2012 Report on the state of Public health in Canada

2012 Report on the state of Public health in Canada
The Chief Public Health Officer’s
Report on the state of
Public health in Canada
2012
Influencing Health —
The Importance of Sex and Gender
Également disponible en français sous le titre : Rapport de l’administrateur
en chef de la santé publique sur l’état de la santé publique au Canada 2012 :
Le sexe et le genre – Leur influence importante sur la santé
The Chief Public Health Officer’s Report on the State of Public Health in
Canada, 2012: Influencing Health – The Importance of Sex and Gender 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, 2012
Cat:. HP2-10/2012E
ISSN: 1917-2656
Message
A Message from
Canada’s Chief Public Health Officer
As a nation, we are healthy. Canada has secured
significant health gains through routine immunization,
smoking cessation programs, reducing and managing the
incidence of infectious diseases, and investing in social
infrastructure. These efforts underline why Canada is one
of the best places in the world in which to live.
However, there are areas in which Canada can improve.
We are seeing decreasing rates of physical activity,
increasing rates of chronic diseases and obesity, and
increasing rates of some sexually transmitted infections
among Canadians. Canada also needs to recognize the
importance of mental health and work towards improving
mental health and well-being for Canadians. The good
news is that all of these are manageable if we, as a
society, create environments that support healthier ways
of life and reduce risks to health.
We all have unique health concerns that need to be
considered. Canadian men, women, boys and girls
experience differences in health risks, access to and
effectiveness of health services and programs, and overall
health outcomes. Canada must take into account and
respond to the differences, as well as the similarities,
between citizens and avoid making generalizations in
order to help secure the best possible health for all
Canadians.
In this report, I have decided to explore the influence of
sex (i.e. biological characteristics) and gender (i.e. sociocultural factors) on public health and the health status
of Canadians. I have also used this report to highlight
key areas where I believe Canada has been effective in
considering the role of sex and gender on health as well
as where we may want to concentrate future efforts.
Attitudes, behaviours, motivations and lifestyles, in
general and as they may relate to sex and gender, often
expose Canadians to differences in risks and opportunities
for health and wellness. It is not as simple as looking at
the differences between women and men and girls and
boys. It is about the pathways on which those differences
develop; how we think about masculinity and femininity
and how they intersect with other determinants to shape
health and well-being; and how we consider sex and
“The future has already arrived. It’s just not evenly distributed yet.”
– William Gibson
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Dr. David Butler-Jones
Chief Public Health Officer of Canada
i
Message
gender when we frame, plan for, implement and evaluate
public health interventions.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
The roles that sex and gender play in public health are
relevant to everyone. We know being male or female
affects our health across the lifecourse. Differences
experienced by men, women, boys and girls (including
individuals across the sex and gender continuums) can
be attributed to biological diversity as well as the social
roles and responsibilities assumed by each of us. It is
clear that sex and gender are important determinants
of health that interact with and affect all other
determinants.
ii
As a society we need to better understand how sex and
gender interact with other determinants of health. Policy
makers need to consider gender-based evidence when
making decisions on programs and initiatives for more
effective and efficient health outcomes. As well, people’s
accounts of their experiences with public health in Canada
can help illustrate why and how particular health issues
affect some groups of people differently than others. This
can help policy makers and planners develop programs
and interventions that meet the needs of Canada’s
diverse population, ensuring that we do not inadvertently
overlook the needs of some groups within the population.
There is a wealth of experience and knowledge in Canada,
and around the world, and there are opportunities for
positive change. Throughout this report, there are many
examples of what is working well and the differences we
can make in the lives of Canadians. Collectively we can
influence our health and create a better and healthier
future for all Canadians.
Dr. David Butler-Jones
Dr. David Butler-Jones is Canada’s first and current Chief Public Health Officer. He heads the Public Health Agency of Canada
which provides leadership on the government’s efforts to protect and promote the health and safety of Canadians. He has
worked in many parts of Canada in both Public Health and Clinical Medicine, and has consulted in a number of other countries.
Dr. Butler-Jones has taught at both the undergraduate and graduate levels and has been involved as a researcher in a broad
range of public health issues. He is a Professor in the Faculty of Medicine at the University of Manitoba as well as a Clinical
Professor with the Department of Community Health and Epidemiology at the University of Saskatchewan’s College of Medicine.
From 1995 to 2002, Dr. Butler-Jones was Chief Medical Health Officer and Executive Director of the Population Health and
Primary Health Services Branches for the Province of Saskatchewan. Dr. Butler-Jones has served with a number of organizations
including as: President of the Canadian Public Health Association; Vice President of the American Public Health Association;
Chair of the Canadian Roundtable on Health and Climate Change; International Regent on the board of the American College
of Preventive Medicine; Member of the Governing Council for the Canadian Population Health Initiative; Chair of the National
Coalition on Enhancing Preventive Practices of Health Professionals; and Co-Chair of the Canadian Coalition for Public Health
in the 21st Century. In recognition of his service in the field of public health, York University’s Faculty of Health bestowed on
Dr. Butler-Jones an honorary Doctor of Laws degree. In 2010, Dr. Butler-Jones was the recipient of the Robert Davies Defries
award, the highest honour presented by the Canadian Public Health Association, recognizing outstanding contributions
in the field of public health.
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, 2012: Influencing
Health – The Importance of Sex and Gender.
I would like to express my appreciation to the consultants
who provided invaluable advice, strategic guidance
and expertise:
I would like to thank the many individuals and groups
within the Public Health Agency of Canada for their
contribution. Specifically, I would like to recognize
the dedicated efforts of the CPHO Reports Unit, Office
of Public Health Practice: Sarah Bernier, Jane BoswellPurdy, Suzanne A. Boucher, Paula Carty, Lindsay
Fitzpatrick, Maureen Hartigan, Sean Hockin, Deborah
Jordan, Jordan Kelly, Russell Mawby, Erin L. Schock,
Jennifer Lynn Scott, Melannie Smith, Andrea Sonkodi
and Crystal Stroud for all their effort throughout the
process of delivering this report.
I would also like to acknowledge the contributions of the
following external reviewers and organizations:
•• André P. Grace, MEd, PhD, Killam Research Professor
and Director of the Institute for Sexual Minority
Studies and Services, Faculty of Education, University
of Alberta;
•• David Hart, PhD, Professor, McCaig Institute for Bone
and Joint Health, University of Calgary;
•• Marlene M. Moretti, MD, CIHR Senior Research Chair,
Professor, Department of Psychology, Simon Fraser
University;
•• Kate Shannon, MPH, PhD, Assistant Professor,
Department of Medicine, University of British
Columbia and Director, Gender and Sexual Health
Initiative, BC Centre for Excellence in HIV/AIDS;
•• Jeannie Shoveller, PhD, Professor, School of
Population and Health, University of British
Columbia; and
•• Donna E. Stewart, MD, University Professor, Faculty
of Medicine, University of Toronto; Director, Women’s
Health and Senior Scientist, University Health
Network, Toronto; Institutional Advisory Board
Member, Institute of Gender and Health, Canadian
Institute of Health Research.
In addition I would also like to recognize the following
organizations for their contributions to this Report:
•• Aboriginal Nurses Association of Canada;
•• Assembly of First Nations;
•• Congress of Aboriginal Peoples;
•• Inuit Tapiriit Kanatami;
•• Mental Health Commission of Canada;
•• Métis National Council;
•• National Aboriginal Health Organization;
•• National Collaborating Centre for Aboriginal Health;
•• Native Women’s Association of Canada; and
•• Pauktuutit Inuit Women of Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• The Honourable Gary Filmon, PC, OC, OM, Corporate
Director, The Exchange Group;
•• 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;
•• David Mowat, MPH, FRCPC, FFPH, Medical Officer
of Health, Region of Peel, Ontario;
•• Peter Glynn, PhD, Health Systems Consultant;
Associate Professor (Adjunct), Department of
Community Health and Epidemiology, Queen’s
University;
•• Daryl Pullman, PhD, Professor of Medical Ethics,
Division of Community Health and Humanities,
Memorial University;
•• Jeff Reading, MSc, PhD, FCAHS, Professor and
Director, School of Public Health and Social Policy,
Faculty of Human and Social Development and Centre
for Aboriginal Health Research, University of Victoria;
•• Cornelia Wieman, MSc, MD, FRCPC, Consultant
Psychiatrist; and
•• Brenda Zimmerman, MBA, PhD, Director, Health
Industry Management Program; Associate Professor
of Strategy/Policy, Schulich School of Business, York
University.
As well, I would like to recognize the contributions made
by the 2011/12 Core Advisory Group: Cate Harrington,
Mana Herel, Semaneh Jemere, Erin Kingdom, Leonora
Montuoro, Emma Moore, Howard Morrison, Roslyn Nudell,
Catherine Rotor, Jan Trumble Waddell, Manon Turcotte,
Emily Weir, Lindsey Williams and Vance White.
iii
Acknowledgements
Special thanks to those from the following federal
government departments, agencies and programs who
collaborated with us on this publication:
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• Aboriginal Affairs and Northern Development Canada;
•• Canada Mortgage and Housing Corporation;
•• Canadian Heritage (Sport Canada);
•• Canadian Institutes of Health Research;
•• Health Canada;
•• Human Resources and Skills Development Canada;
•• Privy Council Office; and
•• Status of Women Canada.
iv
Table of Contents
A Message from Canada’s Chief Public Health Officer...........................................................................i
Acknowledgements........................................................................................................................ iii
Executive Summary..........................................................................................................................1
Introduction...................................................................................................................................7
Why a report on the state of public health in Canada?......................................................................... 7
The goals of the report................................................................................................................... 8
What this report is about................................................................................................................ 8
What does the report cover?............................................................................................................ 9
Chapter 1: The State of Public Health in Canada...............................................................................13
Who we are................................................................................................................................. 13
Our health.................................................................................................................................. 14
Factors influencing health............................................................................................................. 20
Summary.................................................................................................................................... 32
Part II: Sex, Gender and the Health of Canadians
Chapter 2: Sex, Gender and Public Health........................................................................................35
Clarifying sex and gender.............................................................................................................. 35
Why sex and gender matter to public health..................................................................................... 36
Sex, gender and the broader determinants of health.......................................................................... 37
Sex- and gender-based analysis: a tool............................................................................................ 38
Summary.................................................................................................................................... 39
Chapter 3: Sex, Gender and Health Outcomes...................................................................................41
Physical Health............................................................................................................................ 41
Mental Health............................................................................................................................. 42
Sexual Health.............................................................................................................................. 46
Summary.................................................................................................................................... 49
Chapter 4: Incorporating Sex and Gender into Health Interventions...................................................51
Section One: Sex and gender and public health interventions.............................................................. 51
Integrating sex and gender into health research............................................................................ 51
Integrating sex and gender in public health practice...................................................................... 55
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Part I: The State of Public Health in Canada
v
Table of Contents
Section Two: Sex and gender in select health outcomes..................................................................... 57
Sex, gender and physical health.................................................................................................. 57
Sex, gender and mental health and well-being............................................................................... 61
Sex, gender, healthy relationships and sexual health...................................................................... 70
Section Three: Sex and gender and socio-economic determinants........................................................ 80
Summary.................................................................................................................................... 87
Part III: A Path Forward
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Chapter 5: Sex, Gender and Public Health – A Path Forward...............................................................91
vi
A time to act.............................................................................................................................. 91
Appendix A: List of Acronyms.........................................................................................................94
Appendix B: Body mass index cut-points.........................................................................................95
Appendix C: Indicators of Our Health and Factors Influencing Our Health...........................................97
Appendix D: Definitions and Data Sources for Indicators................................................................. 101
References.................................................................................................................................. 113
Figures
Figure 1.1 Population distribution by age group, Canada, 1976, 2011 and 2036.................................. 13
Figure 1.2 Life expectancy at birth by sex and neighbourhood income quintiles, Canada, 2005–2007...... 14
Figure 1.3 Excellent or very good self-perceived health and mental health by age group, Canada, 2010..... 14
Figure 1.4 Proportion of Canadians reporting one or more chronic health conditions
by age group, Canada, 2010......................................................................................... 16
Figure 1.5 Self-reported back problems by sex and age group, Canada, 2010....................................... 16
Figure 1.6 Self-reported high blood pressure by sex, origin and select age groups, Canada, 2010........... 17
Figure 1.7 Self-reported mood disorder by sex and age group, Canada, 2010....................................... 18
Figure 1.8 Number of deaths by select causes and sex, Canada, 2008................................................. 19
Figure 1.9 Age-standardized mortality rate by sex and select causes of death, Canada, 2008................. 20
Figure 1.10 Age-standardized potential years of life lost by sex and select causes
of death, Canada, 2008................................................................................................ 21
Figure 1.11 High school non-completion rate by sex, population aged 20 to 24 years, Canada,
1990/1991 to 2010/2011............................................................................................. 21
Figure 1.12 Unemployment rate by select age groups and sex, Canada, 1990 to 2011............................. 22
Table of Contents
Figure 1.13 Average after-tax income for economic families (two or more persons), 2010 constant
dollars, Canada, 1976 to 2009....................................................................................... 23
Figure 1.14 Population living in low income by sex, Canada, 1976 to 2009........................................... 24
Figure 1.15 Current smokers by sex and age group, Canada, 1999 and 2010.......................................... 24
Figure 1.16 Frequent heavy drinking by sex and age group, Canada, 2010............................................ 25
Figure 1.17 Cannabis use in the past 12 months by sex and age group, Canada, 2010............................ 26
Figure 1.18 Age-specific fertility rate by select age groups, Canada, 1960 to 2009................................. 27
Figure 1.19 Sexually transmitted infection rates by sex and select age groups, Canada, 2009.................. 28
Figure 1.20 Body mass index by sex and age group, Canada, 2007–2009.............................................. 30
Figure 1.22 Dental and eye doctor visits in the past 24 months by sex and age group, Canada, 2010........ 31
Tables
Table 1.1 Our health status.......................................................................................................... 15
Table B.1 Body mass index for children and youth aged 2 to 17 years................................................. 95
Table B.2 Body mass index for adults aged 18 years and older........................................................... 96
Table C.1 Who we are.................................................................................................................. 97
Table C.2 Our health status.......................................................................................................... 98
Table C.3 Factors influencing our health........................................................................................ 99
Table D.1 Low income cut offs after tax, Canada, 2009....................................................................108
Textboxes
The Role of Canada’s Chief Public Health Officer.................................................................................. 9
The Chief Public Health Officer’s Report on the State of Public Health in Canada.................................... 10
Incorporating sex and gender into research...................................................................................... 52
The Health Portfolio’s Sex and Gender-Based Analysis Policy............................................................... 53
Approaches to implementing Aboriginal sex- and gender-based analysis............................................... 54
Changing perspectives with a sex- and gender lens on a public health issue: the HPV example................. 56
Healthy Dads, Healthy Kids............................................................................................................ 58
Canadian Association for the Advancement of Women and Sport and Physical Activity............................ 59
Targeting women: The Heart Truth campaign.................................................................................... 61
Australia’s Men’s Sheds program..................................................................................................... 67
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Figure 1.21 Consulting a doctor by origin and sex, Canada, 2010........................................................ 30
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Table of Contents
Addressing youth and violence....................................................................................................... 71
Healthy Relationships Curriculum – Men for Change........................................................................... 72
Raising awareness about age, gender and sexual health..................................................................... 76
Breaking down barriers: sexual minority youth and education............................................................. 78
Increasing access to sexual health care: the Immigrant Women’s Health Clinic....................................... 79
Supporting Aboriginal fathers........................................................................................................ 85
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Acknowledging the importance of fathers’ involvement...................................................................... 86
viii
Executive Summary
The State of Public Health in Canada
In 2011, the Canadian population was about 33.5 million,
almost equally divided between males and females. While
the proportion of males to females varies somewhat
by age group, from the age of 65 years onward the
proportion of females exceeds that of males.
The life expectancy of Canadians has increased
dramatically over the past century. A male born in Canada
today can expect to live about 79 years and a female
about 83 years. While Canadian women have historically
experienced greater longevity, the gap in life expectancy
at birth between Canadian men and women has decreased.
Many Canadians at every age consider themselves healthy.
The majority of Canadians 12 years and older reported
their health as either excellent (22%) or very good (38%),
while even more reported their mental health as excellent
(37%) or very good (37%). However, not all years are
spent in good health. The health-adjusted life expectancy
(HALE) from 2004 to 2006 shows that males spent
approximately 69.6 years in good health whereas women
spent about 72.1 years in good health.
In 2010, 55% of Canadians aged 12 years and older
reported living with at least one chronic health condition,
the most common being back problems (19%), high
blood pressure (18%) and arthritis (16%). Back problems,
including scoliosis, sciatica and herniated discs, can result
in physical pain and in some cases be disabling. This can
also be the case for any one of the 100 or so different
types of arthritis that affect mainly women (61%).
Almost one-quarter (24%) of Canadians 30 years and older
reported having high blood pressure, a major contributor
to heart disease and stroke, and the proportions increased
with age to 51% among those 65 years and older.
Some Canadians also live with some form of mental
illness. In 2010, mood disorders, such as depression and
bipolar disorder, were the most commonly reported mental
health conditions affecting 6.9% of Canadians 15 years
and older (8.2% of women and 5.0% of men). The highest
reported rates of mood disorder were among older adults
aged 55 to 64 years (8.3%) and Aboriginal people not
living on a reserve (11.7%).
Economic and social factors such as education,
employment and income have a direct bearing on health.
Between the 1990/1991 and 2010/2011 school years,
the percentage of Canadians between 20 and 24 years
who had completed high school increased from 81% to
90% (92% of women and 89% of men). The percentage
of Canadians between 25 and 34 years who completed
a post-secondary education also increased during the
same period, from 44% to 72% for women and from 45%
to 64% for men. In 2011, the unemployment rate for
young Canadians between 15 and 24 years was 14.2%,
with a difference between males (15.9%) and females
(12.4%). Among Canadians aged 25 to 54 years, 6.2%
were unemployed with little difference between men and
women. In 2010, 32% of the working population between
30 and 54 years self-reported having work-related stress,
with similar rates among both men and women.
Tobacco, alcohol and cannabis are the substances most
frequently used by Canadians 15 years and older. While
the overall smoking rate in Canada has been declining,
17% of Canadians reported smoking in 2010 with males
in all age groups consistently reporting higher rates of
smoking compared to females. In the same year, 77%
had consumed alcohol (47% of whom consumed it once
a week or more – 54% of males and 40% of females),
whereas one-in-ten reported using cannabis in the past
year (15% of males and 7% of females). Young adults
between 20 and 29 years have the highest smoking,
drinking and cannabis rates of all age groups in Canada.
Over the past 15 years, reported rates of sexually
transmitted infections (STIs) have increased among the
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
This is the Chief Public Health Officer’s fifth annual
report on the state of public health in Canada. The report
explores sex (i.e. biological characteristics) and gender
(i.e. socio-cultural factors) and their connections with
public health and the health status of Canadians. It
examines how sex and gender interact with each other
and with other determinants of health to influence
health behaviours and symptoms, treatment effects and
access to care. From this examination, the report outlines
interventions, programs and policies that have maintained
and improved the current and future health and wellbeing of Canadians. It also identifies priority areas for
action where Canada as a society can better incorporate
sex- and gender-related issues in public health resulting
in reduced health inequalities.
1
Executive Summary
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
overall population. Young Canadians under the age of
30 years continue to experience the highest reported rates
of chlamydia, gonorrhea and infectious syphilis. In 2008,
74% of all new positive cases of HIV reported were among
men, with the highest rates among men between 40 and
49 years of age (32%). Women represent an increasing
proportion of those with positive HIV test reports in
Canada, and represented 26% of all new cases reported in
2008. Women between 30 and 39 years account for 35%
of reported HIV infections among all females.
2
People who are physically active are at a lower risk of
poor health. Less than one-fifth of adults and one-tenth
of children met the World Health Organization and
Canadian guidelines for physical activity in 2007–2009.
Less healthy eating, including over-consumption,
combined with inadequate physical activity, can lead to
increased body weights, and Canadians are experiencing
increasingly high rates of obesity and overweight. In
2007–2009, 24% of Canadian adults were considered
to be obese and 37% overweight, an increase from the
reported 12% and 32%, respectively, in 1978–1979. For
both adults and children, a larger percentage of males
than females are either overweight or obese.
Sex, Gender and Public Health
While there are no single agreed-upon definitions,
“sex” typically refers to the biological and physiological
characteristics that distinguish females and males, and
“gender” is associated with the socio-cultural factors
that societies ascribe to females and males. However, as
opposed to the traditional binary view of men/women and
male/female, many of the attributes of sex and gender
can be described on continuums to account for the ranges
of characteristics and behaviours that exist.
Public health serves to support, promote and protect
the health of all Canadians. Sex and gender are critically
important to all areas of public health – research,
programs and policies. The interrelationships between sex,
gender and the broader determinants of health influence
risks, opportunities, behaviours and outcomes of men,
women, boys and girls differently across the lifecourse.
Applying a sex and gender lens to health identifies
patterns and gaps in how both can influence health
status. Sex- and gender-based analysis (SGBA) is a
systematic approach to research, policies and programs
that explores biological (sex-based) and socio-cultural
(gender-based) similarities and differences between
women and men, boys and girls. Doing so helps to ensure
that interventions are effective and inclusive.
Sex, Gender and Health Outcomes
Biological and socially constructed differences between
men and women interact to affect individual susceptibility
to particular health risks, health-seeking behaviours,
outcomes and treatments. By examining health outcomes
in the areas of physical health (e.g. hypertension), mental
health (e.g. depression) and sexual health (e.g. STIs), it
can be seen how and why these differences occur in terms
of the influence of sex and gender.
Physiological and biological changes that occur across
the lifecourse affect an individual’s likelihood of
particular health outcomes as well as their responses to
developmental stages and life events. Differences in rates
of hypertension (high blood pressure) and depression in
men and women suggest that sex hormones may play a
significant role in these rates. With increasing androgen
levels (i.e. testosterone) during puberty, blood pressure
is higher in boys than in girls. Conversely, women
may be protected from high blood pressure by female
sex hormones (i.e. estrogens). Between puberty and
menopause, rates of depression in women are two to
three times higher than in men. When levels of estrogens
decrease after menopause, hypertension prevalence
increases in women while rates of depression begin to
decrease. Dramatic hormone changes during pregnancy
and postnatally can also cause forms of hypertension
and can increase the risk of depression among women.
Biological differences between men and women can
also mean that their bodies respond differently to
various bacteria and organisms. For example, women’s
anatomy makes them more susceptible to acquiring
STIs through some forms of sexual contact. Sex
also influences treatment and medication responses
(e.g. antihypertensive medications are significantly less
likely to control women’s blood pressure) as well as
self-reported signs and symptoms (e.g. depressed women
experience more feelings of helplessness, worthlessness
Executive Summary
and persistent sad moods whereas men experience
discouragement, anger and irritability).
Incorporating Sex and Gender into
Health Interventions
Broad and targeted Canadian and international
interventions – research, programs, initiatives and policies
– that have addressed health issues and/or risk factors
and consider and/or incorporate sex and gender into their
design or execution can make a difference to health. A
sex- and gender-based approach is part of systematically
planned interventions that are consistent with population
health approaches.
Canada embarked on its commitment to sex- and genderbased work when evidence surfaced that pointed to gaps
and inequalities created by not addressing research,
programs and policies in the context of sex and gender.
By ratifying the Beijing Declaration, Canada agreed to
promote gender mainstreaming in all relevant policies and
programs such as the Health Portfolio’s Sex and GenderBased Analysis Policy. Embracing the inter-relationships
between sex, gender and the broader determinants of
health needs to become part of mainstream practice in
public health.
Approaches to preventing and managing the onset of
chronic disease must reflect differences among men,
women, boys and girls so as to most effectively address
and/or avoid adverse health outcomes. Being overweight
and/or obese can influence the development of many
chronic diseases. As such, it is important to address
unhealthy weights as early as possible, and school-based,
gender-focused health promotion interventions are ideally
positioned to address the gender differences that occur in
the physical activity and food and beverage consumption
behaviours of boys and girls. Gendered experiences,
stereotypes and societal expectations can influence
approaches to physical activity. Perceptions of girls’ and
boys’ sports and activities can influence participation
across the lifecourse. Communities across Canada offer
programs that educate and encourage women and girls in
sports and challenge gender stereotypes and homophobia.
The perception of cardiovascular disease (CVD) as a
“man’s disease” has affected the cardiac health of women,
who have been under-represented in cardiovascular
research, treatment and health prevention practices. CVD
has only recently been recognized as one of the leading
causes of death and ill health among Canadian women.
Whereas factors such as sex affect symptom presentation
and disease identification, gender can influence health
care seeking behaviours as well as health practitioners’
reactions to symptoms. Heart health organizations in
Canada are targeting women in social marketing, public
awareness and health promotion campaigns to encourage
them to learn about cardiac health.
Sex, gender and mental health
In Canada’s first mental health strategy, gender and
sexuality are considered priority areas in addressing
mental health disparities. Addressing mental health with
a sex and gender lens requires increasing understanding,
providing sex and gender sensitive services, reducing
women’s risk factors and improving capacity of LGBTQ
organizations to address stigma and offer support. Gender
roles, life experiences and event-specific risk factors are
often cited as contributors to common mental disorders
that disproportionately affect women. The reproductive
health of women, particularly postpartum depression
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Gender plays a key role in the health-seeking behaviours
of men and women. Women generally access the health
care system more often than do men and therefore are
more likely to be routinely screened, tested and treated
for health conditions such as hypertension, depression
and STIs. Attitudes and misinformation surrounding STI
testing procedures, the non-detection of symptoms,
questions of confidentiality, and stigma can act as
deterrents to testing for both males and females of all
ages. The socially constructed concept that men must
be tough and strong can foster silence among some men
which may prevent accurate diagnosis and treatment of
depression. Socially constructed gender roles may also
influence different sources of stress among women and
men, increasing their risk for hypertension or poor mental
health (i.e. depression). In addition, power relations
within sexual encounters may affect decisions and the
ability to negotiate the use of protection (e.g. refusal
to use condoms) influencing the risk, incidence and
outcomes of STIs.
Sex, gender and physical health
3
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Executive Summary
4
(PPD), may have long-term health outcomes for mothers
and their children. Addressing the outcomes of maternal
depression involves a greater understanding of the
complex interactions between mental health and other
factors. Efforts to increase community awareness and
understanding of PPD as well as supports to help manage
it are underway. Systematic reviews and evaluations
show that positive outcomes for a mother’s well-being
and infant care are achieved through programs that
offer individual support to help parents make the
transition into parenthood. Also increasingly programs are
recognizing the importance of men’s experiences on their
partners’ pregnancies and mental health, as well as men’s
own experiences influence their own mental health during
fatherhood. Identifying paternal postpartum is lagging
due to the tools used to routinely measure effects in
women need to adapt to better reflect men’s symptomatic
criteria. Additional research is needed to expand the focus
of postpartum to new fathers from various cultural and
socio-economic backgrounds.
Recent research and programs reveal that men are at risk
for a range of mental health problems, which are often
underdiagnosed and under-reported. Four out of five
suicides are completed by men. Addressing issues such as
suicide through prevention practices is challenged by a
number of factors including gender differences in suicide
and suicide ideation. Factors to consider when addressing
the mental health of men and boys include the nondetection of male clinical depressive symptoms, a social
inability to show weakness, low mental health literacy
and the use of risky behaviours such as substance use and
violence that can mask mental health problems. Healthpromoting strategies for men in community settings are
growing. The strategies and programs such as Men’s Sheds
have been shown to be effective in addressing men’s
health issues, while allowing social networking and the
development of practical skills. Mental health practices
found that more men would seek help for mental health
issues if the programs suited those with traditional
male gender roles. Broad-based media campaigns that
challenge male norms must be intensive and target
at-risk populations. In addition, some jurisdictions have
developed suicide prevention strategies that include broad
to targeted initiatives.
Mental health stigma continues to be a barrier to how
people seek and acquire treatment for mental health
disorders. A population health approach is necessary
to address gender-specific risk factors as well as to
improve access and delivery of mental health policies
and programs. Early education and increasing awareness
of mental health disorders is important in challenging
misconceptions about mental illness.
Sex, gender, healthy relationships and
sexual health
Healthy sexuality involves acquiring knowledge, skills and
behaviours for positive sexual and reproductive health
as well as options to avoid negative outcomes (e.g. STIs
and unplanned pregnancies). Interventions that promote
healthy relationships should be delivered as early as
possible so that young men and women learn to value
and understand the importance of respect, equality and
harmony with relationships. To be effective, programs that
target at-risk youth need to address a range of individual
experiences as well as account for other factors such as
gender, culture and sexual orientation. Communities and
schools also play an important role in integrating and
increasing the scope of interventions that help young
people develop healthy relationships including sexual
relationships. Interventions that have shown promise in
supporting the prevention of intimate partner violence
are those that provide the tools to ensure the safety of
victims and potential victims and that address violence
in a broader context of equality, rights and responsibility.
Healthy relationships focused on the concerns of sexual
and gender minorities can also challenge heteronormative
(the view of heterosexuality as the normal or preferred
sexual orientation) understandings of relationships,
opening up possibilities for expanding sexual health
education to address what constitutes healthy
relationships for sexual and gender minority youth and
adults.
Healthy relationships rely on having positive perceptions
of self-image and sexual health. Repeated exposure
to sexualized images can have negative effects on the
cognitive and emotional development of girls and boys
leading to poor body image, low self-esteem, eating
disorders and depression. School-based interventions can
Executive Summary
One area often overlooked is the sexual health practices
of older adults. Despite an increase in cases of STIs
among older adults, interventions designed to prevent
STIs among this population are limited. Practicing safer
sexual behaviours can depend on having access to
relevant health care and information or being able to
comfortably discuss practices with an available health
care practitioner. Stigma associated with sexual health
topics, in particular STIs, is a significant barrier to
testing, early diagnosis, accessing treatment and support
for all ages, genders and sexual orientations. Social
marketing campaigns and sexual educational programs
can be used to proactively address negative perceptions
of sexual health, gender and age and the changing social
trends and sexual practices of older adults.
Sex, gender and socio-economic determinants
Looking at sex and gender by selected health outcomes
is only part of the broader story, as there are many
cumulative socio-economic factors that directly or
indirectly influence health across the lifecourse. Examples
of socio-economic determinants, work, education and
parenting were selected for this report because they
influence other factors such as income. The effect
of gender on how occupational health issues are
experienced, expressed, defined and addressed can help
identify risk factors for both women and men. Genderbased stereotyping (e.g. who does what job, the societal
value attached to particular jobs, and associated risks
of the work) can increase health risks for both men
and women. Risk of injury and disease can be further
confounded by biology, workplace seniority, social status,
age, tasks, techniques and external life experiences.
Being able to identify and track workplace injuries, illness
and pain relies on having a health and safety program in
place that monitors activities. The lack of such a program
and other factors (e.g. reluctance of the employee or
employer to report problems) means that workplace
health outcomes are un- or under-reported. Workplace
interventions need to acknowledge the realities of work
such as risk, location and the role of confounding factors
(e.g. environment, assumptions). Challenging gender
stereotypes and addressing gender bias is necessary to
attract and retain individuals in non-traditional fields
such as nursing. A comprehensive gender analysis of
workplace experiences is necessary to address the worklife issues relevant to retaining male and female workers.
Many Canadians also participate in unpaid and informal
work such as informal care. More women than men provide
some type of informal care, and women spend more than
double the number of hours providing informal care. The
proportion of male caregivers has been increasing, with
men often caring more for partners with mental health
issues and dementia than they had in the past. Men in
caregiving roles have fewer opportunities for community
support and less social services. Research on programs
to support male caregivers is limited given their lack of
recognition in this role. Several programs in Canada that
support caregivers vary from financial support (e.g. wages,
tax relief, and labour policies) to community supports
and services. Results of a meta-analysis of caregiver
interventions determined that supportive interventions
were effective but that the effectiveness was dependent
on other factors including gender and ethnicity as well as
program deliverables (e.g. duration, setting).
Education is an underlying determinant for many health
outcomes. As with other social determinants, sex and
gender make a difference in how education is approached
and used and on the resulting health effects over the long
term. The number of Canadians who successfully complete
high school and seek some level of post-secondary
education, training or certification has increased over the
last two decades. Despite overall educational successes,
questions remain as to why boys are not faring as well
as girls in school. Applying a sex and gender lens to
educational attainment suggests looking at the criteria
used to measure success and checking for possible gender
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
reach a large number of children and youth; they have
been shown to reduce risks of HIV and AIDS, other STIs
and unplanned pregnancies over the long term. However,
barriers to effective school-based sexual health education
programs include allotted time or teaching materials
as well as the comfort level of students, teachers,
families and the community at large. Practices that
show promise include those that address sexual risk and
protective factors as well as non-sexual factors, programs
that increase the knowledge and skills of parents and
community members who interact with youth, and
programs that provide access to health services for all
youth and include diversity.
5
Executive Summary
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
bias in this measurement; the factors that encourage
in-school participation and academic practices and the
suitability of activities for gender and diversity; gender
roles and expectations after graduation; perceptions
of success; and teaching methods and suitability to
learning styles by gender and behaviour and management.
Strong role models at home are important for all children
to achieve academically and socially, and for boys in
particular male role models can positively influence their
academic performance.
6
The role that fathers play in parenting and building
healthy relationships should not be under-estimated.
Where fathers are positively involved, outcomes in their
children’s cognitive, emotional, relational and physical
well-being have been reported. Canada, as a society,
has made some progress in supporting research and/or
programs on fatherhood. Interventions that target fathers
are continuing to grow and recognize the importance
of fathers to the health and well-being of Canadians.
However, more can be done to see that knowledge about
father involvement is disseminated to professionals and
policymakers who wish to support families and healthy
child development.
Sex, Gender and Public Health –
A Path Forward
The majority of Canadians enjoy good to excellent
physical and mental health, and are living longer,
healthier lives. However, disparities do exist in the health
of Canadian women, men, girls and boys. These require a
better understanding of the many factors that contribute
to this difference. Since an individual’s sex and gender
play such a complex and crucial role in influencing
health behaviours, health outcomes and well-being, it
is essential that they be considered in the development,
implementation and evaluation of research, programs and
policies.
Given their extensive impact on every individual, there is
no “one size fits all” solution to address sex- and genderrelated health issues. Therefore, a broad, constantly
evolving understanding of sex and gender as key
determinants of health is essential.
Public health in Canada is a shared responsibility. As a
society, we must continue to understand the importance
of efforts to promote health and well-being, and where
possible, prevent disease and illness. Actions to address
the health and well-being of Canadians must be coordinated and multi-pronged and take into account
Canada’s extensive geography and diversity. Actions must
also be sustainable and not limited to one-time efforts
with short-term impacts. Moving forward requires building
on existing initiatives and measuring their impact so we
are better able to effect change. Understanding what
makes some programs and initiatives work and adapting
them to fit the diversity of Canadians is the challenge
we must face if we want to continue to improve the
health of Canadians. Collectively, Canada has the capacity
to understand and address the specific issues of our
diverse population to ensure that all Canadians have the
opportunity to live as healthy a life as possible.
Introduction
This report, the Chief Public Health Officer’s fifth on the
state of public health in Canada, focuses on how sex and
gender influence public health and the health status of
Canadians.
Why a report on the state of public
health in Canada?
Public health is about optimizing, promoting and
supporting the health of all Canadians through programs,
services and policies.5, 6 It involves collaborating across
Public health is defined as the organized efforts of
society to keep people healthy and prevent injury,
illness and premature death. It is the combination
of programs, services and policies that protect and
promote health.4
Public health also involves influencing the factors inside
and outside the health system that impact our health.
Commonly referred to as the determinants of health,
these factors 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, all of
which affect Canadians throughout their lifecourse.10, 11
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Canada’s Chief Public Health Officer (CPHO) has a
legislated responsibility to report annually to the Minister
of Health and to Parliament on the state of public health.1
(See the textbox “The Chief Public Health Officer’s Report
on the State of Public Health in Canada.”) The Public
Health Agency of Canada (PHAC) and the position of
Canada’s CPHO were established in 2004 to help protect
and improve the health and safety of all Canadians.1-3 In
2006, the Public Health Agency of Canada Act confirmed
the Agency as a legal entity and further clarified the roles
of the CPHO and the Agency.1 (See the textbox “The role
of Canada’s Chief Public Health Officer.”)
many sectors of society to identify and reduce stressors,
risk-taking and other threats to health. By helping people
have healthier, longer lives, the public health system can
relieve some of the pressures on hospitals and the acute
health care system.5, 7-9
7
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Introduction
8
The lifecourse is a path that an individual follows
from birth to death.14 This path can change or evolve
at any life stage (e.g. childhood, adolescence, young
adulthood, mid-adulthood and later life) and varies from
person to person depending on biological, behavioural,
psychological and societal factors that interact to
influence health outcomes of men, women, boys and
girls.14, 15 Life events, cultural norms and social roles
and experiences also interact with different life stages
resulting in various effects and outcomes.16, 17 A lifecourse
approach helps identify health trends and the links
between exposures and outcomes. Applying a sex and
gender lens to health can help identify the patterns
and gaps in how both sex and gender influence people’s
health status.18 Interventions, including public policies,
can then be targeted to address these trends and links to
achieve optimal population health and well-being.14, 19-21
The lifecourse model is a way to study the impact
of physical and social exposures at various stages
in life – from the prenatal period through to later
life – on the health of people and the overall
population.12, 13
The goals of the report
The CPHO’s reports are intended to highlight specific
public health issues that the CPHO has determined
warrant further discussion and action in Canada. They
also inform Canadians about the factors that contribute
to improving their health. These reports do not represent
Government of Canada policy; nor are they limited to
reporting on federal or provincial/territorial activities.
As such, they are not intended to be frameworks for policy
but rather a reflection of the CPHO’s perspective, based on
evidence, on the state of public health across the country.
This particular report illustrates how sex and gender
interact with each other and with other determinants
of health to influence health, health behaviours and
outcomes among Canadians; it outlines interventions,
programs and policies that have maintained and
improved the current and future health and well-being
of Canadians; and it identifies priority areas for action
where Canada as a society can better incorporate sex- and
gender in public health to influence the effectiveness of
health promotion and disease prevention efforts.
What this report is about
This report investigates how sex and gender affect the
health of Canadians and highlights why they are relevant
to all Canadians, regardless of their age, income or
cultural background. It also considers the relevance of
applying a sex and gender lens to research, programs,
initiatives and policies that aim to achieve better health
outcomes for all Canadians.
In developing this report, questions arose about whether
there should be separate reports for women’s and for
men’s health. However, it was felt that separate reports
would be divisive and exclusionary. Instead, this report
draws attention to sex- and gender-rooted health
issues and health inequalities. This report is not meant
to be a compendium of all issues related to sex and
gender. Rather, the intention is to highlight examples
of the progress Canada has made and the challenges
that lie ahead in incorporating sex and gender into the
development, implementation and evaluation of research,
policies and programs in public health.
For the purposes of this report, “sex” refers to the
biological characteristics (i.e. anatomy and physiology)
that distinguish females and males, and “gender” to
socially and culturally constructed roles, relationships,
norms, beliefs, attitudes, personality traits, behaviours
and values that society ascribes to men, women and
gender minority individuals on a differential basis.22, 216
However, it should be noted that there are no universally
accepted definitions or easy separation of the terms.
The Canadian Institutes of Health Research’s Institute of
Gender and Health makes a social/biological distinction
between gender and sex with the caveat that they are
inter-related and potentially inseparable and that the
definitions of sex and gender are evolving.23 Readers of
the Report should keep in mind that the terms “male,”
“female,” “men” and “women” are used interchangeably
as appropriate in each section.
Introduction
The Role of Canada’s Chief Public Health Officer
The Chief Public Health Officer (CPHO):
In a public health emergency, such as an infectious disease outbreak or natural disaster, the CPHO:
•• briefs and advises Canada’s Minister of Health and others as appropriate;
•• works with counterparts in other departments, jurisdictions and countries, as well as with experts and
elected officials, to communicate with Canadians about how to protect themselves and their families;
•• delivers public health information to Canadians via media appearances, public statements, updates to the
PHAC website, and columns and public advertisements in daily and community newspapers;
•• provides direction to PHAC staff, including medical professionals, scientists and epidemiologists, as they
plan and respond to the emergency;
•• leads daily national teleconferences, as appropriate, with federal government scientists and experts to
share information and plan outbreak responses; and
•• co-ordinates with jurisdictions through regular teleconferences with Canada’s provincial and territorial
Chief Medical Officers of Health and others.3
What does the report cover?
This Report is organized into three distinct sections:
The State of Public Health in Canada; Sex, Gender and
the Health of Canadians; and A Path Forward.
The first part of the report describes the health and
well-being of Canadians. Chapter 1, “The State of Public
Health in Canada,” presents a demographic profile of the
Canadian population and examines the current physical,
mental health and sexual health of Canadians. It looks
at socio-economic determinants of health and their
relationship with health status and well-being. It also
describes risk-taking behaviours, including risky sexual
behaviours and substance use and abuse. Where possible,
data is presented to illustrate the similarities and/or
differences in health between individuals in Canada. This
section is not intended to provide an analysis on how sex
and gender impact health outcomes. Instead, it presents a
high-level “snapshot” of health and well-being in Canada.
The second part of the report examines sex and gender
and how they influence health and well-being of
Canadians. Chapter 2, “Sex, Gender and Public Health,”
introduces the concepts of sex and gender and how they
are linked to health behaviours and outcomes, both
directly and through their connection to the determinants
of health. It also briefly explores sex- and gender-based
analysis as a tool for analyzing how both sex and gender
influence health. Chapter 3, “Sex, Gender and Health
Outcomes,” uses specific examples in the areas of
physical, mental and sexual health to illustrate how sex
and gender impact health outcomes, including symptoms,
treatment effects and access to care. It also explores the
reasons why differences occur. Chapter 4, “Incorporating
Sex and Gender into Health Interventions,” examines how
sex and gender can be incorporated into the development
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• is the deputy head responsible for the Public Health Agency of Canada (PHAC), reporting to the
Minister of Health;
•• is the federal government’s lead public health professional, providing advice to the Minister of Health
and the Government of Canada on health issues;
•• manages PHAC’s day-to-day activities;
•• works with other governments, jurisdictions, agencies, organizations and countries on public health matters;
•• speaks to Canadians, health professionals and stakeholders about issues affecting the population’s health;
•• is required by law to report annually to the Government of Canada on the state of public health in Canada; and
•• can report on any public health issue as needed.3
9
Introduction
of research, programs, initiatives and policies that
influence health and well-being. The chapter provides
examples of interventions, and discusses their efficacy in
addressing sex and gender in health.
The third part of the report focuses on how Canada,
as a society, can improve the health and well-being of
Canadians. Chapter 5, “Sex, Gender and Public Health –
A Path Forward,” summarizes the findings from preceding
chapters, highlights priority areas for action, proposes
recommendations and identifies strategies to better
incorporate sex and gender into public health.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
The Chief Public Health Officer’s Report on the State of Public Health in Canada
10
As detailed in the Public Health Agency of Canada Act,
the Chief Public Health Officer (CPHO) is required 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. Upon receipt, the
Minister shall lay the report before Parliament on any
of the first 15 days on which the House is sitting.1
The PHAC 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 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
The inaugural report, The CPHO’s Report on the State
of Public Health in Canada, 2008: Addressing Health
Inequalities, provided the CPHO with the opportunity
to present an overview of public health in Canada,
including the health status of Canadians, as well as the
country’s successes and ongoing challenges in reducing
health inequalities.24
The CPHO’s Report on the State of Public Health in
Canada, 2009: Growing Up Well – Priorities for a Healthy
Future highlighted the health status of children ages
0 to 11 years, and focused on the importance of the
early years on the long-term health of individuals and
populations.15
The CPHO’s Report on the State of Public Health in
Canada, 2010: Growing Older – Adding Life to Years
focused on the health status of Canada’s seniors ages
65 years and over. The report highlighted the fact that
Canada’s seniors are living longer and that many are
experiencing good overall health. The report described
physical and mental health, economic and social
well-being, access to care and services, and abuse and
neglect as some of the main areas of seniors’ health
and well-being.25
The CPHO’s Report on the State of Public Health in
Canada, 2011: Youth and Young Adults – Life in
Transition focused on the health status of Canada’s
youth (12 to 19 years) and young adults (20 to 29
years). The report identified factors that influence their
health and how we can create the conditions necessary
for young Canadians to transition into adulthood. The
report highlighted this period of the lifecourse as it is
a time of significant transition, where many life-long
attitudes and behaviours are established, setting the
stage for future health and well-being.20
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Part I: The State of
Public Health in Canada
11
12
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
CHAPTER
1
The State of Public Health in Canada
Data presented throughout this chapter often come
from surveys. Despite the inherent limitations
of self-reported data, such as the subjectivity
of individual responses and the exclusion of
those living in institutions and on reserves, they
can provide valuable information otherwise not
available.
Who we are
The Canadian population was 33.5 million in 2011,
divided almost equally between males (49%) and females
(51%).26 Projected proportions for 2011 estimate the
Aboriginal population at 1.4 million (62% First Nations,
31% Métis and 4% Inuit), about 4% of the total Canadian
population.27, 28 The foreign-born population is projected
to account for more than 20% of the total population
in 2011.29 Based on 2006 data, males make up 49% and
48% of the Aboriginal and foreign-born populations
respectively.30, 31
The population is also aging. The number of Canadians
65 years and older increased between 1976 and 2011 from
9% to 15% of the total population.26, 28 This proportion
is projected to grow to nearly one-quarter (24%) by
2036 (see Figure 1.1).37 In 2011, children under the age
of 12 and youth between 12 and 19 years accounted
for less than one-quarter of the population (13% and
10% respectively), whereas young- and middle-aged
adults between 20 and 64 years made up 62% of the
population.26 Although the population is divided almost
equally by sex, the proportion of males and females varies
somewhat by age group. From birth to 29 years, males
slightly outnumber females at 51% of the population. The
proportions reverse between 30 and 64 years with females
at 51%.26 From the age of 65 years onward, the male
proportion continues to diminish: 47% males compared
Figure 1.1 Population distribution by age group,
Canada, 1976, 2011 and 203626, 28, 37
Population
in thousands
1976
2011
2036
3,500
3,000
2,500
2,000
1,500
1,000
500
0
90 and older
85 to 89
80 to 84
75 to 79
70 to 74
65 to 69
60 to 64
55 to 59
50 to 54
45 to 49
40 to 44
35 to 39
30 to 34
25 to 29
20 to 24
15 to 19
10 to 14
5 to 9
0 to 4
About 84% of Canadians lived in urban areas in 2011.32, 33
Since 2001, nearly 90% of the country’s population
growth has been concentrated in Canada’s large census
metropolitan areas.34 This is due, in part, to an increasing
number of younger rural residents having moved to urban
areas, leaving senior residents to make up more of the
overall rural population.35 From 2001 to 2006, nearly
1 in 7 Canadians between 25 and 44 years moved from
the downtown areas in Toronto, Vancouver and Montreal
to surrounding suburbs.36 Those most likely to move to
the suburbs included new parents and people with college
or trades diplomas and with after-tax income between
$70,000 and $99,999.36
Age group (in years)
Source: Public Health Agency of Canada using data from Census 2011 and
Canadian Population Estimates and Projections, Statistics Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
This chapter presents an overview of the demographics of
the Canadian population, including their life expectancy
and patterns of ill health, disability and mortality. Also
discussed are determinants that influence health –
income, employment, education, health behaviours and
access to health care. Although some health challenges
can be related to our genetic make-up, evidence shows
that income, education, employment and other social
determinants of health can cause or influence the health
outcomes of individuals and communities. While it is
important to discuss the overall state of public health
in Canada, it is equally important to acknowledge that
not all populations experience health at the same level.
Taking this into account, issues associated with key
populations (by age, sex, origin or other combinations),
are explored further where possible.
13
13
CHAPTER
1
The State of Public Health in Canada
with 53% females between 65 and 79 years, and 37%
males compared with 63% females among Canadians
80 years and older.26
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
An exception to the aging population trend can be found
among Aboriginal peoples who have a much younger
population.38 In 2006, almost one-third (31%) were
between 12 and 29 years (49% males and 51% females)
compared with 23% in the non-Aboriginal population.39, 40
Within the Inuit population in the same year, 35% were
youth and young adults between 12 and 29 years (50%
males and 50% females).39, 40
14
The life expectancy of Canadians has increased
dramatically over the past century to the point where
a male born in Canada today can expect to live about
79 years and a female about 83 years.41 Canadian women
have historically experienced greater longevity, but
between 1992–1994 and 2006–2008, the difference
in life expectancy at birth between Canadian men and
women decreased from 6.1 years to 4.6 years.41 This is
not because women are dying at a younger age, but rather
because men are living longer.41
was the highest among Aboriginal populations (71.9 years
for males and 77.7 years for females), followed by First
Nations (71.1 years for males and 76.7 years for females)
and was lowest among Inuit (62.6 years for males and
71.7 years for females).42 As with the general population,
life expectancy among Aboriginal females is consistently
higher than among males.42
Variations in life expectancy are also seen by income.
As shown in Figure 1.2, life expectancy in higher
income neighbourhoods exceeded those in lower
income neighbourhoods in 2005–2007.43 Females at
every neighbourhood income level have a higher life
expectancy than males, with poor males being particularly
disadvantaged.43 As seen in Figure 1.2, the life expectancy
gap between the lowest and highest income groups is
4.7 years for men but just 2.3 years for women,
suggesting that income levels may have a greater
effect among men.43
Our health
Life expectancy among the Aboriginal population
continues to be lower than among the general Canadian
population. In 2001, life expectancy at birth for Métis
According to the 2010 Canadian Community Health Survey
(CCHS), the majority of Canadians 12 years and older
reported their health as either excellent (22%) or very
good (38%).44 Even more reported their mental health
Figure 1.2 Life expectancy at birth by sex and
neighbourhood income quintiles, Canada, 2005–200743
Figure 1.3 Excellent or very good self-perceived health
and mental health by age group, Canada, 201044
Life expectancy
at birth in years
Males
Percent of the
population
Females
86
84
83.3
83.0
82
78
77.8
76
78.7
84.0
83.3
81.7
80
74
79.1
80.3
80
70
60
Mental health
72
78
74
72
64
53
44
30
20
70
10
Q2
Q3 - Middle
Q4
Q5 - Highest
Income quintile
Source: Greenberg, L. & Normandin, C. (2011). Disparities in life expectancy at
birth. Health at a Glance, April 2011(1), 1-13.
0
72
63
40
75.6
Q1 - Lowest
75
67
50
72
0
Health
90
34
12 to 19
20 to 29
30 to 54
55 to 64
65 to 79 80 and older
Age group (in years)
Source: Public Health Agency of Canada using data from Canadian Community
Health Survey, Statistics Canada.
CHAPTER
1
The State of Public Health in Canada
Table 1.1 Our health status
Our health status
Males
Reported health and life expectancy
Perceived health, very good or excellent* (percent of population aged 12+ years)
Perceived mental health, very good or excellent* (percent of population aged 12+ years)
Life expectancy at birth (years of expected life)
Health-adjusted life expectancy at birth (years of expected healthy life)
Females
Year
60.5
73.3
83.1
72.1
2010
2010
2006–2008
2004–2006
Patterns of ill health
Back problems* (percent of the population aged 12+ years)
Cancer incidence (new cases age-standardized per 100,000 population per year)
Diabetes prevalence (percent of the population aged 1+ years)
Arthritis* (percent of population aged 15+ years)
Asthma* (percent of population aged 12+ years)
High blood pressure* (percent of the population aged 30+ years)
Mood disorders* (percent of the population aged 15+ years)
18.5
456
7.2
12.8
7.1
24.2
5.0
19.6
369
6.4
19.7
9.8
24.4
8.2
2010
2011
2008–2009
2010
2010
2010
2010
Causes of death and premature death (per 100,000 population per year)
Cancers (deaths)
Circulatory diseases (deaths)
Respiratory diseases (deaths)
224.4
211.0
64.2
199.3
208.9
60.3
2008
2008
2008
1,543.8
1,106.6
862.4
446.7
205.3
50.3
1,516.6
444.2
317.6
173.8
162.5
17.9
2008
2008
2008
2008
2008
2008
Cancers, aged 0 to 74 years (PYLL)
Circulatory diseases, aged 0 to 74 years (PYLL)
Unintentional injuries, aged 0 to 74 years (PYLL)
Suicide and self-inflicted injuries, aged 0 to 74 years (PYLL)
Respiratory diseases, aged 0 to 74 years (PYLL)
HIV, aged 0 to 74 years (PYLL)
Abbreviations: HIV, human immunodeficiency virus; PYLL, potential years of life lost.
* Denotes self-reported data.
Note: More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
Source: Statistics Canada, Canadian Cancer Society and Public Health Agency of Canada.
A complete list of indicators, definitions and data sources can be found in Appendix C: Indicators of
Our Health and Factors Influencing Our Health and Appendix D: Definitions and Data Sources for Indicators.
as excellent (37%) or very good (37%).44 While both
proportions decreased with age, a greater decline is seen
for physical health than mental health (see Figure 1.3).44
A slightly higher proportion of females (61%) reported
very good or excellent health, whereas a slightly higher
proportion of males (75%) reported very good or excellent
mental health than females.45
Despite relatively high rates of very good or excellent
perceived health and mental health, not all years are spent
in good health.46 The health-adjusted life expectancy
(HALE) from 2004 to 2006 shows that, of their 78.9 years
of expected life, males spend the equivalent of 69.6 years
in good health. During the same period, females with a life
expectancy of 83.6 years had a HALE of 72.1 years.46
Patterns of ill health
The proportion of Canadians living with specific diseases
and health conditions varies across the population.
Although chronic health conditions are most often
experienced by – and associated with – older members of
the population, more than one-half (55%) of Canadians
12 years and older reported living with at least one of a
number of chronic health conditions (see Figure 1.4).44
The most commonly reported chronic health conditions in
2010 included back problems (19%), high blood pressure
(18%) and arthritis (16%).44 The proportion of females
who reported back problems or high blood pressure (20%
and 18% respectively) was similar to the proportion of
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
59.7
74.5
78.5
69.6
15
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The State of Public Health in Canada
Figure 1.4 Proportion of Canadians reporting one
or more chronic health conditions* by age group,
Canada, 201044
Percent of the
population
Percent of the
population
None
One
Two
Three
Four or more
100
Females
28
25
20
60
21
26
29
24
20
15
40
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Males
35
30
80
16
Figure 1.5 Self-reported back problems* by sex and age
group, Canada, 201044, 48
10
5
20
0
0
12 to 29
30 to 54
55 to 64
65 to 79
80 and older
8
10
12
5
12 to 19
20 to 29
30 to 54
55 to 64
65 and older
Age group (in years)
Age group (in years)
* Other than arthritis and fibromyalgia
* Conditions include asthma, fibromyalgia, arthritis or rheumatism, back
problems, hypertension (high blood pressure), migraines, chronic obstructive
pulmonary disease, diabetes, heart disease, cancer, ulcers, effects of a stroke,
bowel disorders, Alzheimer’s disease, chronic fatigue syndrome, mood disorders,
anxiety disorders, epilepsy, cerebral palsy, spina bifida, hydrocephalus, muscular
dystrophy, dystonia, Tourette’s syndrome, Parkinson’s disease, amyotrophic
lateral sclerosis (ALS), Huntington’s disease and multiple sclerosis.
Source: Public Health Agency of Canada using data from Canadian Community
Health Survey, Statistics Canada.
males who reported these conditions (19% and 18%
respectively).44 For arthritis, however, a significantly
larger proportion of females reported a diagnosis (19%
versus 13%).44
While rates of reported back problems are similar for
males and females, they do vary by age, as shown in
Figure 1.5.44 Although back problems are the most
commonly reported chronic health condition among
Canadians 12 years and older, the data do not identify
the specific nature of the problems affecting those
individuals. Back problems could include a range of
diseases or disorders such as scoliosis, sciatica, or
herniated discs as well as injuries to the spinal cord,
bones or muscle tissue.47 Most of these types of back
problems result in some degree of pain, from mild to
severe, and in some cases disabling. Among Canadians
12 years and older who reported having back problems in
Source: Public Health Agency of Canada using data from the Canadian
Community Health Survey, Statistics Canada.
2010, 50% of the females and 42% of the males also
reported experiencing regular pain or discomfort.44
High blood pressure has been linked to heart attacks,
heart failure, kidney failure, dementia and, among males,
erectile dysfunction and is a major contributor to some of
the top causes of death in Canada.49-51 In 2010, nearly
one-quarter (24%) of Canadians 30 years and older
reported having high blood pressure.44 This proportion
increases with age: 42% of those 55 years and older and
51% of those 65 years and older reported having high
blood pressure.44 It also varies by ethnicity and sex (see
Figure 1.6).44 Increasing physical activity, smoking
cessation and improving eating habits can all reduce the
risk of developing hypertension.52, 53
Over 100 different types of arthritis affect the joints,
ligaments, tendons, bones and other components of the
musculoskeletal system. These range in severity from mild
to crippling.54-56 Over the long term, arthritis can lead
to chronic pain and decreased mobility and function,
predisposing people to depression, cardiovascular disease,
diabetes and other chronic health conditions.54 Key
risk factors associated with arthritis include physical
inactivity, overweight and obesity, joint injuries, smoking,
CHAPTER
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The State of Public Health in Canada
Figure 1.6 Self-reported high blood pressure by sex, origin and select age groups, Canada, 201044
Males
Percent of the
population
Canadian-born
non-Aboriginal
Canadian-born
Aboriginal
Foreign-born
70
70
60
60
50
49
40
34
30
31
45
36
13
40
30 to 54
10
55 to 64
65 and older
0
58
54
42
30
13
Foreign-born
54
32
29
20
12
Canadian-born
Aboriginal
10
10
11
30 to 54
Age group (in years)
55 to 64
65 and older
Age group (in years)
Source: Public Health Agency of Canada using data from Canadian Community Health Survey, Statistics Canada.
occupation, and infection – all of which can be modified
to reduce risk.57
Of the 16% of Canadians over the age of 15 years who
reported being diagnosed with arthritis in 2010, 39%
were men and 61% were women.44 The prevalence of
arthritis was slightly lower among foreign-born (15%);
however, as with those born in Canada, more foreignborn women (19%) than foreign-born men (12%)
reported having it.44 Arthritis is also one of the most
prevalent chronic health conditions among the Aboriginal
population.58 According to the 2006 Aboriginal Peoples
Survey, 20% of respondents 15 years and older reported
being diagnosed with arthritis or rheumatism.59 That same
year, 21% of First Nations not living on a reserve (16%
of men and 25% of women), 21% of Métis (18% of men
and 24% of women) and 12% of Inuit (8% of men and
16% of women) reported being diagnosed with arthritis or
rheumatism by a physician.59
Although not among the most commonly reported
chronic health conditions, asthma, diabetes and cancer
also affect many people. Asthma, which is characterized
by coughing, shortness of breath, chest tightness and
wheezing, was reported by 9% of the population aged
12 years and older (7% of males and 10% of females)
in 2010.45, 60, 61 Early onset of asthma has been linked
to low birth-weight, exposure to tobacco smoke and
family history, whereas later onset has been linked to
genetic predisposition, obesity and increased exposure to
allergens and environmental factors such as pollution.60, 61
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.62 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.62-64
About 178,000 new cases of cancer were expected to be
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
0
Canadian-born
non-Aboriginal
50
52
20
10
Females
Percent of the
population
17
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The State of Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
diagnosed in 2011, 52% in men.65 Cancers of the
breast, lung, colon/rectum and prostate were expected
to account for 54% of all cancers diagnosed in the
same year.65
18
While the top three chronic health conditions most
commonly reported in 2010 were physical conditions,
many Canadians also reported some form of mental illness.
Mental illness can affect people of all ages, cultures,
education and income levels.66 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.66 In addition, sexual
orientation and sexual behaviour is a significant predictor
of mental health issues among vulnerable youth.67
The most commonly self-reported mental health condition
in 2010 was mood disorders such as depression, bipolar
disorder, mania or dysthymia.44, 48 The overall percentage
of Canadians 15 years and older who reported having
been diagnosed with a mood disorder was 6.9%.44 A
greater percentage of females (8.2%) than males (5.0%)
reported mood disorders, overall and within different
age groups (see Figure 1.7).44 Older adults between 55
and 64 years old had the highest reported rates (8.3%)
in the same year.44 The percentage was highest among
Figure 1.7 Self-reported mood disorder by sex and age
group, Canada, 201044
Percent of the
population
Males
Females
12
10
10.0
9.9
8
6.8
6
4
2
0
5.8
5.3
6.7
4.3
6.5
4.2
2.8
15 to 19
20 to 29
30 to 54
55 to 64
65 and older
Age group (in years)
Source: Public Health Agency of Canada using data from Canadian Community
Health Survey, Statistics Canada.
Aboriginal people not living on a reserve (11.7%), with
females having a much larger percentage of self-reported
diagnoses at 14.2% compared with 8.9% for males.44
Rates of mental illness in Canada may be underestimated
as many people remain undiagnosed and those with
severe conditions may not be captured at all.68
Causes of death
In 2008, cancers became the leading overall cause of
death in Canada (30%), followed by circulatory diseases
(29%) and respiratory diseases (9%) (see Figure 1.8).69-88
While cancers are the number one cause of death for
males (31% of male deaths), females most often died
due to circulatory diseases (30% of female deaths).69-88
Deaths related to circulatory disease were most often
due to ischaemic heart (53%), cerebrovascular (20%)
and hypertensive (3%) diseases.77 While ischaemic heart
disease caused more deaths among males (56%), more
females died of cerebrovascular (59%) and hypertensive
(61%) diseases (see Figure 1.8).77 Other causes of death
also affect one sex more than the other. Of deaths
related to injuries and poisoning, almost two-thirds
(64%) were among males.87 Males also accounted for
about three times as many deaths due to assaults (79%),
CHAPTER
1
The State of Public Health in Canada
Figure 1.8 Number of deaths by select causes and sex, Canada, 200869-88
Females
All other
16,804
Cerebrovascular
disease
13,870
All other
43,782
Total deaths
238,617
Transport
2,848
All other
36,683
Cancers
71,948
Assault
565
Falls
3,098
Alzheimer’s disease
and other dementia
16,775
Prostate
3,720
Source: Public Health Agency of Canada using data from Canadian Vital Statistics, Death Database, Statistics Canada.
suicide (75%) and transport incidents (72%).87 On the
other hand, the female proportion of all deaths due to
Alzheimer’s disease and other dementias (68%) was more
double that of men.73, 74
Because the population distributions of males and
females by age are not identical, the age-adjusted sexspecific mortality rates due to these causes, particularly
for deaths in older age groups, may give a better
indication of mortality risk (see Figure 1.9). For example,
although only 12% more of all ischaemic heart disease
deaths occurred among males than females, the agestandardized mortality rate for males was twice that of
Chronic lower
respiratory
diseases
10,923
Breast
5,006
Lung and
bronchus
18,697
Colon, rectum
and anus
7,842
females – 110 deaths per 100,000 population compared
with 55 deaths per 100,000 population.28, 77 Whereas
females die more often from cerebrovascular disease
than do males, the fact that females live to an older
age and suffer those deaths later in life results in males
actually having a higher age-standardized mortality rate
of 31 deaths per 100,000 population compared with
27 deaths per 100,000 female population.28, 77 For deaths
occurring at younger ages when the ratio of females to
males is more even, the differences in cause-specific
age-standardized mortality rates more closely resemble
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Circulatory
diseases
69,945
Respiratory diseases
20,728
Injuries and poisonings
15,439
All other
5,228
Influenza and
pneumonia
5,386
All other
4,419
Hypertensive
disease
2,337
Ischaemic heart
disease
36,934
Suicide
3,700
Males
19
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The State of Public Health in Canada
Figure 1.9 Age-standardized mortality rate by sex and
select causes of death, Canada, 200828, 70, 73, 74, 77, 78, 87
Cause of death
Males
110
55
31
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Cerebrovascular
disease
20
Females
116
Ischaemic heart
disease
27
37
5
Hypertensive
diseases
5
In 2008, most years of lost life were due to premature
deaths associated with cancers (1,530 years per
100,000 population), circulatory diseases (777 years
per 100,000 population) and unintentional injuries (591
years per 100,000 population).89 While men and women
had comparable PYLL rates for cancers and respiratory
diseases, PYLL rates for circulatory diseases, unintentional
injuries, suicide and self-inflicted injuries as well as
human immunodeficiency virus (HIV) infection were more
than double for men than for women (see Figure 1.10).89
57
Injuries and
poisonings
24
16
Suicide
Transport
While knowing the number of deaths due to a particular
disease or condition is important to 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
or condition has on the health of the population. For
example, if a Canadian dies of cancer at age 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).
188
Circulatory
diseases
5
13
5
Factors influencing health
201
Cancers
143
Economic and social factors such as education,
employment and income have a direct bearing on
health.10, 90 While some health challenges can be related
to our genetic make-up, evidence shows that Canadians
with adequate shelter, a safe and secure food supply,
access to education, employment and sufficient income
for basic needs adopt healthier behaviours and have
better health.
55
Lung and
bronchus
36
Respiratory
diseases
35
58
Chronic lower
respiratory
diseases
31
19
Alzheimer’s
disease and other
dementias
30
33
0
25
50
the magnitude of differences in numbers of deaths as
seen in Figure 1.9.
75
100
125
150
175
200
225
Age-standardized mortality rate*
* per 100,000 population
Source: Public Health Agency of Canada using data from Canadian Population
Estimates and Projections, and Vital Statistics, Death Database, Statistics
Canada.
In general, an improvement in any of these can produce
an improvement in both health behaviours and outcomes
at the individual, group or population level. These social
determinants of health strongly interact to influence
overall health, and they show important similarities and
differences by sex.
Education
Between the 1990/1991 and 2010/2011 school years,
the percentage of Canadians between 20 and 24 years
who completed high school increased from 81% to 90%.91
Figure 1.10 Age-standardized potential years of life
lost by sex and select causes of death, Canada, 200889
Years of life lost
per 100,000
population
Males
1,750
1,517
1,250
Males
Females
25
1,544
1,500
Figure 1.11 High school non-completion rate by sex,
population aged 20 to 24 years, Canada, 1990/1991
to 2010/201191
Percent of the
population
Females
1
CHAPTER
The State of Public Health in Canada
20
1,107
1,000
15
862
750
10
163
205
447
174
5
18
50
HIV
Respiratory
diseases
Suicide and selfinflicted harm
Unintentional
injuries
Circulatory
diseases
Cancers
0
318
444
250
Cause
Source: Public Health Agency of Canada using data from Canadian Vital
Statistics, Death Database, Statistics Canada.
Men, however, continue to have consistently higher
non-completion rates when compared with women, with
89% versus 92% completing high school in 2011 (see
Figure 1.11).91 In the 2009/2010 school year, the high
school non-completion rate of 6% for the foreign-born
population aged 20 to 24 years was lower than the overall
Canadian rate.92 Conversely, Aboriginal peoples aged
20 to 24 years not living on a reserve had the highest
rates of high school non-completion, averaging 26% over
the 2007/2008 to 2009/2010 school years – more than
double the rate for the non-Aboriginal population.92
Between the 1990/1991 and 2010/2011 school years, the
percentage of Canadians between 25 and 34 years who
had completed a post-secondary education increased from
44% to 68%.91 Again, differences can be seen between
males and females, with the number of women in this
category increasing sharply from 44% in 1990/1991 to
72% in 2010/2011, whereas the number of men increased
moderately, from 45% to 64% in the same time.91
0
1990/1991
1995/1996
2000/2001
2005/2006
2010/2011
Year
Source: Public Health Agency of Canada using data from Labour Force Survey,
Statistics Canada.
In 2006, two-thirds (70%) of Canada’s foreign-born
population between 25 and 34 years had completed
post-secondary studies, with more women (72%)
completing studies than men (68%).93 About 42% of the
Aboriginal population (37% of First Nations, 34% of Inuit
and 50% of Métis) between 25 and 34 years were postsecondary graduates (diploma, degree or certificate in
apprenticeship or trades, college or CEGEP, or university)
in 2006, with a higher rate among women (45%) than
men (38%).94 In the same year, 9% of Canadians between
25 and 34 years had completed a post-secondary degree
above bachelor level, in comparison with only 2% of the
Aboriginal population.94
Between 1991 and 2009, the number of people who
completed a registered apprenticeship training increased
by 57%.95 Graduation rates increased by 49% for males
and by 176% for females.95 The greatest increases for men
were seen in training to be landscape and horticulture
technicians and specialists; heavy equipment operators;
plumbers, pipefitters and steamfitters; welders; and
hairstylists and aestheticians.95 For women, the greatest
increases were in training to be plumbers, pipefitters
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
500
21
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1
The State of Public Health in Canada
and steamfitters; welders; electricians; carpenters; and
electronics and instrumentation technicians.95
Employment and working conditions
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Unemployment and a stressful or unsafe workplace have
been associated with poorer health outcomes.10, 90 People
who have more control over their work circumstances and
fewer stress-related demands associated with their job
tend to be healthier and live longer than those in more
stressful or riskier work environments.10, 90
22
Over the past century, Canada has transitioned from
being a primary producer of agricultural produce and raw
materials to an industrial nation with a robust service
sector economy. In 1911, more than one-third (37%) of
the employed population worked in agriculture, forestry
and fishing; by 2006 only 3% worked in those same
industries.96, 97 Today, wholesale and retail trade (15%);
health care and social assistance (10%); and educational
services (7%) are the main sectors of the Canadian work
force.97
In 2011, the unemployment rate for young Canadians
between 15 and 24 years was 14.2%, with clear
differences between males (15.9%) and females (12.4%)
(see Figure 1.12).98 While the unemployment rate of
16.6% among recent immigrants in this age group is
higher than the national rate, the rate of 7.8%
among immigrants who have been in Canada more
than 10 years was significantly lower in the same year.99
The unemployment rate for Canadians between 25 and
54 years was 6.2%, with little difference between males
(6.4%) and females (6.0%) in 2011 (see Figure 1.12).98
The unemployment rate among immigrants (8.4%) was
higher than the national rate, regardless of length of
time since immigration (10.8% among recent immigrants;
7.1% among immigrants who have been in Canada
10 or more years).99
Figure 1.12 Unemployment rate by select age groups and sex, Canada, 1990 to 201198
15 to 24 years
Percent of the
labour force
Males
25
25
20
20
15
15
10
10
5
5
0
1990
1995
2000
2005
25 to 54 years
Percent of the
labour force
Females
2010
0
1990
Males
1995
Year
Source: Public Health Agency of Canada using data from Labour Force Statistics Survey, Statistics Canada.
2000
Year
Females
2005
2010
In 2006, the unemployment rate among Aboriginal
peoples between 15 and 24 years was nearly twice the
national rate at 22%, with rates highest among First
Nations (27%) and Inuit (26%) populations.100 In the
same year, unemployment among Aboriginal males and
females between 25 and 54 continued to be high, with
rates of 14% and 12% respectively.100 Inuit populations
between 25 and 54 years had the highest overall
unemployment rates at 19%, whereas Métis populations
had the lowest at 8%.100 The unemployment rate was
highest among Inuit males, between 25 and 54 years,
at 23%.100
According to data collected by the Association of Workers’
Compensation Boards of Canada, about 250,000 accepted
time-loss injuries occurred in 2010.108 The majority
of these (63%) were reported by men, and more than
one-third (34%) were among people working in the
manufacturing, construction, and transportation and
storage industries.108 The same year saw more than 1,000
workplace-related fatalities, mainly of men (96%).108 More
than one-half (57%) of the workplace fatalities were
among Canadians 60 years and older and more than one
half (56%) were in the manufacturing, construction, and
transportation and storage industries, which employed
19% (2,895,900 men compared with 377,200 women) of
the estimated 17,041,000-strong workforce in 2010.108, 109
Income
Canadians have seen an overall increase in personal
income (adjusted for inflation) over time, but increases
have not been consistent for everyone. In fact, the
gap between those with the highest and lowest income
has widened significantly between 1976 and 2009 (see
Figure 1.13).110 Gaps are also seen in the median income
of Aboriginal and foreign-born populations in Canada
compared with the total population. In 2005, the median
total income of the Aboriginal population between 25
and 54 years was just over $22,000, of the foreign-born
population was just over $27,000, and of the total
population in the same age group was over $33,000.111, 112
While their median incomes were lower than that of the
total population, Aboriginal and foreign-born men had
larger incomes ($25,000 and $34,000 respectively) than
Aboriginal and foreign-born women ($20,000 and $23,000
respectively).111, 112
Although women face living in low income more
often than do men, the difference in these rates has
disappeared over time. As of 2009 the low-income rates
stood at 9.5% for men and women (see Figure 1.14).113
The number of children under the age of 18 years living
Figure 1.13 Average after-tax income for economic
families (two or more persons), 2010 constant dollars,
Canada, 1976 to 2009110
Income
(2010 constant $)
Lowest 20%
Average
Highest 20%
100,000
80,000
60,000
40,000
20,000
0
1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009
Year
Source: Public Health Agency of Canada using data from Survey of Labour and
Income Dynamics, Statistics Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
High levels of work-related stress have been linked to
increased risks of physical injury at work, high blood
pressure, cardiovascular disease, depression and other
mental health conditions.101-106 Personal behaviours, such
as smoking, drinking and drug misuse, may also increase
and lead to further health complications.101, 104, 106, 107 In
2010, nearly one-third (32%) of the working population
between 30 and 54 years self-reported having “quite a
bit” or “extreme” work-related stress, with similar rates
among men and women (31% and 34% respectively).44
Although younger adults also reported relatively high
rates of work-related stress, the proportion was higher
among young women than young men (28% compared
with 24%).44 Those between 25 and 54 years who had
not completed high school reported the lowest rates of
work-related stress (27%), whereas those in the same age
group who had completed a post-secondary education
reported the highest rates (34%).44
1
CHAPTER
The State of Public Health in Canada
23
CHAPTER
1
The State of Public Health in Canada
30.4% in 1977 (25.0% of men, 34.7% of women).113 In
addition, 18.7% of Aboriginal and 14.4% of foreign-born
populations lived in low-income households in 2005.111, 112
Figure 1.14 Population living in low income by sex,
Canada, 1976 to 2009113
Percent in
low income
Males
Health behaviours
Females
Individual behaviours, such as being physically active
and eating well, can contribute to good health, whereas
smoking, heavy drinking, drug misuse and sedentary
behaviour can have detrimental health effects. Ultimately,
health behaviours are individual choices that people
make. However, the physical, social and economic
environments where individuals live, work and learn can
influence these choices.114, 115
18
16
14
12
10
8
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
6
24
4
2
0
1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009
Year
Source: Public Health Agency of Canada using data from Survey of Labour and
Income Dynamics, Statistics Canada.
in low-income households has declined from a peak of
18.4% in 1996 to 9.4% in 2009.113 The rate living in
low-income households was more than double (21.5%)
for children under the age of 18 years living in single
parent households headed by women.113 The 5.1% of
Canadian seniors living in low income (3.3% of men and
6.6% of women) in 2009 was also a large decrease from
Smoking
The effects of smoking on health and well-being are
well documented: smoking has been linked to increased
risk of lung cancer, heart disease and stroke.116-118 It
can also interfere with various drug therapies, causing
medications, including antidepressants, to be less
effective.119-121 While the overall smoking rate has declined
since 1999, 17% of Canadians 15 years and older reported
smoking (14% of females and 20% of males) in 2010.122-133
Men have consistently reported higher rates of smoking
compared with women, with young adults between 20
and 29 years reporting the highest smoking rate of all
Figure 1.15 Current smokers by sex and age group, Canada, 1999 and 2010134, 135
Males
Percent of the
population
1999
2010
40
28
27
30
30
25
23
20
13
10
8
5
20 to 29
30 to 54
Age group (in years)
25
15
17
13
15 to 19
32
29
20
19
15
0
2010
35
37
30
10
1999
40
35
25
Females
Percent of the
population
55 to 64
65 and
older
17
16
11
18
13
5
0
15 to 19
20 to 29
Source: Public Health Agency of Canada using data from Canadian Tobacco Use Monitoring Survey, Health Canada.
30 to 54
Age group (in years)
55 to 64
11
8
65 and
older
CHAPTER
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The State of Public Health in Canada
Smoking rates are higher than average among some
sub-populations compared with the Canadian population
as a whole. In 2006, 19% of all Canadians were daily
or occasional smokers compared with 39% of Métis,
46% of First Nations not living on a reserve and 68% of
Inuit.59, 142 Inuit women had the highest smoking rate
among the Aboriginal population at 71%.59 In 2008/2010,
57% of First Nations living on a reserve reported being
daily or occasional smokers.146
Variations in smoking rates can also be seen by education
level. In 2010, smoking rates for people (ages 25 years
and older) who had not completed high school were
double the rate seen in those who had completed a postsecondary education (24% compared with 12%).134
Alcohol consumption
Alcohol is the psychoactive substance most commonly
used by Canadians.147 Alcohol intoxication can lead to
a variety of risks including harmful effects on physical
and mental health, personal relationships, work and
education; in extreme cases, it can even cause death.147-151
In 2006, 78% of the Aboriginal population 15 years
and older had consumed alcohol in the past year.59
Of those, 39% (48% of males compared with 32% of
females) consumed alcohol at least once per week.59
Figure 1.16 Frequent heavy drinking* by sex and age
group, Canada, 2010152
Percent of the
population
50
45
40
35
30
25
20
15
10
5
0
Males
Females
43
33
31
19
17
12
7
15 to 19
20 to 29
30 to 54
9
55 to 64
6
5
65 and older
Age group (in years)
* Consuming five or more alcoholic beverages on one occasion at least once a week.
Source: Public Health Agency of Canada using data from Canadian Alcohol and
Drug Use Monitoring Survey, Health Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
age groups in Canada during the same periods (see Figure
1.15).134-145 In 2010, 22% of young adults were smokers,
with a higher rate among young men (28%) than young
women (17%).134
In 2010, 77% of Canadians 15 years and older had
consumed alcohol in the past year.152 Of those, nearly
one-half (47%) consumed alcohol at least once per week
– 54% of males and 40% of females.152 Among drinkers,
9% (10% of males and 6% of females) consumed 5 or
more drinks at least once a week in the past year.152
Consuming large amounts of alcohol frequently, and
especially over a short period of time, can lead to poor
judgment, impulsive behaviour and alcohol poisoning.153
Rates of frequent heavy drinking – consuming five or
more drinks on one occasion, one or more times per
week – was highest among males in all age groups, with
the highest rates being among young men (see Figure
1.16).152 Variations in heavy drinking can also be seen
by education level. In 2010, rates of heavy drinking for
people (ages 25 years and older) who had not completed
high school were more than double the rate seen in those
who had completed a post-secondary education (13%
compared with 6%).152
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The State of Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Among drinkers, 10% (15% of males compared with 6%
of females) consumed 5 or more drinks at least once a
week in the past year.59 According to the 2002/2003
First Nations Regional Health Survey (RHS), 66% of
First Nations 18 years and older living on a reserve had
consumed alcohol in the past year.154 Of those, 18%
(23% of males compared with 12% of females) consumed
alcohol at least once per week.154 Overall, 9% of First
Nations living on a reserve reported having consumed five
or more drinks on one occasion more than once a week
(11% of males and 5% of females).154
26
Alcohol-related acute-care hospitalizations totalled
1.2 million days in 2002, of which two-thirds were among
males. That same year, there were an estimated 4,258
deaths attributed to alcohol (82% of males), including
1,246 due to cirrhosis of the liver (882 males and 364
females), 909 due to motor vehicle crashes (746 males
and 163 females) and 603 due to suicides (493 males
and 109 females).155
Drug use
Short- and long-term effects of illicit drugs vary. Shortterm effects of cannabis, for example, can include
an increase in heart rate and a decrease in blood
pressure.156-158 It can interfere with concentration, depth
perception and reaction time, affecting driving, among
other things.156-158 Long-term use of cannabis can lead to
respiratory distress and increased risk of cancer and may
cause impaired memory and information processing.156-158
Other illicit drugs – cocaine, hallucinogens and ecstasy –
have been linked to various health and social problems
including panic attacks, paranoia, and risky or violent
behaviour and to physical effects such as convulsions and
increased blood pressure.159-162 Over the long term, and
depending on the substance, harmful effects can include
psychosis, impaired brain function affecting memory
and lung and nasal tissue damage.159-162 The use of illicit
drugs (e.g. abuse, misuse, or dependence) can affect
performance at school and work, and in extreme cases
even cause death.159-162
The drug most commonly used by Canadians in 2010 was
cannabis.163 One-in-ten Canadians over the age of 15
years (15% of males and 7% of females) reported having
used cannabis in the past year.163 While youth and young
Figure 1.17 Cannabis use in the past 12 months by sex
and age group, Canada, 2010152
Percent of the
population
Males
Females
35
30
25
20
29.8
26.0
21.3
15
16.0
10
8.4
5
0
13.9
5.7
15 to 19
20 to 29
30 to 54
3.7
55 to 64
1.8
0.1
65 and older
Age group (in years)
Source: Public Health Agency of Canada using data from Canadian Alcohol and
Drug Use Monitoring Survey, Health Canada.
adults between 15 and 29 years have the highest reported
rates of cannabis use in Canada, males, regardless of
age, have the highest reported rates overall (see Figure
1.17).152 Variations in cannabis use can also be seen by
education level. Other than cannabis, the illegal drugs
most commonly used were hallucinogens (1.1%), ecstasy
(0.7%) and crack/cocaine (0.7%).163
Pharmaceutical drugs prescribed for therapeutic purposes,
including opioid pain relievers, stimulants, tranquillizers
and sedatives, may also be abused due to their
psychoactive properties.147 In 2010, 1% of those who used
psychoactive drugs did so for non-therapeutic reasons.147
Sexual health
There have been significant changes in the age-specific
fertility rates in Canada over the past 50 years (see
Figure 1.18).164-166 The number of births has remained
fairly stable over the past 50 years at more than 370,000
births each year.165-167 The current total fertility rate of
1.7 children per female aged 15 to 49 years has also
changed relatively little since the mid-1970s but is less
than one-half of what it was in 1960.164, 165 Although
Aboriginal women in Canada are also experiencing a
decrease in fertility rates, the rate of 2.6 children per
Figure 1.18 Age-specific fertility rate by select age
groups, Canada, 1960 to 2009164-166
Rate per
1000 women
15 to 19 years
20 to 24 years
25 to 29 years
30 to 34 years
35 to 39 years
40 to 44 years
250
200
150
100
0
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010
Year
Note: Data for Newfoundland excluded for 1960; no data available for 1998 and 1999.
Source: Public Health Agency of Canada using data from Canadian Vital
Statistics, Birth Database, Statistics Canada.
woman aged 15 to 49 years (3.4 children per Inuk woman;
2.9 children per First Nations woman; and 2.2 children per
Métis woman) between 1996 and 2001, is still well above
the Canadian average.164, 168
In 2010, 29% of 15- to 17-year olds reported being
sexually active (28% young boys and 30% of young
girls).44 While rates were considerably lower among the
foreign-born population (13%), rates among Aboriginal
peoples not living on a reserve in 2010 and First Nations
living on a reserve in 2008/2010 were considerably higher
(43% and 47% respectively).44, 146 Among adults between
18 and 49 years, 94% reported being sexually active, with
similar rates among the foreign-born population (91%),
Aboriginal peoples not living on a reserve (96%) and First
Nations aged 18 years and older living on a reserve (72%)
in 2008/2010.44, 146
Rates of sexually transmitted infections (STIs) officially
reported to the Canadian Notifiable Disease Surveillance
System increased among the overall Canadian population
over the past 15 years.169-171 Untreated STIs, whether
symptomatic or not, can have long-lasting effects on
health. STIs have been linked to pelvic inflammatory
disease, infertility, ectopic pregnancies, miscarriages
and low birth-weight babies as well as genital warts and
various types of cancers including cervical, anal and
penile.172, 173
In 2009, young women between 20 and 24 years had the
highest reported rate of chlamydia infection, more than
seven times the overall national rate and more than five
times the overall female rate (see Figure 1.19).169 Young
men of the same age had the highest reported chlamydia
infection rate, although their rate was one-half that of
their female peers.169
The highest rates of reported gonococcal infections in
2009 were among young men and women between 20
and 24 years (see Figure 1.19).171 Among youth between
15 and 19 years, the rate was more than twice as high in
adolescent girls as in adolescent boys; among adults
25 years and older, men had a higher gonorrhea rate than
did women.171
Unlike chlamydia and gonorrhea, reported rates of
infectious syphilis in 2009 were higher in males than in
females in all age groups (see Figure 1.19).170 Young men
between 25 and 29 years had the highest reported rate
The Canadian Notifiable Disease Surveillance System
allows for the monitoring of reportable sexually
transmitted infections (STIs). The number of
reported cases of STIs and the resulting calculated
population rates do not account for all infections
in the population. In many cases, an infected
individual does not show symptoms and as a result
may not be tested.174
with 17.6 cases per 100,000 population.170 The reported
rates of infectious syphilis for females were much lower,
with the highest rate that year being 3.4 cases per
100,000 population for both 20- to 24-year-old and
25- to 29-year-old young women.170
An estimated 65,000 people were living with HIV
infection at the end of 2008.175, 176 Nearly three-quarters
(74%) of all new HIV infections reported in 2008 were
among men, with the highest rates of all new cases being
among men between 40 and 49 years (32%).176 Men
who have sex with men (MSM) accounted for the largest
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
50
1
CHAPTER
The State of Public Health in Canada
27
CHAPTER
1
The State of Public Health in Canada
Figure 1.19 Sexually transmitted infection rates by sex
and select age groups, Canada, 2009169-171
Chlamydia
Rate per
100,000
population
Males
Females
2,000
1,871.4
1,720.3
1,500
1,000
60 and
older
Gonorrhea
Rate per
100,000
population
Males
Females
200
Age group (in years)
0.4
40 to 59
3.2
4.4
30 to 39
22.5
25 to 29
26.4
20 to 24
55.8
15 to 19
70.8
0
103.4
50
141.2
145.6
100
149.0
150
60 and
older
Infectious syphilis
Rate per
100,000
population
Males
Females
20
12.9
30 to 39
40 to 59
Age group (in years)
Source: Public Health Agency of Canada using data from STI (Sexually
Transmitted Infections) Surveillance and Epidemiology.
0.1
25 to 29
1.8
20 to 24
0.9
3.4
15 to 19
3.4
1.2
0
1.9
5
While STIs are generally viewed as affecting younger
people, older Canadians are also at risk. The proportion
of new infections reported among those 40 years and
older has been increasing.169-171, 175-177 Several factors may
contribute to an increased risk such as limited knowledge
associated with transmission, increasing divorce rates,
access to drugs for the treatment of erectile dysfunction,
and misconceptions about sexuality among middle-aged
and older adults by those in the health care and policy
fields.175, 178-183
While human papillomavirus (HPV) is not a notifiable STI
in Canada, the majority (estimated at more than 70%) of
sexually active Canadians will contract an HPV infection
at some point in their lives.173 Although most cases will
be asymptomatic and require no treatment, persistent
infections of certain types of HPV contribute to anal and
genital warts and, anal, cervical and penile cancers.173
Physical activity and healthy eating
13.0
10
Aboriginal people are also disproportionately affected by
HIV in Canada, and more specifically Aboriginal women.
Aboriginal people accounted for 13% of all new HIV
infections in 2008, a rate estimated to be about 3.6 times
higher than among the non-Aboriginal population.175
Between 1998 and 2008, women accounted for nearly
50% of all HIV infections reported among Aboriginal
people compared with 21% among the non-Aboriginal
population.175
17.2
17.6
15
3.4
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Age group (in years)
2.2
40 to 59
4.9
40.0
30 to 39
47.2
262.1
25 to 29
209.7
788.4
20 to 24
556.7
900.7
15 to 19
61.1
28
0
394.4
500
proportion of new positive cases (45%).175, 176 Women
represent an increasing proportion of those with positive
HIV test reports in Canada, and represented 26% of all
new cases reported in 2008.175, 176 Women between 30
and 39 years account for 35% of reported HIV infections
among all females.176 The two main risk factors for HIV
infection among women were heterosexual contact and
injection drug use.175, 176
60 and
older
While many factors can affect a person’s health, research
studies report that people who are the most physically
active are at a lower risk for poor health.184, 185 Physical
inactivity is a modifiable risk factor for a wide range
of chronic health conditions including coronary heart
disease, stroke, hypertension, colon cancer, breast cancer,
type 2 diabetes and osteoporosis.184, 186, 187
1
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The State of Public Health in Canada
The types, quantity and quality of food eaten can also
affect health.191, 192 But eating nutritious foods is also
dependent on accessibility and availability.191-194 Healthy
eating requires having “food security,” that is, having
physical and economic access to sufficient, safe and
nutritious foods to meet the dietary needs and food
preferences for a healthy and active life.195, 196
Levels of physical activity among children between 6 and
19 years were also measured in the 2007–2009 CHMS. As
with adults, the majority of their waking hours – 60%
for boys and 63% for girls – were sedentary.190 WHO and
Canadian guidelines suggest that children and youth
should accumulate at least 60 minutes of moderate-tovigorous physical activity every day.188-190 While only 7%
of children (9% of boys and 4% of girls) attained the
suggested level of activity, 44% (53% of boys and 35% of
girls) were engaged in at least 60 minutes of moderateto-vigorous physical activity at least three days a week.190
Less healthy eating, including over-consumption,
combined with inadequate physical activity can lead to
increased body weight.191, 201 Obesity is a risk factor for
many chronic diseases including high blood pressure,
type 2 diabetes, gallbladder disease, coronary artery
disease, osteoarthritis and certain types of cancer.
Obesity presents a considerable health challenge in
Canada.191 Body mass index (BMI) is a common measure
based on height and weight that is used to determine
healthy and unhealthy weights (see Appendix B: Body
mass index cut-points for detailed BMI breakdown).
While BMI has been seen as an adequate measure for a
portion of the population, standard BMI categories may
not accurately reflect the rate of overweight and obesity
in all populations.202-206 Regardless, BMI is still the most
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
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-tovigorous physical activity per week.187-189 According to
the 2007–2009 Canadian Health Measures Survey (CHMS),
only 17% of males and 14% of females achieved this level
of physical activity, and most Canadian adults between 20
and 79 years spend the majority of their waking hours –
68% for men and 69% for women – being sedentary.187
In 2010, 8% of Canadian households (excluding those
in Prince Edward Island and New Brunswick) reported
experiencing moderate to severe food insecurity at some
point in the previous year.44 Among the provinces, an
income gradient was associated with food insecurity,
as 23% of households in the lowest household income
quintile reported some form of food insecurity compared
with 1% of households in the highest household income
quintile.44 Also, the prevalence of food insecurity was
higher in households with the lowest household education
attainment level (less than completed high school) (14%)
than in those with the highest household education
attainment level (completed post-secondary education)
(6%).44, 196 Further challenges to healthy eating exist in
northern and remote communities due to the availability
of quick, less expensive and less healthy foods.197-199
These communities do not have as many food choices
and healthy foods are often more expensive than in more
populated regions of the country.197-199 In the 2007–2008
Inuit Health Survey, approximately 70% of Nunavut
households reported experiencing moderate to severe food
insecurity over the past year.197, 200
29
CHAPTER
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The State of Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
commonly used measure to classify overweight and
obesity.207
30
In 2007–2009, 24% of Canadian adults were obese and
37% were overweight based on their measured height
and weight.208 This is a substantial increase from the
12% reported as obese and 32% reported as overweight
in 1978–1979.209 Obesity is not only a problem for adult
Canadians, however, measured heights and weights
of Canadian children in the same period showed that
10% of 6- to 17-year-olds were obese and 18% were
overweight.208 As with adults, this is a significant
increase from the 4% reported as obese and 14%
reported as overweight in 1978–1979.209 For both
adults and children, a larger percentage of males than
females were either overweight or obese (see Figure
1.20).208 Differences in income have been linked to
differences in adult obesity rates, yet men and women
seem to be affected differently. While females tend to
show an inverse association between income and obesity
(i.e. as income increases, rates of obesity decrease),
there is no clear pattern for males.191
overweight and obesity (39%) compared with the national
rate (53%).44 However, rates among immigrants who have
lived in Canada for 10 or more years equal the national
rate.44 Among Aboriginal peoples not living on a reserve,
66% of adults 20 years and older and 40% of children
and youth are either overweight or obese, based on
self-reported height and weight.44 For First Nations living
on a reserve or in northern communities, 62% of children
(3 to 11 years), 43% of youth (12 to 17 years) and 75%
of adults (18 years and older) were considered overweight
or obese based on self-reported height and weight
measurements according to preliminary results from
the 2008/2010 RHS.146
Accessing primary care
Self-reported data from the 2010 CCHS suggest that
recent immigrants to Canada have much lower rates of
Access to primary care is fundamental to health. In 2010,
about 85% of Canadians (89% of females and 81% of
males) reported having a regular family doctor.45 While
the majority of Canadians may have a regular family
doctor, not everyone consults a physician annually. Recent
immigrants reported the lowest rates of consulting either
a family doctor or general practitioner (76% of women
and 59% of men) whereas immigrants who had been in
Figure 1.20 Body mass index by sex and age group,
Canada, 2007–2009208
Figure 1.21 Consulting a doctor by origin and sex,
Canada, 201044
Percent of the
population
Underweight
Normal
Overweight
Obese
Percent of the
population
100
100
80
80
60
60
40
40
20
20
0
Males
6 to 17 years
Females
6 to 17 years
Males 18 years
and older
Females 18 years
and older
Source: Public Health Agency of Canada using data from Canadian Health
Measures Survey, Statistics Canada.
0
Canadian-born
non-Aboriginal
Canadian-born
Aboriginal
83
80
72
66
Recent
foreign-born*
Long-term
foreign-born†
86
78
76
59
Males
Females
Sex
Note: * Recent foreign-born has been living in Canada for 10 years or less.
† Long-term foreign-born has been living in Canada for more than 10 years.
Source: Public Health Agency of Canada using data from Canadian Community
Health Survey, Statistics Canada.
CHAPTER
1
The State of Public Health in Canada
Canada for 10 or more years had the highest reported
rates (86% of women and 80% of men).44 Regardless of
whether or not they had a family physician, more women
(83%) reported consulting a physician compared with
men (72%) (see Figure 1.21).44
Nevertheless, immunization coverage is below target
for several vaccine-preventable diseases. Reduced
coverage rates may be the result of barriers to awareness
and access, leading to delays in receiving timely
immunization; varying provincial/territorial immunization
programs for some vaccines across the country; or because
of differing cultural norms and personal beliefs.210, 212 In
Canada, immunization is a shared responsibility among
the federal, provincial and territorial governments.213
In 2010, 72% of the population reported having received
the influenza vaccination in the previous two years.44
Vaccine coverage for seasonal influenza varies among
different age groups, with the highest vaccination rates
(91%) being reported by seniors.44 Among people with
chronic health conditions, 81% were vaccinated in the
previous two years.44 During the same period, 67% of
Aboriginal and 74% of foreign-born populations also
received the seasonal influenza vaccine.44
Accessing non-insured health services, such as dental
and eye care, is equally important. In 2010, 82% of
Canadians reported they had seen a dentist in the
previous two years, though this percentage decreased
with age (see Figure 1.22).44 That same year, 64% of
Figure 1.22 Dental and eye doctor visits in the past 24 months by sex and age group, Canada, 201044
Visited dentist in the past 24 months
Percent of the
population
Males
Females
93
Females
94
81
83
85
73
60
80
80
83
72
71
60
40
40
20
20
0
Males
100
100
80
Visited eye doctor in the past 24 months
Percent of the
population
12 to 19
20 to 29
30 to 54
Age group (in years)
55 to 64
65 and
older
0
76
72
65
62
52
83
88
67
53
44
12 to 19
20 to 29
Source: Public Health Agency of Canada using data from Canadian Community Health Survey, Statistics Canada.
30 to 54
Age group (in years)
55 to 64
65 and
older
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Not only do people seek treatment through Canada’s
publicly funded health care system, they also benefit from
a number of disease prevention and health promotion
services such as immunization. Currently, all of Canada’s
provinces/territories have developed publicly funded
immunization strategies.210 Rates of vaccine-preventable
infectious diseases are low in Canada since the majority
of Canadian children have been immunized against a
range of potentially serious illnesses. In 2009, about
92% of two-year-olds had been immunized against
measles, mumps and rubella, 77% against diphtheria,
pertussis and tetanus and 83% against polio.211
The federal government is responsible for approving
and regulating vaccines, monitoring vaccine safety and
providing evidence-based recommendations on the use of
vaccines in Canada.213, 214 The provinces and territories are
responsible for funding, program planning and delivering
immunization programs in their respective jurisdictions.213
As there is no timely-mechanism or national immunization
registry system to collect immunization records
consistently, the Public Health Agency of Canada has
collaborated with provinces and territories to establish
standards for reporting immunization coverage and
surveys to estimate national immunization coverage.210, 215
31
CHAPTER
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The State of Public Health in Canada
Canadians reported having seen an eye doctor in the
previous two years.44 Unlike dental visits, the percentage
of people seeing an eye doctor in the previous two years
increased with age (see Figure 1.22).44 More women
reported visiting a dentist (83%) or eye doctor (68%)
than did men (81% and 59% respectively).44
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Summary
32
Although the health of Canada’s population is
considered very good, a closer inspection of differing
rates of death, disease and disability among various
groups shows that some Canadians experience worse
health and a lower quality of life than do others.
Many factors influence these outcomes including the
aging of the population, increasing survival rates for
potentially fatal conditions, and changes in personal
choices about eating, physical activity and the use of
substances such as tobacco and alcohol. These are not
the only factors at play; evidence shows that income,
education, employment and working conditions can
affect individual health behaviours and outcomes. The
following chapter will introduce the concepts of sex and
gender and how they are linked to health behaviours and
outcomes, both directly and through their connection to
the determinants of health. It also briefly explores sexand gender-based analysis as a tool for analyzing how
both sex and gender influence health.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Part II: Sex, Gender and
the Health of Canadians
33
34
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Clarifying sex and gender
Although the two terms are often used interchangeably,
sex and gender have different meanings.
While there are no agreed-upon definitions, “sex”
typically refers to the biological and physiological
characteristics that distinguish women and men.216-218
Sex is a multi-dimensional construct that encompasses
characteristics such as hormones, genes, anatomy
and physiology.219 Although sex is often referred to in
binary terms – men/women or male/female – many of
the attributes of sex (e.g. variation in hormone levels,
chromosomal differences, etc.) are often described as
existing on a continuum.216-221
Sex refers to the biological characteristics such as
anatomy (e.g. body size and shape) and physiology
(e.g. hormonal activity or functioning of organs)
that distinguish males and females.22
Gender refers to the array of socially and culturally
constructed roles, relationships, attitudes,
personality traits, behaviours, values and relative
power and influence that society ascribes to two
sexes on a differential basis.22
Similarly, “gender” is commonly associated with
socially and culturally constructed roles, relationships,
behaviours, relative power and other traits that society
ascribes to females, males and people of diverse gender
identities.216, 217, 222, 223 As with sex, gender is often
thought of in binary terms – masculine/feminine or male/
female.217, 218 However, the masculine/feminine division
does not accurately reflect or capture the range of
human experience or the expressions of self and identity
that gender encompasses.216-218 Most of us experience
or embody gender on a spectrum or as a continuum of
characteristics and behaviours rather than as mutually
exclusive categories. While gender and sex are interrelated, sex neither determines gender, nor gender
sex. For example, someone born female might have a
masculine gender identity. Some individuals identify as
transgender, that is, their gender identity and/or gender
expression differ from their biological sex.216, 217, 224-226
Gender has multiple dimensions including, but not limited
to, gender roles, gender identities and gender relations.219
Gender roles, identities, expressions, norms and relations
can serve both as protective and/or risk factors for
health.227 Evidence shows that gender norms – social
expectations of appropriate roles and behaviours for
males and females – influence overall health and wellbeing, as does the social reproduction of these norms in
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
This chapter both explains the concepts of sex and
gender and discusses why and how sex and gender matter
to public health. It describes and broadly examines
the ways in which sex and gender interact with other
determinants of health and how they influence health
behaviours and outcomes. In addition, this chapter
identifies sex- and gender-based analysis (SGBA) as a tool
to help researchers, policy makers and program advisors
understand and address the influence of sex and gender
on health. SGBA can improve the effectiveness and
efficiency of services and programs by showing how to
create supportive conditions for better health and reduce
specific risks and barriers to achieving optimal health for
all Canadians.
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institutions and cultural practices.228, 229 A variety of key
social institutions, such as the family, culture, media,
education, law, and religious and political establishments
shape gender expectations, experiences, roles and
relationships.216, 227 These institutions can also serve to
continue and/or perpetuate social and cultural norms and
images and ideals of masculinity and femininity that are
neither always based in reality nor positive for human
growth and development. These societal perceptions can
also serve to increase pressure and stress for females and
males who are either unable to – or discouraged from –
fulfilling or assuming certain roles and responsibilities
because they do not fit the prescribed norm.216, 217, 227
Gender norms and roles influence attitudes and behaviours
in many areas, including relationships, parenting,
Gender identity refers to how we define ourselves
on the gender continuum (as man, woman
or another identity in a spectrum of gender
identities). This identity can affect our feelings and
behaviours.216, 226 Gender identity is not the same
as sexual orientation – one can identify as female
and be sexually attracted to women, men, neither
or both. Rather, gender identity encompasses one’s
sense of being a woman or man. Most individuals
develop a gender identity within the context
of societal prescriptions about the appropriate
expression of gender for their biological sex (as
female or male). In other words, as we learn to
think of ourselves as female or male, we also
learn what behaviours, emotions, relationships,
opportunities and work are considered appropriate
for females and males.216
Gender roles are the means by which we express
or enact our gender identity.216 They are the
“behavioural norms typically applied to males and
females in societies, that influence individuals’
everyday actions, expectations and experiences, for
example, how we dress or talk, what we aspire to do
and what we feel are valuable contributions to make
as a woman or a man.”216
Gender relations “refer to how we interact with or
are treated by people in the world around us, based
on our ascribed gender. Gender relations affect us at
all levels of society and can either restrict or open
opportunities for us.”216
schooling, work and health practices (e.g. seeking care,
support and treatment).216, 228 Gender roles can also create
economic and cultural pressures that affect the health of
females and males differently.218 Gender norms concerning
work roles, the division of paid and unpaid labour and
the occupations of males versus females can result in
different exposures and vulnerabilities. These, in turn,
result in varying health needs, behaviours and outcomes.
For example, women are more often the primary caregiver
(i.e. of children and/or elderly parents), which can create
obstacles or barriers to education, employment and career
advancement, resulting in increased stress or burden that
impacts their health.218, 230-232
Why sex and gender matter to public
health
Public health serves to support, promote and protect
the health of all Canadians.4 It strives to ensure that all
people – from birth to the end of life – enjoy universal
and equitable access to the basic conditions that are
necessary to achieve optimal health and well-being.5, 6
By helping to provide opportunities to achieve optimal
health and well-being, more Canadians can live longer,
healthier lives.
A greater awareness and understanding of the role of sex
and gender in an individual’s health can help to improve
the health of all Canadians.233 Sex can be a factor that
influences health, for example, men and women may
show different symptomology for diseases and conditions
and may respond differently to drugs and therapeutics
due to physiological and hormonal differences as well as
differences in body composition.218 Some diseases and
conditions may exclusively affect women or men, may be
more prevalent in either of the sexes or may affect men
and women differently.18
Gender is another important variable. It can affect health
as a result of the different roles and responsibilities
ascribed to people according to their gender. For example,
masculinity is often associated with strength and
resilience, which means that some masculine individuals
(whether they are male or female) may be less likely to
seek help for health concerns if they prefer to “tough it
out.” Males tend to take more safety-related risks and are
more often injured.218, 225, 228 On the other hand, femininity
is often associated with appearing “delicate,” which can
discourage some females and males from participating in
certain physical activities that might otherwise improve
their physical and mental health.216, 218
Applying a sex and gender lens to health can help
identify how both influence health status.18 It is crucial
to understand and appreciate the impacts of sex and
gender and to attend to these impacts in public health.219
Doing so facilitates better health for all Canadians and
encourages more comprehensive health research, policies
and programs. This results in public health interventions
that are more effective and inclusive.219, 234, 235
Consideration and integration of sex and gender into
health research, policies and programs is critical to
progress and advancement in population health.236 A
population health approach “considers the full range of
social, economic and physical factors that can influence
health and plans how interventions will be informed,
targeted, implemented and evaluated accordingly.”218
The approach focuses on maintaining and improving the
health status of the entire population to reduce health
inequalities among population groups.11, 237, 238 Taking a
population health perspective that is cognizant of sex and
gender differences can increase knowledge and encourage
awareness and participation. Doing so will aid researchers
and policy makers in developing promising practices that
will help address health issues for all Canadians.216, 217
Sex, gender and the broader
determinants of health
Sex and gender interact with a variety of other
determinants of health to influence individual and
population health.218 Each determinant of health can, in
turn, influence health risks, opportunities, behaviours and
outcomes at every stage of life.10, 16 (See “Determinants
of health.”) Consequently, each determinant of health
by itself is important for optimal health and wellbeing.10 In addition, these factors intersect with each
other, creating complex and varied contexts within
which people make choices and enact behaviours that
ultimately also affect health outcomes across and within
populations.10, 216‑218, 232, 233
Within the broader determinants of health, socioeconomic factors such as income, education and
employment, often referred to as the “social determinants
of health” interact with both sex and gender and can lead
to differences in health status.218, 239 These factors relate
to an individual’s place in society – the circumstances
in which people are born, live, work, play, interact
and age.240, 241 Socio-economic factors can contribute
to inequalities in health outcomes not only between
women and men, but among and between different
Determinants of health
•• income and social status
•• social support networks (e.g. family, peers)
•• education and literacy
•• employment and working conditions
•• social environments (e.g. community,
workplace)
•• physical environments (e.g. housing,
community infrastructure)
•• personal health practices and coping skills
•• healthy child development (including/during
pregnancy)
•• biology and genetic endowment (e.g. sex)
•• health services
•• gender
•• culture (e.g. Aboriginal status, racial and
cultural identities)10
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Exploring gender can be complex due to the dynamic and
changeable nature of the social and cultural environment
in which Canadians live. Cultural norms and values can
shape and determine gender, and such norms and values
differ from place to place and evolve over time. As a
result, our experiences of health are a complex blend
of our “maleness” and “femaleness” mixed with our
cultural identity and social environment.18 Attention to
gender contributes to a greater understanding of how
cultural and social environments can affect both males’
and females’ exposure to disease and injury, access
to resources that promote and protect health, and
differences in risk factors, including the manifestation,
severity, frequency and social and cultural responses to
illness and disease.18
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groups of women and men.218 These factors can influence
opportunities for good health and well-being.10, 240, 241
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Each determinant has the potential to influence a person
differently depending on their sex and gender.218 To
enable all Canadians to achieve good health and wellbeing, people need opportunities to access the conditions
and services necessary to achieve optimal health.216, 217
38
Canadians constitute a diverse population marked by
differences in income, living conditions, geographic
location, level of education, employment, ability, age,
sex, gender, sexual orientation, Aboriginal status and
racial and cultural identities. Diversity can influence
opportunities for health; exposures and susceptibility to
risk; and access to health, social services and supports.
It can also contribute to increased risk or affect
exposures to various risk factors, diseases and health
outcomes, ultimately resulting in inequalities in health
status.22, 242, 243
By understanding and addressing factors that contribute
to inequalities in health, it is possible to influence and
create the conditions for meeting the diverse needs of
individuals, supporting healthy choices, diminishing and/
or reversing unhealthy living practices, mitigating risky
behaviours, reducing barriers and promoting positive
lifelong health.10, 16, 216-218, 240, 241
Sex- and gender-based analysis: a tool
Gender mainstreaming in public health is a process
of working towards systematic and consistent
consideration of both sex and gender in the development,
implementation and evaluation of studies, policies and
programs in the interest of advancing health equality.
While many recognize the benefits of applying a sex and
gender lens to public health action, some challenges
remain.
SGBA is a valuable tool for analyzing how both sex –
rooted in biology – and gender – rooted in social roles
shaped by environment and experience – influence an
individual’s health and well-being.245 Being a man or
woman can have a considerable impact on our resources
and opportunities for good health, exposure and
susceptibility to health risks, access to and effectiveness
Health inequalities are differences in health status
experienced by various people or groups in society.
These can be the result of genetic and biological
factors, choices made or by chance, but often
they are due to unequal access to key factors that
influence health, for example, income, education,
employment and social support.24
Diversity refers to variations or dissimilarities
between and among people. It is often used to
denote observable differences, such as visible
ethnic variations in a population and distinctions
in age or location of residence. However, diversity
can also include differences that are not always
evident, such as sexual orientation and level of
education.216, 217
of health services and programs, and overall health
outcomes.22, 245
SGBA allows for critical examination of research, policies
and programs to ensure they meet the diverse needs of all
women and men, girls and boys. It can help identify how
various factors may differentially affect women’s or men’s
health status, including their access to and interaction
Gender mainstreaming, as defined by the United
Nations Economic and Social Council, is the process
of assessing the implications for women and men of
any planned action, including legislation, policies
or programs, in any area and at all levels. It is a
strategy for making the concerns and experiences
of women and men an integral part of design,
implementation, monitoring and evaluation of
policies and programs in all political, economic and
societal spheres, so that women and men benefit
equally and inequalities are not perpetuated. The
ultimate goal of mainstreaming is to achieve gender
equality.244
Sex- and gender-based analysis (SGBA) is a
systematic approach to research, policies and
programs that explores biological (sex-based)
and sociocultural (gender-based) similarities and
differences between women and men, boys and
girls.22, 218
with the health care system and related public health
and social services (see Chapter 4 “Incorporating Sex and
Gender into Health Interventions” for more information
on how SGBA can be considered and implemented into
public health practice).22, 216, 217, 236
SGBA is both necessary and possible in all areas of
health research, planning and policy-making. It can
help foster a deeper understanding of how women and
men differ in patterns of illness, disease and treatment.
It can also advance research and development on how
these factors and patterns are influenced by social
structures, experiences, norms and culture.216, 217 When this
information is then applied to practice, it can encourage
appropriate and effective developments, recommendations
and interventions, ultimately in an effort to promote,
improve and maintain positive health outcomes for all
women and men, girls and boys and those who do not
strictly identify themselves using these categories.246 It
helps ensure that interventions reach those at greatest
risk and are appropriate to their needs, which improves
both effectiveness and efficiency. It can help to secure
the best possible health for all Canadians.22, 216, 217
Summary
Sex and gender are critically important considerations to
all areas of public health including research, programs
and policies. Understanding the relationships among sex,
gender and the other determinants of health and how
they intersect to influence health opportunities, risks
and outcomes is critical to achieving optimal health and
well-being for all Canadians.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
SGBA is consistent with the population health approach
in that it analyzes variations in health status by sex and
gender. It also demands consideration of the different
ways determinants of health influence the health of
men and women, boys and girls.218 As a tool, SGBA
can challenge the assumption that women and men
are affected in the same way by research, policies and
programs or that the risk, cause, impact and service
delivery of certain health issues are unaffected by sex
and/or gender.22 Rather than assuming that “one size fits
all,” SGBA reminds us to ask questions about differences
and similarities between and among individuals of
different sexes or gender identities.217 By asking these
questions, SGBA can help reduce inaccurate assumptions
and lead to positive changes in how programs are offered
and how we can most effectively allocate resources.216, 217
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Physical Health
As seen in Chapter 1, some of the most common physical
health issues for Canadians are chronic conditions that
affect individuals across the lifecourse. One of the most
prevalent of these is hypertension (high blood pressure),
a leading modifiable risk factor for cardiovascular disease
which, as seen in Chapter 1, is a leading cause of death
for both men and women in Canada.247 Since hypertension
usually has no symptoms, it is easy to overlook its
presence, allowing it to go undiagnosed.247 Although
hypertension is equally prevalent in men and women,
they are neither equally affected nor do they have the
same risks. To help improve the likelihood of screening
and diagnosis, it is useful to understand the level of risk
for men and women, how their risk varies and how the
disease may affect individuals differently because of their
sex and gender. This chronic condition is used to illustrate
those influences on the physical health of Canadians.
How sex influences physical health risks
and outcomes
The two numbers that make up the measure of blood
pressure are systolic pressure (the “top” number)
and diastolic pressure (the “bottom” number).247 The
percentage of Canadian men and women with high
systolic or diastolic pressure or both are roughly equal.
When those numbers are considered separately, however,
women are more often diagnosed with isolated systolic
hypertension (with normal diastolic blood pressure)
than are men, whereas men are diagnosed with diastolic
hypertension more often than are women.248 Systolic
blood pressure has been shown to be a better predictor
of risk for cardiovascular disease and kidney disease than
diastolic blood pressure.249 In addition, hypertension is
a greater risk factor for heart failure for women than for
men.250-252
Prevalence and incidence rates of hypertension increase
with age in both men and women. However, among
those who are younger than age 70, the annual rate
of newly diagnosed cases is slightly higher for men
than for women, whereas from the age of 70 years and
onward it is the reverse, with the annual incidence rate
for women being higher.247 Prevalence also starts out
higher in men, yet tends to be higher in postmenopausal
women than in men of the same age.247, 253, 254 Evidence
shows that sex hormones, specifically androgens such as
testosterone, play a role in those differences. As early
as adolescence, with increasing androgen levels during
puberty, blood pressure is higher in boys than in girls.255
Conversely, premenopausal women may be protected from
hypertension by female sex hormones such as estrogens;
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
This chapter highlights one specific example in each of
the areas of physical health, mental health and sexual
health to illustrate key points in how health outcomes,
including symptoms, diagnostic tools, treatment effects
and access to care, are affected by sex and gender. It is
not meant to provide an in-depth sex- and gender-based
analysis of these issues but rather a brief demonstration
of the ideas. The examples are not necessarily the most
important or critical health issues affected by sex and
gender. Nevertheless, they demonstrate the varied ways
in which sex and gender can influence a range of issues.
Using these illustrations, it can be seen how and why
many health outcomes differ between men and women
and can gain insights into the influences of sex and
gender on those differences.
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
as levels of these decrease after menopause, the
prevalence of hypertension increases.255
42
Two sex-specific forms of hypertension occur only during
pregnancy: gestational hypertension and preeclampsia
can seriously harm both mother and child and can
even be fatal.256 While both conditions resolve after
the birth, they have been shown to increase the risk
of future hypertension or cardiovascular disease for
these women.257-259 Oral contraceptive users, regardless
of age, level of physical activity, family history of
hypertension, body mass index, alcohol consumption,
cigarette smoking or ethnicity, are at increased risk of
hypertension compared with women who do not use oral
contraceptives.254
Men and women also respond differently to treatment
for hypertension. Canadian data show that among those
aged 60 years and older who were using antihypertensive
medications, women were significantly less likely to have
their blood pressure controlled. Similar results have been
found in other countries, but in all cases the sex and
gender influences on this effect are not clear.248
How gender influences physical health risks
and outcomes
Canadian men and women who are aware that they
have hypertension are equally likely to have it treated.248
However, compared with women, men are significantly
less likely to be aware of their hypertension and as
such fewer receive treatment for their condition.248
Men may be less aware of their hypertension because
gender influences their health care-seeking behaviour.
Men tend not to seek out care because social norms
promote the idea that it is more masculine to not been
seen as weak and to “tough it out,” whereas the idea
of caring for one’s health and showing vulnerability are
seen as feminine traits.260
By interacting more often with the health care system
than men, women have more opportunities to have
their blood pressure checked, increasing their awareness
of their hypertension status.44, 261 In 2010, women –
particularly younger women – were consistently more
likely to report having had their blood pressure checked
within the last two years than were men.44 The two most
common reasons given by Canadians who had never had
their blood pressure checked were that they did not think
it was necessary and that they had not “gotten around
to it.” Men and women were equally likely to respond in
this way. However, significantly more women reported
that they had not had their blood pressure checked
because their doctor did not think it was necessary.44
Gender intersects with sexual orientation which can
influence health outcomes. For example, in addition
to the general stresses experienced by all Canadians,
sexual minorities can be affected by the additional
stress associated with the stigma, discrimination and
harassment they often experience.262, 263 Given that stress
is a risk factor for hypertension, this “minority stress”
may help explain the fact that when self-reported rates
of hypertension are broken down by sexual orientation,
outcomes vary from those of the population as a
whole.44, 262-264 The roughly equal rates of hypertension in
men and women hold true among heterosexual Canadians,
but not for gays, lesbians and bisexuals. Rates of
hypertension are higher among gay and bisexual males
than rates among lesbian and bisexual females. Gay and
bisexual males also have higher rates of hypertension
than do heterosexual males, whereas lesbian and bisexual
females have lower rates than do heterosexual females.44
Obesity, sodium intake and lack of physical exercise are
all risk factors for hypertension. These factors, in turn,
are related to gender and socio-economic factors.265, 266
For example, there is some evidence that hypertension
rates vary by income, although the patterns vary
with gender. Canadian data shows that prevalence of
hypertension tends to decrease as income increases for
women, whereas for men it tends to fluctuate as income
changes, with no clear pattern.44
Mental Health
Sex and gender play a critical role in the mental
health and well-being of Canadians. Biology and the
physiological changes that occur over the lifecourse affect
an individual’s likelihood of particular outcomes and also
influence their responses to developmental stages and life
events. For example, biological and socially constructed
differences between men and women interact to affect
individual susceptibility to particular mental health
risks and health-seeking behaviours. They also affect
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Sex, Gender and Health Outcomes
the responses of the health care sector and society as
a whole, to mental health. It is important to recognize
how culturally imposed gender roles affect the control
that some men and women have over the socio-economic
determinants of their mental health.68, 267, 268
As seen in Chapter 1, mood disorders, including bipolar
disorder and depression, are the most common forms of
chronic mental illness, affecting individuals of all ages.269
In 2002, 12.2% of Canadians 15 years or older (15.1% of
females and 9.2% of males) met the criteria for having
experienced an episode of major depression at some point
during their lifetime.68 Rates increased with age after
puberty, except among the oldest age range, and were
consistently higher among females.68 These rates, based
on self-reported data may actually be an underestimate
given the potential for recall bias in survey responses.
Additionally, they do not include those living in care
facilities, such as seniors living in residential care where
it is estimated that 44% of residents live with a diagnosis
or symptoms of depression.272 Survey data also indicate
that the rates of depression among Aboriginal populations
are higher than among Canadians overall. In 2001, 12%
of First Nations adults not living on a reserve suffered
an episode of major depression during the previous year,
compared with only 7% of all Canadians that year. As with
the overall population, First Nations women experience
higher rates of depression than do First Nations men. Only
3.1% of the Inuit population met the criteria of having
experienced a major depressive episode based on 2001
Statistics Canada survey responses.68 However, suicide
rates in Inuit regions are more than 11 times higher than
the rest of Canada.273 It is possible that some incidences
of depression may not be acknowledged, particularly
among men where depression may manifest as alcohol
abuse, violence or conflict with the law.68, 269
The specific example of depression is used here to
examine the influence of sex and gender on the mental
health of Canadians.
How sex influences mental health risks
and outcomes
Depression is the most common mental health problem
among women, among whom it may also be more
persistent and more severe.268, 269, 274 Before puberty
however, rates of depression are slightly higher in boys
than in girls. Between puberty and menopause, rates in
women are two to three times higher than in men. After
menopause, the prevalence rates of depression in women
begin to decline until they become similar to those in
men near the end of the lifecourse.275 This pattern of
sex differences in prevalence rates over the lifecourse
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Of the various mental health issues and illnesses that
affect Canadians, schizophrenia, suicidal behaviours
and mood disorders provide some compelling examples
of the differences in mental health status that may be
related to sex and gender. For example, while rates of
schizophrenia are roughly equal among men and women,
men develop the illness earlier in life whereas women
develop it later when they also display mood symptoms
more prominently.269 In the case of suicide, men account
for four out of every five deaths by suicide in Canada, yet
women attempt suicide more often. Most individuals who
attempt or complete suicide have some form of mental
illness – most often depression.68, 269-271
43
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Sex, Gender and Health Outcomes
suggests that sex hormones may play a significant role
in rates of depression.
How gender influences mental health risks
and outcomes
Women may be at risk of depression both during and after
pregnancy, due in part to the dramatic hormonal changes
that occur at that time.267, 276 Up to 13% of women
experience depression at some point during pregnancy,
and following pregnancy up to 80% of women may
experience mild mood disturbances lasting a few days,
known as the “baby blues,” which generally do not require
clinical treatment.68, 277 However, hormonal and other
physical changes combined with caring for a newborn
and other environmental stressors can trigger postpartum
depression (PPD), a serious condition that affects about
10% to 15% of mothers and is characterized by longlasting depressed feelings, low self-esteem, anxiety and
agitation.68, 276, 278 Previous depressive episodes are a risk
factor; 25% of women with a history of depression and
over one-half of women with previous episodes of PPD
are at risk.68 Research also shows that, compared with
Canadian-born women, immigrant women are more likely
to suffer from PPD; they may be especially vulnerable
if they are socially isolated and lack the support of an
extended family.279, 280 There is also evidence that the risk
of depression increases for women during the transition to
menopause. Again, it is fluctuating hormone levels which
appear to be the cause of the increased risk.281
Gender plays a key role in the diagnosis of depression.
Women report higher levels of distress than do men and
are more likely to seek help from health care professionals
for mental health concerns.68, 267 When experiencing
similar symptoms, women are more likely than men to
perceive an emotional problem. Similarly, even when
men and women present identical symptoms or score
similarly on depression measures, physicians are more
likely to diagnose depression in women than in men.267, 268
Accurate diagnosis is further impeded by men’s tendency
to acknowledge physical symptoms more easily than
emotional ones.270
Although many studies have examined the possible link
between levels of women’s sex hormones and depression,
few have explored any possible connection between male
sex hormones and depression. Research has attempted
to explain lower rates of depression in men in terms
of differences in the way in which male and female
brains respond to stress.282, 283 The results of these are
inconclusive, however, and more research is needed.
Self-reported signs and symptoms of mental health
often differ between men and women. Women tend to
report feelings of helplessness or worthlessness as well
as persistent sad moods, whereas men are more likely
to report feeling discouraged, angry and irritable.269 It
is unclear whether this is a biological difference in the
symptoms or a gender influence in how those symptoms
are described and interpreted.
One of the principal barriers preventing men from seeking
help for mental health problems is the expectation that
they be tough and strong. This societal expectation
may foster a silence that prevents accurate diagnosis
and treatment of psychological disorders. Rather, men
may adopt negative coping mechanisms and act out
with hostility, violence, alcohol and/or drug abuse and
other risky behaviours. This may mask their depression
and result in damaging consequences to themselves or
others.68, 268-270
Because of their socially constructed role, men may be
particularly affected by unemployment and changes in
socio-economic status. A 2005 United Kingdom study
indicated that men who experienced a drop in socioeconomic status were four times more likely to develop
Due to internalized and environmental homophobia,
biphobia and transphobia, and consequential prejudice
and discrimination, sexual and gender minorities
commonly experience anxiety and depression and are
more likely to have thoughts about or complete suicide.286
Historically, Two-Spirit Aboriginal people were valued
members of their communities, recognized for their
special gifts. Since the imposition of a western worldview
they have become stigmatized and devalued, which adds
to distress and impacts on the mental health of some
of these individuals.287, 288 Gender expectations and roles
may also lead to disproportionate rates of poor mental
health among sexual minorities. For example, gay men
in particular transgress the gender role expectations of
“masculinity” (head of the traditional heteronormative
family, etc.). This may lead to stigmatization, alienation
and discrimination, which can cause reduced self-esteem
and internalized homophobia, and hence depression,
substance use and other mental health issues.263, 289, 290
Data from the 2003 and the 2005 CCHS indicate that
comparatively high proportions of bisexuals reported
mental health problems. Bisexual men described their
mental health to be “fair” or “poor” at more than twice
the rate of heterosexual men, whereas bisexual women
were over three times as likely as heterosexual women
to report “fair” or “poor” self-perceived mental health.291
Significantly higher proportions of sexual minority groups
also reported diagnoses of mood and anxiety disorders
than did the heterosexual population. Gay and bisexual
men were almost three times as likely as heterosexual
men to report a mood disorder, while lesbians were oneand-a-half times and bisexual women more than three
times as likely as heterosexual women to report such a
diagnosis.291
Overall, lesbian, gay and bisexual (LGB) Canadians are
more likely to consult mental health service providers and
have higher utilization rates of professionals providing
emotional and mental support. It has been suggested that
there is a positive norm for using mental health services
in LGB communities and that lesbians and bisexual women
in particular may consider psychological counselling to
be important. This health care-seeking behaviour could
be triggered by stress related to discrimination faced by
individuals in this population.291
To date, little research has examined the physical, mental
and sexual health needs and concerns of transgendered
and transsexual youth or adults.286, 292 One recent largescale study that examined the mental health needs of 392
male-to-female and 123 female-to-male transgendered
persons found that low self-esteem was common among
all participants. In addition, 60% were classified as
clinically depressed, and 32% reported attempting
suicide. The study also found that attempted suicide was
significantly associated with depression and low selfesteem as well as with a history of forced sex, drug and
alcohol treatment and gender-based discrimination.293 In
general, gender minorities have difficulty addressing their
trans health needs with health care professionals who are
under-prepared and inadequately trained to deal with the
comprehensive health needs of this population.229
Stress is considered a major risk factor for depression,
and socially constructed gender roles may influence
the different sources of stress experienced by men and
women.68 The 2002 Mental Health and Well-being Survey
asked respondents to identify the most important source
of feelings of stress in their lives. A greater percentage
of men than women reported their work situation and
finances as the most important sources of stress. Women
were more likely to report that caring for a child, personal
or family responsibilities, and health of family were
the most important sources of stress.68 Other sources of
stress for women include environmental factors such as
sexism, heterosexism and the associated discrimination;
experiences of physical and sexual violence, including as
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
poor mental health, including depression, than men
who had improved their socio-economic status. While
more women than men in the study experienced poor
mental health, there was no apparent difference between
those who experienced upward or downward changes in
socio-economic status.284 A study of 2000/2001 Canadian
Community Health Survey (CCHS) data however, found
that men who were recent immigrants and who had
low incomes reported lower rates of depression than
their middle- or high-income counterparts, whereas
low-income recent immigrant women reported higher
rates of depression than their middle-/high-income
counterparts.285 This difference suggests that there
may be an absence of risk for low-income recent male
immigrants or even a low-risk advantage.
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a result of childhood maltreatment or intimate partner
violence; and the pressures of lone parenting.225, 267 These
differences in sources of stress seem to reflect societal
constructions of gender roles and expectations of men as
providers and women as caregivers.
46
Socially determined gender roles more frequently place
women in situations where they have little control over
important decisions concerning their lives. For example,
women more often carry the responsibility of caring for
relatives with physical or mental illnesses while lacking
the social support required to perform this function.
Resultant feelings about such a lack of autonomy can
result in low morale and high stress and are associated
with depression.267
Sexual Health
Sexual health outcomes are often described in terms of
their links to fertility and sexually transmitted infections
(STIs). Sexual health also encompasses attitudes and
behaviours pertaining to sexual acts (e.g. intercourse)
and other factors (e.g. relationships) that may influence
the sexual health of men and women in positive or
negative ways. In this section, nationally notifiable STIs
are used to illustrate the relationship between sex, gender
and sexual health outcomes.
As discussed in Chapter 1, the rates of STIs reported
to the Canadian Notifiable Disease Surveillance System
(CNDSS) differ for men and women. In 2009, young adults
between 20 and 24 years had the highest reported rates
of chlamydia, with the rate among young women twice
that among young men.169 The highest reported rates of
gonorrhea were also among those in the same age group,
but in this case, there was no significant difference
between young men and young women. However, the
infection rate was more than twice as high among
adolescent girls than adolescent boys (15 to 19 years),
whereas among adults 25 years and older, men had higher
rates than women.171 Unlike chlamydia and gonorrhea,
reported rates of infectious syphilis in 2009 were higher
in males than in females in all age groups.170
How sex influences sexual health risks
and outcomes
Biological differences between men and women can result
in differences in susceptibility and in the effects of STIs.
In general, female anatomy makes women more vulnerable
to acquiring STIs through some forms of sexual contact,
which partly accounts for the higher reported rates of
particular STIs in this population.294, 295 Physiological
changes in the cervix during adolescence increase the risk
of infection among girls in this age group.296
If left untreated, STIs can lead to dangerous outcomes
in both men and women. Women with chlamydia or
gonorrhea are at risk of developing pelvic inflammatory
disease that may lead to scarring of the fallopian tubes,
infertility and potentially fatal ectopic pregnancy.296-299
Babies born to women with chlamydia may be premature
or have eye infections or pneumonia, whereas those who
contract gonorrhea during birth can suffer blindness, joint
infections or life-threatening blood infections.297, 298
Although complications from chlamydia and gonorrhea
are less common in men, both can lead to epididymoorchitis (painful swelling of the epididymis portion of the
spermatic ducts and the testes) as well as scarring of the
urethra, possibly resulting in infertility.297, 298, 300
Outcomes of a syphilis infection can be equally serious for
both men and women if left untreated. Syphilis can cause
damage to the brain, heart, bones and other internal
organs, possibly causing death regardless of biological sex
of the infected person. Women who are infected during
pregnancy can also pass this infection to their babies,
which can result in congenital abnormalities, stillbirth,
developmental delays, seizures or death.301, 302
How gender influences sexual health risks
and outcomes
The consistent use of male and female condoms and
dental dams is known to be among the best ways to
prevent STIs.303 Several gender-related issues affect the
use of such protection, however. For example, negotiating
the use of barrier protection during sexual activity is
influenced by the gendered nature of sexual relations and
the power relations between the individuals involved.
Depending on the circumstances, the likelihood of not
using protection may increase, thereby increasing the
risk of contracting STIs.
In male-female relationships, preventing pregnancy
may also motivate the use of condoms. However, such a
decision may be influenced by gender norms and roles in
which the woman has been given the option, and often
the expectation, to control pregnancy prevention for
herself.253 If other contraception methods are being used,
condoms may be considered unnecessary, increasing the
risk of STIs in new or non-monogamous relationships.
For some men, cultural influences, such as being seen as
“macho,” may deter them from using condoms.304, 305 For
men who have sex with men (MSM), increased condom
use in the 1990s paralleled increased knowledge of the
dangers of HIV and AIDS, which indicates the value of
education regarding condom use.306
Both men and women may also participate in consensual
sex for reasons other than personal pleasure, such as the
desire to please others, or in exchange for money, drugs
or other material goods.175, 307 Those involved in survival
sex (exchanging sex for money, drugs, shelter or food),
or who are abused or forced to have sex against their
will may be at a particular disadvantage in negotiating
the use of protection during sexual activity. Survival sex,
unwanted sex and sexual assault more often place women
at risk, although they are a concern for both men and
women.225, 307 All of these situations may make it more
difficult to negotiate the use of condoms or other latex
barriers.175
According to the 2010 CCHS, almost two-thirds (65%) of
sexually active single youth and young adults, between
15 and 29 years, reported using a condom the last time
they had sexual intercourse during the past year.44 The
proportion was higher among males (70%) than females
(60%).44 Less than one-half (47%) of single adults
between 30 and 49 years had used a condom during their
last sexual encounter in the past year – 50% of men
and 43% of women.44 According to the 2008/2010 First
Nations Regional Health Survey (RHS), 18% of sexually
active First Nations youth (between 12 and 17 years)
living on a reserve or in northern communities reported
only occasionally or never using a condom.146 Among
sexually active First Nations adults living on a reserve or
in northern communities, nearly one-half (48%) reported
never using a condom.146
Having unprotected sex with multiple partners may also
increase an individual’s risk of contracting an STI simply
by increasing the chance of being exposed to someone
already infected. In 2010, 14% of Canadians between
15 and 49 years who reported having had sex in the
previous 12 months said they had had more than one
sexual partner (17% of males and 11% of females).44
Younger respondents between 15 and 29 years were
much more likely to report multiple partners than were
those aged 30 to 49 years (27% compared with 7%).
In both age groups, the proportion of males reporting
multiple partners was much higher than the proportion
of females – 32% compared with 22% for the younger
group, and 9% compared with 5% for the older group.44
Although multiple partners were reported across all
types of relationships, those who were single (including
widowed, separated or divorced) reported the highest
proportion overall (36%) of multiple partners in the past
year.44 More specifically, younger (15 to 29 years) divorced
females and younger separated males were the most likely
(77% and 65% respectively) to report multiple partners,
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
In addition to biological sex differences, gender
influences affect the risk, incidence and outcomes of
STIs as well as the likelihood that someone will be tested
for and diagnosed with these conditions. Gender acts
through societal roles and expectations about power
sharing within sexual encounters, to affect sexual health
outcomes.
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while younger widows (0.0%) and older (30 to 49 years)
married females (0.7%) were the least likely.44 Among
sexually active First Nations youth (12 to 17 years), 44%
reported in the 2008/2010 RHS that they had more than
one sexual partner in the past year.146 For First Nations
adults, a higher proportion of males (23%) than females
(17%) reported having more than one partner.146
48
Adolescence is a particularly important period when social
contexts provide clues and cues about what constitutes
safer or riskier sexual behaviour. Early age of sexual debut
has been associated with increased likelihood of early age
pregnancy and STIs.308, 309 In 2010, of those between 15
and 29 years who reported having had sexual intercourse,
the average age of first intercourse for both males and
females was around 17 years with 26% having done so for
the first time before age 16 years (27% of males and 25%
of females).44 In comparison, among adults aged 30 to
49 years, the average age of first sexual intercourse was
a little older than 18 years (slightly younger than age 18
years for males and closer to age 19 years for females).
In addition, only 18% reported that they had had sexual
intercourse before age 16 years, and the proportion was
much higher among males than females (23% compared
with 14%).44 This suggests that the age of sexual debut
in Canadians is decreasing and the gender gap is closing.
According to the 2008/2010 RHS, 47% of Aboriginal
youth between 15 and 17 years reported being sexually
active.146
Although STI rates are highest in Canadians under 30
years of age, they are increasing faster among adults
between 40 and 59 years. The reasons for these increases
in older adults are not entirely clear, but it has been
noted that middle-age or older people are usually ignored
in prevention programs that tend to focus on younger
age groups who are more at risk.310, 311 Older adults rarely
discuss the topic of sexual health during visits with their
physician and often delay seeking treatment, perhaps
due to shame, fear and embarrassment in discussing
their sexual health concerns.177, 310 Given their stage of
life, older adults may consider condom use unnecessary
because they are less concerned about pregnancy risk.310
Timely and appropriate testing, diagnosis and treatment
prevent the spread of STIs and ongoing negative health
consequences. However, as mentioned earlier, gender
norms influence access to care and men and women do
not access health care systems at the same rate or for
the same reasons.260 Since women tend to interact more
frequently with the health care system, they are more
likely than men to have the opportunity for routine
screening or to seek treatment for STIs.44, 312 This may
partly explain the differences in reported infection rates:
because more women are tested, more infections are
diagnosed and reported among women than men.
Various factors may prevent men and women from being
tested for STIs. One is misinformation surrounding
testing procedures, such as the assumption that Pap
tests also test for all STIs, or that STI testing for men
involves a painful urethral swab.313, 314 Males have also
reported concerns related to sexualization of the clinical
experience, fearing that they or the provider may see,
or react to, the interaction sexually since it involves the
genitals.314 Stigma also acts as a deterrent to testing
for males and females of all ages, and is a particular
problem for sexual and gender minorities.313, 315, 316 College
students in the United States reported concerns about
testing for STIs, including the gender of the provider,
accessibility, confidentiality and potential damage to
their reputation.317 In 2009, 27% of surveyed Toronto
youth feared they would be judged or subjected to
embarrassment if they accessed sexual health services.318
Screening sites and clinic procedures have been found
to be more welcoming and directed towards females,
which may discourage males from accessing the services.
Research in British Columbia also found that privacy
concerns, inaccessible clinic hours, clinic decor and
perceived homophobia were barriers to testing for some
young men and women.313
The private and personal nature of sexual health issues
can make it difficult for many individuals to seek
and receive services. This is particularly the case for
marginalized groups whose experiences with gendered
power relations and their intersections with other
social, environmental and structural influences have
important implications for a person’s ability to negotiate
safer sex practices and/or to access appropriate sexual
health services.315, 319 Stigma and discrimination faced
by sexual minorities because they transgress the socially
constructed gender role expectations and notions of
“femininity” and “masculinity” can negatively influence
their health care-seeking behaviours and experiences as
well as whether they disclose their sexual orientation and
behaviours to their health care providers.313, 320
Summary
This discussion demonstrates how sex and gender
influence behaviours, risks, and ultimately, health
outcomes. Approaches to prevent or improve outcomes
and/or provide services for those affected need to take
into account the roles of biological sex and gender in
general. They also need to enhance efforts to address
diversity across sexual orientations, ages and settings.
The examples included in this chapter highlight the
importance of accounting for sex and gender. They also
illustrate the significance of constructing interventions
that appropriately balance individual and structural
approaches to reducing risk and promoting health
over the lifecourse. This information can be used as
a starting point for determining approaches that ensure
all Canadians can benefit from interventions, programs
and supports.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Primary care settings need to continue to improve their
provision of sexual health services so as to meet the
needs of sexual and gender minority individuals.229, 321
Sexual health education has also yet to adequately
address the needs of sexual and gender minorities
individuals; coupled with persistent homophobia and
transphobia in schools, workplaces and other public
arenas, some sexual and gender minority individuals
face multiple vulnerabilities that contribute to STI/
HIV infection risk, and must overcome serious barriers
to enacting sexual self-efficacy (i.e. the belief in one’s
ability to deal effectively with their sexuality).321-323
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This chapter explores broad and targeted Canadian
and international interventions – research, programs,
initiatives and policies – that address health issues and/
or risk factors and consider and/or incorporate sex and
gender into their design or execution. In doing so, this
chapter shows how incorporating sex and gender into
programs, policies and research makes a difference to
health.
•• address a known health inequality or gap;
•• illustrate differences in experiences and outcomes;
•• are available with some measure of effectiveness;
and/or
•• represent a specific region, sub-population or issue
at different stages of the lifecourse.
Portraying a targeted perspective does not negate the
existence or the severity of the health issue among
populations not profiled. For example, profiling a men’s
specific health issue or intervention does not suggest that
the issue or response is isolated to men; rather this is an
example of how Canada, as a society, is considering and
incorporating sex and gender in health interventions.
This chapter is organized into three sections:
•• The first section illustrates how considering
sex and gender is important to health
outcomes as well as health research and
public health practices.
•• The second considers how sex and gender are
related to select physical, mental and sexual
health outcomes.
•• The third shows how sex and gender affect
the socio-economic determinants of health
and contribute to health inequalities.
Addressing determinants of health
appropriately can make a difference to health
and well-being.
Section One: Sex and gender and public
health interventions
Considering sex and gender when developing and
delivering programs, policies and practices is important
to achieving better health outcomes. Doing so, in
part, involves taking actions that generate positive
relationships between sex and gender as well as among
the broader determinants of health. A sex- and genderbased approach is part of systematically planned
interventions that are consistent with population
health approaches.11, 218
Integrating sex and gender into health research
There are many reasons for integrating or considering
sex and gender into health research that include
scientific, methodological and ethical reasons.219, 260, 324‑327
The challenges that remain, however, stem from not
knowing what sex and gender mean and/or how they
apply as well as differences in approach and intensity by
research field. Research standards and methodological
recommendations are being developed across a number of
jurisdictions to address these knowledge gaps.216, 219, 326-330
Historically, research often relied exclusively on
male subjects with specific cultural and racial
characteristics, the resulting data extrapolated to
the entire population.216 Women were systematically
excluded from research to avoid issues with pregnancy
and breastfeeding during research, particularly clinical
trials.216, 331 Later research showed that sex alone had
significant influences on human health in terms of
physiology and chemistry and response to disease, pain
and treatments.216, 219, 328, 331 Failing to implement and
consider sex in research compromised its validity and
the applicability of programs. Following the advocacy
of women’s movements, research began to focus on
sex differences between men and women including the
division of data by sex, treatment of women in clinical
practices and consideration of social issues such as
sex roles and sex-role socialization.233 The evolution of
the concept of gender followed, setting the stage for
differentiation of sex and gender as two distinct concepts
and a recognition that both matter to women’s and men’s
health.233 Understanding that sex- and gender-based
health research was about everyone’s health – not solely
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Examples of programs, policies and research that have
incorporated sex and gender (in textboxes as well as in
the text) are not intended to be a compendium of health
issues. They are intended to complement – not mirror –
the health issues and risk factors identified in Chapter 3
and also consider the broader determinants of health.
The examples are chosen because they:
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about women’s health – was a transformative change
that is still gaining momentum and endorsement across
research areas.217, 233, 328 (See the textbox “Incorporating
sex and gender into research.”)
Canadian researchers have long criticized approaches that
assume that “one size fits all” in terms of programming
and services and revealed the problems associated with
“gender-neutral” approaches when applied to everyday
issues.216, 217, 233, 328
Canada embarked on its commitment to sex- and genderbased work when evidence surfaced that pointed to gaps
and inequalities created by not addressing research,
programs and policies in the context of sex and gender.
By ratifying the Beijing Declaration, Canada agreed to
promote gender mainstreaming in all relevant policies
and programs.217, 342 As part of this agreement, the federal
Health Portfolio uses sex- and gender-based analysis
(SGBA) to develop, implement and evaluate research,
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Incorporating sex and gender into research
52
Canada has been working towards increasing data
capacity in terms of women’s health indicators related
to numerous health issues (e.g. cancer, musculoskeletal
disorders, mental health and violence). Since 1999 and
the establishment of Women’s Health Surveillance: Plan
of Action for Health Canada a number of developments,
including the Women’s Health Surveillance Report
(2003), pointed to the need for sex- and gender-based
indicators.253, 332, 333 The plan recommended on-going
identification of priorities for indicators based on gaps
in women’s health surveillance.332, 333 Measuring the
health status of women is extremely important, partly
because much of the previous knowledge base failed
to include sufficient data on women’s health.253, 333
While some progress has been made, comprehensive
indicators in the area of men’s as well as trans’ health
remain to be fully realized. Measuring status, including
measurements of sex and gender, can work toward
developing comparable and diverse outcomes.334
The Prairie Women’s Health Centre of Excellence
developed A Profile of Women’s Health in Manitoba,
a comprehensive review of over 140 indicators of
Manitoba women’s health including health status,
health services use, socio-economic influences, health
system performance and lifestyle choices.335 The review
is recognized for applying a gender-based analysis
to include, where possible, factors on diversity such
as location, race and culture.335, 336 Similar to the
Manitoba review, Ontario Women’s Health Status Report
also applies a gender-based analysis to both the health
and the determinants of health of Ontario women.
This report looks at the physical, social, emotional,
cultural and spiritual well-being of women and
provides information on the demographics, morbidity
indicators, reproductive health, and health behaviours
of women. It also provides additional information on
sub-populations such as lone mothers, senior women,
immigrant and visible minority women, Aboriginal
women and rural and northern women.337
The Health Behaviours of School-Aged Children (HBSC)
study is an example of research that broadly includes
sex and gender factors as well as the experiences of
adolescent boys and girls to understand their mental
and physical health and their interactions with
the determinants of health.338 Canada is one of 43
countries that collect data every four years on 11-,
13- and 15-year-old boys’ and girls’ health and wellbeing, social environments and health behaviours.338-340
This age is important being as it is a period of
increasing autonomy that significantly influences how
health and health-related behaviours develop.340 The
data allows for cross-national comparisons, trends
analysis as well as more in-depth analysis on particular
topics.340 Findings are analyzed and examined based on
gender; they look beyond the differences between girls
and boys to include underlying issues. For example, a
recent report, The Health of Canada’s Young People:
A Mental Health Focus, looked at mental health issues
and the influence of sex and gender and satisfaction
with life and body, relationships, substance use and
academic performance.338 Also explored are factors
such as relationships with parents, peers and pressure
to conform to cultural as well as social norms.340
As a result of the extensive international HBSC
research findings, the World Health Organization
(WHO) recommended that member states consider
the importance of implementing gender-specific
intervention programs.341
programs and policies. Within the Portfolio, organizations
such as the Canadian Institutes of Health Research
(CIHR) developed guidelines for research applicants to
consider how gender and/or sex might be integrated
in areas of health research (including clinical, health
systems and social factors).23, 343 These guidelines provide
key questions to ask about where and how sex and/or
gender play a role in the research approach, hypotheses,
methods and ethics.343 CIHR also established the Institute
of Gender and Health, which is the only health research
funding institute that specifically focuses on gender, sex
and health.23 CIHR and its partner organizations within
the federal Health Portfolio (including the Public Health
Agency of Canada and Health Canada) are committed to
upholding SGBA. (See the textbox “The Health Portfolio’s
Sex and Gender-Based Analysis Policy.”)
A population health approach relies on consistently
measuring health indicators (variables that assess the
health status as well as factors that influence health)
and identifying trends that provide a comprehensive
picture of the health of the population.13, 239 Effective
research involves understanding the different factors
influencing health outcomes and building knowledge
The Government of Canada’s Health Portfolio has a
policy in place to use SGBA to develop, implement and
evaluate research, programs and policies.220 The current
SGBA policy replaces Health Canada’s Gender-Based
Analysis Policy (2000) and expands to the entire Health
Portfolio (which comprises the following organizations:
Health Canada, Public Health Agency of Canada,
Canadian Institutes for Health Research, the Hazardous
Materials Information Review Commission and the
Patented Medicine Prices Review Board).220 The policy
supports:
•• a comprehensive understanding of variations in
health status, experiences of health and illness,
health service use and interaction with the
health system;
•• the development of sound science and reliable
evidence that captures sex- and gender-based
health differences among people; and
•• the implementation of rigorous and effective
research, programs and policies that address
sex- and gender-based health differences among
people.220
The Portfolio’s SGBA policy has five guiding principles:
accountability to implement and affect change;
continuous improvement by building on experiences
and incorporating lessons learned and best practices;
integrated approach where SGBA is a natural part
of doing business; achieving balance and equal
representation in programs and policies; and shared
responsibility requiring the participation of all staff
in the context of their work and for management to
provide leadership to support SGBA.220 Developments
have included CIHR’s guidelines for Gender and SexBased Analysis in Research and the Health Portfolio
Sex and Gender-Based Analysis Policy. The broad-based
Aboriginal Specific Sex and Gender-Based Analysis
addresses factors that relate to Aboriginal perspectives
on sex and gender.346, 347 While evaluations are still
pending on how effectively and efficiently programs
have engaged SGBA, it is accepted that integrating
SGBA into the development, implementation and
evaluation of all programs can ensure gender equality,
greater effectiveness and efficiency in program delivery
and research rigour.220, 334, 346
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
The Health Portfolio’s Sex and Gender-Based Analysis Policy
Canada’s commitment to SGBA began in the late
1980s and early 1990s when evidence pointed to
gaps created by not developing research, programs
and policies in the context of sex and gender. In
addition, there was a push for gender equality as per
constitutional commitments. In 1995, at the United
Nations Fourth World Conference on Women with
the Beijing Declaration and Platform for Action, the
Government of Canada committed to mainstreaming
gender-based analysis and equality across federal
organizations.217, 342, 344 As a result government
departments agreed to promote gender mainstreaming
in all relevant policies and programs.220 A review by
the Auditor General of Canada in 2009 found mixed
progress in implementing gender-based analysis,
mainly due to a lack of training, knowledge and
guidance about putting it into practice.345
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accordingly.239 Too often data are under-reported,
under-collected or aggregated in ways that mask
variations associated with sex as well as miss other
important factors such as age, ethnicity and socioeconomic status. Sex-based disaggregated data exists
in some areas and show differences, however, there are
Approaches to implementing Aboriginal sex- and gender-based analysis
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Our Voices: A First Nations, Métis and Inuit Sexand Gender Based Analysis
54
Our Voices is an Aboriginal-specific sex- and genderbased analysis (ASGBA) online toolkit that includes
data sources, reports, studies and examples that
are culturally appropriate and important to First
Nations, Métis and Inuit health issues. Our Voices
profiles ASGBA information on select issues for health
status, health determinants and health services.
Organizations, governments, researchers and health
officials as well as individuals can access training and
information on how to apply ASGBA to their work,
thus encouraging better analysis of health issues.
The original goal is to build awareness and capacity,
improve access and better inform Aboriginal women’s
health policy, thus moving towards closing the gap in
health disparities experienced by First Nations, Métis
and Inuit women compared with broader population of
women in Canada.347
Assembly of First Nations – Gender-Based Analysis
Framework
In 2010, the Assembly of First Nations Women’s
Council developed a Gender Based Analysis (GBA)
Implementation Strategy to build capacity and
offer training across First Nations regions and
in communities in order to meet United Nations
Millennium Development Goals of gender equity. This
includes implementation, evaluation and monitoring in
order to effectively mainstream gender-based analysis.
In particular, this approach is used to act against
violence towards Aboriginal women and girls.348
Native Women’s Association of Canada – a culturally
relevant gender-based analysis
While early gender-based frameworks acknowledged the
equitable outcomes and impacts to men and women,
they have not adequately addressed the unique
social and cultural needs and circumstances of all
populations.349, 350 A history of colonization and male-
centred leadership has disproportionately affected the
health of Aboriginal populations in terms of violence,
illness and disease as well as socio-economic factors
such as poverty, underemployment and inadequate
housing.349, 350 A culturally relevant gender-based
analysis offers some understanding of how gender
roles have developed within Aboriginal societies and
the path forward. The Native Women’s Association
of Canada has developed the Culturally Relevant
Gender Application Protocol, a means to incorporate
culture and gender perspectives and an accountability
framework into policy processes.349, 350 The protocol
contains three components: equity in participation;
balanced communication; and equality in results.
Within each component, actions are inventoried with
measures that track performance and opportunities for
best practices and lessons learned. Success is measured
based on developments as well as changes in attitudes
towards gender – and particularly towards women –
and the accountability for long-term outcomes.351
Pauktuutit Inuit Women of Canada – an Inuitspecific gender-based analysis of health
determinants tool
In 2007, Pauktuutit Inuit Women of Canada began
developing an Inuit-specific gender-based analysis tool.
The project consisted of two parts; the first was the
creation of a culturally relevant gender-based analysis
framework, and the second involved culturally relevant
health indicators for Inuit women.352, 353 In 2008/2009,
Pauktuutit used the Inuit-specific gender-based analysis
tool to demonstrate overall how food security impacts
Inuit women and men differently, as well as to assess
how changes to Nutrition North Canada (formerly Food
Mail Program which subsidizes shipping of certain
nutritious foods to isolated northern communities)
might impact Inuit women and men living in the North.
Pauktuutit was able to test their tool and gain valuable
insight into the needs of the Inuit populations and the
unique challenges facing men and women regarding
food security.352, 354
limited analyses that explain and understand why and
how differences occur. Accounting for and highlighting
diversity creates opportunities for better evidenceinformed decision-making. This helps to ensure programs
are designed that are able to meet the needs of those
at greatest risk thereby avoiding an increase in health
gaps.333, 334 Applying SGBA to research helps to explain
the complexity of health determinants, behaviours and
outcomes, why differences occur and what can be done
to address these gaps.333
Integrating sex and gender in public
health practice
Considering sex and gender in public health interventions
involves a broader approach than addressing male
and female health outcomes. A sex- and gender-based
approach to interventions challenges assumptions
that male, female and trans youth and adults similarly
experience health outcomes and the interventions
intended to address health issues.233 Such an approach
also challenges tendencies to focus on differences rather
than understanding the factors that influence these
differences. This approach also encourages planners and
practitioners to identify how differences play out in
programs and to consider how issues are framed, defined
and communicated, how information is collected (and by
whom), and how interventions will address the needs of
diverse groups.218, 233
For example, human papillomavirus (HPV) immunization is
a widely recognized public health practice where applying
a sex- and gender-based approach can show different
perspectives for disease, outcomes and interventions.
(See the textbox “Changing perspectives with a sex and
gender lens on a public health issue: the HPV example.”)
This example is intended to show the difference made by
applying a sex and gender lens and does not assess the
program per se.
The typical “one size fits all” approach masks diversity
among individuals and the broad determinants of health.
While it is easier to ask what is happening with girls
or women and boys or men and to tailor programs
accordingly, this assumes a simple binary classification
of male or female rather than a masculine and feminine
continuum. In addition, gender norms – in terms of
expectations, roles and behaviours – and the continuum
of these norms among social and cultural practices
directly influence the health and well-being of girls and
boys and women and men.228 These expectations can
directly influence attitudes towards health practices such
as prevention, support and treatment as well as social
practices, including relationships with partners, children
and work.216, 217, 228
Gathering information on “males” or “females,” and
assuming that it is indicative of biological sex and/
or being masculine or feminine does not fully address
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Tools that incorporate sex, gender and other aspects of
diversity into health indicators take SGBA to another level
of sophistication. For example, the Aboriginal Women and
Girls’ Health Roundtable (2005) highlighted the need to
develop gender analysis in the context of First Nations,
Métis and Inuit populations. As a result, AboriginalSpecific Sex- and Gender-Based Analysis was developed
to look at specific factors with Aboriginal perspectives
as well as a sex and gender lens thus encompassing the
unique cultural histories and perspectives of First Nations,
Métis and Inuit while highlighting differences between
and among these populations.346, 347 (See the textbox
“Approaches to implementing Aboriginal sex- and genderbased analysis.”) The Our Voices strategy evolved from the
identified need to include issues specific to Aboriginal
women’s health toward a sex- and gender-based approach
to data and programs.346, 347
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important aspects of identity and biology that need to
be addressed in sub-groups of the population. People
who identify as trans (transgendered, transsexual,
transitioning) do not reflect a homogeneous group.
Identifying themselves as “other,” a choice often provided
by surveys, perpetuates invisibility and lack of identity.229
A recent American trend analysis of medical publications
from 1950–2007 showed that sexual and gender minority
persons were largely invisible or excluded from studies
and that medical professionals often did not recognize
the health care needs of this diverse population.357
Assuming gender neutrality can further health disparities
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Changing perspectives with a sex and gender lens on a public health issue: the HPV example
56
Applying a sex and gender lens can influence how
public health is practiced and understood. Addressing
human papillomavirus (HPV) is a good example of
how perspectives of practices can vary when sex and
gender are considered. While much attention has
been paid to the virus and its link to cervical cancer
and the use of vaccination to reduce this risk, HPV is
also related to other cancer outcomes that can also
impact men. HPV has over 100 types and can impact
many areas of the body, with varying outcomes for
men and women.173, 218, 355 Men also play a role in the
transmission of disease.218
Increasing rates of HPV, especially among young
women, and the associated risk of cervical cancer
brought about the development and authorization of
the HPV vaccination for young females (between 9 and
26 years) according to the immunization needs and
schedules of the provinces and territories. In Canada,
immunization is a shared responsibility among federal,
provincial and territorial governments.355 The federal
government is responsible for regulation and oversight
of vaccines while the provinces and territories fund
and deliver immunization programs.213 By 2008,
all provinces and territories had introduced HPV
vaccinations programs for girls as part of their routine
immunization.355 The vaccine is now used to prevent
the infection caused by HPV and its possible long-term
health outcomes, particularly cervical cancer.355
Approaching HPV prevention practices with a sex
and gender lens can reveal different perspectives,
for instance:
•• Pap tests and prenatal screening have identified
that women over 20 years old (who were not
previously vaccinated or screened) are being
increasingly diagnosed with HPV;
•• Studies have shown a high HPV prevalence rate
among heterosexual males and a high rate of
transmission of HPV to female partners from men
with existing penile warts;
•• Men who have sex with men (MSM) are also
at-risk for HPV related cancers (such as throat
and anal); and
•• Those who may be immune compromised are
also at risk for HPV.218, 355
The initial vaccination program does not fully address
risks to those outside of the target group (girls 9 to
26 years) including older women, the role males play in
transmitting HPV, and protecting boys and men against
HPV and HPV-related cancers.355, 356 Applying a sex and
gender lens would suggest considering these different
perspectives. The practice of immunizing only girls may
raise questions to some practitioners, as to why boys
are excluded and how their long-term risks are being
addressed and as well as why do young girls have the
responsibility of addressing transmission.355, 356 Taking
sex and gender considerations into account suggests
that the HPV-related health needs of both young and
older women and men need to be addressed through
public health practices, while continuing to reduce
overall health risks.356 However, consideration does not
necessarily suggest this would be the most effective
practice in terms of costs and risk reduction, nor does
it negate the need for on-going health screening
processes for all individuals.
In early 2012, the National Advisory Committee
on Immunization recommended the use of the HPV
vaccine for all males between 9 and 26 years and
females 9 to 45 years.355 Evaluations will need to
be undertaken to measure how the intervention
affects men, women and various sub-populations.355
New data will need to be collected and analyzed to
compare results to baseline measures and evaluate
effectiveness, including long-term outcomes such
as incidence of related cancers.355
as programs fail to examine sex and other socio-economic
determinants contributing to ineffective interventions
and unintended (but adverse) outcomes.233 While the
continuums of sex and gender are considered throughout
this chapter, the continuum is often lost in the examples
of research, programs and policies, and identifying and
addressing health issues of trans sub-populations is an
on-going challenge.
Section Two: Sex and gender in select
health outcomes
Sex, gender and physical health
Approaches to preventing and managing the onset of
chronic disease must reflect differences among men,
women, boys and girls so as to most effectively address
and/or avoid adverse health outcomes. As outlined in
previous chapters, interventions that focus on disease
prevention and support healthy living (healthy behaviours
and choices) can reduce risk factors for some adverse
health outcomes.184, 358-360 Opportunities to positively
influence health exist at different points across the
lifecourse. Some approaches consider the influence of
sex and gender that have worked to incorporate different
needs within their design and execution.
Promoting healthy weights
Being overweight or obese is a major public health
challenge with many contributing factors.193, 361, 362
Unhealthy weights can influence the development of many
chronic diseases in later life.193, 361-363 Generally, those
who have poor nutrition and lower levels of daily physical
activity are most likely to have excess body weight and
hence an increased risk of developing related adverse
health outcomes across the lifecourse.361, 362 The WHO has
developed strategies to address diet, physical activity and
health.364 It recommends broad inter-sectoral approaches
aimed at several factors, including education, as well as
tailoring interventions that take into account context,
gender roles and culture.364
An Alberta-based study examined whether sex and
gender should be considered in the development and
implementation of healthy weight interventions for
youth.363 The study suggested that because differences
exist between pre-adolescent boys and girls in terms
of behaviours, diet and physical activity, interventions
should incorporate sex and gender. Understanding
differences based on sex and gender as well as other
factors (such as cultural and geographic location) are
important to increasing our understanding of how to
encourage positive healthy practices among youth.363
(See the textbox “Healthy Dads, Healthy Kids.”) The
results of the study reinforce the need for increased sex
and gender consideration in health interventions
to maximise effectiveness and delivery.363
While Canada has recently developed strategies to address
obesity, sex and gender were not specifically highlighted.
Recognizing gender differences in these areas would allow
for the development of more effective health promotion
programming.363, 365, 366 Providing a gender-focused health
promotion intervention could better address physical
activity among girls and healthy eating among boys.363
To be effective, healthy weights programs will also
need to consider the needs of visible minorities, sexual
minorities and those who live in rural and remote regions.
Systematic reviews and meta-analyses found that schoolbased health programs can be effective in promoting
healthy weights.374, 375 The studies have shown the
importance of sex-based programming with a genderbased perspective. Generally, girls benefit from learning
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Embracing the inter-relationships between sex, gender
and the broader determinants of health needs to become
part of mainstream practice in public health.15, 20, 25, 233, 333
The necessary work – in particular, knowledge translation
and dissemination of sex- and gender-based research –
is less than straightforward as the issues are complex and
difficult to measure and communicate.333 Nevertheless,
accounting effectively for sex and gender health
inequalities can contribute to cost savings to the health
system and better services in communities.216, 333 Further,
the exclusion of sex and gender from research, programs
and policies is ultimately unethical.233 The remainder
of this chapter focuses on the effective and promising
approaches and interventions that consider sex and
gender in terms of select examples of health outcomes
as well as the social determinants of health.
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Healthy Dads, Healthy Kids
58
To address the growing concern of unhealthy
weights in Australia, the University of Newcastle
(New South Wales, Australia) developed the Healthy
Dads, Healthy Kids (HDHK) program in 2008/2009 to
help overweight fathers lose weight and positively
influence health behaviours of their children.367-369
This family-based program recruited overweight or
obese men with children between the ages of 5 and
12 years.368-370 Evaluations of the trial program after
6 months revealed that 85% of fathers had achieved
a weight loss greater than 5% of their body weight,
reduced their waist circumferences, lowered their
blood pressure, increased their physical activity levels,
reduced their calorie intake and improved their overall
diet.368-371 Their children had also improved their
physical activity levels, reduced their resting heart
rate and decreased their calorie intake.368-370 Due to
its success, the program has been expanded to other
communities in Australia.370, 372, 373
environments with a social context that emerge though
observation, role-playing/cognition and transition; boys
benefit more from programs targeted in environments
that support their interests.376 Canadian-based research
synthesized best practices on achieving appropriate
evaluation techniques that address childhood obesity
and related chronic diseases.377 This research considered
effectiveness, program development and evaluation as
well as the impact on broad population health and certain
sub-populations. Results indicated that interventions do
not focus on the needs of sub-populations of children and
youth – particularly young males – despite the known
longer-term rates of obesity-related chronic disease
among men.377
that multifactorial interventions, particularly those
involving changes to the school environment, were
effective in promoting healthy eating and physical
activity.380 Research also showed that age and gender
mattered as comprehensive school health programs
showed greater benefits in girls and older students.380
School-based programs were found to be beneficial for
physical activity interventions, but the benefits were
short term, and more could be done to integrate effective
programs that address and encourage maintenance of
healthy weights.377 The comprehensive school health
framework encompasses a whole of school approach
that support students educational outcomes while also
integrating school health.378 The Pan-Canadian Joint
Consortium for School Health, a partnership between
federal, provincial and territorial ministries of health and
education, supports and encourages the interrelationship
between learning and health.378, 379 The Consortium works
across jurisdictions and sectors to share information and
experiences, identify best practices, leverage resources,
minimize duplication, foster partnerships and conduct
further research in promising area.379 Systematic reviews
of comprehensive school health approaches have found
Where men and women are involved in similar physical
activities, gender-neutral statistics on activities and
chronic disease can mask the underlying motivation for
exercise and the effectiveness of programs.219 The socially
constructed contexts in which gender influences physical
activity is important to how interventions are managed.
In addition, policy and program initiatives need gendered
evaluations to assess their effects on and among women
and men, girls and boys.
Sex and gender stereotypes influence perceptions of
ability and physical activity. Enrolments in sports and
physical activities across the lifecourse show stereotypical
preferences. Girls often prefer “feminine” activities, for
example figure skating, instead of more contact style
sports, for example hockey, which see higher enrollment
among boys. Similarly, some older women report feeling
uncomfortable weight training in a gym as they report
perceiving this to be a masculine activity.381 What is
typically considered “locker-room talk” can take on
gendered or sexist language and behaviours; particularly
for those boys who do not perform well in physical
activities and sports. Strong, physically active girls
who exhibit qualities and/or skills socially connected
with boys can be stigmatized as tomboys or have
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their behaviours extrapolated into presumed sexual
orientation.381
Communities across Canada offer programs that educate
and encourage women and girls in sports. Broad-based
initiatives such as the Canadian Association for the
Advancement of Women and Sport and Physical Activity
(CAAWS) have created several projects to promote sport
for girls and women and challenge gender stereotypes
and homophobia. (See the textbox “Canadian Association
for the Advancement of Women and Sport and Physical
Activity.”) In 2009, Canadian Heritage adopted Actively
Engaged: A Policy on Sport for Women and Girls to promote
meaningful opportunities for women and girls as athletes,
coaches, technical leaders and officials, both nationally
and internationally, by having sporting organizations
provide quality experiences and equitable support.384, 385
The objective of the policy is to foster a positive
sporting environment for women and girls that will
transcend through a lifetime of sport participation.386
Evaluations of this approach are to begin five years after
implementation.386
Sex differences in physical capacity, where men often
seem to have more strength and endurance, is also an
Canadian Association for the Advancement of Women and Sport and Physical Activity
For over 30 years, the Canadian Association for the
Advancement of Women and Sport and Physical
Activity (CAAWS) has developed a national network
of programs to promote physical activity and active
lifestyles for girls and women across the lifecourse.
Established to tackle issues around equitable
sport and physical activity, CAAWS seeks to create
environments where girls and women have equal
opportunities to participate and lead in sport and
physical activity.384, 385 The organization has developed
a wide range of documents and activities including the
development of the handbook Towards Gender Equity
for Women in Sport and a policy manual suggesting
ways to put research into action.384 Earlier CAAWS’
programs – [email protected] and Girls Playing on Boys’
Teams – encouraged girls to break down gender barriers
in sport. More recent activities focus on engaging
women “55 – 70+” (e.g. Sport for More) and mothers
(e.g. Mothers in Motion) in active lifestyles.394-396
Programs, such as Active & Free, target girls between
9 and 18 years to choose sport and physical activity
over tobacco, and the program On the Move which has
now expanded to address the needs of Aboriginal and
newcomer (new to neighbourhood) girls and young
women in physical activities.397, 398 CAAWS continues
to build new relationships and find mechanisms to
support sport and physical activity among Canadian
girls and women.385
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Students should be able to participate in physical
education classes and team sports in a safe, inclusive
and respectful environment. Participation in sports,
locker room access and privacy for changing clothes
often create stress for some youth.223 To address the
issue of physical activity for transgender and transsexual
youth, the Canadian Teachers’ Federation created a
guide to assist educators in supporting transgender and
transsexual youth who, like their cisgender peers, should
be able to participate in physical activity classes and
recreational and/or competitive sports.223 Policies and
procedures should be inclusive, regardless of gender
identity or gender expression, in an environment free
of discrimination and harassment.382 Schools can create
this environment by educating staff and coaches, and
by working with parents so transgender and transsexual
youth are understood and accommodated in schooling.383
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
issue.387 For example, the higher number of ankle and
knee injuries among female endurance athletes is seen
as a result of the differences in physical composition
of muscle and tendons.388-393 However, while physiology
plays a significant role, young men often receive more
appropriate care and training at an earlier age.390-393
Women’s participation in sport and physical activities
has required them to challenge gender stereotypes
and roles as well as to seek out community facilities
available to them.387
60
The Public Health Agency of Canada’s Innovation
Strategy illustrates how SGBA as well as health equity
considerations can be incorporated into programs and
practice.399, 400 In 2011, 37 projects funded in the first
phase of the Innovation Strategy’s Achieving Healthier
Weights in Canada’s Communities initiative were reviewed
to determine the manner and extent to which sex, gender,
and equity considerations were taken into account.400
As a result of that analysis, the Agency identified ways
it could improve its own practices to support and
encourage organizations to more clearly consider those
factors in developing, implementing and evaluating their
interventions. Those improvements were reflected in the
next round of solicitations.
•• Project proposals were rated in part on the extent
to which health equity as well as sex, gender and
sexuality roles and factors were integrated in the
implementation, adaptation, and evaluation of the
proposed interventions.
•• The solicitation materials supported organizations in
developing those elements, by:
––providing examples of gender differences in obesity,
and describing different societal expectations
and roles of men and women that could influence
healthy weights (e.g. access to financial resources,
who purchases food, roles in child care and how
that could affect activity and eating patterns of
both caregiver and the children), and
––describing ways to address gender-specific needs in
the design, implementation and evaluation of the
intervention.400
Promoting heart health
Addressing the influence of sex and gender on health
requires challenging assumptions and historic practices.
These assumptions about sex, gender and health influence
perceptions of risk as well as individual and collective
approaches to healthy living. For example, the fact that
women generally live longer than men and that men are
more likely to have heart disease (see Chapter 1 for data)
assumes that women are not impacted by heart disease.242
As a result, past approaches, particularly around
cardiovascular health focused on men’s health which
has influenced the identification and treatment of
disease for women.242
Historically, health and disease research has rarely
considered sex and gender in relation to prevention,
identification, diagnosis, treatment or management of
ill health.242 Cardiovascular health is a prime example
of how research has typically focused on male norms
and standards that apply neither to women nor to all
men.242, 401-403 Evidence shows that factors such as sex affect
symptom presentation and disease identification whereas
gender can influence treatment-seeking as well as health
care practitioners’ reactions to cardiac symptoms.242 The
combined interaction of sex, gender and the broader health
determinants can affect health status, health system
responses and short- and long-term health outcomes.18, 242
Perceptions of cardiovascular disease (CVD) have affected
the health of women, who used to be under-represented
in cardiovascular research, treatment and health
prevention practices.242, 402, 403 CVD has only recently been
recognized as one of the leading causes of death and ill
health among Canadian women.77, 404 Prior to this CVD
was assumed to be a “man’s disease” with only 13% of
Canadian women (and 15% over 35 years) identifying
heart disease as their most significant health concern.405
To address this perception, heart health organizations
began targeting women through social marketing, public
awareness and health promotion programs.406, 407 In 2008,
the Heart and Stroke Foundation of Canada launched The
Heart Truth campaign to call on women to put their own
health first, change their habits, recognize heart attack
and stroke symptoms and seek prompt treatment.406, 407
(See the textbox “Targeting women: The Heart Truth
campaign.”)
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Targeting women: The Heart Truth campaign
Sex, gender and mental health and well-being
Each of the annual Chief Public Health Officer’s reports
has stressed the importance of mental health and wellbeing as well as the need to support individual Canadians
and their families and communities. Applying a sex- and
gender-based approach to mental health interventions can
help better understand how the determinants of health
contribute to mental health and well-being.408
Policies and strategies are beginning to recognize the
role of the broader determinants of health in mental
health. In 2006, the Standing Senate Committee on Social
Affairs, Science and Technology report Out of the Shadows
at Last: Transforming Mental Health, Mental Illness and
Addictions Services in Canada highlighted the relevance
of the broader determinants of health – including sex
and gender – to good mental health.409 The Standing
Senate Committee’s recommendations for a Canadian body
to promote mental health with federal and provincial/
territorial support led to the creation of the Mental Health
Commission of Canada (MHCC) in 2007.409, 410 The MHCC’s
framework emphasizes the importance of a population
health approach as well as the importance of mental
health literacy and of resilience.411 As the socio-economic
determinants interrelate with gender, taking this approach
tools, community kits, broad public service advertising,
media programming and sponsor promotion.407 The
Red Dress is the official symbol of The Heart Truth
campaign. Each year in March, the Red Dress symbol
comes to life at The Heart Truth celebrity fashion show,
the campaign’s signature media event where Canadian
celebrities lend their profile to raise awareness of
women’s risk for heart disease and stroke.407
Evaluations of the Heart Truth campaign in Canada
have shown positive results. Awareness that heart
disease and stroke is a most serious health concern
(32%) and leading cause of death (59%) among
women in Canada (over 35 years) has increased.405
Before the campaign started, overall awareness of
heart disease and stroke as a leading cause of death
was only 33%.405
should implicitly benefit both men and women in tailored
ways. However, the framework was criticized for not citing
specific sex- and gender-based prevention, intervention or
system responses.270, 412
In 2012, the MHCC released Canada’s first mental health
strategy, developed in part from the testimony of
Canadians with mental health problems and illness as
well as of their families.413 Among the six strategic
directions identified in the strategy (promotion and
prevention; recovery and rights; access to services;
disparities and diversity; First Nations, Inuit and Métis;
and leadership and collaboration), gender and sexuality
are considered as priority areas in addressing disparities
and diversity.413 This involves looking at the different
ways that gender influences vulnerability and how
gender needs can be considered in prevention and early
intervention efforts. Addressing the impacts of stigma and
discrimination based on sexual orientation and gender
identity can affect both mental health and how effectively
needs are met.413 Regarding sex and gender, the mental
health strategy recommends:
•• increasing understanding of gender and sexual
orientation;
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
A broad public health campaign, The Heart Truth was
created to raise awareness about heart disease and
stroke among women and encouraged them to reduce
their risk factors. Based on the effective National
Heart Lung and Blood Institute campaign in the
United States, Canada launched its national campaign
through the Heart and Stroke Foundation of Canada
in 2008.406, 407 At that time it was clear that attention
was needed on this issue: the face of heart disease in
Canada was changing, becoming younger, increasingly
female and ethnically diverse.407 Canadian women often
did not understand the breadth of their risk factors
and the connections between risk factors such as high
blood pressure, elevated cholesterol, family history
of heart disease and others. The Heart Truth employs
a multi-pronged approach that involves using life
stories, educational materials, a website, social media
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• providing mental health services that are sensitive to
gender and sexual orientation;
•• reducing risk factors for women’s mental health
(e.g. poverty, caregiving and family violence); and
•• improving the capacity of lesbian, gay, bisexual,
transsexual and questioning (LGBTQ) organizations
to address stigma and offer support within
communities.413
62
The following discussion highlights examples that
demonstrate the influence of sex and gender on mental
health and were chosen based on several factors:
prevalence and/or rate of the issue; a lack of awareness,
stigma and the need to draw attention to the subject/
issue; or issues that affect many populations but in
different ways.
There is a positive relationship between the frequency and
severity of these factors and the frequency and severity
of mental health problems.268, 278 For many, mental health
outcomes result from major life events – having a child,
losing a loved one (as a result of death or separation)
or experiencing poverty or abuse.268, 278 Evidence shows
that protective factors against the development of
mental health problems (such as depression) include
resilience, self-esteem, coping skills and a sense of
control; being able to access and make informed choices
about resources and services; and having a supportive
environment (family, friends, and accessible health and
social service providers).414 Supporting mental health now
and into the future involves building evidence on causes
and mitigating their impacts; promoting mental health
and well-being across the lifecourse; and increasing the
capacity of health care providers to identify and address
not only mental health outcomes but also to identify
and influence broader factors that influence these
outcomes.414, 415
Addressing depression: reproduction and mental
health example
Gender roles, life experiences and event-specific risk
factors (such as intimate partner violence, low socioeconomic status and associated disadvantages) are
often cited as contributors to common mental disorders
that disproportionately affect women.268 The overrepresentation of women in rates of depression and
anxiety suggests that more can be done to address
individual factors such as reducing stress, addressing
risk factors, and developing resilience among girls and
women.268, 411, 416 While there are many underlying factors
that influence women’s mental health and well-being,
this discussion focuses specifically on depression and
reproductive health, and postpartum depression (PPD) in
particular. Despite this focus on women, the discussion
raises questions about what is happening among men and
other sub-populations (e.g. lower socio-economic status)
as they become parents.
Managing reproductive processes and/or life events
(e.g. premenstrual syndrome, childbirth, infertility,
menopause, and sexual distress) can influence mental
health. While many Canadian women (up to 80%)
experience mild mood disturbances after giving birth,
about 10% to 15% of women can be affected by
postpartum depression.276, 278, 417, 418 In fact, this is likely
an under-estimate given that PPD is often stigmatized
and under-diagnosed.417 While the cause of PPD is
unclear, research has identified many contributing
factors (e.g. physiological hormonal changes, life
stress, partner conflict, caring for a newborn, low
self-esteem and lack of social support) that put some
sub-populations at greater risk.68, 276, 278, 419-421 Possible
long-term health impacts include a significant likelihood
of experiencing depression later in life.417, 419 In addition,
adverse outcomes of PPD may influence mother’s
relationship with her infant.417, 419, 420 Addressing PPD
and its risk factors involves consideration of biology
and socio-economic factors as well as knowledge of the
interactions and interrelationships.422 Many studies have
been inconclusive about the effectiveness of prevention
interventions; however there are still opportunities
for interventions to reduce, mitigate and manage the
effects of PPD on families.
The Saskatoon Postpartum Depression Support Program
is a community wellness program that offers support
to mothers managing PPD.423, 424 An evaluation of this
and other similar programs found that most women,
particularly those with their second baby (more women
are underdiagnosed for their first baby and seek help
with the second and subsequent), reported that they
had benefited from a number of aspects of these types
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variety of parenting and support groups.426 Systematic
reviews of similar type programs show that positive
outcomes for a mother’s well-being and infant care can
be achieved through environments and programs that
offer individual treatment and support for those entering
parenthood.417, 418, 424, 427, 428
Mother Reach London & Middlesex (Ontario) educates
and supports women and their families who are at risk
for, or coping with, prenatal and postpartum mood and
anxiety disorders.426 The Mother Reach weekly drop-in
program offers opportunities to gain educational support,
and connect with other mothers with similar issues. A
Father Reach program is also available in the community.
Collaborative agreements with mental health professionals
and other counseling supports are in place to support
families. The Mother Reach Coalition is comprised of a
team of community members and professionals in London
and Middlesex County whose purpose is to provide and
promote public and professional awareness of prenatal
and perinatal mood and anxiety disorder.426 Mother Reach
is held at the Merrymount Family Support and Crisis
Centre where additional education and resource supports
are available along with a Nurse Practitioner led clinic,
mental health counseling, emergency respite care and a
Some sub-populations, such as recent female
immigrants, can experience challenges and barriers
to receiving adequate and equitable care.279, 280, 430
Given the complexity of the psychosocial issues facing
some immigrant women, there is a need to develop a
comprehensive response to these health challenges of
immigration to include:
•• acknowledging that responsibilities and policies
surrounding immigration can contribute to stress;
•• offering adequate community resources and social
services to address broader social determinants of
health;
•• including cultural elements into prevention
strategies;
•• working towards equitable access to culturally
appropriate services;
•• building capacity for marginalized communities; and
•• offering culturally relevant interventions at the
individual level.430
In the area of reproduction and mental health, Canadian
researchers and clinicians have played significant roles
in knowledge development and translation. Since the
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
of programs.418, 421, 424 Overall, most women benefited from
group discussions and peer support. However, others
reported that these programs could be expanded to offer
greater social and cultural relevance (e.g. for older or for
Aboriginal women).417, 418, 424, 425
Addressing the outcomes of maternal depression involves
a greater understanding of the complex interactions
between mental health and other factors. Meta-analysis
results have been inconclusive as to whether socioeconomic factors are predictors for PPD.279, 429 However,
most studies have been limited in reach given they
were conducted on demographically similar populations
(e.g. Caucasian, heterosexual, and relatively high socioeconomic status).279, 429 Also needed are studies on the
moderating effects of psychosocial, cultural and spiritual
factors on depression.279 For some mothers community,
family and traditional values and practices can be
protective and offer support to women and their children.
On the other hand, some mothers may be influenced
by traditional and cultural practices that may underrecognize illness and influence seeking treatment.430
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
1980s, Canadian researchers have been involved in
leadership areas within the North American Society for
Psychosocial Obstetrics and Gynecology, The Marce Society
(for postpartum mental disorders) and the International
Association for Women’s Mental Health. In 1993,
Canadian researchers worked on the first book on this
topic, Psychological Aspects of Women’s Health Care: The
Interface Between Psychiatry and Obstetrics and Gynecology
and subsequent editions have been translated into several
languages and used in clinician training internationally.431
64
Further efforts are being made to increase knowledge
and understand mental health issues in a gender-based
research context in research centres across Canada.422
For example, the Centre for the Study of Gender, Social
Inequities and Mental Health, based at British Columbia’s
Simon Fraser University brings together researchers
and community partners from Canada, United States,
United Kingdom and Australia to work together to
develop programs and policies on intersections between
gender, social inequities and mental health as well as
the necessary interventions.432-434 Research development,
knowledge exchange, training and capacity building
is on-going in five priority areas: mental health policy
and reform; recovery and housing; reproductive mental
health; violence, mental health and substance use; and
the criminal justice system, mental health and substance
use.432, 434
Men’s experiences with impending and new fatherhood,
paternal depression, stress about partners’ pregnancies
and the role they play in women’s mental health are
important factors that are slowly being considered and
implemented in research, programs and policies.417, 435-438
Research has found that depressive symptoms during
new fatherhood as well as partners’ pregnancies and
postpartum periods are also significant problems for
men.270, 438 In particular, having a depressed partner,
a poor relationship between the parents, and low social
support are the most common correlates of depression
in men during pre and post natal periods.438 An increase
in depression in one partner may lead to an increase in
the other.438 While paternal depression among new fathers
is receiving media attention, identifying the problem
is lagging because the tools currently used to assess
depression may not adequately identify symptoms in
men. Scales such as the Edinburgh Postnatal Depression
Scale, Beck Depression Inventory, General Health
Questionnaire and Postpartum Depression Screening
Scale routinely measure effects in women. They can also
be effective to measure paternal depression in men;
however, research suggests that the scales will need to be
adapted to better reflect men’s symptomatic criteria.439-444
Paternal postpartum depression has been studied by
few researchers and has primarily focused on middleclass, married Caucasian fathers. Additional research
is needed to expand the focus to new fathers from
various cultural and socio-economic backgrounds.442, 444
Addressing depression and anxiety of new parents also
requires consideration of the needs of sub-populations,
for example, sexual minorities. More work also is required
to identify and address the reproductive mental health
of men and the role they play in women’s reproductive
mental health.
Preventing suicide: addressing male suicide
Recent research and programs reveal that men are at
risk for a range of mental health problems, in particular
depression.270, 445 Mental illnesses among men are often
underdiagnosed and under-reported and mental health
issues of men are often considered a “silent crisis” and
this suggests the mental health gender gap may not be
as wide as originally thought.270 Differences between men
and women in outcomes and diagnoses may be the result
of factors that are biological, as well as how problems
are socially and culturally framed, how symptoms are
manifested and experienced.68 In addition, focusing on
and addressing the manifested physical symptoms as well
as practicing certain coping strategies (e.g. substance
use) may mask or disregard underlying mental illness.68
Suicide is an example of a gender paradox in public
health. While four out of five suicides are completed
by men, women attempt suicide more often and
also have higher reported rates of depression than
men.68, 269, 270, 274, 446 Thus, addressing suicide through
prevention practices is challenged by a number of factors
including gender differences in suicide and suicide
ideation.447 A sex- and gender-based approach points to
questions about differences in underlying experiences,
social roles and behaviours as well as gender bias in
diagnostic tools.
Suicide among older men is concerning and more needs
to be done to address this at risk population.25, 68, 87 In
2006, the Canadian Coalition for Seniors’ Mental Health
(CCSMH) developed their CCSMH National Guidelines
for Seniors’ Mental Health, which focuses on several
mental health issues facing Canada’s seniors. Suicide
was specifically targeted via the National Guideline, The
Assessment of Suicide Risk and Prevention of Suicide,
which examined seniors’ suicide in social and cultural
contexts, specifically the sex and gender aspects of
behaviour and the role of culture in risk factors.449
Building on the guidelines for the prevention of suicide,
CCSMH developed a Late Life Suicide Prevention Toolkit
for health care providers, physicians, nurses, front-line
workers and mental health professionals and to be used
in health education programs.450
Suicide is often associated with younger men and
notably sexual minority men.25, 68, 451 A 2011 review of
suicide and suicide risks in diverse American sexual
and gender minority populations indicates that there
has been insufficient research on suicidal behaviour
in this population and the extent to which public
health policies, prevention strategies and targeted
interventions are needed and are effective.286 The review
also indicates that, in general, there is no authoritative
or reliable way to establish rates of completed suicide
in the sexual and gender minority population. However,
international research indicates links between sexual
and gender minority status and elevated rates of both
suicide ideation and attempts.286, 452 It also points to
links between mental disorders and suicide attempts of
sexual and gender minorities.286 While mental disorders
are the leading risk factor, the report also points to
other explanatory factors including the social stigma,
prejudice and discrimination that sexual and gender
minorities face at an individual level – rejection by
family and friends, harassment, bullying and physical
violence – as well as on an institutional level with noninclusive laws and policies.286
Some jurisdictions have developed suicide prevention
strategies that include broad to targeted initiatives.
New Brunswick, for example, has been acknowledged for
its broad suicide prevention strategy which identifies
and targets those at greatest risk for suicide.453 The
program builds on existing community-based resources
and the capacity of local partners to know how best to
respond to local needs by engaging in community action,
continuous education and interagency collaboration.453, 454
The Australian government attributes the reduction in its
overall rate of suicide over a 10-year period in part to its
prevention strategy.455 The LIFE Framework (Living is for
Everyone) is based on the premise that all Australians
have a role to play in suicide prevention through broad
population and targeted interventions.455 The LIFE
Framework also indicates that providing effective sexand gender-specific suicide prevention interventions is
important. For men this includes:
•• developing practical, action-oriented approaches and
strategies that provide coping and skills training,
improve employment and parenting skills, help deal
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
While clinical depression is a suicide risk, epidemiological
and clinical research reports that the prevalence of
depression is inversely correlated to the frequency of
suicide.448 Several factors to consider when addressing
men’s suicide are that men are less likely to seek the
necessary help and care; they can be reluctant to show
perceived weakness; they differ from women in the way
symptoms appear and how the illness is diagnosed and
treated; and many inflict self-harm in decisive and violent
means.447 Alcohol and other substance misuse may be a
way of self-medicating depression or anxiety.68, 448
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with stress and anger, encourage openness and
provide opportunities for retired men to socialize;
•• creating friendly and relevant programs and services
within safe environments at appropriate locations;
•• providing services that proactively engage at-risk
men as they may admit having difficulties if the
subject is broached but will not necessarily selfidentify;
•• training local service providers and bringing programs
and services to the places where men are to be found
– workplaces, pubs, sports and service clubs;
•• building capacity to recognize and respond to men’s
needs and value men’s role in the community;
•• addressing health and well-being from a positive
perspective as men respond better to being and
staying healthy than dealing with a problem;
•• building networks of like-minded men for social
support to address loneliness; and
•• promoting mental health screening.456
Applying a sex, gender and diversity lens to health
outcomes can expand the understanding of issues such
as men’s suicide.273 Certain sub-populations, for example,
men living in remote communities and Aboriginal men,
have high rates of suicide.457-459 The Men at Risk program
addresses issues of depression and suicide risk among men
living and working in remote regions of Alberta, including
those in the oil, forestry and agricultural sectors, who
are often isolated from family and community.448, 460
Systematic reviews have shown that there is a broad range
of effective approaches in suicide prevention programs.461
This program follows recognized best practices for suicide
prevention, mental health-care support and counselling.
It uses emotional messages, storytelling and testimonials
from survivors of attempted suicide as well as messages
from mental health professionals. It neither normalizes
nor glamorizes suicide behaviours. The Men at Risk
program can be considered promising in addressing the
unique pressures and challenges facing men in these
distinctive fields and situations.448
Over the last few decades, social change has made
it more difficult for men to connect to the broader
community and with each other.462 Changes to the
employment environment – finding work in isolated and
remote areas, a movement away from traditional labour
and the expectation of being employed and having years
of retirement while healthy – and relationships with
significant partners have created situations where men
may feel isolated, depressed, lonely and overwhelmed by
family responsibilities or else unfulfilled and undervalued.
Such feelings contribute to mental health risks including
suicide. Evidence shows that positive health outcomes
are associated with creating men’s networks. Programs
such as Australia’s Men’s Sheds are contributing to greater
health and well-being among men, particularly older men
and those living in less populated regions.462 (See the
textbox “Australia’s Men’s Sheds program.”) Such programs
address disparities in continued learning, adult education
and social network organizations by focusing on men’s
spaces and learning needs.462
Reluctance to identify a problem, seek help and be
diagnosed can limit the success of suicide prevention
interventions. The decision to seek help often comes
at a point of crisis and not during the development of
illness. The reasons for men being reluctant to seek
help may stem from traditional feelings of masculinity
or a perceived weakness, lack of awareness or control,
or a need to mask symptoms through substance use/
abuse.448, 470 Suicide prevention programs must challenge
perceptions of masculinity and men’s reluctance to
identify need and/or ask for help. Social marketing
tactics can be tailored to inform and encourage men
with mental health problems to seek help.448, 470 Mental
health practitioners and tools used to assess men need
to address barriers to seeking help.470 A review of mental
health practices found that more men would seek help for
mental health issues if the programs suited those with
traditional male gender roles. Traditional counselling that
involves discussing issues were found to be less effective
than structured interventions. Cognitive behavioural
therapy, for example, encourages individuals to replace
traditional coping skills with adaptive behaviours that
replace adverse norms (such as not sharing negative
thoughts) with more effective processes that engage
coping.448, 470 Broad-based media campaigns that challenge
male norms must be intensive and target the at-risk
populations.448, 470
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Australia’s Men’s Sheds program
To include those who are geographically isolated,
a large online and virtual Sheds forum exists for
participants to post about do-it-yourself projects,
Reducing mental health stigma and increasing
access to care
Stigma for any reason – a health issue, culture, gender,
sexual orientation – can affect many and can occur
in a variety of settings. Mental health stigma is the
result of poor understanding that leads to prejudice and
discrimination, and many individuals who have a mental
illness or a mental health problem have experienced
stigma.471 Stigma can negatively affect an individual’s
ability to develop holistically, socialize, go to school,
work and volunteer, and seek care and treatment.471-473
hobbies, lifestyle, family and relationships, mental
health, sports and tips and items to trade (e.g. swap
shop).463, 465 In Australian Indigenous communities,
Men’s Sheds were reported to also be places of healing
and spirituality and for learning about cultural
traditions. In terms of health outcomes, Sheds provides
an opportunity to learn new skills and communicate
and experience less isolation among those with an
illness and/or disability.462
There are over 1,000 sheds registered with the
Australian Men’s Shed Association and Mensheds
Australia and the program continues to grow. They
are broadly supported across communities and partly
funded by the Australian government as an opportunity
to provide men with opportunities to build practical
skills, socialize with other men, and promote health
and well-being.466 Work has also been done to develop
and support materials and structures to offer services
in communities with unique needs, such as those
with physical disabilities, mental health problems,
and the unemployed.466-468 Similar programs have
been replicated in New Zealand, England, Ireland
and Canada.466 The Mensheds Manitoba Inc. runs
a similar peer-run organization in Winnipeg that
provides camaraderie among men.469 The goals of
Mensheds Manitoba Inc. are to reduce social isolation,
loneliness and depression among retired men while
also encouraging members to remain active in their
communities.469
Among social constructs, gender and sexuality can be
tools used to shape status hierarchy whereby, some may
be less likely to attain positions of power and leadership
among specific groups.217, 474 Level of status can manifest
into other forms of inequality such as the value placed
on symptoms and outcomes and how to interact with
health care providers. Since stigma affects many life
opportunities, research and programs must account for
a range of outcomes.217, 471 A full assessment of the
impacts must also recognize that many stigmatizing
circumstances may have contributed to that outcome.474
Several approaches have had promise in breaking
down mental health-related stigma. Early education
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Australia’s Men’s Sheds is a grassroots movement
established to provide a support system for men. The
idea stems from the backyard shed as a place where
men would have traditionally practised crafts and
created networks. The men who participate connect by
sharing common interests and learning and teaching
new skills (e.g. cooking, wood working, automotive
care, weight management).462 More importantly, Sheds
addresses men’s health issues and risk factors. The
premise is that good health is built on a number of
factors such as feeling good, having a valued and
identifiable role in the community, connecting with
friends, maintaining an active body and mind and
nurturing financial and social viability. The program
builds on several determinants of health including
creating supportive environments, developing personal
skills and strengthening community action.462-464 The
program also shows participants that they have a
role to play in their own health and community by
creating projects that are financially viable and that
contribute to the community (e.g. building community
structures).462 As Sheds relationships grow, so too
does self-esteem and a sense of belonging.462 Health
literacy increases through the more formal discussions
on topics that include depression, prostate cancer
and healthy behaviours. Some at-risk participants also
reported fewer thoughts of suicide.462
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(focusing on primary school and then high school) and
increasing awareness of mental health disorders can
challenge misconceptions about mental illness and
reduce associated stigma.471, 475 Teaching children and
youth about mental illnesses can promote empathy and
acceptance before negative attitudes emerge.471 Early
education interventions have also been shown to have
greater benefits in reducing stigma rather than broad
population-based initiatives.471 Programs such as Roots
of Empathy (profiled in the CPHO’s Report on the State
of Public Health, 2009) have been shown to significantly
reduce levels of aggression among school children from
kindergarten to Grade 8 by raising social/emotional
competence and increasing empathy.476, 477 Simultaneously,
learning about discrimination (regardless of disease,
social status, sex, sexual orientation, gender identity,
race or age) can help establish equitable practices that
individuals can adopt into other areas of their lives across
the lifecourse (e.g. workplace).
An American study found that gender roles can moderate
the extent of stigma.478 For example, stereotypes
concerning substance abuse and violence/aggression
generally fall along gender lines. The study results
consistently showed that gender-atypical mental illnessrelated symptoms (i.e. those that are not expected)
evoke positive responses, more sympathy and a greater
sense of support. On the other hand, individuals with
gender-typical (i.e. one that is expected) symptoms
often received adverse reactions that implied
responsibility and blame and were less likely to be seen
as having a genuine mental illness.478 Deviation from
typical gender scripts could be perceived as cause of
illness. Although this study only addressed broad public
perceptions, a greater understanding of the perceptions
of the range of mental health practitioners and other
care providers have about mental health conditions in
relation to sex and gender
is needed.478
Research and programs lag behind in recognizing how
masculine norms and stigma influence care and treatment.
While there are significant sex and gender differences
in mental illness (e.g. brain function, structure and
A population health approach is necessary to address
gender-specific risk factors as well as to improve access
and delivery of mental health policies and programs.11, 481
By expanding the approach to include the social
determinants of health, SGBA of gender discrimination,
policies and programs can be made more effective.217
Overall, practices to encourage men to seek care fall
across several intervention categories: group education
(e.g. discussions and/or awareness building), servicebased (e.g. health and social services), community
outreach (e.g. awareness and local education as well as
informational products) and integrated (a combination
of the other three types).228 Evaluations of these
interventions have shown promise in terms of changes in
behaviours and attitudes related to sexual health, fatherbased programs (building relationships with children) and
reductions in aggression and violence. Results have also
demonstrated the potential for attitudinal changes in
areas such as increased contraception, reliance on sexual/
reproductive programs and partner communication and
decreased physical, sexual and psychological violence
toward a partner (self-reported).228 The results are
effective in the short term but this is often a reflection of
the short term nature of interventions.228
Following consultations with communities, British
Columbia’s Northern Health noted key concepts relevant
to promoting and delivering men’s health programs.
These include:
•• supporting and conducting more research on men’s
health, risk factors and the access and delivery of
health care services;
•• consulting with men to understand the environments
in which they work and live;
•• supporting programs for knowledge translation
between research and program delivery;
•• creating supportive environments by using clear and
relevant messages and by encouraging men to seek
information and speak about health on their own
terms;
•• working within established structures and networks
(e.g. workplace safety programs);
•• specifically focusing on improving health and social
services programs for men at risk as well as access
to these; and
•• developing and delivering innovative outreach
services to involve men in developing programs
to meet their needs (e.g. Men’s Night Out).446, 482
Australia’s Centre for Advancement of Men’s Health and
the Centre for Rural and Regional Health Education use the
Men’s Awareness Network model of health (MAN Model)
for disease prevention and health promotion by improving
ways for men and young males to access the health care
system. The concept of the MAN Model stems from the
need to address traditional masculine behaviours regarding
health but also acknowledges the non-homogeneity of men
and the importance of tailored programs.483 This evidencebased approach to stimulate community responses to
men’s health issues is found in both rural and urban
settings where general practitioners and other health
care professionals communicate with men about health
issues in places where the men congregate. For example,
workplace health programs are often used to address
strategies of safety, stress and relationships. Adding to the
MAN Model, the Lifeskills program extends the program’s
reach to include the specific needs and issues of adolescent
males.483-485 Programs such as Men’s Night Out adopt the
MAN Model to align health promotion activities with
items that attract interest. They hold events in licensed
locations with invited guest speakers (e.g. sport and
television celebrities) to discuss topics that include chronic
conditions, parenting, and accessing or navigating the
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
chemistry), to be complete, research should also take into
account social pressures and environmental factors. Men
typically ignore symptoms, exacerbating disconnections
between physical and mental symptoms. For example,
physical symptoms such as headaches and digestive
problems are not often linked to mental health conditions
with the same symptom assessment criteria as they are
for women. Traditional views on masculinity have often
hidden mental health problems. Perceptions of male
roles and responsibilities around being protectors and
providers are built upon ideals of strength and stoicism.
The social stigma associated with men’s use of mental
health services stems from these traditional ideas of
masculinity. As a result men do not often show signs and/
or acknowledge their own risk factors, have low mental
health literacy, and can mask mental health problems
with other types of coping strategies and risk behaviours
(e.g. substance use and violence).448, 470, 479, 480
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health care system.483 The adoption of the MAN Model Men’s
Health Night program by a range of health organizations in
Australia and Canada have exposed large audiences – since
its inception it is estimated that more than 80,000 men
have participated – to more open discussions about men’s
health that have led to an overall increase in visits to the
family doctor.483, 486 Using the Men’s Night Out program
and health check-up practices, the model has also had
some success in Australian rural and remote Indigenous
communities.483 The Men’s Night Out program has now been
implemented in British Columbia where a series of Men’s
Health Nights, workplace programs and Lifeskills sessions
were held at several post-secondary institutions.483
Raising awareness about the vulnerability of men to
depression is a rising trend and is promising to help
reduce the stigma attached to mental health. A slowly
growing number of focused promotional efforts and
networking groups targeting men and their mental
health awareness are helping break the silence that has
long surrounded this topic. A study in Australia reports
that a men-only prompt list for physicians and patients,
designed to overcome male reticence and low mental
health literacy, assisted 60% of male patients in raising
issues with their doctor.270
There is a growing interest among researchers in
developing preventive interventions aimed at improving
workplace health and well-being and to help reduce the
burden of absenteeism and lost productivity; however,
employers often consider the investment too high.470, 487
The MHCC is working with partners to develop National
Standard of Canada for Psychological Health and Safety
in the Workplace that will provide organizations with the
tools to achieve measurable improvement in psychological
health and safety for Canadian employees.488-490
Canada is making progress in addressing mental health
related stigma in Canada and internationally through
the development of research initiatives, professional
training in mental health stigma, knowledge sharing and
identifying and evaluating anti-stigma programs.
•• In 2009, the MHCC launched a 10-year anti-stigma/
anti-discrimination initiative called Opening Minds.
This is the largest systematic effort to reduce the
stigma of mental illness in Canada, and MHCC will
work with communities, stakeholders and specific
at-risk groups.473 Early evaluations of a number of
the Opening Minds programs are on-going. However,
the Interior Health Authority of British Columbia
evaluated its program using Ontario Central Local
Health Integration Networks anti-stigma training
program. Among results were changes in attitudes
among training participants in areas of social
responsibility, disclosure, self-stigma, prejudice and
devaluation. Positive results will encourage the use
of this anti-stigma training as a resource for delivery
and development of future programs.491
•• A research initiative has been established at
Queen’s University (Kingston, Ontario) an antistigma research initiative that develops outreach
programs.492
•• In 2012, Canada hosted an international
conference gathering 700 researchers, mental
health professionals, policy makers and those
with experience with mental illness from more
than 28 countries. The conference concluded with
the message that everyone has a role to play at
eliminating stigma that prevents individuals from
getting the care they may require.493, 494
•• Canada is represented on the World Psychiatric
Association section on Stigma and Mental Illness with
a Canadian chair and by engaging in activities to
reduce stigma and discrimination as well as improve
inclusion and access for those with mental illness
(and their families).495
•• Mood Disorders Society of Canada and its project
partners have launched a new initiative that offers
physicians an accredited online continuing medical
education program using a contact based approach
based on the best evidence for changing stigmatizing
attitudes and behaviours towards people living with
mental illnesses.496
Sex, gender, healthy relationships
and sexual health
Healthy sexuality involves acquiring knowledge, skills
and behaviours for positive sexual and reproductive
health and experiences across the lifecourse.497-499
It also includes options to avoid negative outcomes
(e.g. sexually transmitted infections [STIs] and unplanned
pregnancies).500 Developing and maintaining healthy
sexuality often involves a number of complex decisions
and relationships.
The WHO states that sexual health includes a
“positive and respectful approach to sexuality,
the possibility of having pleasurable and safe
sexual experiences that are free of coercion,
discrimination, and violence.”501 This section looks
at five areas that are considered necessary to
achieve positive, respectful, pleasurable and safe
sexual experiences:
Building healthy relationships
All healthy relationships – with family, partners and
peers – help build resilience and reduce risks for a variety
of negative health outcomes.502-504 Interventions that
promote healthy relationships should be delivered as early
as possible so that young men and women learn to value
and understand the importance of respect, equality and
harmony with relationships.505 The CPHO’s Report on the
State of Public Health in Canada, 2011 identified the value
of developing healthy relationships during adolescence as
youth become more involved with peers, initiate sexual
relationships and may become parents themselves.20
Dating relationships are particularly important for the
transition into adulthood as such developing healthy
and respectable relationships are important to current
and future relationships.506 Although it can occur at any
age, youth and young adults may be at higher risk for
dating violence, and the most police-reported victims of
dating violence are female.507 To be effective, programs
that target at-risk youth need to address a range of
individual experiences as well as account for other factors
Addressing youth and violence
STOP! Dating Violence among Adolescents (Quebec)
Outrage (Newfoundland and Labrador)
The STOP! Program was developed to prevent dating
violence and promote egalitarian relationships among
Quebec youth aged 14 and 15 years old. The STOP program
is made up of two 75-minute sessions of discussions
about abusive behaviour within dating relationships.
The sessions use examples and focus on the rights of
partners.511-513 Traditionally, the victims are girls and the
perpetrators are boys, but the program also demonstrates
the reverse also occurs.511-514 STOP! has run since 1994,
and evaluations demonstrated increased knowledge about
dating violence both in the short term (one month) and
the medium term (four months).188, 511, 515 In addition,
attitudes towards dating violence had improved among
participants, especially among adolescent girls.515 Due
to the success of the program, PASSAJ program was
developed for 16- and 17-year-olds.511 Aligned with the
components and activities of the STOP! program, PASSAJ
also deals with control and abusive behaviours in dating
relationships and also includes a component on sexual
harassment in work and study situations.511, 516
In 2006, the Government of Newfoundland and
Labrador launched a six-year Violence Prevention
Initiative to address the problem of violence against
those most at risk – women, children, youth, older
persons, disabled individuals, Aboriginal women and
children, as well as adults who are vulnerable based
on their ethnicity, sexual orientation or economic
status.517, 518 In 2006, the Violence Prevention
Initiative created the OutrageNL campaign specifically
to address youth violence. Developed with the input of
youth between 13 and 18 years, this social marketing
campaign uses a variety of media including posters,
websites and television advertisements. The two
television advertisements feature a female and male
youth, respectively, as victims of violence. The website
www.outrageNL.ca provides helpful information to
those who struggle with tendencies toward violence.
It also informs on how to recognize and take action
against violence.519, 520
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• building healthy relationships;
•• communicating: sexualization and healthy
relationships;
•• addressing sex and gender stereotypes and
sexual health;
•• applying comprehensive sexual health
education; and
•• addressing sexual health risks.
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such as gender, culture and sexual orientation. Youth
Relationships Project or RESOLVE Alberta, for example,
have shown promise in reducing relationship violence
by focusing on issues influenced by gender roles.508-510
Communities and schools also play an important role in
integrating and increasing the scope of interventions that
help young people develop healthy relationships including
sexual relationships. In-school programs such as STOP!
and PASSAJ offer broad gender-based programs to all
youth in Quebec schools.511 (See the textbox “Addressing
youth and violence.”)
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An important aspect of building healthy relationships
is the ability to recognize and change unhealthy
relationships, including those that involve various
forms of violence. Developing healthy relationships
may involve challenging harmful gender stereotypes
and sharing power in intimate relationships.521, 522
For example, within heterosexual sexual relationships,
women are stereotypically portrayed as being responsible
for contraception use.253 Unequal and unfair power
imbalances within relationships can directly affect
decisions about contraceptive methods (e.g. refusal
to use condoms).522 Gender stereotypes and power
imbalances can also contribute to violence within
intimate relationships. Interventions that have shown
promise in supporting the prevention of intimate
partner violence are those that provide the tools to
ensure the safety of victims and potential victims and
that address violence in a broader context of equality,
rights and responsibility.523, 524 (See the textbox “Healthy
Relationships Curriculum – Men for Change.”) Healthy
relationships focused on the concerns of sexual and
gender minorities can also challenge heteronormative
(the view of heterosexuality as the normal or preferred
sexual orientation) understandings of relationships,
opening up possibilities for expanding sexual health
education to address what constitutes healthy
relationships for sexual and gender minority
youth and adults.525
Healthy Relationships Curriculum – Men for Change
Over 18 years ago, the Healthy Relationships
Curriculum was developed by Men for Change, a
community group based in Halifax (Nova Scotia),
to promote gender equality and to end violence
by increasing knowledge, skills and changes in
attitudes. Men for Change was started in response to
the massacre of 14 female engineering students at
Montreal’s École Polytechnique in 1989. The Healthy
Relationships Curriculum targets youth in Grades
7 through 9 and supports students as they learn
more about developing and maintaining healthy
relationships.526 The approach involved a three-part
initiative that includes dealing with aggression;
gender equality and media awareness; and building
healthy relationships. The Grade 7 curriculum deals
with aggression, stress, disappointment and rejection
and developing skills in effective communication and
conflict management. The Grade 8 curriculum tackles
gender stereotypes, peer pressure and violence as well
as how to challenge negative messages from popular
media. The Grade 9 curriculum deals directly with
healthy relationships; it builds on communications
skills and embeds the importance of equity.526, 527
Evaluations showed that students in the program
self-reported significant decreases in the number of
incidents of physical violence and use of passiveaggressive strategies, with decreases in the number
of incidents in the second year of the program among
girls and in the third year among boys.526, 528 Program
students also reported an increased awareness of
violence and psychological abuse, significant changes
in attitudes towards abuse and dating violence as
well as an increased intolerance for violence by girls
and violence by boys.526, 528 In addition, students
reported that they were less likely to see television
violence as real, and were more conscious of television
advertising and gender stereotypes. In addition, young
men reported that they were better able to recognize
gender stereotypes and had modified their behaviour
accordingly.526, 528 This program is now used by schools,
women’s shelters, social welfare agencies, and health
agencies and counselling centres across Canada and
the United States.529
Women generally experience higher rates of partner
violence than do men; and some sub-populations,
including Aboriginal women, have rates higher than that
of women in the general population.530 Intergenerational
experiences, poverty, addictions, loss of cultural identity
and poor relationship skills may be contributing factors
for many in violent relationships.531-533 Access to services
and care may be hindered by lack of awareness, geographic
location, perceived ineffectiveness or lack of awareness of
a program, and complex relationships between the victim,
abuser, family and community members.531, 532
three-quarters of the victims of violence in same-sex
partnerships were gay men.535 However, support networks
for men and women experiencing intimate partner
violence in same-sex relationships may be limited due
to social stigma and isolation.536
To address the problem of intimate partner violence,
the Government of the Northwest Territories initiated
the NWT Action Plan on Family Violence 2003–2008.
The goal of this plan was to raise awareness of the
issue of family violence specifically towards women and
children in Northwest Territories.537 The plan was extended
to the second phase, NWT Family Violence Action Plan:
Phase II (2007–2012).537, 538 A key initiative within this
plan includes research, development and implementation
of a pilot program for men who use violence in their
relationship.537, 538 Although the plan has yet to be
formally evaluated, improvements can be seen in terms
of awareness and intersectoral collaboration to ensure
the vision of the plan is being met.538
Communicating: sexualization and healthy relationships
How sexuality is portrayed and described can influence
how individuals view themselves and others in
relationships. Popular culture media – television,
movies, music videos and lyrics, video games and
magazines – expose young people to unrealistic body
shapes and images. The sexualization of men and women
has increased significantly over the past few decades,
especially following the development and uptake of the
Internet.539-543 Such messages start early: even children
and adolescents are being presented with sexualized
themes and experience pressure to act and look like
adults. For example clothing, video games as well as dolls
and action figures, present unrealistic and sexualized body
images.539-541, 543
Young boys and girls are exposed to sexualized
portrayals of young men and women – women more
often than men – through the Internet, television,
radio and print.539-542, 544 Girls and young women often
misconstrue these images as empowering and as such
sexual objectification of women can influence girls
to value their sex appeal over other qualities and/or
activities.540, 541, 543, 545 Numerous research studies have
demonstrated that the sexualization of women reinforces
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Those who self-identified as gay or lesbian were more
than twice as likely as heterosexuals to report having
experienced spousal violence, while those who selfidentified as bisexual were four times more likely than
heterosexuals to self-report spousal violence.534 Nearly
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According to the American Psychological
Association Task Force on the Sexualization
of Girls, “sexualization can occur with anyone
(men, women, boys and girls) when:
74
•• a person’s value comes only from his or her
sexual appeal or behaviour, to the exclusion
of other characteristics;
•• a person is held to a standard that equates
physical attractiveness with being sexy;
•• a person is sexually objectified – that is,
made into a thing for others sexual use,
rather than seen as a person with the
capacity for independent action and decision
making; and/or
•• sexuality is inappropriately imposed upon a
person.”539
the lower status of women and contributes to feelings
of dissatisfaction among girls and women.539-541, 545 Girls
who have been repeatedly exposed to overly sexualized
cultural representations may have their confidence
in and comfort with their own bodies undermined
and may develop self- and body-image issues such as
embarrassment, shame and anxiety.540, 541 Likewise,
repeated exposure to images of young and muscular
males with unrealistic V-shaped torsos emphasizing
broad shoulders, developed arms and chest muscles
and a slim waist may compromise boys’ self-image
and healthy physical development.541, 544
The sexualization of men and women can have negative
effects on cognitive and emotional development and
can affect their mental and physical health outcomes
by contributing to eating disorders, low self-esteem
and depression.539, 540, 543, 545 It can also have a broader
implication on relationships with others. Narrow views of
female and male attractiveness and other societal effects
may exacerbate personal and societal experiences with
sexism, sexual harassment and sexual violence.540, 544
Individuals can learn to interpret, challenge and
ultimately change the negative effects perpetuated
through sexualized and stereotypical portrayals. The
United States’ task force, the National Task Force on Girls
and Women in the Media was formed to develop steps and
goals to promote healthy and positive depictions of girls
and women in the media that:
•• support age-appropriate education about the
negative effects of sexualization of young girls,
adolescents and adults;
•• promote healthy, balanced and positive images of
girls and women in the media; and
•• build young girls’ self-esteem and confidence
to reject messages that sexualize and objectify
them.546, 547
These American-based control measures may have
positive effects on Canadians as American television
is accessible in many Canadian households. Broad
programs to limit the exposure of young girls and boys
to radio and television content, including advertising,
exists through highly developed codes of ethics and
conduct. The Canadian Broadcast Standards Council
requires Canadian broadcasters to be sensitive to sexrole stereotyping, refrain from sex exploitation, and
portray the intellectual and emotional equality of both
sexes.548-550 Regulations in Quebec ban commercial
advertising to children under 13 years of age on French
language television.551 However, these measures have no
effect on out-of-province transmissions. Measuring the
effectiveness of even the strictest controls is challenged
by the inability to fully implement practices within a
global arena where influences may be sourced outside
provincial and national jurisdictions.
Addressing sex and gender stereotypes and
sexual health
The discourse of sexuality – the language used to talk
about sexual health – rarely includes ideas associated
with sexual pleasure and reproduction.552 Women in
particular are exposed to messages that focus on
addressing possible adverse outcomes (e.g. STIs,
unplanned pregnancy). As a result, public health
interventions tend to focus on developing negotiation
skills to protect against negative sexual experiences
and outcomes rather than positive aspects of sexual
interactions and/or pleasure.552 Sexual health education
and discourse also primarily focuses on heterosexual
relationships.552 When non-heterosexual relationships
are covered, it is usually in terms of pathologizing such
relationships, with gay men as a particular target, or
linking them to the spread of STIs and HIV.552
A variety of sexual health education interventions have
been designed to prevent adverse outcomes, many of
which target youth. While the evidence of success is
mixed, several practices appear to hold promise:
effective when combined with other programs such
as clinical services, counselling and social services
to all members of the community regardless of
age.559
Prevention programs must consider different views and
perceptions to be effective. More research is needed to
understand young women’s perceptions and experiences
concerning early pregnancy, contraceptive practices and
access to services.560 In addition, little is known about
young men and their perspectives on women, pregnancy
and their role in the family. New male-based prevention
programs could help to develop skills, understanding and
relationships.558
Sexual health campaigns tend to target youth, but
similar programs and tactics have not been used for
older populations, and a cultural and generational
gulf exists when talking about sexuality among older
adults.180, 182, 561 563 Negative perceptions about older adults’
sexuality persist as do the risks of being uninformed
or ineffectively treated. Despite an increase in cases
of STIs including HIV infection and AIDS among older
adults, interventions designed to prevent infections
among this population are rare.180-182, 562-565 Widowed and
divorced baby boomers may be starting new relationships
and may not have the most recent knowledge on
sexual health.182, 183, 561, 562 Stigma, embarrassment and
discrimination can lead to additional barriers for older
adults (particularly women), to discuss sexual health with
their health care providers.180, 182, 183, 562 A United States
study showed that a large majority of women agreed
that physicians should ask older patients about their
sex lives, but nearly one-half had not talked about sex
and fewer still were offered an HIV or STI test.180, 181, 183
General practitioners reported being reluctant to discuss
sex and STIs with older (particularly female) patients,
and caregivers also reported difficulties addressing older
adults’ sexual health issues especially those of older
women.181-183, 562, 564, 565 Researchers also tend to ignore this
segment of the population (e.g. STI risk reduction clinical
trials do not typically include older people).564, 565
Social marketing campaigns can be used to proactively
address negative perceptions of sexual health, gender
and age.566 Seniors a GOGO is an example of a Canadian
program that is raising awareness and challenging
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• In-school educational programs that combine
addressing teen pregnancy and preventing STIs
have been effective.553 Efforts that address sexual
risk and protective factors as well as non-sexual
factors are more likely to positively influence
behaviours.553 Evaluations show that both male and
female adolescents who received comprehensive sex
education had lower risks for STI acquisition and
unintended pregnancy. They also delay the onset of
sexual activity compared with those who received
abstinence-only or no sex education.553, 554
•• Programs that increase the knowledge and skills of
parents and community members who interact with
youth and have the opportunity to increase youths’
knowledge and information about sexual health.553, 555
•• Programs that provide access to health services for
all youth and that include diversity (applicable to
geographic location, age, gender, sexual orientation
and culture) are more effective.
––Programs that include adolescent boys and young
men in sexual health initiatives and encourage open
discussions about sexual health are effective.556, 557
Too often, prevention programs do not focus on
the sexual education of males and their skills with
contraception and negotiation. This issue is further
complicated by the fact that traditionally young
women have been less empowered to negotiate
safer sex, even if they know about the positive
and negative outcomes.556-558
––Programs that improve life opportunities for youth
(e.g. relieve boredom, support future outlooks) may
also reduce risky sexual behaviour.558, 559
––Sexual health is an important part of life and
sexual health programs could benefit individuals
of all ages. Community-based programs that provide
support, training and resource materials to parents
and adults who work with youth can be effective.559
In addition, comprehensive sexual education is
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stereotypes about age, gender, diversity and sex in a
creative way. (See the textbox “Raising awareness about
age, gender and sexual health.”) Further developments
have led to age and sex sensitivity training for health
care professionals in Alberta.567
Traditional gendered constructs of sexuality focus either
on “performance” or on “lack of interest” based on
assumptions about what constitutes “function” and for
what outcome.182 Discussions about older men’s sexual
health often focus on improving performance.182 The
release and marketing of erectile dysfunction drugs
(e.g. sildenafil) has focused on older men’s sexuality
and the importance of male sexual performance,
responsiveness and capacity. Studies on sexual
enhancement medication seem to perpetrate stereotypes
about women’s sexuality.182, 574 For example, women’s
sexual health is often discussed in a negative context of
low libido, chronic disease and sexual abuse.182 Research
indicates that prevalence of female sexual dysfunction
may be overestimated with women’s sexuality being
measured by standards used to assess men.574 Promoting
gender-sensitive approaches to sexual health to address
underlying health issues such as sexual dysfunction in
the context of the broader determinants of health is
important.574 While undoubtedly more light needs to be
shed on these issues, there are few interventions that
focus on healthy sexuality, well-being and aging.
Applying comprehensive sexual health education
Comprehensive sexual health education increases
knowledge, understanding, personal insight, motivation
and the skills needed to achieve sexual health.559, 575 To be
effective, sexual health education should be relevant and
Raising awareness about age, gender and sexual health
In 2007, the Calgary Sexual Health Centre (Alberta),
the Seniors Action Group (Calgary, Alberta) and The
Foundation Lab (Calgary, Alberta) partnered to form
Seniors a GOGO, a program that raises awareness
about sexuality among adults over 50 years old and
addresses rising incidence of STIs and HIV.563, 565, 567‑569
Initial assessments revealed that education and
prevention tactics were insufficiently effective to
reduce STIs, but that the program needed to address
attitudes towards sexuality, culture, and generational
and traditional practices that were barriers to
healthy sexual practices.563, 565, 567 Seniors a GOGO was
accordingly modified to also look at attitudes towards
sexual health across generations and the experiences
across the lifecourse of the older person. It promotes
healthy sexuality, emphasizing that there is no age
limit on sex.563, 567 Through a series of monologues,
seniors and their audiences explore the experiences
with aging and sexuality of men and women with a
range of sexual orientations who express the need to
be loved, appreciated, admired and engaged in an
intimate and healthy relationship regardless of age and
gender.565, 569‑573
Building on the success of Seniors a GOGO, the Calgary
Sexual Health Centre developed training programs
in collaboration with the University of Calgary
(Alberta), Mount Royal University (Calgary, Alberta)
and non-profit organizations including family services
and extended care facilities.567 These professional
development training programs encourage nursing
students and other health care providers to integrate
sexuality into work with seniors. The success of this
program has been built upon to offer similar programs
in British Columbia, Saskatchewan and Nova Scotia.567
sensitive to gender experiences.559 Education and services
that have positive sexual health messages that are not
exclusively heteronormative have the potential to reach
a wider group, rather than stigmatizing more vulnerable
sub-populations at risk for poor sexual health outcomes.
The Canadian Guidelines for Sexual Health Education
state that educational programs are most effective
when they are comprehensive in scope to help people
achieve positive outcomes (e.g. respect for self and
others, self-esteem, non-exploitive sexual relations
and making informed reproductive choices) and to avoid
negative outcomes (e.g. STIs and HIV infection, sexual
coercion, etc.).559 Age-appropriate school-based sexual
health education is an important and cost-effective
public health strategy that has, over the long term,
been shown to reduce risks of HIV infection and AIDS,
other STIs and unplanned pregnancies.578 Nevertheless,
barriers to effective sexual health education remain.
These include structural issues with in-school teaching
such as allotted teaching time and teaching resources
as well as the comfort level of students, teachers,
families and the community at large.575 In addition,
gender, sexual orientation and culture combine to create
additional barriers. LGBTQ respondents to the Toronto
Teen Survey indicated that LGBTQ issues were invisible in
sexual health education, for example.318, 579 Research on
the sexual health education needs of sexual minorities
demonstrates the complexity of identity, behaviour and
attraction. It also shows that sexuality is complex, diverse
and heterogeneous.580, 581
The research and interventions that focus on sexual and
gender minority adolescents are largely limited by the
predominance of heteronormative approaches to sexuality.
More work needs to be done to develop dependable,
objective methods for conceptualizing and assessing
sexual orientation and gender identity earlier in human
development and for recognizing them as complex
heterogeneous biological, physiological, psychological,
social and cultural constructs.582-585 (See the textbox
“Breaking down barriers: sexual minority youth and
education.”)
Addressing sexual health risks
Addressing STIs requires a multi-faceted approach.
A systematic review of STI and HIV infection prevention
programs indicates four key areas in reducing risky
sexual behaviours:
•• Target those behaviours that are manageable and
attainable as these interventions reduce short- and
long-term risky sexual behaviours and can potentially
reduce STI and HIV infection rates;593, 594
•• Tailor programs for the target populations as
interventions must consider different racial
and cultural practices, ages, behavioural risks,
developmental levels, sexual orientations and gender
identities;593, 594
•• Adapt learning and cognitive theories that include
skill-building and increase awareness and selfefficacy to guide choices, skills and communication
with partners to learn how to articulate safer sex
intentions;594 and
•• Address more than sexual risk by addressing broader
determinants of health.594
Broad population-based interventions and social
marketing campaigns are part of a population health
approach, but they do not specifically address sex and
gender issues.595 Most Canadian adults would have been
exposed to such broad prevention campaigns for safer sex.
Programs like “no glove, no love,” while memorable, are
considered prescriptive, as the message is disconnected
both from the situation and what drives risky sexual
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
The United Nations Educational, Scientific and Cultural
Organization (UNESCO) supports starting sexual health
education early in childhood and continuing it throughout
adolescence. The 2009 two-volume scientific guide
International Technical Guidance on Sexuality Education:
An Evidence-Informed Approach for Schools, Teachers,
and Health Educators provides a detailed rationale
for comprehensive sexual health education, identifies
evidence-informed characteristics of effective sexual
health programs, and describes how to incorporate
key sexuality education topics and learning objectives
into curriculum and programs designed for children
and youth.576, 577 This guide also recognizes population
diversity, including sexual and gender minorities, the
importance of behavioural interventions to promote
positive sexual health outcomes, and the need for
interventions to occur simultaneously in individual,
group and community contexts.576, 577
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behaviours.595 Systematic reviews show that while
people can recall these kinds of messages, the uptake
in terms of modifying behaviours – practicing safer
sex – is less successful.596 While these types of programs
can be useful in establishing overall social norms, they
can be ineffective in reaching those facing particular
barriers to safer sex. This includes individuals from
cultures that particularly discourage sexual activity, from
LGBTQ communities, or in abusive/aggressive or powerimbalanced relationships.313 Targeted approaches may be
more effective when focused on behaviour modifications
while also addressing gender and contextual barriers.595
78
Practicing safer sexual behaviours can also depend
on having access to health care and being able to
comfortably discuss practices with an available health
care practitioner. SGBA has shown that issues surrounding
access to sexual health care differs for men and women
and also depends on other factors such as sexual
orientation and culture.313 For men, barriers range from
concerns about their masculinity being compromised to
fears about specimen collection techniques and physical
examinations.313, 317 For both women and men – and
especially young people, sexual minorities, and/or those
living in small communities – barriers include privacy
concerns, inaccessible clinic hours, homophobia and
heteronormative practices.313 Approaches to preventing
HIV infection and AIDS illustrate how applying a sex and
gender lens can strengthen public health policies and
programs by looking beyond those typically considered
at risk to the diversity within sub-populations.217 Since
the introduction of HIV, investments in prevention, care
and management practices targeting at-risk populations
(e.g. MSM and people who inject drugs) have had
some success in decreasing overall rates of infection.217
However, patterns of infection showed that certain
sub-populations (e.g. women), were representing an
increasing proportion of positive HIV tests.175, 176, 217
Consideration of sex and gender along with other
influencing factors such as age, race, socio-economic
Breaking down barriers: sexual minority youth and education
Australia’s Pride and Prejudice education program
British Columbia’s CampOUT!
Australia’s Pride & Prejudice educational program
was developed through Victoria Health Region as an
educational package that is relevant, appropriate
and adaptable to secondary school settings.586, 587
Teachers were concerned about homophobia and the
stigma associated with sexual diversity. However, they
reported that while they empathized with the sexual
minority students, they lacked adequate training to
guide students.586, 587 The program trains school staff
and offers in-class programs that allow negotiation
and sexual diversity to be subjects within the everyday
curriculum.586, 587 Evaluations showed that after 6 weeks
of the program, students’ attitudes towards sexual
minorities improved, particularly among boys, who had
fewer positive attitudes than did girls before becoming
involved in the program.586, 587 Anecdotal information
suggests that the program allowed for open discussion,
tolerance and greater staff involvement.586, 587
CampOUT! is an intervention program for LGBTQ
between 14 and 21 years who reside in British
Columbia. It provides a social, educational and
health program designed to improve health and
to reduce the risk of HIV.588-591 The program has
provided a unique camping experience for sexual
minority individuals using a combination of social,
health and educational approaches to improve
health opportunities for LGBTQ youth as well as their
heterosexual peers. CampOUT! promotes inclusive
social norms in order to foster successful and healthy
lives for young LGBTQ people within and beyond the
camp experience.588-591 Leadership skills are developed
to increase personal potential and create social
change to address homophobia and heterosexism. To
inspire social cohesion and social change, all of the
camp participants, leaders and sponsors are asked to
commit to addressing stigma related to young people’s
sexual lives.592 CampOUT! appears to hold promise in
addressing social norms and institutional/structural
changes related to homophobia and heterosexism.589
factors as well as risk factors (e.g. heterosexual contact
and injection drugs) were particularly important to
understanding new HIV infections.175, 597 As such,
applying SGBA allows for a greater understanding of how
gender-related roles and responsibilities can describe the
potential impacts of HIV and AIDS policies, programs and
services.598
clients work. (See the textbox “Increasing access to sexual
health care: the Immigrant Women’s Health Clinic.”)
Stigma associated with sexual health topics, in particular
STIs, is a significant barrier to testing, early diagnosis,
care and access to treatment and support for all ages,
genders and sexual orientations.317 While there is value
to providing broad-based information to young people on
the risks of STIs and HIV infection, messages tailored to
gender, culture, age and sexual orientation are important
for at-risk populations. Innovation and creativity are
required to better address the sexual health service needs
of the Canadian population. The Government of Ontario
has published a best practices document to address public
health infection control, case management and contact
tracing.611 This document recommends using social
networks, social marketing and testing and screening
to manage STIs and long-term effects of illness and
infertility.611 The BC Centre for Disease Control recently
developed an online sexual health service program
including online STI and HIV testing service, which
will be launched to complement existing face-to-face
clinical services to improve participation in STI and
HIV testing.612
Risky sexual behaviours are not limited to younger
Canadians.559 The rates of reported STIs have increased
among those between 40 and 59 years, most noticeably
among men.169-171, 183, 253, 561 Sexual health educational
Increasing access to sexual health care: the Immigrant Women’s Health Clinic
The mandate of the Immigrant Women’s Health Centre
(IWHC), an independent sexual health clinic, in
Toronto (Ontario), is to inform women about sexual
health and provide clinical services, counselling,
information, education and outreach. Services at
the centre are culturally sensitive, available in 14
different languages, and administered by an all-female
medical staff.607, 608 STI screening and treatment,
pregnancy tests, birth control counselling, hepatitis B
vaccinations, Pap tests and contraception are provided
free or for minimal fee.608 Connected with the centre is
a mobile health clinic that brings health care services
to where women live/work and thus addresses barriers
of work and family responsibilities.609 Employers
can also request mobile clinics to offer on-site care
and treatments at the workplace with the long-term
goals of reducing employee absenteeism for medical
appointments and illness.608, 609 Follow-up studies found
that these targeted clinics improved accessibility and
use of sexual health care among immigrant women.
The clinic offers some key lessons on how to address
the sexual health needs of this often “invisible”
population, while addressing the diverse situations
and experiences formed by immigration, country of
origin and relationships with family and others. These
types of delivery models could be expanded to improve
access to sexual health care to those who face greater
socio-economic and location barriers.610
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Some sub-populations experience additional barriers to
sexual health services. LGBTQ respondents to the Toronto
Teen Survey reported encountering problems accessing
sexual health services.318, 579 LGBTQ adults may choose to
not communicate about their sexual practices with their
physician or health care provider for fear of repercussion
such as loss of trust with or losing their health care
practitioner in areas of limited services.321, 599‑602
Addressing these issues may require targeted campaigns
and the provision of new points of service.318 In addition,
it is important for health care professionals to increase
their knowledge about the health issues and health
inequalities experienced by some sexual and gender
minorities that are associated with social factors
(e.g. family, school, street violence) and medical factors
(e.g. lack of youth’s knowledge of STIs and health care
professionals’ possible misunderstanding, bias, and/
or homophobia and transphobia).603-606 Certain programs
improve access to health care services by coming to where
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programs must address not only the changing social
trends but also sexual practices of older adults. In 2010,
the United Kingdom was the first country to launch a
national sexual health campaign for those over 50 years
old.613 This program targeted adults who were single and/
or dating and possibly not aware that safer sex applies to
them.613 The campaign included posters representing the
target demographic, thereby increasing opportunities for
self-recognition in the message. As part of this campaign,
the United Kingdom’s Family Planning Agency created a
guidebook that specifically addresses health and social
issues related to sexual health and STIs to help older
adults explore old and new relationships.614
Section Three: Sex and gender and
socio-economic determinants
Looking at sex and gender by selected health outcomes
is only part of the broader story, as there are many
cumulative factors that directly or indirectly influence
health across the lifecourse. In many cases, addressing
socio-economic determinants by sex and gender can also
make a difference. This section looks at employment and
education and how sex and gender influence them. These
examples of socio-economic determinants of health were
selected for this report because they influence other
factors such as income, work-related issues (e.g. stress)
and the social sphere in which people interact, and
because there are opportunities to make a difference
by considering the influence of sex and gender in
interventions.
Work and employment: health and stereotypes
Often men and women work in different types of jobs.615
Employment and working conditions, as well as the
outcomes of employment (e.g. income), are determinants
of health. In its various forms, work – formal and
informal, paid and unpaid – can influence individual
wealth and social status.616 Two factors need to be
considered: employment conditions (e.g. salary, number
of hours, leave opportunities, insurance and benefits)
and job content (e.g. tasks, responsibilities).617
The effect of gender on how occupational health issues
are experienced, expressed, defined and addressed can
help identify risk factors for both women and men.618
Sex- and gender-based stereotyping can increase the
health risks for both men and women.616 Those jobs that
are typically considered women’s (and that employ more
women) tend to involve higher rates of repetition, agility/
dexterity, speed and concentration, whereas men-centric
jobs tend to involve more heavy manual labour.617, 619-621
Risks of injury and disease can be further confounded
by biology, workplace seniority, social status, age, tasks,
techniques and external life experiences.616, 617 Despite
the differences, little information is gathered on women’s
and men’s work and their long-term health effects based
on sex and/or gender. Assumptions about work and the
health risks of work that fall into gender stereotypes of
who does what job and the value and associated risks of
the work, for example, that women’s work is often not
as “risky” as men’s.616 While men generally experience
more occupational accidents, risks still exist for women,
particularly in the jobs that can be undervalued by
stereotyping.108, 616 In cases where men and women
perform the same jobs, tasks, approach and risks can
differ within job types and are often gendered, with men
and women with the same job title being assigned “light”
tasks (e.g. dusting, mopping, refilling) and “heavy” tasks
(e.g. waxing, washing, cleaning at greater heights). In
addition, job-related equipment and protective clothing is
generally designed for men’s physiques and can be a poor
match to an average woman’s body and strength.617, 619, 621
The assumptions about women’s work have biased data
collection such that the indicators are not relevant and
risk can be reassigned.616, 618 Women are also less likely
to receive disability support; almost one-third (29%)
of women received no supplemental income during
injury-related work absences between 1993 and 2005.622
Their workplace health is often invisible, a reality that
is even more pronounced among recent immigrants.622
Occupational health and safety programs and standards
also often have a sex and gender bias with requirements
and equipment developed based on men’s characteristics
and workplace-associated risks.616
Being able to identify and track workplace injuries, illness
and pain relies on having a health and safety program in
place that monitors activities. The lack of such a program
and other factors (e.g. reluctance of the employee or
employer to report problems) means that workplace
health outcomes are un- or under-reported. Workers can
to sexual reproduction are often perceived as female
issues.616 Further, gender perceptions of responsibilities
and tasks matter in the workplace and can contribute to
adverse outcomes such as harassment, stress and underpromotion especially in fields where there are historically
gender stereotypes.616, 623
Jobs with historical gender roles, such as nurses, flight
attendants, construction workers and welders, have
difficulty breaking down gender-based stereotypes.620
For example, male nurses are perceived as better able to
lift and engage in the physical elements of the profession
than their female counterparts.617, 624, 625 Yet it is this
physical requirement that puts male nurses at greater risk.
In addition, 46% of male nurses have been physically
assaulted by a patient compared with 33% of female
nurses.626 The suggested reasons for this gender difference
include that male nurses may have a greater exposure
to violent patients and that social norms may perceive
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
encounter barriers to reporting; for example, pain and
discomfort may be perceived as typical for certain types
of work. An imbalance of power may lead to fear of loss
of work, wages, respect and an inherent blame for one’s
own injury.620 In particular, evidence shows that women’s
occupational injuries and illnesses are under-estimated
and underdiagnosed more often than those of men.616
Compensation claims can often be denied based on
the perception that women’s work is a “safe” type of
work.616 Differences also exist between men and women
regarding treatment and rehabilitation.616 Men are more
likely to be offered training and access to a range of new
jobs and support at home post-injury; women receive
rehabilitation benefits for shorter periods of time but are
more likely to receive support for stress-related illnesses
and musculoskeletal disorders.616 Conversely, little
attention has been paid to men’s mental health issues
or occupational health exposures, and the relationships
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men as physically and emotionally stronger as well as
protective of colleagues.626, 627 Most nurses (60%, and a
higher number of males than females) report that their
job has high physical demands.626, 628 Implementation of
injury prevention practices in this field needs to consider
sex and gender and the role these play in how injuries
occur and how they are managed. A comprehensive gender
analysis of workplace experiences is necessary to address
the work-life issues relevant to retaining male and female
nurses in the field as well as increasing the number of
male nurses (in order to reach the Toward 2020 goal of
10% of all Canadian nurses be male).629 The latter requires
addressing gendered stereotypes in training, promotion
and practices.
Challenging gender stereotypes and addressing gender
bias is necessary to attract and retain individuals in
non-traditional fields.627 Workplace interventions need
to acknowledge the realities of work such as risk, location
and the role of confounding factors (e.g. environment,
assumptions). The approaches must take care not to
isolate those whose job content is outside of the norm
by engaging smaller populations with relevant approaches
where appropriate. For example, while women may have
the largest component of the health nursing services
sector, it is important to understand that men are a
significant minority with different levels of risk that
should be addressed with specified intervention.628
Gender and informal work: supporting caregivers
Many Canadians participate in unpaid and informal work
such as caregiving. Informal care providers play a vital
role in raising children and assisting elderly adults in
their daily activities.630, 631 In 2006, more women than
men (56% and 43% respectively) provide some type of
informal care, and women spend more than double the
number of hours (23 million hours altogether) providing
informal care.230, 231 Social factors such as cultural roles,
social norms and employment status contribute to the
perception that caregiving is a feminine role. Canadian
survey data does show a balance between men and women
and the provision of care to elderly family members.632
However, the type of care differs based on gender roles
and expectations. Men typically perform tasks external to
the home such as maintenance and outdoor work; women
perform more personal care and tasks that take place
inside the home.230, 231, 437, 632, 633
Most caregivers report that they are generally coping or
coping very well with their caregiving responsibilities
and find it rewarding. However, some experience adverse
health and social outcomes.230, 231, 632, 634, 635 Caregiving
can negatively affect paid employment (especially for
those who care for their family) as their responsibilities
may prevent caregivers from working outside of the home
and/or they have to reduce or change their hours of
work.230, 231, 634 Caregivers may also incur expenses that are
not reimbursed and may experience social isolation and/
or poorer health.230, 231, 634 Women in particular were more
likely to report negative health outcomes as a result of
their caregiving. They also had to make changes to their
employment (in terms of numbers of hours and work
patterns) in order to meet caregiving demands.230, 231, 634, 635
Many women also report experiencing the stress of being
in the “sandwich generation,” that is, caring for children
at the same time as caring for aging family members.636
One factor that contributes to the adverse impact of
caregiving is the intensity with which people undertake
their responsibilities. Those who caregive for under ten
hours per week experience fewer adverse effects in terms
of their participation in the labour force.230, 231, 637
Overall, the proportion of male caregivers has been
increasing, with men often caring more for partners
with mental health issues and dementia than they had
in the past. Men in caregiving roles have fewer
opportunities for community support and less social
services. Research on programs to support male caregivers
is limited given their lack of recognition in this role.634
Men in same-sex partnerships find that support for
caregivers is particularly limited by the lack of benefits,
the stigma associated with certain diseases and illnesses
(e.g. HIV and mental health issues) and limited access
to caregiving supports that usually focus on women or
individuals in heterosexual couples.638
Results of a meta-analysis of caregiver interventions
determined that supportive interventions were effective
but that the effectiveness was dependent on other
factors including gender and ethnicity as well as program
deliverables (e.g. duration, setting).651, 652 However, the
effects of the interventions were specific to caregivers and
not global in outcome, and most effective interventions
were tailored to the specific needs of caregivers of
individuals with dementia.651, 653 Further studies revealed
that including gender and acknowledging gender roles
that influence stress and coping strategies was effective
in reducing the burden to caregivers experiencing stress
and coping difficulties.653 While mechanisms are in place
to support caregivers, needs related to gender roles –
impact, burden and outcomes – are not often considered
in terms of the caregiver and the recipient. Gender
influences the broader determinants of health and can
have lasting lifelong effects.
Considering sex and gender in education
Education is an underlying determinant for many future
health outcomes. As with other social determinants,
sex and gender make a difference in how education is
approached and used. Hence they have positive long-term
health influences.10
Young males and females drop out of school for different
reasons. Young men often leave school to work, and
young women often leave due to pregnancy and childcare
requirements.654 However, despite their continued higher
high school drop-out rates, a greater proportion of young
men who drop out do return to successfully complete
their schooling later.91, 655 Thus, interventions that target
youth to stay in school and pursue training and postsecondary education must consider the roles that sex and
gender play.
Despite overall educational successes, questions remain
as to why boys are not faring as well as girls.654 The
Programme for International Student Assessment (PISA)
showed that a large international sample of 15-yearold girls performed significantly better than their
male counterparts on reading tests across participant
countries.654 Boys scored slightly higher in math and
science, but the differences in these scores were much
smaller than those for reading.654
Applying a sex and gender lens to educational attainment
suggests looking at the criteria used to measure
success and checking for possible gender bias in this
measurement; the factors that encourage in-school
participation and academic practices and the suitability
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Supporting caregivers is complex, as individual and
situational needs vary and addressing needs involves
many players including governments, employers,
communities and individuals. Several programs exist in
Canada to support caregivers which vary from financial
support (including wages, tax relief and labour policies)
to community supports and services.639 Labour policies,
such as expanded and flexible paid leave for caregiving,
are believed to help balance work and caregiver tasks.
Canada’s Employment Insurance Compassionate Care
Benefit provides financial support to caregivers who
require time away from their jobs to take care of gravely
ill family members or friends.639, 640 The federal government
provides a range of supports, including the Caregiver Tax
Credit, the Eligible Dependant Tax Credit and the Infirm
Dependant Tax Credit, and the transfer of the unused
amount of the Disability Tax Credit which recognize the
reduced ability of caregivers to earn and consequently pay
income tax as a result of supporting a dependant.639, 641-645
Tax recognition for a dependent spouse is also provided
through the Spousal Credit.646 Under the Medical Expense
Tax Credit, caregivers can claim up to $10,000 in eligible
medical expenses on behalf of a dependent relative.647, 648
In addition, some employers also offer a variety of
flexible work arrangements for employees with family
and caregiving responsibilities (e.g. telework,
flexible work hours, on-site adult daycare centres)
so that employees can better balance work and care
responsibilities.649 These kinds of flexible workplace
initiatives can be mutually beneficial by reducing
costs as a result of absenteeism, higher rates of illness
among working caregivers and the loss of skilled
employees to their caregiving responsibilities.650
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of activities for gender and diversity; gender roles and
expectations after graduation; perceptions of success;
and teaching methods and suitability to learning
styles by gender and behaviour and management. To
varying degrees all of these reasons have been cited
for differences in academic performance and outcomes.
However, addressing issues of performance involves
the consideration of sex and gender as well as other
factors.654, 656 Broad interventions assume homogeneous
populations of girls and boys and may ignore diversity.
For example, boys’ academic outcomes can be influenced
by culture as those who are recent immigrants achieve
higher academic standards than do boys (and girls)
of the same age in the overall population.657
In addition, traditional learning structures may not
be conducive to some children learning in academic
institutions.656 Evidence shows that schools that offer
physical activity programs within daily routine are
better able to meet the needs of all children but
especially those who are often distracted. Physical
activity programs provide opportunities to feel healthy,
expend energy and refocus activities that are particularly
effective for boys’ academic performance. Social factors
are also important contributors.656 Pressure to conform
to expected performance indicators by peers and/
or parents and teachers – for boys to be uninterested
in academics and/or for girls to want to achieve
academically – may influence how boys and girls
respond in school and to peers.
Similarly, coming from a disadvantaged household
(e.g. lower income, lower educational attainment) may
be a motivating factor.656, 658 Girls overcome adversity
more often than do boys; for boys the lack of support
and resources is more often detrimental to their academic
achievement. For some girls family expectations for
achieving high academic performance encourage positive
outcomes; for others, repeated messages of failure are
counterproductive.658 Some girls from families where the
educating of girls is not held in high regard also tend to
have lower academic outcomes.656 The perceived normalcy
of boys misbehaving and performing poorly in school
(“boys will be boys”) results in negative stereotypes that
reduce academic achievement and interest.656 Strong role
models at home are important for all children to achieve
academically and socially, and for boys in particular
male role models can positively influence their academic
performance.656
Supporting fathers
The role that fathers play in parenting and building
healthy relationships should not be under-estimated.659,660
Where fathers are positively involved, outcomes in
children’s cognitive, emotional, relational and physical
well-being are also positive.659-661 People who identify
as fathers, regardless of sex, gender and/or sexual
orientation play key roles in the lives of children,
family and the greater community.660, 662, 663 In particular,
boys with strong relationships with their father and/
or male mentors have greater success in school and in
relationships with others.656 In general, perceptions of
fatherhood and masculinity are changing as roles and
responsibilities in society and families are changing.
Being a good father used to be equated with being a
good worker and provider; however, fathers who are
directly involved with their children define being a
good father as being a good role model.659, 661
Over time, several reasons have been cited for
less paternal involvement including limited and
disruptions to parenting, adverse policies on child
welfare (e.g. residential schools), employment models
(e.g. lack of parental supports for fathers), social norms
(e.g. men not being the primary caretaker) and issues
around guardianship.659, 660, 662
The experiences of many Aboriginal peoples provide
examples of the importance of fathering. The introduction
of residential school systems disrupted parenting in
many First Nations, Inuit and Métis families as well as
the cultural, linguistic, spiritual and family practices
that were passed down through generations by parents,
affecting individual health and well-being.154, 662 Out of
every six First Nations children, one has one or more
parents who attended residential school, and almost 60%
have one or more grandparents who attended a residential
school.154 Thus many Aboriginal men who were first- or
second-generation residential school survivors lacked
positive role models to teach them about parenting,
communicating, showing affection and developing coping
strategies, and there are few community supports and
resources to provide information and skills in the absence
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Supporting Aboriginal fathers
There are promising programs in First Nation, Inuit,
Métis and remote communities to engage parents
and connect them with traditional culture, as well
as offer effective parenting practices and developing
healthy practices and coping skills. Four different
examples from various provinces/territories show a
range of approaches that include combining traditional
knowledge, building life skills and supporting children
with health issues.
Nˉeâh Kee Papa [I Am Your Father] is a Manitoba Métis
Federation program that recognizes that there are
fewer programs for fathers compared to mothers.666 The
Nˉeâh Kee Papa program, which has been open and free
to male participants (and their partners) since 1999,
supports the active involvement of fathers in their
children’s lives and aims to empower fathers to provide
positive emotional support to their children, enhance
their parenting skills, and support healthy family
relationships.664, 666 The program has several thematic
components that address key health and social issues:
getting started, the importance of the father’s role,
proactive parenting, life skills, healthy sexuality, family
and the law, children’s rights, effective communication
and anger management and family practices.664-666
The session, Family of Origin, allows participants to
understand their childhood past and realize how those
events affect them today as adults.
Ilisaqsivik’s Fathers and Sons on the Land (Nunavut)
addresses the changing social constructs of men,
and masculinity and fatherhood. Significant social
and cultural changes in circumstances for Inuit
families (such as the influences and impacts of the
wage economy and capitalism, new technologies,
moving in to communities, Western religions, justice
and governance systems), have altered traditional
beliefs and definitions of men and masculinity among
some Inuit communities, which can contribute to a
confusion identity, lower self-esteem, depression,
substance use and abuse, violence, suicide and loss
of male role models.664 The Fathers and Sons on the
Land program promotes mental, spiritual and physical
well-being by fostering Inuit Quajimajatuqangit,
traditional Inuit knowledge that is also associated
with traditional Inuit societal values. Some of the
ways that these traditions are taught include hunting,
traveling, working with dogs, camping and being
closely connected with the land.664 The sons of the
community (including at-risk youth and young men)
are accompanied by fathers and Elders on trips
during which knowledge “workshops” build and teach
traditional skills, values, language and histories.664
Providing the young men (as well as the older men)
with the opportunities to participate in traditional
activities can help lead to a greater empowerment,
health and wellness that is believed to expand beyond
the individual to the community.664 Items gathered on
the trips, for example, fish and other edibles, are also
shared with the community upon the groups’ return.664
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
The Traditional Parenting Program in Yukon was
established in 1995 with the goal of teaching
parenting skills through Elders’ traditional knowledge
to improve the health and well-being of Aboriginal
peoples.664, 665 Through a series of workshops, that
include father-focused programs, parents are provided
with practical, culturally sensitive training. The
program incorporates modern skills combined with
holistic parenting practices and cultural traditions such
as setting fishnets and snares, berry picking, sewing
and hide tanning are included, as are practices that
continue oral traditions, storytelling, spirituality and
incorporation of the extended family.664
British Columbia’s Full Circle Support program provides
24/7, friendly, father-centred strategies for families
and persons living with Fetal Alcohol Spectrum
Disorder.664, 667 This program offered through the Dze
L K’ant Friendship Centre Society provides proactive
parenting strategies that include life skills, budgeting,
meal planning and leisure activities.667 The Full Circle
Support program uses one-on-one supports to initially
engage fathers and break down barriers of stigma and
separation through positive messaging, supporting
mothers, teaching life skills and applying healthy
activities for children.664
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
of familial connections.662, 664 To address these effects,
promising parenting programs are developing among
Aboriginal peoples that include traditional practices
and aspects of Aboriginal spirituality (e.g. traditional
drumming, dancing, healing ceremonies, and hunting
and fishing) that are working towards engaging fathers
and integrating them and their children into the cultural
traditions.662 (See the textbox “Supporting Aboriginal
fathers.”)
86
Addressing fatherhood diversity is also important. New
and promising initiatives such as Toronto’s Young and
Potential Fathers Initiative (YPF) address cycles of
socio-economic factors, a lack of resources and few role
models for young, racialized fathers in a disadvantaged
neighbourhood.668, 669 The program connects young fathers
with a range of community health and social services
(e.g. employment services, money management, parenting
skills and legal aid); as well as provides spaces for
Acknowledging the importance of fathers’ involvement
Canada has made much progress in acknowledging
importance of fathers’ involvement with their
children and has made strides to increase, knowledge
and practice in this area. Since the 1990s, father
involvement interventions (in terms of networks,
programs and research) have developed substantially.671
Canada’s first father involvement project, ProsPère,
was established in 1994 in two vulnerable Quebec
communities to assess and promote father-involvement
as a protective factor with respect to child abuse.
Initial work included research which assessed
community-based support for fathers with young
children in four diverse communities in the Montreal
region. Work has grown since contributing to the
literature on the role of fathers on child development,
fathers in vulnerable populations, and knowledge
translation.671, 672
In Ontario, the Father Involvement Initiative – Ontario
Network (FII-ON) began in 1997 as a broad-based
coalition and partnership program to promote father
involvement and include fathers into community
services.673 FII-ON adapted and continues to use
a population health approach, acknowledging the
importance of individual and collective factors and the
number of stakeholders involved in the lives of fathers
(e.g. fathers, mothers, private sector, decision makers
and media).671, 673 The initiative’s accomplishments
include increasing knowledge, developing educational
booklets, posters and other social marketing materials,
supporting father involvement programs at the
community, province and national levels, encouraging
the development of knowledge networks and educating
and supporting fathers. This initiative also offers
professional training programs to Community Action
Program for Children (CAPC)/Canadian Prenatal
Nutrition Program (CPNP) projects, Ontario Early Years
Centres as well as public health units.673-675 Similar
networks, Father Involvement – BC Network (FIN-BC)
and the Alberta Father Involvement Initiative also act
as a hubs for information, resources and training about
fathers in British Columbia and Alberta.676
The Father Involvement Research Alliance (FIRA) also
developed from a national partnership building with
researchers, practitioners, policy makers and fathers in
2002.677 Through this initiative FIRA aims to: generate
research agendas, develop, initiate and carry out new
research, develop knowledge sharing approaches,
promote evidence-based strategies, engage a broad
range of interested individuals, organizations and
institutions, and connect to Canadian fathers, mothers
and children about their issues and needs.677 An
academic document entitled “Father Involvement
in Canada: Contested Terrain” is expected to will be
released in late 2012.
Other initiatives such as, “On Fathers’ Ground,” the
first National Project on Fund on Fathers, builds
organizations’ capacity to work with fathers. The
follow-up project, “My Daddy Matters Because…”
conducted a national survey of community father
programs and led to the creation of The Father Toolkit
which was designed to assist programs interested in
promoting father involvement and identifying bestpractices and lessons learned from existing Canadian
father involvement programs.660, 678, 679
fathers to interact with their children, other fathers and
mentors.669, 670
The past decade has seen a significant expansion in
academic interest in father involvement, efforts to be
more inclusive and supportive of fathers in programs
and services for families, the level of knowledge about
fathers’ experiences as parents and how to support them.
However, more can be done to see that knowledge about
father involvement is disseminated to professionals and
policymakers who wish to support families and healthy
child development.680
Summary
Considering sex and gender in public health interventions
is important. This chapter highlights examples of broad
and targeted research, programs and policies where sex
and gender influence health outcomes and the socioeconomic determinants of health. There is a need for
sex- and gender-based approaches that move past
perceptions of male and female dichotomies to
encompass factors such as gender norms and identities,
masculinities/femininities as well as sexual/gender
diversity.
Canada has made progress in incorporating sex and
gender considerations into research as well as a variety
of public health practices, but many challenges remain.
The first section of this chapter sets out the value of
considering sex and gender in public health interventions.
Examples such as the HPV intervention illustrate that
applying a sex and gender lens can provide a range of
perspectives towards health and wellness interventions.
In the second section, examples of physical, mental and
sexual health outcomes illustrate where sex- and genderbased approaches can be applied and where diversity
within sub-populations is also important. Examples of
effectively considering sex and gender in the formulation
and implementation of safer sex messages has encouraged
taking into account other relevant factors such as age,
culture and sexual orientation. The third section considers
the role that sex and gender play in the determinants
of health, and how programs and policies can address
socio-economic inequalities that have the potential to
positively affect health. Programs that support parents
provide opportunities to positively influence the health
and well-being of children as well as the parents
themselves.
The path that considers and incorporates sex and gender
interventions into future public health interventions will
be challenging as interventions evolve to:
•• show that sex and gender influence everyone’s health
and well-being;
•• challenge existing assumptions and stereotypes about
disease and sex and gender (namely that applying
a sex and gender lens is not solely about adding a
women’s component);
•• move towards programs that encompass sex and
gender together with other forms of diversity in
order to remove barriers and reduce stigma; and
•• expand capacity, capture more relevant data and
develop and evaluate programs that include sex,
gender and diversity.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Over time society’s view on father involvement has
evolved. Since the 1970s, Canadian fathers have become
increasingly more involved in their children’s activities
and lives, as a result of a number of factors including
mothers working outside of the family home, greater
gender equity, the need for fathers to socially and
practically support partners and fathers’ desire to be
involved with their children.671 As well Canada, as a
society, has made some progress in supporting research
and/or programs on fatherhood. Interventions that
target fathers are continuing to grow and recognize
the importance of fathers to the health and well-being
of Canadians.671 (See the textbox “Acknowledging the
importance of fathers’ involvement.”)
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Part III: A Path Forward
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A Path Forward
“Until all of us have made it, none of us have made it.“
– Rosemary Brown
This report illustrates the important influence of sex and
gender on the health of Canadians. The good news is that
the majority of Canadians enjoy good to excellent physical
and mental health, and are living longer, healthier lives.
The bad news is that not all Canadians are experiencing
the same good health. Because good health is not equally
shared, it is essential that we understand the many
factors that contribute to this difference.
A time to act
Working across sectors and jurisdictions, there is a reason
to believe that health outcomes can be improved for all
Canadians. In particular, Canada needs to:
•• recognize and understand the importance of sex and
gender in health;
•• foster a shared vision and collective action to ensure
sex and gender are key considerations in public
health research, programs, policy and practices; and
•• build on (and share) sex and gender evidence from
research and practice.
Recognizing and understanding the role of
sex and gender
Canadians must acknowledge and address the role of sex
and gender in all facets of health. In addition, it is also
important to consider the pathways that an individual
takes and how these influence health outcomes. This
report clearly illustrates how sex and gender influence
behaviours, relationships and overall health in constantly
changing ways over the lifecourse.
Fostering a shared vision and collective action
Working across sectors and jurisdictions, society must
foster collective will and leadership to co-ordinate efforts
to ensure that all Canadians are respected and given the
opportunity to fully participate in society. The goal is to
support a population that is as healthy as possible for as
long as possible.
Too often, sex- and gender-based stereotyping can
increase the health risks for individuals. Addressing
the health inequalities that prevent individuals
from achieving the best health possible will require
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Taking action to improve health and well-being will
require time, effort and resources. Everyone (governments,
not-for-profit organizations, communities, individuals,
etc.) has a role to play to make Canada healthier. This
report features many examples of effective, promising
and/or supportive approaches and interventions that
illustrate how sex and gender are important considerations
in developing and implementing the right solutions.
Governments, the private sector, not-for-profit
organizations, educational institutions, communities and
individuals must all broaden their perspectives and check
their preconceptions to ensure that Canada is taking
advantage of opportunities to plan, deliver and develop
effective interventions that take sex and gender into
account. Sex- and gender-based analysis (SGBA) can be
used to tailor programs, policies and interventions in
a careful and respectful manner to help reduce health
inequalities.
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compassion, openness, time, patience, resources and
collaboration, but is an investment worth making.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Building on the evidence
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Given the importance of sex and gender in shaping health
and well-being, it is essential that they be considered
in the development, implementation and evaluation
of research, programs and policies. Too often, they are
either not factored into these areas or else generic
characteristics and scenarios about men and women are
used that assume a “one size fits all” approach. This
overly simplistic tactic risks producing evidence that is
incomplete or misleading. Targeted programs for women
and/or men should be reconsidered to encompass the
diversity of the population and avoid division.
In addition, more data on sex and gender and the
effectiveness of programs are required. It is important
to consider sex and gender in all research activities,
and not just health research. This requires improved
capacity to capture the information needed to identify
trends, future concerns and the effectiveness of
initiatives, interventions and strategies that incorporate
sex and gender. Though broad consideration of sex and
gender across sectors supports an understanding of the
complexities and interactions of health determinants,
behaviours and outcomes, it requires the development of
analytical tools in research and surveillance to properly
investigate these complexities.
Applying a sex and gender lens to research, policy and
programs raises awareness and allows professionals to
identify differences and challenge assumptions about
health. Due to the dynamic nature of the sex and gender
continuum, evaluating outcomes must be a continuous
process that considers the broader range of health
determinants. Having robust evaluations will allow for
better identification of trends and areas where efforts
should be focused. Understanding whether a program
works – and why – improves its effectiveness.
Challenges remain in translating and disseminating
the results of sex- and gender-based research and
programming. To make progress, it is important that
researchers avoid generalization and develop sex- and
gender-specific indicators. Having the appropriate data
and evidence is important for policy makers, public health
practitioners and communities who are planning health
interventions and programs, which is why looking broadly
and finding applicable results from studies is an important
and ongoing challenge.
Making a Difference
Opportunities to prevent illness and promote health can
be introduced through initiatives and interventions that
consider the diverse needs, including sex and gender, of
Canadians. Making the effort to reflect sex and gender
considerations in research and policy is important for
Canada to continue to improve health outcomes.
Moving forward, Canada can learn, adapt and build on
successes. However, it will be important to ensure that
efforts are neither undertaken in isolation nor limited
to one-time projects with short-term impacts. Sex and
gender, and their influence on health, are relevant to all
Canadians. As a society, Canada can better incorporate
sex- and gender-related issues in public health to
influence the effectiveness of health promotion and
disease prevention efforts. Collectively, Canada has the
capacity to understand and address the specific issues of
our diverse population to ensure that all Canadians have
the opportunity to live as healthy a life as possible.
5
CHAPTER
Sex, Gender and Public Health –
A Path Forward
– From words to action –
In this report I have tried to emphasize the importance of sex and gender and their connections with public
health and the health status of Canadians. It is my hope that after reading this report, Canadians will have a
better understanding of why sex and gender are important to health and how taking them into account can help
reduce health inequalities.
Each Canadian should have the opportunity to live as healthy a life as possible. By supporting the integration of
sex and gender in all aspects of research, programs and policies, we can continue to build on our successes and
enhance health and well-being. If every sector of society does their part, we can make a difference. In my role as
Chief Public Health Officer I will:
– Dr. David Butler-Jones
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
•• work to raise awareness of sex and gender and their influence on public health;
•• continue to provide leadership in championing the inclusion of sex and gender considerations at the
Agency and with my federal colleagues;
•• ensure work continues to challenge preconceptions and change perspectives about sex and gender and
their importance to public health;
•• work with my federal colleagues and other sectors to develop, deliver and promote policies and programs
that consider sex and gender as well as the broader determinants of health; and
•• continue to support public health research, policies and initiatives that integrate sex and gender
considerations into their development, implementation and evaluation.
93
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
APPENDIX
A
94
AIDS
ALS
ASGBA
BMI
CAAWS
CAPC
CCHS
CCSMH
CHMS
CIHR
CNDSS
CPHO
CPNP
CVD
FII-ON
FIN-BC
FIRA
GBA
HALE
HBSC
HDHK
HIV
HPV
IWHC
LGB
LGBTQ
LIFE
MAN
MHCC
MSM
PHAC
PISA
PPD
PYLL
RHS
SGBA
STI
UNESCO
WHO
YPF
List of Acronyms
Acquired immunodeficiency syndrome
Amyotrophic Lateral Sclerosis
Aboriginal-specific sex- and gender-based analysis
Body Mass Index
Canadian Association for the Advancement of Women and Sport
Community Action Program for Children
Canadian Community Health Survey
Canadian Coalition for Seniors’ Mental Health
Canadian Health Measures Survey
Canadian Institutes of Health Research
Canadian Notifiable Disease Surveillance System
Chief Public Health Officer
Canadian Prenatal Nutrition Program
Cardiovascular disease
Father Involvement Initiative – Ontario Network
Father Involvement – BC Network
Father Involvement Research Alliance
Gender based analysis
Health-adjusted life expectancy
Health Behaviours of School-Aged Children
Healthy Dads, Healthy Kids
Human immunodeficiency virus
Human papillomavirus
Immigrant Women’s Health Centre
Lesbian, gay and bisexual
Lesbian, gay, bisexual, transgender and questioning
Living is for Everyone
Men’s Awareness Network
Mental Health Commission of Canada
Men who have sex with men
Public Health Agency of Canada
Programme for International Student Assessment
Postpartum Depression
Potential years of life lost
First Nations Regional Health Survey
Sex- and gender-based analysis
Sexually transmitted infection
United Nations Educational, Scientific and Cultural Organization
World Health Organization
Young and Potential Fathers Initiative
APPENDIX
B
Body mass index cut-points
The body mass index (BMI) is a ratio of weight-to-height.681
BMI = weight in kilograms/(height in metres)2
Table B.1 Body mass index cut-points for children and youth aged 2 to 17 years204, 205
Underweight cut-points
BMI less than or equal to:
Overweight cut-points
BMI greater than or equal to:
Obesity cut-points
BMI greater than or equal to:
Age (years)
Boys
Girls
Boys
Girls
Boys
Girls
2
15.14
14.83
18.41
18.02
20.09
19.81
2.5
14.92
14.63
18.13
17.76
19.80
19.55
3
14.74
14.47
17.89
17.56
19.57
19.36
3.5
14.57
14.32
17.69
17.40
19.39
19.23
4
14.43
14.19
17.55
17.28
19.29
19.15
14.31
14.06
17.47
17.19
19.26
19.12
14.21
13.94
17.42
17.15
19.30
19.17
5.5
14.13
13.86
17.45
17.20
19.47
19.34
6
14.07
13.82
17.55
17.34
19.78
19.65
6.5
14.04
13.82
17.71
17.53
20.23
20.08
7
14.04
13.86
17.92
17.75
20.63
20.51
7.5
14.08
13.93
18.16
18.03
21.09
21.01
8
14.15
14.02
18.44
18.35
21.60
21.57
8.5
14.24
14.14
18.76
18.69
22.17
22.18
9
14.35
14.28
19.10
19.07
22.77
22.81
9.5
14.49
14.43
19.46
19.45
23.39
23.46
10
14.64
14.61
19.84
19.86
24.00
24.11
10.5
14.80
14.81
20.20
20.29
24.57
24.77
11
14.97
15.05
20.55
20.74
25.10
25.42
11.5
15.16
15.32
20.89
21.20
25.58
26.05
12
15.35
15.62
21.22
21.68
26.02
26.67
12.5
15.58
15.93
21.56
22.14
26.43
27.24
13
15.84
16.26
21.91
22.58
26.84
27.76
13.5
16.12
16.57
22.27
22.98
27.25
28.20
14
16.41
16.88
22.62
23.34
27.63
28.57
14.5
16.69
17.18
22.96
23.66
27.98
28.87
15
16.98
17.45
23.29
23.94
28.30
29.11
15.5
17.26
17.69
23.60
24.17
28.60
29.29
16
17.54
17.91
23.90
24.37
28.88
29.43
16.5
17.80
18.09
24.19
24.54
29.14
29.56
17
18.05
18.25
24.46
24.70
29.41
29.69
17.5
18.28
18.38
24.73
24.85
29.70
29.84
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
4.5
5
95
APPENDIX
B
Body mass index cut-points
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Table B.2 Body mass index cut-points for adults aged 18 years and older681
96
Classification
BMI category (kg/m2)
Underweight
Normal weight
Overweight
Obese
Obese class I
Obese class II
Obese class III
< 18.5
18.5 – 24.9
25.0 – 29.9
≥ 30.0
30.0 – 34.9
35.0 – 39.9
≥ 40.0
Level of health risk
Increased risk
Least risk
Increased risk
High risk
Very high risk
Extremely high risk
APPENDIX
Indicators of Our Health and Factors
Influencing Our Health
Table C.1 Who we are
Year
Who we are (million people)
33.5
1.17
0.70
0.05
0.39
6.2
2011
2006
2006
2006
2006
2006
0.37
2.53
0.32
0.13
2.28
0.06
0.25
0.25
2006
2006
2006
2006
2006
2006
2006
2006
2.0
4.2
27.1
80.9
2006
2006
2011
2006-2008
Note: Italicized information denotes indicators that have not changed from the previous The Chief Public Health Officer’s Report on the State of Public Health in
Canada, 2011. Some data may not be comparable. More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
* ‘Other’ includes Greenland, Saint Pierre and Miquelon, the category ‘Other country,’ as well as immigrants born in Canada.
Sources: Statistics Canada.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Population (as of July 1, 2010)
Aboriginal
First Nations
Inuit
Métis
Immigrant
By birth place
Africa
Asia and the Middle East
Caribbean and Bermuda
Central America
Europe
Oceania and other*
South America
United States of America
By years since immigration
Recent (<= 10 years)
Long-term (>10 years)
Population centre
Life expectancy at birth (years of expected life)
C
97
APPENDIX
C
Indicators of Our Health and Factors
Influencing Our Health
Table C.2 Our health status
Year
Our health status
Health-adjusted life expectancy and reported health
Health-adjusted life expectancy at birth (years of expected healthy life, females)
Infant mortality rate (under one year) (deaths per 1,000 live births)
Perceived health, very good or excellent* (percent of population aged 12+ years)
Perceived mental health, very good or excellent* (percent of population aged 12+ years)
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Leading causes of mortality (deaths per 100,000 population per year)
Cancers
Circulatory diseases
Respiratory diseases
98
Causes of premature mortality, aged 0 to 74 years (potential years of life lost per 100,000 population per year)
Cancers
Circulatory diseases
Unintentional injuries
Suicide and self-inflicted injuries
Respiratory diseases
HIV
Living with chronic diseases
Cancer incidence (new cases age-standardized per 100,000 population per year)
Diabetes prevalence (percent of the population aged 1+ years)
Obesity (percent of the population aged 18+ years)
Arthritis* (percent of population aged 15+ years)
Asthma* (percent of population aged 12+ years)
Heart disease* (percent of population aged 12+ years)
High blood pressure* (percent of the population aged 20+ years)
Chronic obstructive pulmonary disease* (percent of the population aged 35+ years)
Living with mental illness population aged 15+ years (percent)
Schizophrenia*
Major depression*
Alcohol dependence*
Anxiety disorders*
Alzheimer’s and other dementias* (estimated percent of the population aged 65+ years)
Acquiring infectious diseases
HIV (number of positive HIV tests)
Chlamydia (new cases per 100,000 population annually)
Gonorrhea (new cases per 100,000 population annually)
Infectious syphilis (new cases per 100,000 population annually)
72.1
69.6
5.1
60.1
2004-2006
2004-2006
2008
2010
211.8
209.9
62.2
2008
2008
2008
1,530
777
591
311
184
34
2008
2008
2008
2008
2008
2008
406
6.8
23.9
16.3
8.5
5.0
20.1
4.3
2011
2008-2009
2007-2009
2010
2010
2010
2010
2010
0.3
4.8
2.6
5.3
8.9
2005
2002
2002
2010
2008
2,417
258.5
33.1
5.0
2009
2009
2009
2009
* Denotes self-reported data
Note: Italicized information denotes indicators that have not changed from the previous The Chief Public Health Officer’s Report on the State of Public Health in
Canada, 2011. Some data may not be comparable. More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
Sources: Statistics Canada, Canadian Cancer Society, Public Health Agency of Canada and Alzheimer Society of Canada.
APPENDIX
Indicators of Our Health and Factors
Influencing Our Health
C
Table C.3 Factors influencing our health
Year
Factors influencing our health
9.6
2009
Employment and working conditions, population aged 15+ years (percent)
Unemployment rate
7.4
2011
Food security, population aged 12+ years (percent)
Households reporting moderate to severe food insecurity*
6.7
2010
Environment and housing
Ground-level ozone exposure (parts per billion [population weighted warm season average])
Fine particulate matter (PM2.5) exposure (micrograms per cubic metre [population weighted warm season average])
Core housing need* (percent of the households)
37.0
7.0
12.7
2009
2009
2006
Education and literacy, population aged 25+ years (percent)
High school graduates
Some post-secondary education
Post-secondary graduates
83.4
64.1
58.4
2011
2011
2011
65.4
1,282
2010
2010
Health behaviours
Current smoker* (percent of the population aged 15+ years)
Engaged in leisure time physical activity, moderately active or active* (percent of the population aged 12+ years)
Fruit and vegetable consumption (5+ times per day)* (percent of the population aged 12+ years)
Heavy drinking (5+ drinks on one occasion at least once a month in the past year)* (percent of the population aged 12+ years)
Illicit drug use in the past year* (percent of the population aged 25+ years)
Teen pregnancy rate (pregnancy per 1,000 female population aged 15 to 19 years per year)
16.7
52.1
43.3
15.9
8.2
14.2
2010
2010
2010
2010
2010
2009
Access to health care, population aged 12+ years (percent)
Regular family physician*
Contact with dental professional*
84.8
71.1
2010
2010
Social support and connectedness
Sense of community belonging, somewhat or very strong* (percent of the population aged 12+ years)
Violent crime incidents (per 100,000 population)
* Denotes self-reported data
Note: Italicized information denotes indicators that have not changed from the previous The Chief Public Health Officer’s Report on the State of Public Health in
Canada, 2011. Some data may not be comparable. More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
Sources: Statistics Canada, Health Canada, Environment Canada and Canada Mortgage and Housing Corporation.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Income (percent of the population, based on 1992 low income cut-off)
Persons living in low-income (after tax)
99
100
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
-A-
D
APPENDIX
Definitions and Data Sources for Indicators
Métis (single response) (2006)682, 683
Aboriginal people(s) (2006)682
This is a 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 – each having unique heritages,
languages, cultural practices and spiritual beliefs.
Data Source
Table C.1: Statistics Canada. (2010-10-06). Aboriginal identity
population by age groups, median age and sex, 2006 counts for both
sexes, for Canada, provinces and territories [Data File].
A term commonly used beginning in the 1970s to
replace Indian. Although the term First Nation is
widely used, no legal definition of it exists. Among
its uses, the term ‘First Nations peoples’ refers
generally to the Indian Peoples in Canada, both Status
and Non-Status. Single identity refers to those persons
who reported identifying with First Nations only.
Data Source
Table C.1: Statistics Canada. (2010-10-06). Aboriginal identity
population by age groups, median age and sex, 2006 counts for
both sexes, for Canada, provinces and territories [Data File].
Inuit (single response) (2006)682, 683
Inuit are 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 persons who reported
identifying with Inuit only.
Data Source
Table C.1: Statistics Canada. (2010-10-06). Aboriginal identity
population by age groups, median age and sex, 2006 counts for
both sexes, for Canada, provinces and territories [Data File].
Data Source
Table C.1: Statistics Canada. (2010-10-06). Aboriginal identity
population by age groups, median age and sex, 2006 counts for
both sexes, for Canada, provinces and territories [Data File].
Alcohol dependence (2002)68
Alcohol dependence is defined as tolerance, withdrawal,
loss of control or social or physical problems related to
alcohol use. This measure was estimated using the Alcohol
Dependence Scale (Short Form Score) based on a subset
of items from the Composite International Diagnostic
Interview developed by Kessler and Mroczek for those
aged 15 years and older.
Data Source
Table C.2: Government of Canada. (2006). The Human Face of
Mental Health and Mental Illness in Canada.
Alzheimer’s disease and other dementias
(2008)684
The DSM-III-R criteria were used to classify people as
demented or not. Differential diagnoses used the NINCDSADRDA and DSM-IV criteria for Alzheimer’s disease; the
ICD-10 and the NINDS-AIREN criteria were used to define
vascular dementia; operational criteria for Lewy body
dementia were taken from McKeith et al.(1996). Those
without dementia were classified as cognitively impaired
but not demented (CIND), or as cognitively normal.
Reisberg’s Global Deterioration Scale was used for rating
cognitive and functional capacity in all diagnoses.
Data Source
Table C.2: Smetanin, P., Kobak, P., Briante, C., Stiff, D., Sherman, G.,
& Ahmad, S. (2009). Rising Tide: The Impact of Dementia in Canada
2008 to 2038 ; and Statistics Canada. (2011-03-23). CANSIM Table
051-0001 Estimates of population, by age group and sex for July 1,
Canada, provinces and territories, annual [Custom Data File].
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
First Nations (single response) (2006)
682, 683
A term which is used broadly to describe people
with mixed First Nations and European ancestry
who identify themselves as Métis, distinct from
Indian people, Inuit or non-Aboriginal people.
Single identity refers to those persons who reported
identifying with Métis only.
101
APPENDIX
D
Definitions and Data Sources for Indicators
-B-
Anxiety disorders (2010)48, 68
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Individuals with anxiety disorders experience excessive
anxiety, fear or worry, causing them to either avoid
situations that might precipitate the anxiety or develop
compulsive rituals that lessen the anxiety. This measure
was estimated as the population who reported that they
have been diagnosed by a health professional as having a
phobia, obsessive-compulsive disorder or a panic disorder.
102
Data Source
Table C.2: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Arthritis (2010)45
Population who reported having arthritis, including
rheumatoid arthritis and osteoarthritis, but excluding
fibromyalgia, as diagnosed by a health professional.
Data Source
Table 1.1: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Table C.2: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Asthma (2010)45
Population who reported having asthma as diagnosed
by a health professional.
Data Source
Table 1.1: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Table C.2: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Back problems (2010)48
Persons reporting having back problems, excluding
fibromyalgia and arthritis.
Data Source
Table 1.1: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
-CCancer incidence (2011)65
Estimated number of new cancer cases diagnosed in a
given population during a specific period of time.
Data Source
Table 1.1: Canadian Cancer Society’s Steering Committee. (2011).
Canadian Cancer Statistics, 2011. (Toronto: Canadian Cancer
Society).
Table C.2: Canadian Cancer Society’s Steering Committee. (2011).
Canadian Cancer Statistics, 2011. (Toronto: Canadian Cancer
Society).
Cancers (2008)70
Deaths associated with malignant cancers (ICD-10
C00-C97) including but not limited to cancers of the
lymph nodes, brain and urinary tract.
Data Source
Table 1.1: Statistics Canada. (2011-09-26). CANSIM Table 102-0522
Deaths, by cause, Chapter II: Neoplasms (C00 to D48), age group and
sex, Canada, annual [Data File] and; Statistics Canada. (2011-09-27).
CANSIM Table 051-0001 Estimates of population, by age group and
sex for July 1, Canada, provinces and territories, annual [Custom Data
File].
Table C.2: Statistics Canada. (2011-09-26). CANSIM Table 102-0522
Deaths, by cause, Chapter II: Neoplasms (C00 to D48), age group and
sex, Canada, annual [Data File] and; Statistics Canada. (2011-09-27).
CANSIM Table 051-0001 Estimates of population, by age group and
sex for July 1, Canada, provinces and territories, annual [Custom Data
File].
Chlamydia (2009)169, 174
Contact with dental professional (2010)48
Estimated rate per 100,000 population, where Chlamydia
(Chlamydia trachomatis) was reported to the Public Health
Agency of Canada by provinces and territories.
Persons who have consulted with a dental professional
(dentist, dental hygienist or orthodontist) in the past
12 months.
Data Source
Table C.2: Public Health Agency of Canada. (2011-02-22). Reported
cases and rates of chlamydia by age group and sex, 1991 to 2009
[Data File].
Data Source
Table C.3: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Chronic obstructive pulmonary disease (2010)48
Respondents who reported having chronic obstructive
pulmonary disease, chronic bronchitis or emphysema.
Circulatory diseases (2008)77
Deaths associated with circulatory diseases (ICD-10
I00-I99) including but not limited to ischaemic heart
diseases, cerebrovascular diseases and pulmonary heart
conditions.
Data Source
Table 1.1: Statistics Canada. (2011-09-26). CANSIM Table 102-0529
Deaths, by cause, Chapter IX: Diseases of the circulatory system
(I00 to I99), age group and sex, Canada, annual [Data File]; and
Statistics Canada. (2011-09-27). CANSIM Table 051-0001 Estimates
of population, by age group and sex for July 1, Canada, provinces and
territories, annual [Custom Data File].
Table C.2: Statistics Canada. (2011-09-26). CANSIM Table 102-0529
Deaths, by cause, Chapter IX: Diseases of the circulatory system
(I00 to I99), age group and sex, Canada, annual [Data File]; and
Statistics Canada. (2011-09-27). CANSIM Table 051-0001 Estimates
of population, by age group and sex for July 1, Canada, provinces and
territories, annual [Custom Data File].
Core housing need (2006)685
A household is in core housing need if it does not meet
one or more of the adequacy, suitability or affordability
standards and would have to spend 30 per cent or more
of its before-tax income to pay the median rent of
alternative local housing that meets all three standards.
Adequate housing does not require any major repairs.
Suitable housing has enough bedrooms for the size and
make-up of resident households according to National
Occupancy Standard requirements. Affordable housing
costs less than 30 per cent of before-tax household
income.
Data Source
Table C.3: Canada Mortgage and Housing Corporation. (n.d.).
Housing in Canada Online [Data File].
Current smoker (2010)133
Respondents who have identified themselves as daily
smokers and non-daily smokers (also known as
occasional smokers).
Data Source
Table C.3: Health Canada. (2011-09-07). Canadian Tobacco Use
Monitoring Survey (CTUMS) 2010 [Data File].
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Data Source
Table C.2: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
D
APPENDIX
Definitions and Data Sources for Indicators
103
APPENDIX
D
Definitions and Data Sources for Indicators
-D-
Diabetes prevalence (2008-2009)62
The proportion of individuals that are affected by diabetes
at a given point in time.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Data Source
Table 1.1: Public Health Agency of Canada. (2011). Diabetes in
Canada: Facts and figures from a public health perspective. (Ottawa:
Public Health Agency of Canada).
Table C.2: Public Health Agency of Canada. (2011). Diabetes in
Canada: Facts and figures from a public health perspective. (Ottawa:
Public Health Agency of Canada).
104
-EEngaged in leisure-time physical activity,
moderately active or active (2010)45
Population who reported a level of physical activity,
based on their responses to questions about the nature,
frequency and duration of their participation in leisuretime 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 engaged in by the
respondent, 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
Table C.3: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
-FFine particulate matter (PM2.5) exposure
(2009)686
This indicator uses the warm seasonal (April 1 to
September 30) average of 24-hour daily average
concentrations, which is population-weighted to calculate
trends and averages across monitoring stations located
throughout the country.
Data Source
Table C.3: Environment Canada. (2012-06-18). Ground-Level Ozone
and Fine Particulate Matter Air Quality Indicators Data [Data File].
First Nations (2006)
See Aboriginal people(s)
Fruit and vegetable consumption
(5+ times a day) (2010)45
Indicates the usual number of times (frequency) per day
a person reported eating fruits and vegetables. Measure
does not take into account the amount consumed.
Data Source
Table C.3: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
-GGonorrhea (2009)171, 174
Estimated rate per 100,000 population, where Gonorrhea
(Neisseria gonorrhoeae) was reported to the Public Health
Agency of Canada by provinces and territories.
Data Source
Table C.2: Public Health Agency of Canada. (2011-02-22). Reported
cases and rates of gonorrhea by age group and sex, 1980 to 2009
[Data File].
Ground-level ozone exposure (2009)686
This indicator uses the warm seasonal (April 1 to
September 30) average of daily eight-hour maximum
average concentrations, which is population-weighted to
calculate trends and averages across monitoring stations
located throughout the country.
Data Source
Table C.3: Environment Canada. (2012-06-18). Ground-Level Ozone
and Fine Particulate Matter Air Quality Indicators Data [Data file]
-HAn indicator of overall population health that combines
measures of both age– and sex–specific health status,
and age– and sex–specific mortality into a single
statistic. It represents the number of expected years of
life equivalent to years lived in full health, based on the
average experience in a population. Quebec, Nunavut and
Northwest Territories are not represented.
Data Source
Table 1.1: Public Health Agency of Canada Steering Committee on
Health-Adjusted Life Expectancy. Health-Adjusted Life Expectancy
in Canada: 2010 Report by the Public Health Agency of Canada.
Unpublished.
Table C.2: Public Health Agency of Canada Steering Committee on
Health-Adjusted Life Expectancy. Health-Adjusted Life Expectancy
in Canada: 2010 Report by the Public Health Agency of Canada.
Unpublished.
Heart disease (2010)
48
Respondents who reported having heart disease.
Data Source
Table C.2: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Heavy drinking (5+ drinks on one occasion at
least once a month in the past year) (2010)687
Population who reported having five or more drinks in
a single sitting once a month or more often in the past
year.
Data Source
Table C.3: Health Canada. Canadian Alcohol and Drug Use Monitoring
Survey, 2010 [Public-Use Microdata File]. Ottawa, Ontario: Health
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
High blood pressure (2010)48
Respondents who reported having high blood pressure or
having used blood pressure medication in the past month,
excluding those who reported high blood pressure during
pregnancy only.
Data Source
Table 1.1: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
Table C.2: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
High school graduates (2011)98
Persons who have received, at minimum, a high school
diploma or, in Quebec, completed Secondary V or, in
Newfoundland and Labrador, completed fourth year of
secondary.
Data Source
Table C.3: Statistics Canada. (2012-01-04). CANSIM Table 282-0004
Labour force survey estimates (LFS), by educational attainment, sex
and age group, annual [Custom Data File].
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Health-adjusted life expectancy (2004-2006)46
D
APPENDIX
Definitions and Data Sources for Indicators
105
APPENDIX
D
Definitions and Data Sources for Indicators
HIV (2009)688
By birth place (2006)690
The number of new HIV diagnoses in the population
reported to the Public Health Agency of Canada during a
specified time.
The concept of place of birth applies to the country
of a respondent if born outside Canada. Respondents
are to report their place of birth according to
international boundaries in effect at the time of
enumeration not at the time of birth.
Data Source
Table C.2: Public Health Agency of Canada. (2010). HIV and AIDS in
Canada. Surveillance Report to December 31, 2009. (Ottawa: Public
Health Agency of Canada).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Households reporting moderate to severe food
insecurity (2010)195
106
A situation that exists when people lack physical and
economic access to sufficient amounts of safe and
nutritious food for normal growth and development and
an active and healthy life.
Data Source
Table C.3: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
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
Table C.1: Statistics Canada. (2011-07-04). Immigrant Status
and Place of Birth, Sex and Age Groups for the Population of
Canada, Provinces, Territories, Census Metropolitan Areas and
Census Agglomerations, 2006 Census [Data File].
By years since immigration (2006)691
Year or period of immigration refers to a person who
is a landed immigrant by the period of time in which
he or she first obtained landed immigrant status.
Data Source
Table C.1: Statistics Canada. (2011-07-04). Place of Birth,
Period of Immigration, Sex and Age Groups for the Immigrant
Population of Canada, Provinces, Territories, Census Metropolitan
Areas and Census Agglomerations, 2006 Census [Data File].
Infant mortality rate (under one year) (2008)692
-IIllicit drug use in the past year (2010)
163
Persons who reported using an illicit drug (cannabis,
cocaine, speed, ecstasy, hallucinogens, salvia or heroin)
in the 12 months preceding the interview.
Data Source
Table C.3: Health Canada. (2011-08-02). Canadian Alcohol and Drug
Use Monitoring Survey [Data File].
Immigrant (2006)689
Applies to a person who has been granted the right to
permanently live in Canada by immigration authorities.
It usually applies to persons born outside Canada but
may also apply to a small number of persons born inside
Canada to parents who are foreign born.
Data Source
Table C.1: Statistics Canada. (2011-07-04). Immigrant Status and
Place of Birth, Sex and Age Groups for the Population of Canada,
Provinces, Territories, Census Metropolitan Areas and Census
Agglomerations, 2006 Census [Data File].
Infant mortality rate is the number of infant deaths
occurring within the first year of life during a given year
per 1,000 live births in the same year.
Data Source
Table C.2: Statistics Canada. (2011-09-26). CANSIM Table 102-0506
Infant deaths and mortality rates, by age group and sex, Canada,
annual [Data File].
Infectious syphilis (2009)170, 174
Estimated rate per 100,000 population, where infectious
syphilis (including primary, secondary and early latent
stages) was reported to the Public Health Agency of
Canada by provinces and territories.
Data Source
Table C.2: Public Health Agency of Canada. (2011-02-22). Reported
cases and rates of infectious syphilis by age group and sex, 1993 to
2009 [Data File].
Inuit (2006)
See Aboriginal people(s)
-LLife expectancy at birth (2006-2008)41
Life expectancy is 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.
-MMajor depression (2002)68, 693
Persons who met all criteria for a major depressive
episode in the 12 months prior to the interview. A major
depressive episode is defined as at least two weeks of
depressed mood and/or loss of interest in usual activities
accompanied by at least four additional symptoms of
depression:
•• depressed mood most of the day, nearly every day, as
indicated by either subjective report (for example,
feels sad or empty) or observation made by others
(for example, appears tearful);
•• markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every
day (as indicated by either subjective account or
observation made by others);
•• significant weight loss when not dieting, or weight
gain (for example, a change of more than 5% of
body weight in a month), or decrease or increase in
appetite nearly every day;
•• insomnia or hypersomnia nearly every day;
•• psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings
of restlessness or being slowed down);
•• fatigue or loss of energy nearly every day;
•• feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick);
•• diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others); and
•• recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or
a suicide attempt or a specific plan for committing
suicide.
Data Source
Table C.2: Government of Canada. (2006). The Human Face of Mental
Health and Mental Illness in Canada.
Métis (2006)
See Aboriginal people(s)
Mood disorders (2010)48
Respondents who reported having been diagnosed with a
mood disorder such as depression, bipolar disorder, mania
or dysthymia.
Data Source
Table 1.1: Statistics Canada. Canadian Community Health Survey,
2010: Annual [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
-OObesity (2007-2009)694
According to Health Canada guidelines, the index for body
weight classification 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) is: less than 18.50 (underweight); 18.5 to
24.9 (normal weight); 25.0 to 29.9 (overweight); 30.0 to
34.9 (obese, class I); 35.0 to 39.9 (obese, class II); 40.0
or greater (obese, class III). See Appendix B: Body mass
index cut-points for full tables.
Body mass index (BMI) is calculated by dividing the
respondent’s body weight (in kilograms) by their height
(in metres) squared.
Data Source
Table C.2: Statistics Canada. Canadian Health Measures Survey, 20072009: Cycle 1 [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Data Source
Table 1.1: Statistics Canada. (2011-09-26). CANSIM Table 102-0512
Life expectancy, at birth and at age 65, by sex, Canada, provinces and
territories, annual [Data File].
Table C.1: Statistics Canada. (2011-09-26). CANSIM Table 102-0512
Life expectancy, at birth and at age 65, by sex, Canada, provinces and
territories, annual [Data File].
D
APPENDIX
Definitions and Data Sources for Indicators
107
APPENDIX
D
Definitions and Data Sources for Indicators
-P-
Perceived health, very good or excellent
(2010)45
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Population 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.
108
Data Source
Table 1.1: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Table C.2: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Perceived mental health, very good or excellent
(2010)45
Population 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
Table 1.1: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Table C.2: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Persons living in low-income (after tax)
(2009)695-697
The percentage of 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) when 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 and adjusted
for family size, community sizes and inflation based on
the national Consumer Price Index (see Table D.1). Aftertax income is total income, which includes government
transfers, less income tax.
Data Source
Table C.3: Statistics Canada. (2011-05-25). CANSIM Table 202-0802
Persons in low income, annual [Data File].
Population (2011)698
Estimated population and population according to
the census are both defined as being the number of
Canadians whose usual place of residence is in that area,
regardless of where they happened to be on Census Day.
Also included are any Canadians staying in a dwelling
in that area on Census Day and having no usual place
of residence elsewhere in Canada, as well as those
considered non-permanent residents.
Table D.1 Low income cut offs after tax, Canada, 2009697
Rural Areas
Size of family unit
Urban Areas
($)
Less than 30,000
population ($)
30,000 to 99,999
population ($)
100,000 to 499,999
population ($)
500,000 and over
population ($)
1 person
12,050
13,791
15,384
15,579
18,421
2 persons
14,666
16,785
18,725
18,960
22,420
3 persons
18,263
20,900
23,316
23,610
27,918
4 persons
22,783
26,075
29,089
29,455
34,829
5 persons
25,944
29,692
33,124
33,541
39,660
6 persons
28,773
32,929
36,736
37,198
43,984
7 or more persons
31,602
36,167
40,346
40,854
48,308
Data Source
Table C.1: Statistics Canada. (2012-01-24). Population and dwelling
counts, for Canada, provinces and territories, 2011 and 2006 censuses
[Data File].
Population centre (2011)699
Formerly known as urban population, 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.
Post-secondary graduates (2011)98
Persons 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 colleges, Collège d’Enseignement
Général et Professionnel (CEGEP) and schools of nursing,
as well as certificates below a bachelor’s degree obtained
at a university.
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by 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 circulatory
diseases (2008)700
Potential years of life lost for all circulatory disease
deaths (ICD-10 I00-I99), such as ischaemic heart
disease, and cerebrovascular diseases, is the number
of years of life lost when a person dies prematurely
from any circulatory disease – before age 75.
Data Source
Table C.3: Statistics Canada. (2012-01-04). CANSIM Table 282-0004
Labour force survey estimates (LFS), by educational attainment, sex
and age group, annual [Custom Data File].
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Potential years of life lost700
Premature mortality due to HIV (2008)700
Potential years of life lost are the number of years of life
lost when a person dies prematurely from any cause –
before age 75. A person dying at age 25, for example, has
lost 50 years of life.
Potential years of life lost for human immunodeficiency
virus (HIV) infection deaths (ICD-10 B20-B24) is
the number of years of life lost when a person dies
prematurely from AIDS/HIV – before age 75.
Premature mortality due to cancers
(2008)700
Potential years of life lost for all malignant neoplasms
(ICD-10 C00-C97), such as colorectal, lung, female
breast and prostate cancer, is the number of years
of life lost when a person dies prematurely from any
cancer – before age 75.
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Data Source
Table C.1: Statistics Canada. (2012-01-17). Population and dwelling
counts, for population centres, 2011 and 2006 censuses [Data File].
D
APPENDIX
Definitions and Data Sources for Indicators
109
APPENDIX
D
Definitions and Data Sources for Indicators
Premature mortality due to respiratory
diseases (2008)700
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Potential years of life lost for all respiratory disease
deaths (ICD-10 J00-J99), such as pneumonia and
influenza, bronchitis, emphysema and asthma, is
the number of years of life lost when a person dies
prematurely from any respiratory disease – before age 75.
110
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by 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 suicide and
self-inflicted injuries (2008)700
Potential years of life lost for suicides (ICD-10 X60-X84,
Y87.0) is the number of years of life lost when a person
dies prematurely from suicide – before age 75.
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by 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 unintentional
injuries (2008)700
Potential years of life lost for unintentional injuries
(ICD-10 V01-X59, Y85-Y86) is the number of years
of life lost when a person dies prematurely from
unintentional injuries – before age 75.
Data Source
Table 1.1: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
Table C.2: Statistics Canada. Canadian Vital Statistics, Death
Database, 2008. All computations on these data were prepared
by Public Health Agency of Canada and the responsibility for
the use and interpretation of these data is entirely that of the
author(s).
-RRegular family physician (2010)45
Population who reported that they have a regular medical
doctor. In 2003 and 2005, the indicator in French only
included “médecin de famille”. Starting in 2007, this
concept was widened to “médecin régulier”, which
includes “médecin de famille”.
Data Source
Table C.3: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Respiratory diseases (2008)78
Deaths associated with respiratory diseases (ICD10 J00-J99) including by not limited to respiratory
infections, influenza and pneumonia.
Data Source
Table 1.1: Statistics Canada. (2011-09-26). CANSIM Table 1020530 Deaths, by cause, Chapter X: Diseases of the respiratory system
(J00 to J99), age group and sex, Canada, annual [Data File]; and
Statistics Canada. (2011-03-23). CANSIM Table 051-0001 Estimates
of population, by age group and sex for July 1, Canada, provinces and
territories, annual [Custom Data File].
Table C.2: Statistics Canada. (2011-09-26). CANSIM Table 1020530 Deaths, by cause, Chapter X: Diseases of the respiratory system
(J00 to J99), age group and sex, Canada, annual [Data File]; and
Statistics Canada. (2011-03-23). CANSIM Table 051-0001 Estimates
of population, by age group and sex for July 1, Canada, provinces and
territories, annual [Custom Data File].
-S-
-T-
Schizophrenia (2005)68, 701
Teen pregnancy rate (2009)164
Respondents who reported having been diagnosed with
schizophrenia by a health professional. This is believed to
underestimate the true prevalence since some people do
not report that they have schizophrenia and the survey
did not reach individuals who were homeless, in hospital
or supervised residential settings.
Number of live births per 1,000 female population aged
15 to 19 years.
Sense of community belonging, somewhat or
very strong (2010)45
Population who reported their sense of belonging to their
local community as being very strong or somewhat strong.
Data Source
Table C.3: Statistics Canada. (2011-10-21). CANSIM Table 105-0501
Health indicator profile, annual estimates, by age group and sex,
Canada, provinces, territories, health regions (2011 boundaries) and
peer groups, occasional [Data File].
Some post-secondary education (2011)98
Persons 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
colleges, Collège d’Enseignement Général et Professionnel
(CEGEP), and schools of nursing.
Data Source
Table C.3: Statistics Canada. (2012-01-04). CANSIM Table 282-0004
Labour force survey estimates (LFS), by educational attainment, sex
and age group, annual [Custom Data File].
Data Source
Table C.3: Statistics Canada. (2011-12-19). CANSIM Table 102-4505
Crude birth rate, age-specific and total fertility rates (live births),
Canada, provinces and territories, annual [Data File].
-UUnemployment rate (2011)98
The unemployment rate is the number of unemployed
persons expressed as a percentage of the labour force.
Data Source
Table C.3: Statistics Canada. (2012-01-04). CANSIM Table 282-0004
Labour force survey estimates (LFS), by educational attainment, sex
and age group, annual [Custom Data File].
-VViolent crime incidents (2010)702
Offences that deal with the application or threat of
application, of force to a person including homicide,
attempted murder, various forms of sexual and non-sexual
assault, robbery and abduction.
Data Source
Table C.3: Brennan, S. & Dauvergne, M. (2011). Police-reported crime
statistics in Canada, 2010.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
Data Source
Table C.2: Statistics Canada. Canadian Community Health Survey,
2005: Cycle 3.1 [Share Microdata File]. Ottawa, Ontario: Statistics
Canada. All computations on these microdata were prepared by
Public Health Agency of Canada and the responsibility for the use
and interpretation of these data is entirely that of the author(s).
D
APPENDIX
Definitions and Data Sources for Indicators
111
112
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012
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2012 – Importance of Sex and Gender
The Chief Public Health Officer’s
Report on the state of
Public health in Canada
2012
Influencing Health —
The Importance of Sex and Gender
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