2008 Report on the State of Public Health in Canada

2008 Report on the State of Public Health in Canada
The Chief Public Health Officer’s
Report on the State of
Public Health in Canada
2008
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 2008
This publication can be made available on request on diskette,
large print, audio-cassette and braille.
Photo credit: Hockey player image courtesy of Richard McDonald
- www.richardmcdonald.ca
© Her Majesty the Queen in Right of Canada, represented
by the Minister of Health, 2008
Cat.: HP2-10/2008E
ISBN: 978-0-662-48628-2
Message
A Message from
Canada’s Chief Public Health Officer
This is the fi rst annual report of the Chief Public
Health Officer and, as such, it represents a significant
moment in public health in Canada. The intention
of this report, and those in future, is to speak to
aspects of health in the population, as well as to a
specific issue or theme. It will serve to define some
key public health issues of the day and consider how
they can be approached. It is intended to inform
Canadians and stimulate dialogue on the many factors
that contribute to good health and what can be done
individually and collectively to advance public health
in Canada.
Public health has been defi ned many ways, but I
fi nd it best described as “the organized efforts of
society to improve health and well-being and to
reduce inequalities in health.” In simple terms,
this involves different segments of society working
together for the good of all. Public health is that
collection of programs, services, regulations and
policies, delivered by governments, the private sector
and the not-for-profit sector, that together focus on
keeping the whole of the population healthy. It is also
a way of thinking about, and an approach to, how
we tackle the health issues we face. Fundamentally,
it is focused on understanding and addressing the
factors that underlie illness or good health and asks
questions like “what are the causes of poor health?”
and “how do we address those causes before they
become problems?” Health care, in turn, focuses on
our needs as individuals and what we can do to restore
or improve health. Health care and public health are
complementary and both are necessary in the pursuit
of good health.
The position of Canada’s Chief Public Health Officer
was created in 2004, along with the Public Health
Agency of Canada. These actions were taken, in part,
in response to the SARS outbreak of 2003. The Chief
Public Health Officer has a dual role, something that is
unique in governments. One is to serve at the Deputy
Minister level in the federal public service, heading
the Public Health Agency and advising the Minister of
Health on matters of public health and the function of
the Agency. At the same time, the CPHO communicates
directly with Canadians on important public health
matters. One means of achieving this is through the
requirement that the Chief Public Health Officer report
annually on the state of public health in Canada.
This is the fi rst of those annual reports. A separate
report by the Agency later this year will address the
progress we’ve made since the outbreak of SARS.
Among the good news found in this report is the fact
that the majority of Canadians enjoy good to excellent
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Dr. David Butler-Jones
Canada’s Chief Public Health Officer
i
Message
physical and mental health. We are living longer lives
and, over the past century or more, we have made
significant strides in improving our collective health.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The bad news is that not all health trends are
improving, and not all Canadians are benefiting to the
same degree from these improvements over time. For
example, there is a growing prevalence of obesity and
diabetes in Canada that – if unchecked – may open
the door to the possibility that this generation of
children may be the fi rst in Canada to have a shorter
life expectancy than their parents.
ii
Our goal is to be healthy as long as possible. Although
it is important to focus on the number of extra
months or years we might gain, it is even more critical
to reduce the number of those years that we are
ill or disabled. Most understand this concern from
a quality-of-life perspective, but there is another
issue to consider. People who are less healthy put
pressures on the health and welfare systems. This
leads to longer wait times for those seeking medical
treatment and increases costs for Canadian taxpayers
as a whole. There are also other costs to society, such
as high rates of absenteeism and lower productivity
in workplaces, not to mention the toll that ill health
takes on affected individuals and their families as
they suffer the physical and emotional, as well as
economic and social fall-out of poor health. Healthy
people contribute to healthy economies.
As we strive to achieve good health for as long as
possible, it is important to note that 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.
Beyond these basics are two very important
underlying factors: having a sense of control or
influence over our own lives and future; and loving,
being loved and having family, friends and other
social connections that give us a sense of being part of
something larger than ourselves. These things matter
because health is more than physical – if people care
about you, and you, in return, care about others, if
you have work you enjoy, if you can read, write and
can function well in society – it makes you a healthier
person. It is no coincidence that those who volunteer,
who give of themselves and who take an active part
in their community end up, on average, healthier
and happier.
The choices we make, the work we do, the friends
we keep and the lifestyle we live all matter to our
health. Although they are a personal responsibility,
these choices are often shaped and limited by our
environment and circumstances. These factors
along with others have come to be known as social
determinants of health and they are vital to helping
us understand and improve the health of Canadians.
How these determinants contribute to the differences
in our health matters because some groups of
Canadians experience lower life expectancy than
others. Some have higher rates of infant mortality,
injury, disease and addiction. Some are more obese
and overweight. These differences in health status are
referred to as health inequalities.
It seemed appropriate that the theme of this fi rst
report would focus on the determinants of health and
how they contribute to health inequalities. In some
ways what I am reporting is not new, and should not
come as a surprise. Unfortunately it will be a surprise
to many, given the magnitude of the inequalities
that still exist despite our being among the richest
countries with one of the most sophisticated health
and social systems in the world. Why is it that –
although we are, on average, the healthiest we have
ever been – many in Canada have not shared in that
health and well-being?
I have chosen to focus this report on gaining a better
understanding of these inequalities, and on how
we might reduce them. The reason for this choice is
simple: I would argue that a society is only as healthy
as the least healthy among us. We cannot rate our
collective health and well-being by looking only
at those who are healthiest. Nor can we focus only
on averages, as these mask important differences
between the least and most healthy. We must also
consider those left behind: those who are less healthy,
illiterate, on the streets, or have little or no income.
In fact, this report highlights a variety of projects
and programs in operation throughout the country
and on an international level that are already making
Message
progress. Simple examples include: an initiative
to support the needs of at-risk pregnant women;
a tri-partite agreement to improve an inner-city
community; an organization that works to break the
cycle of poverty by providing low-income families
with affordable housing; programs that help children
prepare for school and reach their full potential; and
a city where at-risk and economically challenged
youth are being given academic, social and fi nancial
support, and where a mobile health unit operates to
assist immigrant women. It is not as if we have no
answers or that they need be overwhelming, as many
communities are already engaged and solutions are
being delivered.
Just as there is no sector of society that is untouched
by health inequalities, there is no person or
organization that cannot make a positive contribution
to their resolution.
Because we determine our health by the type of
society we choose to create, each of us has a part to
play in creating a healthier Canada. Now that’s an
intriguing challenge!
Dr. David Butler-Jones
Dr. David Butler-Jones is Canada’s fi rst and current Chief Public Health Officer. A medical doctor,
David Butler-Jones has worked throughout Canada and consulted internationally in public health and
clinical medicine. He is a professor in the Faculty of Medicine at the University of Manitoba and a
clinical professor with the Department of Community Health and Epidemiology at the University of
Saskatchewan. He is also a former Chief Medical Health Officer for Saskatchewan, and has served in a
number of public health organizations, including as President of the Canadian Public Health Association
and Vice President of the American Public Health Association. In 2007, in recognition of his years
of service in public health, Dr. Butler-Jones received an honorary Doctor of Laws degree from York
University’s Faculty of Health.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
In short, health inequalities are fundamentally
societal inequalities that we can overcome through
public policy, and individual and collective action.
iii
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
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, 2008.
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I would like to express my appreciation to the
consultants who provided invaluable advice, strategic
guidance and expertise:
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I would like to thank the many individuals and groups
within PHAC for their contribution. Specifically, I
would like to recognize the dedicated efforts of the
CPHO Reports Unit, Office of Public Health Practice,
and the members of the 2007/08 Working Groups.
I would also like to acknowledge the external
reviewers and individuals who contributed:
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Kim Barker, Public Health Advisor, Assembly of
First Nations;
Kim Bulger, Métis National Council;
Claudette Dumont-Smith, Senior Health Advisor,
Native Women’s Association of Canada;
Elizabeth Gyorfi-Dyke, Canadian Population
Health Initiative, Canadian Institute for Health
Information;
Duncan Hunter, Associate Professor, Department
of Community Health and Epidemiology, Queen’s
University;
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Special thanks to those from other federal government
departments, agencies and programs that collaborated
with us on this publication:
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Canadian Institute for Health Information;
Health Canada;
Human Resources and Social Development Canada;
Indian and Northern Affairs Canada;
National Collaborating Centre for Aboriginal
Health;
National Collaborating Centre for Determinants of
Health; and
Statistics Canada.
As well as to the writer/editors: Heather Marshall and
Rhoda Boyd.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
•
John Frank, Scientific Director, Canadian
Institutes of Health Research - Institute of
Population and Public Health; Professor, Public
Health Sciences, University of Toronto; Senior
Scientist, Institute for Work and Health, Toronto;
Senator Wilbert J. Keon, The Senate of Canada;
Richard Massé, President and CEO, Institut
national de santé publique du Québec;
David Mowat, Medical Officer of Health, Region of
Peel, Ontario;
Jeff Reading, Scientific Director, Canadian
Institutes of Health Research, Institute of
Aboriginal Peoples’ Health; Professor, Faculty of
Human and Social Development, University of
Victoria;
Brenda Zimmerman, Director, Health Industry
Management Program, Schulich School of
Business, York University; and
Jake Epp, Chairman, Ontario Power Generation,
also contributed to the early development and
formulation of the Report.
•
Ian Johnson, Faculty of Medicine, University of
Toronto;
Denise Kouri, Kouri Research; University of
Saskatchewan;
Elisa Levi, Public Health Research and Policy
Analyst, Assembly of First Nations;
John Millar, British Columbia Provincial Health
Services;
Carla Moore, Director, Atlantic Aboriginal Health
Research Program, Dalhousie University;
Cory Neudorf, Chief Medical Health Officer,
Saskatoon Health Region;
Robert Pampalon, Institut National de Santé
Publique du Québec;
Ginette Paquet, Institut National de Santé
Publique du Québec;
Onalee Randell, Director, Department of Health
and Environment, Inuit Tapiriit Kanatami;
Nancy Ross, Associate Professor, Department of
Geography, Associate, Department of Epidemiology
and Biostatistics, McGill University; and
Erin Wolski, Health Program Coordinator, Congress
of Aboriginal Peoples.
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vi
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Table of Contents
A Message from Canada’s Chief Public Health Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Goals of the report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Who this report is about . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
What the report covers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Chapter 2: Public Health in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
What is public health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Canada’s public health history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
A work in progress. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Chapter 4: Social and Economic Factors that Influence Our Health and
Contribute to Health Inequalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
What makes – and keeps – us healthy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Employment and working conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Food security . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Environment and housing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Early childhood development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Education and literacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Social support and connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Health behaviours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Access to health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Chapter 5: Addressing Inequalities – Where are we in Canada? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Priority areas for action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Social investment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Community capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Inter-sectoral action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Knowledge infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Potential for progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Chapter 3: Our Population, Our Health and the Distribution of Our Health . . . . . . . . . . . . . . . . . . . . . . . . 19
Who we are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Our health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Life expectancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Self-reported health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Causes of death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Causes of premature death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Patterns of ill health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
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Table of Contents
Chapter 6: Moving Forward – Imagine the Possibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
A time to act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Foster collective will and leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Reduce child poverty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Strengthen communities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
A commitment to change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Appendix A: List of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Appendix B: List of National Collaborating Centres for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Appendix C: Health Goals for Canada – A Federal, Provincial and Territorial Commitment to Canadians . . . 75
Appendix D: Defi nitions and Data Sources for Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
viii
List of Figures
Figure 2.1
Figure 3.1
Figure 3.2
Figure 3.3
Figure 3.4
Figure 3.5
Figure 3.6
Figure 3.7
Figure 3.8
Figure 3.9
Figure 3.10
Figure 3.11
Figure 3.12
Figure 3.13
Figure 3.14
Figure 3.15
Figure 3.16
Figure 3.17
Figure 3.18
Figure 3.19
Figure 4.1
Figure 4.2
Factors that influence our health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Population distribution by age, Canada, 1971 and 2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Life expectancy at birth, select OECD countries, 1980-2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Life expectancy at birth by neighbourhood income and sex, urban Canada, 2001 . . . . . . . . . . . . . 22
Life expectancy at birth by neighbourhood income and sex, urban Canada, 1971-2001 . . . . . . . . . 22
Life expectancy at birth by sex, Registered Indian and general population, Canada, 1980-2001 . . 23
Infant mortality rate, select OECD countries, 1980-2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Infant mortality rate by neighbourhood income, urban Canada, 1971-2001 . . . . . . . . . . . . . . . . . 24
Proportion of Canadians with excellent or very good perceived health
by highest household level of education, Canada, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Age-standardized mortality rates for select causes, Canada, 1950-2004 . . . . . . . . . . . . . . . . . . . . 25
Mortality by select causes and age groups, Canada, 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Age-standardized mortality rates for ischemic heart disease by neighbourhood income,
male, urban Canada, 1971-2001. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Age-standardized mortality rates for lung cancer by neighbourhood income, female,
urban Canada, 1971-2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Proportion of Canadians reporting one or more chronic diseases by age group, Canada, 2005. . . . . 28
Age-adjusted prevalence of chronic conditions among First Nations adults
compared to the general Canadian adult population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Self-reported heart disease by educational attainment and sex,
household population aged 45-64 years, Canada, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Self-reported arthritis/rheumatism by educational attainment and sex,
household population aged 45-64 years, Canada, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Measured obesity by educational attainment and sex, household population
aged 19-45 years, Canada (excluding territories), 2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Measured obesity by income and sex, household population aged 46-65 years,
Canada (excluding territories), 2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Population aged 12+ years reporting select mental illnesses within a 12-month period,
Canada, 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Average incomes for economic families, two persons or more, in constant dollars,
Canada, 1996-2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Children aged 0-17 years living in low-income families. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Table of Contents
Figure 4.3
Figure 4.4
Figure 4.5
Figure 4.6
Figure 4.7
Figure 4.8
Child low-income rates in OECD countries based on market sources and disposable income:
late 1990s and early 2000s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Receptive vocabulary scores of children, age 5, by household income levels,
which were or were not read to daily, Canada, 2002-2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Daily smoking by Aboriginal status, 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Smoking and education, aged 15+ years, Canada, 1999-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Percentage of the general population aged 12+ years who were physically active by income,
Canada, 2000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Age-standardized mortality rates for alcohol dependence, by sex and income quintile,
Canada, 1971-2001. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
List of Tables
Our health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Factors influencing our health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Table 3.1
Table 4.1
ix
x
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Executive Summary
This report is the Chief Public Health Officer of
Canada’s fi rst annual report to Canadians on the
state of public health in Canada. It explores the
public health approach, the health of the Canadian
population, variances in health status among the
population and factors that contribute to health
inequalities. Efforts to reduce these inequalities can
be found across the country and at many levels. They
include successful interventions that – through better
understanding, collaboration and collective action –
may serve to reduce Canada’s health inequalities and
improve quality of life for all Canadians.
The report covers the following areas, with main
fi ndings summarized below.
To understand the population approach to health
covered in this report, an overview of public health,
its defi nition, mandate and the key players involved
in this area of responsibility are outlined. This
includes a brief history of public health in Canada
– spanning the earliest efforts to quarantine new
immigrants in the 19th century and the introduction
of vaccines, pasteurized milk, food safety, sanitation
and clean drinking water, to the introduction of
Medicare as a major advance in helping all Canadians
to access health care.
The success of the public health approach is
underlined by an examination of public campaigns
that have made a positive impact on the health of
Canadians: the introduction of mass immunization;
reducing tobacco use; and increasing seatbelt use.
These achievements, along with new and enduring
health challenges, serve as a benchmark for the
continuous improvements in public health to maintain
Canada’s global standing as one of the healthiest
nations in the world.
When asked to rate their own health, most Canadians
consider themselves to have either excellent or
very good health. Life expectancy has increased
substantially over the last century and is currently
one of the highest in the world at just over 80
years. The infant mortality rate has also improved,
decreasing by 80% from 27 deaths per 1,000 live
births in 1960 to 5 per 1,000 live births in 2004.
The main causes of death in Canada are circulatory
diseases, cancer and respiratory diseases. Premature
deaths are most often due to cancers, circulatory
diseases, injuries (both unintentional and intentional)
and chronic respiratory disease. Other illnesses and
conditions also impact the health of the population
– and some, like diabetes and obesity – are on
the rise. Although the number of Canadians who
die prematurely and suffer from poor health is
low in comparison to other countries, those who
do so tend to belong to specific sub-populations
– Aboriginal Peoples, residents of northern and
remote communities, and those with low income and
education.
Social and Economic Factors
that Influence Our Health
and Contribute to Health
Inequalities
Why do some people enjoy good health while others do
not? These inequalities in health status are partially
due to social and economic factors that influence
health behaviours and health outcomes.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Public Health in Canada
Our Population, Our Health
and the Distribution of Our
Health
1
Executive Summary
Socio-economic and personal factors profiled within
this report include:
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
•
•
•
•
•
•
•
•
•
2
income;
employment and working conditions;
food security;
environment and housing;
early childhood development;
education and literacy;
social support systems;
health behaviours; and
access to health care.
This list does not cover all factors that influence
health, but represents areas that are currently
understood and where action has been proven to
influence outcomes. For example, while genetics
play an important role in health and illness, and
geneticists have made great strides in understanding
what impacts can be made, this factor currently has
less of an ability to bring about change in population
health than other factors.
In general, health status follows a gradient where
people in less advantageous socio-economic
circumstances are not as healthy as those at each
subsequently higher socio-economic level. In other
words, those with the lowest incomes and education,
inadequate housing, poor working conditions,
detrimental health behaviours, limited access to
health care and who lack early childhood support
and/or social supports are more likely to develop
poorer physical and mental health outcomes than
those living in better circumstances. This is true
for each level (or rise) along the gradient. However,
improvement to one or more of these factors can
result in an improvement in overall health. Many
programs and services targeted at reducing social
and health inequalities through improvements to,
or by mitigating, socio-economic factors have been
undertaken in Canada at all levels. Successful,
promising and/or unique responses are profiled for
each factor.
Despite these efforts, however, certain trends
continue to raise concerns. For example, the gap
between those with the highest and lowest incomes
in Canada continues to grow and poverty rates for
some children, Aboriginal Peoples, recent immigrants
and persons with disabilities are significantly higher
than for the general population. As well, Canada’s
child poverty rate is higher than many similarly
developed countries. Food security is also a critical
issue, with the prevalence of school food programs
and food banks on the rise. Inadequate housing and
homelessness continue to plague Aboriginal Peoples,
immigrants, low-income earners and marginalized
youth; while urban sprawl and other environmental
conditions are a growing concern for many.
Unemployment rates are at a 30-year low, but remain
higher among certain populations such as recent
immigrants. For those who are employed, rates of
injury in the workplace continue to be higher among
blue collar workers and men, while work-related stress
is more prevalent among women. Although Canada
ranks among the top five Organisation for Economic
Co-operation and Development (OECD) countries for
high school completion rates, some young Canadians
remain at risk of leaving school prematurely. For
those who seek higher educations, women are now
outnumbering men. If this trend continues, a difference
in health outcomes between genders attributable to
differences in education levels may emerge.
Social connectedness also plays an important role
in health. Urban dwellers are less likely than rural
dwellers to report feeling a part of their community
and seniors are more likely to report feeling lonely
and isolated. These populations represent two of the
fastest growing populations in Canada. Aboriginal
Peoples continue to struggle with social exclusion,
lower workforce participation and disconnection
from their traditions and culture. As a result, they
more often experience poorer health outcomes than
the national average. Research suggests, however,
that Aboriginal communities with some level of
self-government and cultural continuity have better
health outcomes.
Individual health behaviours – both positive and
negative – are influenced by an individual’s social
and economic environments. Among the general
population, rates of smoking and death related to
alcohol dependence have declined, but poor eating
habits and unsafe sexual practices are on the rise
with related increases to incidences of diabetes and
some sexually transmitted diseases, respectively.
In addition, although rates of physical activity are
increasing, the incidence of obesity continues to rise
Executive Summary
indicating that improvement in this area needs to
continue. Compared to the national average, these
negative behaviours are more often reported among
certain populations.
•
•
•
•
Addressing Inequalities –
Where are we in Canada?
Social policies and programs that improve health
outcomes have been in place in Canada for decades,
with new and promising interventions and approaches
continually at the ready. Efforts are widespread and
include action on the part of governments, the private
sector, not-for-profit organizations, communities
and individuals. Despite this, health inequalities
persist and – in some cases – are growing. One reason
is an incomplete understanding of what works and
what doesn’t, which makes focusing these efforts
challenging. Unfortunately, Canada’s ability, as a
country, to measure and report on the health impacts
of many of these efforts is not strong and can be
developed further. What is clear is that actions
targeting individual health choices and behaviours
must also consider the social and environmental
conditions that shape these choices. Among such a
diverse population, no single approach or solution
is optimal. Ideally, a balance between targeted
interventions for some and universal programs for all
is best but the appropriate mix requires further study.
Although clarification and better understanding is
needed in many areas, waiting for all the answers is
not an acceptable option given what is already known,
what can be done and the consequences of neglect
while waiting.
•
social investments, particularly investments in
families with children living in poverty and in
early child development programs;
community capacity through direct involvement
in solutions, enhanced cross-sectoral cooperation, better defi ned stakeholder roles and
increased measuring of outcomes;
inter-sectoral action through integrated,
coherent policies and joint actions among parties
within and outside of the formal health sector at
all levels;
knowledge infrastructure through a better
understanding of sub-populations, the pathways
through which socio-economic factors interact to
create health inequalities, how best practices from
other jurisdictions can be adapted to improve
Canadian efforts and through more advanced
measurement of the outcomes of the various
interventions undertaken; and
leadership at the public health, health and crosssectoral levels.
Moving Forward
Canada has the capacity to address the full range
of issues that can adversely affect the health of
Canadians. An impressive past record of improving
quality of life and health provides a strong foundation
from which to act on becoming the healthiest nation
with the smallest gap in health. It is a goal that is
well within reach if the collective will to do so can
be harnessed and directed through strong leadership
and a fi rm commitment by individuals, community
members and decision-makers to effect change.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
While Canadians have universally insured health
care, some experience difficulty accessing it. While
it may seem obvious that residents of northern and
remote communities have geographical accessibility
issues, Aboriginal Peoples, immigrants and others
can face additional challenges ranging from cultural
insensitivities to language barriers. Among the
marginalized, infant mortality rates can be much
higher than the general population even though
many live in close proximity to some of the most
sophisticated hospitals in the world.
Attention should be given to the following priority
areas for addressing health inequalities:
3
4
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
CHAPTER
1
Introduction
The Public Health Agency of Canada was established
in September 2004 to strengthen Canada’s capacity to
protect and improve the health of Canadians and to
help reduce pressures on the health care system. In
2006, the Public Health Agency of Canada Act confi rmed
the Agency as a legal entity and the appointment of
a Chief Public Health Officer of Canada to speak to
Canadians about important public health matters. It
also established the legal requirement for the Chief
Public Health Officer of Canada to report on the state
of public health through an annual report.1
country. In some instances, special terms are used
to identify particular groups. The term ‘Aboriginal’ is
used to refer collectively to all three constitutionally
recognized groups − Indian, Inuit and Métis. Although
not constitutionally recognized, the newer term ‘First
Nation’ is used to describe Status Indians recognized
under the federal Indian Act. When data exists to
support discussion about these distinct population
groups, specific details are provided for clarity.
Health Inequalities
Goals of the report
As much as this report is a mechanism to increase
awareness, it is also meant to inspire action to help
create opportunities for all Canadians to be as healthy
as they can be − mentally, physically and socially.
It is hoped that this report will spur increased
collaboration among Canada’s leaders, public health
practitioners, employers, educators, researchers,
community groups, the media and individuals to
improve Canadians’ health and overall well-being.
Who this report is about
This report is about all Canadians, regardless of their
age, sex, income or heritage. Throughout the report
the term ‘Canadian’ is used to speak to all people
who reside within the geographic boundaries of the
Health inequities refer to inequalities
in health that are a result of socially
influenceable factors (e.g. poverty, barriers
to education or health care). These types of
inequalities are deemed to be unfair or unjust.
This report generally uses the term health
inequalities, recognizing that the equal
distribution of health is an ideal, and that
some health inequalities are also health
inequities.2
What the report covers
What is public health? Chapter 2 provides an
overview of the public health approach and the public
health system, as well as the role they play in the
health of Canadians. This chapter also offers examples
of public health success stories and challenges to show
the potential for improving the lives of Canadians.
Are Canadians Healthy? Chapter 3 discusses the
health of Canadians, including leading causes of
death, the prevalence of diseases and the impact of
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The theme of this first report is health inequalities. It
is intended to shed light on public health in Canada,
the state of Canadians’ health, as well as the country’s
successes and ongoing challenges in reducing health
inequalities. It is intended to inform Canadians of the
many factors that contribute to good health and what
can be done individually and collectively to advance
public health in Canada. Most of all, this document
is designed to stimulate national discussion about
what could be done. Ideally, it will encourage a broad
dialogue on how health is viewed in society and how
Canada, as a society, can achieve a balance between
an effective health care system that meets society’s
need for healing and broader public health activities
that keep us from becoming sick or getting sicker. These
are not competing ideas, but complementary ones.
Health inequalities are differences in health
status experienced by various individuals or
groups in society. These can be the result of
genetic and biological factors, choices made
or by chance, but often they are because of
unequal access to key factors that influence
health like income, education, employment
and social supports.
5
CHAPTER
1
Introduction
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
injuries. It also considers worrying trends that might
impact Canadians’ future health and well-being.
This includes a discussion of health inequalities that
clearly underlines the fact that health outcomes and
issues are not the same for everyone.
6
What factors influence our health and what
is being done to address inequalities? Chapter
4 highlights how economic, social and personal
factors, including income, education, early childhood
development, health behaviours, health care and
social support influence health. Differences in these
factors that are most problematic and that can be
influenced through social interventions are discussed.
It also offers snapshots of various actions that have
been undertaken across Canada to reduce social,
economic and behavioural inequalities in order to
improve health. These examples provide insight into
who is affected, how effective Canada has been at
addressing health inequalities as well as where the
country may want to concentrate future efforts in
this area.
What has been learned? And what are the
challenges ahead? In Chapters 5 and 6, the lessons
learned from previously discussed public health
research, interventions and international and
community level practices are discussed. Common
elements that are important to addressing health
inequalities are outlined. Within these common
threads, gaps are identified where more work needs to
be done. The report concludes with an invitation from
Canada’s Chief Public Health Officer to move forward
collaboratively, proactively and inter-sectorally
to realize common goals for a healthy Canadian
population.
As you read the report please
take time to consider how you
might answer some
key questions:
Do these examples resonate and/or reflect
actions that could be taken in your community
(as individuals, politicians, business leaders,
etc.)?
How can you participate in reducing health/
social inequalities?
Where we have not achieved the best results
possible, what are the barriers that remain?
What have we, as Canadians, not done?
Who else could you work with to better
address the challenges that remain?
CHAPTER
2
Public Health in Canada
What is public health?
In Canada, there is a tendency to equate health
with health care. That is understandable, given that
Medicare is not only a source of national pride but
also an important contributor to Canadians’ health.
Yet, there is certainly more to health than hospitals
and medical services.3, 4
While health care focuses on treating individuals
who are not well, public health works to keep people
from becoming sick or getting sicker. Both work to
limit the impact of disease and disability.3 While
individuals receive and benefit from services of the
public health system, public health programs target
Public health challenges Canadians to recognize that
physical and mental health are intricately connected
to the environment and society.7 The way Canada, as
a country, deals with issues such as poverty, housing,
sanitation and environmental protection directly and
indirectly influences the health of the population. The
presence or lack of family support and social networks,
access to education and jobs, workplace safety, and
community cohesion and development also influence
health.8
Those involved in public health are often invisible
to Canadians until serious health events such as
SARS, Avian Influenza or West Nile Virus occur.
Emergency preparedness and response, in the face of
infectious disease outbreaks or other health-related
emergencies, is certainly one of the primary functions
of public health. However, disease and injury
prevention, and the promotion of healthy lifestyles
and environments are also central responsibilities
of public health.6 Unhealthy eating habits, too little
Housing
Age, sex and
hereditary
factors
In d
i
ia
ne
ra
Soc
s
Health care
services
on
Agriculture
and food
production
r ks
rs
to
al lifestyle f
ac
du
i
v
iti
Education
wo
Ge
c u l t u ra l a n d e n v i r
,
c
i
onm
om
n
o
en
Living and working
ec
ta
conditions
o
lc
i
c
o
o
s
Unemployment
Work
ommunity
c
environment
ne
nd
Water and
a
t
sanitation
l
nd
l
Figure 2.1 Factors that influence our health9
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Public health is defi ned as the organized
efforts of society to keep people healthy and
prevent injury, illness and premature death.
It is a combination of programs, services and
policies that protect and promote the health of
all Canadians.5
entire populations − not just individuals – by identifying
and reducing health threats through collaborative
action involving many sectors of society.2, 6
7
CHAPTER
2
Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
physical activity, smoking, alcohol and drug abuse
are major contributors to many chronic diseases, as
are environmental factors and social conditions that
do not support healthy lifestyles or that directly
impair health. For this reason, disease prevention
and health promotion efforts are applied to a range
of largely avoidable or deferrable conditions such
as heart disease, diabetes, cancer and Human
Immunodeficiency Virus-Acquired Immune Deficiency
Syndrome (HIV-AIDS).
8
Although Canadians are among the healthiest people
in the world, public health data and research reveal
that some groups are more likely to experience poorer
health and earlier death than others.2 Understanding
the causes of these inequalities through health
surveillance and population health assessment
activities, and developing interventions that reach
these groups are also essential elements of public
health action.10
that work toward common goals. Equally vital
are indirect players, including media outlets that
report health-related news in Canada and provide
healthy living information, social marketers, fitness
instructors, adults who set good examples for children
by taking care of their own health, and employers
who provide time or flexible work arrangements
for employees to be physically active and to care
for children or older or sick relatives. So too, are
engineers and transportation workers who make
Canada’s highways safer, food producers who follow
regulations to ensure that what we eat is safe, and
not-for-profit groups that fight poverty and encourage
Canadians to get active, recycle and reduce energy
consumption.
While there are many ways to describe public health
activities, within Canada and in the legislation for
the Public Health Agency, the below six activities are
generally referenced.
Public health is a responsibility shared by many
actors including federal, provincial and territorial
governments, municipalities as well as Aboriginal
Peoples’ organizations and their governments.3
Governments enact laws and regulations to protect
the public from health hazards posed by such things
as contaminated water, second-hand smoke or
working conditions that endanger employee health
and safety. Health professionals, in a variety of
settings, work under or in concert with these laws
and regulations at the community level.6 Among other
things, they monitor and assess health conditions
and chronic diseases, investigate infectious disease
outbreaks, inspect restaurant kitchens and water
supplies, provide vaccinations, and offer advice and
support/counselling on issues including nutrition,
physical activity, tobacco and alcohol control, injury
prevention and sexual health.
Health protection – Actions to ensure water,
air and food are safe, a regulatory framework
to control infectious diseases, protection from
environmental threats, and expert advice to food
and drug safety regulators.
While governments enact laws, develop policies and
provide resources to fund public health organizations,
it takes the combined effort of networks both within
and outside the public health system to address
population-wide health challenges. These health
networks include professionals such as physicians,
nurses, public health inspectors, health promoters,
dental workers and nutritionists.6 They may also
include community agencies, volunteer organizations,
the academic community and international bodies
Disease and injury prevention – Investigation,
contact tracing, preventive measures to reduce
the risk of infectious disease emergence and
outbreaks, and activities to promote safe, healthy
lifestyles to reduce preventable illness and injuries.
Health surveillance – The ongoing, systematic
use of routinely collected health data for the
purpose of tracking and forecasting health
events or health determinants. Surveillance
includes: collection and storage of relevant data;
integration, analysis and interpretation of this
data; production of tracking and forecasting
products with the interpreted data, and
publication/dissemination of those products; and
provision of expertise to those developing and/
or contributing to surveillance systems, including
risk surveillance.
Population health assessment – Understanding
the health of communities or specific populations,
as well as the factors that underlie good health
or pose potential risks, to produce better policies
and services.
Health promotion – Preventing disease,
encouraging safe behaviours and improving
health through public policy, community-based
interventions, active public participation, and
advocacy or action on environmental and socioeconomic determinants of health.
The population approach to improving health is not
really new; it has played out in various forms over the
history of humankind. As it has evolved, it has not
been without serious challenges and failures. Many
health problems that have plagued the developed
world in the past – such as previously common
infectious diseases, unsafe water and sewage, and
workplace hazards – may no longer seem important,
but their absence should not be taken for granted.
It is important to remember that public health
advances often involved great struggles to overcome
major obstacles and sometimes fierce opposition. As
well, societies’ solutions may not have always been
appropriate and, in some cases, may even have worsened
the problems or helped some people but not others.
Obesity – An Illustration of the Public Health Approach
In Canada, 65% of men and 53% of women are
either overweight or obese.12 Among children and
youth (aged 2 to 17 years), rates of obesity have
almost tripled – from 3% in 1978 to 8% in 2004,
and another 18% are considered overweight.13
Obesity is a key risk factor for heart disease, joint
problems and Type 2 diabetes, so it is critical that
Canada fi nd a way to reverse this trend.14
How is this done? The public health approach
fi rst requires an understanding of the causes of
obesity in the population and then of the ways to
influence or mitigate these causes. On the surface,
the cause of obesity may seem simple: individuals
consume more energy, or calories, than they burn.
But why do some people consume more calories
than others and/or lead less active lives? Is it
simply that people do not realize the impact of
their choices? Or is it that behaviours are part of
a broader situation determined by life experience:
early childhood development; education; the
stress and pace of life; the cost, availability and
accessibility of nutritious food; super-sizing; and
lack of opportunities for physical activity?
To address obesity, then, there needs to be an
understanding of these broader influences, how to
help people make healthy choices the easy choices
and how to create conditions for better health.
This will, in turn, involve an examination of the
factors that affect access to healthy food, food
choices, consumption, recreation and physical
activity. These include, for example, agriculture
practices, food processing, advertising, education,
income, time pressures, urban planning,
transportation systems, urban green spaces and
recreation facilities.
The more the causes and effects of obesity are
examined, the clearer it becomes that solutions
must address a complex and inter-connected
network of underlying issues. It requires the right
mix of interventions, followed by an evaluation
of those interventions. This is a difficult, but
worthwhile, endeavour. When this type of effort is
made and the root causes of obesity are examined
and tackled, other positive impacts on health and
quality of life result.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Emergency Preparedness and Response –
Planning for both natural disasters (e.g. floods,
earthquakes, fi res, dangerous infectious diseases)
and man-made disasters (e.g. those involving
explosives, chemicals, radioactive substances or
biological threats) to minimize serious illness,
overall deaths and social disruption.6, 11
2
CHAPTER
Public Health in Canada
9
CHAPTER
2
Public Health in Canada
Canada’s public health history
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Prior to Europeans arriving and settling in North
America, Canada was inhabited by millions of
Indigenous peoples.15 The origins of public health
in this country can be traced back to traditional
Aboriginal teachings that highlight the importance of
maintaining and restoring balanced health through
social and environmental sensitivity.16, 17 These longstanding traditions were jeopardized following the
arrival of European settlers who brought new diseases
and a way of life that led to a serious deterioration in
the lives of Canada’s Indigenous Peoples.16
10
The threat of infectious diseases began to impact
Indigenous peoples in North America in the early
seventeenth century, with the fi rst historically
recorded outbreaks occurring between 1734 and
1741. The arrival of settlers not only meant illness
and death for Aboriginal Peoples, but also a loss of
traditional lands, resources and livelihoods – creating
a new lifestyle involving competition, exploitation
and a loss of long-standing norms, values, and societal
and spiritual practices. These factors, along with
others, allowed for an all too easy transition from a
state of good health to ill health.16
1830-1900
Early settlers were not spared from infectious
diseases.15 In 1832, an estimated 20,000 lives were lost
in Upper and Lower Canada from a cholera epidemic.
In an attempt to contain the disease, the Lower
Canada Board of Health created a quarantine station
for new arrivals on Grosse Île in the St. Lawrence
River. Quarantine measures were enforced by the
military to prevent the spread of the disease through
Upper and Lower Canada.18
In 1847, the next wave of infectious disease,
typhus, killed 6,000 of the estimated 100,000 Irish
settlers fleeing the potato famine in their home
country.19 Again, quarantines of new immigrants
were instituted. Unfortunately, this may have
actually fuelled the spread of typhus since people in
quarantine were more likely to contract the disease.
The Aboriginal population was exceptionally susceptible
to these disease outbreaks because they lacked
immunity to the new infections and their resistance
to disease was further jeopardized through exposure
to less healthy ways of life. Countless Aboriginal people
succumbed to epidemics of smallpox, tuberculosis,
diphtheria, typhus, measles and syphilis. In some
cases, whole communities all but disappeared.15
While Canada battled these waves of disease, research
was underway in Europe to identify the sources
of, and potential solutions to, these challenges. In
1842, a British report, The Sanitary Conditions of
the Labouring Population of Great Britain, concluded
that clean water, sewers and adequate housing were
essential to prevent the spread of infectious disease.20
The report led directly to the first Public Health Act
in the United Kingdom in 1848, which established
a central Board of Health with local boards.21 The
Board of Health often felt opposition from those who
considered the Act to be a threat to “property rights
and personal freedom” and the British government
refused to renew the Act after the fi rst five years.22
In 1867, Britain established the British North America
Act (became the Constitution Act in 1982). The Act
was used to create the Canadian Confederation and
enforced the division of power between the provinces
and the federal government. Within Sections 91
and 92, the newly created Dominion of Canada was
responsible for the creation of quarantine and marine
hospitals and the provinces were responsible for the
establishment, maintenance and management of
hospitals and asylums.23
Few public health initiatives were developed and
activities were haphazard during the remainder of
the 19th century, varying from city to city and from
province to province. This may have been because, by
the turn of the century, there was “a very remarkable
decrease in the communicable diseases with which
we are familiar” (1900 Annual Report of the Provincial
Board of Health for Ontario), thanks in large part to
improvements in water and sanitation and public
infrastructure.24
Water, Sanitation and
Health in Canada
There is no doubt that advances in sanitation,
water treatment and distribution directly
contributed to a reduction in mortality rates
in Canada and the elimination of water-borne
diseases such as cholera and typhoid.27, 28, 29
Today, standards and policies supporting
legislation exist at all levels of government to
deal with water quality and sanitation.30 The
majority of citizens have the benefit of highquality water treatment systems, although
some Canadian communities – particularly
those that are small, rural and remote – may
face boil water advisories. These are issued
to reduce the risk of waterborne diseases
when conditions suggest possible increases of
microbiological contamination.31
Canada is continuing its work on developing
and employing innovative technologies while
maintaining a careful watch on water and
sanitation systems across the country.32 At the
same time, it is shifting its focus toward a more
sustainable use of fresh water that favours
reduced water demand over increased supply.33
While waterborne diseases came mostly under control,
other contagious diseases remained the leading causes
of death in Canada.34 Diseases including scarlet fever,
diphtheria, measles, whooping cough, and tuberculosis
continued to put the public’s health at risk.15 In
Ontario alone, 36,000 children died from diphtheria
between 1880 and 1929.35 In the mid-1880s smallpox
remained a threat, with Montréal experiencing the
last major epidemic in a North American city.36
1900-1950
In the early part of the 20th century, public health
activities continued to be largely uncoordinated and
mostly in response to infectious disease outbreaks.
Aboriginal Peoples’ health and social conditions
reached a low point, as traditional ways of life (e.g.
consuming whole foods, maintaining high activity
levels, practicing natural medicine) continued to be
significantly weakened and suppressed.16
However, some significant public health developments
did emerge during this period. For example,
immunization against smallpox and diphtheria
had begun in Ontario schools.37, 38 About the same
time, cities such as Toronto and Montréal began to
pasteurize milk against bovine tuberculosis and
towns, such as Peterborough, began using chlorination
to disinfect drinking water.39, 40, 41
Public health activities accelerated when Canadian
soldiers returned home from the First World War,
bringing with them the Spanish influenza of
1918-1919.42 An estimated 40 to 50 million people
were killed worldwide by the pandemic, including
approximately 50,000 Canadians.42, 43 Once on Canada’s
shores, the virus spread quickly across the country,
even to remote communities.43
Conscious of the need to manage federal health
functions, the Canadian Public Health Association
played a key role in advocating for the creation of a
Department of Health in 1919.44, 45 The department
retained functions of quarantine and ensuring
food and drug standards, but also acquired new
responsibilities to implement campaigns against
sexually transmitted infections (STIs) and
tuberculosis, as well as to promote child welfare.45
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The link between water, sanitation and health
has been known for centuries – tainted water
supplies and deficient sanitation practices
can cause illness and death among those
exposed to these conditions.25, 26 Although
Canada has an abundance of fresh water,
disease outbreaks related to water and sewage
practices were commonplace among early
settlers. It wasn’t until the beginning of
the last century that officials embraced the
water/waste/health connection and began to
actively pursue adequate sanitation and clean
water systems with an eye to improving and
maintaining public health.
2
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Public Health in Canada
11
CHAPTER
2
Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The next two decades were periods of major
contrasts. Most Canadians’ standard of living was
on the rise as employment and incomes increased
and education and housing improved, resulting in
better living conditions and enhanced nutrition.
Childhood immunization against infectious diseases
was becoming commonplace, life-altering scientific
discoveries – such as insulin and penicillin – led
to treatments for diabetes and infection, and new
techniques were introduced to treat injuries, all of
which helped to improve the health of Canadians.
12
However, the Canadian economy and society were
dealt a serious blow during the Great Depression of
the 1930s. As farmers went bankrupt and industries
in towns and cities collapsed, people lost their homes
and livelihoods. The uprooted and unemployed became
migrants and, in some cases, vagrants – homeless,
hungry and frequently ill. The Depression was quickly
followed by the Second World War (1939-1945), which
again took a toll on the health of individuals and the
well-being of society. As well, the prevalence of polio,
another highly contagious, frequently disabling and
sometimes fatal disease, during this era reinforced
that infectious diseases remained a serious threat to
public health.46
These events laid the groundwork for contemporary
concepts of public health as Canada recognized
its obligation to look after returning soldiers and
the population at large. A range of initiatives were
launched to strengthen the social fabric of the
country, from the construction of new housing to the
provision of education for returning soldiers and their
families.47, 48, 49
The Case for Immunization
Before the benefit of mass immunization,
generations of Canadians lived with the
threat of a range of debilitating diseases that
frequently swept through their communities.
Polio, for example, left many people paralyzed
or otherwise disabled. At its peak in 1953,
it caused nearly 500 deaths in Canada. Two
years later, an injectable polio vaccine was
introduced and incidence of the disease dropped
dramatically.46 By 1994, all of the Americas
were certified polio free.50 Today, it has been
eliminated from most parts of the world.
Measles is another contagious disease that has
affl icted millions worldwide. According to the
WHO (2002), it is the leading global cause of
vaccine-preventable death in children under
the age of five.51 Before the introduction of
a measles vaccine in the early 1960s, Canada
averaged 300,000 to 400,000 annual cases.52
By 1995, that number had dropped to 2,362
and adopting an improved two-dose program
in 1996 has resulted in a further decline.53
Canada’s success in reducing and eliminating
vaccine-preventable diseases can be largely
attributed to high vaccine coverage rates.
However, work in this area is ongoing as
certain populations continue to exhibit lower
coverage rates.54, 55 This may be the result of
barriers to awareness and access, or because of
differing cultural norms.56
Today, Canada maintains various surveillance
systems to assure Canadians that vaccines
continue to be safe and effective and to allow
early interventions and control measures to
be implemented in the event of a disease
outbreak.54, 56
Canada’s fi rst food guide was introduced in 1942 to
reduce nutritional deficiencies resulting from wartime food rationing.57 This development was followed
by the 1944 family allowance, a universal program
to help families raise healthier children.58 In 1947,
Saskatchewan introduced the fi rst hospital insurance
program to ensure that personal fi nances would not be
a barrier to receiving health treatment.59
1950-present
Following the Second World War, the country
prospered and the health of the population improved.
By 1950, mortality rates were reduced by one quarter
compared to those of 1921 (9 per 1,000 compared with
12 per 1,000) and the number of deaths attributable
to infectious diseases was significantly reduced.34, 62
The post-war economic boom resulted in new jobs and
rising affluence. More people were completing higher
levels of education and more women participated
in the workforce.63, 64 While women of the previous
generation had advocated for the right to vote, women
of the post-war era fought for better educational and
job opportunities, equal wages, and paid maternity
leave, resulting in an improvement to the factors (or
determinants) that impact health.63, 65 In addition,
broad social programs such as the Canada Pension Plan
(CPP) and Old Age Security (OAS) were introduced.66
Access to acute hospital services was guaranteed
through the 1957 Hospital Insurance and Diagnostic
Services Act, while the 1966 Medical Care Act afforded
access to insured medical services.59 In 1962, the
Medical Services Branch of the Department of National
Health and Welfare was established with a primary
mandate of supporting Indian and Inuit Health.67
Trimming Tobacco Use in Canada
A hundred years ago, it was believed that
tobacco was beneficial and its use was
encouraged. By 1965, half the Canadian
population over 15 years old smoked.78 As
smoking rates continued to rise, research
uncovered the truth – tobacco use is an
addiction that harms the health of the smoker
and those exposed to second-hand smoke.79
Once these dangers were understood, Canada
began to take action through tobacco control
strategies involving concerted effort across
all levels of government, including: education
and promotion, taxation, introduction of
smoking by-laws and cessation support.
The most recent data from the 2006 Canadian
Tobacco Use Monitoring Survey (CTUMS) show
that these efforts have paid off. Only 19% of
the Canadian population now smokes.80 In
addition:
•
•
•
more than half of Canadians who have
ever smoked have quit;
every region in the country is
experiencing success in decreasing
smoking rates among all age groups; and
Canada is one of the fi rst countries in the
world to see a decrease in youth smoking.
Today, Canada is universally recognized as
a leader in tobacco control and shares its
experience with other nations under the WHO
Framework Convention on Tobacco Control.81
Despite these achievements, Canada needs to
continue pursuing tobacco reduction efforts
– especially among populations with higher
rates of smoking and where children are still
regularly exposed to second-hand smoke.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
During this same period, a broader understanding
of health was emerging at the international level
by global bodies like the World Health Organization
(WHO). In 1948, the WHO defi ned health as: “A state
of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.”60 The
newly formed organization set standards and agreed
on regulations to promote health among member
countries and began providing assistance to promote
disease surveillance.61
2
CHAPTER
Public Health in Canada
13
CHAPTER
2
Public Health in Canada
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
This period also presented new challenges, however,
as people were living longer and chronic diseases and
injuries increasingly became the more common cause
of disability and death.68 Other trends emerged, such
as widespread smoking, increased social drinking,
the recreational use of drugs, a resurgence of STIs
and the introduction of new infections like HIV-AIDS.
Meanwhile, the proliferation of cars led to a reduction
in physical activity as well as an increase in smog,
air pollution, and injury and death related to motor
vehicle crashes.69, 70, 71
14
The discipline of epidemiology began to explore
the causes of these trends with a view to their
prevention.5 Many studies identified associations
between smoking and lung cancer; diet, physical
activity and heart disease; seatbelt use and road
traffic injuries; and air pollution and worsening of
asthmatic conditions.72, 73, 74, 75, 76, 77
Globally, Canada was at the forefront of the public
health approach with the 1974 Federal publication of
New Perspectives on the Health of Canadians by then
Minister of Health Marc Lalonde. The report helped
Canadians to understand that achieving good health
requires more than just a good health care system
and it emphasized the importance of human biology,
environment, lifestyle, health care organization and
the need to “understand what contributes to sickness
and death, and to facilitate the identification of
courses of action that might be taken to improve
health.” It also highlighted the impacts of social
influences on health and underscored that social
inequalities can lead to health inequalities. And the
report emphasized the need for greater inter-sectoral
collaboration in research, community development,
social marketing and public policy to adequately
address the various factors that determine health.82
The Lalonde Report had a profound impact on public
health practice around the globe, highlighting the
benefits of investment in promoting health and
preventing illness and injury to reduce pressure on
the health care system.83 It led to renewed efforts
to develop new approaches in health promotion,
community advocacy and the use of legislation.
The Proven Benefits of Buckling Up
Between 1975 and 2003, traffic fatalities
decreased by over 50% in Canada even though
the number of drivers and cars on the road
increased substantially.84 Part of the reduction
may be credited to an increase in seatbelt use
with 90% of Canadians now buckling up when
riding in or driving a motorized vehicle.85
Achieving this improvement was not easy.
Seatbelts did not become standard equipment
in Canadian vehicles until the late 1960s.86
Use was voluntary and very limited until the
next decade when medical professionals linked
the use of seatbelts in traffic crashes with
lower incidences of serious injury and death.87
Public awareness campaigns followed, as did
legislation making seatbelt use mandatory.
The fi rst law was passed in Ontario in 1976.
By the late 1980s, all provinces and territories
had adopted similar legislation.88
Although rates of traffic deaths and injuries
have greatly improved, more can be done
– especially with respect to child safety.
Roadside checks have shown that just 51% of
children are buckled up and more than 80% of
car seats are improperly installed.89
As a result, new public awareness campaigns
have been launched and legislation for
mandatory vehicle booster-seat use has been
passed by seven provinces to ensure the safety
of children too big for a car seat but too small
for an adult seatbelt.90
2
CHAPTER
Public Health in Canada
Another reminder came in 2003 with the arrival of
Severe Acute Respiratory Syndrome (SARS) in Canada.
Caused by a virus that originated in Asia, SARS
claimed the lives of 30 Canadians and significantly
damaged segments of the Canadian economy.105 In
the aftermath of SARS, it became clear that the next
infectious disease emergency may now be just a plane
ride away. Canadians also realized that, for all the
strengths of Canada’s health care system, exceptional
care alone is not enough to protect them from the full
range of threats to their health and safety.
In keeping with the Ottawa Charter, the decade that
followed was a productive one for Canada in the health
and health promotion fields. Early in the 1990s, the
creation of a Breastfeeding Committee for Canada sought
to establish breastfeeding as the cultural norm across
the country and a new Canadian Institute for Health
Information provided an independent means of amassing
essential data and imparting analysis on Canada’s
health system and the health of Canadians.95, 96
Several key reports were also released, including the
Report of the Royal Commission on Aboriginal Peoples
(1996) and the first and second reports on the Health
of Canadians (1996 and 1999).97, 98 The Tobacco Act,
passed in 1997, provided new regulations on the
manufacture, sale, labelling and promotion of tobacco
products.99 And at the end of the decade, efforts to
improve the nation’s understanding of population
health culminated in the creation of a Canadian
Population Health Initiative (CPHI).100 The growing
burden of HIV infections and outbreaks of invasive
meningococcal disease that affected school and collegeaged youths served once again as reminders that
infectious diseases remained a challenge.101, 102, 103, 104
Mission
The lessons of SARS, including recommendations
from Dr. David Naylor’s report, Learning from SARS:
Renewal of Public Health in Canada, were the primary
drivers behind the creation of the Public Health
Agency of Canada in 2004.2, 6 The Agency has essential
responsibilities related to preventing diseases and
injuries, promoting good health, preparing for
emergencies and strengthening the public health
infrastructure in Canada. Additionally, it strives to
understand and address the basic factors that determine
individual and population health in Canada.107
Public Health Agency of Canada
To promote and protect the health of
Canadians through leadership, partnership,
innovation and action in public health.
Vision
Healthy Canadians and communities in a
healthier world.106
Also in 2004, Canada’s First Ministers committed to
the development of “goals and targets for improving
the health status of Canadians through a collaborative
process”.108 The following year, the Public Health
Agency of Canada led the broad consultation and
validation process that culminated in a set of goals
(the Health Goals for Canada) that were agreed on by
the Federal, Provincial and Territorial Ministers of
Health (see Appendix C).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
In the early 1980s, the Canada Health Act was passed,
updating the preceding Hospital Insurance and
Diagnostics Services Act and the Medical Care Act. It
ensured comprehensive, universal and accessible
insured health care services to all Canadians without
cost or discrimination based on age, health status
or fi nancial situation.91 During this decade, Canada
further developed the concept of health promotion
with the publication of Achieving Health for All: A
Framework for Health Promotion as tabled by then
Minister of Health Jake Epp in 1986.92 The Epp
Report placed greater focus on the determinants
of health – specifically identifying income-related
health inequalities as an area for priority action
and recognizing that health behaviours are not
just a by-product of personal choice, but also of
the surrounding environment.93 In the same year,
Canada responded to the growing international public
health movement by hosting the fi rst International
Conference on Health Promotion. The Ottawa Charter for
Health Promotion, presented at the conference, called
on countries to establish strategies and programs
for health promotion through building healthy
public policy, creating supportive environments,
strengthening community actions, developing
personal skills and reorienting health services.94
15
CHAPTER
2
Public Health in Canada
Most recently, Canada hosted the 19th International
Union for Health Promotion and Education World
Conference − Health Promotion Comes of Age: Research,
Policy & Practice for the 21st Century. The event, held
in 2007, provided an opportunity to reaffi rm the
commitment and vision of the Ottawa Charter, as
well as the chance to look to the future and enhance
partnerships and inter-sectoral collaborations for
health promotion.109
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
A work in progress
16
Canada has made great strides in implementing
public health initiatives to maintain and improve the
health of Canadians. Considerable challenges remain
however, as recent decades have seen the rise of new
diseases as well as the continuation of old problems
that still threaten the health of the population.
For example, 2,923 Canadians lost their lives on
Canada’s roads in 2005 despite safety improvements
over the years.110 Although this number is in decline
due to better roads and safer cars, speeding, and
dangerous and impaired driving are still serious risks.
Physical environments can also result in adverse
health effects. Conditions associated with climate
change − such as rising temperatures and extreme
weather events – and migrating species/diseases,
such as West Nile Virus, can lead to illness and
death among vulnerable populations.111 Air quality
is of great concern as the number of ‘smog days’ is
increasing in Canadian cities and the impact on health
for children, seniors and those suffering from preexisting illness such as cardiovascular and respiratory
diseases, is significant.112
The necessity of clean water and reliable infrastructure
was reinforced with the E.coli contamination of the
community water supply in Walkerton, Ontario in
2000 where the water-borne infection claimed seven
lives and left almost half the town’s population ill.113
The following year, the community water supply in
North Battleford, Saskatchewan was contaminated
with cryptosporidia which caused between 5,800 and
7,100 people to become ill.114
Sedentary lifestyles and escalating obesity rates are
risk factors for preventable conditions, such as Type 2
diabetes, which reduce Canadians’ quality of life and
put their lives at risk.12, 14 Each year in Canada, about
three quarters of all deaths result from circulatory
diseases, cancers, diabetes and respiratory illnesses.115
Moreover, 51% of all years lost to premature death
were caused by cancer, circulatory diseases and
respiratory diseases in 2001.116
Serious health challenges such as stress, mental
illnesses and suicide also continue to be major
problems. One in five participants in the 2002 Mental
Health and Well-being Survey indicated that they
had experienced a mental illness (such as anxiety
disorders, depression and substance dependence) at
some point during their lifetime. Mental illnesses
affect people in all occupations, education levels,
socio-economic conditions and cultures. And, despite
the fact that most Canadians will be affected by
mental illness themselves, or through a family
member, friend or colleague, reducing the stigma
associated with mental illness continues to be the
greatest challenge to treatment and care.117, 118
There is also an unequal distribution of health
in Canada. Poverty, which is often linked to low
education and employment levels, is also linked to
people being less healthy on average. Research has
shown repeatedly that persons with low incomes are
more likely to experience illness and use the health
care system, and those who are ill are often more
likely to become economically disadvantaged.119, 120, 121
Studies also show that other factors like education,
early childhood development and social support can
compound or mitigate these inequalities.7, 122 Poverty
then is not simply an issue of lack of money, but a
cluster of disadvantages of which economic poverty is
a key driver. This will be explored further in Chapters
3 and 4.
2
CHAPTER
Public Health in Canada
For all the progress that has been achieved to date,
it is clear that considerable work remains to be done.
However, these ongoing challenges do not diminish
the extraordinary strides in Canada’s public health
history. In the past century, life expectancy for
women has soared from 50 to 83 years and from 47 to
78 years for men.123, 124 Improved sanitation, living
conditions, community development measures, and
innovations such as immunization have dramatically
demonstrated effectiveness in preventing premature
death and improving Canadians’ health and quality
of life. Continuous improvement in public health
action will be required throughout the 21st century to
sustain this impressive record.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
17
18
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
CHAPTER
3
Our Population, Our Health and
the Distribution of Our Health
The 2007-2008 United Nations Human Development
Index – which considers life expectancy, education
and standard of living – ranks Canada fourth overall
out of 177 countries.125 Despite this ranking, some
negative health trends in Canada are worsening and
there continues to be an uneven distribution of health
across the population. This chapter gives an overview
of the Canadian population and the overall health of
the nation, including the main causes of disease,
death and disability, and how Canada compares with
others health-wise on an international level. The
factors influencing these health trends are explored in
Chapter 4.
Population in
thousands
600
500
400
300
200
100
0
According to the 2006 Census, there are over 31.6
million people in Canada.126 A diverse population,
Canada’s inhabitants can trace their ethnic roots to
the four corners of the world and claim more than
200 languages as their mother tongue.127 Canada is so
big it spans six time zones yet, even though it is the
second largest country in the world in terms of land
area, it ranks only 36th in terms of population.128
Aboriginal Peoples account for close to 4% of the
population. About 60% identified themselves as First
Nations, 33% as Métis, 4% as Inuit and 3% as Other
or a combination of Aboriginal identities in the last
Census.129
In the nine-year period between 1997 and 2005 there
were approximately 3 million births and 2 million
deaths in Canada.130, 131 During the same period, more
than 2 million new immigrants arrived.132
Most Canadians live in urban settings with over 80%
of the population residing in towns and cities.133 It
is a growing trend. Since 2001, nearly 90% of the
country’s population growth has been concentrated in
Canada’s large census metropolitan areas.134
The population is also aging. The number of Canadians
aged 65 years and older has more than doubled since
1970 and their share of the population has increased
from 8 to 14% in the same period.135 Children under
10 years of age (11%) and youth between the ages
of 10 and 19 years (13%) account for less than
one quarter of the population, while young- and
0
15
30
45
60
75
90+
Age
1971
2006
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistic Canada. CANSIM Table
051-0001.
middle-aged adults aged 20 to 64 years make up
62% of the population.126 Figure 3.1 highlights
how the age distribution of Canada’s population
has changed since the early 1970s when a larger
portion of the population was found in the younger
age groups compared to today when most of the
population falls within the middle and older age
groups.135 An exception to this trend can be found
among Aboriginal Peoples who have a much younger
population.136
Our health
Given the diversity of the Canadian population, how
is it possible to determine the state of Canadians’
health or the factors that influence it? The answers lie
in the use of statistics, known as health indicators,
that measure and monitor trends in the health of
Canadians. The indicators shown in Table 3.1 highlight
how long people can expect to live on average,
what percentage of the population experiences
particular health challenges, or how frequently
Canadians acquire and live with specific diseases and
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Who we are
Figure 3.1 Population distribution by age, Canada,
1971 and 2006
19
CHAPTER
3
Our Population, Our Health
Table 3.1 Our health
Value
Description
Year
31.6
1.17
0.70
0.39
0.05
6.2
million people
million people
million people
million people
million people
million people
2006
2006
2006
2006
2006
2006
0.37
2.53
0.32
0.13
2.28
0.06
0.25
0.25
million people
million people
million people
million people
million people
million people
million people
million people
2006
2006
2006
2006
2006
2006
2006
2006
2.0
4.2
80.2
million people
million people
percent of the population
2006
2006
2006
Life expectancy and reported health
Life expectancy at birth
Health-adjusted life expectancy at birth
Infant mortality rate
Excellent or very good health *
Excellent or very good mental health *
80.4
69.6
5.4
60.1
72.9
years of expected life
years of expected healthy life
deaths per one thousand live births
percent of the population aged 12+ years
percent of the population aged 12+ years
2005
2001
2005
2005
2005
Leading causes of mortality
Circulatory diseases
Malignant cancers
Respiratory diseases
227.5
209.4
61.3
deaths per 100,000 population per year
deaths per 100,000 population per year
deaths per 100,000 population per year
2004
2004
2004
Causes of premature mortality (ages 0 to 74)
Malignant cancers
Circulatory diseases
Unintentional injuries
Suicide and self-inflicted injuries
Respiratory diseases
Human Immunodeficiency Virus (HIV)
1,574
854
640
394
162
46
potential years of life lost per 100,000 population per year
potential years of life lost per 100,000 population per year
potential years of life lost per 100,000 population per year
potential years of life lost per 100,000 population per year
potential years of life lost per 100,000 population per year
potential years of life lost per 100,000 population per year
2001
2001
2001
2001
2001
2001
2.6
5.5
24.3
16.4
8.3
4.8
18.3
4.4
percent of the population
percent of the population aged 1+ years
percent of the population aged 18+ years
percent of the population aged 12+ years
percent of the population aged 12+ years
percent of the population aged 12+ years
percent of the population aged 20+ years
percent of the population aged 35+ years
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Who we are
20
Population
Aboriginal
First Nations
Métis
Inuit
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)
Urban population
Our health status
Causes of ill-health and disability
Living with chronic diseases
Malignant cancers
Diabetes
Obesity
Arthritis/rheumatism *
Asthma *
Heart disease *
High blood pressure *
Chronic obstructive pulmonary disease *
Living with mental Illness
Schizophrenia
Major depression
Alcohol dependence
Anxiety disorders
Alzheimer’s and other dementias *
Acquiring infectious diseases
HIV
Chlamydia
Gonorrhea
Infectious Syphilis
0.3
4.8
2.6
4.8
6.0-10.0
2,300-4,500
202.2
33.1
4.6
2003
2004-2005
2005
2005
2005
2005
2005
2005
percent of the population aged 12+ years
percent of the population aged 15+ years during a 12-month period
percent of the population aged 15+ years during a 12-month period
percent of the population aged 15+ years during a 12-month period
percent of the population aged 65+ years in North America
2002
2002
2002
2002
2003
estimated number of new cases
new cases per 100,000 population
new cases per 100,000 population
new cases per 100,000 population
2005
2006
2006
2006
* Denotes self-reported data
Note: Some data may not be comparable. More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
Sources: Public Health Agency of Canada using data from Statistics Canada and National Diabetes Surveillance System.
disabilities. These indicators are widely accepted as
a meaningful gauge of overall population health and
can be used to provide an indication of how healthy
Canadians are over time and in comparison to other
countries.137, 138
Life expectancy
Life expectancy in Canada has increased dramatically
over the past century to the point where a person
born here today can expect to live for about 80 years,
based on current death rates in all age groups.139 Over
a lifetime, some periods may be spent in less than
full health, but it is estimated that Canadians can
expect to live the equivalent of 70 of those 80 years
in full health.140 This number is arrived at using a
health-adjusted life expectancy, which is a measure of
overall population health that takes into account the
effects of illness and disability on peoples’ quality of
life. Consequently, Canadians can expect to live a long
life, with the expectation that a good health-related
quality of life will be enjoyed for most of those years.
Canadians’ life expectancy at birth in 2004 was one
of the highest in the world at just over 80 years –
about 2.5 years more than the U.S. and 2 years less
than Japan (the highest at 82 years).141 Figure 3.2
shows the steady increase in life expectancy for seven
OECD countries, including Canada, over the last 25
years. It also shows that Canadian life expectancy is
improving, but it is not doing so at the same rate as
some other top health-ranked countries such as Japan
and Australia.
Figure 3.2 Life expectancy at birth, select OECD
countries, 1980-2004
Life expectancy (years)
84
82
80
78
76
74
72
0
1980
1985
1990
1995
2000
2004
Year
Japan
Norway
Australia
United Kingdom
Canada
United States
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Organisation for Economic
Co-opertation and Development (OECD) Health Data, 2007.
Socio-economic health gradient describes the
enduring pattern of the rise of health status
with each level of socio-economic status.142
Although Canada does well overall in terms of life
expectancy, certain populations within Canada do not
fare as well. In urban Canada, Canadians with lower
levels of education have lower life expectancy, as do
those living in lower-income neighbourhoods.143
In Figure 3.3, the urban population is divided into
quintiles (Q), or fifths, based on the percentage of
the population in their neighbourhoods below the
low-income cut-offs.144 The 20% of the population in
the neighbourhoods with the highest incomes (Q1)
have a higher life expectancy than those in each of
the neighbourhoods with lower incomes (Q2 to Q5).
The effect of health outcomes improving with each
increase in income level is known as a social gradient
in health.145, 146 Figure 3.3 also shows that the
gradient is different for men and women, with a much
steeper gradient for men.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Two types of health indicators are presented in
Table 3.1; those that originate from official
information and data sources such as the census,
death records, hospitalization records, disease
registries or direct measurement; and those that are
self-reported from population-representative surveys
where respondents identify having experienced, being
diagnosed with or living with a variety of diseases
and injuries as well as rating their quality and state
of general and mental health. Most of these indicators
are presented as rates or proportions of the overall
Canadian population.
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Figure 3.3 Life expectancy at birth by neighbourhood
income and sex, urban Canada, 2001
Figure 3.4 Life expectancy at birth by neighbourhood
income and sex, urban Canada, 1971-2001
Life expectancy (years)
Age (years)
84
85
82
80
80
75
78
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
70
22
76
65
74
0
1971
72
1976
1981
1986
1991
1996
2001
Year
0
Female
Q5 - Poorest
Q4
Q3
Q2
Q1 - Richest
Income quintiles
Males
Male
Q1 - Richest
Q1 - Richest
Q3
Q3
Q5 - Poorest
Q5 - Poorest
Females
Q - population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Q - population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
Source: Wilkins et al. (2007), Statistics Canada.
Figure 3.4 illustrates that over time, life expectancy
has increased steadily at all income levels.144 The
figure also shows, however, that while the gaps
between inhabitants in neighbourhoods with the
highest and lowest incomes and between men and
women are narrowing, they have persisted since
the early 1970s with even the lowest-income women
having a longer life expectancy than men with the
highest income. The size of these gaps is not insignificant
– they are in fact equivalent to the increase in many
countries’ life expectancies which took more than two
decades to achieve (see Figure 3.2).141
First Nations people listed in the Indian Register,
according to requirements set out in the Indian Act,
also have lower life expectancy.147, 148 Figure 3.5 shows
that while the life expectancy for Registered Indians
has increased since 1980, it has remained below that
of the general population for both male and female
populations.149 Although the gap is narrowing, a
persistent difference remains between First Nations
people and other Canadians.
Figure 3.5 Life expectancy at birth by sex, Registered
Indian and general population, Canada, 1980-2001
Figure 3.6 Infant mortality rate, select OECD countries,
1980-2004
Age (years)
Infant mortality rate
85
14
80
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Our Population, Our Health
12
75
10
70
8
65
6
60
2
50
0
1980
1985
1990
1995
2001
Year
Female
0
1980
1985
1990
1995
2000
2004
Year
Male
United States
Australia
All females
All males
Canada
Norway
Registered Indian
Registered Indian
United Kingdom
Japan
Source: Indian and Northern Affairs Canada, Basic Departmental Data, 2004.
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Organisation for Economic
Co-opertation and Development (OECD) Health Data, 2007.
Infant mortality
The infant mortality rate is a particularly sensitive
indicator that, internationally, well reflects the
overall human development, health and education
status of women and the strength of the public
health environment of a nation.150, 151 Canada’s
infant mortality rate has improved over the past
four decades, dropping by 80% from more than 27
deaths per 1,000 live births in 1960 to 5 per 1,000 live
births in 2004.152, 153 Figure 3.6 illustrates the steady
decrease in infant mortality rates for seven OECD
countries, including Canada, over the last 25 years.141
Some differences may exist in the way various
countries record infant births and deaths, so that
infant mortality rates are not necessarily directly
comparable. However, for countries similarly
developed in comparison to Canada, such differences
do not negate the fact that infant mortality rate is
still considered a reliable indicator of a country’s
overall health and is often used as an international
comparison tool.151 Canada’s infant mortality rate
is slightly higher than some countries (Japan and
Norway have the lowest infant mortality rate at
around 3 deaths per 1,000 live births), but it is
comparable to Australia and the United Kingdom, and
lower than the U.S. (7 infant deaths per 1,000 live
births).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
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Despite the fact that Canada’s infant mortality rate is
in line with other OECD countries, some populations
within Canada experience higher rates of infant
death. Figure 3.7 shows the infant mortality rate
over time for low-, middle- and high-income urban
neighbourhoods.144 While the rate is decreasing in all
quintiles (despite a moderate increase after 1996),
and the gap between the rate in the various quintiles
has also been decreasing over time, a significant
difference in infant mortality rates still exists between
neighbourhoods with the highest and lowest incomes.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Figure 3.7 Infant mortality rate by neighbourhood
income, urban Canada, 1971-2001
24
Per 1,000 live births
25
20
15
10
5
0
1971
1976
1981
1986
1991
1996
2001
Year
Q5 - Poorest
Q3
population is Inuit) is more than three times the
national rate at 16 deaths per 1,000 live births.156, 148
Self-reported health
Although measured indicators are important, how
people feel about their own health is an important
indication of overall health status. Despite the
inherent limitations of survey data, such as the
subjectivity of individual responses, self-reported
data can provide useful information otherwise not
available. When Canadians are asked about their
health, most indicate that they consider themselves
to be healthy. The 2005 Canadian Community Health
Survey found that the majority of Canadians over
12 years of age, about 16 million (60%) report their
health as either excellent (22%) or very good (38%).157
Even more (73%) report their mental health as
excellent (37%) or very good (36%).158
As with other health indicators, however, some
Canadians fare less well. Individuals living in
households with the lowest levels of education are less
likely to report having excellent or very good general
or mental health.159 Figure 3.8 shows that only 47%
of individuals living in households with the lowest
levels of education (Grade 8 or less) report excellent or
very good health. Each additional level of education is
associated with an increase in the proportion of those
reporting excellent or very good health.
Q1 - Richest
Q - population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
Infant mortality rates among Aboriginal Peoples and
those living in Canada’s northern communities are
estimated to be higher than the general population.
The infant mortality rate among First Nations people
living on reserve is estimated at 7 deaths per 1,000
live births.148 This rate may be an underestimate
because of current limitations associated with data
coverage and quality related to Aboriginal infant
births and deaths in Canada.154 Recent research
related to First Nations in British Columbia puts the
estimate as high as 7.5 deaths per 1,000 live births for
First Nations living in rural areas.155 The estimated
rate in Nunavut (where approximately 85% of the
The Aboriginal Peoples Survey 2001 found that
slightly lower proportions (56%) of the Aboriginal
population aged 15 years and older living off reserve
reported their health as either excellent or very good
(North American Indian 55%, Métis 58% and Inuit
56%).160 For those living on reserve, the 2002-2003
First Nations Regional Longitudinal Health Survey
found that the proportion reporting excellent or very
good health was even lower at 40%.161
Figure 3.8 Proportion of Canadians* with excellent or
very good perceived health by highest household level
of education, Canada, 2005
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Our Population, Our Health
are living longer. The overall age-standardized
mortality rate for all ages and sexes combined has
declined from 1,219 deaths per 100,000 population in
1950 to 572 per 100,000 in 2004.164, 165, 166
Figure 3.9 Age-standardized mortality rates for select
causes, Canada, 1950-2004
ASMR per 100,000
population
1,250
Percentage
of population
1,150
100
950
80
750
550
40
350
20
300
University Degree
(> Bachelor)
Bachelor
College Certificate
or Diploma
Some postsecondary
Secondary school
graduate
Grade 11 to 13
Grade 9 to 10
Grade 8 or less
University Certificate
(< Bachelor)
250
0
150
100
50
Educational attainment
Perceived health
200
Perceived mental health
0
1950
1960
1970
1980
1990
2000
Year
* Population aged 12+ years.
All cause
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, Canadian
Community Health Survey (CCHS-SHR) 2005.
Causes of death
If recent trends continue, six out of ten Canadian
deaths in 2008 will be attributable to either circulatory
diseases (largely heart attack, heart failure or stroke)
or cancers. While the absolute numbers are high, the
rate at which people are dying prematurely of these
diseases is lower today than in the past considering
the increase in population size.162
Over the last half century, taking into account
changes in the age distribution of the population from
year to year (by age-standardization), the overall
mortality rate for all causes combined has declined
steadily (see Figure 3.9).163 In other words, Canadians
Ischaemic heart disease
Cancers
Cerebrovascular disease
ASMR – Age-standardized mortality rate.
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, CANSIM Tables.
Much of the decline in overall mortality rates is
attributable to the more than 70% decline in death
rates related to circulatory diseases – most notably
ischemic heart disease and cerebrovascular disease
(including stroke). Age-adjusted mortality rates across
all cancer sites have not changed significantly since
the 1950s.164, 165, 166
Patterns, rates and causes of mortality vary within
the population according to different factors such as
age, sex and income.167 The pattern of mortality by
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
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Figure 3.10 Mortality by select causes and age groups, Canada, 2004
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Aged 0-19 years (2%)
26
Aged 20-44 years (4%)
Perinatal Conditions
All Cancers
Congenital anomalies
Circulatory diseases
Injuries and poisonings
Injuries and poisonings
All other conditions
All other conditions
Ages 65+ years (78%)
Aged 45-64 years (16%)
All Cancers
All Cancers
Circulatory diseases
Circulatory diseases
Injuries and poisonings
Injuries and poisonings
All other conditions
All other conditions
Source: Public Health Agency of Canada using Statistics Canada, CANSIM Tables.
age group is presented in Figure 3.10 and shows both
the different causes of death and their proportion
of all deaths for Canadians of different ages. For
example, although deaths due to injuries and
poisonings represent a substantial proportion of all
deaths in children and youth aged 0 to 19 years, in
relation to the entire population the actual number
of those deaths is small given that deaths in that age
group account for less than 2% of all deaths.168 In
contrast, beginning around age 45, the majority of
deaths are due to circulatory diseases and cancers and
represent the majority of all deaths in Canada.169 As
would be expected, most deaths (for all causes) occur
in the older age groups (78%), regardless of their
relative importance in younger age groups.
Mortality rates also vary by neighbourhood income.144
Death rates due to ischemic heart disease are
decreasing for men (as shown in Figure 3.11), and the
gap between those living in the highest- and lowestincome neighbourhoods is narrowing.144 Most of this
‘gap narrowing’, however, occurred between 1971
and 1991, with almost no further narrowing in the
subsequent decade.
In other cases the opposite is true. Death rates for
lung cancer in women are increasing for all income
levels and the mortality gap between highest- and
lowest-income neighbourhoods is widening
(see Figure 3.12).144 Much of this pattern is a
reflection of past smoking practices among Canadian
women.170, 171, 172
Figure 3.11 Age-standardized mortality rates for
ischemic heart disease by neighbourhood income, male,
urban Canada, 1971-2001
ASMR per 100,000
population
450
400
350
300
250
200
150
100
50
0
1971
1976
1981
1986
1991
1996
2001
Q5 - Poorest
Q3
Q1 - Richest
ASMR – Age-standardized mortality rate.
Q – population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
Figure 3.12 Age-standardized mortality rates for lung
cancer by neighbourhood income, female, urban Canada,
1971-2001
Causes of premature death
While the number of deaths due to a particular
disease is important to understanding the health of
the Canadian population, so too is the age at which
these deaths occurred. For example, if a Canadian
dies of cancer at age 45, 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). 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.
In Canada, the overall PYLL rate has been decreasing
over time. However, cancers, circulatory diseases,
injuries (both unintentional and intentional) and
chronic respiratory disease continue to be the most
significant early killers of Canadians. In 2001, these
four causes accounted for more than 70% of the
total 5,102 PYLLs per 100,000 population in Canada for
all causes combined. In general, infectious diseases
are not responsible for large numbers of premature
deaths in Canada with the greatest contributor, HIV,
adding only 46 PYLLs per 100,000 population in 2001
– less than 1% of the total years of life lost
prematurely that year.116
Research indicates that where you live can have an
impact on years of life lost to early death. Canadians
living in more northern regions have a PYLL rate
higher than the national average (e.g. the PYLL rate
for residents of Nunavut is 2.5 times higher than
average). This is due mainly to unintentional injuries,
suicides and self-infl icted injuries. Those in the
central and west coast areas of the country have PYLL
rates lower than the average.116
ASMR per 100,000
population
40
35
30
25
20
15
10
5
0
1971
1976
1981
1986
1991
1996
2001
Year
Q5 - Poorest
Q3
Q1 - Richest
ASMR – Age-standardized mortality rate.
Q – population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
There is also a PYLL difference between low- and
high-income neighbourhoods. In 2001, more total
years were lost to premature death in lowerincome urban neighbourhoods than in the 20% of
neighbourhoods with the highest incomes. If the ageand sex-specific mortality rates in the highest-income
quintile had applied to the entire population, the
total PYLL for all urban neighbourhoods would have
been reduced by approximately 20% – the equivalent
of eliminating all premature deaths due to injuries in
those neighbourhoods.144, 173
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Patterns of ill health and disability
The diseases which cause the majority of premature
deaths in Canada also cause ill health and disability
across the population. In 2003, close to 3% of
Canadians were living with some form of cancer and
in 2005 roughly 5% reported having heart disease.174, 175
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The proportion of Canadians living with specific
diseases and health conditions varies throughout
the population. The burden of disease, injury or
disability also varies; some diseases are cause for
concern not because they affect large proportions of
the population, but because the burden on individual
health and quality of life is substantial.
Although chronic diseases are most often experienced
by, and associated with, older members of the
population, 42% of all Canadians over the age of 11
report living with at least one of a number of diverse
chronic diseases (see Figure 3.13).176, 177
Figure 3.13 Proportion of Canadians reporting one or
more chronic diseases* by age group, Canada, 2005
Aboriginal Peoples, on the other hand, have higher
rates of many chronic diseases than the Canadian
average.8, 179 Figure 3.14 shows that, with few
exceptions, the proportion of First Nations adults
living on a reserve who report being diagnosed with
some chronic conditions is higher than that of the
overall population.180
Figure 3.14 Age-adjusted prevalence of chronic
conditions among First Nations adults compared to the
general Canadian adult population
Percentage of
population
100%
Chronic
Conditions
80%
Arthritis/
rheumatism
High blood
pressure
60%
Allergies
40%
Diabetes
20%
Asthma
0%
12-19
20-44
45-64
65-79
Heart
disease
80+
Age group
None
One
Cataracts
Two
Three
Four+
*Diseases include asthma, arthritis or rheumatism, high blood pressure,
bronchitis, emphysema, chronic obstructive pulmonary disease (COPD),
diabetes, epilepsy, heart disease, cancer, effects of a stroke, Crohn’s disease,
colitis, Alzheimers, cataracts, glaucoma, thyroid condition, schizophrenia,
mood disorders, anxiety disorder, and eating disorder for persons aged 12+
years.
Source: Public Health Agency of Canada using Statistics Canada,
Canadian Community Health Survey, 2005.
28
In many cases, certain segments of the population are
affected at different rates. For example, persons born
in Canada are more likely to have any one of a number
of diagnosed chronic diseases or conditions compared
to those who have immigrated to Canada. This is
true even after accounting for differences in age,
education, and income between the two populations.
Canadian-born women are three times more likely to
experience a chronic disease or condition than women
who have immigrated to Canada within the last four
years. It is only those immigrants, men and women
alike, who have lived in Canada for thirty years or
more who have the same odds of experiencing a
chronic disease or condition as their Canadian-born
counterparts.178
Thyroid
problems
Chronic
bronchitis
Cancers
0%
5%
10%
15%
20%
25%
30%
35%
Percentage
First Nations (2002/03)
General Canadian population (2003)
Source: First Nations Regional Longitudinal Health Survey (RHS).
And as with life expectancy, infant mortality rates
and PYLL, the proportion of the population living
with many specific causes of ill-health and disability
also differs according to factors such as income and
education. For example, Figure 3.15 shows a social
gradient in the prevalence of heart disease for Canadians
aged 45 to 64 years by level of education.181
Other diseases and health conditions which are not
necessarily the most common causes of premature
death are, however, prevalent in the population and
contribute significantly to the ill health of Canadians.
Percentage of
population
Diabetes
Approximately one in twenty Canadians has
diabetes.182 The vast majority of Canadians with
diabetes (about 90%) have Type 2 diabetes, which is
strongly related to overweight and obesity, as well as
genetics. This type of diabetes can often be prevented
through exercise, healthy eating and maintaining
a healthy body weight.183 A smaller proportion of
diabetics with the Type 1 form, which usually begins
in early life, owe their condition to a much stronger
genetic component.184
As with other diseases and health conditions, certain
populations experience higher than average rates
of diabetes. Among First Nations adults living on
reserve or in First Nations communities, the diabetes
prevalence is approximately 20% − four times the rate
of the general population.180
12
10
8
6
4
2
0
Less than
secondary
graduation
Secondary
graduation
Some postsecondary
Post-secondary
graduation
Hypertension
Educational attainment
Males
Females
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, Canadian
Community Health Survey (CCHS) 2005.
Hypertension, or high blood pressure as it is better
known, is a major contributor to some of the top
causes of death in Canada, such as heart disease and
stroke.185 About 18% of Canadians aged 20 years or
older report being diagnosed with high blood pressure.
For those over the age of 44, the proportion climbs to
31%.186, 187 The risk of developing high blood pressure
increases with age and varies by ethnicity and gender.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Figure 3.15 Self-reported heart disease by educational
attainment and sex, household population aged 45-64
years, Canada, 2005
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Increasing levels of exercise, quitting smoking and
improving eating habits can all reduce the risk of
developing hypertension. For example, the number of
Canadians with high blood pressure would be reduced
by a third if everyone consumed a diet with healthy
levels of sodium (i.e. levels that are significantly lower
than the current average dietary intake).188, 189
Figure 3.16 Self-reported arthritis/rheumatism by
educational attainment and sex, household population
aged 45-64 years, Canada, 2005
Percentage of
population
45
40
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Arthritis/Rheumatism
30
Approximately 16% of Canadians aged 12 years and
older report having arthritis or rheumatism and it
is the most prevalent chronic condition among First
Nations adults (see Figure 3.14).177, 180 Figure 3.16
shows a social gradient for this condition, where the
proportion of those reporting arthritis or rheumatism
generally decreases with an increase in household
level of education for those aged 45 to 64 years.187
Arthritis is not a single disease, but rather a collective
term for more than 100 related rheumatic diseases
– each with its own risk factors. Risk factors for the
major types of arthritis and rheumatism include age,
genetics, obesity, injury and autoimmune
disorders.190, 191, 192 Although arthritis is most often
associated with the joints, rheumatic diseases can
also affect the internal organs and skin. People living
with this illness often endure years living with pain,
and attempts to manage it can also lead to depression
and anxiety.191, 192 In some cases, it becomes necessary
for the individual to undergo joint replacement
therapy. The Canadian Joint Replacement Registry
reported that degenerative osteoarthritis, the most
common form of arthritis from middle age onward, was
responsible for 81% of primary hip replacements and
93% of primary knee replacements in 2004-2005.193
Obesity
Obesity currently presents a considerable health
challenge in Canada (see the Chapter 2 text box
“Obesity: A Public Health Approach”). It can lead to
serious ill health due to its link with heart disease,
cancer, Type 2 diabetes, osteoarthritis and other
health outcomes.14, 195 In 2005, 24% of Canadians
18 years and older were considered to be ‘obese’
(i.e. with a body mass index equal to or above 30.0)
and an additional 35% were considered ‘overweight’
(i.e. with a body mass index of 25.0 to 29.9) based
on their measured height and weight.196 This is a
substantial increase from the 14% reported as obese
35
30
25
20
15
10
5
0
Less than
secondary
graduation
Secondary
graduation
Some postsecondary
Post-secondary
graduation
Educational attainment
Males
Females
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, Canadian
Community Health Survey (CCHS) 2005.
in 1978-1979.12 Obesity is not only a problem for adult
Canadians; measured heights and weights of Canadian
children in 2004 showed 8% of those aged 2 to 17
years as being obese and 18% as overweight.13
Given current levels of physical inactivity and poor
nutritional practices (see Chapter 4), obesity rates
in Canada are expected to continue to climb. Recent
research has reported that obesity rates for Canadian
men are among the highest in the world.197 As these
rates increase, so will the frequency of ill health
outcomes associated with being overweight and obese,
resulting in more disability and disease and many
premature deaths. It has been estimated that more
than 8,000 deaths in 2004 could be attributed to
obesity among Canadians aged 25 years and older.14
Differences in income and education, as well as
whether an individual was born in Canada, have
been linked to differences in obesity rates.178, 198 For
Canadians aged 19 to 45 years, those who did not
Body Mass Index,
Obesity and Health Risks
The body mass index (BMI) is a ratio of
weight-to-height calculated as:
BMI = weight (kg)/height (m)2.
Research studies in large groups of people
have shown that the BMI can be classified
into ranges associated with health risk.
There are six categories of BMI ranges in the
weight classification system. These are:
3
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Figure 3.17 Measured obesity by educational attainment
and sex, household population aged 19-45 years, Canada
(excluding territories), 2004
Percentage of
population
40
35
30
25
20
15
BMI Category
(kg/m2)
Risk of developing
health problems
Underweight
Normal weight
Overweight
Obese class I
Obese class II
Obese class III
<18.5
18.5-24.9
25.0-29.9
30.0-34.9
35.0-39.9
>=40.0
Increased
Least
Increased
High
Very high
Extremely high
10
5
The risk of developing weight-related health
problems increases the further one’s BMI falls
outside the ‘normal weight’ category.194, 195
complete high school are much more likely to be obese
compared to those who did complete high school or
had any level of post-secondary education
(see Figure 3.17).198
In terms of income levels, men and women seem to be
affected differently. As shown in Figure 3.18, among
those aged 46 to 65 years, obesity rates for women
tend to increase as income decreases for the three
groups with the highest incomes whereas, for men,
obesity rates tend to increase as income increases.198
While it is not entirely clear why this relationship is
reversed for men, some experts suggest that higher
smoking rates and physically demanding jobs may
contribute to lower rates of obesity in men with lower
levels of income.
0
Less than
secondary
graduation
Secondary
graduation
Some postsecondary
Post-secondary
graduation
Educational attainment
Males
Females
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, Canadian
Community Health Survey (CCHS) 2004.
Among Aboriginal Peoples living off reserve 38%
of adults and 20% of children are obese (based on
measured height and weight).12, 13 For First Nations
living on reserve or in First Nations communities,
36% of both adults and children are considered to
be obese based on self-reported height and weight
measurements.161
Self-reported data from 2005 suggest that recent
immigrants to Canada have a much lower prevalence of
obesity (less than 7% of that population). Immigrants
who have lived in Canada for some time are more
likely to be obese (roughly 13%), although their actual
prevalence of obesity is still lower than the overall
national rate.200 Also of note, more rural Canadians are
obese than those living in urban areas (29% and 20%
respectively).201
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Classification
31
CHAPTER
3
Our Population, Our Health
Figure 3.18 Measured obesity by income and sex,
household population aged 46-65 years, Canada
(excluding territories), 2004
Figure 3.19 Population aged 12+ years reporting
select mental illnesses within a 12-month period,
Canada, 2002
Percentage of
population
Percentage
of population
45
7
40
6
35
5
30
4
25
3
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
20
32
2
15
1
10
0
Bi-polar
disorders
5
Major
depression
0
Lowest
Lower-middle
Middle
Upper-middle
Panic
disorder
Agoraphobia
Social
anxiety
disorder
Schizophrenia
Type of mental illness
Highest
Males
Females
Income
Males
Females
Source: Public Health Agency of Canada, Centre for Chronic Disease
Prevention and Control, Health Status Indicators - Chronic Disease
Prevalences.
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Statistics Canada, Canadian
Community Health Survey (CCHS) 2004.
Mental illness
In 2002, almost 5% of Canadians reported having
experienced symptoms consistent with a major
depressive episode over the previous 12 months
and 20% reported having experienced symptoms of
depression, bipolar and/or a major anxiety disorder
at some point in their lifetime.117, 177 The WHO
estimated unipolar depression (depression without
manic episodes) to be the number one single disease
cause of overall ‘burden of disease’ (i.e. the impact of
premature death and disability combined) in Canada
in 2002.202 With the exception of bipolar disorders (i.e.
depression with manic episodes), more women than
men report symptoms consistent with depression and
anxiety disorder in Canada (see Figure 3.19).177
An additional concern related to mental illness is
suicide, which accounted for the fourth largest number
of potential years of life lost to premature mortality
in 2001.116 In 2004, the suicide rate in Canada was
roughly 11 suicide deaths per 100,000 population with
the rate for men (17 per 100,000) more than triple
the rate for women (5 per 100,000). Men aged 85 to
89 years old experience the highest rates of suicide
compared to other age groups, while suicide rates for
women peak between the ages of 50 to 54 years.117, 203
Infectious diseases
Rates of officially reported STIs have been on the rise
in Canada in recent years, particularly chlamydia,
infectious syphilis and gonorrhea. Between 1997 and
2006, reported chlamydia rates increased 78% (114 to
202/100,000), gonorrhea rates increased 122% (15 to
33/100,000) and infectious syphilis rates increased
1,050% (<1 to 5/100,000).204, 205 There is likely a
Some infectious diseases are more prevalent among
Aboriginal Peoples than the general population. In
2006, there were 27.4 reported new active and relapsed
tuberculosis cases per 100,000 in the Aboriginal
population, compared to just 5 per 100,000 in the
total Canadian population.209 Aboriginal Peoples also
accounted for more than 27% of all reported positive
HIV tests in 2006 in the 11 provinces/territories that
report ethnicity with their tests, although they are
estimated to make up only 6% of the population in
those provinces/territories.210
Summary
Although the health of Canada’s population is
considered very good – especially in comparison
to many other countries – a closer inspection of
differing rates of death, disease and disability
among various groups show that some Canadians are
experiencing worse health and a lower quality of life
than others. Several forces in society influence these
rates, including: the aging of the population; better
medical interventions that improve survival rates for
potentially fatal conditions; and a change in people’s
personal choices about eating, physical activity and
the use of substances such as tobacco and alcohol.
These are not the only factors at play as there is good
evidence that issues such as poverty, early childhood
development, education, employment and working
conditions, and aspects of the design and structure
of communities have a profound effect on people’s
individual health behaviours and health outcomes.
Chapter 4 explores some of the factors that influence
health and its distribution in this country.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
combination of factors which may explain this rise.
In the case of gonorrhea and chlamydia, screening
rates have increased – especially among men –
because of new less invasive testing. Other factors,
such as increases in risky sexual behaviour, lack of
knowledge regarding STI transmission and a more
relaxed attitude toward safe sex practices, are also
likely contributors and require further investigation.
Although genital herpes and human papillomavirus
(HPV) are not nationally reportable, they are also
common in Canada.204 While many STIs often produce
no symptoms initially, they can cause serious
health consequences if left untreated, including
pelvic inflammatory disease, ectopic pregnancy and
infertility.206, 207 It is now known that certain types of
HPV infections are responsible for almost all cases of
cervical cancer.208
3
CHAPTER
Our Population, Our Health
33
34
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
What makes – and keeps –
us healthy
If good health is not shared equally by Canadians,
then understanding the many factors – or
determinants – that contribute to health and
differences in health status is essential to identifying
and implementing solutions to this challenge.
Age, sex and heredity are key factors that determine
health. The choices we make also matter, but these
choices are influenced by environments, experiences,
cultures and other factors (the determinants of
health). And for some, even when the best choices
known are made, their health outcomes are limited by
these other factors.
Economic and social drivers such as income, education
and social connectedness have a direct bearing on
health.145, 167 These socio-economic determinants
strongly interact to influence health and, in general,
an improvement in any of these can produce an
improvement in both health behaviours and outcomes
among individuals and/or groups.
but are nonetheless affected by the demands they face
at home and at work and the degree to which they
have control and decision-making influence in those
settings. Generally, the degree to which people feel
they have control over their circumstances is related
to how healthy they are. Increased exposure to stress,
as well as a lack of resources, skills, social support and
connection to the community can contribute to less
healthy coping skills and poorer health behaviours
such as smoking, over-consumption of alcohol and less
healthy eating habits.7, 122
The structure of society also influences health through
the distribution of public goods and resources. In
fact, the extent to which these are equally shared
across the population has been shown to influence
the health of the population.2 Social support, social
networking and connection to culture can protect
against the health affects of living in disadvantaged
circumstances. As well, having a good start in
life can help set the trajectory for a healthier life.
Research now shows that many challenges for
adults (e.g. mental health issues, obesity, heart
disease, criminality, low literacy) have roots in early
childhood. Providing children with environments
that are stimulating, supportive and include positive
parental involvement – particularly during the fi rst six
years of life – can influence health (e.g. by mitigating
poor health outcomes in later life).212
The following socio-economic determinants of health
will be discussed in further detail in this chapter.
The order of this discussion reflects the importance
of the broader economic and social context for health
behaviours, access to health care and ultimately the
health of the population.
The determinants include:
Those with very low incomes, for example, often lack
resources and access to nutritious food, adequate
housing, safe walking paths and working conditions,
which can impact negatively on their health.7 As well,
they may face financial and life stress, which – over time
– can have health consequences such as high blood
pressure, or immune and circulatory complications.145
On the other hand, those who have adequate income
and employment are likely to experience health
outcomes that are less dependent on material needs
•
•
•
•
•
•
•
•
•
income;
employment and working conditions;
food security;
environment and housing;
early childhood development;
education and literacy;
social support and connectedness;
health behaviours; and
access to health care.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Health inequalities are differences in health
status experienced by various individuals or
groups in society. These can be the result of
genetic and biological factors, choices made or
by chance, but often they are because of unequal
access to key factors that influence health like
income, education, employment and social
supports.2
4
CHAPTER
Social and Economic Factors that
Influence Our Health and Contribute
to Health Inequalities
35
CHAPTER
4
Social and Economic Influences
Table 4.1 Factors influencing our health
Value
Description
Year
10.8
percent of the population based on 1992 low-income
cut-off levels
2005
6.3
percent of the population aged 15+ years
2006
9.2
percent of the population aged 12+ years
2004
Ground-level ozone exposure
38.1
parts per billion (population weighted)
2005
Fine particulate matter (PM2.5) exposure
9.5
micrograms per cubic metre (population weighted)
2005
Unable to access acceptable housing
13.7
percent of the population
2001
79.7
percent of the population aged 25+ years
2006
Some postsecondary education
60.1
percent of the population aged 25+ years
2006
Postsecondary education
54.2
percent of the population aged 25+ years
2006
62.3
percent of the population aged 12+ years
2005
951
per 100,000 population
2006
Daily smoking *
18.6
percent of the population aged 15+ years
2006
Engaged in leisure time physical activity *
52.2
percent of the population aged 12+ years
2005
Fruit and vegetable consumption
5+ times a day *
41.2
percent of the population aged 12+ years
2005
Heavy drinking (5+ drinks on one occasion
21.8
percent of the population aged 12+ years
2005
Any illicit drug use *
12.6
percent of the population aged 12+ years
2002
Teen pregnancy
30.5
pregnancies per 1,000 female population aged 15 to
19 years
2004
Regular family physician *
86.4
percent of the population aged 12+ years
2005
Contact with dental professional *
63.7
percent of the population aged 12+ years
2005
Income
Persons living in low income (after-tax)
Employment and working conditions
Unemployment rate
Food security
People reporting food insecurity *
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Environment and housing
36
Education and literacy
High school graduates
Social support and connectedness
Very or somewhat strong sense of
community belonging *
Violent crimes committed
Health behaviours
12+ times in a year) *
Access to health care
* Denotes self-reported data
Note: Some data may not be comparable. More detailed information can be found in Appendix D: Definitions and Data Sources for Indicators.
Sources: Public Health Agency of Canada using data from Health Canada, Statistics Canada, Canada Mortgage and Housing Canada and
Environment Canada.
Table 4.1 shows both measured statistics and selfreported indicators of key socio-economic factors
that influence the health of the overall population.
These statistics are collected from sources such as
the census, filed income and tax records, scientific
monitors (e.g. air quality instruments), and police/
enforcement records for criminal and/or violent
offences. The self-reported indicators in this table
rely on information provided by individuals on health
behaviours (e.g. daily smoking, sexual practices),
access to health care (e.g. visiting a physician), food
security and having a sense of community. What
follows is a description of these key factors, how they
affect different groups of Canadians and how they
vary across the population.
4
CHAPTER
Social and Economic Influences
Canadians have seen an overall increase in personal
income (adjusted for inflation) over time due to
decreases in unemployment and increases in basic
wages, but the poverty rate has not decreased
proportionately. In fact, the gap between those with
the highest and lowest incomes is widening
(see Figure 4.1).213
Figure 4.1 Average incomes for economic families, two
persons or more, in constant dollars, Canada, 1996-2005
Income
(2005 constant dollars)
$180,000
$160,000
Income
Income – alone, or in concert with other factors – is
a significant contributor to health and, consequently,
health inequalities. Research indicates that there is
a significant difference in disease prevalence and in
years of life lost between the highest-income quintile
and each income quintile lower than that of the
highest. As noted in Chapter 3, if all neighbourhoods
had the age- and sex-specific mortality rates of
the highest-income quintile neighbourhoods, then
the total potential years of life lost for all urban
neighbourhoods would have been reduced by
approximately 20%. This number is equivalent to more
than the total years of life lost annually to injuries
(19%) across all neighbourhoods (the second leading
cause of premature death).143, 173
$120,000
$100,000
$80,000
$60,000
$40,000
$20,000
$0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Highest 20%
Average
Lowest 20%
Source: Statistics Canada, Income in Canada, 2005.
While there is some debate as to how to measure
poverty, and in the absence of a consistent national
defi nition, this report uses the after-tax low-income
cut-off (LICO). LICO is a reference point for the
income level at which an individual or families may
fi nd it difficult to meet their basic needs.213 Poverty,
however, is more complex than just lack of money
(material poverty). It also includes social poverty
(or the ability to be a part of society).214 This is
particularly relevant considering the long-term
impacts on children growing up in poverty. The rates
presented here may under-represent the extent of
poverty – in terms of the numbers living in poverty
and the persistent social impacts of poverty.
In 2005, the overall poverty rate in Canada (i.e.
persons living in low-income after tax) was estimated
at close to 11%.213 Poverty rates are estimated to
be significantly higher than average among certain
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
$140,000
Also included in this chapter are interventions that
show how these factors can be impacted through
specific policies and programs. They have been
developed and delivered by different sectors of
Canadian society − including the public health
sector − that have been working together, as well
as independently, applying growing knowledge and
experience of what affects health and quality of life to
reduce inequalities. For some interventions, evidence
exists regarding their demonstrated value. Others have
been identified as ‘promising’ but have not been fully
studied or evaluated to prove their effectiveness. An
effort has been made to highlight activities across a
range of age groups, populations and environments
across Canada.
37
CHAPTER
4
Social and Economic Influences
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
groups: lone parents (26%); work limited persons
(21%); recent immigrants (19%); and off-reserve
Aboriginal Peoples (17%). As well, they are higher
in some neighbourhoods within Canadian cities.215
Lower-income families and individuals at the lowest
income levels tend to be concentrated in lower-income
neighbourhoods.216 As a result, they not only deal with
individual poverty but with the impacts of living in
the economically disadvantaged community around
them. Concentration of poverty adds to the total
impact of individual poverty on health when this
results in neighbourhoods with fewer resources and
services, more crime and less social support.261
38
Although Canada does not have a coordinated and
integrated national strategy to combat poverty, some
provinces and other bodies have introduced their
own strategies to address poverty – particularly for
children and families. Quebec and Newfoundland and
Labrador have introduced poverty reduction strategies,
and the Assembly of First Nations has recently
launched a strategic plan to decrease poverty through
creating opportunities, building on community assets
and structural change for management of resources.217,
218, 219
Focus on Poverty
Quebec’s Family Policy
Saskatchewan’s Initiative
Quebec’s Family Policy was put in place in 1997. It
includes an integrated child allowance, enhanced
maternity and parental leave, extended benefits
for self-employed women, and subsidized early
childhood education and child care services.
Through this policy, the province has been able
to establish a network of child care centres
for children aged four years and younger from
existing non-profit daycare centres and home
agencies. The centres offer low-cost care and
are no cost for parents on social assistance.
Elementary schools in the public system also
provide low-cost before- and after-school care
and full-day kindergarten is provided to all fiveyear-olds.220, 221 In addition, some school boards
offer full-day kindergarten to four-year-olds
from low-income families. Since 1997, Quebec’s
steady decline in poverty rates has resulted in
the greatest overall decrease among provinces
resulting in a 2005 child poverty rate lower
than the national average.213 While much of this
decline is due to economic growth, government
policies are also believed to have contributed to
lower poverty rates.217
Recognizing the health benefits of employment
(such as social networks and self esteem), as
well as the fact that some low-income working
families experience fi nancial difficulties paying
employment-related expenses (e.g. income taxes
and contributions, transportation, clothing
and child care) in addition to meeting basic
needs, Saskatchewan introduced an initiative
in 1997, which supports a number of programs
and services to help low-income people achieve
fi nancial security, including: the Saskatchewan
Employment Supplement; the Saskatchewan Child
Benefit; and Family Health Benefits (providing
additional health coverage for children).218, 223
Further assistance is available in the form of
child care subsidies, discount bus passes, rental
housing supplements and transitional employment
allowances. Eligibility for benefits is based
on an income threshold rather than welfare
eligibility. By 2004, Saskatchewan had seen 41%
fewer families dependent on social assistance
(6,800 families and almost 15,000 children) and
a substantial increase in after-tax disposable
income among families working for minimum
wage.218
CHAPTER
4
Social and Economic Influences
It is estimated that 788,000 children under the age
of 18 currently live in poverty, representing a decrease
over the last decade from a peak of 18.6% of all
children in 1996 to 11.7% in 2005
(see Figure 4.2).8, 213, 224
Figure 4.2 Children aged 0-17 years living in low-income
families (after tax), Canada, 1996-2005
Figure 4.3 Child low-income rates in OECD countries
based on market sources and disposable income: late
1990s and early 2000s
Percentage of
child population
in low Income
30
25
Percentage of
children
20
20
18
16
15
14
10
10
8
6
5
4
2
Year
Before Taxes and Transfers
Source: Public Health Agency of Canada using Statistics Canada, CANSIM
Table 202-0802.
Figure 4.3 shows that while the number of Canadian
children living in low-income families is lower than
in the U.S., it is more than double that of Nordic
countries such as Finland, Sweden and Norway.8 This
suggests that Canadian policies and programs have
not been as effective as some other OECD countries.
Generally, western and northern European countries
with a history of providing universal benefits for
families with children have the lowest rates of child
poverty once taxes and transfers are taken into
account.8, 225
Finland (2000)
Norway (2000)
France (2000)
Sweden (2000)
Belgium (1997)
2005
Hungary (1999)
2004
Netherlands (1999)
2003
Germany (2001)
2002
Greece (1999)
2001
Poland (1999)
2000
Canada (2000)
1999
UK (1999)
1998
Portugal (1999)
1997
NZ (2000/01)
1996
US (2000)
0
0
After Taxes and Transfers
Source: Adapted from Corak, M. (provided by Canadian Population
Health Initiative, 2007).
While Canada has had limited success in addressing
childhood poverty, the ability to reduce seniors’
poverty has been much better demonstrated (see text
box).123 Although there are no specific studies that
have traced the effect of an increase in overall health
among seniors with a reduction in seniors’ poverty,
the evidence linking health and income suggests that
the health of Canada’s seniors has benefited overall as
a result of these social investments.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
12
39
CHAPTER
4
Social and Economic Influences
Employment and working conditions
Supporting Seniors Through
Poverty Reduction
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
National Public Pensions
40
At the start of the last century, public
pensions were non-existent. At that time,
Canadian seniors were much more likely to be
economically disadvantaged than the general
population. Considering that income is an
important health determinant, this meant
that seniors were at greater risk of poor health
because of their fi nancial circumstances.226
When Old Age Security (OAS) was introduced
in 1952, it was Canada’s fi rst universal
pension. It was followed in the mid-1960s
by the employment-based Canada Pension
Plan (CPP) and Quebec Pension Plan (QPP),
and the income-tested Guaranteed Income
Supplement (GIS). A Spouse’s Allowance
(SPA) and Widowed Spouse’s Allowance – also
income-tested – followed in 1975 and 1985,
respectively.227 Provincial/territorial income
supplements for seniors were also added along
the way. Today, over 95% of seniors receive
income from OAS, GIS or SPA. As well, 96% of
senior men and 86% of senior women receive
CPP/QPP benefits. As Canada’s public pension
system matured, more seniors than ever
became eligible for benefits and their aftertax income increased by 18% between 1980
and 2003.123 This maturation has been cited
as a key factor in the major shift of Canada’s
prevalence of low-income among seniors –
from one of the highest among industrialized
nations in the 1970s to one of the lowest
today.8, 228
Employment provides Canadians with economic
opportunities which can influence individual and
family health. However, the working environment can
also significantly impact physical and mental health
through type of work and working conditions.2, 7
In 2006, Canada’s unemployment rate was at a 30-year
low of 6.3%. Although most regions in Canada have
seen a decline in the unemployment rate over time,
regional differences range from 3.8% in the Prairies
to 9.9% in Atlantic Canada.229 Additionally, recent
immigrants (within 5 years of immigration) have a
higher rate of unemployment (11.5%), despite being
more likely than their Canadian-born counterparts to
hold a university degree.230
In Canada, regulations and policies such as labour codes,
workers’ compensation, leave and disability benefits,
as well as job-site safety practices have worked to
universally protect Canadian employees. However,
workplace-related injury, disability and death still
occur and some workers are more affected than others.
In 2003, 630,000 Canadians experienced at least one
activity-limiting occupational injury. Blue collar
workers (sales and service, transport, equipment
operation, primary industry and manufacturing)
experience over four times the injury rates
experienced by white collar workers (business,
administrative, management, and occupations in
health, science, social science and arts). Men (5.2%)
experience more work-related injuries than women
(2.2%). Although the type of occupation is the key
to determination of risk, higher-income men (over
$60,000) and women (over $40,000) were less likely to
experience injury compared to those men and women
at lower income levels.231
Stress related to employment in the form of job strain
(work demand and control), satisfaction, perception of
physical risk and issues of job security is a significant
health concern for many Canadians.232 Overall, more
women than men report feeling work-related stress.
Perception of work stress also increases with levels of
education and household income.117 However, those in
the lowest income households also report experiencing
high rates of stress coinciding with job insecurity and
job dissatisfaction.232, 117
Over the last 20 years, the average workday for paid
and unpaid work has steadily increased for Canadian
adults aged 25 to 54 years, from 8.2 hours in 1986 to
8.8 hours in 2005. Like paid working hours, unpaid
work can be a source of stress for some Canadians.
Generally, women report feeling more time-stressed
than men. While both women and men report
participation in paid work has increased, women’s time
involved in unpaid work has decreased (from 4.8 to 4.3
hours per day) and men’s has increased (from 2.1 to 2.5
hours per day) between 1986 and 2005.233
Food security
Healthy eating requires being ‘food secure’ (i.e. having
physical and economic access to sufficient, safe and
nutritious foods to meet the needs of a healthy and
active life).236 In 2004, 9% of all Canadian households
reported being food insecure at some point in the
previous year as a result of financial challenges.237
There is a large difference in reported food insecurity
between households in the lowest and highest income
levels (48.3% vs. 1.3%). And there is evidence that
individuals with higher social and economic status
more regularly consume nutritious foods (fruits and
vegetables, dairy products, lean meats, whole grains)
than individuals with lower social and economic
status. Research shows that there is also an education
gradient associated with food insecurity, as 13.8%
of households with the lowest education attainment
level (less than high school) reported some form of
income-related food insecurity compared to 6.9%
of households with the highest education attained
(completion of post-secondary education).237
One in ten households with children, particularly
young children, experience food insecurity.237 When
children go to school hungry or poorly nourished,
their energy levels, memory, problem-solving skills,
creativity, concentration and behaviour are all
negatively impacted. Studies have shown that 31%
of elementary students and 62% of secondary school
students do not eat a nutritious breakfast before
school.238 Almost one quarter of Canadian children in
Grade 4 do not eat breakfast daily and, by Grade 8,
that number jumps to almost half of all girls.239
The reasons for this vary – from a lack of available
food or nutritious options in low-income homes, to
poor eating choices made by children and/or their
caregivers. As a result of being hungry at school,
these children may not reach their full developmental
potential – an outcome that can have a health impact
throughout their entire lives.
The growth in the number of food banks and school
breakfast programs in Canada reflects the fact that
food insecurity is increasingly being recognized as
a problem in Canada (see text box). The importance
of these types of programs cannot be overstated. At
the same time, however, it is crucial to address the
underlying causes of food insecurity: lack of income;
education; knowledge; employment and other barriers
to accessing affordable and nutritious food. In 1996,
Canada joined 186 other nations at the World Food
Summit in endorsing its goal to reduce the number
of undernourished people worldwide by half no later
than 2015. Canada’s Action Plan for Food Security,
launched in 1998, is a response to this commitment
and builds on a number of other existing international
and domestic commitments affecting food security
that Canada has made.240
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Longer hours and less predictable hours at work
can also impact the home/family environment.
An important aspect of healthy infant and child
development is the role parents play in the lives
of their children. In 2001, Canada’s employment
insurance program extended parental-leave benefits up
to one year. As a result, both the numbers of parents
taking leave and the length of leave have increased.234
However, many mothers still do not take extended
maternity leave – some mothers choose not to take
leave, some are not eligible (e.g. self-employed)
or some cannot afford to live on employment
insurance benefits (55% of their salary) that are not
supplemented by their employer.235
4
CHAPTER
Social and Economic Influences
41
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
CHAPTER
4
42
Social and Economic Influences
As part of the plan, Canada agreed to report on
these actions to Canadians every two years. To date,
these reports demonstrate the extensive network of
participants, both directly and indirectly, supporting
food security issues and how – in many cases – gaps
are being filled indirectly through general safety
net activities with no specific mandate in regards
to food security.241 Activities and commitments
within Canada include: meal programs for schools and
shelters; food banks; subsidized air transportation of
nutritious and perishable foods; food safety regulation
and surveillance (i.e. contaminants); emergency
requirements – safety and access; and research and
reporting on nutrition, the extent of food security
problems and the underlying socio-economic factors of
these problems.
Environment and housing
Where a person lives matters since both natural and
built environments influence health. It creates the
context for determinants of health such as income,
employment, social networks and personal behaviours.
Physical environment
Although health related to the environment is
primarily outside the scope of this report, the physical
environment can also contribute to health inequalities
(e.g. adequacy of housing, indoor air quality and
water supply). Environmental challenges associated
with changing conditions, particularly climate,
are expected to place increased health burdens on
society and the infrastructure now and towards the
foreseeable future.
Tackling Hunger
Breakfast for Learning
Since 1992, a non-profit organization called
Breakfast for Learning has been providing
funding, nutrition education and other resources
to community-based student nutrition programs
across the country with a goal to ensuring that
every child in Canada attends school without
hunger.242 Since its inception, Breakfast for
Learning has moved from initial funding for
20 programs to an investment in over 3,000
programs in every province and territory in
the country. With a network of over 30,000
volunteers, it has served healthy breakfasts,
lunches and snacks to over 1.5 million Canadian
school children to date.243, 244, 245 Although there
is a lack of data on breakfast programs meeting
goals, school staff have reported improvements
in scholastic performance, improved behaviour
and attentiveness among some students. Also,
volunteers in this program report high satisfaction
rates and a feeling of sense of community.246
The success of Breakfast for Learning in terms
of reaching so many school children is largely
attributed to the community-level involvement
and management of each program. The needs of
each area are determined by the combined efforts
of governments, private businesses, community
agencies, volunteers, food banks, parents and
educators.
Food Banks
In 2006, the Canadian Association of Food Banks
(CAFB) moved over 8.5 million pounds of foodindustry donations (worth $18 million) to its
members through the National Food Sharing
System.247 In addition to food received from the
CAFB, community-run food banks collect and
distribute an estimated 150 million pounds of
food per year.248 Canada’s first food bank opened
in Edmonton, Alberta in 1981.249 As of March 2007,
there were 673 food banks and 2,867 affiliated
agencies operating across the country in every
province and territory. That same month, those
food banks and agencies served over 2 million
meals and provided groceries to more than 720,000
individuals. Over the last 18 years, reliance on
food banks has increased 91% and, until food
security is better addressed in Canada, those
numbers will likely remain high.250
Outdoor air pollution causes health effects that
include coughing, aggravation of asthma and other
respiratory diseases, as well as the exacerbation
of cardiovascular disease. This results in increases
in emergency room visits, hospital admissions and
premature death as air quality degrades. Research
indicates even low concentrations of these pollutants
can result in adverse health effects.251 An increase in
air pollutants contributes to an increase in morbidity
and premature mortality. Health Canada estimates
that, in eight Canadian cities, air pollution is
responsible for 5,900 excess deaths per year.252
For the majority of Canadians, water quality is
considered to be safe, with 85% of Canadians receiving
their water supply from treated municipal water
works.253 Nevertheless, there are still challenges
to be addressed, particularly in small and remote
communities and on First Nations reserves.254
Built environment
The majority of Canadians (80%) live in urban areas.133
These built environments can influence physical and
mental health through factors such as community
design, adequate housing, access to safe water,
good sanitation, safe neighbourhoods, and adequate
access to education, recreational services, public
transit and child care.7, 167, 261 In essence, the built
structure provides the setting for many of the social
determinants of health.216
In Canada, the built environment is undergoing
significant change and one of the greatest challenges
is urban sprawl. Urban growth now typically
includes the creation of low-density, decentralized
communities that include suburban residential, strip
retail and employment development.
Building Healthier
Urban Communities
The Vancouver Agreement
When a public health emergency was
declared in Vancouver’s Downtown Eastside
neighbourhood, the governments of
Canada, British Columbia and Vancouver
came together to work toward an effective
and sustainable solution. Crime, drug
trafficking and drug use had contributed
to epidemic rates of HIV infection and had
created an unstable environment where
residents felt threatened and defeated.
Through a unique five-year tripartite
initiative called the Vancouver Agreement,
three levels of government were able to
combine their services and expertise and
work with residents, community groups and
businesses toward the creation of a healthier
community. Results have included: lower
death rates due to alcohol and drug use
(including overdoses), HIV-AIDS and suicide;
greater access to health services through the
opening of four new health clinics in the
community, expanded addiction treatment
services and an after-hours youth crisis
response program; and initiatives that
have made a difference to residents – from
employment for street youth in the city’s
hotel industry to a mobile after-hours dropin centre for sex workers who regularly face
violence and abuse. The initial Agreement
was created in 2000 and in 2005 it was
renewed for an additional five-year period.
It has been recognized through national
and international awards and replicated by
Western Economic Diversification Canada
through similar arrangements in other
western Canadian cities.255, 256, 257
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Particulate matter and ozone are two key components
of smog. In southern Ontario and southern Quebec,
an indicator of exposure to ground-level ozone
concentration has increased by about 17% and 15%
respectively between 1990 and 2005, while there
has been no discernible change in the indicator for
particulate matter over the same time period. No
trends were discernible for either pollutant in other
parts of the country.251
4
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The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
While city centres (cores or central business districts)
have traditionally provided the greatest source of
employment, reliance on suburban employment has now
grown as the growth of cities has increased outward.
For example, although, the number of jobs in Canada’s
city centres has increased, the number of jobs in
Canada’s suburbs has increased four times as much.258
44
Decentralized residential and employment areas
have also led to the development of extensive road
networks and greater reliance on vehicle commuting.
The number of Canadians who drive to work increases
with distance away from the city centre: at 5
kilometres from the centre, 58% of the population
drive; and at 20 kilometres away, 80% drive.259 This
increase in vehicle use and commuting has resulted
in higher incidences of vehicular injury in suburban
areas, as well as higher rates of heart and respiratory
diseases and obesity, and elevated stress related
to both commuting among congested traffic and
increased noise levels.260, 261
Urban land uses can positively and negatively
influence health behaviours. For example, ‘walkability’
measures the extent to which an urban environment
supports residents moving between places using
an active, safe and more environmentally friendly
form of transit such as walking or biking. However,
walkability is dependent on whether the community
design includes recreational pathways and sidewalks,
safe levels of lighting, and compatible land uses that
ensure pleasant safe spaces for both recreational
and transit activities.261 In more ‘walkable’
neighbourhoods, people tend to have increased
physical activity levels which may lead to lower rates
of obesity.262
Similarly, the built environment can influence access
to affordable and nutritious foods. There is evidence
that compared to higher-income neighbourhoods, lowincome neighbourhoods often have limited grocery
stores (particularly those selling fresh produce), offer
nutritious foods at a higher cost and have a greater
concentration of fast food services – all of which may
contribute to poorer eating habits among residents.
Designing Healthy and
Sustainable Cities
Healthy Cities
The Healthy Cities initiative is an
internationally led approach to building a
stronger movement for public health at the
urban level. Applying public health criteria
to choices made in communities about
land use and urban design can improve the
health of the communities’ populations.268
Coinciding with a trend toward urbanization,
the population in Canada and similarly
developed countries is aging. To address the
issues arising from these dual trends, the
WHO launched an age-friendly cities project
in 2005 with funding from the Government of
Canada, the Government of British Columbia
and Help the Aged UK.269 The project aims to
encourage communities to create age-friendly
physical and social urban environments that
will better support older citizens in making
choices that enhance their health and wellbeing and that will allow them to participate
in their communities, contributing their
skills, knowledge and experience.270 After
consulting with older citizens and their
caregivers/service providers in 33 cities
representing 22 countries, the WHO created
a “Global Age-Friendly Cities Guide” for any
government, organization and/or individual
interested in identifying and improving the
age-friendly status of a city.269, 271 Groups
in various countries, including Canada,
are already developing networks through
use of the Guide to support each other
and share best practices.269 In September
2006, the Federal, Provincial and Territorial
Ministers Responsible for Seniors endorsed
participation in a second component of the
project called the “Age-Friendly Rural and
Remote Communities Initiative”.272
Although urban areas provide many opportunities
for social contact with others, they can also
create anonymity and isolation.265 Regardless of
neighbourhood density, many urban dwellers say
that they do not know their neighbours, a number
of elderly residents live alone, and those who are not
connected with the greater community can experience
isolation.265, 267
Housing
Housing, or lack thereof, is a critical component of
an individual’s environment. In Canada, 13.7% of
Canadians report being unable to access acceptable
housing. The term acceptable housing used here refers
to housing that is affordable (costing less than 30%
of before-tax income), does not require major repairs
and is not overcrowded.273 The Canada Mortgage
and Housing Corporation reports that ‘affordability’
is the least frequently met of these criteria for
acceptability.274
Health outcomes related to housing are complex,
as housing can directly and indirectly impact
health. Inadequate housing may produce direct
effects in extreme climates. Respiratory disease/
poor lung function and allergies related to moulds
from cold, damp or poorly ventilated houses may
develop.278 Other health conditions can arise related
to exposure to specific toxic substances like lead and
asbestos from substandard plumbing and insulation,
environmental tobacco smoke and residential radon
from contaminated soil.279
Addressing Affordable Housing
Habitat for Humanity Canada
Habitat for Humanity Canada, a member of
the Habitat for Humanity International, is a
national, non-profit organization that works
to break the cycle of poverty for low-income
Canadian families by providing them with
safe, affordable housing and promoting
homeownership. Habitat homeowners work
alongside volunteers to build the homes,
which are funded through donations of money,
supplies, land and labour from community
partners that range from individuals to
corporations.275 At completion, homes are sold
to partner families at no profit. Mortgages
are interest-free and capped at 30% of the
homeowner’s income, with all payments going
to a revolving fund that fi nances the building
of more houses.276 Since 1985, when the fi rst
group in Winkler, Manitoba began its work,
Habitat for Humanity Canada has built more
than 1,200 homes across the country through
its 72 affiliates located in all 10 provinces
and two of the three territories.275 Habitat
homeowners are reported to benefit through
improved fi nances, less reliance on social
services and the chance to build equity in a
home. About 40% of recipient parents report
seeing an improvement in their children’s
school grades and 22% reported that it was
attributable to their children being healthier
and better able to concentrate since moving
into Habitat housing. Over half of recipient
parents reported seeing an improvement in
their children’s behaviour and 60% attributed
this to their children being happier, more
outgoing and feeling more confident.277
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The built environment can also provide opportunities
for social interaction through an array of social
networks and organizations. Generally, the larger
the urban centre, the greater the number and
complexity of social networks. Social engagement in
the community builds trust, efficacy and a sense of
belonging that is associated with improved mental
and immunological health.117 Urban centres tend to
be less culturally and socially homogeneous and have
diverse populations. Within these cities, communities
comprised of close networks of people of similar
cultural and social perspectives offer the benefits of
community such as social support.265 Research has
shown, for example, that recent immigrants can better
integrate into Canadian cities that have communities
with strong social and cultural support networks.266
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45
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
CHAPTER
4
46
Social and Economic Influences
Overcrowding and poorly ventilated houses can
also increase susceptibility to disease. The number
of people per dwelling has been known to greatly
impact the physical and mental health of inhabitants,
including raising the risk of acquiring tuberculosis.278
This is especially true for many Canadian Aboriginal
populations and for immigrants from some countries
where older generations infected with tuberculosis in
childhood may experience disease reactivation later in
life that can infect others in the home.280 Both groups
experience a higher rate of overcrowding than the
general population and also account for the highest
rates of new and relapsed cases of tuberculosis in
Canada.209, 281 Among Aboriginal populations in 2006,
rates of new and relapsed cases of tuberculosis were
at 27.4 per 100,000 compared to only 5 per 100,000
in the overall population. Among immigrants, rates
of new and relapsed tuberculosis cases were 14.8 per
100,000.209
Homelessness is also a health issue. It is difficult to
measure how many people in Canada are homeless
as homelessness is a continuum with a variety of
short and long term experiences.282 The most recent
number often cited – 150,000 people – is believed to
be an underestimate.283 Some of these people become
homeless as a result of inadequate income, living in
a community with inadequate housing, or having a
mental illness, which may hinder opportunities for
employment and income.284 While homelessness can
affect a broad range of people, approximately one
third of the homeless are between the ages of 16 and
24 years.285 A third of street youth report trading
sex for shelter, money and substances, particularly
cigarettes (80% of street youth smoke daily) and have
higher rates of STIs and blood-borne infections than
youth in the general population. A lack of housing
contributes to a vicious circle influencing eligibility
for income supports, community benefits, voter
registration and employment options that could bring
about changes in living conditions. As well, about half
of youth living on the street have been involved with
the child welfare system at some point during their
lifetime. An equal share were abused as children and
left home as a result. Many street youth dropped out
or were expelled from school. In 2003, for both male
and female street youth, the main source of income
was social welfare.286
Early childhood development
The earliest years are pivotal to a child’s growth and
development. Nurturing caregivers, positive learning
environments, good nutrition and social interaction
with other children all contribute to early physical
and social development in ways that can positively
affect health and well-being over a lifetime.8 A poor
start to life often leads to problems that can impact
health and long-term prospects.
There are three main areas critical to healthy child
development:
•
•
•
adequate income – family income should not be
a barrier to positive childhood development, and
support mechanisms should be in place for all
children to have a good start in life;
effective parenting and family functioning
– effective parenting skills are fundamental to
child development, however, parents may also
require employer support for flexible work hours
and maternity/parental leaves, as well as broader
social support for family based opportunities and
resources; and
supportive community environments – all
members of the community have a responsibility
for the healthy development of children.
Communities need to provide accessible health
and social programs and resources for families
with children.8
Overall, Canada’s children are developing well in terms
of physical, mental and emotional well-being. The WellBeing of Canada’s Children: Government of Canada Report
2008, indicates that the majority of Canadian children
show average or advanced levels of development
in terms of motor and social development (83.6%),
verbal (86.5%), number (83.7%) and cognitive (85.2%)
development. As well, most Canadian children do not
show signs of emotional anxiety (85.3%), physical
aggression (85.8%), or behaviours associated with
hyperactivity or inattention (93.4%).294
However, there is evidence that a health gradient in
childhood development exists according to social and
economic factors. Generally, children from families
with lower income and lower levels of education have
poorer overall health and higher rates of cognitive
difficulties, behavioural issues, hyperactivity and
obesity through childhood.294, 295, 296, 297, 298
Readiness to learn, a measure of children’s early
success in terms of abilities, attitudes and behaviours
as children start school, is an indicator of the
benefits of positive early experiences.299 Vancouver’s
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Social and Economic Influences
Community Asset Mapping Project found that children
who lived in lower-income families scored lower
on measured outcomes of school readiness such as
knowledge, skills, maturity, language and cognitive
development.300 Figure 4.4 shows that a child’s
receptive vocabulary score increases as household
income level increases. It also indicates that parental
involvement in children’s early learning is important
to success across all incomes. In each income group,
especially among families with the lowest incomes,
children who were read to daily had better receptive
vocabulary scores than children not read to daily.299
Community Action Program for Children
Healthy Child Manitoba
The Community Action Program for Children
(CAPC) provides long-term funding to community
groups and coalitions offering programs to address
the health and development of children (aged 0
to 6 years) who are living in conditions of risk
(e.g. low income, single parents, newcomers to
Canada).287 CAPC recognizes that communities
have the ability to identify and respond to the
needs of children and places a strong emphasis on
partnerships and community capacity building.
Approximately 450 CAPC projects operate in more
than 3,000 communities throughout Canada and
deliver approximately 1,800 programs that serve
an estimated 110,000 participants (children and
parents/caregivers) in a typical month.288 CAPC
projects involve partnerships which may include
health organizations, educational institutions,
community associations, early childhood or family
resource centres and child protection services.287
National and regional evaluations of CAPC have
found numerous benefits for families participating
in CAPC programs, including lower rates of
maternal depression and sense of isolation, and
less emotional and behavioural issues reported
among children.289
In March 2000, the Manitoba government
established Healthy Child Manitoba, a longterm, cross-departmental prevention strategy
for putting children and families fi rst.290, 291 The
Healthy Child Committee, comprised of eight
ministries, develops and leads child-centred
public policy across government and ensures
inter-departmental co-ordination with respect to
programs and services for children, adolescents
and families.290 A corresponding Deputy
Ministers’ committee and cross-departmental
working groups, ensure that children’s issues and
well-being are a shared priority. Healthy Child
Manitoba supports 26 province-wide parent-child
coalitions to promote and support communitybased programs that reflect each community’s
diversity and unique needs.292 Priorities include:
prenatal benefits and community programs:
FASD prevention and support; healthy schools;
healthy adolescent development and the recent
introduction, province-wide, of the Triple P
Positive Parenting Program.291 Results from
program specific evaluations have ranged from
improved parenting skills and a better sense of
community connectedness for families involved
in home visiting programs, to an 80% enrolment
rate in an alcohol and drug treatment program for
participants in the Stop FAS mentoring program
for women who have used alcohol or drugs during
current or previous pregnancies.291, 293
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Examples of Community Level Support for Children
47
CHAPTER
4
Social and Economic Influences
Figure 4.4 Receptive vocabulary scores* of children,
age 5, by household income levels, who were or were
not read to daily, Canada, 2002-2003
Culturally Relevant
Programming for Children
Score
110
Aboriginal Head Start Program
105
Canada’s Aboriginal Head Start in Urban and
Northern Communities (1995) and Aboriginal
Head Start On Reserve (1998) programs were
established to address the unique challenges
facing First Nations, Inuit and Métis children
and their families. The programs are designed
to prepare Aboriginal children (up to the
age of six) for their school years by helping
to meet their emotional, social, health,
nutritional and psychological needs. They
provide an opportunity for preschoolers to
learn traditional languages, culture and
values – along with school readiness skills –
while acquiring healthy living habits.303 At
the same time, their parents and caregivers
learn about healthy child development,
practical child safety tips, and available
community resources and services. Due to the
role of each community in the establishment
of the program for their children, the
spiritual and cultural dimensions of
Aboriginal life are included in the activities.
A recent evaluation of Aboriginal Head Start
in Urban and Northern Communities has
shown:
100
95
90
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
85
48
0
Below LICO
LICO to less
than 2 times
LICO
2 times LICO to
less than 3 times
LICO
3 times LICO
or above
Household income level
Not read to daily
Read to daily
LICO – Low-income cut-off.
*A score of 75 corresponds to the lower 5th percentile of the receptive
vocabulary score distribution.
Source: Public Health Agency of Canada using Statistics Canada,
National Longitudinal Survey of Children and Youth, 2002/2003.
The inability to access early childhood programs as
a result of distance, availability or affordability is a
significant barrier. Aboriginal and immigrant children
may experience additional barriers if local child
programming is not culturally relevant or delivered in
a familiar language (see text box). The consequences
of these disadvantages include children growing into
adults with lower educational attainment, weaker
literacy and communication skills, fewer employment
opportunities and poorer overall physical and mental
health.301, 302
There is clearly recognition in Canada of the
importance of early childhood development. As noted
in a recent report issued by the federal Minister of
Health’s Advisor on Healthy Children and Youth,
the nation’s growth is dependent on investing in
children’s health. This report also states, however,
that Canada can and should do better in terms of the
health and wellbeing of its children and youth.307 As
previously noted, rates of childhood poverty in this
country continue to be higher than other similarly
•
•
•
•
significant gains for children in the
areas of physical, personal and social
development and health;
positive changes in family nutrition and
health practices;
demonstrated school readiness with
strong skills among graduates; and
increased practice of cultural traditions
and use of native languages.304
Today more than 13,600 children and their
families in urban and northern communities
and on reserve across Canada are benefiting
from the Aboriginal Head Start programs.305, 306
developed nations. Although caution must be used
when comparing international health and development
indicators, it is also of concern that among 21
similarly developed nations Canada ranks 12th on
average across six dimensions of child well-being.307, 308
In addition, while the United Nations Report Card on
Child Well-being in Rich Countries ranks Canada high on
the dimensions of educational and material well-being
(2nd and 6th), we fair much worse in terms of family
and peer relationships (18th) and behaviours and risks
(17th).308
Education and literacy
Completing high school can help improve quality of
life for young people by providing them with the
tools and confidence they need to lead healthier,
more productive and prosperous lives that benefit
them as individuals and, in turn, benefit their
communities. Across the country, over 17 million
Canadians are high school graduates – about 80%
of Canadian adults over the age of 25.310 This puts
Canada among the top five OECD countries in terms of
high school completion rates.311 There are, however,
regional differences: British Columbia residents have
high school completion rates that are higher than
the Canadian average, while those in Quebec and the
Atlantic regions fall below the average.310 First Nation
populations also have lower levels of education than
the Canadian average, with just under half having
graduated from high school.161
In Canada, the high school dropout rate has decreased
since the 1990s to 10% among 20- to 24-year-olds.312
Despite this improvement some young Canadians
continue to remain at risk of quitting school
prematurely, especially disadvantaged youth who lack
the supports they need to reach their full potential.
Compared to Canadians who complete high school,
those who drop out are: more likely to receive social
assistance and unemployment payments; more likely
to become jailed; more prone to illness and injuries;
and more likely to have poor knowledge about health
behaviours.313 They are also less aware of and less apt
to use preventive health services and less likely to
participate (e.g. volunteer) in community activities.314
Differences are found between men and women and
their participation in post-secondary education.
The number of women who hold a university degree
has risen sharply (21% in 1991 to 34% in 2001),
whereas the number of men who hold a university
degree has increased at a lesser rate (16% in 1991
to 21% in 2001).318 It is also notable that the gap
between the proportion of men and women enrolling
in post-secondary education is increasing. Women,
who have been traditionally under-represented at
post-secondary institutions, now account for six out
of ten undergraduates at Canadian universities.319
Considering the influence of education on health, a
health gap related to lower education levels among
men may emerge if males continue to be underrepresented in higher education.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Generally, being well-educated equates to a better
job, higher income, greater health literacy, a wider
understanding of the implications of unhealthy
behaviour and an increased ability to navigate the
health care system – all of which lead to better health.
The data in Chapter 3 indicate that Canadians with
lower levels of education often experience poorer
health outcomes, including reduced life expectancy
and higher rates of infant mortality. Similarly, a
recent U.S. study found much higher early mortality
rates among lower-educated populations compared to
more educated populations. This study estimated that
if all adults had the same mortality rate as those with
the highest education, then the potential reduction
in premature mortality (or early death) would be
equivalent to eight times the number of deaths
averted by medical advances over the same period.309
4
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Social and Economic Influences
49
CHAPTER
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Social and Economic Influences
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Education and income are often inter-related in
terms of their impacts on health. Median earnings
by education level attained indicate that the higher
the education obtained, the higher the average
earnings (2001). In fact, those with a universitylevel diploma/certificate earn, on average, more than
twice the income ($48,648) of those who have not
completed high school ($21,230).320 Although more
women are now pursuing a post-secondary education
in comparison to men, their average full-time
employment wage has not increased proportionately.318
The wage gap between men and women has only
decreased by 2% (from 20 to 18% between 1991 and
2001) for full-time employment wages.318
50
In general, there is a correlation between levels of
education and literacy where the more educated
a person, the more likely he or she is to have a
comparable ability to read and comprehend written
material. The term ‘literacy’ is now understood
to include not only the ability to read, write and
calculate, but also to understand and apply learned
information in everyday life activities and decisions.
Illiteracy can have a direct impact on health, for
example, through the incorrect use of medications or
safety risks associated with the misuse of potentially
hazardous chemicals in the home or workplace.
About nine million Canadians (42% of those aged 16 to
65 years) perform below the literacy level considered
the minimum necessary to succeed in today’s economy
and society.314 The statistics are even more troubling
for certain groups, including seniors, immigrants and
Aboriginal Peoples.
Enhancing Opportunities for Education
Pathways to Education
Regent Park, located in the centre of Toronto
is considered Canada’s most economically
disadvantaged public housing project. The
community has limited infrastructure and
resources, and, until recently, offered few
reasons for youth to hope for a better future.
Over 80% of residents are visible minorities and
for 60% English is a second language.315 The
neighbourhood has the highest concentration
of low-income families in Toronto and twice the
number of single-parent families as the rest of the
city. With no secondary school in the community,
56% of the area’s high-school age kids dropped
out of high school in 2001 – twice the Toronto
average.316 That same year, the Regent Park
Community Health Centre decided to step in and
take action. They believed that today’s Regent
Park youth could become tomorrow’s leaders – so
they created Pathways to Education to break
the cycle of poverty and increase the chances
that youth would complete secondary school and
carry on to post-secondary education.315 The
program provides academic, social, fi nancial and
advocacy supports to at-risk and economically
disadvantaged youth, including access to tutors,
career mentors, student-parent support workers,
free transit tickets to get to and from school
(tied to attendance), and bursaries for college or
university for all students who go on to accredited
post-secondary programs.317 A recent independent
evaluation of the program found that:
•
•
•
•
over 90% of Regent Park’s high school
students were enrolled in the program;
school drop-out rates had significantly
decreased from 56 to 10% and absenteeism
had decreased by 50%;
the number of young people from this
community attending college or university
quadrupled from 20 to 80%; and
teen pregnancy rates fell 75%.316
The Pathways to Education Program is now being
expanded to five other communities, with plans to
reach more than 20 communities across Canada.315
Social support and connectedness
Family, friends and a feeling of belonging to a
community give people the sense of being a part of
something larger than themselves. Satisfaction with
self and community, problem-solving capabilities and
the ability to manage life situations can contribute
to better health overall.98 The extent to which people
participate in their community and feel that they
belong can positively influence their long-term
physical and mental health.
Social cohesion is a measure of social connectedness
that is based on how much people participate in their
community and how satisfied they are with their lives
in those communities. A frequently used measure of
social cohesion is voter turnout.311 Participation in the
political system suggests that individuals believe their
participation in the democratic process matters and
that they are invested in the community by caring
about the outcome. Young adults do not vote as often
as their older counterparts; however, they are more
likely to participate in politically related activities
such as petitions, meetings and boycotts.322 Overall,
fewer Canadians participate in elections than in the
past. Generally, those who do participate are more
likely to vote in national and provincial/territorial
elections than in municipal elections.323 The trend
is reversed for First Nations voters, whose rate of
participation in national elections is relatively low but
is high for First Nations community elections.324
Levels of social connectedness are also shaped by how
safe a person feels and the level of violence to which
he or she is exposed or perceives a threat – both of
which can impact mental and physical health.167 One
measure of safety in a community is the crime rate.
Canadians perceive that crime rates are increasing.325
Previous victims, in particular, believe this and feel
unsafe during daily activities. In reality, the overall
crime rate has decreased about 30% since peaking
in 1991, and the violent crime rate in Canada has
remained unchanged. Currently, the rate of violent
offences is approximately 951 per 100,000 population,
and is higher in rural areas (1,067 incidents per
100,000 population), than in urban areas (830 per
100,000 population).327, 328 In Canada’s territories, the
rate of violent victimization is almost three times
higher and the rate of physical assault is almost four
times higher than reported in the provinces.329
Often violence and maltreatment occur in places
where individuals should expect to feel the safest. The
disturbing problem of family violence continues, and
involves a range of abusive behaviours on the part of
someone in a relationship of trust and/or dependency.
About 8% of women and 7% of men report having
experienced an incidence of violence with a current
or previous partner.330 Women report experiencing
more serious forms of violence than men, and are
also more likely to incur injuries as a result of the
violence. Reported spousal abuse among Aboriginal
women and men off reserve is much higher than the
national average (e.g. 21% compared to 7% for physical
and sexual abuse in 2004).331 Approximately 4% of
seniors living in their own homes reported experiences
of abuse or neglect, most commonly material abuse
involving the misuse of the victim’s money or property
by a caretaker.332
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Four out of five Canadians report that in times of
crisis, they rely on someone (e.g. friends, family
members) as a confidante, for advice and for care.
Relying on individuals or communities for assistance
during these times is considered essential for good
mental health and coping skills.2 In terms of feeling
a sense of community, about 62% of Canadians report
this.321 Generally, people living in rural Canada are
more likely to report feeling a part of their community
than people living in urban areas, as are people with
higher incomes.
4
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51
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4
Social and Economic Influences
Improving Social Connectedness
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Santropol Roulant
52
Santropol Roulant is a Montréal-based not-forprofit organization founded in 1995 to provide
inexpensive, nutritious meals to seniors and
others living with a loss of autonomy.338 It
was initially conceived as a youth employment
initiative to provide meaningful work
experience to young people in the community
while meeting the dietary needs of vulnerable
populations, but has since grown to serve
an even greater purpose.339 In addition to
preparing and delivering meals, the volunteers
and staff also provide friendship and caring.
Young people seem to make a special impact
on the meal recipients with their youthful
energy and outlook. The connections being
made are unique – forged from a genuine
interest between generations, with sometimes
differing linguistic and cultural backgrounds,
instead of through family or obligation.340
With urban isolation on the increase among
seniors, this new approach to community is
an important part of what Santropol Roulant
delivers. Other Santropol activities include
the creation of a roof-top garden to provide
fresh organic fruits and vegetables to its
kitchen, and a roof-top garden guide and
start-up kits that are available to individuals
and groups interested in making their own
urban garden.341, 342 It is hoped that rooftop
gardening will help reconnect people in their
area to healthy foods, the environment and to
the greater community.343
Santropol Roulant currently relies on over 100
volunteers to run its program each week.344
Given the soaring costs of hospitalization
($700 per day to treat a malnourished
patient), the potential savings to taxpayers
from this service is estimated at $2.4 million
over the last five years.345
Children are also victims of violence and
maltreatment. In 2003, there were more than 235,000
investigations of maltreatment involving children
from birth to 15 years in Canada. For nearly half of
the investigations (49%), reports of maltreatment were
substantiated by an investigating agency. At least
one parent was the alleged perpetrator in 82% of child
maltreatment investigations in Canada (excluding
Quebec).333 Children who witness family violence often
exhibit negative behaviours, physical aggression,
emotional disorders, hyperactivity and destructive
behaviours.331, 334 In addition, a survivor of child
abuse is seven times more likely to become dependent
on substances and ten times more likely to commit
suicide.335
Rates of violence experienced by youth are four times
higher than for children. Among 14- to 17-year-olds
who reported being assaulted, over 50% were assaulted
by a close friend, co-worker or an acquaintance, 20%
were assaulted by a stranger and 16% by a family
member.336 And most often the violent acts occur in
a public place. At younger ages (between 11 and 15
years old), 25% of males and 21% of females reported
being bullied as a result of their race, ethnicity or
religion.337
Loneliness and isolation can have adverse impacts
on the health of many Canadians, particularly some
seniors. More than 6% of Canadians over the age of
65 reported not having any friends compared to 3%
of those aged 55 to 64. Those seniors who reported
having no friends are also less likely to report being in
excellent or very good health.123
Social exclusion is experienced when some people
or groups have limited control and access to social,
economic, political and cultural resources.145
Aboriginal Peoples have a long history of unequal
access to and control over education and health care,
as well as lands and natural resources, which has
resulted in social disconnection.216
Health can be influenced by historical and cultural
experiences that not only affect individuals but whole
communities.216 For example, residential schools had
a significant impact on the health and well-being
of many First Nations adults and consequently their
children and grandchildren.281, 346 Almost half of
residential school survivors report that the experience
negatively affected their mental and physical health
through isolation from family, separation from
community, and a loss of identity and language.347
Among their children, 43% believe the residential
school experience had a negative effect on their
parents’ parenting skills.161
the Canadian average, while more than half of the
First Nations communities in the province have not
had any suicides in many years. Further research on
language groups and community identity suggest that
cultural preservation and continuity, as well as living
in communities with self-government, settled land
claims, and access to self-managed education, health,
cultural and policing services all have positive impacts
on the health of the local population. The British
Columbia studies found that communities with some
level of self government and/or multiple community
control factors present had the lowest rates of
suicide.348, 349
Connectedness Through Self-Determination
The Eskasoni Primary Care Project
The Eskasoni project began with the decision of one
community of nearly 3,000 Mi’kmaq people on
Cape Breton Island, Nova Scotia to manage their
own health care.350 Overseeing the project was a
collaborative effort involving a Tripartite Steering
Committee made up of representatives from the
Eskasoni Band Council, the Nova Scotia Department
of Health, the First Nations and Inuit Health Branch
of Health Canada, and Dalhousie University’s
Department of Family Medicine.8 The approach
sought to break down barriers to accessing health
care and allow involved community members to
become proficient at planning, executing and
evaluating their own health programming. The
fi rst step was the building of a new health centre
to bring programs and services under one roof and
to streamline recordkeeping. Physician services
were then revamped to replace the one-doctor,
fee-for-service approach with a multi-doctor, multidiscipline approach based on salaried positions.
The results – better quality of care, lower health
care costs, greater accessibility to services, and
high client and staff satisfaction – have been well
worth the investment: 96% of all pregnancies are
now followed from pre- to post-natal care within
the community; costs for prescription drugs have
decreased, despite a population increase; and
referrals from physicians to a nutritionist/health
educator for managing diabetes have increased by
850%.351, 352 In addition, 73% of centre users report
receiving an appointment with their family doctor
within 24 hours or less and 90% within 48 hours.
Annual visits to the family doctor are also down
from a high of 11 visits per year to approximately
4. Trips to the out-patient/emergency department
at the regional hospital are down 40%. With fewer
trips off reserve for care, medical transportation
costs were reduced by $200,000 in the three-year
period after the centre opened.351
In 2004, the five Cape Breton Bands (Eskasoni,
Potlotek, Wagmatcook, We’koqma’q and Membertou
First Nations) came together through the Tui’kn
Initiative to build upon and expand the Eskasoni
model of primary health care to all Cape Breton
First Nations communities.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
High rates of suicide among First Nations people,
particularly among youth, are linked to social
exclusion and disconnection from their traditions
and culture. However, research suggests that it is
a mistake to assume these challenges are systemic
within First Nations communities and points to
protective factors that can reduce these risks.
Research from British Columbia has revealed that 90%
of Aboriginal youth suicides in the province occur in
just 10% of First Nations communities. Suicide rates
in these communities sometimes reach 800 times
4
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53
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4
Social and Economic Influences
Health behaviours
Individual behaviours, such as staying physically
active and eating well, can contribute to good
health. Other behaviours, such as smoking, heavy
drinking and illicit drug use, can have detrimental
health effects. Ultimately, health behaviours are
individual choices that people make. However, these
behaviours are influenced by the social and economic
environments where individuals work, live and learn.7, 9
Figure 4.5 Daily smoking by Aboriginal status, Canada, 2001
Percentage of
Daily Smoking
80
70
60
50
40
30
Smoking
Canada
20
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
10
54
While the overall smoking rate in Canada is declining,
19% of the Canadian population (over 15 years old)
still reports smoking (women 17%; men 20%).353
Smoking is responsible for high rates of disease and
death. It is a risk factor for lung cancer, head, neck
and throat cancers, heart disease, stroke, chronic
respiratory disease and other conditions.354 It is
estimated that 16.6% of all Canadian deaths are
attributable to smoking.355 And the cost of smoking in
Canada – in terms of services such as health care, and
the loss of productivity in the workplace or at home
resulting from premature death and disability – is
estimated at $17 billion per year.355
Most Canadian smokers (90%) report beginning to
smoke during their teens.356 However, most do not
quit until later in life. Among all Canadians who have
ever smoked, 59% have quit. For those smokers in
their early 20s (20- to 25-year-olds), only 25% have
reported quitting, while among those over the age of
45, 71% have reported quitting.353
0
First Nations
Métis
Inuit
Aboriginal status
Source: Public Health Agency of Canada using Health Canada’s Data
Analysis and Information System (DAIS), Aboriginal Peoples Survey, 2001
and Health Canada, Canadian Tobacco Use Monitoring System, 2001.
Figure 4.6 shows that although smoking rates have
been falling for all education levels, there continues
to be a marked difference between the percentage of
smokers who have completed university and those who
have not.361
Figure 4.6 Smoking and education, aged 15+ years,
Canada, 1999-2006
Percentage of
daily smsoking
35
30
A socio-economic gradient exists for smoking where
– in general – as income and education levels drop, a
larger proportion of people report daily smoking.357
The highest smoking rates can be found among
Canadians with lower income, Aboriginal populations
and people living in Northern Canada, which likely
contributes to the higher rates of cardiovascular and
respiratory diseases found in these populations.357, 358, 359
Figure 4.5 shows the proportion of daily tobacco
smoking, excluding those who use tobacco solely
for traditional purposes, among Aboriginal Peoples
compared to the overall population in 2001.360
25
20
15
10
5
0
1999
2000
2001
2002
2003
2004
2005
2006
Year
Some Secondary
Completed College
Completed Secondary
Completed University
Source: Public Health Agency of Canada using Health Canada, Canadian
Tobacco Use Monitoring System 1999-2006.
Physical activity
Leisure physical activity levels vary across different
populations and income levels, which may be a
product of available leisure time. The rate of
leisure-time physical activity is highest among those
at the highest end of the income spectrum
(see Figure 4.7). About 62% of Canadians over age 12
in the highest-income quintile report being physically
active compared to 44% among the lowest-income
quintile.366
Figure 4.7 Percentage of the general population aged
12+ years who were physically active by income,
Canada, 2005
Percentage
70
60
50
Research studies report a linear relationship between
physical activity and health such that the most
physically active are at the lowest risk of poor
health.364 Physical inactivity is a modifiable risk
factor for a wide range of chronic diseases including
cardiovascular disease, diabetes mellitus, cancer and
depression.364 Compared to people who are physically
active, those who report being physically inactive
are also more likely to report their mental health as
fair or poor. It is estimated that $5.3 billion (2.6%)
of the total direct health-care costs in Canada are
attributable to physical inactivity.365
Only just over half (52%) of Canadians over age 12
reported being physically active or moderately active
during leisure time in 2005. However, about 70% of
those who are inactive during leisure time report
some level of physical activity at non-leisure times.
During normal daily activity: 8% report carrying or
lifting heavy loads; 25% report frequently carrying
light loads and climbing stairs; 42% report frequently
standing or walking; and 24% report spending 6 or
more hours a week bicycling or walking as a means of
transportation.366
40
30
20
10
0
Lowest
Low-middle
Middle
High-middle
Highest
Income
Source: Statistics Canada, Physically Active Canadians.
Generally, women in all income groups report 5 to 10%
lower levels of physical leisure-time activity than men
and the gap between high- and low-income women
is greater than it is for men. Across Canada there is
regional variation in physical activity levels with a
clear east-west gradient. Provinces in Western Canada
report higher rates of active or moderate leisure-time
physical activity (e.g. 59% in British Columbia) versus
the East (e.g. 44% in Prince Edward Island). Overall,
Canada’s largest cities (over 2 million in population)
report lower rates of leisure-time physical activity
than the national average.366
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
For some, exposure to smoke is not a choice. About 9%
of children under the age of 12 and 15% of Canadian
households are regularly exposed to environmental
tobacco smoke – often called ‘second-hand smoke’.80
Among affected children, 51% live in the lowestincome quintile households compared to 18% who live
in the highest-income quintile households.362 Recent
measures to protect children from second-hand smoke
include legislation to ban smoking in vehicles carrying
children that was recently passed in Nova Scotia.
Other provinces are considering the same measures,
including British Columbia, Manitoba, Ontario and
New Brunswick.363 Rates of smoking during pregnancy
– a known risk factor for unhealthy fetal growth and
development – continue to decline in Canada. Yet,
9.8% of women who were pregnant in the last five
years also reported smoking during their pregnancy.353
4
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Social and Economic Influences
55
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4
Social and Economic Influences
Encouraging Healthy Lifestyles
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
ActNow BC
56
ActNow BC is a multi-year health and
wellness campaign that was launched by the
Government of British Columbia in March
2005. The campaign’s programs and initiatives
champion healthy eating, physical activity,
ending tobacco use and healthy choices during
pregnancy.367 Through its many partnerships,
ActNow BC is present in schools, workplaces
and communities throughout the province.
Since the start of the program, more than 130
towns, cities and First Nations communities
have registered as “Active Communities”; 100%
of school districts – encompassing over 1,300
elementary and middle schools with more than
360,000 students – have additional physical
activity throughout the school day through
Action Schools! BC; and the Ministry of Health
has piloted a Workplace Wellness initiative
that extends the approach to workplaces
across the province.368, 369, 370
ActNow BC is also partnering with the
National Collaborating Centre for Aboriginal
Health, First Nations Health Council, Métis
Nation BC and the BC Association Friendship
Centres to bring the healthy living approach
to Aboriginal communities in the province.
The goal is to ‘close the gap in health’ between
Aboriginal Peoples and the overall population
of British Columbia.371 Though early in
the process, ActNow BC’s uptake has been
promising and it has already been highlighted
by the Health Council of Canada (December
2007) as having the potential to have a
positive effect on the incidence of diabetes
and other chronic diseases in the province.372
Healthy eating
The types, quantity and quality of food eaten also
affect health. Aside from nutritional value, the
availability and affordability of nutritious food and
the individual food choices made are important. Less
healthy eating, combined with inadequate physical
activity, can lead to increased body weights. For
adults, obesity is a risk factor for many chronic
diseases including hypertension, Type 2 diabetes,
gallbladder disease, coronary artery disease,
osteoarthritis, and certain types of cancer.14 The
annual economic burden of unhealthy eating in
Canada has been estimated at $6.6 billion, including
direct health-care costs of $1.3 billion.373 Only 41.2%
of Canadians aged 12 years and over report consuming
fruits and vegetables at least five times per day.374
Eating healthy foods – such as fresh fruit and
vegetables, fibre-rich foods and those with a lower
fat content – is related to their accessibility and
affordability. Northern and remote communities do
not have as many food choices and healthy foods are
often more expensive than in more populated regions
of the country. A further challenge to healthy eating
is the availability of quick, less expensive and less
healthy foods. A recent University of Alberta study
found that more fast-food restaurants are situated in
Edmonton neighbourhoods where residents have lower
incomes and education levels and most people are
renters rather than home owners compared to other
neighbourhoods in the city.264
Parental practices such as breastfeeding can
positively influence an infant’s start in life. Canada’s
breastfeeding initiation rates have increased
dramatically over the last four decades (25% of
mothers initiated breastfeeding in 1965 compared to
87% of mothers in 2003).375 Breastfeeding initiation
rates vary between populations and are generally
lower for younger mothers (76% of those aged 15 to 19
years), single mothers (78%), Aboriginal off-reserve
mothers (82%), First Nations on-reserve mothers
(63%), and higher among immigrant mothers (92%)
(see text box).376 Although more mothers are now
initiating breastfeeding in Canada, many do not
maintain the practice. While the Canadian Paediatric
Society (2005) recommends that babies be breastfed
exclusively for six months, only 39% of Canadian
mothers report exclusive breastfeeding for four
Promoting Healthy Eating
Canada Prenatal Nutrition Program
months and 17% report exclusive breastfeeding for six
months or more.377, 378, 379 Overall, 48% of Canadian
mothers breastfeed for six months or more (exclusive
and non-exclusive) which is lower than rates in other
countries such as Sweden (70.6% in 2003).380, 381
Alcohol consumption
The majority of Canadians over the age of 15 drink
alcohol (77%).386 Some epidemiological evidence
indicates that there are protective health effects from
moderate alcohol consumption, specifically in relation
to circulatory diseases.355 However, excess alcohol
consumption over both the short and long term can
negatively influence health.386 Alcohol abuse also has
high economic and social costs. Alcohol-related acutecare hospitalizations totalled 1.6 million days in 2002.
That same year, there were 4,258 deaths attributable
to alcohol, of which 1,246 were due to cirrhosis, 909 to
motor vehicle crashes and 603 to suicides.355
Deaths related to alcohol dependence have declined
over time, but remain higher for low-income men
(see Figure 4.8).144 Differences between income levels
exist for both men and women but are greater for
men. Overall, the age-standardized mortality rate for
alcohol dependence has declined in all groups, with
the greatest decline for low-income men.144
Approximately 641,000 Canadians − roughly 3% of the
total population − are considered alcohol-dependent
and about 21% of all adult Canadians over the age of
19 reported engaging in heavy drinking (five or more
drinks on one occasion, 12 or more times a year) in
2005.386, 387
A greater share of individuals at the lowest income
level (about 5%), report behaviours consistent with
being dependent on alcohol.386 Because alcohol
dependence is a chronic condition that takes many
years to cause death from disease, and during that
period an alcoholic’s earning power may be reduced by
the condition, some of the gaps in these death rates
among income levels may be due to ‘reverse causation’
where the disease can reduce income before it kills.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
For more than a decade, the Canada Prenatal
Nutrition Program (CPNP) has provided longterm funding to community groups to develop
or enhance programs for at-risk pregnant
women and their children.382 The CPNP is
delivered through two separate organizations:
First Nations and Inuit Health Branch of Health
Canada and the Public Health Agency of Canada
(PHAC).382 CPNP aims to: improve the health of
both infant and mother; reduce the incidence
of unhealthy birth weights; promote and
support breastfeeding; build partnerships; and
strengthen community supports for pregnant
women.382 One way it does this is working
closely with other programs and organizations
to ensure that there is a continuum of
community-based support for women, and
their children and families.383 CPNP also
provides services like food supplementations,
nutritional counselling, prenatal vitamins, food
and food coupons, prenatal health and lifestyle
counselling (including smoking cessation),
breastfeeding education and support, food
preparation training, infant care and child
development, as well as referrals to other
services and agencies.382 The PHAC stream
of CPNP now serves about 50,000 women
annually through more than 330 projects in
over 2,000 communities across Canada.384 In
addition, more than 9,000 women take part
in the First Nations and Inuit Health Branch
stream of the program each year.382 Initial
program evaluation results indicate that
compared to similar high-risk populations,
CPNP program participants had higher birth
weights with increased program participation
and higher breastfeeding rates than the
general population.382, 385 Participants also
reported that, as a result of the programs, they
experienced improved access to services and
information on better nutrition and parenting,
felt less isolated and stressed, and had greater
self-confidence.382
4
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Social and Economic Influences
57
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4
Social and Economic Influences
Figure 4.8 Age-standardized mortality rates for
alcohol dependence, by sex and income quintile, urban
Canada, 1971-2001
ASMR per 100,000
population
12
10
8
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
6
58
4
2
0
1971
1976
1981
1986
1991
1996
2001
Illicit drug use
In 2002, 12.6% of Canadians over the age of 15
reported using illicit drugs in the previous 12 months
(9.4% of women and 15.9% of men). Approximately 1%
of Canadians self-reported behaviours consistent with
being dependent on illicit drugs, with the proportion
being the highest among those with the lowest
incomes (3%). However, as with alcohol dependence,
illicit drug dependence among low-income Canadians
could be related to reverse causation.386 Although
fewer people die directly from higher levels of illicit
drug use than from alcohol and tobacco use, such
deaths generally occur at a young age making years
of life lost due to early death high (62,110 years in
2002).355 These deaths are primarily due to overdose,
drug-attributable suicide and infectious diseases
(hepatitis C and HIV infections) acquired as a result of
drug-use activities.355
Sexual health
Year
Male
Female
Q5 - Poorest
Q5 - Poorest
Q1 - Richest
Q1 - Richest
ASMR – Age-standardized mortality rate.
Q – population divided into fifths based on the percentage of the
population in their neighbourhood below the low-income cut-offs.
Source: Wilkins et al. (2007), Statistics Canada.
First Nations on reserve report lower rates of alcohol
use (65.6%) but higher rates of heavy drinking than
the overall population. More than 42% of First Nations
youth on reserve report using alcohol and 27% report
heavy drinking at least once a month. In addition,
approximately 64% of First Nations reported that no
progress was being made within these communities on
reducing both frequent alcohol and drug use.161
Drinking during pregnancy can result in serious
health and development problems for children as a
result of Fetal Alcohol Spectrum Disorder (FASD) – a
preventable life-long disability. It is estimated that
1% of children born in Canada have FASD.388
Unsafe sexual practices – including early initiation,
infrequent use of condoms and multiple partners –
increase the risk of acquiring STIs and unplanned
pregnancies.122 Youth and young adults have the
highest rates of STIs in Canada, particularly street
youth who have rates 10 to 12 times higher than
their peers in the general population and a greater
susceptibility to the hepatitis B virus (i.e. 40% are not
vaccinated against it).204, 286
Overall, Canadian youth are becoming sexually
active at younger ages than previous generations.389
About 90% of 14- to 17-year-olds surveyed believe
they are knowledgeable about sexual health;
however, one quarter of Grade 9 and 10 students
who reported being sexually active also reported
not using contraceptives.337, 390 A second crossCanada survey also found that two thirds of Grade
9 students incorrectly believed there is a vaccine to
prevent HIV-AIDS.390 A recent increase in officially
reported STI rates may therefore partially be a result
of major misconceptions about these diseases. Despite
inconsistent contraception use and an increase in
STIs, teen pregnancy rates (including live births, fetal
losses and induced abortions) are decreasing.391
Access to health care
Access to health care is fundamental to health.
Approximately 80% of the Canadian population reports
visiting a regular family physician and 64% report
being in contact with a dental professional.392, 393 More
women than men report that they have contacted a
medical doctor in the previous year and that they
have a regular family physician.392
Unfortunately, some people face barriers to health
care services including physical inaccessibility,
socio-cultural issues or the cost of non-insured
health services (e.g. eye and dental care, mental
health counselling and prescription drugs).394, 395
A Canadian study on immigrant women’s health
reports that while immigrant women view health and
prevention in similar ways to Canadian-born women,
a difference exists in their ability to access the
resources needed to stay healthy.396 Reasons include:
language difficulties experienced by immigrants from
countries of origin where French or English is not a
primary language; a lack of cultural sensitivity among
health-care providers – especially for women clients;
and the fact that many immigrant women who are
employed work long hours in low-paying jobs, while
struggling to maintain households and care for young
children.397, 396, 398 Social supports are also often
lacking. These challenges can lead to a deterioration
of health, as can emotional distress caused by feelings
of displacement and isolation.396
Access to health care is also an issue for Aboriginal
populations who live off-reserve, as they are less likely
than the overall population (77% compared to 79%) to
regularly visit a physician, and more likely to report
having unmet health care needs (20% compared to
13%).402 First Nations adults living on-reserve cite
barriers to accessing the health care system ranging
from extensive wait times, services not covered by
benefits, a shortage of doctors/nurses in the area
and the cost of transportation, to complaints that
services provided were inadequate or not culturally
sensitive.161
Canadians in remote communities also face difficulties
accessing the health care system. Looking at the
Northwest Territories, both Aboriginal (59%) and
non-Aboriginal (76%) populations report lower rates
of contact with a health care professional than the
general population (79%).402 Both populations (49%
and 22%, respectively) are also more likely to use
available nursing services compared to the general
Canadian population (10%) indicating the vital
role nursing stations play in the health of remote
communities.402
Summary
To address health inequalities, the WHO states that
countries must make addressing the ‘structural’
stratification of their societies a priority. This means
reducing the gap between those at the highest
and lowest income levels through actions that will
eradicate poverty and increase opportunities for
employment, education and early child development
among the entire population. That, in turn, will help
to reduce the health inequalities currently found
among the Canadian population.
The successful interventions profiled in this chapter
are a beginning. They reinforce that public health
partners representing all sectors of society are making
inroads in identifying and implementing effective
interventions that are making a measurable difference
in Canadians’ lives. These successes provide a starting
point from which to draw inspiration, think, plan
and act.
What follows is a discussion of Canada’s efforts, as a
country, to address health inequalities with an eye to
where future efforts may be directed.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Not only do people seek treatment through Canada’s
publicly funded health care system, they benefit from
a number of disease prevention and health promotion
services. These services are generally integrated into
front-line care (sometimes referred to as ‘primary
care’) and range from childhood vaccinations to
disease screening to advice on healthy living and
mental health counselling.
4
CHAPTER
Social and Economic Influences
59
CHAPTER
4
Social and Economic Influences
Improving Access to Care
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Toronto’s Mobile Health Unit
60
A unique pilot project was created in 1981 to bring
health services to immigrant women who could not
afford time away from their jobs to take care of
their own health needs.399 Today, Toronto’s Mobile
Health Unit – part of the Immigrant Women’s Health
Centre – is still providing women in factories,
shelters, community centres and other locations
with the opportunity to receive primary care at no
cost from female health care providers experienced
in cultural and gender sensitivity and the
challenges facing immigrant women.400 The project
was launched after discussions with immigrant
women revealed that, although they looked after
their children’s health care needs, their own needs
were often unmet due to a number of barriers.401
These included an unwillingness to take unpaid
time off work, lack of child care, language issues
and discomfort with male health-care providers.396
In response, the Mobile Health Unit can be called
in, preceded by a team of counsellors who visit
the work site in advance and talk to the women
in their native languages about a range of health
care issues like pap tests and breast exams.399, 401
Once comfortable, the women will often seek more
information (e.g. birth control, mental health).
Then appointments are booked for the day the unit
will be on site. At work sites visited by the unit,
employers report experiencing lower employee
absenteeism caused by health issues and off-site
medical appointments.401, 398 The need for accessible
and culturally sensitive health care continues to be
an issue for all regions of Canada where immigrants
and refugees settle. The Toronto unit, for example,
currently has a three- to four-month waiting list
and constantly fields calls from employers and
organizations outside of the city limits that it
cannot serve.401
TeleHomeCare in
Prince Edward Island
West Prince TeleHomeCare program began in 1999
as a pilot project in TeleHospice. The pilot project
was created to compensate for a shortage of nurses
in the area, increasing the ability of existing staff
to monitor terminally ill patients living in rural and
isolated areas of the community who wish to stay
at home. Due to its success, the program has been
expanded to include patients with complex health
needs such as mental health, diabetes, congestive
heart failure, and chronic obstructive pulmonary
disease.403
Through the use of an innovative videoconferencing system, nurses can provide care,
instruction and education to patients through a
telephone line and two-way video screen. Blood
pressure, heart rate, weight and blood oxygen levels
can be monitored through attachments. Patients
like the service because they stay at home, with
little disruption to their lives, but can consult with
medical staff as required. Though care is facilitated
through technology, patients like the interactive
component and feel personally connected to
providers that they can see and hear in real time
during their daily exchanges. Caregivers also
appreciate the ability to consult with nursing staff.
Since launching the tele-hospice service, the West
Prince Health region has seen a 73% reduction
in days of hospitalization, 15% fewer emergency
room visits, 46% fewer hospital admissions and a
20% drop in doctor’s office appointments among
clients.404
It has also garnered national and international
recognition as a model for the cost-effective use
of technology to address the health-care needs of
persons living in rural and remote locations.405
Canadians take pride in the fact that they live in a
healthy and egalitarian society. However, the evidence
in the previous chapters should serve as notice
that this is not a state of affairs shared across the
population. The situation is not irreversible, as shown
by the interventions highlighted in this report. These
demonstrate examples of effective actions that can
be undertaken to address inequalities and improve
people’s health status.
Of course, solutions are not always easy or
straightforward. What works for one individual or
community may not work for another. Understanding
the reasons for this, and identifying what does and
does not work, is key. Part of the challenge is that
many of Canada’s social investments do not have the
explicit goal of reducing health inequalities, and so
their impact is never measured in those terms. In fact,
Canada does not have a strong record on measuring
the outcomes of many of its investments, not just
those involving public health.2, 7, 82, 92, 406 Impact
measurement is an area where better investment
would be warranted.
While there is work to do in terms of measuring
the impact of Canada’s policies and programs, some
things are already very clear. The fi rst is that it is not
enough to focus solely on individual health choices
and behaviours, as peoples’ actions are very much
shaped by the social and environmental conditions in
which they live and work. A balanced mix of targeted
interventions for some and universal programs for
all is more likely to work in a country as vast and
complex as Canada.2, 7 This kind of balance ensures
that, regardless of personal circumstances, Canadians
experience those conditions necessary for better
health and for making healthy choices easier choices.
Leading-edge Knowledge
A number of reports are expected in 2008 that
will contribute greatly to a better understanding
of promising approaches to addressing health
inequalities and determinants of health.
Among them are reports from:
WHO Commission on Social Determinants of
Health - Canada is a significant contributor
to the Commission, which was established
to reduce health inequalities within and
between countries through policy and action.
The Commission will release several reports
of interest, including its fi nal report and
recommendations, reports of country partners’
experiences in addressing health inequalities
and research synthesis reports from the
Commission’s Knowledge Networks.
Senate Sub-Committee on Population
Health - Established in 2006, this subcommittee is mandated to examine the
multiple determinants of health and make
recommendations to Parliament regarding
how to more effectively address them through
action across government departments.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
This chapter provides an accounting of where Canada
is in terms of addressing health inequalities and
identifies areas that require priority consideration in
order to achieve further change. Chapter 6 provides
more specific direction on how Canada, as a country,
can move forward in three key areas.
5
CHAPTER
Addressing Inequalities
– Where are we in Canada
61
CHAPTER
5
Addressing Inequalities
Finally – and most importantly – waiting until all the
evidence is in before taking action is not an option.
Some health inequalities are widening, necessitating
that Canada move further and faster to alleviate the
conditions that contribute to their existence in the
first place.144 Failing to do so will impact all Canadians.
Priority areas for action
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Evidence indicates that the following priority areas
can make a difference in reducing health inequalities:
62
•
•
•
•
•
social investment;
community capacity;
inter-sectoral action;
knowledge infrastructure; and
leadership.2, 407
Social investment
Canada has strong social policy foundations that have
helped to make it both healthier and more egalitarian.
Programs like the Canada and Quebec Pension Plans,
Old Age Security, Employment Insurance, publicly
funded health care and universal primary and
secondary education have all helped to establish a
minimum standard of living. This minimum standard
is a critical factor in the health of Canadians.
However, Canada may not be keeping pace with the
progress being made in other countries, especially
(as noted) in areas like child poverty.307, 408 If this
continues, increasing numbers of Canadians may
not achieve their health potential and increased
inequalities will follow, impacting the nation’s
collective economic and social well-being.
Community capacity
Working to strengthen communities is a critical
component of any comprehensive plan to address health
inequalities and is an area of strength in Canada.
Programs and initiatives that rely on input and
participation at the community level – like the
Community Action Program for Children and
Aboriginal Head Start − enable communities to be
directly involved in identifying their needs and
tailoring appropriate solutions. In addition to building
capacity within communities, investments in such
initiatives are often managed by coalitions of local
stakeholders, ensuring more comprehensive, crosssectoral approaches. Much has been learned about how
to reach people and influence behaviours and health
outcomes as a result of these partnerships.
The influence of community-level initiatives is
limited by the communities’ inability to address
or override the broader societal factors affecting
the health of their inhabitants.409 At times, social
programs and policies operating in an uncoordinated
way may negate the good work of community-level
initiatives and consequently discourage the pursuit of
fi nancial independence for individuals. For example,
if social assistance recipients lose money or benefits
as the result of increasing their income or gaining
employment, they are essentially discouraged from
becoming independent and leaving social assistance.
In these cases, government benefits programs work
contrary to their purpose.410 Complementary and
coherent action is therefore needed over broader social
policy and investments.
Greater support for the various efforts being made
in community health can also make a difference.
This requires considering and more strongly defining
the roles that can be taken by governments, nongovernmental organizations and the private sector.
Finally, it is essential to measure longer-term progress
being made in communities so that programs can be
supported consistently based on their impact and
effectiveness.
Inter-sectoral action
Throughout this report it has been demonstrated
that factors such as adequate income, education and
housing are critical to maintaining good health.
Most interventions in these areas fall outside of the
mandate of the formal health sector. Therefore, to
effectively prevent and improve health inequalities,
all levels of government, the private and nongovernmental sectors, and international organizations
must work together towards integrated, coherent
policies and actions.
Canada has experience working across sectors. These
efforts generally fall into four categories:
•
•
•
supporting communities to solve complex issues
(e.g. the Vancouver Agreement);
population-specific approaches to address multiple
determinants of health (e.g. Healthy Child
Manitoba);
issues-based collaboration (e.g. ActNow BC, Joint
Consortium on School Health); and
providing tools for cross-departmental policy
review (e.g. Quebec Public Health Act – see text
box).
Canada can build on these efforts, especially where
mutual benefits across sectors (health, social and
economic) hold the greatest promise.
Knowledge infrastructure
There is good and improving knowledge of what is
required to address the social determinants of health
that lead to inequalities in this country. The roles
that the public (individuals and communities), civic
leaders and decision-makers (government, not-forprofit and private sectors) can play in addressing these
inequalities are also well understood.409 This provides
a good foundation from which to build:
•
•
•
better information about specific sub-populations
and regions of this country that consistently
demonstrate poorer health outcomes;
further research to more clearly understand
how determinants interact to create health
inequalities; and
stronger insight into how to apply practices
that have proven effective in other jurisdictions
domestically and internationally.411
Most important, however, is the need to determine
whether current and future efforts in addressing
health inequalities are working. This can only be
achieved by monitoring results over time. This, in
turn, depends on the use of better reporting systems
and tools, increasing the availability of data, and
better co-ordination and co-operation across sectors
and jurisdictions. Some work is underway to address
these requirements but support for further efforts is
critical.
Leadership
Bringing about action requires more than good ideas
or honourable ideals. The many examples outlined in
this report have underscored that, ultimately,
high-level leadership in all sectors – health and
otherwise – is crucial to reducing health inequalities.
While socio-economic conditions and specific
health problems vary globally, all countries have
portions of their population at higher risk of health
challenges.7, 10, 122, 412, 413, 414, 418 Some, however,
have moved from concern to concerted action by
establishing a commitment to reducing health
inequalities. In particular, the Nordic countries and
the United Kingdom (U.K.) have identified health
inequalities as a priority and conducted audits of the
roles that government departments can and do play in
reducing social and health inequalities.412, 414 The U.K.
has set specific goals, objectives and targets to reduce
inequalities, with implications across a number of
sectors, and they have committed to measuring impact
and reporting on progress.
Domestically, Quebec is at the forefront of efforts to
reduce health inequalities through new approaches
to leadership and healthy public policy. Considering
the approaches taken by various governments can
help Canada’s efforts to evolve and improve as new
information and best practices emerge (see text box).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
•
5
CHAPTER
Addressing Inequalities
63
CHAPTER
5
Addressing Inequalities
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Potential for progress
64
With the creation of the position of Chief Public
Health Officer, as well as the establishment of the
Public Health Agency of Canada, there is strengthened
national public health leadership in Canada. When
the Agency was formed, its legislation provided the
authority to communicate with other sectors regarding
public health issues in order to foster collaboration
towards better health for all Canadians. It also
mandated the Chief Public Health Officer to report
on the state of public health and identify the issues
which impact the health of Canadians. This report
has been submitted to the Minister of Health and
Parliament as part of that mandate.
Along with the creation of the Agency came the
development of the Pan-Canadian Public Health
Network.422 The network is comprised of federal,
provincial and territorial representatives, and is a
forum for discussion across Canada on public health
issues. As well, the National Collaborating Centres
for Public Health were created to translate existing
and new research evidence into public policy. The
six centres are located in different regions across the
country and each one specializes in a priority area
(see Appendix B).
These are new tools and resources that, when
combined with efforts like those highlighted
throughout this report by the health sector and other
sectors (e.g. education and social services), provide
Canada with an unprecedented opportunity to effect
positive change in public health. The question is: are
Canadians up to the challenge?
Government Approaches to Tackling Health Inequalities and
the Social Determinants of Health
The U.K. approach
In 1998, the U.K. government undertook a study
of health inequalities, examining the social,
economic and environmental factors affecting
peoples’ health. A subsequent report provided
40 recommendations to tackle the underlying
issues at the root of health disparities. It also
emphasized that addressing the short-term
consequences of ill health is not enough and that
efforts must be made in partnership with the
voluntary, community and business sectors, as
well as individual citizens to prevent ill health
and promote healthy living.415
The following year, “The National Health Services
(NHS) Plan: A Plan for Investment, A Plan for
Reform” committed government to local targets
to reduce health inequalities with reinforcement
from proposed national health inequalities
targets.416 A cross-cutting federal review followed
in 2002 that examined how government spending
could be applied to greatest effect on health
inequalities.417
Based on this research and advice, the National
Public Service Agreement (PSA) committed
government to, by 2010, reducing inequalities
in health outcomes by 10% as measured by
infant mortality and life expectancy at birth. A
high-level, government-wide strategy called “A
Programme for Action” was then developed. The
fi rst principle of the strategy was to stop the
U.K.’s health gap from widening further, before
trying to narrow it.412
Status reports on the progress made since
the initiation of the program have shown an
improvement in two of the indicators associated
with health inequality: child poverty and housing.
There is also evidence of a narrowing of the gap
in heart disease mortality, cancer, influenza
vaccinations and educational attainment. Life
expectancies were found to be higher overall
since 1997-1999 and the life expectancy gap
seemed to be narrowing in three fi fths of the 70
local authority areas with the worst health and
deprivation indicators. The one exception was
infant mortality rates where the gap widened since
the baseline period.413
The strategy is based on the premise that health
inequalities should be tackled through a process
called ‘levelling up’ where those who enjoy the best
health should strive to maintain it while national
efforts focus on helping the rest of the population
to bring their health up to that same level.414
A plan to target health
inequalities in Norway
Quebec’s Public Health Act (Article 54)
•
•
•
•
reduction of social inequalities that contribute
to health inequalities;
reduction of social inequalities in healthrelated behaviour and use of health services;
use of targeted initiatives to promote social
inclusion; and
development of knowledge and cross-sectoral
tools.
A unique approach to public health in the province
of Quebec has other provinces and, indeed, other
countries, taking notice.419 By requiring other
government departments to consult with the
Minister of Health and Social Services in regard
to decisions or actions that could impact public
health – a broader, more comprehensive and
inclusive approach to public health strategies and
interventions has been taken.420 The consulting
component of this ‘whole of government’ approach
came into law with the adoption of Article 54
in Quebec’s Public Health Act in 2001. It states
that new measures provided for in an Act or
regulation in all provincial ministries be assessed
to determine significant impacts of proposed
actions on the health of populations. A health
impact assessment (HIA) process is currently used
to carry out these determinations, an approach
that is fairly new to Canada outside of Quebec but
more common in some European countries.420 At
the national level, Canada’s National Collaborating
Centre for Healthy Public Policy is currently
studying HIA in relation to Article 54 and public
policy, and will disseminate its fi ndings to the
public health community.421
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
The general health of the population of Norway is
considered quite good by international standards.
Like other nations, however, not everyone in the
population enjoys the same level of health – in
order to have an average you must have people
whose health is either better than average or
worse. On June 6, 2007 the Norwegian parliament
(Storting) adopted a 10-year “National Strategy
to Reduce Social Inequalities in Health” which
identifies key actions to be taken in four priority
areas:
5
CHAPTER
Addressing Inequalities
65
66
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
It is well documented that the top three causes
of premature death in this country are cancers,
circulatory diseases and unintentional injuries.116
But there are some things that might surprise
Canadians.
This is not to say that lower education and income
directly cause early death. There is no evidence to
make the claim of clear linear cause and effect in that
regard. But what can be said is that, in general, people
are less healthy in relation to lower levels of education
and income, and much of why and how this occurs is
not well understood.
In the last chapter, priority areas for action were
discussed. This chapter considers what could be done
in regards to Canada’s three most pressing priorities –
fostering leadership and collective will, reducing child
poverty and strengthening communities.
Imagine if all Canadians and all sectors applied their
energy, resources and resolve to address the full range
of issues that can affect health.
It is estimated that $1 invested in the early years
saves between $3 and $9 in future spending on the
health and criminal justice systems, as well as on
social assistance.423 Imagine the long-term benefit to
taxpayers then, if Canada were to achieve progress
on child poverty rates as good or better than world
leaders such as Finland, Norway and Sweden.8, 424
Imagine if the extraordinary success of Regent Park’s
“Pathways to Education” project was replicated
nation-wide.316 While we have some of the highest
rates of high school completion in the world, think
what Canada could achieve if all young people had
the supports they needed to fi nish a secondary
education and the corresponding increase that would
bring to the number of youth moving on to college or
university. Consider the impact of those highly skilled
and educated workers on Canada’s competitiveness and
future prosperity, not to mention the likely health
benefits to these individuals.
Imagine how much healthier people would be if
every Canadian had access to adequate housing. The
impacts would be profound for many communities,
but in particular for people living on First Nations
reserves where half of existing housing falls short of
Canada Mortgage and Housing Corporation standards
and where, partly as a consequence, tuberculosis
rates are eight to ten times higher than the general
population.209, 278 Could individual ownership help
Canada move in that direction?
What would be the impact if all First Nations and Inuit
communities had agreements in place for education
and health services that provided them with increased
control over their communities’ future?
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
If levels of education and income are viewed as rungs
on a ladder, there is evidence that shows that every
step down from the top brings with it a reduction in
health.9, 98, 122, 145 Those not at the highest levels of
education and income are less healthy, and collectively
lose more years of life to premature death. Evidence
suggests that if all Canadians had the same rate
of premature death as the most affluent one fifth
of Canadians, there would be a 20% reduction in
premature mortality across the population.144 This
would be equivalent to wiping out all premature
deaths from either injuries or cardiovascular
diseases.144 However, this is not simply a matter of
extremes between those at the highest and lowest
incomes, or between the most and least educated. It is
a gradient where at every level there is a difference in
health status.
6
CHAPTER
Moving Forward
– Imagine the Possibilities
67
CHAPTER
6
Moving Forward
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Imagine the improvements in peoples’ quality of life
if, by addressing the factors that influence health,
physical and social environments were created in
which Canadians could easily make good choices to
achieve and maintain the highest state of health
possible.425 Far fewer Canadians would be treated for
chronic conditions like heart disease, cancer, Type 2
diabetes and emphysema. And waiting lists for hip
and knee replacement would be shortened.
68
None of this is beyond the realm of possibility. In fact,
all Canadians pay a high price by failing to address
these issues. There are direct costs to the health care
system resulting from health inequalities, and these
costs will only grow if the causes of health inequalities
are not addressed.2 There are also indirect costs, such
as lost productivity, that have negative repercussions
for the entire economy.2, 98, 426
Foster collective will and leadership
If Canadians are serious about wanting to be the
healthiest country in the world, addressing health
gaps must become a priority.
Working across sectors and jurisdictions, there is
reason to believe health inequalities can be reduced
while advancing other social goals such as reducing
crime and fostering civic participation. Through
collective will and leadership Canada can achieve this
goal by:
•
A time to act
Improvements in quality of life over the past century
have helped Canada to become one of the healthiest
nations in the world.141, 427 Conditions are ripe to take
this a step further by aiming to be the healthiest
nation with the smallest gap in health. Employment
levels are at an all-time high, Canada also boasts one
of the best-educated populations in the world, with a
higher proportion of post-secondary graduates than
almost any other country.314
Clearly, the necessary means and talent exist to tackle
the wide array of health inequalities that prevent
individuals from achieving their dreams and goals,
and which limit Canada’s ability to achieve its full
economic and social potential.
•
•
•
What can be done?
building recognition of the importance of
preventing disease and injury, and of promoting
health. While a strong and accessible health
care system will always be vitally important,
prevention is preferable to treatment and has
the potential to yield a significant return on
investment.328 Public health is about more
than being ready to respond in times of health
emergencies – it is about keeping the population
healthy at all times so that the impact of health
emergencies can be kept to a minimum;
identifying the appropriate indicators and
creating the tools required to measure and
monitor progress, as well as addressing
knowledge and data gaps that prevent effective
measurement. By establishing a point of
comparison, it will be possible to assess Canada’s
progress, or lack thereof, in responding to health
inequalities – over time and in relation to other
countries;
cultivating a whole-of-society response.
Canadians’ health is a shared responsibility and
individuals, communities, public, private and notfor-profit sectors all have a role to play; and
engaging leaders at all levels and across all sectors
of society to act as champions, helping people to
think about the contribution they can make to
ensuring that all Canadians have the opportunity
to achieve the best possible health.
6
CHAPTER
Moving Forward
Reduce child poverty
Strengthen communities
There is a growing body of evidence that some of the
greatest returns on taxpayers’ investments are those
targeted to Canada’s youngest citizens.429 Every dollar
spent in ensuring a healthy start in the early years
will reduce the long-term costs associated with health
care, addictions, crime, unemployment and welfare.430
As well, it will ensure Canadian children become
better educated, well adjusted and more productive
adults.431
People living closest to the problem are often closest
to the solution.432 This has been proven repeatedly by
innovative projects ranging from the Eskasoni primary
care initiative that offers culturally appropriate
approaches to Aboriginal health and Toronto’s mobile
health clinic meeting the needs of immigrant women
living in a major urban centre, to the food security
programs that feed hungry school children all across
Canada, and bringing unemployed youth in Montreal
together with isolated seniors.
•
•
•
•
•
income redistribution policies, programs and
initiatives so that all families have the resources
needed for healthy child development;
opportunities for healthy early learning
and childhood development, housing and
infrastructure, post-secondary education,
employment and employment supports;
targeted interventions aimed at supporting
children living in low-income families;
collective contributions that can be made to
alleviate child poverty; and
best practices and lessons learned from other
jurisdictions with proven success in reducing child
poverty rates.
The community is where all sectors converge and
where it is often easiest for the various players to
come to the table to establish local priorities and
develop shared strategies to address inequalities.432
Communities are also in a position to mitigate the
health impacts of factors like low income and poor
access to education, and can play a pivotal role in
creating environments that are supportive of healthy
choices for all citizens.
Every effort must be made to build on the existing
knowledge, experience, energy and investments
already in place in Canadian communities to reduce
inequalities in both health and the factors that
influence health, including:
•
•
•
•
working collaboratively to support community
efforts to create sustainable conditions that
enable and promote good health;
making it easier for communities to access the
skills and resources for local programs;
developing and sharing community-generated and
national-level data from which non-governmental
and community groups can draw; and
supporting and sharing research and knowledge to
encourage the replication of successful initiatives
across the country that can spur further
innovations and improvements in inequalities in
health.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Canada has had success in reducing poverty among
seniors in recent decades.8, 123 We have the ability to
achieve the same kind of progress with children. This
requires further examination of:
69
CHAPTER
6
Moving Forward
A commitment to change
“The journey of a thousand miles begins with one step”
— Lao Tzu
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Ultimately, public health comes down to us. Some might call it cliché, but the reality is that as
individuals, community members and decision-makers we all have a part to play in either improving or
risking public health. Understanding the issues and connections may, at the very least, help us avoid
being part of the problem. This includes the inequalities that exist in the health of our population,
in our own lives and those of our family members, in our schools and workplaces, and within our
neighbourhoods and communities.
70
A society is only as healthy as its least healthy members. None of us is immune to Canada’s health
problems and the inequalities that limit our potential as a nation. In this report, I have presented many
examples of policies and programs, both large and small, that are making real differences in the lives
of Canadians and that are working to reduce inequalities in our health. As we each take ownership of
this issue to the best of our capabilities, we can help to ensure that all Canadians have the opportunity
to be as completely healthy as possible. We can do this by, for instance, taking part in our democratic
processes, getting actively involved in our communities, promoting healthy choices and reaching out
to individuals and groups in need of support. Volunteering, interestingly, in addition to the good work
we may do, is associated with better health for the volunteer as well. Why? Health is more than merely
the absence of disease or the presence of physical well-being. It is about having those basic, solid
foundations for life and society in place, and ensuring we have community, connections, friendship,
control over our lives and influence over our own destinies.
As I said at the beginning of this report, our health is influenced by the type of society we choose to
create. We all have a role to play in creating the physical, economic, social and cultural conditions that
are the foundation of good health. And what we do, even in small ways, can make a difference.
By paying attention to and addressing these underlying determinants of health, not only do we level
the playing field for all Canadians, we effectively support the functioning of society and Canada’s
competitiveness as a nation. As fewer are left behind more will prosper.
Dr. David Butler-Jones
Appendixes
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
71
72
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Acquired Immune Deficiency Syndrome
ASMR
Age-standardized Mortality Rate
BMI
Body Mass Index
CAFB
Canadian Association of Food Banks
CANSIM
Canadian Socio-economic Information Management System
CAPC
Community Action Program for Children
CCHS
Canadian Community Health Survey
CEGEP
Collège d’Enseignement Général et Professionnel
CPHI
Canadian Population Health Initiative
CPHO
Chief Public Health Officer
CPP
Canada Pension Plan
COPD
Chronic Obstructive Pulmonary Disease
CPNP
Canada Prenatal Nutrition Program
CTUMS
Canadian Tobacco Use Monitoring Survey
DAIS
Data Analysis and Information System
FASD
Fetal Alcohol Spectrum Disorder
GIS
Guaranteed Income Supplement
HIA
Health Impact Assessment
HIV
Human Immunodeficiency Virus
HPV
Human Papillomavirus
HUI
Health Utility Index
LFS
Labour Force Survey
LICO
Low-income Cut-off
NHS
National Health Service
OAS
Old Age Security
OECD
Organisation for Economic Co-operation and Development
PHAC
Public Health Agency of Canada
PSA
Public Service Agreement
PYLL
Potential Years of Life Lost
Q
Quintile
QPP
Quebec Pension Plan
RHS
First Nations Regional Longitudinal Health Survey
SARS
Severe Acute Respiratory Syndrome
SPA
Spouse’s Allowance
STI
Sexually Transmitted Infection
U.K.
United Kingdom
WHO
World Health Organization
A
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
AIDS
APPENDIX
Acronyms
73
APPENDIX
B
National Collaboration Centres
The National Collaborating Centre for Aboriginal Health
University of Northern British Columbia, Prince George
The National Collaborating Centre for Determinants of Health
St. Francis Xavier University, Antigonish
The National Collaborating Centre for Environmental Health
BC Centre for Disease Control, Vancouver
The National Collaborating Centre for Healthy Public Policy
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Institut national de santé publique du Québec, Montréal
74
The National Collaborating Centre for Infectious Diseases
International Centre for Infectious Diseases, Winnipeg
The National Collaborating Centre for Methods and Tools
McMaster University, Hamilton
APPENDIX
Health Goals for Canada
C
A Federal, Provincial and Territorial Commitment to Canadians
108
Overarching Goal
As a nation, we aspire to a Canada in which every person is as healthy as they can be – physically, mentally,
emotionally and spiritually.
Health Goals for Canada
Canada is a country where:
Basic Needs (Social and Physical Environments)
The air we breathe, the water we drink, the food we eat, and the places we live, work and play are safe and
healthy – now and for generations to come.
Belonging and Engagement
Each and every person has dignity, a sense of belonging, and contributes to supportive families, friendships
and diverse communities.
We keep learning throughout our lives through formal and informal education, relationships with others and
the land.
We participate in and influence the decisions that affect our personal and collective health and well-being.
We work to make the world a healthy place for all people, through leadership, collaboration and knowledge.
Healthy Living
Every person receives the support and information they need to make healthy choices.
A System for Health
We work to prevent and are prepared to respond to threats to our health and safety through coordinated
efforts across the country and around the world.
A strong system for health and social well-being responds to disparities in health status and offers timely,
appropriate care.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Our children reach their full potential, growing up happy, healthy, confident and secure.
75
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
APPENDIX
D
76
Definitions and Data Sources
Population (2006)433
First Nations (2006)434
The census enumerates the entire Canadian
population, which consists of Canadian citizens (by
birth and by naturalization), landed immigrants and
non-permanent residents and their families living
with them in Canada. Non-permanent residents are
persons who hold a work or student permit, or who
claim refugee status.
A term which came into common usage 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 nonStatus.
The census also counts Canadian citizens and landed
immigrants who are temporarily outside the country
on Census Day. This includes federal and provincial
government employees working outside Canada,
Canadian embassy staff posted to other countries,
members of the Canadian Forces stationed abroad, all
Canadian crew members of merchant vessels and their
families.
Data Source: Statistics Canada. (2007). Population and
dwelling counts, for Canada, provinces and territories,
2006 and 2001 censuses – 100% data (table). Population
and Dwelling Count Highlight Tables. 2006 Census.
Statistics Canada Catalogue no. 97-550-XWE2006002.
Ottawa.
434
Aboriginal (2006)
This is a collective name for all of the original peoples
of Canada and their descendants. The Constitution
Act of 1982 specifies that the Aboriginal Peoples in
Canada consist of three groups - Indians, Inuit and
Métis. Indians, Inuit and Métis peoples have unique
heritages, languages, cultural practices and spiritual
beliefs.
Data Source: Statistics Canada. (2008). Aboriginal
Peoples in Canada 2006: Inuit, Métis, and First Nations,
2006 Census. Statistics Canada Catalogue no. 97-558XIE. Ottawa. Analysis Series, 2006 Census.
Data Source: Statistics Canada. (2008). Aboriginal
Peoples in Canada 2006: Inuit, Métis and First Nations,
2006 Census. Statistics Canada Catalogue no. 97-558XIE. Ottawa. Analysis Series, 2006 Census.
Indian434
A term which collectively describes all the Indigenous
People in Canada who are not Inuit or Métis. Indians
are one of three peoples recognized as Aboriginal in
the Constitution Act of 1982, along with Inuit and
Métis. Three categories apply to Indians in Canada:
Status Indians, non-Status Indians and Treaty
Indians.
Métis (2006)434
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.
Data Source: Statistics Canada. (2008). Aboriginal
Peoples in Canada 2006: Inuit, Métis and First Nations,
2006 Census. Statistics Canada Catalogue no. 97-558XIE. Ottawa. Analysis Series, 2006 Census.
Inuit (2006)434
Inuit are the Aboriginal People of Arctic Canada who
live primarily in Nunavut, the Northwest Territories
and northern parts of Labrador and Quebec.
Data Source: Statistics Canada. (2008). Aboriginal
Peoples in Canada 2006: Inuit, Métis and First Nations,
2006 Census. Statistics Canada Catalogue no. 97-558XIE. Ottawa. Analysis Series, 2006 Census.
Immigrant (2006)435
A landed immigrant is a person who has been granted
the right to live in Canada by immigration authorities.
Data Source: Statistics Canada. (2007). Immigrant
Status and Period of Immigration (9), Knowledge of
Official Languages (5), Detailed Mother Tongue (103),
Age Groups (10) and Sex (3) for the Population of
Canada, Provinces, Territories, Census Metropolitan Areas
and Census Agglomerations, 2006 Census - 20% Sample
Data (table). Topic-based tabulation. 2006 Census of
Population. Statistics Canada Catalogue no. 97-557XCB2006021. Ottawa. Released December 4, 2007.
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. Countries should
be coded according to the most recent ISO codes and it
is recommended that they be aggregated into regions
according to the most recent United Nations’ standards
for the reporting of demographic and social data.
Data Source: Statistics Canada. (2007). Profile of
Language, Immigration, Citizenship, Mobility and
Migration for Canada, Provinces, Territories, Census
Divisions and Census Subdivisions, 2006 Census (table).
2006 Electronic Profiles. 2006 Census of Population.
Statistics Canada Catalogue no. 94-577-XCB2006001.
Ottawa. Released December 4, 2007.
By years since immigration (2006)435
Year/Period of immigration refers to a person who is a
landed immigrant by the period of time in which he or
she fi rst obtained landed immigrant status.
Data Source: Statistics Canada. (2007). Immigrant Status
and Period of Immigration (9), Knowledge of Official
Languages (5), Detailed Mother Tongue (103), Age Groups
(10) and Sex (3) for the Population of Canada, Provinces,
Territories, Census Metropolitan Areas and Census Agglomerations, 2006 Census - 20% Sample Data (table). Topicbased tabulation. 2006 Census of Population. Statistics
Canada Catalogue no. 97-557-xcb2006021. Ottawa.
Released December 4, 2007.
Urban population (2006)437
An urban area 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.
Data Source: Statistics Canada. (2007). Population
and dwelling counts, for urban areas, 2006 and 2001
censuses – 100% data (table). Population and Dwelling
Count Highlight Tables. 2006 Census. Statistics Canada
Catalogue no. 97-550-XWE2006002. Ottawa. Released
March 13, 2007.
Life expectancy at birth (2005)438
Life expectancy is the number of years a person
would be expected to live, starting from birth (for
life expectancy at birth) and similarly for other age
groups, on the basis of the mortality statistics for a
given observation period.
Data Source: Statistics Canada. (n.d.). Table 102-0511
- Life expectancy, abridged life table, at birth and at age
65, by sex, Canada, provinces and territories, annual
(years), CANSIM (database).
Health-adjusted life expectancy
at birth (2001)439
Health-adjusted life expectancy is the number of years
in full health that an individual can expect to live
given the current morbidity and mortality conditions.
Health-adjusted life expectancy uses the Health
Utility Index (HUI) to weigh years lived in good
health higher than years lived in poor health. Thus,
health-adjusted life expectancy is not only a measure
of quantity of life but also a measure of quality of life.
Data Source: Statistics Canada. (n.d.). Table 102-0121
- Health-adjusted life expectancy, at birth and at age
65, by sex and income group, Canada and provinces,
occasional (years), CANSIM (database).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
By birth place (2006)436
D
APPENDIX
Definitions and Data Sources
77
APPENDIX
D
Definitions and Data Sources
Infant mortality rate (2005)440
Infant mortality rate is the number of infant deaths
during a given year per 1,000 live births in the
same year.
Data Source: Statistics Canada. (n.d). Table 102-0507
- Infant mortality, by age group, Canada, provinces and
territories, annual, CANSIM (database).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Excellent or very good self-rated
health (2005)441
78
Population (aged 12 years and over for data from the
Canadian Community Health Survey and National
Population Health Survey, North component) who rate
their own health status as being either excellent, very
good, good, fair or poor.
Data Source: Statistics Canada. (n.d.). Table 105-0422
- Self-rated health, by age group and sex, household
population aged 12 and over, Canada, provinces,
territories, health regions (June 2005 boundaries) and
peer groups, every 2 years, CANSIM (database).
Excellent or very good self-rated
mental health (2005)441
Population aged 12 years and over who rate their own
mental health status as being excellent, very good,
good, fair or poor.
Self-reported mental health provides a general
indication of the population suffering from some form
of mental disorder, mental or emotional problems,
or distress, not necessarily reflected in self-reported
(physical) health.
Data Source: Statistics Canada. (n.d.). Table 1050421 - Self-rated mental health, by age group and
sex, household population aged 12 and over, Canada,
provinces, territories, health regions (June 2005
boundaries) and peer groups, every 2 years, CANSIM
(database).
Death due to circulatory
diseases (2004)442
Death due to circulatory diseases classified as
International Classification of Disease Codes: I00-I99.
Data Source: Statistics Canada. (n.d.). Table 102-0529 Deaths, by cause, Chapter IX: Diseases of the circulatory
system (I00 to I99), age group and sex, Canada, annual
(number), CANSIM (database).
Statistics Canada. (n.d.). Table 109-5315 - Estimates of
population (2001 Census and administrative data), by
age group and sex, Canada, provinces, territories, health
regions (June 2005 boundaries) and peer groups, annual
(number), CANSIM (database).
Death due to malignant cancers
(2004)443
Death due to malignant cancers classified as
International Classification of Disease Codes: C00-C99.
Data Source: Statistics Canada. (n.d.). Table 102-0522
- Deaths, by cause, Chapter II: Neoplasms (C00 to D48),
age group and sex, Canada, annual (number), CANSIM
(database).
Statistics Canada. (n.d.). Table 109-5315 - Estimates of
population (2001 Census and administrative data), by
age group and sex, Canada, provinces, territories, health
regions (June 2005 boundaries) and peer groups, annual
(number), CANSIM (database).
D
APPENDIX
Definitions and Data Sources
Death due to Respiratory
Diseases (2004)444
Premature mortality due to
circulatory diseases (2001)438
Death due to respiratory diseases classified as
International Classification of Disease Codes: J00-J99.
Potential years of life lost (PYLL) for all circulatory
disease deaths (ICD-10 I00-I99) and specific causes
[ischaemic heart disease (ICD-10 I20-I25), cerebrovascular diseases (stroke) (ICD-10 I60-I69) and all other
circulatory diseases (ICD-10 I00-I02, I05-I09, I10-I15,
I26-I28, I30-I52, I70-I79, I80-I89, I95-I99)] is the number
of years of life lost when a person dies prematurely
from any circulatory disease – before age 75.
Data Source: Statistics Canada. (n.d.). Table 102-0530 Deaths, by cause, Chapter X: Diseases of the respiratory
system (J00 to J99), age group and sex, Canada, annual
(number), CANSIM (database).
Potential years of life lost438
Potential years of life lost (PYLL) is 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.
Premature mortality due to
cancer (2001)438
Potential years of life lost (PYLL) for all malignant
neoplasms (ICD-10 C00-C97) and for specific sites
[colorectal (ICD-10 C18-C21), lung (ICD-10 C33-C34),
female breast (ICD-10 C50) and prostate cancer (ICD-10
C61)] is the number of years of life lost when a person
dies prematurely from any cancer – before age 75.
Data Source: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
Data Source: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
Premature mortality due to
unintentional injuries (2001)438
Potential years of life lost (PYLL) 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: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
Premature mortality due to suicide
and self-inflicted injuries (2001)438
Potential years of life lost (PYLL) 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: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Statistics Canada. (n.d.). Table 109-5315 - Estimates of
population (2001 Census and administrative data), by
age group and sex, Canada, provinces, territories, health
regions (June 2005 boundaries) and peer groups, annual
(number), CANSIM (database).
79
APPENDIX
D
Definitions and Data Sources
Premature mortality due to
respiratory diseases (2001)438
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Potential years of life lost (PYLL) for all respiratory
disease deaths (ICD-10 J00-J99) and for specific
causes [pneumonia and influenza (ICD-10 J10-J18),
bronchitis/emphysema/asthma (ICD-10 J40-J43, J45J46) and all other respiratory diseases (ICD-10 J00-J06,
J20-J22, J30-J39, J44, J47, J60-J70, J80- J84, J85-J86,
J90-J94, J95-J99)] is the number of years of life lost
when a person dies prematurely from any respiratory
disease – before age 75.
80
Data Source: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
Premature mortality due to HIV
(2001)438
Potential years of life lost (PYLL) for human immunodeficiency virus (HIV) infection deaths (ICD-10 B20B24) is the number of years of life lost when a person
dies prematurely from HIV-AIDS – before age 75.
Data Source: Statistics Canada. (n.d.). Table 102-0311
- Potential years of life lost, by selected causes of death
and sex, population aged 0 to 74, three-year average,
Canada, provinces, territories, health regions and peer
groups, occasional, CANSIM (database).
Malignant cancers (2003)186
Indicates the total number of people who are currently
living with a diagnosis of cancer in 2003 and are still
alive 15 years after their cancer has been diagnosed.
These estimates are based on survival rates from
Saskatchewan, which are applied to the Canadian
incidence data.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control. (2007).
Health Status Indicators – Chronic Disease Prevalences.
Diabetes (2004-2005)182
Individuals were counted as having been diagnosed
with diabetes when they had at least one
hospitalization with a diagnosis of diabetes or had at
least two physician visits with a diagnosis of diabetes
within a two-year period.
Data Source: Public Health Agency of Canada. (2007).
Diabetes in Canada: Highlights from the National Diabetes
Surveillance System 2004/2005. Unpublished data.
Obesity (2005)445
According to the WHO and Health Canada guidelines,
the index for body weight classification is: less than
18.50 (underweight); 18.50 to 24.99 (normal weight);
25.00 to 29.99 (overweight); 30.00 to 34.99 (obese,
class I); 35.00 to 39.99 (obese, class II); 40.00 or
greater (obese, class III).
The index is calculated for the population aged 18
years and over, excluding pregnant females and
persons less than 3 feet (0.914 metres) tall or greater
than 6 feet 11 inches (2.108 metres).
Body mass index (BMI) is calculated by dividing the
respondent’s body weight (in kilograms) by their
height (in metres) squared.
Data Source: Statistics Canada. (n.d.). Table 1050407 - Measured adult body mass index (BMI), by age
group and sex, household population aged 18 and over
excluding pregnant females, Canadian Community Health
Survey (CCHS 3.1), Canada, every 2 years, CANSIM
(database).
Arthritis/Rheumatism (2005)446
Respondents (aged 12+ years) who report having
arthritis or rheumatism, excluding fibromyalgia.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control. (2007).
Health Status Indicators – Chronic Disease Prevalences.
D
APPENDIX
Definitions and Data Sources
Asthma (2005)446
Schizophrenia (2002)447
Respondents (aged 12+ years) who report having:
• asthma;
• asthma symptoms or attacks in the past 12
months; or
• taken medicine for asthma such as inhalers,
nebulizers, pills, liquids or injections.
Respondents (aged 12+ years) reporting schizophrenia
as diagnosed by a health professional.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
Heart disease (2005)446
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
High blood pressure (2005)446
Major depression (2002)447
A major depressive episode is a period of two weeks
or more with persistent depressed mood and loss of
interest or pleasure in normal activities, accompanied
by symptoms such as decreased energy, changes
in sleep and appetite, impaired concentration, and
feelings of guilt, hopelessness or suicidal thoughts.
Respondents (aged 15+ years) who reported
experiencing the following associated with major
depressive episode were considered to fit the
criteria for the 12-month period prevalence of major
depression:
•
Respondents (aged 20+ years) who report having:
high blood pressure;
been diagnosed with high blood pressure; or
taken high blood pressure medication.
•
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
•
•
•
•
Chronic obstructive pulmonary
disease (2005)446
Respondents (aged 35+ years) who report having
chronic obstructive pulmonary disease.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
•
•
•
a period of two weeks or more with depressed
mood or loss of interest or pleasure and at least
five additional symptoms;
clinically significant distress or social or
occupational impairment;
the symptoms are not better accounted for by
bereavement;
meet the criteria for lifetime diagnosis of major
depressive episode;
report a 12-month episode; and
report marked impairment in occupational or
social functioning.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Respondents (aged 12+ years) who report having heart
disease.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
81
APPENDIX
D
Definitions and Data Sources
Alcohol dependence (2002)447
Alcohol dependence is defi ned as tolerance,
withdrawal, loss of control or social or physical
problems related to alcohol use.
A respondent (aged 15+ years) who reported having
five drinks or more on one occasion at least once a
month during the past 12 months and had five drinks
or more during another 12-month period.
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
82
Anxiety disorders (2002)447
A respondent (aged 15+ years) who reported
experiencing any of the following criteria associated
with agoraphobia, panic disorder and social phobia
in the past 12 months was considered to meet the
criteria for anxiety disorders:
•
•
•
•
•
•
a panic attack in the past 12 months;
significant emotional distress during a panic
attack in the past 12 months;
fear or avoidance of social or performance
situation(s) in the past 12 months;
clinically significant distress or impairment in
social, occupational or other important areas of
functioning;
anxiety about being in at least two different
places or situations from which escape might
be difficult or embarrassing, along with fear of
having a panic attack; and
avoidance of situations associated with
agoraphobia; or endurance of situations with
marked distress or anxiety; or requiring the
presence of a companion in the situations.
Data Source: Public Health Agency of Canada, Centre
for Chronic Disease Prevention and Control, Health
Status Indicators – Chronic Disease Prevalences.
Alzheimer’s and other dementias
(2000)448
Person’s aged 65+ years who have been diagnosed as
having Alzheimer’s disease, vascular disease, frontal
lobe dementia or Lewy Body disease (ICD10 F01, F03,
G30-G31).
Data Source: Mathers, C.E. & Matidle, L. (2002). Global
burden of dementia in the year 2000: Summary of
methods and data sources.
HIV (2005)210
The number of new HIV infections occurring in 2005.
Data Source: Public Health Agency of Canada. (2007).
HIV/AIDS EPI Updates, November 2007. Surveillance
and Risk Assessment Division, Centre for Infectious
Disease and Control.
Chlamydia (2004)449
Rate per 100,000 population where Chlamydia
(Chlamydia trachomatis) has been identified by a
laboratory.
Data Source: Public Health Agency of Canada. (2007).
Reported cases of notifiable STI from January 1 to
September 30, 2006 and January 1 to September 30, 2007
and corresponding annual rates for 2006 and 2007.
Gonorrhea (2004)450
Rate per 100,000 population where Gonorrhea
(Neisseria gonorrhoeae) has been identified by a
laboratory.
Data Source: Public Health Agency of Canada. (2007).
Reported cases of notifiable STI from January 1 to
September 30, 2006 and January 1 to September 30, 2007
and corresponding annual rates for 2006 and 2007.
APPENDIX
D
Definitions and Data Sources
Infectious syphilis (2004)451
Unemployment rate (2006)453
Rate per 100,000 population where Infectious syphilis
(including primary, secondary and early latent stages)
has been identified by a laboratory.
The unemployment rate is the number of unemployed
persons expressed as a percentage of the labour force.
Data Source: Public Health Agency of Canada. (2007).
Reported cases of notifiable STI from January 1 to
September 30, 2006 and January 1 to September 30,
2007 and corresponding annual rates for 2006 and 2007.
Low-income cut-off (LICO)213
Data Source: Public Health Agency of Canada. (2007).
Analyses were performed using Health Canada’s DAIS
edition of anonymized microdata from the Labour
Force Survey – 3701; Table 282-0004 - Labour Force
Survey Estimates (LFS), by Educational Attainment,
Sex and Age Group, Annual (Persons Unless Otherwise
Noted), prepared by Statistics Canada.
Persons living in low income after tax (2005)452
Below are the low-income cut-off after-tax thresholds for person(s) in varying community sizes for 2005.
Data Source: Statistics Canada. (2007). Income in Canada 2005 (Statistics Canada Catalogue no. 75-202-XIE). Ottawa.
Rural Areas
Size of family unit
Urban Areas
Less than
30,000
30,000 to
99,999
100,000 to
499,999
500,000
and over
1 person
11,264
12,890
14,380
14,562
17,219
2 persons
13,709
15,690
17,502
17,723
20,956
3 persons
17,071
19,535
21,794
22,069
26,095
4 persons
21,296
24,373
27,190
27,532
32,556
5 persons
24,251
27,754
30,962
31,351
37,071
6 persons
26,895
30,780
34,338
34,769
41,113
7 or more persons
29,539
33,806
37,713
38,187
45,155
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
A statistical measure of the income threshold below
which Canadians likely devote a larger share of income
than average to the necessities of food, shelter and
clothing.
83
APPENDIX
D
Definitions and Data Sources
People reporting food insecurity
(2004)237
households according to National Occupancy Standard
requirements).
A situation that exists when people lack secure access
to sufficient amounts of safe and nutritious food for
normal growth and development and an active and
healthy life.
Data Source: Lewis, R.E. Jakubec, L. (April, 2004).
2001 Census Housing Series: Issue 3 Revised; The
Adequacy, Suitability, and Affordability of Canadian
Housing. Canada Mortgage and Housing Canada.
Housing Indicators and Demographics. Policy and
Research Division. (Socio-economic Series 04-007).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Data Source: Health Canada. (2007). Canadian
Community Health Survey cycle 2.2, Nutrition (2004):
Income-Related Household Food Security in Canada.
Office of Nutrition Policy and Promotion, Health
Products and Food Branch.
84
Ground-level ozone exposure (2005)251
This indicator uses the seasonal average of daily
eight-hour maximum average concentrations, which is
population-weighted to calculate trends and averages
across monitoring stations located throughout the
country.
High school graduates (2006)310
Persons who have received, at minimum, a high school
diploma or, in Quebec, a completed Secondary V or, in
Newfoundland and Labrador, completed fourth year of
secondary.
Data Source: Environment Canada. (2007). Ground-level
ozone exposure indicator, Canada, 1990 to 2005.
Data Source: Public Health Agency of Canada. (2007).
[Analyses were performed using the Health Canada’s
DAIS edition of anonymized microdata from the
Labour Force Survey - 3701; Table 282-0004 - Labour
force survey estimates (LFS), by educational attainment,
sex and age group, annual (persons unless otherwise
noted), prepared by Statistics Canada.]
Fine particulate matter (PM2.5)
exposure (2005)251
Some post-secondary education
(2006)310
This indicator uses the seasonal average of daily
twenty four-hour maximum average concentrations,
which is population-weighted to calculate trends
and averages across monitoring stations located
throughout the country.
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: Environment Canada. (2007). Fine
particulate matter (PM2.5) exposure indicator, Canada,
2000 to 2005.
Unable to access acceptable
housing (2001)273
Refers to affordable dwellings (costing less than 30%
of before-tax household income), adequate dwellings
(those reported by their residents as not requiring
any major repairs) and suitable dwellings (having
enough bedrooms for the size and make-up of resident
Data Source: Public Health Agency of Canada. (2007).
[Analyses were performed using the Health Canada’s
DAIS edition of anonymized microdata from the
Labour Force Survey-– 3701; Table 282-0004 - Labour
force survey estimates (LFS), by educational attainment,
sex and age group, annual (persons unless otherwise
noted), prepared by Statistics Canada.]
D
APPENDIX
Definitions and Data Sources
Post-secondary education (2006)310
Daily smoking (2006)456
Persons who have completed a certificate (including
a trade certificate), diploma or a minimum of a
university bachelor’s degree 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.
Respondents who have identified themselves as
daily smokers and non-daily smokers (also known as
occasional smokers).
Very or somewhat strong sense of
community belonging (2005)454
Population aged 12 years and over who describe their
sense of belonging to their local community as very
strong or somewhat strong.
Data Source: Statistics Canada. (n.d.). Table 1050490 - Sense of belonging to local community, by age
group and sex, household population aged 12 and over,
Canada, provinces, territories, health regions (June 2005
boundaries) and peer groups, every 2 years, CANSIM
(database).
Violent crimes committed (2006)455
Offences that deal with the application or threat of
application, of force to a person including homicide,
attempted murder, various forms of sexual and nonsexual assault, robbery and abduction, as well as
traffic incidents that result in death or bodily harm.
Data Source: Statistics Canada. (July 18, 2007).
Crime Statistics, 2006. The Daily. (Statistics Canada
Catalogue no. 11-001-XIE).
Engaged in leisure-time physical
activity (2005)366
Population aged 12 years and over reporting level
of physical activity, based on their responses to
questions about the frequency, duration and intensity
of their participation in leisure-time physical activity.
Respondents are classified as active, moderately active
or inactive based on an index of average daily physical
activity over the past three months.
Data Source: Gilmour, H.(August 2007). Physically
Active Canadians. Statistics Canada Health Reports.
18(3). (Statistics Canada Catalogue no. 82-003.)
Fruit and vegetable consumption
5+ times a day (2005)374
Population aged 12 years and over who reported that
they consume fruits and vegetables five or more times
per day.
Data Source: Statistics Canada. (n.d.). Table 105-0449
- Fruit and vegetable consumption, by age group and
sex, household population aged 12 and over, Canada,
provinces, territories and selected health regions (June
2005 boundaries), every 2 years, CANSIM (database).
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Data Source: Public Health Agency of Canada. (2007).
[Analyses were performed using the Health Canada’s
DAIS edition of anonymized microdata from the
Labour Force Survey - 3701; Table 282-0004 - Labour
force survey estimates (LFS), by educational attainment,
sex and age group, annual (persons unless otherwise
noted), prepared by Statistics Canada.]
Data Source: Health Canada. (December, 2006).
Smoking status and average number of cigarettes smoked
per day, by age group and sex, age 15+ years, Canada
2006.
85
APPENDIX
D
Definitions and Data Sources
The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2008
Heavy drinking (5+ drinks on one
Contact with dental
387
occasion 12+ times in a year)(2005)
professional (2005)393
86
Population aged 12 years and over who reported
having five or more drinks on one occasion, twelve or
more times a year.
Persons who have consulted with a dental professional
(including dentists and orthodontists) in the past 12
months
Data Source: Statistics Canada. (n.d.). Table 105-0431
- Frequency of drinking in the past 12 months, by age
group and sex, household population aged 12 and over
who are current drinkers, Canada, provinces, territories,
health regions (June 2005 boundaries) and peer groups,
every 2 years, CANSIM (database).
Data Source: Statistics Canada. (n.d.). Table 105-0460 Contact with dental professionals in the past 12 months,
by age group and sex, household population aged 12
and over, Canada, provinces, territories, health regions
(June 2005 boundaries) and peer groups, every 2 years,
CANSIM (database).
Illicit drug use (2002)386
Illicit drug use by persons aged 15 years and older,
in Canada, excluding the Territories, who have used
any illicit drug (including cannabis, cocaine, speed,
ecstacy, hallucinogens, heroin, or sniffing solvents).
Data Source: Tjepkema, M. (2004). Alcohol and Illicit
Drug Dependence. Supplement to Health Reports, 15,
9-63.
Teen pregnancy (2004)391
Total number of pregnancies (including live births,
induced abortions and fetal loss) for women under the
age of 20.
Data Source: Statistics Canada. (n.d.). Table 106-9002
- Pregnancy outcomes, by age group, Canada, provinces
and territories, annual, CANSIM (database).
Regular family physician (2005)357
Refers to a family or general physician seen for most
of an individual’s routine care.
Data Source: Statistics Canada. (n.d.). Table
105-3024 - Population reporting a regular family
physician, household population aged 15 and over,
Canada, provinces and territories, occasional, CANSIM
(database).
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123 Statistics Canada. (2007). A Portrait of Seniors in Canada. Ottawa. Catalogue no. 89-519.
124 Statistics Canada. (n.d.). Table 105-0511 –Life Expectancy, abridged life table, at birth and at age 65, by sex, Canada, provinces and
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126 Statistics Canada. (2007). Age (123) and Sex (3) for the Population of Canada, Provinces, Territories and Federal Electoral Districts (2003
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152 Public Health Agency of Canada. (1999). Measuring Up: A Health Surveillance Update on Canadian Children and Youth – Infant Mortality.
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154 Smylie, J. & Anderson, M. (2006). Understanding the health of Indigenous peoples in Canada: key methodological and conceptual
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155 Luo, Z.C., Kierans, W.J., Wilkins, R., Liston, R.M., Uh, .S.H. & Kramer, M.S. (2004). Infant mortality among First Nations versus non-First
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