ISBN MR21-36/2002E 0-662-32452-8
This strategic plan was written by Dr. John Frank, Scientific Director, and Erica Di Ruggiero, Assistant Director, CIHR-IPPH, under the guidance of the Institute Advisory Board.
As the CIHR Institute of Population and Public Health's Scientific Director, it is a great privilege to lead this innovative national health organization with a very broad mandate to support research into the complex interactions, which determine health, and its application to improve the health of individuals, communities and global populations. I bring to this role over 25 years of experience as a primary care physician, and a public health researcher and teacher, in a range of settings both nationally and internationally. This background explains my strong commitment to inter-disciplinary partnered research, with close links to those who need to use research results, for improving policies and programs that impact on our nation's health.
At this time, I am very pleased to introduce the Institute's first strategic plan. This document complements the Strategic Directions Outlook issued in June 2001, outlining the main priorities and activities of the Institute in its first year of operation. It is also based on the insights gained during the Institute's consultation sessions with population and public health (PPH) stakeholders across Canada, a review of the strategic plans of international research organizations with similar mandates, and a planning retreat with the Institute's Advisory Board. Although this three-to-five-year strategic plan will be revised and updated annually, it is intended as a guide for Institute activities to be pursued over the longer-term, subject to the periodic approval of the Institute Advisory Board.
The creation of such a plan could not have occurred without the guidance and thoughtful contributions of our Institute Advisory Board members, IPPH staff, as well as the comprehensive feedback from PPH stakeholders during our pan-Canadian consultation tour, conducted in partnership with the Canadian Institute for Health Information - Canadian Population Health Initiative (CIHI-CPHI).
I look forward to working with colleagues in our sister Institutes and other partners to better respond to the needs of population and public health researchers, policy makers and practitioners across the country, and to support the creation and synthesis of existing PPH knowledge, and its timely application into policy and practice. These are indeed exciting times for fostering excellence in health research in Canada.
Warm regards,
John Frank MD, CCFP, MSc, FRCP(C)
Scientific Director, CIHR - Institute of Population and Public Health
Professor, Public Health Sciences, University of Toronto
Senior Scientist, Institute for Work and Health, Toronto
Executive Summary
Part 1 - Institute Scope and Rationale
Part 2 - IPPH's Future Directions: 2002 and Onward
Part 3 - IPPH's Strategic Plan
Part 4 - Management and Evaluation
References
Mission
The CIHR Institute of Population and Public Health (IPPH) will support:
Vision
Canada will be a world leader in inter-disciplinary population and public health (PPH) research and research application, fostering evidence-based policies and programs, and training in the fields of public health, health promotion, and occupational and environmental health. The Institute will also influence, through scientific consultation, the wide range of broader public, voluntary, and private sector activities that profoundly impact on the health of populations.
The Institute of Population and Public Health's strategic research priorities build onthe Strategic Outlook themes published in CIHR's Towards a National Health Research Agenda document. Each strategic research priority is explained in greater detail in the full strategic plan.
- Capacity Building
- Understanding and Addressing the Impacts of Physical and Social Environments on Health
- Analyzing and Reducing Health Disparities
- Environmental and Genetic Determinants of Disease in Human Populations
- Global Health
Capacity Building
Capacity for cutting-edge and relevant PPH research, and for its use by decision-makers, needs to be strengthened, especially in certain regions of the country, by building on Canada's competitive advantages and research niche in PPH. Traditional academic departments are often too isolated from each other, and from PPH policy and program stakeholders, to facilitate integration of the necessary perspectives. Innovative institutional collaborations are required to foster active collaboration between a range of investigators and with PPH research users, and to improve career prospects for the new generation of PPH researchers committed to research and its application. These efforts are essential if the IPPH is to effectively support CIHR's overarching vision of innovative "cross-pillar" research that actually improves the health of Canadians.
Goal
To create, with the Institute's partners (researchers, research funders and users) novel funding vehicles and collaborations to pursue excellence while addressing particular PPH capacity challenges in Canada, including:
Innovative institutional collaborations are required to foster active collaboration between a range of investigators and with PPH research users, and to improve career prospects for the new generation of PPH researchers committed to research and its application.
Understanding and Addressing the Impacts of Physical and Social Environments on Health
As individuals pass through life's stages, their health is affected by a sequence of "macro- and micro- environments" or "contexts" - both physical and social - such as home/family, daycare/school, workplace/recreation, care-settings (at home and institutional) for the disabled and elderly, "neighbourhood/community", region and society or nation-state levels. Numerous public, private and voluntary sector policies and programs are intended to improve the quality of these environments, but the effects are not always optimal in terms of human health.A major research program, led by the IPPH and partner organizations, will examine the health impacts of such policies and programs, devise improvements that should benefit population health status, rigorously evaluate the effects of those changes, and synthesize this body of knowledge for ease of use by decision-makers.
Goal
To create a trans-disciplinary national network of researchers, policy-makers, program administrators and public health professionals who can identify and study these important social and physical determinants of health and their interactions, and design and carry out interventions to improve critical "life-course-environments", to achieve population-level health benefits.
Analyzing and Reducing Health Disparities
The health status of virtually all populations varies widely across subgroups, defined by socio-economic status, gender, race/ethnicity, geography (e.g. rural/urban/intra-urban), etc. In Canada, many of these disparities in health status are poorly characterized and documented. Other disparities, while documented, have remained largely unchanged over many years. Comprehensive research programs are needed to describe, investigate and especially reduce such disparities. These programs will need to utilize a trans-disciplinary approach, that acknowledges the many possible origins of health disparities, including differences in the biological, socio-economic, physical, and cultural characteristics of populations and their environments, as affected by local policies and programs that impact on health.
Goal
To develop, together with partner organizations such as the Canadian Population Health Initiative of CIHI, other CIHR Institutes, and the National Institutes of Health, Canada's expertise in assessing and addressing disparities in health status across subpopulations - both nationally and globally.
Environmental and Genetic Determinants of Disease in Human Populations
Virtually all of the major diseases affecting industrialized nations are jointly determined by the interaction of our individual genetic endowments, and the complex sequence of environmental factors - physical, chemical, biological and social - to which we are exposed over the life-course. The new knowledge that is emerging from genomic research must be balanced by equally sophisticated assessments of environmental exposures (which generally change over time, unlike an individual's genome), in order to elucidate the full causal pathways leading to disease and premature death. To accomplish these goals, innovative research strategies will be required, and it may be necessary to conduct complex, large and long-term longitudinal studies that integrate these measurements and accurately link them to precisely ascertained health outcomes. Such research will require close collaboration across scientific disciplines.
Goals
IPPH will work with other CIHR Institutes and other stakeholders to:
Global Health
Canada's health status is increasingly affected, like that of many countries, by ecological, technological, economic, political and socio-cultural forces. Understanding these "upstream" global forces, and their health impacts, in this country and others (especially poorer nations) - is essential to ensuring the future health of Canadians. It is also ethically imperative to work on global issues, if we are to act as responsible global citizens.
Goal
To improve Canada's ability to investigate and intervene on those underlying forces that challenge global health, by enhancing, in a sustainable manner, the capacity of national and international researchers and research-users to collaboratively develop and apply global health knowledge for evidence-based public health practice.
The Institute will focus on "what we can do best with limited resources" (e.g. integrating social/biomedical science perspectives on the origins of global health problems) while collaborating with other CIHR Institutes and funding partners under the Global Health Research Initiative, Health Canada, the Canadian International Development Agency (CIDA) and the International Development Research Centre (IDRC), as well as other partners such as, but not limited to, the Canadian Society for International Health (CSIH), the Social Sciences Humanities Research Council (SSHRC), the Canadian Public Health Association (CPHA), the Association of Universities and Colleges of Canada (AUCC), the Pan American Health Organization (PAHO), the World Health Organization (WHO), World Bank, International Monetary Fund (IMF), and the Department of Foreign Affairs and International Trade (DFAIT.
The Canadian Institutes of Health Research (CIHR) is Canada's major federal funding agency for health research. Its objective is to excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system. CIHR Institutes support individuals, groups and communities of researchers for the purpose of implementing, within its mandate, the objective of the CIHR.
The Institute of Population and Public Health (IPPH) has been created by the Governing Council of CIHR with a very broad mandate, one that is inherently integrative. While there are many national Institutes of Public Health in the world, there appears to be only one "Institute of Population and Public Health". The rationale behind this dual focus is critical to this Institute's strategic plan, since the history of these two fields in Canada is not widely appreciated.
While there are many national Institutes of Public Health in the world, there appears to be only one "Institute of Population and Public Health".
Public Health-The Institute's Role
Public Health's Paramount Role in Communicable Disease Control
Public Health has a proud tradition and track record of communicable disease control (especially in outbreaks, including regulation and inspection of food handling, and water/sewage treatment facilities). Recent evidence in fact suggests that gains in life expectancy over the last century in the developed world are due more to these public health activities than to modern clinical medicine (Centres for Disease Control and Prevention (CDC) Atlanta, 1999).
Less widely known is the continuing need for these same infectious disease control services, because of new and emerging threats to the public's health globally.
Key among the new concerns of infectious disease control experts in Canada are:
The New Public Health
In addition, program and policy developments over the last twenty years have moved public health's mandate beyond this list of traditional "disease surveillance and control" responsibilities to also include initiatives aimed at individuals, families and communities, and a focus on improving the health status of the entire population and reducing inequalities between population groups. Local Public Health Departments across Canada are involved in activities such as:
A number of Public Health Departments are also involved in interventions to address the broad social determinants of health, including health-impact-analysis and advocacy of various income redistribution policies, community development and sustainable development projects, as well as initiatives to promote food security and access to quality, affordable and safe housing.
Consequently, the evidentiary research base for public health practice is now very broad indeed, as reflected above and in the extra-ordinary list of such topics found in the description of the Institute's mandate.
What is lacking in Canada is overall direction and coordination, concerning what research evidence is particularly missing and needed from the world's scientific literature, for public health practice in Canada. The Institute will need to work together with a wide range of partner organizations, including all levels of government responsible for Canadian public health programs and services, to strengthen the capacity for this direction and coordination. From that capacity will flow an ongoing assessment of the current needs of the public health community for scientific knowledge, including the sort of research IPPH and its partners will fund in the future.
Why "Population Health"?
The inclusion of "Population Health" in the Institute's title is no accident. Pioneered in Canada (Mustard & Frank, 1991; Evans, Barer & Marmor, 1994; Frank, 1995; Poland, Coburn, Robertson, Eakin et al., 1998), the term refers to a broad trans-disciplinary approach to understanding the fundamental determinants of human health, especially the interaction of physical and social environments with genetic predispositions, over the life-course, at both individual and community levels, in whole societies . (See diagram below.)
This field has a number of key themes - hypotheses about natural phenomena that it studies:
Theme 1
The ubiquitous social ordering of health status, across many societies, health outcomes, and time-periods, provides an invaluable clue to how human health is determined.
A key feature of investigators working in this field, in line with the long-term policy goal of "reducing social inequalities in health", is an interest in socio-economic gradients as invaluable windows on how health is fundamentally determined (Adler, Boyce, Chesney, Cohen, Folkman, Kahn & Syme, 1994; Amick, Levine, Tarlov & Chapman-Walsh, 1995; Blane, Brunner & Wilkinson, 1996; Syme, 1996; Adler, McEwen & Stewart, 1999; Keating & Hertzman, 1999; Marmot & Wilkinson, 1999; Berkman & Kawachi, 2000). It is the pervasive, persistent and ubiquitous nature of health gradients by socio-economic status, in particular, that makes the case for their importance as clues as to basic processes underlying our health. It is precisely the pan-systemic, multi-body-system nature of the diverse diagnostic entities that demonstrate such gradients that argues so strongly for the influence of social factors on health being mediated by physiological "orchestra-leader" (regulatory) systems in the body, such as psycho-neuroendocrine and psychoneuro-immunologic cascades - as described below. This fundamental insight is common to all the writings cited above, and lies behind a great deal of current health research in Canada, the United States and the United Kingdom.
Theme 2
The macro- and micro- "social environments" around each person all contribute strongly to the social determination of health - but in fact these environments are multiple and nested within each other. These include individual, family, neighbourhood, community, region, and society or nation-state.
Recognition of the importance to the common weal of these nested social structures is not new to social geographers and sociologists. What is new is the recent re-discovery of levels of social aggregation, by social - and other epidemiologists. This has led in turn to their enthusiastic embrace of the idea, and of new biostatistical tools ("multi-level-models") to analyze such complex data in better ways, that can parse out the contribution of factors and their interactions operating at each level, to jointly influence health (Diez-Roux, 1998).
Theme 3
Above the level of individual personal characteristics influencing health, population-level patterns of socio-economic characteristics, especially the degree of inequality in income/wealth/education and perhaps political power in a society, may influence its overall average level of health, in comparison with that of other societies.
This bold hypothesis, still the subject of intense international research efforts to confirm it (Lynch, Davey Smith, Kaplan & House, 2000; Ross, Wolfson, Dunn, Bertholot, Kaplan & Lynch, 2000, Mackenbach, 2002), is generally attributed to Richard Wilkinson of the UK (see Unhealthy Societies: Afflictions of Inequality) (Wilkinson, 1996). Whether or not it proves to be entirely generalizable (what "laws of health determination" are?), this idea has stimulated a whole new approach to public health research, wherein attributes of entire population distributions of risk factors, including socio-economic ones, are linked to average health outcomes at the population level. The approach is strongly reminiscent of the late UK epidemiologist Sir Geoffrey Rose's admonition to "seek the causes of incidence (at the level of populations) rather than the causes of cases (at the level of individuals") (Rose, 1985). Thus, there is renewed interest in social determinants of health, such as income inequality, that can be defined only at the societal level. This interest has spurred social epidemiologists and policy analysts to investigate whether "social capital", "social trust", and other correlates of relative income and wealth equality across populations, help to determine overall health status, and if so, how (Kawachi, Kennedy, Lochner & Prothow-Stith, 1997; Lynch & Kaplan, 1997; Putnam, 2000; Lynch, Davey Smith, Hillemeier, Shaw, Raghunathan & Kaplan, 2001).
Theme 4
Patterns of the influence of social factors over an individual's health status develop incrementally over the life-course. Such a perspective is essential to understanding, and to probably successfully intervening on these factors in order to improve health status.
This insight, concerning the health of a species that, after all, lives over 80 years on average under ideal conditions, may at first sight seem blindingly obvious! However, the integration of such insight into actual research protocols is not so simple, since both the research granting agencies and investigators tend to have much shorter time horizons. However, recent work, especially in the United Kingdom by Barker (1997), and with the unique British Birth Cohorts (Power & Hertzman, 1997; Power & Matthews, 1997), has underscored the inadequacy of short-term studies for fully enlightening us on, for example, the delayed health sequelae of adverse perinatal exposures and early childhood experiences, including the upstream roots of many behavioural and other disease risk factors in late life.
Theme 5
The Biological Pathways that mediate the social influences on our health are very important research priorities, if we are to fully grasp how health is determined and therefore how to intervene to optimize health in our respective societies.
This view is not yet completely agreed upon by all researchers in the field. Lingering doubts remain - particularly among some social scientists. But most researchers in the field feel that failure to integrate in our approach the burgeoning knowledge-base in genetics/molecular biology, neurosciences, immunology and endocrinology, among other key laboratory specialties (Kelly, Hertzman & Daniels, 1997; Sternberg & Gold, 1997; Coe, 1999), can only weaken our potential to help shape health and social policy in the future, so as to benefit the populations whose health we study.
Thus, the CIHR-IPPH is charged with two complementary and intertwined research mandates - to catalyze investigation into the basic determinants of health, as well as into the effectiveness and efficiency of specific public health practices and programs, and broader pan-sectoral policies, that can improve population health status. Obviously, neither of these sorts of investigation can lead to actual improvements in the health of Canadians, unless they are coupled with effective knowledge exchange activities. Our approaches to the latter are outlined, particularly under the strategic area "Capacity Building".
In keeping with the mandate of CIHR, which is "to excel, according to internationally accepted standards of scientific excellence in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products, and a strengthened Canadian health care system", the Institute of Population and Public Health will respond to the population and public health challenges of the 21st century through an effective portfolio of research, capacity building, knowledge translation and strategic partnership activities.
Research
IPPH will support the development of a robust and far-sighted population and public health research agenda, which builds upon Canada's competitive advantages and unique strengths, responds to the needs of policy makers and practitioners, and fosters excellence in the creation of new population and public health knowledge. A focus on population health draws upon established Canadian research strengths in population health determinants - understanding "upstream" forces and their health impacts.
Capacity Building
Our recent discussions with stakeholders across the country underscored the considerable regional disparities in capacity, both in terms of the creation of knowledge and its application. The very uneven nature of research capacity for creating and coordinating the sort of complex inter-disciplinary teams and community/policy-maker/decision-maker partnerships, that are now widely regarded as critical to ensuring high-quality PPH research, was particularly noted. While some of this "uneven playing field" across Canada is specific to regional and provincial/territorial comparisons, it is also evident across topic areas, and academic disciplines (some of the latter - such as the humanities and some social sciences - are far less "connected" to CIHR and to other health disciplines on campuses), as well as across universities within even the traditional "have" provinces.
IPPH, in collaboration with other Institutes and partners such as the Canadian Population Health Initiative (CPHI), will develop funding vehicles such as Research Development Grants and small Research Centre Grants to help "level the playing field" across the country, and strengthen the capacity of researchers, policy makers and practitioners, while continuing to support the pursuit of excellence in PPH research and its application. Fostering inter-disciplinarity and opportunities for knowledge exchange between different disciplines, which need to work in concert to solve complex population and public health problems, will also be a focus of IPPH's capacity building strategies.
The emphasis needs to not only be placed on building the capacity of researchers but also research users, whose ability to effectively apply research to policy and practice has been greatly hampered by insufficient development of the public health service infrastructure in Canada.
IPPH proposes to engage in a dialogue with federal and provincial/territorial partners to heighten awareness of the significant role the public health sector plays in improving the health status of the population as part of Canada's health system. Together, we will develop a concerted action plan to strengthen public health capacity in Canada.
IPPH proposes to engage in a dialogue with federal and provincial/ territorial partners to heighten awareness of the significant role the public health sector plays in improving the health status of the population as part of Canada's health system.
Knowledge Translation
The field of population and public health has a strong history in knowledge translation (or "dissemination" or "diffusion of innovations" as it is more often referred to in the health promotion literature). CIHR defines knowledge translation as "the exchange, synthesis, and ethically-sound application of knowledge - within a complex system of interactions among researchers and users - to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and strengthened health care system". During our consultation sessions, a number of challenges and opportunities related to the synthesis, exchange and transfer of the knowledge acquired through research initiatives were raised. Participants identified three priorities for action:
Through strategic partnerships with the CPHI and other Institutes, and novel funding mechanisms, IPPH will integrate knowledge translation as part of all its activities, involving potential users of research at the earliest stages of research project development, which will ultimately result in health benefits for Canadians.
Our Mission
The CIHR Institute of Population and Public Health (IPPH) will support:
Our Vision
Canada will be a world leader in inter-disciplinary PPH research and research application, fostering evidence-based policies and programs, and training in the fields of public health, health promotion, and occupational and environmental health. The Institute will also influence, through scientific consultation, the wide range of broader public, voluntary, and private sector activities that profoundly impact on the health of populations.
Our challenge is to identify priorities that are trans-disciplinary in nature, and foster a convergence of different disciplinary perspectives, as is normally required to solve population and public health problems.
Our Community
Addressing Canada's population and public health challenges through relevant research, policy and program interventions requires the active involvement and cooperation of many fields of practice, such as occupational and environmental health, and health promotion. A number of fields of practice have in fact contributed to the development of population health sciences. These include the basic sciences (such as various branches of human biology), epidemiology and biostatistics, social sciences, and more recently political science, law, geography and the humanities. Similarly, many disciplines are involved in population and public health research, policy and practice. Our challenge is to identify priorities that are trans-disciplinary in nature, and foster a convergence of different disciplinary perspectives, as is normally required to solve population and public health problems.
Our community consists of researchers, policy makers and practitioners working in academia, government, and non-governmental organizations, at national, provincial/territorial, regional and local levels, all working to improve the health of Canadians. A profile of selected key stakeholders and partners, some of whom were consulted during our recent pan-Canadian consultation tour with the Canadian Population Health Initiative (CPHI) can be found below. A full list of our stakeholders would be very long indeed, but among them we include:
The policy development community of importance to PPH includes representatives from:
Lastly, practitioners include representatives from the following organizations:
Partners
Internal
IPPH is committed to working collaboratively on CIHR cross-institute initiatives to serve the needs of our respective research communities. Examples of cross-cutting initiatives currently being explored by CIHR, where IPPH is involved either as a lead institute or is supporting other Institutes leading in these areas, include but are not limited to: Rural and Northern Health, Environmental Health and Health Disparities. Where possible, common funding vehicles will be employed such as research development and small Research Centre Grants, to build research and knowledge translation capacity.
External
IPPH is exploring a number of partnerships, primarily within the public sector. Collaborative efforts currently underway are briefly highlighted below. We also include our many stakeholders as partners in PPH research and knowledge exchange. Further detail is found under each relevant strategic area.
Canadian Institute for Health Information - Canadian Population Health Initiative (CIHI-CPHI):
Building on the success of a joint pan-Canadian consultation tour in the Fall 2001, IPPH is very pleased to be collaborating with the Canadian Institute for Health Information's Canadian Population Health Initiative to foster and advance a coordinated population and public health research and knowledge exchange agenda in Canada. Opportunities for jointly funding programs are already being explored.
We are pleased to be collaborating with CPHI to establish a mechanism (i.e. Roundtable Meetings) to provide a forum for ongoing dialogue and interface between Health Canada, Statistics Canada, CPHI, IPPH and other interested CIHR Institutes. This roundtable will help identify common research and knowledge-exchange priorities and opportunities for joint funding and collaboration, building on the results of the joint IPPH/CPHI pan-Canadian consultation tour. We hope to also engage other federal departments, such as Environment Canada and Human Resource Development Canada via the Roundtable.
Global Health Partners:
IPPH is pleased to be the lead Institute at CIHR, who along with the International Development Research Centre (IDRC), the Canadian International Development Agency (CIDA) and Health Canada have signed a Memorandum of Understanding (MOU), which provides a framework for working together towards a coordinated global health research agenda, focussing on what Canada does best. In addition to the four MOU partners, non-governmental organizations with a history of working in the global health arena are involved - the Canadian Society for International Health (CSIH) and the Canadian Public Health Association (CPHA), as well as the Association of Universities and Colleges of Canada (AUCC), and our partners in developing countries. Together, these organizations constitute the Canadian Global Health Research Coalition. IPPH's partnership with these and other organizations will be further described in the relevant strategic area section of the plan.
Health Canada:
Forging partnerships with various levels within Health Canada is very much in keeping with the knowledge translation agenda of CIHR and its Institutes. As such, it is critical to ensure that IPPH research priorities are policy-relevant, and that relationships are forged with policy makers to ensure that they are engaged in the formulation of answerable research questions, by the Institute in its new granting initiatives, with positive effects on policy and practice.
Provincial/Territorial Ministries:
We will continue to develop our relationships with Provincial/Territorial Ministries of Health and/or Social Services, to help underscore the importance of addressing population and public health problems from an "upstream" perspective, and to highlight the importance of public health as a critical infrastructure within our health system - one that needs to be bolstered to ensure effective program and policy activity at the regional and local level. We are also very cognizant that a "broad determinants of health" view necessitates the engagement of multiple Ministerial sectors such as environment and labour at all levels of government - federal, provincial/territorial and regional/municipal/local.
Statistics Canada:
We are pleased to be collaborating with Statistics Canada, given our common interest in the development, exploitation and coordination of access to existing databases. During our pan-Canadian consultation tour, researchers expressed the need to gain better access to existing databases, an interest in strengthening their capacity to better utilize Canada's anonymized and linkable databases (administrative and other), and in developing capacity in mixed research methods to fully exploit existing databases. We will explore with Statistics Canada and other interested CIHR Institutes, such as the Institute of Health Services and Policy Research (IHSPR), and partners such as Health Canada and the Canadian Institute for Health Information, the possibility of hosting joint workshops and implementing other capacity-building activities to respond to this expressed need.
It is critical to ensure that IPPH research priorities are policy-relevant, and that relationships are forged with policy makers to ensure that they are engaged in the formulation of answerable research questions.
Association of Workers Compensation Boards of Canada (AWCBC):
In Canada, occupational health, with the exception of employers and employees (which is under federal jurisdiction), is the responsibility of Workers Compensation Boards or Commissions of the provinces. Contact with researchers or research-funding organizations, such as CIHR, is very uneven across Canada but nonetheless significant and growing. The Association of Workers' Compensation Board of Canada, which represents all the boards and commissions across Canada, is strongly promoting the establishment of a national occupational health research agenda.
Through its research committee, AWCBC is committed to developing sustainable linkages with CIHR, notably IPPH, through national or multi-provincial partnership arrangements. Of note, AWCBC hosted a major conference on knowledge transfer in November 2001 and has been very supportive of the Canadian Association of Researchers in Work and Health (CARWH), who are leading the establishment of a national research agenda in work and health for Canada.
Strategic Areas
The following strategic areas are complementary to the corresponding sections of the Strategic Directions Outlook (SDO) issued in June 2001 by the Institute. The SDO outlined the basic rationale for all but one of the following strategic areas (Health Disparities - addressed below), and should be reviewed for this purpose. Goals, objectives and suggested activities are listed for each strategic area below.
Strategic Area 1: Capacity Building
In line with CIHR's Strategic Directions Outlook, IPPH is committed to "Building international leadership through national excellence in health research". However, capacity for cutting-edge and relevant PPH research, and for its use by decision-makers, needs to be further strengthened in Canada, especially in certain regions of the country, by building on Canada's competitive advantages and developing our research "niche" in PPH.
A portfolio of different capacity-building strategies is required to be responsive to the varying needs of researchers, policy makers and practitioners nationally, and to facilitate effective interactions among these players. Approaches to capacity building can range from individually focused activities such as personnel/investigator awards, to supporting the development of teams and networks, to research development grants to develop integrated programs of research and knowledge translation, to the establishment of research infrastructure ranging from small research centres to full-sized institutes. The many traditional university departments relevant to public and population health are, however, often too isolated from each other, and from PPH policy and program stakeholders, to facilitate integration of the necessary perspectives.
Goal
To create, with the Institute's partners (researchers, research funders and users), novel funding vehicles and collaborations to pursue excellence while addressing particular PPH capacity challenges in Canada, including:
Objectives and Activities
1. Increase the Quality and Evolution of Training Opportunities in PPH
2. Strengthen Research Transfer for Public Health Practice (by working together with other stakeholders, such as Provincial/Territorial Ministries of Health and/or Social Services, Health Canada and the Canadian Public Health Association)
3. Support Infrastructural Investments for PPH Research and Its Transfer
4. Assess Research Usage of Population-Based Health Databases in Canada and Develop an Action Plan to Address Identified Gaps (in partnership with IHSPR and other players - Provincial/Territorial Ministries of Health and/or Social Services, Statistics Canada, Health Canada, the Canadian Institute for Health Information -Canadian Population Health Initiative)
Strategic Area 2: Understanding and Addressing the Impacts of Physical and Social Environments of Health
Goal
To create a trans-disciplinary national network of researchers, policy-makers, program administrators and public health professionals who can identify and study these important social and physical determinants of health and their interactions, and design and carry out interventions to improve critical "life-course-environments*", to achieve population-level health benefits.
* These macro- and micro- environments or "contexts", which surround individuals, are both physical and social in nature, and are nested within each other. They include the environments at the individual and family level such as the home, as well as the neighbourhood/community, region, and society or nation-state levels.
Objectives and Activities
1. Support the identification of research needs/gaps/opportunities related to such "life-course environments" (i.e. contexts) and the interventions required to improve them
2. Build national networks to link research, policy makers, program administrators and public health professionals
3. Support consortia of stakeholders to lead national research priority-setting efforts
4. Explore the feasibility of developing collaborative funding mechanisms to support innovative multi-level interventions with interested funding agencies and relevant stakeholders
Strategic Area 3: Characterizing and Reducing Health Disparities
This is a "newly" identified theme by the Institute's Advisory Board based on the pan-Canadian consultations with the Canadian Population Health Initiative. It was therefore not discussed in the Institute's Strategic Directions Outlook issued in June 2001. A brief rationale is provided here for its inclusion in this Strategic Plan.
The health status of virtually all populations varies widely across subgroups, defined by socio-economic status, gender, race/ethnicity, and geography (e.g. rural/urban/intra-urban) across societies. In Canada, many of these disparities in health status are poorly characterized and documented. Other disparities, while documented, have remained largely unchanged over many years. Comprehensive research programs are needed to describe, investigate and especially reduce such disparities. These programs will need to utilize a trans-disciplinary approach, that acknowledges the many possible origins of health disparities, including differences in the biological, socio-economic, physical, and cultural characteristics of populations and their environments, as affected by local policies and programs that impact on health.
It is not surprising that the US, the UK, and other countries, are currently launching new research and policy/program initiatives in understanding and reducing disparities in health status. Whether the particular subpopulations whose health status is being compared are rural/urban, regional, gender-based, or of differing ethno-racial or socio-economic status, there is both a strong intellectual argument and a practical ethical mandate to investigate and act on health disparities.
From a research point of view, it is by the elucidation of the sources of such systematic differences in health that we often obtain the best insights as to how human health is actually determined (as argued in the section - "Why Population Health?"). From the point of view of policy makers and practitioners, paying attention to the health problems of higher-risk communities is both ethically appropriate and good public health practice. In Canada's case, the specific comparisons, which may provide the best insights into the determinants of population health, may well be across socio-economic levels in our society, where large health disparities still exist, more than thirty years after the introduction of universal Medicare. However, there is merit in also studying more systematically, the other sorts of contrasts described above such as geographic and ethno-racial disparities in health, since these may yield powerful additional insights into the origins of Canadians' major health problems.
Goal
To develop, together with partner organizations such as the Canadian Population Health Initiative of CIHI, other CIHR Institutes, and the National Institutes of Health, Canada's expertise in assessing and addressing disparities in health status across subpopulations - both nationally and globally.
[Note: Health Disparities has been identified as a CIHR - wide cross-cutting initiative.]
Objectives and Activities
1. Determine the Best Means of Enhancing Health Disparities Research in Canada, and its Translation into Effective Actions to Reduce Disparities
2. Foster International Collaboration with NIH and other Interested Partners to Enhance the Generalizability of Health Disparities Research, Building on "What Canada Does Best"
3. Build and Sustain a Network of Centres to Support the Transformation from Analysis to Interventions to Address Health Disparities
Strategic Area 4: Environmental and Genetic Determinants of Disease in Human Populations
In applying a broad "determinants of health" perspective to guide Canadian research, the IPPH aims to ensure that the full range of important contributors to the causation of most common causes of ill health in our society are elucidated. Virtually all major diseases and health conditions affecting industrialized nations are jointly determined by the interaction of our individual genetic endowments and their patterns of expression, with the complex sequence of environmental factors - physical, chemical, biological and social to which we are exposed over the life-course.
The new knowledge that is emerging from genomic research needs to be balanced by equally sophisticated assessments of environmental exposures (which generally change over time, unlike an individual's genome), in order to elucidate the full causal pathways leading from health to disease and premature death. To accomplish these goals, innovative research strategies will be required, and it may be necessary to conduct complex, large and long-term longitudinal studies that integrate these measurements and accurately link them to precisely ascertained health outcomes. Such research will require close collaboration across scientific disciplines.
In early 2001, the IPPH and the Institute of Genetics (IG) identified gene-environment interactions as an inter-institutional collaborative focus. Two workshops were held in June and September 2001, involving senior population geneticists and genetic epidemiologists ("the Joint IPPH-IG Core Committee"), to explore how to move forward in this area.
Deliberations at the meetings revealed some of the important inter-disciplinary communication challenges that require attention for these research communities to collaborate effectively. Furthermore, during IPPH/CPHI's cross-country consultation tour, not all population and public health stakeholders understood the merit of pursuing a thematic focus on gene-environment interactions. Thus, the Institute Advisory Board revisited and further developed this concept, which has led to the development of a series of short (less than 1 year), medium (within 2 years) and long-term (2 to 5 years) objectives and activities, aimed at both clarifying and moving this important research area forward.
Goal
IPPH will work with other CIHR Institutes and stakeholders to:
Develop specific Canadian expertise in the genetic, ethical, legal and social (GELS) implications of the new molecular biology, and to explore its policy implications in the context of population and public health (PPH).
[Note: This strategic area has been identified as a CIHR cross-cutting initiative].
Objectives and Activities
1. Develop a short-term, consensus-based approach to select the most promising health outcomes, among the common, largely chronic diseases (e.g. asthma, juvenile and/or Type II diabetes), and disease precursors (e.g. obesity/hypertension/hyperlipidemia) for major epidemiological studies of complex traits and gene-environment interactions, based on strategic advantages for research in Canada
2. Develop a short-term consensus-based approach to facilitate in-depth examination of GELS (genetic, ethical, legal and social) implications of genomics on PPH research and policy
3. Develop a medium-term plan that results in a series of RFAs for research studies related to the combined effects of environmental and genetic factors in PPH
4. Develop a long-term plan to fund the development of research infrastructure to provide leadership and support for this emerging, inter-disciplinary research area
Strategic Area 5: Global Health
Canada's health status is increasingly affected, like that of many countries, by ecological, technological, economic, political and socio-cultural forces. Understanding these "upstream" global forces, and their health impacts - in this country and others (especially poorer nations) - is essential to ensuring the future health of Canadians. It is also ethically imperative to work on global issues, if we are to act as responsible global citizens. Canadian researchers have a long-standing history of contributing to Global Health Research (GHR) that must be further supported and developed. Finally, Canada can learn from low and middle-income countries, particularly concerning health impacts of those broad social and economic policies that can only be studied by comparisons across nation-states over time.
Goal
To improve Canada's ability to investigate and intervene on those underlying forces that challenge global health, by enhancing, in a sustainable manner, the capacity of national and international researchers and research users to collaboratively develop and apply global health knowledge for evidence-based public health practice.
The Institute will focus on "what we can do best with limited resources" (e.g. integrating social and biomedical science perspectives on the origins of global health problems) while collaborating with other CIHR Institutes and funding partners under the Global Health Research Initiative. Partners include Health Canada, the Canadian International Development Agency (CIDA), and the International Development Research Centre (IDRC), as well as other organizations such as, the Canadian Society for International Health (CSIH), the Social Sciences and Humanities Research Council of Canada (SSHRC), the Canadian Public Health Association (CPHA), the Association of Universities and Colleges of Canada (AUCC), PAHO (WHO), World Bank, International Monetary Fund (IMF), and the Department of Foreign Affairs and International Trade (DFAIT).
Objectives and Activities
1. Engage in Global Health Research Coalition activities acting in the capacity of lead CIHR Institute (in collaboration with other Institutes, and MOU partners - IDRC, CIDA and Health Canada, as well as other Canadian and international non-governmental organizations)
2. Support the Strategic Advancement of a Coordinated Global Health Research Agenda in Canada
Management
IPPH's Scientific Director, staff and the Institute Advisory Board in accordance with its terms of reference is responsible for effectively monitoring the implementation of the strategic plan and ensuring appropriate allocation of resources, and facilitating annual updates of the plan, in response to emerging priorities, stakeholder input and other considerations.
Toronto-based IPPH Staff:
John Frank, MD, CCFP, MSc, FRCP(C)
Scientific Director
Erica Di Ruggiero, BSc, MHSc, RD
Assistant Director
Vera Ndaba
Financial/Event Officer
Gail D. Bryant
Executive Assistant
Ottawa-based IPPH Staff:
Michelle Gagnon, BScN, MBA
Senior Associate, Partnerships and Knowledge Translation
Institutes of Population and Public Health and Health Services
and Policy Research
Institute Advisory Board Members:
Dr. Jean-Yves Savoie, PhD (Chair)
Chief Executive Officer
Institut de recherche en santé et en securité du travail
Dr. Nancy Edwards, BScN, MSc, PhD (Vice-Chair)
Associate Professor
Faculty of Health Sciences, University of Ottawa
Dr. Robert Burnham, MD, FRCPC
Director
BC Centre for Disease Control, University of British Columbia
Dr. David Butler-Jones, MD, MHSc, CCFP, FRCPC, FACPM
Associate Clinical Professor
Faculty of Medicine, University of Saskatchewan
Dr. Paul Gully (Interim Health Canada representative)
Senior Director General
Population and Public Health Branch, Health Canada
Dr. Catherine Hankins, MD, MSc, CCFP, FRCPC
World Health Organization
Dr. Clyde Hertzman, MD, MSc, FRCPC
Professor, Department of the Health Care and Epidemiology
Faculty of Medicine, University of British Columbia
Dr. Danielle Laberge, MSc, PhD
Professor
Department of Sociology, University of Québec at Montréal
Dr. John McLaughlin, MSc, PhD, FACE
Head, Henry S. Rosenberg, Division of Epidemiology and Biostatistics
Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto
Dr. John Millar, MD
Vice President
Research and Population Health, Canadian Institute for Health Information
Dr. Annette O'Connor, BScN, MScN, PhD
Interim Director, Clinical Epidemiology Unit
Ottawa Health Research Institute, University of Ottawa
Dr. Lesley Pinder, MD
Family Physician, St. Stephen, New Brunswick
Dr. Christiane Poulin, MD, MSc
Associate Professor
Faculty of Medicine, Dalhousie University
Dr. Leonard Syme, PhD
Professor Emeritus of Epidemiology,
School of Public Health, University of California at Berkeley
Dr. Michael Wolfson, PhD
Assistant Chief Statistician
Analysis and Development, Statistics Canada
Dr. T. Kue Young, MD, CM, MSc, FRCPC, DPhil
Professor
Department of Public Health Sciences, University of Toronto
Evaluation
Being accountable through transparent reporting to our partners and other stakeholders in the population and public health research, policy and practice communities, as well as to the Canadian public, is key to the success of CIHR and its Institutes.
In keeping with the CIHR evaluation plan outlined in A Performance Measurement Framework for the Canadian Institutes of Health Research, IPPH is collaborating with other Institutes and the CIHR Evaluation Branch to develop and implement an evaluation plan to measure and report on its ongoing performance. We are working to ensure that instrument development, data collection, analysis and reporting are undertaken in a cost-effective and consistent manner, to facilitate comprehensive reporting across Institutes, where appropriate.
Following is a preliminary overview of what CIHR is proposing to measure within each outcome category, some of which will be best assessed centrally (e.g. quality of peer review process) whereas others will be more appropriately measured at the level of individual Institute(s).
The following measures are simply intended to illustrate what CIHR plans to measure within each outcome category. They do not yet reflect the evaluation plan of Institutes. More refined measures, indicators and data sources are being determined by IPPH, in collaboration with the IAB, other Institutes and the CIHR Evaluation Branch.
Measures of Outstanding Research Productivity
Examples:
Measures of People/Research Capacity - our contribution to increasing the number of trained and highly capable researchers and other research professionals in the PPH field. Examples:
Measures of Partnerships and Public Engagement -our role in developing and sustaining partnerships and linkages with researchers and research organizations, research users such as policy makers and practitioners, as well as the general public. Examples:
Measures of Translation and Use of Knowledge -translation, communication and dissemination of research knowledge, and how this translates in terms of impacts on improved health and health care. Examples:
Measures of Organizational Excellence -coordination role regarding national health research issues, evolutionary and learning nature of the organization and quality of the agency's management and work environment. (Note: this could readily apply at the level of the Institute, which is how the measures are described below). Examples:
Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL.
Socioeconomic status and health: the challenge of the gradient.
American Psychologist 1994;49:15-24.
Adler NE, McEwen BS, Stewart J.
Socioeconomic Status and Health in Industrialized Nations: Social, Psychological and Biological Pathways.
New York: Annals of the New York Academy of Sciences, Volume 896, 1999.
Amick B, Levine S, Tarlov A, Chapman-Walsh D. 1995, Society and Health.
New York: Oxford University Press.
Barker DJP. Fetal nutrition and cardiovascular disease in later life.
Brit Med Bull 1997;53:96-108.
Berkman L, Kawachi I. Social Epidemiology.
New York: Oxford University Press. 2000.
Blane D, Brunner E, Wilkinson R. Health and Social Organization.
London: Routledge. 1996.
Centre for Disease Control. (1999). Ten great public health achievements -United States, 1900-1999.
MMWR. Morbidity and Mortality Weekly Report, 48(12), 241-243
Coe C. Psychosocial factors and psych-neuro- immunology within a lifespan perspective. In Keating DP and Hertzman C (Eds) Developmental Health and the Wealth of Nations.
New York The Guilford Press. 1999, 201-219.
Diez-Roux AV. Bringing context back into epidemiology: variables and fallacies in multilevel analysis.
Am J Public Health 1998;88:216-221
Evans RG, Barer M, Marmor TE. Why are Some People Healthy and Others Not?
Hawthorne, New York: Aldine de Gruyter. 1994.
Frank JW. The determinants of health: a new synthesis from Canada.
Current Issues in Public Health 1995;1:233-40.
Kawachi I, Kennedy BP, Lochner K, Prothow-Stith D/ Social capital, income inequality, and mortality.
Am J Public Health 1997;1491-1498.
Keating D, Hertzman C Developmental Health and the Wealth of Nations.
New York: The Guilford Press. 1999.
Kelly S, Hertzman C, Daniels M. Searching for the biological pathways between stress and health.
Annu Rev Public Health 1997;18:437-462.
Lynch JW, Davey Smith G, Hillemeier, Shaw M, Raghunathan T, Kaplan G. Income inequality, the psychosocial environment, and health: comparisons of wealthy nations.
Lancet 2001;358:194-200.
Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment or material conditions.
BMJ 2000;320:1200-1204.
Lynch JW, Kaplan GA. Understanding how inequality in the distribution of income affects health.
J Health Psych 1997;2:297-314.
Mackenbach J. (2002). Income inequality and population health.
British Medical Journal, 324, 1-2.
Marmot M, Wilkinson R. Social Determinants of Health.
London: Oxford University Press. 1999.
Mustard JF, Frank JW. The Determinants of Health. Canadian Institute for Advanced Research Population Health Program. Toronto:
CIAR Publication # 5, August 1991 (49 pages).
Poland B, Coburn D, Robertson A, Eakin J, et al. Wealth, equity and health care: a critique of the "Population Health" perspective on the determinants of health."
Soc Sci Med 1998;46;785-798.
Power C, Hertzman C. Social and biological pathways linking early life and adult disease.
Brit Med Bull 1997;53:210-221.
Power C, Matthews S. Origins of health inequalities in a national population sample.
Lancet 1997;350:1584-1589.
Putnam R. Bowling Alone.
New York: Simon and Schuster. 2000
Rose G. Sick individuals and sick populations.
International J Epidemiol 1985;14:32-38.
Ross N, Wolfson MC, Dunn JR, Bertholot J-M, Kaplan GA, Lynch JW. Relation between income inequality and mortality in Canada and in the United States: cross-sectional assessment using census data and vital statistics. BMJ 2000; 320:898-902.
Sternberg EM, Gold PW. The mind-body interaction in disease.
Scientific American 1997;7:8-15.
Syme SL. Rethinking disease: Where do we go from here?
Ann Epidemiol 1996;6:463-468.
Wilkinson R. Unhealthy Societies: Afflictions of Inequality.
London: Routledge. 1996.
For further information, please contact:
Canadian Institutes of Health Research (CIHR)
Institute of Population and Public Health (IPPH)
Suite 207-L, Banting Building
100 College Street
Toronto, ON M5G 1L5
416 946-7878 (tel)
416 946-7984 (fax)
