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Objective: Since 2002, a course entitled 'Evidence-Based Public Health (EBPH): A Course in Noncommunicable Disease (NCD) Prevention' has been taught annually in Europe as a collaboration between the Prevention Research Center in St Louis and other international organizations. The core purpose of this training is to strengthen the capacity of public health professionals, in order to apply and adapt evidence-based programmes in NCD prevention. The purpose of the present study is to assess the effectiveness of this EBPH course, in order to inform and improve future EBPH trainings., Methods: A total of 208 individuals participated in the European EBPH course between 2007 and 2016. Of these, 86 (41%) completed an online survey. Outcomes measured include frequency of use of EBPH skills/materials/resources, benefits of using EBPH and barriers to using EBPH. Analysis was performed to see if time since taking the course affected EBPH effectiveness. Participants were then stratified by frequency of EBPH use (low v. high) and asked to participate in in-depth telephone interviews to further examine the long-term impact of the course ( n = 11 (6 low use, 5 high use))., Findings: The most commonly reported benefits among participants included: acquiring knowledge about a new subject (95%), seeing applications for this knowledge in their own work (84%), and becoming a better leader to promote evidence-based decision-making (82%). Additionally, not having enough funding for continued training in EBPH (44%), co-workers not having EBPH training (33%) and not having enough time to implement EBPH approaches (30%) were the most commonly reported barriers to using EBPH. Interviews indicated that work-place and leadership support were important in facilitating the use of EBPH., Conclusion: Although the EBPH course effectively benefits participants, barriers remain towards widely implementing evidence-based approaches. Reaching and communicating with those in leadership roles may facilitate the growth of EBPH across countries.

Depuis le rapport de la Commission sur les Déterminants Sociaux de la Santé, plusieurs pays ont commencé à intégrer à leurs plans de santé la question des déterminants et de leur impact sur les inégalités de santé. En France, la création des Agences Régionales de Santé en 2009 est considérée comme une opportunité pour agir sur les inégalités sociales de santé (ISS) avec les instances régionales, départementales et locales qui détiennent les leviers appropriés. A la suite d'une analyse thématique des projets régionaux de santé, visant à identifier l'intégration des ISS ainsi que les approches retenues pour les aborder, quatre régions ont été étudiées plus finement. Des entretiens collectifs et individuels ( N = 45 interviewés) ont été menés auprès d'acteurs de terrain et institutionnels, afin de mieux comprendre et identifier les types de programmes et processus pour réduire les ISS. Nos analyses font ressortir une prise en compte généralisée des ISS dans les documents de planification et de programmation des instances régionales, des stratégies régionales qui restent centrées sur les populations vulnérables avec une faible considération du gradient social, l'existence d'instances de concertations intersectorielles dans les quatre régions qui constituent un potentiel de gouvernance important à mieux exploiter, l'existence de modalités de suivi et d'évaluation des ISS qui restent à consolider, et une forte mobilisation de plusieurs secteurs dans les processus régionaux de consultation des publics et des acteurs, mais des résultats variables, souvent reliés au niveau de ressources investies et des approches privilégiées. L'analyse de ces expériences françaises démontre un intérêt croissant pour l'action sur les déterminants sociaux de la santé et les ISS ; mais leur opérationnalisation, toujours en cours, appelle à des analyses plus fines qui permettront de mieux éclairer les politiques publiques.

The control of noncommunicable diseases (NCDs) was addressed by the declaration of the 66th United Nations (UN) General Assembly followed by the World Health Organization's (WHO) NCD 2020 action plan. There is a clear need to better apply evidence in public health settings to tackle both behaviour-related factors and the underlying social and economic conditions. This article describes concepts of evidence-based public health (EBPH) and outlines a set of actions that are essential for successful global NCD prevention. The authors describe the importance of knowledge translation with the goal of increasing the effectiveness of public health services, relying on both quantitative and qualitative evidence. In particular, the role of capacity building is highlighted because it is fundamental to progress in controlling NCDs. Important challenges for capacity building include the need to bridge diverse disciplines, build the evidence base across countries and the lack of formal training in public health sciences. As brief case examples, several successful capacity-building efforts are highlighted to address challenges and further evidence-based decision making. The need for a more comprehensive public health approach, addressing social, environmental and cultural conditions, has led to government-wide and society-wide strategies that are now on the agenda due to efforts such as the WHO's NCD 2020 action plan and Health 2020: the European Policy for Health and Wellbeing. These efforts need research to generate evidence in new areas (e.g. equity and sustainability), training to build public health capacity and a continuous process of improvement and knowledge generation and translation., (© The Author(s) 2015.)

Given that chronic diseases account for 88% of all deaths in Canada, robust surveillance and monitoring systems are essential for supporting implementation of health promotion and chronic disease prevention policies. Canada has a long tradition of monitoring premature mortality expressed as potential years of life lost (PYLL), dating back to the seminal work by Romeder and McWhinnie in the late 1970s, who pioneered the use of PYLL as a tool in health planning and decision-making. The utility of PYLL for monitoring progress was expanded in the 1990s through the national comparable Health Indicators Initiative, following which PYLL has been monitored for several decades nationally, provincially, regionally and locally as part of health systems' performance measurement. Yet the potential for using PYLL in health promotion and chronic disease prevention has not been maximized. Linking PYLL with public health programs and initiatives aimed at health promotion and chronic disease prevention, introduced starting in the 1990s, would inform whether these efforts are making progress in addressing the burden of premature mortality from chronic diseases. Promoting the use of PYLL due to chronic diseases would contribute toward providing a more complete picture of chronic diseases in Canada.

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008–13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats—which include chronic disease—that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

Objectives: The aim of the Population Health Intervention Research Initiative for Canada (PHIRIC) is to build capacity to increase the quantity, quality and use of population health intervention research. But what capacity is required, and how should capacity be created? There may be relevant lessons from the Canadian Heart Health Initiative (CHHI), a 20-year initiative (1986-2006) that was groundbreaking in its attempt to bring together researchers and public health leaders (from government and non-government organizations) to jointly plan, conduct and act on relevant evidence. The present study focused on what enabled and constrained the ability to fund, conduct and use science in the CHHI., Methods: Guided by a provisional capacity-building framework, a two-step methodology was used: a CHHI document analysis followed by consultation with CHHI leaders to refine and confirm emerging findings., Results: A few well-positioned, visionary people conceived of the CHHI as a long-term, coherent initiative that would have impact, and they then created an environment to enable this to become reality. To achieve the vision, capacity was needed to a) align science (research and evaluation) with public health policy and program priorities, including the capacity to study "natural experiments" and b) build meaningful partnerships within and across sectors., Conclusion: There is now an opportunity to apply lessons from the CHHI in planning PHIRIC.

Chronic Diseases (CDs) are the leading causes of death and disability worldwide. CD experts have long promoted the use of integrated and intersectoral approaches to strengthen CD prevention efforts. This qualitative case study examined the perceived benefits and challenges associated with implementing an intersectoral network dedicated to CD prevention. Through interviewing key members of the Alberta Healthy Living Network (AHLN, or the Network), two overarching themes emerged from the data. The first relates to contrasting views on the role of the AHLN in relation to its actions and outcomes, especially concerning policy advocacy. The second focuses on the benefits and contributions of the AHLN and the challenge of demonstrating non-quantifiable outcomes. While the respondents agreed that the AHLN has contributed to intersectoral work in CD prevention in Alberta and to collaboration among Network members, several did not view this achievement as an end in itself and appealed to the Network to engage more in change-oriented activities. Managing contrasting expectations has had a significant impact on the functioning of the Network.

A number of major challenges face surveillance systems in the field of chronic disease. The complex interplay of risk factors and determinants that result in chronic disease is calling into question traditional surveillance systems in terms of what is collected to inform policy decisions. At the same time, the complexity presents an opportunity to broaden the evidence base on which arguments can be based for chronic disease intervention to increase their potential to influence policy makers. This article describes some initiatives in Canada to enhance the capacity and utility of surveillance systems and their associated data to inform policy making in the field of chronic disease.

Decision makers consider numerous factors besides surveillance data in establishing public health policies and programmes. In an evidence-informed system, it is important to collect, interpret, and present information that has maximum impact on the broader policy agenda.Successful policies and programmes are rational, feasible, and practical, with wide public support. Surveillance systems must align and interact with the other parts of the policy infrastructure. There must be continuous links between data providers, collectors, and users. Data must be representative of population variations.For chronic diseases, the major challenge is multiple risks. Surveillance systems must capture many factors from many sources. Data must be presented in plain language and tailored to the needs of various users - politicians, policy makers, health providers, researchers, and the public. Data must be linked to other policy areas such as taxation. Economic arguments, including modelling, strongly influence decisions. Broad data ownership through alliances also has significant impact.

Background: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health., Methods: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought., Results: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation., Conclusion: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Too often, public health decisions are based on short-term demands rather than long-term research and objectives. Policies and programmes are sometimes developed around anecdotal evidence. The Evidence-Based Public Health (EBPH) programme trains public health practitioners to use a comprehensive, scientific approach when developing and evaluating chronic disease programmes. Begun in 2002, the EBPH programme is an international collaboration. The course is organized in seven parts to teach skills in: 1) assessing a community's needs; 2) quantifying the issue; 3) developing a concise statement of the issue; 4) determining what is known about the issue by reviewing the scientific literature; 5) developing and prioritizing programme and policy options; 6) developing an action plan and implementing interventions; and 7) evaluating the programme or policy. The course takes an applied approach and emphasizes information that is readily available to busy practitioners, relying on experiential learning and includes lectures, practice exercises, and case studies. It focuses n using evidence-based tools and encourages participants to add to the evidence base in areas where intervention knowledge is sparse. Through this training programme, we educated practitioners from 38 countries in 4 continents. This article describes the evolution of the parent course and describes experiences implementing the course in the Russian Federation, Lithuania, and Chile. Lessons learned from replication of the course include the need to build a "critical mass" of public health officials trained in EBPH within each country and the importance of international, collaborative networks. Scientific and technologic advances provide unprecedented opportunities for public health professionals to enhance the practice of EBPH. To take full advantage of new technology and tools and to combat new health challenges, public health practitioners must continually improve their skills.

This paper addresses a fundamental question in evidence based policy making--can scientists and policy makers work together? It first provides a scenario outlining the different mentalities and imperatives of scientists and policy makers, and then discusses various issues and solutions relating to whether and how scientists and policy makers can work together. Scientists and policy makers have different goals, attitudes toward information, languages, perception of time, and career paths. Important issues affecting their working together include lack of mutual trust and respect, different views on the production and use of evidence, different accountabilities, and whether there should be a link between science and policy. The suggested solutions include providing new incentives to encourage scientists and policy makers to work together, using knowledge brokers (translational scientists), making organisational changes, defining research in a broader sense, re-defining the starting point for knowledge transfer, expanding the accountability horizon, and finally, acknowledging the complexity of policy making. It is hoped that further discussion and debate on the partnership idea, the need for incentives, recognising the incompatibility problems, the role of civil society, and other related themes will lead to new opportunities for further advancing evidence based policy and practice.

The use of evidence-based reasoning and decision-making theory and practice is becoming increasingly commonplace in most of the health sciences. Public health, which encompasses health protection, disease prevention and health promotion, has traditionally been more evidence-based than clinical medicine. However, more must be done to grade evidence in the absence of classical clinical trials or other experimental proof. Decisions in public health also rely on economical, social and political considerations, but how can evidence in these fields be graded for the best possible decision-making in public health? Moreover, evidence is often unequally distributed in relation to different focus groups. For example, evidence in the area of women's health should be as extensive as it is in the area of men's health. Medicine has traditionally been more ethically inclined than many other fields of human endeavour. In light of this, should we require all decision makers involved in health policies (i.e. politicians, economists, and other stakeholders) to be equally ethically minded? Decisions made without using the best evidence in setting the priorities of health programs and health policies may be ethically questionable. However, the burden and responsibility no longer lie exclusively on the shoulders of physicians and nurses. Evidence-based problem solving and decision-making in health sciences are only approximately a decade old. As a result, the already impressive, but still incomplete accomplishments of the evidence-based medical world require further advancements.

Objective: To report the associations of plasma triglyceride, high density lipoprotein cholesterol (HDL-C) and low density lipoprotein cholesterol (LDL-C) with nonlipid coronary artery disease risk factors. In particular, the associations for persons with high triglyceride and low HDL-C levels were examined., Design: A stratified random probability sample of 29,855 men and women aged 18 to 74 years from the Canadian Heart Health Surveys (1986 to 1992) in 10 provinces. Blood samples were obtained from 18,555 participants who had fasted for 8 h or more. Plasma lipids were determined at the J Alick Little Lipid Research Laboratory, Toronto, Ontario, with standardization of the Centers for Disease Control Lipid Standardization Program, Atlanta., Outcome Measures: Fasting plasma total cholesterol, triglyceride, LDL-C and HDL-C levels., Main Results: The prevalence of men with triglyceride levels above 1.7 mmol/L and HDL-C levels below 0.9 mmol/L was 10%, compared with 3% for men with triglyceride levels below 1.7 mmol/L and HDL-C levels below 0.9 mmol/L. The prevalence of women with triglyceride levels above 1.7 mmol/L and HDL-C levels below 0.9 mmol/L was 3% compared with a prevalence of less than 1% for women with triglyceride levels below 1.7 mmol/L and HDL-C levels below 0.9 mmol/L. Even when plasma LDL-C was low at less than 3.4 mmol/L, there was an age trend for increasing prevalences of the combination of triglyceride levels 2.3 mmol/L or greater and HDL-C levels less than 0.9 mmol/L in both sexes. The prevalence of a triglyceride levels 2.3 mmol/L or greater combined with an HDL-C level below 0.9 mmol/L was increased in groups who were cigarette smokers, diabetic, hypertensive, obese or sedentary, or who had higher LDL-C levels in both sexes, and the increase was even greater in the presence of two or more of these other risk factors., Conclusions: Among men or women with low HDL-C and high triglyceride levels, smoking, diabetes, sedentariness, hypertension and obesity were much more prevalent than among those at low risk with high HDL-C and low triglyceride levels.

Objective: To report the prevalence of lipid and nonlipid coronary artery disease risk factors in women classified by use of oral contraceptives or sex hormone replacement therapy., Design, Setting and Participants: A population-based cross-sectional survey in nine Canadian provinces (not including Nova Scotia) between 1988 and 1992 invited 13,506 women aged 18 to 74 years to participate. During a clinic visit after a home interview, a blood sample was obtained following a fast of 8 h or more from 8637 women., Outcome Measures: Fasting plasma total cholesterol, triglycerides, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, blood pressure, smoking status, self-reported diabetes, and self-reported use of oral contraceptive or sex hormone replacement therapy pills., Main Results: The prevalence of oral contraceptive use was 41% for women 18 to 24 years old and 20% for women 25 to 34 years old. The prevalence of sex hormone replacement therapy was 4% for women 35 to 44 years old, 20% for women 45 to 64 years old and 11% for women 65 to 74 years old. Users of sex hormone replacement therapy aged 35 to 44 years had slightly higher mean LDL cholesterol than nonusers (3.04 versus 2.89 mmol/L). Users and nonusers aged 45 to 54 years had similar LDL cholesterol levels, and users aged 55 to 64 and 65 to 74 years had lower LDL cholesterol and higher HDL cholesterol levels, respectively, than nonusers. Triglyceride levels were higher in oral contraceptive users and in younger women on sex hormone replacement therapy than in nonusers. In the general population of Canada the use of oral contraceptives in women less than age 35 years had only a marginal effect on the prevalence of lipid and nonlipid risk factors. Women aged 18 to 24 years using oral contraceptives had a higher mean LDL cholesterol level of 2.73 versus 2.35 mmol/L for nonusers. The prevalence of lipid and nonlipid risk factors in women using sex hormone replacement therapy increased slightly for those aged 35 to 54 years and decreased in women aged 55 to 74 years. A lower percentage of women using sex hormone replacement therapy, aged 55 to 74 years, had high risk LDL cholesterol levels (21% versus 36% for nonusers). A larger percentage of women using sex hormone replacement therapy had low risk HDL cholesterol levels (54% versus 29% for nonusers). The nonlipid risk factor profile for women aged 35 to 54 years on sex hormone replacement therapy was less favourable than for nonusers: obesity was more common (36% versus 28%, respectively), hypertension was higher (22% versus 12%, respectively), and the proportion of women with one or more nonlipid risk factors was higher. The nonlipid risk factor profile for women 55 to 74 years of age who were using sex hormone replacement therapy was more favourable than for nonusers: obesity was lower (31% versus 47%, respectively), smoking was lower (7% versus 16%, respectively), sedentary behaviour was lower (28% versus 37%, respectively), and fewer women had two or more of these risk factors (31% versus 52%, respectively)., Conclusion: The findings suggest that women at higher risk for coronary artery disease tend to have a lower prevalence of use of sex hormone replacement therapy.

Background: Currently there are at least 22 countries worldwide where national, regional or pilot population-based breast cancer screening programmes have been established. A collaborative effort has been undertaken by the International Breast Cancer Screening Network (IBSN), an international voluntary collaborative effort administered from the National Cancer Institute in the US for the purposes of producing international data on the policies, funding and administration, and results of population-based breast cancer screening., Methods: Two surveys conducted by the IBSN in 1990 and 1995 describe the status of population-based breast cancer screening in countries which had or planned to establish breast cancer screening programmes in their countries. The 1990 survey was sent to ten countries in the IBSN and was completed by nine countries. The 1995 survey was sent to and completed by the 13 countries in the organization at that time and an additional nine countries in the European Network., Results: The programmes vary in how they have been organized and have changed from 1990 to 1995. The most notable change is the increase in the number of countries that have established or plan to establish organized breast cancer screening programmes. A second major change is in guidelines for the lower age limit for mammography screening and the use of the clinical breast examination and breast self-examination as additional detection methods., Conclusion: As high quality population-based breast cancer screening programmes are implemented in more countries, they will offer an unprecedented opportunity to assess the level of coverage of the population for initial and repeat screening, evaluation of performance, and, in the longer term, outcome of screening in terms of reduction in the incidence of late-stage disease and in mortality.

The question of how to enhance the dissemination of knowledge and the use of innovations related to disease prevention and health promotion was posed to an international group of experts at an invitational research conference held in Vancouver, British Columbia in March 1995. The Canadian Conference on Dissemination Research Strengthening Health Promotion and Disease Prevention was co-sponsored by 15 voluntary organizations, government agencies and industries. It examined advances and gaps in the study of diffusion and adoption of preventive knowledge and practices among health professionals and the public. It was the first national conference of its kind devoted to dissemination research and dissemination of research specifically in health promotion and disease prevention. This paper summarizes the major issues raised in the papers presented at this conference. Policies and strategies for strengthening dissemination research and the dissemination of health promotion knowledge and practices are suggested.

The Canadian Heart Health Initiative is a country-wide strategy for the prevention of cardiovascular disease. Initiated with a 15-year horizon, it has resulted in extensive networks and coalitions involving Health Canada, the 10 provincial departments of health and over 1,000 organizations. There are five phases: policy development through country-wide consultations (1986-88); provincial heart health surveys (1986-91); research demonstration programs (1989-97); and evaluation (1994-97). The dissemination research phase studies the adoption of interventions by communities and health systems. As a paradigm for dissemination of health policy, some key features of the Initiative are translation of the science base in prevention into community programs; consensual policy development; federal and provincial co-funding arrangements; key role played by the public health system; capacity building; organization and management model linking activities at the national, provincial and community levels. The methodologies and capacities developed are applicable to other health promotion and disease prevention areas.

Although screening for cervical cancer has been shown to be effective in reducing the morbidity and mortality associated with this disease, and despite many attempts to encourage the development of provincial programs, as of 1995 no province had a comprehensive screening program for cervical cancer. Participants at the Interchange '95 workshop, held in Ottawa in November 1995, reviewed the recommendations of the 1989 National Workshop on Screening for Cancer of the Cervix and identified factors that have impeded their implementation. Participants discussed the need for comprehensive information systems, quality control and strategies to increase recruitment of unscreened and underscreened women. They concluded that the formation of a Cervical Cancer Prevention Network involving key stakeholders will facilitate the development and implementation of provincial programs to ensure optimal screening. They agreed that, in the interim, recommendations for practising physicians should remain as they were following the 1989 workshop.

The 1987 Report of the federal/provincial working group on cardiovascular disease prevention entitled "Promoting Heart Health in Canada" was developed about the time the new concepts for health promotion were emerging in government policy. The public health strategy supported in "Promoting Heart Health in Canada" captured the approach advocated in the Ottawa Charter for health promotion: need for environmental, intersectorial approaches and healthy public policy. The implementation of this policy framework had led to the Canadian Heart Health Initiative. It provided a step by step approach to the implementation of the ten provincial heart health programs. Key assets for the Initiative include the development of effective partnerships with over 300 organizations at the provincial, national and international levels; a large database on risk factors and over 40 demonstration communities which should contribute to interventional knowledge in the area of prevention. The heart health model provides an approach to address increasingly complex health issues that we can expect to face in the year 2000.

Background: Self-management teaching programs are becoming an important asset in the management of pediatric asthma., Objective: The study was designed to evaluate the impact of self-management teaching programs on the morbidity of pediatric asthma., Methods: The meta-analysis included randomized clinical trials, published between 1970 and 1991, addressing the outcome of morbidity. Studies were retrieved from searches of MEDLINE, American Journal of Nursing International Index, and Dissertation Abstracts Online Database. The quality of studies was assessed with the scale of Chalmers. The pooled effect size was calculated by the method of Hedges., Results: The literature search retrieved 23 randomized clinical trials, but 12 studies had to be excluded. Global score of quality of studies (Chalmers' scale) was fair, 51.6% +/- 9.9%. As indicated by the effect size (ES) of the pooled studies, self-management teaching did not reduce school absenteeism (ES: 0.04 +/- 0.08), asthma attacks (ES: 0.09 +/- 0.14), hospitalizations (ES: 0.06 +/- 0.08), hospital days (ES: -0.11 +/- 0.08), or emergency visits (0.14 +/- 0.09)., Conclusion: Self-management teaching programs do not seem to reduce morbidity, and future programs should focus more on intermediate outcomes such as behavior.

Health professionals can play a major role in prevention. They are perceived as a reliable and credible source of health information and they have contact with a large percentage of the population every year. In Canada, a key development for the integration of prevention in clinical practice was the establishment of the Canadian Task Force on the Periodic Health Examination. The Task Force has provided guidance on effective preventive interventions in the clinical setting over the past 15 years. The challenge lies in the implementation of these guidelines. We need to find innovative ways to disseminate and promote them. In this context, the creation of a National Partnership for Quality in Health is an important avenue for the coordination of practice guideline development and implementation in this country. An emerging concern in the delivery of preventive services is the coordination of activities of health professionals within the public health sector, with those of clinical care. In Canada, such a comprehensive and coordinated approach has been put into practice through the Canadian Heart Health Initiative.

Objective: To estimate the prevalence and distribution of the coexistence of major cardiovascular disease (CVD) risk factors among Canadian adults., Design: Population-based cross-sectional surveys., Setting: Nine Canadian provinces, from 1986 to 1990., Participants: A probability sample of 26,293 men and women, aged 18 to 74 years, was selected from provincial health insurance registries. For 20,582 of these participants, at least two blood pressure (BP) measurements were taken using a standardized technique. At a subsequent visit to a clinic, two additional BP readings, anthropometric measurements and a blood specimen for plasma lipid analysis were obtained., Outcome Measures: The percentage distribution of subjects by number of major risk factors (smoking, high BP and elevated blood cholesterol level) and by concomitant factors (body mass index [BMI], ratio of waist to hip circumference [WHR], physical activity, diabetes, awareness of CVD risk factors and education)., Main Results: Sixty-four percent of men and 63% of women had one or more of the major risk factors. Prevalence increased with age to reach 80% in men and 89% in women aged 65 to 74 years. Prevalence of two or three risk factors was highest among men in the 45-54 age group (34%) and in women in the 65-74 age group (37%). The most common associations were between smoking and high blood cholesterol level (10%) and between high BP and high blood cholesterol level (8%). Prevalence of high BP and elevated blood cholesterol, alone or in combination, increased with BMI and WHR. Smoking, elevated blood cholesterol, BMI and prevalence of one or more risk factors increased with lower level of education. Less than 48% of participants mentioned any single major risk factor as a cause of heart disease. Awareness was lowest in the group with fewest years of education., Conclusion: The findings of this study call for an approach to reduce CVD that stresses collaboration of the different health sectors to reach both the population as a whole and the individuals at high risk.