Chronic Disease Tool

In 2007/2008, CPHA worked with four health regions across the country to pilot a new chronic disease planning tool to help bring a comprehensive approach into regional dialogue and planning.

The Tool, Strengthening Chronic Disease Prevention and Management through Dialogue, Planning and Assessment, presents eight Critical Success Factors for strengthening chronic disease prevention and management, with guiding questions for each.

Download the Introduction to the tool

Download Introduction to the Tool (PDF: 108k)

Use of the Tool is supported by a How-to Guide and Case Studies.   The How-to Guide includes a series of modules that outline the key stages involved in using the Tool.  The Case Studies present information on how the tool was piloted in four sites across Canada.

Additional resource


A Tool for Strengthening Chronic Disease Prevention and Management - through Dialogue, Planning and Assessment

1.0 The Need for a Tool

Many Canadians are at risk of developing heart disease, diabetes, cancer and other chronic conditions. These diseases account for a large proportion of disability, death and health inequity among Canadians, much of which is preventable.

To prevent chronic disease and related health problems, investment is needed in a full set of strategies and actions that make it easier for people to take care of their health. This includes creating environments that promote and protect health, as well as shifting how we plan and manage our health services.

Chronic disease efforts in public health, primary care and community are important parts of a comprehensive approach, but have tended to move along parallel tracks. With growing interest in ‘thinking like a system’, this planning and assessment tool (the Tool) provides a structure and process for bringing together those working to prevent and manage chronic disease in health regions across the country. It helps us to think about, discuss and assess current practice, capacities and opportunities for action.

2.0 Thinking Like a System – Eight Critical Success Factors with Guiding Questions

CPHA began working with a national advisory committee in April 2006 to review what we know about public health capacity in Canada to prevent and control chronic disease. Based on the findings, a draft tool was developed and reviewed by key informants and focus group participants across the country. In 2007/2008, four health regions began piloting the Tool. It is presented as a work-in-progress.

The Tool presents eight Critical Success Factors for strengthening chronic disease prevention and management, with guiding questions for each. The questions are designed to bring evidence-informed approaches into regional dialogue and planning. These Critical Success Factors are:

  1. Common Values and Goals
  2. Focus on Determinants of Health
  3. Leadership, Partnership and Investment
  4. Public Health Capacity and Infrastructure
  5. Primary Care Capacity and Infrastructure
  6. Community Capacity and Infrastructure
  7. Integration of Chronic Disease Prevention and Management
  8. Monitoring, Evaluation and Learning.

Taken as a whole, the Critical Success Factors present a ‘big picture’ view to help guide a comprehensive approach to chronic disease planning. This view takes into consideration how the different parts of the health system connect to prevent chronic disease and related complications.

3.0 Using the Tool

The Tool is intended to be a flexible resource for use by health regions across the country, adaptable to different contexts. It is one among many tools and resources available that may help you in collaborating with colleagues and community members to do this work.

The Tool helps to make connections among those doing chronic disease work, taking steps to build understanding, break down silos and better integrate prevention and management efforts. It does this by:

  • Engaging stakeholders in dialogue
  • Promoting information exchange
  • Assessing current policy, planning and practice, and
  • Identifying actions, roles and shared responsibilities for preventing and managing chronic disease

For each Critical Success Factor, there are a series of guiding questions presented in worksheet format. Each worksheet includes:

  • The question with a brief description or example
  • A rating scale with indicators outlining the possible range of practice (0=nothing in place through to 4=better/promising practices in place)
  • A space to note your own rating information or indicators
  • A space for tracking comments, opportunities/challenges or areas for follow-up identified through the assessment

The rating scale is intended to provide some general cues about what better/promising practices might look like for each component. The indicators in the scale are based on research and practice examples from academic and grey literature, and from input from key informants in the field.

The Tool and supporting resources include:

4.0 Who should use the Tool?

This Tool is intended for collaborative use by a range of stakeholders who influence and share responsibility for chronic disease planning. This includes organizational leaders, planners, managers and coordinators who work in:

  • Regional health authorities and local health integration networks (responsibility areas for chronic disease, primary care, population health and health promotion)
  • Public health services/programs (responsibility areas for screening, health promotion/education, community epidemiology, health planning, assessment and disease surveillance)
  • Community health centres, clinics (community and hospital-based)
  • Chronic disease prevention and/or management programs (community and hospital-based)
  • Communities of practice for health promotion, chronic disease prevention and/or management
  • NGOs, coalitions and networks (disease-specific, risk factor-specific, age-specific)
  • Community groups/members
  • Non-health sector partners (school, workplace, municipalities, recreation and community services, immigrant service organizations)

5.0 Key Concepts Behind the Tool

The Assessment Tool is based on the following key concepts:

  • Building prevention into the system
  • Integrated models for chronic disease prevention and management
  • Capacity-building
  • Collaboration

The importance of shifting health services towards health promotion, disease prevention, community-based care and chronic disease management has been repeated in every major health report and consultation over the past 15 years. However, system-wide change to better prevent and manage chronic disease is complex.

Moving in this direction, a number of provinces and health regions are working with the B.C. Expanded Chronic Care model, an integrated model for preventing and managing chronic disease. The model includes population health promotion, social determinants of health and enhanced community participation as an integral part of health system work on chronic disease issues.

The Critical Success Factors in the Tool build on this approach, bringing population health and prevention approaches into dialogue and assessment. This figure illustrates the Critical Success Factors.

figure showing the critical success factors

Critical Success Factors for Comprehensive Chronic Disease Prevention and Management Strategies
Adapted from the Capital District Health Authority & IWK Health Centre Model
Chronic Disease Prevention and Management

The blue factors around the outside of the circle provide the “foundation” for work on chronic disease prevention and management. They are required to move forward in other areas and include: Focus on Determinants of Health; Common Values and Goals; Leadership, Partnerships and Investment.

The green factors are the areas where adequate capacity and infrastructure are limited in our current health system. Building these areas up is necessary to strengthen chronic disease prevention and management. Capacity is needed in all parts of the system, including: Public Health; Primary Care; Community.



The other Critical Success Factors centre on how stakeholders monitor, evaluate and improve their work and the mechanisms in place to better integrate efforts: Monitoring, Evaluation and Learning (yellow); and Integration of Chronic Disease Prevention and Management (red).

This work was made possible through financial contributions from the Public Health Agency of Canada.


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