Illness In Canada Research Articles

The environmental burden of disease in Canada: Respiratory disease, cardiovascular disease, cancer, and congenital affliction

Background Exposure to environmental hazards contributes to many chronic diseases, yet the magnitude of their contribution to the total disease burden in Canada is not well understood. Objectives To estimate the environmental burden of disease (EBD) in Canada for respiratory disease, cardiovascular disease, cancer, and congenital affliction. Quantifying the contribution of environmental exposures to the overall burden of disease could play an important role in shaping public health and environmental policy priorities. Methods The World Health Organization (WHO) recently estimated the environmental burden of disease globally by using a combination of comparative risk assessment data and expert judgment to develop environmentally attributable fractions (EAFs) of mortality and morbidity for 85 categories of disease. We use the EAFs developed by the WHO, EAFs developed by other researchers, and data from Canadian public health institutions to provide an initial estimate of the environmental burden of disease in Canada for four major categories of disease. Results Our results indicate that: 10,000–25,000 deaths; 78,000–194,000 hospitalizations; 600,000–1.5 million days spent in hospital; 1.1 million–1.8 million restricted activity days for asthma sufferers; 8000–24,000 new cases of cancer; 500–2500 low birth weight babies; and between $3.6 billion and $9.1 billion in costs occur in Canada each year due to respiratory disease, cardiovascular illness, cancer, and congenital affliction associated with adverse environmental exposures. Conclusions The burden of illness in Canada resulting from adverse environmental exposures is significant. Stronger efforts to prevent adverse environmental exposures are warranted, including research, education, and regulation.

Healthcare Workers Infected with Blood-Borne Illnesses in Canada

Healthcare workers infected with blood-borne illnesses present profound ethical and legal problems. While we seek to protect patients from threat and respect their right to bodily integrity and informed consent, we also recognize the right to privacy and the human rights interests of the infected worker to be free from discrimination.

Modelling and risk factor analysis of Salmonella Typhimurium DT104 and non-DT104 infections

A clear understanding of risk factors is very important to develop appropriate prevention and control strategies for infection caused by such pathogens as Salmonella (S.) Typhimurium. The objective of this study is to utilise intelligent models to identify significant risk factors for S. Typhimurium DT104 and non-DT104 illness in Canada, and compare findings to those obtained using traditional statistical methods. Previous studies have focused on analysing each risk factor separately using single variable analysis (SVA), or modelling multiple risk factors using statistical models, such as logistic regression (LR) models. In this paper, neural networks and statistical models are developed and compared to determine which method produces superior results. In general, simulation results show that the neural network yields more accurate prediction than the statistical models. The network size, number of training iterations, learning rate, and training sample size in the neural networks are discussed to improve the performance of systems.

Demographic determinants of acute gastrointestinal illness in Canada: a population study

BackgroundGastrointestinal illness is an important global public health issue, even in developed countries, where the morbidity and economic impact are significant. Our objective was to evaluate the demographic determinants of acute gastrointestinal illness in Canadians.MethodsWe used data from two population-based studies conducted in select communities between 2001 and 2003. Together, the studies comprised 8,108 randomly selected respondents; proxies were used for all respondents under 12 years and for respondents under 19 years at the discretion of the parent or guardian. Using univariate and multivariate logistic regression, we evaluated the following demographic determinants: age, gender, cultural group, and urban/rural status of the respondent, highest education level of the respondent or proxy, number of people in the household, and total annual household income. Two-way interaction terms were included in the multivariate analyses. The final multivariate model included income, age, gender, and the interaction between income and gender.ResultsAfter adjusting for income, gender, and their interaction, children under 10 years had the highest risk of acute gastrointestinal illness, followed by young adults aged 20 to 24 years. For males, the risk of acute gastrointestinal illness was similar across all income levels, but for females the risk was much higher in the lowest income category. Specifically, in those with total annual household incomes of less than $20,000, the odds of acute gastrointestinal illness were 2.46 times higher in females than in males.ConclusionUnderstanding the demographic determinants of acute gastrointestinal illness is essential in order to identify vulnerable groups to which intervention and prevention efforts can be targeted.

CIHI Survey: Hospital Readmissions for Patients with Mental Illness in Canada

In-patient hospital mental health services represent a fraction of the spectrum of services in place for those who seek treatment for a mental illness. It is often when the conditions of the illness become most severe that inpatient hospital services are sought. Hospitalization is an important means of stabilizing deteriorating psychiatric conditions, of re-establishing discontinued regimens of prescribed medication and of helping to transition individuals to outpatient and community-based services. Hospitalizations for mental illness impose a high cost in terms of healthcare expenditures (Jacobs et al. 2006) and a disruptive burden on the personal and professional lives of the individuals suffering from mental illness. Many such individuals experience a “revolving door” of multiple re-hospitalizations. This article provides information on the patterns of oneyear readmissions (for any reason) to acute care hospitals in Canada among patients with mental illness as the most responsible diagnosis in their index admission during 2002–2003. It is based on data from the Hospital Morbidity Database and Hospital Mental Health Database of the Canadian Institute for Health Information (CIHI). Readmissions were deemed if the individual had more than one episode of hospitalization during the period 2002–2003 to 2003–2004.

Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2007 Update

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.

Work Initiatives for Persons with Severe Mental Illnesses in Canada: A Decade of Development

This research study portrays work initiatives for persons with serious mental illness in Canada. It considers 2 earlier papers on vocational programs and services to point out developments and current status in the field. Through a content analysis of documents collected from work initiatives across Canada, core values, models, and practices in the area of work integration are presented. Findings point to a consistent belief in the capacity of consumers to develop their work potential, to engage in the labour force, and to experience the many benefits of work. Results also reveal evidence of an increased emphasis on consumer initiatives, partnerships within the community, and negotiation of environmental factors, including workplace accommodations. Examples of work initiatives are provided, and suggestions for further research are offered.

Primary Health Care, Mental Health, And the Dietitian's Role

Purpose: Individuals with mental illness are at nutritional risk because of health, social, and economic factors. To address this problem, the Canadian Collaborative Mental Health Initiative (CCMHI) and Dietitians of Canada (DC) commissioned the development of a toolkit that outlines the role of the registered dietitian (RD) and advocates for RDs in primary health care (PHC) mental health programs.Methods: The development of the toolkit followed a fourstage process: a comprehensive literature review, a focus group discussion with a national working group, interviews with consumers about RD services, and evaluation of the toolkit.Results: The costs of mental illness in Canada are at least $6.85 billion per year. Currently, little evidence exists on how RD services can reduce these expenses. The focus group identified accessibility as the predominant issue facing individuals with mental illness. To explain consumer experiences with RD services, a three-tier theory based on in-depth interviews was developed. Consumer experiences with RDs occur in five categories: financial concerns, perception of service, status of mental illness, engagement, and self-esteem (tier 1). These are further influenced by five individual and contextual factors, e.g., social environment, the mental illness (tier 2), which are weighed as benefits and barriers instrumental in determining actions (tier 3).Conclusions: The evaluation of the final draft of the RD toolkit confirmed that it reflected the visions of PHC. The toolkit is intended to act as a blueprint for action. Dietitians are encouraged to use its contents to advocate for positions in mental health PHC settings.

Virulent

Researchers have characterized a virulent strain of Clostridium difficile associated with outbreaks of severe illness in Canada and Europe and found clues to why this strain causes unusually severe disease (Warny et al. Lancet. 2005;366:1079-1084).

The economic burden of schizophrenia in Canada in 2004

ABSTRACTObjective: To estimate the financial burden of schizophrenia in Canada in 2004.Methods: A prevalence-based cost-of-illness (COI) approach was used. The primary sources of information for the study included a review of the published literature, a review of published reports and documents, secondary analysis of administrative datasets, and information collected directly from various federal and provincial government programs and services. The literature review included publications up to April 2005 reported in MedLine, EMBASE and PsychINFO. Where specific information from a province was not available, the method of mean substitution from other provinces was used. Costs incurred by various levels/departments of government were separated into healthcare and non-healthcare costs. Also included in the analysis was the value of lost productivity for premature mortality and morbidity associated with schizophrenia. Sensitivity analysis was used to test major cost assumptions used in the analysis. Where possible, all resource utilization estimates for the financial burden of schizophrenia were obtained for 2004 and are expressed in 2004 Canadian dollars (CAN$).Results: The estimated number of persons with schizophrenia in Canada in 2004 was 234 305 (95% CI, 136 201–333 402). The direct healthcare and non-healthcare costs were estimated to be CAN$2.02 billion in 2004. There were 374 deaths attributed to schizophrenia. This combined with the high unemployment rate due to schizophrenia resulted in an additional productivity morbidity and mortality loss estimate of CAN$4.83 billion, for a total cost estimate in 2004 of CAN$6.85 billion. By far the largest component of the total cost estimate was for productivity losses associated with morbidity in schizophrenia (70% of total costs) and the results showed that total cost estimates were most sensitive to alternative assumptions regarding the additional unemployment due to schizophrenia in Canada.Conclusions: Despite significant improvements in the past decade in pharmacotherapy, programs and services available for patients with schizophrenia, the economic burden of schizophrenia in Canada remains high. The most significant factor affecting the cost of schizophrenia in Canada is lost productivity due to morbidity. Programs targeted at improving patient symptoms and functioning to increase workforce participation has the potential to make a significant contribution in reducing the cost of this severe mental illness in Canada.

IMPACT OF CLIMATE AND AGRICULTURE ON ENTERIC ILLNESS IN ATLANTIC CANADA: IMPLICATIONS OF CLIMATE CHANGE

ISEE-252 Introduction: The University of Guelph, the Public Health Agency of Canada and Environment Canada are working together on a national project investigating the incidence of enteric illness in Canada, describing the complex relationships between disease incidence and weather parameters, water quality and quantity, and the potential impact that global climate change will have on these parameters. Several case studies have been identified to examine the relationship between reported waterborne disease and weather events. This project will describe temporal and spatial trends in cases of enteric illness in Atlantic Canada and examine the relationship between weather parameters (temperature and precipitation) and the incidence of enteric illness in Atlantic Canada accounting for temporal and spatial clustering. This information will then be used to evaluate the potential impact that climate change will have on the incidence of enteric illness in this region. Methods: Disease data were extracted from the Canadian Institute for Health Information Discharge Abstract Database for the time period 1992–1998. Cases were classified as acute gastroenteritis using ICD9 codes. Agricultural indicators were derived from the 1996 Canadian Census of Agriculture and combined with remotely sensed land use data to get a more accurate estimate of where agricultural practices impact the surrounding environment. Daily weather values for precipitation and temperature were obtained from the Meteorological Service of Canada. Spatial and temporal trends were examined for the study period. Interpolation methods will be used to transform disease rates into smoothed rates over the province to facilitate analysis at a finer geographical resolution. Associations between acute gastroenteritis, agricultural indicators and weather parameters will be examined using a random effects modelling framework. Results: Preliminary results showed a seasonal pattern that peaked in spring to early summer for all provinces. Spatial patterns of disease incidence in one province indicated a south to north increase in disease rates when expressed at a watershed level, however this trend disappeared when rates were expressed using a community level political boundary. Further analysis will examine the association between disease incidence, agricultural intensity and weather parameters (such as the previous week's precipitation level). It is hoped that examining data at the weekly level will give a clearer picture of role that weather and agriculture play in disease transmission since the disease events occur on a relatively fine time scale. Climate change scenarios will be applied to the findings to better understand of how global climate change may affect the risk of enteric illness in Atlantic Canada. Discussion: The results of these studies will help identify geographic areas and populations vulnerable to an increased risk of enteric illness. These studies will allow Canadian policy makers to better understand and manage current risks of waterborne enteric illness, and to devise strategies to adapt to an uncertain climatic future and the potential for more extreme weather events.

Community-based care for people with severe mental illness in Canada

The development of mental health services for people with severe mental illness has in many ways paralleled that in other countries, particularly the United States. As reliance on inpatient psychiatric care has been sharply reduced, a wide range of community supports have been developed. Several distinct institutional and legal features have contributed to shaping the nature of these community supports, which are described herein. At present, the result is a highly fragmented system of care. Key evidence-based practices, notably assertive community treatment, supported employment, and integrated treatment for concurrent severe mental illness and substance use disorder, achieve considerable integration at the clinical level, but remain relatively unavailable in most provinces. The policy of regionalization of services risks inhibiting the development of such practices, which require more centralized technical assistance and monitoring. An evolutionary approach of gradually introducing integrated, evidence-based programs may provide the most feasible strategy for improving the system..

Migration, Mental Illness and Terry Watada’s The Tale of a Mask

Developed and produced at Toronto’s Workman Theatre Project (WTP) in 1993, Terry Watada’s play The Tale of a Mask weaves a Japanese folktale with a contemporary tragedy inspired by a double murder and suicide in Vancouver. Since 1991, the WTP has collaborated with playwrights to develop plays that educate audiences about mental illness and destabilize representations that perpetuate stigma. The Tale of a Mask was developed as part of a WTP initiative to investigate multiculturalism, immigration, and mental illness in Canada. The eponymous mask of the title, the author argues, acts as an enigmatic symbol for mental illness read differently by different cultures.

Migration, Mental Illness and Terry Watada's The Tale of a Mask

Developed and produced at Toronto's Workman Theatre Project (WTP) in 1993, Terry Watada's play The Tale of a Mask weaves a Japanese folktale with a contemporary tragedy inspired by a double murder and suicide in Vancouver. Since 1991, the WTP has collaborated with playwrights to develop plays that educate audiences about mental illness and destabilize representations that perpetuate stigma. The Tale of a Mask was developed as part of a WTP initiative to investigate multiculturalism, immigration, and mental illness in Canada. The eponymous mask of the title, the author argues, acts as an enigmatic symbol for mental illness read differently by different cultures. Elabore et realise au Workman Theatre Project (WTP) de Toronto en 1993, The Tale of a Mask de Terry Watada est un conte japonais populaire entrelace avec une tragedie contemporaine inspiree par un double meurtre et suicide a Vancouver. Depuis 1991, le WTP a collabore avec des dramaturges pour elaborer des pieces de theâtre qui renseignent les auditoires sur les maladies mentales et destabilisent les representations qui perpetuent les stigmates. The Tale of a Mask a ete elabore dans le cadre d'une initiative du WTP pour examiner de plus pres le multiculturalisme, l'immigration et les maladies mentales au Canada. Le masque mentionne dans le titre represente, d'apres l'auteure, un symbole enigmatique de la sante mentale percu differemment par differentes cultures. How might mental illness be performed on a contemporary Canadian stage? This deceptively simple question lies at the heart of an innovative theatre company attached to the Centre for Addiction and Mental Health in Toronto. Since 1989, the Workman Theatre Project (WTP) has sought to produce plays about mental illness. Their more than 20 productions have had the dual aim of giving voice to artists who have experienced mental illness and educating the public in order to combat the stigma of mental illness. In The Last Taboo: A Survival Guide to Mental Health in Canada (2001), Scott Simmie and Julia Nunes argue that many people who have received mental health services in Canada cite stigma as worse than mental illness itself: social discrimination, stigma, and isolation may compound and exacerbate the suffering of people diagnosed with mental illness. Moreover, stigma may prevent people suffering with mental illness from seeking help, professional or otherwise. Left to cope with illness on their own, people may become vulnerable to a host of ill effects, a range of self-destructive behaviours, or suicide. For WTP members, such high stakes create a forceful need to combat stigma-a need that informs much of their creative work. The project's dramaturgical process involves collaboration between commissioned professional playwrights, actors and directors with an interest in mental illness issues, and project members.1 At its broadest level, the WTP seeks both to destabilize mental illness representations that perpetuate stigma and to highlight the impossibility of ever wholly fixing or knowing mental illness on stage. Terry Watada's The Tale of a Mask, staged at the WTP in 1993, was developed and performed as part of a broader WTP initiative to investigate multiculturalism, immigration, and mental illness in Canada. It is a tragedy based on the real life and death of Fumiyo Takabe, a Japanese immigrant who became profoundly isolated and depressed in her new home of Vancouver in 1990 and took her own life and that of her husband and sons.2 The Tale of a Mask tells a parallel story about a central character named Aiko Shinde, her husband Masato, and her son Kentaro, who experience isolation, stigma, and cultural misunderstanding when they immigrate to Toronto from Japan in 1992. In a state of extreme depression, Aiko kills Masato, Kentaro, and herself. While the play's broad narrative seems to posit a direct relationship between real and represented events, its formal structure aims to do the opposite. …

The role of clopidogrel in the emergency department

Despite major advances in the management of acute coronary syndromes (ACS), 1 in 3 Canadians die from cardiovascular disease. In 1998, the total economic burden of cardiovascular illness in Canada was $159 434.5 million dollars — $83 953.9 million in direct costs and $75 479.6 in indirect costs. During the past 20 years, several pharmacologic adjuncts have been investigated with hopes of ameliorating the consequences of ACS. Notably, clopidogrel has become a common component of ACS therapeutic regimens since its introduction in 1998. Both new medications and those already accepted as standard treatment deserve critical evaluation to ensure they are safe and effective.

VULNERABILITY OF WATERBORNE DISEASES TO CLIMATE CHANGE IN CANADA: A REVIEW

This project addresses two important issues relevant to the health of Canadians: the risk of waterborne illness and the health impacts of global climate change. The Canadian health burden from waterborne illness is unknown, although it presumably accounts for a significant proportion of enteric illness. Recently, large outbreaks with severe consequences produced by E. coli O157:H7 and Cryptosporidium have alarmed Canadians and brought demands for political action. A concurrent need to understand the health impacts of global climate changes and to develop strategies to prevent or prepare for these has also been recognized. There is mounting evidence that weather is often a factor in triggering waterborne disease outbreaks. A recent study of precipitation and waterborne illness in the United States found that more than half the waterborne disease outbreaks in the United States during the last half century followed a period of extreme rainfall. Projections of international global climate change scenarios suggest that, under conditions of global warming most of Canada may expect longer summers, milder winters, increased summer drought, and more extreme precipitation. Excess precipitation, floods, high temperatures, and drought could affect the risk of waterborne illness in Canada. The existing scientific information regarding most weather-related adverse health impacts and on the impacts of global climate change on health in Canada is insufficient for informed decision making. The results of this project address this need through the investigation of the complex systemic interrelationships between disease incidence, weather parameters, and water quality and quantity, and by projecting the potential impact of global climate change on those relationships.

From stool to statistics: reporting of acute gastrointestinal illnesses in Canada.

Limitations associated with the under-reporting of enteric illnesses have long been recognized but the extent and variation of this under-reporting in Canada has not been examined. Given the public health value of surveillance data, a closer examination of under-reporting of enteric illnesses in Canada was warranted. Paper-based surveys were administered (a) to all laboratories in Canada licensed to process stool specimens and (b) to all local public health authorities in two provinces. Of the laboratories surveyed, 67% (n=274) conducted on-site testing of stool specimens for enteric bacteria, 31% (n=126) for parasites and 10% (n=42) for viruses. In the year 2000, these laboratories processed 459,982 stool specimens, of which 5%, 15%, 8% and 19% were positive for enteric bacteria (excluding C. difficile), C. difficile, parasites and viruses, respectively. Variations in laboratory testing and health authority reporting protocols and policies were identified. Of the laboratory-confirmed cases of AGI reported to local public health authorities, 5% (n=846) were not reported to provincial counterparts. A significant proportion of AGI cases submitting stool specimens are not captured in Canada's passive surveillance system due to unknown etiology. A much smaller proportion of laboratory-confirmed cases reported to local public health authorities are not captured at the provincial or national level. Given that the number of laboratory-confirmed AGI cases represents such a small fraction of all community cases, strategies to compensate for under-reporting and efforts directed at harmonizing laboratory and local public health authority policies and practices would be welcomed.

From Stool to Statistics

Background: Limitations associated with the under-reporting of enteric illnesses have long been recognized but the extent and variation of this under-reporting in Canada has not been examined. Given the public health value of surveillance data, a closer examination of under-reporting of enteric illnesses in Canada was warranted. Methods: Paper-based surveys were administered (a) to all laboratories in Canada licensed to process stool specimens and (b) to all local public health authorities in two provinces. Results: Of the laboratories surveyed, 67% (n=274) conducted on-site testing of stool specimens for enteric bacteria, 31% (n=126) for parasites and 10% (n=42) for viruses. In the year 2000, these laboratories processed 459,982 stool specimens, of which 5%, 15%, 8% and 19% were positive for enteric bacteria (excluding C. difficile), C. difficile, parasites and viruses, respectively. Variations in laboratory testing and health authority reporting protocols and policies were identified. Of the laboratory-confirmed cases of AGI reported to local public health authorities, 5% (n=846) were not reported to provincial counterparts. Conclusion: A significant proportion of AGI cases submitting stool specimens are not captured in Canada’s passive surveillance system due to unknown etiology. A much smaller proportion of laboratory-confirmed cases reported to local public health authorities are not captured at the provincial or national level. Given that the number of laboratory-confirmed AGI cases represents such a small fraction of all community cases, strategies to compensate for under-reporting and efforts directed at harmonizing laboratory and local public health authority policies and practices would be welcomed.

Risk factors for Salmonella typhimurium DT104 and non-DT104 infection: a Canadian multi-provincial case-control study.

To identify risk factors for sporadic Salmonella Typhimurium definitive phage-type 104 (DT104) and non-DT104 diarrhoeal illness in Canada, we conducted a matched case-control study between 1999 and 2000. Cases were matched 1:1 on age and province of residence. Multivariate analysis suggested that recent antibiotic use [odds ratio (OR) 5.2, 95% confidence interval (CI) 1.8-15.3], living on a livestock farm (OR 4.9, 95% CI 1.9-18.9), and recent travel outside Canada (OR 4.1, 95% CI 1.2-13.8) are independent risk factors for DT104 illness. Similar analyses suggested that recent travel outside North America is a sizable risk factor for non-DT104 illness (OR 66.8, 95% CI 6.7-665.3). No food exposure was a risk factor in either analysis. Educating health-care providers and the public about appropriate antibiotic use and antimicrobial resistance is important. Appropriate administration of antibiotics to livestock, particularly cattle, and hygienic measures such as handwashing after contact with farm animals may reduce risk. Travel represents an important and probably underestimated risk factor for sporadic illness with S. Typhimurium. Improved national surveillance and detailed investigation of travel-related illness are required.

Citizens shaping policy: The Canadian Mental Health Association's framework for support project.

Abstract Fifteen plus years of work in mental health policy development from a community development perspective under the aegis of the Canadian Mental Health Association are described. The evolution of a model de-emphasizing formal mental health services and emphasizing partnerships between consumers, family members, the community at large, and mental health service providers is presented. Particular attention is paid to the value of re-investing in natural support systems both through the diversion of funds to such groups and the recognition of such systems as integral components of the cultural response to serious mental illness. This paper is a description of a long-term policy development process undertaken by the Canadian Mental Health Association (CMHA) at the national, divisional (provincial/territorial), and branch (local) levels, focusing on the problem of serious mental illness in Canada. It is presented in this context because participation in the project over time played an essential role in the first author's nomination for the CPA award for distinguished contributions to community or public service. It is hoped that the presentation will encourage some psychologists to broaden the perspectives they have of mental illness and serve as encouragement to others who have already begun the shift from a medical to a community-centred understanding. This presentation in no way assumes that the project approaches a final understanding of the complex matter of mental illness but rather that the CMHA's Framework for Support, (Trainor, Pomeroy, & Pape, 1999) can serve as a tool for coming to richer understandings than have perhaps been the case. The discussion which follows is retrospective and is but one of many possible characterizations of the development of the Framework Project over time. In many respects it differs significantly from the characterization of the project in the above volume. The CMHA is Canada's oldest and largest non-- government organization focusing on the situation of persons with serious mental illness. Founded at the beginning of the 20th century, it has its roots in the mental hygiene reform movement associated with Clifford Beers (1917) in the United States and Clarence Hincks in Canada (Griffin, 1989). Later in the century it produced the landmark policy document, More for the Mind (Tyhurst, 1963), advocating the process of de-institutionalization and the development of appropriate forms of community care. The formulation in More for the Mind paralleled developments in the U.S. that came to be known as the Community Mental Health Movement. The widely recognized shortcomings of the process of deinstitutionalization and the failure to build a viable community mental health system subsequently led to a re-examination of the principles set forth in More for the Mind. Through the efforts of the CMHA Mental Health Services Committee, a kind of in-house think-tank drawing on volunteer mental health experts, a new charter document, A Framework for Support (Trainor & Church, 1984), was developed. Throughout the process of developing the document and the nearly 20 years of initiatives that have sprung from it, an iterative process of ideas and concerns from local communities being modified, interpreted, and animated by projects emanating from the national office has characterized the project (Morwood, 1999). If one wishes to locate the project conceptually in methodological space, it stands as a rich exemplar of the action research tradition described in the Canadian context by Sommer (1999). While it embodies the principles he identified, it moves beyond in attempting to make research learnings a tool in subsequent policy development. The Framework for Support Project can, in retrospect, be seen as having gone through three overlapping phases, the third of which continues to be played out at this time. In the first phase, the locus of activity was largely within CMHA and was directed towards the creation of the charter document (Trainor & Church, 1984) and teasing out its implications. …