Planning and assessment tool for chronic disease prevention and management

A Planning Tool for Integrated Chronic Disease Prevention


With so many diseases rooted in the same causes, more and more health jurisdictions are aiming to create comprehensive chronic diseases prevention strategies. While this makes eminent sense, addressing a wide range of diseases from various elements within the health system can be a huge challenge. Is it possible to build prevention into the chronic disease management system? Which diseases, causes or behaviours become priorities? What partners, in the health system and the community, should be included?

The Canadian Public Health Association has developed a tool to help answer these questions and more - the Planning and Assessment Tool for Chronic Disease Prevention and Management through Dialogue, Planning and Assessment. This "how-to" guide works through a process that helps coordinate efforts between public health, primary care and the community - all critical to building a comprehensive approach. The tool aims to engage stakeholders in dialogue; promote information exchange; assess current policy, planning and practice; and identify actions, roles and shared responsibilities for preventing and managing chronic illness.

The Regional Municipality of York used the Planning and Assessment Tool to plan its chronic disease prevention strategy. Allison Bailey, a public health nurse and team leader for Continuous Quality Improvement in the Healthy Living Division of the Public Health Branch, led the process.  She came across the Planning and Assessment Tool on the website of the National Collaborating Centre for Methods and Tools (NCCMT), by doing a simple Google search. She was familiar with the NCCMT site, so knew she had hit upon a useful instrument.

The tool presents eight Critical Success Factors (see text box) for strengthening chronic disease prevention and management, with questions that guide participants through each factor. Each question has a rating scale and provides examples of practice indicators.

The team at York Region devoted nine days to working through the toolkit to develop their strategy. While it was an intense process, Allison says it was worth it. "At first it was a little daunting, but I really see value of the work. It provided exciting learning opportunities and helped us conceptualize where we wanted to go." The tool supported change among staff for collaborative action to reduce chronic diseases and the underlying inequities that impact their development. It also encouraged a climate of innovation and is facilitating integrated program delivery as it is being implemented.

Allison sees the benefits of using the Planning and Assessment Tool to directly involve staff in decision-making and develop truly integrated programming across groups. "The social marketing campaign that resulted from this process is the first that was done by the division as a whole. We were able to highlight key components across programs, so that our messages are better linked."

Eight Critical Success Factors:

  • Common Values and Goals
  • Focus on Determinants of Health
  • Public Health Capacity and Infrastructure
  • Primary Care Capacity and Infrastructure
  • Community Capacity and Infrastructure
  • Integration of Chronic Disease Prevention and Management
  • Monitoring, Evaluation and Learning
  • Leadership, Partnership and Investment

A review of the Planning and Assessment Tool for Chronic Disease Prevention and Management through Dialogue, Planning and Assessment is available at the NCCMT website, at

Information about York Region's social marketing campaign can be seen here:

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