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Care for All: International Framework for Self‑Management Support

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The View: Perspectives on Chronic Disease Prevention and Management. Ottawa: The Conference Board of Canada, 2015.
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REPORT AUGUST 2015
The View.
Perspectives on Chronic Disease Prevention and Management
The View: Perspectives on Chronic Disease Prevention
andManagement
Dan Bilsker, Shahnaz Davachi, Lorrie Lancaster, Sue Mills, and Peter Sargious
(Ed.)
Acknowledgements
The Conference Board of Canada would like to thank the authors for contributing
their articles and for the teamwork involved in ensuring a seamless delivery of
this publication.
The opinions expressed in these articles are solely those of the authors.
To cite this repor t: Bilsker, Dan, Shahnaz Davachi, Lorrie Lancaster, Sue Mills, and Peter Sargious
(Ed.). The View: Perspectives on Chronic Disease Prevention and Management. Ottawa: The
Conference Board ofCanada, 2015.
©2015 The Conference Board of Canada*
Published in Canada | All rights reserved | Agreement N o. 40063028 | *Incorporate d as AERIC Inc.
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CONTENTS
i Preface
Article 1
1 Positive Coping With HealthConditions: Self-Care for Mood Problems in the Context
ofChronic Illness
Article 2
10 Addressing Chronic Disease Through the Social Determinants of Health: TheShifting
Emphasis inAlberta
Article 3
19 Care for All: International Framework for Self-ManagementSupport
Article 4
33 For Healthier Generations
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PREFACE
The View: Perspectives on
Chronic Disease Prevention
and Management
THE VIEW
Perspectives on Chronic Disease Prevention and Management
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Chronic diseases have changed, and will
continue to change, the way we think about
health, wellness, and health care. In 2012,
more than one-half (55 per cent) of Canadians
aged 12years and older reported living with
at least one chronic health condition.1 Nearly
one-quarter of seniors in Canada live with
three or more chronic diseases, accounting for
a significant percentage of the use of health
services among seniors.2 And younger age
groups are living with chronic conditions at
much higher rates than generations before them.
Health and health care in the 21st century is
largely about chronicdisease.
Since 2009, a group of thought leaders from across Canada have
gathered under the umbrella of The Conference Board of Canada’s
Centre for Chronic Disease Prevention and Management (CCDPM) to
share experiences and learn about emerging practices on this important
theme. Chaired by Dr. Peter Sargious, the CCDPM network provides an
invaluable opportunity for members and invited guests to examine key
issues, trends, and approaches to preventing and managing chronic
diseases. In this inaugural issue of The View: Perspectives on Chronic
Disease Prevention and Management, we are pleased to share some of
these insights from a recent meeting focused on self-management.
1 Public Health Agency of Canada, The Chief Public Health Officer’s Report on the State
of Public Health in Canada, 2014, 50. www.phac-aspc.gc.ca/cphorsphc-respcacsp/2014/
assets/pdf/2014-eng.pdf.
2 Ibid., 6.
Louis Thériault
Vice-President, Public Policy
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About the Centre for Chronic Disease Prevention
and Management
Health, health care, and wellness are integral to the research and network
activities at The Conference Board of Canada. The Board’s research hub on
health, the Canadian Alliance for Sustainable Health Care (CASHC), together
with the Board’s executive health networks, including the Centre for Chronic
Disease Prevention and Management, provide opportunities for sharing and
collaboration on issues that impact the quality, effectiveness, and sustainability
of the Canadian health care system.
The Centre for Chronic Disease Prevention and Management (CCDPM)
was designed to confront the pressures that chronic conditions place on our
economy, health systems, individual quality of life, workforce productivity, and
the health of our communities. The CCDPM engaged senior executives from
all levels of government, health and community care organizations, industry,
research institutes, and academia in comprehensive and frank dialogue and
knowledge exchange on issues, innovative solutions, barriers and opportunities
in chronic disease prevention and management. In an effort to build on the
legacy of CCDPM, we have now created the Council for Healthy Living. This
council will engage stakeholders from various sectors and disciplines to enable
knowledge exchange and stimulate collaborative efforts aimed at advancing
strategies for promoting health, better managing chronic diseases, and
improving the quality of life of Canadians.
Peter Sargious MD, MPH, FRCPC
General Internist,
Assistant Dean,
Cumming School of Medicine,
University of Calgary
About the Centre’s Chair
Dr. Peter Sargious is Assistant Dean, Innovation and Development, in the Office
of Continuing Medical Education, Cumming School of Medicine, University of
Calgary. In 2001, Dr. Sargious co-founded Calgary Health Region’s Chronic
Disease Management Portfolio, including the Living Well Program, which offers
thousands of Calgarians support in managing chronic illnesses. Dr. Sargious
THE VIEW
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serves as Executive Lead, Chronic Disease Management, for W21C, a health
system research and innovation centre. Dr. Sargious has been chair of the
CCDPM since its inception in 2009.
Collectively, governments, health professionals, communities, and the
private sector have chronic disease prevention and management on
their radar. Tremendous effort is being directed toward individuals and
populations to prevent and manage chronic diseases. Healthy active
living strategies have been launched and targeted programs, services,
and products developed—all with the goal of encouraging people to
be physically active, eat healthy, take care of their mental health, and
carefully manage any chronic conditions. Key to the success of all of
these efforts is an engaged, educated, and motivated individual.
Self-management can be understood in many ways: from an individual
seeking to understand how to be healthy and fit and prevent illness, to
someone who is coping with a chronic condition and looking for the best
way to manage symptoms and prevent further decline. It is arguably
the most important part of any program, intervention, or treatment that
is designed to help someone prevent or manage a chronic condition.
Atreatment plan for an existing chronic disease is unlikely to succeed
ifthe individual isn’t engaged in setting the plan, implementing it, making
adjustments along the way, and assessing the benefits.
In this issue, we feature four articles that spotlight individual and
population initiatives focused on the self-management of chronic disease
prevention and management.
Dan Bilsker, Clinical Psychologist and Adjunct Professor, Simon Fraser
University, writes about the issue of mood self-management among
individuals coping with chronic illness, and describes an innovative tool,
The Positive Coping With Health Conditions workbook. This workbook is
designed to be an easy-to-use tool for patients who want to improve how
they cope with the mood impacts of their health condition. Dan notes
that self-management tools, such as this workbook, are increasingly
recognized as important in actively engaging individuals in managing
thepsychological issues that can accompany a physical health condition.
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Shahnaz Davachi, Program Lead, Provincial Strategic Coordination,
Primary Health Care, Alberta Health Services, describes her former work
providing culturally and socially appropriate chronic disease prevention
and management services to diverse and vulnerable patient populations
in Alberta. Shahnaz writes that, in Alberta, there has been a movement
to adapt innovative chronic disease management models of care for
ethnocultural, Aboriginal, and homeless populations. Based on research
and experience, she offers a number of steps that health planners
and decision-makers can take to better address the health needs of
vulnerable populations.
Are the current approaches to self-management supports in Canada
appropriate? Are Canada’s efforts reflective of recent international
developments and leading-edge thinking? Sue Mills, Clinical Professor,
School of Population and Public Health, University of BritishColumbia,
explores these questions and more as she describes her work in
helping to develop the International Chronic Condition Self-Management
Support Framework. Sue challenges readers to consider whether current
self-management supports are meeting the needs of disadvantaged and
underserved populations in Canada, and highlights how this framework
can address the current gaps in self-managementprograms.
Lorrie Lancaster, Manager of Communications, Vivo, shares how
a public recreation centre in Calgary is thinking outside the box—
and its walls—to create a new model for Canada’s public recreation
sector. Lorrie describes how Vivo has focused on helping children,
youth, and adults realize their personal best in health through its
Raise the Bar campaign. She shares initial results from the campaign
initiatives, including the Child + Youth Action Research Project and
the Healthy Living School, and suggests that the Vivo model could
shape the future of public recreation in Canada and its role in raising
healthiergenerations.
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ARTICLE 1
Positive Coping With
HealthConditions: Self-Care
for Mood Problems in the
Context of Chronic Illness
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This article provides an overview of the issue
of mood self-management in chronically ill
individuals and describes an innovative tool
for facilitating this kind of self-care. The tool
is aworkbook called Positive Coping with
Health Conditions.
A focus on self-management in chronically ill individuals brings together
three streams of clinical research: an increasing emphasis on chronic
disease management; mounting evidence that chronic physical illnesses
are often associated with mental health problems; and evidence pointing
to supported self-management for mental health problems as a useful
intervention modality.
Chronic Disease Management
Over the last couple of decades, the health care system has increasingly
adopted a chronic disease management (CDM) approach. CDM has
a number of innovative features, such as care delivery through teams
with well-defined roles. One of the essential features is support for self-
management by patients.1 Supporting chronic disease patients’ self-
management means recognizing that ongoing care will inevitably be a
collaborative enterprise. This support also reflects research findings that
patients can improve their own health outcomes.2,3 There has been a
substantial growth in the availability of self-management support groups
for patients dealing with a range of chronic diseases. Most of these
self-management groups have used the self-management framework
developed by Dr. Kate Lorig and her colleagues at the Stanford
University School of Medicine.4
1 Wagner, “Chronic Disease Care.”
2 Jovicic, Holroyd-Leduc, and Straus, “Effects of Self-Management Intervention.”
3 Gibson and others, “Self-Management Education.”
4 Lorig and others, “Effect of a Self-Management Program.”
Dan Bilsker
Clinical Psychologist
Adjunct Professor,
Faculty of Health Sciences,
Simon Fraser University
Clinical AssistantProfessor,
Faculty of Medicine,
University of
BritishColumbia
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In addition to the increasing availability of self-management groups,
there has been a growing expectation that physicians educate and
encourage patients with regard to self-management activities. However,
this expectation has only recently been accompanied by systematic
training in methods for supporting self-management. As noted by Mary
Ann Sevick, “The literature on how to best support self-management
efforts in those with complex chronic diseases is lacking.”5
Chronic Disease and Psychological
HealthProblems
A number of chronic illnesses are associated with elevated rates of
depressive symptomatology. For example, studies of patients with
coronary heart disease have found the incidence of depressive
symptomatology to be as high as 30 to 50 per cent, compared with
a baseline of 15 per cent in the general population.6 It has also been
demonstrated that depression is an important coronary risk factor.
Despite multiple methodological differences from study to study, the data
from prospective adequately powered etiologic and prognostic studies
with objective outcome measures and recognized indices of depression
are remarkably consistent in their support of depression as a risk factor
for both the development and the worsening of chronic heart disease.7
This is a complex area of research where the nature of causal relations
between psychiatric symptomatology and chronic disease is unclear. For
example, it is unclear the extent to which a disorder such as depression
may directly contribute to worsened prognosis in chronic illness. But the
research findings do indicate that mental health problems occur with
surprisingly high frequency in those with chronic disease and should be
addressed by the health care system.
5 Sevick and others, “Patients With Complex Chronic Diseases,” 438.
6 Lesperance and Frasure-Smith, “Depression in Patients With Chronic Disease.
7 Frasure-Smith and Lesperance, “Reflections on Depression as a Cardiac Risk
Fac tor,”S 23 .
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Supported Self-Management for Mental
HealthProblems
Systematic reviews and clinical guidelines have called for the integration
of supported self-management into care for mental health problems.
Supported self-management for mental health problems has two main
components. The first component is a self-management tool—usually
a workbook given to the patient—that teaches self-management skills
derived from treatment research. The second component is support
by the health care provider, who offers encouragement and advice.
This component requires minimal time and effort by the health care
provider. Supported self-management may be provided as a stand-
alone intervention or as an adjunct to other treatment, depending on the
severity and complexity of a particular situation.
Most of the outcome research in this area has focused on self-
management for depression. It has been demonstrated that individuals
with mild to moderate depression show significant benefit from being
provided with self-management materials.8 In primary care, depressed
individuals who are provided self-management material show a
generally positive attitude toward intervention, significant uptake, and
increased knowledge of effective change strategies.9 A recent review
of self-management tools for mental health problems concluded
that “the majority of trials reported some significant advantages
in outcome associated with self-help treatments.10 Depression
care guidelines produced by the UK National Institute for Clinical
Excellence recommend: “For patients with mild depression, health care
professionals should consider recommending a guided self-help program
based on cognitive-behavioural therapy (CBT).11
8 McKendree-Smith and Scogin, “Self-Administered Treatments for Depression.”
9 Robinson and others, “The Education of Depressed Primary Care Patients.”
10 Bower, Richards, and Lovell, “The Clinical and Cost-Effectiveness of Self-Help,” 838.
11 National Collaborating Centre for Mental Health, Management of Depression, 5.
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A Tool for Mood Self-Management in
HealthConditions
The Positive Coping with Health Conditions workbook is available
for free download at www.carmha.ca/selfcare/. It has been designed
to beuser-friendly—easy for patients to use to enhance their coping
with the mood impacts of their health condition. Also available for
free download from that site is a relaxation training audio file that
accompaniesthe workbook material, as well as handouts explaining
specific self-management skills.
Within the workbook, there are several components:
First, there is a self-assessment screening tool that helps patients
identify areas in which they may be experiencing mental health
problems—including depressed mood, worry and anxiety, anger and
irritability, or social isolation. This screening tool has been validated with
patients presenting to a cardiac rehabilitation program, helping to identify
those who are encountering significant mental health issues and require
support in this area.
Second, a series of coping skills are explained in a step-by-step manner.
Each of these skills has a substantial evidence base and has been
shown to be relevant for enhancing an individual’s ability to cope with
mood and other psychological difficulties, whether involving depression,
anxiety, anger, or social withdrawal. The coping skills are as follows:
Relaxation. Teaching an individual to relax physically and mentally helps
to interrupt the vicious circle between symptoms/pain and excessive
physical tension or worry. The website provides a relaxation training
audio file (17 minutes in length) that is easy to use and acceptable
to most patients. Regular practice of the relaxation method will help
individuals to become more effective in this valuable skill.
Managing Worry. This skill helps the individual identify “worry
thoughts”—thoughts that exaggerate negative consequences, interfere
with daily activities and go in circles rather than leading to actual
problem-solving behaviour. Once these worry thoughts are identified,
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theindividual is encouraged to challenge them and replace them with
self-statements that are realistic, fair, and helpful. The individual is also
encouraged to set aside worry times specifically dedicated to “worrying
toward solution.”
Problem-Solving. An individual who learns to deal more effectively with
circular worrying will naturally shift more toward useful problem-solving.
This skill shows how problem-solving can more effectively be carried
out by going through a series of structured steps: identifying a workable
problem; coming up with several possible actions; writing down the
positives and negatives for each; making a specific and scheduled action
plan; and so on.
Activating Your Life. One of the frequent difficulties with chronic health
conditions is that individuals may limit their activities, whether physical or
social, and thus feed into magnified depression or anxiety. Excessively
limiting one’s activities will reduce well-being in a notable way. This
skill helps the individual identify areas within which activities may be
increased, set specific feasible goals for gradual increase in activity,
and sustain this new activity pattern. But it also encourages people to
distinguish between hurt and harm (i.e., to define those activities that
should not be carried out according to advice from their health care
provider and those that may be uncomfortable at first, but are well
worthimplementing).
Managing Depressive Thinking. Dealing with a chronic health condition
can lead an individual to become unnecessarily pessimistic and self-
critical—magnifying the limitations associated with this condition and
seeing the future in an exaggeratedly catastrophic way. Depressive
thinking will tend to reduce this individual’s life satisfaction, hamper
their following through with appropriate medical self-care, and generally
increase the suffering associated with the health condition. This skill
shows individuals how to identify depressive thoughts, and challenge
them and replace them with more adaptive and realistic ones.
Managing Anger. As with the skill of managing depression, this
skill helps individuals identify anger thoughts—i.e., self-statements
that magnify the harm done to us by others, increase one’s sense
of resentment, and thus interfere with the quality of relationships
Dealing with a
chronic health
condition can
lead an individual
to become
pessimistic
andself-critical.
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regarding the support one can obtain from others. Managing anger
helps individuals find more adaptive and helpful ways of thinking about
situations and people.
Relationship-Building. This skill is based on the work of a research
team at the University of Washington, which has studied interactions
within relationships and identified critical components of those
interactions that determine the quality of the relationship. This skill
helps the individual respond to “connecting bids” by others in a way that
is likely to enrich the relationship. For individuals dealing with health
conditions, the support and reward available from relationships is critical.
Third, the workbook includes a series of stories that illustrate the
application of the coping skills by individuals dealing with chronic health
conditions. These stories make the application of these coping skills
easier to grasp.
Finally, the workbook explains in some detail how to apply these
coping skills to problems frequently encountered by individuals with
chronic health conditions. The conditions include pain, impaired sleep,
insufficient physical activity, and problematic eating habits.
Conclusion
There has been a gradual evolution in our approach to health conditions,
increasingly recognizing the active role of the patient in the recovery
process. This self-management tool is designed to support active
engagement of the individual in managing psychological problems
triggered by or negatively affecting the health condition.
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About the Author
Dan Bilsker, PhD, is a psychologist who consults for a mental health
services research group at Simon Fraser University. His academic
appointments are Adjunct Professor, Faculty of Health Sciences,
SimonFraser University and Clinical Assistant Professor, Faculty of
Medicine, University of British Columbia. He oversees a project to
enhance the system of mental health care in Canada by disseminating
brief behavioural interventions for mood disorders. Dan is the lead author
ofthe report A Roadmap to Men’s Health for the Men’s Health Initiative
of BC (2010), and has led several projects to produce self-management
workbooks, available at www.carmha.ca/selfcare/:
Antidepressant Skills Workbook (2005), available in French, Chinese,
and Punjabi;
Dealing with Depression for Teens (2005);
Antidepressant Skills at Work (2007);
Positive Coping with Health Conditions (2009).
Bibliography
Bower, P., D. Richards, and K. Lovell. “The Clinical and Cost-
Effectiveness of Self-Help Treatments for Anxiety and Depressive
Disorders in Primary Care: A Systematic Review.British Journal
ofGeneral Practice 51, no. 471 (2001): 838–45.
Frasure-Smith, N., and F. Lesperance. “Reflections on Depression as
aCardiac Risk Factor.” Psychosomatic Medicine 6, no. Suppl 1 (2005):
S19S25.
Gibson, Peter, and others. “Self-Management Education and Regular
Practitioner Review for Adults With Asthma.Cochrane Database of
Systematic Reviews 2 (2005).
Article 1 | The Conference Board of Canada
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Jovicic, A., J. Holroyd-Leduc, and S. Straus. “Effects of Self-
Management Intervention on Health Outcomes of Patients With Heart
Failure: A Systematic Review of Randomized Control Led Trials.”
BMCCardiovascular Disorders 6, no. 243 (2006).
Lesperance, F., and N. Frasure-Smith. “Depression in Patients With
Chronic Disease: A Practical Review.” Journal of Psychosomatic
Research 48 (2000): 379–91.
Lorig, K., D. Sobel, P. Ritter, D. Laurent, and M. Hobbs. “Effect of
aSelf-Management Program on Patients With Chronic Disease.”
Effective Clinical Practice 4 (2001): 256–62.
McKendree-Smith, N., M. Floyd, and F. Scogin. “Self-Administered
Treatments for Depression: A Review.” Journal of Clinical Psychology 59,
no. 3 (2003): 275–88.
National Collaborating Centre for Mental Health . Management of
Depression in Primary and Secondary Care. 2004. www.nice.org.uk/
guidance/CG23/niceguidance (accessed January 14, 2008).
Robinson, P., and others. “The Education of Depressed Primary Care
Patients: What Do Patients Think of Interactive Booklets and a Video?”
Journal of Family Practice 44 (1997): 562–71.
Sevick, M., and others. “Patients With Complex Chronic Diseases:
Perspectives on Supporting Self-Management.” Journal of General
Internal Medicine 22, no. Suppl 3 (2007): 438–44.
Wagner, E. “Chronic Disease Care.” British Medical Journal 328,
no.7433 (2004): 177–78.
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ARTICLE 2
Addressing Chronic
Disease Through the Social
Determinants of Health:
TheShifting Emphasis
inAlberta
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Canada’s Global Village Reality
Canada is a diverse nation with a social and
cultural mosaic as indicated by its Aboriginal
peoples; immigrant and visible minority
populations; and linguistic, religious, and
economic characteristics. According to the 2011
National Household Survey (NHS), 20.6 per cent
of Canada’s total population were foreign-born,
17.2 per cent of the foreign-born population
were recent immigrants, and 19.1 per cent
belonged to a visible minority. The Aboriginal
population in Canada has experienced faster
growth rates than the general population.1
There has also been an alarming increase in the
number of socially vulnerable populations in
Canada.2 Thediversity of Canada’s population
will continue to increase significantly during the
nexttwodecades.
Chronic Disease, Diversity and Disparity
Although Canadians, in general, rank among the healthiest in the world,
health is not evenly distributed across Canada’s population. There
are indications that specific populations such as Aboriginal people,
South Asians, Africans, and Hispanics, experience chronic conditions
like diabetes and heart disease at three to five times the rate of the
general population and face higher risk for morbidity and mortality.3
Furthermore, people who experience homelessness and extreme
1 Statistics Canada, National Household Survey.
2 Gaetz and others, “The State of Homelessness.”
3 Gholap and others, “Type 2 Diabetes.”
Shahnaz Davachi,
PhD,RD
Program Lead, Provincial
Strategic Coordination,
Primary Health Care,
AlbertaHealth Services
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poverty are also significantly impacted by multiple physical and mental
chronic conditions. Despite high needs, vulnerable populations often
face significant challenges to managing their chronic physical and mental
healthconditions.
What Happens When Chronic Disease Is Another
Obstacle Among Many?
A strong body of research tells us that our physical and mental well-
being and access to health care, to a large extent, are determined by a
variety of situational factors known as the social determinants of health.4
These factors (such as housing, poverty, and job and food insecurity)
have a profound impact on the causes of chronic disease and its self-
care, particularly in the context of the most vulnerable segments of our
population. (See Table 1.)
In Alberta, this reality is supported by my former research and
experience working with the homeless and other vulnerable populations
whose disparities in lifelong management of chronic disease are
4 Mikkonen and Raphael, Social Determinants of Health.
Table 1
The Social Determinants of Health in Canada
1. Aboriginal status 8. Gender
2. Disability 9. Housing
3. Early life 10. Income and income distribution
4. Education 11. Race
5. Employment and working conditions 12. Social exclusion
6. Food insecurity 13. Social safety net
7. Access to health services 14. Unemployment and job security
Source: Mikkonen and Raphael.
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amplified by complex interaction between the environmental, physical,
psychosocial, and economic determinants. These determinants include
transience, food insecurity, poverty, the struggle to meet basic survival
needs, limited resources to self-manage, mistrust of providers, and
systemic factors related to the way our primary health care is provided.
(SeeExhibit1.) The homeless and other vulnerable people who suffer
from mental illness and addictions experience additional challenges
when coping with chronic disease. One of my community champions
who works closely with homeless people once told me that “mental
illness in vulnerable people is a disparity within the disparity.” Because of
these challenges, many people who are extremely vulnerable don’t have
the required resources to manage their chronic diseases and simply give
up on improving their own health.
Exhibit1
Barriers to Effective Chronic Disease Care among Vulnerable Populations
Source: Dr. Shahnaz Davachi.
Late diagnosis
Poor disease control
Complications
High urgent care, inpatient
and hospital use
High and early mortality
Personal Daily
Struggles
Safe shelter
Warm meals and clothing
Stigma and prejudices
• Maintaining safety
Medical
Challenges
Lack of control over diet/medication
Lack of regular medical care, insurance
Access to medications, self-care
Mental illness
Health
Care/Provider
Challenges
Complex health issues
Transient population, care continutiy
Compliance challenges
Health literacy
Lack of provider awareness and skills
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The Compelling Need for Addressing Chronic
Disease Through the Social Determinants
ofHealth
Like any other complex social and public health issue, chronic disease
care strategies for vulnerable people are most effective when they are
integrated, innovative, broad-based, holistic, and, more importantly,
address patients’ psychosocial needs.
For the past couple of decades, there has been an emergence of
limited initiatives in Canada aimed at addressing the unique health
and socio-cultural needs of vulnerable populations. For example, the
Diabetes Education Community Network of East Toronto (DEC NET)
has adopted a unique approach to self-management for multiple
vulnerable populations, which incorporates an understanding of
socialdeterminants.5
Since 2002, Alberta has effectively recognized the cyclical impact
of social determinants on chronic disease in vulnerable populations.
Thisrecognition has motivated a strong cultural shift in adapting
innovative chronic disease management models of care for
ethnocultural, Aboriginal, and homeless populations. Community and
patient engagement has provided effective motivation in incorporating
an understanding of social determinants in health service planning
andprovision for vulnerable populations.
The Alberta Health Services Chronic Disease Prevention and
Management Program for the homeless in Calgary represents an
innovative and partnership-based service delivery model that has
adequately addressed broader determinants of health by working
with the homeless community.6 Comprehensive chronic disease care
pathways, which focus on the medical management of chronic disease,
have proven effective for the mainstream population. However, a
community-driven and holistic approach, provided by a compassionate
5 Toronto East General Hospital, Diabetes Education.
6 Davachi and Ferrari, “Homelessness and Diabetes.”
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multidisciplinary team at a large homeless shelter in Calgary (where
homeless people congregate), has been more effective in enhancing
access, and improving self-management efficacy and health outcomes
for this uniquely challenged population.
Prior to the development of this program, while I was Director, Diverse
Populations, we sat down with homeless people and listened to their
stories about their unique challenges in coping with chronic conditions.
We learned of their challenges adopting self-management practices
when faced with poverty and food insecurity. Problems in accessing
health services are an additional barrier. In an unedited story of her life,
Karen, a homeless woman with type 2 diabetes, commented that “years
of hard manual jobs, homelessness, lack of social and family support,
and heavy reliance on fast foods (which I could afford), had finally taken
their toll on me and caused my diabetes.” This powerful engagement
helped us shift our chronic disease care model in a way that responded
to the immediate and long-term needs and social determinants of
the homeless. One of the most critical lessons we learned from this
exceptional experience was that a psychosocial and holistic approach
that treats the whole person, rather than a bio-medical approach that
treats a diseased organ, is more effective in vulnerable populations.
Weneed to meet people “where they are at” in the trajectory of their
chronic illness.
Programming for the homeless and other vulnerable populations in
Alberta is based on the guiding principles and recommendations of the
Targeted Chronic Disease Prevention and Management Approaches
forDiverse and Vulnerable Populations in Alberta.7
7 Alberta Health Services, Targeted Chronic Disease Prevention and Management
Approaches.
A psychosocial and
holistic approach
that treats the
whole person is
more effective
in vulnerable
populations.
THE VIEW
Perspectives on Chronic Disease Prevention and Management
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Shifting the Emphasis
Although there has been an encouraging emergence of initiatives
focusing on the unique needs of vulnerable populations in Alberta and
Canada, program-level change may not be enough as there remain
systemic challenges that hinder our efforts. Here are some issues that
health planners and decision-makers need to acknowledge to better
address the health needs of vulnerable populations:
There is inadequate commitment at multiple levels to implement policies
and dedicate resources that deliver sustainable and integrated chronic
disease services for vulnerable populations. As we strive for more
effectiveness and efficiency, strategies for addressing chronic disease
in vulnerable populations will require diverse, innovative, flexible,
multifaceted, multi-sectoral, and well-coordinated models of care.
In vulnerable populations, non-medical factors are key determinants
of self-efficacy and self-management behaviours. Effective self-
management strategies require attention to factors such as poverty,
food insecurity, safe and affordable housing, and social support. These
factors are beyond the scope of the health system alone to address.
There is a critical need for more coordination and collaboration among
the key partners—health care, communities, organizations serving
vulnerable populations, policy- and decision-makers, and researchers.
Traditional chronic disease prevention and management (CDPM)
strategies heavily focus on improving an individual’s capacity to manage
her/his own chronic disease by making daily decisions about healthy
lifestyles and medications. I am not alone in countering that this is not
always feasible, based on patients’ life situations and other more urgent
needs. Effective self-management in vulnerable people requires access
to the resources they need to take control of their conditions. Therefore,
self-management support must go beyond education and bridge the
gap between the complexity of patients’ lives and their chronic disease
self-management goals.
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There is a tremendous opportunity for coordination between the
International Self-Management Framework in British Columbia and the
Targeted Chronic Disease Prevention and Management Approaches
for Vulnerable Populations in Alberta to look at the “bigger picture” and
develop self-management strategies for vulnerable populations that are
accessible, affordable, and practical.
Finally, chronic disease disproportionately impacts vulnerable people.
Long-term and effective strategies, which address the links between
the social determinants and chronic disease, lie in modifying the root
causes and trends in our health care and social systems that create
disparities for vulnerable populations. Strategies could also be developed
proactively to mitigate those disparities. Achieving cultural and social
appropriateness in patient care is a “means,” not an end.
Ask not ‘what disease’ the person has, but rather ‘what person’
has the disease.”
William Osler, MD (1849–1929)
About the Author
The former Director of Diverse Populations for Alberta Health Service,
Shahnaz Davachi holds a PhD in Community Nutrition, University of
Surrey, U.K., and a Post-Doctoral Fellowship with a focus on health
program planning, Faculty of Medicine, University of Calgary, Alberta.
For the past few decades, Shahnaz has taken an active leadership
role in identifying and addressing social determinants that impact
access and health outcomes of high-needs populations. In her current
leadership role as the Program Lead, Provincial Strategic Coordination,
Shahnaz is responsible for fostering strategic partnerships with multiple
stakeholders and coordinating and integrating comprehensive primary
health care services in Alberta. She has delivered multiple presentations
at international, national, and provincial conferences and serves in an
expert advisory and consulting capacity for a variety ofcommittees.
THE VIEW
Perspectives on Chronic Disease Prevention and Management
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Bibliography
Alberta Health Services. Targeted Chronic Disease Prevention and
Management Approaches for Diverse and Vulnerable Populations
inAlberta. 2012. www.albertahealthservices.ca/hp/if-hp-ed-cdm-gen-
div-prov-frame-diverse-vuln-pop.pdf.
Davachi, Shahnaz, and Isabel Ferrari. “Homelessness and Diabetes:
Reducing Disparities in Diabetes Care Through Innovations
and Partnerships.” Canadian Journal of Diabetes 36, no. 2
(April2012): 75–82. www.canadianjournalofdiabetes.com/article/
S1499-2671(09)33050-6/fulltext.
Gaetz, Stephen, Jesse Donaldson, Tim Richter, and Tanya Gulliver.
“The State of Homelessness in Canada 2013.Canadian Homelessness
Research Network Press. 2013. www.homelesshub.ca/ResourceFiles/
SOHC2103.pdf.
Gholap, Nitin, Melanie Davies, Kiran Patel, and Kamlesh Khunti. “Type
2 Diabetes and Cardiovascular Disease in South Asians.” Primary Care
Diabetes 5, no. 1 (2011): 45–56. www.primary-care-diabetes.com/article/
S1751-9918%2810%2900097-5/abstract.
Mikkonen, Juha, and Dennis Raphael. Social Determinants of Health:
The Canadian Facts. Toronto: York University School of Health Policy and
Management, 2010. www.thecanadianfacts.org/The Canadian Facts.pdf.
Statistics Canada. National Household Survey (NHS): Immigration,
Placeof Birth, Citizenship, Ethnic Origin, Visible Minorities, Language
and Religion. 2011. www.statcan.gc.ca/daily-quotidien/130508/
dq130508b-eng.htm.
Toronto East General Hospital. Diabetes Education Community Network
of East Toronto (DEC NET). www.tegh.on.ca/bins/content_page.
asp?cid=3-2956.
Find Conference Board researc h at www.e- librar y.ca
ARTICLE 3
Care for All: International
Framework for
Self-ManagementSupport
THE VIEW
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SMS In Canada: What Do We Know?
Self-management support (SMS) in health policy
and practice is a relatively new development in
Canada. In 1994, Health Canada funded a multi-
phase project called the Supporting Self-Care
Project. The project sought to better understand
and promote approaches used by health care
professionals in supporting self-care, with
a particular emphasis on networking and
building partnerships.1 In 1997, Health Canada
provided $150 million in a Health Transition Fund
(1997–2001) for projects to “test and evaluate
innovative ways to deliver health care services.”2
This fund was used to advance health care
reforms across Canada. The fund included
SMS initiatives in hopes of improving health
outcomes and reducing the financial burden
ofchronic conditions in some provinces.
In recent years, policies that consider SMS to be an important aspect
ofhealth services are rapidly growing in Canada, along with an increase
in the number and kinds of SMS programs being offered.3 Federal and
provincial governments, health authorities, professional associations,
andnon-governmental organizations are:
producing SMS-related policy documents;
embedding SMS in clinical practice guidelines and chronic disease
management strategies;
1 Canadian Nurses Association, Supporting Self-Care.
2 Health Canada, About the Health Transition Fund.
3 British Columbia Ministry of Health, Self-Management Support; Mills and others,
“Needs,Gaps and Opportunities”; Paterson and others, Chronic Diseases
Self-Management Practice.
Sue Mills, PhD
Clinical Professor,
School of Population and
Public Health, University
ofBritishColumbia
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training health care professionals in self-management
support techniques;
implementing community-based self-management programs among
other SMS-related initiatives.
In the past five years, SMS has also emerged as an important area
of interest at the national level as demonstrated through initiatives
and publications (e.g., Self-Management Support for Canadians With
Chronic Health Conditions4; and Helping Patients Help Themselves:
AreCanadians With Chronic Conditions Getting the Support They
Needto Manage Their Health?5).
To gain a fuller grasp of current activity in Canada and to illuminate
where gaps might exist, Mills and others conducted an environmental
scan in 2010–11.6 Self-management support was addressed to
some degree in 86 policy-related documents (strategies, guidelines,
frameworks, polices, and discussion papers). Although only 10 of these
focused solely on self-management support, this finding demonstrates
how self-management-related ideas are becoming increasingly
embedded in many aspects of chronic disease care (chronic disease
management, primary care, health system reform, and healthyaging).
Almost half of the documents were applicable to populations with a
range of chronic conditions. Yet, no policies specifically considered SMS
in relation to issues pertaining to care or services for those living with
multiple long-term conditions. The disease-specific documents (just over
50 per cent) were largely directed toward populations with diabetes and
heart and respiratory diseases. Only 3 policy-related documents focused
on mental health conditions.
Seventy-five self-management programs—structured programs applied
at the individual or group level that specifically aim to improve the
way individuals self-manage their chronic conditions, optimize their
4 Health Council of Canada, Self-Management Support for Canadians.
5 Health Council of Canada, Helping Patients Help Themselves.
6 Mills and others, “Needs, Gaps and Opportunities.”
THE VIEW
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health, and live well7—were being used by many provinces.8 The
Chronic Disease Self-Management Program (CDSMP)—a peer-led,
six-week lifestyle modification course9—comprised about one-third
of the programs that were being implemented across Canada. The
content of the remaining 50 self-management programs was similar
to the standardized CDSMP curriculum, suggesting that there is not
a huge variation in our approach to self-management interventions in
different regions. Most of the SMS programs have been designed for
participants with a range of different chronic conditions. Not unlike the
policy developments, disease-specific programs were often for diabetes
and cardiovascular and respiratory diseases. The main exception was
a slightly stronger focus on mental health conditions, chronic pain,
and rheumatic diseases at the program level. The complexity of self-
managing co-existing chronic conditions was not explicitly addressed
inany of the programs we found.
Importantly, only a small number of these policies and programs
considered SMS in relation to underserved and disadvantaged
populations. About half of the policy-related documents discussed
disadvantaged groups (either in terms of socio-demographic
characteristics or underserved health care status) and made general
recommendations (e.g., policies/programs should aim to decrease
inequities, target disadvantage groups, and/or consider cultural/linguistic
adaptations to increase accessibility). Only five documents implicitly
discussed disadvantaged groups or related issues in relation to SMS.
Asimilar trend is seen at the programmatic level. Disadvantaged groups
were the target population for only 2 of the 25 CDSMP versions being
used in Canada. Of the other self-management programs examined,
7 out of the 50 were designed for disadvantaged groups—including
7 Mills and others, Current Directions in Self-Management Support.
8 Mills and others, “Needs, Gaps and Opportunities.”
9 Lorig and others, Living a Healthy Life.
There is not a
huge variation in
our approach to
self-management
interventions in
different regions.
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Aboriginals, Canadian Portuguese, Black Canadians, Cambodians,
Muslims, South Asians, Latin Americans, people living in rural
communities, and seniors.10
SMS Challenges: Where Are the Gaps?
As suggested by the above findings, Canadian self-management, and
support-related policies and programs have been largely designed for
mainstream populations. Current gaps include:
insufficient SMS initiatives at policy and program levels for underserved
and disadvantaged populations;
lack of consideration for the powerful role of social factors in shaping the
way diverse and vulnerable groups self-manage their chronic conditions
in daily life, and the overall social and health inequities they experience;
unequal SMS developments for different chronic conditions, including
mental health conditions and physical conditions outside of diabetes and
heart and respiratory diseases;
inattention to the complexities of living with multiple conditions and the
challenges they create for individual self-management as well as self-
management supports.11,12
Canada’s SMS landscape is similar to that of many Western countries,13
although other countries seem to be acknowledging and addressing
these gaps more urgently. Self-management support initiatives
in disadvantaged and underserved populations has gained more
prominence in recent years and is advancing in the U.S.,14 U.K.,15 and
10 Mills and others,” Needs, Gaps and Opportunities.
11 Bayliss and others, “Descriptions of Barriers to Self-Care.”
12 Jowsey and others, “Challenges for Co-Morbid Chronic Illness Care.”
13 Barlow and others, “Self-Management Approaches”; Bur y, Newbould, and Taylor, A Rapid
Review; Jordan and Osborne, “Chronic Disease Self-Management.”
14 Glazier and others, “A Systematic Review of Interventions.”
15 Khunti and others, “Educational Interventions for Migrant South Asians.”
THE VIEW
Perspectives on Chronic Disease Prevention and Management
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Australia16 for some specific populations. Further, recognition of the
multiple chronic condition issue is on the rise,17 but has not been a major
part of SMS dialogue in Canada to date.
SMS initiatives in many provinces reflect a sincere intent to improve the
lives of people living with chronic conditions. However, we seem to lag
in the development of multi-faceted and nuanced SMS approaches that
address the needs of diverse groups. These developments have largely
not been accompanied by the critical reflection on self-management
support seen in the academic literature, in the policy experiences of
other nations, and in discussions at national/international forums—with
some exceptions.18 Innovative SMS developments are occurring in many
countries including Canada (e.g., Alberta Health Services’ approach to
chronic disease management in diverse and vulnerable populations; the
Intercultural Online Health Network19; and the Centre for Collaboration,
Motivation and Innovation20). But, these experiences are often not
shared or debated outside of local decision-making environments and
conference settings.
It is clear that to move forward, we need to start asking tough questions
about self-management support initiatives. These questions include
how the initiatives can and cannot help improve the health of Canadian
chronic condition populations, potentially reduce chronic condition
impacts on our health care systems, and address inequities. Given the
number of resources being directed toward SMS initiatives, we also need
to ask: Is the current approach in Canada appropriate? Are we moving
in a direction that reflects international developments and leading-edge
thinking? Do we have a common vision?
16 McDonald and others, Action on Health Inequalities.
17 U.S. Department of Health and Human Services, Multiple Chronic Conditions; Health
Council of Canada, Self-Management Support for Canadians.
18 Hyman and others, “Self-Management, Health Service Use.”
19 Intercultural Online Health Network, Welcome.
20 Centre for Collaboration, Motivation and Innovation, The Centre for Collaboration,
Motivation and Innovation.
To move forward,
we need to start
asking tough
questions about
self-management
support initiatives.
Article 3 | The Conference Board of Canada
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International SMS Framework: What Is Our
Vision Going Forward?
To provide vision and stimulate activities that can begin to address these
gaps as well as other needed areas of SMS development, 23 experts
in self-management support from six countries developed a strategic
framework.21,2 2 It was reviewed by more than 200 reviewers (policy-
makers, health care providers, program directors/managers/planners,
patients, advocates, patient group representatives, researchers, and
educators) in 16 countries (Australia, Austria, Brazil, Canada, Denmark,
Germany, Israel, Netherlands, New Zealand, Norway, Singapore, Spain,
Sweden, Switzerland, United Kingdom, and the United States) using
an e-survey process.23 The framework contains self-management and
self-management support definitions, a collective vision, eight guiding
principles, seven strategic directions, and a number of examples of
context-specific support actions to stimulate local action.24 The content
reflects strong agreement among our international community of survey
respondents about the direction the SMS field needs to head to achieve
our common goals.25
The goals of the International SMS Framework are to:
help countries develop comprehensive and coordinated SMS strategies;
help decision-makers working at all levels to advance SMS initiatives in
policy and practice;
encourage the development of further evidence.26
The framework situates SM behaviour as the product of complex
interactions between social environments and individual factors.
And,itemphasizes the role of broader social structures and processes
21 Mills and Vaden, “Workshop Report.”
22 Mills, Brady, Sargious, and Zibakhsh, “Building Common Ground.”
23 Mills and others, “Using E-Consultation to Build Consensus.”
24 Mills and others, “Towards Consensus on Self-Management Support.”
25 Mills and others, “Using E-Consultation to Build Consensus.”
26 Mills and others, “Towards Consensus on Self-Management Support.”
THE VIEW
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in self-management behaviour—essential considerations for developing
SMS initiatives for diverse groups. The description of SMS extends
previous health care centric understandings to include an essential
integration between health and social services and individuals’ personal
systems of family and community support. (See “Definition of Self-
Management Support.”)
Definition of Self-Management Support
Self-management support is defined as a grouping of structures, systems,
policies, services, and programs that extend across health care, social sectors
(i.e., social services, welfare agencies), and communities to support and improve
the way people manage their own chronic conditions, optimize their health, and
live well.27
The guiding principles for SMS illuminate essential ethical considerations
that need to be addressed—such as developing SMS that is equitably
available and accessible; is respectful of choice and autonomy; and
maximizes benefits and minimizes harms. The principles also highlight
the need for SMS initiatives to be evidence- and needs-informed.28
The strategies and support actions promote a health equity agenda by
expanding the reach and range of services and, in particular, developing
programs that target vulnerable groups and address their specific needs
(e.g., living with multiple chronic conditions). The actions also encourage
considering individual capacities, reducing barriers, and developing
health care professional training. (See “Strategic Directions.”)
27 Ibid.
28 Ibid.
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Strategic Directions
The strategic directions are to:
involve consumers;
expand reach and range of services;
advance evidence;
improve effectiveness and appropriateness of services;
strengthen inter-sector linkages;
foster multi-sector commitment and accountability;
build infrastructure.29
Moving Forward
The CCSMS Framework represents a collective understanding of where
we need to go with SMS to better serve the needs of diverse chronic
care populations as well as health and social systems of care. It should
evolve and change over time as our experience grows and our evidence
base becomes more developed. The framework fosters collaborations
among policy-makers, practitioners, researchers, and consumers, and
also promotes the development of evidence in the self-management
support field. Collaborative forms of engagement will help us move
toward a more advanced approach to self-management support that
recognizes the complexities inherent in self-managing chronic conditions
and the diverse needs of different populations.
Discussions on the CCSMS Framework among decision-makers working
at multiple levels can help stimulate debate on the self-management
support field in Canada and challenge and expand our thinking of future
possibilities. Although the framework has not been formally released,
we have anecdotal reports that some organizations have been using the
draft framework as a guide to develop SMS and chronic condition-related
policies, programs, and services in Canada, the U.S., and abroad.
29 Ibid.
THE VIEW
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Policy-makers and practitioners working in different organizations and at
different levels can use it as a conceptual structure for considering how
current activities align with the framework’s self-management support
principles and strategies.
The framework can also play a role in helping to encourage knowledge
and capacity development through health care provider training, provide
educational curricula for medical students, and guide research projects
and grant proposals to advance knowledge development and future
research. Most importantly, the framework can be used as an impetus
tocreate dialogue and take action on specific SMS gaps outlined earlier.
These gaps include insufficient SMS initiatives for underserved and
disadvantaged populations; the lack of consideration of social factors
and processes that greatly shape self-management behaviour; unequal
SMS developments for different chronic conditions; and inattention to
thecomplexities of living with multiple conditions.
Overall, the CCSMS Framework is an important collaborative step
forward in the SMS field that has the potential to help us advance
evidence, reduce inequities, and improve the health of Canadians
livingwith chronic health conditions.
Acknowledgements
A special thank you to Dr. Peter Sargious for his contributions in
developing and promoting the international framework; Dr. Teresa Brady
for her thoughtful comments on this article and strong involvement in the
framework development process; and Ms. Javiera Pumarino for assisting
with the editing and formatting of this article.
About the Author
Dr. Sue Mills conducts research on chronic disease management and
self-management support, particularly in relation to disadvantaged
and underserved populations. She takes an action-oriented and
participatory approach to research. Sue brings together teams of
Article 3 | The Conference Board of Canada
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researchers, policy-makers, practitioners, and consumers to develop
policy and practice-relevant knowledge that can help improve the health
of chronically ill populations at local and provincial levels. She led the
development of an international framework for self-management support
that was reviewed by more than 200 individuals in 16 countries. Most
recently—with a team of international researchers and knowledge users
from governments, health authorities, and clinical practice—Dr. Mills
conducted a realist synthesis on self-management interventions for
disadvantaged populations.
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Bayliss, E.A., J.F. Steiner, D.H. Fernald, L.A. Crane, and D.S. Main.
“Descriptions of Barriers to Self-Care by Persons With Co-Morbid
Chronic Diseases.” The Annals of Family Medicine 1, no. 1 (2003):
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AHealthcare Intervention. Victoria, BC: British Columbia Ministry
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Schools of Nursing, and Association of Canadian Medical Colleges.
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Glazier, R.H., J. Bajcar, N.R. Kennie, and K. Willson. “A Systematic
Review of Interventions to Improve Diabetes Care in Socially
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gc.ca/hcs-sss/ehealth-esante/infostructure/finance/htf-fass/about-
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Australia186, no. 2 (2007): 84–87.
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Jowsey, T., Y.-H. Jeon, P. Dugdale, N.J. Glasgow, M. Kljakovic, and
T.Usherwood. “Challenges for Co-Morbid Chronic Illness Care and
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ARTICLE 4
For Healthier Generations
THE VIEW
Perspectives on Chronic Disease Prevention and Management
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Tragically, for the first time in history, our
children’s life expectancy is not estimated to
outpace our own. The facts are staggering.
Physical inactivity and sedentary lifestyles,
especially among children and youth, have
become a national crisis. Year after year, Canada
gets a failing grade in kid’s physical fitness with
nearly one in three children either overweight or
obese. This puts our children at risk for serious
health problems normally found only in adults.
That motivated Vivo for Healthier Generations—a leading Calgary
recreation centre, along with its innovation and research arm—to
ask why it does what it does. If Vivo shifted its thinking and actions,
could more lives be enriched? Could a public recreation centre have
a tangible,measurable impact on moving whole communities toward
healthier lifestyles?
Vivo believes the answer is a resounding yes!
For six years, Vivo successfully fulfilled the role of a destination where
the community’s sport and recreation needs were met with the provision
of cutting-edge spaces, programs, and services. Through the lens of a
traditional recreation service model, Vivo effectively served its purpose
as a popular community hub that promoted fitness in a holistic manner.
But, the affirmative answers to those burning questions above prompted
Vivo to begin working differently, and to transcend the boundaries of
an old-fashioned recreation centre, to compel people to be active, save
lives, increase workforce productivity, foster innovation, and strengthen
community connections.
In 2010, the visionary board of directors and leadership team started to
question whether the focus on what they were providing was enough
toservice the greater needs of individuals and families in the community.
And so a revolutionary evolution began to take place throughout the
Lorrie Lancaster
Manager, Communications,
Vivo for Healthier
Generations
Article 4 | The Conference Board of Canada
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organization that shifted attention to the underlying causes of why.
Vivowas in the business of promoting fitness and well-being. This was
the first step in the organization redefining itself as a part of the nation’s
proactive public health and wellness sector—embracing a new role
and accepting new work to help Canadians become active and healthy
forlife.
Vivo introduced a shift toward raising healthier generations. It started
operating as a social enterprise—a non-profit society with federal
charitable status, governed by the Nose Creek Sports and Recreation
Association, and with a stated commitment to:
provide healthy living leadership and innovation;
pioneer solutions to child, youth, and adult physical inactivity;
create a new model for Canada`s public recreation centres.
As a social enterprise, Vivo’s leadership is conscious of, and deliberate
in, pursuing both financial and social bottom lines. By contract with the
City of Calgary, Vivo is obliged to be financially self-sustaining through
revenues from pass sales, user fees for programs and services, leases
Developing physical
competence and
confidence through
spontaneous play and
games. Source: Vivo for
Healthier Generations.
THE VIEW
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and rentals, fund development, and entrepreneurial pursuits that align
with its purpose and values. With its new mission and strategic intent,
however, Vivo now actively strives to achieve social change in the
community and across the nation.
Raising the Bar
Examining what Vivo does, and affirming why it does it, effectively
laid the groundwork for evolving to the new mission to “raise healthier
generations” in Calgary and beyond. However, the question of how
then dominated the equation. Where does one begin tackling a problem
of that magnitude? Starting with children and youth, Vivo focused on
pioneering local solutions to Canada’s national challenge of sedentary
behaviour and physical inactivity through the Raise the Bar campaign.
Raise the Bar started as a national, generational campaign to rally
and challenge individuals, families, communities, and organizations
ofall types to make the changes required to live happy, active, healthy
lifestyles, The campaign was inspired by a desire to help children, youth,
and adults realize their personal bests when it comes to health. It is an
important step in proving how Canada’s public recreation centres can
have a measurable, more intentional, and purposeful social impact.
Raise the Bar’s three-fold goal is to:
raise healthier generations by increasing the physical activity levels of
children, youth, adults, and whole communities—thereby reversing the
current trend of sedentary lifestyles;
strengthen Calgary’s neighbourhood connections by engaging partners
in a vision to build a stronger, safer, and healthier community for all;
become a national leader in child, youth, and adult physical activity.
Current Raise the Bar initiatives include:
Child + Youth Action Research Project
Healthy Living School
Raise the Bar
is an important
step in proving
how Canada’s
public recreation
centres can have
ameasurable
social impact.
Article 4 | The Conference Board of Canada
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Child + Youth
The Child + Youth Action Research Project is a first of its kind, action-
based, multi-year, collaborative effort between education, recreation, and
the community. The project involves research personnel in the fields of
kinesiology, physical education, and recreation from Vivo, Mount Royal
University (MRU), and the University of Calgary.
Too often recreation, education, and health sectors work in isolation
trying to increase physical activity. Vivo’s community-based action
research study attempts to bridge the gap by providing innovative
approaches to programming, capitalizing on evidence-based practices,
and promoting collaboration and cooperation across sectors.
PhaseI of the research study was launched in February 2012 in
collaboration with Mount Royal University. PhaseI established baseline
fitness levels for children and youth by assessing motor proficiency
skills, body mass index, and moderate to vigorous physical activity
levels. Todate, the study has engaged more than 600 children and their
Measuring children’s
locomotor abilities to
establish a baseline
for physical literacy.
Source: Vivo for Healthier
Generations.
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families. PhaseI key learnings were announced in late May 2013 via the
first in a series of Report Cards. The research team continues to work
closely with families to provide follow-up information and care.
PhaseII of the project involves creating and delivering new programs
toincrease young peoples’ physical activity levels, enabling Vivo to
track and measure improvements over the next decade. The information
and results have been used to inform the design and delivery of a
pilot program at Vivo, launched in January 2014. These programs
seek to prove that a purposeful, holistic curriculum can increase
motor proficiency to create a generation of children and youth who
are competent and confident in the fundamental movement skills, and
thusmore physically active for life.
Healthy Living School
One program is called Healthy Living School. (See “Healthy Living
Starts Here.”) By combining curriculum-based concepts with hands-on
experiences, the program partners hope to inspire students and teachers
to make positive healthy living changes.
Healthy Living Starts Here
Adopting a healthy lifestyle contributes to character building, a sense of social
responsibility, and leads to strong community connections.
By taking children out of their classrooms and into the “real world,” the Healthy
Living School program partners—Vivo, Campus Calgary, and Cenovus Energy—
spark young minds to explore and discover healthy living strategies.
Connecting classroom curriculum with resources and experts from their
community creates meaningful and engaging learning opportunities that
will inspire students and teachers to make positive changes lasting well
beyond their week at Healthy Living School. Through a combination of active
sessions, journalling, and special presentations, students learn essential
skills in relationship-building, nutrition, physical literacy, goal-setting, and
leadershipdevelopment.
Article 4 | The Conference Board of Canada
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Working together with community leaders, students gain an inside perspective
that connects and engages them on a personal level. Interactive classroom
presentations generate reflective and thoughtful conversations with the
students regarding topics in world events, community stewardship, and
healthandwellness.
Students make links to a variety of integrated curriculum-based concepts and
learning opportunities through hands-on experiences during their week at Vivo.
These connections trigger a love of lifelong learning and an appreciation that
education is not confined to the classroom, but can be found in the home, at
school, at work, in nature, and in the community.
Skills and behaviours practised by the students during their journey at Healthy
Living School will be carried forward as they grow to adulthood—leading to
healthier, more innovative, productive, caring leaders who work actively to
strengthen the fabric of their community.
Challenges and Learnings
Launching and managing a project of this scope and complexity has
not been without its challenges. The need to be flexible and responsive
tothe data and participants has been paramount.
Recruitment in itself was a time-consuming task. It was important to
reach families who weren’t already enjoying active, healthy lifestyles.
Targeted efforts were made to infiltrate the community to reach non-
users, but the split is still smaller than preferred. The question of how
tofind thetipping point that motivates a person to adopt change or a new
viewpoint is one that Vivo will continue to seek answers for over the span
of thestudy.
Managing expectations for parents of program participants has also been
surprising. In many cases, the study is taking them out of their comfort
zone. In order for the research study to yield real world results, program
participants need to be retained and engaged over a 10-year period.
THE VIEW
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Thismeans supplying families with ongoing feedback, tools, resources,
and education, making the benefits tangible for them—removing any
barriers and providing personalized programming.
As the project is in its infancy, interesting learnings are only now
becoming apparent. First and foremost, it’s important to note that the
mission to raise healthier generations is a process over time. Change
isn’t instantaneous; it’s incremental. But in the long run, it is vital for the
future health of our country.
Playing a more purposeful role in keeping Canadians healthy requires a
complete transformation of governance, programming, operations, and
financing on behalf of the organization. In essence, all members of the
team must buy into the vision and begin viewing their job functions and
the programs and services they provide through a different filter—moving
away from traditional operations and ways of thinking and nurturing a
culture of passion, conviction, and innovation.
The findings from PhaseII were released in spring 2014, with many
phases to unfold prior to the project culmination in 2020. While PhaseI
addressed the question of which shifts the community needs to make
tolive their best life, PhaseII turned the lens on the sector, asking which
shifts recreation providers need to make to promote healthy active
lifestyles. Initial findings indicate that children in registered programs
spend up to 61 per cent of their time lying, standing, or sitting while
instruction takes place, indicating a real need for more intentional
programming and instructor training. PhaseIII will involve putting
knowledge into practice to assist families in making healthy lifestyle
decisions at home, at work, at school, and at play.
Vivo has an exciting vision to share ongoing results with a variety
of potential knowledge users, including children and families,
recreation centres, government, and other policy-makers as well as
the general public. Ultimately, this will result in a transportable model
for the application of intentional programming and the generation of
partnerships between different disciplines working toward the same goal.
The mission to
raise healthier
generations is
aprocess over
time and is vital
forour country’s
future health.
Article 4 | The Conference Board of Canada
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Conclusion
By being more purposeful, the recreation sector can become a social
and economic contributor to communities across the country. The cost of
doing nothing is enormous. Canadians are less active than ever, putting
increasing pressure on an already unsustainable health care system—
especially acute care. Corporate Canada, particularly those impacted
by global competition, must increase productivity and efficiencies that
are achieved, in large part, by employing a healthy workforce. If public
recreation fails to make this shift, health care and economic productivity,
not to mention community viability and family cohesion, will be negatively
impacted with significant economic implications.
By co-creating with the community; working together across
organizations and across sectors; considering social, cultural, and
generational factors; and reaching beyond Vivo’s walls, the organization
has begun its journey to effect measurable and lasting change in
attitudes, values, and behaviours to motivate individuals and families
tobegin taking responsibility for their own health and activity levels.
Vivo is leading the way for the creation of a new blueprint for Canada’s
public recreation sector. As a social enterprise, Vivo is proving that a
strong social mission, a nimble entrepreneurial spirit, and a willingness
to pioneer can create a viable, purposeful, and relevant 21st-century
organizational model—an evidence-based prototype transportable
to other jurisdictions across the country. This is the future of public
recreation in Canada.
THE VIEW
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About the Author
A writer, a mother, a wife, a 20-year communications professional and,
most importantly, a human being, Lorrie Lancaster is a rare native
Calgarian whose roots date back five generations in Canada. A love of
words like mellifluous, festooning, and incandescence has fueled a life-
long passion for language and reading. Lorrie dedicates her talents to a
future united in the correct usage of “your” and “you’re,” not to mention
“their,” “there,” and “they’re.” A fervent advocate for raising healthier
generations, Lorrie has served as chief storyteller for Vivo for Healthier
Generations for the past three years.
About The Conference Board of Canada
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In response to the escalating burden of chronic illness in Australia, recent health policies have emphasised the promotion of patient self-management and better preventive care. A notable omission from these policies is the acknowledgment that patients with chronic illness tend to have co-morbid conditions. Our objectives were: to identify the common challenges co-morbidity poses to patients and carers in their experiences of self-management; to detail the views and perceptions of health professionals about these challenges; and to discuss policy options to improve health care for people with co-morbid chronic illness. The method included semi-structured interviews and focus groups with 129 purposively sampled participants. Participants were people with Type 2 diabetes, chronic obstructive pulmonary disease and/or chronic heart failure as well as carers and health care professionals. Content analysis of the interview data was conducted using NVivo7 software. Patients and their carers found co-morbidity influenced their capacity to manage chronic illness in three ways. First, co-morbidity created barriers to patients acting on risk factors; second, it complicated the process of recognising the early symptoms of deterioration of each condition, and third, it complicated their capacity to manage medication. Findings highlight challenges that patients with multiple chronic conditions face in relation to preventive care and self-management. Future clinical policy initiatives need to move away from single illness orientation toward strategies that meet the needs of people with co-morbid conditions and strengthen their capacity to self-manage. These patients will benefit directly from specialised education and services that cater to the needs of people with clusters of co-morbidities.
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To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations. Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions. Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (>10 contact times) delivered over a long duration (>or=6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge. This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up.
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♦ Chronic disease self-management education programs aim to empower patients through providing information and teaching skills and techniques to improve self-care and doctor–patient interaction, with the ultimate goal of improving quality of life. ♦ The recent 2006–07 federal budget allocated an unprecedented $515 million over 5 years for activation of patient self-management activities, commencing this financial year. ♦ Previous attempts in other countries to incorporate self-management education activities into the health care sector have faced setbacks because of inadequate integration into primary care. ♦ Engagement of health care professionals and their endorsement of self-management activities is critical to success. <br /
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The objective of this research was to explore self-management practices and the use of diabetes information and care among Black-Caribbean immigrants with type 2 diabetes. The study population included Black-Caribbean immigrants and Canadian-born participants between the ages of 35 to 64 years with type 2 diabetes. Study participants were recruited from community health centres (CHCs), diabetes education centres, hospital-based diabetes clinics, the Canadian Diabetes Association and immigrant-serving organizations. A structured questionnaire was used to collect demographics and information related to diabetes status, self-management practices and the use of diabetes information and care. Interviews were conducted with 48 Black-Caribbean immigrants and 54 Canadian-born participants with type 2 diabetes. Black-Caribbean immigrants were significantly more likely than the Canadian-born group to engage in recommended diabetes self-management practices (i.e. reduced fat diet, reduced carbohydrate diet, non-smoking and regular physical activity) and receive regular A1C and eye screening by a health professional. Black-Caribbean immigrant participants were significantly more likely to report receiving diabetes information and care through a community health centre (CHC) and nurses and dieticians than their Canadian-born counterparts. CHCs and allied health professionals play an important role in the management of diabetes in the Black-Caribbean immigrant community and may contribute to this group's favourable diabetes self-management profile and access to information and care. Additional research is necessary to confirm whether these findings are generalizable to the Black-Caribbean community in general (i.e. immigrant and non-immigrant) and to determine whether the use of CHCs and/or allied health professionals is associated with favourable outcomes in the Black-Caribbean immigrant community as well as others.
Self-Management Support for Canadians With Chronic Health Conditions: A Focus for Primary Health Care. Toronto: Health Council of Canada
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Health Council of Canada. Self-Management Support for Canadians With Chronic Health Conditions: A Focus for Primary Health Care. Toronto: Health Council of Canada, 2012. -. Helping Patients Help Themselves: Are Canadians With Chronic Conditions Getting the Support They Need to Manage Their Health. January 2010. www.healthcouncilcanada.ca/rpt_det.php?id=139.
Living a Healthy Life With Chronic Conditions
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Lorig, K., H.R. Holman, D. Sobel, D. Laurent, V. González, and M. Minor. Living a Healthy Life With Chronic Conditions. Boulder, CO: Bull Publishing, 2006.
The International Roundtable on the Self-Management of Chronic Conditions Summary Report: 'Minding the Gap': Building a Framework to Bridge Evidence, Policy and Practice in Self-Management Support for People With Chronic Conditions. Vancouver: British Columbia Centre of Excellence for Women
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Mills, S., R.H. Osborne, T.J. Brady, A.E. Rogers, and E. Vanden. The International Roundtable on the Self-Management of Chronic Conditions Summary Report: 'Minding the Gap': Building a Framework to Bridge Evidence, Policy and Practice in Self-Management Support for People With Chronic Conditions. Vancouver: British Columbia Centre of Excellence for Women's Health, 2009.
Towards Consensus on Self-Management Support: The International Chronic Condition Self-Management Support Framework Journal article submitted for publication. THE VIEW Perspectives on Chronic Disease Prevention and Management Find Conference Board research at www
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