. Advisory Committee on Cancer Control, National Cancer
Institute of Canada. Bridging research to action: a
framework and decision-making process for cancer
control. Can Med Assoc J 1994;151(8):1141–6. O
25
Status Report
Canadian Coalition on Cancer Surveillance
Barbara Foster and Anna Maria Boscaino, for the CCOCS Management Committee
Background
In Canada, there are many separate systems collecting
and storing cancer data. For the most part these systems
work independently of one another and use varying
methods of data collection and analysis. As a result,
much of the existing surveillance information on cancer
is not available in an integrated format. The Canadian
Coalition on Cancer Surveillance (CCOCS) was created
to lead the development of an integrated national cancer
surveillance system. Once operational, this system will
link existing provincial and national systems, in effect
creating a “network of networks,” and it will provide
information for cancer control planners, providers and
policy-makers of today and tomorrow. Surveillance is an
integral component of the cancer control continuum, and
the CCOCS is working in tandem with the Canadian
Strategy for Cancer Control initiative.
A five-year business plan for the CCOCS, developed
in 1998, outlined the areas paramount to the development
of a national cancer surveillance system. Seven working
groups have addressed cancer information management
gaps by consulting and building consensus with expert
cancer stakeholders to develop standards and guidelines.
Sub-working groups have evolved to work on the specific
recommendations of their leader working groups.
Numerous national initiatives have generated new
challenges and opportunities. These include the formalization of the Canadian Association of Provincial Cancer
Agencies [see related Status Report in this issue], the
Road Map Initiative (Statistics Canada and the Canadian
Institute for Health Information), the National Health
Surveillance InfoStructure (Health Canada) and the
Canadian Strategy for Cancer Control (Health Canada,
National Cancer Institute of Canada, Canadian Cancer
Society and the Canadian Association of Provincial
Cancer Agencies) [see related Status Report in this
issue]. The CCOCS has been responsive to these changes.
Revisions have been made to the strategic plan that adapt
and redirect our strategies, but the vision and dedication
of all the key players remain strong. This status report
presents the progress of the CCOCS to date, including its
accomplishments and anticipated next steps.
Partnerships
The CCOCS has cemented strong partnerships with a
range of key cancer stakeholders, from non-governmental
organizations and federal/provincial/territorial departments, to researchers and clinicians, professional
societies and consumers. Organizations and individuals
have contributed by providing representatives on one or
more working groups, disseminating information,
supplying expert advice or funding activities or projects
recommended by the CCOCS.
Leadership
The Coalition’s organizational structure consists of
the Management Committee, the Advisory Committee
and working groups. The Management Committee
includes representatives of the organizations that have
contributed funds towards this initiative. With the
guidance of the Advisory Committee, the Management
Committee approves projects and activities, sets
priorities, liaises with other national organizations, seeks
alternative funding sources and oversees the general
direction and management of the CCOCS.
The Advisory Committee—the original planning
group—includes the key funders, all working group and
sub-working group leaders, other key cancer stakeholders
and consumers. The Advisory Committee coordinates
input from the working groups, accepts or rejects their
recommendations/directions, recommends priorities,
prepares cost estimates and considers input from similar
national organizations for possible integration with the
activities of the CCOCS. The working groups comprise
representatives with the professional expertise necessary
to determine the requirements and directions for the
various components of a national cancer surveillance
program.
Author References
Barbara Foster and Anna Maria Boscaino, Cancer Bureau, Laboratory Centre for Disease Control, Health Canada, Ottawa, Ontario
Correspondence: Barbara Foster, Coordinator, Secretariat to the Canadian Coalition on Cancer Surveillance, Laboratory Centre for Disease Control,
Health Canada, Tunney’s Pasture, Address Locator: 0601C1, Ottawa, Ontario K1A 0L2
26
Chronic Diseases in Canada
Vol 21, No 1
Funding
The CCOCS Advisory Committee prepared an
estimated five-year budget for the development of a
national cancer surveillance system. Funding was
secured from partners and other organizations to move
forward on the first year’s activities. The actual budget
was less than one tenth of the desired amount. Nevertheless,
with limited financial and human resources from key
partners (Health Canada, Laboratory Centre for Disease
Control [Christina Mills], the National Cancer Institute
of Canada [Barbara Whylie, Chair], the Canadian Association of Provincial Cancer Agencies [Bertha Paulse]
and the Canadian Cancer Registry [Diane Robson]) and
funding for specific projects from Statistics Canada and
the Canadian Institute for Health Information, the CCOCS
has adjusted some of its priorities and made steady
progress toward reaching its desired concrete goals,
although the time lines have been altered and the scale
has been somewhat reduced. The following section
briefly outlines the various activities now being pursued
by the CCOCS.
Current Activities
Legislative Framework Working Group
Deliverable goal
· Compendium of surveillance system legislation
affecting the collection, use and disclosure of
cancer-specific health information with the required
recommendations to develop model legislation
concerning privacy, access and security
The Legislative Framework Working Group, under
the leadership of Eric Holowaty (Cancer Care Ontario),
has contracted an academic-based group of lawyers to
conduct an inventory and analysis of provincial, territorial and federal legislation affecting the collection, use
and disclosure of health information in 13 jurisdictions.
The resulting report will recommend suggested changes
to current legislation and/or the creation of new model
legislation. The report will be circulated to cancer stakeholders, including the Canadian Strategy for Cancer
Control and those in other disease areas who are dealing
with similar legislative issues.
Patient Management Working Group
Deliverable goals
· Expanded set of core variables related to patient
demographic information and treatment that is
accepted by all jurisdictions
· Confirmation of the feasibility of collecting these
variables
· Collection of the variables by all provincial and
territorial cancer registries and by the national
cancer registry
2000
·
Collection of consistent and accurate stage
information on all appropriate incident cancer cases,
and development of enabling tools
The Patient Management Working Group, under the
direction of Bill Evans (Cancer Care Ontario), is moving
forward through several activities within the following
theme areas.
·
Quality and consistency of the core data set
definitions (see Quality Management section)
·
Staging collection and completeness
·
Treatment data (radiotherapy: data availability and
standards)
In the staging arena, the CCOCS is collaborating with
key cancer stakeholders and, in particular, it holds a seat
on the National Cancer Institute of Canada (NCIC)
Staging Subcommittee. This committee advocates the
use of tumour node metastasis (TNM) staging on a
national basis for all newly diagnosed cancer patients.
Statistics Canada and the NCIC are co-funding the
Minimum Investigations Required to Stage Project, which
will provide an educational resource for physicians to
ensure consistency, accuracy and quality of staging
information for the four most common cancers.
The Radiotherapy Sub-working Group, led by John
Hay (British Columbia Cancer Agency), is surveying the
36 radiotherapy treatment facilities across Canada to
establish a baseline of the information now being
collected and the definitions used. The results of the
survey will form the basis of the next phase of the
project: the piloting of the collection of radiation
treatment information in two or three provinces. Survey
results are expected to be compiled by late spring 2000.
Quality Management Working Group
Deliverable goal
· Implementation of a quality management program
that ensures compliance with a generally accepted set
of quality standards and promotes continuous
improvement in the accuracy and utility of the data
collected
The CCOCS hosted the “Maximizing Our Potential”
Case Ascertainment Workshop in Ottawa, May 12–13,
1999 (funded by Health Canada). The workshop
participants developed recommendations for actions
needed to establish a quality management program
within the Canadian Cancer Registry. The CCOCS
Management Committee was instrumental in bringing
the recommendations forward and soliciting funding. To
this end, a standards development project has been
funded by the Road Map Initiative (Statistics Canada). It
is hoped that this project will result in generally accepted
quality standards and methods for case ascertainment for
the provincial and territorial cancer registries. Statistics
Canada has also agreed to devote dedicated human
resources toward standards development, to develop
27
procedures for managing coding inconsistencies and to
create benchmark indicators for the provincial and
territorial cancer registries.
Implementation of the Patient Management Core Data
will inevitably fall to the Canadian Council of Cancer
Registries, which has agreed to form a task force to
discuss strategies and next steps. The CCOCS Advisory
Committee requested that the Data Definitions Working
Group (Chair—Darlene Dale, Cancer Care Ontario) of
the Canadian Council of Cancer Registries apply its
expertise in the area of definitions and quality assurance
for the refinement of the Patient Management Core Data
Set. This group has accepted the challenge, and a
February 2000 meeting was held to move this forward.
Population/Public Health Working Group
Deliverable goal
· Acceptance by provincial, territorial and federal
organizations of the need for a core data set of cancer
risk factors and screening behaviours, followed by
development of such a data set
The Population/Public Health Working Group, led by
Howard Morrison (Health Canada, Laboratory Centre for
Disease Control) and Odette Laplante (Quebec Ministry of
Health), has created a resource of standardized questions
in the areas of screening and risk factors, categorized as
knowledge, attitudes and behaviours. Within the screening
component, the following sites will be addressed: breast,
cervical, colorectal, prostate and emerging (genetics).
Smoking, nutrition, physical activity and environmental/
occupational health will be dealt with in the risk factors area.
This working group has also developed a link with
Statistics Canada and, specifically, the Canadian
Community Health Survey (CCHS), a new initiative that
will sample the Canadian public on a wide variety of
health-related and demographic questions (sample size
130,000). The CCHS is receptive to input from the
Population/Public Health Working Group on subject
areas such as nutrition and smoking. A meeting of the
working group is planned for spring 2000 to finalize
questions, discuss dissemination strategies and brainstorm on how best to interact with other disease groups
whose risk factors are similar, e.g. cardiovascular disease.
Costs Working Group
The Costs Working Group is led by Hugh Walker
(Queen’s University) with Brian Schmidt (British
Columbia Cancer Agency) as leader of the Management
Information System (MIS) Sub-working Group. The
MIS Sub-working Group met on January 25–26, 1999,
to augment and improve the MIS Guidelines Chart of
Functional Accounts for use within provincial cancer
agencies. These guidelines are administered by the
Canadian Institute for Health Information. Once
approved by the Institute and the MIS coordinators, it
is anticipated that the cancer-specific MIS guidelines
will be operational in the provincial cancer agencies
in the year 2001.
28
Chronic Diseases in Canada
A future meeting of provincial chief finance officers
from each provincial cancer agency will address
opportunities and problems after implementation of
the guidelines. One of the activities of the meeting will
be to discuss the creation, use and dissemination of a
report based on the application of the guidelines, which
will provide interprovincial comparisons and national
analyses from a costing perspective. The Canadian
Association of Provincial Cancer Agencies will be a
major target audience for the report.
Cancer Progress Report Working Group (formerly
Knowledge Synthesis)
Deliverable goal
· Creation and implementation of a process for regular
production and publication of data to monitor and
report on cancer progress
The CCOCS hosted the Cancer Progress Report
Working Group Workshop on June 16, 1999, in Toronto,
led by John McLaughlin (Mount Sinai Hospital). The
workshop resulted in a draft report that suggested the
following themes with appropriate indicators to be
included in a national cancer progress report: prevention,
detection, treatment and palliation. The Cancer Bureau in
Health Canada’s Laboratory Centre for Disease Control
has agreed to take the lead in implementing the cancer
progress report; the CCOCS secretariat will assist with
coordination and act as liaison with appropriate partners.
Collaboration
Information management and technological needs for
cancer surveillance will be addressed by the Canadian
Strategy for Cancer Control’s informatics theme working
group to ensure continuity and prevent duplication.
Members of the CCOCS Advisory Committee, led by
Roy West (Memorial University), have formed the basis
of the surveillance theme working group of the Canadian
Strategy for Cancer Control. This working group will
deal with the surveillance needs of the topic working
groups within the Strategy. The collaboration between
the two initiatives will ensure continuity and
enhancements to both initiatives and maximize the
results of CCOCS activities underway at present.
Conclusion
The CCOCS has had its share of successes while at
the same time overcoming many challenges and changes.
An important factor in its success is the synergistic links
that have been formed with key cancer stakeholders from
across the country, all of whom are committed to the
vision of creating a national cancer surveillance system.
As well, agreements are continuing to be made between
federal, provincial and territorial governments to collect
and maintain relevant cancer information and databases
according to a common set of definitions and quality
standards.
Vol 21, No 1
Challenges remain in advocating the necessary
resources, system development and information sharing
needed for surveillance. It is anticipated that the
collaboration with the Canadian Strategy for Cancer
Control and the Canadian Association of Provincial
Cancer Agencies will be instrumental in this domain.
2000
The CCOCS is aware that more individuals, groups and
organizations need to be informed of the overall
objectives and specific activities of the CCOCS, and to
this end a concerted effort is being made in the area of
communications. O
29
Status Report
Canadian Association of Provincial Cancer Agencies
Donald R Carlow
The Canadian Association of Provincial Cancer
Agencies (CAPCA) is a national organization consisting
primarily of provincial cancer agencies. Having evolved
gradually over the past 20 years, it recently became a
formalized organization committed to making a
significant contribution to Canada’s overall cancer
control effort. The purpose of this status report is to
provide information about CAPCA, its history, what it
is, what it does, where it is going and some indication of
how it will get there. Although still in its early stages,
the Association has great potential to make a significant
impact on cancer control in Canada.
Role of Provincial Cancer Agencies
In order to understand CAPCA’s potential, it is
important to know the role and function of individual
provincial cancer agencies throughout Canada. Seven of
the ten Canadian provinces have formally structured
provincial cancer agencies, most of which are
responsible for a provincial system of cancer control. In
general, these provincial systems usually embody the
following goals in their missions.
·
Reducing the incidence of cancer
·
Reducing mortality from cancer
·
Improving the quality of life of those living with
cancer
For the most part, these agencies apply knowledge
and best practices to a spectrum of activities, including
prevention, screening, diagnosis, treatment, rehabilitation/
support and palliative care. They also carry out
professional, technical, patient and public information
activities as well as conducting significant levels of basic
research, translational research, clinical research and
population-based epidemiologic research. All of the
foregoing is aimed at achieving the key elements of
their missions. Many of the provinces have cancer acts
that clearly define these responsibilities; those without
cancer acts have government-approved mandates
established under provincial societies’ acts or other
enabling legislation.
A few decades ago, most provincial cancer agencies
were devoted largely to clinic-based, modality-oriented
treatment, such as radiation and systemic therapy.
There has been gradual progression toward developing
population-based systems of cancer control and
geographically distributed services, along with networks
and linking systems to achieve consistent patient-centred,
evidence-based care. Although the extent to which
provincial cancer agencies have adopted this full
population-based mandate still varies, there has been
significant movement toward the full realization of such
a system in most provinces, and this is occurring at an
increasing rate.
In many respects, provincial cancer agencies can be
seen as the driving force behind cancer control activities
within each province. This is not to say that they perform
all these activities alone. Rather, they work in an
extensive number of collaborative relationships. For
example, there are links with the Canadian Cancer
Society in areas such as cancer prevention and cancer
information, with various regional health authorities in
delivering care outside the formal cancer system, with
academic institutions in areas such as research and
education, with hospice societies and palliative care
associations in pain and symptom control and palliative
care, and with host hospitals as they relate to the
provision of diagnostic and support services.
History of CAPCA
The Canadian Association of Provincial Cancer
Agencies had its modest beginnings approximately
20 years ago when many of the western provinces saw
the need to have provincial cancer agencies get together
to discuss matters of common interest and to share issues
and developments in the various provinces. In the
mid-1980s other provinces joined, participating in a
somewhat loosely structured organization that held
annual meetings in different locations throughout the
country. By the late 1980s all Canadian provinces were
involved, and slowly the focus shifted to a more
structured approach. Meetings then included information
Author References
Donald R Carlow, Chief Executive Officer, Canadian Association of Provincial Cancer Agencies; and President and Chief Executive Officer, British
Columbia Cancer Agency, 400 – 555 West 12th Avenue, East Tower, City Square, Vancouver, British Columbia V5Z 3X7; Fax: (604) 877-6146
30
Chronic Diseases in Canada
Vol 21, No 1
sharing, education, workload comparative data sharing,
collaboration with national partners and policy
development. Linkages were developed with many
organizations such as the Cancer Bureau at Health
Canada’s Laboratory Centre for Disease Control and the
Canadian Council on Health Services Accreditation, as it
related to defined standards development for
accreditation of provincial cancer agencies and cancer
centres supported by trained accreditation surveyors.
CAPCA has actively participated in the Canadian
Coalition on Cancer Surveillance [see related Status
Report in this issue], a coalition concerned with
developing, standardizing and integrating cancer control
information. It has also been involved in recent
collaborative efforts to establish the Canadian Strategy
for Cancer Control [see related Status Report in this
issue]. CAPCA has made submissions and
representations to the emerging Canadian Institutes of
Health Research for the possible establishment of an
institute for cancer research. In addition, it has
undertaken some cooperative activity in human resource
planning for cancer services for Canada.
Considerable work has been done to develop
interprovincial workload comparisons for a variety of
services. This has enabled provincial cancer agencies to
compare resource use, benchmark best practices, learn
from each other and undertake initiatives in several
provinces to improve practices. CAPCA has given
significant input into other national initiatives, such as
the standards developed by the Canadian Association of
Psychosocial Oncology and the cancer staging project
undertaken by the Canadian Committee on Cancer
Staging with financial support from the Canadian Cancer
Society and the National Cancer Institute of Canada
(CCS/NCIC).
It has also been encouraging to see the development
of key groups within CAPCA. Collaborating with the
CCS/NCIC, a research group has met on several
occasions in connection with CAPCA’s annual meeting.
Recently, a systemic therapy group was established,
which is devoted to developing consistent standards for
chemotherapy administration across Canada.
Recognizing that the Association could contribute
even more to the development of cancer control in
Canada, CAPCA decided to become more formal, to
establish more clearly its mission and vision and to
define a board and policy-setting structure. A landmark
meeting in Vancouver in February 1998 accomplished
the initial work on a mission and vision, which served as
the basis for developing a formal set of bylaws for the
Association that were recently approved under the
Canada Corporations Act. This led to the first formal
meeting of the Board of Directors in Quebec City on
October 28, 1999.
Mission
The Canadian Association of Provincial Cancer
Agencies is a national organization representing
2000
provincial and territorial agencies engaged in cancer
control. CAPCA exists to support the reduction of the
burden of cancer through effective leadership,
collaboration, communication and advocacy for cancer
control.
The mission of CAPCA will be achieved through
these activities.
·
Providing leadership in the coordination of cancer
control matters as the national voice of organized
cancer control development and program delivery
·
Promoting the collaborative development and
adoption of standards and guidelines for all aspects of
cancer control
·
Contributing to the development and implementation
of a national cancer control strategy
·
Advocating organized cancer control nationally and
provincially
·
Collaborating with other organizations to advocate
public policy change to improve cancer control
·
Effectively communicating and working with key
partners such as the CCS/NCIC, Health Canada and
the Council of Deputy Ministers of Health
Vision
While further elaboration of CAPCA’s vision will
take place over the next months, it is clear that our
provincial cancer agencies, individually and collectively,
are a significant part of Canada’s effort to reduce the
burden of cancer throughout this country. They are a
significant source of new knowledge about cancer,
including new developments and more effective means
to prevent, diagnose and treat this disease. Cancer
agencies are the main providers of advances in cancer
control to patients, families and the public and, as well,
they are the major providers of education for health care
professionals, patients and families. Cancer agencies and
their centres are not only local and regional resources,
but through their collective efforts, are an important
national resource capable of contributing far beyond
what they do within their own jurisdictions. In many
respects, provincial cancer agencies embody those steps
concerned with translating research into policy and
practice, as they carry out cancer control activities within
each of the provinces.
It is important to understand that the existence of
provincial cancer agencies in seven out of ten provinces
is unique in comparison with other countries.
Developing a national cancer strategy with clear goals
and specific directions, linked to an already existing
well-developed system for implementation, provides an
unparalleled opportunity for Canada to have a model
system of cancer control delivery with outcomes that
cannot be matched anywhere else in the world.
The vision for CAPCA will be underpinned by the
key principles outlined below.
31
·
An understanding of the profound and universal
impact of cancer and the importance of an invincible
alliance among agencies, centres, constituents and
collaborators—in other words, CAPCA cannot fulfill
its mission alone and will work with many others
·
Recognition of the importance of unity and common
purpose to enable CAPCA and its partners to make
significant contributions to cancer control
·
A continuing ability to enhance the linkage between
research, policy and practice as a fundamental tenet of
cancer control
·
An understanding that an effective cancer care
delivery system is an important element of cancer
control
Elements of the vision that have been under active
discussion include the following.
·
CAPCA will function as a multi-centre, multi-nodal,
virtual, national organization linked by common
strategies, policies, standards and practices for cancer
control and supported by unifying structures that
include the effective application of technology
·
CAPCA will strive to achieve consistent standards of
cancer control and care with the best practices of its
constituents moved up to the national level and
consistently applied across all provinces
·
CAPCA will develop effective mechanisms for the
consistent dissemination of standards and information
that will translate into practice
With the realization of this vision, Canada has an
opportunity to achieve significant improvements in
cancer outcomes and could be seen by the rest of the
world as an example of a model system of cancer
control—a standard by which other systems could be
measured.
Membership
CAPCA’s membership includes active and associate
members. Active members are all the provincial cancer
agencies and other provincial and territorial
organizations with similar responsibilities for cancer
control. Associate members include organizations or
agencies involved in cancer control, the CCS/NCIC
being a prime example.
Board of Directors
Each active member organization is entitled to
appoint to the Board one director who is either its chief
executive officer or another senior staff member.
Associate members shall be entitled to elect two
directors from among their respective boards or senior
staff. The Board of Directors includes three trustees
drawn from the boards of provincial cancer agencies and
appointed by the committee of trustees that serves
CAPCA.
32
Chronic Diseases in Canada
The Board structure was formally defined at its first
meeting in Quebec City, as outlined in Table 1.
TABLE 1
Structure of CAPCA’s Board of Directors
Officers
Chair — Peter Crossgrove, Cancer Care Ontario
Vice-chair — Rick Hester, CancerCare Manitoba
Secretary-Treasurer — Andrew Padmos, Cancer Care Nova Scotia
Active members
Bertha Paulse — Newfoundland
Andrew Padmos — Nova Scotia
Eshwar Kumar/Louis-Marie Simard (will alternate) — New Brunswick
Luc Deschênes — Quebec
Dagny Dryer — Prince Edward Island
Ken Shumak — Ontario
Brent Schacter — Manitoba
Bob Allen — Saskatchewan
Jean-Michel Turc — Alberta
Donald Carlow — British Columbia (and chief executive officer)
Associate members
To be formally appointed
The chair of the Board is a trustee appointed by the
Board on the recommendation of the committee of
trustees. The executive committee of the Board
comprises the three officers and the chief executive
officer.
Initial Activities
CAPCA is in the early stages of its development.
There are several ongoing Canadian initiatives that
could have an impact on CAPCA’s future, such as
outcomes of the Canadian Strategy for Cancer Control
and the possibility of an institute for cancer research
within the Canadian Institutes of Health Research. Under
these circumstances, CAPCA will approach the next
stage of its evolution in a manner that is flexible and
adaptable, and its initial resource requirements will be
modest. The head office will be located first in British
Columbia. Many of CAPCA’s goals will be achieved
through a decentralized approach wherein activities will
occur throughout Canada in a balanced, equitable and
well-coordinated manner. In effect, it will be a virtual
organization linking the various components together.
Initial activities will include further developing of
revenue for start-up based upon a membership dues
structure; creating the head office with space, equipment,
technology support, Web site and key staff; and
establishing board committees, structures and processes.
A major activity will be establishing a process to develop
national treatment policies, guidelines and protocols. It is
our hope that CAPCA can become the home for several
important national initiatives in areas such as radiation
therapy, systemic therapy and human resource planning
Vol 21, No 1
as well as making links with other national
organizations.
CAPCA will undertake significant coordinated
initiatives in research, monitoring and surveillance;
developing standards, strategy and policy; planning and
coordinating human resources; disseminating
information; establishing partnerships; developing
mechanisms for patient and public input; and
establishing key relationships with patient and public
advocacy groups. It will also work with primary partners
2000
such as the Canadian Strategy for Cancer Control,
federal health authorities, the Council of Deputy
Ministers of Health, the Canadian Institutes of Health
Research, the CCS/NCIC, the Association of Canadian
Medical Colleges, the Canadian Council on Health
Services Accreditation, the Canadian Coalition on
Cancer Surveillance, the Canadian Committee on Cancer
Staging and many others. CAPCA will work toward
establishing important international connections so that it
may learn from other countries and contribute to
worldwide efforts in cancer control. O
33
Status Report
National Enhanced Cancer Surveillance System:
A Federal-Provincial Collaboration to Examine
Environmental Cancer Risks
Kenneth C Johnson
The Laboratory Centre for Disease Control at Health
Canada is the steward of the National Enhanced Cancer
Surveillance System. The system was developed in the
mid-1990s through a successful federal-provincial
collaboration between the Environmental Risk
Assessment and Case Surveillance Division (Cancer
Bureau) and the provincial cancer registries.a
The central component of the National Enhanced
Cancer Surveillance System was built by collecting
detailed, risk factor questionnaire information from a
Canada-wide sample of 20,755 recently diagnosed
patients with cancer (18 types) and 5,039 population
controls. The data set includes over 1,000 cases of
11 major types of cancer in Canada and up to 700 cases
of some rarer forms of cancer. In parallel, the
Environmental Quality Database was developed to
facilitate examination of the relationships between
cancer and the quality of air and water in Canada.
Geographic evaluation of national cancer incidence data
(e.g. assessments of cancer cluster findings) and a
communication component complete the system.
Data collected under the National Enhanced Cancer
Surveillance System serve the national public health
interest and disease surveillance by facilitating analyses
to improve our knowledge of the role of environmental
factors as influences on cancer in Canada. These data
also allow the study of behavioural risk factors.
a
The Canadian Cancer Registries Epidemiology Research Group
comprises a principal investigator from each of the provincial cancer
registries involved in the National Enhanced Cancer Surveillance
System: Bertha Paulse (Newfoundland Cancer Foundation),
Ron Dewar (Nova Scotia Cancer Registry), Dagny Dryer (Prince
Edward Island Cancer Registry), Nancy Kreiger (Cancer Care
Ontario), Eric Kliewer (CancerCare Manitoba), Diane Robson
(Saskatchewan Cancer Foundation), Shirley Fincham (Division of
Epidemiology, Prevention and Screening, Alberta Cancer Board) and
Nhu Le (British Columbia Cancer Agency).
The National Enhanced Cancer Surveillance system can
facilitate quick, yet thorough, analyses of cancer–environment
issues that are important to the Laboratory Centre for
Disease Control in its role as a key player in disease
surveillance. A wide variety of analyses are now underway
both federally and provincially. Below are two examples
of analyses of considerable importance at Health Canada.
Passive and Active Smoking and Breast Cancer
Of particular interest are the provocative results
described in the recently published article “Passive and
Active Smoking and Breast Cancer in Canada, 1994–97”
(see below). The article contributes to the emerging
evidence suggesting a link between second-hand tobacco
smoke and breast cancer. If the relationships suggested
by this analysis and six other related published studies
are confirmed, environmental tobacco smoke could
prove an important breast cancer risk factor.
Chlorination of Drinking Water and Cancer
Risk Assessment
Analyses are also underway to examine the association
between chlorination disinfection by-products (CDBPs)
in drinking water and bladder cancer, to support the current
Health Canada (Health Protection Branch) initiative to
re-evaluate national drinking water guidelines for CDBPs.
This will be the first instance of a thorough analytic
epidemiologic study being undertaken to examine the
relationship between CDBPs and cancer in Canada, for
locations outside of the province of Ontario. Additionally,
by linkage to sophisticated water sampling analyses done
by Health Canada’s Environmental Health Directorate,
the system can produce epidemiologic analyses of specific
CDBPs that have never been evaluated in this detail.
Finally, the system allows for detailed study of more
than a dozen other cancers and CDBPs, many of which
have never been examined in depth anywhere in the world.
Author References
Kenneth C Johnson, Environmental Risk Assessment and Case Surveillance Division, Cancer Bureau, Laboratory Centre for Disease Control, Health
Canada, Tunney’s Pasture, Address Locator: 0601C1, Ottawa, Ontario K1A 0L2; E-mail: [email protected]
34
Chronic Diseases in Canada
Vol 21, No 1
Collaborative Research Opportunities
If you are interested in receiving more information on
the data access policy and procedures or would like to
discuss possible analyses using data from the National
Enhanced Cancer Surveillance System data, please
contact Ken Johnson (see Author References).
Selected Recently Published Journal Articles
Johnson KC, Mao Y, Argo J, Dubois S, Semenciw R,
Lava J. The National Enhanced Cancer Surveillance
System: a case-control approach to environmentrelated cancer surveillance in Canada.
Environmetrics 1998;9:495–504.
Mao Y, MacNeill IB, eds. Proceedings of the Workshop
on Retrospective Exposure Assessment Using Emission
Inventories. Environmetrics 1998;9(5):493–598.
Villeneuve PJ, Johnson KC, Kreiger N, Mao Y, and the
Canadian Cancer Registries Epidemiology Research
Group. Risk factors for prostate cancer: results from
the Canadian National Enhanced Cancer Surveillance System. Cancer Causes Control 1999;10(5):355–67.
Johnson KC, Hu J, Mao Y, and the Canadian Cancer
Registries Epidemiology Research Group. Passive
and active smoking and breast cancer risk in Canada,
1994–97. Cancer Causes Control. 2000;11:211–21.
Parkes R, Kreiger N, James B, Johnson KC. Effects on
subject response of information brochures and
small cash incentives in a mail-based case-control
study. Ann Epidemiol 2000;10(2):117–24.
Srivastava A, Kreiger N. Relation of physical activity
to risk of testicular cancer. Am J Epidemiol
2000;151(1):78–87.
Villeneuve PJ, Johnson KC, Hanley AJG, Mao Y, and
the Canadian Cancer Registries Epidemiology
Research Group. Alcohol, tobacco and coffee
consumption and the risk of pancreatic cancer:
results from the Canadian Enhanced Surveillance
System case-control project. Eur J Cancer Prev
2000;9:49–58. O
Announcement
Formation of the Canadian Prostate Cancer Research
Initiative
The Canadian Prostate Cancer Research Initiative (CPCRI) has been formed in direct response to
recommendations from the National Forum on Prostate Cancer in 1997. The CPCRI is an alliance among Health
Canada, the National Cancer Institute of Canada, the Canadian Cancer Society and the Canadian Prostate Cancer
Network. Its purpose is to strengthen existing capacities and stimulate new efforts across Canada in prostate
cancer research, with an emphasis on strategic initiatives to fill gaps, build capacity in important research areas
and to respond to unique opportunities.
The Board of Directors, representing the founding partners, will provide governance and strategic direction
and will seek additional funding sources for prostate cancer research. The Management Committee will direct the
Initiative’s research programs by establishing research priorities and policies, overseeing the scientific review
process, making research funding recommendations and raising awareness of issues surrounding prostate cancer
research.
The Management Committee includes community representatives and expertise from the range of professional
disciplines involved in prostate cancer research (laboratory science, radiation oncology, surgical oncology,
medical oncology, epidemiology, behavioural science and health policy). Current members are George E Connell
(Chair), Marvin Brodsky, Lorna Butler, Yves Fradet, Mary Gospodarowicz, Charles Hollenberg, Robert Kerbel,
François Meyer, Peter M Venner, George Richards and David Brittain.
For information about the CPCRI, please contact Gareth Taylor at (416) 934-5656.
2000
35
Book Reviews
Health Promotion Planning:
An Educational and Ecological Approach (third edition)
By Lawrence W Green and Marshall W Kreuter
Mountain View (California): Mayfield Publishing Company, 1999;
xxxi + 621 pp; ISBN 0-7674-0524-2; $98.95
Health Promotion Planning: An Educational and
Ecological Approach is the third edition of a book that
has been a core reference on health promotion planning
for the past 10 years. This edition, like the others, is
based on the PRECEDE-PROCEED framework. It uses
an analytic approach to help planners decide what health
issues to address and how to address them. This is a
challenging task given the complexity of planning using
the health promotion principles of community involvement
and comprehensive, effective response to community
needs. The book provides a specific approach with
detailed steps to accomplish this task.
The framework around which the book is built starts
with a social assessment of the factors influencing the
quality of life of the population, followed by an
epidemiologic assessment of the health issues affecting
quality of life. Phase 3 is a behavioural and environmental
evaluation of the factors influencing the health and
health problems of the population. In Phase 4 an
educational and ecological assessment is done to identify
the predisposing, enabling factors influencing both
behaviour and lifestyle and the environment. At this
point, program priorities, targets and objectives have been
identified; in Phase 5 the key administrative and policy
factors are identified to assist the planner to develop
programs that will have the greatest chance of success. The
final four phases involve implementation and conducting
evaluations of the process, impact and outcomes.
The book is organized into five sections: an overview
of health promotion and the framework; a chapter on
each of the five assessment planning phases; a chapter on
evaluation basics; a chapter on specific applications of
the planning framework in each of four settings—
community, occupational, school and health care; and
a final new chapter on a computer application of the
framework called EMPOWER. Each chapter has
exercises and a detailed list of references. The glossary
at the end assists the reader to navigate through
sometimes confusing terminology.
The authors take an academic, thoughtful approach to
presenting the information in the book. The rationale for
each step as well as the theoretical and research basis are
36
Chronic Diseases in Canada
included in each chapter. This is nicely balanced with
attention to the practical realities of working in the
complexities of “real life”. The authors do not shy away
from stating their values. Although these may not be
shared by everyone, their inclusion points to the need to
include a values discussion in every planning exercise.
While this book provides steps in each planning
phase, it is not a simple “how to” book. It presents
options for consideration by planners as they tailor their
own process. This is one of the book’s strengths, but
readers must be prepared to exercise their own judgement and use their own experience to make the best use
of it. Readers will find this book most useful as a
reference to which they can turn during the course of a
planning exercise. It is possible to use it starting at any
of the points in the five-stage assessment process,
although the authors do repeatedly emphasize that unless
program decisions are grounded in meeting real
community needs, they may not be effective.
The book will appeal to a wide range of individuals
involved in health promotion planning. It takes a broad
view of health promotion activities, from those directed
at underlying determinants such as poverty to specific
interventions in the health care setting. This comprehensiveness is a valuable aspect to the book because
practitioners in different settings can identify both the
similarities and differences in their practice. The book
would be very useful for an academic course in health
promotion planning at either the senior undergraduate or
graduate level.
While much of the third edition has material that was
available in the previous edition, there is enough new
material to make it a good buy for even those who have
the previous text. For example, the addition of the word
“ecological” in the title is a good example of how the
authors have incorporated recent thinking into this
edition. The reference list includes many new references,
and it is very useful to have many of the key health
promotion references listed in one place.
Vol 21, No 1
Overall rating:
Excellent
Strengths:
Broad approach to health promotion that
reflects recent thinking in the field
Uses a systematic, logical approach to
planning
Strong theoretical and research basis
Includes evaluation as an essential
component of program planning
Includes examples of the use of the planning
framework in “real life” situations
Gives options and rationale for each
planning phase to support a tailored
approach
Weaknesses:
Dense nature of the text itself (so much
information at such a significant depth could
benefit from a larger page and font to
facilitate the ease of reading)
Some sections have less detail than others
Audience:
Health promotion program planners and
managers; public health and community
health service providers; federal, provincial/
territorial, regional government health
departments; non-governmental
organizations; students and educators in
senior undergraduate and postgraduate
health programs in universities and colleges;
researchers
Paula J Stewart
Paula J Stewart & Associates
Community Health Consultant
1093 Chablis Park
Orleans, Ontario K1C 2T5
Quantitative Estimation and Prediction of
Human Cancer Risks
IARC Scientific Publications No 131
Edited by S Moolgavkar, D Krewski, L Zeise, E Cardis and H Møller
Lyon (France): International Agency for Research on Cancer, 1999;
xiii + 322 pp; ISBN 92-832-2131-1; $122.50
This volume from the International Agency for
Research on Cancer consists of nine papers by different
authors, each of which provides a discussion of an aspect
of cancer risk assessment.
The relationship between exposure to risks and the
development of cancer at a particular site in a human is
seldom known with any degree of precision. This is so
partly because understanding of the mechanics of
carcinogenesis is not complete. Also, dose-response
curves for most carcinogens and most human cancer
sites are not well understood. Extrapolation from animal
experiments using high levels of exposure to humans
affected by low levels of exposure is often open to
question. The synergistic effects of exposures to multiple
risks are poorly understood.
Another point to be considered is the fact that long
latencies are associated with most cancers, and assessing
the effects of exposures in the distant past is problematic.
Estimating the exposure dose of most individuals to most
carcinogens is an imprecise science. Furthermore, the
reasons why some humans are more susceptible than
2000
others to the development of malignant tumours at certain
sites are in the early stages of study. With some notable
exceptions, cigarette smoking being one, the relative
risks of everyday exposures tend to be small and difficult
to measure with sufficient precision to distinguish between
a small effect and no effect, which adds another layer of
complexity to the problem of quantifying risk effects.
Nevertheless, many carcinogens have been identified.
Regulations regarding manufacturing, distribution and
use of many of these substances are in place, at least in
developed parts of the world. However, even though a
substance is known to be a carcinogen, it will not necessarily be banned from manufacture or use. For example,
it is possible for a pesticide to be implicated in causing
cancer and yet still be widely used because of its value in
enhancing crop yields. When deciding upon regulation
of a substance, regulatory agencies must take into account
economic impact as well as carcinogenic risk.
The fact that regulation, not necessarily prohibition,
of carcinogens must be carried out in the face of great
complexity in the exposure/outcome relationship,
37
requires that “quantitative estimation and prediction of
human cancer risks” at least be attempted. This book
essentially surveys the current state of the science. The
following chapter titles reveal the extent of the work
reviewed in the volume.
1. “Quantitative estimation and prediction of human
cancer risk: its history and role in cancer
prevention”
2. “Quantitative estimation and prediction of cancer
risk: review of existing activities”
3. “Principles of the epidemiological approach to
QEP” [quantitative estimation and prediction of
human cancer risk]
4. “Measurement of exposure and outcome in
epidemiological studies used for quantitative
estimation and prediction of risk”
5. “Long- and medium-term carcinogenicity studies
in animals and short-term genotoxicity tests”
6. “Empirical approaches to risk estimation and
prediction”
7. “Mechanisms of carcinogenesis and biologically
based models for estimation and prediction of risk”
8. “Review of specific examples of QEP”
9. “Future perspectives, unresolved issues and
research needs”
This volume shows the effects of taking considerable
care in preparation and editing. Hence, without undue
struggle, the reader will be able to gain an appreciation
of the problems, complexity and progress associated
with the various aspects of cancer risk assessment. The
extensive bibliography included in each chapter will
allow those with a thirst for deeper insight into quantitative estimation and prediction of human cancer risk
than is provided in this admirable volume to go to the
literature and slake that thirst.
Ian B MacNeill
Professor Emeritus
Department of Statistical and Actuarial Sciences
University of Western Ontario
London, Ontario N6A 5B7
Epidemiology of Childhood Cancer
IARC Scientific Publications No 149
By Julian Little
Lyon (France): International Agency for Research on Cancer, 1999;
xiv + 386 pp; ISBN 92-832-2149-4; $104.50
Although childhood cancer accounts for only about
1% of all cancers in Canada and even fewer deaths, its
public health importance is high, in part because of the
long-term health implications for survivors. Childhood
cancer differs in many ways from its adult counterpart,
including site of occurrence, as well as histologic and
clinical behaviour, and thus needs to be considered
separately. Though there are many useful textbooks
about the epidemiology of cancer, Epidemiology of
Childhood Cancer is the first to synthesize and describe
the various aspects of childhood cancer epidemiology in
one monograph.
An overview of design issues relating to the conduct
of epidemiologic studies is presented in Chapter 1,
including the consideration of alternative explanations
for study findings. Several current hypotheses relating to
complex routes of exposure for some childhood cancer
risk factors are also briefly discussed. Two examples are
Greaves’ hypothesis on population mixing and acute
lymphocytic leukemia, and the relation of N-nitroso
compounds to brain tumours.
38
Chronic Diseases in Canada
The second chapter covers the descriptive
epidemiology of childhood cancer and is organized
according to the histology-based Birch and Marsden
(Manchester) classification system. For each diagnostic
group, geographical patterns, age-specific incidence and
sex ratios, ethnic origin and time trends are described.
Additionally, variation in rates according to socioeconomic status as well as other spatial and temporal
clustering are defined where applicable. Finally, for
certain childhood cancers, distinct epidemiologic
features are discussed such as skeletal subtype
distribution for osteosarcomas.
Chapters 3–10 present the current knowledge of major
risk factors for childhood cancer, organized by exposure
rather than cancer type. Chapter 3 focuses on genetic
factors and the proportion of each cancer type believed
to be the consequence of specific genetic syndromes
and/or familial aggregations. Unfortunately, this chapter
suffers from the limitations of any text about a fast
developing area, in that it is already out of date.
Vol 21, No 1
Chapters 4 and 5 examine particular exposures in
relation to childhood cancer risk. First, the effects of
ionizing radiation on childhood cancer outcomes (mostly
leukemia) are discussed in Chapter 4. Specific examples
of residential exposure from both point source (i.e. bombs,
nuclear plant accidents) and diffuse origin (i.e. nuclear
installations, background radiation) are reviewed. Then
Chapter 5 provides a detailed discussion of EMF
(electromagnetic field) exposure assessment as well
as a review of pertinent studies.
The associations between paternal occupational and
environmental exposures to chemicals and dusts are
addressed in Chapter 6. Most studies have focused on the
positive association with leukemia, though the few studies
examining other childhood cancers are also reviewed here.
The seventh chapter discusses the hypothesis that
childhood cancer risk is related to maternal and infant
infection. Most of this text reviews studies on leukemia,
though there are small sections on lymphoma, brain
tumours and other childhood cancers. Maternal and
paternal lifestyle habits and their association with cancer
in the offspring are examined in the next chapter, including
diet and vitamin supplements, as well as tobacco, alcohol
and recreational drug use. Associations between specific
types of childhood cancer and maternal age, birth order
and prior reproductive history are considered in Chapter
9, while the index child’s medical history in relation to
cancer risk is discussed in Chapter 10.
The final Chapter 11 summarizes the evidence on
risk factors for each diagnostic group according to the
strength of published findings, based loosely on the
Brandford-Hill criteria. The chapter contains excellent
reference tables outlining the evidence for leukemias,
2000
lymphomas, central nervous system tumours, neuroblastoma and Wilms’ tumour. The continuing problems of
accurate and valid exposure assessment and non-biased
selection of control subjects are addressed. The authors
assert that objective markers of exposure need to be
developed and used in more epidemiologic studies.
Furthermore, adequate sample sizes for subtype analysis
require the involvement of co-operative groups, and
studies should be expanded to include subjects from
outside North America and Europe.
This book is an excellent primer for anyone contemplating research into the epidemiology of childhood
cancer. The review of etiologic studies is exhaustive and
critical, though an update will need to be done shortly as
the monograph only includes studies published before
mid-1997. In such a quickly evolving field, especially
when combined with molecular biology, regular updates
are necessary. Moreover, the monograph should expand
its discussion of biologic mechanisms; though mentioned
in certain sections, a separate chapter may be useful.
Nonetheless, Epidemiology of Childhood Cancer is an
extremely thorough and well-documented reference book
including clear and detailed tables and an extensive
bibliography. It should be included in the library of
anyone interested in childhood cancer epidemiology.
Amanda Shaw
Cancer Bureau
Laboratory Centre for Disease Control
Health Canada, Tunney’s Pasture
Address Locator: 0601C1
Ottawa, Ontario K1A 0L2
39
New Resources
NOTICE!
Canadian Cancer Statistics 2000
National Cancer Institute of Canada
Toronto (Ontario), 2000
Canadian Cancer Statistics 2000 is now accessible on
the Internet at <www.cancer.ca/stats>.
You can download and/or print any sections, graphs,
tables, etc. or all of this document from the above Web
site.
If you would like to receive a hard copy of this
publication, contact
·
your local office of the Canadian Cancer Society,
·
your regional office of Statistics Canada
or
·
Canadian Cancer Society (National Office)
10 Alcorn Avenue, Suite 200
Toronto, Ontario M4V 3B1
Tel: (416) 961-7223
Fax: (416) 961-4189
E-mail: [email protected]
National Population Health Survey
Highlights No 2: Physical Activity of
Canadians
Health Canada
Ottawa (Ontario), 1999
Health Canada has released the National Population
Health Survey Highlights No 2: Physical Activity of
Canadians, which is based on results from cycle 2,
1996/97 of the National Population Health Survey
(NPHS). The Highlights series was developed to provide
descriptive information on health issues covered by the
NPHS. Several groups within and outside of Health
Canada contributed to the development of Highlights
No 2, including the Fitness and Active Living Program
Unit of the Health Promotion and Programs Branch, the
Cancer Bureau and the Bureau of Cardio-respiratory
Disease and Diabetes at the Laboratory Centre for
Disease Control, and the Canadian Fitness and Lifestyle
Research Institute.
Highlights No 2 and supplementary data tables are
also available on the Cancer Bureau’s Web site at
<www.hc-sc.gc.ca/hpb/lcdc/bc/nphs/index.html>.
If you would like to receive a hard copy of this package,
contact
Cancer Bureau
Laboratory Centre for Disease Control
Health Canada, Tunney’s Pasture
Address Locator: 0602E2
Ottawa, Ontario K1A 0L2
University of Ottawa Community Medicine Residency Program
alumni(ae) to hold reunion breakfast at CPHA Annual Conference 2000
Between 1977 and 1998, the Community Medicine Residency Program at the University of Ottawa provided training in
public health, offering unique opportunities for Community Medicine residents to work at federal and international levels as
well as local levels. Sadly, that experience is no longer as readily available to the current generation of trainees, but the dozens
of practitioners who went through the Program continue to extend its impact through their research, teaching and practice in
Canada and abroad.
The Canadian Public Health Association (CPHA) is holding its 91st annual scientific conference and general meeting in
Ottawa from October 22 to 25, 2000. What better opportunity for former residents to return to Ottawa and celebrate this
formative experience, meet with colleagues and staff and learn about the new Institute of Population Health; there may even be
new facilities to tour. Watch for the conference program to see the details about our alumni(ae) breakfast, and please let us
know if you are planning to join us.
Best regards,
Chris Mills (cohort of 1990)
E-mail: [email protected]
40
Chronic Diseases in Canada
Vol 21, No 1
Calendar of Events
May 7–10, 2000
Victoria, British Columbia
“Science and Policy in Action”
First International Conference on Women, Heart
Disease and Stroke
Heart and Stroke Foundation of Canada,
American Heart Association, Health Canada,
Centers for Disease Control and Prevention
and Canadian Cardiovascular Society
Taylor & Associates
18 – 5370 Canotek Road
Gloucester, Ontario K1J 9E8
Tel: (613) 747-0262
Fax: (613) 745-1846
E-mail: [email protected]
<www.hsf.ca/women&cvd2000>
May 7–10, 2000
Ottawa, Ontario
“Exposure Assessment for Disinfection
By-products in Epidemiologic Studies: An
International Workshop”
Sponsored by Health Canada and the US
Environmental Protection Agency
Tye Arbuckle
Bureau of Reproductive and Child Health
Laboratory Centre for Disease Control
Health Canada, Tunney’s Pasture
Address Locator: 0701D
Ottawa, Ontario K1A 0L2
E-mail: [email protected]
<www.hc-sc.gc.ca/hpb/lcdc/events/
expo2000/index.html>
May 17–19, 2000
Denver, Colorado
USA
“Health Promotion Excellence in the New
Century: Ascending New Heights”
18th National Conference on Health Promotion
and Public Health Education and the 2000
SOPHE Midyear Scientific Meeting
Sponsors: Centers for Disease Control and
Prevention, Association of State and Territorial
Directors of Health Promotion and Public
Health Education and Society for Public Health
Education
<www.sophe.org>
<www.astdhpphe.org>
May 28–30, 2000
Ottawa, Ontario
“Charting the Course for Literacy and Health in
the New Millennium”
First Canadian Conference on Literacy and
Health
Organized by the Canadian Public Health
Association’s National Literacy and Health
Program
CPHA Conference Department
400 – 1565 Carling Avenue
Ottawa, Ontario K1Z 8R1
Tel: (613) 725-3769
Fax: (613) 725-9826
E-mail: [email protected]
<www.nald.ca/nlhp.htm>
June 11–13, 2000
Edmonton, Alberta
“Statistics and Health 2000”
International conference organized by the
Biostatistics Research Group (BRG), Statistics
Centre, University of Alberta
KC Carrière (Program Committee Chair)
Tel: (780) 492-4230
Fax: (780) 492-6826
E-mail: [email protected]
<www.stat.ualberta.ca/~brg>
June 14–18, 2000
Ottawa, Ontario
“Beyond 2000: Healthy Tomorrows for Children
and Youth”
Conference hosted by the Canadian Institute of
Child Health, the Canadian Paediatric Society
and the Canadian Academy of Child
Psychiatrists
Jackie Millette
Manager, Education Department
Canadian Paediatric Society
100 – 2204 Walkley Road
Ottawa Ontario K1G 4G8
Tel.: (613) 526-9397, ext 228
Fax: (613) 526-3332
E-mail: [email protected]
<www.cps.ca/beyond2000>
2000
41
June 15–17, 2000
Seattle, Washington
USA
33rd Annual Meeting of the Society for
Epidemiologic Research
Jacqueline C Brakey
Registration Co-ordinator, Conferences
University of Utah
Tel: (801) 581-5809
Fax: (801) 581-3165
E-mail: [email protected]
<www.conferences.utah.edu>
June 20–22, 2000
Jonquière, Quebec
“From DNA to the Community: An International
Meeting on Community Genetics”
Sponsors: Corporation de recherche et d’action
sur les maladies héréditaires and Health
Canada
ID Rusen
Bureau of Reproductive and Child Health
Laboratory Centre for Disease Control
Health Canada, Tunney’s Pasture
Address Locator: 0701D
Ottawa, Ontario K1A 0L2
Tel: (613) 946-9742
Fax: (613) 941-9927
E-mail: [email protected]
July 3–7, 2000
Montreal, Quebec
IXth International Symposium in Medical
Geography
“An Agenda for the Geography of Health and
Health Care in the New Century”
Jean-Pierre Thouez
Département de géographie
Université de Montréal
C.P. 6128, succ. Centre-Ville
Montréal, Québec H3C 3J7
Tel: (514) 343-8054
Fax: (514) 343-8008
E-mail: [email protected]
<www.attcanada.net/~geo2000>
July 9–28, 2000
Newton Lower Falls,
Massachusetts
USA
Epidemiology Research Institute
20th Annual Epidemiology Summer Program
Epidemiology Research Institute
One Newton Executive Park
Newton Lower Falls, MA
USA 02462-1450
Tel: (617) 244-1200
Fax: (617) 244-2669
E-mail: [email protected]
<www.epidemiology.com>
August 6–11, 2000
Chicago, Illinois
USA
11th World Conference on Tobacco OR Health
Hosts: American Cancer Society, American
Medical Association and Robert Wood
Johnson Foundation
11th World Conference on Tobacco OR
Health
c/o American Medical Association
515 North State Street
Chicago, IL
USA 60610
Attn: Anne Jenkins, Conference Manager
Tel: (312) 464-9059
Fax: (312) 464-4111
E-mail: [email protected]
<www.wctoh.org>
August 23–27, 2000
Victoria, British Columbia
ITCH 2000: “From Potential to Practice”
International Conference on Information
Technology in Community Health
ITCH 2000
c/o School of Health Information Science
University of Victoria
PO Box 3050, STN CSC
Victoria, BC V8W 3P5
Tel: (250) 721-8576
Fax: (250) 472-4751
E-mail: [email protected]
<www.itch.uvic.ca>
42
Chronic Diseases in Canada
Vol 21, No 1
October 22–25, 2000
Ottawa, Ontario
“Health for All in the Year 2000"
Canadian Public Health Association
91st Annual Conference and
Ontario Public Health Association
51st Annual Conference
CPHA Conference Services
400 – 1565 Carling Avenue
Ottawa, Ontario K1Z 8R1
Tel: (613) 725-3769
Fax: (613) 725-9826
E-mail: [email protected]
<www.cpha.ca>
June 12–15, 2001
Toronto, Ontario
Congress of Epidemiology 2001
Combined meeting of American College of
Epidemiology, American Public Health
Association’s Epidemiology Section, Canadian
Society for Epidemiology and Biostatistics and
Society for Epidemiologic Research
<www.epi2001.org>
July 1–6, 2001
Vancouver, British
Columbia
“Global Aging: Working Together in a Changing
World”
17th Congress of the International Association of
Gerontology
Call for papers: June 1, 2000; Abstract deadline:
December 31, 2000
Congress Secretariat
Gerontology Research Centre
Simon Fraser University at Harbour
Centre
2800 – 515 West Hastings Street
Vancouver, BC V6B 5K3
Tel: (604) 291-5062
Fax: (604) 291-5066
E-mail: [email protected]
<www.harbour.sfu.ca/iag>
1999 Peer Reviewers
We are extremely grateful to the following
people for their enormous contribution
to Chronic Diseases in Canada as
peer reviewers in 1999.
Alexander C Allen
Marie P Beaudet
Jean-François Boivin
Penny Brasher
Jacques Brisson
Linda Dodds
John Frank
James Frankish
Paul Gully
Brian F Habbick
James A Hanley
Lisa Hartling
Shauna Hudson
Claire Infante-Rivard
Grace M Johnston
Judith Klotz
2000
Joan Lindsay
Sylvie Marcoux
Loraine Marrett
Wayne J Millar
JoAnn Perry
Ali H Rajput
Elizabeth J Robinson
Margaret L Russell
A Senthilselvan
Robert A Spasoff
Larry Svenson
Shi Wu Wen
Donald T Wigle
Kathryn Wilkins
Xiaodi Xie
43
Indexes for Volume 20, 1999
Volume 20 Contents
No 1, 1999
Guest Editorial on Public Health Aspects of Breast Cancer
Gene Testing in Canada.....................................................
Development of Record Linkage of Hospital Discharge
Data for the Study of Neonatal Readmission...................... 77
Shiliang Liu and Shi Wu Wen
1
Simon B Sutcliffe
Public Health Aspects of Breast Cancer Gene Testing in
Canada. Part 1: Risks and Interventions ............................
2
J Mark Elwood
Claudine Laurier, Wendy Kennedy, Jean-Luc Malo, Michèle Paré,
Daniel Labbé, André Archambault and André-Pierre Contandriopoulos
The Cost of Suicide Mortality in New Brunswick, 1996 ...... 89
Public Health Aspects of Breast Cancer Gene Testing in
Canada. Part 2: Selection for and Effects of Testing.......... 14
J Mark Elwood
Public Health Aspects of Breast Cancer Gene Testing in
Canada. Part 3: A Model of Potential Need and
Demand .............................................................................. 21
J Mark Elwood
Deaths Due to Dementia: An Analysis of
Multiple-cause-of-death Data.............................................. 26
Kathryn Wilkins, Greg F Parsons, Jane F Gentleman and
William F Forbes
Short Report
Health Consequences of Smoking Among Canadian
Smokers: An Update........................................................... 36
Larry F Ellison, Howard I Morrison, Margaret de Groh and
Paul J Villeneuve
Book Reviews
Population Health: Concepts and Methods ........................ 40
Reviewed by John Frank
Dale Clayton and Alberto Barceló
Workshop Report
Canadian National Workshop on Measurement of
Sun-related Behaviours ...................................................... 96
Chris Lovato, Jean Shoveller, Christina Mills and an Expert Panel
Book Review
Injury Prevention: An International Perspective.
Epidemiology, Surveillance, and Policy ..............................101
Reviewed by Margaret Herbert
Calendar of Events ............................................................. 102
No 3, 1999
Suicides Among Canadian Farm Operators .......................105
William Pickett, Will D King, Taron Faelker, Ronald EM Lees,
Howard I Morrison and Monica Bienefeld
Mortality Attributable to Tobacco Use in Canada and its
Regions, 1994 and 1996.....................................................111
Eva M Makomaski Illing and Murray J Kaiserman
Public Health and Preventive Medicine in Canada,
Fourth Edition ..................................................................... 41
Reviewed by Clyde Hertzman
Calendar of Events ............................................................. 43
1998 Peer Reviewers ......................................................... 45
Indexes for Volume 19, 1998.............................................. 46
No 2, 1999
Prevalence and Geographic Disparities in Certain
Congenital Anomalies in Quebec: Comparison of
Estimation Methods ............................................................ 51
Robert Choinière, Michel Pageau and Marc Ferland
Monograph Series on Aging-related Diseases:
XII. Parkinson’s Disease—Recent Developments
and New Directions............................................................. 58
44
Rate and Cost of Hospitalizations for Asthma in Quebec:
An Analysis of 1988/89, 1989/90 and 1994/95 Data .......... 82
Mental Health of the Canadian Population:
A Comprehensive Analysis.................................................118
Thomas Stephens, Corinne Dulberg and Natacha Joubert
Commentary
Ethical Issues in the Use of Computerized Databases
for Epidemiologic and Other Health Research ...................127
Wilfreda E Thurston, Michael M Burgess and Carol E Adair
Status Report
Conceptual Framework for Child Maltreatment
Surveillance ........................................................................132
Lil Tonmyr and Gordon Phaneuf
Book Review
Epidemiologic Methods for Health Policy ...........................134
Reviewed by Vivek Goel
New Resources .................................................................. 135
Natalie Kontakos and Julie Stokes
Calendar of Events ............................................................. 137
Chronic Diseases in Canada
Vol 21, No 1
No 4, 1999
Commentary
The Brave New World—What Can We Realistically
Expect to Achieve Through Cancer Control Early in
the New Millennium? ..........................................................139
Anthony B Miller
Short Report
A Simple Method for Estimating Incidence from
Prevalence..........................................................................151
Gerry B Hill, William F Forbes and Jean Kozak
Marital Status, Dementia and Institutional Residence
Among Elderly Canadians: The Canadian Study of
Health and Aging ................................................................154
Betsy Kristjansson, Barbara Helliwell, William F Forbes and
Gerry B Hill
Book Review
Social Determinants of Health ............................................158
Reviewed by Robert A Spasoff
New Resources .................................................................. 159
Calendar of Events ............................................................. 160
Volume 20 Subject Index
ASTHMA
Rate and cost of hospitalizations for asthma in Quebec: an
analysis of 1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
BOOK REVIEWS
Epidemiologic methods for health policy. 20(3):134–5.
Injury prevention: an international perspective. Epidemiology,
surveillance, and policy. 20(2):101.
Population health: concepts and methods. 20(1):40–1.
Public health and preventive medicine in Canada, 4th edition.
20(1):41–2.
Social determinants of health. 20(4):158.
CANCER
The brave new world—what can we realistically expect to
achieve through cancer control early in the new millennium?
[commentary]. 20(4):139–50.
Canadian National Workshop on Measurement of Sun-related
Behaviours [workshop report]. 20(2):96–100.
Guest editorial on public health aspects of breast cancer gene
testing in Canada. 20(1):1–2.
Rate and cost of hospitalizations for asthma in Quebec: an
analysis of 1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
DEMENTIA
Deaths due to dementia: an analysis of
multiple-cause-of-death data. 20(1):26–35.
Marital status, dementia and institutional residence among
elderly Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
A simple method for estimating incidence from prevalence
[short report]. 20(4):151–3.
DIABETES
A simple method for estimating incidence from prevalence
[short report]. 20(4):151–3.
DISEASE CONTROL
The brave new world—what can we realistically expect to
achieve through cancer control early in the new millennium?
[commentary]. 20(4):139–50.
ENVIRONMENTAL HEALTH
Canadian National Workshop on Measurement of Sun-related
Behaviours [workshop report]. 20(2):96–100.
Health consequences of smoking among Canadian smokers:
an update [short report]. 20(1):36–9.
GEOGRAPHIC VARIATIONS
Public health aspects of breast cancer gene testing in
Canada. Part 1: Risks and interventions. 20(1):3–13.
Mortality attributable to tobacco use in Canada and its
regions, 1994 and 1996. 20(3):111–7.
Public health aspects of breast cancer gene testing in
Canada. Part 2: Selection for and effects of testing.
20(1):14–20.
Prevalence and geographic disparities in certain congenital
anomalies in Quebec: comparison of estimation methods.
20(2):51–7.
Public health aspects of breast cancer gene testing in
Canada. Part 3: A model of potential need and demand.
20(1):21–5.
INFANT AND CHILD HEALTH
CARDIOVASCULAR DISEASES
Development of record linkage of hospital discharge data for
the study of neonatal readmission. 20(2):77–81.
Health consequences of smoking among Canadian smokers:
an update [short report]. 20(1):36–9.
COST OF ILLNESS
The cost of suicide mortality in New Brunswick, 1996.
20(2):89–95.
2000
Conceptual framework for child maltreatment surveillance
[status report]. 20(3):132–3.
Prevalence and geographic disparities in certain congenital
anomalies in Quebec: comparison of estimation methods.
20(2):51–7.
45
INTENTIONAL AND UNINTENTIONAL INJURIES
SCREENING
The cost of suicide mortality in New Brunswick, 1996.
20(2):89–95.
The brave new world—what can we realistically expect to
achieve through cancer control early in the new millennium?
[commentary]. 20(4):139–50.
Suicides among Canadian farm operators. 20(3):105–10.
MENTAL DISORDERS
Guest editorial on public health aspects of breast cancer gene
testing in Canada. 20(1):1–2.
Deaths due to dementia: an analysis of
multiple-cause-of-death data. 20(1):26–35.
Public health aspects of breast cancer gene testing in
Canada. Part 1: Risks and interventions. 20(1):3–13.
Marital status, dementia and institutional residence among
elderly Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
Public health aspects of breast cancer gene testing in
Canada. Part 2: Selection for and effects of testing.
20(1):14–20.
Mental health of the Canadian population: a comprehensive
analysis. 20(3):118–26.
Public health aspects of breast cancer gene testing in
Canada. Part 3: A model of potential need and demand.
20(1):21–5.
A simple method for estimating incidence from prevalence
[short report]. 20(4):151–3.
METHODOLOGIC ISSUES
Development of record linkage of hospital discharge data for
the study of neonatal readmission. 20(2):77–81.
Prevalence and geographic disparities in certain congenital
anomalies in Quebec: comparison of estimation methods.
20(2):51–7.
SENIORS’ HEALTH
Deaths due to dementia: an analysis of
multiple-cause-of-death data. 20(1):26–35.
Marital status, dementia and institutional residence among
elderly Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
A simple method for estimating incidence from prevalence
[short report]. 20(4):151–3.
Monograph series on aging-related diseases: XII. Parkinson’s
disease—recent developments and new directions.
20(2):58–76.
OCCUPATIONAL HEALTH
STATUS REPORTS
Suicides among Canadian farm operators. 20(3):105–10.
Conceptual framework for child maltreatment surveillance
[status report]. 20(3):132–3.
PARKINSON’S DISEASE
Monograph series on aging-related diseases: XII. Parkinson’s
disease–recent developments and new directions.
20(2):58–76.
POPULATION SURVEILLANCE
Conceptual framework for child maltreatment surveillance
[status report]. 20(3):132–3.
TOBACCO ISSUES
Health consequences of smoking among Canadian smokers:
an update [short report]. 20(1):36–9.
Mortality attributable to tobacco use in Canada and its
regions, 1994 and 1996. 20(3):111–7.
WOMEN’S HEALTH
Mental health of the Canadian population: a comprehensive
analysis. 20(3):118–26.
Guest editorial on public health aspects of breast cancer gene
testing in Canada. 20(1):1–2.
PUBLIC POLICY
Public health aspects of breast cancer gene testing in
Canada. Part 1: Risks and interventions. 20(1):3–13.
Ethical issues in the use of computerized databases for
epidemiologic and other health research [commentary].
20(3):127–31.
RESEARCH DESIGN
Ethical issues in the use of computerized databases for
epidemiologic and other health research [commentary].
20(3):127–31.
RESPIRATORY DISEASES
Rate and cost of hospitalizations for asthma in Quebec: an
analysis of 1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
46
Chronic Diseases in Canada
Public health aspects of breast cancer gene testing in
Canada. Part 2: Selection for and effects of testing.
20(1):14–20.
Public health aspects of breast cancer gene testing in
Canada. Part 3: A model of potential need and demand.
20(1):21–5.
SUMMARY WORKSHOP/CONFERENCE REPORTS
Canadian National Workshop on Measurement of Sun-related
Behaviours [workshop report]. 20(2):96–100.
Vol 21, No 1
Volume 20 Author Index
Adair, Carol E
Thurston WE, Burgess MM, Adair CE. Ethical issues in the
use of computerized databases for epidemiologic and
other health research [commentary]. 20(3):127–31.
Archambault, André
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Barceló, Alberto
Clayton D, Barceló A. The cost of suicide mortality in New
Brunswick, 1996. 20(2):89–95.
Bienefeld, Monica
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Burgess, Michael M
Thurston WE, Burgess MM, Adair CE. Ethical issues in the
use of computerized databases for epidemiologic and
other health research [commentary]. 20(3):127–31.
Choinière, Robert
Choinière R, Pageau M, Ferland M. Prevalence and
geographic disparities in certain congenital anomalies in
Quebec: comparison of estimation methods. 20(2):51–7.
Clayton, Dale
Clayton D, Barceló A. The cost of suicide mortality in New
Brunswick, 1996. 20(2):89–95.
Contandriopoulos, André-Pierre
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Elwood JM. Public health aspects of breast cancer gene
testing in Canada. Part 3: A model of potential need and
demand. 20(1):21–5.
Faelker, Taron
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Ferland, Marc
Choinière R, Pageau M, Ferland M. Prevalence and
geographic disparities in certain congenital anomalies in
Quebec: comparison of estimation methods. 20(2):51–7.
Forbes, William F
Hill GB, Forbes WF, Kozak J. A simple method for estimating
incidence from prevalence [short report]. 20(4):151–3.
Kristjansson B, Helliwell B, Forbes WF, Hill GB. Marital status,
dementia and institutional residence among elderly
Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
Wilkins K, Parsons GF, Gentleman JF, Forbes WF. Deaths
due to dementia: an analysis of multiple-cause-of-death
data. 20(1):26–35.
Frank, John
Frank J. Population health: concepts and methods [book
review]. 20(1):40–1.
Gentleman, Jane F
Wilkins K, Parsons GF, Gentleman JF, Forbes WF. Deaths
due to dementia: an analysis of multiple-cause-of-death
data. 20(1):26–35.
Goel, Vivek
Goel V. Epidemiologic methods for health policy [book
review]. 20(3):134–5.
de Groh, Margaret
Ellison LF, Morrison HI, de Groh M, Villeneuve PJ. Health
consequences of smoking among Canadian smokers: an
update [short report]. 20(1):36–9.
Helliwell, Barbara
Kristjansson B, Helliwell B, Forbes WF, Hill GB. Marital status,
dementia and institutional residence among elderly
Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
Dulberg, Corinne
Stephens T, Dulberg C, Joubert N. Mental health of the
Canadian population: a comprehensive analysis.
20(3):118–26.
Herbert, Margaret
Herbert M. Injury prevention: an international perspective.
Epidemiology, surveillance, and policy [book review].
20(2):101.
Ellison, Larry F
Ellison LF, Morrison HI, de Groh M, Villeneuve PJ. Health
consequences of smoking among Canadian smokers: an
update [short report]. 20(1):36–9.
Hertzman, Clyde
Hertzman C. Public health and preventive medicine in
Canada, 4th edition [book review]. 20(1):41–2.
Elwood, J Mark
Elwood JM. Public health aspects of breast cancer gene
testing in Canada. Part 1: Risks and interventions.
20(1):3–13.
Elwood JM. Public health aspects of breast cancer gene
testing in Canada. Part 2: Selection for and effects of
testing. 20(1):14–20.
2000
Hill, Gerry B
Hill GB, Forbes WF, Kozak J. A simple method for estimating
incidence from prevalence [short report]. 20(4):151–3.
Kristjansson B, Helliwell B, Forbes WF, Hill GB. Marital status,
dementia and institutional residence among elderly
Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
47
Illing, Eva M Makomaski
Illing EMM, Kaiserman MJ. Mortality attributable to tobacco
use in Canada and its regions, 1994 and 1996.
20(3):111–7.
Joubert, Natacha
Stephens T, Dulberg C, Joubert N. Mental health of the
Canadian population: a comprehensive analysis.
20(3):118–26.
Kaiserman, Murray J
Illing EMM, Kaiserman MJ. Mortality attributable to tobacco
use in Canada and its regions, 1994 and 1996.
20(3):111–7.
Kennedy, Wendy
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
King, Will D
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Kontakos, Natalie
Kontakos N, Stokes J. Monograph series on aging-related
diseases: XII. Parkinson’s disease–recent developments
and new directions. 20(2):58–76.
Malo, Jean-Luc
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Miller, Anthony B
Miller AB. The brave new world—what can we realistically
expect to achieve through cancer control early in the
new millennium? [commentary]. 20(4):139–50.
Mills, Christina
Lovato C, Shoveller J, Mills C. Canadian National Workshop
on Measurement of Sun-related Behaviours [workshop
report]. 20(2): 96–100.
Morrison, Howard I
Ellison LF, Morrison HI, de Groh M, Villeneuve PJ. Health
consequences of smoking among Canadian smokers: an
update [short report]. 20(1):36–9.
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Pageau, Michel
Choinière R, Pageau M, Ferland M. Prevalence and
geographic disparities in certain congenital anomalies in
Quebec: comparison of estimation methods. 20(2):51–7.
Kozak, Jean
Hill GB, Forbes WF, Kozak J. A simple method for estimating
incidence from prevalence [short report]. 20(4):151–3.
Paré, Michèle
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Kristjansson, Betsy
Kristjansson B, Helliwell B, Forbes WF, Hill GB. Marital status,
dementia and institutional residence among elderly
Canadians: the Canadian Study of Health and Aging.
20(4):154–7.
Parsons, Greg F
Wilkins K, Parsons GF, Gentleman JF, Forbes WF. Deaths
due to dementia: an analysis of multiple-cause-of-death
data. 20(1):26–35.
Labbé, Daniel
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Laurier, Claudine
Laurier C, Kennedy W, Malo J, Paré M, Labbé D,
Archambault A, Contandriopoulos A. Rate and cost of
hospitalizations for asthma in Quebec: an analysis of
1988/89, 1989/90 and 1994/95 data. 20(2):82–8.
Phaneuf, Gordon
Tonmyr L, Phaneuf G. Conceptual framework for child
maltreatment surveillance [status report]. 20(3):132–3.
Pickett, William
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Shoveller, Jean
Lovato C, Shoveller J, Mills C. Canadian National Workshop
on Measurement of Sun-related Behaviours [workshop
report]. 20(2):96–100.
Lees, Ronald EM
Pickett W, King WD, Faelker T, Lees REM, Morrison HI,
Bienefeld M. Suicides among Canadian farm operators.
20(3):105–10.
Spasoff, Robert A
Spasoff RA. Social determinants of health [book review].
20(4):158.
Liu, Shiliang
Liu S, Wen SW. Development of record linkage of hospital
discharge data for the study of neonatal readmission.
20(2):77–81.
Stephens, Thomas
Stephens T, Dulberg C, Joubert N. Mental health of the
Canadian population: a comprehensive analysis.
20(3):118–26.
Lovato, Chris
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48
Chronic Diseases in Canada
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Wen, Shi Wu
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Wilkins K, Parsons GF, Gentleman JF, Forbes WF. Deaths
due to dementia: an analysis of multiple-cause-of-death
data. 20(1):26–35.
49
CDIC: Information for Authors
Chronic Diseases in Canada (CDIC) is a peer-reviewed
scientific journal published four times a year. Contributions
are welcomed from outside of Health Canada as well as
from within this federal department. The journal’s focus is
the prevention and control of non-communicable diseases
and injuries in Canada. This may include research from
such fields as epidemiology, public/community health,
biostatistics, behavioural sciences and health services.
CDIC endeavours to foster communication among public
health practitioners, chronic disease epidemiologists and
researchers, health policy planners and health educators.
Submissions are selected based on scientific quality, public
health relevance, clarity, conciseness and technical
accuracy. Although CDIC is a Health Canada publication,
authors retain responsibility for the contents of their papers,
and opinions expressed are not necessarily those of the
CDIC Editorial Committee or of Health Canada.
Feature Articles
Most feature articles are limited to 4000 words of text
(excluding abstract, tables, figures and reference list) in the
form of original research, surveillance reports, metaanalyses, methodological papers, literature reviews or
commentaries. The maximum text length for Short Reports
is 1200 words.
Under normal circumstances, two other types of feature
articles (both 3000 words maximum) will be considered as
submissions only from authors within Health Canada:
Status Reports describing ongoing national programs,
studies or information systems of interest to chronic disease
researchers and public health practitioners; and
Workshop/Conference Reports of relevant workshops, etc.
organized or sponsored by Health Canada.
Authors outside of Health Canada may submit reports for
our Cross-country Forum (3000 words maximum) to
exchange information and insights about the prevention and
control of chronic diseases and injuries from research or
surveillance findings, programs under development or
program evaluations.
Additional Article Types
Letters to the Editor (500 words maximum) commenting on
articles recently published in CDIC will be considered for
publication. Book/Software Reviews (500–1300 words
maximum) are usually solicited by the editors. In addition,
the editors occasionally solicit Guest Editorials on specific
topics.
Submitting Manuscripts
Submit manuscripts to the Editor-in-Chief, Chronic
Diseases in Canada, Laboratory Centre for Disease
Control, Health Canada, Tunney’s Pasture, CDIC Address
Locator: 0602C3, Ottawa, Ontario K1A 0L2.
Since Chronic Diseases in Canada adheres in general
(section on illustrations not applicable) to the “Uniform
Requirements for Manuscripts Submitted to Biomedical
Journals” as approved by the International Committee of
Medical Journal Editors, authors should refer to the
Canadian Medical Association Journal 1997 Jan 15;
156(2): 270–7 for complete details (or at
<www.cma.ca/publications/mwc/uniform.htm>).
Each submission must have a covering letter signed by all
authors that identifies the corresponding author (including
fax number) and states that all authors have seen and
approved the final manuscript and have met the authorship
criteria of the Uniform Requirements.
The covering letter should also include a full statement
regarding any prior or duplicate publication or submission
for publication. Written permission from anyone mentioned
by name in the acknowledgements should appear at this
time. Suggestions for appropriate peer reviewers are
appreciated as well.
Manuscripts may be submitted in either English or French
and will be published in both languages, if accepted.
Submit four complete printed copies of a manuscript,
double-spaced, on standard-sized paper with one-inch
margins. Each section (i.e. title page, abstract and key
words, text, acknowledgements, references, tables and
figures) should begin on a separate, numbered page.
If a manuscript is accepted for publication, send the final
hardcopy version with the accompanying text file in
WordPerfect or ASCII, in IBM-compatible format,
specifying the software version.
Abstract and Key Words
An unstructured abstract (one paragraph, no headings) not
exceeding 150 words (100 words maximum for Short
Reports) must accompany each manuscript with three to
eight key words noted below, preferably from the Medical
Subject Headings (MeSH) of Index Medicus.
Tables and Figures
Tables and figures should be as self-explanatory and
succinct as possible. They should not simply duplicate the
text, but should illuminate and supplement it, and they
should not be too numerous. Place them on separate pages
after the references, numbered in the order that they are
mentioned in the text.
Provide explanatory material for tables in footnotes,
identifying the table footnotes by lower-case superscript
letters in alphabetical order.
Figures must be limited to graphs or flow charts/templates;
we are unable to publish photographic illustrations at this
time. Specify the software used (preferably Harvard
Graphics) and supply raw data (in hardcopy form) for all
graphs. Do not import figures into the text of the
manuscript.
Authors must obtain written permission from the copyright
holder to reproduce or adapt any tables or figures that have
been published previously.
References
References should follow the Vancouver style, numbered
consecutively in the order that they first appear in the text
(identified by numbers in superscript or within parentheses)
and arranged numerically in the reference list. References
cited only in tables or figures should be numbered as above
according to the first mention of the particular table/figure
in the text. Remove any endnote/footnote word-processing
feature used to generate a reference list.
Authors are responsible for verifying the accuracy of
references. The use of references to unpublished
observations/data or personal communications is
discouraged; if used, do not include with numbered
references but in the text in parentheses and obtain
permission for these citations.
Chronic Diseases in Canada
a publication of the
Laboratory Centre for Disease Control
Health Protection Branch
Health Canada
Editor-in-Chief ............................ Lori Anderson
Scientific Editor ....................... Christina J Mills
Associate Scientific Editor ............. Gerry B Hill
Associate Scientific Editor ........ Stephen B Hotz
Associate Scientific Editor .......Robert A Spasoff
Desktop Publisher ................... Robert Friedman
CDIC Editorial Committee
Donald T Wigle, Committee Chair
Environmental Health Directorate
Health Canada
Jean-François Boivin
McGill University
Jacques Brisson
Université Laval
Chronic Diseases in Canada (CDIC) is a quarterly scientific journal
focusing on current evidence relevant to the control and prevention of
chronic (i.e. non-communicable) diseases and injuries in Canada.
Feature articles may include research from such fields as epidemiology,
public/community health, biostatistics, behavioural sciences and health
services. Scientific articles are peer reviewed. The journal publishes a
unique blend of public and private sector authors, with information for
authors in every issue. Subscription is available free upon request.
Authors retain responsibility for the contents of their papers, and
opinions expressed are not necessarily those of the CDIC Editorial
Committee or of Health Canada.
Neil E Collishaw
Physicians for a Smoke-Free Canada
James A Hanley
McGill University
Clyde Hertzman
University of British Columbia
C Ineke Neutel
Élisabeth-Bruyère Research Dept
Sisters of Charity of Ottawa Health
Service Inc.
Kathryn Wilkins
Health Statistics Division
Statistics Canada
When submitting change of address,
please enclose your old address label.
Mailing Address:
Chronic Diseases in Canada
Telephone:
Editor-in-Chief
Scientific Editor
Circulation
Fax
Laboratory Centre for Disease Control
Health Canada, Tunney's Pasture
Address Locator: 0602C3
Ottawa, Ontario K1A 0L2
(613) 957-1767
(613) 957-2624
(613) 941-1291
(613) 952-7009
Indexed in Index Medicus/MEDLINE, PAIS
(Public Affairs Information Service) and
EMBASE, the Excerpta Medica database
This publication can also be accessed electronically on the World Wide Web site
of the Laboratory Centre for Disease Control at <http://www.hc-sc.gc.ca/hpb/lcdc>.

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