Public Health Epidemiology in Ontario and Statistics Canada – Opportunities / Challenges / Questions

1. Public Health Epidemiology in Ontario and Statistics Canada – Opportunities / Challenges / Questions Michael Wolfson Statistics Canada October 15, 2007

2. Statistics Canada Provides: • a wide variety of data • geographic data infrastructure • various summary indicators • analytical studies and reports • record linkage capacity • simulation modeling tools

3. (ont web site) (http://www.health.gov.on.ca/transformation/providers/information/im_resources.html)

4. Ontario Government Tools • “The Health Analysts Toolkit” • “Ontario Health Planning Survey Guide” • “Ontario Health Planning Data Guide” • produced by Health Systems Intelligence Project of the Ontario MOHLTC – Jan 2006 • provides an excellent review of many data sets, including those from Statistics Canada

5. Champlain LHIN - Map

6. Champlain / NW LHINs - Pop

7. Champlain LHIN - SES

8. Champlain LHIN - HS

9. Champlain LHIN - RFs

10. Champlain LHIN - Chronic

11. Definitions • cross-sectional survey (CCHS etc.) • provides a “snapshot” of a population at a certain point in time • longitudinal survey (NPHS) • surveys the same group of people repeatedly over time • provides dynamic information on the “trajectories” followed by a population • Permits examination of cause-effect relationships

12. CCHS “.1’s” – Objectives • Support pan-Canadian health surveillance • nationally-comparable population health data for provinces and health regions • Support health research on small populations and rare characteristics  • Make information readily available to a diversified user community in a timely fashion • Offer a flexible survey instrument, including a rapid response option for emerging issues

13. CCHS “.1” Design • large sample: originally ~ 130,000 respondents per year, every other year • Stratified to produce estimates for sub-provincial health regions, provinces, territories & Canada • Residents of private households aged 12+ • mix of personal and telephone interviews • Interview of 40-45 minutes • broad range of content

14. CCHS “.1’s” – Content • household basics – demography, SES • common content (30 minutes) • asked of all respondents • Core content (20 minutes) included in questionnaire every year • Theme content (10 minutes) rotates according to consensus-based long-term plan • optional content (10 minutes)

15. CCHS “.1” Example Results - Smoking

16. Example of optional content selection CCHS 2.1

17. Example of optional content selectionCCHS 2.1 (cont’d)

18. CCHS “.1” - Survey Redesign • Continuous collection • started in Jan. 2007 • ~65,000 respondents per year, every year • non-overlapping 2-month collection periods • Questionnaire / Content • Common content split into theme and core content • Long-term plan for theme content • Maintain optional content • Capacity to include a maximum of 2 min. of extra content “on the fly” (Rapid Response) • Data will be available more often • Annual data release

19. CCHS “.1” Theme Content Long-term plan Rapid Response - $ (max of 2 minutes)

20. CCHS “.2” – Objectives • (originally in intervening years) • support in-depth research on specific topics or themes • cycle 1.2 (2002) → Mental Health and Well-being • cycle 2.2 (2004) → Nutrition • (cycle 3.2 → CHMS) • cycle 4.2 (2008) → Healthy Aging • provincial level (only) detail

21. CCHS Cycle 1.2 (2002) Mental Health & Well-being – Objectives • estimate prevalence in the general population of selected mental health disorders • provide information on the utilization of mental health services and perceived health needs • provide data on the disability / impact associated with mental health problems to both individuals and society • examine links between mental health and social, demographic, geographic and economic characteristics

22. CCHS Cycle 1.2 (2002) – Design • Target population: • persons aged 15+ living in private dwellings in the ten provinces (excludes territories) • Sample size ~37,000 respondents • Personal interview • limited (14%) telephone follow-up • telephone, non-proxy only • Five mental health disorders assessed • major depression, mania disorder, panic disorder, social phobia and agoraphobia • as well as alcohol and illicit drug dependence • Supplement on Canadian Forces • also assessed GAD and PTSD • active members and reserves

23. Alcohol use & dependence Chronic Conditions Distress Eating troubles Gambling General health Height & weight Illicit drug use & dependence Medication use Physical activities Psychological well-being Restriction of activities Services Social support Spirituality Stress Two-week disability Work stress Screening (diagnostic modules) Depression Mania Panic disorder Social phobia Agoraphobia Administration Income Labour force Socio-demographics CCHS 1.2 - Mental Health & Well Being

24. Results from the CCHS Cycle 1.2 (2002) - Measured Mental Disorders or Substance Dependence / Past 12 Months

25. CCHS Cycle 2.2 (2004) Nutrition – Objectives • estimate the distribution of usual dietary intake • in terms of food groups, dietary supplements, nutrients and eating patterns through a dietary recall computer application • for a representative sample of Canadians at provincial and national levels • measure the prevalence of household food insecurity among various population groups in Canada • gather anthropometric measurements • body height and weight • collect correlate information • physical activity • selected health conditions • socio-demographic characteristics

26. CCHS Cycle 2.2 (2004) Nutrition – Design • Target population • persons of all ages living in private dwellings in the ten provinces (excluding the territories) • Sample size ~35,000 • 1/3 of respondents asked second dietary recall to provide information on usual intake • personal interview for the 1st interview • telephone interview for the 2nd recall interview • Stratified by 10 provinces and 15 age-sex groups corresponding to Dietary Reference Intake groupings

27. Food consumption 24-hour dietary recall USDA Automated Multiple Pass Methodology Modified for Canadian marketplace All foods and beverages 5 steps - improve chances of recalling all foods eaten Quick List Forgotten Foods Time and Occasion Detail Cycle Final Probe 2nd interview 10,000 of 35,000 respondents 24-hour recall only Other topics Alcohol Consumption (age 12+) Children’s Physical Activity (age 6 to 11) Chronic Conditions (all) Fruit and Vegetable Consumption (age 6 mo.+) General Health (age 12+) Household Food Security (all) Measured Height and Weight (age 2+) Physical Activity (age 12+) Sedentary Activity (age 12 – 17) Self Reported Height and Weight (10% sample, age 18+) Smoking (age 12+) Vitamin and Mineral Supplements (all) Women’s Health (women age 9+) Socio-Demographics (all) Labour Force (age 15 – 75) Income (all) CCHS Cycle 2.2 (2004) Nutrition – Content

28. Results from CCHS Cycle 2.2 (2004) % above upper end of recommended range of total calories from fat, by age group and sex, population aged 4+, Canada excluding territories 2. Significantly different from estimate for previous age group of same sex (p < 0.05) Notes : Estimates of energy intake include calories from alcoholic beverages. Based on usual consumption. Excludes women who were pregnant or breastfeeding. E = use with caution / F = too unreliable to be published Data source : 2004 Canadian Community Health Survey: Nutrition

29. Results from CCHS Cycle 2.2 (2004) distribution of BMI, population aged 12 to 17, Canada excluding territories, 1978/79 and 2004

30. CCHS Cycle 4.2 Healthy Aging Objectives • factors, influences and processes that contribute to healthy aging • health, social and economic determinants Design • respondents aged 55+ • sample size – to be determined • collection July 2008 to May 2009 • computer Assisted Personal Interview (CAPI) • possible link to CLSA / longitudinal survey

31. Health Services Access Survey (HSAS) • Fill gap in “Quality of service” indicator area • Access to 24/7 first contact health services • Waiting times for key diagnostic and treatment services • HSAS 2001 • Collected as follow-up supplement to CCHS (.1) • 14,210 respondents • representative national-level estimates • sample buy-ins (P.E.I., Alta., B.C.) • HSAS 2003 & 2005 • Integrated in CCHS (.1): sub-sample of 32,000+ respondents • representative provincial-level estimates • HSAS 2007 • CCHS (.1) 2007 annual theme • Asked of a sub-sample of 32,000+ respondents • Future uncertain….

32. Joint Canada / United States Survey of Health (JCUSH) - Objectives Objectives • Examine Canada-US differences in health status and use of health care services • Identify possible areas for collaboration in questionnaire design / development Design • Conducted jointly by Statistics Canada (STC) and the National Center for Health Statistics (NCHS) • Target population 18+ in private dwellings • Collection: fall 2002 to spring 2003 • All interviews by telephone, conducted from STC regional offices • Sample size ~3,500 Canada / ~5,200 US • Standard approach across both countries

33. Canadian Health Measures Survey (CHMS) – Background • high-priority topics – e.g. environmental toxins, metabolic syndrome, physical fitness, other CHD risk factors – can only be assessed through direct physical measures • other high priority health information collected through self-report surveys or administrative records is subject to reporting error – e.g. obesity, hypertension • directly measured attributes can be measured more precisely / reported on continuous scales

34. CHMS – Objectives • estimate the numbers of individuals in Canada with selected health conditions, characteristics, and elevated levels of major risk factors • estimate the distributional patterns of selected diseases, risk factors and protective characteristics • monitor trends, based to the extent possible on available historical data • ascertain relationships among risk factors, protective behaviours, and health status • explore emerging public health issues and new measurement technologies • assess the validity of prevalence estimates based on self- and proxy-reported information • collect a nationally representative sample of genetic material and other covariates for future genetic research • provide a potential platform and infrastructure for ongoing physical measures surveys and add-on studies • share our experience with others

35. CHMS – Parameters • combination of household interview + direct measures completed in mobile exam clinic • national estimates, n = 5,000 over 2 years • atypical sample design – 15 clusters selected from 97% of population (due to cost, logistics) • Ages 6-79 (6-11, 12-19, 20-39, 40-59, 60-79) • 2007-2009 in the field

36. National Population Health Survey (NPHS) – Objectives • Support research into the dynamic processes of health • Provide data for analytical studies that will assist in understanding the determinants of health • Evaluate the relationships between socio-economic and demographic characteristics of individuals with their health status and its evolution over time • Aid in the development of public health policy

37. NPHS – Household Component • Main component of NPHS • persons in private households in the ten provinces • first cycle in 1994-95 → every two years • Cross-sectional sample • served cross-sectional purposes: 1994, 1996, 1998 • subset of questionnaire – all members of household • detailed health information – selected household respondent • Longitudinal sample • same selected household respondent revisited each cycle • 17,276 respondents initially • detailed health information from selected respondent • socio-demographic information on household each cycle • including household composition, income, education

38. NPHS – Other Components • Intended to complement main NPHS household component • Institutions component • Residents of long-term care institutions (4+ beds) in the ten provinces • 5 cycles of data: 1994-95 → every two years to 2002-03 • Sample ~2,200 respondents → national level data • High mortality: ~1/3 of respondents each cycle • North component • Household residents in each territory • 3 cycles of data, 1994-95 → every two years to 1998-99 • Sample ~2,000 respondents → territorial level data • Territories covered by the CCHS “.1’s” since 2000

39. Cross-sectional vs longitudinal findingsShift work and the health of males . Longitudinal results: Working shift was associated with increased health risks over time. Working a non-standard schedule in 94/95 was predictive of developing chronic diseases over the next 4 years. Cross-sectional results: The odds of having been diagnosed with a chronic disease did not differ for men who worked shift compared with those working a regular daytime schedule N. B. bars represent 95% confidence intervals; colour change occurs at mean relative risk Source: NPHS

40. Some Other Survey Data Sets • population census – disability screener • major surveys • HALS / PALS – Health / Participation and Activity Limitations Surveys (post-censal) • NLSCY – National Longitudinal survey of Children and Youth • related surveys • SHS/FAMEX – Survey of Household Spending, formerly FAMily EXpenditure survey • GSS – General Social Survey

41. Cancer Registration In Canada • Originated at varying times across country Provincial level 1st : 1935 BC & Sask • NCIRS: 1969 - 1991 at Statistics Canada • 1992 : CCR established – new standards

42. CanadianCancer Registry (CCR) Key Features • Reference Year - 1992 • Person Oriented Data Set - Person & Tumor Records - Data Definitions/Standards • National Coverage • Internal Duplicate Protocol • CMDB Linkage & Clearance

43. CCR: How it is used • Calculate cancer incidence and survival statistics • Occupational, environmental and other medical follow-up studies • Production of the Canadian Cancer Statistics monograph • Research programs i.e. tobacco control, product safety, workplace health and safe environments • Assess the impact of new technologies and treatments

44. self health a 5

45. self health b 6

46. type of smoker ecumen map cchs type of smoker ecumene map

47. An Almost Familiar World Map www.worldmapper.org; cartogram algorithm: Mark Newman

48. Area Proportional toPopulation

49. Area Proportional toGDP 2002

50. Area Proportional toHIV(prevalence ages 15 – 49)