SANTÉ QUÉBEC. Québec a THE JUSTIFICATION FOR AND THE RELEVANCE AND UTILITY OF THE SANTÉ QUÉBEC HEALTH SURVEY WA 900 DC2.1 Q44 E V.

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1 SANTÉ QUÉBEC THE JUSTIFICATION FOR AND THE RELEVANCE AND UTILITY OF THE SANTÉ QUÉBEC HEALTH SURVEY Technical Manual No Aline Émond WA 900 DC2.1 Q44 E V v.a. Québec a a INSPQ - Montréal

2 ENQUÊTE SANTÉ QUÉBEC , boul. de Maisonneuve ouest Bureau 400 Montréal (Québec) H3A 3C2 (514) Institut national de santé publique du Québec 4835, avenue Christophe-Colomb, bureau 200 Montréal (Québec) H2J3G8 Tél.: (514) THE JUSTIFICATION FOR AND THE RELEVANCE AND UTILITY OF THE SANTÉ QUÉBEC HEALTH SURVEY Technical Manual No Aline Émond November 1988 This survey was conducted by the ministère de la Santé et des Services sociaux (MSSS) and the Départements de santé communautaire (departments of community health)(dscs) under the direction of Aline Émond.

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4 Table of Contents Page FOREWORD 5 1. introduction 8 2. Ideological links between Santé Québec and the Canada Health Survey Definition of health Purpose of the Canada Health Survey Data selected by the Canada Health Survey Santé Québec's objectives Specific objectives Operational objectives Relevance of the content Utility Health Canada Survey WHO Santé Québec Conclusion 17 BIBLIOGRAPHY 19 ACKNOWLEDGEMENTS 20 3

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6 FOREWORD The Québec Health survey was commissioned by the ministère de la Santé et des Services sociaux together with the 32 départements de santé communautaire (DSC). The survey is intended to respond to the needs of planners and decision-makers and to supplement existing information concerning various aspects of both the physical and psychological wellbeing of the inhabitants of Québec. The survey focussed on three main areas: the factors determining state of health, the state of health per se and the consequences arising from the state of health. There is currently a lack of sufficient data concerning health status. Existing data are based mainly on cases which are already taken care by official health care system. No systematic study has yet been made of illness not treated within the system, such as selfmedication, risk factors, or long-term consequences of treated or untreated ailments. The Québec Health survey was begun in 1980 upon the completion of the Canada Health Survey, and even sooner when it became evident that the Québec component of its sample was too small and unrepresentative of the Québec regions. The definition of the contents of the survey was based on three main sources: - the contents of the Canada Health Survey; - the components of the 1983 pilot study carried out in the DSCs of Verdun and Rimouski; - the specific objectives outlined by representatives of the ministère de la Santé et des Services sociaux responsible for the project, and the recommendations of task forces in charge of developing the questionnaires. The list of topics covered and of questions used in the questionnaire was established by various committees. Some revision of the formulation of questions was necessary in order to reduce the administration time of the questionnaire and make the selfadministered questionnaire more readily comprehensible. Following the recommendations of consultants and task forces, certain topics were excluded in this initial survey (see Table 1 listing the topics to be reviewed). These topics will undergo further study in order to be included in a future survey. The relevance of topics included in the survey (see Table 1 ) will then be examined in detail to determine their predictive value with regards to the objectives to be achieved. Scope of the survey The choice of topics and questions to be included in the survey was determined by an evaluation of the usefulness and pertinence of data as well as by an evaluation of its comparability with other information sources. Moreover, the survey was designed as a continuation of the Canada Health Survey. Finally, the methods and questions used in this first Québec Health survey originate almost entirely from questionnaires or surveys, utilized or carried out in contexts similar to those of the Québec Health survey. We wanted to avoid questions non validated in a population context. 5

7 Table 1 Topics included in the Québec Health survey (1987)(*) DETERMINING FACTORS HEALTH STATUS CONSEQUENCES [ lifestyle family history environment physical perceived/observed psychological positive/negative social use of health services effect on ability to function SPECIFIC TOPICS LIFESTYLE alcohol use tobacco use physical activities use of motor vehicles sleeping preventive measures for women drug abuse PHYSICAL HEALTH activity limitation short-term conditions chronic conditions vision/hearing accidents/injuries impairments general perception USE OF HEALTH SERVICES professionals consulted place of consultasion use of medication FAMILY HISTORY personal history family history ENVIRONMENT occupation income age sex education social support stressful events PSYCHOLOGICAL HEALTH suicide psychological problems positive mental health SOCIAL HEALTH social problems EFFECT ON ABILITY TO FUNCTION disability days mobility need for assistance effect on roles Topics not included in the 1987 survey to be reviewed for.nclusion in future mental health of children under 15. biomedical data (e.g. cholesterol, glucose, blood pressure, etc.) eating habits sexual behaviour occupational health (*) This list is modelled on that of the Canada Health Survey. 6

8 Survey methodology The target population of the 1987 survey includes ail households of all of the provincial health regions in Québec except for region 10 (Nouveau-Québec) and the Indian reservations. The household samples were taken in first stage sample units (FSSU). These units were determined from the division of the Province into 11 provincial health regions and then into 32 DSCs (département de santé communautaire). Each of the 32 DSCs was divided into geographic areas. These areas are made up of a census tract or a group of contiguous census groups. In urban DSCs the geographic areas which constitute FSSUs are made up of blocks, parts of blocks or block clusters. Samples were taken in two different stages in each DSC. The first stage consisted of a random sample of FSSUs proportional to the number of private households in the FSSU (according to the 1981 census). The second stage consisted of selecting a random sample of households taken from the FSSUs chosen previously. In this way, a total of households were chosen. The list of private households in each of the FSSU chosen was completed by an on-site enumeration. The enumeration precedes each wave of data collection. Data collection Data are collected by private interviews held directly in the households chosen and by a self-administered questionnaire. Data collection are completed in the course of eight waves of three weeks held throughout 1987 so as to take into account seasonal health problems. The households are equally divided among the eight waves. Thus, at each wave, each of the provincial health regions, each of the DSCs and one-eighth of the FSSUs chosen were visited. Ten households are chosen per FSSU per wave. Survey organization This survey is a unique undertaking made possible by the concerted efforts of a large number of partners from the health and social sen/ices network, the Ministère and the universities of Québec. The project was initiated by planners of the Ministère in response to their need for data. A firts serie of objectives of the survey were then established and a contract signed with Douglas Hospital for the development of an instrument to measure mental health. Following these initial stages, a pilot study was planned in collaboration with Douglas Hospital and the Ministère with the active participation of the DSCs of Rimouski and Verdun. This led to a combined effort on the part of the DSCs and the ministère ae la Santé et des Services sociaux to carry out the 1987 Québec Hea'th survey. The two parties agreed to assign the management of the project to a Project Manager answering directly to an administrative committee. The latter was made up of six members, three from each party. This committee is responsible for ensuring the scientific and technical quality of the survey and supervising the Project Manager's activities. It also facilitates the participation of the parties' human resources of the project. The methodology was developed in cooperation with the Bureau de la Statistique du Québec. The development of the questionnaire and of the analysis framework was carried out with the help of recommendations from the DSCs, the Ministère and of the universities. Data collection and entry was contracted out to a private firm following a call for bids. The technical papers The series of technical papers of which this publication forms a part is aimed at examining various aspects of the Québec Health survey. The purpose of these documents is to provide information to prospective users of the survey and to serve as reference instruments for the planning of future surveys scheduled for 1992 and Aline Emond Project Manager 7

9 1. INTRODUCTION The Santé Québec health survey was conducted to ascertain the general state of Quebecers' health on a province-wide basis and gauge the situation prevailing in 1987, while refining information for each DSC territory. In terms of its objectives and methodology, the Québec health survey was an extension of the Canada Health Survey. It reflected the concerns of the MSSS and the health and social services networks, aimed at maintaining and improving the state of health of Quebecers, while ensuring the rational use of resources allocated to this sector. The survey took into account changes in health problems over the past decade and needs expressed by the MSSS and the social affairs network. The Santé Québec health survey was largely inspired by the Castonguay-Nepveu Commission report (1970) and a federal report entitled A New Perspective of the Health of Canadians (1974). Generally speaking, Santé Québec adopted the same objectives as major health surveys mentioned by WHO. This technical manual discusses the overall goal of the survey and various specific objectives. The relevance of the content and the socio-sanitary context underlying the objectives, and the potential utility of the data obtained, will also be examined.

10 2. IDEOLOGICAL LINKS BETWEEN SANTÉ QUÉBEC AND THE CANADA HEALTH SURVEY Affinities between Santé Québec and the Canada Health Survey centre as much on basic concepts and the fundamental objectives of the survey as on the methodology and instruments used. The Canada Health Survey was designed to measure the state of health of Canadians; the only province-wide data on health available come from the federal survey. However, the sample was taken 10 years ago and covered only Québec households. Extrapolating data to all Quebecers is difficult; no comparable data allows us to measure the state of their health today. Problems discussed when the Canada Health Survey was launched are still valid today. Moreover, Santé Québec has adopted essentially the same objectives as the federal health survey. For this reason. Santé Québec has examined closely the Canada Health Survey in terms of objectives, methodology and various other factors; its concern with measuring the state of health is the same as that which prevailed during the federal survey. In their proposal to îhe government to establish the Canada Health Survey, organizers stressed the lack of health data, revealed by the 1965 Lalonde Commission report, and the reasons for which they wished to measure the state of health of Canadians. Robert Kohn from the Royal Commission on Health Services noted that considerable funds were earmarked for health care. At the time the report was submitted, roughly 9.5 percent of GNP was spent by various levels of government on health care. In 1985, Québec allocated 9.2 percent of GNP to this sector. Given the funds being invested in health care, it was entirely germane to obtain adequate measurements of health. It was essential to ascertain the state of health of Canadians and to assess health trends. Senior civil servants and politicians responsible for health programs at various levels of government demanded this information, deemed essential to evaluate existing programs, reach decisions on the need to launch new programs or modify existing ones, and to establish priorities. Social and health researchers were also unquestionably interested in obtaining a measurement of the state of health of Canadians, to improve understanding of medical and social problems and to remedy a number of health problems. A wide range of health professionals might be able to work more efficiently if day-to-day activities were correlated with general measurements of health. Individuals could better assess their health if they were able to compare it to a number of health standards in the general population. There was a definite need for a general indicator of health. Moreover, the measurements of health obtained had to be understood and used by a variety of persons with different interests. The measurements had to be sufficiently general to reflect the health of all Canadians and make possible the comparison of subgroups and the analysis of health trends. Ideally, all of these requirements should be satisfied through the development of a health index, or a minimum of indices should it prove technically impossible to develop a single index. The concern for elaborating a measurement of health made it necessary to establish a data bank; the Canada Health Survey and the Santé Québec health survey were moving in that direction. 2.1 Definition of health It was necessary to obtain a general measurement of health and, consequently, the data required to establish such a measurement. What is health? It is a highly subjective notion of well-being which each individual perceives differently. A variety of definitions were proposed, to take into account the subjective nature of health. Among the most comprehensive definitions, mention should be made of those of the World Health Organization: "Health is a state of physical, social and mental well-being rather than the absence of illness or disability." This definition is very general; it may reflect a social aim rather than a true definition of health. It encompasses aspects of wellbeing that we cannot hope to measure with health indices. Another similar but perhaps more realistic definition was proposed in A New Perspective of the Health of Canadians: "... a state of well-being sufficient to adequately accomplish a certain level of physical, mental and social activities, bearing in mind age." While this definition is fairly broad, it is the basis for notions which are rather hard to quantify in relation to a health index. 9

11 Be that as it may, this was the starting point of the Canada Health Survey; it provides a framework for measures to be taken with regard to the survey and reflects a functional approach to the notion of health. 2.2 Purpose of the Canada Health Survey The survey was designed to assess the state of health of Canadians; in particular, it is individuals who have had little or no contact with the health system who were to be observed. In the case of individuals who have made use of health care, it is essential to obtain information on a wide array of events which make it possible to draw conclusions about the state of health of the population, as existing data banks only provide information on episodes or observation units rather than on the individuals themselves. Only through a national health survey could officials obtain the data needed to establish a consistent measurement of the state of health of Canadians. A health survey is an essential instrument among various techniques for measuring health. The health index or general measurement of the state of health must be drawn from existing statistics and data derived from the survey. The survey alone does not provide a measurement of health although it is a vital component of such a measurement. Without the data collected during the survey, it would be impossible to measure the state of health. The objective of the Canada Health Survey was to obtain data on the state of health of Canadians, as a prelude to developing a general measurement of health, which reflects the definition in the Lalonde report. The Santé Québec health survey maintained this objective with respect to Quebecers. 2 3 Data selected by the Canada Health Survey The themes and questions in the Canada Health Survey were selected on the basis of an analysis of existing data and various health indices proposed in the literature. Recommendations respecting questions dealing with disabilities and questions on lifestyle habits such as the use of tobacco and alcohol, nutrition and exercise reflect the definition of health and concerns prevalent at the time. In keeping with the Canada Health Survey, Santé Québec examined the concerns of the Lalonde report with a view to establishing which measurements of the state of health it wished to focus on. The Lalonde report states that the survey is one way of improving the health of Canadians. It stresses that "the establishment of a regular national health survey to determine the prevalence and nature of acute and chronic physical and mental health problems may make it possible to assess the state of health and the needs of the population, and to measure changes therein. Santé Québec and the Canada Health Survey pursued the same goal in this respect. The Lalonde report also stresses the importance of "establishing a special program to identify health indicators and high-risk groups; evaluating the nature and gravity of physical and mental health risks; and proposing measures designed to lower health risks." The need to adopt such measures was even greater in 1986 than at the time the Lalonde report appeared or the Canada Health Survey was conducted; data on the state of health were stili topical. Furthermore, the report noted the need for new data on health; it indicated that statistics usually used to measure the state of health take into account mortality, hospital morbidity and patients treated but not hospitalized. There is little or no information on illnesses treated by patients themselves, or illnesses which are cured spontaneously or which are not diagnosed. The report stresses that "to obtain key indicators of the general level of health, it is essential to be able to measure all ailments affecting the population, including all types of disability, from serious conditions which often require hospitalization and medical treatment to slight upsets and chronic benign conditions" (Lalonde, 1974). Later, the Canadian group responsible for evaluating the program respecting statistics on the state of health also insisted on the importance of conducting periodic surveys on the state of health of the population. It added that a health survey must be included in a broader program of health statistics and make it possible to obtain relevant data with a minimum of resources. In addition, such surveys must be conducted at regular intervals. WHO also maintains that surveys are probably the simplest data collection instrument for measuring the state of health. 10

12 Canadian and Québec health statistics are sufficiently developed to provide information on infant and maternal mortality rates, life expectancy and fairly broad classifications of hospital morbidity and the causes of death. Compared with countries such as the United States, Québec has a wealth of information on operations and treatment provided by institutions in the health network. Such data is, however, too raw to enable decision-makers to gradually transform a health care system into a health system. To do so, we need data on the health of Quebecers, whether or not they have recourse to the health services networks.

13 3. SANTÉ QUÉBEC'S OBJECTIVES 3.2 Operational objectives The 1987 Santé Québec health survey centres, like the Canada Health Survey, on the need to obtain more complete information to facilitate program planning and the elaboration of health policies. The information sought will be used to broadly monitor the state of health and establish priorities, and to elaborate, implement and evaluate preventive and remedial measures. When the health survey was officially launched on November 17, 1986, Santé Québec stated its objectives thus: Generally, the agency was concerned with collecting new data from Quebecers on: lifestyle habits; The following operational objectives were adopted: To provide readily accessible data to the MSSS, DSCs and other agencies in the network which enable them to identify problems and needs, evaluate their programs and guide future interventions; To answer a number of questions related to current problems dealt with by the MSSS and the DSCs, for example: the design and elaboration of a health monitoring system in Québec; updating policies respecting mental health. the state of their physical and mental health; restrictions on their everyday activities; recourse to health care and services; socio-economic and environmental variables. Specific objectives are outlined below. 3.1 Specific objectives To identify problems, needs and high-priority sectors of intervention in the field of health; To establish links between various categories of data: lifestyle habits - state of health or disability - recourse to services - socio-economic variables and so on; To monitor major health trends and other variables by repeating the survey; To provide special information on mental health; To ensure complementarity with other sources of data currently available. 12

14 4. RELEVANCE OF THE CONTENT Based on a broad notion of health, the Canada Health Survey and Santé Québec wished to obtain information in three broad categories: 1. a breakdown of risk factors, combinations of such factors and the characteristics of populations exposed to risks; 2. the state of physical and mental health, the breakdown of health problems and the characteristics of the healthy and the sick; 3. the consequences of health problems, their gravity, variety and distribution, and the characteristics of Canadians suffering from such problems. The Canada Health Survey used a simple model to illustrate possible relationships between these categories of information; Santé Québec adopted the same model. However, as the survey was conducted at a specific time, it is impossible to fully assess the causal relationships involved. Such inference cannot be achieved in transversal studies. Information on risk factors is needed to identify potential problems and develop the appropriate counter-measures. Data on the state of health make it possible to permanently monitor states of health and health trends covered by various programs. The basic topics covered by the survey have been drawn from this model. Potential utility was the foremost criterion for selecting topics in both the federal and Québec health surveys. Overall, Santé Québec adopted the same topics as the Canada Health Survey, following consultations and deliberations by analysis committees on the needs of users. Particular emphasis was placed on data respecting the curtailment of activities, self-treatment and untreated problems, exposure to known risks which could cause health problems, the impact of poor health, emotional well-being and various positive aspects of health. The direct cost of illnesses causing disability and their impact on the health care system have been extensively documented. However, less is known about the indirect cost of such illnesses, and their effect on the social, family and economic life of the individual. Until now, no reliable information has been available which enables us to review these problems and better. Data collected by the Canada Health Survey in and Santé Québec in 1987 complement existing statistics and offer new perspectives on the health of Quebecers and Canadians. The consequences of health problems must be established before priorities can be set and the reactions and behaviour of individuals faced with these problems can be monitored. Reliable figures are needed in each of these three categories if we are to make accurate estimates with regard to different parameters in the population; we also need a sounder base on which to evaluate variations in time, and extensive, varied data to establish representative profiles and document the multifaceted relationships which affect health. These needs cannot be satisfied with data bases now available, which stress recourse to the health services system. This is true of Canada as a whole and of Québec. However, a reliable data base can be elaborated in a satisfactory manner using information collected from a representative sample of the population. 13

15 5. UTILITY Potential users of data from the Canada Health Survey justified the inquiry in the same way as the World Health Organization in its discussion of national surveys; the same concerns were expressed in government departments and the community health network by advocates of the Santé Québec survey. 5.1 Canada Health Survey The Canada Health Survey was designed to collect data to enable the federal and provincial governments and other agencies to plan health care services, and health and disease prevention programs. Repeating the survey would enable organizers to observe changing trends, a useful component of evaluation. For those concerned, enlightened planning and proper evaluation imply the following sub-objectives: the establishment of priorities concerning health problems based on new information on the impact of such problems on individual lives; the identification of risk groups or groups in poor health. Establishing more clearly the target clienteles of various programs and making more accurate forecasts of demand for health care would make the health care system more cost efficient. Establishing a nation-wide data base would make it possible, in addition to achieving both objectives, to: - obtain key measurements of exposure to risks and the state of health; - interpret similar data with regard to smaller units, such as municipalities or provinces, or specialized groups, e.g. type of occupation or external clientele; - make comparisons over time, using data from future surveys. The survey also makes it possible to conduct epidemiological studies of a number of risk groups or health problems, and the relationship between various risks and health problems within the limits of data drawn from a transversal study. The innovative Canada Health Survey made it possible to reproduce or modify data collection procedures in the provinces or among various agencies, limit costs and increase an understanding of local conditions, based on nation-wide statistics. Santé Québec used this model. 5 2 WHO According to WHO: it is essential to clearly establish what purpose information provide by a health survey will serve. It is not sufficient to say that it will be used to plan, program, budget and evaluate; greater precision is possible and necessary to avoid wasting valuable resources. Generally, there are at least four essential fields in which the information supplied by surveys, and health information derived from other sources, may be useful (WHO, 1985). Accurate, relevant health data are generally required to establish priorities, reach decisions respecting intervention or the organization of services, evaluate results and conduct temporal and spatial comparisons with data from other sources. Depending on how national health data is organized, the four fields mentioned earlier may necessitate surveys to obtain the needed data. Obviously, the choice of priorities and decisions regarding resources and services do not focus solely on data, but also concern politics and political negotiations. However, the relevant data can only help politicians make enlightened choices. Policy decisions are not based exclusively on health information, but generally fall within the purview of managers and demand sound administrative information. In practical terms, political choices and operational decisions are naturally intertwined. When it comes time to decide whether a survey is opportune, the need for information must be assessed and both levels of decision-making viewed as part of a continuum. It is important to fully comprehend that, regardless of how precise the information collected is and how refined the analyses carried out are, managers and politicians can draw conclusions which are at odds with those of researchers. Each of them has particular objectives and would like his information to prevail. However, if the information is widely disseminated, it will encourage adjustments which enhance the state of health of various populations. Major health surveys, including the Santé Québec survey, focus on the four concerns outlined earlier 14

16 and, more particularly, endeavour to answer the questions of individuals, be they politicians, managers or researchers, directly concerned with taking initiatives in certain fields or better understanding the forces at work. However, general consensuses result from these special interests. The general health survey is useful because it makes it possible to establish a relationship between recourse to health services and health indicators, and between health indicators and socio-economic indicators. According to WHO, properly structured surveys centred on the population are usually more useful and more efficiently produced than multiple surveys based on groups or categories. Santé Québec emphasized this perspective. A modern system of health statistics and information should only contemplate the organization of health surveys while taking into account the possible existence of the necessary data from other sources and the advantage of linking, consolidating or at least coordinating surveys dealing with analogous or related problems. The acquisition, analysis and presentation of data from all sources are relatively costly, and consume resources which could be devoted to supplying services. A dynamic health information system is essential to establishing priorities, managing services and evaluating the effect of such services. The golden rule to be followed is to acquire data economically and disseminate it judiciously, to ensure that the same data are used for a variety of purposes (WHO, 1985). 5.3 Santé Québec Santé Québec maintains that the 1987 health survey had to provide information for use in health planning, and evaluating policies and programs. However, the following questions were discussed: If the survey is to be used for planning, should it focus on information needs with regard to short-term planning? Should it also dwell on the need for data to facilitate mediumand long-term planning? just as other important variables do, e.g. accessibility of services, the presence or lack of alternative services, and the perception individuals have of the health system and the services available. All of these factors must be taken into account in planning. The Santé Québec survey must satisfy some of the short-term needs of planners; it must also identify needs which, until now, have been neglected. To ensure that the survey is of some use in identifying needs, survey officials attempted to better define the specific objectives which would make it possible to choose themes and specify which questions would be asked and which groups targeted. However, it should be remembered that the questions selected cover major concerns for which no other data from other sources is available and which could not be collected from less costly sources. It must also be acknowledged that the advantage of a survey conducted in house-holds is that it allows relationships to be established between health data and other socioeconomic and demographic data, thereby producing a composite picture of the state of health and wellbeing of the population. Moreover, the survey must also fall into line with policies respecting regionalization and decentralization and may facilitate decision-making on the allocation of resources. For example, it provides data which foster the equitable allocation of resources among the regions, bearing in mind regional particularities concerning health risks or problems and not just the size of the population when budgets are established. The survey makes possible the systematic collection of information which will facilitate the strategic evaluation of the policies and programs of the MSSS, DSCs and other agencies, in terms of the extent to which they satisfy needs and the relevance of their objectives. In addition, the survey may make it possible to verify the relative importance of problems in order to ascertain various agencies' ability to intervene. It might also facilitate negotiations with doctors, by providing information which will encourage or curtail certain medical services. The survey should enable departments of community health to more fully assume their responsibility for monitoring the state of health. A consensus was also reached on the importance of obtaining a subjective and objective measurement of the state of health, i.e. account must be taken of individuals' perception of their health. Such a perception partially tempers the recourse to health services, 15

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18 6. CONCLUSION The Santé Québec health survey reflects a conceptual framework in which health is deemed to be a continuous, dynamic process of adaptation by men and women to their environment. Lifestyle habits, various social roles and so on enable human beings to confront and adapt to the environment. Moreover, various physical, social and cultural facets of the environment also affect individuals, either facilitating or complicating adaptation. If the specific objectives of the health survey are achieved, better knowledge of the interrelationships between health and the environment should help identify those variables which can and must be modified in different environments. It will also be possible to improve the state of health of Quebecers by implementing programs better adapted to the problems discerned among them, allocate resources more fairly, establish broader guidelines, and stress preventive care in health programs. However, even the most explicit objectives cannot be achieved through a single survey. To achieve these objectives, surveys must be repeated at regular intervals. 17

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20 Bibliography Bernier, Lorraine, et al Recours aux services de santé, Document de travail. Santé Québec health survey, June Chénard, Lucie, et al. Mesures de l'état de santé, Sous-groupe de travail. Santé Québec health survey analysis committee, July Clarkson, May. Santé Québec : Démarche conceptuelle et opérationnalisation. Working document, Études et politiques de santé, MAS, June Clarkson, May, et al. Facteurs associés à l'état de santé, Sous-groupe de travail. Santé Québec health survey analysis committee, Collishaw, N.E. The Proposed National Health Survey and the Measurement of Health. Working Paper Series No. 74-2, Health and Welfare Canada, Colvez, Alain. Quatre documents sur l'introduction de nouveaux indicateurs de santé pour la planification. Service des études épidémiologiques, MAS, December Service des études épidémiologiques, December MAS, indicateurs psychologiques de l'état de santé des Québécois. Service des études épidémiologiques, MAS, September Owen Consulting Group Ltd. Health Status Statistics Program Evaluation: Executive Summary and Recommendations and Report. Statistics Canada, Program Evaluation Division, May Stephen, Tom. Canada Health Survey. Basic Content: Specifications for Development. April The Health of Canadians: Report of the Canada Health Survey (draft outline), October World Health Organization, Regional Office for Europe. Target for Health for All. Target in Support of the European Regional Strategy for Health for AH. Copenhagen, Conseil des Affaires sociales et de la famille. Objectif: santé. Gouvernement du Québec, Direction générale des publications gouvernementales, Department of Health, Education and Welfare. Healthy People. The Surgeon General's Report on Health Promotion and Disease Prevention. US Government Printing Office, Department of Health and Human Services, Public Health Service. Promoting Health/Preventing Disease: Objectives for the Nation. US Government Printing Office, Jackson, Ray. Les soins de santé préventifs : les questions en jeu. Study document. Science Council of Canada, May Melanson-Ouellet, Andrée. Indicateurs psychologiques de l'état de santé des Québécois. 19

21 A cknowledgements I would like to thank May Clarkson, Lucie Chénard and Denis Drouin for their valuable comments.

22 M 4600 V.A. AUTEUR Sant.Ê Québec The justification for and the relevance and utility of the ban Lé M 4600 V.A.

23 Gouvernement du Quebec Ministère de ta Santé et des Services sociaux