{"http:\/\/dx.doi.org\/10.14288\/1.0379866":{"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool":[{"value":"Education, Faculty of","type":"literal","lang":"en"},{"value":"Other UBC","type":"literal","lang":"en"},{"value":"Non UBC","type":"literal","lang":"en"},{"value":"Kinesiology, School of","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider":[{"value":"DSpace","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#identifierCitation":[{"value":"BMC Public Health. 2019 Jul 11;19(1):935","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/contributor":[{"value":"Centre for Hip Health and Mobility","type":"literal","lang":"en"},{"value":"Vancouver Coastal Health Authority. Research Institute","type":"literal","lang":"en"}],"https:\/\/open.library.ubc.ca\/terms#rightsCopyright":[{"value":"The Author(s).","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/creator":[{"value":"Faulkner, Guy E. J., 1970-","type":"literal","lang":"en"},{"value":"Ramanathan, Subha","type":"literal","lang":"en"},{"value":"Kwan, Matthew","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/issued":[{"value":"2019-07-15T16:05:01Z","type":"literal","lang":"en"},{"value":"2019-07-11","type":"literal","lang":"en"}],"http:\/\/purl.org\/dc\/terms\/description":[{"value":"Background:\r\n                Interventions that promote health and wellbeing among young adults are needed. Such interventions, however, require measurement tools that support intervention planning, monitoring and evaluation. The primary purpose of this study is to describe the process in developing a framework for a Canadian post-secondary health surveillance tool known as the Canadian Campus Wellbeing Survey (CCWS).\r\n              \r\n              \r\n                Methods:\r\n                Nineteen health service providers or mental health experts from 5 Canadian provinces participated in a 3-round Delphi survey by email and an in-person roundtable meeting to identify wellbeing and health behavior measurement priorities and indicators for the CCWS.\r\n              \r\n              \r\n                Results:\r\n                The final CCWS framework consisted of 9 core sections: mental health assets, student experience, mental health deficits, health service utilization\/help seeking, physical health\/health behaviors, academic achievement, substance use, nutrition, and sexual health behavior. Panelists generally agreed on a set of indicators, and reached consensus for at least one indicator per core section.\r\n              \r\n              \r\n                Conclusion:\r\n                This CCWS framework is the first step in developing a common surveillance mechanism tailored to the Canadian postsecondary context. Future work will include online consultation with health service providers from a broader range of post-secondary institutions, an in-person meeting with research and measurement experts to finalize survey items, and formative testing. The CCWS will play a valuable role in developing population health initiatives targeting the increasing number of young Canadians attending postsecondary institutions.","type":"literal","lang":"en"}],"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO":[{"value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/70997?expand=metadata","type":"literal","lang":"en"}],"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note":[{"value":"RESEARCH ARTICLE Open AccessDeveloping a coordinated Canadian post-secondary surveillance system: a Delphisurvey to identify measurement prioritiesfor the Canadian Campus Wellbeing Survey(CCWS)Guy Faulkner1,2* , Subha Ramanathan1, Matthew Kwan3 and the CCWS Expert Panel GroupAbstractBackground: Interventions that promote health and wellbeing among young adults are needed. Suchinterventions, however, require measurement tools that support intervention planning, monitoring and evaluation.The primary purpose of this study is to describe the process in developing a framework for a Canadianpost-secondary health surveillance tool known as the Canadian Campus Wellbeing Survey (CCWS).Methods: Nineteen health service providers or mental health experts from 5 Canadian provinces participated in a3-round Delphi survey by email and an in-person roundtable meeting to identify wellbeing and health behaviormeasurement priorities and indicators for the CCWS.Results: The final CCWS framework consisted of 9 core sections: mental health assets, student experience, mentalhealth deficits, health service utilization\/help seeking, physical health\/health behaviors, academic achievement,substance use, nutrition, and sexual health behavior. Panelists generally agreed on a set of indicators, and reachedconsensus for at least one indicator per core section.Conclusion: This CCWS framework is the first step in developing a common surveillance mechanism tailored to theCanadian postsecondary context. Future work will include online consultation with health service providers from abroader range of post-secondary institutions, an in-person meeting with research and measurement experts tofinalize survey items, and formative testing. The CCWS will play a valuable role in developing population healthinitiatives targeting the increasing number of young Canadians attending postsecondary institutions.Keywords: Mental health, Health behavior, College, University, Students, SurveysBackgroundChronic diseases (including heart disease, stroke, cancer,diabetes and hypertension) are major causes of morbidityand mortality worldwide. There is growing evidence thatsuggests that the initiation of major chronic diseases suchas atherosclerosis, obesity, and diabetes \u2013 related tomodifiable health behaviors \u2013 are emerging as early as thesecond and third decades of life [1\u20133]. Poor mental healthis also one of the largest challenges facing youth, particu-larly as they transition from late adolescence into emer-ging adulthood [4, 5]. Students enrolled in postsecondaryeducation become situated in a position of greater inde-pendence, and the behaviors acquired or reinforced duringthis period can help shape their future health and well-being [6]. Unfortunately, existing evidence suggests thatthis is a period of significant increases in health-riskbehaviors, including increases in smoking, binge drinkingand decreases in physical activity and fruit and vegetableconsumption [7\u20139].\u00a9 The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http:\/\/creativecommons.org\/licenses\/by\/4.0\/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/) applies to the data made available in this article, unless otherwise stated.* Correspondence: guy.faulkner@ubc.ca1School of Kinesiology, University of British Columbia , Lower Mall ResearchStation, 2259 Lower Mall, Room 337, Vancouver, BC V6T 1Z4, Canada2Centre for Hip Health and Mobility, Vancouver Coastal Health ResearchCentre, 2635 Laurel Street, Vancouver V6T 1M9, BC, CanadaFull list of author information is available at the end of the articleFaulkner et al. BMC Public Health          (2019) 19:935 https:\/\/doi.org\/10.1186\/s12889-019-7255-6Population-based prevention initiatives can be cost-effective, alleviating the burden in the health-care systemthrough future reductions of expenditures [10]. Toinform intervention at the post-secondary level, a mech-anism is required to assess the prevalence and correlatesof mental health and health behaviors at a local level. Inturn, this information may guide interventionprioritization, selection, implementation, and ongoingevaluation and program\/health service refinement. Can-adian colleges and universities are becoming increasinglycommitted to fostering student health and wellnessthrough programming and services. In particular, at the2015 International Conference on Health PromotingUniversities and Colleges in Kelowna, British Columbia,the Okanagan Charter was established to 1) guide andinspire health promotion action, 2) generate dialogueand research on and off campuses and 3) mobilize cross-sector action to integrate health in all policies andpractices [11]. To date, 12 postsecondary campuses fromCanada have adopted the Okanagan Charter and accom-panying calls to action: \u201c1. To embed health into allaspects of campus culture, across the administration,operations and academic mandates. [and] 2. To leadhealth promotion action and collaboration locally andglobally\u201d [11]. However, adhering to these actionsrequire surveillance tools that support planning, moni-toring and evaluation.In the absence of a coordinated Canadian system forcollecting health data, some colleges and universitieshave been subscribing to the U.S.-based National CollegeHealth Assessment service of the American CollegeHealth Association (NCHA-ACHA). This tool, however,has a number of notable limitations. First, the survey isoverly long and cumbersome with more than 300 items;second, several measures and survey tools suffer from anumber of limitations [12]; third, many questions maynot be of priority to Canadian stakeholders (e.g., seatbeltuse) and questions in the survey reflect American healthguidelines; fourth, Canadian stakeholders have expressedthe need for a salutogenic tool that reflects mentalhealth assets; and finally, the administration of theNCHA is neither comprehensive nor coordinated withCanadian research\/data, thereby limiting the opportun-ities for institutional comparisons and to identify bestpractices. The NCHA is restricted to individual-level be-haviors based on the cycle that each institution sub-scribes to, and is not ideal for institutional-levelcomparisons. For example, we may want to understandwhat programs and policies are associated with healthierstudent level profiles. If institutions from across Canadaadopt a common surveillance tool, it becomes possibleto determine over time which institutions are successfulin changing health behaviors of interest. In turn, this in-formation might pinpoint promising policies orstrategies associated with such change, which can subse-quently be implemented at other institutions. This alsoprovides the capacity for quasi-experimental and naturalexperiments at the local, provincial or national level[13]. Creating an agile Canadian health and wellness sur-veillance system will serve as a critical knowledge ex-change platform.The primary purpose of this study is to describe theprocess in developing a framework for a contextuallyrelevant post-secondary health surveillance tool inCanada, known as the Canadian Campus WellbeingSurvey (CCWS). The focus of this work is in developinga student-level survey to measure individual wellbeingand health behaviors. Future work will also considerapproaches to capturing information at an institutionallevel regarding programs, policies and resources associ-ated with wellbeing among students. We conducted aDelphi survey and consensus panel meeting to identifymental health and health behavior measurementpriorities and indicators, which will help to inform thedevelopment of a 20-min survey tool. This timeframewas chosen to minimize participant dropout, and is inline with industry recommendations for online surveys[14]. A secondary purpose is to increase awareness ofthis evolving project among the public health commu-nity, and present a framework for which health surveil-lance systems may be developed in other countries withinstitutions adopting the Okanagan Charter.MethodsExpert panel participantsAll study procedures were approved by the UBCBehavioural Research Ethics Board (H18\u201300238). Intotal, seventeen health service providers (e.g., direc-tors of wellness\/wellbeing services, campus healthpromoters, physicians from student wellness centers)from 12 post-secondary institutions across 5 Canadianprovinces were invited by email and a follow-up tele-phone call to participate in a Delphi survey androundtable meeting to develop the CCWS framework.Panelists were identified by the facilitation team (GF,MK, SR) and through snowballing techniques, withconsideration given to available budget, geographicdistribution and expertise in student health. A studentsenator versed in campus mental health initiativeswas also invited to provide a student voice to thepanel. One final expert was invited from a provincialorganization focusing on mental health initiativeswithin post-secondary settings. All invited panelistsaccepted the invitation to participate. Some panelistsconsulted with colleagues when completing eachsurvey, and so the Delphi results reflected perspec-tives from a total of 26 members.Faulkner et al. BMC Public Health          (2019) 19:935 Page 2 of 11Delphi surveyA three-round Delphi survey was administered by email(March\u2013April 2018) to identify institutional priorities forcore sections and indicators for a 20-min CCWS. TheDelphi survey is a structured method for building con-sensus by administering a series of simple questionnairesto a panel of experts [15, 16]. The Delphi technique hasbeen widely used for identifying measurement indicatorsin health and healthcare because it enables synthesis ofknowledge from a geographically and experientially di-verse group of experts with available evidence [15, 16].Comments and feedback can be shared anonymously,prompting unbiased consideration by panel experts[15, 16]. The Delphi approach was also chosen toencourage a sense of ownership of the developinginstrument which may promote future institutionaluptake. The surveys and accompanying questions areavailable from the authors upon request. With up totwo reminder emails sent the day before and on theday that each survey was due, a response rate of100% was achieved for the three survey rounds. Thecorrespondence process was handled by the secondauthor.In this Delphi survey, a list of nine core sections andaccompanying indicators were generated by the facilita-tion team based on section headings from populationsurveys, including several deployed in college settings(i.e., National College Health Assessment, HealthyMinds Study, Positive Health Surveillance IndicatorFramework from the Public Health Agency of Canada,and the Canadian Health Measures Survey). This list (anExcel spreadsheet) was emailed to panelists in Round 1,and panelists were asked to prioritize core sections frommost to least important, and also rate indicators withineach section from most to least important. A final taskwas to add any new indicators they perceived wereabsent from the list, and provide comments that couldbe collated and anonymously shared with the group.Panelists were given three weeks to complete Round 1.In Round 2, the spreadsheet list was re-ordered basedon mean group ratings, with the addition of core sec-tions and indicators suggested by panelists. Separatespreadsheets were emailed to each panelist with thegroup mean and standard deviations for each sectionand indicator group, and individual Round 1 rankings.The task for Round 2 was to compare individual rank-ings with group means and standard deviations, revise asdesired, and respond to any comments included. DuringRound 1, several panelists felt that indicator groupsoften included overlapping indicators and expressed theneed to use the same rank for these overlapping items.In response, the facilitation team decided that panelistscould use the same rank for overlapping items in Round2. Panelists were given two weeks to complete Round 2.For Round 3, the spreadsheet was re-ordered as was donein Round 2 with identical instructions sent to panelists.Panelists were given one week to complete Round 3.Roundtable meeting: Canadian Campus Wellbeing SurveyFollowing all three rounds of the Delphi survey, panelistsmet at an in-person meeting to review Delphi findingsand discuss considerations for implementing the CCWS(e.g., dealing with privacy and data sharing; improvingresponse rates). Representatives from all 12 post-secondary institutions were present. The roundtablemeeting was held May 10\u201311, 2018 at the University ofBritish Columbia, Vancouver, Canada, to discuss the pri-ority ranking results of the Delphi survey. A key meetingobjective was to refine the consensus framework into aset of core sections and indicators that could be assessedwithin a 20-min timeframe.Final results of the Delphi were presented to the entiregroup (see Table 1 for M, SD and core section rankings),and then panelists were split into three groups forroundtable sessions focusing on specific core sections.Roundtable discussions focused on three questions: a)whether the core section priority rankings were accept-able; b) within each section, prioritize specific indicatorsthat must be included in the CCWS; and c) discuss indi-cators to be excluded from the core CCWS module.ResultsCore sections and indicatorsThe final core section framework from the Delphi surveyand roundtable meeting was nearly identical to the 9 sec-tions generated by the facilitation team from previous sur-veys, with some changes to the section labels and prioritysequence. Through the iterative Delphi survey, a sectionoriginally labeled \u201ccampus climate and culture\u201d encom-passed broader social determinants of health in eachround, and was renamed \u201cstudent experience\u201d to captureoff-campus student experiences. Another section origin-ally labeled \u201ceating and body image\u201d was renamed \u201cnutri-tion\u201d to reflect that selected indicators focused on foodsecurity and eating habits most closely related to healthoutcomes. All other sections and labels were retainedfrom the framework generated by the facilitation team,with minor changes with respect to priority sequence.The final indicator framework from the Delphi survey(see Table 1, column 4) was an extensive list. This finalframework was used as a prompt for discussions duringthe roundtable meeting. At the meeting, the primarytask was to devote time to each core section and identifywhich indicators were critical to include, and which oneswere low-priority for a 20-min core survey.Roundtable groups used five main strategies to shortenthe indicator list: 1) collapsing similar indicator concepts;2) removing indicator concepts that are controversial andFaulkner et al. BMC Public Health          (2019) 19:935 Page 3 of 11Table 1 Core section and indicator framework for the CCWSM(SD) Core sections M(SD) Final Delphi survey indicators Roundtable meeting indicators1.7(0.9) Mental healthassets1.6(1.5) Resilience aResilience (e.g., control and self-efficacy,coping)2.3(1.1) Psychological wellbeing aPsychological wellbeing(e.g., self-rated mental health)3.6(2.4) Flourishing aFlourishing (e.g., life satisfaction, happiness)4.4(1.8) Coping aSense of meaning or purpose5.1(2.4) Self-rated mental health6.1(1.6) Stress management techniques(e.g., stress mindset)7.1(1.7) Life satisfaction7.5(2.2) Control and self-efficacy(e.g., fixed or growth mindset)7.8(1.9) Happiness8.7(2.4) Self-esteem8.9(3.4) Self-determination10.9(1.3) Sense of meaning or purpose(e.g., spirituality)2.0(1.1) Studentexperience1.3(0.5) Sense of belonging (and conversely,social isolation and loneliness)aPerceptions of campus climate (e.g.,supportive learning environments, mentalhealth support, equity and inclusion, safety,institution cares for student wellbeing)2.5(1.3) Perceptions of campus climate(e.g., supportive learning environments)aOverall social experience and socialconnectedness (e.g., meaningfulconnections, healthy relationships, socialsupport)3.6(1.6) Social support on campus(e.g., sense of community)bSense of belonging to any campus context(e.g., clubs, residences, sport teams);conversely, social isolation and loneliness3.6(1.9) Overall social experience and socialconnectedness (e.g., meaningfulconnections, healthy relationships,social support)bNegative experiences (e.g., sexism, racism,violence, discrimination)4.1(1.4) Experiences of equity and inclusion(e.g., diversity); and conversely, negativeexperiences: sexism, racism, violence,discrimination)bFinancial wellbeing (e.g., access to safe andaffordable housing, living arrangements)5.7(2.1) Financial wellbeing (access to safe andaffordable housing, living arrangements)6.8(1.7) Feelings of safety (e.g., physical andpsychological)7.3(2.3) Built and natural environments(e.g., access\/exposure to nature, beautiful\/calm environments, learning spaces fordiverse needs, time spent outdoors)7.6(1.4) Engagement in extra-curricular activities8.9(1.3) VolunteerismFaulkner et al. BMC Public Health          (2019) 19:935 Page 4 of 11Table 1 Core section and indicator framework for the CCWS (Continued)M(SD) Core sections M(SD) Final Delphi survey indicators Roundtable meeting indicators3.3(1.5) Mental healthdeficits1.6(1.0) Anxiety aSources of perceived dis-stress coupledwith extent of impact2.4(1.2) Depression bAnxiety3.3(1.6) Sources of stress coupled with extent ofimpactbDepression3.6(1.5) Psychological stress bSuicidal tendencies (i.e., planning, notideation)4.5(1.1) Emotional dysregulation (e.g., inability tomanage emotions)5.5(1.5) Suicidal tendencies6.6(0.8) Non-suicidal self-injury4.1(1.0) Health serviceutilization\/help-seeking1.6(0.9) Knowledge and perceptions of campusmental health servicesaKnowledge of mental health services,perceptions of campus mental healthservices, general sources of support(e.g., friends, family)1.9(0.8) Help-seeking intentions (e.g., intentions toaccess other support services (e.g., careercounseling, accessibility services, academicsuccess center))aAccess to mental health services (e.g.,stigma, timely access to counseling services\/health professionals, gaps in health serviceson campus)3.8(1.3) Use of health service facilities on campus bHelp-seeking intentions (e.g., intentions toaccess other support services (e.g., careercounseling, accessibility services, academicsuccess centre))4.1(1.6) Access to mental health services (e.g., timelyaccess to health professionals\/services; gapsin health services on campus)bUse of health professional services(e.g., counseling\/therapy, medicalprofessionals, emergency room)4.4(1.5) Use of health professional services (e.g.,counseling\/therapy)5.1(1.8) Perceived stigma (e.g., self-stigma, stigmafrom others)6.1(1.9) Sources of health information (e.g., use ofonline or e-resources)6.6(1.8) Diagnosis of mental illness or condition (e.g.,complex mental health diagnosis; AttentionDeficit Hyperactive Disorder; Autism\/Autismspectrum)History of mental health services\/medication9.0(1.4) Use of medication4.9(1.0) Physical health\/health behaviours1.9(1.5) Sleep (e.g., sleep difficulties) aSleep (e.g., sleep difficulties)2.6(1.3) Physical activity aPhysical activity3.5(1.9) Perceived health status aSedentary behavior4.2(1.4) Sedentary behavior bPerceived health status4.5(2.2) Overall wellbeing bOverall wellbeing4.9(1.4) Screen time bScreen time5.5(1.3) Social media bSocial media (e.g., influence on socialnorms and self-perceptions)Faulkner et al. BMC Public Health          (2019) 19:935 Page 5 of 11Table 1 Core section and indicator framework for the CCWS (Continued)M(SD) Core sections M(SD) Final Delphi survey indicators Roundtable meeting indicators7.9(0.4) Body Mass Index5.4(1.5) Academicachievement1.4(0.5) Issues affecting academic performance(e.g., academic barriers)aCurrent academic Grade Point Average(GPA) (e.g., changes in GPA, academicperformance, academic comparisonswith peers)2.1(1.2) Overall academic experience (e.g.,satisfaction with academic achievement)bIssues affecting academic performance(e.g., academic barriers)3.2(0.7) Experiences with faculty bOverall academic experience(e.g., satisfaction with academicachievement and performance)4.2(0.9) Experiences with academic support services bExperiences with faculty, TA, sessionalinstructors4.8(1.6) Current academic Grade Point Average(GPA)bExperiences with academic support services4.9(1.0) Academic accommodations bAcademic accommodations (e.g., wellbeingissues and academic concessions)6.7(0.8) Substance use1.4(1.0) Alcohol aAlcohol2.5(1.1) Marijuana\/cannabis use (e.g., vaping) aMarijuana\/cannabis use (e.g., vaping)3.2(1.6) Perception of risk regarding substance use(e.g., drinking and driving, substance useliteracy, harm reduction)aDrugs excluding marijuana\/cannabis (e.g.,opioids, study drugs (e.g., Adderall, Ritalin),use of another person\u2019s prescriptionmedication)4.6(1.5) Drugs excluding marijuana\/cannabis, use ofanother person\u2019s prescription medicationbPerception of risk and social norms forsubstance use (e.g., drinking and driving,substance use literacy, harm reduction)4.9(2.3) Tobacco-use (e.g., smoking, vaping) bTobacco-use (e.g., smoking, vaping)5.9(1.5) Peer alcohol use6.6(1.5) Peer substance use (e.g., norms ofsubstance use)6.7(1.4) Motivations for substance use(e.g., peer pressure)8.8(2.1) Stimulants (e.g., caffeine, medications,energy pills)7.6(0.6) Nutrition1.1(0.3) Food security (e.g., access to affordable andnourishing food; alignment with eatinghabits and preferences)aFood security (e.g., access to affordable andnourishing food, alignment with eatinghabits and preferences)2.4(1.1) Consumption of fruits and vegetables bConsumption of fruits and vegetables3.7(1.7) Eating disorder symptoms (and disorderedeating behaviours)bConsumption of sugar-sweetenedbeverages4.1(1.7) Weight (body) concerns\/perceptions (e.g.,body dissatisfaction, body image norms)4.4(1.2) Consumption of different food groups5.1(1.4) Consumption of sugar-sweetened beverages6.0(1.9) Consumption of water7.1(1.1) Availability of nutritional informationFaulkner et al. BMC Public Health          (2019) 19:935 Page 6 of 11likely to be triggering for students, leading to surveydropout; 3) prioritizing indicators with known links tohealth outcomes; 4) prioritizing indicators that arerelevant to student populations based on interests,habits or stage of development, and 5) any selectedindicators must be applicable to any college or uni-versity, regardless of individual characteristics like sizeand location. Where there was disagreement in thesmaller discussion groups regarding indicators toretain, panelists generally deferred to subject-area ormeasurement experts for further guidance. Overall,decisions were made based on institutional priorities,but members acknowledged that a range of consider-ations will be important during the next stage ofCCWS question development for this surveillance toolto be applicable and useful for diverse institutionsand populations (e.g., staff; colleges). Column 5 ofTable 1 (\u2018Roundtable meeting indicators\u2019) identifiesthe final indicators as a result of both the DelphiSurvey and the roundtable discussions. During theroundtable, participants were invited to vote as agroup as to the final inclusion of an indicator.Mental health assetsAll three-discussion groups agreed on the inclusion offour indicators: resilience, psychological wellbeing,flourishing and sense of meaning or purpose. Concernswere expressed that some of these terms\/indicators arebuzzwords that may lose currency over time. Sense ofmeaning or purpose, while identified as the lowest ratedindicator in the Delphi survey, needed to be includedwithin the broader context of flourishing within a post-secondary setting. Members felt that sense of meaningor purpose had fallen to the bottom of the mental healthassets indicator list because it had become lumpedtogether with spirituality (which was not perceived ascritical to measure in the core survey). Consensus wasreached in including sense of meaning as an indicator.Student experienceThe student experience section (formerly campusclimate and culture) was one that grew over the courseof the Delphi survey and encompassed diverse aspects ofstudent life including social experiences, financial well-being and feelings of safety. For this reason, a dedicatedroundtable session was set aside to discuss this sectionand was guided by the following questions: 1) What ismeant by campus climate and culture?; 2) What specificconstructs are measurable?; 3) What information wouldbe useful for comparisons with other institutions; 4)What is already being captured in other institutional-based surveys? (i.e., National Survey of StudentEngagement); and, 5) What survey questions have beenuseful in your own experience?All groups reached consensus on including percep-tions of campus climate, and overall social experienceand social connectedness as indicators. In terms ofsense of belonging, smaller group discussions revealedthat this indicator should assess whether students feltconnected to any campus-based groups, regardless ofthe specific context (e.g., are students connected tosport teams, residences, special interest groups, etc.).When it came to negative experiences, some panelistsfelt that this indicator should include measures of ex-posure to sexual harassment and abuse, as distress,mental health, physical health and substance abuseare tightly linked with experiences of sexual abuseand other forms of violence. Furthermore, manyprovinces and post-secondary institutions haverecently developed policies and offices around theseissues. Excluding this topic may lead to criticisms thatthe CCWS is not aligned with student and institu-tional concerns and priorities. Finally, although therewas debate on whether it was feasible to include acomplex indicator like financial wellbeing in theCCWS, questions related to safe and affordablehousing was identified as an assessment priority bysome institutions.Table 1 Core section and indicator framework for the CCWS (Continued)M(SD) Core sections M(SD) Final Delphi survey indicators Roundtable meeting indicators9.0(0.3) Sexual healthbehaviour1.1(0.5) Safe sex practices aSafe sex practices (e.g., contraceptive use)2.1(0.5) Contraceptive use bSexual satisfaction3.5(1.2) Sexual activities4.2(1.0) Sexually transmitted infections4.5(1.5) Sexual orientation4.8(1.0) Sexual satisfactionNotes: Core sections and indicators are presented in priority sequenceMeans and standard deviations refer to the final core section and indicator scores after the three Delphi roundsaAll three roundtable discussion groups agreed on the inclusion of this indicator in the final core surveybOne or two roundtable discussion groups agreed on the inclusion of this indicator in the final core surveyFaulkner et al. BMC Public Health          (2019) 19:935 Page 7 of 11With respect to indicators that were not retained, rea-sons for removal from the final CCWS frameworkvaried. For example, some members felt that assessingperceptions of the built and natural environment wasimportant while others believed that it may be possibleto capture this information from an institutional auditor other data sources. When it came to experiences ofequity and inclusion, proper assessment may be beyondthe scope of the CCWS. Engagement in extra-curricularactivities and volunteering may not make sense forstudents, given their academic and work commitments.A better approach would be to look at whether studentsfeel engaged and a sense of belonging to somethingbeyond academics and work.Mental health deficitsAll groups identified sources of perceived distresscoupled with extent of impact as a critical indicator. Dis-tress, not stress, was the construct of interest, i.e., isstress impairing you? Some but not all groups retainedanxiety and depression\/depressive symptoms as indica-tors. As conversation evolved, panelists agreed that itwas essential for both experiences and diagnosis of thesedeficits to be captured. An indicator that many believedshould be included (though mindful of how it was mea-sured and assessed) was suicidal ideation. There was,however, little consensus on this issue. For some,assessing suicidal ideation did not lead to actionable in-formation. For others, the issue was considered to beimportant politically, as it receives media attention, andis something that can be taken to provincial entities orto university administration with potential fundingimplications.Health service utilization\/help-seekingAll groups prioritized two indicators: a composite ofknowledge of mental health services, perceptions ofcampus mental health services, and general sources ofsupport; and, access to mental health services. Access toservices should, in particular, reflect any stigma relatedto seeking mental health support. Some, but not allgroups, retained help-seeking intentions and use ofhealth professional services.With respect to indicators not retained in the final list,decisions were generally based on lack of applicabilityfor a Canada-wide monitoring system, and lack of\u201cactionable\u201d information. For example, use of healthservice facilities may be best assessed locally to reflectunique aspects of individual institutions. Diagnosis ofmental illness or condition, history of mental health ser-vices\/medication and use of medication may medicalizethe CCWS and is unlikely to provide information thatcampus services and programming could act upon.Physical health\/health behavioursAll groups prioritized indicators of sleep, physical activ-ity and sedentary behavior. Several members felt thatthat perceived health status and overall wellbeing couldbe captured with quick single-item questions and wouldtherefore be useful to include. There was some debatewhether social media and screen time fit into the corestudent survey. In the end, because social media andscreen time was topical for student populations, theyemerged as priorities, with a view to consider questionson whether they were interfering with students\u2019 studiesand wellbeing, and how social media influenced socialnorms and self-perceptions. There was not muchinterest in body mass index, given the self-report natureof the survey and uncertainty regarding the validity ofbody mass index for racially diverse populations.Academic achievementAll groups agreed on including an indicator of academicperformance as it relates to wellbeing; but importantly,there were variations in terms of how to best capturethis. Generally, there was an acknowledgement of thelimitations or inherent biases associated with self-reported Grade Point Average. However, there was littleconsensus regarding the best way to capture academicperformance with some discussion of whether perceivedchanges \u201cfrom last semester\u201d in Grade Point Averagemay be appropriate. All Delphi indicators were retainedfrom this section by at least one group.Substance useAlcohol and marijuana\/cannabis use were consideredessential in assessing by all groups. Members recom-mended adding questions about opioids and \u201cstudydrugs\u201d to be in tune with emerging substance use con-cerns among post-secondary students. Perception of riskfor substance use was also highlighted as an importantindicator to assess, because campus programming andservices may address social norms and underlying issues.NutritionWhile nutrition was acknowledged as an importantcomponent of wellbeing there was also consensus thatmeasurement challenges may restrict what could beasked within a short survey. All three groups didconsider food (in)security as essential to measure. Somegroups advocated for including questions on sugar-sweetened beverage consumption while others recom-mended assessing daily consumption of fruits andvegetables.Sexual health behaviorAll groups agreed on the inclusion of safe sex practicesas an important indicator of sexual health behavior.Faulkner et al. BMC Public Health          (2019) 19:935 Page 8 of 11Panelists agreed that it was not possible to addresssexual activities and sexually transmitted diseases in the20-min survey, and there were likely other databases(e.g., those maintained by student health services) cap-turing this information. There were also some sugges-tions that focusing on sexual satisfaction may be a morepositively framed way to assess sexual health.DiscussionThis paper describes the first step within our implemen-tation of a comprehensive and coordinated Canadianpost-secondary health surveillance system that integratespublic health policy, practice, evaluation, surveillanceand research. The long-term goal is to develop acomprehensive surveillance system that will enable post-secondary institutional leaders and health services to a)identify population-level estimates of health behaviorand wellbeing; b) identify intervention priorities at theirinstitutions; and c) evaluate intervention implementa-tion. In conducting this preliminary work, we wereencouraged by the level of interest and commitment ofour participating panel members in moving forward indeveloping, and eventually collectively administering, theCanadian Campus Wellbeing Survey (CCWS). Overall,there was consensus that a common surveillance mech-anism that was tailored to the Canadian postsecondarycontext was very much needed.The starting point for the surveillance mechanism iscreating the content of the student-level survey of healthbehavior and wellbeing. Results showed consensus in thecore section priority rankings, and general agreement inthe top-rated indicators from each core section to be in-cluded in the CCWS. Within each core section, consen-sus was reached for at least one indicator. Highest levelsof agreement emerged for the top-rated mental healthassets section, as all discussion groups independentlyagreed on four priority indicators to include in the finalframework. In particular, there was demand for theCCWS to move away from a mental illness model toone that operationalizes mental health as symptoms ofpositive feelings and positive functioning in life [17].This is in contrast with the most commonly used tool inCanada, the NCHA, and also the more recent WorldHealth Organization World Mental Health SurveysInitiative International College Student Project (WMH-ICS), which is exclusively focused on mental disorders[18, 19]. The concepts of flourishing and resilience wereconsidered central to the CCWS.There was also consistent recognition of the bi-directional relationship of wellbeing and health behaviors,and the continued importance of monitoring the mostconsistent behavioral risk factors for premature chronicdisease including tobacco use, physical activity andsedentary behavior, and binge drinking. Sleep emerged asa health behavior that was considered essential to assessas well. Given emerging trends in Canadian populationguidelines and research looking at movement across acontinuum from sleep to sedentary behavior, and light,moderate and vigorous activity, [20\u201323]. assessing thesemovement behaviors will ensure alignment with the newadult guidelines under development.Most debate was reserved for capturing and definingthe parameters for measures related to campus climateand student experiences. Clearly, measuring a sense ofbelonging or social connectedness was consistently im-portant for panel members, and in line with theoreticalframeworks such as Self-Determination Theory, [24].that highlight the importance of connectedness forwellbeing. There is also growing evidence that a feelingof connectedness itself protects against engagement inhealth-risk behaviors [25]. There was polarity whenthinking about measuring experiences of equity and in-clusion (e.g., diversity); and conversely, negative experi-ences including sexual assault, racism, or discrimination.Discussion groups considered how much overlap thereshould be with other existing institutional surveys thatcould be deployed to more adequately examine thesesensitive issues.In developing the CCWS, a decision was made todevelop a 20-min core survey that is relevant to allCanadian postsecondary settings and potentiallyapplicable for faculty, staff and campus neighborhoodresidents. This will necessitate some difficult decisionsin focusing on the top-ranked indicator(s) in each coresection. This is made easier by harmonizing the CCWSwith other complementary surveys conducted in Canada.For example, there was less interest in a detailed explor-ation of alcohol and drug use within the CCWS giventhe recent Health Canada initiative to develop a postsec-ondary drug and alcohol survey in collaboration withthe Postsecondary Education Partnership- AlcoholHarms (PEP-AH) [26]. More detailed exploration ofissues regarding sexual violence and campus climate ingeneral could be assessed through the EAB Climate Sur-vey [27]. As the CCWS grows, there is the potential todevelop additional modules (e.g., sexual health) that canbe included in concert with the core module dependingon institutional interest. In other words, the CCWS willbe flexible and able to accommodate additional ques-tions for individual institutions. This flexibility will beimportant to address emerging concerns such as opioiduse on particular campuses or the rapidly changingnature of social media. While not in the current scopeof our work, the CCWS is also designed so it could beimplemented for assessing the wellbeing of staff, facultyor campus neighborhood residents.The next stage of developing the CCWS will involveonline consultation with health service providers from aFaulkner et al. BMC Public Health          (2019) 19:935 Page 9 of 11broader range of post-secondary institutions through theCanadian Association of College & University StudentServices (CACUSS) (e.g., colleges, polytechnic institutes,rural and northern locations), to solicit additionalfeedback on the proposed CCWS framework. This willbe followed by an in-person meeting with research andmeasurement experts to identify and finalize CCWSitems. The CCWS will use measures with demonstratedreliability and validity that are consistent with nationalsurveillance tools. Formative testing at pilot universityand college sites will take place early 2019 to ensure thatthe survey is relevant to, understood by, and convenientfor post-secondary students to respond to, and can becompleted within a 20-min timeframe. The aim is to de-ploy the CCWS at select post-secondary sites in the2019\u20132020 academic year.The methodological approach we adopted was success-ful as a first step in developing a common surveillancemechanism tailored to the Canadian postsecondary con-text. It also created a space for collegial discussion of theimportance of creating a national platform for knowledgeexchange and evolving a stronger community of practice.There were some limitations to the approach. First, givenbudgetary and time constraints, participants were selectedthrough personal contacts of the research team and wereindividuals who had expressed interest in developing anew student level survey for use in Canada. It is notknown how different perspectives may be from other in-stitutions not represented. Further consultation regardingthe framework is planned throughout 2019. Second, con-sensus was not always met on some topics for inclusion.An example was perceptions of the built environment. Insuch cases where there was no clear consensus, theresearch team erred on the side of caution in excludingthe indicator with a view that future modules could becreated to assess topics of interest to institutions. The goalof creating a twenty-minute survey was central to suchdecisions. Finally, the Delphi Survey was not anonymousas the second author was aware of individual responsesthroughout the survey process. At the same time, indica-tor rankings and comments were collated and sharedanonymously with the group.In parallel with the work on the CCWS is the plannedcreation of a national standard for post-secondary stu-dent mental health to support student success on cam-puses across Canada. The Mental Health Commission ofCanada (MHCC) will be leading the project to establishthe standard in collaboration with other Canadian orga-nizations [28]. Most critically, there are plans to developa formalized audit tool for institutions to assess progresstoward meeting those standards, which would be com-plementary to the individual-level CCWS. For example,this institutional-level tool can be linked to the CCWSto explore how institutional variability in policies andprograms may explain variability in student-level well-being outcomes. Importantly, these tools will be essentialto the evaluations of campus-based programs, policies,and initiatives implemented based on the OkanaganCharter and its Call for Action. Bringing togetherstudent and institutional-level data has the potential tocreate a powerful knowledge exchange platform forCanadian institutions to identify what works best, forwhom, and under what circumstances \u2013 and such evalu-ative mechanisms should be a priority for any institutionadopting the Okanagan Charter.ConclusionMuch work remains in finalizing the CCWS, piloting itsadministration, and addressing the pragmatic institu-tional concerns related to sensitive issues such as datasharing, reporting, and management. Developing a com-mon Canadian surveillance and knowledge exchangesystem at the postsecondary level is an ambitious vision,but we believe integral to population health initiativestargeting the increasing number of young Canadiansattending postsecondary institutions.AbbreviationsCCWS: Canadian Campus Wellbeing Survey; NCHA: National College HealthAssessmentAcknowledgementsGF is supported by a Canadian Institutes of Health Research-Public HealthAgency of Canada (CIHR-PHAC) Chair in Applied Public Health.The following are members of the CCWS Expert Panel Group: GayaArasaratnam, Concordia University; Joan Bottorff, University of BritishColumbia, Okanagan; Alison Burnett, University of Guelph; Peter Cornish,Memorial University; Rosie Dhaliwal, Simon Fraser University; Matt Dolf,University of British Columbia; Tracey Hawthorn, University of BritishColumbia, Okanagan; Kandi McElary, Mount Royal University; RachelleMcGrath, Mount Royal University; Catharine Munn, McMaster University;Clayton Munro, Langara College; Michelle Bowers, Langara College; BenPollard, University of British Columbia; Janine Robb, University of Toronto;James Sanford, Acadia University; Andrew Szeto, University of Calgary; DavidLowe, University of Toronto; Marium Hamid, University of British Columbia;Cheryl Washburn, University of British Columbia. All authors contributed tothe Delphi Survey and panel meeting, and approved the final draft of themanuscript. All members of this panel consented to being listed here.Ethics approval and consent to participantsAll participants consented online (ticking a box to their consent) to theirstudy participation. The study received approval from the UBC BehaviouralResearch Ethics Board (H18\u201300238).Authors\u2019 contributionsGF, SR and MK contributed to the design and implementation of the research,to the analysis of the results, and to the writing of the manuscript. CCWS ExpertPanel Group members provided intellectual content through the Delphi surveyand the roundtable meeting, and provided feedback on drafts of themanuscript. All authors have read and approved the manuscript.FundingThe Rossy Foundation and the University of British Columbia provided directfunding, and the University of British Columbia and University of Torontowere collaborating partners on this project. The funders had no input on thedesign of the study and collection, analysis, and interpretation of data orwriting of the manuscript.Faulkner et al. BMC Public Health          (2019) 19:935 Page 10 of 11Availability of data and materialsThe datasets used and\/or analyzed during the current study are availablefrom the corresponding author on reasonable request.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1School of Kinesiology, University of British Columbia , Lower Mall ResearchStation, 2259 Lower Mall, Room 337, Vancouver, BC V6T 1Z4, Canada. 2Centrefor Hip Health and Mobility, Vancouver Coastal Health Research Centre, 2635Laurel Street, Vancouver V6T 1M9, BC, Canada. 3Department of FamilyMedicine, McMaster University, 100 Main Street, Hamilton L8P 1H6, ON,Canada.Received: 22 November 2018 Accepted: 28 June 2019References1. Lynch J, Smith GD. 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