2014 Report on the state of Public health in Canada

2014 Report on the state of Public health in Canada
The Chief Public Health Officer’s
Report on the state of
Public health in Canada
2014
Public Health in the Future
Également disponible en français sous le titre :
Le rapport de l’administrateur en chef de la santé publique sur l’état de la santé publique au Canada, 2014 :
La santé publique et l’avenir
Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014: Public Health in the Future
is available on the Internet at the following address:
http://publichealth.gc.ca/CPHOReport
This publication can be made available in alternative formats upon request.
© Her Majesty the Queen in Right of Canada, as represented by the Minister of Health, 2014
Publication date: September 2014
This publication may be reproduced for personal or internal use only without permission provided the
source is fully acknowledged.
PRINT Cat.: HP2-10/2014E PDF Cat.: HP2-10/2014E-PDF
ISSN: 1917-2656
ISSN: 1924-7087
Pub.: 140286
A MESSAGE FROM CANADA’S CHIEF
PUBLIC HEALTH OFFICER
This year, the Public Health Agency of Canada marks
its tenth anniversary and seventh annual report. While
it’s remarkable how much has changed in that short
period, it’s even more telling to consider, from a broader
perspective, what the pace of that change means for
our future.
This report looks forward on some of the challenges and
opportunities influencing public health and Canada down
the road. As with other reports it is not a compendium,
nor does it address all the important future impacts, but
rather some key ideas and evidence to generate debate,
discussion and ultimately practical action. This report
makes it clear that the issues we face impact us all
directly. We know our population is aging. We know
our environment is changing. And we know the pace
of technological change is faster than ever. What does
all of this mean for our health and well-being?
Some of our most pressing questions have no simple
answers. As the world transitions, how can we best
manage this change in a way that improves rather
than diminishes health?
One thing is certain—we can’t afford to consider any
of these changes in isolation. That’s why we must go
beyond traditional public health borders and venture
into some relatively new territory. This report examines
what we know about what is changing, and includes
examples of potential impacts moving forward.
At this time, I would like to express our sincere thanks
to Dr. David Butler-Jones for his significant contribution
to protecting and promoting the health and safety of
Canadians over the past 10 years as Canada’s first Chief
Public Health Officer.
Dr. Gregory Taylor
A MESSAGE FROM CANADA’S CHIEF PUBLIC HEALTH OFFICER
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
ACKNOWLEDGEMENTS
Many individuals and organizations have contributed
to the development of The Chief Public Health Officer’s
Report on the State of Public Health in Canada, 2014:
Public Health in the Future.
English and French editors:
Strategic consultants:
External advisors and reviewers:
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The Honourable Gary Filmon, PC, OC, OM, LLD,
Chairman, Exchange Income Corporation;
John Frank, MD, Director, Scottish Collaboration
for Public Health Research and Policy; Chair, Public
Health Research and Policy, University of Edinburgh;
Professor Emeritus, Dalla Lana School of Public Health,
University of Toronto;
Peter Glynn, PhD, Health Systems Consultant;
David Mowat, MBChB, MPH, FRCPC, FFPH, Medical
Officer of Health, Region of Peel, Ontario;
Daryl Pullman, PhD, Professor of Medical Ethics,
Division of Community Health and Humanities,
Memorial University;
Jeff Reading, MSc, PhD, FCAHS, Professor , School
of Public Health and Social Policy, Faculty of Human
and Social Development, University of Victoria;
Cornelia Wieman, MSc, MD, FRCPC, Assistant Professor,
Department of Public Health Sciences, Faculty of
Medicine, University of Toronto and Co-Director of the
Indigenous Health Research Development Program;
and
Brenda Zimmerman, MBA, PhD, Director, Health
Industry Management Program; Associate Professor
of Strategy/Policy, Schulich School of Business,
York University.
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The Public Health Agency of Canada:
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CPHO Reports Unit: Jane Boswell-Purdy, Paula Carty,
Maureen Hartigan, Doug Hopkins, Jennifer Lew,
Chrystal Reaney, Jennifer Lynn Scott, Melannie Smith,
Andrea Sonkodi and Crystal Stroud; and
2014 Core Advisory Group: Rukshanda Ahmad,
Renee Couturier, Monika Dankova, Kelly De Cecco,
Margaret de Groh, Amanda Hayne-Farrell, Mana Herel,
Jason King, Deirdre MacGuigan, Nick Previsich,
Shannon Russell, Tiffany Smith, Manon Turcotte,
Ben Wilson and Tom Wong.
Joanna Odrowaz; and
Anna Olivier (Athéna Rédaction).
Michel Amar, MSc, Michel Amar and Associates;
Pierre-Gerlier Forest, PhD, Director, Institute for
Health and Social Policy, Johns Hopkins University;
Judith Guernsey, PhD, MSc, Professor, Faculty
of Medicine, Dalhousie University;
Mauricio Hernandez Avila, MD, Director General,
National Institute of Public Health, Mexico;
Janice Keefe, PhD, Professor of Family Studies
and Gerontology, Mount Saint Vincent University;
Warren Kindzierski, PhD, Associate Professor,
School of Public Health, University of Alberta;
Jay McAuliffe, MD, MPH, Center for Global Health,
United States Centers for Disease Control
and Prevention (CDC);
Moira McKinnon, MBBS, FAFPHM, Australian Capital
Territory Health, Canberra;
Pekka Puska, MD, PhD, MPolSc, President,
International Association of National Public Health
Institutes, Past Director General, National Institute
for Health and Welfare, Finland;
Ruta Valaitis, RN, PhD, Associate Professor, School
of Nursing, Faculty of Health Sciences, McMaster
University; and
Kumanan Wilson, MD, FRCPC, MSc, Senior
Scientist, Clinical Epidemiology, Ottawa Hospital
Research Institute.
Aboriginal organizations:
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Assembly of First Nations;
Inuit Tapiriit Kanatami; and
Pauktuutit Inuit Women of Canada.
ACKNOWLEDGEMENTS
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Federal government departments, agencies and
other organizations:
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Aboriginal Affairs and Northern Development Canada;
Canada Mortgage and Housing Corporation;
Canadian Coalition for Public Health in the
21st Century;
Canadian Institutes of Health Research;
Council of Chief Medical Officers of Health (CCMOH)
Sub Committee;
Employment and Social Development Canada;
Environment Canada;
Health Canada;
Mental Health Commission of Canada;
Natural Resources Canada;
Privy Council Office; and
Public Safety Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
TABLE OF CONTENTS
A MESSAGE FROM CANADA’S CHIEF PUBLIC HEALTH OFFICER.
ACKNOWLEDGEMENTS.
INTRODUCTION..
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Public health and Canada’s Chief Public Health Officer. .
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Health issues and an aging population.
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Changing demographics, aging and society. .
Continuing efforts.
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A changing climate. .
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Climate risks to health: now and in the future. .
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Moving forward: addressing climate change health risks and vulnerabilities. .
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Health promotion and protection.
Education and awareness.
Continuing efforts.
MOVING FORWARD.
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Planning for the future.
A way forward.
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APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS.
Who we are. .
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Factors influencing health.
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Health status.
Summary.
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DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH. .
Surveillance.
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PUBLIC HEALTH IN A CHANGING CLIMATE.
Continuing efforts.
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CHANGING DEMOGRAPHICS, AGING AND HEALTH..
A changing population.
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What this report is about. .
What this report covers.
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TABLE OF CONTENTS
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APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS.
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APPENDIX C: THE CHIEF PUBLIC HEALTH OFFICER’S REPORTS ON THE STATE OF PUBLIC HEALTH IN CANADA..
REFERENCES.
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LIST OF TABLES
Table A.1 Who we are..
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Table A.2 Factors influencing health.
Table A.3 Health status.
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Table B.1 BMI and health risk.
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Table B.2 Low income cut-offs after tax, Canada, 2011. .
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LIST OF FIGURES
Figure 1. Population by age group, Canada, 1971, 2013 and 2056. .
Figure 2. Number of centenarians, Canada, 2001 to 2056.
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Figure 3. Annual national temperature departures and long-term trend, Canada, 1948 to 2013. .
Figure 4. Pathways by which changes in climate can increase risks to health. .
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Figure 5. Canadian flu activity and Google Flu Trends, the week of September 28, 2003,
through the week of March 30, 2014. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.1 Population by age, Canada, 1973 and 2013.
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Figure A.2 Population distribution by origin, Canada, 2011. .
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Figure A.3 Population distribution by population density, Canada, 2011. .
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Figure A.4 Life expectancy at birth by sex, Canada, 1931 and 2009/2011. .
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Figure A.5 Population completing high school or post-secondary school by sex,
Canada excluding territories, 1990 to 2013. . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.6 Unemployment and underemployment rate by age group, Canada excluding territories, 2013.
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Figure A.13 Children and youth attaining suggested levels of physical activity by age group and sex,
Canada, March 2007 to February 2009.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.14 Adults attaining suggested levels of physical activity by age group and sex, Canada,
March 2007 to February 2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.11 Population reporting somewhat or very strong sense of community belonging by
age group and area of residency, Canada, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.12 Police-reported violent crime rate, Canada, 2000 to 2012.
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Figure A.9 Annual average fine particulate matter concentrations, Canada and select regions, 2000 to 2011.
Figure A.10 Households in core housing need by origin, Canada, 1996 and 2006.
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Figure A.7 Canadians living in low income after tax by age group and select household type,
Canada excluding territories, 1978 to 2011. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.8 Annual average ozone concentrations, Canada and select regions, 2000 to 2011. .
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
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Figure A.15 Population reporting fruit and vegetable consumption, 5 or more times per day,
by sex, Canada, 2007 and 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.16 Recommended number of Canada’s Food Guide servings per day.
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Figure A.17 Household food insecurity by household type, Canada, 2007/2008 and 2011/2012.
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Figure A.18 Current smokers by sex, Canada excluding territories, 1985 to 2012. .
Figure A.19 What is a standard drink?.
Figure A.20 Exceeding low-risk drinking guidelines for acute effects by age group and sex,
Canada excluding territories, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.21 Exceeding low-risk drinking guidelines for chronic effects by age group and sex,
Canada excluding territories, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.22 Cannabis use in the past 12 months by age group, Canada excluding territories, 2012.
Figure A.23 Illicit drug use in the past 12 months excluding cannabis by age group,
Canada excluding territories, 2012. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.26 Very good or excellent self-perceived health by age group, Canada, 2003 and 2012. .
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Figure A.27 Life expectancy and health-adjusted life expectancy at birth by sex, Canada excluding territories,
2000/2002 and 2005/2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure A.28 Teen birth rate, Canada, 1930 to 2011.
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Figure A.24 Having a regular medical doctor and contact with a medical doctor by age group, Canada, 2012. .
Figure A.25 Last time visited dentist by select age groups, Canada, 2012. .
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Figure A.29 Canadians reporting one or more chronic health condition by age group, Canada, 2012.
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Figure A.30 Age-standardized incidence rates (ASIR) and age-standardized mortality rates (ASMR)
for all cancers by sex, Canada, 1984 to 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.31 Diagnosed diabetes by age group, Canada, 2004/2005 and 2008/2009. .
Figure A.32 Measured rates of childhood and adolescent overweight and obesity by sex,
Canada excluding territories, 1978/1979 and 2009/2011. . . . . . . . . . . . . . . . . . . . . .
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Figure A.33 Measured rates of adult overweight and obesity by sex, Canada excluding territories,
1978/1979 and 2009/2011. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Figure A.34 Arthritis by age group and sex, Canada, 2012..
Figure A.35 Asthma by age group and sex, Canada, 2012.
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Figure A.36 Chronic obstructive pulmonary disease (COPD) by age group and sex, Canada, 2012. .
Figure A.37 Heart disease by age group and sex, Canada, 2012.
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Figure A.38 High blood pressure by age group and sex, Canada, 2012.
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Figure A.39 Reported rates of chlamydia by sex, Canada, 1995 to 2011.
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Figure A.40 Reported rates of gonorrhea by sex, Canada, 1995 to 2011.
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Figure A.41 Reported rates of infectious syphilis by sex, Canada, 1995 to 2011.
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Figure A.42 Estimated number of new HIV infections for selected years, Canada. .
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Figure A.43 Reported new active and re-treatment tuberculosis cases by origin, Canada, 2002 to 2012.
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Figure A.44 Reported new active and re-treatment tuberculosis cases by Aboriginal status, Canada, 2012. .
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Figure A.45 Very good or excellent self-perceived mental health by age group, Canada, 2003 and 2012.
Figure A.46 Mood disorders and major depressive episodes by age group and sex, Canada, 2012. .
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Figure A.47 Generalized anxiety disorder by age group and sex, Canada, 2012.
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Figure A.48 Hospitalizations for schizophrenia in acute care hospitals, by age group and sex, Canada, 2010.
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Figure A.49 Projected prevalence of Alzheimer’s disease or other dementia by age group, Canada, 2011 and 2031.. 57
Figure A.50 Infant mortality rate, Canada, 1921 to 2011.
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Figure A.51 Change in age-standardized mortality rate by select causes of death, Canada, 2000 and 2011.
Figure A.52 Age-standardized rate of potential years of life lost (PYLL) by select causes, Canada,
2000/2002 and 2005/2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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LIST OF TEXTBOXES
Setting a global agenda for aging.
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The aging First Nations, Inuit and Métis populations and chronic conditions.
Global Action against Dementia..
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Myths associated with an aging population.
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The Canadian Longitudinal Study on Aging..
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Lyme disease: an emerging infectious disease in Canada. .
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22
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24
Air Quality Health Index.
The Rothamsted trap.
Using technology to increase testing for sexually transmitted infections. .
ImmunizeCA. .
. . . . . . . . . . . . . . . . . . . . . . . . . . .
29
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30
T2X: Getting the message to teens. .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fukushima radiation threat: Informing the public through social media..
Looking to the future. .
31
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33
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34
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40
Global Public Health Intelligence Network.
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
INTRODUCTION
Public health and Canada’s
Chief Public Health Officer
Public health is defined as the organized efforts of
society to keep people healthy and prevent injury,
illness and premature death and disability, improving
health and well-being and reducing inequalities in health.
It focuses on preventing disease and optimizing the health
of the population rather than the illnesses of individuals.
It is the combination of programs, services and policies
that protect and promote health. The Public Health Agency
of Canada (the Agency) and the position of Canada’s Chief
Public Health Officer (CPHO) were established in 2004 to
help protect and improve the health and safety of all
Canadians. In 2006, the Public Health Agency of Canada
Act (the Act) confirmed the Agency as a legal entity and
further clarified the roles of the CPHO and the Agency.1
Through the Act, the CPHO has a legislated responsibility
to report annually to the public via the Minister of Health
and Parliament on the state of public health in Canada.
The CPHO’s reports are intended to highlight specific
public health issues that the CPHO has determined
warrant further discussion and action in Canada. As
much as this report is a mechanism to increase awareness,
it is also meant to inspire action to build upon existing
health programs and initiatives and develop new solutions
to promote, improve and maintain optimal health and
well-being for all Canadians.
What this report is about
This report, rather than looking only at health status,
particular disease outcomes or public health initiatives
affecting Canadians today, considers how those issues
may be affected by broader factors that are likely to
influence public health in the future.
Public health in Canada has certainly come a long
way from its early 18th century activities of quarantine
measures to reduce the spread of disease.2 Key innovations
and milestones such as improvements in hygiene and
sanitation late in the 19th century and the introduction
of immunization programs early in the 20th century have
had significant impacts on the increased life expectancy
and improved health of Canadians over the last nearly
200 years.2 More recently, events such as the outbreaks
of severe acute respiratory syndrome (SARS) and H1N1
and the re-emergence of infectious diseases such as
measles have shone a light on the important role public
health plays in fostering the best possible health and
well-being of Canadians. We have certainly learned from
these events and will be able to apply our knowledge
to help shape the direction public health will take in
the future. However, there are also many unknowns
that will also drive public health in the future.
Public health issues can emerge quickly and unexpectedly,
and those working in public health must remain flexible
and responsive to address any future challenges. Public
health involves influencing the factors, inside and outside
the health system, that impact health. These include
income and social status, social support networks,
education and literacy, employment and working
conditions, social environments, physical environments,
personal health practices and coping skills, healthy child
development, biology and genetic endowment, health
services, gender and culture. These determinants of
health affect all Canadians throughout their lifecourse.
When considering how public health will address these
determinants in the future, we need to provide the
context within which public health will be operating.
Although it is impossible to know exactly what that
context will be, we do know that public health will need
to take into account, among other things, who is being
helped, where those people are living and what tools
they have at their disposal to carry out their efforts.
INTRODUCTION
1
What this report covers
The who, where and what of public health in the
future will encompass many things.
WH0: Changing demographics, aging
and health
We know that the age distribution of the Canadian
population is shifting. Canadians born during the baby
boom will soon represent the largest proportion of the
population as seniors. Public health needs to be concerned
about this large and growing senior population as well
as future generations of seniors. This section broadly
explores Canada’s changing demographics and their
influence on select health and social issues. This section
looks at both the current burden of disease for seniors
that will continue to impact individuals and societies
in the future, as well as troubling health trends among
younger age groups that will have short and long term
public health implications.
WHERE: Public health in a changing climate
People have become increasingly cognizant of their
environment and its impact on their health. The
environment section of the report addresses the where
of public health in the future by exploring our changing
2
climate and its impact on health. This section briefly
outlines the ways in which the climate is changing,
followed by an examination of how those changes
in climate and weather are influencing the health of
Canadians. It also identifies broad areas of action that
can be taken to prepare for and adapt to change in
order to mitigate climate-related health risks.
WHAT: Digital technology as a tool
for public health
Public health uses numerous tools to deliver its programs
and services. In looking at what tools may be used in the
future, technology seems an obvious choice for examining
the what of public health in the future. Technology is
constantly and rapidly changing, permeating all aspects of
Canadians’ lives. It has also become a tool for public health
to inform and assist Canadians on health and safety issues.
This section contains examples of how digital technology
in particular can be and is being used to address several
key functions of public health, including health promotion
and protection, education and awareness, and surveillance.
It also notes some of the challenges and opportunities
around the use of certain technologies and how this may shape public health practices in the future.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
HIGHLIGHTS
••
••
••
••
Canada’s population continues to change in ways that will influence public health in
the future.
•• People 65 years old and over represent Canada’s fastest growing age group. This trend
is expected to continue for decades.
•• Most of Canada’s current population growth stems from immigration rather than
natural increase.
Today’s seniors face chronic, mental health and neurological conditions as well as
injuries, and concerning trends are also evident among younger age groups.
Demographic shifts have brought about societal change with implications for
health including changes to work, retirement, pensions, families, caregiving and
intergenerational relations.
Continued research and investment in public health practices will be required to address
demographic changes in the future.
CHANGING DEMOGRAPHICS, AGING
AND HEALTH
The structure, composition and distribution of the
population influences public health. Canada’s population
has—and continues to—change. This section explores
Canada’s population, looking specifically at the shift
toward an older demographic and its influence on health.
This section:
••
••
includes a broad examination of demographic trends
and how these will influence public health in the
future; and
discusses select health issues and other factors
where public health attention or action can improve
healthy aging.
A changing population
Canada’s population continually undergoes changes in
pattern and growth. From confederation until the turn of
the 20th century, Canada’s population grew slowly, at an
annual growth rate of 1.3%, and this growth was primarily
due to natural increase—more births than deaths.4–6
Between 1941 and 1971, the baby boom and increased
immigration pushed Canada’s annual population growth
to about 2.1%.4 Since then, the rate of annual population
growth has stabilized at slightly above 1%.4, 5, 7
Since 2001, population increase has mostly been as
a result of immigration.4, 5 In 2011, Canada’s overall
foreign-born population represented 20.6% of Canada’s
total population (with varying length of residency in
Canada).8 The majority of newcomers (those who
immigrated in the past 5 years) migrated during their
working years (median age is 31.7 years).8 While numbers
of immigrants are increasing, their fertility rate (birth of
second-generation immigrants) is similar to the overall
Canadian rate.4 The global aging population may also
influence Canadian migration patterns in the future.
Compared to the overall Canadian population, First
Nations, Inuit and Métis populations are younger and
growing at a faster rate.9–11 Reasons for this population
increase include an increased fertility rate, regional
CHANGING DEMOGRAPHICS, AGING AND HEALTH
3
4
3,000
2,500
2,000
1,500
1,000
500
0 to 4
5 to 9
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 to 89
90+
0
AGE GROUP (YEARS)
Projection based on medium growth scenario (M1).
*
FIGURE 2. Number of centenarians, Canada, 2001
to 205615, 16
Observed
Projected*
70,000
60,000
50,000
40,000
30,000
20,000
10,000
56
51
20
46
20
41
20
36
20
31
20
26
20
21
20
16
20
13
20
11
20
20
20
06
0
01
The proportion of the Canadian population who are seniors
is increasing (see Figure 1).15, 16 Canadians are living longer
and life expectancy has increased dramatically for both
men and women (see Appendix A).17, 18 In 2013, the
number of seniors rose to an all-time high of 5.4
million—15.3% of the total population; by 2056 it is
estimated that one quarter of the population (13 million)
will be aged 65 years and older.15, 16 In particular, people
aged 85 years and over make up the fastest growing age
group in Canada—from 309,000 in 1993 to 702,000 in
2013 (an increase of 127%).15 This age group is projected
to grow to 2.9 million by 2056.16 In 2013, the number of
centenarians (those aged 100 years and over) was almost
7,000, nearly double the 2001 total.15 This population is
estimated to increase to 64,000 by 2056 (see Figure 2).16
2013
3,500
20
Canada’s aging population
2056*
1971
Population (in thousands)
The higher fertility rates among some populations
combined with the higher levels of immigration may be
able to slow—but not prevent—the increasingly aging
population.14 The first year that Canada’s baby boom
generation (those born between 1946 and 1965) reached
age 65 years was 2011. Since then the number of seniors
(people aged 65 years and over) has begun to exceed
other age groups. Canada will move toward zero or
negative natural growth as the death rate exceeds
the birth rate.4, 5 Public health must consider these
demographic changes—the net result of an older
population, their impacts on current and long-term
health and how best to plan and address the public
health needs of all populations in that context.
FIGURE 1. Population by age group, Canada, 1971,
2013 and 205615, 16
Number
migration and legislative changes.10 A portion of
population growth can be attributed to changes in
self-reported ethnic identity (referred to as ethnic
mobility).10–13 It is also important to note that there are
significant variations between and among populations
and across regions.9, 10 While projections indicate that
First Nations, Inuit and Métis populations will continue
to have higher fertility and growth rates than the overall
Canadian rates in the near future, in the longer term,
these rates will start to decrease due to a decline in
fertility and effects of ethnic mobility and the larger
proportion will also age.11, 12
YEAR
Projection based on medium growth scenario (M1).
*
Global aging perspectives: setting directions
for public health
Canada is not alone in planning for an aging population.19
Both developed and developing countries are experiencing
an increase in the number of people aged 60 years and
over.20–22 The United Nations (UN) estimates the global
population of people over 60 years old will increase
from 765 million in 2010 to 2 billion by 2050 and the
population aged over 80 years will reach nearly 400
million by then.23 This shift has encouraged global
planning for an aging population (see the textbox
“Setting a global agenda for aging”).19
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Setting a global agenda for aging
The global aging population was first considered
an area of interest among academic and policy
communities over three decades ago.19, 21, 24 The UN
Vienna International Plan of Action on Ageing was
established at the first World Assembly on Ageing
in 1982.24 The Plan raised awareness about global
longevity and offered broad guidelines and general
principles to meet the challenge of progressively
aging societies.24 The language used in the
document focused on dependence and protection
of older people.25
By 2002, the Second World Assembly on Ageing
took a markedly different approach by focusing
on and recognizing the potential of older people’s
contributions to societal development.19, 25, 26
Focusing on three policy areas, the Madrid
International Plan of Action on Ageing (MIPAA)
called for changes in attitudes, policies and
programs across the following domains: i) older
people and development, ii) advancing health and
well-being into old age, and iii) ensuring enabling
and supportive environments.26 The Plan also called
for “mainstreaming aging,” that is, integrating
aging into existing processes and programs as
well as including seniors in policy development,
implementation and evaluation.19, 26, 27
In 2012, member states were asked to evaluate
their progress on implementing the MIPAA. Canada’s
report notes that various policies and programs to
support seniors had been put in place, but that
challenges remained. These included increasing
demands on care and healthcare, stress on public
pensions, rates of poverty among seniors and
issues with affordability of housing.28
Public health and the aging population
The long-term impact of an aging population on society
is largely unknown, but public health professionals must
plan for future health issues associated with an aging
population and the expected increase in demand for
programs and practices. Public health has a role to play in:
••
••
••
••
optimizing health and well-being for all ages by
contributing to reducing the impact of disease and
injury through prevention and health promotion
activities across the lifecourse;
addressing risk factors and the determinants of
health by advocating change to address the root
causes of disease as well as differences in health
between populations;
factoring complex health problems into planning
by considering those living with multiple health
conditions (comorbidities) and developing broad
policies as well as individual and population
interventions that tackle these conditions; and
creating a society for all ages by taking into account
the needs of all populations and intergenerational
issues, as well as promoting healthy behaviours from
birth to old age as well as encouraging age-friendly
universally accessible environments.
Health issues and an aging population
An aging population indicates that society has met many
of the requirements needed for people to live longer and
healthier lives.29, 30 Still, many health trends and issues
that are of concern have their foundation in younger age
groups, suggesting that more can be done to ensure
healthy aging in younger age groups. As well, many of
today’s seniors live with one or more chronic diseases,
have a mobility issue, or experience a mental health
problem.29–31 Key health issues are highlighted here
because they represent:
••
••
trends among younger age groups that can adversely
affect health over the long term; and/or
a significant burden of disease for seniors, with
rates that are of concern and/or increasing and a
related cost that will continue to impact individuals
and societies.
CHANGING DEMOGRAPHICS, AGING AND HEALTH
5
healthcare system.30, 46, 47 In 2012, 85% of seniors aged
65 to 79 years and 90% of seniors aged over 80 years
reported having at least one chronic condition.38, 48 About
24% of seniors have three or more chronic diseases and
account for 40% of all healthcare use among seniors.30
Currently, people aged 85 years or older with no chronic
disease use half as many health services as people aged
65 to 74 years who have three or more chronic diseases.30
Public health can help alleviate this by focusing on the
earlier, pre-senior years and upstream efforts to protect
younger Canadians from disease and injury and promote
healthier practices.
Living with chronic conditions can also weaken the
immune system and increases the likelihood of
complications due to interactions between medications.
This vulnerability can increase susceptibility to infectious
diseases such as seasonal influenza, food and water-borne
infections as well as healthcare-associated infections.49, 50
Chronic conditions
The incidence and impact of chronic conditions in the
later years can be influenced by experiences and health
issues from earlier in the lifecourse.32 These include being
overweight or obese, healthy diet and physical activity,
mental health problems or injuries.29, 33–36 Yet, apart from
an overall decrease in smoking rates, younger age groups
have less healthy behaviours and less healthy weights and
are living longer with chronic diseases and mental health
concerns than previous generations.37–44 While the causes
of some diseases are unknown, healthy behaviours such as
participating in physical activity can positively influence
healthy aging.29, 45
A range or combination of health issues such as living
with one or more chronic diseases, having an acute
disease or condition and/or experiencing a loss of
cognition or mobility can adversely influence quality
of life. Comorbidities also increase demands on the
6
About 76% of Canadian seniors in private households
reported using at least one medication (prescription and/or
over-the-counter) to manage chronic diseases, decrease
pain and increase physiological function, and 13% had
used five or more medications in the past two days.51
The proportions are even higher among seniors living in
institutions, where 97% used one medication and 53%
used five or more.51 Problems associated with multiple
or frequent use of medications can result in reduced
effectiveness, more side-effects or dependency and
increased risk of falls.51, 52 It is estimated that about 50%
of prescriptions are not taken properly by seniors, and
about 20% of hospitalizations of people who are 50 years
and over are the result of problems with medications.52
Medication use (and associated drug-related spending)
is projected to continue to increase based on an expected
increased use among seniors and current medication
practices among younger populations.53 Some of these
medications may be taken because of physician–patient
miscommunication, inaccessibility to other therapies,
lack of medication reviews and reliance on multiple
pharmacies or physicians.54 In particular, as the baby
boom generation ages, a substantial increase in substance
misuse is anticipated as this age group uses more
medications than did previous generations.55 To help
address this issue, Health Canada, through the Drug
Strategy Community Institute Fund (DSCIF), has called
for proposals to improve prescriber education through the
development of guidelines, training and tools.56, 57
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
The aging First Nations, Inuit and Métis populations and chronic conditions
Compared to the overall population, First Nations, Inuit and Métis populations are generally younger and
experience higher rates of certain health conditions including diabetes, heart disease, tuberculosis, HIV infection
and AIDS.9, 39, 58–61 Aging has not been the primary focus for First Nations, Inuit and Métis public health, given
the higher infant mortality rates and lower life expectancies compared with the general population.9, 62 However,
as the relative size of the senior population is growing and the age of onset for chronic diseases among First
Nations, Inuit and Métis is generally earlier than that in the non-Aboriginal population attention needs to be
paid to health conditions of seniors.59 Among First Nations adults aged 60 years and over living on a reserve,
about 90% reported living with one or more chronic diseases and about 47% reported living with four or more
chronic conditions in 2008/2010.63, 64
The health needs of First Nations, Inuit and Métis seniors are magnified by determinants of health such as living
in poverty or inadequate housing, and experiencing discrimination and challenges with language and cultural
differences.59, 65 First Nations, Inuit and Métis seniors are also more likely than the younger generations to live
in rural and remote areas with limited access to healthcare, home care and support.65 Research also shows that
seniors living with one or more chronic diseases tend to cluster regionally, suggesting that more can be done
to maintain health and prevent illness and injury within those regions as well as earlier in the lifecourse.59
Researchers suggest that traditional public health research that focuses on addressing disease within First
Nations, Inuit and Métis populations is limited if it does not move beyond describing problems to attempting
solutions.59 Such research focuses mostly on ill health and disability rather than the underlying determinants
of health.59 Opportunities exist for public health professionals to develop global networks of indigenous research
and collaborative practices to address unique challenges and implement solutions that build on the strengths
of indigenous populations.66
Mental health across the lifecourse
Mental health problems and mental illness can occur
at any point in the lifecourse.67, 68 The current mental
health status of younger generations will be an important
indicator for aging in the future. Those living with poor
mental health or a mental illness are at greater risk of
developing physical and mental health problems later
in life. For example, depression raises the risk of heart
disease and stroke and reduced longevity.34, 69
Certain risk factors for poor mental health tend to increase
with age.22, 67 These risk factors include recurrent or chronic
mental illnesses that were ineffectively addressed earlier
in life; late onset disease; chronic diseases with known
mental health complications (e.g. cerebrovascular disease,
chronic obstructive lung disease and Parkinson’s disease);
and cognitive, behavioural and psychological symptoms
associated with dementia or other neurological condition.67
As well, seniors who have experienced trauma or distress
earlier in life, such as First Nations, Inuit and Métis seniors
who had attended residential schools, have been shown
to have poorer mental health outcomes later in life.70
One in four Canadian seniors have a mental health
problem or a mental illness.71 The most common mental
health issues were mood and anxiety disorders, cognitive
and mental disorders due to a medical condition (including
dementia and delirium), substance misuse (including
prescription drugs and alcohol) and psychotic disorders.67
Between 2008 and 2009, 44% of Canadian seniors living
in long-term care facilities were diagnosed with or showed
symptoms of depression.72 Seniors had the highest rate of
reported symptoms for anxiety disorders with about 5%
to 10% of adults 65 years and over affected.67, 73
Older adults may face serious and undertreated
mental health issues. Often the diagnoses of age-related
health conditions focus on cognitive decline and do
not acknowledge possible mental health problems.67
Underlying health issues and/or their treatment can also
mask symptoms of mental illness.67 Changing Directions,
Changing Lives: The Mental Strategy for Canada (2012)
made a number of recommendations related to changing
outcomes for seniors’ mental health in the future.74 These
included countering the impact of age discrimination on
mental health; helping older adults participate in
CHANGING DEMOGRAPHICS, AGING AND HEALTH
7
meaningful activities, sustain relationships and maintain
good physical health; and increasing the capacity of older
adults and those who support them to identify mental
illnesses, dementia, elder abuse and risk of suicide and
the importance of intervening when signs first emerge.74
Public health can focus efforts upstream by developing
early identification and intervention programs.67
Interventions such as the Seniors’ Mental Health Policy
Lens are intended to facilitate environments that promote
and support the mental health of older adults.75
Considering dementia and other
neurological conditions
The number of Canadians who experience and live with
neurological conditions is expected to increase as will
the costs of these conditions for individuals, families,
healthcare and society.76 However, difficulties in
diagnosis, data accuracy and capture (particularly in
institutional settings) creates gaps in information which
makes forecasting the future prevalence, duration and
potential impacts of these diseases complex.76 Still,
these information challenges do not diminish the
importance of these issues.
Globally, the significant burden of dementia (an umbrella
term for a variety of brain disorders including Alzheimer’s
disease) for families, societies, and health systems is
expected to grow substantially.22, 77, 78 The World Health
Organization estimated that 35.6 million people lived with
dementia worldwide in 2010, and predicts this number will
double by 2030 and more than triple by 2050.79 Although
the risk of developing dementia increases with age, it
is not a normal part of the aging process. In 2011, an
estimated 340,200 (2%) of Canadians 40 years and over
had Alzheimer’s disease and other dementias and this
number is expected to double in 20 years.76 The rate
at which new cases of Alzheimer’s disease and other
dementias are diagnosed is also expected to increase. In
2011, the incidence rate for Canadians 40 years and over
was 3.6 cases per 1,000, and this is expected to rise to
5.3 cases per 1,000 by 2031.76 Increasing numbers of other
neurological conditions more prevalent among older age
groups, such as Parkinson’s disease, will also need to be
considered by public health professionals in the context
of Canada’s aging population. Parkinson’s disease affected
84,700 Canadians in 2011 and, like dementias, this
number is expected to double by 2031.76
8
Increases in the number of those diagnosed or living
with a neurological or related disability will impact direct
(e.g. healthcare) and indirect costs (e.g. lost income) in
Canada.76 Most people with dementia will require some
level of care—from assisted daily living to residential
nursing care.79 Canadian institutional long-term care
demands in 30 years’ time are projected to be 10 times
the current demand solely based on increases in dementia
need and decreasing supply of caregivers.80 The estimated
costs of these demands do not include the social and
mental burden of illness on individuals and their
families, which cannot be adequately measured based on
calculations focusing solely on money or time.31, 80 Informal
dementia care is projected to rise from a current estimate
of 19 million unpaid hours per week to 39 million unpaid
hours per week over the next 20 years.81
Planning for an increase in demand for care will require
more research and the identification of disease and best
practices on meeting needs including interventions that
support people with dementia and their caregivers.22, 30, 80
A new research hub, the Canadian Consortium on
Neurodegeneration in Aging, aims to bring together
research on improving the quality of life and services
for those living with the effects of neurodegenerative
diseases and their caregivers.82
In 2010, the estimated global costs—including direct and
indirect—of dementia were estimated to be approximately
US $604 billion.79 The 2013 G8 Summit Global Action
against Dementia focused on research and the growing
public health and economic impacts of dementia (see
the textbox “Global Action against Dementia”).83 Canada
endorsed the declaration released at the Summit and, as
part of the 12 commitments it outlines, is co-leading one
of the Legacy Events that aims to foster collaborative
efforts between academia and industry.83, 84
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Global Action against Dementia
On December 11, 2013, the United Kingdom hosted
Global Action against Dementia to acknowledge the
burden facing many countries and to build upon
relevant research. Summit members committed to
approaching the problem together and called for more
research and innovation to determine how to improve
the quality of life of people with dementia and their
caregivers. Members were encouraged to invest in
research and work towards finding a disease-modifying
therapy (and ultimately a cure) by 2025. Sharing
information and data from dementia research across
involved countries will achieve the best return on
investment in research.83 As part of global efforts, a
World Dementia Council has been created to provide
independent non-governmental leadership for
research, innovation, development and care.85
One step in reducing the impact of dementia is to
increase public understanding of the diseases and their
risk factors.77 Evidence suggests that engaging in healthy
behaviours (particularly nutrition and physical activity)
as well as reducing comorbidity can decrease the risk
of dementia, delay onset and reduce the severity of its
impacts.77, 80, 86, 87 In addition, underlying chronic diseases
and conditions such as type 2 diabetes, hypertension and
obesity can influence the risk for Alzheimer’s disease and
other dementias, preventing and managing chronic
diseases is important.77, 80, 86, 88
Preventing injuries and falls
Across all age groups, injuries are a major cause of
disability and death and are one of the leading causes of
hospitalization in Canada.89, 90 Residual effects of injuries
suffered earlier in life or new injuries during the senior
years can significantly impact aging, mobility and
independence.89, 91 Of particular concern to seniors are
injuries as a result of falls.92 Such injuries will continue
to be a public health issue in Canada in the future.89
Between 20% and 30% of Canadian seniors will
experience a fall in any given year.89 Almost half of these
falls result in a minor injury, and 5% to 25% cause serious
injury.92 Considering the current rate of falls and projected
population growth, estimates show Canada could expect
between 2.1 and 3.1 million falls among seniors in
2036.16, 89
Falls among seniors can result in acute injury,
traumatic brain injury, chronic pain, reduced quality of
life, precipitation of long-term care and even death.89, 91–93
Although preventable, most falls are a result of a
combination of compounding factors (including biological,
behavioural, environmental and/or socioeconomic
factors).89 These factors can interact to influence a
person’s ability to keep or regain balance.89 Having
underlying health conditions or disabilities can increase
the likelihood of sustaining injuries with falls.89, 93 Falls
can result in painful fractures that often require surgery
and can have long-term health consequences including
increased vulnerability to other health conditions.89, 94
Recovery from a fall involves not just physical healing but
also psychological adjustment.91–93 Periods of immobility
can lead to further frailty and increased loss of autonomy.
Post-fall syndrome can lead to fear and anxiety of
additional falls, loss of independence and immobility.89, 91
While older people’s falls are of concern, the increase in
chronic conditions among younger people, as well as less
healthy behaviours, can affect their future mobility and
increase their risk for falls during their senior years.93–95
Research on fall prevention has increased over the last
decade, and there are a number of ways known to reduce
the risk of falls.89 Broad population-based practices such
as falls prevention guidelines, education and awareness
programs have been shown to reduce falls.89, 96 As well,
individual risk assessment practices have been effective.89
Creating accessible and encouraging environments
can also make a difference.26, 97, 98 Many seniors live in
environments that fail to meet their physical and mental
health, transport and social needs.29, 31, 99 In response,
an international age-friendly movement has evolved
to identify community-based factors, such as land use
planning and urban design, that can improve the health
outcomes for seniors.97, 98 The goal of adopting the
age-friendly approach is to ensure that seniors are
involved in community-level decision making that allow
programs and policies to facilitate seniors aging in a place
of their choice and independent living.97, 98 Ensuring that
infrastructure, housing, services and technologies are
universally accessible can create a safer environment
for all ages.26, 100 By applying principles of universal
design (creation of environments and products are
inclusive to the largest number of people without
requiring modifications) there are opportunities to
support all populations.29, 99–101
CHANGING DEMOGRAPHICS, AGING AND HEALTH
9
Changing demographics, aging
and society
As the population changes, how societies organize
themselves and relate also changes. With an aging
population there are expected issues with supply and
demand of select services such as health services.29, 30
There are also changes in relationships including
families and society.
Shifting views on aging
With a changing population the structure of elements
of society such as family, work and other social networks
also evolve. These elements are important determinants of
health, and how they change and interact for individuals
and within populations will also shape future health
outcomes. Planning for changing demographics involves
challenging attitudes and perceptions about aging and
the roles of seniors, family and societal organizations
(see the textbox “Myths associated with an aging
population”).102, 103
Myths associated with an aging population
There are several myths associated with an aging
population including that:
mental and physical deterioration can be expected;
healthcare is a primary issue for older persons;
• investment in older people is a waste of resources;
• older workers take away jobs from younger
people; and
• all older people have similar needs.102, 103
•
•
Valuing aging starts with challenging these myths and
changing attitudes.29, 31, 104 With aging, as with most life
transitions, there are changes but not all are negative.
Also, disease is not driven by age alone. Healthcare is
an important component for all populations, and while
seniors can be larger users, other issues such as staying
active and living independently are more often a focus.102
In addition, evidence suggests that investments into
healthy aging can reduce healthcare and related costs.29, 105
10
Tackling ageism is a global priority and efforts have
been made to establish positive ways to view aging.31, 106
One component of these efforts is to empower seniors to
fully and effectively participate in the economic, political
and social lives of their communities through incomegenerating and voluntary contributions.26, 29, 104 In 2009,
the Canadian Federal/Provincial/Territorial Ministers
Responsible for Seniors created The Seniors’ Policy
Handbook: A guide for developing and evaluating policies
and programs for seniors to help policy planners consider
seniors’ perspectives, diversity, and current and future
issues.107 Work still can be done to develop national
programs to address ageism and promote societies for
all ages.
Securing a future
With the portion of the population aged 65 and older
increasing, concern for health issues associated with
not meeting basic needs may arise.29, 108 Without meeting
seniors’ basic needs—adequate food, shelter, security
and healthcare— seniors’ health could be compromised.96
Over the last two decades, Canada has been effective at
reducing overall poverty among people 65 years and
over.109 Still, 5.2% of seniors live in low-income after-tax
households (see Appendix A).109 As well, with an
increasing proportion of seniors in the population there is
some question about the state of pensions and economic
security in the future. Although the debate continues
across jurisdictions, efforts are being made to ensure that
Canada’s retirement income system is sustainable, reflects
demographic change and continues to meet the seniors’
needs.110 For example, age of eligibility for the Old Age
Security (OAS) program has been increased from 65 to 67
years (effective 2023) and Canadians can now defer OAS
pension for up to five years to receive a higher pension.110
Changes were also made to the Canada Pension Plan (CPP)
to increase flexibility and sustainability in the future. As
well, the Guaranteed Income Supplement was increased to
assist low-income seniors.110–114 Additional annual targeted
tax relief has been created by increasing the Age Credit
and Pension Income Credit, raising the age limit for
maturing savings in Registered Retirement Savings Plans
and introducing pension income splitting.115
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
The ability to meet future economic needs in years
to come will be influenced by the composition of the
senior population. The senior population will continue
to be diverse and vulnerable segments—the very old,
unattached, Aboriginal seniors, and those with
disabilities—will require further consideration. In light
of the current demographic composition and projected
change, a significant proportion of future seniors will
clearly be foreign-born.4, 8 Although variation exists, the
low-income rate among senior immigrants has declined
and was halved between 1980 and 2005.116 The longer
immigrant seniors live in Canada, the more their
economic situation converges with the trends of the
overall population.117–119 Also, issues may go underdetected given that recent immigrant seniors tend to
live with extended family, act as parent/grandparent
caregivers or rely on support networks.117
Access to economic supports and the benefits typically
eligible for seniors often require having been previously
employed and having made long-term contributions to
earnings and pension programs. This is often not the
case or exists at a reduced level for recent immigrant
seniors.117, 119 Canada has developed over 50 social security
arrangements with other countries to facilitate benefits
for immigrant seniors; however, other barriers can be
experienced.117, 120 Further investigation into the well-being
of this population will help guide policies for public health
and other sectors and identify future health needs.117
Families and partnerships and society
Demographic changes have created complex,
multi-generational and diverse families and communities.121
Changes in partnerships, number of children and increased
social activity among seniors have altered the roles of
older people in Canadian families and partnerships.104, 121
In 2011, most Canadian seniors (92%) lived in private
households and some lived in collective dwellings (8%),
however of those collective dwellings almost half were
85 years and over.122 The number of seniors who live
with a spouse or a partner increased between 1981 and
2011.122, 123 As the life expectancy of men and women has
begun to converge, the number of years in a partnership
and living in private households has increased. Still, a
significant number of seniors—35% of women and 17%
of men—live alone.123 Living alone does not necessarily
mean living in isolation, however, level of social
engagement or marginalization can depend on an
individual’s access to community facilities, transportation
and affordable activities as well as having meaningful
roles in the community.29, 96, 98, 124
Intergenerational relations have also shifted as a result
of demographic change.31, 121 On the one hand, familial
relations and obligations have changed and distance
between family members changed and widened.121 On the
other, there have been societal shifts in attitudes about
the important role of external factors such as primary and
institutional care and assistance with daily living.104, 121
Despite these changes, middle generations, commonly
referred to as the “sandwich generation,” who support
both younger and older family members in some capacity
are reporting growing stress.125, 126
Intergenerational tensions are often seen as a risk of
demographic change. Within society, sharing resources
between generations raises debate as to who pays
when and how much.22, 105 With a larger proportion of
the population in one age group questions remain as to
whether public investments should focus on the needs
of one population at the expense of others. Policy makers
will need to achieve intergenerational equity to not
polarize generations and/or populations.22 A focus on
healthy aging should investigate younger populations,
those who are foreign-born as well as those living in
remote communities.
Focusing on care
As the demand for support services from informal and
formal networks is expected to double over the next
30 years, the question for public health is how to best
meet the needs of Canada’s seniors and their caregivers
now and in the future.125, 128 Age-related care can be
complex and involve both formal (healthcare, home and
long-term care) and informal (non-paid, often family care)
practices.129 While many types of care require attention,
this section only discusses informal care.
CAREGIVING involves a number of tasks, some
of which are done in combination. These include
transportation, housework, house maintenance
and outdoor work, scheduling and coordinating
appointments, managing finances, helping with
medical treatments and providing personal care.125, 127
CHANGING DEMOGRAPHICS, AGING AND HEALTH
11
At some point, almost half of Canadians will have provided
care to someone with a long-term health, disability or
age-related need.125 Spouses/partners provide the most
care hours per week (14 hours), followed by children
caring for a parent (10 hours).125 In 2012, almost half
of all caregivers over the previous year were providing
some care for a parent or parent-in-law.125 When asked,
caregivers identify age and specific diseases (such
as cancer, cardiovascular disease, mental illness and
Alzheimer’s disease and dementia) as the most common
reasons for needed care.125, 127
As the population ages and population distributions
change, the availability of adult-child caregivers may
decrease.128, 130 Meeting future demands will require
consideration of the next generations’ needs and the
supply of caregivers.131 Factors that influence the
caregiving supply are living spouses and an increase in
senior volunteers since the large majority of caregivers are
seniors.128, 132, 133 As well, the decline in births and survivor
children (especially among the elderly seniors) means that
there will be fewer children to provide parental care.132 In
many communities, especially those in remote and rural
areas, over-dependence on a few local caregivers (primarily
women) and an out-migration of younger family members
and volunteers, can contribute to resource deficits in
areas where formal care services may also be less available
and/or adequate.134 Given these changes, in the future
Canada may need to rely more on a formal care system
paid for by individuals and/or society.128, 131
Despite the demands of caregiving, many (73% of
employed caregivers) report that they are satisfied with
the current balance between their work and home life.125
Still, caregivers also report feeling tired, stressed, worried
or anxious.125 The numbers of adverse feelings increases
with number of hours committed to caregiving per
week.125, 135 Beyond the effects on individuals, there
are broad impacts of caregiving on the labour market,
governments and the economy.136 Employee turnover and
missed paid work due to informal caregivers’ obligations
was estimated to cost Canadian employers $1.28 billion
in lost productivity in 2007.137 In the same year, the cost
of replacement for unpaid caregivers was estimated to be
$24 billion.138 To address this issue, the Government of
Canada announced the intent to develop and launch a
Canadian Employers for Caregivers Plan to engage with
employers on cost-effective workplace solutions that will
help maximize caregivers’ labour market participation.
The Plan will include the creation of an employer panel
that would identify promising workplace practices that
support caregivers.115
12
In the short term, a range of policies could support family
and friend caregivers caring for older Canadians—flexible
labour practices, income security, home/continuing care
as well as health promotion and caregiver education and
training.128 Creating flexible workplaces may enable
caregivers to continue working while also reducing the
negative consequences of job interruption, reduced income
and lower retirement pensions. In the longer term, reduced
availability of caregivers may increase reliance on the
formal system.128, 131 As a result, broad-based home care,
greater community involvement and private enterprise
(for individual paid care) may need to be utilized more.
Such practices involve increased expenditures for
individuals as well as use of privately offered care.128
However, privately offered care is not accessible and
affordable to all who may require it.131 Broad and
comprehensive social approaches to deliver care may
be necessary to improving wages and benefits, training
standards, availability in remote areas, and improving
recruitment and retention of these essential workers.131
Participating in community and work
Demographic change has raised concern for a possible
inequitable burden of labour and community participation
across population groups.22 From the early 1920s to the
mid-1960s, about 60% of Canadians were working age,
but then, the baby boom population increased this
proportion to nearly 70%.14 In the future, this proportion
is expected to decline rapidly and the number of workingage Canadians will fall from about 5 for every senior in
2012 to about 2.7 for every senior by 2030.14 Views on
retirement are evolving as people now tend to reach
the age of retirement healthier and more active than in
previous generations.29 Some older people may want to
be employed for the sake of a second or subsequent
career, whereas for others, employment may also be a
necessity to make ends meet.22, 139 As more seniors work
longer for financial reasons, social engagement and
activity, the average age for retirement is increasing.139, 140
Canada no longer has a mandatory age of retirement.113
Seniors’ participation in the labour force has more
than doubled since 2000, from 6.0% in 2000 to 13.0%
in 2013.141 In particular, for those aged 65 to 69 years,
the participation rate more than doubled between 2000
and 2012 from 11.4% to 25.5%.141 Seniors’ participation
in the labour force attenuates some of the impacts of a
decreasing labour pool, leverages investments made in
seniors’ knowledge and skills, and provides opportunities
for older Canadians to remain engaged and socially
connected.22, 31, 142
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Not all seniors are working into old age. Older workers
report health problems as the most common reasons for
premature exclusion from the workforce.143 Of the 35%
of workers who left work before their expected age of
retirement, about 24% reported having three chronic
conditions.143 Older workers suggest that having
opportunities to change work patterns (work part-time
or have flexible hours), change careers or work in more
accessible and age-friendly environments would extend
their participation in the workforce.142, 144 An UN report
noted that employers who effectively supported older
workers did so by offering flexible hours and promoting
personal-development programs to keep workers active
by participating in physical and mental activities.145 They
also provided flexible work schedules to accommodate
the needs of workers who are also caregivers to older
individuals and increased part-time work opportunities
among seniors.144 Making such changes to the workplace
benefits all of society and can be enabled by collaborations
across workplaces and jurisdictions.142, 144
Extended periods of retirement are often spent in good
health and provide opportunities to be involved with
family and/or community. While seniors provide the
highest average number of volunteer hours, volunteering
and community involvement tends to decline with age.146
Seniors programs depend on volunteers and much informal
care is given by seniors.104 All sectors can contribute
to increasing Canada’s volunteer sector by encouraging
future volunteers. People who volunteer when they are
young are more likely to continue these contributions
later in life.104, 146, 147 In the future, public health may
depend on the work of volunteers and can promote
evidence that points to protective factors for health
associated with volunteering and being involved in
community.147, 148
Continuing research and understanding
population change
Looking ahead to how Canada will adapt to a changing
demographic involves projecting and forecasting based on
current and known realities. The health issues impacting
today’s seniors are known but it is less clear what role
these health issues will play in the future or how factors
that influence the health of today’s younger Canadians are
interconnected and will evolve over time and as individuals
age.22, 29, 30 Canada has identified the need for research
on aging and evidence to support the enhancement of
programs, services, policies and care. The Canadian
Longitudinal Study on Aging (CLSA) was established to
contribute to meeting these needs (see the textbox
“The Canadian Longitudinal Study on Aging”).149
The Canadian Longitudinal Study on Aging
The CLSA is a long-term national study developed to better understand aging.149 CLSA investigators are following
about 50,000 men and women aged between 45 and 85 years for 20 years or longer to gather information on
various factors that influence their health (including biological, medical, psychological, social, lifestyle and
economic factors).149, 150
Collecting long-term data will supply researchers, public health professionals, healthcare providers and policy
makers with valuable information on how Canadians age. This information will contribute to disease prevention
practices and improvement in health service delivery; a better understanding of the impact of socioeconomic
factors that influence aging over the lifecourse; and the body of information needed to guide and improve
age-related health policies and programs.149, 150
The CLSA is a strategic initiative of the Canadian Institutes of Health Research (CIHR), and support for this
study comes from CIHR, the Canadian Foundation for Innovation and the Public Health Agency of Canada as
well as partners with Veterans Affairs Canada and the provinces of British Columbia, Alberta, Manitoba, Ontario,
Quebec, Nova Scotia, Prince Edward Island and Newfoundland and Labrador.149, 151 As well, universities and
academic/research institutions are leading and partnering with governments and supporter organizations to
deliver the CLSA.149, 151
CHANGING DEMOGRAPHICS, AGING AND HEALTH
13
In addition to looking at aging populations more research
is needed to consider how to address health issues of all
populations and age groups over time to ensure the
health of the population across the lifecourse.
Continuing efforts
While Canada has made great strides in implementing
public health initiatives to maintain and improve the
health of Canadians as they age, considerable challenges
remain. The continued prevalence of unhealthy lifestyles
and of chronic diseases challenges healthy aging now and
is likely to continue to do so. Public health can invest in
research, prevention and promotion programs and policies
for seniors as well as younger Canadians to help reduce
the burden of disease and increase the capacity for
healthy aging over the next generation and beyond.
PUBLIC HEALTH CAN:
••
••
••
••
••
14
tackle chronic disease early by promoting healthy practices and preventing the onset
of disease;
act on the growing burden of dementia by increasing research, raising awareness and
improving opportunities for those living with disease;
develop and sustain supportive environments for all ages to reduce and prevent injuries
and falls;
work across sectors to meet the basic needs of seniors and take into account diversity
of the older populations in the future; and
value aging and its role in society and build intergenerational relations by developing
policies, programs and practices designed to support all ages.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
HIGHLIGHTS
••
••
••
••
••
The impacts of changing climate are already evident in Canada and projected to continue.
Climate change can exacerbate many existing health concerns and present new risks
to the health of Canadians.
Adaptive capacity in Canada is generally high but is unevenly distributed between
and within regions and populations.
Public health action is needed to reduce vulnerability and risks.
Some adaptation is taking place in Canada, both in response to and in anticipation
of the impacts of climate change.
PUBLIC HEALTH IN A CHANGING CLIMATE
The global climate is changing and Canada, like many
other countries, is vulnerable.152–154 Changes in climate
are expected to increase risks to health in many ways,
including through more extreme weather events and
the associated impacts on community infrastructure,
decreased air quality and diseases transmitted by insects,
food and water.152–155 Although efforts are underway to
protect the health of Canadians, continued action will
be needed as climate changes.153, 154, 156
This section includes:
••
••
••
a brief overview of how the climate is changing;
a discussion on how changes in climate are
influencing the health of Canadians; and
a consideration of broad public health measures
that can be taken to prepare for and adapt to
climate change.
A changing climate
The global climate has changed considerably over the
past century, and notably so over the last 30 years.157–159
This is evidenced by changes in average climate conditions
and in climate variability as well as extreme climate
events across the globe.154, 157, 159
Many of the changes observed globally include warming
of the oceans and surface temperatures, melting ice and
snow in seas and lakes, rising sea levels and coastal
erosion.157, 159, 160 In turn, research indicates that these
environmental changes are altering precipitation patterns
and increasing the potential for more severe and frequent
extreme weather conditions (i.e. periods of excessive
warmth or cold, wetness or dryness) resulting in hazardous
events such as heat waves, ice storms, droughts, floods,
hurricanes, wildfires, landslides and avalanches.154, 157, 159
In simplest terms, the difference between weather
and climate is a measure of time. WEATHER refers
to the atmospheric conditions—the sunshine, cloud
cover, winds, rain, snow and excessive heat—of a
specific place over a short period of time. CLIMATE
refers to the average atmospheric conditions that
occur over long periods of time. In other words,
a changing climate refers to changes in long-term
averages of daily weather (e.g. precipitation,
temperature, humidity, sunshine, wind velocity
and other measures of weather).152, 155
PUBLIC HEALTH IN A CHANGING CLIMATE
15
The story does not end here: climate models project
continued changes in climate conditions across
the globe.159, 161
FIGURE 3. Annual national temperature departures
and long-term trend, Canada, 1948 to 2013162
Departure from 1961–1990 average
Linear trend of 1.6°C
4.0
Degrees Celcius
3.0
2.0
1.0
0.0
-1.0
-3.0
1948
1951
1954
1957
1960
1963
1966
1969
1972
1975
1978
1981
1984
1987
1990
1993
1996
1999
2002
2005
2008
2011
-2.0
YEAR
Canada is no exception to these changes.153–155 The
annual average temperatures across Canada have
increased by 1.6 degrees Celsius over the past 66 years
(see Figure 3).162 The impacts of environmental change
are particularly visible in Canada’s North: winters are
shorter and summers are warmer resulting in changes
to ice conditions affecting hunting and fishing, the
distribution and migratory behaviour of some wildlife
species are being altered and more frequent forest
fires.153–155, 160, 163–167
Climate risks to health:
now and in the future
Changes in climate can potentially have widespread
direct and indirect effects on people’s physical, social
and mental health and well-being.152, 154, 155, 168–170
In particular, climate change can influence extreme
heat-related morbidity and mortality; health conditions
such as asthma and allergies, respiratory diseases,
cancer and cardiovascular diseases and stroke associated
with decreased air quality; infectious diseases related
to changes in vector biology and migration and
water and food contamination; and mental health and
stress-related disorders (see Figure 4).154, 155, 168 Extreme
weather events can also impact critical community
infrastructure, in turn, adversely affecting overall health
and well-being.152, 154, 155, 168 The burden of these health
issues is anticipated to increase as the changes in climate
advance in the absence of further adaptations.154, 155, 168
FIGURE 4. Pathways by which changes in climate can increase risks to health155, 168
POTENTIAL HEALTH EFFECTS
Asthma, allergies and respiratory diseases
• Cancer
• Cardiovascular disease and stroke
• Heat-related morbidity and mortality
• Vector-borne diseases
• Water-borne diseases
• Food-borne diseases and nutrition
• Mental health and stress-related disorders
•
DRIVERS
Natural causes
• Greenhouse gases
• Human activity
•
CHANGE IN
GLOBAL CLIMATE
ENVIRONMENTAL OUTCOMES
• Extreme temperatures
• Changes in precipitation patterns
• More severe and frequent extreme weather events
(e.g. floods, droughts, wildfires)
• Decline in air quality
• Changes in vector biology and migration
MITIGATION
ADAPTATION
Adapted from Portier, C.J. et al. (2010).
16
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Any climatic effect on health can be more severe when
sensitivities and vulnerabilities are present. The very
young and the very old as well as those with underlying
health conditions may experience greater climate-related
health risks than the general population.154, 155 Broader
determinants of health such as age, socioeconomic
conditions, housing and community infrastructure,
geographic location and access to support and social
services can contribute to increased sensitivities and
vulnerabilities.124, 155, 171 Ensuring that basic needs are
met will be important for people and communities to
adapt to changes in the environment.
The following brief overview describes some of the
potential health effects of increased temperatures,
changes in precipitation and extreme weather events.
These sections are not comprehensive assessments of
the risks from climate change on health. Rather, they
are meant to encourage broad discussions about some
of the health issues that may potentially warrant further
public health consideration.
Heat-related morbidity and mortality
Projected increases in the frequency and severity of
extreme weather events such as heat waves, ice storms,
floods, wildfires, landslides, avalanches and hurricanes
may increase the risk of weather-related illnesses,
injuries, disability and death.152, 154, 155 The impact on
health will vary based on the severity of the extreme
weather event and the level of preparedness of
communities and individuals. Given the unpredictability
of such events, emergency management and response
efforts and critical infrastructures play a role in the
degree that these events can affect health.152, 154, 155, 172
Extreme heat events are posing a growing public health
risk in Canada.152, 155, 173–176 Over-exposure to extreme heat
can place excessive stress on the body. Such stress can
lead to skin rashes, heat cramps, loss of consciousness
and heat exhaustion. It can also cause heat stroke that
may result in severe and long-lasting health consequences
and death. Heat can also exacerbate pre-existing chronic
respiratory, cerebral and cardiovascular conditions and
affect mental health and well-being.155, 168, 174, 176–180
Canadian and international research indicates that daily
mortality rates can increase when temperatures rise
above 25 degrees Celsius.174, 181, 182
A range of factors can influence vulnerability to
heat-related health risks.152, 154 Age, housing and access
to cool spaces and air conditioning, social isolation,
neighbourhood characteristics, and the use of certain
medications can increase risks associated with extreme
heat.174, 180, 183 Extreme heat is of greater concern to
seniors, infants and children, and those with underlying
health issues.154, 155, 174, 180
As the number of Canadians living in urban centres
increases, heat-related health risks may increase even
more.174 The urban built environment has the potential
to exacerbate the effects of heat.174 For example,
high concentrations of non-reflective surfaces such as
buildings, roadways and parking lots can generate, absorb
and slowly release heat resulting in urban centres being
several degrees warmer than surrounding areas. Expanding
parks and green spaces and increasing the density of trees
in and around cities can help to reduce this effect.174, 184
Health conditions influenced by poor
air quality
Air pollution episodes in Canada are projected to get
longer and more severe with climate change.185 Certain
aspects of air quality—in particular ground-level ozone
concentrations and airborne fine particulate matter
(PM2.5)—can impact health.185–187 In addition, pollen
(due to altered growing seasons), mould (from flooding),
dust (because of droughts) and smoke (from wildfires and
wood smoke) resulting from changes in climate can also
impact health.155, 168, 188–190 Air pollution can exacerbate
health concerns if also combined with extreme heat.191
Broadly, exposure to poor outdoor air quality has been
associated with a number of adverse health concerns
including allergies, respiratory (e.g. asthma, lung damage)
and cardiovascular diseases (cardiac dysrhythmias)
and cancer.192–198 Negative health effects can increase
as air quality decreases. Studies have shown that it can
exacerbate pre-existing health conditions and contribute
to increased rates of emergency room visits, hospital
admissions and premature death.185–187, 192, 193, 196, 199
Reaction to air pollution differs with each person.
Those most sensitive to health risks associated with
poor air quality include children, pregnant women,
seniors, people living with respiratory and cardiovascular
diseases, and those living in highly populated areas that
are more likely to experience episodes of elevated poor
air quality.154, 185–187, 196
PUBLIC HEALTH IN A CHANGING CLIMATE
17
Vector-borne diseases
Recent studies on vector-borne diseases show that
climate trends can influence disease transmission by
shifting the geographic range and seasonality of vectors,
increasing reproduction rates and shortening the
incubation period of pathogens.154, 155, 200–202 Changing
climate conditions may also heighten the risk of exposure
to vector-borne diseases as habitats expand and become
better able to support the vectors.200–203 As a result,
Canada may experience the emergence of diseases that
are currently rare (see the textbox “Lyme disease: an
emerging infectious disease in Canada”).203–210
Lyme disease: an emerging
infectious disease in Canada
Climate change has contributed to the emergence
of Lyme disease in northeastern United States and
in most southern areas of Canada including parts
of British Columbia, Manitoba, Ontario, Quebec,
New Brunswick and Nova Scotia, and can potentially
affect the spread of the disease into new geographic
regions.207–209, 211 Lyme disease can cause skin rash,
arthritis, nervous system disorders and in extreme
cases, debilitation and death.212 It is caused by
a bacterium transmitted by infected ticks (most
commonly black-legged, or deer tick, Ixodes
scapularis). Warmer temperatures can accelerate
tick life cycles, create more favourable conditions
for survival and for finding hosts, and increase
the risk that new tick populations will become
established in new parts of Canada.205, 206, 208–210, 213
West Nile virus (WNv), a mosquito-borne illness, is
another good example of the relationship between climate
and disease migration. First documented in Canadian birds
in 2001, WNv has since spread rapidly and is now found
in most of the country.155, 214, 215 The first human case of
WNv was reported in 2002. Since then, more than 5,454
cases of human WNv disease have been reported to the
Public Health Agency of Canada with cases concentrated
in a number of urban and semi-urban areas of southern
Quebec and southern Ontario, rural and semi-urban areas
of British Columbia and in rural populations in the
Prairies.154, 155, 204, 215, 216 Changes in climate can shorten
the life cycle of the mosquito, accelerate its rate of
reproduction, expand its geographic range and lengthen
the overall transmission season.213, 216–218 While most of
18
those infected have no symptoms or mild flu-like
symptoms from which they fully recover, WNv can cause
severe illness, including meningitis and encephalitis and
its long-term effects are not fully understood.219, 220
Food- and water-borne diseases
The potential effects of climate trends on food- and
water-borne illnesses, nutrition and food security, while
mostly indirect, can nonetheless, significantly impact
health.154, 155, 168, 221, 222 Food-borne illnesses tend to peak
during warmer summer months, illustrating a strong
seasonal pattern. This can, in part, be attributed to
changes in food consumption and preparation practices
that can increase risk of food spoilage and food-borne
diseases. However, some of this seasonal increase can
be associated with increased temperature. Warmer
weather can allow bacteria to grow more readily in food
and can favour flies and other pests that affect food
safety. The occurrence of Salmonella, Campylobacter and
E. coli infections in Canada has been linked to increased
temperature. Research in Australia and the United
Kingdom has found similar findings.154, 155, 222–229
Food security can also be influenced by changes in
climate.154, 221, 230 Extreme weather events such as
flooding, drought and wildfires can affect food systems
by impacting crop production, food availability, markets
and related costs. Changes in rainfall can lead to drought
or flooding, or warmer or cooler temperatures can affect
the length of the growing season.154, 221, 231–233 Being food
insecure can lead to poor nutrition and thus an increased
risk of unhealthy weight and having chronic health
conditions and mental illness.234 This is of particular
concern for remote and northern communities in
Canada.153–155, 164, 235–239 Changes in climate can affect the
distribution and availability (through fishing and hunting)
of some of the traditional food sources that contribute to
the diet of most northern Canadians. Unpredictable ice
and weather conditions can restrict access to some foods.
Changes in distribution and availability also affect
aspects of Aboriginal peoples’ cultural and social
identity.153–155, 165–167, 240–243 The availability of safe drinking
water and the risk of water-borne infections is a particular
concern in remote and northern communities.154, 155, 167, 244
Extreme weather and climate conditions have also been
linked to a number of reported water-borne disease
outbreaks in Canada.155, 245–247 Frequent and intense rainfall
can increase the risk of water contamination. Extreme
rainfall can also threaten fisheries through contamination
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
with metals, chemicals and other toxicants that are
released into the environment.154, 155, 168 Most commonly,
storm water run-off flushes contaminants into waterways
and shallow groundwater sources.155, 245, 248 If combined
with poor water management systems or aging or
compromised water utility infrastructures (e.g. treatment
facilities, distribution systems), the risk of exposure to
water-borne diseases may increase.154, 155, 245, 248 The
public health implications of drinking-water contamination
in Walkerton, Ontario, in 2000 is a good illustration.
Heavy rainfall, combined with ineffective drinking-water
management systems and operating practices, resulted in
more than 2,300 cases of illness and 7 deaths after
drinking water became contaminated with E. coli O157:H7
and Campylobacter jejuni.249
Conversely, drought-caused decreases in water levels
can concentrate contaminants in water.155, 168, 188, 250, 251
Similarly, higher temperatures can affect the growth
and survival of bacteria, overwhelming water treatment
plants, particularly older water systems.152, 154, 155
Droughts can also increase demand and pressure on
water supplies.154, 155 For good health, Canadians require
access to safe, secure drinking water supplies.
Mental health and stress-related disorders
Changes in climate and the subsequent disruption to
the social, economic and environmental determinants
of health can influence an individual’s mental health
and well-being. Extreme weather events can lead to
geographic displacement of populations, damage or
loss of property and injury and/or death of loved
ones.152–155, 252–257 These circumstances can, in turn, lead
to acute traumatic stress and chronic mental illness, such
as anxiety and depression, post-traumatic stress disorder,
sleep difficulties, social avoidance, irritability and drug
or alcohol abuse.155, 168, 252, 256–259 People already vulnerable
to poor mental health, mental illness and stress-related
disorders may be at an increased risk of exacerbated
effects.154, 155
Mental health in rural and remote northern communities
and the influence of changes in climate is of particular
concern.169, 255, 260–262 The Inuit Mental Health Adaptation
to Climate Change (IMHACC) project, a community-based
initiative that examined the relationship between
climate change and mental health and well-being in
five communities in Nunatsiavut, Labrador, found that
disruption in land-based activities due to changes in
weather, snowfall and ice stability, and wildlife and
vegetation patterns are affecting the way of life, cultural
identity and social connectedness of Inuit communities.263
These societal changes are negatively influencing Inuit
people’s mental health.260–264
The severity of mental health impacts following extreme
weather events can depend on the level of coping and
the availability of support services during and after the
event.155, 168, 255 Rural and remote northern communities
tend to have limited resources and insufficient support
services.155
Other indirect exposures and health effects
Significant indirect impacts on health as a result of
climate change can occur through the effects on
physical infrastructures (e.g. roads, storm water and
flood control systems, houses and buildings) within
communities.154, 155, 265 Changes in climate, particularly
severe and frequent extreme weather events, can
undermine or compromise systems and infrastructures
and thus increase risks to health and safety.152, 154, 155, 168
Infrastructure in northern communities is also particularly
vulnerable to changes in temperature and precipitation
patterns.164, 266 Existing chronic health conditions can also
be potentially exacerbated when critical infrastructure has
been weakened or overloaded.155, 168
Moving forward: addressing climate
change health risks and vulnerabilities
As changes in climate have become more evident, so
has the need for public health to anticipate, manage and
respond to the effects these changes pose.155, 156 However,
addressing these health impacts is challenging. The issues
are broad and complex.154–156 Public health must strive to
prevent and adapt to current as well as anticipated and
unforeseen threats and identify the most vulnerable
populations.154
Responses to climate change can draw upon existing,
core, long-standing public health functions such as
research, education and awareness, surveillance and
monitoring, and emergency planning. Protecting
Canadians from climate change will, to a great extent,
not entail the development of new programs. Rather, it
will require modifying and strengthening existing public
health policies and practices to make them more effective
and to target particularly vulnerable populations.152, 155
Responding to the public health challenges posed by
changes in climate also requires a multijurisdictional,
PUBLIC HEALTH IN A CHANGING CLIMATE
19
multidisciplinary and integrated response. Strengthening
existing relationships and fostering new partnerships
among all levels of government, academia, nongovernmental organizations, communities and individuals
should be the focus.154, 155, 267
The broad strategies discussed below—by no means a
comprehensive list—illustrate the range of different
possible adaptation strategies.
Mitigation and adaptation
Strategies for mitigating and adapting to changes in
climate can help protect the environment and minimize
or avoid certain adverse health effects now and for future
generations.152–156 Mitigation refers primarily to actions
taken to slow, stabilize or reverse the effects of climate
change by reducing greenhouse gases.268 Adaptation refers
to the actions taken to anticipate, prepare and lessen
those effects of climate change that cannot be prevented
through mitigation. While mitigation efforts will primarily
occur in other sectors, public health has a definite role to
play in informing Canadians about research on healthrelated impacts and implementing effective adaptation
measures to reduce risks to health.152–156
Building capacity as an adaptation
to climate change
The capacity of individuals and communities to cope and
adapt to current and anticipated changes in climate can
significantly influence the degree to which these changes
will impact their health.155, 156 Adaptive capacity in Canada
is generally high but can be unevenly distributed.154, 155
A number of factors affect how people and communities
understand, experience and respond to climate change,
in some cases increasing risks and susceptibility to health
impacts.154, 155, 269 Broader determinants of health, such as
age, income, housing conditions, and community factors
such as population density, level of economic development,
income level and distribution, local environmental
conditions and the quality and availability of health
services all influence vulnerability to changes in
climate.152, 153, 155, 270–272
Factors that influence (both positively and negatively)
community resilience to climate change need to be
considered.269 Community-based research initiatives can
support innovation and inform strategic planning and
capacity building efforts and be an important source of
20
knowledge.273, 274 The EnRiCH project (Enhancing Resilience
and Capacity for Health), led by the University of Ottawa,
is an example of a recent project that examined community
resilience and developed, tested and evaluated community
mobilization interventions to enhance resilience in at-risk
communities.275, 276 An important factor that can enable
communities to be resilient in the face of extreme weather
events and deteriorating community infrastructure is strong
neighbourhood connectivity and cohesion.269, 274 Similarly,
Australia developed a strategic framework that identified
social cohesion as valuable in guiding local climate change
planning and action.170, 277
Vulnerability to climate-related health risks can be
reduced through prevention and adaptation.154, 269
Encouraging public participation at all levels (e.g. local,
regional and national) helps communities prepare for
and respond to the health risks of climate change.278
Health Canada’s Climate Change and Health Adaptation
Program for Northern First Nations and Inuit Communities
supports the development of community projects across
Canada’s North that focus on climate-influenced health
issues.169, 243, 279 The program is unique in recognizing that
the adaptive capacity of communities varies and that
they experience different challenges. It encourages
communities to become more engaged by integrating
local knowledge with science-based knowledge to develop
promising local adaptation strategies that address
vulnerabilities.243, 279–281 From 2008 to 2011, the program
funded 36 community-based projects and developed a
variety of communication materials (e.g. on drinking
water, food security and safety, and land, water and ice
safety) to support decision making on health-related
issues.243, 279–281 Through these measures, communities
have also increased their knowledge and understanding
of the health effects of climate change. This knowledge
enables communities to find ways to address vulnerabilities
at a community level, mitigate risks, adapt to the
challenges and protect health.279–281
More research into how populations and communities
are vulnerable to changes in climate is needed to inform
decision making.155, 270, 271, 282 Vulnerability assessments
can foster a better understanding of risks posed by climate
change and inform the development and implementation
of effective adaptation measures.269, 278, 282, 283 Assessments
need to be ongoing to address current and future risks
and barriers to adaptation.282, 283
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Continuing investment in research
Health research is both valuable and important.
More research into climate change can foster a greater
understanding of how these changes influence the health
of Canadians.154 For example, the Public Health Agency
of Canada’s Preventative Public Health Systems and
Adaptation to a Changing Climate Program (2011–2016)
was initiated to conduct research and enhance surveillance
methods, engage public health stakeholders and inform
decision making on climate change adaptation.284 Such
research can help to answer specific questions or address
existing knowledge gaps and shed more light on potential
climate-related health risks. As well, contributing more
knowledge to climate change discussions can help develop
more appropriately targeted and evidence-based public
health adaptation initiatives. Research can help identify
more effective strategies and tools to protect those
Canadians who are more vulnerable to exposures and risks.
Research is also needed to enhance response capacity to
handle the challenges that climate change is expected
to place on public health in the future.152, 154, 155, 284
Increasing education and awareness
Public communication and education initiatives play an
important role in establishing healthy behaviours and
choices.154, 155, 285 A more informed public, aware of the
steps that can be taken to reduce risks and protect health,
can also bring about changes in the environmental
conditions that affect their health.154, 155, 285 For example,
a health promotion approach to reducing sources of air
pollution would encourage and support the use of more
environmentally friendly means of transportation
(e.g. walking, biking and using public transit), while
promoting a more active and healthy lifestyle.286
Ways to educate and raise awareness about climaterelated health risks include broad public messaging on
environmental health issues and targeted campaigns
that focus on a specific sector (or target audience) and
a particular health issue. Approaches that raise awareness
of potential health risks and also provide specific advice
on how Canadians can best protect themselves are also
beneficial.285, 287 Such approaches, which encourage people
to play an active role in their own health and safety by
being prepared could include public health messaging
on health, safety tips, health marketing materials and
educational toolkits for public health professionals’
use.288, 289 It can also be useful to consider different
communication strategies and outlets, such as new
technologies and social media, in order to disseminate
messaging more effectively.154, 285
Health promotional materials have been created to inform
Canadians about reducing their exposure to the WNv.290–292
Efforts have also targeted those at an increased risk of
exposure such as active seniors and those who spend
more time outdoors.292 The province of Alberta utilized
a series of marketing strategies including informational
radio interviews called Let’s Go Outdoors, insertions in
newspapers and magazines targeted to high risk areas
and a general public awareness campaign Fight the Bite.292
As part of the WNv public education campaign, First
Nations and Inuit Health regional staff provided
consultations to First Nations residents and community
and healthcare workers to educate about WNv and the
steps to take against it.293 Other provinces/territories and
regions across the country have used similar strategies.155
The Public Health Agency of Canada has developed a
comprehensive action plan to educate and raise awareness
of both the general public and healthcare professionals on
Lyme disease to mitigate the risks to Canadians posed by
the disease. The Action Plan on Lyme Disease will feature
a series of communication activities including advertising
campaigns, outreach materials, media engagement such
as interviews, conference presentations and webinars,
and social media activities.211
Developing approaches to communication that are
effective at getting people to adopt health-promoting
behaviours is a central challenge.154, 285, 294, 295 Research
indicates that, despite public health messaging, people
may not be acting on the information and making choices
or changes to reduce health risks.154, 294–296 For example,
heat-health communication campaigns aim to increase
knowledge of the potential risks to health from extreme
heat and to influence individuals to adopt protective
behaviours.287 A review found that people had poor
perception of heat-health risks and were confused by
existing heat-health messages, and that messaging did
not target the appropriate audiences.294, 296 Effective public
outreach initiatives need to be delivered during periods
of high risk (e.g. before and during the warmer months
and during extreme heat events) and through a variety
of communication outlets such as media (mass/broadcast
and targeted), interpersonal networks and community
events (see the textbox “Air Quality Health Index”).174
PUBLIC HEALTH IN A CHANGING CLIMATE
21
Air Quality Health Index
The Air Quality Health Index (AQHI) is a health risk scale that describes conditions hourly and provides twice
daily Environment Canada forecasts on the mixture of pollutants in the air.297–299 Included are messages on how
to reduce the short term associated risks as well as health advice targeted to specific vulnerable groups—children,
seniors and people with cardiovascular and respiratory disease—as well as the general population. The goal of
the index is to support Canadians in making informed decisions that can reduce associated risks to health from
exposure to poor air quality.155, 297, 298, 300
People can disassociate air quality health risks from their own situation, either by underestimating their own
exposure or assuming the risks apply to other people who are more vulnerable.155, 294 Most Canadians know that air
quality advisories are provided in their area. However, this information initially had a limited impact in attracting
attention and prompting actions to reduce personal exposure, even during poor air quality events.155, 297, 300 In
response, a number of social marketing initiatives were undertaken to make the AQHI as effective as possible at
reaching sensitive populations. Media partnerships, particularly with The Weather Network, were also formed to
increase the reach of AQHI through television, print, radio, automated telephone and the Internet.155, 297, 298, 300
Partnerships were also developed with other government agencies and non-governmental organizations who work
directly with sensitive populations.300
An early evaluation of the AQHI showed an increased awareness of risks and use of information and products
among at-risk groups. A later evaluation, in 2010, noted further opportunities to broaden the use of information
and products.297, 300, 301 Outreach efforts with non-governmental health organizations have led to broad support
by the Canadian health community with positive signs with respect to public awareness.302
To increase the effectiveness of communication
campaigns, collaboration is needed to deliver consistent,
audience-appropriate and easily understood messages.
Communication materials should target vulnerable
populations and their caregivers and proactive action
strategies should consider differences in perceptions,
knowledge and abilities. The effectiveness of public
communication and education initiatives can be improved
by engaging the community to identify risks, develop
and share best practices, and tailor activities and
products to the needs of specific regions, communities
and populations.174, 287, 294, 295
There is also a need to improve awareness and knowledge
of the risks to health caused by climate change. Adaptation
measures among public health and emergency management
professionals and the general public can help in developing
effective communication materials whose aim is to reduce
health risks associated with climate change. Developed
through Health Canada’s Heat Resiliency Initiative, the
report Communicating the Health Risks of Extreme Heat
Events: Toolkit for Public Health and Emergency Management
Officials identifies communication strategies, based on
leading research and practice, to influence behaviours
through health promotion campaigns.287
22
Building and sustaining healthy environments
Improving the potential of communities to promote
health in the face of climate change will be an ongoing
challenge. More is needed to make Canada’s infrastructure
more resilient, particularly in relation to extreme weather
events.154, 155, 303 The state and age of roads, sanitation
facilities, wastewater treatment systems, flood control
structures and building standards and codes are integral
to the protection of health.154, 155, 303 Recent impacts of
extreme weather events like the 2013 Southern Alberta
floods demonstrated the need to develop new
infrastructure designs that can better withstand more
intense weather events.304, 305 Initiatives to help support
rebuilding aging infrastructure, such as the 2014 New
Building Canada Plan are also important.306 As current
infrastructure is upgraded and replaced, it is important
to consider new and updated design values, revised
codes and building standards, and new approaches to
incorporating climate change considerations into
planning designs.154, 155, 307
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
In addition, it is important to consider the opportunities
and limitations of various aspects of infrastructure in
urban and rural areas in Canada in terms of their capacity
to adapt to climate change.153–155 About 82% of Canadians
live in urban areas and this population is growing.15, 308
While urban areas tend to be wealthier and have more
access to services (e.g. healthcare, social services and
education), they also tend to depend more on critical
infrastructures (e.g. energy, transportation and water)
and experience more severe heat stress and poorer air
quality.153, 309 The impact of extreme weather can also
be exacerbated in highly populated areas. Also, with
increased urbanization and population pressures,
Canadians are moving into more marginal land, such as
coastlines and floodplains. New construction and urban
plans and designs should take into account protection
from weather-related natural hazards, as these settlement
patterns could increase health risks.154, 155, 310–314
Likewise, smaller, remote and rural communities can
experience challenges, particularly due to limited support
services, resources and infrastructure, resulting in residents
being less protected.153, 315 Infrastructure in northern
communities is particularly vulnerable to changing ice
conditions and can present additional challenges to the
design, development and management of infrastructure
in the North.154, 167, 266, 272 Access to tools that enable these
communities to adapt infrastructure to these changing
conditions is necessary.266, 272, 316 The Northern Infrastructure
Standardization Initiative, led by the Standards Council
of Canada (SCC) with support from Aboriginal Affairs
and Northern Development Canada, is one measure taken
to address this issue.317 The initiative supports adapting
northern infrastructure to a changing climate by changing
critical codes and standards to address the effects of
climate change on new infrastructure as well as
maintaining and repairing existing infrastructure. The
SCC aims to identify gaps and needs in existing codes and
standards to support infrastructure and ensure it reflects
the unique circumstances of this region in light of changes
in climate.266, 316
As mentioned, strategic and smart land-use planning is
essential.155, 318 The design of cities and roadways, and
the location of places of work and home and other aspects
of land use all affect the health of Canadians.154, 309, 319 For
example, planning can influence how much Canadians need
to use motor vehicles to get around, which also influences
transportation’s role as one of the major sources of air
pollution.309, 320 Neighbourhood designs that include
high-quality pedestrian environments and a mix of land
uses (e.g. planting trees, increasing green spaces, patterns
of subdivisions, housing and buildings, etc.) can improve
health by promoting active forms of transportation,
reducing air pollution and associated respiratory ailments
and lowering the risk of motor vehicle-related
accidents.309, 318–324
While these measures are not direct public health
functions, there is still a role for public health to play.
Public health officials can inform and educate the public
about health risks, advocate for changes that promote
and improve health and work together with land-use and
building planners, community and regional officials to
encourage the adoption of health-promoting changes
in urban planning and community infrastructure.318
Surveillance and monitoring
Research data and analysis gathered from public health
surveillance systems and tools can support a number
of public health functions.325 In the case of infectious
diseases, it can help to identify changes in disease
trends, including patterns associated with changes in
climate (see the textbox “The Rothamsted trap”).213, 326
It can also be used as a reporting function to identify
vulnerable or affected individuals and communities in
PUBLIC HEALTH IN A CHANGING CLIMATE
23
order to implement response and disease control measures
to reduce further exposure to health risks.325 During the
WNv season, the Public Health Agency of Canada, together
with other national, provincial and territorial public
health authorities, produces a weekly WNv MONITOR
report and map. This report summarizes the activity of
the virus across Canada. Information in these reports can
be used by provincial and municipal health authorities to
ensure Canadians know how to reduce their exposure to
risk.327, 328 As well, research gathered through surveillance
initiatives can provide a clearer picture of health concerns
to facilitate informed decision making and appropriate
public health action. This ensures efforts are targeted
and resources appropriately allocated where they are
most needed.325 Research data informs and supports the
development of policies and strategic plans such as the
Public Health Agency of Canada’s Action Plan on Lyme
disease.211 All of these measures are important in
preventing and controlling infectious diseases.329
The Rothamsted trap
In collaboration with Brock University and the
Public Health Agency of Canada, Niagara Region
Public Health constructed a Rothamsted trap to
capture insects that may serve as carriers of
infectious diseases.213, 326, 330 The trap, measuring
40-feet high, acts like a vacuum, collecting around
300 insects per day from May to October.331 The
trap was modelled after the work of Rothamsted
Research, an agricultural research centre in the
United Kingdom that first developed the traps.331
Although in service in Europe for a number of years,
this Rothamsted trap is the first to be used in
Canada.213, 326, 330 As part of the Pilot Infectious
Disease Impact and Response System program,
this is an initiative in vector identification and
disease surveillance. It can help researchers detect
new/exotic disease vectors before human disease
cases are reported. It can also support current
vector-borne disease strategies and public health
responses.213, 326, 330
24
Early warning systems have been developed as a
precautionary measure to detect a number of climaterelated health risks including air quality concerns
(see the textbox “Air Quality Health Index”), wildfires,
extreme heat and ultraviolet radiation.155, 191, 287, 332
These forecasting tools can help in mobilizing public
health action by issuing public advisories and alerts
to mitigate health risks before impending dangerous
health conditions occur. These systems also support
broader surveillance and information sharing
initiatives.155, 175, 191, 287, 332–335
Several communities in Canada, as well as in Australia,
Europe and the United States, have developed heat-health
action plans and warning systems such as Heat Alert and
Response Systems (HARS).174, 333–337 HARS are developed
to reduce heat-related morbidity and mortality during
extreme heat by alerting the public, including vulnerable
populations, about the risks and providing individuals
with information and other resources to help them protect
themselves during an extreme heat event.174, 338 Since
2008, Health Canada has worked with federal, provincial
and municipal partners to implement a Heat Resiliency
Initiative which supports the development of HARS.
This initiative also aims to strengthen the capacity of
communities, healthcare professionals and individuals
to manage heat-related health risks.339 Evaluations of the
few existing HARS demonstrates that these systems can
help to protect people from illness and death associated
with extreme heat events particularly when based on
knowledge of community- and region-specific weather
conditions that result in increased heat-related health
concerns.174, 334, 338 Future efforts may consider public risk
perceptions in relation to changing behaviours to protect
health; choosing alternative communication strategies
that increase awareness and change behaviours;
conducting vulnerability assessments to identify and
target interventions; monitoring HARS activities and
evaluating them at the end of the heat season; and
implementing long-term preventative actions that reduce
heat exposure and negative health outcomes.154, 174, 338, 340
Emergency planning
The potential for more frequent and severe extreme weather
events necessitates effective emergency management
measures. Indeed, planning for the unexpected is a key
challenge posed by climate change.155, 341 Climate-related
emergencies can escalate quickly in scope and severity,
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
cross provincial and regional boundaries, take on
international dimensions and significantly impact
health.154, 155 Extreme weather events can overwhelm
the capacity of communities and local governments
to respond—particularly if they are unprepared. It is
important to consider how extreme weather events
can compromise critical infrastructure and emergency
services, limit access to support services and resources
and challenge efforts by emergency management
personnel to manage exposure and reduce impact.269, 341
Comprehensive risk management measures that
(pre-impact) reduce, prevent, prepare for and mitigate
emergencies, and help in the (post-impact) response
and recovery can reduce health risks and protect health,
lessen the impact on critical public services and preserve
infrastructure and the environment.269, 341–344 Proactive
planning can also bring to light gaps or areas of
deficiencies and limited resources, and identify more
vulnerable population groups, to redirect or enhance
efforts and resources where needed.155 As well, the use
of risk assessments and evaluations can help to reduce
vulnerability and mitigate potential impacts. All of these
community emergency management measures can help
to increase community resilience.269, 341
Continuing efforts
Canadians remain vulnerable to the effects of climate
change and its impacts on the health. Public health has
considerable experience in reducing risks to health from
environmental change; this experience can be drawn
upon to meet the challenges posed by climate change.
Long standing, core public health functions can
provide a strong basis for protecting Canadians from
climate-related health risks. Efforts made now can
significantly reduce vulnerability to the health impacts
of future changes in climate.
PUBLIC HEALTH CAN:
••
••
••
••
••
••
continue research to better understand how changes in climate affect health particularly
that of vulnerable Canadians;
increase awareness among public health professionals and the general public about
the health risks of a changing climate;
be proactive and consider short- and long-term climate changes;
find ways to adapt to reduce the impacts on health;
optimize ongoing assessments and share best practices and lessons learned to develop
more effective public health adaptation programs; and
support multijurisdictional, multidisciplinary collaborative approaches to tackle the
challenges of climate change in Canada.
PUBLIC HEALTH IN A CHANGING CLIMATE
25
26
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
HIGHLIGHTS
••
••
••
••
Technology can be used in numerous ways to improve, promote and monitor health.
Within the field of public health, technology can be a tool for researchers, public health
professionals, communities and individual Canadians.
The ubiquitous nature of computers and their related technologies can play a key role
in implementing and delivering health promotion and prevention programs.
Social media is an emerging and rapidly changing technology that lends itself to key
areas of public health, particularly those that involve the sharing of information, such
as improving health literacy and surveillance.
DIGITAL TECHNOLOGY AS A TOOL FOR
PUBLIC HEALTH
As technology has evolved, so has its use and application
to public health. The telephone has gone from being a
tool to transmit electrocardiograph data early in the
20th century to a way for patients to receive health
information and advice from health professionals
remotely, via telehealth systems.345, 346 Canadians have
become accustomed to the technology that routinely
surrounds them when they access health services or
programs, from computerized health information systems
and electronic medical records to diagnostic tools and
treatment equipment. Personal computers and mobile
device apps are used to connect with health-related
information and tools. Behind the scenes, scientific
researchers make use of technology to develop new
methods and tools for public health and also to create
new technology itself.
Technology can provide public health professionals,
communities and individuals with a wide range of tools
to address issues of public health more efficiently and
quickly in a more connected way. As technology continues
to advance, its role in public health will also change. The
vast range of available technologies will continue to be
used in educating, informing, training and communicating
with both the public and public health professionals; in
surveillance and data collection for detecting infectious
disease outbreaks; in monitoring of chronic disease and
injuries; in monitoring and evaluating programs; in
making transparent and evidence-based decisions; to
improve the speed and accuracy of diagnoses; and in
providing new and more effective treatments. New and
innovative uses of technology for public health will
also emerge as the field continues to grow and evolve.
This section presents just some of the ways in which
certain digital technologies can be and are being used
to address several key functions of public health.
DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH
27
Health promotion and protection
Health promotion is a core function of public health.
Public health practitioners and professionals work with
communities, agencies and individuals to develop and
implement programs and interventions aimed at positively
influencing health behaviours.347
EHealth interventions
Once a program or intervention is developed it must then
be delivered. Technology can help by providing the means
through which such programs and interventions are
offered. In particular, eHealth interventions allow public
health to benefit from current technologies.348
EHEALTH is defined as “health services and
information delivered or enhanced through the
Internet and related technologies.”349
A literature review assessed the ways that particular types
of eHealth interventions, are being used to encourage the
adoption of health promoting/protecting behaviours.348
EHealth interventions can take numerous forms and
address a vast range of issues.348 To provide a manageable
and focused assessment, the review excluded eHealth
interventions involving telehealth, telemedicine,
television or radio, use of electronic health records,
gaming or videogames, and personal wearable devices,
and interventions were narrowed to include traditional
public health functions.348 The literature identified
studies in the United States, the Netherlands, the United
Kingdom, Australia and Canada that used websites and
web portals; email and text messaging; goal setting;
assessment and monitoring/tracking; risk assessments;
online training, counselling/motivational interviewing;
tailored feedback and peer and expert advice; and
social network sites, live chats and discussion boards
as intervention tools.348 The public health issues addressed
through the interventions included diet, nutrition, healthy
weights, increasing physical activity, smoking cessation,
sexual health promotion, immunization uptake, substance
use reduction and general and/or multiple lifestyle
issues.348 The intervention approaches were classified
into three categories: web-based; mHealth (mobile
technologies, such as cell phones, tablets etc.); and
computer-based (stand-alone computers without
Internet, such as a computer kiosks or CD-ROMs).348
28
The studies included in the review mostly targeted
adults from the general population as well as adolescents,
college/university students and adults in workplace
settings.348 A large number of the studies targeted
youth in relation to improving healthy eating and physical
activity.348 Young adults were also most often involved
in studies related to sexual health such as increasing
screening for sexually transmitted infections (STIs)
and adopting healthier sexual behaviours.348 Employee
interventions targeted multiple lifestyle behaviours,
mostly related to healthy eating and increasing physical
activity.348 Only a few studies analyzed interventions with
seniors; one examined seniors’ use of mobile phones and
another focused on a web intervention, with both aiming
to increase older adults’ level of physical activity.348 In
light of the aging demographic in Canada, the increased
use of the Internet among those over 55 years of age,
the lack of interventions for this population and the
promise shown in the above studies, this is a potential
area for growth.348
Canadian studies focused mostly on web-based or online
(enhanced and/or interactive websites or web portals)
programs and on one texting intervention.348 The studies
addressed a variety of health topics: uptake of vitamin C,
reduction in alcohol use, reduction in smokeless tobacco
use, increase in physical activity, general health-seeking
behaviours, reduction in drug use and increased access to
information on sexual risk behaviours and testing for STIs
(see the textbox “Using technology to increase testing for
sexually transmitted infections”). Interestingly, over half
of these studies targeted adolescents and young adults.348
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Using technology to increase testing for
sexually transmitted infections
In 2011, Ottawa Public Health launched the Get
Tested. Why Not? campaign targeting 15 to 29 year
olds. The campaign focuses on increasing STI testing
for chlamydia and gonorrhea, as well as increasing
access to health information. The campaign uses
a bilingual, youth-friendly website to provide
information and answers to questions about STIs.
Website visitors are able to assess their risk for
STIs and their appropriateness for testing. They
can then download a testing requisition form
directly from the website and use it to have a
biological (urine) sample submitted to any local
participating laboratory. lthough visitors are advised
to follow-up with their regular doctor or at a sexual
health centre immediately should they have any
symptoms, this approach eliminates the need to
visit a primary care provider before being tested.350
After the first year of the campaign, surveyed
participants indicated gaining more knowledge,
such as information about services for STI testing
and risks of contracting STIs, and felt that they
would change their behaviours, such as asking
partners to get tested and to use condoms.350 In
2013, Ottawa Public Health launched a new sister
site to Get Tested. Why Not? called Sex It Smart.
The intent is to support safer sex practices by not
only encouraging testing to prevent the spread of
STIs but also increasing access to free condoms.
Individuals/agencies can go online and order free
condoms that will be mailed directly to their home
or prepared for agency pick-up.607
Overall, study results indicated that eHealth interventions
are feasible in controlled settings and that individuals
are generally open to using technology to monitor and
improve health behaviours, attitudes and beliefs.348 In
some cases, certain features of the technology, for
example, brief, relevant and positive text messages,
were better at enhancing engagement.351
The effectiveness of interventions varied based on the
health topic. Alcohol use reduction/prevention studies
and sexual health studies showed mostly positive and
significant outcomes, whereas smoking cessation and
multiple risk factor studies showed both positive
and negative outcomes, depending on the type of
intervention.348 The eHealth intervention studies associated
with the most positive and significant outcomes were those
that mixed components (e.g. website plus face-to-face
support), tailored components to individual needs
(personalized feedback or advice) and integrated behaviour
change theory, irrespective of health topic.348 In addition,
many studies showed effects over the short term (less
than 6 months), but longer-term results were lacking.348 In
assessing the level of effectiveness of such interventions,
reported study limitations such as self-reported outcome
measures, limited ability to generalize of results due to
small sample sizes, high attrition rates and loss to follow
up must be kept in mind.348
As with other uses of technology as a public health
tool, accessibility should be taken into account to
ensure equitable program and service delivery. For
example, in all but one of the mHealth intervention
studies, participants had to have a cell phone, and in
some cases, a data plan.348, 352 Using text messaging can
potentially marginalize populations with low literacy levels
or without access to a mobile phone.348 Interventions need
to match the target population and be integrated into the
pool of public health interventions.348 EHealth strategies
need to deliver health information through culturally and
socioeconomically acceptable formats; increase skills in
delivering accessible health information; and engage
online social network members who assume leadership
roles as well as trusted people (e.g. elders).348, 353 To
address health equity concerns, factors that need to be
considered include lack of physical access to technology;
lack of meaningful access (information needs to be
designed to reach and appeal to diverse populations);
language abilities and eHealth literacy skills; age;
disability; and cultural relevance of tools.348, 354 It is
critically important to engage end users in co-designing
interventions to ensure relevance, uptake and sustained
use of eHealth interventions.348
DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH
29
There is definitely room for careful application of
eHealth interventions in public health in Canada, with
attention needed to address challenges to health equity.
There is also a need to support further research of
eHealth applications in the Canadian context.348 New
interventions, including some that have already been
implemented, continue to be developed (see the
textbox “ImmunizeCA”).
ImmunizeCA
Immunization is one of the great success stories
of public health.355 The reduction in the number of
cases of vaccine-preventable diseases in Canada has
been key in contributing to improved overall health
and increased life expectancy.355 All Canadian
provinces and territories have a recommended
immunization schedule for their residents and a
system for recording those immunizations.356
However, it can be difficult for individuals to keep
track of, and manage, their own immunizations or
those of their children, which may lead to missed
or incomplete immunizations. In March 2014, the
new ImmunizeCA mobile application (app) was
released to help Canadians track and manage their
immunizations and records more easily.357
ImmunizeCA is a bilingual app developed with
funding from the Public Health Agency of Canada
through collaboration between the Canadian Public
Health Association, Immunize Canada and the
Ottawa Hospital Research Institute.357 The app
provides access to personal immunization records,
schedules and information specific to Canadian
children, adults and travellers.357, 358 It is
customizable to the user’s age, gender and home
province or territory allowing the information to
be tailored to their particular situation.359 In
addition to storing personal records it allows quick,
easy access to reliable, expert information about
immunization schedules, vaccine-preventable
diseases and vaccines.358 It also allows people
to manage appointments and provides alerts for
disease outbreaks in the area.358
The new ImmunizeCA app is available for
Android, iPhone and BlackBerry systems and can
be downloaded for free from Google Play, iTunes
and BlackBerry World.358
30
Looking at the way in which technology is being used
to encourage health-promoting and protecting behaviours,
it is clear that the potential exists to improve use of
social networks.348 Some individual health behaviours and
resulting chronic conditions, such as smoking and obesity,
have been shown to be “contagious” to some degree, that
is, they tend to “spread” within social networks.360–362 If
an individual has social connections to others who smoke
or are obese, they are more likely to smoke or be obese
themselves.360–362 Knowing this, social media in particular
could be used to identify public health programs and
interventions and target individuals, rather than an entire
network, with the intention that individual change will
spread to others.360
Education and awareness
Improving health literacy
Public health uses education and awareness programs
to influence health behaviours and increase knowledge
so that Canadians are better able to manage and
understand their own health and that of others.2 However,
to play a role in managing one’s own health requires
a certain degree of health literacy, that is, the ability
to access, understand and apply the relevant health
information.267 The Canadian Council on Learning found
that 60% of all Canadians over the age of 15 do not
have the necessary level of health literacy to obtain,
understand and act on health information or make
appropriate health decisions.363, 364
Public health can use technology in various ways to
improve Canadians’ knowledge and awareness of their
health. One way is to use technology as a tool to improve
health literacy. A main component of health literacy
is the capacity to obtain the basic health information
needed to make appropriate health decisions.365 Although
information on its own is likely insufficient to bring about
a change in behaviour, it is still a necessary component.
Social media has the potential to help Canadians get
that information.366
HEALTH LITERACY is “the ability to access,
understand, evaluate and communicate information
as a way to promote, maintain and improve health
in a variety of settings across the life-course.”267
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
The Internet is an extremely common source of health
information in North America.366, 368 A 2012 survey
found that three-quarters of adults in the United States
searched for health information online in the previous
year.369 In Canada, 70% of home Internet users searched
for medical or health information online in 2009, up from
59% only two years earlier.368 With more than 200 million
monthly active users worldwide on Twitter and more than
one billion on Facebook, social media is positioned to
connect millions of Canadians with important public
health information.370, 371
Although social media is popularly believed to be the
domain of younger people, research in the United States
found that almost two-thirds of Internet users aged 50
to 64 years and almost one-half of those aged 65 years
and older were using social networking sites such as
Facebook and Twitter in 2013.372 Consequently, it only
makes sense that health organizations reach out to this
ready-made audience.366
Aside from its built-in user base, social media has a
number of features or aspects that make it an effective
means of sharing health information. For example,
minimal effort is necessary to share information in real
time.373 Organizations can take advantage of the existing
infrastructure, which may make using it inexpensive.373
The multidirectional nature of the communications
allows for quicker and more extensive distribution
of the information than traditional methods.373
Simply having access to the information, however, is
just one aspect of health literacy; the user must also
be able to understand and evaluate the information to
make appropriate health decisions.267 The information
and approach must therefore be adjusted to users’ levels
of reading and comprehension.366 In addition, knowing
how family, social context, culture and education play
a role is key.374, 375 These influences can affect how
individuals receive health information, perceive health
problems, express their symptoms and their views on
what, and by whom, treatment should be provided.375, 376
SOCIAL MEDIA refers to interactive “websites and
applications that enable users to create and share
content or to participate in social networking.”367
Exclusive reliance on text in health messages
can be a barrier to health literacy.377 Online health
information providers should also consider alternative
and complementary media formats—photographs,
illustrations, animation, video, live seminars and
interactive games—and learning environments that
allow Canadians with literacy or language issues to
more easily understand the information (see the
textbox “T2X: Getting the message to teens”).374, 377
T2X: Getting the message to teens
Funded by the National Institutes of Health in
the United States, Teen 2 Xtreme (T2X) is a website
(www.t2x.me) developed for teens to use social
networking to improve health literacy.378–380
The website is intended for teens only and includes
content written both by teens and professionals.378, 380
Visitors can learn more about relevant health and
life issues such as nutrition, sexual health, smoking,
stress and violence and others.378, 380 The site uses
numerous interactive resources including blogs, video
sharing, text messaging, games and chats to get the
information out.378, 379
Teens can chat 24/7 and in real time with health
experts, participate in online health-oriented social
networking and access educational campaigns that
allow them to text keywords to a designated number
and receive a response on their mobile devices with
customized content on the T2X website.378 Current
educational campaigns include Talking to Your
Doctor, ReThink Your Drink (which discourages
consumption of soft drinks), Pertussis, Meningitis,
Stop Bullying and Smoking Prevention.381 Members
participating in a particular campaign complete a
pre- and post-test of their knowledge of the topic
and their change in intention about a related health
behaviour. Results so far are positive.381 For example,
among teens participating in the ReThink Your Drink
campaign, post-tests showed a 21% improvement in
knowledge, 26% change in attitude and 19% change
in intention for positive behavioural change.381
DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH
31
The strength of social media is the ease with which users
can exchange information, rather than merely passively
receive one-way statements.382 Dynamic back-and-forth
interchanges can take place with peers or with healthcare
professionals. People find it helpful to discuss symptoms,
treatments and concerns with their peers with similar
health issues or similar questions.377, 383 Social media
allows Canadians to do so from the comfort and privacy
of their own homes. This allows them to ask questions
they might be too embarrassed to ask their doctors.377
Communicating with people with whom they perceive they
share a problem can help patients open up.377 In addition,
it may be easier to understand information shared by peers
than the jargon used by some healthcare professionals.377
People can connect with each other where otherwise they
may never have due to barriers in geography, distance or
the rarity of their condition.383 This access to a broader
range of information can increase their knowledge and
help them make better, more informed decisions about
their health.377, 383 Even between peers the information
exchange can go beyond text to include photos or video.
For example, a fertility specialist in the United States
asked one of his patients to produce a video showing
her self-administering her daily in vitro fertilization (IVF)
injections. The video was then posted on YouTube for
other patients to watch to help them overcome their
fears and gain confidence in their own abilities.377
The aspects of social media that make it well suited
as a positive tool for health literacy are also its main
drawbacks. The speed and range of messages that pass
through social media, along with its largely un-moderated
format, create potential risks.374, 377 The risk of spreading
inaccurate, biased or incomplete information or
misinformation is considerable given that basically
anyone is allowed to post anything they want.366, 374, 377
The source of the information may be missing, thus
preventing assessment of the credibility of the
information.374 The information may be correct, but
written in such a way that it could be misunderstood
and have negative health consequences.366, 374 The viral
nature of social media then allows this information or
misinformation to spread very quickly, especially during
times of public anxiety or fear.366, 374
Some of the risks associated with social media can be
lessened, however, by building trustworthy websites and
by monitoring and moderating content. Official websites
such as those of the Public Health Agency of Canada, the
United States Centers for Disease Control and Prevention
(CDC) and the World Health Organization (WHO) can be
promoted to Canadians as trustworthy and credible. The
content of social media websites should be monitored
to prevent spam, malicious content or privacy violations
without eliminating the individual user’s ability to freely
post content.374
Social media tools are only of use if people are able to
access and use them, which not all Canadians can.377, 385, 386
Barriers to access include cost, location, low literacy
levels, disability and factors that relate to people’s
capacity to use these technologies appropriately and
effectively.377, 386 These are the barriers faced most often
by some of the most vulnerable Canadians who are also
some of those most in need of improved health literacy.
They include older Canadians, people living in low-income
households and those living in remote and northern
communities, which may include First Nations, Inuit
and Métis people.387
Moving past the barriers requires improving access to
technology and, when necessary, tailoring the information
and messages to those with limited health literacy. In
terms of access, one solution is to make the technology
publically available in schools, libraries and health clinics
or doctors’ offices.377 In fact, most schools and libraries
already offer public computer use; some may also have
staff on hand who can assist or instruct users.377 Placing
accessible computers in clinics or other places used for
health-related reasons would allow people to access
information that may be pre-screened or recommended
by knowledgeable staff.377 For those with low general
literacy or physical limitations that may make traditional
browsing difficult, touchscreens with visual cues and
icons could help eliminate those barriers.377
Health organizations may also consider privacy
issues and the value of employee time as reasons
against adopting social media as a tool for public
communication.384 They must also be careful not to cross
the fine line between providing general information and
giving specific medical advice in a public venue.384
32
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Surveillance
Surveillance—the collection, analysis and reporting of
data in order to track and forecast health events and
determinants—is central to any public health system.325
Through surveillance public health officials can identify
and respond to public health threats, create practical,
evidence-based policies and programs, and meet
Canada’s international public health obligations.325
Global health surveillance
Just as the Internet and social media can provide
individuals with important information, they can also be
a source of invaluable data for public health professionals
“PUBLIC HEALTH SURVEILLANCE is the ongoing,
systematic collection, analysis, and interpretation
of health data, essential to the planning,
implementation and evaluation of public health
practice, closely integrated with the dissemination
of these data to those who need to know and linked
to prevention and control.”388
and official organizations around the world. Global health
surveillance has changed, and it continues to adapt
in light of the worldwide influence of the Internet.389
Information can flow freely and rapidly, allowing for the
quicker detection of outbreaks and speedy dissemination
of information between officials and to the public.389
In addition, the sources of information available online
provide a different perspective to that offered by
traditional health reporting.389
The Internet and social media’s value as surveillance
tools lies in the fact that changes in information and
communication patterns on the Internet can act as an
early-warning system for epidemics and outbreaks or
other changes in population health.389–391 Conversely,
public health officials can use data about the information
being shared by the public to target public health
campaigns, educate, correct misinformation and alleviate
fears.390, 392 This is what WHO did during the days following
the Japanese tsunami in 2011.393 Social media was used as
a communication tool to allow WHO to manage critical
health information being shared with the public after the
incident (see the textbox “Fukushima radiation threat:
Informing the public through social media”).393
Fukushima radiation threat: Informing the public through social media
During the Japanese tsunami and Fukushima radiation emergency of 2011, WHO used social media to manage
the global health crisis. Because some people were afraid of possible radiation poisoning from the damaged
Fukushima nuclear reactor following the tsunami, they began drinking wound cleaner in the hope that the iodine
in it would protect them. Others took iodine pills. WHO became aware of this through social media three days
after the tsunami. The organization turned to Facebook and Twitter to warn the public that drinking the wound
cleaner could be harmful and that they should see a medical professional rather than self-medicating with the
iodine pills.
Three days later, WHO observed via social media that misinformation about iodine was leading people in China
to hoard iodized salt and some people to consume seaweed or seaweed supplements for their iodine. Once again,
WHO turned to social media to address the behaviour, tweeting that neither seaweed nor salt contain enough
iodine to help against radiation poisoning and that, in fact, consuming too much iodized salt could cause
poisoning. Just two days later, the success of WHO’s social media communications was evident when it was
reported that Chinese consumers were trying to return their salt to retailers.
Social media facilitated the speed and ease with which WHO was able to respond to this particular global
health crisis and continues to be used by WHO to educate, build awareness and clarify rumours.393
DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH
33
In addition to informal web and social media posts of
members of the public, public health surveillance can
make use of online secondary data such as news reports,
expert newsletters and aggregate information that has
already been synthesized, analyzed and/or reported.390, 394
A number of Internet surveillance systems that use a
more selective approach and choose high quality, expertcurated secondary data sources are in use. These include
the Global Public Health Intelligence Network (GPHIN),
developed in Canada in 1997, and HealthMap, developed
in the United States in 2006.389, 390, 394 These systems use
an automated process to monitor and analyze online
sources, facilitating early detection of global public
health threats (see the textbox “Global Public Health
Intelligence Network”).389, 390, 394–396
Global Public Health Intelligence Network
The concept of Internet-based surveillance is not
new. One of the earliest systems to be developed
was the Global Public Health Intelligence Network
(GPHIN), which was launched in 1997 as part of
WHO’s Global Outbreak and Alert Response Network
(GOARN).389 GPHIN is an electronic public health
early-warning system developed by the Public
Health Agency of Canada to help identify globally
significant disease outbreaks and other health threats
from around the world by taking advantage of the
existing globalized virtual communications.389, 390, 395
GPHIN’s aim is to disseminate timely alerts to help
control outbreaks, the spread of infectious disease,
contamination of food and water, bioterrorism,
natural disasters and exposure to chemical agents
and nuclear materials.396
This global surveillance initiative is an Internet-based
surveillance system that monitors open source
information, such as news wires, discussion groups
and websites, in nine languages and retrieves
relevant reports.395, 397 These reports are reviewed
by a team of multidisciplinary analysts who apply
their interpretive and analytical skills to identify
and flag to GPHIN members those public health
events that may have serious public health
implications.397 GPHIN’s state-of-the-art reporting
techniques proved crucial in the early stages of
the 2003 SARS outbreak.389
34
Syndromic surveillance
Syndromic surveillance, just as its name suggests, aims to
track symptoms associated with a defined syndrome, such
as influenza-like illness or acute respiratory illness, rather
than depending on laboratory-confirmed disease data.398–400
Traditionally, this surveillance is carried out through reports
from official sources such as emergency departments or
primary care providers.398, 401 Nowadays, however, members
of the general public can also contribute directly to these
data through social media.399, 402 While people discuss their
symptoms, illnesses and state of health with others in open
forums, they are providing additional information for these
surveillance systems.399, 400
One area that has benefitted from the use of social
media-based syndromic surveillance is influenza
monitoring. Although diagnostic tests can be used to
identify individual cases of influenza, the prevalence of
influenza in the population at any given time can only
be estimated.402 Those estimates often rely on syndromic
surveillance to capture symptoms related to influenza-like
illness (ILI). However, not all people experiencing
symptoms will visit an emergency department or physician,
so traditional methods do not capture these data.401 In
addition, traditional systems rely on a limited number
of sentinel sites for reporting and delays are frequent.401
Capturing user-generated ILI-related information on the
Internet may provide a more complete real-time picture
of influenza trends and cases.401–403
Google has taken that concept and created Google Flu
Trends (GFT).403, 404 The idea behind GFT is that people
with ILI perform search queries on their symptoms to find
information that helps them self-diagnose. GFT tracks the
search queries looking for keywords and phrases related to
ILI. In fact, the estimates of influenza activity from the
system have been shown to be highly correlated with data
reported by official public health organizations around the
world (see Figure 5).403, 404
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
FIGURE 5. Canadian flu activity and Google Flu Trends, the week of September 28, 2003, through the week of
March 30, 2014405–408
Canada data*
Google Flu Trends estimate†
Influenza estimate
120
100
80
60
40
20
0
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
YEAR
Influenza-like illness per 1,000 patient visits.
Estimates based on Google search data.
*
†
As good as these web-based systems are, however,
they are not as accurate as traditional systems and can
lead to incorrect estimates.409 In 2009, GFT greatly
underestimated the prevalence of ILI at the beginning
of the H1N1 pandemic in the United States.410 Despite
altering its algorithm after Pandemic H1N1, GFT severely
overestimated peak flu levels for early in 2013 in the
United States.409 Yet even with their limitations, systems
such as GFT can still provide useful information. However,
they are not meant as a replacement for traditional
surveillance and reporting systems, but rather, they
should be seen as complimentary to them. In fact,
research has shown that a combination of data from
both GFT and the CDC in the United States produced
better estimates than either system on its own.409
As people’s Internet browsing behaviours only record
proxy measures of influenza, they cannot measure
other influenza-related data such as healthcare usage
or the clinical spectrum of cases.401 This type of data
can be collected, however, by having individuals use
an Internet-based questionnaire to record their specific
symptoms and healthcare usage over time.401 These
Internet-based cohort systems have been implemented
in several European countries, namely Belgium and the
Netherlands (under the name “Der Grote Griepmeting”—
the Great Influenza Survey), Portugal (“Gripenet”) and
Italy (“Influweb”).401 These systems have been shown
to provide results in line with those from traditional
surveillance methods and may be able to detect increased
influenza activity more rapidly.401 Such systems can work
alongside traditional systems to provide complementary
additional information.401
Infectious disease outbreaks and trends are not the
only things that can be captured through the mining
of Internet and social media activity. People’s online
searches, discussions and postings can also provide
information useful in identifying issues surrounding
chronic diseases, including mental illness.411, 412 For
example, social media mining can show pockets of poor
mental health or mental illness in communities, thereby
allowing the relevant health service to develop early
intervention strategies.412 Researchers in Taiwan found
suicide to be correlated with lottery sales as an indirect
indicator of feelings of hopelessness at the social level.413
A South Korean study tested the hypothesis that social
DIGITAL TECHNOLOGY AS A TOOL FOR PUBLIC HEALTH
35
media data such as weblog contents are more promising
sources to gauge the public mood than activity such as
lottery sales. The study found a significant association
between social media data and the national suicide rate
and resulted in a predictive model that could potentially
be used to develop new models for use in forecasting
and prevention of suicide.414
Continuing efforts
This section has only touched on a very small piece of
the picture in terms of the countless possibilities for the
relationship between public health and technology. For
instance, the idea of technology as a public health issue
itself, such as the dangers of texting and driving, the
impact of social media on mental health or the change
in youth interaction via social media as it relates to
bullying, also needs to be addressed as technology
continues to permeate more and more of Canadians’
everyday lives. In addition, this report has not explored
the very important ethical, legal and privacy concerns
surrounding the use of social media as a source of data.
These are legitimate concerns that must be brought to
the forefront of any planning and discussions around
this topic.
There are endless ways in which public health and
technology do, can and will come together. Although
the role of technology in public health in the future is
as yet unknown, Canadians can take a cue from today
and try to plan for and guide the relationship.
PUBLIC HEALTH CAN:
••
••
••
••
36
support continued research into new technologies or the use of existing technologies
as tools for public health;
evaluate the efficacy of tools to ensure that technologies are not adopted under the
assumption that all are beneficial or worthwhile;
consider any barriers that may exist for the user or the recipient, such as language,
culture, literacy level, geographic location, etc., to avoid potentially increasing any
health inequalities when implementing technology-based tools; and
ensure implementation of technologies in programs and policies is flexible, open, and
responsive to new developments given the rapid rate at which technologies change.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
MOVING FORWARD
The who, where and what of factors influencing public
health touch on a broad range of topics, but all conclude
with key priority areas that will drive public health into
the future. The common underlying theme through the
three independent sections of this report is one of change.
Populations, environments and technologies are in flux,
and public health, and other sectors, must plan and be
adequately prepared for these increasingly rapid changes.
Change can bring benefits, for example, technological
advancements and universal design of built environments
that contribute to public health. But change will also
bring challenges such as caring for a growing elderly
population. Public health has a role to play in building
upon the benefits and addressing the challenges. However,
given that we don’t know exactly what the future holds,
we need to be flexible and ready to respond quickly to
any possible challenge that may arise. Each section in this
report concludes that public health functions—protecting
and preventing against disease and promoting health—
are relevant not only now, but also in the future. Nor
are they exclusive to what we conventionally think of
as public health.
Planning for the future
People, organizations and sectors continually plan for
the future. Every day, Canadians invest in education
for their children, buy houses and save for retirement.
People also make individual choices towards staying
healthy by eating well and exercising. In addition,
governments plan for appropriate infrastructure to
support a vibrant sustainable economy, an educated
healthy workforce, and a better future for its citizens
among other mid- and long-term priorities. Many
decisions are made to minimize adverse outcomes and
increase benefits based on our view of future scenarios.
While no one can see into the future, people can build
upon resources that are available to them at the time.
Planning for public health also involves investing and
making choices with the goal of securing a healthier
future for the greatest number of people and reduced
health inequalities in that future. To do this, public
health professionals will need to build upon current
strategies as well as incorporate new approaches,
address new challenges and adapt to new tools. This
involves considering what happens if risk factors or
conditions of ill health worsen or change over time
and assessing how changes to populations, environments
and technologies will impact health. The health of the
population now and in the future remains the primary
priority of public health.
The three sections of this report outline the efforts
that need to be continued moving forward and highlight
certain priorities for public health in the future.
Focus on traditional public health
approaches and practices
While approaches and technologies are branching into
exciting new areas and capturing interest, public health
will still rely on basic fundamental principles and strategies
to prevent disease and injury and protect and promote
health and well-being. Differences in health outcomes
between populations require that public health programs
and practices must continue to consider the broader
determinants of health in planning. As well, the three
sections of this report confirmed that lifecourse matters.
Healthy aging, for example, is a lifelong process that
involves many practices, decisions and adaptations to
change throughout the preceding years.
MOVING FORWARD
37
Invest in health research
Address vulnerability and foster resilience
This report has identified several areas where research will
be important to public health in the future. Having better
information allows for better identification of long-term
trends and areas where public health investment and
efforts should focus. Further investigation is needed into
how to use and capture the health information available
through new technologies and social media. More research
is required on specific health concerns (e.g. neurological
conditions including dementia) that continue to burden
Canadians. And finally, research on the effectiveness of
programs and interventions and possible improvements
is required. Robust evaluations can contribute to overall
knowledge and provide important information on whether
programs are reaching their targeted goals and populations
and are applicable in other regions or situations.
Differences in health outcomes, access to technologies
and services, vulnerable populations and environments
are common issues across the three sections of this
report. These differences can result in gaps in health
status among populations. Vulnerability can also
influence the ability to adapt to change, ultimately
widening the gaps between those with and without
opportunities for good health.
Continue and improve public
health surveillance
Continued and improved surveillance will be a necessary
component of public health in the future. Investments
in surveillance can result in improvements in early disease
detection and prevention as well as in identification
of associated behaviours and risk factors. Effective
surveillance can also project and forecast outcomes, trigger
early warnings and communicate strategies for domestic
and global public health events, as well as identify issues
that require further study. Using surveillance systems to
facilitate early warnings and public health advisories (e.g.
Air Quality Health Index) may be an effective practice to
reduce the health impacts of natural and climatic change.
Continue education and awareness programs
Education programs and practices must adapt to
changes in health as well as populations, environments
and technologies and public health messages must
achieve a balance between positive and negative
messages. Programs must be evaluated to measure the
clarity of the message, whether the program reaches its
target audiences and if behaviours changed. For example,
heat advisories are showing promise at changing
behaviours (e.g. limiting physical activity on extreme
heat days) to reduce health risks.
38
Develop opportunities for remote communities
Remote communities were noted as having harsher
environments, unequal access to resources and other
factors that adversely influence health outcomes. While
technology can be used to deliver some aspects of public
health programs in remote communities, it is not complete
and limited access, lack of trained human resources (and
reduced capacity to train) as well as cultural and regional
relevance impede use of technology.
Collaborate to create supportive and
sustainable environments
Establishing partnerships and working collaboratively
to support community efforts to create sustainable
conditions can enable and promote good health.
Successful programs and initiatives, such as age-friendly
communities, rely on the participation of seniors and
other community members at all stages of program
development and implementation.
Build community capacity
Investments in disadvantaged communities and people
will make a difference in creating public health for all
and achieving health equity. The underlying issues are
as diverse as individuals, and need to be understood
and addressed accordingly. Despite a focus on the role
global systems will play in public health in the future,
communities are the critical players in the development
and implementation of comprehensive and effective
public health strategies. Every effort must be made to
build on the knowledge, experience and investments
already in place in Canadian communities.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Take intersectoral action
Encouraging collaboration with non-health related sectors
to create and promote healthy public policies is key since
health issues involve many factors that fall outside the
mandate of public health and the healthcare sector. To
effectively prevent adverse health outcomes and improve
health opportunities in the future, all levels of government,
non-governmental organizations, the private sector,
communities and individuals must work together towards
integrated and coherent policies and actions. In addition,
many changes and health issues are linked to global
systems such as a changing climate. Future public health
efforts will rely on international collaborations,
partnerships, knowledge sharing and international laws
and policies. Opportunities continue to exist for Canada
to play a leadership role and work across sectors to tackle
multiple determinants of health and develop broad
cross-sectoral strategies.
A way forward
Preparing for the future means adapting to, and planning
for, change. Public health in the future will involve building
on the strengths of current public health approaches,
adapting practices to meet changes and working with
partners across sectors and various levels of government.
Progress will involve capitalizing on these areas:
••
••
••
••
••
furthering investment in public health programs
and services to enhance health, reduce risks and to
support the development of strong evidence, being
accountable to this evidence, and increasing capacity
for further research and surveillance;
focusing attention on education and awareness
and maximizing the benefits of technologies to
communicate messages and breakdown
misinformation;
building supportive and sustainable environments
that incorporate natural and social factors;
fostering strong public health leadership in Canadian
communities and internationally; and
promoting policies across all sectors and levels
of government that help create and support
healthy populations.
MOVING FORWARD
39
Looking to the future
Our collective health is influenced by the type of society we choose to create. When we look forward, we need
to ask not what will drive public health, but how we can work together and leverage ever-changing factors to
achieve health for all. Understanding the issues and connections will better prepare us for the unknown, build
resilience and give us the resources required to meet future needs.
Healthy aging is important to all Canadians. Our seniors continue to benefit society through their active
participation in the workforce, in the voluntary sector and as active members of our communities and families.
It is troubling that young populations, our future seniors, are showing signs of ill health and, in some cases,
at a greater level than their predecessors. These trends indicate that public health still has much work to do
in preventing disease and promoting good health and well-being across the lifecourse.
There are numerous known health impacts of changing physical and social environments. We must adapt and
find ways to build resilience and support among those who have not shared the same benefits. We must build
communities in tune with the physical environment. We must create urban communities that are universally
accessible and adaptive. As well, we must work with our community and global partners to make the necessary
changes as public health risks respect no borders.
Technology has changed how we interact and communicate. Much can be learned about health and perceptions
of health through, for example, what people are posting online. Technology allows us to expand our understanding
of public health issues, to increase surveillance and monitoring as well as create an understanding of susceptibility.
While technological change is exciting, we still need to be cautious and respect ethical and privacy concerns. We
must ensure that the new technologies are truly benefitting those we are targeting and that we are not creating
new inequalities.
Public health in the future will be the realization of the efforts we make today. We can all work together to:
establish healthy practices from childhood to old age;
participate in society and volunteer to benefit ourselves and others;
• sustain our physical environment, protect natural spaces and enhance built environments;
• participate in the global community;
• challenge stigma and raise awareness about health; and
• recognize that inequality harms us all and work to improve opportunity for everyone.
•
•
If the future is all about change, we can be the change that sets the future.
Dr. Gregory Taylor
40
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
APPENDIX A: THE HEALTH AND WELL-BEING
OF CANADIANS
Many factors can impact and influence the health of
a population. Being able to identify who we are using
characteristics such as age and sex, and factors that
may influence overall health, such as education, income
and personal behaviours, can help to explain some
health outcomes.
Who we are
Population
Canada’s population has increased by 56% over the
past 40 years and exceeded 35 million people in 2013.15
As estimated by the 2011 National Household Survey,
1.4 million people in Canada identified as Aboriginal
(61% First Nations, 32% Métis and 4% Inuit), while
6.8 million identified as being foreign born.9, 415 The
majority of Canadians (61%) lived in large urban
population centres in 2011.15, 308
Life expectancy
The life expectancy of Canadians has increased
dramatically, by approximately 19 years for males
and 22 years for females, over the past threequarter century.17, 18
1973
Canadian-born non-Aboriginal
First Nations (single identity)
Métis (single identity)
Inuit (single identity)
Multiple Aboriginal identity
or other Aboriginal identities
Immigrants recently moved
(≤ 10 years)
Immigrants with longer residency
(> 10 years)
FIGURE A.1 Population by age, Canada, 1973* and 201315
*
FIGURE A.2 Population distribution by origin,
Canada, 20119, 15, 415
2013
FIGURE A.3 Population distribution by population density,
Canada, 201115, 308
500
Small population centres
(1,000 to 29,999 population)
400
Medium population centres
(30,000 to 99,999 population)
300
200
Large urban population centres
(100,000 population and over)
100
Rural population
(Less than 1,000 population)
0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
68
72
76
80
84
88
92
96
100+
Population (in thousands)
600
AGE (YEARS)
Population totals at 90 years in 1973.
*
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
41
FIGURE A.4 Life expectancy at birth by sex, Canada,
1931 and 2009/201117, 18
1931
2009/2011
FIGURE A.5 Population* completing high school or
post-secondary school by sex, Canada excluding territories,
1990 to 2013416
High school (Male)
Post-secondary (Male)
90
100
80
90
70
60
50
Male
Female
Percent of population
Life expectancy at birth
100
Education, employment and income
Education
Better education generally leads to better overall
health.124, 418, 419 The number of Canadians who have
completed high school has steadily increased over
the past 20 years.416 The number of people, particularly
females, who have completed a post-secondary
education has also increased.416
Employment
Unemployment has been associated with poorer health
outcomes.124, 171 Unemployed workers are twice as likely as
their employed counterparts to experience psychological
problems such as depression, anxiety, low self-perceived
health and poor self-esteem.419, 420
70
60
50
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
YEAR
Population aged 25 to 44 years.
*
FIGURE A.6 Unemployment and underemployment rate
by age group, Canada excluding territories, 2013417
Unemployment rate
Underemployment rate
25
Percent of population
Factors influencing health
80
40
SEX
High school (Female)
Post-secondary (Female)
20
15
10
5
0
15 to 24
25 to 54
55 to 64
AGE GROUP (YEARS)
Like unemployment, underemployment—people working
part-time because they cannot find full-time employment,
discouraged employment seekers and those waiting
to hear about possible employment—is unequally
distributed across the population.421 Younger workers,
females and visible minorities report higher rates
of underemployment.421
42
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
65 and older
Household income
Overall, the percentage of people living in after-tax
low-income households has decreased.109 Research has
linked living on low income to lower life expectancy,
increased rates of suicide and other burdens of disease
such as diabetes and cardiovascular disease.124, 419, 422–424
A household is said to be in low income when they are
likely to spend 20% or more of their total post-tax income
on necessities (food, clothing and footwear, and shelter),
compared to an average family of the same size in the
same broad community size.425
FIGURE A.7 Canadians living in low income after tax by age group and select household type, Canada excluding
territories, 1978 to 2011109, 426
UNDER 18 YEARS
18 to 64 years
Two-parent familes
65 years and older
50
45
40
35
30
25
20
15
10
5
0
All other
Percent of population
60
45
30
15
19
7
19 6
78
19
80
19
8
19 2
8
19 4
86
19
88
19
9
19 0
92
19
9
19 4
96
19
98
20
0
20 0
02
20
0
20 4
06
20
08
20
10
19
19
7
19 8
8
19 0
82
19
8
19 4
86
19
88
19
9
19 0
92
19
9
19 4
96
19
98
20
0
20 0
02
20
0
20 4
06
20
08
20
10
0
YEAR
YEAR
18 TO 64 YEARS
In economic families
*
65 YEARS AND OLDER
Unattached individuals
In economic families*
75
75
60
60
Percent of population
45
30
15
45
30
15
0
19
7
19 6
78
19
80
19
8
19 2
84
19
86
19
88
19
9
19 0
92
19
9
19 4
96
19
9
20 8
0
20 0
02
20
0
20 4
06
20
08
20
10
0
Unattached individuals
YEAR
19
76
19
7
19 8
80
19
82
19
8
19 4
86
19
88
19
9
19 0
92
19
9
19 4
96
19
98
20
0
20 0
02
20
0
20 4
06
20
08
20
10
Percent of population
Female lone-parent familes
75
76
Percent of population
Under 18 years
YEAR
Economic family refers to a group of two or more people who live in the same dwelling and are related to each other by blood, marriage, common-law or adoption.
*
A couple may be of opposite or same sex. Foster children are included.
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
43
Environment, housing and community
Ozone concentrations and fine particulate matter
Poor outdoor air quality, including smog, can exacerbate
respiratory and cardiovascular diseases, increasing
emergency room visits, hospital admissions and premature
deaths.185, 186, 427 The two main components of smog are
ozone concentrations and fine particulate matter.185
FIGURE A.8 Annual average ozone concentrations, Canada
and select regions, 2000 to 2011428–433
Annual ambient concentration
in parts per billion
Canada
Southern Quebec
Praries & northern Ontario
Atlantic Canada
Southern Ontario
British Columbia
40
A household is considered to be in core housing need if
it does not meet one or more of the adequacy, suitability
or affordability standards and it would have to spend
30% or more of its before-tax income to pay the median
rent (including utility costs) of alternative local market
housing that meets all three standards.456 Nationally,
the percentage of households in core housing need has
decreased from 15.6% to 12.7% between 1996 and 2006.456
35
30
25
20
Housing conditions
Housing, a critical component of a person’s environment,
was identified as a basic requirement for health in the
1986 Ottawa Charter for Health Promotion.124, 440 Living in
poor housing conditions (e.g. indoor air pollution caused
by moulds, off-gassing from modern materials) has been
linked to respiratory conditions, lead poisoning, injuries
from falls and decreased mental health.419, 441 Physical
design of housing can also affect health. Accessibility
features, for example ramps and grab bars, can improve
quality of life for those with disabilities or frailties.442–452
Those who cannot access affordable housing may
experience increased levels for stress and feel more
vulnerable and insecure.419
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
YEAR
FIGURE A.9 Annual average fine particulate matter
concentrations, Canada and select regions, 2000
to 2011434–439
Annual ambient concentration in
micrograms per cubic metre
Canada
Southern Quebec
Praries & northern Ontario
Atlantic Canada
Southern Ontario
British Columbia
11
9
7
5
3
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
YEAR
44
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
FIGURE A.10 Households in core housing need by origin,
Canada, 1996 and 2006453–455
2006
2006 Canadian average
Urban
50
100
40
90
Percent of population
Percent of households
1996
1996 Canadian average
FIGURE A.11 Population reporting somewhat or very
strong sense of community belonging by age group and
area of residency, Canada, 201238, 48
30
20
10
70
60
12 to 19
20 to 34
35 to 44
45 to 64
65 and older
ng
-
te
rm
ce
nt †
50
AGE GROUP (YEARS)
Lo
Re
ig
ra
nt
t
Im
m
In
ui
is
Mé
t
nd
ia
n
80
No
n
-S
ta
tu
sI
In
di
an
us
at
St
Ab
or
ig
i
na
l*
0
Rural
maintainer immigrated to Canada in the 5 years prior to the Census. For
2006, the primary maintainer arrived between 2001 and 2005. For 1996,
the primary maintainer arrived between 1991 and 1995.
Community belonging
Family, friends and a feeling of belonging to a community
gives people the sense of being a part of something larger
than themselves.457 The extent to which people participate
in their community and feel that they belong can positively
influence their long-term physical and mental health.458
Violent crime
One measure of safety in a community is the crime rate.
While many Canadians believe that crime rates in their
neighbourhoods have either stayed constant (62%) or
increased (26%), in reality they have actually been
decreasing.459–461
1,600
1,500
1,400
1,300
1,200
1,100
1,000
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
Recent immigrant households represent those households whose primary
†
FIGURE A.12 Police-reported violent crime rate, Canada,
2000 to 2012460, 461
20
50% of household members self-identified as Aboriginal; or a family household
that meets at least one of two criteria: at least one spouse, common-law partner,
or lone parent self-identified as an Aboriginal; or at least 50% of household
members self-identified as Aboriginal. Data excludes farm, band, and reserve
households (for which shelter costs are not collected by the Census); households
with incomes of zero or less; and households whose shelter costs equal or exceed
their incomes.
Rate per 100,000 population
An Aboriginal household is defined as: a non-family household in which at least
*
YEAR
Health behaviours
Physical activity
Studies report that physical inactivity can increase the
risk for poor health outcomes such as coronary heart
disease, stroke, hypertension, colon cancer, breast cancer,
type 2 diabetes, depression, arthritis and osteoporosis.462
In order to maximize the health benefits associated with
being physically active, World Health Organization (WHO)
and Canadian guidelines suggest that adults should
accumulate at least 150 minutes of moderate-to-vigorous
physical activity per week; while 60 minutes of moderateto-vigorous physical activity every day is recommended
for children and youth aged between 5 and 17 years.463, 464
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
45
FIGURE A.13 Children and youth attaining suggested levels
of physical activity by age group and sex, Canada, March
2007 to February 200941
Male
Female
Percent of population
25
20
15
10
Fruit and vegetable consumption
Eating habits also play a key role in achieving and
maintaining health.465, 466 Eating fresh fruits and
vegetables daily can help in preventing a variety of
diseases including type 2 diabetes, heart disease,
osteoporosis and certain types of cancer.465, 467
5
0
6 to 10
11 to 14
15 to 19
AGE GROUP (YEARS)
FIGURE A.14 Adults attaining suggested levels of physical
activity by age group and sex, Canada, March 2007 to
February 200942
Male
FIGURE A.15 Population* reporting fruit and vegetable
consumption, 5 or more times per day, by sex, Canada,
2007 and 2012468
Female
2007
15
10
5
0
2012
75
20
Percent of population
Percent of population
25
20 to 39
40 to 59
60 to 79
60
45
30
15
0
AGE GROUP (YEARS)
Male
Female
SEX
Population aged 12 years and older.
*
FIGURE A.16 Recommended number of Canada’s Food Guide servings per day467
CHILDREN
AGE IN YEARS
2–3
Sex
46
4–8
TEENS
9–13
Girls and Boys
Vegetables and fruit
4
5
6
ADULTS
14–18
19–50
51+
Females
Males
Females
Males
Females
Males
7
8
7–8
8–10
7
7
Grain products
3
4
6
6
7
6–7
8
6
7
Milk and alternatives
2
2
3–4
3–4
3–4
2
2
3
3
Meat and alternatives
1
1
1–2
2
3
2
3
2
3
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
FIGURE A.18 Current smokers† by sex, Canada excluding
territories, 1985 to 2012473, 474
Male
Female
50
Percent of population
40
30
20
10
12
20
09
20
06
20
03
20
00
20
97 *
19
94
19
91
19
19
19
FIGURE A.17 Household food insecurity by household type,
Canada, 2007/2008 and 2011/2012469
88
0
85
Food security
The number of households in Canada reporting moderate
to severe levels of food insecurity has been increasing.469
Being able to eat healthily requires being food secure—
having “… physical and economic access to sufficient,
safe and nutritious food to meet … dietary needs and
food preferences for an active and healthy life” at all
times.470 Food insecurity among Aboriginal households
in Canada can be 3 to 6 times higher than among
non-Aboriginal households (depending on the study
and Aboriginal sub-population), with populations living
in northern and isolated communities being especially
at risk.234–236, 471, 472
YEAR
Data for 1996/1997 from same survey year.
*
Severe
Moderate
Population aged 15 years and older.
†
Percent of households
12
10
8
6
4
2
0
2007/
2008
2011/
2012
TOTAL
HOUSEHOLDS
2007/
2008
2011/
2012
HOUSEHOLDS WITH
CHILDREN LESS THAN
18 YEARS OLD
2007/
2008
2011/
2012
HOUSEHOLDS WITH
NO CHILDREN
SEVERE FOOD INSECURITY: Indication of reduced food intake and disrupted
eating patterns.
MODERATE FOOD INSECURITY: Indication of compromise in quality and/or
quantity of food consumed.
Tobacco use
Smoking and exposure to second-hand smoke have
been linked to an increased risk of a number of diseases
and conditions that affect cardiovascular and respiratory
systems.475, 476 Tobacco smoke also includes known
cancer-causing substances.476 Despite decreases in
the prevalence of smoking among all Canadians over
the past three decades, Aboriginal people’s rates of
non-traditional tobacco use continue to be high (31%
of Métis, 58% of Inuit, and 57% of First Nations
people on reserve).473, 474, 477–479
Alcohol use
Alcohol intoxication can harm physical and mental health,
affect personal relationships, people’s ability to work and
study and in extreme cases can cause death.480, 481 For
females, consuming 3 drinks or more on a single occasion
exceeds the low-risk guidelines for acute effects, while
consuming more than 10 drinks a week with more than
2 drinks most days exceeds the low-risk guidelines for
chronic effects.482 For males, consuming 4 drinks or more
on a single occasion exceeds the low-risk guidelines for
acute effects, while consuming more than 15 drinks a
week with more than 3 drinks most days exceeds
the low-risk guidelines for chronic effects.482
FIGURE A.19 What is a standard drink?480
REGULAR BEER
341 ml = 12 oz
(5% alcohol)
WINE
142 ml = 5 oz
(12% alcohol)
FORTIFIED WINE
85 ml = 3 oz
(16–18% alcohol)
HARD LIQUOR
43 ml = 1.5 oz
(40% alcohol)
NOTE: Some beers have more alcohol content than one standard drink.
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
47
FIGURE A.20 Exceeding low-risk drinking guidelines* for
acute effects by age group and sex, Canada excluding
territories, 2012483
FIGURE A.22 Cannabis use in the past 12 months by age
group, Canada excluding territories, 2012483, 484
Cannabis use
Female
Female Total
Percent of population
50
40
30
20
15 to 17
18 to 19
20 to 34
35 to 44
45 to 64
AGE GROUP (YEARS)
*
15 to 19
20 to 34
35 to 44
45 to 64
65 and
older
40
Illicit drug use
Canadian total
25
Percent of population
Female
Female Total
50
Percent of population
5
FIGURE A.23 Illicit drug* use in the past 12 months
excluding cannabis by age group, Canada excluding
territories, 2012483, 484
Male
Male Total
30
20
15
10
5
0
20
15 to 19
20 to 34
35 to 44
45 to 64
AGE GROUP (YEARS)
10
65 and
older
Includes cocaine, speed, ectasy, heroin and hallucinogens including salvia.
*
15 to 17
18 to 19
20 to 34
35 to 44
AGE GROUP (YEARS)
45 to 64
65 and
older
Alcohol consumption in the past 7 days.
Illicit drug use
The use of illicit drugs (i.e. abuse, misuse or dependence)
can affect performance at school and at work and, in
extreme cases, cause death.485–488 Illicit drug use has been
linked to various health and social problems including
panic attacks, hallucinations, psychosis, paranoia and
risky or violent behaviour.485–488 In Canada, the most
commonly used illicit drug is cannabis.482 Pharmaceutical
drugs prescribed for therapeutic purposes, including
48
10
AGE GROUP (YEARS)
FIGURE A.21 Exceeding low-risk drinking guidelines* for
chronic effects by age group and sex, Canada excluding
territories, 2012483
*
15
65 and
older
Alcohol consumption in the past 7 days.
0
20
0
10
0
Canadian total
25
Percent of population
Male
Male Total
opioid pain relievers, stimulants, tranquillizers and
sedatives, may also be abused due to their psychoactive
properties.482 In 2012, of those who used psychoactive
pharmaceutical drugs, 6.3% reported abusing them.482
Contact with medical doctor
Access to healthcare is fundamental to health.489, 490
In 2012, the majority (85%) of Canadians reported
having a regular medical doctor.468 Of those who reported
not having a regular medical doctor, nearly one-half
(46%) indicated they had not tried to contact one.38, 48
Barriers such as language, sociocultural differences,
physical inaccessibility and transportation can also
limit access.419, 491–493
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Contact with dental professional
Good oral health is a key component to a healthy life.
Poor oral health can result in a range of negative health
outcomes including gum disease, lung infections, diabetes
and heart disease.494, 495 Despite the importance of oral
health, many Canadians do not visit a dental health
professional every year.38, 48 Overall, the promotion of good
oral health habits such as making healthy food choices,
brushing teeth twice daily with fluoridated toothpaste,
regular flossing and visits to a dental care provider can
all help to prevent decay and maintain a healthy mouth
for a lifetime.496
Health status
Perceived health and health-adjusted life expectancy
Overall, the majority of Canadians feel that their health is
either very good or excellent.468 Between 2003 and 2012,
very good or excellent self-perceived health increased
through most age groups.468 While life expectancy and
perceived health have increased, not all years are spent
in good health.468, 497, 498
FIGURE A.26 Very good or excellent self-perceived health
by age group, Canada, 2003 and 2012468
FIGURE A.24 Having a regular medical doctor and contact
with a medical doctor by age group, Canada, 2012468
Contact with medical doctor
Percent of population
100
90
80
70
80
60
40
20
0
60
12 to 19
20 to 34
35 to 44
45 to 64
65 and
older
AGE GROUP (YEARS)
50
12 to 19
20 to 34
35 to 44
45 to 64
AGE GROUP (YEARS)
65 and
older
FIGURE A.25 Last time visited dentist by select age
groups, Canada, 201238, 48
1 to <3 years
3 to <5 years
5 or more years
FIGURE A.27 Life expectancy and health-adjusted life
expectancy at birth by sex, Canada excluding territories,
2000/2002 and 2005/2007497
Health-adjusted life expectancy
90
Years of life
Percent of population
Total life expectancy
100
Never
50
40
30
80
70
20
60
10
50
0
2012
100
Percent of population
Has a regular medical doctor
2003
12 to 19
20 to 34
35 to 44
45 to 64
AGE GROUP (YEARS)
65 and
older
2000/2002
2005/2007
MALE
2000/2002
2005/2007
FEMALE
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
49
FIGURE A.28 Teen* birth rate, Canada, 1930 to 2011499–501
Live births per 1,000 females
70
60
FIGURE A.29 Canadians reporting one or more chronic
health condition* by age group, Canada, 201238, 48
One
Percent of population
Teen birth rate
Rates of teen births have been declining since the late
1950s.499–501 The decline in teen births can be attributed
to several factors including an increase in the availability
and use of contraceptives, legalized abortion, changing
social values and an increased awareness of risks
associated with unprotected sex.502–504
50
100
90
80
70
60
50
40
30
20
10
0
15 to 19
40
Two
20 to 34
35 to 44
Three
Four or more
45 to 64
65 and older
AGE GROUP (YEARS)
30
20
Conditions include asthma, arthritis, back problems, high blood pressure,
*
migraines, chronic bronchitis, diabetes, heart disease, cancer, ulcers,
effects from stroke, urinary incontinence, bowel disorders, Alzheimer’s disease,
mood disorders and anxiety disorders.
10
1930
1934
1938
1942
1946
1950
1954
1958
1962
1966
1970
1974
1978
1982
1986
1990
1994
1998
2002
2006
2010
0
Chronic conditions
500
400
300
200
100
6
20
08
20
10 *
20
12 *
4
20
0
2
20
0
0
6
19
9
4
19
9
2
19
9
0
19
9
8
19
9
6
19
8
19
8
4
†
0
19
8
Cancer incidence
An estimated 187,600 new cases of cancer were expected
to be diagnosed in 2013.505 Cancers of the lung, breast,
colon/rectum and prostate were expected to account for
more than one-half (52%) of all cancers diagnosed in the
same year.505 Although mortality rates for both males and
females declined, the age-standardized incidence rate for
all cancers increased between 1984 and 2013 for females,
but remain fairly stable for males.505
Female (ASIR)
Female (ASMR)
600
Rate per 100,000 population
Although chronic health conditions are most often
experienced by—and associated with—older members
of the population, in 2012 more than one-half (55%)
of Canadians aged 12 years and older reported living
with at least one chronic health condition.38, 48
Male (ASIR)
Male (ASMR)
20
0
Females aged 15 to 19 years.
8
*
FIGURE A.30 Age-standardized incidence rates (ASIR)†
and age-standardized mortality rates (ASMR)* for all
cancers by sex, Canada, 1984 to 2013505
20
0
YEAR
YEAR
*
ASMR for 2010 through 2013 are estimated based on all provinces and
territories. Actual data were available to 2009. These estimates are based
on long-term trends and may not reflect recent changes in trends.
†
ASIR for 2011 through 2013 are estimated based on all provinces and territories.
Actual data were available to 2010 except for Quebec (2007). These estimates
are based on long-term trends and may not reflect recent changes in trends.
50
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
FIGURE A.31 Diagnosed diabetes by age group, Canada,
2004/2005 and 2008/200939, 506
2004/2005
FIGURE A.32 Measured rates of childhood and adolescent*
overweight and obesity by sex, Canada excluding territories,
1978/1979 and 2009/201140, 515
Obese
60
45
30
15
0
2008/2009
Percent of population
30
1978/
1979
2009/
2011
1978/
1979
TOTAL
25
2009/
2011
1978/
1979
2009/
2011
GIRLS
BOYS
Children and youth aged 5 to 17 years.
*
20
15
FIGURE A.33 Measured rates of adult* overweight and
obesity by sex, Canada excluding territories, 1978/1979
and 2009/201140, 515
10
5
0
79
t
an o 84
d
ol
de
r
74
to
AGE GROUP (YEARS)
Obesity
Obesity is a complex issue that involves a range of
biological, behavioural and societal factors.33, 509 Physical
activity, sedentary behaviours, screen time, diet and
socioeconomic status can all contribute to increased
body weight.509 Links have been made between obesity
and chronic health conditions (type 2 diabetes, asthma,
gallbladder disease, osteoarthritis, chronic back pain),
cancers and cardiovascular diseases.509–511 Body mass
index (BMI) is a common measure based on height and
weight that is used to determine healthy and unhealthy
weights. While BMI is considered an adequate measure for
portions of the population, standard BMI categories may
not accurately reflect the rate of overweight and obesity
in all populations including Inuit and seniors.512–514
Percent of population
85
75
Overweight
75
80
69
to
64
to
65
70
59
to
54
to
55
60
49
to
44
to
45
50
39
to
34
to
35
40
29
to
24
to
30
25
to
to
19
Obese
20
1
Overweight
75
Percent of population
Diabetes prevalence
According to the 2008/2009 Canadian Chronic Disease
Surveillance System, close to 2.4 million Canadians aged
one year and older were living with diagnosed diabetes.39
Although both type 1 and type 2 diabetes have been
linked to genetic anomalies, type 2 diabetes is also
associated with being overweight or obese.39, 507 People
living with diabetes have an increased risk of developing
cardiovascular problems, kidney disease, blindness and
diabetic foot ulcers.508
60
45
30
15
0
1978/
1979
2009/
2011
TOTAL
1978/
1979
2009/
2011
MALE
1978/
1979
2009/
2011
FEMALE
Adults aged 18 to 64 years.
*
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
51
FIGURE A.34 Arthritis by age group and sex, Canada,
2012468
Percent of population
40
30
20
10
8
6
4
2
0
20 to 34
35 to 44
45 to 64
65 and older
12 to 19
20 to 34
35 to 44
45 to 64
AGE GROUP (YEARS)
65 and
older
FIGURE A.36 Chronic obstructive pulmonary disease
(COPD) by age group and sex, Canada, 2012468
Male
Female
12
10
8
6
4
2
0
10
0
12
Female
50
Female
Male
Percent of population
Male
FIGURE A.35 Asthma by age group and sex, Canada, 2012468
Percent of population
Arthritis
The term “arthritis” describes more than 100 conditions
that affect joints, the tissue surrounding joints and
other connective tissue.516, 517 Osteoarthritis and
rheumatoid arthritis are two of the most common
types.516, 518, 519 In 2012, 15% (4.4 million) of Canadians
aged 15 years and older reported that they had been
diagnosed with arthritis.468 Disability associated with all
forms of arthritis results from problems in body function
or structure (reduced mobility of joints, pain and body
stiffness), limitations or restrictions in carrying out
activities of daily living including self-care (showering,
toileting and dressing) or mobility (transferring from
beds to chairs and walking around the house) and
problems a person may experience in their involvement
in life situations (working or participating in social
activities).516, 520, 521
35 to 44
45 to 64
65 and older
AGE GROUP (YEARS)
AGE GROUP (YEARS)
Respiratory conditions
Chronic respiratory diseases include asthma, chronic
obstructive pulmonary disease (COPD), cystic fibrosis,
sleep apnea and occupational lung disease.522, 523 Two
important respiratory diseases are asthma and COPD.
Asthma is characterized by coughing, shortness of breath,
chest tightness and wheezing.523, 524 Early onset of asthma
has been linked to low birth-weight and exposure to
tobacco smoke including second-hand smoke and parental
smoking, whereas later onset has been linked to obesity
and increased exposure to allergens and environmental
factors such as pollution.476, 523–525 COPD is an umbrella
term for a number of chronic lung diseases characterized
by shortness of breath, cough and sputum production.523, 526
52
In 2012, 8% of the population aged 12 years and older
reported having asthma and 4% of the population aged
35 years and older reported having COPD.468
Heart disease
Heart disease is a broad term for a group of conditions
affecting the structure and functions of the heart.527, 528
The conditions include ischemic heart disease, heart
failure, rheumatic heart disease and congenital heart
disease.528 In 2012, 5% of Canadians aged 12 years and
older reported having heart disease.38, 48 Reported rates
of heart disease increase with age, with seniors aged 65
to 79 years and 80 years and older reporting the highest
rates of heart disease (15% and 24%, respectively).38, 48
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
FIGURE A.37 Heart disease by age group and sex,
Canada, 201238, 48
Male
Female
Percent of population
25
20
15
10
5
0
20 to 34
35 to 44
45 to 64
65 and older
AGE GROUP (YEARS)
Sexually transmitted infections
Rates of sexually transmitted infections (STIs) officially
reported to the Canadian Notifiable Disease Surveillance
System (CNDSS) have increased in the overall Canadian
population over the past 15 years.531 Untreated STIs,
whether symptomatic or not, can have long-lasting
effects making early detection and treatment important.
STIs have been linked to pelvic inflammatory disease,
infertility, ectopic pregnancies and low birth-weight
babies as well as various types of cancers including
cervical, anal and penile and increased risk of acquiring
human immunodeficiency virus (HIV).531–539 These trends
must be interpreted with caution, since both laboratory
testing methods and clinical screening practices have
changed over time.531
CHLAMYDIA
High blood pressure
High blood pressure, also known as hypertension, increases
the risk of stroke, heart attack or failure, dementia, kidney
disease, eye problems and erectile dysfunction.529 In 2012,
18% (5.4 million) of Canadians aged 12 years and older
reported having high blood pressure.38, 48
FIGURE A.38 High blood pressure by age group and sex,
Canada, 201238, 48
Male
Female
FIGURE A.39 Reported rates of chlamydia by sex, Canada,
1995 to 2011531, 540
60
45
Canadian total
30
Male
Female
400
15
0
20 to 34
35 to 44
45 to 64
65 and older
AGE GROUP (YEARS)
Infectious diseases
Despite progress in preventing and controlling infectious
diseases, they continue to be a major health issue and
public health concern.2, 329 While most infections are
minor and go unreported, some can be serious; many
cases are preventable.329, 530
Rate per 100,000 population
Percent of population
75
Chlamydia, an infection caused by the bacterium
Chlamydia trachomatis, is the most commonly reported
bacterial STI in Canada.531 Chlamydial infections are
frequently asymptomatic.535 In the absence of screening,
a lack of symptoms can increase the risk of unknowingly
spreading the disease as well as the risk of longer-term
health implications for infected individuals. Nationally
reported chlamydia rates have increased each year since
1997, resulting in a relative increase of 62% between
2002 and 2011.531 The infection disproportionately
affects younger people, particularly females, although
it is common in both sexes.531
350
300
250
200
150
100
50
0
1995
1997
1999
2001
2003
2005
2007
2009
2011
YEAR
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
53
Gonorrhea, an infection caused by the bacterium Neisseria
gonorrhoeae, is the second most commonly reported
bacterial STI in Canada.531 Over the last 30 years, multiple
strains of gonorrhea have become less susceptible to
certain first-line antibiotics such as penicillin, tetracycline
and, more recently, quinolones and third-generation oral
and injectable cephalosporins.531, 541–544 Reported rates of
gonorrhea have steadily increased over time, with an
overall increase of 41% from 2002 to 2011.531
FIGURE A.40 Reported rates of gonorrhea by sex, Canada,
1995 to 2011531, 540
Rate per 100,000 population
Canadian total
50
45
40
35
30
25
20
15
10
5
0
1995
1997
1999
2001
2003
Male
2005
2007
Female
2009
2011
YEAR
SYPHILIS
Syphilis is an infection caused by the bacterium
Treponema pallidum.531 From 1993 to 2000, reported rates
of infectious syphilis were relatively stable, but the rates
began to sharply increase in 2001.531 Between 2002 and
2011, reported syphilis rates increased 232%.531 The
dramatic increase in cases of syphilis has been most
notable among men who have sex with men.531, 539, 545
Syphilis infection can increase susceptibility to HIV
infection.531, 537–539 Co-infection of syphilis among people
living with HIV and AIDS is increasing.531, 537–539
54
FIGURE A.41 Reported rates of infectious syphilis by sex,
Canada, 1995 to 2011531, 540
Canadian total
Male
Female
12
Rate per 100,000 population
GONORRHEA
10
8
6
4
2
0
1995
1997
1999
2001
2003
2005
2007
2009
2011
YEAR
HIV
HIV attacks the immune system and can develop into a
chronic progressive illness that can make an individual
vulnerable to other infections and to chronic diseases.547
HIV is transmitted from one person to another through
exposure to infected blood or body fluids during
unprotected sexual intercourse or by sharing or using
contaminated needles.547 An HIV-positive mother can
also transmit the virus to her infant during pregnancy,
delivery or breastfeeding if she is not taking antiretroviral
medication.547, 548 Having an STI such as chlamydia or
syphilis can increase the risk of HIV transmission and
becoming infected with HIV.531, 537–539 Approximately
3,175 new HIV infections occurred in 2011, similar to the
estimated number of new infections in preceding years.546
However, as many as 25% of Canadians infected with HIV,
or 17,980 people, may be unaware of their infection and
thus may be unknowingly infecting others.546
In Canada, HIV infection is not evenly distributed but
rather is concentrated in certain at-risk populations,
such as men who have sex with men (47% of all new
infections) and people who inject drugs (17%).546 The
rate of new HIV infection among people originating
from HIV-endemic countries is about 9 times higher than
that in the Canadian-born population whereas Aboriginal
people experience an HIV infection rate 3.5 times higher
than the non-Aboriginal population.546 The number of
Canadians living with HIV is increasing because new
infections continue to occur but fewer people are dying
prematurely as a result of the disease due to the
availability of effective antiretroviral treatments.546
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Number of new HIV infections
FIGURE A.42 Estimated number of new HIV infections*
for selected years, Canada546
7,000
6,000
5,000
4,000
3,000
2,000
1,000
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
0
YEAR
Bars indicate range of uncertainty.
*
FIGURE A.43 Reported new active and re-treatment
tuberculosis cases by origin, Canada, 2002 to 2012555–559
Canadian-born
Aboriginal
Canadian-born
non-Aboriginal
Foreign-born
Rate per 100,000 population
35
30
25
20
15
10
5
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
YEAR
FIGURE A.44 Reported new active and re-treatment
tuberculosis cases by Aboriginal status, Canada, 2012555
270
Rate per 100,000 population
Tuberculosis
Tuberculosis (TB) is an infectious bacterium that is
spread from person to person primarily through the
air.549–551 TB bacteria of the lungs or airways enter the
air when a person with active TB disease exhales by
coughing, sneezing or even just talking.549, 551 The bacteria
can remain air-borne for several hours and then be
inhaled by other people who may, in turn, become
infected.549, 551 Over time, an infected person may develop
active TB disease.549, 552 Known risk factors for developing
either latent TB infection or active TB disease include
having a weakened immune system or underlying illness
such as HIV or diabetes; coming into close contact with
people with known or suspected TB (e.g. sharing living
space or living in communities with high rates of TB
disease); having a personal history of active TB; having
received inappropriate or inadequate treatment for TB
disease in the past; living in a low-income household,
in crowded and inadequately ventilated housing or
being homeless; being malnourished; having a history
of smoking or substance abuse; being a resident in
an institutional setting such as a long-term care or
correctional facility; and working with people at risk
of developing TB.552, 553 Despite the overall low incidence
of TB disease in Canada, the burden of TB is higher in
Canadian Aboriginal populations and in foreign-born
Canadians compared to other Canadians.554–559
260
250
30
20
10
0
First Nations
with status—
On reserve
First Nations
with status—
Off reserve
Inuit
Métis
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
55
Mental health and mental illness
Mental health is an important aspect of the overall health
and well-being of all Canadians.74 It can affect people of
all ages, cultures, education and income levels, however,
those with a family history of mental illness, substance
abuse issues, certain chronic health conditions or who
have experienced stressful life events are more at risk.560, 561
A considerable body of research supports the concept
that mental health and mental illness are not on opposite
ends of a single continuum.560 Rather mental health and
mental illness exist on two separate but related continua,
therefore, mental health is more than the absence
of mental illness.562
Mood disorders and major depression
Mood disorders—such as depression, bipolar disorder,
mania or dysthymia—are the most commonly self-reported
mental health conditions.38, 48 Mood disorders can create
feelings of distress or impairment in social, work and
school settings as well as other areas of everyday life.560
Major depressive disorder, one type of mood disorder, is
typically a recurrent illness with relapses where the more
severe and long-lasting the initial symptoms are the less
likely a person is to fully recover.560, 565
FIGURE A.46 Mood disorders and major depressive
episodes by age group and sex, Canada, 201244
Male—Major depressive episode
Male—Any mood disorder
Female—Major depressive episode
Female—Any mood disorder
FIGURE A.45 Very good or excellent self-perceived mental
health by age group, Canada, 2003 and 201238, 48, 563, 564
2003
2012
Percent of population
100
90
80
10
8
6
4
2
0
25 to 44
45 to 64
Male
10
8
6
4
2
15 to 24
25 to 44
45 to 64
AGE GROUP (YEARS)
15 to 19
20 to 34
35 to 44
45 to 64
65 and older
AGE GROUP (YEARS)
56
Female
12
60
50
65 and older
FIGURE A.47 Generalized anxiety disorder by age group
and sex, Canada, 201244
0
70
15 to 24
AGE GROUP (YEARS)
Percent of population
Perceived mental health
It is difficult to determine the state of the population’s
mental health and rates of mental illness because data are
limited. Nevertheless, the data available through surveys,
studies and databases help to illustrate the mental health
of Canadians. According to the 2012 Canadian Community
Health Survey, the majority of Canadians 15 years and
older reported their mental health as very good or
excellent (72%).38, 48
Percent of population
12
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
65 and older
FIGURE A.48 Hospitalizations for schizophrenia* in acute
care hospitals, by age group and sex, Canada, 201015, 567
Male
Female
Hospitalizations
per 100,000 population
120
100
80
60
40
20
10
to
20 19
to
25 24
to
30 29
to
35 34
to
40 39
to
45 44
to
50 49
to
55 54
to
60 59
to
65 64
to
70 69
to
75 74
to
8 7
85 0 t 9
an o 8
d 4
ol
de
r
0
AGE GROUP (YEARS)
Using most responsible diagnosis.
*
2031
2011
300,000
250,000
200,000
150,000
100,000
50,000
de
r
ol
84
an
d
85
80
to
79
74
to
75
69
to
70
64
to
65
59
60
to
54
to
55
49
to
to
50
45
to
44
0
40
Schizophrenia
Schizophrenia has a profound effect on person’s ability to
function effectively in all aspects of life—self-care, family
relationships, income, school, employment, housing,
community and social life.560, 566 Early in the disease
process, people with schizophrenia may lose their ability
to relax, concentrate or sleep and may withdraw from
friends and not even recognize that they are ill.560, 566 With
effective early treatment to control symptoms, people can
prevent further symptoms and increasing symptom severity
and can optimize their chance of leading full, productive
lives.560, 566 While rates of schizophrenia are roughly equal
in males and females, males tend to develop the illness
earlier in life whereas females develop it later.560, 566
FIGURE A.49 Projected prevalence of Alzheimer’s disease
or other dementia by age group, Canada, 2011 and 203181
Prevalent cases (person years)
Anxiety
Most people have experienced moments of anxiousness
at some point in their lives, but for those living with
an anxiety disorder, these feelings are amplified and can
interfere with relationships, school and work performance
and social and recreational activities.560 People living with
an anxiety disorder may avoid situations that intensify
their anxiety or develop compulsive rituals that lessen the
anxiety.560 Symptoms of anxiety disorders often manifest
earlier in life.560
AGE GROUP (YEARS)
Alzheimer’s disease
Alzheimer’s disease and other dementias are
progressive degenerative neurological conditions
that are more common among seniors.76, 80 Alzheimer’s
disease progresses from mild to severe.568 Mild forms
of Alzheimer’s can cause problems such as getting lost,
having difficulty handling money or paying bills, taking
longer to complete routine tasks, repeating sentences,
poor judgment and small changes in mood or
personality.568 Moderate Alzheimer’s disease causes
damage to parts of the brain that control language,
reasoning, sensory perception and conscious thought
resulting in increased memory loss and confusion.568
Those with severe Alzheimer’s disease experience
significant shrinkage of brain tissue that results in an
inability to communicate, as well as complete dependence
on others for care.568 In 2011, an estimated 340,200 of
Canadians ages over 40 years were living with a diagnosis
of Alzheimer’s disease or other dementias and this number
will probably more than double within 20 years.76
Causes of death
Infant mortality
During the last century, infant mortality has dropped from
a rate of more than 100 deaths per 1,000 live births in the
early 1920s to 4.8 per 1,000 live births in 2011.569, 570, 572
The significant decline in infant death rates has been
attributed to improved sanitation, nutrition, standard of
living, level of education and family planning.504, 573 The
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
57
main causes of death in infancy are related to congenital
malformations (e.g. Down syndrome and malformations
of the heart), as well as disorders due to premature
birth or low birth-weight.574, 575
FIGURE A.51 Change in age-standardized mortality
rate by select causes of death, Canada, 2000 and
201115, 577, 580, 581, 584, 585, 592
2000
Other
causes
FIGURE A.50 Infant mortality rate, Canada, 1921
to 2011569–571
Injuries and
poisonings
100
80
Transport
Suicide
All injuries and poisonings
Respiratory
diseases
60
40
20
Influenza and pneumonia
Chronic lower
respiratory diseases
All respiratory diseases
Hypertensive diseases
Circulatory
diseases
1921
1925
1929
1933
1937
1941
1945
1949
1953
1957
1961
1965
1969
1973
1977
1981
1985
1989
1993
1997
2001
2005
2009
Rate per 1,000 live births
All other causes
Alzheimer’s and dementia
Falls
120
0
2011
YEAR
Cerebrovascular diseases
Ischaemic heart diseases
All circulatory diseases
Potential years of life lost
While knowing the number of deaths due to a particular
disease or condition is important for understanding the
health of the Canadian population, so too is knowing the
age at which those deaths occur. Measuring the number
of potential years of life lost (PYLL) to premature death
provides a better sense of the impact a given disease
orcondition has on the health of the population. For
example, if a Canadian dies of cancer aged 45 years, he
or she has potentially lost 30 years of life (conservatively
assuming a life expectancy of 75 years at birth, as is
commonly done in these calculations).594 In 2009, most
years of lost life were due to premature deaths associated
with cancers, circulatory diseases and unintentional
injuries.595
Prostate
Cancers
Breast
Lung and bronchus
0
25
0
0
20
0
15
10
0
AGE-STANDARDIZED MORTALITY RATE*
per 100,000 population.
*
FIGURE A.52 Age-standardized rate of potential years
of life lost (PYLL) by select causes, Canada, 2000/2002
and 2005/2007594
2000/2002
2005/2007
HIV
Respiratory dsieases
Suicide and
self-inflicted injuries
Unintentional injuries
Circulatory diseases
Malignant cancers
0
200
400
600
800 1,000 1,200 1,400 1,600
AGE-STANDARDIZED RATE OF PYLL*
per 100,000 population.
*
58
50
0
50
10
0
0
15
20
0
All cancers
25
Leading causes of mortality
In 2011, cancers were the leading overall cause of
death in Canada (31%), followed by circulatory
diseases (27%) and respiratory diseases (9%).574–593
Since population distributions are not identical, agestandardized mortality rates (ASMR) provide a better
indication of mortality risk within a population. Between
2000 and 2011, the ASMR have decreased among cancers,
circulatory diseases, respiratory diseases and injuries and
poisonings.15, 577, 584, 585, 592 During the same period, deaths
from Alzheimer’s and other dementias increased.15, 580
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Summary
Although the health of Canadians is considered to be
very good by international standards, a closer inspection
of differing rates of death, disease and disability among
various groups shows that some of us experience worse
health and a lower quality of life than others. Many
factors influence these outcomes, including the aging
of the population, increasing survival rates for potentially
fatal conditions and changes in behaviours related to
eating, physical activity and the use of substances such
as drugs, tobacco and alcohol. These are not the only
factors at play; evidence shows that income, education,
employment and working conditions can also affect
individual health behaviours and outcomes.
TABLE A.1 Who we are
Who we are (million people)
Population (as of July 1, 2013)
Aboriginal peoples
Year
35.2
2013
1.40
2011
First Nations (single identity)
0.85
2011
Inuit (single identity)
0.06
2011
Métis (single identity)
0.45
2011
Multiple Aboriginal identity
0.01
2011
Other Aboriginal identities
0.03
2011
6.78
2011
Africa
0.49
2011
Asia
3.04
2011
Caribbean and Bermuda
0.35
2011
Central America
0.15
2011
Europe
2.13
2011
Oceania and other*
0.07
2011
South America
0.29
2011
United States
0.26
2011
Recent (≤ 10 years)
2.15
2011
Long-term (> 10 years)
4.62
2011
Immigrant
By birthplace
By years since immigration
Population centre residents
28.1
2011
Life expectancy at birth (years of expected life, females)
83.6
2009/2011
Life expectancy at birth (years of expected life, males)
79.3
2009/2011
“Other” includes countries such as Saint Pierre and Miquelon, Bonaire, Saint Eustatius and Saba; Falkland Islands (Malvinas); Greenland; Saint Barthélemy;
*
Saint Martin (French part); and South Georgia and the South Sandwich Islands, the category “Other country,” as well as immigrants born in Canada.
NOTE: Definitions and data sources can be found in Appendix B.
SOURCE: Statistics Canada.
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
59
TABLE A.2 Factors influencing health
Factors influencing our health
95% CI
Year
84.4
—
2013
Some post-secondary education (%)
64.6
—
2013
Post-secondary graduates (%)*
59.6
—
2013
Unemployment rate (%)†
7.1
—
2013
Persons living in low income, after tax
(% of the population, based on 1992 low income cutoff )
8.8
—
2011
33.0
—
2011
6.6
—
2011
Core housing need (% of households in need)
12.7
—
2006
Urban core housing need (% of urban households in need)
13.2
—
2010
Sense of community belonging, somewhat or very strong (%)‡,§
66.1
(65.3–66.8)
2012
—
2012
2012
Education, employment and income
High school graduates (%)*
*
Environment, housing and community
Ozone concentrations (parts per billion)
Fine particulate matter concentrations (micrograms per cubic metre)
Violent crime incidents (per 100,000 population per year)
1,190.1
Health behaviours
Physical activity during leisure-time, moderately active or active (%)‡,§
53.9
(53.1–54.6)
Fruit and vegetable consumption, 5+ times per day (%)
40.6
(39.8–41.3)
8.3
(8.0–8.7)
16.1
(15.0–17.3)
2012
9.9
(8.8–11.0)
2012
Exceeds low-risk drinking guidelines for chronic effects (%)†,‡
14.4
(13.1–15.7)
2012
Illicit drug use in the past year (%)
10.6
(9.4–11.8)
2012
Contact with medical doctor (%)‡,§
78.7
(78.1–79.4)
2012
Contact with dental professional (%)‡,§
65.5
(64.6–66.4)
2012
‡,§
Households reporting moderate to severe food insecurity (%)‡,§
Current smoker (%)†
Exceeds low-risk drinking guidelines for acute effects (%)†,‡
†,‡
*
Population aged 25+ years. †
‡
Self-reported data.
§
Population aged 15+ years.
Population aged 12+ years.
NOTE: Definitions and data sources can be found in Appendix B.
SOURCES: Statistics Canada, Environment Canada, Canada Mortgage and Housing Corporation and Health Canada.
60
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
2012
2011/2012
TABLE A.3 Health status
Our health status
95% CI
Year
Health-adjusted life expectancy and perceived health
Perceived health, very good or excellent (%)*,†
59.9
(59.2–60.6)
2012
Health-adjusted life expectancy at birth (years of expected health life, females)
71.2
(71.0–71.4)
2005/2007
Health-adjusted life expectancy at birth (years of expected health life, males)
68.9
(68.7–69.0)
2005/2007
Teen birth rate (live births per 1,000 female population
aged 15 to 19 years per year)
12.6
—
2011
Chronic conditions
Cancer incidence (new cases age-standardized per 100,000 population per year)
398.6
Diabetes prevalence (%)‡
—
2013
6.8
(6.83–6.85)
2008/2009
Obesity (%)§
26.2
(25.3–27.1)
2009/2011
Arthritis (%)*,||
15.4
(15.0–15.9)
2012
Asthma (%)*,†
8.1
(7.7–8.5)
2012
Chronic obstructive pulmonary disease (%)*,¶
4.2
(3.9–4.5)
2012
Heart diseases (%)*,†
4.9
(4.5–5.3)
2012
18.4
(17.6–19.2)
2012
Chlamydia (new cases per 100,000 population annually)
290.4
—
2011
Gonorrhea (new cases per 100,000 population annually)
33.1
—
2011
5.1
—
2011
—
2012
4.8
—
2011
High blood pressure (%)*,†
Infectious diseases
Infectious syphilis (new cases per 100,000 population annually)
New HIV diagnoses (number of new positive HIV tests)
2,062
Tuberculosis (new active and re-treatment cases per 100,000 population annually)
Mental health and mental illness
Perceived mental health, very good or excellent (%)*,†
71.7
(71.0–72.4)
2012
Major depressive episode (%, previous 12 months)*,||
4.7
(4.3–5.1)
2012
Alcohol use or dependence (%, previous 12 months)*,||
3.2
(2.8–3.5)
2012
Anxiety disorders, generalized (%, previous 12 months)*,||
2.6
(2.3–2.8)
2012
Schizophrenia or psychosis (ever diagnosed)*,||
1.3
(1.1–1.5)
2012
Alzheimer’s disease and other dementias (per 1,000 population)*,#
3.6
—
2011
4.8
—
2011
Cancers
211.0
—
2011
Circulatory diseases
192.7
—
2011
Respiratory diseases
64.3
—
2011
Causes of death
Infant mortality rate (deaths under one year per 1,000 live births)
Leading causes of mortality (deaths per 100,000 population per year)
Causes of premature mortality, aged 0 to 74 years (potential years of life
lost per 100,000 population per year)
Cancers
1,504.0
—
2009
Circulatory diseases
755.4
—
2009
Unintentional injuries
546.3
—
2009
Suicide and self-inflicted injuries
322.2
—
2009
Respiratory diseases
208.0
—
2009
28.3
—
2009
HIV
*
||
Self-reported data.
Population aged 15+ years.
†
#
Population aged 12+ years.
Population aged 40+ years.
‡
Population aged 1+ years.
§
Population aged 18+ years.
¶
Population aged 35+ years.
NOTE: Definitions and data sources can be found in Appendix B.
SOURCES: Statistics Canada, Canadian Cancer Society, Public Health Agency of Canada and Alzheimer Society of Canada.
APPENDIX A: THE HEALTH AND WELL-BEING OF CANADIANS
61
62
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
APPENDIX B: DEFINITIONS AND DATA SOURCES
FOR INDICATORS
Multiple Aboriginal identity (2011)597
People who identify themselves with more than one
Aboriginal group.
—A—
Aboriginal peoples (2011)596
The collective name for the original peoples of
North America and their descendants. The Constitution
Act (1982) recognizes three groups of Aboriginal
peoples—Indians, Inuit and Métis.
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
Other Aboriginal identities (2011)9
Aboriginal identities not included elsewhere.
First Nations (single identity) (2011)
A term commonly used in the 1970s to replace
“Indian.” Although the term First Nation is now
widely used, no legal definition of it exists. Among
its uses, the term “First Nations peoples” refers to the
Indian peoples in Canada, both Status and Non-Status.
Single identity refers to those people who reported
identifying solely as First Nations.
9, 596
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
Inuit (single identity) (2011)9, 596
The Aboriginal people of Arctic Canada who live
primarily in Nunavut, the Northwest Territories and
northern parts of Labrador and Quebec. Single identity
refers to those people who reported identifying solely
as Inuit.
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
Métis (single identity) (2011)9, 596
People with mixed First Nations and European
ancestry who identify themselves as distinct from
Indian people, Inuit or non-Aboriginal people.
Single identity refers to those people who reported
identifying solely as Métis.
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
Alcohol use or dependence (2012)44
Population aged 15 years and over classified as meeting
criteria for alcohol abuse or dependence in the 12 months
before the interview.
Alcohol dependence is characterized by a recurrent
pattern of use where at least three of the following
occur in the same 12-month period: increased tolerance,
withdrawal, increased consumption, unsuccessful attempts
to quit, a lot of time lost recovering or using, reduced
activities, and continued drinking despite persistent
physical or psychological problems caused or intensified
by alcohol.
Alcohol abuse is characterized by a recurrent pattern
of use where at least one of the following occurs: failure
to fulfill major roles at work, school or home; use in
physically hazardous situations; recurrent alcohol-related
problems or continued use despite social or interpersonal
problems caused or intensified by alcohol. By definition,
people who meet the criteria for alcohol dependence are
excluded from meeting the criteria for alcohol abuse.
Data source
Statistics Canada. (2013–09–17). Table 105–1101—Mental
Health Profile, Canadian Community Health Survey—Mental
Health (CCHS), by age group and sex, Canada and provinces,
occasional (number), CANSIM (database) [Data File].
Data source
Statistics Canada. (2013). Aboriginal Peoples in Canada: First
Nations People, Métis and Inuit. (Ottawa: Statistics Canada).
APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS
63
Alzheimer’s disease and other dementias (2011)81
Alzheimer’s disease is a degenerative disease of the
brain with characteristic pathological features and is the
most common form of dementia. Dementia is a syndrome
characterized by loss of memory, the ability to think,
as well as changes in mood, behaviour and ability to
communicate. Other common types of dementia include
vascular dementia, front temporal dementia, or Lewy body
dementia, each with distinct clinical and pathological
features. In this report, the term ‘other dementias’
includes these forms as well as instances of dementia
not classified by type.
Data source
Public Health Agency of Canada. (2014). Mapping Connections:
An Understanding of Neurological Conditions in Canada.
(Ottawa: Public Health Agency of Canada).
Anxiety disorder, generalized (2012)44
Population aged 15 years and over classified as meeting
criteria for generalized anxiety disorder in the 12 months
before the interview. Generalized anxiety disorder is
characterized by a pattern of frequent, persistent worry
and excessive anxiety about several events or activities
during a period of at least 6 months. Symptoms of
generalized anxiety disorder include restlessness or
feeling keyed up or on edge, being easily fatigued,
difficulty concentrating, irritability, muscle tension,
shakiness, sleep disturbance (difficulty falling asleep or
staying asleep or restless, unsatisfying sleep), excessive
sweating, palpitations, shortness of breath and various
gastrointestinal symptoms.
Data source
Statistics Canada. (2013–09–17). Table 105–1101—Mental
Health Profile, Canadian Community Health Survey—Mental
Health (CCHS), by age group and sex, Canada and provinces,
occasional (number), CANSIM (database) [Data File].
Arthritis (2012)468
Population aged 15 years and over who reported that
they have been diagnosed by a health professional as
having arthritis. Arthritis includes rheumatoid arthritis
and osteoarthritis, but excludes fibromyalgia.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
64
Asthma (2012)468
Population aged 12 years and over who reported that
they have been diagnosed by a health professional as
having asthma.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
—C—
Cancer incidence (2013)505
Estimated number of new cancer cases diagnosed in
a given population during a specific period of time
(usually one year) and calculated as the rate per
100,000 population.
Data source
Canadian Cancer Society’s Advisory Committee on Cancer
Statistics. (2013). Canadian Cancer Statistics 2013.
(Toronto: Canadian Cancer Society).
Cancers (2011)577
Deaths associated with malignant cancers (ICD–10
C00–C97) expressed as a rate per 100,000 population,
over a specific time-period.
Data source
Statistics Canada. (2014–01–27). Table 102–0522—Deaths,
by cause, Chapter II: Neoplasms (C00 to D48), age group and sex,
Canada, annual (number), CANSIM (database) [Data File]; and
Statistics Canada. (2013–11–22). Table 051–0001—Estimates
of population, by age group and sex for July 1, Canada, provinces
and territories, annual (persons unless otherwise noted), CANSIM
(database) [Data File].
Chlamydia (2011)531
Estimated rate of chlamydia (Chlamydia trachomatis)
per 100,000 population was reported to the Public Health
Agency of Canada by the provinces and territories.
Data source
Public Health Agency of Canada. (2014). Report on Sexually
Transmitted Infections in Canada: 2011. (Ottawa: Public Health
Agency of Canada).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Chronic obstructive pulmonary disease (2012)468
Population aged 35 years and over who reported that
they have been diagnosed by a health professional as
having chronic obstructive pulmonary disease, chronic
bronchitis or emphysema.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
Circulatory diseases (2011)584
Deaths associated with circulatory diseases
(ICD–10 I00–I99) expressed as a rate per 100,000
population, over a specific time-period.
Core housing need (2006)456
A household is in core housing need if it does not meet
one or more of the adequacy, suitability or affordability
standards and it would have to spend 30% or more of its
before-tax income to pay the median rent (including
utility costs) of alternative local market housing that
meets all three standards:
••
••
Data sources
Statistics Canada. (2014–01–27). Table 102–0529—Deaths,
by cause, Chapter IX: Diseases of the circulatory system (I00
to I99), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]; and Statistics Canada. (2013–11–22).
Table 051–0001—Estimates of population, by age group and
sex for July 1, Canada, provinces and territories, annual (persons
unless otherwise noted), CANSIM (database) [Data File].
Contact with dental professional (2012)48
Population aged 12 years and over who reported that they
have consulted with a dental professional (dentist, dental
hygienist or orthodontist) in the past 12 months.
Data source
Statistics Canada. Canadian Community Health Survey, 2012:
Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared
by the Public Health Agency of Canada and the responsibility
for the use and interpretation of these data is entirely that
of the author(s).
••
Adequate housing does not require any major repairs,
according to residents. Major repairs include defective
plumbing or electrical wiring or structural repairs to
walls, floors or ceilings.
Suitable housing has enough bedrooms for the size
and make-up of resident households according to
National Occupancy Standard (NOS) requirements.
Enough bedrooms based on NOS requirements means
one bedroom for each cohabiting adult couple;
unattached household member aged 18 years and
over; same-sex pair of children aged under 18 years;
and additional boy or girl in the family, unless there
are two opposite sex children under 5 years of age,
in which case they are expected to share a bedroom.
A household of one individual can occupy a bachelor
unit (i.e. a unit with no bedroom).
Affordable housing costs less than 30% of before-tax
household income. For renters, shelter costs include
rent and any payments for electricity, fuel, water and
other municipal services. For owners, shelter costs
include mortgage payments (principal and interest),
property taxes, and any condominium fees, along with
payments for electricity, fuel, water and other
municipal services.
Data source
Canada Mortgage and Housing Corporation. (2009). 2006
Census Housing Series: Issue 3—The Adequacy, Suitability,
and Affordability of Canadian Housing, 1991–2006. (Canada:
Canada Mortgage and Housing Corporation).
Contact with medical doctor (2012)468
Population aged 12 years and over who reported that
they have consulted with a medical doctor in the past
12 months. Medical doctor includes family or general
practitioners as well as specialists such as surgeons,
allergists, orthopaedists, gynaecologists or psychiatrists.
For population aged 12 to 17, includes pediatricians.
Urban core housing need (2010)598
Core housing need in urban households, where urban
households are defined as those in census metropolitan
areas (CMAs) and census agglomerations (CAs).
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
Data source
Canada Mortgage and Housing Corporation. (2013).
Canadian Housing Observer 2013. (Canada: Canada Mortgage
and Housing Corporation).
APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS
65
Current smoker (2012)37
Population aged 15 years and over who have identified
themselves as either daily smokers or non-daily smokers
(also known as occasional smokers).
Data source
Health Canada. (2013–10–01). Table 1. Smoking status and
average number of cigarettes smoked per day, by age group
and sex, age 15+ years, Canada 2011 [Data File].
—D—
Diabetes prevalence (2008/2009)39
The proportion of people who are affected by diabetes
at a given point in time.
Data source
Public Health Agency of Canada. (2011). Diabetes in Canada:
Facts and figures from a public health perspective. (Ottawa:
Public Health Agency of Canada).
—E—
Exceeds low-risk drinking guidelines for acute
effects (2012)599
Population aged 15 years and over who consume more
than 3 drinks (for women) or 4 drinks (for men) on
any single occasion.
Data source
Health Canada. (2013). Canadian Alcohol and Drug Use
Monitoring Survey (CADUMS). Detailed tables for 2012.
Exceeds low-risk drinking guidelines for chronic
effects (2012)599
Population aged 15 years and over who consume more
than 10 drinks a week for women, with more than 2
drinks a day most days and 15 drinks a week for men,
with more than 3 drinks a day most days.
Data source
Health Canada. (2013). Canadian Alcohol and Drug Use
Monitoring Survey (CADUMS). Detailed tables for 2012.
—F—
First Nations (2011)
See Aboriginal people(s).
Fruit and vegetable consumption, 5+ times
per day (2012)468
Indicates the usual number of times (frequency) per day
a person, aged 12 years and over, reported eating fruits
and vegetables. Measure does not take into account the
amount consumed.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
—G—
Gonorrhea (2011)531
Estimated rate of gonorrhea (Neisseria gonorrhoeae)
per 100,000 population was reported to the Public Health
Agency of Canada by the provinces and territories.
Data source
Public Health Agency of Canada. (2014). Report on Sexually
Transmitted Infections in Canada: 2011. (Ottawa: Public Health
Agency of Canada).
—H—
Health-adjusted life expectancy (2005/2007)497
Health-adjusted life expectancy is the number of years
in full health that an individual can expect to live
given the current morbidity and mortality conditions.
Health-adjusted life expectancy uses the Health Utility
Index (HUI) to weigh years lived in good health higher
than years lived in poor health. Thus, health-adjusted life
expectancy is not only a measure of quantity of life but
also a measure of quality of life.
Data source
Statistics Canada. (2012–05–23). Table 102–0122—Healthadjusted life expectancy, at birth and at age 65, by sex and
income, Canada and provinces occasional (years), CANSIM
(database) [Data File].
Fine particulate matter concentrations (2011)434
The national annual average fine particulate matter (PM2.5)
indicator is based on the annual average concentrations
recorded at 56 monitoring stations across Canada.
Data source
Environment Canada. (2013–11–01). Fine particulate matter
concentrations, Canada, 2000 to 2011 [Data File].
66
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
—I—
Heart disease (2012)48
Population aged 12 years and over who reported that
they have been diagnosed by a health professional as
having heart disease.
Illicit drug use in the past year (2012)484
Population aged 15 years and over who reported using
an illicit drug (cannabis, cocaine/crack, speed, ecstasy,
hallucinogens, heroin or salvia) in the 12 months
before the interview.
Data source
Statistics Canada. Canadian Community Health Survey, 2012:
Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared
by the Public Health Agency of Canada and the responsibility
for the use and interpretation of these data is entirely that
of the author(s).
Data source
Health Canada. (2013). Canadian Alcohol and Drug Use
Monitoring Survey (CADUMS). Detailed tables for 2012.
Immigrant (2011)600
A person who is, or has ever been, a landed immigrant/
permanent resident. This person has been granted the right
to live in Canada permanently by immigration authorities.
While “immigrant” usually applies to persons born outside
Canada, it may also apply to a small number of persons
born inside Canada to parents who are foreign-born.
High blood pressure (2012)
Population aged 12 years and over who reported that
they have been diagnosed by a health professional as
having high blood pressure or having used blood
pressure medication in the past month.
48
Data source
Statistics Canada. Canadian Community Health Survey, 2012:
Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared
by the Public Health Agency of Canada and the responsibility
for the use and interpretation of these data is entirely that
of the author(s).
Data source
Statistics Canada. (2014–03–04). Citizenship, Place of Birth,
Immigrant Status and Period of Immigration, Age Groups and
Sex for the Population in Private Households of Canada, Provinces,
Territories, Census Metropolitan Areas and Census Agglomerations,
2011 National Household Survey [Data File].
High school graduates (2013)416
Population aged 25 years and over who have received
a high school diploma or, in Quebec, completed
Secondary V or, in Newfoundland and Labrador,
completed fourth year of secondary.
By birth place (2011)601
Birth place refers to the name of the province, territory
or country in which the person was born. It may refer to
a province or territory if the person was born in Canada.
It refers to a country if the person was born outside
Canada. The geographic location is specified according
to boundaries current at the time the data are collected,
not the boundaries at the time of birth.
Data source
Statistics Canada. (2014–01–10). Table 282–0004—Labour
force survey estimates (LFS), by educational attainment,
sex and age group, annual, CANSIM (database) [Data File].
Households reporting moderate to severe
food insecurity (2011/2012)469
This variable is based on a set of 18 questions and
indicates whether households both with and without
children were able to afford the food they needed in the
previous 12 months. The levels of food security are defined
as: 1- Food secure: No, or one, indication of difficulty with
income-related food access; 2- Moderately food insecure:
Indication of compromise in quality and/or quantity of
food consumed; 3- Severely food insecure: Indication of
reduced food intake and disrupted eating patterns.
Data source
Statistics Canada. (2013–12–11). Table 105–0546—Household
food insecurity measures, by presence of children in the household,
Canada, provinces and territories occasional (number), CANSIM
(database) [Data File].
Data source
Statistics Canada. (2014–03–04). Citizenship, Place of Birth,
Immigrant Status and Period of Immigration, Age Groups
and Sex for the Population in Private Households of Canada,
Provinces, Territories, Census Metropolitan Areas and Census
Agglomerations, 2011 National Household Survey [Data File].
By years since immigration (2011)600
Years since immigration refers to the period in which
the immigrant first obtained his or her landed
immigrant/permanent resident status.
Data source
Statistics Canada. (2014–03–04). Citizenship, Place of Birth,
Immigrant Status and Period of Immigration, Age Groups and
Sex for the Population in Private Households of Canada,
Provinces, Territories, Census Metropolitan Areas and Census
Agglomerations, 2011 National Household Survey [Data File].
APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS
67
Infant mortality rate (2011)572
The number of infant deaths occurring within the first
year of life, during a given calendar year, per 1,000 live
births in the same calendar year.
Data source
Statistics Canada. (2013–09–24). Table 102–0504—Deaths
and mortality rates, by age group and sex, Canada, provinces
and territories, annual, CANSIM (database) [Data File].
Infectious syphilis (2011)531
Estimated rate of infectious syphilis (including primary,
secondary and early latent stages) per 100,000 population
was reported to the Public Health Agency of Canada by
the provinces and territories.
Data source
Public Health Agency of Canada. (2014). Report on Sexually
Transmitted Infections in Canada: 2011. (Ottawa: Public Health
Agency of Canada).
Inuit (2011)
See Aboriginal people(s).
—L—
Life expectancy at birth (2009/2011)602
The number of years a person would be expected to live,
starting at birth, if the age- and sex-specific mortality
rates for a given observation period (such as a calendar
year) were held constant over his/her life span.
Data source
Statistics Canada. (2013). Deaths, 2010 and 2011. The Daily,
September 25, 2013.
—M—
Major depressive episode (2012)44
Population aged 15 years and over classified as meeting
criteria major depressive episode in the 12 months before
the interview. Major depressive episode requires at least
one episode of 2 weeks or more with persistent depressed
mood and loss of interest or pleasure in normal activities,
accompanied by problems such as decreased energy,
changes in sleep and appetite, impaired concentration
and feelings of guilt, hopelessness, or suicidal thoughts.
Métis (2011)
See Aboriginal people(s).
—N—
New HIV diagnoses (2012)603
The number of newly diagnosed cases of human
immunodeficiency virus (HIV) in the population reported to
the Public Health Agency of Canada during a specified time.
Data source
Public Health Agency of Canada. (2013–11–29). At a Glance—HIV
and AIDS in Canada: Surveillance Report to December 31st, 2012.
—O—
Obesity (2009/2011)604
Body Mass Index (BMI) is a method of classifying body
weight according to health risk. It is calculated for the
population aged 18 years and over, excluding pregnant
females and persons less than 3 feet (0.914 metres)
tall or greater than 6 feet 11 inches (2.108 metres).
BMI is calculated as follows: weight in kilograms divided
by height in metres squared. According to World Health
Organization and Health Canada guidelines, health risk
levels are associated with each of the following BMI
categories (see Table B.1).
Data source
Statistics Canada. Canadian Health Measures Survey, 2009–2011:
Cycle 2 [Share Microdata File]. Ottawa, Ontario: Statistics Canada.
All computations on these microdata were prepared by the Public
Health Agency of Canada and the responsibility for the use and
interpretation of these data is entirely that of the author(s).
TABLE B.1 BMI and health risk604
Weight
BMI (kg/m2)
Health risk
Underweight
Under 18.5
Increased
Normal weight
18.5–24.9
Least
Overweight
25.0–29.9
Increased
Obese class I
30.0–34.9
High
Obese class II
35.0–39.9
Very high
Obese class III
40 or greater
Extremely high
Data source
Statistics Canada. (2013–09–17). Table 105–1101—Mental Health
Profile, Canadian Community Health Survey—Mental Health
(CCHS), by age group and sex, Canada and provinces, occasional
(number), CANSIM (database) [Data File].
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Ozone concentrations (2011)428
The national annual average ozone (O3) indicator is
based on the annual average of the daily maximum
8-hour average concentrations recorded at 127
monitoring stations across Canada.
Perceived mental health, very good
or excellent (2012)468
Population aged 12 years and over who reported
perceiving their own mental health status as being either
excellent or very good. Perceived mental health refers
to the perception of a person’s mental health in general.
Perceived mental health provides a general indication
of the population suffering from some form of mental
disease, mental or emotional problems, or distress,
not necessarily reflected in perceived health.
Data source
Environment Canada. (2013–11–01). Ozone concentrations,
Canada, 1997 to 2011 [Data File].
—P—
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
Perceived health, very good or excellent (2012)468
Population aged 12 years and over who reported
perceiving their own health status as being either
excellent or very good. Perceived health refers to the
perception of a person’s health in general, either by
the person himself or herself, or in the case of a proxy
response, by the person responding. Health means not
only the absence of disease or injury but also physical,
mental and social well-being.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
Persons living in low income, after tax (2011)425
Canadian families who are likely to spend 20 percentage
points more of their total post-tax income on necessities
(food, clothing and footwear, and shelter) compared to
an average family of the same size, in the same broad
community size. Low income is based on the consumption
patterns for 1992, revised in 2005, and adjusted for
family size, community sizes and inflation based on the
national Consumer Price Index. After-tax income is total
income, which includes government transfers, less income
tax (see Table B.2).
Data source
Statistics Canada. (2013–06–27). Table 202–0802—Persons in
low income families, annual, CANSIM (database). [Data File].
TABLE B.2 Low income cut-offs after tax, Canada, 2011425
Community Size
Rural Areas
Size of
family unit
Census Agglomeration
Census Metropolitan Area
($)
Population less than
30,000 ($)
Population less than
30,000 ($)
Population 100,000
and 499,999 ($)
Population 500,000
and over ($)
1 person
12,629
14,454
16,124
16,328
19,307
2 persons
15,371
17,592
19,625
19,872
23,498
3 persons
19,141
21,905
24,437
24,745
29,260
4 persons
23,879
27,329
30,487
30,871
36,504
5 persons
27,192
31,120
34,717
35,154
41,567
6 persons
30,156
34,513
38,502
38,986
46,099
7 or more persons
33,121
37,906
42,286
42,819
50,631
APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS
69
Physical activity during leisure-time, moderately
active or active (2012)468
Population aged 12 years and over who reported a
level of physical activity, based on their responses to
questions about the nature, frequency and duration
of their participation in leisure-time physical activity.
Respondents are classified as active, moderately active
or inactive based on an index of average daily physical
activity over the past three months. For each leisure-time
physical activity the respondent engages in, average
daily energy expenditure is calculated by multiplying the
number of times the activity was performed by the average
duration of the activity by the energy cost (kilocalories
per kilogram of body weight per hour) of the activity. The
index is calculated as the sum of the average daily energy
expenditures of all activities. Respondents are classified
as follows: 3.0 kcal/kg/day or more = physically active;
1.5 to 2.9 kcal/kg/day = moderately active; less than
1.5 kcal/kg/day = inactive.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex, Canada,
provinces, territories, health regions (2012 boundaries) and peer
groups, occasional, CANSIM (database) [Data File].
Population (2013)15
Estimates are based on the 2011 Census counts adjusted
for census net undercoverage including adjustment
for incompletely enumerated Indian reserves and the
components of demographic growth that occurred
since that census.
Data source
Statistics Canada. (2013–11–22). Table 051–0001—Estimates
of population, by age group and sex for July 1, Canada, provinces
and territories, annual (persons unless otherwise noted), CANSIM
(database) [Data File].
Population centre residents (2011)605
A population centre has a minimum population
concentration of 1,000 persons and a population
density of at least 400 persons per square kilometre,
based on the current census population count. All areas
outside population centres are classified as rural areas.
Population centres include all the population living
in the cores, secondary cores and fringes of census
metropolitan areas (CMAs) and census agglomerations
(CAs), as well as the population living in population
centres outside CMAs and CAs.
Data source
Statistics Canada. (2014–01–13). Population and dwelling
counts, for population centres, 2011 and 2006 censuses (table).
Population and Dwelling Count Highlight Tables. 2011 Census
[Data File].
Post-secondary graduates (2013)416
Population aged 25 years and over who have completed
a certificate (including a trade certificate) or diploma
from an educational institution beyond the secondary
level. This includes certificates from vocational schools,
apprenticeship training, community college, Collège
d’Enseignement Général et Professionnel (CEGEP), and
school of nursing. Also included are certificates below
a bachelor’s degree obtained at a university.
Data source
Statistics Canada. (2014–01–10). Table 282–0004—Labour force
survey estimates (LFS), by educational attainment, sex and age
group, annual (persons unless otherwise noted), CANSIM
(database) [Data File].
Potential years of life lost594
Potential years of life lost is the population average of
the number of years of life lost, across all persons dying
prematurely from any cause—before the age of 75 years,
over a specific period of time. A person who dies at age
25 years, for example, has l ost 50 years of life.
Premature mortality due to cancers (2009)594, 595
Potential years of life lost for all malignant neoplasms
(ICD–10 C00–C97) is the population average of the
number of years of life lost, across all persons dying
prematurely from any cancer before age 75 years,
over a specific period of time.
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
Premature mortality due to circulatory
diseases (2009)594, 595
Potential years of life lost for all circulatory disease
(ICD–10 I00–I99) is the population average of the
number of years of life lost, across all persons dying
prematurely from any circulatory disease before age
75 years, over a specific period of time.
Premature mortality due to suicide and
self-inflicted injuries (2009)594, 595
Potential years of life lost for suicides (ICD–10
X60–X71, X75–X84, Y87.0) is the population average
of the number of years of life lost, across all persons
dying prematurely from any self-inflicted injury
before age 75 years, over a specific period of time.
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
Premature mortality due to HIV (2009)594, 595
Potential years of life lost for human immunodeficiency
virus (HIV) infection (ICD–10 B20–B24) is the
population average of the number of years of life lost,
across all persons dying prematurely from HIV before
age 75 years, over a specific period of time.
Premature mortality due to unintentional
injuries (2009)594, 595
Potential years of life lost for unintentional injuries
(ICD–10 V01–X59, Y85–Y86) is the population average
of the number of years of life lost, across all persons
dying prematurely from any unintentional injury before
age 75 years, over a specific period of time.
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
Premature mortality due to respiratory diseases
(2009)594, 595
Potential years of life lost for all respiratory disease
(ICD–10 J00–J99) is the population average of the
number of years of life lost, across all persons dying
prematurely from any respiratory disease before age
75 years, over a specific period of time.
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
Data source
Statistics Canada. Canadian Vital Statistics, Death Database,
2009. All computations on these data were prepared by the
Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of
the author(s).
—R—
Respiratory diseases (2011)585
Deaths associated with respiratory diseases (ICD–10
J00–J99) expressed as a rate per 100,000 population,
over a specific time-period.
Data sources
Statistics Canada. (2014–01–27). Table 102–0530—Deaths, by
cause, Chapter X: Diseases of the respiratory system (J00 to J99),
age group and sex, Canada, annual (number), CANSIM (database)
[Data File]; and Statistics Canada. (2013–11–22). Table
051–0001—Estimates of population, by age group and sex for
July 1, Canada, provinces and territories, annual (persons unless
otherwise noted), CANSIM (database) [Data File].
APPENDIX B: DEFINITIONS AND DATA SOURCES FOR INDICATORS
71
—S—
Schizophrenia or psychosis (2012)44
Population aged 15 years and over who reported that
they have ever been diagnosed by a health professional
with schizophrenia or psychosis.
Data source
Statistics Canada. (2013–09–17). Table 105–1101—Mental
Health Profile, Canadian Community Health Survey—Mental
Health (CCHS), by age group and sex, Canada and provinces,
occasional (number), CANSIM (database) [Data File].
Sense of community belonging, somewhat
or very strong (2012)468
Population aged 12 years and over who reported their
sense of belonging to their local community as being
very strong or somewhat strong.
Data source
Statistics Canada. (2013–06–17). Table 105–0501—Health
indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2012 boundaries)
and peer groups, occasional, CANSIM (database) [Data File].
Some post-secondary education (2013)
Population aged 25 years and over who worked toward,
but did not complete, a degree, certificate (including
a trade certificate) or diploma from an educational
institution, including a university, beyond the secondary
level. This includes vocational schools, apprenticeship
training, community college, Collège d’Enseignement
Général et Professionnel (CEGEP), and school of nursing.
416
Data source
Statistics Canada. (2014–01–10). Table 282–0004—Labour
force survey estimates (LFS), by educational attainment, sex
and age group, annual, CANSIM (database) [Data File].
Tuberculosis (2011)555
Number of cases of new active and re-treatment
tuberculosis cases per 100,000 population.
Data source
Public Health Agency of Canada. (2014). Tuberculosis in
Canada, 2012. (Ottawa: Public Health Agency of Canada).
—U—
Unemployment rate (2013)416
The unemployment rate is the number of unemployed
persons (those who, during the reference week, were
without work, had actively looked for work in the past
four weeks, and were available for work as well as persons
on layoff or who had a new job to start in four weeks or
less) expressed as a percentage of the labour force.
Data source
Statistics Canada. (2014–01–10). Table 282–0004—Labour force
survey estimates (LFS), by educational attainment, sex and age
group, annual, CANSIM (database) [Data File].
Urban core housing need (2010)
See Core housing need.
—V—
Violent crime incidents (2012)606
Offences that deal with the application, or threat of
application, of force to a person. These include homicide,
attempted murder, various forms of sexual and non-sexual
assault, robbery and abduction.
Data source
Statistics Canada. (2013–07–25). Table 252–0051—Incidentbased crime statistics, by detailed violations, annual (number
unless otherwise noted), CANSIM (database) [Data File].
—T—
Teen birth rate (2011)501
Number of live births per 1,000 female population
aged 15 to 19 years.
Data source
Statistics Canada. (2013–03–18). Table 102–4505—Crude birth
rate, age-specific and total fertility rates (live births), Canada,
provinces and territories, annual (rate), CANSIM (database)
[Data File].
72
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
APPENDIX C: THE CHIEF PUBLIC HEALTH
OFFICER’S REPORTS ON THE STATE OF PUBLIC
HEALTH IN CANADA
The Public Health Agency of Canada Act requires the Chief Public Health Officer to submit an annual report on the
state of public health in Canada to the Minister of Health within six months of the end of each fiscal year. The Minister
lays the report before each House of Parliament on any of the first 15 days on which the House is sitting after receipt
of the report.1
The Act specifies that the CPHO:
••
••
••
may prepare and publish reports on any issue related to public health;
may, in any report, refer to public health problems and their causes, as well as any measures that may, in his
or her opinion, be effective in preventing or resolving those problems; and
must, to the extent possible, set out the source of the data and information used in the preparation of the
report and methodology employed to arrive at the report’s findings, conclusions or recommendations.1
Previous reports from the Chief Public Health Officer of Canada are shown below.
ADDRESSING HEALTH INEQUALITIES
GROWING UP WELL—
PRIORITIES FOR A HEALTHY FUTURE
GROWING OLDER—
ADDING LIFE TO YEARS
YOUTH AND YOUNG ADULTS—
LIFE IN TRANSITION
INFLUENCING HEALTH—
THE IMPORTANCE OF SEX AND GENDER
INFECTIOUS DISEASE—
THE NEVER-ENDING THREAT
APPENDIX C: THE CHIEF PUBLIC HEALTH OFFICER’S REPORTS ON THE STATE OF PUBLIC HEALTH IN CANADA
73
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2014
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574. Statistics Canada. (2014–01–27). Table 102–0536—Deaths,
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and chromosomal abnormalities (Q00 to Q99), age group
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576. Statistics Canada. (2014–01–27). Table 102–0521—Deaths,
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(A00 to B99), age group and sex, Canada, annual (number),
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577. Statistics Canada. (2014–01–27). Table 102–0522—Deaths,
by cause, Chapter II: Neoplasms (C00 to D48), age group
and sex, Canada, annual (number), CANSIM (database)
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578. Statistics Canada. (2014–01–27). Table 102–0523—Deaths,
by cause, Chapter III: Diseases of the blood and blood-forming
organs and certain disorders involving the immune mechanism
(D50 to D89), age group and sex, Canada, annual (number),
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579. Statistics Canada. (2014–01–27). Table 102–0524—Deaths, by
cause, Chapter IV: Endocrine, nutritional and metabolic diseases
(E00 to E90), age group and sex, Canada, annual (number),
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580. Statistics Canada. (2014–01–27). Table 102–0525—Deaths,
by cause, Chapter V: Mental and behavioural disorders (F00 to
F99), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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581. Statistics Canada. (2014–01–27). Table 102–0526—Deaths,
by cause, Chapter VI: Diseases of the nervous system (G00 to
G99), age group and sex, Canada, annual (number), CANSIM
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http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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582. Statistics Canada. (2014–01–27). Table 102–0527—Deaths,
by cause, Chapter VII: Diseases of the eye and adnexa (H00 to
H59), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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590. Statistics Canada. (2014–01–27). Table 102–0535—Deaths,
by cause, Chapter XV: Pregnancy, childbirth and the puerperium
(O00 to O99), age group and sex, Canada, annual (number),
CANSIM (database) [Data File]. Retrieved on January 28, 2014,
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583. Statistics Canada. (2014–01–27). Table 102–0528—Deaths,
by cause, Chapter VIII: Diseases of the ear and mastoid process
(H60 to H95), age group and sex, Canada, annual (number),
CANSIM (database) [Data File]. Retrieved on January 28, 2014,
from http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020528
591. Statistics Canada. (2014–01–27). Table 102–0538—Deaths,
by cause, Chapter XVIII: Symptoms, signs and abnormal clinical
and laboratory findings, not elsewhere classified (R00 to R99),
age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014,
from http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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584. Statistics Canada. (2014–01–27). Table 102–0529—Deaths, by
cause, Chapter IX: Diseases of the circulatory system (I00 to
I99), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020529
585. Statistics Canada. (2014–01–27). Table 102–0530—Deaths, by
cause, Chapter X: Diseases of the respiratory system (J00 to
J99), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020530
586. Statistics Canada. (2014–01–27). Table 102–0531—Deaths, by
cause, Chapter XI: Diseases of the digestive system (K00 to
K93), age group and sex, Canada, annual (number), CANSIM
(database) [Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020531
587. Statistics Canada. (2014–01–27). Table 102–0532—Deaths,
by cause, Chapter XII: Diseases of the skin and subcutaneous
tissue (L00 to L99), age group and sex, Canada, annual
(number), CANSIM (database) [Data File]. Retrieved on
January 28, 2014, from http://www5.statcan.gc.ca/cansim/
pick-choisir?lang=eng&p2=33&id=1020532
588. Statistics Canada. (2014–01–27). Table 102–0533—
Deaths, by cause, Chapter XIII: Diseases of the musculoskeletal
system and connective tissue (M00 to M99), age group
and sex, Canada, annual (number), CANSIM (database)
[Data File]. Retrieved on January 28, 2014, from
http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020533
589. Statistics Canada. (2014–01–27). Table 102–0534—Deaths,
by cause, Chapter XIV: Diseases of the genitourinary system
(N00 to N99), age group and sex, Canada, annual (number),
CANSIM (database) [Data File]. Retrieved on January 28, 2014,
from http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
eng&p2=33&id=1020534
592. Statistics Canada. (2014–01–27). Table 102–0540—Deaths, by
cause, Chapter XX: External causes of morbidity and mortality
(V01 to Y89), age group and sex, Canada, annual (number),
CANSIM (database) [Data File]. Retrieved on January 28, 2014,
from http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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593. Statistics Canada. (2014–01–27). Table 102–0542—Deaths,
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U99), age group and sex, Canada, annual (number), CANSIM
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http://www5.statcan.gc.ca/cansim/pick-choisir?lang=
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595. Statistics Canada. Vital Statistics—Death Database, 2009.
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