Canada Health Survey should provide useful information if carefully used DAVID WOODS What if somebody did a survey of Canadians' health status? Not one of those empirical things where we're told we're too fat, or pop too many pills, or where that infuriating 60-year-old Swede who's fitter than a 30-year-old Canadian is again trotted out for our admiration, but a really hard, statistical analysis of the nation's health. Well, it's under way. Operating out of appropriately Spartan quarters in the Ottawa suburbs is something called Canada Health Survey, Enqu&e Sante Canada. A joint venture of the Department of National Health and Welfare, which funds it to the tune of $700 000 a year and of Statistics Canada which (presumably preferring to deal in even rounder numbers) contributes $1 million, CHS is already analysing the results of a pretest of health status conducted in Peterborough last year. By next year, a huge sampling will have been undertaken of the national population's health status, and the results should have considerable impact on future health care planning and delivery. Better data How did this seemingly ambitious project come about? The reasons put forward in a CHS overview appear compelling enough: "Response to widespread demands for better data on health status, especially on self-limiting and self-treated conditions and their consequences. Health status data now available have been termed inadequate in coverage and content as existing methods have tended to focus on collecting data on treated problems rather than untreated morbidity, positive health parameters or risk exposure among the population at large... Development work began in November 1975 with, appropriately, the De-
partment of National Health and Welfare concerning itself mainly with the "whats" of the survey, and Statistics Canada with the "hows". Decisions about content of the survey have come about through consultation with health officials, and the topics are wide-ranging and relevant. So far as method is concerned, the idea is to conduct 40 000 interviews each year "proportional to the square root of provincial populations." Peterborough trial A trial run of the survey was conducted last July and August in Peterborough Ont, that "average", "typical" Canadian city which has become a mecca for market testers and whose citizens must surely have yielded up more of their facts and fancies to analytical scrutiny than any others anywhere in the world. In any event, the response rate of 86% from 262 households in the CHS pretest was creditable and provided the surveyors with helpful insights. Next month another stage of the survey, involving 744 households in three provinces, will begin. The last time a comparable national project was undertaken was the Canadian Sickness Survey in 1951. The very name of this new venture - Canada Health Survey - indicates its difference in approach and emphasis. While the 1951 survey looked at ill health, disease care patterns, and expenditures (well before the advent of universal medicare in Canada) on hospital and other health services, the CHS will examine both positive and negative aspects of health. The Canada Health Survey will, for example, concern itself with risk factors, with health status of well people and with patterns of use of the health care system. Further, the CHS will be a continuous, open-ended project; the CSS sur-
1302 CMA JOURNAL/JUNE 4, 1977/VOL. 116
vey was conducted over a 12-month period. As Thomas Stephens, PhD, director of the new survey's content and analysis division, puts it: "A fundamental theme of (CHS) planning has been to focus on collecting useful information and in making it available to users." Not that Stephens dismisses the parent survey. "The CSS," he says, "had credibility and usefulness ... people still quote their findings. But what's become clear since those findings were made available, he believes, and even more so since publication of federal Health and Welfare Minister Marc Lalonde's "A New Perspective on the Health of Canadians", is that there's a crying need for hard data about health; that's one reason why the CHS will be interviewing people in their own homes rather than simply flipping through medicare records. Such records, says Stephens, obviously show only those people who have actively sought out medical care. The CHS, he says, will be measuring such hard-to-define factors as fitness and psychological wellbeing; moreover, he points out, the continuous nature of the new survey will allow for comparisons over time: are we as a nation getting healthier or less healthy? Naturally, the 35 people from a variety of disciplines who make up the CHS working team would hope that the information they collect will translate eventually into improved health for Canadians - although they are not noticeably evangelic about the work they're doing. But if they are able to uncover worthwhile information about the various kinds of health risks, and about how those risk factors are distributed throughout the population, appropriate preventive measures should be initiated not only by individuals, but by com-
munities, provinces and perhaps nationally. Returning to the trial run in Peterborough, Tom Stephens says that this was really an attempt to get the machinery of the survey in working order. For this reason, the 262 households were surveyed only for their occupants' physical condition and fitness readings and to iron out the whole business of statistical validity. The more sophisticated testing involving lifestyle and mental health data will be brought into the next phase of the survey beginning this summer. So the Peterborough survey, conducted by local nurses, was mainly a trial of survey procedures; even so, the information gleaned about height and mass and blood pressure will have some relevance. Relevance, Stephens emphasizes, is what the CHS is all about. While noting that "we're just the people who collect the information" he says that none the less there is continuing contact with the health system planners ... getting them to say what they need to know in order to do a better job. With the lifestyle data for instance, it is going to be possible to find out not only who smokes, but what they smoke and whether or not they inhale; with medications, are they being taken independently or on a physician's advice; who bothers to get his blood pressure checked voluntarily? The data that finally emerge will provide a geographic, demographic breakdown for study and for action. The "whos" and the "wheres" will be added to the "whats" and "hows" as it is discovered whether lifestyle patterns predominate in men or women, rich or poor, Albertans or Ontarians. The Peterborough survey did not say much about people's willingness to embark on healthier lifestyles, but it spoke volumes about wholehearted acceptance of, and cooperation in, surveys of this kind; unless, of course, the burgers of Peterborough have given up all resistance to repeated enquiries about their various proclivities. In any event, only 5% of those asked actually refused to take part. The remaining 13% of nonrespondents were simply unavailable for questioning. If the response rate is as strong nationally, the CHS computers will indeed be able to produce what Stephens calls "quality information" not only to the people surveyed, but to health workers, health planners and health researchers; the latter, particularly, may be about to be offered a goldmine of statistical data to work with. Another virtue claimed for the CHS is its flexibility: if the survey continues indefinitely - as present plans call for -it will be possible to tailor it
to changing informational needs, to add and subtract information and to survey subsections of the main questionnaire, providing details on, say, cardiovascular risk. Eventually, says statistician and survey manager John Coombs, CHS will conduct surveys in 1000 households a month. Each will be in two phases: an interviewer-administered questionnaire on health matters and a self-administered one on lifestyle and behaviour patterns. At the second interview a surveyor will collect the self-administered questionnaire and, if it is from a designated household, conduct the various physical tests called for. You might ask what all of this has to do with the practising physician; after all, if the survey points up that we are indeed an overfed, overweight, overmedicated, underexercised people, so what? Just having that information (and we have it right now) is not going to change anything. Tom Stephens says that MDs will become consumers of the CHS output. They will be able to place the individual patient into an age/occupation/risk category, to compare that patient's cholesterol level, say, with national levels and to engage in preventive medicine by education and motivation. Since each individual surveyed will get a readout of his own health status he will be able to go to his physician to take appropriate therapeutic or preventive action. "A massive annual checkup for certain broad parameters of health," is the way Stephens describes it. Dr. John Bennett, director of scientific councils for the CMA, says organized medicine's involvement in the CHS began 2 years ago when the survey people invited the association to nominate a medical adviser. The CMA named Dr. Jack Kilgour, medical director for the Metropolitan Life company. "We at the CMA," says Bennett, "gave our blessing to the CHS project, and Kilgour sat down wih the survey people to help develop a protocol. He also had a hand in the trial run at
Peterborough, where the CMA saw to it that the local medical profession was briefed about what was going on there." Before cooperating with the CHS, the CMA understandably wanted to satisfy itself about certain questions. The association invited survey personnel to make a presentation to its Council on Community Health. Was this just another government make-work project? How would the collected information be applied and who would have access to it? Then concern was expressed about how truthful the answers would be to such survey questions as "how much alcohol do you drink?" While the CMA agreed that the Peterborough trial was a success in terms of response, the association has a residue of concern, says Dr. Bennett, about the use the data will be put to. He hastens to point out that this stems not from a feeling that there are Orwellian Big Brother motives behind it all, but that there may be misuse of the data or misinterpretation or overreaction to some of the findings. Asked if anything new is likely to emerge from the CHS, Bennett says, "Who knows at this stage? But if any thing comes out it will be to show people they are unhealthy (as opposed to sick)." He agrees with Tom Stephens that survey data will help the physician in his educational work with patients and give him some hard facts to work with. "The MD," says Dr. Bennett, "will be on firmer ground in showing patients they will benefit from a change in lifestyle, that inhaling clean air is better than breathing smoke-filled air or that cross-country skiing is preferable to slumping in front of a television set." Dr. Bennett concludes that, with the provinces being forced to pick up the health care tab, new ways will have to be found to reduce costs by focusing on preventive medicine. Despite its modest budget and its modest offices, the Canada Health Survey could very well achieve that farfrom-modest goal. And help us to reach the healthy status of that 60-yearold Swede in the process.E
CCHA REPORT continued from page 1300 Kellogg Foundation, was completed by the CCHA in 1976. "This project has already had a major impact on the health field in Canadian hospitals," states the report. "Effective for all surveys of general hospitals commencing in January, 1977, standards have been revised to require that hospitals be able to show proof that they have a well-structured system of continuing patient care appraisal if
they are to gain accreditation for 3 years." The CCHA in 1976 conducted its first surveys of an ambulatory care centre for emotionally disturbed children and of alcohol treatment centres. Also the largest surveyors' conference ever was held in March, 1976. The report explains the increased cost of conducting an improved surveyors' conference is included in the 1977 budget and is one factor in the necessary increases in fees to hospitals and member associations. U
CMA JOURNAL/JUNE 4, 1977/VOL. 116 1303
partment of National Health and Welfare concerning itself mainly with the "whats" of the survey, and Statistics Canada with the "hows". Decisions about content of the survey have come about through consultation with health officials, and the topics are wide-ranging and relevant. So far as method is concerned, the idea is to conduct 40 000 interviews each year "proportional to the square root of provincial populations." Peterborough trial A trial run of the survey was conducted last July and August in Peterborough Ont, that "average", "typical" Canadian city which has become a mecca for market testers and whose citizens must surely have yielded up more of their facts and fancies to analytical scrutiny than any others anywhere in the world. In any event, the response rate of 86% from 262 households in the CHS pretest was creditable and provided the surveyors with helpful insights. Next month another stage of the survey, involving 744 households in three provinces, will begin. The last time a comparable national project was undertaken was the Canadian Sickness Survey in 1951. The very name of this new venture - Canada Health Survey - indicates its difference in approach and emphasis. While the 1951 survey looked at ill health, disease care patterns, and expenditures (well before the advent of universal medicare in Canada) on hospital and other health services, the CHS will examine both positive and negative aspects of health. The Canada Health Survey will, for example, concern itself with risk factors, with health status of well people and with patterns of use of the health care system. Further, the CHS will be a continuous, open-ended project; the CSS sur-
1302 CMA JOURNAL/JUNE 4, 1977/VOL. 116
vey was conducted over a 12-month period. As Thomas Stephens, PhD, director of the new survey's content and analysis division, puts it: "A fundamental theme of (CHS) planning has been to focus on collecting useful information and in making it available to users." Not that Stephens dismisses the parent survey. "The CSS," he says, "had credibility and usefulness ... people still quote their findings. But what's become clear since those findings were made available, he believes, and even more so since publication of federal Health and Welfare Minister Marc Lalonde's "A New Perspective on the Health of Canadians", is that there's a crying need for hard data about health; that's one reason why the CHS will be interviewing people in their own homes rather than simply flipping through medicare records. Such records, says Stephens, obviously show only those people who have actively sought out medical care. The CHS, he says, will be measuring such hard-to-define factors as fitness and psychological wellbeing; moreover, he points out, the continuous nature of the new survey will allow for comparisons over time: are we as a nation getting healthier or less healthy? Naturally, the 35 people from a variety of disciplines who make up the CHS working team would hope that the information they collect will translate eventually into improved health for Canadians - although they are not noticeably evangelic about the work they're doing. But if they are able to uncover worthwhile information about the various kinds of health risks, and about how those risk factors are distributed throughout the population, appropriate preventive measures should be initiated not only by individuals, but by com-
munities, provinces and perhaps nationally. Returning to the trial run in Peterborough, Tom Stephens says that this was really an attempt to get the machinery of the survey in working order. For this reason, the 262 households were surveyed only for their occupants' physical condition and fitness readings and to iron out the whole business of statistical validity. The more sophisticated testing involving lifestyle and mental health data will be brought into the next phase of the survey beginning this summer. So the Peterborough survey, conducted by local nurses, was mainly a trial of survey procedures; even so, the information gleaned about height and mass and blood pressure will have some relevance. Relevance, Stephens emphasizes, is what the CHS is all about. While noting that "we're just the people who collect the information" he says that none the less there is continuing contact with the health system planners ... getting them to say what they need to know in order to do a better job. With the lifestyle data for instance, it is going to be possible to find out not only who smokes, but what they smoke and whether or not they inhale; with medications, are they being taken independently or on a physician's advice; who bothers to get his blood pressure checked voluntarily? The data that finally emerge will provide a geographic, demographic breakdown for study and for action. The "whos" and the "wheres" will be added to the "whats" and "hows" as it is discovered whether lifestyle patterns predominate in men or women, rich or poor, Albertans or Ontarians. The Peterborough survey did not say much about people's willingness to embark on healthier lifestyles, but it spoke volumes about wholehearted acceptance of, and cooperation in, surveys of this kind; unless, of course, the burgers of Peterborough have given up all resistance to repeated enquiries about their various proclivities. In any event, only 5% of those asked actually refused to take part. The remaining 13% of nonrespondents were simply unavailable for questioning. If the response rate is as strong nationally, the CHS computers will indeed be able to produce what Stephens calls "quality information" not only to the people surveyed, but to health workers, health planners and health researchers; the latter, particularly, may be about to be offered a goldmine of statistical data to work with. Another virtue claimed for the CHS is its flexibility: if the survey continues indefinitely - as present plans call for -it will be possible to tailor it
to changing informational needs, to add and subtract information and to survey subsections of the main questionnaire, providing details on, say, cardiovascular risk. Eventually, says statistician and survey manager John Coombs, CHS will conduct surveys in 1000 households a month. Each will be in two phases: an interviewer-administered questionnaire on health matters and a self-administered one on lifestyle and behaviour patterns. At the second interview a surveyor will collect the self-administered questionnaire and, if it is from a designated household, conduct the various physical tests called for. You might ask what all of this has to do with the practising physician; after all, if the survey points up that we are indeed an overfed, overweight, overmedicated, underexercised people, so what? Just having that information (and we have it right now) is not going to change anything. Tom Stephens says that MDs will become consumers of the CHS output. They will be able to place the individual patient into an age/occupation/risk category, to compare that patient's cholesterol level, say, with national levels and to engage in preventive medicine by education and motivation. Since each individual surveyed will get a readout of his own health status he will be able to go to his physician to take appropriate therapeutic or preventive action. "A massive annual checkup for certain broad parameters of health," is the way Stephens describes it. Dr. John Bennett, director of scientific councils for the CMA, says organized medicine's involvement in the CHS began 2 years ago when the survey people invited the association to nominate a medical adviser. The CMA named Dr. Jack Kilgour, medical director for the Metropolitan Life company. "We at the CMA," says Bennett, "gave our blessing to the CHS project, and Kilgour sat down wih the survey people to help develop a protocol. He also had a hand in the trial run at
Peterborough, where the CMA saw to it that the local medical profession was briefed about what was going on there." Before cooperating with the CHS, the CMA understandably wanted to satisfy itself about certain questions. The association invited survey personnel to make a presentation to its Council on Community Health. Was this just another government make-work project? How would the collected information be applied and who would have access to it? Then concern was expressed about how truthful the answers would be to such survey questions as "how much alcohol do you drink?" While the CMA agreed that the Peterborough trial was a success in terms of response, the association has a residue of concern, says Dr. Bennett, about the use the data will be put to. He hastens to point out that this stems not from a feeling that there are Orwellian Big Brother motives behind it all, but that there may be misuse of the data or misinterpretation or overreaction to some of the findings. Asked if anything new is likely to emerge from the CHS, Bennett says, "Who knows at this stage? But if any thing comes out it will be to show people they are unhealthy (as opposed to sick)." He agrees with Tom Stephens that survey data will help the physician in his educational work with patients and give him some hard facts to work with. "The MD," says Dr. Bennett, "will be on firmer ground in showing patients they will benefit from a change in lifestyle, that inhaling clean air is better than breathing smoke-filled air or that cross-country skiing is preferable to slumping in front of a television set." Dr. Bennett concludes that, with the provinces being forced to pick up the health care tab, new ways will have to be found to reduce costs by focusing on preventive medicine. Despite its modest budget and its modest offices, the Canada Health Survey could very well achieve that farfrom-modest goal. And help us to reach the healthy status of that 60-yearold Swede in the process.E
CCHA REPORT continued from page 1300 Kellogg Foundation, was completed by the CCHA in 1976. "This project has already had a major impact on the health field in Canadian hospitals," states the report. "Effective for all surveys of general hospitals commencing in January, 1977, standards have been revised to require that hospitals be able to show proof that they have a well-structured system of continuing patient care appraisal if
they are to gain accreditation for 3 years." The CCHA in 1976 conducted its first surveys of an ambulatory care centre for emotionally disturbed children and of alcohol treatment centres. Also the largest surveyors' conference ever was held in March, 1976. The report explains the increased cost of conducting an improved surveyors' conference is included in the 1977 budget and is one factor in the necessary increases in fees to hospitals and member associations. U
CMA JOURNAL/JUNE 4, 1977/VOL. 116 1303
