Part 1: Implementation Processes Supporting Population Health Intervention Research

[ Table of Contents ]

The following cases show how population health intervention research is supported through a variety of implementation processes such as intersectoral collaboration, knowledge synthesis and the development of decision-making tools.

Expanding Evidence Reviews and Knowledge Translation

This realist review is an example of a comprehensive knowledge translation project focused on gathering, contextualizing, synthesizing, sharing and applying the knowledge produced from population health interventions designed to support homeless adults with concurrent mental health and substance use disorders. The authors build on traditional approaches to evidence review and synthesis by partnering with communities to explore evaluations from community-based programs and to conduct a qualitative investigation into promising program strategies and contextual factors that support their success.

Case 1 – Valuing context and collaboration in population health intervention research: a realist review of community treatment approaches for homeless adults with concurrent disorders

Kelly Murphy, Dr. Patricia O'Campo, Emily Holton, Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON

Corresponding author: Kelly Murphy, murphyke@smh.ca

Introduction

Homeless people experience significant, persistent inequities in health and access to health care services compared to the general population. When a homeless person has a concurrent mental health and substance use disorder (concurrent disorder), it puts them at even more disadvantage. The prevalence of concurrent disorders in the homeless population is estimated to be 10-20 percent across North America, although the actual prevalence may be far greater (BC Ministry of Social Development and Economic Security, 2001). In a 2007 community consultation, inner city health service providers described the need for better, more integrated and more responsive services for their homeless clients with concurrent disorders. To help guide policy and program planning, providers said a stronger evidence base was needed to explain what types of community-based interventions best retain and engage clients, and reduce their problems with mental health problems and substance use.

To respond to this request, our interdisciplinary research team carried out a realist-informed, community-partnered evidence synthesis in 2007-2008. We took an integrated knowledge translation approach to promote research uptake and implementation. Community partners were involved in all aspects of the project, including identifying the research question, determining the scope of review, assessing the relevance of literature, and disseminating results. Project partners were the Centre for Research on Inner City Health; Access Alliance Multicultural Health and Community Services; the Ontario Federation of Indian Friendship Centres; Sistering, a Women's Place; Street Health; and South Riverdale Community Health Centre in Toronto.

Our goal was to advise the Ontario Ministry of Health and Long-Term Care and Local Health Integration Networks about appropriate services for homeless people with concurrent disorders. We also wanted to show how grassroots collaborations can contribute to positive health and social service system change, and identify a new method for synthesizing population health intervention research evidence.

Project description and lessons learned

Because it includes and synthesizes all studies in a field—both positive and negative—a systematic review is more comprehensive than an individual research study, and should offer more reliable evidence to guide decision making. However, standard systematic reviews privilege studies that use randomized controlled trial methodology, and population health interventions are often too complex, adaptive, and dependent on context to standardize for randomized controlled trials. To address these concerns, our approach drew heavily from realist methodology, an approach that accommodates analysis of contextual factors and is aimed to illuminate not only whether a complex intervention works, but also "for whom it works, in what circumstances, in what respects, and how" (Pawson, Greenhalgh, Harvey & Walshe, 2005). Realist review is appropriate for studying many different kinds of interventions and populations. It accommodates many types of evidence (for example, randomized controlled trials, qualitative studies, grey literature, case studies) and assesses the quality of evidence using multiple criteria, including relevance of the research method for the study question (Pawson, Greenhalgh, Harvey & Walshe, 2005).

Altogether, we collected evaluations of 10 different community-based programs for homeless clients with concurrent disorders delivered in a range of community settings (for example, drop-ins, residential facilities). Information related to program contexts, successes and failures was extracted and further supplemented by key informant interviews. From the 10 programs, we identified six promising program strategies that reduce problems with mental health and, to a lesser degree, substance use.

As is often the case with complex population health interventions, no stand-alone strategy was identified. Successful concurrent disorder programs implemented two or more of the following promising strategies in various combinations: client choice in treatment decision making, positive interpersonal relationships between client and provider, assertive community treatment approaches, supportive housing, supports for instrumental needs, and nonrestrictive program approaches. We found that these promising program strategies function, in part, by promoting and supporting autonomy.

Our review also showed that the existing research literature does not address the priority subpopulations identified by our stakeholders, namely: homeless women, newcomers and refugees, and Aboriginal Peoples with concurrent disorders. We did not find any program evaluations with an explicit harm reduction approach, although such approaches matter a great deal to our partners and their clients. This lack of evidence about services for marginalized groups is an important health equity problem that needs to be addressed. In our Community Report (St. Michael's Hospital Centre for Research on Inner City Health, 2009), agencies described how a lack of research evidence limits innovation and opportunities to learn from innovation.

A key strength of our review is that we applied a health equity lens in our analyses. We did not look at concurrent disorders programs in general; we focused on programs designed for marginalized adults and unpacked what works for complex groups. A related strength is that we were able to integrate providers' knowledge of 'what matters' and researchers' skills in uncovering 'what works and how.' Partners' involvement throughout the knowledge synthesis process ensured that the project focused on an issue of real importance to decision makers. We co-developed terms of reference early on and found it to be a very helpful tool for outlining roles and responsibilities in advance. Our challenges were primarily related to staffing; it was difficult for community agencies to dedicate a great deal of time or resources to the project. Changes in community agency management also posed a challenge, resulting in shifting priorities and commitment to the project.

Implications for research, policy and practice

We disseminated our realist review results through our collaboratively written, Community Report (St. Michael's Hospital Centre for Research on Inner City Health, 2009) and a scholarly journal article. The latter was very well received by academic reviewers because it demonstrated use of the realist approach for synthesizing evidence on complex urban health interventions (O'Campo, Kirst et al, 2009).

The Community Report is a knowledge translation innovation that other integrated knowledge translation teams may find useful to adopt. The report (a full colour, eight-page booklet) described our team, policy change objectives, our research methodology, and our findings and key messages. In developing the report, partners identified what information would be of greatest interest to program planners and policy makers. Based on these recommendations, we included an appendix with contextual information and an annotated description of each of the 10 concurrent disorder programs that were reviewed. This material was not included in the journal article, and the researchers would not have known to include it without a dialogue with partners. Partners also vetted the Community Report for appropriate language. Our discussions about language illuminated the need not simply to use plain language, but also to emphasize health equity and to use context-appropriate language. For example, partners discouraged use of the label "assertive community treatment" in our report because of controversies associated with such programs in Toronto. Working alone, the researchers on our team would not have had this insight. Based on such advice, we adopted less contentious language. Partners also described and wrote several sections of the report concerning gaps in the research literature (see above).

We launched the Community Report at a widely publicized workshop that included responses from policy stakeholders in the Ontario Ministry of Health and Long-Term Care, the City of Toronto, and the Toronto Central Local Health Integration Network. The report was accepted by the Ministry as input to inform its new Mental Health and Addictions Strategy, and by the Toronto Central Local Health Integration Network to inform new mental health planning for homeless populations. Our findings also contributed to an evidence base to support implementation in Toronto of the Mental Health Commission of Canada's Research Demonstration Project on Homelessness and Mental Health. Following the launch of the report, our research agency team has continued to collaborate on spin-off projects related to concurrent disorder program evaluation.

The report was well received and the project has led to ongoing relationships for a number of reasons. First, the project was timely and responded to a clearly articulated need: revising mental health and addictions policies were high provincial government and regional priorities. Moreover, the report focused on issues of real relevance in our context, and delivered clear descriptions of promising, health-equity focused interventions that could be adopted and adapted to address concurrent disorders.

The information we included in the synthesis was not easy to find. The majority of research studies provided scant explanation of program delivery processes, population characteristics (for example, ethnicity), program philosophies or program contexts (for example, characteristics of the physical, social, cultural, legal and economic environment). Yet this information about context may be what matters most in decision makers' assessments of whether complex population health interventions can be transferred or generalized to new contexts. To respond to this knowledge gap, we supplemented our literature synthesis with interviews with key informants and authors. This information should help stakeholders understand the contexts in which successful programs were implemented and better judge whether those results can be generalized to new contexts.

To provide practical support for healthy public policy decisions, it is crucial that researchers study interventions and populations that matter to stakeholders. It is also necessary, in primary data collection, to provide thicker descriptions of population health interventions (that is, detailed descriptions of programs, populations, environments, factors affecting implementation, factors affecting equitable or inequitable outcomes and a consideration of the reasons for anomalous results). Describing and explaining interventions in detail from the perspectives of providers, planners and clients is a component of realist-informed research designs (Pawson & Tilley, 1997). These data can be collected effectively using qualitative methods, especially in collaboration with program staff, clients and affected communities. Taking these extra steps will enable researchers to generate more comprehensive results, and it will provide research users with information that is essential for planning evidence-informed population health interventions.

Acknowledgements

This research was supported by a Canadian Institutes of Health Research Strategic Training Initiative in Health Research grant (STO-64598), the Ontario Ministry of Health and Long-Term Care, and the Alma and Baxter Ricard Chair in Inner City Health. We would like to thank the following individuals who participated in the research activities: Gladis Chow, Susan Clancy, Jessica Hill, Axelle Janczur, Erika Khandor, Rosane Nisenbaum, Lynne Raskin, Anjali Sharma, Janet Smylie, Melissa Tapper, Charoula Tsamis, Qamar Zaidi, Carolyn Ziegler, and Marcqueline Chiona Zulu.

References

BC Ministry of Social Development and Economic Security. (2001). Homelessness—causes and effects: A profile, policy review and analysis of homelessness in British Columbia. Retrieved from Government of British Columbia website.

O'Campo, P., Kirst, M., Schaefer-McDaniel, N., Firestone, M., Scott, A., & McShane, K. (2009). Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: A realist approach to synthesizing evidence. Journal of Urban Health 86(6) 965-989.

Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage.

Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005).Realist review: A new method of systematic review designed for complex policy interventions. Journal of Health Services Research and Policy 10 21-34.

St. Michael's Hospital Centre for Research on Inner City Health. (2009). Community treatment approaches for homeless adults with concurrent disorders: What works for whom, where, why, and how? Retrieved from St. Michael's Hospital website.

Supporting the Understanding of Population Impacts of Urban Planning

This health impact assessment project is an example of comprehensive research to develop, refine, test and validate tools that support incorporating population health principles into urban planning activities. Developed through the collaboration of researchers, local public health departments and municipal partners, the project supported practical tools for action on social and physical environments that influence our ability to engage in physical activity and active living.

Case 2 – A practical tool for health impact assessment in urban planning

James R. Dunn, McMaster University, Hamilton, ON, and Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON
Marisa Creatore, Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON
Evan Peterson, Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON
Jonathan Weyman, Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON
Gayle Bursey, Peel Public Health, Regional Municipality of Peel, ON
Jane Loppe, Peel Public Health, Regional Municipality of Peel, ON
Bhavna Sivanand, Peel Public Health, Regional Municipality of Peel, ON
Richard Glazier, Institute for Clinical and Evaluative Sciences and Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, ON
David Mowat, Peel Public Health, Regional Municipality of Peel, ON

Corresponding author: Dr. James Dunn, jim.dunn@mcmaster.ca

Introduction

The Region of Peel is one of Ontario's fastest-growing regions. Each year, Peel adds 20,000 new residents, supported by significant amounts of land development activity on the urban fringe. It is well established that traditional suburban, automobile-oriented development is associated with low levels of physical activity and high rates of obesity among residents. Obesity and inactivity are, in turn, significant risk factors for diabetes and related complications. The impact of the physical environment on health behaviour often precludes or strongly influences individual choice. This is particularly true for disadvantaged populations and requires a population-level intervention. Historically, regulations and standards have been used frequently as population health interventions. Indoor smoking bans are a good example.

The literature on the built environment and health has repeatedly shown that specific attributes of the built environment are associated with poorer health outcomes. More specifically, Canadian research has shown that walkable and activity-friendly neighbourhoods are associated with higher physical activity levels, lower body weights and lower rates of diabetes among residents of Toronto (Glazier & Booth, 2007). In contrast, Peel has among the lowest active transportation rates in Canada (Bray, Vakil & Elliott, 2005).

Conditions related to obesity and inactivity (for example, diabetes and hypertension) are increasing in Peel, prompting Peel Public Health to investigate ways to promote active living in the Region. In 2009, scientists at the Centre for Research on Inner City Health, Peel Public Health and the Region of Peel collaborated to develop a practical tool (Dunn, Creatore, Peterson, Weyman & Glazier, 2009) that would help the Region's Planning Department assess new land development applications submitted by property developers for their impact on the health-promoting aspects of the built environment, with an emphasis on physical activity.

Project description and lessons learned

To create an assessment tool for new urban development applications, our team engaged in a five-stage process.

First, we conducted an exhaustive search of the published and grey literature to identify built environment measures and standards required for improvements in physical activity levels.

Second, we extracted a series of built environment elements for which there was evidence of a relationship with health and, for each element identified, we attempted to determine specific quantifiable measures, along with targets and ranges for those measures that have been shown to impact health. With these elements and measures, we developed an initial tool, modelled after Leadership in Energy and Environmental Design for Neighbourhood Development (LEED-ND) assessment tools.

Third, based on our initial tool, we conducted a series of informal consultations and formal workshops with Peel Public Health staff, Peel planning staff, planning staff from the municipalities of Mississauga, Caledon and Brampton (which compose the Region of Peel), relevant provincial officials as well as private planning firms. During these consultations and workshops, we sought to identify important substantive and feasibility issues, clarify current practices and gauge the acceptability and feasibility of options for implementing the Tool.

Fourth, we compared the standards suggested by the initial tool and their concordance with existing regional and municipal standards and bylaws.

Finally, we conducted a quantitative validation and feasibility study of the tool using geographic information systems in a small number of Peel communities.

The Tool includes seven elements drawn from the literature, and accompanying measures for each of the elements. The elements are:

  • density (for example, dwelling density)
  • service proximity (for example, availability of stores, jobs)
  • land use mix (for example, diversity of land uses, including retail, commercial, residential)
  • street connectivity (for example, density of connections in road network)
  • road network and sidewalk characteristics (for example, road width)
  • parking (for example, minimum parking standards per residential unit)
  • aesthetics and human scale (for example, street setbacks, building height, street width ratios)

This project represented a type of research seldom done in population health: implementation research, with an academic research team and knowledge users. Two key lessons emerged from this unique experience:

  • Most published population health research presents data to demonstrate associations, but this is not well suited to defining thresholds and establishing standards.
  • The built environment measures used in published research are not always easily adaptable to practical use by institutions that enforce standards.

Implications for research, policy and practice

The outcome of our consultations and policy gap analysis led our team to conclude that application of the Peel Healthy Development Tool to the private development sector would be possible only after further refinement. Our findings suggested that, among other barriers to implementation, developers and builders have limited discretion over many of the built environment elements that contribute to healthy development. Specifically, achieving a number of the targets and ranges the Tool recommended was prevented by transportation engineering standards, municipal bylaws and other standards. Therefore, a series of next steps need to be undertaken before a tool of this nature can be implemented. These include but are not limited to:

  • demonstrating that all actions taken towards achieving healthy urban development standards are for the greater good (for example, public safety, economic, environmental) and not just for walkability (an important part of Ontario planning law as the municipality may impose standards that are for the greater good)
  • revising municipal and regional planning and transportation standards to conform with Tool recommendations, allowing developers to meet health and policy standards simultaneously
  • using a comprehensive, multi-sectoral approach to resolve the inconsistencies between standards across all levels of government, between municipalities and between departments that restrict healthy urban development
  • adapting future versions of the Tool to account for the significant differences between smaller infill redevelopment and larger greenfield development
  • making rezoning and infill development more viable for developers in order to increase density and mixed land use zones
  • using a top-down approach to prioritize overall public health in both transportation and urban planning, avoiding policies that serve private vehicular travel at the expense of the active transport network

To support implementation, our team also developed a report (Dunn, Creatore, Peterson, Weyman & Glazier, 2009) for Peel that identified Peel by-laws that may conflict with the Tool's recommended standards and policy amendments needed to support health-oriented planning.

This project was conducted with close collaboration between the research team, Peel Public Health and a number of partners in other departments in the Region and in Peel's constituent municipalities. Consequently, Peel has begun implementing the recommendations, and the Healthy Development Tool is used as a key reference in decisions to change land-use policy and engineering standards.

Since the report was submitted, the Region of Peel has accomplished a great deal in its efforts to adopt healthy urban development standards. Specifically, the following policy changes have already been achieved:

  • amendments to Regional and Municipal Official Plans requiring health impact indicators and assessments as well as encouraging public awareness
  • amendments to engineering standards to increase walkability and active transportation, and proposed changes to provincial policy statements
  • integration of health background studies at the earliest stage of planning as part of a complete development application

As far as we know, the Region of Peel is the first jurisdiction in North America to create a process for screening land development applications to promote healthy built environments. Although the process to develop a Peel Healthy Development Tool did not proceed exactly as expected, it was still very successful and is expected to make a significant impact on the healthfulness of the Region's built environment for many years to come. Because of the timely and unique nature of this work, and the common health challenges faced today by many communities related to low levels of physical activity and increased rates of obesity, the work is expected to be of great interest to other jurisdictions. Although challenging and somewhat unconventional for academic researchers, implementation research is extremely rewarding when conducted with a decision making organization that has a political mandate to implement policy and is as committed to evidence-based policy as Peel Public Health.

Acknowledgements

Region of Peel
James R. Dunn is supported by a CIHR-Public Health Agency of Canada Chair in Applied Public Health

References

Bray, R., Vakil, C., & Elliott, D. (2005). Report on public health and urban sprawl in Ontario: A review of the pertinent literature. Retrieved from the Ontario College of Family Physicians website.

Dunn, J., Creatore, M., Peterson, E., Weyman, J., & Glazier, R.H. (2009). Peel healthy development evaluation tool. Retrieved from the Peel Public Health website.

Glazier, R.H., & Booth, G.L. (Eds). (2007). Neighbourhood environments and resources for healthy living: A focus on diabetes in Toronto. Retrieved from the St. Michael's Hospital website.

Creating Tools for Future Population Health Planning

This project involves collaboration among intersectoral partners to create and evaluate a tool to support better population-based planning. The tool presents qualitative and quantitative information on community health, well-being, and characteristics to lay the foundation for understanding community variation, promoting health equity, and supporting policies and programs that act on structures in the physical and social environment. The project provides an example of how actors from within and outside of health are working together to improve the well-being of communities.

Case 3 – Presenting the Québec Eastern Townships Community Scorecard: better knowledge, more timely action

Ginette Boyer, Planning, Programming and Research Officer, CSSS-IUGS, Sherbrooke, QC
Jean-François Allaire, Research professional, Observatoire estrien du développement des communautés, Sherbrooke, QC
Michel Des Roches, Planning, Programming and Research Officer, Direction de santé publique et de l'évaluation de l'Estrie, Sherbrooke, QC
Victorine Keita, Research Professional, CSSS-IUGS, Sherbrooke, QC
Paul Morin, Professor, Department of Social Services, Université de Sherbrooke, Sherbrooke, QC
Paule Simard, Researcher, Québec National Institute of Public Health, Québec, QC

Corresponding author: Ginette Boyer, gboyer.csss-iugs@ssss.gouv.qc.ca

Introduction

There is no shortage of data available in the various sectors where a population health intervention might be implemented, such as employment, education and public health. However, data are often not integrated in a way that can answer questions about local issues, such as why some communities fare better than others with comparable statistical profiles.

To address these concerns, various actors in Québec from a range of sectors have begun to partner on common approaches to foster the implementation of population health interventions and promote health equity around issues such as mental health, healthy weights, and academic dropout rates. Specifically, the Observatoire estrien du développement des communautés (OEDC), in collaboration with the Eastern Townships Directorate of Public Health, was directly inspired by the work of Boisvert and Milette (2009) to develop the Eastern Townships Community Scorecard.

As implementation of the tool progresses, an increasing number of institutions and community organizations from various municipalities and sectors in Québec have begun using this small-scale data to refine their strategic planning, the design of population health interventions and grant applications.

Project description and lessons learned

The Scorecard's objectives are two-fold:

  1. the evolution of health and wellness indicators in 66 local communities in Québec Eastern Townships (approximately 5,000 people) from one census to the next;
  2. Reinforce community development practices as an intervention strategy on social determinants of health

This Scorecard is both a tool to better understand community characteristics and a local intersectoral mobilization initiative. An evaluation of the project is contributing to advancing work on territorial intelligence (Bertacchini, 2010) and community development (Ninacs & Leroux, 2002).

The tool includes quantitative data on local communities and qualitative data from consultations with key citizens and stakeholders on diverse aspects of development for each community. This helped to achieve an accurate global vision of the communities while reporting on only the most relevant indicators for each potential intervention sector.

The use of this tool influences the implementation process for population health interventions. The tool can be used for mapping or to determine relevant quantitative information, and also enables the user to select specific highlights that provide further insight into the numbers. Thus, with the support of the OEDC, development workers can review various indicators and use knowledge from their own communities to identify what may be influencing outcomes. For example, the continuous turnover of administrative and teaching staff in primary schools may be identified in conjunction with high academic dropout rates. Throughout such connections the seeds for implementing population health interventions and promoting health equity are planted.

This project is defined by three complementary characteristics: participatory, intersectoral and adaptable. All decisions on the design and use of the Scorecard are made by the Implementation Committee comprising at least one pair of partners from two different organizations in each regional county municipality territory. Whether identifying criteria for delineating communities, selecting quantitative indicators or developing a communication strategy for decision makers and citizens, members of the Implementation Committee guide, offer suggestions, critique, share successes and challenges and, in general, support the joint development of the project.

Several challenges are involved in the project, particularly surrounding ethical issues. For example, beyond the strictly methodological considerations related to the challenges of producing small-scale data, the project accounted for the potential risk of stigmatization by publishing data on a scale of roughly 5,000 people rather than across municipalities of only a few hundred (potentially identifiable) inhabitants. Another major challenge involves the capacity of organizations to not only bring together communities to engage with this tool, but also support people from these communities who decide to take action. To address the latter challenge, work is underway to develop a regional fund dedicated to community development.

The intersectoral nature of this initiative adds to its reach. Members of the Implementation Committee are frequently connected to other organizations within their home territory. As the Observatoire is an intersectoral hub itself, its leadership sets the tone by attempting to support communities so they might possess a common vision of their situation and rally around one or more intervention initiatives.

Finally, there is no single way to use the Scorecard. Every regional county municipality and community must determine its own context and adapt the tool accordingly. Some integrate information from the Scorecard into a project to counter the exodus of youth from rural areas while others have used the tool to develop social development policy or a guide for intersectoral action. This potential for tailoring was quickly identified as one of the essential factors in mobilizing both citizens and stakeholders.

Implications for research, policy and practice

A systematic knowledge transfer and communications process aims to enhance the utility of the data and to promote awareness, discussion and uptake by the greatest possible number of people from different sectors (Lemire, Souffez & Laurendeau, 2009). For example, this involved:

  • involving local actors in the design and planning of each stage of the project;
  • producing facilitation tools;
  • developing a local approach to obtain information on community dynamics and facilitating communities to engage in the data;
  • publishing of all resources online;
  • holding multiple targeted meetings with decision makers, elected representatives, community development workers and citizens;
  • discussing the evaluation results with partners

A participatory study (Simard, Allaire, Boyer, Morin & Des Roches, in preparation) documents the process of implementing the project in the first nine local communities (of 66) where action was attempted. Six communities are in rural regional county municipality (one per regional county municipality) and the three others are within the City of Sherbrooke. The partners agreed to follow the evolution of the four action principles that they hoped would permeate the Scorecard's implementation: citizen participation, intersectoral collaboration, empowerment of individuals, organizations and communities, and autonomy of local partners. Over a period of roughly 18 months, preliminary results showed that partners from six of the seven regional county municipality territories gradually adopted and used the Scorecard—primarily as a guide for social policy development and strategic planning for municipalities, government agencies and regional county municipality areas. For the Scorecard to move beyond data generation and become a truly effective tool for community mobilization, key actors need to be involved and the tool needs to be integrated into established interventions and planning practices.

Based on expectations expressed by the partners at the start of this project, the citizen participation component is in need of further work. The mobilization of citizens has been a primary concern in only a single pilot community. However, the partners associated with the Implementation Committee belong to organizations whose mandates frequently span an entire regional county municipality territory, even if they intervene at the local community level (as documented in the Scorecard). This can pose several challenges when one's expressed community of roughly 5,000 people (a grouping of neighbourhoods or towns) does not necessarily correspond to an administrative unit that holds the main levers of action (town or city, but also regional county municipality).

Implementation of the Scorecard will take place in half of the 66 communities of the Eastern Townships in the coming months. The addition of statistical data originating from other databases (for example, school commissions or police departments), a community development training project, and the addition of various tools on the website, are being considered.

Community development has been a longstanding preoccupation for the Eastern Townships. The Community Scorecard's creation has shed light on the limitations of current intersectoral work as well as the desire to develop new collective practices within the various development agencies in every territory (rural agencies, community organizers, economic or cultural development practitioners, etc.).

Acknowledgements

Thanks to all members of the Implementation Committee for their invaluable contributions. A special thank you to Ghislaine Beaulieu, Normand Laforme and Pierrot Richard for their participation in the follow-up committee.

The project was financially supported by the CSSS-IUGS and the other CSSS of the Eastern Townships, Direction de santé publique et de l'évaluation de l'Estrie, Conférence régionale des élus de l'Estrie, Emploi-Québec, Centraide Estrie, les Sociétés d'aide au développement des collectivités de l'Estrie, the city of Sherbrooke, la Corporation de développement économique communautaire de Sherbrooke, and the Statistique Canada Community Liaison Program.

References

Bertacchini, Y. (no date). Intelligence territoriale: Le territoire dans tous ses états. Retrieved December 22, 2010 from the Archive Ouverte en Sciences de l'Information et de la Communication website.

Boisvert, R., & Milette, C. (2009). Le développement des communautés au Québec : la part de l'intelligence collective, Santé publique, Volume 21, no 2, p. 183-190.

Lemire, N., Souffez, K., & Laurendeau, M.-C. (2009). Animer un processus de transfert des connaissances: Bilan des connaissances et outil d'animation (français seulement) . Retrieved from the Institut national de santé publique du Québec website.

Ninacs, W.A., & Leroux, R. (2002). La santé des communautés: Perspectives pour la contribution de la santé publique au développement social et au développement des communautés (français seulement). Retrieved from the Institut national de santé publique du Québec website.

Simard, P., Allaire, J.-F., Boyer, G, Morin, P., & Des Roches, M. (in preparation) Évaluation du processus d'implantation du Tableau de bord des communautés en Estrie. Programme de subvention en santé publique 2008-2010.

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