Public health affects everybody – it’s inescapable but paramount. Recent societal changes seen in the UK formed from public health policy include the five-a-day healthy eating initiative, the smoking ban and the sugar tax.In Canada, the Canadian Public Health Association (CPHA) is the independent national voice and trusted advocate for public health, speaking up for people and populations to all levels of government. Through its work, CPHA has operated untiringly to improve Canadian public health, having previously advocated for national health insurance in the late 1930s, fluoridation in the early 1970s, and establishment of the first national HIV/AIDS education and awareness programme in the 1980s.Dr Suzanne Jackson has worked in the public health field since the early 1980s and is the current Chair of CPHA (2017–18). In her career, she has seen numerous positive global public health changes but is aware that more needs to be done. She sat down with us at Research Outreach to discuss this, and more, in further detail.
Hello Suzanne! Can you give us an overview of what the CPHA does?
CPHA is primarily a member-driven organisation. Its members represent a diverse range of roles and professions in public health – nurses, physicians, inspectors, nutritionists, dentists, health promoters and researchers.
The Board defined a strategic vision for CPHA in 2015 that represents an overview of what we do. Two goals are related to the organisation (engaged membership, financial stability), and the remaining four goals relate to our main role. These include:
- National, independent evidence-based voice for public health in Canada
- Represent the public health community’s interests in public health system renewal
- Convenor of partners to identify solutions to public health issues
- Inspire and motivate change in support of health equity
We run a big conference every year to exchange the latest information about what is going on in public health, we convene a national table for all provincial and territorial public health associations to meet several times a year (mostly by teleconference), we research policy issues of interest to our membership, and we also develop position statements which form the basis of our advocacy to government departments, media and other organisations.
CPHA also runs some projects under contract to government and others to create resources or training opportunities for public health workers. We serve as the home for the Canadian Journal of Public Health and we communicate with our members regularly about events, new reports and publications, and jobs in the field of public health in Canada.
The CPHA marked its centenary in 2010. What impact do you think the organisation has had on Canadian public health since it was founded? Are there any achievements that really stand out for you?
I have always been proud of CPHA for taking positions on public health at the leading edge. As a worker in the system, it was great to see the leadership offered by taking a stand on issues ahead of what the rest of the field was doing. For example, we are making an important contribution to what to do about climate change.
My involvement in the field goes back to the mid-80s when CPHA co-sponsored the Ottawa Charter conference with WHO in 1986. Since then, this has led to a remarkable 30 years of global attention to health promotion following the same guidelines – no other field can argue such global consistency. Not only that, but, also in 1986, CPHA established the first national HIV/AIDS education and awareness programme.
CPHA also held positions on the dangers of smoking and second-hand smoke that added to the pressures to change policy felt by all levels of government. However, the way I remember it is that some very committed and brave Medical Officers of Health in Ottawa and Toronto persuaded their local Boards of Health to adopt innovative by-laws, serving as members of CPHA and leaders in public health in the country. The anti-smoking in public places by-laws were a remarkable public health achievement.
Among many other major public health milestones, CPHA notably advocated for national health insurance in 1939, abortion in 1972, water fluoridation in 1977, and against nuclear weapons in 1982.
What is the importance of research in CPHA’s work?
Careful policy research about the level of evidence in the literature in relation to identifying the key components of a policy issue is very important. CPHA prides itself in providing timely, evidence-informed public health guidance and perspectives to public health professionals and policy makers. It ensures that its positions and statements can be backed up by the best available evidence. We also re-evaluate our positions periodically to ensure that we do not become dogmatic and that we are informed
by the most recent evidence.
An evidence-based approach is important for us to be a credible voice for public health in Canada and to advocate for change to public policy to the federal government.
What involvement does CPHA have in the development of public health policy?
We have had some influence. For example, the Chief Public Health Officer’s Report in 2015 focused on alcohol and our position paper was referred to several times.
Our 2014 recommendations to the House of Commons’ Standing Committee on Health regarding e-cigarettes were repeated practically verbatim in the Committee’s report. These recommendations are echoed in the current Bill S-5 in the Senate.
Our 2016 recommendations to the Task Force on the Legalisation and Regulation of Cannabis are clearly represented in the Task Force’s recommendations to government.
Although we cannot be sure of the extent of our influence at other levels, I believe that CPHA papers and resources have been used by public health officers across the country to advocate for changing policies at the local public health unit level. They have been used in the preparation of media reports about health issues in Canada. Media exposure affects public opinion which, in turn, affects politicians and policy makers.
I have always been proud of the Canadian Public Health Association for taking positions on public health at the leading edge
As a specialist in health promotion, can you explain what is meant by health promotion? What are the benefits of considering an issue from a health promotion perspective?
As per the Ottawa Charter, 1986, health promotion is “the process of enabling people to increase control over their health.” I see four main ‘hooks’ coming from this definition and these guide my teaching and practice.
- Focus on determinants of health – the factors that affect people’s health are broad and include peace, clean environment, resilient ecosystem, education, income. This means that health promoters focus on changing policy to affect such broad factors. This was originally conceived as building healthy public policy, but it has now evolved into “whole of government” policies and “health in all policy”. This also forces attention on “creating supportive environments” and “intersectoral collaboration.”
- Focus on the positive – health promotion focuses on achieving something positive – health – it is goal-oriented rather than problem or disease oriented. Instead of looking at people as bundles of problems and deficits, health promoters look at people as collections of strengths and assets. This means using a “situational analysis” rather than a “needs assessment” in programme planning as well as focusing on achieving goals framed in a positive way.
- Focus on participation – in order to enable people to increase control over their health, they need to be involved directly in the decisions that affect their health. This means using participatory approaches to planning, evaluation and research. This means listening at the individual level, using group consensus methods at the community level, and community development approaches and participatory decision-making at the societal level. “Strengthening community action” was the original Ottawa Charter strategy.
- Using multiple strategies at multiple levels – given the breadth of work required in health promotion from the individual to family to community to societal levels, many kinds of strategies are required from health education, community development, intersectoral collaboration to building healthy public policies. Health promotion is about affecting change at individual, community and societal levels and there are many theories and strategies guiding this work.
The benefits of considering an issue from a health promotion perspective is that one considers a range of causes of the causes – one looks at what can be achieved positively rather than reducing a deficit, and a range of possible strategies are considered.
In June, CPHA is hosting the Public Health 2017 conference. Could you tell us a bit more about this? How important is it for the public health community?
CPHA hosts Canada’s largest annual public health conference to share current research, promote best practices and improve health and well-being. The conference is an important opportunity for public health workers and researchers to meet, network and exchange views on interventions and concepts that are working. CPHA holds the conference in different parts of the country each year to make it easier for people in that area to come and highlight achievements in different parts of Canada. This year it is being held in Halifax and next year it will be in Montreal. It keeps us connected to what is going on in all parts of the country and it is good for inspiring the next generation of public health workers.
One of CPHA’s goals has been to increase understanding that health is determined by many factors outside of the health care system. So, for example, living with violence, or in fear of violence. What are the advantages of bringing factors outside the health care system to bear on the understanding of health?
Realising that there are factors outside the health system that affect health helps to identify the policy changes needed to affect the greatest numbers of people at the population level. Inequities become clear and this is also important to recognise in policy. Looking upstream keeps us from blaming people living in difficult circumstances for their health problems and steers us away from taking an individual behaviour change approach.
I like the way public health goes beyond individual behaviour change to look at the conditions that create health
When other sectors recognise the parts they play in creating unhealthy or healthy conditions, partnerships can emerge. So, for example, CPHA partners with the Canadian Produce Marketing Association to promote the consumption of vegetables and fruits.
As mentioned in the previous question, CPHA has drawn attention to the impact on health of living with violence, or in fear of violence. This has been most notable in the case of missing and murdered Indigenous women. If violence was clearly identified as a priority health issue in federal policy, what difference do you think that would make to violence against Indigenous women in Canada?
Violence in all its forms is a key determinant of mental illness. Making societies free from discriminatory practices, bullying and other forms of violence, promotes mental wellness. If we don’t address this issue, people will still suffer unnecessarily from mental stress and illness.
If violence prevention is clearly identified as a priority health issue in federal policy, it sets a clear direction for other policies at the provincial and municipal levels. Given the federal involvement directly in Indigenous issues in Canada, a clear policy should have a direct influence on decreasing violence towards Indigenous women. The policy would have to be holistic and recognise the intergenerational trauma of residential schools. It would also need to put in place other components that would be required to reduce structural or system level violence, such as dealing with housing, water and sanitation, food security, youth health, employment and income, and cultural connections. And very importantly, the policy process should engage Indigenous peoples in its formulation, so that further system violence of exclusion from decision-making is not perpetuated. CPHA is currently working with Indigenous leadership in Canada to work out how their perspectives can be included in CPHA advocacy positions and relationships.
There is currently a growing opioid crisis in Canada, which is resulting in large numbers of overdose deaths. What are CPHA’s strategies for dealing with this issue?
As our position statement on the Opioid Crisis states, we believe that the current emphasis on changing prescribing practices and disrupting the availability of drugs are limited strategies. These are interventions aimed at the downstream impact of problematic substance use. CPHA is recommending that Canadians address the underlying causes of problematic substance use such as trauma, racism, colonialism, criminalisation, and poverty.
In addition, CPHA advocates for involvement of people with lived experience with opioids in discussions about the best approach to take; take a harm reduction approach (e.g. more safe consumption facilities in communities; make naloxone available over the counter); develop legislation to protect first responders to overdoses; strengthen surveillance information to monitor the situation and evaluate progress.
Finally, can you tell us what is it about public health that interests you personally?
I really like that public health takes a population focus and tries to make sure everyone is reached using public health measures (e.g. immunisations, nutrition, school health, healthy babies, tobacco legislation). I like the systems or structural approach to much of public health successes (e.g. restaurant inspections, water monitoring, sanitary systems, tobacco by-laws, seatbelt legislation). I like the way public health looks at the causes of the causes and goes beyond individual behaviour change to look at the conditions that create health and works at the policy level. I also like the values of equity, cultural sensitivity, focusing upstream, environmental concerns, participatory approaches, and the interest in evidence.
- For more information on CPHA – the Canadian Journal of Public Health, their conference or the Association itself – please visit their website at www.cpha.ca