Second Report on the Health of Canadians

Second Report
on the Health
of Canadians
Prepared by the Federal, Provincial and Territorial Advisory Committee on Population Health
for the Meeting of Ministers of Health, Charlottetown, P.E.I., September 1999
Également offert en français sous le titre : Pour un avenir en santé : Deuxième rapport sur
la santé de la population canadienne.
This publication can be made available in alternative formats upon request.
© Her Majesty the Queen in right of Canada, represented by the Minister of Public
Works and Government Services Canada, 1999
Permission is granted for non-commercial reproduction related to educational or service
planning purposes, provided there is a clear acknowledgement of the source.
Cat H39-468/1999E
ISBN 0-662-27625-6
Preface
Toward a Healthy Future: Second Report on the Health of Canadians is the result of a
collaborative effort by the Federal, Provincial and Territorial Advisory Committee on
Population Health (ACPH), Health Canada, Statistics Canada, the Canadian Institute
for Health Information and a project team from the Centre for Health Promotion,
University of Toronto.
The role of the Advisory Committee is to advise the Conference of Deputy
Ministers of Health on national and interprovincial strategies to improve the health
status of the Canadian population and to provide a more integrated approach to health.
As the title suggests, this is the second report to summarize and comment on the
state of the nation’s health. The first report was released in September 1996. The current
report differs from the first one in several ways. It puts more emphasis on the influence of
gender and socioeconomic status on health. Chapters on healthy child development and
biology and genetics have been added in order to paint a picture that includes all of the
major determinants of health. The section on the physical environment has been expanded
to provide a better understanding of how it impacts on the health of all Canadians.
This report summarizes the most current information we have on the health of
Canadians, and invites the reader to consider the implications of these findings for current
and future policies, practices and research. It is a tool to alert policy makers, practitioners
and the public to current and future challenges in health, and to help identify actions that
can be taken to improve the health of Canadians.
More detailed statistics and information are provided in the Statistical Report on the
Health of Canadians (1999), published under separate cover by the ACPH.
Print copies of this report and the Statistical Report on the Health of Canadians are
available from Provincial and Territorial Ministries of Health or from:
Publications
Health Canada
Tunney’s Pasture (AL0900C2)
Ottawa, ON K1A 0K9
Telephone: (613) 954-5995
Fax: (613) 941-5366
E-mail: [email protected]
Toward a Healthy Future
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Preface
The full text of both reports can be found on the Internet at the following Web site:
http://www.hc-sc.gc.ca. The Statistical Report is also available at http://www.statcan.ca
and at http://www.cihi.ca.
Members of the Federal, Provincial and Territorial Advisory Committee on
Population Health welcome your comments on this report. A questionnaire is included
at the end of the report for this purpose.
Toward a Healthy Future
Acknowledgements
The Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH)
wishes to acknowledge the many individuals who contributed to the development and
production of Toward a Healthy Future: Second Report on the Health of Canadians.
Members of the project team from the University of Toronto, Centre for Health
Promotion, were: Irving Rootman (Director of the Centre), Peggy Edwards (writer), Reg
Warren (analyst), Rick Wilson (coordinator) and Katherine Joly (production of earlier
drafts).
Helpful reviews of earlier versions were provided by members of the ACPH Working
Group and the Health Canada Working Group. The contribution of Thomas Stephens,
scientific editor of the Statistical Report on the Health of Canadians, is also acknowledged.
Design, editing and production were provided by Allium Consulting Group Inc.
(Ottawa). Translation was done by Communications Essema.
Project management was provided by Carol Silcoff (Health Canada), assisted by
Stephanie Wilson (until September 1998) and Lynda Bottoms (until January 1999). The
following Health Canada staff also contributed to project planning and implementation:
Nancy Hamilton, Suzanne Desilets, Dyanne Wilson, Johanna Laporte, Jacqueline Goudal,
Jerry Dybka, Roslyn Nudell, Jeffrey Pender, Elisabeth Gebhardt, Marie-Josée Thérrien
and Rolande Ostiguy (and others too numerous to mention).
Members of the ACPH, the ACPH Working Group and the Health Canada Working
Group are listed in Appendix A. The ACPH wishes to thank John Millar for chairing the
Working Group until December 1998, and Shaun Peck and Kim Elmslie for co-chairing
since that date.
Toward a Healthy Future
Executive Summary
This report summarizes the most current information we have on the health of Canadians.
As such, it is a tool to alert policy makers, practitioners and the public to current and
future challenges in population health and to identify actions that will improve the health
of all Canadians.
What Makes Canadians Healthy or Unhealthy?
This deceptively simple story speaks to the complex set of factors or conditions that
determine the level of health of every Canadian.
“Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was
some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there and there is
no one to supervise them.
But why does he live in that neighbourhood?
Because his parents can’t afford a nicer place to live.
But why can’t his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn’t have much education and he can’t find a job.
But why ...?”
Toward a Healthy Future
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Executive Summary
As this story suggests, health, illness and early death depend on a variety of factors
or “determinants” that surround individuals, families and nations. Getting to the root
cause of Jason’s illness and the other major health problems we face in Canada today
requires action on the broader determinants of health. It also requires that we continue
to provide high-quality health services that will help Jason heal.
This report shows that factors in the socioeconomic and physical environment, as
well as early childhood experiences, personal health practices and biology, have a major
impact on health. These factors operate independently of the amount of money we spend
on health care. The highlights of these findings are summarized in the next section.
Highlights
How Healthy Are Canadians?
◆ Canada ranks in the top three developed countries in the world in measures of life
expectancy, self-rated health and mortality rates. Life expectancy in Canada has
reached a new high: 75.7 years for men and 81.4 years for women (Chapter 1).
◆ Most recent immigrants to Canada are in good health and the great majority of our
older citizens enjoy independence and good health as they age (Chapters 1, 3, 5, 7).
◆ In 1996, Canada’s infant mortality rate dropped below the level of six infant deaths
per 1,000 live births for the first time ever (Chapters 1, 3).
◆ The United Nations (UN) ranks Canada first in the world on its human
development index. That standing drops to 10th place, however, when the UN
Human Poverty Index for industrialized countries is applied (Chapter 1).
Gender and Age Influence Health
◆ Men are more likely to die prematurely than women, largely as a result of heart
disease, fatal unintentional injuries, cancer and suicide. Rates of potential years of life
lost before age 70 are almost twice as high for men than women and approximately
three times as high among men aged 20 to 34 (Chapter 1).
◆ While women live longer than men, they are more likely to suffer depression, stress
overload (often due to efforts to balance work and family life), chronic conditions
such as arthritis and allergies, and injuries and death resulting from family violence
(Chapters 1, 2).
◆ While overall cancer death rates for men have declined, they have remained
persistently stubborn among women, mainly due to increases in lung cancer
mortality. Teenage girls are now more likely than adolescent boys to smoke. If
increased rates of smoking among young women are not reversed, lung cancer rates
among women will continue to climb (Chapters 1, 3, 5).
◆ Older Canadians are far more likely than younger Canadians to have physical
illnesses; however, youth (aged 12 to 19) report the lowest levels of psychological
well-being (Chapters 1, 3, 7).
Toward a Healthy Future
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Executive Summary
◆ Unintentional injuries are still the leading cause of death among children and youth,
as well as a tragic and costly cause of disabling conditions among young Canadians.
Boys and young men experience more unintentional injuries and more severe
injuries than girls and young women (Chapters 1, 3).
◆ Rates of physical activity drop quickly as age increases, and males are more active
than females in every age group. Regular, moderate activity is associated with better
health, reduced risk for chronic illnesses and longer life (Chapter 5).
Income and Income Distribution Affect Health
◆ Only 47% of Canadians in the lowest income bracket rate their health as very good or
excellent, compared with 73% of Canadians in the highest income group (Chapter 1).
◆ Low-income Canadians are more likely to die earlier and to suffer more illnesses than
Canadians with higher incomes, regardless of age, sex, race and place of residence
(Chapters 1, 2).
◆ At each rung up the income ladder, Canadians have less sickness, longer life
expectancies and improved health (Chapters 2, 3).
◆ In 1995, children, youth and unattached seniors (mostly women) were most likely to
be living in low-income situations (below Statistics Canada low-income cut-off)
(Chapters 2, 3).
◆ In 1995, almost 50% of single-parent, mother-led families were in low-income
situations. However, poverty was not restricted to single-parent families. From 1990
to 1995, the percentage of married couples with children in low-income situations
rose from 9.5% to 13% (a total of almost 460,000 families) (Chapter 2).
◆ A greater proportion of Aboriginal families are experiencing problems with
housing and food affordability than Canadian families as a whole (Chapter 4).
In 1995, a disturbing 44% of the Aboriginal population lived in low-income
situations (Chapter 2).
◆ Studies suggest that the distribution of income in a given society may be a more
important determinant of health than the total amount of income earned by society
members. Large gaps in income distribution lead to increases in social problems and
poorer health among the population as a whole (Chapters 1, 2, 8).
◆ Overall, inequities in income distribution remained relatively constant in Canada
between 1985 and 1995. This was largely due to the effect of redistributive taxes and
transfer payments, which helped to offset a growing income gap between the 10%
of Canadians with the lowest incomes and the 10% of Canadians with the highest
incomes (Chapter 2). Trends in income inequality beyond 1995 are worth monitoring
in future analyses.
◆ Changes in income distribution are closely related to changes in employment and
wages. In recent years, some workers have been gaining, most notably older workers
and those who are highly skilled. Others, especially young workers and lower-paid,
lower-skilled men have experienced declines.
Toward a Healthy Future
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Executive Summary
◆ While women are making progress in the workplace, they still earn less than men,
mainly because they hold the majority of the lowest paying jobs .
The Social Environment Affects Health
◆ By and large, Canadians are a caring people. They report high levels of social support,
caring for others, voluntarism and civic participation. These are important buffers in
times of stress (Chapter 2).
◆ Family violence has a devastating effect on the health of women and children in both
the short and long term. In 1996, family members were accused in 24% of all assaults
against children; among very young children, the proportion was much higher. In
1997, about 40% of female homicide victims were killed by a man with whom they
had experienced an intimate relationship (Chapter 2).
◆ In a 1996 study of 15-year-olds, half of boys and one-quarter of girls said that bullying
was a problem (Chapter 3). While the incidence of violent youth crime has decreased
in recent years, it remains much higher than it was a decade ago (Chapter 2).
Education and Literacy Affect Health
◆ Canadians with low literacy skills are more likely to be unemployed and poor, to
suffer poorer health and to die earlier than Canadians with high levels of literacy
(Chapters 1, 2).
◆ In 1994–1995, about 17% of Canadians scored in the lowest prose literacy category.
Another 26% achieved the second level, which means that they can read, but not well
(Chapter 2).
◆ In 1995, Canada had twice the proportion of citizens who lacked adequate literacy
skills as Sweden, the number-one ranked country on this index (Chapter 1).
◆ People with higher levels of education have better access to healthy physical
environments (Chapter 4) and are better able to prepare their children for school
than people with low levels of education (Chapter 3). They also tend to smoke less,
to be more physically active and to have access to healthier foods (Chapter 5).
◆ In 1996, more young Canadians (especially women) were gaining advanced degrees
than ever before. However, there are a core of young people who leave high school
early. Most often, they are young men who are having difficulty in school and have
limited emotional and financial support for staying in school. Young women who
leave school early tend to do so because of pregnancy or other family problems
(Chapters 2, 3).
The Physical Environment Affects Health
◆ The prevalence of childhood asthma has increased sharply over the last two decades,
especially from birth to age 6. Children (especially poor children) are more vulnerable
to airborne contaminants and other environmental toxins than adults. In 1995, at
least 1.4 million children were exposed to environmental tobacco smoke in their
homes (Chapter 4).
Toward a Healthy Future
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Executive Summary
◆ In 1996, many Canadians faced a housing affordability crisis. Some 58% of lone-parent
families and 59% of older Canadians living in one-person households were spending
more than 30% of their income on housing. As many as 200,000 Canadians were
estimated to be homeless, including increasing numbers of women and children,
Aboriginal people, adolescents and persons with mental illnesses (Chapter 4).
◆ Climate change and environmental hazards in the food supply may have a
particularly negative effect on Aboriginal people (Chapter 4).
Personal Health Practices Affect Health
◆ Tobacco use accounts for at least one-quarter of all deaths of adults between the ages
of 35 and 84 (Chapter 1). Smoking rates have increased substantially among young
people, particularly among young women in the last 10 years. Smoking rates among
Aboriginal people are double the overall rate for Canada as a whole and the age of
onset for tobacco use is substantially younger among Aboriginal children in some
communities (Chapters 1, 5).
◆ Multiple risk-taking and unsafe sex practices remain high among young people,
particularly among young men (Chapter 5). Multiple drug use (e.g. combination of
alcohol, tobacco and cannabis) has increased among high school students in regions
where this has been surveyed.
◆ The proportion of new AIDS cases attributed to men who have sex with men declined
steadily from nearly 80% in the 1980s to just over 50% in 1997. By contrast, 20% of
adult AIDS cases in 1997 were attributed to injection drug use, compared to 2% prior
to 1990, and 5% in 1993.
Health Services Affect Health
◆ Disease and injury prevention activities in areas such as immunization (Chapter 3)
and the use of mammography (Chapter 6) are showing positive results. These
activities must continue if progress is to be maintained.
◆ Advances in the treatment of HIV/AIDS and other diseases have helped to increase
the length of life and quality of life of people living with life-threatening illnesses
(Chapter 1).
◆ The annual growth rate of Canada’s insured health-care expenditures fell from 11.1%
(between 1975 and 1991) to 2.5% between 1991 and 1996 (Chapter 6). Despite this
slowdown, Canadians did not report a significant increase in unmet health-care
needs (Chapter 6), and most measures of population health continued to improve
(Chapter 1).
◆ There has been a substantial decline in the average length of stay in hospital. Shifting
care into the community and the home raises concerns about the increased financial,
physical and emotional burdens placed on families, especially women (Chapters 2
and 6). The demand for home care has increased in several jurisdictions, and there
is a concern about equitable access to these services (Chapter 6).
Toward a Healthy Future
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Executive Summary
◆ Little information on the quality of care or the impact of restructuring was available.
However, the public’s assessment of the overall quality of the health-care system,
although still largely favourable, has deteriorated since the beginning of this decade.
In February 1998, 29% of Canadians rated Canada’s health-care system as “excellent”
or “very good,” down from 61% in 1991 (Chapter 6).
◆ Access to universally insured care remains largely unrelated to income; however, many
low- and moderate-income Canadians have limited or no access to health services such
as eye care, dentistry, mental health counselling and prescription drugs (Chapter 6).
◆ Expenditures for medications and the use of prescription drugs have increased
dramatically since 1975. In 1996–97, 30% of Canadians aged 12 and over and 46%
of Canadians aged 75 and older used three or more medications (Chapter 6).
Biology and Genetics Affect Health
◆ Studies in neurobiology have confirmed that when optimal conditions for a child’s
development are provided in the investment phase (between conception and age 5),
the brain develops in a way that has positive outcomes for a lifetime (Chapters 3, 7).
◆ Aging is not synonymous with poor health. Active living and the provision of
opportunities for lifelong learning may be particularly important for maintaining
health and cognitive capacity in old age (Chapter 7).
Key Population Groups
This report describes decreased opportunities for optimal well-being among three key
population groups: children, youth and Aboriginal people.
Early Childhood
With nurturing and consistent support in later years, many children can overcome early
disadvantages. However, the preferred strategy is to prevent problems by providing all
children with the kinds of social, economic and physical environments they need in order
to thrive.
Efforts to maximize healthy child development in the early years will require direct
action by the health sector as well as collaboration with the other sectors (e.g. education,
social services, housing and taxation) and the many people and institutions that affect
child development (e.g. families, schools, communities, workplaces, governments and
the media).
◆ A loving, secure attachment between parents/caregivers and babies in the first 18
months of life helps children to develop trust, self-esteem, emotional control and
the ability to have positive relationships with others in later life (Chapters 3, 7).
Support to families and parents through a broad range of strategies is the best
way to help children get this important head start in healthy development.
◆ Experiences from conception to age six have the most important influence of any time
in the life cycle on the connecting and sculpting of the brain’s neurons. Positive
stimulation early in life improves learning, behaviour and health right into adulthood.
Toward a Healthy Future
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Executive Summary
◆ Infants and children who are neglected or abused are at higher risk for injuries, a
number of behavioural, social and cognitive problems later in life, and death
(Chapters 2, 3, 7). In 1996, almost 70% of children under age 3 who were victims
of assault were assaulted by family members (Chapter 2).
◆ Readiness for school is an important indicator of developmental maturity and
future success in school. In 1996–97, approximately 15% of preschoolers arrived at
school with low cognitive scores; 14% had high scores in behavioural problems. Safe,
cohesive neighbourhoods, high-quality childcare and growing up with a mother who
has a higher level of education are all factors that positively affect school readiness
(Chapters 3, 7).
◆ A healthy childhood begins before conception and continues through the prenatal
period. Good prenatal nutrition and support to pregnant women can help reduce
low birthweight and other problems associated with birth. In 1996, 5.8% of all live
births in Canada resulted in low birthweight babies (a total of 21,025 babies)
(Chapters 1, 2, 3, 7).
◆ Despite a parliamentary resolution to eliminate child poverty by the year 2000, the
proportion of young children who lived in low-income families increased from one
in five in 1990 to one in four in 1995. These proportions are higher in Aboriginal
and recently arrived immigrant communities, and in families headed by very young
parents and female lone parents (Chapter 2).
◆ Children in low-income families and neighbourhoods are at higher risk for infant
death and low birthweight. They are more likely to experience developmental delays,
to be exposed to environmental contaminants that have a negative effect on health,
and to experience higher rates of both unintentional and intentional injuries than
children who grow up in families with higher incomes (Chapters 2, 3).
◆ At the same time, there is no economic cut-off point above which all children do
well. The greatest proportion of children who experience difficulties are found in the
bottom 20% of the socioeconomic scale. However, due to the large size of the middle
class in Canada, the greatest number of children not doing as well as they might is
in the middle socioeconomic group.
Young People
Just as it is important to invest in early childhood, this report points to the immediate need
to invest in Canada’s youth. Young people deserve love and respect for who they are. They
are also central to Canada’s investment in its future as a caring and productive nation.
Young people themselves must be involved in identifying both problems and solutions,
and in providing input to policy and program decisions related to their well-being.
◆ A number of things are going well with young people. For example, youth voluntarism
has increased dramatically and the number of young women completing postsecondary levels of education is at its highest point ever (Chapter 2).
Toward a Healthy Future
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Executive Summary
◆ At the same time, distressing trends in the psychosocial well-being of Canada’s youth
are reported in virtually every chapter of this report.
◆ Negative health predictors among young women include high levels of reported
stress and depression and low levels of psychological well-being (Chapter 1). Many
young women report that they smoke to manage stress (Chapters 1, 5).
◆ Among young men, high rates of suicide (especially in Aboriginal communities) and
unintentional injuries contribute to early deaths (Chapter 1). Early school leaving
and multiple risk-taking behaviours (including drinking and driving and drinking
and unsafe sex) are symptoms of despair that do not bode well for the current or
future health of Canada’s young men (Chapters 2, 5).
◆ Despite some recent improvements, unemployment and underemployment remain
pervasive problems for young people. This is related to increases in the number of
young people who live in low-income situations and the number of young lowincome families in Canada (Chapter 2).
Canada’s Aboriginal People
Aboriginal communities have the main role in enabling their people to take control
of and improve their health. However, meeting this goal will require the support of all
Canadians. Policy makers and practitioners who are non-Aboriginal need to work with
Canada’s Aboriginal people to find culturally appropriate ways to improve their health
and well-being.
◆ Despite reductions in infant mortality rates, improvements in education levels, and
reductions in substance use in many Aboriginal communities, First Nations and
Inuit people remain at higher risk than the Canadian population as a whole for
illness and early death (Chapters 1, 3).
◆ Aboriginal people suffer from chronic diseases such as diabetes and heart disease
more so than the general population and there is evidence that these conditions are
increasing among Aboriginal groups (Chapter 1).
◆ Despite major improvements since the 1970s, infant mortality rates are still twice as
high in First Nations communities than in Canada as a whole (Chapters 1, 3).
◆ It has been estimated that the suicide rate among the Aboriginal population averages
two to seven times that of the population of Canada as a whole. Young Aboriginal men
(especially Inuit males) are most likely to commit suicide (Chapters 1, 3).
◆ Aboriginal young people are at higher risk for unintentional injuries and early deaths
from drowning and other causes (Chapters 1, 5).
◆ A greater proportion of Aboriginal families face problems with housing and food
affordability than Canadians as a whole.
Toward a Healthy Future
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Executive Summary
Addressing Current and Future Challenges
to Health in Canada
This report suggests the need for a comprehensive and collaborative approach to improving
the health of Canadians that addresses the root causes of illness and early death. This kind
of strategy has been named a “population health approach” by the federal, provincial and
territorial health departments in Canada.
A Population Health Approach
A population health approach focuses on the interrelated conditions that underlie health
and then uses what is learned to suggest actions that will improve the well-being of all
Canadians. A population health approach uses both short- and long-term strategies to:
•
improve the underlying and interrelated conditions in the environment that enable
all Canadians to be healthy, and
•
reduce inequities in the underlying conditions that put some Canadians at a
disadvantage for attaining and maintaining optimal health.
Priorities for Action
While there are many challenges to improving health, the ACPH recognized the
importance of highlighting three broad priority areas for action. The selection of these
priorities was based on the evidence contained in this report, as well as the collective
experience and expertise of the committee members and their partners. See Chapter 8
for an expanded discussion of key strategies for action.
1. Renewing and reorienting the health sector requires collaborative efforts to:
•
take action to meet emerging challenges in health promotion, disease and injury
prevention and health protection, as well as in treatment services,
•
increase the accountability of health services through improved reporting on the
quality of health services and increasing access to needed services,
•
increase our understanding of how the basic determinants of health influence
collective and personal well-being,
•
evaluate and identify policy and program strategies that work, and
•
influence sectors outside of health which can significantly affect health status.
2. Investing in the health and well-being of key population groups addresses recent trends
that indicate decreased opportunities for optimal well-being among three groups:
children, youth and Aboriginal people.
3. Improving health by reducing inequities in literacy, education and the distribution of
incomes in Canada speaks to the findings in this report showing direct links between
poor health and early death, and low levels of income, education and literacy.
Toward a Healthy Future
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Executive Summary
The Need for Dialogue and Collaboration
Obviously, the health sector has a key direct role in improving health. But, since many
of the determinants of health are outside the traditional health system, building alliances
with other sectors is a primary strategy for improving the health of the population. Other
health-determining sectors that need to be involved include finance, justice, housing,
education, the physical environment, employment, recreation, transportation and social
services.
The ideal outcome of these collaborations will be healthy public policies in a variety
of health-determining sectors, as well as in the health sector itself. The health sector
cannot do it all, nor can it impose its agenda on other sectors. It can, however, initiate
dialogue and partnerships with other sectors, and act as a collaborator for change.
All sectors stand to benefit from improvements in health and the conditions that
affect health. Healthy, well-educated, productive citizens who nurture their young people
and live in a civic, egalitarian, sustainable society feel in control of their destiny. They are
better prepared to address the local, provincial or territorial, national and global challenges
of the new millennium.
Collaboration in the pursuit of the public’s health needs to occur at all levels —
families, neighbourhoods, communities, provinces and territories, regions and national.
Partners need to include voluntary, professional, business, consumer and labour
organizations, private industry, governments and representatives of communities of
faith, various cultures, population groups and disadvantaged groups.
Moving Ahead
This report points to some important trends and challenges that need to be addressed.
Trends, however, are not destiny. It is possible to achieve positive health outcomes through
the implementation of a broad population health strategy that has a role for all: public,
private and not-for-profit.
As we enter a new century, there is an expectation that our past achievements and
collective commitment to improving the well-being of all Canadians will provide us with
some exciting opportunities to address the challenges presented in this report. We can
give no greater gift to the next generation than a healthy future.
Toward a Healthy Future
Table of Contents
Preface .....................................................................................................................................iii
Acknowledements ....................................................................................................................v
Executive Summary ...............................................................................................................vii
Introduction .............................................................................................................................1
Toward a Healthy Future.....................................................................................................1
About This Report...............................................................................................................3
Data Sources and Limitations of This Report ...................................................................4
The Canadian Population ...................................................................................................6
A Population Health Approach ..........................................................................................7
Endnotes for Introduction ..................................................................................................8
PART A: How Healthy Are Canadians?
1. The Health Status of Canadians .......................................................................................11
Highlights...........................................................................................................................13
Self-Rated Health...............................................................................................................14
Psychological Well-Being ..................................................................................................15
Selected Diseases and Conditions.....................................................................................17
Chronic Diseases ...........................................................................................................17
Depression .....................................................................................................................18
HIV and AIDS...............................................................................................................18
Injuries...........................................................................................................................19
Disability and Activity Limitations...................................................................................20
Major Causes of Death......................................................................................................21
Cardiovascular Disease .................................................................................................21
Cancer............................................................................................................................21
Unintentional Injuries ..................................................................................................23
Suicide............................................................................................................................23
Homicide .......................................................................................................................25
Infant Mortality.............................................................................................................25
Deaths Attributable to Smoking ..................................................................................25
Life Expectancy at Birth ....................................................................................................26
Potential Years of Life Lost................................................................................................26
How Does Canada Compare to Other Countries?..........................................................28
Toward a Healthy Future
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Table of Contents
Discussion ..........................................................................................................................31
Endnotes for Chapter 1 .....................................................................................................33
PART B: What Makes Canadians Healthy or Unhealthy?
2. The Socioeconomic Environment ....................................................................................39
Highlights...........................................................................................................................41
Income and Health ............................................................................................................43
Fifteen-Year Trends in Low Income .............................................................................43
Trends in Low-Income Status, 1990 to 1995 ...............................................................45
Income Distribution .....................................................................................................49
Education and Literacy .....................................................................................................50
Educational Attainment................................................................................................51
Literacy ..........................................................................................................................52
Employment and Unemployment....................................................................................54
Working Conditions..........................................................................................................57
Job Satisfaction and Work Stress..................................................................................57
Unpaid Work .................................................................................................................58
Injuries at Work ............................................................................................................59
The Social Environment....................................................................................................60
Social Support ...............................................................................................................60
Violence at Home..........................................................................................................60
Violence in the Community.........................................................................................61
Volunteering ..................................................................................................................61
Civic Participation ........................................................................................................62
Charitable Donations....................................................................................................63
Discussion ..........................................................................................................................63
Endnotes for Chapter 2 .....................................................................................................67
3. Healthy Child Development .............................................................................................71
Highlights...........................................................................................................................73
Growing Up Healthy .........................................................................................................74
Prenatal and Infancy Period .........................................................................................75
Preschoolers...................................................................................................................79
School-Age Children.....................................................................................................80
Adolescence ...................................................................................................................82
Some Key Issues Affecting Healthy Child Development.................................................84
Child and Family Poverty.............................................................................................84
Security and Safety of Children and Youth .................................................................85
Changing Family Structures.........................................................................................86
The Importance of Parenting and High-Quality Child Care.....................................87
The Need for Integrated Service Delivery ...................................................................87
Discussion ..........................................................................................................................88
Endnotes for Chapter 3 .....................................................................................................90
4. Physical Environment .......................................................................................................95
Highlights...........................................................................................................................96
Sustainable Development and Health ..............................................................................97
Toward a Healthy Future
xix
Table of Contents
Ecological Footprints ....................................................................................................98
The Natural Environment.................................................................................................98
Ozone Depletion ...........................................................................................................98
Sun Exposure and Protection.......................................................................................99
Climate.........................................................................................................................100
Air ................................................................................................................................101
Environmental Toxins.................................................................................................102
Water............................................................................................................................102
Food .............................................................................................................................102
The Built Environment ...................................................................................................104
Environmental Tobacco Smoke..................................................................................104
Transportation.............................................................................................................105
Affordable, Adequate Housing ...................................................................................105
Homelessness ..............................................................................................................106
What Canadians Are Doing ............................................................................................107
Discussion ........................................................................................................................108
Endnotes for Chapter 4 ...................................................................................................110
5. Personal Health Practices ................................................................................................113
Highlights.........................................................................................................................114
Trends in Health Practices ..............................................................................................115
Physical Activity ..........................................................................................................115
Healthy Eating.............................................................................................................117
Healthy Weights ..........................................................................................................117
Tobacco Use.................................................................................................................119
Use of Alcohol .............................................................................................................121
Illicit Drug Use ............................................................................................................122
Disturbing Trends in Substance Use and Abuse .......................................................123
Use of Safety Equipment for Injury Prevention........................................................124
Gambling .....................................................................................................................126
Sexual Practices ...........................................................................................................126
HIV Testing .................................................................................................................127
Multiple Risk Behaviours ...........................................................................................128
Discussion ........................................................................................................................130
Endnotes for Chapter 5 ...................................................................................................132
6. Health Services.................................................................................................................135
Highlights.........................................................................................................................137
Health Service Expenditures ...........................................................................................138
Service Delivery ...............................................................................................................141
Hospitals ......................................................................................................................142
Emergency Services.....................................................................................................143
Home Care ..................................................................................................................144
Long-Term Care ..........................................................................................................145
Quality of Care............................................................................................................145
Access to and Utilization of Health Services..................................................................145
Toward a Healthy Future
xx
Table of Contents
Visits to a General Practitioner or Family Physician ................................................146
Pap Smear Tests...........................................................................................................146
Mammograms .............................................................................................................147
Access to Health Professionals Other Than a Physician ...............................................148
Dental Visits ................................................................................................................148
Eye Examinations and Corrective Lenses ..................................................................149
Visits to a Chiropractor ..............................................................................................149
Mental Health Services ...............................................................................................150
Medication Expenditures and Use..................................................................................150
Unmet Health-Care Needs..............................................................................................152
Alternative Health Services .............................................................................................153
Discussion ........................................................................................................................154
Endnotes for Chapter 6 ...................................................................................................156
7. Biology and Genetic Endowment...................................................................................157
Highlights.........................................................................................................................158
Linking Biology and the Environment...........................................................................158
Biology and Birth Defects ...............................................................................................159
New Reproductive and Genetic Technologies (NRGTs) ...............................................161
The Biology of Brain Development................................................................................163
Aging and Health.............................................................................................................163
Effects of Other Determinants of Health on Healthy Aging....................................166
Discussion ........................................................................................................................167
Endnotes for Chapter 7 ...................................................................................................169
PART C: Improving Health
8. Improving Health ............................................................................................................173
Reason to Celebrate .........................................................................................................173
The Use of a Population Health Approach ....................................................................173
Priorities for Action.........................................................................................................175
1. Renewing and Reorienting the Health Sector .......................................................175
2. Investing in the Health and Well-Being of Key Population Groups ....................178
3. Improving Health by Reducing Inequities in Income Distribution
and in Literacy and Education ...............................................................................184
A Vision for the Future ...................................................................................................188
Conclusion .......................................................................................................................189
Endnotes for Chapter 8 ...................................................................................................189
Appendices
Appendix A: Members of the Federal, Provincial and Territorial Advisory
Committee on Population Health (ACPH), Working Groups
and Production Consultants .........................................................................193
Appendix B: Selected Health Indicators — Canada, the Provinces and Territories ........201
Appendix C: Selected Resource Documents.......................................................................217
Appendix D: Key Word Index .............................................................................................219
Toward a Healthy Future
Introduction
Toward a Healthy Future
A
s Canadians stand poised to enter a new millennium, we have much to
celebrate. By almost any measure, Canada is a highly desirable, healthy
place in which to live. For the past two years, the United Nations has
ranked Canada in the top spot on its Human Development Index, which takes
life expectancy, educational attainment and income into account. Canadians
are living longer with fewer disabilities in old age. Fewer babies are dying in the
first year of life and early deaths from heart disease continue to decline. Many
Canadians are taking positive steps to improve their health: overall, we smoke less
and exercise more. The safety of our food and the quality of our air and drinking
water are among the best in the world. And, despite recent stresses in the healthcare system, Canadians continue to enjoy and value universal access to medically
insured health services.
This overall high standard of health, however, is not shared equally by all sectors
of society. There are clear disparities in health status by gender, age, socioeconomic
status and place of residence. Indeed, the 1998 United Nations Report on Human
Development took Canada to task for failing to ensure that everyone has a chance
to take advantage of its enviable living standards. In its annual report, the UN said
that “Canada and France have significant problems with poverty and their
progress in human development has been poorly distributed.”1
In addition to problems relating to inequities, the current report shows that
the majority of early deaths and illnesses that Canadians suffer are preventable.
For example, almost all disease, disability and early death caused by tobacco use,
intentional injuries and unintentional injuries can be prevented.
Toward a Healthy Future
2
Introduction
Interprovincial/territorial differences are presented in Appendix B. No province or
territory emerges as the healthiest overall, and there are, in some cases, large differences
between the provinces and territories on specific indicators of health. These data should
be interpreted with caution, however, due to differences in sampling and information
collection methods. Unfortunately, data from the Yukon Territory and Northwest
Territories (NWT) are limited because the results of the National Population Health
Survey in those jurisdictions were still in the process of analysis. Nunavut data were
included in the NWT database and had not yet been separated out.
In the chapters that follow, we will see how a variety of factors affect health,
including gender, age, genetics, personal health practices, coping skills, social support,
working conditions, the physical environment and early childhood experience. Perhaps
the most powerful influence on health, however, is socioeconomic status, which is
measured in this report by income and education levels. Whether
we look at how people rate their own health, premature mortality,
psychological well-being or the incidence of chronic disease,
variety of factors
socioeconomic status remains strongly related to health status.
The evidence presented in this report also shows that an active
affect health, including
socioeconomic gradient is at work. In other words, people’s health
gender, age, genetics,
improves on virtually all measures and in all of the factors that
influence health as levels of income and education increase.
personal health practices,
This report also concludes that there is a persistent gap in health
status between Canadians with high incomes and those with low
coping skills, social
incomes. Chapter 2 explains why the distribution of income within
a given society is just as important to population health as the overall
support, working
income level of that society. Indeed, it is estimated that if the same
conditions, the physical
death rates as for the highest income earners applied to all Canadians,
over one-fifth of all potential years of life lost before age 65 could be
environment and early
prevented.
Despite the persistence of troubling inequities in health, most
childhood experience.
Canadians are living longer and their overall health continues to
improve. In an aging society, this is good news. As we enter a new
century, our progress and potential for technological advances are cause for optimism.
As we look forward to a healthy future, it is especially important to invest in our most
precious human resources. While Canadian children and young people may be at the
peak of their physical health, this report suggests some disturbing findings on their
economic and social well-being.
We can give no greater gift to the next generation than a healthy future. This report
helps us take stock of where we stand in terms of health and will help us measure our
progress by looking at changes over time. This is an essential first step in addressing the
challenges to health in the next millennium.
A
Toward a Healthy Future
3
Introduction
About This Report
This report summarizes the most current national information we have on the health
of Canadians and invites the reader to consider the implications of these findings for
current and future policies, practices and research. It is not a report card on the healthcare system. Rather, it is a tool to alert policy makers, practitioners and the public to
current and future challenges in health and to identify broad strategies that can address
the major factors that influence health. Since it is the second in a series of reports on
the health of Canadians, it also serves as an important monitoring tool by offering
benchmarks for gauging progress in the future.
In this report, health is viewed as far more than the absence of disease. It uses the
World Health Organization’s definition in which health is seen as a complete state of
physical, mental, social and emotional well-being. Health is a resource for living that
enables people of all ages to realize their hopes and needs, and to change or cope with
the environments around them.2
In keeping with this broad understanding of health, this report has been structured
around the major factors that influence health. These factors — which include but extend
beyond traditional health-care services — were identified as “prerequisites for health”
in the 1986 Ottawa Charter for Health Promotion.3 In 1994, the Federal, Provincial and
Territorial Advisory Committee on Population Health (ACPH) released a document entitled
Strategies for Population Health: Investing in the Health of Canadians4 that expanded on
this concept. This paper identified the following key influences or “determinants” of
health: living and working conditions (the socioeconomic environment), the physical
environment, health services, early childhood development, social support, personal
health practices and coping skills, and biology and genetic endowment. While each
of these influences is dealt with in a separate section of this report, it is the interplay
of all of these factors that ultimately determines the health of individuals, families and
communities. This way of examining health is termed the population health approach.
In addition to the factors mentioned above, gender, culture and membership in
specific population groups have significant effects on health status. Within the limits
of data availability, every attempt was made in this report to comment on the influence
of these factors on health status and the determinants of health.
Toward a Healthy Future: Second Report on the Health of Canadians was prepared by
the ACPH in collaboration with Statistics Canada, Health Canada, the Canadian Institute
for Health Information and a project team from the Centre for Health Promotion,
University of Toronto. As the title suggests, it is the second report to summarize and
comment on the state of the nation’s health. The first, Report on the Health of Canadians,
was released in September 1996.5
The current report differs from the first one in several ways. It assumes a greater
focus on inequities and the influence of gender on health. Chapters on healthy child
development and biology and genetics have been added in order to paint an overall
picture that includes all of the major determinants of health. The section on the physical
environment has been expanded to provide a better understanding of how this
determinant impacts on the health of Canadians.
Toward a Healthy Future
4
Introduction
Each chapter begins with a highlights section that provides a snapshot of the key
information, which is followed by a more detailed discussion of selected aspects of the
population’s health and a brief discussion of the major findings and challenges arising
from the information in the chapter. The final chapter suggests a vision of health for the
new millennium and points to recurring themes, challenges and strategies brought out
in the preceding chapters. As such, it provides a menu of key challenges for both shortand long-term action.
Data Sources and Limitations of This Report
Each year in Canada, massive amounts of information are collected on the health of
Canadians. This includes vital statistics such as births and deaths, information on
people’s contacts with the health-care system, and information from outside the
traditional health sector on such important matters as traffic injuries, housing and
employment. These data are collected through surveillance systems that monitor new
and emerging health problems, as well as national, provincial and local health surveys.
There is no one easy, comprehensive way to summarize all of this information in
a single, manageable report. It was necessary, therefore, to select and focus on a limited
range of issues and emerging trends that describe key aspects of the health of Canadians,
and the factors that affect health. This report draws primarily on data contained in the
Statistical Report on the Health of Canadians;6 which were drawn from a variety of sources
that are topical, recent and national in scope. The 1994–95 and 1996–97 cycles of the
National Population Health Survey (NPHS), the 1996 Census and the National Longitudinal
Survey on Children and Youth (1994–95 and 1996–97) are major information sources
for this report. The reader is encouraged to turn to the Statistical Report on the Health of
Canadians and the publications from the National Longitudinal Survey on Children and
Youth for information on topics not covered in this report.
Whenever possible, other reliable data sources and reports were consulted and
credited in discussions of health issues; however, it was impossible to fully address the
diversity of Canada’s population in one national report. Information on Aboriginal
people, newcomers to Canada and provincial/territorial differences have been included
when reliable national data were available, but reporting is inconsistent throughout the
text. In this regard, there may be a need to produce a number of supplementary reports
that take a more specific and detailed look at provincial comparisons and influences on
health such as gender, income, culture and membership in a specific population group.
In other cases, such as the exploration of early child development and health, a
number of other excellent reports already exist (see Appendix C). This report is not
intended to duplicate these efforts but to summarize what we know from a broad,
national perspective about healthy child development as a key factor in the current and
future health status of Canadians. The chapter on biology and genetics provides an
introductory look at this important determinant of health. A specific, more detailed
report on this topic would be extremely useful.
The use of a number of different sources means that there are discrepancies in the
age categories that are reported. The 1996–97 NPHS has a distinct advantage over other
national surveys in that age classifications are more detailed than those used in past
surveys. This allows the reader to see differences among youth, for example, who look
Toward a Healthy Future
5
Introduction
and act very differently at ages 12 and 19. It also allows the reader to consider the “cohort
effect.” For example, the generation of Canadians who are now over the age of 75 may
have had a very different life experience than Canadians in younger generations. The
cohort effect is especially relevant when we think about predictions for the future. At the
same time, the factors that influence health are likely to have an intergenerational effect
unless they are reversed. For example, children who grow up in low-income,
disadvantaged neighbourhoods are more likely to raise their own children in the same
kind of neighbourhood, unless they are given opportunities to break out of this cycle.
This report also looks at time trends, with a concentration on changes in the
various indicators contained in the previous report. In some cases, longer periods of
time are used to provide a more balanced look at changes over time. However, time
trends between the two NPHS surveys offer the most reliable comparisons, since the
methodology and sample size were similar.
While the use of large, national data sources ensures an accurate overall perspective
on the health of Canadians, there are often insufficient numbers to make reliable
observations about subcategories within specific demographic groups or populations,
such as Aboriginal people. Provincial comparisons of health indicators in Appendix B
should be interpreted with caution because of small sample sizes in some provinces.
Even statistics within provinces tend to mask the heterogeneous nature of groups within
a particular jurisdiction. For example, while overall measures of health may be high in
a particular province, there may be large differences among cultural or socioeconomic
subpopulations within that jurisdiction that are not captured by large databases. Unless
otherwise noted, provincial and territorial estimates in this report are not age-standardized.
At the time of writing, data from the 1996–97 National Population Health Survey
in the Northwest Territories and the Yukon Territory were still in the process of analysis
by Statistics Canada. As well, the new territory of Nunavut officially came into being —
an historic and important event for Canada. Data from Nunavut, however, were not yet
separated from the NWT database. While every attempt was made to glean information
from other surveys and documents, this report falls short of providing a clear picture
of the health of Canada’s Northern residents.
Information on Aboriginal people should be treated with caution, since
undercoverage in the 1996 Census was considerably higher among Aboriginal people than
other segments of the population. Some 77 Indian and Inuit reserves and settlements
(containing an estimated 44,000 people) were incompletely enumerated. In addition,
there was very little information available distinguishing findings among the diverse
subgroups within the Aboriginal population (e.g. Inuit, Métis, Registered Indians [on and
off reserve], and Unregistered Indians). Fortunately, initial results from the First Nations
and Inuit Regional Health Survey — which included questions similar to those in the
National Population Health Survey and was carried out with First Nations peoples living
on reserve and with Inuit communities in Labrador — became available toward the end
of the writing process. Further analysis of this survey will add important information to
what is contained here.
While a number of specific gaps in data are identified throughout the report, two
areas deserve special mention. The first relates to the lack of data on the quality of health
services (not the quantity) and the fact that most health service data are hospital-based.
As the health system increasingly moves into the community, more information on
Toward a Healthy Future
6
Introduction
community-based care is required. The second gap relates to the paucity of populationbased measures of health. As discussed in Chapter 1, virtually all the information in this
report is based on individual health measures. Future reports of this type would benefit
from additional measures of collective well-being based on sound methodologies and a
combination of indices.
The Canadian Population
The age and sex composition of a population can have a dramatic effect on aspects of
health such as fertility rates and the use of health services. The following paragraphs
contain some key statistics based on the 1996 Census.
In 1996, there were just over 30 million people living in Canada. About 27% of the
population was aged 19 or younger and some 12% were 65 years of age or older. This
reflects a significant decline in the proportion of the population made up of children and
young people in Canada, as well as the aging of the population as a whole. The number
of Canadians aged 20 to 64 rose from 53% in 1971 to 61% in 1996; over the same time
period, the population aged 65 and over increased from 8% to 12%. Because of the longer
life expectancy of women, there were more women than men past age 65; in all of the
younger age groups, the numbers of males and females were virtually equal. The
proportion of Canadians aged 65-plus is expected to more than double by 2041 to
approximately 10 million people (representing between 22% and 25% of the population).
About 3% of the Canadian population is Aboriginal in origin. In 1996, there
were approximately 1,192,600 Aboriginal persons living in Canada, of whom 507,200
were Registered Indians, 57,000 Inuit, 205,800 Métis and 422,600 non-status/other.
Canada’s Aboriginal population is much younger than the general population.
The average age of the Aboriginal population included in the 1996 Census was 25.5 years,
some 10 years younger than the average of the general population. Children under age 15
accounted for 35% of all Aboriginal people, as compared with only 20% of the general
population.
The majority of Canadians live in Ontario (38%) and Quebec (24%). There are vast
differences in provincial population size and the territorial populations are smaller than
that of the smallest province (Prince Edward Island). While the majority of Canadians
live in large urban centres, a substantial number of people live and work in rural areas.
In 1996, 17% of the Canadian population — some 5 million people — were
immigrants. Immigrants (people born outside Canada whose parents are not Canadian)
have been a vital part of Canadian society for more than 400 years. Canada’s population
is becoming increasngly diverse. Earlier waves of immigrants from Europe have largely
been replaced by newcomers from Asia, the Middle East and Africa. In 1996, there were
some 226,000 newly-landed immigrants in Canada; about one in six immigrants were
classified as refugees. Forty-seven percent of 1996 immigrants were between 25 and 44
years of age. Three-quarters of recent immigrants settled in Ontario or British Columbia,
with Quebec and Alberta attracting the next largest proportions of Canada’s newest
arrivals. Recent immigrants have been especially attracted to Canada’s three largest
urban areas: Toronto, Vancouver and Montréal.
Toward a Healthy Future
7
Introduction
Recent immigrants, regardless of their country of birth, tend to be in better health
than Canadian-born residents. This is probably a function of the immigration process —
people in good health are more inclined to emigrate than those in poor health, and
potential immigrants must first undergo medical screening for serious conditions. The
longer immigrants remain in Canada, however, the more their health is likely to resemble
that of Canadian-born citizens.7
A Population Health Approach
In January 1997, the ACPH defined population health as follows:
Population health refers to the health of a population as measured by health
status indicators and as influenced by social, economic and physical
environments, personal health practices, individual capacity and coping skills,
human biology, early childhood development, and health services.
As an approach, population health focuses on the interrelated conditions and
factors that influence the health of populations over the life course, identifies
systematic variations in their patterns of occurrence, and applies the resulting
knowledge to develop and implement policies and actions to improve the health
and well-being of those populations.
Definitions
◆
First Nations population refers to those persons who are registered as Indians under
the terms of the Indian Act and whose names appear in the Indian Register maintained
by the Department of Indian Affairs and Northern Development.
◆
Aboriginal refers to all indigenous persons of Canada of North American, Indian, Inuit
or Métis ancestry, including those in the Indian Register.
◆
Statistics Canada defines immigrants as “people who are, or have been at one time,
landed immigrants in Canada.” A landed immigrant is a person who has been granted
the right to live in Canada permanently by immigration authorities. Some are recent
arrivals, while others have resided in Canada for a number of years. Recent immigrants
are people who came to Canada within the last five years.
Toward a Healthy Future
8
Introduction
The goal of a population health approach is to maintain and improve the health
status of the entire population and to reduce inequities in health status between groups.
This requires a thorough, ongoing examination of both health status and the factors that
determine or influence health. Current data and evidence from the literature are then
used to make decisions about future efforts in research, policy and programs. This report
and its predecessor are important tools for understanding and implementing a population
health approach in Canada.
Endnotes for Introduction
1.
2.
3.
4.
5.
6.
7.
United Nations Development Program. Human Development Report 1998. New York: Oxford
University Press, 1998.
World Health Organization, Health and Welfare Canada, Canadian Public Health Association.
Ottawa Charter for Health Promotion. Ottawa: CPHA, 1986.
Ibid.
Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for
Population Health: Investing in the Health of Canadians. Ottawa: Minister of Supply and
Services Canada, 1994.
Federal, Provincial and Territorial Advisory Committee on Population Health. Report on the
Health of Canadians. Prepared for the Meeting of Ministers of Health, Toronto, September
1996. Ottawa: Health Canada, 1996.
Federal, Provincial and Territorial Advisory Committee on Population Health. Report on the
Health of Canadians: Technical Appendix. Prepared for the Meeting of Ministers of Health,
Toronto, September 1996. Ottawa: Health Canada, 1996.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.” Health Reports 7, 4 (Spring 1996): 33–45 (Statistics Canada Cat. No. 82-003-XPB).
Toward a Healthy Future
Part A:
How Healthy Are Canadians?
1
The Health Status of Canadians
Good health enables individuals to lead productive and fulfilling lives.
For Canada as a whole, a high level of health contributes to increased
prosperity and overall social stability.
— Report on the Health of Canadians, 1996.
his chapter focuses on three related questions: “How healthy are
T
Canadians?”, “Is the health of Canadians improving?” and “Who is
healthy and who is not?” The answers to these questions will help
focus our efforts to improve the well-being of all Canadians.
For the most part, Canadians enjoy a high level of health on virtually all
measures of health. Positive health status and improvements in health, however,
are not shared equally by all Canadians. This chapter shows that age and gender
influence health status in a number of ways. It also shows that income and health
status are closely related on nearly all measures of health.
This chapter uses a broad range of health indices or measures to describe the
health of Canadians. All of these — with the exception of the United Nations
Human Development Index — are measures of individual health status. Future
reporting on the status of health among the Canadian population as a whole
would benefit from additional collective indices based on sound methodologies
and a combination of a number of measures.
Toward a Healthy Future
12
The Health Status of Canadians
Definitions and Measures
◆
Self-rated health describes how individual Canadians experience and assess
their own physical and mental health.
◆
Psychological well-being includes three measures: Sense of coherence is a
perception that life is meaningful, challenges are manageable and life events
are comprehensible. Self-esteem refers to an individual’s sense of self-worth and
mastery describes the extent to which people believe that their life chances are
under their control.
◆
Selected diseases and conditions looks at the incidence and prevalence of
selected diseases and health conditions over time.
◆
Disability days measures how often health problems forced an individual to
cut down on regular activities (at work, school or home) for the better part of
a day in the preceding two weeks.
◆
Activity limitation measures the degree to which an individual is limited in
performing their normal activities at work, home or school due to a long-term
(more than six months) disability or health problem.
◆
Major causes of death reports on the principal causes of death.
◆
Infant mortality refers to the death of a live born infant within the first year
of life. Perinatal deaths are the combination of stillbirths and early neonatal
deaths (deaths within the first seven days of life).
◆
Life expectancy at birth measures the number of years a Canadian baby born
today can expect to live, based on current mortality data.
◆
Potential years of life lost describes the number of potential years lost when
a death occurs prior to the age of 70.
◆
Human Development Index is a composite measure used by the United
Nations to compare the progress of various countries on human development.
It measures life expectancy, educational attainment and adjusted income.
Three additional measures — the Human Poverty Index, the Gender-Related
Development Index and the Gender Empowerment Measure — were added
in the 1998 United Nations report. These are explained later in this chapter.
Toward a Healthy Future
13
The Health Status of Canadians
Highlights
Many Canadians enjoy a high level of health that continues to improve.
Self-rated health: Sixty-three percent of adult Canadians say that their health is excellent
or very good and only 9% rate their health as fair or poor. These rates, which have been
stable since 1985, represent one of the highest levels of self-rated health among citizens
of developed countries.
Infant mortality: In 1996, Canada’s infant mortality rate (5.6 per 1,000 live births)
dropped below the level of six infant deaths per 1,000 live births for the first time. While
this is an important achievement, it is still quite far above the infant mortality rate of
Japan, which is the lowest in the world (3.8 deaths per 1,000 live births).
Life expectancy: Based on current mortality patterns, a Canadian child born in 1996 can
expect to live to the age of 78.6 (males 75.7, females 81.4). This life expectancy represents
a new high in Canada, and is one of the highest in the industrialized world, behind only
Switzerland and Japan (of the 12 OECD countries reporting this information).
Gender and age have varying effects on health status.
◆ Men are far more likely than women to die before age 70, mainly because of gender
differences in deaths due to heart disease, cancer, suicide and unintentional injuries.
Rates of potential years of life lost are almost twice as high for men than women and
approximately three times higher among men aged 20 to 34.
◆ While women live longer than men, they are more likely to suffer from long-term
activity limitations and chronic conditions such as osteoporosis, arthritis and
migraine headaches.
◆ While older Canadians are far more likely than young Canadians to have physical
illnesses and conditions, youth (aged 12 to 19) report the lowest levels of
psychological well-being. Young women are particularly likely to report feeling
depressed.
◆ Suicide rates among young men are high in Canada, compared to other countries.
Suicides among Aboriginal groups (especially Inuit) have been reported to be two
to seven times more frequent than in the population at large.
◆ While unintentional injuries among children have decreased over time, they are still
the leading cause of death among children and youth. They are also a significant cause
of disability in children and young people. Boys and young men tend to experience
more unintentional injuries and more severe injuries than girls and young women.
Toward a Healthy Future
14
The Health Status of Canadians
Canadians with low incomes are more likely to suffer illnesses and to die early than
Canadians with high incomes.
◆ Only 47% of Canadians at the lowest income level rate their health as excellent or
very good, compared with 73% of Canadians in the highest income group.
◆ Low-income Canadians are more likely to die earlier and to suffer more illnesses than
Canadians with high incomes. It is estimated that if the death rates of the highest
income earners applied to all Canadians, more than one-fifth of all years of life lost
before age 65 could be prevented.
Inequities in income distribution and literacy downgrade Canada’s rank from first in
the world to tenth on the United Nations Human Development Index.
◆ The 1998 United Nations Human Development Report ranked Canada best in the
world (among 174 countries) in terms of human development as measured by life
expectancy, educational attainment and adjusted income.
◆ This standing dropped to tenth place when the Human Poverty Index for industrialized
countries (which takes into account literacy, unemployment, percentage of people
living below the poverty line and the percentage of people not expected to live past
age 60) was applied. The UN Report suggests that this drop is because “Canada has
significant problems of poverty and their progress in human development has not
been evenly distributed.”
Canada’s Aboriginal people are at higher risk for poor health and early death than the
Canadian population as a whole.
◆ Despite major improvements since 1979, infant mortality rates among First Nations
people are still twice as high as that of the Canadian population as a whole.
◆ Life expectancy is significantly lower among Aboriginal people than for the overall
Canadian population. High rates of suicide and fatal unintentional injuries among
First Nations and Inuit young people partly account for this difference.
◆ The prevalence of all major chronic diseases, including diabetes, heart problems,
cancer, hypertension and arthritis/rheumatism is significantly higher in Aboriginal
communities than in the general population and appears to be increasing.
Self-Rated Health
Self-rated health status has been shown to be a reliable predictor of health problems,
health-care utilization and longevity.1 In the 1996–97 NPHS, one-quarter of Canadians
aged 12 and over described their health as excellent, and more than one-third rated it as
very good. Less than one in ten Canadians described their health as fair or poor. Women
were slightly less likely to rate their health as excellent or very good (62%) than men
(65%). Fair or poor self-rated health status increased with each successive age group,
from 2% of 12- to 14-year-olds to 27% of Canadians over age 75.2
Toward a Healthy Future
15
The Health Status of Canadians
Percentage
Exhibit 1.1 shows a
Self-Rated Health, by Income Level,* Canadians
Exhibit 1.1
definite gradient in self-rated
Aged 12+, 1996–97
health that is strongly linked
to income. Among adult
80
73
Canadians in the lowest
67
70
income brackets, 47% rated
61
60
their health as excellent or
50
very good and 21% described
50 47
their health as fair or poor.
40
Among Canadians with
30
the highest income levels,
21
19
73% described their health as
20
10
excellent or very good, while
7
10
5
only 5% rated their health as
0
fair or poor. Canadians who
Lowest
Middle
Highest
lived in the lowest income
Low middle
Upper middle
households were four times
Income level
more likely to report fair or
poor health than those who
lived in the highest income
Excellent/Very good
Fair/Poor
households.
* Income levels in this figure and those to follow that are based on the NPHS represent total household
There were substantial
incomes before taxes and are adjusted for family size and age-standardized.
provincial differences in
Source: Statistics Canada. National Population Health Survey, 1996–97.
self-rated health. Only 17%
of Saskatchewan residents
viewed their health as excellent, compared with 27% of people living in Quebec. Nova
Scotians were most likely to see their health as fair or poor (10%), while residents of
Newfoundland (7%) and Quebec (8%) were least likely to rate their health as fair or poor.
Psychological Well-Being3
In the 1994–95 National Population Health Survey (NPHS), sense of coherence, selfesteem and mastery scores were based on a series of standardized interview questions.
“High,” “adequate” and “low” scores were based on peaks in the distribution of scores.
This allows for inter-group comparisons, but negates the meaningfulness of statements
about absolute levels of psychological well-being.
In 1994–95, some 28% of Canadians had a high sense of coherence (a view of the
world that life is meaningful, events are comprehensible and challenges are manageable).
Forty-nine percent had high self-esteem and 21% had a high sense of mastery (the extent
to which individuals feel that their life chances are under their own control). As this was
the first time these questions were asked in a national health survey, no time trends
or comparisons to other countries can be provided. But, within Canada, there are
pronounced variations in these measures among different age groups.
In contrast to the high levels of physical health usually found among youth,
psychological well-being is, on average, lowest among the youngest age groups. Sense
of coherence increased with age: seniors over age 75 were three times more likely than
Toward a Healthy Future
16
The Health Status of Canadians
Exhibit 1.2
Three Indicators of Psychological Well-Being,
by Age Group, Canada, 1994–95
75+
65–74
55–64
Age group
45–54
35–44
25–34
20–24
18–19
15–17
12–14
0
10
20
30
40
50
60
% of population aged 12+ (18+ for sense of coherence)
High sense of coherence
High self-esteem
High sense of mastery
Source: Statistics Canada. National Population Health Survey, 1994–95.
Exhibit 1.3
18- and 19-year-olds to score high on
sense of coherence. As Exhibit 1.2
shows, self-esteem and mastery
improve with age to a peak in middle
adulthood, followed by a modest
decline in later years.
These age-related patterns are
consistent with measures of poor
psychological health such as depression,
which declines with age (discussed
later). This positive association
between psychological well-being and
age is a reversal from that experienced
a generation ago, when seniors were
more likely than younger Canadians
to be depressed.4
Males were slightly more likely
than females to report a high sense of
mastery, but the difference was small for
this attribute and almost nonexistent
for the other two. The lack of
differences in reported self-esteem
between young men and women is
surprising, since many other studies
have concluded that young women
have lower levels of self-esteem than
young men.5
As Exhibit 1.3 shows, all three
measures of psychological well-being
were positively linked to income level.
Self-esteem and mastery were also
positively related to level of education.
Percentage of Canadians Reporting Low Self-Esteem, Low Sense of Mastery and Low Sense of
Coherence, by Income Level, 1994–95
Income level
Lowest
Middle
Highest
Low self-esteem
Low sense of mastery
18%
13%
10%
31%
22%
12%
Source: Statistics Canada. National Population Health Survey, 1994–95.
Toward a Healthy Future
Low sense of coherence
47%
33%
26%
17
The Health Status of Canadians
Selected Diseases and Conditions
Chronic Diseases
A comparison of the 1994–95 and 1996–97 National Population Health surveys revealed
that the major self-reported chronic diseases with the highest number of new cases were
non-arthritic back problems and arthritis/rheumatism. Women reported higher incidence
rates than men for most chronic diseases, although in some cases these differences were
not statistically significant.
In the 1994–95 NPHS, 81% of all people over age 65 and living in private households
reported that they had at least one chronic condition. Arthritis and rheumatism were the
most common chronic health problems reported. Three percent of Canadians aged 12
and over reported having diabetes that had been diagnosed by a health professional. For
Canadians over age 65, the rate was just above 10%. While there were no substantial
differences in the prevalence of diabetes between the sexes or between urban and rural
residents, it was significantly
higher among Canadians with
First Nations/Canada Ratio of Age-Adjusted Prevalence
Exhibit 1.4
low incomes.6
for Selected Chronic Diseases, 1997
According to a recent
article by Young and
Disease
Ratio:
Ratio:
colleagues, the prevalence
Men
Women
of all self-reported major
Diabetes
3:1
5:1
chronic diseases was
Heart problems
3:1
3:1
significantly higher in
Cancer
2:1
2:1
Hypertension
3:1
3:1
Aboriginal communities than
Arthritis/rheumatism
2:1
2:1
in the general population,
and appears to be increasing
Source: First Nations and Inuit Regional Health Survey, 1997.
(Exhibit 1.4).7 For example,
the rate of diabetes among First Nations and Inuit men was 3 times the rate for all
Canadian men; for First Nations and Inuit women, the diabetes rate was 5 times the
rate for all Canadian women.
In 1994–95, chronic conditions were less common among immigrants (50%)
than among the Canadian-born population (57%). Recent non-European immigrants
had a particularly low prevalence of chronic conditions (37%), but as their duration of
stay in Canada increased, so did the prevalence of chronic conditions. Fifty-one percent
of long-term non-European immigrants reported at least one chronic condition.8
Toward a Healthy Future
18
The Health Status of Canadians
This finding is likely due to a number of factors. First, Canada’s immigration
policies tend to favour immigrants who are in good health. Second, many immigrants
and refugees are young when they arrive. The reasons why the prevalence of chronic
conditions increases the longer they stay in Canada is less well understood. The normal
aging process is clearly a factor. Also, after arrival, the adoption of unhealthy lifestyle
practices such as smoking (which is more common among certain groups in Canada
than in other countries) may also be a factor.9
Depression10
The 1996–97 NPHS showed that some 6% of Canadians aged 12 and over were at
possible or probable risk of depression. Although the rates of depression reported by
women (8%) were slightly higher than those reported by men (5%), the rates for both
men and women were lower than in 1994–95. Young women aged 15 to 19 were the most
likely of any age-sex group to exhibit signs of depression (8% to 9%). For both males and
females, depression was more likely to occur in the younger years (especially at ages
18 and 19).
For both men and women, the risk of depression was highest among those with the
lowest incomes. Thirteen percent of women in the lowest income group were at risk of
depression, compared with 5% of women in the highest income group. For men, the rate
of depression ranged from 11% among those in the lowest income bracket to 4% among
men with high incomes.
Exhibit 1.5
Reported AIDS Cases and Reported AIDS Deaths
in Canada, 1979 to 1998
HIV and AIDS
As of June 30, 1998, a total of 15,935
cumulative AIDS cases had been
reported in Canada; however, because
of reporting delays the true figure was
1500
likely to be about 20,000. Almost
Cases reported
three-quarters of reported AIDS cases
(more than 11,000 persons) had died
1000
by this date. Since 1995, there has
been a dramatic decline in the annual
Reported AIDS deaths
number of reported AIDS cases and
500
in the number of reported AIDS
deaths (Exhibit 1.5). This may be due,
0
at least in part, to new anti-retroviral
1981
1985
1989
1993
1997 1998 treatments that delay the onset of
1979
1983
1987
1991
1995
AIDS and help people with AIDS
Year of diagnosis/year of death
live longer.11
Males outnumber females by
Source: Bureau of HIV/AIDS, STD and TB, LCDC, December 1998.
14 to 1 in both number of reported
cases and death, but this ratio is
beginning to change. Prior to 1995, women comprised only of 6% of all adult cases;
by 1997, the percentage had risen to 13%.12
Incidence
2000
Toward a Healthy Future
19
The Health Status of Canadians
Annual incidence
Exhibit 1.6 shows the estimated
Estimated Number of New HIV Infections in Canada,
Exhibit 1.6
number of new HIV infections
1975 to 1996
occurring each year in Canada. The
5000
method of back-calculation from
AIDS cases was used from 1975 to
1989, but not for subsequent years
4000
because of new treatments that delay
the development of AIDS and the long
3000
interval between HIV infection and
AIDS. After 1989, other methods were
1989–1994
2000
used to estimate the average number
of annual HIV infections for the years
1000
1989 to 1994 as a whole (shown as a
block in Exhibit 1.6) and for the year
1996. There were an estimated 4,200
0
new HIV infections in Canada in 1996.
1977
1981
1985
1989
1993
1996
This is lower than the estimated peak in
1975
1979
1983
1987
1991
1995
annual HIV infections of 5,000 or more
Source: Bureau of HIV/AIDS, STD and TB, LCDC, July 1997.
that occurred in the mid-1980s, but is
higher than the estimate of 2,500 to
3,000 per year for the period 1989 to 1994. The majority of the recent increase in HIV
infections appears to be occurring among injection drug users who now represent half of
all new infections. (See Chapter 5 for more information.) Furthermore, available data
suggest increasing HIV infection rates among Aboriginal persons and women.13
Those who present for HIV testing and test positive represent only a portion of the
population with HIV infection. At the end of 1996, Health Canada determined that of
the estimated 40,000 Canadians living with HIV, some 11,000 to 17,000 people were still
unaware of their infection.14
Injuries
In 1995–96, there were 217,000 hospital admissions due to injury. By far, the highest rates
of hospital admissions due to injuries were among senior Canadians over the age of 65
(235 per 10,000 population among senior women and 152 per 10,000 population among
senior men). The rate of hospital admission due to injury was much lower among people
under the age of 45. In this age group, males accounted for 69% of all injury admissions.15
The vast majority of injuries are unintentional — nearly two out of three hospital
admissions due to injury are the result of falls and motor vehicle crashes. Injuries
intentionally inflicted by another person accounted for 5% of all hospital admissions
due to injury, while self-inflicted injuries accounted for approximately 2% of injury
admissions.16
While the rate of injury due to falls is particularly high among Canadians over the
age of 60, falls remained an important cause of injury among children under the age of
11, and youth aged 11 to 20. Among children, the next most important cause of injuryrelated admission to hospital in 1996 was poisoning. For adolescents and adults under
the age of 60, the second most important cause was motor vehicle crashes.17
Toward a Healthy Future
20
The Health Status of Canadians
Disability and Activity Limitations18
Percentage
As Exhibit 1.7 shows, between the 1994–95 and 1996–97 cycles of the NPHS, there
was a decrease in the percentage of Canadian women and men who reported one or
more disability days during a two-week period, and who reported a continuing health
condition that limited their normal activities at home, school or work. Exhibit 1.7 shows
a particularly impressive decrease in activity limitations between the two surveys. Most
of the improvements were among Canadians over age 55. Women were more likely than
men to report both disability days and
Percentage of Men and Women Reporting Disability
long-term activity limitations.
Exhibit 1.7
Days and Activity Limitations, Aged 12+, 1994–95
According to the NPHS, and as
and 1996–97
shown in Exhibit 1.8, Canadians who
have activity limitations were also more
1994–95
1996–97
likely to have low incomes. Among
Disability days
men in the lowest income group,
◆ Men
13%
12%
32% reported an activity limitation,
◆ Women
17%
14%
compared with 12% of men in the
Activity limitations
highest income bracket. Among
◆ Men
20%
15%
women, the rate of reported activity
◆ Women
21%
17%
limitations ranged from 28% in the
lowest income group to 16% in the
Source: Statistics Canada. National Population Health Survey, 1994–95 and 1996–97.
highest income group. The
relationship between income and
disability is not yet clear. Do activity
limitations and disabilities lead to lowPercentage of Canadian Men and Women Reporting
income status or does low-income
Exhibit 1.8
Activity Limitation or Handicap, by Income Level,
status lead to disabilities? While both
Aged 12+, Canada, 1996–97
factors are likely at play, this is an
35
important area for further
32
investigation.
28
30
Overall, immigrants to Canada
25
were less likely than the Canadian-born
population to have any long-term
19
20
17
16
disability. However, the relationships
15
between gender, socioeconomic status
12
and disability hold true for immigrants
10
as well. Disability was more strongly
related to low household incomes and
5
to being a woman than to immigrant
0
status.19
Men
Women
Income level
Lowest
Middle
Highest
Source: Statistics Canada, National Population Health Survey, 1996–97.
Toward a Healthy Future
21
The Health Status of Canadians
Major Causes of Death
In Canada, death rates for most of the major causes have declined since 1970,
particularly in the case of coronary heart disease. The exception to this is the cancer
death rate which continued to increase until the mid 1980s and then declined steadily
among men and stabilized in women.
Cardiovascular Disease
Deaths per 100,000 population
Cardiovascular disease is the major cause of death in Canada. The two major
components of cardiovascular disease are ischemic heart disease, including acute
myocardial infarction or heart attack, and cerebrovascular disease and stroke. In 1996,
cardiovascular disease accounted for
37% of all deaths in Canada. While
Death Rates Due to Ischemic Heart Disease and
Exhibit 1.9
more men than women died of
Stroke, Canada, 1950 to 1996*
ischemic heart disease (22% versus
500
19%), more women died of stroke
(9% versus 6%).20
400
As Exhibit 1.9 shows, deaths
IHD — Males
from cardiovascular disease have
been declining in Canada since
300
IHD — Females
1970 among both men and women,
although more slowly in women.
200
Stroke — Males
Canada has one of the lowest rates
of cardiovascular disease mortality
100
among all developed countries.21
Stroke — Females
The Atlantic provinces have
0
had consistently higher mortality
1950
1960
1970
1980
1990 1996
rates than the western provinces for
cardiovascular disease. Provincial
*Age-standardized to the 1991 Canadian population.
prevalance rates of smoking, high
Source: Statistics Canada, Health Statistics Division. Health Indicators, 1999
(Statistics Canada Cat. No. 82-221-XCB).
blood pressure and obesity run
parallel to the rates for
cardiovascular disease. 22
Cancer
23
Cancer in its many forms is the second leading cause of death and the leading cause of
potential years of life lost before age 70. Among men, declining rates for most forms of
cancer were offset by dramatic increases in the detection of (but not mortality from)
prostate cancer, primarily due to the introduction of PSA testing. The incidence of new
cancer diagnoses in women has remained relatively stable since the early 1980s. Cancer
death rates have declined slowly for men since 1990, while they have remained relatively
stable among women over the same period.
Toward a Healthy Future
22
The Health Status of Canadians
As Exhibit 1.10 shows, the
incidence of prostate cancer was the
highest among new cancers in men.
140
The 1993 peak of new cases of
Prostate incidence
prostate cancer was due to the
120
introduction of PSA testing. At the
100
same time, death rates from this type
Lung incidence
of cancer have remained relatively
80
stable. Since prostate cancer is most
Lung mortality
often detected in old age and is a slow
60
growing cancer, many men who are
40
diagnosed with prostate cancer die
Prostate mortality
of other causes.
20
The number of new cases of
0
lung cancer has declined among men
1972 1976 1980 1984 1988 1992 1996
since the 1980s, likely due to a decline
1970 1974 1978 1982 1986 1990 1994 1998
in male smoking rates over the past
* Incidence rates from 1994 to 1998 are estimated. Mortality rates from 1996 to 1998
30 years. However, lung cancer death
are estimated.
rates still far exceed death rates due
Source: National Cancer Institute of Canada. Canadian Cancer Statistics 1998.
to prostate cancer.
As Exhibit 1.11 shows, the
Incidence
and
Mortality
Rates
for
Selected
Cancer
Sites,
Exhibit 1.11
incidence of both breast and lung
Age-Standardized, Females, Canada, 1970 to 1998*
cancer have been increasing among
women since the 1970s. Breast
120
cancer was estimated to be the most
common newly diagnosed cancer in
100
Breast incidence
1998; however, the leading cause of
80
cancer death was still predicted to be
lung cancer.
60
Thus, while cancer remains a
Lung incidence
serious problem, we are beginning
40
Breast mortality
to see signs that prevention and
control strategies are working for
20
a number of different cancer sites.
Lung mortality
These favourable results are obscured,
0
however, by continuing increases in
1972 1976 1980 1984 1988 1992 1996
1970 1974 1978 1982 1986 1990 1994 1998 lung cancer incidence and mortality
among women (largely as a result of
* Incidence rates from 1994 to 1998 are estimated. Mortality rates from 1996 to 1998
increased smoking) and the recent
are estimated.
Source: National Cancer Institute of Canada. Canadian Cancer Statistics 1998.
transient surge in prostate cancer
incidence (but not mortality) in males.
Time will tell whether the early detection of prostate cancer affects the mortality rate.
Provincial differences in cancer incidence and deaths are rather marked. Nova Scotia
has the highest male age-standardized incidence and death rates, due largely to higher
lung cancer rates than the Canadian average. Among women, the highest new case
incidence rate is also in Nova Scotia; the highest death rates are in Nova Scotia and Prince
Edward Island.
Incidence and Mortality Rates for Selected Cancer Sites,
Age-Standardized, Males, Canada, 1970 to 1998*
Rate per 100,000 population
Rate per 100,000 population
Exhibit 1.10
Toward a Healthy Future
23
The Health Status of Canadians
Unintentional Injuries
Unintentional injuries are the third most important cause of death overall, accounting for
8,663 deaths (29 per 100,000 population) in 1996. However, they remain the leading cause
of death among Canadians age 1 to 44, and as such are a major contributor to potential
years of life lost. Although many sources persist in referring to such events as “accidents,”
it is estimated that 90% of deaths due to unintentional injuries are preventable. And,
despite a 50% reduction in such deaths among children between 1970 and 1991,
unintentional injuries remain the major cause of death among children and youth.24
Injuries and poisonings are the number one cause of death in the First Nations
population (crude rate 154 per 100,000 population). In 1993, the age-standardized injury
rate for First Nations persons was 3.8 times higher than that for Canadians in general.
Native children and youth have much higher death rates due to injury than do other
Canadians. For Aboriginal infants, the rate of death is almost four times greater; for
preschoolers, it is five times higher; and among teenagers, the injury-related death
rate is three times higher.25
Overall, motor vehicle crashes are the major cause of deaths due to unintentional
injury. In 1994, they accounted for 38% of deaths, followed by falls (31%), poisonings
(9%), drownings and suffocation (5%) and fires (4%). Motor vehicle crashes are a
particularly important cause of injury and death among children and youth. However,
due in part to increases in seatbelt usage and reductions in impaired driving, the number
of deaths due to motor vehicle traffic crashes has declined impressively in recent years —
from 5,253 in 1977 to 3,082 in 1996.26 Falls remain an especially important cause of
death among the elderly, accounting for nearly three out of every four deaths due to
unintentional injury among Canadians over the age of 70.27
Suicide
Suicide is a tragic event and an important cause of potential years of life lost. In 1996,
there were 3,941 suicides in Canada — almost 11 per day.28 Trends and rates associated
with suicide need to be interpreted with caution, however, since official statistics tend
to under-report suicide. In addition, changes over time may reflect differences in the
official reporting and certification of suicide deaths.
There are dramatic sex and age differences in suicide rates. In 1996, males were
four times more likely than females to commit suicide. The highest rate for male suicides
was among men aged 20 to 24 (29 per 100,000 population) and 35 to 44 (30 per 100,000
population). For women, the highest rate of suicide was among those aged 45 to 54
(10 per 100,000 population).29
Young men’s suicide attempts are far more likely to have a fatal outcome than
young women’s. The reasons for this are not clear, but presumably relate to male–female
differences in reaching out for help, the nature of underlying problems, learned responses
to stress and the use of lethal methods (such as firearms and hanging) by young men.
Toward a Healthy Future
24
The Health Status of Canadians
Deaths per 100,000 population
Women attempt suicide more often than men, but the ratio is a subject of debate
due to wide variations in how the data are gathered. The population of attempters is large
and heterogeneous and may differ in important ways from that of suicide completers.
For example, most attempters will not ultimately die from suicide, though they may try
repeatedly; and many people who die by suicide have not made a previous attempt.30 It is
likely that more suicidal acts committed
by women are intended as non-fatal,
Suicide
Rates
for
Youth
Aged
15–19
and
20–24,
Exhibit 1.12
Canada, 1950 to 1996
as compared to those by men.31
Compared with other countries,
30
Canada’s rates of youth suicide are
Males 20–24
high. In 1973, Canada was the only
25
country among 21 western countries
Males 15–19
in which the suicide rate for male
20
youth aged 15 to 24 equalled or
exceeded the rate for the general
15
population of males. By 1987, only
10
four other countries shared this
Females 20–24
pattern.32 Between 1991 and 1993, the
5
suicide rate for Canadian male youth
Females 15–19
was exceeded only in Australia and
0
the Russian Federation (among 10
1950
1960
1970
1980
1990 1996
industrialized countries); the female
Source: Statistics Canada, Health Statistics Division. Health Indicators, 1996 and
rate was higher than that of all other
unpublished tabulations.
countries except Sweden and the
Russian Federation.33
As Exhibit 1.12 shows, there has been a steady and significant increase in suicide
rates among young men aged 15 to 24 since 1950. The 1996 rate of 18.5 per 100,000
among 15- to 19-year-old males was almost twice as high as the 1970 rate. Suicide rates
among young men aged 20 to 24 were even higher. These rates reached a peak in the
early 1980s and have fluctuated around this level ever since. In 1996, the male suicide
rate for this age group was 29 per 100,000. During the 1990s, there has been an average
of almost 39 suicides per year by children aged 10 to 14 (mostly boys), up from the
average of 27 per year during the 1980s.34
Suicide among Aboriginal groups in Canada has been reported to be two to seven
times more frequent than in the population at large. In the Northwest Territories
(NWT) and Nunavut combined, considerable attention has focused on an apparent
increase in the occurrence of suicide in a number of communities. In 1992, the annual
age-standardized suicide rate for the NWT and Nunavut combined was estimated at
23 per 100,000 population compared with 13 per 100,000 for Canada as a whole.35
In Nunavut, Inuit people represent the majority of the population. A comprehensive
study conducted in 1997 on suicide in the NWT and Nunavut combined found that in
a comparison of ethnic groups, the highest rate of suicide occurred among the Inuit, at
79 per 100,000, compared with 29 per 100,000 for the Dene and 15 per 100,000 for all
other ethnic groups, comprised primarily of non-Aboriginal persons. A comparison of
three five-year time periods between 1982 and 1996 revealed increasing rates of suicide,
particularly for Nunavut. Young Inuit males were the most likely group to commit
Toward a Healthy Future
25
The Health Status of Canadians
suicide. Thirty-six percent of those who committed suicide had experienced a recent family
or relationship break-up and 21% were facing criminal proceedings. Understanding these
and other reported circumstances on the risk of suicide requires further investigation.36
Other groups at high risk of suicide include people who suffer from depression and
people with substance abuse problems. Studies show that gay men, lesbians and people
who have experienced child sexual abuse may also be at higher risk.37
Homicide
There were 581 homicides reported in Canada in 1997 — a decline of 9% from 1996. This
continues a steady decline in the homicide rate in Canada. Following rapid increases in
the late 1960s and early 1970s, the rate of homicide in Canada in 1997 reached its lowest
point since 1969. Males accounted for nearly two-thirds (64%) of all homicide victims
and 84% of accused persons.38
Canada’s 1997 homicide rate of 1.92 per 100,000 was less than one-third that of the
United States (6.70), but higher than that of most European countries, including England
and Wales (1.00) and France (1.66).
There were 193 homicides committed with firearms in 1997, 19 fewer than in 1996.
Despite this drop, firearms continue to be used in about one out of three homicides.39
Infant Mortality
In 1996, infant mortality rates fell below 6 per 1,000 live births for the first time.40 While
this is an important achievement, it is still quite far above the infant mortality rate of
Japan, which is the lowest in the world (3.8 deaths per 1,000 live births).41
Perinatal complications were the most important single cause of both infant mortality
and perinatal death.42 There are substantial differences in infant mortality rates among the
various income groups in Canada. Although rates among First Nations people have fallen
dramatically since 1979, the 1994 infant mortality rate was twice as high among First
Nations people than in the Canadian population as a whole.43 These findings are explored
in more detail in Chapter 3 on Healthy Child Development.
Deaths Attributable to Smoking
As a cause of early death, smoking far outweighs suicide, motor vehicle crashes, AIDS
and murder combined.44 In Canada, smoking is estimated to be responsible for at least
one-quarter of all deaths for adults between the ages of 35 and 84.45 In 1991, more than
45,000 deaths were attributed to smoking.46 Overall, men are still more likely than women
to smoke and to smoke heavily; hence, death rates due to smoking are substantially higher
among males than females. This gender difference, however, can be expected to disappear
as smoking rates converge.
Toward a Healthy Future
26
The Health Status of Canadians
Life Expectancy at Birth
Mortality rate (%, ages 65 to 70)
Based on current mortality patterns, a Canadian child born in 1996 could expect to live
to the age of 78.6 (males 75.7; females 81.4). This life expectancy represents a new high in
Canada, possibly due to declines in the mortality rates for several of the leading causes of
death. At all ages, women have a greater life expectancy than men. The gap in life expectancy
at birth has continued to narrow, however, from 7.5 years in 1978 to 5.7 in 1996.47
Immigration contributes to
high life expectancy rates in Canada.
Exhibit 1.13 Career Earnings and Death for 500,000 Canadian Men
Immigrants, particularly those from
non-European countries, have lower
16
mortality rates and higher life
14
expectancies than residents who are
Canadian-born. In 1991, 41% of male
12
and 57% of female non-European
10
immigrants could expect to live to
8
age 85, compared with 23% of male
and 45% of female Canadian-born
6
residents.48
4
According to a 1991 study by
Robine
and Ritchie, Canadian men
2
in the highest quarter of income
0
0
20
40
60
80
100 distribution can expect to live 6.3
years longer and 14.3 more years free
Average earnings ($000s, ages 45 to 64, 1988)
of disability than those in the lowest
quartile. For women, the differences
Source: Wolfson, M.C., et al. “Career Earnings and Death: A Longitudinal Analysis
are 3 and 7.6 years respectively.49
of Older Men.” Journal of Gerontology: Social Sciences, 47, 4 (1993): S167–S179.
Another study, conducted by
Michael Wolfson in 1993, shows the
strong inverse relationship between career earnings and age of death for Canadian men;
as earnings increased, the rate of premature mortality decreased (Exhibit 1.13). Wolfson’s
findings also suggest that this pattern is not primarily due to people being unable to
work because of illness and thus unable to earn higher incomes, but rather because low
economic status leads to exposure to unhealthy life conditions, and thus to poorer health
and earlier death.50
Consistent with these findings are the results of a study on the life expectancy of
status Indians, many of whom live in low-income situations. As Exhibit 1.14 shows, the
life expectancy of the status Indian population in 1990 was seven years less than that for
the overall Canadian population in 1991.51
Potential Years of Life Lost52
Potential years of life lost (PYLL) concerns the loss of life before age 70. Therefore,
addressing the causes of PYLL would be expected to make a major difference to life
expectancy and health status in general.
Toward a Healthy Future
27
The Health Status of Canadians
Exhibit 1.14
Life Expectancy, First Nations Population (1990) and
Total Population, Canada (1991)
85
81
Years
80
75
74
74
70
67
65
60
Women
Men
Total population
First Nations population
Sources: Department of Indian Affairs and Northern Development (Status Indians);
Statistics Canada, Births and Deaths, 1993.
Exhibit 1.15
Potential Years of Life Lost (PYLL), by Cause of Death,
Canada, 1970 to 1996
500
PYLL (thousands)
400
Unintentional injuries
Cancer
300
200
Heart disease
Suicide
100
Respiratory
Stroke
0
1970 1972 1975 1978 1981 1984 1987 1990 1993 1996
Source: Statistics Canada, Health Statistics Division. Health Indicators, 1999
(Statistics Canada Cat. No. 82-221-XCB).
In 1996, there were more than
1 million PYLL due to all causes.
As Exhibit 1.15 shows, the most
important cause of PYLL was cancer
(30% of total). Unintentional injuries
(19%) and heart disease (13%) were
the second and third most important
causes. Cancer has been the leading
cause of PYLL since 1984 and, along
with suicide, is the only major cause
of PYLL to have increased since 1970.
Between 1970 and 1996, there was
a marked improvement in premature
mortality due to unintentional injuries
among young Canadians, especially for
ages 10 to 19.
Potential years of life lost per
100,000 population allows us to
compare the burden of premature
mortality among various groups.
Overall, these rates are almost twice
as high among men as among women,
and approximately three times higher
among men aged 20 to 34. The higher
rates of premature mortality among
men in general are attributed largely to
the higher rates of cancer, heart disease,
suicide and unintentional injuries.
PYLL per 100,000 population
varies substantially by province and
territory, from a low of 3,453 in
Ontario to highs of 4,742 in the Yukon
Territory and 7,695 in the Northwest
Territories and Nunavut combined
(Exhibit 1.16). The rates of PYLL in
the Northwest Territories and Nunavut
are more than double that for the rest
of Canada. Premature deaths from
unintentional injuries and suicides in
the three territories account for much
of the difference.
Toward a Healthy Future
28
The Health Status of Canadians
Exhibit 1.16
Potential Years of Life Lost per 100,000 Population, by Cause and by Province and Territory, 1996
Total
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon Territory
Northwest Territories
and Nunavut
Neoplasms
Accidents
Suicide
Respiratory
Heart
disease
Stroke
All
others
3,721
3,687
3,983
3,736
4,032
3,453
4,066
4,203
3,943
3,986
4,742
1,152
1,189
1,264
1,126
1,192
1,079
1,147
1,086
1,009
960
775
759
829
860
758
735
601
936
964
963
828
1,788
224
188
367
394
660
284
351
508
529
279
457
77
144
147
77
108
110
140
161
129
102
86
663
642
592
589
521
475
546
523
492
385
559
110
138
64
82
98
93
121
82
86
75
0
737
557
689
711
717
810
824
879
735
1,357
1,078
7,695
1,479
2,309
1,480
370
481
269
1,308
Note: Small differences occur between the total and the sum of the cause columns because of rounding.
Source: Health Canada, Laboratory Centre for Disease Control, Calculated from Statistics Canada, Health Statistics Division. Health Indicators, 1999 (Statistics Canada
Cat. No. 82-221-XCB).
There are marked differences between socioeconomic groups in terms of PYLL.
A 1995 study by Wilkins found that residents of the poorest neighbourhoods had death
rates from circulatory disease, lung cancer, injuries and suicide that were significantly
higher than rates for residents of the richest neighbourhoods. In other words, people who
are economically disadvantaged do not suffer more from a particular disease, but show
an increased vulnerability to early death due to a variety of causes. Wilkins concluded
that if the death rates of the highest income group for all causes of death applied to all
Canadians, more than one-fifth of all years of life lost before age 65 could be prevented.53
How Does Canada Compare to Other Countries?
Many health measures indicate that Canadians enjoy a standard of health that is among
the best in the world. Compared to other developed countries that are members of the
Organisation for Economic Co-operation and Development (OECD), Canada ranks third
in life expectancy, behind only Switzerland and Japan. Canadian mortality rates are among
the lowest in the industrialized world, behind only those of South Korea, Japan, Iceland
and Switzerland. And among countries reporting self-rated health status, Canada ranks
behind only Norway, and well ahead of such countries as Sweden, Spain, Finland,
Germany and South Korea (Exhibit 1.17).54
Yet, there is clearly room for improvement.
Although Canada’s infant mortality rate has decreased steadily, the rate of improvement
may have been lower than that in most industrialized countries. In 1990, Canada ranked
fifth among 17 OECD countries; by 1996, it ranked 12th. That year, Canada’s rate of 5.6
deaths per 1,000 live births was lower than those of only the United States, New Zealand,
Greece, Australia and the United Kingdom.55 However, this more recent ranking may be
largely due to changes in the way infant mortality is reported in various countries.
Toward a Healthy Future
29
The Health Status of Canadians
The concept of “human development”
Exhibit 1.17 Percentage Reporting Good or Better Self-Rated
was introduced by the United Nations
Health, Aged 15+, Selected OECD Countries, 1995
(UN) in 1990 as an alternative view of
development that is not equated solely with
Norway
92
economic growth. The indices used by the
CANADA
90
Human Development Index to measure
progress (life expectancy, education and
United States
90
standard of living) provide an important
Sweden
77
international measure of population health.
Spain
72
Canadians have been extremely proud of
their first place ranking among more than
Finland
69
170 countries in the last two reports of the
Germany
46
United Nations. The country’s performance
South Korea
44
on human development falls considerably,
however, when additional measures are
60
80
40
20
0
100
56
used to account for inequities.
Percentage
In 1998, the UN introduced two new
Note: Data for Canada are from 1996–97 and include “excellent” health.
measures of human development. The first
Source: OECD. OECD Health Data ’98 (software); Statistics Canada. National
is the Human Poverty Index-2 (HPI-2),
Population Health Survey, 1996–97, special tabulations.
which measures the way poverty is
manifested in industrialized countries,
including deprivation in survival, knowledge and disposable personal income, and social
exclusion (measured by long-term unemployment). The second indicator is the gender
empowerment measure, which measures women’s opportunities to participate in decision
making in economic, professional and political domains. Exhibit 1.18 summarizes the
four measures of human development used by the United Nations in its 1998 report.
Exhibit 1.18
United Nations Measures of Human Development
Longevity
Knowledge
Human
Development Index
Life expectancy
Literacy rate and
school enrolment
Adjusted per
capita income
Gender-Related
Development Index
Male and female
differences
Male and female
differences
Male and female
differences
Human Poverty
Index-2
(for developed
countries)
Percentage
of people not
expected to live
past age 60
Functional
illiteracy rate
Percentage of people
living below income
poverty line: less than
50% of mean
disposable income
Unemployment
(12 months
or more)
Women’s earned
income share
as a percentage
of men’s
Women’s
participation
in politics and
decision-making
positions
Gender
Empowerment
Measure
Standard of living
Source: United Nations Development Program. Human Development Report 1998.
Toward a Healthy Future
Participation
30
The Health Status of Canadians
As Exhibits 1.19 and 1.20 show, Canada ranked number one in the world on the
Human Development Index as a whole and when gender was factored into the three
measures of human development. When the HPI-2 is applied, however, Canada drops to
tenth place out of the 17 countries to which this measure was applied (Exhibit 1.21). The
UN Report suggests that the reason for the drop is that “Canada has significant problems
of poverty and [its] progress in human development has not been evenly distributed.”
Supporting documentation in the Report shows that, in 1995, Canada had more than
twice the number of citizens who lacked adequate literacy skills than Sweden, Sweden
being the number one ranked country on this index. In addition, 11.7% of the Canadian
population (1990) lived below the income poverty line, compared with 6.7% in Sweden
and 5.9% in Germany.
Interestingly, the extent of human poverty as measured by the HPI-2 had little
to do with the average level of income. The United States, with the highest per capita
income among the 17 countries, also had the highest index of human poverty. Sweden,
which ranked first in the HPI-2, was 13th in average income. This suggests two things:
Exhibit 1.19
1
2
3
4
5
6
7
8
9
10
Human Development Index, 1995*
World Rank (1=best)
Exhibit 1.20
CANADA
France
Norway
U.S.A.
Iceland
Finland
Netherlands
Japan
New Zealand
Sweden
1
2
3
4
5
6
7
8
9
10
* 174 countries total
Exhibit 1.21
1
2
3
4
5
6
7
8
9
10
Gender-Related Development Index, 1995*
World Rank (1=best)
CANADA
Norway
Sweden
Iceland
Finland
U.S.A.
France
New Zealand
Australia
Denmark
* 102 countries total
Human Poverty Index-2, 1995*
World Rank (1=best)
Exhibit 1.22
Sweden
Netherlands
Germany
Norway
Italy
Finland
France
Japan
Denmark
CANADA
1
2
3
4
5
6
7
8
9
10
Gender Empowerment Measure, 1995*
World Rank (1=best)
Sweden
Norway
Denmark
New Zealand
Finland
Iceland
CANADA
Germany
Netherlands
Austria
* 174 countries total
* 17 industrialized countries
Source: United Nations Development Program. Human Development Report 1998.
Toward a Healthy Future
31
The Health Status of Canadians
first, that “poverty” is not just about income — it is also about reduced opportunities
in employment, education and political life. Second, development progress is closely tied
to the degree of inequity in income distribution in any given country.
Exhibit 1.22 suggests that Canada needs to provide more opportunities for women
to participate in decision-making positions in the political, business and professional
communities and to decrease the wage gap between men and women. Again, per capita
income had little to do with the degree to which a country empowers women. In some
cases, developing countries did better than industrialized countries; for example, Trinidad
and Barbados were ahead of the United Kingdom and Ireland on this measure.
Discussion
Reducing Inequities
As Canada stands poised to enter a new millennium, reducing persistent inequities
in health status remains one of our greatest challenges to achieving population health.
Canadians with low incomes and low levels of education (which are often related) are
more likely to have poor health status, no matter which measure of health is used. They
are also more likely to die earlier than other Canadians, no matter which cause of death
is considered.
This chapter also shows that poor health is not just the result of economic deprivation
— indeed, an active gradient is at work. In other words, health status improves for all
Canadians with each step up the economic ladder. Current thinking suggests that this
may be related to increased susceptibility to disease processes related to the stresses of
disadvantage and the coping skills people possess, in addition to increased exposure to
threats in the physical environment.57
This report recognizes the inherent challenges in achieving the goal of reduced
inequities. Virtually all societies struggle with this problem. Achieving complete equality
in health status among all Canadians is an unrealistic goal. But achieving “equitable” or
fair access to the opportunities and supportive environments all people need to be healthy
is both a laudable and achievable goal in a caring, civilized society. The United Nations
report on human development suggests that efforts to reduce relative poverty, and to
increase opportunities in education, employment, wages and participation in political and
economic spheres are the key strategies for reducing inequities and, therefore, improving
the health and well-being of Canadians.
Addressing Differences in Population Groups
This report and others point to the urgent need to find effective ways to improve the health
of Canada’s Aboriginal people. Failure to address inequities in the health and
socioeconomic status of Aboriginal people will inevitably lead to continuing disparities
and to an increase in illness, suffering and early deaths for this population.
Aboriginal communities have the lead role in finding ways to enable their people to
take control of and improve their health. However, to do so will require all policy-makers
and practitioners (both Aboriginal and non-Aboriginal) to work with Canada’s Native
peoples to find culturally appropriate ways to improve their health and well-being.
Toward a Healthy Future
32
The Health Status of Canadians
Gender Has an Important Influence on Health
In the last half of this century, women have lived longer than men; however, the gap in
life expectancy at birth between women and men has continued to narrow — from 7.5
years in 1978 to 5.7 years in 1996.58 This may be due to a number of factors including
increases in stress on women and decreases in the major causes of premature death
among men, especially ischemic heart disease and lung cancer.
While this reduction in two of the major causes of death among men is welcome,
premature mortality rates continue to be substantially higher among men than women.
If male mortality rates are to be further reduced, increasing attention needs to be paid
to other major causes of death among men, including fatal injuries and suicide.
While a decrease in lung cancer deaths is good news for men, cancer death rates have
remained stubbornly persistent for women, mainly due to continuing increases in lung
cancer mortality. At the same time, smoking rates among young women have continued
to escalate (see Chapter 5). Indeed, adolescent women are now more likely to smoke than
adolescent men. Unless the trend toward increased smoking among young women is quickly
reversed, lung cancer will increasingly become a major killer of women.
Quality of life is as important as quantity. While women live longer than men, they
also suffer more from chronic diseases and disabilities. Efforts to prevent these problems
in the senior years are essential to maintaining and improving the health of both women
and men, but may be particularly important to women.
This chapter (and others to follow) also suggests a need to address the psychosocial
well-being of young people. Low scores for psychological well-being, high scores for
probable depression and high rates of suicide are warning signs that many of Canada’s
young people are greatly troubled. Increases in substance use and multiple risk
behaviours, which will be discussed in subsequent chapters, are further signs of youth
distress. The next chapter suggests that enhanced employment opportunities, incentives
for higher education and nurturing communities are all prerequisites for improving the
well-being of Canada’s young people.
Increasing Health Promotion and Disease and
Injury Prevention Activities in Key Areas
Most of the causes of disease, disability and early death explored in this chapter are
preventable. In the cases of heart disease and cancer, we are beginning to see some positive
results from ongoing efforts to prevent and reduce these diseases. These initiatives (and
others) need to continue, with an increased focus on Canadians with low incomes and
low levels of education.
Deaths and disabilities due to smoking and unintentional injuries are almost all
preventable. As such, they must remain a high priority for policy-makers and practitioners.
In terms of injuries, we need to pay attention to and better understand gender and age
differences in risk-taking behaviour, the causes of both intentional and non-intentional
injuries, and how they are best prevented. Reducing the very high rates of injury and
injury-related deaths among Aboriginal young people must also be a priority for action.
Toward a Healthy Future
33
The Health Status of Canadians
Endnotes for Chapter 1
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Adams, O. “Health Status.” In Health and Welfare Canada. Canada’s Health Promotion Survey
1985: Technical Report. Ottawa: Minister of Supply and Services Canada, 1988 (Cat. No. H39119/1988).
Statistics Canada. National Population Health Survey, 1996–97. Special tabulations.
Statistics Canada. National Population Health Survey, 1994–95. Special tabulations.
Stephens, T. Population Mental Health in Canada. Report prepared for the Mental Health
Promotion Unit, Health Canada, May 1998.
Edwards, P. Self-Esteem, Sport and Physical Activity. Ottawa: Canadian Association for the
Advancement of Women and Sport and Physical Activity, 1993.
James, R., Kue Young, T., Cameron, A., et al. “The Health of Canadians with Diabetes.” Health
Reports 9, 3 (Winter 1997): 47–52.
Young, T., O’Neill, J., Elias, B., et al. “Chronic Diseases.” First Nations and Inuit Regional
Health Survey. Ottawa: First Nations and Inuit Regional Health Survey National Steering
Committee, 1999.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.” Health Reports 7, 4 (Spring 1996): 33–45. (Statistics Canada Cat. No. 82-003-XPB).
Ibid.
Statistics Canada. National Population Health Survey, 1994–95 and 1996–97. Special tabulations.
Health Canada, Laboratory Centre for Disease Control (LCDC), Bureau of HIV/AIDS,
Sexually Transmitted Diseases (STD) and TB. Special tabulations.
Health Canada. HIV and AIDS in Canada, Surveillance Report to December 31, 1997. Ottawa:
Health Canada, Laboratory Centre for Disease Control, Bureau of HIV/AIDS, STD and TB,
April 1998.
Health Canada, Laboratory Centre for Disease Control (LCDC), Bureau of HIV/AIDS,
Sexually Transmitted Diseases (STD) and TB, Epi Update: Estimates of HIV Prevalence and
Incidence in Canada, November 1998.
Health Canada. “HIV Testing Among Canadians: An Estimated 11,000 to 17,000 Current HIV
Infections May Not Be Diagnosed.” Epi Updates, Ottawa: Health Canada, Laboratory Centre
for Disease Control, Bureau of HIV/AIDS, STD and TB, May 1998.
Canadian Institute for Health Information. National Trauma Registry Report: Hospital Injury
Admissions, 1995–96. Ottawa: CIHI, 1998.
Ibid.
SmartRisk Foundation. The Economic Burden of Unintentional Injury in Canada. Toronto:
SmartRisk Foundation, 1998.
Statistics Canada. National Population Health Survey, 1994–95 and 1996–97.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.”
Statistics Canada, Health Statistics Division, unpublished vital statistics for 1996, special
tabulations.
Statistics Canada, Health Statistics Division. Health Indicators, 1999. (Statistics Canada Cat.
No. 82-221-XCB).
Heart and Stroke Foundation of Canada. Heart Disease and Stroke in Canada. Ottawa: Heart
and Stroke Foundation of Canada, 1997.
National Cancer Institute of Canada. Canadian Cancer Statistics, 1998. Toronto: National
Cancer Institute of Canada, 1998.
SmartRisk Foundation. The Economic Burden of Unintentional Injury in Canada. Toronto:
SmartRisk Foundation, 1998.
Toward a Healthy Future
34
The Health Status of Canadians
25. MacMillan, H., Walsh, C., Jamieson, E., et al. “Children’s Health.” First Nations and Inuit
Regional Health Survey. Ottawa: First Nations and Inuit Regional Health Survey National
Steering Committee, 1999.
26. Transport Canada. Total Collisions and Casualties 1977–1996. Ottawa: Transport Canada,
1999, www.tc.gc.ca/roadsafety/Stats/stats96/st96tote.htm
27. SmartRisk Foundation. The Economic Burden of Unintentional Injury in Canada.
28. Statistics Canada, Health Statistics Division. Health Indicators, 1997. (Statistics Canada Cat.
No. 82-221-XDE).
29. Ibid.
30. Health Canada. Suicide in Canada. Update of the Report of the Task Force on Suicide in
Canada. Ottawa: Minister of Supply and Services Canada, 1994 (Cat. No. H39-107/1995E).
31. Canetto, S., Sakinofsky, I. “The Gender Paradox in Suicide.” Suicide and Life-Threatening
Behaviour 28, 1 (1998): 1–23.
32. Health Canada. Suicide in Canada. Update of the Report of the Task Force on Suicide in
Canada.
33. United Nations Children’s Fund. Progress of Nations, 1996. New York: UNICEF, 1996.
34. Statistics Canada, Health Statistics Division. Health Indicators, 1997.
35. Health Canada. Suicide in Canada: Update of the Report of the Task Force on Suicide in
Canada. Ottawa: Health Programs and Services Branch, 1995 (Cat. No. H39-107/1995E).
36. Isaacs, S., Keogh, S., Menard, C., et al. “Suicide in the Northwest Territories: A Descriptive
Review.” Chronic Diseases in Canada 19, 4 (1998): 152–6.
37. Health Canada. Suicide in Canada: Update of the Report of the Task Force on Suicide in
Canada. Ottawa: Health Programs and Services Branch, 1995 (Cat. No. H39-107/1995E).
38. Fedorowycz, O. “Homicide in Canada, 1997.” Juristat 18, 12 (1998) (Statistics Canada Cat.
No. 85-002-XPE).
39. Kong, R. “Canadian Crime Statistics, 1997.” Juristat 18, 11 (1998) (Statistics Canada Cat. No.
85-002-XPE).
40. Statistics Canada. “Births 1996.” The Daily, July 8, 1998 (Statistics Canada Cat. No.
11-001-XIE).
41. Organisation for Economic Co-operation and Development. OECD Health Data 98
(CD-ROM).
42. Statistics Canada. Compendium of Vital Statistics 1996. Ottawa: Statistics Canada, 1999
(Statistics Canada Cat. No. 84-214-XPE).
43. Health Canada, Medical Services Branch. Health Programs Analysis, First Nations and Inuit
Health Programs. Ottawa: MSB, 1996.
44. Ellison, L., Morrison, H.I., de Groh, M., et al. Health Consequences of Smoking among
Canadian Smokers: An Update. Health Canada, Laboratory Centre for Disease Control, 1998.
45. Collishaw, N.E., Leahy, K. “Mortality Attributable to Tobacco Use in Canada.” Canadian
Journal of Public Health 79 (1988): 166–9.
46. Ellison, L., Mao, Y., Gibbons, L. “Projected Smoking-Attributable Mortality in Canada,
1991–2000.” Chronic Diseases in Canada 16 (1995): 84–9.
47. Statistics Canada. Compendium of Vital Statistics 1996. Ottawa: Statistics Canada, Fall 1998
(Statistics Canada Cat. No. 84-214-XPE).
48. Chen, J., Wilkins, R., Ng, E. (Statistics Canada). “Health Expectancy by Immigrant Status,
1986 and 1991.” Health Reports 8, 3 (Winter 1996): 29–37.
49. Robine, J., Ritchie, K. “Healthy Life Expectancy: Evaluation of Global Indicators of Change in
Population Health.” British Medical Journal 302 (1991): 457–60.
50. Wolfson, M., Rowe, G., Gentleman, J., et al. “Career Earnings and Death: A Longitudinal
Analysis of Older Men.” Journal of Gerontology: Social Sciences 47, 4 (1993): S167–79.
Toward a Healthy Future
35
The Health Status of Canadians
51. Department of Indian Affairs and Northern Development (Status Indians). Statistics Canada,
Births and Deaths, 1993.
52. Statistics Canada, Health Statistics Division. Health Indicators, 1999.
53. Wilkins, R. “Mortality by Neighbourhood Income in Canada, 1986 to 1991.” Presented at the
Conference of the Canadian Society for Epidemiology and Biostatistics, St. John’s,
Newfoundland, August 1995.
54. Organisation for Economic Co-operation and Development. OECD Health Data 98
(CD-ROM).
55. Statistics Canada. Compendium of Vital Statistics 1996.
56. United Nations Development Program. Human Development Report 1998. New York: Oxford
University Press, 1998.
57. Evans, R. Why Are Some People Healthy and Other People Not? Canadian Working Paper
Number 20. Toronto: Institute for Advanced Research, Program in Population Health,
December 1992.
58. Statistics Canada. “Deaths 1996.” The Daily, April 16, 1998 (Statistics Canada Cat. No.
11-001-XIE). See Statistics Canada Internet site: www.statcan.ca
Toward a Healthy Future
Part B:
What Makes Canadians Healthy
or Unhealthy?
2
The Socioeconomic Environment
What matters in determining mortality and health in a society is less the
overall wealth of the society and more how evenly wealth is distributed.
The more equally wealth is distributed, the better the health of that society.
— Editor, The British Medical Journal, 1996.1
T
he important influence of the environment on health has been recognized
for some time. Over 25 years ago, A New Perspective on the Health of
Canadians suggested that health was influenced by four key factors or
fields: lifestyle, biology and genetics, health care and the environment.2 Within
the latter, social and economic conditions (described here as the socioeconomic
environment) have a significant effect on individual and collective well-being.
The influence of another component of this field, the physical environment, is
explored in Chapter 4.
The previous chapter confirmed that health status is directly related to
economic status. Although there is clear agreement that income is related to
health, why this is so requires further study. As well, there is no consensus as to
which is the best measure of socioeconomic status (SES). Some researchers prefer
to use education level or occupation, while others use income. This report uses
income as a proxy for SES in most cases, although education is discussed when it
is particularly relevant to the topic. A full exploration of the links between income
and health is beyond the scope of this report. A separate report exploring this
issue would be a welcome addition to the field.
While there are many factors in the social and economic environments that
affect health, this chapter focuses on five key influences: income (and income
distribution), education and literacy, employment and unemployment, working
conditions, and factors in the social environment.
Toward a Healthy Future
40
The Socioeconomic Environment
Definitions and Measures
◆
The socioeconomic environment refers to living and working conditions in both the economic
and social realms. Key influences on health in the economic dimension of the environment
include income and income distribution. Major determinants on the social side of the environment
include education and literacy, employment and working conditions, levels of social support,
violence in the community and in the home, civic participation, and voluntarism.
◆
Low income refers to economic families and unattached individuals who have incomes below
Statistics Canada’s low income cut-offs (LICOs) 1992 base. These cut-offs were selected on the
basis that families and unattached individuals with incomes below these limits usually spend
more than 54.7% of their incomes on food, shelter and clothing, and hence are considered
to live in strained circumstances.
◆
Statistics Canada has repeatedly emphasized that the LICOs are quite different from measures
of poverty and the department does not endorse their use as such. However, LICOs reflect a
consistent and well-defined methodology that identifies those who are significantly worse off
than the average person or family. In the absence of an accepted definition of poverty, these
statistics have been used by many analysts to study the characteristics of relatively deprived
groups in Canada.
◆
Poverty is used in this chapter as one way of describing low-income status.
◆
The economic family concept is used to establish LICOs rather than to describe a census family.
An economic family consists of all persons in a household who are related to each other by
blood, marriage, common-law or adoption. An unattached individual is a person 15 years old
or over who is living alone or living in a household where he/she is not related to anyone else.
◆
Total income represents the income an individual receives from all sources, including wages
and salaries, farm and non-farm self-employment, government transfer payments, investment
income, retirement pensions and other money income.
◆
Income data are presented in constant dollars. Incomes from previous censuses are adjusted
for changes in the price of goods and services using the Consumer Price Index. For example,
the actual average income of a census family in 1995 was $54,000 compared with $51,300
in 1990. This is an increase of 6.4% before adjustment. When changes in prices are taken into
account, real (constant dollar) family income for 1995 declined by 4.8% compared with 1990.
◆
The Gini Index or coefficient is a well-established measure of income inequality. If incomes were
distributed in a fully equitable manner, each person would receive the same share of income.
The Gini Index measures how far real distribution is from this theoretical reference point. In theory,
the Gini coefficient can vary between 0 (perfect distribution) and 1 (complete concentration
in a single person). In practice, Gini coefficients of per capita income vary between 0.25 and
0.60. The larger the Gini coefficient, the greater the inequality in income distribution.
◆
Prose literacy refers to the ability to read and comprehend a passage of text; document
literacy describes the ability to complete standard forms such as job applications; quantitative
literacy (sometimes called numeracy) requires basic computation skills. Literacy skills are allotted
to one of five levels, five being the highest.
◆
Aboriginal people include those who reported themselves as North American Indian,
Métis or Inuit in the 1996 Census. Visible minority refers to people other than Aboriginal
Canadians who are members of a race other than Caucasian.
Toward a Healthy Future
41
The Socioeconomic Environment
Highlights
Income level and health
◆ People with higher incomes generally live longer, healthier lives than people with
lower incomes.
◆ Between 1990 and 1995, the proportion of Canadians with low-income status
increased from 16% to 20%.
◆ In 1995, young children (under the age of 6) and youth (aged 18 to 24) were most
likely to live in low-income situations. An estimated 1.3 million children under the
age of 15 lived in low-income households in 1995 — an increase of 300,000 children
in just five years.
◆ Between 1980 and 1996, there was a substantial and welcome drop in the number
of older Canadians who fell below Statistics Canada’s low income cut-off (LICO).
However, one in five seniors (mostly unattached women) is still likely to be living in
a low-income situation.
◆ Aboriginal people and visible minorities continue to be over-represented in the
population with low-income status. In 1995, about 36% of the visible minority
population and 44% of the Aboriginal population lived in low-income situations.
◆ In 1995, almost 50% of single-parent mother-led families were in low-income
situations. However, poverty was not restricted to single-parent families. From 1990
to 1995, the percentage of married couples with children in low-income situations
rose from 9.5% to 13% (a total of almost 460,000 families). In 1995, the average
low-income two-parent family with children lived some $11,641 below the LICO.
Earnings, income distribution and health
◆ The distribution of income in a given society may be a more important determinant
of population health than the total amount of income earned by society members.
◆ Overall, income distribution inequalities remained relatively constant in Canada
between 1985 and 1995. This was largely due to the effect of redistributive taxes and
transfer payments, which offset a growing income gap between the 10% of Canadians
with the lowest incomes and the 10% of Canadians with the highest incomes. Trends
in income inequality beyond 1995 were not available for this report; however, they
are worth monitoring in future analyses.
◆ Some groups have been gaining in wage rates and earnings, notably older workers and
the more highly skilled and paid; others have experienced dramatic declines, notably
low-skilled young males, youth in general, and lower-paid, lower-skilled men.
◆ While women are making gains in average earnings, they continue to face a
significantly higher risk for earning a low income than do men. In 1996, 19% of
adult women fell under the low-income category compared with 13% of adult men.
Toward a Healthy Future
42
The Socioeconomic Environment
Education, literacy and health
◆ Educational status and literacy levels are important determinants of health and
well-being.
◆ In the 1996–97 National Population Health Survey (NPHS), only 19% of respondents
with less than a high school education rated their health as “excellent” compared with
30% of university graduates.
◆ In the last 15 years, levels of schooling have continued to rise for all population
groups in Canada. In 1996, there were more than four times as many female
university graduates as in 1971.
◆ In 1994–95, about 17% of Canadians fell into the lowest prose literacy category
(level 1); another 26% achieved level 2 in prose literacy, which means they can
read but not well.
Employment and health
◆ Continuing high rates of unemployment and underemployment among youth,
Aboriginal people, adults with low levels of education and people living in certain
regions in the eastern provinces are linked to health disadvantages for Canadians in
these groups.
The social environment and health
◆ Working conditions (paid and unpaid), social support and levels of personal security
at home and in the community are important influences on health.
◆ Working conditions and role overload (balancing work and family life) are major
stresses for women, especially young women.
◆ Canadians reported high levels of social support, caring for others, volunteerism and
civic participation. These are important buffers in times of stress.
◆ Partner and child abuse, the most common forms of family violence, have a devastating
effect on the health and well-being of women and children in both the short and
long term. In 1996, family members were accused in 24% of all assaults against
children. In 1997, about 40% of female homicide victims were killed by a man with
whom they had experienced an intimate relationship.
Toward a Healthy Future
43
The Socioeconomic Environment
Income and Health
The previous chapter demonstrated the close relationship between income status, health
status and other determinants of health. For example, Canadians in the lowest income
group were four times more likely than Canadians in the highest income group to report
their health as only fair or poor, two times more likely to have a long-term activity
limitation and only one-third as likely to have dental insurance (the latter is discussed
in Chapter 6). Certainly, differences in health status are evident in a comparison of the
highest and lowest income groups. But an active gradient in health status from low to
middle and upper levels of income can also be observed in virtually all measures of both
mortality and morbidity. In other words, high-income Canadians are more likely to be
healthy than middle-income Canadians, who are in turn healthier than low-income
Canadians.
Since income and health status are closely linked, it is important to understand
current trends in income status. This section provides a brief overview of both long-term
and recent (1990–1995) trends related to low-income populations in Canada, as determined
by Statistics Canada low income cut-offs (LICOs). (See Definitions and Measures at the
beginning of this chapter.) Unless otherwise stated, total income figures are taken from
the 1991 Census (reflecting 1990 data) and the 1996 Census (reflecting 1995 data).
Unfortunately, reliable national data after 1995 were not available at the time of writing.
Income Versus Wealth
The distribution of income in society is intimately linked to the distribution and concentration
of wealth — but the two are by no means the same. Wealth is a much broader concept
than income, and includes ownership of both financial (income, savings, investments,
stocks and bonds, etc.) and other assets (real estate, home ownership, buildings, land,
art, etc.). The relationship between wealth and health has received far less attention
than that between income and health. Both subjects warrant further research.
Fifteen-Year Trends in Low Income
3
According to the 1996 Census, about 16% (or 1.3 million) of all economic families in
Canada fell below the low income cut-off in 1995. Likewise, about 20% of individual
Canadians (just over 5.5 million people) lived below the LICO rate.
As Exhibit 2.1 shows, the prevalence of low-income persons across all age groups
fluctuated between 1980 and 1996, from 16% in 1980 to a high of 19% in 1983 and 1984,
then back to a low of 14% in 1989. Low-income prevalence again crept back up to over
18% in 1996, almost to the same level as in the mid-1980s.
During this time period, however, the face of low income changed dramatically.
There was a substantial and welcome drop in the number of older Canadians who fell
below the LICO. It should be noted, however, that in 1995 one senior out of five (mostly
unattached women) still lived below the LICO.
At the same time, there was a fairly dramatic increase in the proportion of lowincome children (under age 18) and families, particularly in the early 1990s. In 1995,
21% of children lived in low-income households.
Toward a Healthy Future
44
The Socioeconomic Environment
This suggests that public policies
Exhibit 2.1
designed to maintain and improve
seniors’ economic standing, combined
with the entry of a new cohort (with
35
higher incomes) into this age group
30
significantly reduced poverty among
Seniors 65+
older Canadians. At the same time,
25
Children under age 18
economic downturns and changes
20
in family structure and employment
pushed child and family poverty rates
15
Total
to their highest levels in over 15 years.
10
In 1995, the nearly 21 million
individuals who were income recipients
5
(from all sources, including wages,
0
self-employment, government transfers,
1980
1985
1990
1996
investment income, pensions and
other income) had an average total
Source: Statistics Canada. Income Distribution by Size in Canada, 1996
(Statistics Canada Cat. No. 13-207).
income of $25,196, down 6% from
1990 after adjustment for inflation.
This decrease wiped out gains made
during the second half of the 1980s.
Average Family Income (1996 Dollars), Canada,
Exhibit 2.2
As a result, average total income in
1978 to 1996
1995 was almost identical to that in
1985, and slightly below the level
60,000
58,910
of 1980.
As Exhibit 2.2 shows, average
58,000
56,629
family incomes (in constant dollars)
55,901
fluctuated widely between 1978 and
56,000
1996. Between 1980 and 1984, there
55,134
was a steady decrease in average family
54,000
income, reaching a low of $52,931 in
1984. Average family incomes then
52,931
52,000
rose to a high of $58,910 in 1989. After
that, family incomes largely decreased,
50,000
settling at $56,629 in 1996. In other
1978
1982
1986
1990
1994 1996
words, in 1996, average family incomes
Source: Statistics Canada. Income Distribution by Size in Canada, 1996
equalled those of 1988, despite an
(Statistics Canada Cat. No. 13-207).
economic recovery following the
downturn of the early 1990s.
In 1996, the majority of family expenditures were concentrated in taxes (22%)
and necessities such as shelter (17%), food (12%) and transportation (12%). These
four costs combined accounted for almost two-thirds of the average Canadian family’s
expenditures.4 Chapter 4 on the physical environment suggests that shelter costs have
become particularly problematic for many low-income Canadians in recent years.
Average family income (1996 Cdn. $)
Percentage
Percentage of Canadians with Low Incomes, by Age,
Canada, 1980 to 1996
Toward a Healthy Future
45
The Socioeconomic Environment
While LICO rates provide us with the percentage of the population who live below
predetermined income levels, they do not differentiate between the people who are living
in abject poverty and those who earn just a few dollars less than the LICO. For that, we
need measures of the depth of poverty. Exhibit 2.3 shows the depth of poverty (or income
deficiency between family income and the LICO) by family type in 1990 and 1995. In
terms of the proportion of families in low-income situations, female lone-parents remain
the worst off — almost 50% were in low-income situations, living $10,165 below the
LICO in 1995. However, poverty is not restricted to single-parent families. From 1990
to 1995, the percentage of married couples with children who lived in low-income
circumstances rose dramatically from 9.5% to 13%. In 1995, the average low-income,
two-parent family with children lived some $11,641 below the LICO.5
Exhibit 2.3
Income Deficiency,* by Family Structure, Canada, 1990 and 1995
Low income
(%)
Number of lowincome families
Average total
income ($)
Family income
deficiency* ($)
1990
All economic families
13
961,835
13,615
10,111
Married couples only
9
210,145
11,345
8,233
Married couples with children
9.5
332,200
15,951
10,963
Male lone-parent families
18
24,290
11,665
9,929
Female lone-parent families
44
300,240
12,092
10,337
All economic families
16
1,267,205
13,778
10,223
Married couples only
10
252,765
11,223
7,398
Married couples with children
13
456,930
16,199
11,641
Male lone-parent families
24
39,325
11,612
9,412
Female lone-parent families
48
396,245
12,032
10,165
1995
* Income deficiency is the difference between family income and the applicable low income cut-off.
Source: Statistics Canada. “Census 1996: Sources of Income, Earnings and Total Income and Family Income.” The Daily, May 12, 1998
(Statistics Canada Cat. No. 11-001-XIE).
Trends in Low-Income Status, 1990 to 1995
Overall, between 1990 and 1995, the proportion of Canadians with low-income status
increased from 16% to 20%, but certain groups in the population were harder hit than
others. In 1995, children, youth and unattached seniors (mostly women) were the most
likely to be classified as low income.
Toward a Healthy Future
46
The Socioeconomic Environment
Number and Percentage of Children, Youth and Seniors Living in Low-Income Situations, Canada,
1990 and 1995
Exhibit 2.4
1990
1995
Low-income
number
% of low
income
Low-income
number
% of low
income
Children under age 6
447,230
20
582,905
26
Children, aged 6 to 14
576,100
17
761,620
22
Youth, aged 15 to 17
180,455
16.5
229,210
20
Youth, aged 18 to 24
548,805
21
675,365
26
Adults, aged 65 to 69
169,410
16
182,730
17
Adults, aged 70 and over
415,135
23
441,265
20.5
Source: Statistics Canada. “1996 Census: Sources of Income, Earnings and Total Income and Family Income.” The Daily, May 12, 1998
(Statistics Canada Cat. No. 11-001-XIE).
Percentage
Exhibit 2.4 shows the increase in the number of children and youth (ages 0 to 24)
who lived in low-income circumstances. In 1995, very young children (under the age of 6)
and youth (aged 18 to 24) were most likely to be poor.6
As Exhibit 2.5 shows, there has been virtually no change in the gap between the
percentage of men and women who fall into the low-income category. This inequity
has persisted despite the fact that men’s average income dropped 7.8% between 1990
($33,733) and 1995 ($31,117), while women’s incomes dropped only 2% (from $19,630
to 19,208). One of the reasons for this
disparity is that women still hold the
Percentage
of
Women
and
Men
with
Low
majority of the lowest paying jobs.
Exhibit 2.5
Incomes, Canada, 1980 to 1996
According to the 1996 Census, women
dominate in all but five of the 25
35
occupations at the bottom of the earning
30
scale. Women aged 18 to 24 and age 70
and over were most likely to be living in
25
low-income circumstances in both 1990
Women
20
and 1995. Almost half of female lone
parents (some 400,000 families) lived
15
below the LICO.7
Men
10
5
0
1980
1985
1990
1996
Source: Statistics Canada. Low Income Persons, 1980 to 1996
(Statistics Canada Cat. No. 13-569-XPB).
Toward a Healthy Future
47
The Socioeconomic Environment
Percentage
Percentage
Exhibit 2.6 demonstrates how Aboriginal people and visible minority populations
are more likely to live in low-income situations. In 1995, about 36% of the visible minority
population in Canada and 45% of children under the age of 6 in visible minority families
were in a low-income situation. At least
44% of the Aboriginal population and a full
Percentage of the Aboriginal Population,
60% of Aboriginal children under the age
Exhibit 2.6
Visible Minority and Total Population with
of six lived below the LICO. These figures
Low Incomes, by Age Group, Canada, 1995
likely underestimate the problem, since
60
some 44,000 people living on reserves and
settlements were incompletely enumerated
50
in the 1996 Census.
Aboriginal population
Provincial Differences: From 1990
40
to 1995, the proportion of the population
Visible minority population
with low incomes increased in every
30
province except Saskatchewan. The largest
increases in the number and proportions
20
of low-income Canadians occurred in
Total population
10
Ontario. In 1995, the highest rates of
low income continued to be reported by
0
residents of Quebec (23%), Newfoundland
6–14
18–24
35–44
55–64
70+
(21%) and Manitoba (21%).
Under 6
15–17
25–34
45–54
65–69
As Exhibit 2.7 shows, the largest
Source: Statistics Canada. “1996 Census: Sources of Income, Earnings
increases in low-income persons both
and Total Income and Family Income.” The Daily, May 12, 1998 (Statistics
numerically and proportionately were
Canada Cat. No. 11-001-XIE).
registered in Canada’s most populous
provinces. In 1990, Ontario had the lowest
low-income rate in the country (13%);
Percentage of Population with Low Incomes,
Exhibit 2.7
by 1995, 18% of Ontario residents faced
by Province, 1990 and 1995
low-income circumstances — an increase
25
of nearly one half million people in that
23
province. Substantial increases in low21
21
20
19
19
19
19
20
income rates also were registered in Quebec
18
1818 18
18
17
17
(19% in 1990 and 23% in 1995) and British
16
16
15
Columbia (16% in 1990 and 20% in 1995)
14
15
13
(Exhibit 2.7).
Families: As Exhibit 2.8 shows, the
10
proportion of all types of low-income
families increased between 1990 and 1995.
5
Families headed by young parents aged 15
to 24 were particularly hard hit. Female-led
0
single-parent families were still the most
NF PEI NS NB QC ON MB SK AB BC
likely to live in low-income situations.
1990
1995
Source: Statistics Canada. “1996 Census: Sources of Income, Earnings and
Total Income and Family Income.” The Daily, May 12, 1998 (Statistics
Canada Cat. No. 11-001-XIE).
Toward a Healthy Future
48
The Socioeconomic Environment
Exhibit 2.8 also shows the dramatic increase in child and youth situations of low
income. Despite a parliamentary resolution to eliminate child poverty by the year 2000,
the proportion of children (under age 15) and youth (ages 15 to 24) living below the LICO
rose from one in five in 1990 to one in four in 1995.
Living in poverty is not just a risk for single-parent families. While there is a greater
proportion of single-parent families living below the poverty line, in absolute numbers,
low-income families are more likely to be headed by two parents (Exhibit 2.8).
Exhibit 2.8
Average Family Incomes, Percentage of Families with Low Income, by Family Type and Number
of Low-Income Families, 1990 and 1995
Average family income
1990
1995
◆ Two-parent families (all ages)
$61,053
$58,763
◆ Lone-parent families with young parents (ages 15 to 24)
$29,313
$23,115
◆ Male-led, lone-parent families (all ages)
$45,557
$40,974
◆ Female-led, lone-parent families (all ages)
$29,652
$27,721
9%
12%
◆ Male-led, lone-parent families
18%
24%
◆ Female-led, lone-parent families
44%
48%
◆ Children under age 15
20%
25%
◆ Youth ages 15 to 24
21%
26%
577,075
759,630
24,290
39,325
300,240
396,245
Percentage of families with low income, by family type
◆ Two-parent families
Percentage of children and youth in low-income families
Total number of low-income families
◆ Two-parent families
◆ Lone-parent, male led
◆ Lone-parent, female led
Source: Statistics Canada. “1996 Census: Sources of Income, Earnings and Total Income and Family Income.” The Daily, May 12, 1998
(Statistics Canada Cat. No. 11-001-XIE).
Toward a Healthy Future
49
The Socioeconomic Environment
Income Distribution
Total family income, including
income support ($’000)
There is strong evidence that the health of a given population depends on the equality of
income distribution rather than on average income. The greater the disparities between
rich and poor, the greater the health consequences. Or, as Sir Frances Bacon observed:
“Money is like muck — not good unless it be well spread.” 8
There is a well-established literature on the measurement of income inequality.
Typical indicators are the income shares of various income quintile groups and summary
measures such as the Gini Index. The Gini coefficient measures inequalities in the
distribution of income. Essentially, the larger the Gini coefficient, the greater the inequality
in distribution of income.
A recent article by Michael Wolfson and Brian Murphy concludes that income
inequality in Canada remained relatively stable between 1985 and 1995. The authors
examined family disposable income, defined as total income less federal and provincial
income taxes and payroll taxes (CPP, QPP, UIC), adjusted for family structure. They
found that the Gini coefficient (which measures income inequality) was actually slightly
lower in 1995 than in 1985.
In comparing Canada and the United States, Wolfson and Murphy further suggest
that if the value of publicly funded health services had been included in the analysis,
Canadian family incomes would have risen relative to those in the United States, and
inequality among Canadian incomes would have diminished.9
Some economists prefer to measure inequalities by simply comparing groups in
the wealthiest and poorest 10th percentiles. This measurement is easy to understand and
relates quite closely to the Gini coefficient. It does not, however, show the distribution in
middle-income groups — a factor that can alter the overall picture of inequality. Using
this measure, the Toronto Centre for
Social Justice has shown growing income
Income Disparity among Families with Children
disparities between the wealthiest and
Exhibit 2.9
Under Age 18, in 1996 Dollars, Canada,
poorest families in Canada. According
1981 and 1996
to that study, the average incomes of
138
the top 10% of families with children in
140
124
1973 were 8.5 times those of the bottom
122
120
10%; by 1996, this ratio had increased to
108
10.2. Exhibit 2.9 shows how the earned
100
incomes of the wealthiest 10% of families
80
rose from $122,000 in 1981 to $138,000
in 1996. In contrast, the earned incomes
60
of the poorest families with children
40
remained largely unchanged between
10
1981 and 1996 (approximately $14,000).
14
14
20
Since earnings are the main source
of income for most Canadians, changes
0
Richest 10%
Poorest 10%
Disparity
in income inequalities are closely related
to changes in wage rates, earnings and
1996
1981
working time among Canadian workers.
In recent years, some groups have been
Source: Yalnizyan, A. The Growing Gap. Toronto: Centre for Social Justice, 1998.
Toward a Healthy Future
50
The Socioeconomic Environment
gaining, most notably older workers and those who are highly paid and skilled, while
others — particularly young workers and lower-paid, lower-skilled men — have
experienced declines.11
Government transfer payments and personal income taxes play an important role
in reducing income inequality in Canada. The effect of government transfer payments
and personal income taxes in reducing income inequalities is evident in the Gini
coefficient results shown in Exhibit 2.10. In 1995, the difference in the Gini coefficient
before transfers (.458) and after taxes (.300) was nearly 16 percentage points.12
Exhibit 2.10 also shows that income inequality before transfers and taxes rose
substantially between 1970 and 1995. However, income inequalities after taxes and
transfers actually decreased from .316 to .300.
Exhibit 2.10
Gini Coefficients for the Income Distribution of Families, 1970 to 1995
1970
1980
1985
1990
1995
◆ Total income
0.352
0.351
0.359
0.357
0.373
◆ Income before transfers
0.388
0.401
0.425
0.425
0.458
◆ Income after taxes
0.316
0.293
0.304
0.295
0.300
Note: The larger the Gini coefficient, the greater the inequality in income distribution.
Source: Rashid, Abdul. “Family Income Inequality, 1970–1995.” Perspectives (Winter, 1998). Statistics Canada Cat. No. 75-001-XPE: 12–17.
Trends in income equality beyond 1995 were not available for this report, but recent
reductions in transfer payments in several jurisdictions are worrisome. Government
transfer payments are crucial for low-income families. They account for 55% of average
total income for low-income families, increasing to 66% among low-income, female
lone-parent families. Trends beyond 1995 are worth monitoring in future analyses.
In addition to understanding inequities in income distribution in Canada, it is
important to consider where poor people are most likely to live. Studies have shown a
growing concentration of poverty in certain core areas of Canada’s larger urban centres. In
1990, Winnipeg, Montréal and Quebec City combined had about one-seventh of Canada’s
population. They accounted for nearly half of Canada’s distressed urban neighbourhoods.
In Winnipeg, Aboriginal people were vastly over-represented in such areas.13 Children
and youth growing up in these neighbourhoods are particularly vulnerable to the social
disadvantages and marginalization associated with distressed neighbourhoods, which may
in turn feed a self-perpetuating cycle of poverty and poor health.
Education and Literacy
In this section, data on educational attainment were taken from the 1996 Census.
Information on literacy skills was drawn from the 1997 International Adult Literacy
Survey which explored the prose, document and quantitative literacy of Canadians as
well as citizens in other countries.
Toward a Healthy Future
51
The Socioeconomic Environment
Educational Attainment
Percentage of population
Educational attainment is widely acknowledged as one of the key components of
socioeconomic status and is positively associated with health status and health behaviours.14
For example, in the 1996–97 National Population Health Survey, only 19% of respondents
with less than high school education rated their health as “excellent,” compared with almost
30% of university graduates.15
As Exhibit 2.11 shows, from 1971 to 1996, there was a significant decline in the
proportion of Canadians aged 15 and over with less than a Grade 9 education (from
32% to 12%) and a corresponding increase in the proportion of Canadians who had
completed some post-secondary schooling (from 17% to 34%). Interestingly, 1996 was
the first census year to record more university graduates than people reporting less than
Grade 9 education.16
Overall, women were slightly more likely than men to have ended their formal
education after high school. Women in their 20s, however, were more likely to be college
and university graduates than men of the same age. One of the most significant changes
between 1971 and 1996 was the increase in the number of women attaining university
degrees. There were over four times as many women university graduates over age 25
in 1996 as there were in 1971.17
The data show a strong inverse relationship between age and education: with each
older cohort, there was a greater proportion who had not finished high school. There
was also considerable variation among provinces and territories in the proportion of
Canadians who had not completed high
school, ranging from 45% in Newfoundland
Exhibit 2.11 Highest Level of Schooling, Age 15+, Canada,
to 31% in British Columbia and 28% in the
1971 to 1996
Yukon Territory. University degrees were
50
most likely in Ontario (17%) and the Yukon
Grades 9–13
Territory (17%) and least in proportion in
18
Newfoundland (10%).
40
Aboriginal people were less likely to
Some post-secondary
have high levels of formal education than
30
Canadians 15 years and over in the total
population. However, comparisons of 1981
20
and 1996 data show that Aboriginal people
Less than Grade 9
are making marked educational progress.
10
During that time, the proportion of
University degree
Aboriginal Canadians with less than a high
0
school education dropped from 59% to
1971
1976
1981
1986
1991
1996
45%. Among Aboriginal people aged 20
Source: Statistics Canada. “1996 Census: Education” The Nation Series
to 29, the proportion with a college degree
(Statistics Canada Cat. No. 93F0028XDB95002).
or diploma rose from 19% to 23% and the
proportion of university graduates rose
from 3% to 4%.19
Employment earnings increased with the number of years of education. This
was particularly true for Canadians with a university degree, and reflects the continued
demand for highly educated labour in Canada. Canadians who didn’t complete high
school reported earnings of $18,639 in 1995. This was significantly below the Canadian
Toward a Healthy Future
52
The Socioeconomic Environment
average of $26,474, and less than half the average earnings of Canadians with a university
degree ($44,658). Although average earnings declined in all education categories from
1990 to 1995, the largest downturns were felt by Canadians with less than a Grade 9
education.20
Parents’ education levels are clearly strongly linked to the school readiness of
children.21 As Exhibit 2.12 shows, children with a parent who had attended college or
university were far more likely to score in the “advanced” category of school readiness
than children whose parent(s) had attained lower levels of education. See Chapter 3
for more information on the concept of school readiness.
Exhibit 2.12
School Readiness of Children, Aged 4 and 5,
by Parents’ Education,* Canada, 1994–95
Literacy
Literacy and numeracy skills are essential
for full participation in today’s world. Society
rewards individuals who are proficient and
12
College/
penalizes those who are not, in employment
66
University
23
opportunities, job success, citizenship and
15
active participation in the community. People
Trade/Business
73
with low literacy skills often feel alienated
school
12
and have difficulty finding and accessing
17
health information and services. As a result,
73
High school
they suffer poorer health than those who
10
have higher literacy skills. Literacy is also
35
Less than
important to nations, as these skills enable
57
high school
8
the creation of a labour force that is capable
of competing in a changing world and
80
20
0
60
10
50
30
70
40
contributing to economic growth.22
Percentage of children
The 1997 International Adult Literacy
Survey explored three aspects of literacy:
Normal
Advanced
Delayed
prose, document and quantitative literacy
(numeracy). Skill levels on each of these
* Education of most-schooled parent.
measures are allotted to one of five levels
Source: Human Resources Development Canada and Statistics Canada.
(five being the highest).
Growing Up in Canada: National Longitudinal Survey of Children and Youth.
November 1996 (Statistics Canada Cat. No. 89-550-MPE, No. 1).
In 1994–95, only 57% to 58% of
Canadians aged 16 to 65 attained Level 3 or
greater (out of five levels) in prose, document and quantitative literacy. Literacy distribution
in Canada was similar to that in the United States, although there was a slightly larger
proportion at Level 1 in the United States. Both countries had relatively large numbers at
Level 1 (most notably for the document scale) and Level 4–5. The Netherlands showed
great consistency across the board, while Sweden ranked at the highest levels in all three
measures of literacy. When comparing the Level 4–5 of each measure, out of the 11
countries/regions listed, Canada ranked second highest in both prose and document
literacy and fifth highest in quantitative literacy.23
In 1994–95, about 17% of Canadians aged 16 to 65 were determined as fitting in
the lowest level of prose literacy. Another 26% achieved the second lowest level. These
Canadians can read only simple material that does not contain complex instructions.
While there is a clear connection between educational attainment and literacy levels,
Toward a Healthy Future
53
The Socioeconomic Environment
about 20% of Canadians had lower literacy levels than would be predicted by their level
of schooling and about 16% had higher levels. Clearly, education does not “fix” a person’s
literacy skills for a lifetime.24
The International Adult Literacy Survey showed considerable variation in Canadians’
literacy skills:25
• Generally, there were higher proportions of adults with high skill levels in the western
provinces and larger proportions with low skill levels in the east.
• The unadjusted results for youth were clustered into three groups: Manitoba and
Saskatchewan scored more than one year of schooling above the national average;
British Columbia, Alberta, Nova Scotia and Quebec scored near the national average;
and Ontario, New Brunswick, Newfoundland and Prince Edward Island scored about
one year of schooling below the national average. Almost one-half of the variation was
attributable to differences in youths’ socioeconomic background.26
• A significant majority of young Quebeckers (both anglophones and francophones)
performed at Level 3 and above on the prose and quantitative scales. The skill levels
of francophones outside Quebec were largely equivalent on the document and
quantitative scales; however, their scores on prose literacy tended to be lower than
those of francophones living in Quebec. This may point to the benefits of increased
access to education in one’s mother tongue.
• While a significantly larger proportion
of immigrants had Level 1 literacy skills
in their new country’s language, the
proportion of immigrants with Level 4
and 5 skills in English or French
was higher than the proportion of
non-immigrant Canadians. This finding,
which sets Canada apart from the other
countries who participated in the
International Adult Literacy Survey, likely
reflects Canadian immigration policies
that welcome both business-class
immigrants (who are likely to have
excellent literacy skills) as well as refugees
and family-class immigrants (who are less
likely to be skilled in English or French).
Percentage of Working-Age Adults Residing
in Low-Income Households, by Level of Prose
Literacy, Men/Women, 1994
Exhibit 2.13
59
60
50
Percentage
• Women’s scores in prose literacy
were higher than men’s across all ages.
There were no significant differences
in document literacy scores. Men scored
higher than women in quantitative literacy,
but only in the age groups 16 to 25 and
over 65.
40
40
29
30
22
20
16
11
10
*
0
Level 1
Level 2
Level 3
Level 4-5
Prose literacy
Men
Women
* Number too small to report.
Source: International Adult Literacy Survey (Schalla and Schellenberg, 1998).
Toward a Healthy Future
54
The Socioeconomic Environment
•
More than 1.6 million Canadians over the age of 65 performed at Level 1 in literacy.
Poor literacy skills lower seniors’ quality of life and increase their health and safety risks.
•
An unemployed person was about three times as likely to score in the Level 1 category
than someone who was employed. Workers with higher literacy skills were also
employed more weeks per year than those with low literacy skills.
There is a large income penalty for Canadians with low literacy scores. Among
Canadians with the lowest levels of prose literacy, 47% lived in low-income households,
compared with 8% of Canadians with the highest levels of prose literacy. Women with
low literacy skills were particularly vulnerable. Among women with Level 1 prose literacy,
the low-income rate was 59%; this decreased to 22% among women with Level 3 skills.
Among men with Level 1 prose literacy, 40% lived in low-income households, compared
with 11% of those with Level 3 prose literacy skills (Exhibit 2.13).27 Recipients of social
assistance had markedly lower literacy skills than either the general population or
Canadians who received employment insurance benefits.28
Employment and Unemployment
Employment has a significant effect on a person’s physical, mental and social health. Paid
work provides not only money, but also a sense of identity and purpose, social contacts
and opportunities for personal growth. When a person loses these benefits, the results can
be devastating to both the health of the individual and his or her family.29 Unemployed
people have a reduced life expectancy and suffer significantly more health problems than
people who have a job.30
In December 1998, just over
11.8 million people were working
Exhibit 2.14 Unemployment Rates,* by Province,
full-time in Canada, up 8% from the
December 1997 and 1998
start of the decade. In contrast, the
proportion of part-time workers
Newfoundland
increased 24.4% over the decade to just
Prince Edward Island
over 2.7 million. In December 1998,
New Brunswick
some 1.3 million Canadian workers
Nova Scotia
were unemployed and the seasonally
Quebec
adjusted unemployment rate was 8%.31
NATIONAL
Since the recession of the early
British Columbia
1990s, rates of unemployment have
Ontario
slowly eased from 11.2% in 1992 to 8% in
Saskatchewan
December 1998. However, there are large
Manitoba
differences in unemployment rates in
Alberta
different parts of the country and among
5
20
0
15
10
different groups. In December of 1998,
Percentage
the seasonally adjusted unemployment
rate was 18.7% in Newfoundland, 15.4%
December 1998
December 1997
in Prince Edward Island, 11.6% in New
* Seasonally adjusted.
Brunswick and 10.6% in Nova Scotia.
Source: Statistics Canada. Labour Force Survey, December 1998. The Daily,
January 8, 1999.
Toward a Healthy Future
55
The Socioeconomic Environment
Percentage
Western provinces reported the lowest
rates of unemployment: Alberta (5.7%),
Exhibit 2.15 Labour Force Participation, by Sex, Age 15+,
Canada, 1970 to 1997
Manitoba (5.9%) and Saskatchewan (6.3%)
32
(Exhibit 2.14).
80
As Exhibit 2.15 shows, the overall size
Male
of the Canadian labour force has grown
70
significantly in the last 30 years, largely as
a result of increased participation rates by
60
women. The massive influx of women into
the paid labour force is of particular note
Female
50
not only for its economic and health
implications, but also because women have
traditionally had a high rate of participation
40
in unpaid work (Exhibit 2.16). This will be
discussed later in this section.33
30
Much of the growth in the labour
1972
1976
1980
1984
1988
1992
1996
1970
1974
1978
1982
1986
1990
1994 1997
force has been in part-time jobs and selfemployment, both of which do not provide
Source: Statistics Canada, Health Statistics Division. Health Indicators, 1999
benefits and pensions. In 1998, about 30%
(Statistics Canada Cat. No. 82-221-XCB).
of adult women working part-time were
doing so involuntarily, and an additional
20% worked part-time so they could care for their children.34
As in other developed countries, the nature of work is also changing in Canada.
Globalization, changing market structures and the advent of new technologies have had
a profound effect upon the Canadian wage economy. Employment growth in Canada and
the structure of employment in all sectors are shifting toward knowledge- and technologyintensive industries. This widespread “upskilling” reinforces the continued shift in demand
from low-skilled to high-skilled workers.35
As a result, many Canadian workers are anxious about their ability to keep up with
the changing requirements of the labour market. According to recent research, one-third
of Canadian workers believe that their skills are already obsolete, and almost 40% believe
that their job skills will become obsolete within 10 years. There are as many people in
Canada who believe they could lose their jobs in the next couple of years as there are
those who feel secure.36
Toward a Healthy Future
56
The Socioeconomic Environment
Men, Women and Work, 1995 (Unless Shown Otherwise)
Exhibit 2.16
There are several important differences between the participation of men and women in the wage
economy and in unpaid work.
Men
Women
◆ Full-time paid employment (including self-employment)a
56%
a
◆ Increase in self-employment between 1991 and 1996
11%
b
◆ Average employment income
◆ Work full-time
$43,000
◆ Work part-time
$18,000
c
◆ Unemployment rate
◆ Under age 25
20%
◆ Age 25 to 44
8%
◆ Age 45 to 64
7%
b
◆ Time devoted to paid employment (hours per week)
45.7
b
◆ Employed and devoting 15 hours a week to unpaid housework
25%
b
◆ Employed and devoting 30 hours a week to unpaid housework
6%
b
◆ Employed, in a two-parent family and devoting 30+ hours a week to child care
23%
b
◆ Employed, in a two-parent family and devoting 60+ hours a week to child care
8%
43%
21%
$30,000
$13,000
18%
8%
8%
40.8
50%
20%
55%
25%
Sources:
a Statistics Canada. “1996 Census: Labour Force Activity, Occupation and Industry, Place of Work, Mode of Transportation to Work, Unpaid Work.”
The Daily, March 17, 1998.
b Statistics Canada. “1996 Census: Sources of Income, Earnings and Total Income, and Family Income.” The Daily, May 12, 1998.
c Statistics Canada. Historical Labour Force Statistics, 1997 (Statistics Canada Cat. No. 71-201-XPB).
Labour Force Participation and Unemployment,
by Education Level, Canada, 1995
Exhibit 2.17
100
83
Percentage
80
76
70
60
69
51
40
26
20
15
16
9
10
8
5
Canadians with limited educational
attainment have the highest unemployment
rates and the lowest participation rates in
the wage economy. As Exhibit 2.17 shows,
only 26% of Canadians with less than a high
school education were active participants
in the labour force, and 15% were
unemployed. Among those with some high
school, 51% participated in the labour force,
and 16% were unemployed. By contrast,
83% of Canadians with a university degree
were active participants in the labour force,
and only 5% were unemployed.
0
Some
Some
Degree
high school
post-secondary
< High school
High school
Post-secondary
graduate
certificate
Unemployment rate
Participation rate
Source: Statistics Canada. “1996 Census: Sources of Income, Earnings and
Total Income, and Family Income.” The Daily, May 12, 1998.
Toward a Healthy Future
57
The Socioeconomic Environment
First Nations people experienced
Exhibit 2.18 Employment and Unemployment among the
high rates of unemployment
First Nations Population, 1996
(as defined by Statistics Canada),
as shown in Exhibit 2.18. Other
On reserve
Off reserve
groups who tend to have higher
◆ Labour force participation rate
52%
57%
rates of unemployment than
average include the visible minority
◆ Unemployment rate
29%
26%
population and people with mental
Source: Statistics Canada. 1996 Census. Department of Indian Affairs and Northern
and physical disabilities.37
Development Custom Tabulation, August 1998.
After years of decline, the
availability of jobs for youths aged
15 to 24 revived somewhat in 1998, jumping 7% compared to 1997. Continuing high
unemployment rates among young people, however, remain a major concern. In 1997,
25.5% of young people aged 15 to 17 were looking for work; unemployment rates were
18.4% among young people aged 18 to 19 and 13.6% among those aged 20 to 24. Youth
unemployment rates have remained consistently higher than adult rates in the latter part
of this century, although changes from 1997 to 1998 have reduced that gap slightly.38
At the same time, young people who do find work are increasingly employed in parttime work. Between 1980 and 1995, the part-time share of all employment for young men
doubled (from 20% to 40%); for young women, it increased 81% (from 28% to 51%).39
In 1998, about 23% of young people working part-time would have preferred to work
full-time; 68% were working part-time because they were also going to school.40
Working Conditions
Well over half of adult Canadians spend a substantial amount of time at work each day.
Conditions at work (both physical and psychosocial) can have a profound effect on people’s
health and emotional well-being.41 Participation in the wage economy, however, is only
part of the picture. Many Canadians (especially women) spend almost as many hours
engaged in unpaid work, such as doing housework and caring for children or older
relatives. When these two workloads are combined on an ongoing basis and little or no
support is offered, an individual’s level of stress and job satisfaction is bound to suffer.
42
Job Satisfaction and Work Stress
Overall, men are more likely than women to be satisfied with their jobs, and job satisfaction
for both sexes significantly increases with age. Between 1991 and 1995, the proportion
of Canadian workers who were “very satisfied” with their work declined, and was more
pronounced among female workers, dropping from 58% to 49%. Reported levels of work
stress followed the same pattern. In the 1996–97 NPHS, more women reported high work
stress levels than men in every age category. Women aged 20 to 24 were almost three times
as likely to report high work stress than the average Canadian worker.
Toward a Healthy Future
58
The Socioeconomic Environment
Percentage of Employed Persons Reporting
High Work Stress, by Household Type,
Age-Standardized, Canada, Aged 15+, 1994–95
Exhibit 2.19
5.6
Single parent
4.3
2.6
Couple alone
43
Unpaid Work
1.8
4.1
Unattached
3.3
Couple with
children
4.4
3
0
1
3
2
4
5
6
Percentage
Female
Male
Source: Statistics Canada. National Population Health Survey, 1994–95.
Hours Per Week Devoted to Unpaid Housework,
Employed Men and Women Living Together,
with Children under Age 15, 1996
Exhibit 2.20
60
60
50
Percentage
As Exhibit 2.19 shows, while reports of
“high” work stress were generally low, there
were notable differences among different
types of households. Almost 6% of female
single parents reported high work stress,
nearly double the percentage reported by
individuals in couples with no children.
40
34
30
24
17
20
10
0
15+ hours
30+ hours
Men
Women
Source: Statistics Canada. “1996 Census: Labour Force Activity, Occupation
and Industry, Place of Work, Mode of Transportation to Work, Unpaid Work.”
The Daily, March 17, 1998.
Whether they are employed outside
the home or not, Canadian women bear
a disproportionate burden of unpaid
housework. One out of two fully employed
women reported doing at least 15 hours
per week of unpaid housework in the 1996
Census, compared with one out of four
working men. Nearly one out of five working
women performed 30 hours or more of
housework each week, compared with fewer
than one out of every 15 working men.
As Exhibit 2.20 shows, the burden of
housework increased substantially for both
men and women when there were children
in the household: 60% of working women
and 34% of working men with children
under the age of 15 reported doing at least
15 hours per week of unpaid housework.
For both men and women, the amount of
time spent on paid employment competes
with time available for child care. As
Exhibit 2.21 shows, responsibility for child
care falls disproportionately on women.
Among employed women in two-parent
families with a child under the age of 6,
more than one out of two women reported
spending at least 30 hours per week on
unpaid child care, while one out of four
women reported 60 hours or more. Among
men in similar circumstances, fewer than
one out of four reported spending 30 hours
or more per week on unpaid child care,
while fewer than one in 10 spent more than
60 hours on child-care responsibilities.
Toward a Healthy Future
59
The Socioeconomic Environment
Exhibit 2.21
Hours Per Week Devoted to Child Care, Men
and Women Living Together, with Children
under Age 6, by Employment Status, 1995
77
80
70
60
Percentage
Overall, 19% of women and 14% of
men reported providing care to seniors.
Women provided more hours of care for
seniors on average than did men, but 7%
of women and 4% of men provided at least
five hours per week of unpaid care to
seniors. Responsibility for caring for older
parents or relatives generally increases with
age: 25% of women aged 45 to 64 provided
care to seniors in the week prior to the
1996 Census, compared with 17% of men
in the same age group.
58
50
40
30
20
Injuries at Work
55
10
33
23
25
19
8
Employees who become ill or injured as
0
a result of workplace conditions suffer
60+ hours — Men
60+ hours — Women
pain, a lowered quality of life and reduced
30+ hours — Men
30+ hours — Women
earning potential. Employee illness and
injury are also a significant expense
Employed
Not employed
for employers in the form of workers’
Source: Statistics Canada. “1996 Census: Labour Force Activity, Occupation
compensation and health benefit claims,
and Industry, Place of Work, Mode of Transportation to Work, Unpaid Work.”
absenteeism, increases in turnover, and
The Daily, March 17, 1998.
lowered performance on the job. In 1994,
there was one compensation claim
resulting from injury for every 13 workers, amounting to direct medical costs of
more than $250 per person and perhaps twice as much again in indirect costs.44
Overall, there has been a steady decrease in the rate of reported time-loss work
injuries, from 49 injuries for every 1,000 workers in 1987 to 28 per 1,000 in 1996. Young
men aged 15 to 29 were most at risk: their injury rate was 43 per 100,000 workers —
57% above the average for all ages and both sexes. The rates of compensated injuries
were highest in forestry and logging, although rates in transportation, wholesale trade,
manufacturing and construction were well above average. Among white-collar industries,
government and the health-care sector had the two highest rates of time-loss injuries
in 1996.45
According to the 1996–97 NPHS, an estimated 2 million Canadians aged 12 and
over suffered a repetitive strain injury (RSI) in the past 12 months. Injuries to the back
or spine accounted for the greatest share of RSIs among men (20%), while injuries to the
wrist, hand or fingers were the most common among women (25%). For both sexes, the
greatest proportion of RSIs occurred at work or school.
Toward a Healthy Future
60
The Socioeconomic Environment
The Social Environment
Families and friends provide needed emotional support in times of stress, and help
provide the basic prerequisites of health such as food, housing and clothing. The caring
and respect that occur in social networks, as well as the resulting sense of well-being, seem
to act as a buffer against health problems. Indeed, some experts in the field believe that
the health effect of social relationships may be as important as established risk factors
such as smoking and high blood pressure.46
The importance of social support also extends to the broader community. Civic
vitality refers to the strength of social networks within a community, region, province
or country. It is reflected in the institutions, organizations and informal giving practices
that people create to share resources and build attachments with others.47
This section looks at five indicators of a supportive social environment: access
to social support, personal security (violence in the home and in the community),
volunteering, participation in community organizations, and charitable donations.
Social Support
In the 1996–97 National Population Health Survey (NPHS), more than four out of five
Canadians reported that they had someone to confide in, someone they could count on
in a crisis, someone they could count on for advice and someone who makes them feel
loved and cared for. Similarly, in the 1994–95 National Longitudinal Survey of Children
and Youth, children aged 10 and 11 reported a strong tendency toward positive social
behaviour and caring for others.48
In the 1996–97 NPHS, women were more likely than men to report high levels
of support. High levels of support declined with age: adolescents and young adults were
most likely to report that they had high levels of support while seniors were least likely to
do so. Nonetheless, almost three-quarters of seniors reported having access to high levels
of social support.
When household types were taken into account, unattached individuals enjoyed the
highest levels of social support (89% for women and 82% for men) and single parents
had the lowest (81% for women and 72% for men). Income was also related to the level
of social support. People with the lowest income levels had the lowest percentage of high
support (74%) compared with those with the highest incomes (89%).
Violence at Home
Women and children are most often the victims of family violence, which can have a
devastating effect on health and well-being in both the short and long term.
In 1996, children under age 18 were the victims of 22% of assaults reported to police
agencies, accounting for a total of almost 23,000 reported assaults. Children represented
a much larger proportion of sexual assault victims (60%) than physical assault victims
(18%). Family members were accused in 24% of all assaults against children. Almost 70%
of victims under the age of 3 were physically assaulted by family members, and parents
accounted for 85% of such assaults.49
Toward a Healthy Future
61
The Socioeconomic Environment
In 1993, approximately one-third of Canadian women over the age of 16 reported
violence at the hands of an intimate partner at some point during their lives.50 In 1996,
almost 22,000 incidents of spousal assault were reported to police; 89% of these assaults
were against women.51 Four out of five women and children living in shelters or transition
centres in 1995 were there to escape an abusive situation, the majority from abuse by a
partner (or father).52
Women who are assaulted often suffer severe physical and psychological health
problems; some are even killed. In 1997, 80% of victims of spousal homicide were
women, and another 19 women were killed by a boyfriend or ex-boyfriend. In all, about
40% of female homicide victims were killed by a man with whom they had an intimate
relationship at some point in their lives.53
In 1996, older adults (age 65 and older) were victims in 2% of violent crimes reported
to police. Family members were involved in 20% of reported cases: 44% involved children
and 34% involved spouses.54
Violence in the Community
55
Since peaking in 1991, the national crime rate (including homicide, attempted murder,
robbery, break-ins, motor vehicle theft and impaired driving) declined 19% by 1997.
However, this national rate is still more than double what it was three decades ago. From
1996 to 1997, the national crime rate dropped 5%. Decreases in provincial rates ranged
from 2% in Nova Scotia to 10% in Prince Edward Island. Only Saskatchewan (+4%) and
Alberta (+2%) reported increases in their crime rates.
From 1996 to 1997, rates of violent crime decreased in 16 of 25 metropolitan areas.
Rates were lowest in Sherbrooke and Trois Rivières, and highest in Thunder Bay and
Regina. Regina reported the highest increase in violent crime during this period (29%).
There were 193 homicides committed with firearms in 1997, 19 fewer than in 1996.
Despite this drop, firearms continue to be used in about one-third of all homicides. The
rate of firearm robberies has been falling since 1991, including a 20% drop in 1997.
A total of 111,736 young people aged 12 to 17 were charged with Criminal Code
offences in 1997 — a drop of 7% from the previous year. More than half were charged
with property crimes, while 20% were charged with violent crimes. Despite this decline,
the rate is still more than double that of a decade ago.
In recent years, concern has been growing about increasing violence by young
women. Over the last 10 years, the rate of female youths charged with violent crimes
has increased twice as fast as that of male youths. In 1997, however, the rate for female
youths was still only one-third the rate for their male cohorts.
56
Volunteering
Canadians are actively involved in supporting their communities and there has been a
substantial increase in volunteer activities in Canada over the last 10 years. Thirty-one
percent of adult Canadians reported volunteering with not-for-profit organizations in
1996–97 — a 40% increase in the number of volunteers since 1987. These 7.5 million
volunteers contributed more than 1 billion hours of time — the equivalent of 578,000
full-time jobs.
Toward a Healthy Future
62
The Socioeconomic Environment
Volunteering Rate, by Age Group and Sex,
Canada, 1987 and 1997
Exhibit 2.22
35
33
29
30
Percentage
25
33
31
30
33
30
27
24
20
18
15
10
5
0
Men
Women
15–24
25–44
45+
Age group
1997
1987
Source: Hall, M., et al. Caring Canadians, Involved Canadians: Highlights from
the 1997 National Survey of Giving, Volunteering and Participating. Ottawa:
Minister of Industry, 1998.
Participation in Community Organizations in
Canada, by Household Income Level, 1996–97
Exhibit 2.23
80
71
70
60
Percentage
60
54
50
40
45
34
30
20
10
0
$20,000–$39,999 $60,000–$79,999
<$20,000
$40,000–$59,999
$80,000+
Household income level
Women (33%) were slightly more likely
to report participating in volunteer activities
than men (29%). However, men reported
devoting more hours to volunteer activities,
averaging 160 hours per year as compared
with 140 hours for women.
In general, rates of volunteering
increased with income level. The rate of
volunteer participation among Canadians
with incomes less than $20,000 (22%)
was half that of wealthy Canadians (44%).
This may reflect the inability to pay for
the direct costs of volunteering such as
transportation to a program or clothing
costs, as well as poorer health status of
low-income Canadians.
Exhibit 2.22 shows that the biggest
increase in volunteering occurred among
youth aged 15 to 24. In this age group, the
1997 volunteer rate rose to 33% from 18%
in 1987. Youth volunteers tended to have
different motivations for volunteering than
other participants. They were particularly
likely to volunteer to improve job
opportunities (54%), to explore their
own abilities (68%) and to use their skills
and abilities (82%).
Civic Participation
One in two Canadians reported being
involved in a community organization
(e.g. work-related, sports and recreation,
religious, school-related, cultural, educational
and political groups).
Men (53%) reported a slightly higher
rate of civic participation than women
(49%), and Canadians aged 35 to 64
reported the highest rates of participation
of any age group. The strongest predictor
of civic participation was socioeconomic
status. As income increased, so too did the
likelihood of participating in community
organizations (Exhibit 2.23).
Source: Hall, M., et al.Caring Canadians, Involved Canadians: Highlights
from the 1997 National Survey of Giving, Volunteering and Participating.
Ottawa: Minister of Industry, 1998.
Toward a Healthy Future
63
The Socioeconomic Environment
Charitable Donations
Exhibit 2.24
Distibution of All Financial Donations by Size
of Annual Donation, Canadian Donors Aged 15+,
1997
100
86%
80
Percentage
Eighty-eight percent of Canadians made
donations, either financial or in-kind, to
charitable and not-for-profit organizations
in 1996–97. Women (81%) were somewhat
more likely than men (75%) to have made
financial donations during 1995–96.
Direct financial contributions
totalled an estimated $4.5 billion. Health
organizations received the largest number
of individual donations; however, religious
organizations received the largest amount
of all money donated.
The third of donors who made the
largest financial donations ($150 or more)
accounted for 86% of the total value of
financial donations (Exhibit 2.24).
60
40
33.3%
20
0
13%
1%
<$39
$40–$149
$150 or more
Amount of donations
Discussion
Percent of donors
In looking at the socioeconomic
environment as a determinant of health,
it is useful to first consider the two related
parts separately — trends in economic
status (including income distribution)
and factors in the social environment.
33.3%
33.3%
Percent of donations
Source: Hall, M., et al.Caring Canadians, Involved Canadians: Highlights from
the 1997 National Survey of Giving, Volunteering and Participating. Ottawa:
Minister of Industry, 1998.
Income, Income Distribution and Health
In terms of economic status, the first concern is for individuals and families living in
low income situations. As shown in Chapter 1, people with higher incomes live longer,
healthier lives than people with low incomes. This relationship persists, regardless of
gender, culture or race, even though the causes of illness and death may vary.57
Low income in Canada is often related to gender. Women, especially single mothers
and unattached seniors, remain particularly vulnerable. As we have seen in this chapter,
low-income status is also linked to age. In 1995, very young children (under the age of 6)
and youth (aged 18 to 24) were most likely to live below the LICO. Despite the recent
resolution of governments and non-governmental organizations to end child poverty
by the year 2000, we have seen the proportion of young children living in low-income
situations increase from one in five to one in four in 1995. To many Canadians, this is
unacceptable in a country as prosperous as Canada.
Children are poor because their families are poor. Increases in poverty among all
family types are directly related to a number of trends: cyclical recessions in the economy;
the growth of earning inequities (especially between young and older workers); changes
in family structure; reduced access to affordable housing (see Chapter 4); and reductions
in social assistance in some juristictions. A renewed effort to address child and family
poverty is required, as is a solid plan for doing so.
Toward a Healthy Future
64
The Socioeconomic Environment
A second concern relates to the distribution of income in Canada. A growing body
of literature on health suggests that as the gap widens between the rich and poor, so too
does the gap in health status in any given population.58 This chapter has shown that tax
redistribution policies and transfers are critical to reducing income inequities. Increasing
opportunities for education, lifelong learning and employment in meaningful work are
also important.
Efforts to reduce economic inequities in Canada stand to benefit middle- and upperincome Canadians, as well as those with low-income status. In the long run, investing
money and effort in reducing disparities now will save both money and suffering in terms
of increasingly poor health status in the future.
Reducing inequities is also important for sustaining the overall quality of life in
communities across Canada. Richard Wilkinson has shown that societies with greater
economic inequalities begin to “disintegrate” — that is, they show evidence of decreased
social cohesion or citizen commitment to society.59
Employment and Health
Despite a slight recovery in 1998, persistent high levels of unemployment combined
with dramatic increases in the amount of part-time or temporary work have led to large
relative declines in average wages among young Canadians. These trends have reduced
young people’s opportunities for upward economic mobility. In other words, the current
generation of youth are less likely to achieve or surpass their parents’ standard of living.
These trends have also contributed to the increase in poverty among young families.
If Canada is to remain a vibrant and productive society in the new millennium,
young people in Canada must be provided with increased opportunities for meaningful
employment.
Women earn significantly less than men, even when their education and literacy
skills are equal. Job insecurity is higher for women than men because more women work
part-time or lose job seniority if they take time off to be with young children. Women
are disadvantaged relative to men in terms of job satisfaction because they are more likely
to work in situations affording them little control over the pace and content of their
tasks.60 The relationship between lack of control at work and poor health has been well
documented.61
When it comes to unpaid work, the situations of women and men diverge even more.
The role overload documented in this chapter is extremely stressful. In one recent study,
85% of working women said that there were not enough hours in the day to accomplish
everything they needed to do and more than one-quarter had thought about quitting
their job because the effort of balancing work and family life was too stressful.62
At the same time, young women in their 20s are now more likely than their male
counterparts to graduate from college and university. As well, low-skilled male workers
were particularly hard hit by recent recessions. As employment opportunities continue
to shift from low-skilled to high-skilled, knowledge-dependent jobs, young men need
to be encouraged to stay in school.
Toward a Healthy Future
65
The Socioeconomic Environment
Education, Literacy and Health
In most cases, employment, education and income are inextricably linked. The world
of work is increasingly demanding: it is estimated that two-thirds of new jobs in the
year 2000 will require more than 17 years of education.63 For young people, educational
attainment is the single most important factor in determining whether or not they obtain
a job that will enable them to support themselves and a family. In 1994, for example, the
unemployment rate for Canadians aged 25 to 29 with no more than a primary school
64
education was almost four times the rate for young people with a univeristy education.
There are many factors that help or hinder a young person’s desire and ability to
pursue an education. The 1995 School Leavers Follow-Up Survey65 suggests that young
people who leave high school before graduation (22% of young men and 14% of young
women) are more likely to:
• dislike school, skip classes and have friends not attending school
• come from families who did not think high school completion was very important
• come from lower socioeconomic backgrounds
• be married and have dependent children
• have failed an elementary grade and have lower grade averages
• cite work-related reason (mostly males) for leaving (e.g. having to work for financial
reasons, preferring work to school)
• cite family motivations for leaving (mostly female) (e.g. pregnancy/marriage, problems
at home).
These findings suggest that efforts to help young people stay in school should include
support for early childhood development (see Chapter 3), the provision of nurturing
school environments, community support for troubled young people, renewed focus on
preventing adolescent pregnancy, and the provision of support for students who cannot
afford to stay in school.
While the increase in the number of university graduates (particularly young women)
is welcome, several recent reports have pointed to a growing concern about the increasing
costs of attending college and university. While many young men and women from highincome families take advantage of post-secondary education opportunities that lead to
professional careers, increasingly, students from low- and middle-income families cannot
afford to pursue a higher education without incurring a large debt.66
Literacy levels, which are usually, but not always, related to levels of education, are
important predictors of employment, active participation in the community and health
status. They are also important predictors of the success of a nation. As discussed in
Chapter 2, Canada’s first-place ranking on the UN Human Development Index drops
to 10th when factors such as income distribution and literacy are factored in. In 1995,
Canada had more than twice the proportion of citizens who lacked adequate literacy
skills as Sweden, the number one ranked country on the Human Poverty Index for
industrialized countries.67
Toward a Healthy Future
66
The Socioeconomic Environment
The Social Environment and Health
A growing body of evidence suggests that decreased social capital is a precursor of increased
illness and death.68 Kawatchi and Kennedy, who found that high levels of trust and group
membership in U.S. states were associated with reduced mortality rates, make the case that
economic inequities contribute to increases in crime and violence, deteriorating health and
education systems and other social problems.69
While this report suggests that crime is decreasing in most jurisdictions, crime levels
remain higher than a decade ago. Family violence and abuse remain pervasive social
problems. And many Canadians are concerned about recent, highly publicized incidents
of youth alienation and violence at school.
Family violence and abuse have a devastating effect on health in both the long
and short term. Everyone — family members, neighbours, health and social service
professionals, teachers, police, community leaders, employers, voluntary organizations,
the justice system and governments — has a role to play in preventing family violence
by intervening to protect victims, who are most often women and children. This
violence will not be eliminated until society as a whole makes it unacceptable.
The strongest predictors of wife assault are the young age of a couple (18 to 24 years),
chronic unemployment of male partners, living in a common-law relationship, witnessing
abuse as a child, and the presence of emotional abuse in the relationship. Research also
shows that children who are abused or witness abuse are at increased risk of becoming
perpetrators of violence themselves.70 Thus, family violence is both an intergenerational
and systemic issue. Efforts to prevent family violence must include strategies to employ
young people in meaningful jobs, and to help prepare them for intimate, egalitarian
relationships and the role of parenting.
The information in this chapter on social support, giving and civic participation
suggests that Canadians are, by and large, a caring society. Richard Wilkinson and others
who have studied this area in detail suggest that the pursuit of a positive social fabric and
narrower income differentials is complementary to both economic growth and improved
population health.71, 72
The Role of the Health Sector
Some people may question this in-depth discussion on the socioeconomic environment
in a health report. The reason is simply this: the evidence in this report and others suggests
that many of the root causes of poor health lie in the socioeconomic conditions in which
people live. Many of these conditions fall under the mandate of sectors outside of health,
including education, justice, housing, employment and others. The health sector cannot
impose its agenda on other sectors, but it can initiate dialogue and act as a collaborator
in collective efforts to improve the well-being of all Canadians. This is a somewhat new
and sometimes difficult role, but one that will become increasingly important as we learn
more about the underlying determinants of health.
Toward a Healthy Future
67
The Socioeconomic Environment
Endnotes for Chapter 2
1.
2.
3.
4.
5.
6
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
British Medical Journal. “Editorial. The Big Idea.” British Medical Journal 312 (April 20,
1996): 985.
Health and Welfare Canada. A New Perspective on the Health of Canadians. Ottawa: Health
and Welfare Canada, 1974.
Statistics Canada. Income Distribution by Size in Canada, 1996. (Statistics Canada Cat. No.
13-207).
Statistics Canada. Family Expenditures Survey, 1996. (Statistics Canada Cat. No. 62-555-XPB).
Statistics Canada. “1996 Census: Sources of Income Earnings and Total and Family Income.”
The Daily, May 12, 1998 (Statistics Canada Cat. No. 11-001-XIE).
Ibid.
Statistics Canada. Low Income Persons, 1980 to 1996. (Statistics Canada Cat. No. 13-569-XPB).
Evans, R., Barer, M., Marmor, T. (eds.) Why Are Some People Healthy and Others Not? The
Determinants of Health of Populations. New York: Aldine De Gruyter, 1994: 23.
Wolfson, M., Murphy, B. (Statistics Canada). “New Views on Inequality Trends in Canada and
the United States.” Monthly Labour Review (April 1998): 2–23.
Yalnizyan, A. The Growing Gap. Toronto: Centre for Social Justice, 1998.
Picot, G. “What Is Happening to Earnings Inequality in the 1990s?” Statistics Canada 1998.
ISBN 0-660-17528-0. See Statistics Canada Internet site: www.statcan.ca
Rashid, A. “Family Income Inequality, 1970–1995.” Perspectives (Winter 1998): 12–17
(Statistics Canada Cat. No. 75-001-XPE).
Hatfield, M. Concentrations of Poverty and Distressed Neighbourhoods in Canada. Working
Paper W-97-IE. Ottawa: Applied Research Branch, Human Resources Development Canada,
1997.
Millar, W., Stephens, T. “Social Status and Health Risks in Canadian Adults: 1985 and 1991.”
Health Reports 5 (1992): 143–56 (Statistics Canada Cat. No. 82-003-XPB).
Statistics Canada. National Population Health Survey, 1996–97. Special tabulations.
Statistics Canada. “1996 Census: Education.” The Nation Series. (Statistics Canada Cat.
No. 93F0028XDB96001).
Ibid.
Ibid.
Statistics Canada. “1996 Census: Education.” The Daily, April 14, 1998 (Statistics Canada Cat.
No. 11-001-XIE). See Statistics Canada Internet site: www.statcan.ca
Ibid.
Ross, D.P., Scott, K., Kelly, M.A. “Overview: Children in Canada in the 1990s.” In Human
Resources Development Canada and Statistics Canada. Growing Up in Canada: National
Longitudinal Survey of Children and Youth, 1996 (Statistics Canada Cat. No. 89-550-MPE,
No. 1).
Statistics Canada and Organisation for Economic Co-operation and Development. Literacy,
Economy and Society: Results of the First International Adult Literacy Survey. Ottawa: Statistics
Canada, 1995 (Statistics Canada Cat. No. 89-545-E).
Ibid.
Government of Canada. Reading the Future: A Portrait of Literacy in Canada. Report on the
International Adult Literacy Survey, 1997 (Statistics Canada Cat. No. 89-551-XPE).
Statistics Canada and Organisation for Economic Co-operation and Development. Literacy,
Economy and Society: Results of the First International Adult Literacy Survey.
Willms, J.D. “Literacy Skills of Canadian Youth.” International Adult Literacy Survey Series,
September 1997 (Statistics Canada Cat. No. 89-552-MPE, No. 1).
Toward a Healthy Future
68
The Socioeconomic Environment
27. Schalla, V., Schellenberg, G. The Value of Words: Literacy and Economic Security in Canada.
Ottawa: Statistics Canada, May 1998 (Statistics Canada Cat. No. 89-552-MPE).
28. Government of Canada. Reading the Future: A Portrait of Literacy in Canada.
29. Canadian Public Health Association. The Health Impacts of Unemployment: A Position Paper.
Ottawa: CPHA, 1996.
30. Evans, R. Why Are Some People Healthy and Other People Not? Canadian Working Paper
Number 20. Toronto: Institute for Advanced Research, Program in Population Health,
December 1992.
31. Statistics Canada. “Labour Force Update: An Overview of the Labour Market.” The Daily,
January 27, 1999.
32. Ibid.
33. Statistics Canada, Health Statistics Division. Health Indicators, 1999. (Statistics Canada Cat.
No. 82-221-XCB).
34. Statistics Canada. “Labour Force Update: An Overview of the Labour Market.”
35. Human Resources Development Canada. Labour Market Developments in Canada. Ottawa:
HRDC, February 1997.
36. EKOS Research Associates. What Does Workplace Change Mean for Different Segments of the
Canadian Labour Market? EKOS, 1995.
37. Statistics Canada. “Labour Force Update: An Overview of the Labour Market.”
38. Ibid.
39. Betcherman, G., Leckie, N. Youth Employment and Education Trends in the 1980s and 1990s.
Working Paper #W03. Ottawa: Canadian Policy Research Networks Inc., 1997.
40. Statistics Canada. “Labour Force Update: An Overview of the Labour Market.”
41. Institute for Work and Health. How the Workplace Can Influence Employee Illness and Injury.
Toronto: National Roundtable on Employee Health, Institute for Work and Health, 1998.
42. Statistics Canada. National Population Health Survey, 1994–95.
43. Statistics Canada. “1996 Census: Labour Force Activity, Occupation and Industry, Place of
Work, Mode of Transportation to Work, Unpaid Work.” The Daily, March 17, 1998.
44. Association of Workers’ Compensation Boards of Canada. Canadian Workers’ Compensation
Basic Statistical and Financial Information 1990–93. Edmonton: Association of Workers’
Compensation Boards of Canada, 1995.
45. Statistics Canada, Health Statistics Division. Special tabulations of data from the Association
of Workers’ Compensation Boards of Canada and Labour Force Survey, 1996.
46. Mustard, F., Frank, J. The Determinants of Health. Canadian Institute for Advanced Research
Publication #5. Toronto: CIAR, 1991.
47. Canadian Council on Social Development. The Progress of Canada’s Children, 1997. Ottawa:
CCSD, 1997.
48. Human Resources Development Canada and Statistics Canada. Growing Up in Canada:
National Longitudinal Survey of Children and Youth. Ottawa: HRDC and Statistics Canada,
1996 (Statistics Canada Cat. No. 89-550-MPE, No.1).
49. Statistics Canada, Canadian Centre for Justice Statistics. Assaults Against Children and Youth
in the Family, 1996. Ottawa: Statistics Canada, November 1997 (Statistics Canada Cat. No.
85-002-XPE, Vol. 17, No. 11).
50. Statistics Canada. Violence Against Women Survey, 1993. Ottawa: Statistics Canada, 1994.
51. Statistics Canada, Canadian Centre for Justice Statistics. Uniform Crime Reporting Survey,
1996. Ottawa: Statistics Canada, 1997.
52. Statistics Canada, Canadian Centre for Justice Statistics. Family Violence in Canada:
A Statistical Profile, 1998. Ottawa: Statistics Canada, May 1998 (Statistics Canada Cat.
No. 85-224-XPE).
Toward a Healthy Future
69
The Socioeconomic Environment
53. Statistics Canada, Canadian Centre for Justice Statistics. Canadian Crime Statistics, 1997.
Ottawa: Statistics Canada, July 1998 (Statistics Canada Cat. No. 85-002-XPE, Vol. 18, No. 11).
54. Statistics Canada, Canadian Centre for Justice Statistics. Family Violence in Canada:
A Statistical Profile, 1998.
55. Statistics Canada. “Crime Statistics.” The Daily, July 22, 1998, based on “Canadian Crime
Statistics.” Juristat 18, 11 (1997) (Statistics Canada Cat. No. 85-002-XPE).
56. Hall, M., Knighton, T., Reed, P., et al. Caring Canadians, Involved Canadians: Highlights from
the 1997 National Survey of Giving, Volunteering and Participating. Ottawa: Minister of
Industry, 1998.
57. Frank, J., Mustard, J.F. “The Determinants of Health from a Historic Perspective.” Daedalus.
Journal of the American Academy of Arts and Science (Fall 1994): 1–19.
58. Evans, R., Barer, M., Marmor, T. (eds.) Why Are Some People Healthy and Others Not? The
Determinants of Health of Populations.
59. Wilkinson, R.G. Unhealthy Societies: The Afflictions of Inequality. London: Routledge, 1996.
60. Messing, K. “Women’s Occupational Health: A Critical Review and Discussion of the Issues.”
Women and Health 25, 4 (1994): 39–69.
61. Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies for
Population Health: Investing in the Health of Canadians. Ottawa: Minister of Supply and
Services Canada, 1994.
62. Lee, C., Duxbury, L., Higgins, C. Employed Mothers: Balancing Work and Family Life. Ottawa:
Canadian Centre for Management Development, 1994.
63. National Literacy Secretariat. Creating a Learning Culture: Work and Literacy in the Nineties.
Ottawa: Minister of Supply and Services, 1990.
64. Betcherman, G., Leckie, N. Youth Employment and Education Trends in the 1980s and 1990s.
65. Human Resources Development Canada. High School May Not Be Enough: An Analysis of the
School Leavers Follow-Up Survey, 1995. Ottawa: HRDC, 1998.
66. Canadian Council on Social Development. The Progress of Canada’s Children, 1997.
67. United Nations Development Program. Human Development Report 1998. New York: Oxford
University Press, 1998.
68. Wilkinson, R.G. Unhealthy Societies: The Afflictions of Inequality.
69. Kawachi, I., Kennedy, B. “Health and Social Cohesion: Why Care About Income Inequality?”
British Medical Association Journal 314 (1997): 1037–40.
70. Statistics Canada, Canadian Centre for Justice Statistics. Family Violence in Canada: A
Statistical Profile, 1998.
71. Wilkinson, R.G. Unhealthy Societies: The Afflictions of Inequality.
72. Marmor, T. “Improvement of Social Environment to Improve Health.” Lancet 351 (1998):
57–60.
Toward a Healthy Future
3
Healthy Child Development
Every day one thousand children are born in Canada. Making sure that
they grow up healthy, happy, successful and safe is a key responsibility
for parents, communities and society as a whole.
— Federal, Provincial and Territorial Council of Ministers on Social Policy Renewal in
A National Children’s Agenda: Developing a Shared Vision.
I
n the last decade of the 20th century, new evidence on the effects of early
experiences on brain development, school readiness and health in later
life has sparked a growing consensus about early child development as
a powerful determinant of health in its own right. At the same time, we have
been learning more about how all of the other determinants of health affect
the physical, social, mental, emotional and spiritual development of children
and youth. For example, a young person’s development is greatly affected by
his or her housing and neighbourhood (Chapters 1 and 4), family income and
level of parents’ education (Chapter 2), access to nutritious foods and physical
recreation (Chapter 5), genetic makeup (Chapter 7) and access to dental and
medical care (Chapter 6).
A variety of recent publications have done an excellent job of profiling the
health and well-being of Canada’s children and youth. The reader is directed to
Appendix C for other key reports on this topic. This chapter cannot duplicate the
depth of information and analysis found in these documents. Rather, it provides
a brief overview of some of the key indicators of healthy child development,
with a particular focus on the effects of socioeconomic status and gender on
these indicators. Where data were available, information on differences among
population groups has also been provided.
Toward a Healthy Future
72
Healthy Child Development
Most Canadian children are physically healthy. However, important indicators of
well-being and healthy development among children and youth follow the same trends
as were observed for adults in Chapters 1 and 2 of this report. In some cases, children
and young people in Aboriginal communities appear to be particularly at risk.
Definitions and Measures
◆
National Longitudinal Survey of Children and Youth (NLSCY), developed jointly
by Human Resources Development Canada and Statistics Canada, is a comprehensive
survey that follows the development of children in Canada and paints a picture of their
lives. The survey monitors children’s development and measures the incidence of various
factors that influence their development, both positively and negatively. The first cycle
of the NLSCY, conducted in 1994–95, interviewed some children and the parents of
approximately 23,000 children up to the age of 11. The second cycle, carried out in
1996–97, interviewed the same children and their parents and thus provides unique
insights into the evolution of children and their family environments over time. Unless
stated otherwise, the information in this chapter is drawn from Cycle 1 of the NLSCY.
◆
Secure attachment: As parents and caregivers respond affectionately to their babies,
a responsive, trusting relationship develops in which they gain confidence that their
parents will protect them and meet their needs. This relationship is referred to as a
secure attachment.
◆
School readiness: The NLSCY assessed school readiness in two ways. The Peabody
Picture Vocabulary Test was used to assess cognitive competency. Children within 15
points of a score of 100 were termed “normal”; those below this cut-off — “delayed,”
and those above — “advanced.” To measure behavioural competence, mothers
completed a 43-item questionnaire including questions about aggression, anxiety,
conduct and social problems.
◆
Child and family poverty: While Statistics Canada is careful not to refer to the low
income cut-offs (LICOs) as poverty lines, the LICO is the most widely used measure to
define child poverty rates. As stated in Chapter 2, the LICO was selected on the basis
that families below these cut-offs spend more than 54.7% of their total incomes on
basic shelter, food and clothing, and hence are considered to be in constrained
circumstances.
◆
Infant mortality refers to the death of a live born infant within the first year of life.
◆
Perinatal deaths are the combination of stillbirths and early neonatal deaths (within
the first seven days of life).
Toward a Healthy Future
73
Healthy Child Development
Highlights
The foundation for healthy growth and development in later years is established to a
large degree in the first six years of life.
◆ Experiences from conception to age six have the most important influence of any
time in the life cycle on the connecting and sculpting of the brain’s neurons. Positive
stimulation early in life improves learning, behaviour and health into adulthood.
◆ Low birthweight (less than 2,500 grams or about 5.5 pounds) can result in mental
and physical disabilities, and sometimes death. In 1996, 5.8% of all live births in
Canada resulted in low birthweight babies (a total of 21,025 babies).
◆ Tobacco and alcohol use during pregnancy can lead to poor birth outcomes. In the
1996–97 National Population Health Survey, about 36% of new mothers who were
former or current smokers smoked during their last pregnancy (about 146,000 women).
The vast majority of women reported that they did not drink alcohol during their
pregnancy.
◆ A secure attachment with a nurturing adult influences a child’s capacity for cognitive,
social and emotional development. Children whose parent(s) are depressed or otherwise
troubled are most at risk for losing the opportunity to establish a secure attachment in
the first 18 months of life. Children living with depressed parents were almost four
times as likely to be living in low-income households than high-income households.
◆ Readiness for school is an important indicator of developmental maturity and future
success in school. The 1996–97 NLSCY found that approximately 15% of all
preschoolers arrived at school with low cognitive scores; 14% of all children had
high scores on measures indicating behavioural problems.
Efforts are needed to maximize all children’s opportunities for healthy development.
◆ Poverty compounds the stresses that all families face and can have a negative effect
on children’s development. In the early 1990s, child and family low-income rates
remained high and continued to increase in some circumstances. In 1995, 24% of
children in Canada aged 0 to 14 years and 23% of young people aged 15 to 24 lived
in low-income families. Children under the age of 6 were most likely to be poor
(26%). Almost 50% of families headed by a single mother were poor.
◆ Poor children are not always disadvantaged and disadvantaged children are not
always poor. According to the NLSCY, positive parenting, nurturing neighbourhoods
and high-quality child care may decrease the chances of developmental problems in
children.
◆ While the majority of children in lone-parent families are doing well, data from
the NLSCY show that children in lone-parent families run a greater risk of poor
developmental outcomes, especially if the parent’s approach to child rearing is hostile
or ineffective, if they live in extremely poor families, or if they live in troubled
neighbourhoods.
Toward a Healthy Future
74
Healthy Child Development
◆ At the same time, there is no economic cut-off point above which all children do
well. The greatest proportion of children who experience difficulties are found in the
bottom 20% of the socioeconomic scale. However, due to the large size of the middle
class in Canada, the greatest number of children not doing as well as they might is
in the middle socioeconomic group.
◆ Family violence, which occurs in families of all income levels, can have a devastating
effect on children’s health and development in both the short and long term. In
1996, family members were responsible for one-fifth of physical assaults and onethird of sexual assaults on children. Girls were the victims in 80% of sexual assaults
and in over half of all physical assaults by family members.
While Canada’s youth are doing well in many ways, a number of indicators combine
to show a disturbing picture of the well-being of this group.
◆ In the 1996–97 National Population Health Survey, Canadian adolescents (especially
young women), reported the lowest levels of psychological well-being among all age
groups. Depression was most common among 18- and 19-year-olds of both sexes,
and young women aged 15 to 19 were the most likely of any sex-age group to exhibit
signs of depression (9%).
◆ Canada’s continuing high rate of suicide among young people (mainly young men)
is a particularly troubling indicator of young people’s distress. It has been estimated
that suicide rates are two to seven times higher in the Aboriginal population than in
the general population. Young Aboriginal men (especially young Inuit males) are the
most likely to commit suicide.
Growing Up Healthy
Unintentional injuries are the leading cause of death among children and youth and are
particularly high among young people aged 15 to 19. Death rates due to injuries are much
higher among Aboriginal young people. For example, when Indian children are compared
with the total Canadian population of children, the rate of death from injuries is almost
four times greater for infants; for preschoolers, the rate is five times greater. Indian teenagers
are three times more likely to die due to injuries than the total population of adolescents
in Canada.1
Childhood cancer is the second leading cause of death among children aged 1 to
2
19 and asthma (see Chapter 4) is the leading cause of hospitalization for children under
the age of 12.3
Health is also about the quality of life that children and youth enjoy. This chapter
points to the fact that young people’s quality of life depends to a large degree on both
risk factors and protective factors in the environment in which they grow up.
This section looks at four stages of child development: the prenatal and infancy
period (from conception to 18 months), the preschool years from 18 months to age 5
(approximate age when children enter the formal school system), the school years from
ages 6 to 12, and adolescence from ages 13 to 18. In each of these stages, there are key
windows of opportunity for investing in healthy development.
Toward a Healthy Future
75
Healthy Child Development
Prenatal and Infancy Period (Conception to 18 Months)
In this first stage, the basic “sculpting” of a child’s brain takes place and children are most
dependent on their parents and caregivers. Pre-birth factors such as maternal nutrition
and the use of alcohol and tobacco during pregnancy can permanently influence a child’s
development. After birth, an infant’s relationship with caregivers has an important influence
on how connections are made among the brain cells. These connections may affect a child’s
immediate and future cognitive, emotional and behavioural development.4
Infant mortality
Income quintile
Infant mortality is recognized internationally as one of the most important measures
of the health of a nation and its children. It is also an important indicator of the health
of pregnant women. Canada’s infant mortality rate has declined dramatically in the last
35 years. In 1996, it dropped below the level of six infant deaths per 1,000 live births for
the first time.5 While this is an important achievement, it is still quite far above the
infant mortality rate of Japan, which is the lowest in the world (3.8 deaths per 1,000
live births).6
In 1995, 2,321 infants in Canada
Infant Mortality Rate, by Income Quintile,
Exhibit 3.1
Urban Canada, 1991
died before their first birthday. Of these
deaths, 68% occurred in the neonatal
period (the first twenty eight days of life)
Lowest
7.5
and 32% occurred in the postneonatal
Lower
period. The two leading causes of death
6.7
middle
in the neonatal period were conditions
Total Urban
originating in the perinatal period such
5.8
Canada
as respiratory distress, prematurity and
Middle
5
low birthweight (60%), and congenital
anomalies (33%). The two leading
Upper
5.1
middle
causes of postneonatal deaths were
sudden infant death syndrome (SIDS)
4.5
Highest
and congenital anomalies, accounting
for 31% and 23% of postneonatal
0
8
1
5
7
2
3
4
6
7
deaths, respectively.
Infant mortality rate per 1,000 live births
Experience has shown that death
Source: Wilkins, R. Mortality by Neighbourhood Income in Urban Canada,
rates from SIDS can be lowered
1986 to 1991.
substantially by keeping infants on
their backs while sleeping, breastfeeding
infants, keeping infants in a smoke-free and drug-free environment, and ensuring
that they are warm but not hot.8
Differences in infant mortality rates are pronounced among the various income groups
in Canada. In 1991, the overall infant mortality rate in urban Canada was 5.8 per 1,000.
As Exhibit 3.1 shows, the infant mortality rates of the high, upper-middle and middle
income groups fell below the Canadian average, while the lower-middle and low income
groups experienced higher than average infant mortality rates.9
Toward a Healthy Future
76
Healthy Child Development
Stillbirth, Neonatal and Postneonatal Death
Rates Among First Nations and Canadian
Populations, 1994
Exhibit 3.2
7.9
8.0
6.9
Rate per 1,000 births
7.0
6.0
6.0
4.8
5.0
4.2
4.0
3.0
2.1
2.0
1.0
0.0
Stillbirths
Neonatal
Canadians
Postneonatal
First Nations
Source: Health Canada, Medical Services Branch. Health Programs Analysis —
First Nations and Inuit Health Programs, 1996.
The infant mortality rate among First
Nations people fell from 28 per 1,000 live
births in 1979 to 12 per 1,000 in 1994.
Most of this decline, however, occurred
before 1987. Since then, rates have been
comparatively stable. Infant mortality is
still twice as high among First Nations
people than in the Canadian population as
a whole. As Exhibit 3.2 shows, the 1994
neonatal mortality rate among First Nations
people was close to the national average.
In contrast, rates during the postneonatal
period were at least three times higher
among First Nations infants than infants
in the general population, and stillbirth
rates were also higher. For First Nations
infants, the main causes of death in the
postneonatal period were sudden infant
death syndrome (SIDS), congenital
anomalies and respiratory conditions
such as bronchitis and pneumonia.10
Birthweight
The weight of infants at birth is a principal determinant of both their survival and their
health in childhood. Low birthweight (less than 2,500 grams or about 5.5 pounds) can
result in mental and physical disabilities, and sometimes death. In 1996, 5.8% of all live
births in Canada resulted in low birthweight babies (a total of 21,025 babies).11 More than
half of low birthweights are due to premature births (before the 37th week of gestation);
the rest are due to a lack of nourishment in utero, pregnancy-induced hypertension and/or
heavy smoking by the mother during pregnancy.
Studies have shown that greater maternal education is associated with a decreased
likelihood of low birthweight, regardless of race.12 Low birthweight outcomes in Canada
are concentrated among very young and older mothers (Exhibit 3.3). While mothers over
age 45 are more likely to experience medical complications that could affect birthweight,
a recent study using NLSCY data concluded that neither young mothers nor mothers who
are single parents are particularly at risk for having a child with adverse birth outcomes,
once income and maternal education levels are taken into account.13
According to the First Nations and Inuit Regional Health Survey, the rate of low
birthweight among Aboriginal people in 1996–97 did not differ significantly from
national norms in 1994–95. However, the rate of high birthweight (above 4,000 grams)
was significantly higher (18% versus 12%). High birthweight is associated with higher
neonatal mortality.14
Toward a Healthy Future
77
Healthy Child Development
Exhibit 3.3
Low Birthweights in Canada, by Mother’s Age, 1996
Age of mother
No. of births <2,500 g*
% of all live births
10–14
21
9.3
15–19
1,516
7.0
20–24
3,934
5.9
25–29
6,107
5.3
30–34
6,195
5.6
35–39
2,730
6.4
40–44
487
8.1
45+
23
10.0
Total
21,025
5.8
* Note: Excludes births in age groupings where age of mother is unknown.
Source: Statistics Canada. “Births 1996.” The Daily, July 8, 1998 (Statistics Canada Cat. No. 11-001-XIE).
Tobacco and alcohol use during pregnancy
The use of tobacco and alcohol during pregnancy can contribute to poor birth outcomes.
Research has shown that the infants of women who smoke during pregnancy are oneand-one-half times more likely to be of low birthweight than infants of non-smokers.15
In 1996–97, about 36% of new mothers (following the birth of a first or subsequent
child) who were former or current smokers smoked during their previous pregnancy
(about 146,000 women). The prevalence of smoking while pregnant is highly related to
education. Among those who had ever smoked, some 61% of pregnant women with less
than a high school education smoked during their pregnancy, compared to only 14% of
women with a university education.16 Over 40% of teen mothers smoked during their
pregnancies; they were twice as likely to smoke as were women aged 25 and older. Teen
mothers who smoke and have low levels of education are more likely to have a low
birthweight baby, but no more so than older mothers who smoke and have comparable
levels of education. Thus, it appears that income and education — not age — are the
major predictors of smoking during pregnancy.17
Women who drink during pregnancy tend to be older and of higher socioeconomic
status than non-drinkers. In the 1996–97 National Population Health Survey, the vast
majority of women reported that they did not drink alcohol during their pregnancy. Very
few women (only 2.5% of those who drank) reported that they had consumed at least five
drinks at one time and only 7% reported drinking throughout their entire pregnancy.18
While these overall numbers are relatively low, there is no question that alcohol use
during pregnancy can have harmful effects on children, and excessive use can cause
fetal alcohol syndrome and fetal alcohol effects (see Chapter 6). Both of these conditions
are preventable. Since a safe limit for alcohol use during pregnancy has not yet been
established, the prudent choice for women who are or may become pregnant is to abstain
from alcohol use.
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78
Healthy Child Development
Teen pregnancy
Adolescent pregnancy is another important indicator for early childhood development.
Teen childbearing often leads to poor economic and social outcomes for adolescent
parents and their children. Adolescent mothers are less likely to attain a high level of
education and more likely than other women to live in poverty. They also tend to be
less emotionally mature than older mothers, since they themselves are still dealing
with developmental issues. Therefore, without support, teen moms may find it difficult
to provide the consistent nurturing the infant and child require to make a secure
attachment in the first 18 months.
In 1995, there were a total of 38,502 teenage pregnancies (including live births,
abortions and stillbirths). The number of teenage pregnancies decreased among 15- to
19-year-olds from the mid-1970s to 1988, and then increased slightly. The number of
pregnancies among 13- and 14-year-olds decreased slowly from the mid-1970s to a low
of 573 in 1988; since then it has remained at about 600.19 While the number of teen
pregnancies in 1995 was still well below their historic highs, increasing rates of teen
pregnancies (from 41 per 1,000 women aged 15 to 19 in 1987 to 47 per 1,000 in 1995) is
a worrisome trend.20 Research suggests that effective strategies to reduce teen pregnancies
include high-quality sex education, accessible clinical services, open discussion of human
sexuality in the mass media and actively involving parents and teenagers in such programs.21
Breastfeeding practices
There are numerous benefits from breastfeeding, including protection against infectious
diseases, healthy development of the brain and nervous system, and improved bonding
between mother and child.22, 23 Breastfeeding has increased since the 1980s when about
two-thirds of women breastfed their babies. In 1996–97, 79% of all recently pregnant
women breastfed their last child. There is a strong relationship between a mother’s level
of education and the choice to breastfeed. In 1996–97, recent mothers with less than a
high school education were least likely (60%) to have breastfed their last child, while
university-educated mothers were the most likely (95%) to have done so. Similarly,
mothers with less than a high school education were almost twice as likely as mothers
who had completed high school and almost four times more likely than mothers who
were university graduates to smoke while breastfeeding.24
Secure attachment
Recent research has also confirmed the necessity of infants and young children to form
a secure attachment to a parent or loving caregiver if they are to experience optimal
emotional and social development. A secure attachment provides the basis for a child’s
capacity to develop trust, self-esteem, self-regulation, self-soothing and relationships with
others. It influences language and cognitive development and gives infants the confidence
they need to explore their world. Secure attachment has also been shown to establish
connections in the brain that can reduce anxiety and allow the brain to take in new
stimuli. The critical period for secure attachment occurs in the first 18 months of life.25
Children whose parent(s) are depressed or troubled are most at risk for losing the
opportunity to establish a secure attachment in the first 18 months of life. A number of
risk factors for depression among parents have been identified. According to the 1996–97
National Population Health Survey, single parents were far more likely to be depressed
Toward a Healthy Future
79
Healthy Child Development
(9%) than couples with children (3%).26 The 1994–95 NLSCY found a striking association
between parental depression and household income. Children living with depressed
parents were almost four times as likely to be living in low-income households than in
high-income households.27
Preschoolers (18 Months to Age 5)
The preschool years are a time of rapid cognitive, behavioural, emotional and social
development. Stimulation, consistent nurturing from loving adults, active play and early
learning opportunities during this period can stimulate children’s readiness to learn and
help to overcome disadvantages related to poverty and other problems.
School readiness
Immunization
Percentage
Readiness for school is an important indicator of developmental maturity and future success
in school.28 The 1996–97 NLSCY found that approximately 15% of children arrived at
school with low cognitive scores; 14% of children had high scores on measures indicating
behavioural problems. (See the Definitions and Measures box earlier in this chapter.)
Children whose mothers had low levels of education tended to have lower cognitive
and behavioural competency scores. As Exhibit 3.4 shows, 32% of children whose mothers
had not completed high school obtained low cognitive competency scores and 18% received
scores indicating behavioural problems,
compared to 13% and 14% of children whose
Children Who Obtain Low Competence Scores or
mothers had more than a high school level of
Exhibit 3.4
Exhibit High Behavioural Problems, by Mother’s
education. The 1996–97 NLSCY also found a
Level of Education, 1996–97
clear association between household income
35
32
and school readiness for both cognitive and
behavioural competence. In addition, children
30
living in neighbourhoods that were identified
25
by mothers as unsafe and low in cohesiveness
21
were less likely to be ready for school than
20
18
children in better neighbourhoods.29
15
15
10
13
14
Since vaccines were first introduced, Canada
5
has seen a 95% reduction in vaccinepreventable diseases among children and the
0
total elimination of polio. Mass catch-up
High school > Post-secondary
< High school
campaigns and the implementation of a twograduate
dose measles immunization program in 1996
Mother’s level of education
led to a seven-fold decrease in the incidence
of reported measles from 1995. This puts
% Low cognitive scores
Canada in a very good position to achieve
its goal of eliminating measles by 2005. In
% High behaviour problems
contrast, the reported incidence of pertussis
Source: Kohen, D., Hertzman, C., Brook-Gunn, J. Affluent Neighbourhoods
(whooping cough) in 1994–95 (approximately
and School Readiness. Human Resources Development Canada, 1998.
34 per 100,000 population) was the highest in
(Data from 1996–97 NLSCY).
a decade. The rate of pertussis was highest in
the Yukon Territory and Northwest Territories.30
Toward a Healthy Future
80
Healthy Child Development
The very success of immunization programs may well be one of their greatest
challenges. As generations of children grow up in the absence of diseases that used to
wreak havoc on the population, they are less inclined to seek continued protection. As
well, parental confidence in some vaccines has been eroded by exaggerated and often
erroneous reports of serious adverse reactions. At the same time, due to the patchwork
implementation of vaccine programs across Canada, there is a risk that relatively benign
childhood diseases such as chicken pox may become lethal for adults because of
alterations in the disease due to partial vaccination. Thus, vigilance in attaining and
maintaining a national commitment to necessary immunization programs remains a
public health priority.31
School-Age Children (Ages 6 to 12)
The period between the ages of 6 and 12 builds on the experiences of the earlier years.
Children become more independent at this stage and environments beyond the home
and family play more important roles in their lives. As in the preschool years, opportunities
for stimulation help to keep school-age children “on track” and they help disadvantaged
children achieve developmental levels comparable with those achieved by their more
advantaged peers.32
Unintentional injuries
As noted earlier in the chapter, unintentional injuries (mostly resulting from motor
vehicle crashes) are the major cause of death among children aged 6 to 12.33
Injuries are also a major source of suffering. In the World Health Organization
1993–94 cross-national survey of school-aged children, 21% of 11-year-old Canadian
girls and 25% of boys of the same age
reported an injury that caused them to
Cause
of
Most
Serious
Injury
Reported
by
Exhibit 3.5
11-Year-Old Boys and Girls, Canada, 1993–94
miss school or required medical attention
in the past 12 months. Canada’s injury rates
were high compared to those of other
Other*
countries. Among 22 reporting countries,
Fighting
only Scotland, Wales, Israel, Belgium and
France had higher injury rates. As shown in
Automobile accident
Exhibit 3.5, the largest group of injuries
Being struck or
were those that occurred during sporting
cut by an object
activities and play. The second largest
Bicycling or
roller skating
group were those that involved the child
Falling off something
falling off or tripping over something.34
or tripping
In addition to having a greater
Sport or playground
incidence of injuries at all ages and stages,
injury
boys also suffer more severe injuries than
0
35
15 20
30
10
5
25
girls do. The reasons for these differences —
Percentage
which may include greater risk taking by
boys, the different nature of childhood
Female
Male
activities and inborn differences in
* "Other" was a response choice.
impulsivity and activity level — are still a
Source: King, A., et al. The Health of Youth: A Cross-National Survey,
matter of debate.35
1993–1994. World Health Organization, 1997: 124.
Toward a Healthy Future
81
Healthy Child Development
The incidence and consequences of injuries also vary with income status. Some
studies have shown that poor children have a two-fold greater risk of death due to injury
than children who are not poor.36
Relationships with peers and siblings
A child’s ability to get along with others becomes particularly important when he or
she enters school and begins to engage in neighbourhood activities with other children.
Overall, the NLSCY showed that the overwhelming majority of children aged 4 to 11
years had very positive relationships with their peers and siblings.37 However, emotional
and behavioural problems in childhood pose a heavy burden of suffering on some
children and families.
Emotional and behavioural competence
The emotional and behavioural competence of children aged 4 to 11 was measured in the
NLSCY on a number of scales, based on detailed questionnaires filled out by the parent
who best knew the child (usually the mother) and separate questionnaires that were filled
out by the children (aged 10 and 11 only). The study found marked differences between
girls and boys and among income groups on a variety of measures of emotional and
behavioural problems. Boys were more likely than girls to have one or more of these types
of problems (Exhibit 3.6) and to have higher scores on all of the individual measures. The
most marked difference was in hyperactivity among the youngest age group, where the
rate in boys was more than twice that in girls (14% compared to 6.1%).38
Exhibit 3.6
Percentage of Boys and Girls Experiencing One or More Emotional and Behavioural
Problems, Canada, 1994–95
Boys
◆ Aged 4 to 7
◆ Aged 8 to 11
◆ Aged 4 to 11
Girls
27.4%
31.0%
29.9%
◆ Aged 4 to 7
◆ Aged 8 to 11
◆ Aged 4 to 11
19.1%
24.0%
22.4%
Source: Offord, D., Lipman, E. “Emotional and Behavioural Problems.” Growing Up in Canada: National Longitudinal
Survey of Children and Youth. Ottawa: Human Resources Development Canada and Statistics Canada (1996): 123.
In view of the gender differences in hyperactivity reported in the NLSCY, it is not
surprising that boys were diagnosed with attention-deficit hyperactivity disorder (ADHD)
far more often than girls. While many experts believe that ADHD is an inherited condition,
others argue that the socialization of male children plays an important role. A better
understanding of the biomedical and social nature of sex and gender differences related
to behaviour in children is needed.
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82
Healthy Child Development
Frequency of Psychological Problems in
Children, by Adjusted Household Income
Level (as per LICO), 1994–95
Exhibit 3.7
39
40
35
Percentage
30
30
29
27
25
23
23
20
20
19
15
11
10
7
5
8
7
3.6
3.4
4
1.9
0
Very poor
Poor
Not poor
Exhibit 3.7 shows the marked differences
revealed among income groups on measures
of emotional and behavioural disorders,
repeating a grade, impairment in social
relationships and having one or more
psychosocial problems. For all variables, very
poor children were the most disadvantaged
and well-off children, the least.39
The NLSCY has found that safe,
nurturing neighbourhoods, residence and
school stability, and parenting styles may
have a marked effect on a child’s emotional
and social development (discussed later).
Involvement in activities such as sports,
recreation and arts can also protect children
from emotional and social problems.40
Well-off
Adolescence (Ages 13 to 18)
Income level
One or more emotional or behaviour disorders
Repeated a grade
Impairment in social relationships
One or more problems
Source: Offord, D., Lipman, E. “Emotional and Behavioural Problems.” Growing
Up in Canada: National Longitudinal Survey of Children and Youth. Ottawa:
Human Resources Development Canada and Statistics Canada (1996): 124.
In adolescence, young people begin to
establish an independent life course and
to make decisions that can have lifelong
consequences. As they search for a unique
and stable identity, they experience the
dramatic physical and emotional changes
associated with puberty. Peers become
increasingly influential; however, strong
support from families, schools and
communities remains essential to healthy
development in this stage.
NLSCY Definitions
In the NLSCY (1994–95) the following definitions were used:
◆
Very poor = Adjusted family income below 75% of the LICO
◆
Poor = Adjusted family income between 75% and 100% of the LICO
◆
Not poor = Adjusted family income up to 25% above the LICO
◆
Well-off = Adjusted family income more than 25% above the LICO
Toward a Healthy Future
83
Healthy Child Development
Adolescents in Canada are doing well on several fronts. On the whole, young people
today have higher levels of education than the previous generation. The International
Adult Literacy Survey found nearly one-third of Canadian youth to have among the
highest level of literacy skills among reporting countries, second only to Swedish youth.41
In 1998, the Canadian Council on Social Development found that an increasing number
of cities and towns in Canada were involving young people in civic life initiatives, such as
round tables and civic committees.42 As shown in Chapter 1, youth rates of volunteering
with charitable organizations have risen substantially and the number of criminal charges
against youth has continued to drop since 1991.
Psychological well-being
At the same time, a number of indicators combine to show a disturbing picture of the
psychosocial well-being of Canada’s youth. In the 1996–97 National Population Health
Survey, Canadian adolescents reported low levels of self-esteem, sense of mastery and
sense of coherence when compared to other age groups. Depression was most common
among 18- and 19-year-olds of both sexes, and young women aged 15 to 19 were the
most likely of any sex-age group to exhibit signs of depression (9%). Young Canadians
aged 18 and 19 were the most likely to report high life stress levels (37%), compared to
the national rate of 26% (see Chapter 1).
In the World Health Organization cross-national survey, students in Canada, France,
Finland, Israel and Northern Ireland were consistently more likely than students in 16
other countries to report feeling depressed once a week. Measures of psychological wellbeing for 13- and 15-year-olds were consistently lower for females than for males.43
Canada’s continuing high rate of suicide among young people (mainly young men)
is a particularly troubling indicator of young people’s distress. It is estimated that the
suicide risk for Aboriginal youth is much higher than that of their peers in the general
population.
Substance use and abuse is another important indicator of adolescent well-being.
As shown in Chapter 5, there appears to have been a resurgence in adolescent drug use
in the 1990s, as well as an increase in multiple risk-taking behaviours.
As noted in Chapters 1 and 5, teenage girls are now more likely than teenage boys
to smoke. Many young women report that they smoke to manage stress and to keep their
weight down.44
A commitment to learning and staying in school are other signs of healthy
development in the adolescent stage (discussed in Chapter 2). The decision to drop out
of school early is influenced by family support, structure and income. For example,
students from single-parent and large families are much more likely to leave school early.
Drop-out rates are higher in rural areas and small communities, especially Aboriginal
communities.45
Other factors that help young people stay in school include parental expectations
and involvement by parents in a young person’s school life. Teachers and the overall
school environment are also important to school success. Children and youth who see
their teachers as fair and caring are more likely to have positive attitudes toward school
and increased motivation to achieve.46
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84
Healthy Child Development
As discussed in Chapter 2, the economic, employment and psychosocial consequences
of early school leaving are greater today than they were 10 or 20 years ago, and are likely
to be even more acute in the next millennium. High school dropouts will increasingly
find themselves unemployed, marginalized and looking for work at the lowest levels of
the job market.
Some Key Issues Affecting Healthy Child
Development
Child and Family Poverty
Children are poor because their families are poor and most children’s development is
closely tied to the socioeconomic status of their families and the communities they live
in. As Exhibit 3.8 shows, child poverty is not restricted to single-parent families. In 1996,
730,000 poor children under the age of 18 lived in two-parent families, compared with
673,000 poor children in female-led single-parent families. Nonetheless, it is also true that
a far higher proportion of children of single parents lived in low-income circumstances,
particularly those who lived with lone-parent mothers.47
Exhibit 3.8
Number of Poor Children (Under Age 18), by Family Type, Canada,
1980 and 1996
1980
1996
Two-parent family — 612,000
Two-parent family — 730,000
Other — 52,000
Single-parent mother — 320,000
Other — 78,000
Single-parent mother — 673,000
Source: National Council of Welfare. Poverty Profile 1996. Spring 1998: 79 (Using LICOs).
Young parents — who are most likely to have preschool children — tend to have the
fewest financial resources at their disposal. Children living in a family in which a parent
was under age 30 in 1996 were three times more likely to be living in a low-income
household than children in a family in which a parent was 40 years of age or older.48
Cycle 2 of the NLSCY showed that 7 out of 10 children living in low-income families
in 1994 were also living in low-income environments in 1996. Lower income, then, while
escapable, is persistent at least in the short term for most children in poor families.
Few people would dispute the direct and devastating consequences of living without
the means to afford safe housing and adequate food. Chapter 4 points out that a great
many young families in Canada have trouble paying their rent. A recent study of NLSCY
Toward a Healthy Future
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Healthy Child Development
data showed that among the 16,639 families studied, 206 had experienced hunger in the
last year, 72 of them frequently. Children who went hungry were more likely to live in
large cities, to live in lone-parent families and to live in families that depend on social
assistance. However, more than half of the families with hungry children also reported
having wages or salaries as a source of income. Thus, it appears that some working poor
families — as well as those on social assistance — are experiencing food security problems.
The study also found that parents were seven times more likely to go hungry themselves
when there was little food available.49
In addition to the obvious effects of restricted access to adequate food and shelter on
children’s health, economist David Ross has concluded that some 31 different indicators
measured in the NLSCY and the NPHS all show that as family income falls, the likelihood
that children will experience problems increases. Rates of poor health, hyperactivity and
delayed vocabulary development have been shown to be higher among children in lowincome families than among children in middle- and high-income families. Children’s
likelihood of participating in organized sports activities was dramatically lower if they lived
in low- and modest-income families. Almost 16% of older teens in low-income families
were at loose ends — they did not attend school, nor did they have a job — compared to
less than 4% of teens in high-income families.50
Although the proportion of children not doing well is higher nearer the bottom
of the income scale, there are children in all socioeconomic groups who do not do well.
There are several implications of this finding:
• There is no economic cut-off point above which all children do well.
• Because of the large middle class in Canada, the number of children not doing as well
as they might is greatest in the middle-income group.
• Programs and policies for positive early child development and parenting must apply to
all sectors of society if we wish to decrease the steepness of the socioeconomic gradient.
• Income is not the only factor in healthy child development. Other factors such as positive
parenting and access to early developmental programs also affect development.51
Interestingly, the 1996–97 NLSCY found that many immigrant and refugee children
were doing better emotionally and academically than their Canadian-born peers, even
though far more of the former lived in low-income households. Dr. Morton Beiser, one of
the authors of the study, suggested that “poverty among the Canadian-born population
may have a different meaning than it has for newly arrived immigrants. The immigrant
context of hope for a brighter future lessens poverty’s blows; the hopelessness of majorityculture poverty accentuates its potency.” The author also suggests that poor immigrant
families seem particularly able to provide emotional stability to their children, and therefore the effects of poverty may be limited to material deprivation and not emotional or
social deprivation.52
Security and Safety of Children and Youth
Reported instances of child abuse (including children injured as a result of assault, abuse,
battery or neglect) increased from 1970 to 1995.53 In 1996, children under age 18 were
victims in 22% of the violent crimes reported to police. Family members were responsible
for one-fifth of physical assaults and one-third of sexual assaults on children. Parents were
Toward a Healthy Future
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Healthy Child Development
the most likely perpetrators in cases of family-related physical (64%) and sexual (43%)
assaults against children. Fathers were responsible for 73% of physical assaults and 98%
of sexual assaults committed by parents.54
Girls were the victims of reported assaults by family members more often than boys:
victims were female in 80% of sexual assaults and in over 50% of all physical assaults.
Girls and boys were vulnerable to abuse by family members at different stages of their
development. Girls were more likely to be sexually assaulted at 12 to 15 years of age,
compared with 4 to 8 years of age for boys. The likelihood of being physically assaulted
by a family member increased with age for girls, reaching a peak at age 17. For boys, the
peak age for physical assault was 13.55 Young women aged 18 to 24 were the most likely
of all age groups to report being assaulted by a partner.56
Other forms of violence and maltreatment that negatively affect children’s
development include neglect (which has not been well documented or studied), physical
and verbal abuse among siblings, and witnessing spousal violence. The latter appears to
have a strong influence on young people’s subsequent risk behaviours, including substance
abuse and criminal behaviour.57 Children who witness their mother being abused by their
father or by another male partner display higher rates of withdrawal, low self-esteem,
depression and emotional problems. They also tend to have lower school achievement.58
While the main responsibility for protecting children and youth rests with parents,
child welfare agencies are responsible for investigating allegations of mistreatment and
intervening if necessary. As a last resort, these agencies can take children who are at risk
of abuse into public care until they reach adulthood. During the early and mid-1990s,
the number of children in care increased while resources and funding for child protection
initiatives and support services for families were reduced in several jurisdictions.59 Children
and youth in care are particularly vulnerable to stress and instability — often living in
a variety of foster homes. The best approach to prevent children from experiencing this
scenario is for all of society to support parents and families. But at the same time, we must
be vigilant in our efforts to ensure that all children enjoy their right to a safe and secure
environment in which to grow up.60
One study conducted in Toronto found that about two-thirds of street youth had
been physically abused and one-fifth had been sexually abused by someone living with
them. More than half of them (58%) reported that this abuse directly contributed to
their decision to live on the street. Once on the street, young people are exposed to all
kinds of physical violence and sexual exploitation.61
Recently, bullying by older, aggressive children and youth has been recognized as
a serious form of childhood victimization. A 1996 study of 15-year-olds found that half
of boys and one-quarter of girls felt that bullying was a problem.62
Changing Family Structures
Between 1991 and 1996, the number of common-law families increased by 28%, the number
of lone-parent families increased by 19% and the number of married-couple families
increased by 2%. The number of children living in families increased by 6% overall;
however, virtually all of this growth was in common-law and single-parent families.63
Many children whose parents divorce or separate will live with a single parent for a while
and then in a blended family with a stepparent and (often) new siblings.
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Healthy Child Development
The dramatic increase in the number of lone-parent families in Canada, which is
mainly due to parental breakups, can have significant effects on child development. While
the majority of children in lone-parent families are doing well, data from the NLSCY
show that they run a greater risk of poor developmental outcomes, especially if their
parents’ approach to child rearing is hostile or ineffective, if they live in extremely poor
families, or if they live in troubled neighbourhoods. The first of these factors — negative
parenting — seems to have the greatest influence.
The emotional process of separation and divorce has significant social, psychological
and economic consequences for children and parents, especially for women who most
often assume the role of home parent. According to the NLSCY, the movement of children’s
families into and out of lower-income situations was attributable primarily to family
breakdown and reformation.
The Importance of Parenting and High-Quality Child Care
64
According to the NLSCY, positive parenting may decrease the chances of developmental
problems in children. “Positive” parenting was defined as parents who carefully monitored
children’s performance, provided a caring environment and encouraged independence.
These three traits are characterized as an “authoritative” style of parenting, in contrast to
an “authoritarian” style (being overly demanding and lacking warmth) and a “permissive”
style (being overly indulgent and setting few limits).
The 1996–97 NLSCY found that about one-third of parents might be characterized
as “authoritative” and that both positive and negative parenting practices are found in
rich and poor families alike. This suggests that good parenting matters to everyone and
that all parents would benefit from brief training programs to improve their parenting
skills. While more research is needed (due to concerns about methodology), it also suggests
that positive parenting may, to some extent, counteract the negative effects of poverty and
other disadvantages.
The National Forum on Health and other groups have repeatedly pointed out that
parenting capacity is highly affected by wages and working environments. The Vanier
Institute of the Family has calculated that the average Canadian family requires 77 weeks
of paid work to cover basic annual expenses.65 As discussed in Chapter 2, many young
parents have unstable, low-paying jobs. And, since there are only 52 weeks in a year, most
families are thus required to have two wage earners. Meeting the demands of both work
and family is a formidable challenge for working parents, especially women (see Chapter
2). Evidence from the NLSCY suggests that, in addition to positive parenting, several
other factors have a positive effect on children’s behaviour and relationships. These include
supportive neighbourhoods, residential and school stability and access to high-quality
child care while parents are working or studying. Unfortunately, although the number of
families requiring child care while parents work or study has grown in every jurisdiction
over the last decade, operating grants to child-care centres were frozen or decreased in all
but two provinces and one territory between 1990 and 1995.66
67
The Need for Integrated Service Delivery
Both health and social service delivery systems have an important influence on healthy
child development. These sectors have experienced restructuring and cost reductions in
most jurisdictions over the last 10 years.
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Healthy Child Development
Social services, which address both the basic needs of children and youth (including
the need for protection) and aspects of their social and psychological development, may
be particularly vulnerable to budget cuts. While universally insured health services are
available to all children under the Canada Health Act, social services are not.
As revealed in Chapters 2 and 4, many young families are encountering difficult life
circumstances, such as unemployment and changes in family structure, which require
social services like mediation counselling, child welfare services and child care, as well
as related supports such as employment training programs and subsidized housing.
Social services — particularly those that support effective parenting and early development
— also contribute to helping children make a successful transition into the formal
education system.
Recently, there has been a renewed emphasis on finding ways to connect the
contributions of various sectors (e.g. health, social services, education, justice, recreation
and housing) in the common pursuit of healthy child and youth development. There are
numerous benefits to an integrated approach including better coordination of services
and more comprehensive services that respond to both the individual and collective
needs of children and families.
Discussion
This chapter points to the usefulness of a child development framework when examining
the indicators of both health and positive development for Canada’s children and youth.
In the first stage (prenatal to age 18 months), broad, intersectoral strategies are
required to promote positive birth outcomes and to support new parents so that all
babies can make a loving and secure attachment with a parent(s) or other adult caregivers.
Positive parenting and opportunities for early learning are critical to successful development
in the second stage. During the school years, efforts to help children achieve positive social
and behavioural skills and to advance their cognitive development are essential. In the
adolescent period, there is an emerging, clear need to address the social and emotional
well-being of young people.
There are also a number of cross-cutting concerns that affect children in all stages
of development, including socioeconomic status, family transitions (see Chapter 2),
environmental contaminants (see Chapter 4) and family violence.
Overall, this report points to the need to emphasize broad strategies to strengthen
families and healthy child development, which are summarized below.
Invest in the Early Years
As we have seen in this section, healthy child development has its roots in our earliest life
experiences. Investing in prenatal health and the first five years of life is good for children,
and for the economy. Indeed, one study showed that every dollar spent in early intervention
can save seven dollars in future expenditures on health and social spending.68 Despite
this knowledge, governments and communities tend to commit greater financial
investments later in the life cycle, thus missing the most critical time to promote human
competence and potential. Investing in the early stages of life must become a priority.
Toward a Healthy Future
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Healthy Child Development
Reduce Inequities Between Children Living in Different
Socioeconomic Situations
Efforts to improve conditions that maximize all children’s healthy development and
well-being will have a positive impact on all children, especially those living in the
worst socioeconomic conditions. In fact, improving conditions for those living in low
socioeconomic conditions has been shown to help improve conditions for those living
in high socioeconomic conditions. All children require access to nurturing, stimulating,
supportive, caring and safe environments. Children’s rights to these basic determinants
of health are protected under the United Nations Convention on the Rights of the Child,
which was ratified by Canada in 1991. At present, access to these factors differs by
socioeconomic status.
Support Parents and Families
Parents are the most important people in children’s lives and families are the focus of
child rearing. Therefore, it is ironic that so little time is spent preparing young people to
parent. Efforts to give young people and young parents the information and support they
need to parent well are investments in the healthy development of children. Families involved
in the processes of separation and divorce are exposed to high levels of psychological and
economic stress and may require extra help with parenting at this time.
The information in this chapter has demonstrated a consistent link between a mother’s
education and several indicators of a healthy start in life. Investing in the early years of
childhood includes investing in young people, especially young women, before they become
parents. School and community programs are also needed to help young men learn to be
good partners and nurturing parents, and to help them build skills related to fathering.
Enhance the Psychological and Emotional Well-Being of Young People
This chapter, combined with Chapters 1, 2 and 5, shows an emerging and disturbing
picture of the psychological and social well-being of youth in Canada. High rates of
depression and stress and low rates of self-esteem are invariably linked to the broader
picture presented in Chapter 2 of socioeconomic conditions and unemployment among
young people. As they enter a new century, young people in the transition to adulthood
face a very different environment than their parents did. In fact, the natural pattern of
development is changing rapidly. Young people are staying at home and in school longer
because they no longer have a straightforward transition from school to employment.
Easy access to permanent, full-time jobs is a thing of the past. They are coping with more
stresses and at a younger age than the generation before them. Early school leaving and
substance abuse among certain groups are signs of adolescent stress.
Young people are Canada’s leaders in the next century. A comprehensive intersectoral
strategy involving health, education, social services, the private sector and young people
themselves is urgently needed to find effective ways to support the healthy development
of youth in changing times.
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Healthy Child Development
Pay Attention to Gender Differences
When broad strategies for healthy child development are discussed, there often is no
distinction made between the health status, capacities and needs of boys and girls.
Certainly, all children require similar supports to grow up healthy. However, the data
presented in this chapter suggest that a strategy for children must always take into account
the differences in how girls and boys experience the process of development. For example,
reducing injuries and behaviour problems appears to be a priority for boys; reducing
family violence and the early onset of smoking is a priority for girls and young women.
Uphold the Right of Children and Youth to a Safe and Secure
Environment
“Failure to protect the physical, mental and emotional development of children (and
young people) is the principal means by which humanity’s difficulties are compounded
and its problems perpetuated.” This statement from UNICEF’s State of the World’s Children
1990 Report is the fundamental principle underlying the need to protect all of Canada’s
children and youth from abuse, neglect and exploitation and to ensure that they have a
safe and stable home.
Accept and Share Responsibility
The public is highly supportive of efforts to help children meet their full potential and
the health of children is now solidly on the agenda of all governments. But governments
cannot do it alone. It does, indeed, take a whole village to raise a healthy child. Community
action is an important complement to government action. Neighbourhoods must be safe
and supportive of healthy child development. The private sector must also be involved,
since the time/income dynamic has important implications for parenting capacity. When
governments, businesses, communities, families and young people work together, children
and youth have the best chance of growing up to be healthy, productive adults.
Endnotes for Chapter 3
1.
2.
3.
4.
5.
6.
7.
MacMillan, H., Walsh, C., Jamieson, E., et al. “Children’s Health.” First Nations and Inuit
Regional Health Survey. Ottawa: First Nations and Inuit Regional Health Survey National
Steering Committee, 1999.
Hutchcroft, S., Clarke, A., Mao, Y., et al. This Battle Which I Must Fight: Cancer in Canada’s
Children and Teenagers. Ottawa: Supply and Services Canada, 1996.
Canadian Institute for Health Information. Hospital Morbidity Database, 1995–96. Ottawa:
CIHI.
Keating, D., Mustard, J.F. “The National Longitudinal Survey of Children and Youth:
An Essential Element for Building a Learning Society in Canada.” In Human Resources
Development Canada and Statistics Canada. Growing Up in Canada: National Longitudinal
Survey of Children and Youth, 1996 (Statistics Canada Cat. No. 89-550-MPE, No. 1).
Statistics Canada. “Births 1996.” The Daily, July 8, 1998 (Statistics Canada Cat. No. 11-001XIE).
Organisation for Economic Co-operation and Development. OECD Health Data 98
(CD-ROM).
Health Canada, Laboratory Centre for Disease Control, Canadian Perinatal Surveillance
System. Infant Mortality 1998. Based on Statistics Canada. Mortality-Summary List of Causes,
1995. (Statistics Canada Cat. No. 84-209-XPB).
Toward a Healthy Future
91
Healthy Child Development
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Health Canada, Canadian Foundation for the Study of Infant Deaths, Canadian Paediatric
Society, Canadian Institute for Child Health. Joint Statement: Reducing the Risk of Sudden
Infant Death Syndrome in Canada, 1999. Ottawa: Health Canada, 1999.
Wilkins, R. “Mortality by Neighbourhood Income in Canada, 1986 to 1991.” Presented at the
Conference of the Canadian Society for Epidemiology and Biostatistics, St. John’s,
Newfoundland, August 1995.
Health Canada, Medical Services Branch. Health Programs Analysis, First Nations and Inuit
Health Programs. Ottawa: Medical Services Branch, 1996.
Statistics Canada. “Births 1996.” The Daily, July 8, 1998 (Statistics Canada Cat. No. 11-001-XIE).
National Centre for Health Statistics. Health, United States 1998 with Socioeconomic Status
and Health Chartbook. Hyattsville, Maryland: National Centre for Health Statistics, 1998.
Connor, S., McIntyre, L. “How Tobacco and Alcohol Affect Newborn Children.” Presented
in December 1998 at Investing in Children: A National Research Conference, 1998. Based on a
chapter by the same authors to be published in Vulnerable Children in Canada for the Applied
Research Branch, Human Resources Development Canada.
MacMillan, H., Walsh, C., Jamieson, E., et al. “Children’s Health.” First Nations and Inuit
Regional Health Survey.
Single, E., Robson, L., Xie, X., et al. The Costs of Substance Abuse in Canada. Ottawa: Canadian
Centre on Substance Abuse, 1995.
Statistics Canada. National Population Health Survey, 1996–97. Special tabulations.
Connor, S., McIntyre, L. “How Tobacco and Alcohol Affect Newborn Children.”
Statistics Canada. National Population Health Survey, 1996–97.
Statistics Canada, Health Statistics Division. Health Indicators, 1999. (Statistics Canada Cat.
No. 84-214-XPE).
Canadian Council on Social Development. The Progress of Canada’s Children, 1998. Ottawa:
CCSD, 1998: 39.
Ketting, E., Visser, A.P. “Contraception in The Netherlands: The Low Abortion Rate
Explained.” Patient Education and Counselling 23, 3 (1994): 166–71.
Hanson, L., et al. “Breastfeeding as Protection Against Gastroenteritis and Other Infections.”
Acta Paediatricia Scandinavia 74 (1985): 641–2.
Lanting, C., et al. “Neurological Differences Between Nine-Year-Old Children Fed Breast Milk
or Formula Milk as Babies.” Lancet 334 (1994): 1319–22.
Statistics Canada. National Population Health Survey, 1996–97.
Steinhauer, P. “Developing Resiliency in Children from Disadvantaged Populations.”
Determinants of Health: Children and Youth, Volume 1. Canada’s Health Action: Building on
the Legacy, Volume I. National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
Statistics Canada. National Population Health Survey, 1996–97.
Human Resources Development Canada and Statistics Canada. Growing Up in Canada:
National Longitudinal Survey of Children and Youth. Ottawa: HRDC and Statistics Canada,
1996 (Statistics Canada Cat. No. 89-550-MPE, No. 1).
Doherty, G. Zero to Six: The Basis for School Readiness. (# R-97-8E). Ottawa: Applied Research
Branch, Human Resources Development Canada, 1997.
Kohen, D., Hertzman, C., Brooks-Gunn, J. “Affluent Neighbourhoods and School Readiness.”
Presented in December 1998 at Investing in Children: A National Research Conference, 1998.
Based on the research paper Neighbourhood Influences on Children’s School Readiness prepared
by the same authors for the Applied Research Branch, Human Resources Development Canada.
Health Canada. “The Canadian National Report on Immunization, 1996.” Canada
Communicable Diseases Report 1997. Supplement, 23 (1997).
Federal, Provincial and Territorial Advisory Committee on Population Health, Working
Group on Public Health. Issue Paper on Vaccine Preventable Diseases (Immunization
Programs), January 4, 1999.
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Healthy Child Development
32. Doherty, G. Quality Matters: Excellence in Early Childhood Programs. Don Mills: AddisonWesley, 1995.
33. SmartRisk Foundation. The Economic Burden of Unintentional Injury in Canada. Toronto:
SmartRisk Foundation, 1998.
34. King, A., Wold, B., Tudor-Smith, C., et al. The Health of Youth: A Cross-National Survey,
1993–1994. World Health Organization Regional Series: European Series; No. 69. Printed
in Canada, 1997, ISBN 92-890-1333-8.
35. Morrongiello, B. “Preventing Unintentional Injuries among Children.” Determinants of Health:
Children and Youth, Volume 1. Canada’s Health Action: Buiding on the Legacy, Volume I.
National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
36. Ibid.
37. Ross, D.P., Scott, K., Kelly, M.A. “Overview: Children in Canada in the 1990s.” In Human
Resources Development Canada and Statistics Canada. Growing Up in Canada: National
Longitudinal Survey of Children and Youth, 1996 (Statistics Canada Cat. No. 89-550-MPE,
No. 1).
38. Offord, D., Lipman, E. “Emotional and Behaviour Problems.” In Human Resources
Development Canada and Statistics Canada. Growing Up in Canada: National Longitudinal
Survey of Children and Youth, 1996 (Statistics Canada Cat. No. 89-550-MPE, No. 1).
39. Ibid.
40. Jones, M.B., Offord, D.R. “Reduction of Antisocial Behaviour in Poor Children by Nonschool Skill Development.” Journal of Child Psychology and Psychiatry 30 (1989): 737–50.
41. National Literacy Secretariat. Creating a Learning Culture: Work and Literacy in the Nineties.
Ottawa: Minister of Supply and Services, 1990.
42. Canadian Council on Social Development. The Progress of Canada’s Children, 1998. Ottawa:
CCSD, 1998: 42.
43. King, A., Wold, B., Tudor-Smith, C., et al. The Health of Youth: A Cross-National Survey.
44. Ontario Tobacco Research Unit. Cigarette Smoking and Young Women’s Presentation of Self.
Health Canada, 1996 (Cat. H39-366/1996E).
45. Anisef, P. “Making the Transition from School to Employment.” Determinants of Health:
Children and Youth, Volume 1. Canada’s Health Action: Building on the Legacy, Volume I.
National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
46. Connolly, J., Hatchette, V., McMaster, L. “Academic Achievement in Early Adolescence: Do
School Attitudes Make a Difference?” Presented in December 1998 at Investing in Children: A
National Research Conference, 1998. Based on a research paper by the same authors prepared
for the Applied Research Branch, Human Resources Development Canada.
47. National Council of Welfare. Poverty Profile 1996. Ottawa: National Council of Welfare,
Spring 1998.
48. Statistics Canada. “1996 Census: Sources of Income, Earnings and Total Income and Family
Income.” The Daily, May 12, 1998 (Statistics Canada Cat. No. 11-001-XIE).
49. McIntyre, L., Connor, S., Warren, J. “A Glimpse of Child Hunger in Canada.” Presented in
December 1998 at Investing in Children: A National Research Conference, 1998. Based on a
research paper by the same authors prepared for the Applied Research Branch, Human
Resources Development Canada.
50. Ross, D. “Rethinking Child Poverty.” Insight, Perception, 22.1. Ottawa: Canadian Council on
Social Development, 1998: 9–11.
51. The Honourable McCain, M.N., Mustard, J.F. Early Years Study: Final Report. Toronto: Report
from the Reference Group, April 1999.
52. Beiser, M., Hou, F., Hyman, I., et al. “New Immigrant Children: How Are They Coping?”
Presented in December 1998 at Investing in Children: A National Research Conference, 1998.
Based on a research paper of the same name prepared for the Applied Research Branch,
Human Resources Development Canada.
Toward a Healthy Future
93
Healthy Child Development
53. Brink, S., Zessman, A. Measuring Social Well-Being: An Index for Social Health in Canada.
Ottawa: Human Resources Development Canada, June 1997 (Report #R-97-9E). Appendix III
Canadian Social Indicator Data, 1970 to 1995.
54. Statistics Canada, Canadian Centre for Justice Statistics. Assaults Against Children and Youth
in the Family, 1996. Ottawa: Statistics Canada, November 1997 (Statistics Canada Cat. No.
85-002-XPE, Vol. 17, No. 11).
55. Ibid.
56. Statistics Canada. Violence Against Women Survey, 1993. Ottawa: Statistics Canada, 1994.
57. Manion, I., Wilson, S. An Examination of the Association between Histories of Maltreatment
and Adolescent Risk Behaviours. Ottawa: Health Canada, National Clearinghouse on Family
Violence, 1995.
58. Health Canada, National Clearinghouse on Family Violence. Wife Abuse — The Impact on
Children. Ottawa: Health Canada, 1996.
59. Canadian Council on Social Development. The Progress of Canada’s Children, 1997. Ottawa:
CCSD, 1997: 30.
60. Ontario Expert Panel on Child Protection. Protecting Vulnerable Children, 1998. Toronto:
A report to the Minister of Community and Social Services, March 1998.
61. Smart, R.G., et al. Drifting and Doing: Changes in Drug Use among Toronto Street Youth.
Toronto: Addiction Research Foundation, 1992.
62. Canadian Council on Social Development. The Progress of Canada’s Children, 1997: 10.
63. Statistics Canada. “1996 Census: Marital Status, Common-Law Unions and Family
Composition.” The Nation Series, 1997 (Statistics Canada Cat. No. 11-001-XIE).
64. Chao, R., Willms, J.D. “ Do Parenting Practices Make a Difference?” Presented in December
1998 at Investing in Children: A National Research Conference, 1998. Based on a paper to
be published in Vulnerable Children in Canada for the Applied Research Branch, Human
Resources Development Canada.
65. Vanier Institute of the Family. Canadian Families. Ottawa: Vanier Institute of the Family,
1994.
66. Canadian Council on Social Development. The Progress of Canada’s Children, 1998: 29.
67. Health Canada. “Health Services and Social Services.” Healthy Development of Children
and Youth. Ottawa: Health Canada (in press).
68. Montréal Diet Dispensary. 111th Annual Report, 1990–91. Montréal: Montréal Diet
Dispensary, 1991.
Toward a Healthy Future
4
Physical Environment
We do not inherit the land from our fathers,
we borrow it from our children.
— Aboriginal saying.
rom a global perspective, Canadians enjoy a relatively healthy physical
F
environment. We have one of the safest food supplies in the world, the
overall quality of our air and drinking water is good, and the built (or
human-made) environment is generally clean and healthy. The quality of the
Canadian environment, however, cannot be taken for granted. In recent years,
there has been a growing concern that some of the pollutants we release into
our environment will persist and pose a risk to human health. Indeed, in a 1996
survey, almost two out of three Canadians said that their health had been affected
by pollution, and more than one out of two people said they were very concerned
1
about air quality.
At the same time, there is a growing realization that Canada also has a global
responsibility to protect and strengthen the world’s environmental resource base.
Air pollution and other environmental problems aren’t restricted by national
boundaries. Sustaining the health of the planet for future generations is our
ultimate challenge.
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96
Physical Environment
The physical environment is an important determinant of health in its own right.
At certain levels of exposure, contaminants in our air, water, food and soil can cause a
variety of adverse health effects, including cancer, birth defects, respiratory illness and
gastrointestinal ailments. In the built environment, factors related to housing, indoor
air quality, and the design of communities and transportation systems can significantly
influence our physical and psychological well-being.
The physical environment is also linked to other determinants of health. Active living
requires green spaces, clean water and protection from exposure to excessive ultraviolet
rays. Healthy eating depends on the availability of safe, nutritious foods. Healthy working
conditions require safe workplaces that maximize comfort, productivity and well-being.
Healthy child development can be dramatically affected by the physical environment
because children are particularly vulnerable to environmental contaminants.
In a recent review in the Canadian Journal of Public Health, Chaudhuri discussed the
potent mix of poverty, childhood and environmental hazards. “Not only do poor children
generally live in the most polluted parts of cities, they also tend to be less well-nourished,
to live in the poorest quality and most unhealthy housing, and to have parents who work
in the most dangerous and stressful jobs.”2
This chapter begins with a brief discussion of the concept of sustainable development.
It then looks at a selected number of factors in the natural and built environments that
have a significant effect on health. The reader is referred to a number of other sources in
Appendix C for more detailed and comprehensive information than can be covered in
this chapter.
Highlights
From a global perspective, the quality of the physical environment in Canada is
relatively good. However, certain groups of Canadians are affected more than others
by hazards and problems in the physical environment.
◆ Children are more vulnerable to environmental contaminants. Poor children are
particularly likely to be exposed to multiple contaminants as a result of living in
substandard housing and in neighbourhoods adjacent to high transportation
corridors and polluting industries.
◆ The prevalence of childhood asthma, a respiratory disease that is highly sensitive to
airborne contaminants, has increased sharply over the last two decades, especially
among the age group 0 to 5. It was estimated that some 13% of boys and 11% of
girls aged 0 to 19 (more than 890,000 children and young people) suffered from
asthma in 1996–97.
◆ Children and outdoor workers may be especially vulnerable to the health effects
of a reduced ozone layer. Excessive exposure to UV-B radiation can cause sunburn,
skin cancer, depression of the immune system and an increased risk of developing
cataracts.
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Physical Environment
Environmental tobacco smoke (ETS) is a major health hazard in the built environment.
◆ Some 300 Canadian non-smokers die each year from ETS-related lung cancer. Deaths
due to ETS-related heart disease are estimated to be much higher.
◆ Infants and young children are particularly vulnerable to the negative health effects
of environmental tobacco smoke. In 1995, at least 1.4 million children were exposed
to ETS in their homes.
◆ In 1995, municipal bylaws on smoke-free spaces covered 63% of the population of
Canada. The nature of smoking restrictions varied considerably from setting to setting,
and in most commercial settings the lowest levels of restrictions were in place.
Access to affordable, safe housing has become a major concern for many low-income
Canadians.
◆ In 1996, a growing number of Canadians, including 58% of lone-parent families and
59% of older Canadians living in one-person households were spending more than
30% of their income on housing.
◆ As many as 200,000 Canadians were estimated to be homeless or living in substandard
housing. Homeless Canadians included increasing numbers of women and children
and other groups in special circumstances, including adolescents, persons with mental
illness and Aboriginal people.
Sustainable Development and Health
The Report of the World Commission on the Environment defines sustainable development
as “a process in which the exploitation of sustainable resources, the direction of investment,
the orientation of technological development and institutional change are all in harmony
and enhance both current and future potential to meet human needs and aspirations.”3
Thus, sustainable development combines economic, social and environmental goals
and takes into account their effects on health. If our natural and built environments, our
economy and our social structure are not sustainable, then the health of Canadians will
inevitably suffer.
On a global scale, the World Health Organization identifies two broad classes of
environmental threats to health: “traditional hazards” associated with lack of development,
and “modern hazards” associated with unsustainable development. Traditional hazards
related to poverty and insufficient development include inaccessible safe drinking
water, inadequate sanitation in the household and community, indoor air pollution from
cooking and heating, and inadequate solid waste disposal. Modern hazards are related
to development that lacks health and environmental safeguards, and unsustainable
consumption of natural resources. These include climate change, stratospheric ozone
depletion, urban air pollution, water pollution and transboundary pollution.4
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98
Physical Environment
Ecological Footprints
Mathis Wackernagel and colleagues have developed a crude but
useful concept called “the ecological footprint,” which measures
dependence on natural resources to sustain oneself. A nation’s
ecological footprint corresponds to the land and water it uses
to produce the resources it consumes and absorb the waste it
generates. Wackernagel estimates that, globally, approximately
1.7 hectares per capita are available for human use and that this
will decline to approximately 1.0 hectare per capita over the next
30 years. In 1993, the size of Canada’s footprint was estimated
to be 7.0 hectares per capita. In other words, Canadians consume
far more than their share of the world’s precious resources.5
The Natural Environment
This section focuses on six aspects of the natural environment: ozone depletion, climate,
air, environmental toxins, water and food.
Ozone Depletion
Stratospheric ozone acts as a natural filter by shielding the earth’s surface from the sun’s
ultraviolet (UV) rays. Excessive exposure to UV-B radiation may cause sunburn, skin
cancer, depression of the immune system and an increased risk of developing cataracts
in humans.6 Children and outdoor workers may be especially vulnerable to the health
effects of a reduced ozone layer.
Melanoma, an often fatal type of skin cancer, is caused by periods of intense and
intermittent exposure to ultraviolet radiation. The incidence and death rates from melanoma
steadily increased from 1969 to 1985 among women and from 1969 to 1989 among men,
when overall rates started to decline due to reductions among the younger age groups.
In 1999, there were an estimated 3,500 new cases of melanoma and 770 deaths from
melanoma. New cases and deaths among men were about double the rates for women.7
Cataracts were reported by 659,000 Canadians aged 18 and older in the 1996–97
National Population Health Survey (NPHS).
The manufacture and release of ozone-depleting substances (chlorofluorocarbons
or CFCs) used in air conditioning, refrigeration equipment, some fire extinguishers,
solvents and pesticides contribute to the thinning of the ozone layer. In Canada, there
have been substantial fluctuations in measured stratospheric ozone levels over the last
15 years. According to Environment Canada, the levels have ranged from a high of 15%
below pre-1980 levels in 1993, to 6% in 1996 and 2% in 1998.
Canada, along with 150 other countries that signed the 1987 Montreal Protocol, is
making a serious effort to phase out the use of ozone-depleting substances. From 1987
to 1996, new supplies of ozone-depleting substances have fallen from 27.8 kilotonnes to
0.8 kilotonnes.8 However, given the long half-lives of existing CFCs, this problem will
persist into the new millennium.
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Physical Environment
Sun Exposure and Protection
9
Sun Exposure: Most serious sun exposure in Canada occurs during the summer months,
during outdoor work and leisure-time activity. In 1996, a national survey on sun exposure
and protective behaviours found that three out of four summer outdoor workers were
male, and 72% were under 45 years of age. Two out of three outdoor workers (both sexes)
were exposed to the sun for two or more hours per day.
In the general population, 35% of men and 21% of women reported more than
two hours of leisure-time sun exposure per day during the summer months. One out
of two adults were sunburned at least once during the summer months; nearly half were
sunburned while participating in outdoor recreation activities, while one-third were
sunburned while working outdoors.
The highest rates of sun exposure were among children under the age of 12. About
96% of parents said that, on average, their children were exposed to the sun for 30 minutes
or more each day during the summer months. More than one out of two reported sun
exposure of two hours per day or more. Forty-five percent of parents reported that one
or more of their children had a sunburn during the summer months.
Protective Behaviours: Because melanoma and cataracts are long-term outcomes
of excessive sun exposure, dermatologists and other public health authorities advise people
to limit their midday sun exposure. This is especially important for children, whose skin
and eyes may be more susceptible, and who have more years of potential exposure.
When asked about protective behaviours, 72% of adult Canadians said that they
seek shade, avoid the midday sun (66%), use sunscreen on their face (53%), use sunscreen
on their body (42%), wear sunglasses (70%), wear a hat (59%), or wear protective
clothing (67%).
There is substantial room for
Under-Utilized Measures for Reducing
Exhibit 4.1
improvement in efforts to protect children
Children’s Sun Exposure, Canada, 1996
from excessive sun exposure (Exhibit 4.1).
In the 1996 National Survey on Sun
Suncreen-body
11
Exposure and Protective Behaviours, 22%
of parents said that their children rarely or
Sunscreen-face
12
never sought shade or avoided the midday
Wear a hat
12
sun (29%). Parents also reported that their
children rarely or never wore a hat (12%),
Protective clothes
17
did not wear sun protective clothes (17%),
Seek shade
22
rarely or never used sunscreen (11%, 12%),
and did not use sunglasses (60%).
Avoid midday sun
29
60
Use sunglasses
0
10
20
30
40
50
Percentage of parents who say
children rarely or never ...
Source: Statistics Canada. Sun Exposure Survey, 1996. (Statistics Canada
Cat. No. 62M0019XDBGPE).
Toward a Healthy Future
60
100
Physical Environment
Climate
Average global air temperature has risen by about 0.5° C over the past century. As a
northern country, Canada is likely to experience greater temperature changes than most
regions of the world. The impacts of continued global warming are expected to be both
positive and negative. Already, Canada has experienced longer growing seasons, increased
forest yields and record agricultural harvests, as well as an increase in severe weather and
in the frequency and severity of smog episodes. On the global front, possible consequences
of warming also include threats to food security, decreased cold-related illnesses but
increased heat-related illnesses, and the possible emergence of tropical diseases in temperate
climates such as Canada.10
The balance of evidence suggests that greenhouse gases such as carbon dioxide,
methane and nitrous oxide are contributing to the current global warming trend. Much
of the growth in global atmospheric carbon dioxide concentrations is the result of human
activity — in particular, the burning of fossil fuels and deforestation.
As Exhibit 4.2 suggests, global carbon dioxide emissions from fossil fuels have
continued to rise with increasing global energy consumption. Canada ranks second
highest in the world in per capita carbon dioxide emissions and the majority of these
emissions come from the burning of fossil fuels.
CO2 Emissions Per Capita, 1995
Global CO2 Emissions, 1950 to 1995
25
Brazil
1.6
China
2.7
Mexico
20
Billions of tons yearly
Exhibit 4.2
3.9
South Africa
7.4
Japan
9
Germany
10.3
Canada
USA
20.5
5
10
15
10
East Asia
South Asia
5
14.8
0
Industrial countries
15
20
25
0
1950
Latin America & Caribbean
Arab States
Southeast Asia & Pacific
Sub-Saharan Africa
1960
1970
1980
1990
Metric tons yearly
Source: United Nations Human Development Report 1998 (CDIAC 1996: UN 1996 and 1997: UNESCO 1997; World Bank 1997).
New York: Oxford University Press, 1998.
Toward a Healthy Future
1995
101
Physical Environment
Air
Exhibit 4.3
Even though we have reduced the levels
of many air pollutants, evidence suggests
that many Canadians are still adversely
affected. As Exhibit 4.3 shows, the impact
of air pollution on health may vary from
subtle, subclinical effects to hospital
admissions and early deaths. A recent study
published in the Canadian Journal of Public
Health found a substantial increase in
the death rates in 11 Canadian cities when
smog was at its worst. Although rates
varied from city to city, exposure to
ambient air pollution was associated with
an increased risk of premature mortality
in each of the cities studied. The study
concluded that the combined effects of
various pollutants accounted for as much
as one out of every 11 non-accidental
deaths.11
The Health Effects of Air Pollution
Premature
mortality
Severity of effect
Hospital admissions
Emergency room visits
Visits to doctor
Reduced physical performance
Medication use
Symptoms
Impaired pulmonary function
Proportion of population affected
Source: Health Canada. Outdoor Air and Youth Health: A Summary of
Research Related to the Health Effects of Outdoor Air Pollution in the Great
Lakes Basin. 1996: 3. Adopted from the Canadian Respiratory Journal 2, 3
(1995): 155–160.
What Is Smog?
The word “smog” was coined to describe the combination of smoke and fog in the
atmosphere, which is often visible as a brownish yellow haze over urban areas.
Smog is a complex product of vehicle exhaust and industrial pollution that tends
to form during hot, sunny days. Ground-level ozone is the principal ingredient
of smog. Acidic air pollutants are also present.
One of the most common health problems related to airborne contaminants is
asthma — a respiratory disease that affects more than 2 million Canadians.12 Asthma
results in about 49,000 hospital separations and 198,000 in-hospital days each year.13
In addition to the serious impact asthma has on the quality of life of many Canadians,
it poses a heavy burden on the nation’s health-care expenditures.
It is estimated that more than 89,000 Canadian children 0 to 19 years of age
suffer from asthma (approximately 13% of boys and 11% of girls).14 Over half of all
hospitalizations for asthma occur among this age group; the majority are aged 0 to 4.
This young age group has also experienced the greatest increase in hospitalization rates
due to asthma. From 1971 to 1995, the rate increased more than three-fold.15
Toward a Healthy Future
102
Physical Environment
Environmental Toxins
Canadians are concerned about the effect of exposure to toxic substances on their health,
their children’s health and that of future generations, as well as the impact these substances
have on the ecosystem.
All Canadians are exposed to a variety of natural and human-made toxic substances.
The nature and degree of exposure vary significantly from region to region and with
varying eating habits.16 Children are more vulnerable to environmental contaminants
because of their rapid growth and metabolic immaturity. Their greater food, air and fluid
intake relative to body weight makes them especially vulnerable to excessive exposure levels
of contaminants that might have less profound health consequences among adults. As
well, they are just beginning a lifetime of exposure to cumulative environmental hazards,
the likes of which no other generation has experienced.
Another area of emerging concern is the possible effect of certain chemicals known
as endocrine disrupters, which resemble human hormones. Some scientists suggest that
there is a link between specific chemicals or chemical mixtures and disruptions in female
and male reproductive functions and/or the occurrence of certain cancers.17 Further
research is needed before such links can be demonstrated or ruled out.
Water
In Canada, the overall quality of our drinking water remains high. About 87% of
Canadians receive treated municipal drinking water, and Canada has one of the lowest
incidences of waterborne diseases in the world.18
The incidence of waterborne diseases is several times higher in First Nations
communities than in the general population, in part because of inadequate or non-existent
water treatment systems. The Assembly of First Nations, in partnership with Health Canada,
is taking steps to improve this situation.19
Keeping Canada’s natural water resources clean for both human consumption and
recreational use remains a basic priority for population health. While there has been a
concerted effort to correct past abuses in areas such as the Great Lakes and St. Lawrence
basins, other water sources continue to come under pressure from industrial and municipal
pollution, landfill leachates, agricultural run-off and inadequately treated sewage.20
Food
Food security is one of the essential prerequisites for health identified in the Ottawa
Charter for Health Promotion.21 In 1996–97, 6% of Canadians (approximately 1.5 million)
reported that, at some point during the previous year, their household had run out of
money and couldn’t buy food. Of these, more than one out of four (27% or approximately
400,000 Canadians aged 12 and over) said that they had received food from a food bank,
soup kitchen or other charitable agency, and 62% (910,000) said that they did not always
have enough food to eat.
Low-income households were the most likely to report running out of food (28%),
receiving food from a food bank or other organization (10%) and not always having
enough food to eat (21%). Among single parents, 18% of women and 8% of men reported
Toward a Healthy Future
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Physical Environment
that they had run out of food during the previous year; 7% of lone-parent women and 3%
of lone-parent men reported not always having enough food to eat; and 4% of women,
as well as 3% of men, reported using a soup kitchen or other organization.22
A 1998 report from the Canadian Association of Food Banks showed that the number
of Canadians using food banks more than doubled between 1989 and 1998, and the
number of communities with food banks more than tripled during that time. The report
also stated that in 1998, more than 250,000 children and young people under age 18 were
recipients of food banks. Although children and youth made up only one-quarter of Canada’s
population that year, they represented 42% of the people who depended on food banks.23
This finding is in keeping with the increase in the number of low-income families (see
Chapter 2) and with the 1996–97 NLSCY results on child hunger (see Chapter 3).
Food shortages appear to be a serious problem in certain Aboriginal communities.
According to the Aboriginal People’s Survey conducted in 1993, 8% of all respondents
over 15 years of age reported food availability as a problem during the previous year. The
percentage was highest among Inuit people (13%). In total, 8% of all Indians living on
reserve and 9% of Indians living off reserve reported food availability as a problem.24
In terms of quality, Canadians are blessed with one of the safest food supplies in the
world. According to Health Canada’s Market Basket Surveys, the levels of contaminants
to which Canadians are exposed in their food are far below national and international
guidelines.25
An interesting example of the complex interactions between food, culture and
the environment was reported in a recent study related to mercury contamination in
First Nations communities. This study suggested that the presence of environmental
contaminants can have profound effects on the way of life of Aboriginal communities
beyond the physical health risks posed by the contaminants themselves. Many Aboriginal
communities view human health within a model that embodies physical, emotional,
intellectual and spiritual well-being. Thus, a food advisory in an Aboriginal community
can mean far more than removing a certain food from one’s diet. A quote from the report
makes the point most eloquently: “Inuit foods give us health, well-being and identity. Inuit
foods are our way of life. For us to be fully healthy, we must have our foods, recognizing
the benefits they bring. Contaminants do not affect our souls. Avoiding our food from
fear does.”26
Any discussion of food resources in Canada is bound to bring to mind the tragic
loss of the cod stocks in Atlantic Canada, and more recently the reduction of salmon
stocks in British Columbia. The failure to ensure sustainability of these precious food
stocks has had a devastating effect on the economic status and way of life of Canadian
families and communities whose livelihoods depend on fishing. The sustainable
management of natural food sources will continue to be a challenge in the next
millennium.
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104
Physical Environment
The Built Environment
Most Canadians spend more time indoors than outdoors. We are as much a part of our
built environment as we are part of our natural environment. The built environment
includes our homes, schools, workplaces, parks, business areas and roads. It extends
overhead in the form of electric transmission lines, underground in the form of waste
disposal sites and subway trains, and across the country in the form of highways. This
section looks at three aspects of the built environment: tobacco smoke as a key
contaminant in indoor air quality, transportation and affordable housing.
Environmental Tobacco Smoke
Health Canada has estimated that more than 300 Canadian non-smokers die each
year from lung cancer caused by exposure to environmental tobacco smoke (ETS).27
The number who die from heart disease as a result of ETS is likely much higher, since
researchers have estimated that at least 10 times the number of non-smokers die from
ETS-related heart disease than from ETS-related lung cancer.28
Many municipalities now have restrictions on smoking in public settings in an effort
to protect the health of both smokers and non-smokers. In 1995, municipal bylaws on
smoke-free spaces covered 63% of the population of Canada. The nature of smoking
restrictions imposed by municipalities varied from the lowest level of restriction
(designated, unventilated smoking areas) to the highest level of restriction (total ban
with an explicit provision for enforcement). In commercial settings (such as restaurants
and shopping malls), the most common requirements were designated, unventilated
smoking areas.29
There were significant interprovincial
variations
in municipal smoking restrictions.
Percentage of Daily Smokers* with at Least
The population covered by bylaws ranged
Exhibit 4.4
One Child (Under Age 15) Who Permit Smoking
from 3% in Newfoundland to 81% in
in the Home, by Province, Canada, 1995
Ontario. For most provinces, municipal
bylaw coverage was greater in 1995 than
Prince Edward Island (numbers too small)
in 1991, with the exception of Manitoba,
18
British Columbia
where coverage actually decreased during
25
Ontario
that time.30
27
CANADA
Pregnant women, fetuses and young
29
Alberta
children are particularly susceptible to the
29
Quebec
effects of ETS, which include complications
30
Manitoba
33
of pregnancy and low birthweight, increased
Nova Scotia
33
risk of sudden infant death syndrome and
Saskatchewan
34
ear infections, reduced lung development,
Newfoundland
36
and increased severity of asthma and other
New Brunswick
31
5
0
10 15 20 25 30 35 40 respiratory illnesses.
In 1995, at least 1.4 million Canadian
Percentage of daily smokers
children were exposed to ETS in their homes.
The majority of these children lived with
* Smokers aged 15+ who live in a home in which smoking is permitted.
parents aged 25 to 44 — the age group that
Source: Statistics Canada. General Social Survey 1995 (Cycle 10), special
smokes the greatest number of cigarettes
tabulations from the Housing, Family and Social Statistics Division.
Toward a Healthy Future
105
Physical Environment
daily. Level of education was directly linked with the chance that daily smokers would
observe some form of smoking restriction in the home — the more educated the smoker,
the greater the chance of restrictive smoking behaviour.32
On a provincial basis (Exhibit 4.4), about one-third of daily smokers in New
Brunswick, Newfoundland, Saskatchewan and Nova Scotia potentially exposed at least
one child to ETS. Daily smokers in Quebec who did not live in a home where smoking
was restricted potentially exposed a minimum of 491,000 children to ETS in the home,
representing the largest group out of all of the provinces.
A study of smoke-free workplaces in 1994 showed that 26% of male employees and
11% of female employees worked in environments in which there were no restrictions on
smoking. Workers in Quebec were most likely to be in workplaces that allowed smoking
“anywhere” (30%) or “in most places” (13%).33
Transportation
Most Canadians enjoy a high degree of mobility and personal freedom, thanks primarily
to the automobile. In 1993, there were more than 12 million cars in Canada, almost one
for every two people. This love affair with the automobile, however, comes with a price.
The widespread and frequent use of cars reduces air quality. Traffic congestion creates
stress and car crashes can wound and kill. Motor vehicle crashes account for nearly half of
all accidental deaths in Canada each year. They are the third leading cause of death overall
and the most common cause of death for children and young people under age 35.34
Walking and cycling are two of the most popular forms of alternative transportation.
Many Canadian drivers say that they would walk and cycle more if street and community
designs were more favourable to these practices.35 Since the majority of Canadians are
insufficiently active to achieve health benefits, increased support for active forms of
transportation would benefit individual health as well as collective air quality.
According to the 1996 Census, 73% of working Canadians drove their own automobile
to work; 7% travelled as a passenger in a private vehicle; 10% used some form of public
transportation; 7% walked to work; and 1% bicycled.
Men were more likely to drive to work (79%) than were women (67%); women were
more likely than men to travel to work as a passenger, by public transportation, or on
foot. Men (1.6%) were slightly more likely than women (0.6%) to report riding a bicycle
to work.
Affordable, Adequate Housing
The Ottawa Charter for Health Promotion recognizes adequate shelter as a basic
prerequisite of health. A number of physical factors in the home environment can have
a negative influence on health, including a lack of access to piped water and sanitary
facilities, high levels of noise, poor indoor air quality, inadequate refuse storage and
collection facilities, overcrowding, poor lighting, building defects and pests.36 In 1991,
the Canada Mortgage and Housing Corporation reported that one in five Canadians
who paid rent lived in inadequate or unsuitable housing.37 In 1993, Aboriginal people
often reported poor housing as a major problem. Inadequate housing and crowded living
conditions may be factors in increased rates of respiratory infections and other infectious
diseases in Aboriginal children, compared with non-Native children.
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Physical Environment
From 1991 to 1996, the number of Canadians who owned a house increased by
10%. But at the same time, shelter became less affordable for many other Canadians.
From 1991 to 1996, average shelter costs for owners decreased by approximately 1%,
while their average household incomes declined by 5%. Among renters, average shelter
costs declined by 3%, while average household incomes declined by 12%. Young Canadians
were particularly hard hit. Among young people under the age of 30, average household
incomes declined by more than 17%, while rent declined by less than 5%. As a consequence,
during that period, a full 43% of renters had a housing affordability problem — that is,
more than 30% of their income was spent on shelter, as compared with 17% of owners.38
In 1996, 27% of couples without children who rent had an affordability problem.
This increased to 30% among couples with children, to 51% among one-person households,
to 58% among lone-parent families, and to an incredible 76% among lone-parents under
the age of 30. Very high rates of affordability problems (59%) also were experienced by
Canadians aged 65 and over living in one-person households.39
These findings reflect the growth in number of young low-income families in Canada
in the early 1990s (see Chapter 2). At the same time, decreases in government spending on
social housing forced a growing number of families with children to seek accommodation
in the private marketplace where housing may be more expensive or of poorer quality than
subsidized non-profit housing.40
Homelessness
No condition demonstrates the importance of adequate housing for health better than
the problem of homelessness. Homeless people have a range of chronic health problems
due to their extreme poverty, lack of stable housing and exposure to the elements on the
street. They are less likely to receive adequate medical care and more likely to draw heavily
upon emergency medical services.41
The causes of homelessness are complex. They include poverty, changes in the housing
market, reductions in social assistance, family violence, substance abuse and changing
mental health services. As a result, the face of the typical homeless Canadian has changed;
the composition of this group now includes increasing numbers of women and children
and other groups in special circumstances, such as adolescents, persons with mental
illness and Aboriginal people.42 A review by Beavis cites these factors as well as
socioeconomic marginalization, poor housing and severely depressed conditions on
reserve and in remote communities as major risk factors in Aboriginal homelessness.
The author also notes that “the majority of runaways and street youth in Pacific cities
are Aboriginal people, with more females than males.”43
Although estimating the total number of homeless people is difficult, as early as 1986,
130,000 to 200,000 Canadians were estimated to be homeless or living in substandard
housing,44 and there is compelling evidence that this number has been increasing. For
example, several groups have estimated that in Toronto alone, 25,000 people were
homeless in 1996 — double the number in 1994. The Good Shepherd Hostel reported a
30% increase in people using its shelter between 1995 and 1996; and the Metro Children’s
Aid Society reported a 33% increase in households sharing accommodation and a 52%
increase in families in shelters over the same period.45
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Physical Environment
A 1998 Environics’ survey showed strong public support for action on homelessness.
More than 80% of respondents disagreed with the statement “homelessness really only
harms the people who are homeless themselves; there is no real cost to the rest of society.”
More than 80% agreed that “the homeless population is changing and now includes
more young people, women and families than used to be the case.” And, more than one
out of two Canadians endorsed the notion that “governments should spend more on
preventing homelessness, even if the money must come out of other areas or possibly
from increased taxes.”46
A 1996 review of the literature by
Percentage Reporting Environmentally-Inspired
Novac concluded that homelessness and
Exhibit 4.5
Actions in the Past Year, Aged 18+, Canada,
violence are inextricably linked for women.
1997–98
Novac noted that “homeless women with
Urged policy
histories of family disruption and abuse
13
changes
distinguish being housed from being
safe, so that homelessness is a problem
Expressed concern
15
for women, but it also is a strategy for
Based vote
27
escaping violence. The relationship
on policy
between violence and homelessness
Supported
28
among women is complex, since there
environmental group
is also a great risk of violence when
Gathered
51
information
women are homeless.”47
A recent study by Caputo and
Avoided a product
59
colleagues concluded that street youth
are a heterogeneous group, and that the
50
60
0
30
10
20
40
magnitude of the problem continues
Percentage
to be subject to debate. They note that
“involvement in the street lifestyle can
Source: Environics Research Group Ltd. The Environmental Monitor, 1998,
include participation in illegal activities
Cycle 1.
such as stealing, shoplifting or breaking
and entering … A major reason for involvement in such activities is to acquire the
resources needed to meet basic needs while living on the street. In addition, participation
in the street lifestyle involves alcohol and other drug use, participating in high risk sexual
activities and facing the hazards of living in marginal circumstances. These hazards
include violence and other threats to a person’s physical and emotional well-being.”48
What Canadians Are Doing
In addition to taking up active forms of alternative transportation, in 1997–98, large
numbers of adult Canadians reported taking a range of other actions to preserve their
physical environment or to protect their health against perceived environmental hazards.
Among ongoing actions to preserve the environment, recycling and/or composting —
reported by 88% of Canadians — were the most common, while 64% of Canadians
bought environmentally sensitive products and 69% reported that they used energy-saving
devices. In each of these areas, action was reported more frequently by women than by
men, and by highly educated Canadians, particularly those with university degrees.49
Toward a Healthy Future
108
Physical Environment
Exhibit 4.5 shows how Canadians are increasingly inclined to make a political or
public statement about their environmental concerns. Over half of all adults (59%)
claimed to have avoided certain consumer products for environmental reasons in the
previous year, while many others gathered information about environmental issues
(51%) and/or voted for or against political candidates or parties because of their stand
on environmental issues (27%).
Individual action is reinforced and complemented by the many collective efforts of
Canadians to improve and protect the environment in their communities, and to support
group efforts to preserve certain aspects of the physical environment. In 1997–98, 28%
of Canadians said that they supported an organized environmental group.
Discussion
Sustainable Development
In terms of creating and sustaining physical environments that promote health, the
greatest challenge we face is to create a more sustainable society. Sustainable development
calls for a balanced approach in which economic vitality, environmental integrity, human
development and social well-being are all considered and equally weighed when decisions
are made. This balance must be achieved not only in a Canadian context, but also globally.
Encouraging Canadians and Canadian institutions to “think globally and act locally” is
still a good strategy.
The Natural Environment
In the natural environment, reducing fossil fuel emissions is an immediate and long-term
priority. Fossil fuel combustion is believed to be a major cause of both climate change
and air pollution. The two problems are also related from a health perspective. As the
global climate warms, air pollution and smog production will worsen, resulting in further
increases in respiratory illnesses and deaths.
The Kyoto Protocol of December 1997 established emission reduction targets for the
year 2012. Canada agreed to reduce its greenhouse emissions by 6% below 1990 levels
between the years 2008 and 2012. The health and quality of life of Canadians and others
will benefit greatly from the immediate and long-term implementation of intersectoral
strategies to increase energy efficiency and reduce fossil fuel emissions. Reducing air
pollution will also reduce the billions of dollars lost in early deaths and spent on health
services to treat asthma and other respiratory diseases.
The Built Environment
Within the built environment, air quality is seriously compromised by environmental
tobacco smoke which takes a large toll on health, especially the health of children.
Concerted action on this issue needs to continue.
The data reported in this chapter suggest that Canada is experiencing a housing
affordability crisis. As family incomes and support for social housing have dropped in
many jurisdictions, housing costs have remained high, especially for renters. One of the
quickest and most direct ways to decrease the inequities discussed throughout this report
is to increase access to affordable housing for all Canadians. Working with Aboriginal
Toward a Healthy Future
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Physical Environment
people both on and off reserve to ensure that housing is adequate in both quantity and
quality must be a top priority.
There is also a growing number of Canadians who believe that homelessness in one
of the world’s richest countries is a national and community disgrace that should be rectified.
A recent study that looked at predictors of entry into shelters and subsequent housing
stability for a cohort of families in New York City showed that subsidized housing was the
best predictor of residential stability after shelter living. The odds of stability were 21 times
greater for families who received housing subsidies than for those who did not. Compared
to the availability of affordable housing, mental or physical health problems did not
appreciably cause family homelessness or impede later stability.50
This study suggests that a reinvestment in social housing by all levels of government
is an important strategy for ameliorating the current crisis in both housing affordability
and homelessness. It may also be one of the best ways to prevent homelessness in the
first place.
As this chapter shows, Canadians have demonstrated a growing interest in and concern
about issues related to the physical environment and its link to health. Policy-makers and
leaders who are managing health risks in the environment need to be sure that the public
is both informed and involved in the decision-making process. At the same time, groups
working on different but related issues need to be encouraged to collaborate and build
stronger alliances in the pursuit of common goals. As we have seen in this report so far,
child health, environmental protection, consumer information and income distribution
are inextricably linked.
While there are many unanswered questions concerning the physical environment,
two areas stand out as particularly important for further research efforts. The first is a need
to answer some broad questions related to the effects of environmental contaminants and
changes on human health, especially as they relate to the health of children.
At the 1997 G-8 Denver Summit, the Declaration on Children’s Environmental Health
(of which Canada is an official signatory) identified seven areas of concern that require
further study and information sharing in terms of policy and program solutions:
• increasing our understanding of the particular exposures and sensitivities of infants
and children to environmental contaminants and exchanging information on relevant
regulatory decisions and standards
• further reducing maternal and child exposure to lead
• ensuring microbiologically safe drinking water for all Canadian families
• reducing air quality threats
• reducing the exposure of pregnant women, children and youth to environmental
tobacco smoke
• reducing threats to children’s health from endocrine-disrupting chemicals
• reducing the impact of global climate change on children’s health.51
The second related area for investigation concerns the potential impacts of
environmental endocrine-disrupting chemicals on human reproduction functions. The
recently announced Toxic Substance Research Initiative will help address this issue.52
Toward a Healthy Future
110
Physical Environment
Endnotes for Chapter 4
1.
Environics Research Group Ltd. The Environmental Monitor, 1997, Cycle 4. Toronto:
Environics, 1997.
2. Chaudhuri, N. “Child Health, Poverty and the Environment: The Canadian Context.” In
What on Earth? A National Symposium on Environmental Contaminants and Children’s
Health. Canadian Journal of Public Health 89, Supplement 1 (1998): 26–30.
3. United Nations. Environmental Perspective to the Year 2000 and Beyond. New York: United
Nations, 1987.
4. World Health Organization. Health and Environment in Sustainable Development: Five Years
After the Earth Summit. Geneva: World Health Organization, 1997.
5. Wackernagel, M., Onisto, L., Linares, A.C., et al. Ecological Footprints of Nations: The Rio+5
Forum Study. Mexico: Universidad Anahuac de Xalapa, 1997.
6. World Health Organization. The Sundsvall Handbook. From the Third International
Conference on Health Promotion, Sweden, June 9–15, 1991.
7. National Cancer Institute of Canada. Canadian Cancer Statistics, 1999. Toronto: National
Cancer Institute of Canada, 1999.
8. Health Canada. Health and Environment: Partners for Life. Ottawa: Minister of Public Works
and Government Services Canada, 1997.
9. Statistics Canada. Sun Exposure Survey, 1996. (Statistics Canada Cat. No. 62M0019XDBGPE).
10. Last, J., Guidotti, T., Hertzman, C., et al. Implications of Global Change for Human Health. The
Royal Society of Canada, 1995.
11. Burnett, R., Cakmak, S., Brook, J. “The Effect of Urban Air Ambient Pollution Mix on Daily
Mortality Rates in 11 Canadian Cities.” Canadian Journal of Public Health 89, 3 (1998): 152–6.
12. Statistics Canada. National Population Health Survey 1996–97.
13. Health Canada, Laboratory Centre for Disease Control, Unpublished tabulations, 1998.
14. Statistics Canada. National Population Health Survey 1996–97.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Health Canada, Laboratory Centre for Disease Control, Unpublished tabulations, 1998.
Health Canada. Health and Environment: Partners for Life.
Chaudhuri, N. “Child Health, Poverty and the Environment: The Canadian Context.”
Health Canada. Health and Environment: Partners for Life.
Ibid.
Organisation for Economic Co-operation and Development. Environmental Performance
Reviews: Canada. Paris: OECD, 1996.
World Health Organization, Health and Welfare Canada, Canadian Public Health
Association. Ottawa Charter for Health Promotion, 1986.
Statistics Canada. National Population Health Survey 1996–97. Special tabulations.
Canadian Association of Food Banks. Hunger Count 1998: A Report on Emergency Food
Assistance in Canada. Ottawa: CAFB, 1998.
Statistics Canada. “Language, Tradition, Health, Lifestyle and Social Issues.” Aboriginal Peoples
Survey, 1991. Ottawa: Statistics Canada, 1993.
Health Canada. Health and Environment: Partners for Life.
Gilman, A., Dewailly, E., Feeley, M., et al. Canadian Arctic Contaminants Assessment Report.
Ottawa: Department of Indian Affairs and Northern Development, 1997.
Makomaski Illing, E., Kaiserman, M. “Mortality Attributable to Tobacco Use in Canada and
Its Regions, 1991.” Canadian Journal of Public Health 86, 4 (1995): 257–65.
Toward a Healthy Future
111
Physical Environment
28. U.S. Department of Health and Human Services, U.S. Environmental Protection Agency.
Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders. Washington:
U.S. Environmental Protection Agency, 1993.
29. Health Canada. Smoking Bylaws in Canada, 1991. Ottawa: Health Canada, Environmental
Health Directorate, 1992.
30. Stephens, T., and Associates, Goss Gilroy Inc. A Survey of Smoking Policies in Various Settings
in Canada. Ottawa: Health Canada, 1997.
31. U.S. Department of Health and Human Services. Preventing Tobacco Use among Young People:
A Report of the Surgeon General. Atlanta: U.S. Public Health Service, Centers for Disease
Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health, 1994.
32. Statistics Canada. General Social Survey, Cycle 10: The Family, 1995. Special tabulations
calculated by the Housing, Family and Social Statistics Division.
33. Health Canada. Survey of Smoking in Canada, Cycle 2, 1994. Fact Sheet #7. Health Canada,
1994.
34. Transport Canada. Motor Vehicle Traffic Collision Statistics, 1997. Ottawa: Transport Canada,
1999. See Transport Canada Web site: www.tc.gc.ca/roadsafety/Stats/stats96/st96tote.htm
35. Statistics Canada. “1996 Census: Labour Force Activity, Occupation and Industry, Place of
Work, Mode of Transportation to Work, Unpaid Work.” The Daily, March 17, 1998.
36. World Health Organization. Health and Environment in Sustainable Development: Five Years
After the Earth Summit.
37. Toronto Coalition Against Homelessness. One Is Too Many: Findings and Recommendations
of the Panel of Public Enquiry into Homelessness and Street Deaths in Toronto. Toronto:
Coalition, May 25, 1996.
38. Statistics Canada. “1996 Census: Private Households, Housing Costs, and Social and
Economic Characteristics of Families.” The Daily, June 9, 1998.
39. Ibid.
40. Canadian Council on Social Development. The Progress of Canada’s Children, 1998. Ottawa:
CCSD, 1998: 26.
41. Novac, S., Brown, J., Bourbonnais, C. No Room of Her Own: A Literature Review on Women
and Homelessness. 1996. See CMHC Web site:
www.cmhc-schl.gc.ca/Research/Homeless/F_women.html
42. Canadian Public Health Association. Position Paper on Homelessness and Health. Ottawa:
CPHA, 1997.
43. Beavis, M., Klos, N., Carter, T., et al. Literature Review: Aboriginal People and Homelessness.
1997. See CMHC Web site: www.cmhc-schl.gc.ca/research/homeless
44. Begin, P. Homelessness in Canada. Current Issue Review. 89-8E. Ottawa: Minister of Supply
and Services, 1994 (Statistics Canada Cat. No. YM32-1/89-8-1994-09E).
45. Toronto Coalition Against Homelessness. One Is Too Many: Findings and Recommendations
of the Panel of Public Enquiry into Homelessness and Street Deaths in Toronto.
46. Environics. Survey of Canadians’ Attitudes Toward Homelessness: June 1996, March 1997
and March 1998. Survey Results. 1998. See CMHC Web site:
www.cmhc-schl.gc.ca/research/homeless/F_ public.html
47. Novac, S., Brown, J., Bourbonnais, C. No Room of Her Own: A Literature Review on Women
and Homelessness.
48. Caputo, T., Weiler, R., Anderson J. The Street Lifestyle Study. Ottawa: Health Canada, 1997
(Cat. No. H39-382/1997E).
49. Environics Research Group Ltd. The Environmental Monitor, 1998, Cycle 1. Toronto:
Environics, 1998.
Toward a Healthy Future
112
Physical Environment
50. Shinn, M., Weitzman, B., Stojanovic, D., et al. “Predictors of Homelessness among Families in
New York City: From Shelter Request to Housing Stability.” American Journal of Public Health
88, 115 (November 1998): 1651–7.
51. Editors. “1997 Declaration of the Environmental Leaders of the Eight on Children’s
Environmental Health.” In What on Earth? A National Symposium on Environmental
Contaminants and Children’s Health. Canadian Journal of Public Health 89, Supplement 1
(1998): 5–8.
52. Health Canada and Environment Canada. Toxic Substances Research Initiative. See Health
Canada Web site: www.hc-sc.gc.ca/main/hc/web/ehp/ehd/tsri/index.htm
Toward a Healthy Future
5
Personal Health Practices
“There is today, greater recognition that the socioeconomic environment plays
an important role in influencing individual lifestyles.”
— Canadian Public Health Association, Health Impacts of Social and Economic
Conditions: Implications for Public Policy, 1997.
A
broad range of personal health practices influences the health of
Canadians. However, there is a growing recognition that personal life
“choices” are greatly influenced by the socioeconomic environments in
which people live, learn, work and recreate. This chapter examines eight personal
health practices: alcohol and tobacco use, illicit drug use, selected safety practices,
sexual behaviours that increase risk for sexually transmitted diseases, HIV testing,
physical activity, healthy eating and gambling. Trends in body weight — to a large
extent the result of physical activity and eating practices — are also reported here.
Efforts Canadians make to protect themselves and their children from excessive
sun exposure are discussed in Chapter 4. Information on the effects of income,
education and other broad determinants on personal health practices is provided
when it was available.
Toward a Healthy Future
114
Personal Health Practices
Highlights
Many Canadians are making impressive efforts to improve their health.
◆ Almost half of the Canadian population aged 12 and older reported changing some
behaviour to improve their health in the year before the 1996–97 National Population
Health Survey.
◆ Overall, smoking rates have dropped impressively among Canadians aged 15 and over
— from 47% in 1970 to 30% in 1990. Since then, there has been some fluctuation,
but no clear trend in overall smoking rates.
◆ There has been an impressive decline over the past 20 years in fatal motor vehicle
crashes, attributable at least in part to increases in seatbelt use and reductions in
impaired driving.
Nevertheless, there remains considerable room for improvement in personal health
practices. Considering the stresses on young people observed in other chapters, it is not
surprising that adolescents and young adults are particularly vulnerable to negative
health practices.
◆ Rates of smoking have increased substantially among adolescents and youth,
particularly among young women, over the past five years. Rates of smoking among
young women aged 12 to 19 remain substantially higher than among young men.
◆ Smoking rates among Aboriginal people are double the overall rate for Canada as a
whole. The age of onset for the use of tobacco, alcohol and other drugs is substantially
younger for Aboriginal children than for children in the population as a whole.
◆ Multiple drug use — particularly the combination of alcohol, tobacco and cannabis
— among high school students has increased substantially, at least in all regions that
have been surveyed.
◆ Multiple risk-taking behaviours, including such hazardous combinations as alcohol,
drug use and driving, and alcohol, drug use and unsafe sex, remain particularly high
among young people, especially young men.
◆ The proportion of overweight men and women in Canada increased steadily between
1985 and 1996–97 — from 22% to 34% among men and from 14% to 23% among
women.
◆ Rates of physical activity drop quickly as age increases and there are large differences
between males and females. In the 12 to 14 age group, 54% of boys and 33% of girls
were active in their leisure time. By age 20 to 24, the percentage who were active
dropped to 39% among males and 22% among females.
◆ In 1994–95, 51% of sexually active 15- to 19-year-old women who had more than one
sex partner and 29% of sexually active young men in the same age group reported
that they had had sex without a condom in the past year. Among 20- to 24-year-olds,
53% of sexually active women and 44% of men reported having had sex without a
condom during the previous year.
Toward a Healthy Future
115
Personal Health Practices
Injection drug use (IDU) and its relationship to HIV infection and hepatitis C is a
major concern.
◆ In 1997, 20% of adult AIDS cases were attributed to injection drug use, compared with
less than 2% prior to 1990 and 5% in 1993.
◆ Injection drug use is believed to be associated with perhaps 70% of hepatitis C virus
infections.
Trends in Health Practices
Almost half the Canadian population aged 12 and older reported changing some behaviour
to improve their health in the year before the 1996–97 National Population Health Survey.
A slightly larger proportion reported that some future change was needed. Women were
more likely than men to report changes in the past year, to recognize the need for changes
and to intend to make those changes in the coming year. Women and men who recognized
the need for change were most likely to say that more exercise was the personal health
practice that was most needed. A lack of time and will were cited as the main barriers
to making lifestyle changes.
Behaviour changes were reported most often in Ontario (50%) and least often in
Saskatchewan (39%).1
Physical Activity
Lack of physical activity is recognized as
a significant risk factor for coronary heart
disease and other serious health problems.
Conversely, active living provides many
health benefits including a reduced risk
of cancer, diabetes, heart disease and
osteoporosis, and an enhanced feeling
of well-being.2
Surveys have shown a substantial
increase in Canadians’ levels of leisure-time
physical activity between 1981 and 1995.3
During 1996–97, 21% of Canadians aged
12 and over were classified as physically
active during their leisure time; another
23% were moderately active, while more
than half (57%) were inactive. These rates
are similar to those of 1994–95, when
58% of Canadians were classified as
physically inactive. As Exhibit 5.1 shows,
men continued to report higher rates
of physical activity and lower rates of
sedentary behaviour than women at
all ages. The data reveal that, after
Exhibit 5.1
Leisure-Time Physical Activity Levels, by Age
Group and Sex, Canada, 1996–97
Men
Women
Total all ages
Ages 75+
Ages 65–74
Ages 55–64
Ages 45–54
Ages 35–44
Ages 25–34
Ages 20–24
Ages 18–19
Ages 15–17
Ages 12–14
80 70 60 50 40 30 20 10 0
0 10 20 30 40 50 60 70 80
Percentage
Percentage
Inactive
Moderate
Active
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
116
Personal Health Practices
NPHS Definition
◆
In the National Population Health Survey (NPHS), level of activity is classified
by assigning estimated kilocalories used per kilogram of body weight per day:
active = 3.0 or more, moderate = 1.5 to 2.9, inactive = less than 1.5.
age 18, there was a significant drop in
activity levels for young men. The number
Exhibit 5.2
of girls and women who were active declined
progressively from adolescence on.
70
An analysis of the 1994–95 NPHS
62
60 59 62
59
showed
that non-European immigrants
60
58
54
53
were particularly likely to have been inactive
51
50
in their leisure time (67%), regardless of
48
their length of time in Canada. By contrast,
40
the proportion of immigrants from European
30
countries who reported inactive leisure
varied from 59% of recent to 51% of
20
long-term immigrants (less than among
Canadian-born citizens.)4
10
In the 1996–97 NPHS, the highest
0
rates
of leisure-time physical activity were
Lowest
Middle
Highest
reported by men and women with the
Low middle
Upper middle
highest incomes. As shown in Exhibit 5.2,
Income level
only 48% of men in the highest income
bracket were physically inactive, compared
Men
Women
with 53% of Canadian men in the lowest
income bracket. Among women with high
Source: Statistics Canada. National Population Health Survey, 1996–97.
incomes, 51% were physically inactive,
compared with 60% of women with the
lowest income level. Lower-income Canadians may be more likely to have jobs that involve
physical labour, and this may affect their need or desire to engage in leisure time physical
activity. But there are other barriers to participation relating to income, including the
costs of equipment and user fees for participation in recreational activities. Further
research is needed on the links between income and participation in physical activity.
According to the Canadian Fitness and Lifestyle Research Institute, only one-third of
Canadian children and youth are physically active enough to meet the optimal standards
for healthy development. One of the reasons for this may be the cost of participating in
sports and recreation. In 1995, nearly half of families with incomes below $20,000 per
year cited high costs as a reason for not participating in physical activities compared with
one-third of families earning $60,000 per year or more.5
Percentage
Percentage of Canadians Who Are Not
Physically Active During Leisure Time,
by Sex and Income Level, Aged 12+, 1996–97
Toward a Healthy Future
117
Personal Health Practices
Healthy Eating
Percentage
Diet in general and the consumption of fat in particular are linked to some of the major
causes of death, including cancer and coronary heart disease. However, little data exist
on the actual dietary intake of Canadians.
In the 1994–95 NPHS, 45% of men and 47% of women rated their eating habits as
excellent or very good; 16% of both men and women described their eating habits as fair
or poor. Canadians with low incomes were more likely to describe their eating habits as
fair or poor than those in upper income brackets.
Dietary fat was a source of concern for many Canadians: 59% of persons aged 12
and over said they were concerned about fat in their diet and claimed to be taking action
to reduce their consumption of fat. Two-thirds of women (67%) reported taking action
to reduce dietary fat, compared with 50% of men. Similarly, one-third of women (32%)
reported making efforts to increase carbohydrates and fibre in their diets, compared with
about one in five men (20%).
Low-income Canadians were more
Percentage of Canadians Who Believe That
likely to express concerns about the cost
Exhibit 5.3
Low Fat Foods Are Expensive, Aged 12+, by
of low-fat foods than were high-income
Income Level, 1994–95
Canadians. As Exhibit 5.3 shows, 40%
of Canadians in the lowest income
40
40
40
bracket believed that low-fat products
37
were expensive, compared with 32%
34
35
32
of Canadians with the highest incomes.
30
Similarly, 27% of low-income Canadians
believed that grain products were
25
expensive, compared with only 8%
20
of Canadians with high incomes.6
Healthy Weights
15
10
While body weight is not a personal health
5
practice, it is, to a large extent, determined
0
by eating and physical activity practices.
Lowest
Middle
Highest
Body weights above the healthy weight
Low middle
Upper middle
range (i.e. a Body Mass Index over 27)
Income level
are linked to a variety of health problems,
Source: Statistics Canada. National Population Health Survey, 1994–95.
including cardiovascular disease, diabetes
and some forms of cancer. Body weights
below the healthy weight range (i.e. a Body Mass Index under 20) may also be a sign
of current or impending health problems, including the eating disorders anorexia
and bulimia.7
Toward a Healthy Future
118
Personal Health Practices
Percentage of Underweight* and Overweight
Canadians (Ages 20–64),** by Sex, 1985 to
1996–97
Exhibit 5.4
35
Overweight men
30
Overweight women
Percentage
25
20
15
* BMI < 20 (self-reported)
Underweight women
10 ** BMI > 27 (self-reported)
Underweight men
5
0
1985
1990 1991
1994–95 1996–97
Note: BMI refers to Body Mass Index.
Source: General Social Survey Cycles 1 (1985) and 6 (1991); Health Promotion
Survey (1990); and National Population Health Surveys, 1994–95 and 1996–97,
special tabulations.
Percentage of Men and Women Who Smoke
Cigarettes, Aged 15+, Canada, 1970 to 1996–97
Exhibit 5.5
60
Percentage
50
40
Men
Total
Women
30
20
10
0
1970
1974
1978
1983 1986
1990 1994–95 1996–97
Source: Pederson, L. Smoking. In Health Promotion Survey 1990: Technical
Report; and Statistics Canada. National Population Health Surveys, 1994–95
and 1996–97, special tabulations.
A number of surveys (Exhibit 5.4) have
shown that the proportion of overweight
men and women in Canada increased steadily
between 1985 and 1996–97 — from 22%
to 34% among men and from 14% to 23%
among women. In 1996, the problem of
excess weight was particularly pronounced
among men and women aged 45 to 64. Men
in this age group (58%) were much more
likely than women (37%) to be overweight.
The chances of being overweight decreased
with each successive level of education.
Income was also a factor; being overweight
was most common among adults in lowincome groups.8
The increasing prevalence of excess body
weight is a trend that has been observed in
many developed countries.9 Dietary changes
and decreases in daily physical activity levels
as well as the aging of the baby boomers have
been cited as the most likely reasons for this
trend, but further study is required.
As shown in Exhibit 5.4, in the 1996–97
NPHS, women (14%) were nearly five times
more likely than men to be underweight
(3%). The problem of low body weight
remained most pronounced among women
age 20 to 24, among whom one out of
four were below the healthy weight range.
Despite the substantially higher proportion
of overweight men in Canada, women (40%)
were still more likely than men (23%) to
report recent attempts at weight loss. This
desire to lose weight extended to many
women who were already within the healthy
weight range.
Little information is available on
attempts to gain weight. However, concerns
have been raised about young males trying
to gain weight and muscle bulk through the
use of steroids and other substances.10
Toward a Healthy Future
119
Personal Health Practices
Tobacco Use
Percentage of Men and Women Who Smoke
Cigarettes, by Age Group, Canada, 1996–97
Exhibit 5.6
40
38
36
31
31
29
30
Percentage
37
36
34
35
30
31
25
25
26
22
21
20
20
15
15
10
10
13
9
6
5
0
35–44
15–17
20–24
55–64
75+
12–14
18–19
25–34
45–54
65–74
Age
Women
Men
Source: National Population Health Survey, 1996–97.
Percentage of Men and Women Who Smoke
Cigarettes, by Income Level, 1996–97
Exhibit 5.7
40
40
36
35
35
31
30
Percentage
Studies over time (Exhibit 5.5) have shown
that overall, smoking rates have dropped
impressively among Canadians aged 15 and
over — from 47% in 1970 to 30% in 1990.
Since 1990, there has been some fluctuation,
but no clear trend in smoking rates. The
success of public health campaigns to reduce
smoking rates, however, have not been equally
successful with all population groups. Three
groups — young women and women and
men with low-income status — lag behind.
In the 1996–97 NPHS, 30% of Canadian
men and 25% of women aged 12 and over
reported being daily or occasional smokers.
This represents a slight decline from 1994–95
when 31% of men and 28% of women
reported smoking cigarettes. The rate of
smoking among men exceeded the rate for
women in every age group — with the
exception of youth aged 12 to 17 (Exhibit
5.6). Continuing a trend observed in
1994–95, the rate of smoking among girls
aged 12 to 14 (10%) and 15 to 17 (29%)
remained substantially higher than among
young men of the same age (6% and 22%
respectively).11
Rates of smoking varied substantially
by income level, with the highest rates of
smoking reported by men (40%) and women
(36%) in the lowest income bracket. As
Exhibit 5.7 shows, smoking decreased to a
low of 16% and 13% among men and women
in the highest income bracket.12
The highest rates of smoking in Canada
are reported by Aboriginal people, about
double the overall rate in the Canadian
population as a whole. In 1997, adult smoking
rates within the Aboriginal population were
highest among young people aged 20 to 24
(72%) and 25 to 29 (71%) (Exhibit 5.8). The
use of smokeless tobacco by Aboriginal youth
in the Northwest Territories and northern
Saskatchewan also poses a significant health
problem.13
28
25
24
25
20
20
16
15
13
10
5
0
Low middle
Lowest
Middle
Upper middle
Highest
Income level
Men
Women
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
120
Personal Health Practices
In 1994–95, recent non-European
immigrants were significantly less likely
than the Canadian-born population to
80
smoke (Exhibit 5.9). For all immigrants,
72 71
the number who smoke generally increased
67
70
62 60
with the length of time in Canada. Unlike
59
60
for the Canadian-born population, there
54
48
was no clear association between smoking
50
and income status.14
37 35
40
There was little increase in the rate
30
of
smoking
among adolescents and youth
23
from 1994–95 to 1996–97. However, data
20
from provincial surveys of students suggest
10
that the major increases in youth smoking
0
occurred somewhat earlier, attributable at
25–29 35–39 45–49 55–59 65–74
least in part to the availability of low-cost
20–24 30–34 40–44 50–54 60–64
75+
smuggled cigarettes, and the subsequent
roll-back in tobacco taxes and prices. Data
Age
from Ontario, for example, suggest that
Source: Reading, J. “The Tobacco Report.” First Nations and Inuit Regional
rates of smoking among students in grades
Health Survey, 1997.
7, 9, 11, and 13 increased sharply from 1991
to 1997. In 1991, 22% of both male and female students reported smoking at least one
cigarette during the previous year. By 1997, this had increased to 28% among boys and
29% among girls.15
Percentage of Aboriginal Adults Who Smoke
Cigarettes, by Age Group, 1997
Percentage
Exhibit 5.8
Exhibit 5.9
Prevalence of Smoking by Immigrant Status,
Duration of Residence and Sex, Canada, 1994–95
Current Smokers
Men
Women
Long-term non-European
immigrants
Recent non-European
immigrants
Long-term European
immigrants
Recent European
immigrants
Long-term non-European
immigrants
Recent non-European
immigrants
Long-term European
immigrants
Recent European
immigrants
All immigrants
All immigrants
Canadian-born
Canadian-born
0
5
10
15
20
25
30
35
40
Age-adjusted percentage
Regular
0
5
10
15
20
25
30
35
Age-adjusted percentage
Occasional
Regular
Occasional
Source: National Population Health Survey, 1994–95. Published in Chen, J., Ng, E., Wilkins, R. ( Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.” Health Reports 7, 4 (Spring 1996): 42.
Toward a Healthy Future
40
121
Personal Health Practices
In Nova Scotia, rates of smoking among students in grades 7, 9 and 11 increased
significantly from 26% in 1991 to 36% in 1998 (34% among boys and 38% among girls).
Rates reported in surveys in the other Atlantic provinces during 1998 were similar,
ranging from 27% in Prince Edward Island to 33% in New Brunswick, and 38% in
Newfoundland.16
Use of Alcohol
Percentage
While the moderate use of alcohol is not harmful for some people, excessive use can
lead to a range of health and social problems, including motor vehicle crashes involving
impaired drivers. According to Transport Canada, there were 3,082 motor vehicle traffic
deaths in 1996 — an impressive decline from the 5,253 traffic deaths in Canada two
decades earlier. There has also been a significant decline in the number of fatally injured
impaired drivers over the past 20 years. Nevertheless, the rate of alcohol involvement in
fatal traffic crashes remains unacceptably high. Among fatally injured drivers, 35% were
legally impaired; the number of innocent victims who were injured or killed was not
available for this report.17
According to the NPHS, in 1996–97, 53% of Canadians (63% of men and 43% of
women) drank alcohol at least once per month — a slight decrease from 1994–95. Women
were more likely to be non-drinkers than men. Men (42%) were more likely than women
(21%) to report consuming five or more drinks on at least one occasion during the past year
— a commonly used indicator of “heavy” or “binge” drinking. There are differences in how
alcohol affects men and women, however, so the consumption of less than five drinks by
women could be interpreted as heavy (problematic) drinking among women.
In the 1996–97 NPHS, the proportion
of men and women who drank at least
Percentage of Canadians Who Had 5+ Drinks
Exhibit 5.10 at Least Once in the Past Year, by Income Level
once per month rose steadily with increases
and Sex, 1996–97
in income. Men and women with higher
incomes also tended to be heavier drinkers.
50
Among men in the two lowest income
43
levels and who were drinkers, 24%
40
37
reported at least one episode of heavy or
“binge” drinking, compared with 43% of
29
30
men in the highest income bracket. The
24
24
rate of heavy drinking among women
19
drinkers in the lowest income level was
20
14
13%. This dropped to 10% at the next
13
12
10
income level, then slowly climbed to 19%
10
at the highest income level (Exhibit 5.10).
This is due in part to the fact that lower
0
income Canadians are less likely than
Low middle
Middle high
upper income Canadians to consume any
Lowest
Middle
Highest
alcohol at all. However, among lower
Income level
income Canadians who did drink alcohol
during the previous year, their rate of heavy
Men
Women
drinking tended to slightly exceed that
of higher income earners.
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
122
Personal Health Practices
Percentage
According to the 1996–97 NPHS, among Canadians who have a driver’s licence and
consume alcohol, 10% admitted to driving after consuming “too much” alcohol. Men (13%)
were much more likely than women (5%) to report driving after drinking. The highest
rate of driving after drinking (18%) was reported by young drivers aged 18 and 19.
Canadians with low incomes were less
likely than Canadians with high incomes to
Exhibit 5.11 Percentage of Canadians Who Drove After
drink and drive. As Exhibit 5.11 shows, only
Drinking, by Income Level and Sex, 1996–97
6% of men and 2% of women in the lowest
income level reported driving after drinking,
14
compared with 14% of men and 4% of
14
women with the highest incomes. This is
12
in keeping with the fact that low-income
11
Canadians drink less overall and are also
10
9
less likely to own cars.
8
Alcohol use, underage drinking, heavy
6
drinking and alcohol-related problems
6
5
among young people remain a persistent
4
4
concern. And there are disturbing indications
3
from provincial surveys that rates linked
2
2
2
2
to these behaviours and problems may be
increasing. For example, the Nova Scotia
0
Low middle
Middle high
Student Drug Use Survey reported that
Lowest
Middle
Highest
57% of students drank alcohol in 1998 —
an increase of 12% from 1991. Similar rates
Income level
of drinking were reported by students in
the other Atlantic provinces (Prince Edward
Men
Women
Island, 53%; New Brunswick, 56%;
Newfoundland, 58%) and in Ontario (60%).18
Source: Statistics Canada. National Population Health Survey, 1996–97.
In Nova Scotia, 21% of Grade 7 students
and 58% of Grade 9 students (the vast
majority of whom are below the legal drinking age) reported drinking alcohol in the
previous year.19 Similarly, in Newfoundland and Labrador, 20% of Grade 7 students and
59% of Grade 9 students reported drinking alcohol. In Ontario, 32% of Grade 7 students
and 56% of those in Grade 9 reported drinking during the previous year.20
Motor vehicle traffic crashes are a leading cause of death among young people
in Canada. In Nova Scotia, 8% of students admitted to driving a motor vehicle within
an hour of consuming two or more alcoholic drinks. More than one out of four students
(27%) had been passengers in a motor vehicle with a driver who had had “too much to
drink,” and 10% of students had driven a motor vehicle within one hour of using a drug
(other than alcohol or tobacco).21
Illicit Drug Use
Generally, the reported use of illicit drugs in Canada is low: in the 1994–95 NPHS, less
than 1% of Canadians used crack cocaine, LSD or speed. Seven percent of Canadians
(1.7 million) reported the use of marijuana. Use of illicit drugs was highest among young
people and especially among those with some post-secondary education — presumably
current students in many cases.
Toward a Healthy Future
123
Personal Health Practices
Recent surveys of students in Ontario and the Atlantic provinces show that the use
of cannabis has been increasing. In 1997, one out of four Ontario students (25%) reported
using cannabis in the previous year — an increase from 12% in 1991.22 Rates reported in
surveys in the Atlantic provinces were similar and often higher, including rates of 22% in
Prince Edward Island, 30% in Newfoundland and 31% in New Brunswick. The use of
cannabis by students in Nova Scotia has dramatically increased — from 17% in 1991 to
38% in 1998.23
Disturbing Trends in Substance Use and Abuse
In addition to a major concern about increased tobacco use among adolescent women,
three other trends deserve special attention: increasing rates of HIV infections among
injection drug users, a resurgence in multiple drug use among adolescents, and the high
rates of substance use by young children in Aboriginal communities.
Injection drug use and increases in HIV infection
Percentage
Toward a Healthy Future
Number
Since the early 1980s when HIV infection was concentrated in the population of men who
have sex with men, the Canadian picture has continued to evolve. In 1996, approximately
half of the estimated 3,000 to 5,000 HIV infections that occurred in Canada were among
injection drug users.24
The proportion of AIDS cases
attributed to injection drug use
Exhibit 5.12 Number of Annual IDU AIDS Cases Diagnosed and
Percentage of All Known AIDS Cases, 1983 to 1997
(IDU) increased until 1996 and then
decreased slightly in 1997, likely due to
25
200
the availability of new, more effective
treatments and perhaps due to decreased
20
reporting completeness (Exhibit 5.12). For
150
men, the percentage of IDU-related cases
15
of AIDS increased from 0.7% before 1988,
100
to 2.4% between 1988 and 1992, and to
10
6.5% between 1993 and 1997. For women,
the percentage increased from 4.1% to
50
14.7% and finally to 24.9% for the same
5
25
time periods.
The HIV epidemic among injection
0
0
drug users is well documented in Canada’s
1984 1986 1988 1990 1992 1994 1996
largest cities. For example, the prevalence
1983 1985 1987 1989 1991 1993 1995 1997
of HIV infection among injection drug
Years of diagnosis
users in Vancouver increased from about
4% in 1992–93 to 23% in 1996–97; in
Percentage of all AIDS cases
Montreal, it increased from about 5%
prior to 1988 to 19.5% in 1997. The
Number of IDU AIDS cases (reporting adjusted daily)
problem, however, is now being seen
Note: IDU means “injection drug use.”
outside major urban areas as well. Given
Source: Health Canada. HIV/AIDS, Epi Updates, May 1998.
the geographic mobility of injection drug
124
Personal Health Practices
users and their social and sexual contact with non-users, there is an urgent need to deal
with this problem in Canada’s large cities as well as in areas outside the major urban
centres, including Aboriginal communities.26
In addition to contributing to the onset of AIDS, IDU is also the major mode of
transmission of hepatitis C in Canada. Injection drug use is now the major risk factor
for the hepatitis C virus (HCV) accounting for perhaps 70% of all HCV infections.27
Increasing use of multiple drugs among adolescents
After a period of decline during the 1980s, the 1990s have seen a resurgence in adolescent
drug use (based on data gathered from regions that have been surveyed). Between 1993
and 1995, the use of eight of 20 drugs increased significantly in Ontario.28 Nova Scotia
also reported significant increases in the use of 12 different drugs by students between
1991 and 1998: alcohol, cigarettes, cannabis, LSD, non-prescription stimulants, prescription
stimulants, psilocybin or mescaline, non-prescription tranquilizers, cocaine or crack, PCP,
heroin and inhalants.29
Student use of a combination of alcohol, tobacco and cannabis has increased
substantially in all regions that have been surveyed. In Nova Scotia, for example, the
percentage of students reporting use of all three of these drugs increased from 12% in
1991 to 25% in 1998;30 in Newfoundland, the percentage increased from 18% to 23%
during the same time period.31
Substance use by young children in some Aboriginal communities
While much attention has been focused on adolescent substance use in both Aboriginal
and non-Aboriginal communities, one of the most disquieting facts about addiction in
some Aboriginal communities is the alarming rate of substance use by young children.
Studies continue to show that the age of onset for the use of tobacco products, alcohol,
solvents and cannabis is substantially younger for Aboriginal children than for children
in the population as a whole, and that Aboriginal children are entering Canadian
treatment facilities at younger ages.32 In the 1993 report of Aboriginal Peoples in Urban
Centres, 67% of participating Friendship Centres reported that children were consuming
alcohol and sniffing solvents during school hours, after school, on the streets and in their
homes.33
Use of Safety Equipment for Injury Prevention
Safety equipment has proven successful in preventing several types of unintentional
injuries. Common examples include:
• safety belts for automobiles
• helmets for motorcycles, bicycles, all-terrain vehicles, and snowmobiles
• flotation devices (PFDs, lifejackets) for watercrafts
• smoke detectors for protection against house fires and smoke inhalation
• child-proof container lids on medication and other potentially hazardous products
to prevent poisoning.
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125
Personal Health Practices
Percentage
As documented in annual drowning reports of the Canadian Red Cross Society from
1993 to 1998, among victims of boating drownings, wearing rates for flotation devices
were only about 10%. For Aboriginal victims, wearing rates were lower — about 5%.
Even among drowning victims who were non-swimmers or weak swimmers, wearing
rates were equally low.34
Unlike the situation for safety belts in cars where wearing of the belt is mandatory,
the law does not require boaters to wear a flotation device. Since most boating drowning
incidents involve either sudden unanticipated falls into water or capsizes and swampings
under adverse conditions, many boaters who are not wearing a flotation device at the
moment of the incident are unable to find one, put it on, and rescue themselves.35
At present, all Canadian provinces have mandatory seatbelt legislation. In 1998, a
roadside survey by Transport Canada found that 89% of vehicle occupants were wearing
seatbelts. The highest rates of seatbelt usage were in Quebec (92%), Saskatchewan (90%)
and British Columbia (90%); all 10 provinces achieved wearing rates of more than 82%.
In the Yukon Territory, 82% of vehicle occupants were found to be wearing seatbelts, but
the rate dipped to 53% in the Northwest Territories.
Among drivers of passenger cars, the rate of seatbelt use was 92%, an increase from
82% a decade earlier. Prior to seatbelt legislation in Canada, only an estimated 15% to
30% of Canadians wore seatbelts. These results, together with the impressive reduction
in motor vehicle fatalities in Canada, reflect
the profound influence that legislative
Percentage of Canadians Aged 12+ Who Always
Exhibit 5.13 Wear a Helmet When Riding a Bicycle, by
action outside of the health sector can
Income Level, 1996–97
have on the health of Canadians.36
In the 1996–97 NPHS, 29% of
40
Canadians aged 12 and over reported
40
always wearing a helmet when riding a
35
bicycle. Women (31%) were slightly more
30
likely than men (28%) to report use of a
30
25
25
helmet. The rate of helmet use was highest
25
22
among those aged 12 to 14 (40%), but
20
plummeted to its lowest level (15%)
among youth aged 15 to 19.
15
Two of the most powerful determinants
10
of bicycle helmet use are income and
5
provincial legislation. Among Canadians
in the lowest income group, 25% reported
0
Low middle
Middle high
always using a helmet when riding a bicycle,
Lowest
Middle
Highest
compared with 40% of Canadians in the
highest income group (Exhibit 5.13).
Income level
Recently, three provinces (British
Source: Statistics Canada. National Population Health Survey, 1996–97.
Columbia, Nova Scotia and Ontario) enacted
legislation involving the use of bicycle
helmets. As shown in Exhibit 5.14, rates of helmet use were substantially higher in these
three provinces. Fifty-three percent of British Columbians, 37% of Nova Scotians and
33% of Ontarians reported always wearing a helmet when they ride their bicycle. By
contrast, in provinces without comparable legislation (where sufficient data were available),
helmet wearing rates varied from a high of 26% in Alberta to a low of 12% in Manitoba.
Toward a Healthy Future
126
Personal Health Practices
Exhibit 5.14
Percentage of Canadians Aged 12+ Who Always
Wear a Helmet When Riding a Bicycle, by Province,
1996–97
Gambling
Percentage
Government-regulated casinos and video
lottery terminals (VLTs), introduced in the
1990s, have turned gambling into a multi60
billion dollar industry in Canada. In 1997,
53
Canadians wagered $6.8 billion on some
50
form of government-run gambling activity
37
40
— 2.5 times the amount wagered in 1992.
33
Gambling profits increased in every
30
province and in both territories over the
26
21
past five years, and now account for
19
20
between 1% (British Columbia) and 4%
12
(Manitoba) of total government revenues
10
in each province.37
In 1996, the majority of households
*
*
0 *
in
Canada
(82%) gambled some money,
NF PEI NS NB QC ON MB SK AB BC
spending an average of $423 during the
*Small sample size.
year. Among households that gambled,
Source: National Population Health Survey, 1996–97.
those with incomes of less than $20,000
spent an average of $296, or about 2.2% of their total household income. Those with
$80,000 or more spent $536, only 0.5% of their total income.38
While gambling may be a harmless pastime for some people, problem gambling has
deleterious effects on the well-being of individuals and families. The nature and extent of
problem gambling is only beginning to be documented in Canada. However, a 1997–98
Nova Scotia study of video lottery terminal (VLT) players showed cause for concern. This
study concluded that 16% of those who play VLTs on a regular basis could be considered
“problem VLT gamblers.” This group of gamblers contributes just over one-half of the
net revenue for video lottery gambling. For the most part, these adults report significant
guilt and anxiety, as well as difficulties in coping and feeling at a loss as to how to control
their VLT gambling.39
A study of students in Nova Scotia showed that three out of four students (75%)
participated in gambling activities during the previous year. About 2% of students reported
that betting money caused them problems and 2% stated that they would like to stop
betting but do not think they can.40
Sexual Practices
In addition to unplanned pregnancies, unsafe sexual behaviours can lead to serious
conditions such as sexually transmitted diseases (STDs), infertility and HIV infection.
HIV infection can be prevented by practising safe sex, which entails the use of a condom
during any form of insertive intercourse or the adoption of non-insertive forms of sexual
interaction that avoids person-to-person transfer of body fluids which may harbour HIV
(for example, semen, vaginal fluid and blood).
Toward a Healthy Future
127
Personal Health Practices
HIV Testing
In 1996–97, 15% of men and 15% of
women aged 18 and over reported in the
NPHS having had an HIV test at some
point in their lives. Adults aged 25 to 34
were most likely to have had an HIV test.
Exhibit 5.15
Percentage of Sexually Active 15- to 24-Year-Olds
Who Never or Sometimes Used a Condom in
the Past Year, by Age Group and Sex, Canada
(Excluding Territories), 1994–95
60
Percentage
50
53
51
44
40
29
30
20
12
10
0
15–19
20–24
Age group
Females
Males
Source: Galambos, N., and Tilton-Weaver, L. “Multiple-Risk Behaviour in
Adolescents and Young Adults.” Health Reports 10, 2 (Autumn, 1998).
(Data based on 1994–95 NPHS).
Exhibit 5.16
Percentage of Sexually Active 15- to 24-Year-Olds
with at Least Two Sex Partners, Who Did Not Use
Condoms in the Past Year, by Age Group and Sex,
Canada (Excluding Territories), 1994–95
25
21
21
20
17
Percentage
In the 1994–95 NPHS, among sexually
active 15- to 19-year-olds (excluding those
with a single sex partner and who were
married, in a common-law relationship,
divorced or widowed), 51% of females
and 29% of males reported having had sex
without a condom in the past year. Among
youth aged 20 to 24, 53% of sexually active
females and 44% of sexually active males
reported having had sex without a condom
during the previous year (Exhibit 5.15).41
Twenty-one percent of sexually active
males aged 20 to 24 reported that they had
multiple sexual partners and did not use
condoms in the past year, as did 17% of
females aged 20 to 24, 21% of females aged
15 to 19 and 15% of males aged 15 to 19
(Exhibit 5.16).42
Findings from the four-province
Atlantic Student Drug Use Survey (1998)
were consistent with these results. The
Atlantic study found that 26% of Grade 9
students, 37% of Grade 10 students and
58% of Grade 12 students had sexual
intercourse during the previous year.
Among sexually active students, 40% had
more than one sexual partner. Fifty percent
of sexually active students had unplanned
intercourse on at least one occasion when
under the influence of alcohol or another
drug. Condoms were not consistently used,
particularly among older students.43
15
15
10
5
0
15–19
20–24
Age group
Females
Males
Source: Galambos, N., and Tilton-Weaver, L. “Multiple-Risk Behaviour in
Adolescents and Young Adults.” Health Reports 10, 2, (Autumn, 1998).
(Data based on 1994–95 NPHS).
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128
Personal Health Practices
An in-depth analysis of sexual health practices in 1997 revealed that among
Canadians who reported having two or more sexual partners in the past year and not
using condoms consistently, 53% of men and 38% of women had never been tested.
This finding suggests that substantial numbers of Canadians may be HIV-positive, but
unaware of their infection.44
Multiple Risk Behaviours
Risk behaviours generally emerge during adolescence and have important implications
for both the immediate and future health of Canada’s young people. While most youth
experiment with at least one potentially risky behaviour, a minority engage in several. As
noted in references to the recent Atlantic student surveys, certain combinations can be
particularly hazardous, such as alcohol, illicit drug use and impaired driving; or alcohol,
other drug use and unsafe sexual practices.
A recent analysis based on the 1994–95 NPHS that examined multiple risk behaviours
by youth aged 15 to 24 focused on smoking, binge drinking, sex with multiple partners
and sex without a condom. Males were somewhat more likely than females to engage in
multiple risk behaviours. Among males, 32% reported no risk behaviours; 26% engaged
in one risk behaviour; two risk behaviours were reported by 24% of males and 19%
reported engaging in three or four risk behaviours. Among females (also aged 15 to 24),
39% reported engaging in none of the four risk behaviours; 28% reported one risk
behaviour; 19% reported two risk behaviours and 14% engaged in three or four of these
behaviours.45
The patterns of risk behaviour differed as well. Among females who engaged in a
single risk behaviour, nearly half reported binge drinking and about one-third reported
smoking. Among single-risk males, binge drinking was by far the most typical risk
behaviour — reported by 80%. The most common two-risk combination for both sexes
was smoking and binge drinking. However, among males, almost as many reported the
combination of binge drinking and unsafe sex.46
Young Canadians: A Summary of Personal Health Practices
(Unless otherwise noted, the source of the information presented in this section is the
1996–97 NPHS.)
Adolescence and early adulthood are times when young people make important decisions
related to sexuality, physical activity, nutrition and the use of alcohol, tobacco and
other drugs. As we take a closer look at these years, we find significant differences in
behaviours among young and older teens and those in their early 20s, and between
males and females.
Physical activity: Rates of leisure-time physical activity dropped quickly as age increased,
and there were large differences between males and females:
Percentage who are classified as “active” in their leisure time
Age
Males
Females
12 to 14
54%
33%
15 to 17
53%
31%
18 and 19
39%
26%
20 to 24
32%
22%
Toward a Healthy Future
129
Personal Health Practices
A Summary of Personal Health Practices
… continued
Smoking: Rates of smoking are higher among young women aged 12 to 17 than young
men in the same age group. In the age group 18 to 24, men are more likely to smoke
than women.
Healthy weights: Young women were more likely than young men to be concerned
about their weight. In 1994, 28% of girls aged 12 to 14, 38% of those aged 15 to 19,
and 43% of those aged 20 to 24 were trying to lose weight. Over half of the women
in the age group 20 to 24 who were trying to lose weight were already within the
healthy weight range.47
Healthy eating: Among 15-year-olds, only 39% of girls and 40% of boys ate whole wheat
bread once a day or more; 25% of girls and 32% of boys ate candy or chocolate bars
once a day or more.48 Forty-eight percent of young women but only 19% of young
men aged 15 to 19 reported that they were taking action to reduce dietary fat.
Drinking: The amount of alcohol consumed at one time increased with age for both
genders. After age 18, young men drank significantly more than young women. At
ages 18 and 19, young women were slightly more likely than young men to drive
after drinking; after age 20 this pattern was dramatically reversed.
Age
12
15
18
20
to 14
to 17
and 19
to 24
Percentage of drinkers who drank five
or more drinks on at least one occasion
Percentage who
drove after drinking
Male
Female
Male
Female
16%
53%
71%
71%
15%
46%
59%
60%
—
—
17%
23%
—
—
19%
9%
Bicycle helmet use: While 12- to 14-year-olds were the most likely of all age groups
to wear a bicycle helmet (40%), young people aged 15 to 19 were the least likely
to wear one (15%).
Sexual practices: Among sexually active young people (aged 20 to 24), 48% reported
that they never or sometimes used condoms in the past year. In the age group 15
49
to 19, 40% reported inconsistent or non-use of condoms.
Multiple risk behaviours: Young men were more likely than young women to report
multiple risk-taking behaviours. While smoking and binge drinking was the most
common combination for both sexes, almost as many young men reported binge
drinking combined with unsafe sex.50
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Personal Health Practices
Discussion
Influences on Personal Health Practices
This chapter has demonstrated that income, education and culture, in some circumstances,
have a powerful influence on personal lifestyle “choices.” This suggests that information,
health education and efforts to teach personal behaviour change skills are not enough. It
also suggests that Canadians with low incomes need access to the resources and supports
available to higher-income Canadians when it comes to active living, healthy eating and
other personal health practices.
This chapter also illustrates the efficacy of broad policy and legislative approaches that
change the environment around individuals. For example, increases in smoking behaviour
among young people after taxes on cigarettes were reduced substantiate the well-known
fact that youth tobacco use is extremely price sensitive.51 The success of seatbelt (and, to
some extent, bicycle helmet) legislation suggests that legislative strategies may be as effective
as (and possibly even more effective than) health education in supporting behavioural
change. Probably a combination of strategies would be most effective.
Priorities for Action
As shown in Chapter 1, lung cancer cases and deaths due to lung cancer among women
continue to increase. The trend toward increased smoking among girls in Canada
foreshadows an epidemic of lung cancer in women 30 years from now, as well as
substantially increased rates of heart disease if present rates continue. Why have strategies
to reduce and prevent smoking among young people been less effective with girls than
with boys? What are the factors in the surrounding environment that cause young women
to smoke? What is the relationship between smoking, physical activity and young women’s
desire to be thin? It is time to ask these questions to young women themselves and to work
with them to devise comprehensive strategies to reduce smoking behaviour.
While preventing smoking initiation altogether is most desirable, delaying the onset
of smoking (for both sexes) has also been shown to be an important strategy. Starting to
smoke at an early age (e.g. 15 or younger) is associated with heavy smoking and a lower
probability of quitting in later life.52 Thus, efforts to prevent or delay the initiation of
smoking in preadolescence and early adolescence may be particularly important, especially
among girls and in Aboriginal communities in which young people tend to begin smoking
and tobacco use at very young ages.
The recent U.S. Surgeon General’s Report on Physical Activity53 has confirmed that
increased levels of physical activity by all age groups can result in both health gains and
reduced costs in the health-care system. Effecting a change in the level of activity among
the inactive population stands to accomplish the most in terms of population health
gains. Accordingly, the federal, provincial and territorial ministers responsible for fitness,
recreation and sport set a goal of reducing the number of inactive Canadians by 10%
by the year 2003. To achieve this goal, there will need to be a concerted effort to remove
the barriers to active living among low-income, multicultural and indigenous groups.
The factors most often cited as deterring low-income adults, children and youth from
Toward a Healthy Future
131
Personal Health Practices
participating in sport, recreation and fitness activities include lack of time, cultural
concerns, lack of motivation, and user fees. In view of the low activity levels of Canadian
children, renewed efforts to bring quality daily physical activity into school programs
also need to be supported.
The launching of Canada’s Guide to Healthy Physical Activity provides an important
opportunity to raise awareness and knowledge about the whys and hows of active living
— much in the same way that Canada’s Food Guide to Healthy Eating has helped to educate
Canadians about healthy eating.
Encouraging Canadians to become more active is especially important in light of
the increase in the number of Canadians who carry excess weight, and are therefore at
increased risk for diabetes and heart disease. Efforts to promote healthy weights will need
to combine three messages — active living, healthy eating and positive body image. These
three behaviours are most likely to lead to healthy weights without increasing weight
preoccupation among vulnerable groups.54
Efforts to increase active living will need to be sensitive to the fact that sun exposure
is often greatest while engaging in activities associated with an active lifestyle. Reducing
sun exposure for children can be accomplished by providing more shaded areas in public
places and parks, scheduling outdoor events at hours outside midday, making hats and
sunscreen available, educating parents and children about the need to wear sunglasses
and training child and youth workers about sun safety (see Chapter 4).
The dramatic increase in the relationship between HIV/AIDS and injection drug
use is a major concern. Injection drug use also accounts for the great majority of cases
of hepatitis C infection, and is associated with a wide range of related health and social
problems.
In the new millennium, the mobility of injection drug users and global access to
injection drugs are likely to increase. Reducing HIV infection and other harms associated
with injection drug use (IDU) is a complex issue that brings into play legal and ethical
issues, as well as having major implications for the health and social service systems in
each province and territory. A comprehensive plan to address this problem is required
now. Strategies should take a harm-reduction approach, with the objective being to
normalize the life of the individual, reduce criminal activity associated with injection
drug use, reduce the incidence of IDU and unprotected sexual activity, and facilitate a
return to employment. Further research is urgently required on this issue since the problem
is complex and its magnitude and characteristics are not well documented.
Risk-taking behaviours among youth remain stubbornly high, and in many areas like
tobacco use, binge drinking and cannabis use, they appear to be increasing. Of particular
concern is the trend of a significant proportion of adolescents and youth engaging in
hazardous combinations of multiple risk behaviours. Recent surveys show alarming rates
of multiple risk behaviours among high school students. These rates pale in comparison,
however, to those for out-of-the-mainstream youth and street youth.
In a recent review of research and consultation documents that captured young
people’s views, youth were critical of the nature of the information and the timing of their
courses in sex education. Many wanted a broader approach that would include more
exploration of topics like love, the positive aspects of sexuality and sexual preference.
Youth in small communities expressed concerns about access to condoms and the lack
of privacy and confidentiality in their environment.55
Toward a Healthy Future
132
Personal Health Practices
As noted in previous chapters, there are many reasons to be concerned about
the health of Canada’s young people, including high rates of abuse, poverty and
unemployment; low rates of self-esteem and psychological well-being; and high rates of
death due to fatal unintentional injuries and suicides. In an environment characterized
by such powerful, negative determinants of health, the tendency of some youths to
engage in risk behaviours is not surprising.
Since A New Perspective on the Health of Canadians first identified lifestyle behaviours
as a primary determinant of health, many governmental and non-governmental programs
have worked to change individual behaviours. This approach has worked for some —
but less so for those lacking the requisite environmental, social and personal supports
and resources. Efforts to educate individuals and build personal skills for change must
now work hand-in-hand with efforts to structure an environment around the individual
that supports healthy lifestyle decisions. Nowhere is this likely to be more important than
with youth.
Endnotes for Chapter 5
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Statistics Canada. National Population Health Survey, 1996–97.
Bouchard, C., Shephard, R., Stephens, T. (eds.) Physical Activity, Fitness and Health:
International Proceedings and Consensus Statement. Champaign, IL: Human Kinetics
Publisher, 1994.
Canadian Fitness and Lifestyle Research Institute. “How Active Are Canadians?” (Bulletin
No. 1). Progress in Prevention. 1996.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.” Health Reports 7, 4 (Spring 1996): 33–45 (Statistics Canada Cat. No. 82-003-XPB).
Canadian Fitness and Lifestyle Research Institute. “Barriers to Physical Activity” (Bulletin
No. 4), “Physical Activity in Children” (Bulletin No. 8), “The Economics of Participation”
(Bulletin No. 10). Progress in Prevention. 1996.
Health Canada. Report on the 1994–95 National Population Health Survey: Nutrition
Component. Unpublished report prepared for the Nutrition Programs Unit, 1996.
Health and Welfare Canada. Canadian Guidelines for Healthy Weights: Report of an Expert
Group Convened by the Health Promotion Directorate. Ottawa: Minister of Supply and
Services, 1989.
Statistics Canada. National Population Health Survey, 1996–97.
Stephens, T. International Trends in the Prevalence of Physical Activity and Other Health
Determinants. Presentation to the 1998 Fédération international de médecine sportive,
World Congress of Sport Medicine, Orlando, May 1998.
Canadian Centre for Drug-Free Sport. National School Survey on Drugs and Sport. Ottawa:
Canadian Centre for Drug-Free Sport, August 1993.
Statistics Canada. National Population Health Survey, 1994–95 and 1996–97.
Statistics Canada. National Population Health Survey, 1996–97.
Reading, J. “The Tobacco Report.” First Nations and Inuit Regional Health Survey. Ottawa:
First Nations and Inuit Regional Health Survey National Steering Committee, 1999.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.”
Ontario Tobacco Research Unit. Monitoring the Ontario Tobacco Strategy: Youth and Tobacco
in Ontario, 1997. Toronto: Ontario Tobacco Research Unit, University of Toronto, 1997.
Province of Nova Scotia. Nova Scotia Student Drug Use, 1998: Highlights Report. Halifax: Nova
Scotia Department of Health, Drug Dependency, Dalhousie University, Communications
Nova Scotia, 1998.
Toward a Healthy Future
133
Personal Health Practices
17. Transport Canada. Fatality Statistics. Ottawa: Transport Canada, 1999. See Transport Canada
Web site: www.tc.gc.ca/roadsafety/Stats/stats96/st96bace.html
18. Nova Scotia Department of Health and Dalhousie University. Nova Scotia Student Drug Use,
1998: Technical Report. Halifax: Nova Scotia Department of Health and Dalhousie University,
1998.
19. Ibid.
20. Addiction Research Foundation (Ontario). Ontario Student Drug Survey, 1997: Executive
Summary. See Addiction Research Foundation Web site: www.arf.org/isd/xsum97.html
21. Province of Nova Scotia. Nova Scotia Student Drug Use, 1998: Highlights Report.
22. Addiction Research Foundation (Ontario). Ontario Student Drug Survey, 1997: Executive
Summary.
23. Nova Scotia Department of Health and Dalhousie University. Nova Scotia Student Drug Use,
1998: Technical Report.
24. Health Canada. “AIDS and HIV in Canada (1998).” HIV/AIDS Epi Update. Ottawa: Health
Canada, Health Protection Branch, Laboratory Centre for Disease Control, Bureau of
HIV/AIDS, STD and TB, May 1998.
25. Ibid.
26. Ibid.
27. Health Canada. Guidelines and Recommendations on the Prevention and Control of Hepatitis
C: Canada Communicable Diseases Report, July, 1995. Ottawa: Health Canada, 1995.
28. Addiction Research Foundation (Ontario). Ontario Student Drug Survey, 1997: Executive
Summary.
29. Nova Scotia Department of Health and Dalhousie University. Nova Scotia Student Drug Use,
1998: Technical Report.
30. Ibid.
31. MacDonald, C., Holmes, P. Newfoundland and Labrador Student Drug Use Survey, 1998.
St. John’s: Department of Health and Community Services, Government of Newfoundland
and Labrador, November 1998.
32. Scott, K., Kishk Anaquot Health Research and Program Development. “Indigenous
Canadians.” 1997 Canadian Profile: Alcohol, Tobacco and Other Drugs. Ottawa: Canadian
Centre on Substance Abuse and the Addiction Research Foundation, 1998.
33. David, D. Aboriginal Peoples in Urban Centres, Report of the National Roundtable on Aboriginal
Urban Issues. Royal Commission on Aboriginal Peoples, 1993: 68.
34. Canadian Red Cross Society. National Drowning Report: Analysis of Water-Related Fatalities in
Canada for 1996. Ottawa: Canadian Red Cross Society, 1998; and Canadian Red Cross
Society. Drownings and Other Fatalities During Boating: National Report. Ottawa: Canadian
Red Cross Society, 1997.
35. Barss, P., Smith, G., Baker, S., Mohan, D. Injury Prevention: An International Perspective —
Epidemiology, Surveillance and Policy. New York: Oxford University Press, 1998.
36. Transport Canada. Seat Belt Use in Canada, June 1998 Survey Results. Ottawa: Transport
Canada, Road Safety. See Transport Canada Web site: www.tc.gc.ca/roadsafety
37. Statistics Canada. “The Gambling Industry: Raising the Stakes.” The Daily, December 9, 1998.
38. Ibid.
39. Nova Scotia Department of Health, Drug Dependency Services. Nova Scotia Video Lottery
Players’ Study, 1997–98. Halifax: Nova Scotia Department of Health, 1998.
40. Province of Nova Scotia. Nova Scotia Student Drug Use, 1998: Highlights Report.
41. Galambos, N., Tilton-Weaver, L. “Multiple-Risk Behaviour in Adolescents and Young Adults.”
Health Reports 10, 2 (Autumn 1998).
42. Ibid.
Toward a Healthy Future
134
Personal Health Practices
43. Nova Scotia Department of Health and Dalhousie University. Nova Scotia Student Drug Use,
1998: Technical Report.
44. Canada Health Monitor, January 1997 (unpublished data) and Houston, S.M., Archibald,
C.P., Sutherland, D. Sexual Risk Behaviours Are Associated with HIV Testing in the Canadian
General Population. 7th Annual Conference on HIV/AIDS Research, Quebec City, May 1998.
45. Galambos, N., Tilton-Weaver, L. “Multiple-Risk Behaviour in Adolescents and Young Adults.”
46. Ibid.
47. Statistics Canada. National Population Health Survey, 1994–95.
48. King, A., Wold, B., Tudor-Smith, C., et al. The Health of Youth: A Cross-National Survey.
World Health Organization Regional Series: European Series, No. 69. Printed in Canada,
1997, ISBN 92-890-1333-8.
49. Galambos, N., Tilton-Weaver, L. “Multiple-Risk Behaviour in Adolescents and Young Adults.”
50. Ibid.
51. Chen, J., Millar, W. “Age of Smoking Initiation: Implications for Quitting.” Health Reports 9, 4
(Spring 1998): 39–46.
52. Ibid.
53. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the
Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic Disease Prevention and Health
Promotion, 1996.
54. Health Canada. Blueprint for Action: An Integrated Approach (VITALITY). Ottawa: 1989.
55. Caputo, T. Hearing the Voices of Youth: A Review of Research and Consultation Documents.
Prepared for Health Canada, March 1998.
Toward a Healthy Future
6
Health Services
The vast majority of Canadians who participated in our research
were immensely proud of the type of health care system that has been
built in Canada. They had an abiding sense of the values of fairness
and equality, and do not want to see a system in which the rich
are treated differently from the poor.
— National Forum on Health, Values Working Group Report, 1997.
ealth services, particularly those designed to maintain and promote
H
health and prevent disease and injury, contribute to population health.
Preventive and primary health-care sevices such as prenatal care, well
baby clinics and immunization are important for maternal and child health
(Chapter 3). Services that educate children and adults about health risks and
healthy choices, and those that encourage them to adopt healthy living practices,
make an important contribution (Chapter 5). Services to help seniors maintain
their health and independence are important as well (Chapter 7). And
community environmental health services help ensure the safety of our food,
water and living environments (Chapter 4).
When people are sick, they look to the curative side of health services to
help them regain their health. This chapter focuses on some of the key aspects
of treatment and secondary prevention that are part of the health services
continuum of care. It also takes a brief look at the use of complementary or
alternative care in Canada.
Toward a Healthy Future
136
Health Services
The principles of the Canada Health Act apply to the provision of medically insured
services in all Canadian jurisdictions. These include universality, portability, accessibility,
comprehensiveness and public administration. This chapter examines several aspects of
health services in Canada, with a particular emphasis on accessibility.
A single chapter on health services cannot do justice to the complexity of this
determinant of health. As stated at the outset, this report is not intended to be a “report
card” on the health-care system. It does, however, shed light on some of the major
challenges to a system that has been undergoing restructuring. It draws primarily on
information in the Statistical Report on the Health of Canadians related to four dimensions
of health services: health expenditures and the provision of services, access to and utilization
of health services, unmet health-care needs and alternative care. Information on the quality
of services was not readily available; when it does become available, it should be the focus
of a complementary, more detailed report on health services as a determinant of health.
In the 1990s, all of the provinces and territories underwent health-care reform to
varying degrees. Certain trends emerged over time, including a shift from centralized
governing bodies to regional health authorities, a growing shift in emphasis from
institutionally focused care to community-based care, decision making based on need
and the best available evidence, and funding of health services at sustainable levels.
Over the past several years, governments have been successful in slowing health-care
expenditures. However, the effects of these restrictions, including the increased burden on
women, families and communities, and longer waiting times for institutional and
community services, have yet to be documented at a national level.
Definitions and Measures
◆
Unmet health-care needs: In the NPHS, “unmet health-care needs” were based on selfreport; that is, a person required some health care on at least one occasion but did not
receive it. Respondents who had at least one unmet health-care need in the past year
were asked to identify the category: physical, emotional/mental, regular check-up or
care of an injury.
◆
Home care: In the NPHS, home care was defined as health-care or homemaker services
received at home with all or part of the cost borne by the government.
As noted in a recent report, “the efforts of all levels of government to improve
their fiscal health have taken their toll on the health-care system, as well as the public’s
confidence in it.” The public’s assessment of the overall quality of the health-care system,
although still largely favourable, has deteriorated significantly since the beginning of
this decade. In February 1998, 29% of Canadians rated Canada’s health-care system as
“excellent” or “very good,” down from 61% in May 1991.1
This points to the need for increased accountability for the effectiveness and quality
of services by both governments and managers within the system. Canadians need to
know how well the system performs in relieving pain and suffering, restoring, promoting
and protecting health, and providing compassionate care to vulnerable groups.
Toward a Healthy Future
137
Health Services
This form of accountability is an emerging priority for regional health authorities and
governments across Canada. Indeed, the lack of data systems to collect this information
is a major gap.
At the same time, an examination of current and emerging trends shows that
despite financial slowdowns, the core principle of universality has not been noticeably
compromised. Access to insured medical services in Canada remains largely unrelated
to income. On the other hand, access to needed health services outside of the insured
system, including dental services and prescription medications, is seriously restricted
for many low-income Canadians. Those who have neither private nor publicly assisted
supplementary health benefit plans are most likely to “fall between the cracks.”
Highlights
In the early to mid-1990s, governments were successful in slowing public healthcare expenditures. However, for the most part, universality of access has not been
jeopardized, and detrimental effects to health appear to have been largely avoided.
◆ In spite of population growth, the annual growth rate of Canada’s insured healthcare expenditures fell from 11.1% (between 1975 and 1991) to 2.5% between 1991
and 1996. This was largely as a result of reductions in Canadian Health and Social
Transfer payments, which increased pressures to control spending and reform the
system. However, the 1999 federal budget provided a significant increase in health
transfer payments over the next few years.
◆ Consistent with a decline in hospital expenditures, there has been a decline in the
total days spent in hospitals and in the average length of stay. The shift in the place
of care away from the hospital to the community and the home raises concerns
about the increased financial, physical and emotional burdens placed on families,
particularly on women.
◆ Despite slowdowns in health-care spending, most major measures of population
health in Canada have continued to improve. By most internationally recognized
indicators of health status, Canada continues to rank among the healthiest countries
in the world (Chapter 1).
Concerns remain about access to non-insured services and the quality of care.
◆ At the time of writing, there were few data available on quality of care or the impacts
of restructuring upon quality of care. A 1998 survey reflected Canadians’ growing
dissatisfaction with the quality of care. Only 24% of Canadians described the overall
quality of care they received during the previous year as “excellent” and only 28%
described their overall hospital experience as “excellent.” Further research on quality
of care is required.
Toward a Healthy Future
138
Health Services
◆ Access to dental services, vision correction and required prescription drugs was
strongly linked to income and insurance coverage. Canadians with low incomes who
did not have publicly assisted insurance or employee health benefits were the most
likely to have little or no access to these necessary services.
◆ In spite of shorter hospital stays, reduced utilization of emergency services and an
increase in the proportion of older Canadians (who are most likely to use home-care
services), data from the NPHS showed that publicly sponsored home-care service
use did not increase significantly between 1994–95 and 1996–97. However, some
provincial utilization data suggest that public expenditures and the use of home care
did increase during that time. Further research is required to clarify this discrepancy.
◆ It is reasonable to assume that while there were likely some unmet needs in home care,
most of the increased need for help at home was picked up by informal caregivers,
who are most often women. While most women who cared for others did not claim
that this was a burden, some 27% said that their caregiving affected their own health
and two-thirds of working women aged 25 to 44 reported job repercussions as
a result of their caregiving activities. Further research on these issues is required.
◆ Expenditures for medication and the use of prescription drugs have increased
dramatically since 1975. Thirty percent of Canadians over age 12 and 46% of
Canadians aged 75 and older reported using three or more medications over a twoday period in 1996–97. While 74% of high-income Canadians had prescription drug
plans, this benefit was available to only 53% of middle-income Canadians and 38%
of low-income Canadians.
Better measures and information gathering systems are needed to increase
accountability.
◆ This chapter identifies a number of information gaps related to the effectiveness of
health services and to the reasons for utilization changes in areas such as home care
and emergency services. In addition, more information is needed on long-term care,
mental health services and palliative care.
Health Service Expenditures
Countries with the highest health expenditures do not necessarily have the best health
outcomes. Recent data from the Organisation for Economic Co-operation and Development
(OECD) illustrate this point. Exhibit 6.1 shows Canada’s health expenditures per capita,
expenditures as a percentage of gross domestic product (GDP), life expectancy at birth and
potential years of life lost (PYLL) per 100,000 population, as compared with seven other
OECD nations: the United States, Germany, France, Australia, Japan, New Zealand and the
United Kingdom.
Although the United States ranked first among the eight OECD nations in
expenditures per capita and expenditures as a percentage of GDP, it ranked last in terms
of life expectancy and potential years of life lost. Part of the explanation for this may be
that much of the U.S. spending on health services is private spending, whose benefits are
Toward a Healthy Future
139
Health Services
not distributed equally across the population. Thus, while those who can pay for health
insurance (or pay directly for services) may be healthier, the uninsured or under-insured
derive limited benefits from the overall level of health-care spending. In contrast, Japan
ranked only sixth in terms of health-care expenditures per capita, and seventh in terms
of percent of GDP devoted to health care, but first overall on both life expectancy and
potential years of life lost. Canada ranked third overall in health expenditures per capita,
and fourth in terms of percentage of GDP devoted to health care, but second in terms
Exhibit 6.1
Health Expenditures, Life Expectancy and Potential Years of Life Lost (PYLL): Selected OECD Countries
Country
Health-care
expenditures
per capitaa
Rank
United States
$4,909
1
Germany
$2,339
Canada
Total health
expenditures
% of GDP
Rank
Life
expectancy
(1996)b
Rank
PYLL per Rank
100,000
populationc
14%
1
76.1
8
6496
8
2
10.4%
2
76.8
7
4921
5
$2,095
3
9.3%
4
78.5
2
4368
3
France
$2,051
4
9.9%
3
78.1
4
4977
6
Australia
$1,805
5
8.3%
5
78.2
3
4148
2
OECD median
$1,747
—
7.6%
—
77.2
—
4763
—
Japan
$1,741
6
7.3%
7
80.3
1
3421
1
New Zealand
$1,352
7
7.6%
6
77.1
5
6059
7
United Kingdom $1,347
8
6.7%
8
76.9
6
4653
4
Notes:
a 1997, US $, adjusted for cost-of-living differences
b Life expectancy at birth
c 1995
Source: Organisation for Economic Co-operation and Development. OECD Health Data 1998. (CD ROM)
of life expectancy, and third in potential years of life lost.
The OECD comparison suggests that enhancing health goes far beyond how
much money is spent on health services. It also confirms that despite recent slowdowns
in health-care spending, the overall health of Canadians has continued to improve, as
documented in Chapter 1.
In recent years, governments have made a concerted effort to control public
expenditures on health services. While this has not resulted in a reduction in the absolute
amount of money being spent, it has slowed the relentless double-digit, yearly increases
of past decades.
In 1996, Canada’s total health expenditures (public plus private) were $75.3 billion,
representing 9.2% of the Gross Domestic Product. Between 1975 and 1991, Canada’s
total health expenditures increased at an average annual rate of 11.1%. Between 1991
and 1996, the average annual rate of growth fell to 2.5% (Exhibit 6.2). The slowdown was
most noticeable in expenditures related to hospitals and physicians.
Toward a Healthy Future
140
Health Services
Historically, increases in total health
expenditures tend to be related more to
Exhibit 6.2
increases in the prices of health-related
goods and services than to either population
12
growth or increased utilization.2 As such, it
11.1
is important to consider health expenditure
9.8
10
data with the effects of inflation removed
(i.e. in constant dollars).
8
As Exhibit 6.2 shows, health-care
expenditures on a per capita basis increased
6
by 9.8% between 1975 and 1991. Between
1991 and 1996 the per capita rate of growth
4
in spending fell dramatically to 1.2%.
2.5
Much of this slowdown in expenditures
2
1.2
appears to have been attributable to a
0
$6 billion reduction in Canada Health
1991–96
1975–91
and Social Transfer payments between
1991 and 1996. However, the federal budget
of February 1999 provided significantly
Current $
Per capita $
increased levels of health-care funding.
In 1996, there was considerable
Source: Canadian Institute for Health Information. National Health Expenditure
Trends, 1975–1998.
variation in health-care spending across the
country (Exhibit 6.3). High per capita costs
in the Northwest Territories (including Nunavut) and the Yukon Territory reflect the cost
of providing services in a large geographic area with a small population base.
All provinces and territories experienced a pronounced drop in rates of expenditure
growth after 1991. These rates were based on the total health-care spending by both public
and private sectors. Some regions — Saskatchewan, Alberta, Nova Scotia, Quebec and
the Yukon Territory — had decreases in expenditure growth in the mid-1990s, while the
others grew after 1991 at rates that were low compared to those of the previous 20 years.
In 1996, hospitals accounted for the largest share ($25.9 billion, or 34.3%) of all
health expenditures, followed by expenditures for physicians ($10.7 billion; 14.3%) and
drugs ($10.2 billion; 13.6%). From 1991 to 1996, hospital expenditures declined by 0.1%
annually, spending on physicians increased at a rate of 1.0% annually, while expenditures
on drugs increased at an annual rate of 5.9%.3 This constitutes an important
reorientation of spending priorities in Canada — with relatively more money being spent
on the provision of drugs and relatively less on hospitals and physicians.
Percentage
Average Annual Change in Total Health
Expenditures, Current Dollars and Dollars
Per Capita, Canada, Selected Periods
Toward a Healthy Future
141
Health Services
Exhibit 6.3
Health Expenditures (Total, per Capita, and Proportion of Gross Domestic Product),
by Province and Territory, Canada, 1996
$ (millions)
$ per capita
% of GDP
75,304.1
2,513
9.2
1,295.9
2,267
12.1
337.2
2,467
11.8
◆ Nova Scotia
2,144.6
2,274
10.9
◆ New Brunswick
1,807.1
2,371
10.8
◆ Quebec
17,059.0
2,309
9.5
◆ Ontario
29,545.1
2,624
8.9
◆ Manitoba
2,941.4
2,579
10.4
◆ Saskatchewan
2,525.7
2,477
9.0
◆ Alberta
6,648.9
2,380
7.1
10,524.8
2,728
9.9
◆ Yukon Territory
102.6
3,267
8.7
◆ Northwest Territories
371.9
5,564
12.9
◆ Canada
◆ Newfoundland
◆ Prince Edward Island
◆ British Columbia
Source: Canadian Institute for Health Information. National Health Expenditure Trends, 1975–1998.
Service Delivery
Reporting on service delivery across Canada is fraught with difficulties due to limitations
of the available databases. System-based data collected at the provincial and territorial
levels and compiled nationally are primarily hospital-based, whereas the system is
increasingly community-based. Self-report data do not always match service delivery
data. And sometimes data collected in some regions may not be aggregated or
comparable at the national level. All of these issues must be addressed if we are to have
accurate information on which to base measures of accountability for health services
and their governance.
Toward a Healthy Future
142
Health Services
Hospitals
Exhibit 6.4
Total Hospital Days,* by Major Causes,
Canada, 1995–96
In 1995–96, diseases of the circulatory
system accounted for the most hospital
Circulatory
6.336
days, followed by mental disorders
Mental
disorders
5.689
(Exhibit 6.4). These estimates exclude
Nervous system
hospitalization in psychiatric institutions,
2.832
which normally result in stays of longer
Cancer
2.601
duration. If the latter are included, mental
Injury, poison
2.444
disorders account for the most hospital
Respiratory
2.292
days — over 15 million in 1993–94.4
Digestive
2.094
In contrast, hospitalization for
Musculoskeletal
1.428
childbirth accounted for 3.9% of hospital
Childbirth
1.377
days and the average length of stay was
Genito-urinary
1.050
quite short (2.9 days). Two areas that
diseases
changed ranking order between 1990–91
0
1
5
6
7
4
2
3
and 1995–96 were nervous system
Days (millions)
disorders, which accounted for more
hospital days than cancer in 1995–96, and
* Excluding psychiatric institutions.
musculoskeletal diseases which accounted
Source: Canadian Institute for Health Information. Hospital Morbidity
Database, 1994–95 and 1995–96.
for more days than childbirth that year.
These changed standings were consistent
with the increasing prevalence of chronic conditions such as arthritis, rheumatism
and back disorders and the major role of nervous system disorders, and back and limb
problems as causes of activity limitation during the same period.5
Consistent with the decline in hospital expenditures, there has been a substantial
reduction in the number of hospitals in Canada as well as fundamental changes to the
ways in which they deliver services. From 1986–87 to 1994–95, the number of public
hospitals decreased by 14%, and the number of approved beds in public hospitals declined
by 11%. As well, a common trend emerged in all categories of public hospitals: the number
of outpatient visits increased, while inpatient days decreased.6
Changes in hospital stay practices are particularly relevant to women in at least two
ways. First, due to childbearing and the tendency for women to live longer than men,
women account for more days in hospital and more hospital separations. As such, changes
in hospital policies regarding length of stay are relevant to women as clients. Second, early
release policies have the potential to increase the burden of caregivers at home — who
tend most often to be women.
In 1995–96, Canadians spent 35.5 million patient days in general and allied specialty
hospitals (excluding psychiatric institutions) — a decline from 41.4 million days spent in
hospital during 1990–91. These declines occurred despite an increase in the population
of 1.8 million during that time period. The average length of hospital stays also declined
from 11.5 days in 1990–91 to 11.0 in 1995–96 (Exhibit 6.5).
Toward a Healthy Future
143
Health Services
Separations and days (millions)
In 1996–97, 25% of Canadians aged 12
and over reported at least one visit to an
emergency department. As Exhibit 6.6
shows, there has been a substantial decline
in visits to emergency departments in
Canada (31% from 1991–92 to 1995–96).
Visits per 1,000 population
Emergency Services
300
200
100
0
1976–77 1981–82 1986–87 1991–92
1995–96
Source: Statistics Canada. Health Indicators, 1999. (Statistics Canada
Catalogue No. 82-221-XCB).
Toward a Healthy Future
Average stay (days)
The average length of stay in hospital
Hospital Days, Average Stay and Separations,
Exhibit 6.5
increases significantly with age, and time
Canada, 1990 to 1995
in hospital remains highly skewed toward
older Canadians. Thus, with an aging
12
50
population, the decline in hospital days is
Average days’ stay
10
all the more remarkable. This may reflect
40
the continuing improvements in the health
Total days’ stay
8
of older Canadians observed in Chapter 1
30
and, as such, should help to allay concerns
6
about the medical costs associated with
20
an aging population. On the other hand,
4
it may be that greater efficiencies were
10
achieved with young and middle-aged
2
Total separations
patients, possibly due to the increasing use
of ambulatory care, technological changes
0
0
and improvements in drug therapies. It
1990 1991 1992 1993 1994 1995
may also be that the burden of early release
Source: Canadian Institute for Health Information. Hospital Morbidity
from hospital was shifted to family
Database, 1994–95 and 1995–96.
members and community services. Further
research is needed to evaluate these factors.
Contrary to the overall trend to reduce the length of hospital stay, there has been
an upward trend in the average length of stay for treatment of mental disorders (that is,
an increase in the number of patient-days in both acute-care and psychiatric hospitals,
combined with a decline in the total number of hospital admissions for mental disorders).
This suggests that less serious cases are increasingly being treated without hospitalization,
while more severe and persistent cases continue to require inpatient treatment.7 Whether
trends in psychiatric hospitalization reflect
changes in the mental health of the
Emergency Clinic Visits, Canada, 1976–77 to
population as well as changes in the service
Exhibit 6.6
1995–96
system is a matter for research. Since most
mental health care is now delivered in the
700
community, the absence of a national
600
database for community mental health
services makes it difficult to examine mental
500
health service delivery and its implications
400
for population health.
144
Health Services
This may be partly attributable to the closing of hospital emergency departments, as well
as to an increase in the number of walk-in clinics and other types of urgent care treatment
services. Further database development and research are required to clarify the factors
associated with this change.
Home Care
As the population ages and health-care services are reorganized, home-care services
become increasingly important as a potential means to maintain health and independence,
and to contain costs. There is some uncertainty, however, regarding the use of publicly
funded home-care services in Canada. According to the 1996–97 NPHS, 2% of Canadians
aged 18 and over (450,000) reported use of publicly funded home-care services — a rate
largely unchanged from 1994–95. At the same time, many provinces reported increasing
provision of home-care services and related expenditures over the same period. For
example, data provided by the Ministry of Health in British Columbia showed an increase
in home-care visits from 627,000 (176 per 1,000 population) in 1994–95 to 856,000 (223
per 1,000 population) in 1996–97.8 This discrepancy may reflect an increase in the number
of visits per person, rather than an increase in the number of persons receiving homecare services. Further research is required to help clear up this apparent contradiction.
The rates of reported home-care
Percentage Who Received Formal Home Care
utilization reported in the 1996–97 NPHS
in
Past
Year,
by
Presence
of
Chronic
Conditions,*
were highest among seniors, particularly
Exhibit 6.7
Household Population Aged 18+, Canada
older women and people who lived alone.
(Excluding Territories), 1994–95
Half of home-care recipients reported their
health as “poor” or “fair”; 56% had two
High blood pressure
7.5
or more chronic conditions and 28% had
Arthritis/Rheumatism
8
spent eight or more nights in hospital in the
Chronic bronchitis
8.5
previous year. The home-care services most
2+ chronic conditions
9
commonly accessed were nursing (46%)
Glaucoma
10
and housework (42%).
Diabetes
11
As shown in Exhibit 6.7, the odds
Cancer
14
of
receiving
publicly funded home care for
Heart disease
14.8
people suffering from the effects of stroke,
Cataracts
16
urinary incontinence, cancer and other
Urinary incontinence
17
conditions were higher than for those with
26
Effects of stroke
arthritis, even though a home-care worker’s
15
25
5
30
20
0
10
case load would likely include more people
Percentage receiving formal home care
with arthritis. This reflects the fact that
while arthritis is more common than stroke
* As diagnosed by a health professional.
in the non-institutionalized population,
Source: Statistics Canada. National Population Health Survey, 1994–95.
treatment for stroke is more intense.9
There was a clear inverse relationship between household income and receiving
publicly funded home care. This may reflect the poorer health status of people with low
incomes, the fact that many older people who are prime users of health care have low
incomes, and the reality that people with higher incomes are better able to afford private
home-care services.
Toward a Healthy Future
145
Health Services
Well over half of those needing help to carry out daily activities including personal
care, housework and shopping did not report receiving publicly funded home care. These
findings are consistent with a recent study in Saskatchewan of hospital patients discharged
to their homes. Sixty percent of those who were assessed in hospital as requiring home
care did not go on to receive formal services.10
Based on the information reported in Chapter 2 on informal support, it is reasonable
to assume that many Canadians who did not access home care received informal assistance
from family members and neighbours. As well, it is quite probable that some needs were
not met.
Long-Term Care
As the population ages, discussion increasingly focuses on how to keep people in the
community and out of health-care institutions. But when health fails, sometimes the
only option is long-term residential care.
According to the NPHS, in 1995–96, just under one-quarter of a million Canadians
were living in long-term care institutions. The vast majority (81%) of these institutional
residents were aged 65 and over, and among this age group, 73% were women. Over onehalf (58%) of older residents did not belong to groups or participate in group activities
in the institution. An even larger proportion had no close friends outside the facility.
Nevertheless, many older residents received support from a family member: 61% saw
a relative once a week or more.11
Quality of Care
At the time of writing, virtually no data were available to describe the quality of health
care in Canada, or to evaluate the impacts of health system restructuring on the quality
of care received, including such important dimensions as the impacts of shifting care
to communities and homes, the closure of hospital beds, and the waiting time to see
a health specialist and/or to access health services. However, a recent poll revealed that
only 24% of Canadians felt that the overall quality of care they received in the past 12
months was “excellent” and only 28% described their overall hospital experience as
“excellent.” There is a clear need for further research on quality of care issues.12
Access to and Utilization of Health Services
The most common focal point for the delivery of health services in Canada continues
to be the general practitioner. Consistent with the principles of the Canada Health Act,
the provision of these services does not seem to be related to the income of the patient.
Nevertheless, there appear to be persistent language and cultural barriers to the provision
and/or the utilization of services in certain circumstances.
Toward a Healthy Future
146
Health Services
Percentage of Canadians Reporting Two or
More Visits to a Doctor, by Sex and Age Group,
1996–97
Exhibit 6.8
100
80
71
Percentage
69
59
60
53
50
41
40
45
39
66
64
62
44
45
83
80
75
71 72
62
50
20
0
15–17
20–24
35–44
55–64
75+
25–34
45–54
65–74
12–14
18–19
Age
Women
Men
Source: Statistics Canada. National Population Health Survey, 1996–97.
Percentage of Women Aged 18+ Reporting a
Pap Smear Test in the Past Three Years, by
Income Level, 1996–97
Exhibit 6.9
76
80
70
Percentage
60
76
71
60
64
50
40
30
Visits to a General Practitioner
or Family Physician
According to the NPHS, during 1996–97,
87% of women and 73% of men reported
at least one visit to a physician. Women aged
18 to 54 were two to three times as likely
as men in this age group to have seen a
physician during the previous year. The
highest rates of multiple physician visits
were among Canadians aged 65 and over.
In this age grouping, the rates of visits
reported by men and women were most
similar. In fact, among those aged 75 and
over, men (83%) were slightly more likely
than women (80%) to report two or more
visits to a physician (Exhibit 6.8).
Information was not available on the
reasons for these visits, although it is well
documented that patterns of utilization are
markedly different for women than for
men. Further investigation into these
differences is needed.
Lower-income Canadians reported
somewhat more frequent visits to a
physician, which is consistent with the
higher rates of health problems among
economically disadvantaged Canadians.13
An analysis of the number of contacts with
a medical doctor showed almost no variation
between both short- and long-term
immigrants and the Canadian-born
population.14 However, there may be
differences in patterns of utilization of
specific services based on country of birth,
as illustrated by the finding related to women
receiving Pap tests.
20
Pap Smear Tests
10
Cervical cytology screening with a Pap smear
can significantly reduce the incidence of and
mortality from cervical cancer. Currently, Pap
smears are recommended every three years
until age 69 for women aged 18 and over. In
1996–97, 72% of Canadian women aged 18+
reported having a Pap smear within the
preceding three years; 13% reported never
0
Low middle
Lowest
Middle
Upper middle
Highest
Income level
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
147
Health Services
Percentage
having had a Pap smear. This was a slight
Percentage of Women Who Have Never Had
but important improvement over 1994–95
Exhibit 6.10 a Pap Smear Test, by Age Group and Place
when 70% of women aged 18 and over
of Birth, 1994–95
reported having a recent Pap smear, and
15% reported never having had one.
39
40
Rates of Pap smear testing were related
36
35
to education and income: 76% of women in
the highest income bracket reported having
30
been tested within the previous three years,
24
25
compared with only 60% of women in the
18
20
lowest income group (Exhibit 6.9).
16
Rates of Pap smear testing were even
15
more strongly related to country of birth,
10
7
7
according to a recent analysis based on
6
the 1994–95 National Population Health
5
Survey.15 Among women aged 25 to 34
0
who were born in North America, only
25–34
35–64
Age
7% reported never having had a Pap smear
test. This increased to 16% among women
South America
North America
of the same age who cited South America
Asia
Europe
as their place of birth; to 24% of women
born in Europe; and to 39% of women
Source: Statistics Canada. National Population Health Survey, 1994–95.
born in Asia. Similar results held for older
women as well. Among women aged 35 to
64, the proportion who had never had a Pap smear increased from 7% among those
born in North America to 18% among women born in South America and to 36%
among those born in Asia (Exhibit 6.10).
Mammograms
Early detection of breast cancer by
mammograms has been shown to reduce
mortality among women aged 50 to 69.
Currently, mammography screening is
recommended every two years for women in
this age group. Most provincial and territorial
governments have established organized
programs to provide mammographic screening
to women in this age group, and some also
accept women above and below these ages. As
well, considerable mammography screening is
conducted in diagnostic clinics. Exhibit 6.11
shows the proportion of women aged 50 to 69
in 1996–97 who reported that they had had a
mammogram within the last two years.
Exhibit 6.11
Proportion of Women Aged 50 to 69 Reporting
Having Had a Screening Mammogram within
the Last Two Years, 1996–97
Province
%
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
29
56
40
60
49
59
50
50
56
54
Newfoundland
Prince Edward Island
Nova Scotia
New Brunswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
148
Health Services
Access to Health Professionals Other Than
a Physician
Unlike access to universally insured medical services, access to health-related goods and
services that are not universally insured (such as dental procedures, eyeglasses and mental
health services by a non-physician) is strongly linked to income. Most income assistance
programs offer some degree of vision care and dental coverage (although the terms of
the coverage may be more restrictive than the terms for private and employer-sponsored
coverage). Thus, inequities in access to these services and to (prescription) drugs are most
likely greatest among Canadians who work for low wages and/or in jobs that do not offer
supplementary health-care benefits. As we have seen in Chapters 2 and 3, women, young
people and young families are most likely to be in this category. This has important
implications for access to preventive dentistry for children and to needed eye care for
all family members.
Dental Visits
Percentage
The next most common type of visit to a health professional other than a physician was to
a dentist. Sixty-four percent of women and 60% of men aged 12 and older reported a dental
visit during 1996–97. The highest rate of dental visits was reported by youth aged 12 to 14
(67%), 15 to 17 (71%), and 18 to 19 (61%), but the frequency dropped sharply to 48%
among young people aged 20 to 24.
Income level and dental insurance
were powerful determinants of accessibility
Percentage of Canadians with Dental Insurance,
to dental care: lower-income Canadians were
and Percentage Who Reported Having Visited a
Exhibit 6.12
the least likely to have dental insurance or
Dentist, within the Past Year, by Income Level
to have visited a dentist during the past year.
(Age-Standardized), 1996–97
Among Canadians in the low middle income
100
group, only 25% had dental insurance and
only 45% visited a dentist during 1996–97.
81
80
By contrast, 73% of high-income Canadians
73
67 67
had dental insurance, and 81% reported
visiting a dentist during the previous year
60
56 55
(Exhibit 6.12).
45
42
Interprovincial differences in dental
40
insurance coverage were marked, ranging
26
25
from lows of 40% in Quebec and 43% in
20
Newfoundland to highs of 62% in Alberta
and 63% in Ontario.
0
Low middle
Lowest
Middle
Upper middle
Highest
Income level
Insured
Visited dentist
Source: Statistics Canada. National Population Health Survey, 1996–97.
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149
Health Services
In 1997, Aboriginal people reported lower rates of dental visits than the national
rate, despite First Nations and Inuit people having dental care coverage as a non-insured
health benefit. According to the First Nations and Inuit Regional Health Survey, 51% of
the Aboriginal population on reserve reported visiting a dentist during the previous year.16
In 1994–95, relatively few recent non-European immigrants (40%) contacted a
dentist, but the figure for those who had arrived more than a decade earlier was 58%.17
Eye Examinations and Corrective Lenses
Percentage
Regular eye examinations to assess vision, prescribe corrective lenses and check for
eye diseases such as glaucoma are important to well-being and one’s ability to carry out
daily activities. Provincial plans vary in their coverage of eye examinations. Most cover
an annual checkup by an ophthalmologist or optometrist, but supplementary insurance
generally is needed to pay for any corrective lenses that may be prescribed.
The 1996–97 NPHS shows that,
during 1996–97, 42% of Canadians (44%
Percentage of Canadians with Eye Glass/Contact
of women and 39% of men) reported
Lens Insurance; Percentage Who Reported Having
having had an eye examination. As with
Exhibit 6.13
Had an Eye Examination within the Past Year,
visits to a dentist, visits to an eye specialist
by Income Level (Age-Standardized), 1996–97
were strongly related to income. As income
increased, so too did the likelihood of
70
64
having insurance for corrective lenses and
58
60
of having a recent eye examination. Only
21% of Canadians in the lowest income
47
50
42
bracket reported having eyeglass or contact
39 37 38
37
40
lens insurance, and only 37% reported a
recent eye examination. Sixty-four percent
30
of Canadians in the highest income
22
21
20
category reported having insurance and
47% reported a recent eye examination
10
(Exhibit 6.13).
Again, there were wide variations
0
Low middle
Upper middle
between provinces. The proportion of
Lowest
Middle
Highest
citizens with insurance for visual correction
Income level
varied from a low of 26% in Saskatchewan,
to 34% in Quebec, 56% in New Brunswick
Had an eye exam
Insured
and a high of 57% in Ontario.
Visits to a Chiropractor
Source: Statistics Canada. National Population Health Survey, 1996–97.
According to the 1996–97 NPHS, in
1996–97, 10% of men and 11% of women reported at least one visit to a chiropractor.
Visits to a chiropractor were also strongly related to income. Twelve percent of highincome Canadians reported a recent visit to a chiropractor, compared with only 6% of
Canadians with low incomes.
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150
Health Services
Mental Health Services
Services in psychiatric hospitals are excluded from funding under the national health
insurance program, but are funded by the provinces and territories. Psychiatric services
in general hospitals, by a general practitioner or, upon referral, by a specialist (e.g. a
psychiatrist) are also provided for by the provinces and territories under their respective
health insurance plans. When delivered as part of a general hospital inpatient or outpatient
service, nursing, psychology, occupational therapy, social work and other clinical services
are normally covered by public health insurance plans. The provinces and territories may
choose to extend this basic coverage by funding certain community-based mental health
services delivered by non-physician practitioners.18 Although social assistance programs
and private health insurance plans may provide limited coverage for non-physician mental
health services delivered outside of a hospital setting, it is reasonable to assume that low
income remains a significant obstacle to accessing such services.
The 1996–97 NPHS results indicate that 3% of Canadians consulted a social worker
and 2% consulted a psychologist during the preceding year. In addition, although the NPHS
does not shed much light on this issue, many visits to family physicians are for a mental
or emotional health problem.
Medication Expenditures and Use
Between 1975 and 1994, Canadian expenditures on drugs increased from $1.1 billion to
$9.2 billion. Expenditures per person, adjusted for inflation, more than doubled, rising
from $108 to $232. Drug expenditures increased faster than any other major category
of health care: their share of total health spending between 1975 and 1994 rose from
8.7% to 12.7%. Prescription drugs made up about 70% of this total — $6.5 billion in
1994. The remainder was spent on over-the-counter drugs and personal health supplies.
While private funding accounts for much
of the total spent on all drugs, the public
Percentage of Canadians Aged 12+ Who Used
Exhibit 6.14 Medication in the Past Month, by Type of
share of prescription drug expenditures
Medication, Canada, 1996–97
has substantially increased since 1975.19
In recent years, increased spending
Diet pills 1%
on drugs has slowed down, but not as
Steroids 1%
Diabetes meds.
2%
much as for hospitals and physicians. In
Tranquilizers
3%
1996, spending on drugs accounted for
3%
Laxatives
$10.2 billion or 13.6% of all health
3%
Diuretics
3%
Sleeping pills
expenditures.20
3%
Antidepressants
In 1996–97 almost two-thirds of
Heart meds.
4%
Codeine, etc.
5%
Canadians (60% of men and 67% of
Asthma meds.
5%
women) reported that they took some form
8%
Allergy meds.
8%
Stomach remedies
of medication (prescription or over-theAntibiotics
8%
counter) in the last two days, and half of
9%
Blood pressure meds.
18%
Cough/cold meds.
these persons (30% overall) reported that
5
20 they took three or more medications at the
0
15
10
same time.
Percentage
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
151
Health Services
Percentage
Exhibit 6.14 shows the most common types of medications used. In addition to these,
16% of women aged 12 to 49 reported using birth control pills and approximately 11% of
women aged 30 and over were taking hormones.
Generally, medication use increased with age, although the use of allergy medications
was highest among youth under the age of 25. Forty-nine percent of Canadians aged
12 to 14 reported the use of at least one medication within the previous two days. This
increased steadily across age groups to 89% among seniors aged 75 and over. Twentynine percent of young Canadians aged 12 to 14 used three or more medications. This
rose to 44% of men and 47% among women aged 75 and older. These proportions are
substantially higher than the 20% of seniors who reported using the same number of
medications a generation earlier.21
Across all age groups, women were more likely than men to be taking one or two
medications, but less likely to be taking three at the same time. Women (5%) were more
likely than men (2%) to be using antidepressants.
The prescription drug costs of almost two-thirds of Canadians aged 12 and over
are covered to some extent by government plans and employee insurance. Similarly,
prescription drugs are considered a non-insured health benefit for First Nations and Inuit
peoples. Nevertheless, it appears that lower-income Canadians who are not eligible for
social assistance benefits are at greatest
disadvantage (Exhibit 6.15). While 74% of
Percentage of Canadians with Insurance for
high-income Canadians had prescription
Prescription Medications; and Percentage Taking
drug plan subsidies, this benefit was
Exhibit 6.15
Three or More Medications in the Past Two Days,
available to only 53% of middle-income
by Income Level (Age Standardized), 1996–97
Canadians and 38% of low-income
80
Canadians.
74
72
Drug insurance coverage from
70
government plans or employee insurance
60
varied among the provinces. Residents
53
of Alberta (67%), Nova Scotia (67%)
50
and Ontario (66%) were most likely to
38
40 38 37
33
have drug insurance and residents of
31
28
27
30
Saskatchewan (40%) and Manitoba
(47%) were least likely to report having
20
drug insurance.22 However, since the
10
NPHS results exclude children under the
0
age of 12, provincial coverage might not
Low middle
Upper middle
be fully reflected, particularly in cases in
Lowest
Middle
Highest
which these plans focus on children.
Income level
Insured
Using 3+ medications
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
152
Health Services
Percentage of Canadians Reporting Unmet HealthCare Needs, by Province, 1994–95 and 1996–97
Exhibit 6.16
8
8
7
7
Percentage
4
4
2
2
4
4
4
3
3
3
6
5
5
5
6
6
6
6
4
4
3 3
2
1
0
NF PEI NS NB QC ON MB SK AB BC
Province
1996–97
1994–95
Source: Statistics Canada. National Population Health Survey, 1994–95 and
1996–97.
Percentage of Men and Women Reporting
Unmet Health-Care Needs in the Past Year,
by Income Level, 1996–97
Exhibit 6.17
12
11
Percentage
10
8
8
8
7
7
6
5
5
4
4
3
3
2
0
Low middle
Lowest
Middle
Upper middle
Highest
Income level
Men
Unmet Health-Care Needs
In 1996–97, 5% of Canadians aged 12 and
over (1.2 million) said that they had at least
one unmet health-care need during the
previous year (i.e. they required some health
care on at least one occasion but did not
receive it). This is a slight increase from
1994–95 when 4% of the population
reported unmet health-care needs. Overall,
6% of women and 4% of men reported
unmet health-care needs. More than 75%
of those who reported an unmet need
identified a physical health problem; 9%,
an injury; and another 9%, an emotional
health problem.
Although the overall level of unmet
needs remained low, there were increases
in every province except Quebec. In
1996–97, there was almost a threefold
interprovincial variation in unmet healthcare needs, ranging from a low of 3% in
both Newfoundland and Quebec to a high
of 8% in Alberta (Exhibit 6.16). These
apparent increases in unmet health-care
needs should be interpreted with caution,
however, due to small sample sizes.
The highest rate of unmet health-care
needs was reported by Canadians in the
lowest income bracket. This relationship
applied to both immigrant and Canadianborn citizens. Eleven percent of women and
7% of men with low incomes reported at
least one unmet health-care need (Exhibit
6.17). Among women in the lowest income
group who reported unmet health-care
needs, 17% identified an emotional health
issue as the source of their need. This may
reflect the high levels of stress reported by
women with low incomes (Chapter 1) and
the fact that access to psychological and
counselling services (except by a psychiatrist
or other physician, or in a hospital setting)
is not covered by public insurance schemes.
Women
Source: Statistics Canada. National Population Health Survey, 1996–97.
Toward a Healthy Future
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Health Services
Alternative Health Services
The number of Canadians aged 12 and over who reported using the services of an
alternative health-care practitioner such as an acupuncturist, homeopath or massage
therapist within the previous 12 months increased from 5% in 1994–95 to 7% in 1996–97.
Exhibit 6.18 shows the most common types of alternative health-care services used.
Women were one and one-half times
more likely than men to have used
alternative care providers in the previous
Percentage of Canadians Aged 12+ Who Use
year. The highest rates of use of these
Exhibit 6.18 Alternative Health-Care Practitioners, by Type,
services were among women aged 25 to 44
Canada, 1996–97
(11%) and women aged 45 to 64 (10%).
Use of alternative health-care
Massage therapist
49
providers was higher among Canadians
Homeo/Naturopath
22
with a university education and among
Acupuncturist
18
those with higher incomes. Nine percent
of Canadians with a university degree
Other
10
reported the use of alternative health-care
Herbalist
7
providers, compared with 3% of Canadians
Reflexologist
3
with less than a high school education.
This profile suggests that well-educated
Spiritual healer 1
Canadians may be more aware of different
Relaxation therapist 1
approaches and more likely to be able
to afford them. It may also reflect a
20
0
10
30
50
40
dissatisfaction with the current medical
Percentage of those who use any alternative care*
model of care and a perceived need for
* Total exceeds 100% due to multiple responses.
a more holistic approach to medical care.
Source: Statistics Canada. National Population Health Survey, 1996–97.
The use of alternative health-care
service providers was highest in British
Columbia (11%), which may reflect the diverse ethnocultural characteristics of residents
of that province. Unfortunately, the NPHS did not include residents of the Yukon Territory
and Northwest Territories (including Nunavut) where the use of alternative health-care
practices is more widespread. For example, in the 1993 Yukon Health Promotion Survey,
6% of Yukon residents reported the use of a massage therapist; 5% visited a traditional
healer; and 2% visited an acupuncturist.23
A recent Angus Reid Report shows that when the category of alternative care is
expanded to include complementary and alternative treatments such as herbal remedies
as well as practitioners, the proportion of adult Canadians who reported having used
such products or services increased to 42%.24
As more and more Canadians visit complementary therapists and make use of herbal
and other alternative medicines, there is a growing concern about the need to evaluate
the effectiveness of alternative therapies and the interactions between therapies. At the
same time, the public is increasingly asking governments to protect consumers by setting
standards and controls on the manufacturing and sale of alternative medicines.
Toward a Healthy Future
154
Health Services
Discussion
Quality and Accountability
As this chapter shows, significant slowdowns in health services costs were achieved with
little increase in unmet needs and without compromising overall measures of population
health or the right of all Canadians to universally insured medical services. At the same
time, public surveys showed an increasing discontent with the quality of services they
received. There was growing anxiety about the financial, physical and emotional stress
placed on families, especially women, due to gaps in care, waiting times for institutional
and community services, and the early release of sicker patients from hospital.
In order to make Canada’s health-care system more responsible and accountable to
the public, it is necessary to move toward an integrated, high-quality system that provides
the care Canadians need in an effective and affordable manner. To do this, the system
needs better measures of accountability using a range of indicators to track the outcomes
and cost-effectiveness of medical interventions. Combining these measures with a set of
indicators that report on the overall health of the population in a certain region, province
or territory could be a powerful incentive for agencies inside and outside the formal
health-care system to collaborate on common goals that will enhance both individual
and population health.
Access to Services
Canadians can be proud of the fact that income is not generally a barrier to universal
medical services. The dramatic increase in mammography use is a positive example of
how public education combined with efficient screening services can make a dramatic
difference in the use of proven preventive measures. Yet large disparities in access to
uninsured health services remain. More information on the age and sex of groups
most affected by these inequities is needed.
Most Canadians would agree that dental care, vision care and counselling services
are not “frills.” For many, access to these services is essential to basic health and to leading
a productive life in modern society. Yet many Canadians fall between the cracks: without
private or publicly assisted insurance, they have restricted or no access to these services.
Reducing this inequity needs to be a priority for policy-makers across the country. Whether
this is achieved through the creation of universal access programs or the provision
of specific support to Canadians without insurance for these services is a subject for
discussion and debate.
Home Care and Community Services
Advances in drug therapies that have made it possible for people to leave hospital earlier
and changes in the nature of ailments for which people are admitted to hospital over the
last 20 years suggest that the need for effective community health- and home-care services
will continue to escalate in the next 20 years. Chronic conditions such as arthritis, nervous
system disorders and the outcomes of stroke are best treated outside of an acute-care
hospital, as long as community nursing and home-care support services are available.
Toward a Healthy Future
155
Health Services
The dramatic change in the length of hospital stay for childbirth also requires
community backup services. A 24- to 48-hour stay in hospital is appropriate for healthy
mothers who have support at home. Without this help, however, new mothers may face
problems such as breastfeeding difficulties, exhaustion and depression. In addition to the
mother’s suffering, these problems affect maternal-child bonding and can have long-term
consequences for a child’s emotional and mental development.
The National Forum on Health and other groups have recommended that home care
and certain other community services be made insured services. This would ensure that all
Canadians have access to an integrated continuum of care that includes services in health
promotion and prevention, primary care, acute care, post-acute care, chronic care and
palliative care. Within this scenario, incentives should be geared to ensuring that people have
access to services in the most appropriate, cost-effective settings, and due regard should be
given to the burden on caregivers, many of whom are women.
The information presented in this report supports this notion. However, the literature
on population health also suggests that services alone are not the answer to improving
health. High-quality services must be supported by policies and programs in communities
and workplaces that allow people time and opportunity to care for each other, without
compromising their own health or financial security.
Medications
The use of medications has increased dramatically over the last 20 years. The number of
Canadians of all ages using more than three medications has risen significantly, including
almost half of Canadians over age 75. In some respects, this is not surprising, considering
the influx of new drugs that improve quality of life for older people with disabilities and
the fact that many more Canadians are living past age 75, when the incidence of health
problems requiring medication tends to increase.
There are, however, major concerns associated with multiple drug use, including
increased risks for falls and hospitalization due to harmful side effects. In recent years,
groups of older adults, pharmacists and organizations of health-care professionals have
carried out major campaigns to educate both physicians and older Canadians about the
dangers of multiple drug use. These efforts will need to continue. At the same time, more
detailed data and analysis of this complex issue are required, including information on
the use of more than three drugs and specific outcomes of this use.
Policy-makers need to pay close attention to the costs of prescription drugs. Two areas
deserve particular attention. First, policy-makers who regulate payments and physicians
who prescribe drugs will need to adopt a rational, evidence-based approach to the complex
challenge of containing drug expenditures that is fully informed by and acceptable to
consumers. To do this, more information on the links between increased spending on
drugs and resulting cost savings in hospitals is needed. Secondly, as drug therapies become
increasingly important in the treatment of illness, policy-makers must address the fact
that some 25% of Canadians — mostly lower-income Canadians — may have restricted
or no access to drug insurance.
Toward a Healthy Future
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Health Services
Endnotes for Chapter 6
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
The Angus Reid Report. Canadians’ Perspectives on Their Health Care System. Public Policy
Focus. Toronto: Angus Reid, March/April 1998: 17–25.
Canadian Institute for Health Information. National Health Expenditure Trends, 1975–1998.
Ibid.
Statistics Canada. Mental Health Statistics, 1993–94. Ottawa: Statistics Canada, 1996 (Statistics
Canada Cat. No. 83-245-XPB).
Canadian Institute for Health Information. Hospital Morbidity Database, 1994–95 and
1995–96.
Tully, P., Saint-Pierre, E. “Downsizing Canada’s Hospitals, 1986–87 to 1994–95.” Health
Reports 8, 4 (Spring 1997).
Statistics Canada. Mental Health Statistics, 1993–94. Ottawa: Statistics Canada, 1996 (Statistics
Canada Cat. No. 83-245-XPB).
Health Services Utilization and Research Commission (Saskatchewan). Hospital and Home
Care Study. Summary Report 10. Saskatoon: Health Services Utilization and Research
Commission, 1998.
Wilkins, K., Park, E. “Home Care in Canada.” Health Reports 10, 1 (Summer 1998): 29–37
(Statistics Canada Cat. No. 82-003-XPB).
Health Services Utilization and Research Commission (Saskatchewan). Hospital and Home
Care Study.
Tully, P., Mohl, C. “Older Residents of Health Care Institutions.” Health Reports 7, 3 (1995).
Blendon, R., et al. 1998 Commonwealth Fund International Health Policy Survey. Harvard:
The Commonwealth Funds, October, 1998.
Statistics Canada. National Population Health Survey, 1996–97.
Chen, J., Ng, E., Wilkins, R. (Statistics Canada). “The Health of Canada’s Immigrants in
1994–95.” Health Reports 7, 4 (Spring 1996): 33–45 (Statistics Canada Cat. No. 82-003-XPB).
15. Health Canada. Factors Important in Promoting Cervical Cancer Screening Behaviours among
Canadian Women: Regional Comparisons. Unpublished report for the Disease Prevention
Division, 1996.
16. Weins, F., McIntyre, L. (Statistics Canada). “Health and Dental Services for Aboriginal
People.” First Nations and Inuit Regional Health Survey. Ottawa: First Nations and Inuit
Regional Health Survey Steering Committee, 1999.
17. Chen, J., Ng E., Wilkins, R. “The Health of Canada’s Immigrants in 1994–95.”
18. Health and Welfare Canada. Mental Health Services in Canada, 1990. Minister of Supply and
Services Canada, 1990 (Cat. No. H39-182/1990E, ISBN 0-662-18047-X): 13.
19. Health Canada. National Health Expenditures in Canada, 1975–1994. Ottawa: Health Canada,
1996.
20. Canadian Institute for Health Information. National Health Expenditure Trends,
1975-1998. CIHI, 1998.
21. Health and Welfare Canada and Statistics Canada. The Health of Canadians: Report of the
Canada Health Survey. Ottawa: Minister of Supply and Services Canada, 1981.
22. Statistics Canada. National Population Health Survey, 1996–97.
23. Government of Yukon. An Accounting of Health: What the Numbers Say. Whitehorse: Bureau
of Statistics, 1994.
24. Angus Reid Group. “Canadians and Alternative Medicines and Practices.” The Angus Reid
Report 12, 5 (September/October 1997).
Toward a Healthy Future
7
Biology and Genetic Endowment
The basic biology and organic make-up of the human body
are a fundamental determinant of health.
— Federal, Provincial and Territorial Advisory Committee on Population Health
in Strategies for Population Health: Investing in the Health of Canadians.
n the last half of the 20th century, Canadians have witnessed remarkable
I
advances in biotechnology and genetic research that could never have been
imagined 50 years ago. In 1953, scientists determined that DNA controlled
heredity, setting off a race to figure out how DNA functions. In 1996, the U.S.
government launched the Human Genome Project — a 15-year, $3-billion effort
to decipher DNA. The first successful heart transplant was performed in South
Africa in 1967. In 1978, the first “test-tube baby” was born. Nineteen years later
(1997), Scottish researchers cloned a sheep using cells from an adult sheep’s udder.
Some of the genetic and biotechnical advances we have today and can expect
in the near future have the capacity to save and enhance lives. Some are repugnant
to societal values. Some are too new to have been thoroughly assessed by either
the scientific community or the public. However, all have the potential to affect
health, family formation and the lives of subsequent generations.
Toward a Healthy Future
158
Biology and Genetic Endowment
At the same time, research in biology, epidemiology and social science is beginning to
expand our knowledge about the links between biological pathways and the determinants
of health. For example, exciting new research on brain formation has shed new light on
how stimulation in a baby’s environment interacts with biology to influence healthy
child development in earliest infancy. As the population ages in Canada and around the
world, there is growing interest in the links between the biology of aging and how an
individual or a population’s position on the socioeconomic ladder translates into health
or disease in later life.
Highlights
◆ A growing body of evidence suggests that healthy eating in the preconception period
increases the chances of a safe and successful pregnancy outcome. After conception,
an expectant mother’s diet and use of tobacco, alcohol and other drugs can affect
both her health and that of the fetus.
◆ When an infant is cared for by a nurturing, sensitive, involved adult, a “secure
attachment” is formed. This attachment helps establish connections in the brain
that can reduce anxiety and allow the brain to take in and incorporate new stimuli.
◆ New reproductive and genetic technologies that are designed to overcome infertility
or manipulate the conventional conception process have raised many profound social,
ethical, legal and health issues. These concerns will become increasingly important as
science progresses in the next century.
◆ Aging is not synonymous with poor health. A large majority of older Canadians
continue to report high levels of well-being on measures such as self-rated health
and long-term activity limitations. Older Canadians, however, report significantly
lower levels of health and higher rates of certain health problems than younger
Canadians. This is particularly true of older Canadians living in low-income
situations.
◆ Studies on education level and dementia suggest that exposure to education and
lifelong learning may create reserve capacity in the brain that compensates for
cognitive losses that occur with biological aging.
◆ Active living has proven potential to prevent or slow some of the declines associated
with biological aging.
Linking Biology and the Environment
While heredity is an important determinant of health, there is considerable evidence to
suggest that its effects are strongly moderated by the social and physical environments.
Studies of migrant populations provide some of the best evidence of this relationship.
For example, Japanese who moved to California and adopted an American lifestyle had
higher rates of coronary artery disease than those who maintained a more traditional
Japanese lifestyle.1 Their genetic makeup did not protect them from the disease patterns
of their new host country. Work with rhesus monkeys has shown the powerful influence
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Biology and Genetic Endowment
of the social environment, particularly the effects of a loving parent. Studies have shown
that monkeys born with a genetically inherited negative personality trait fare better when
they are reared by a nurturing mother.2
New studies have shown that the nervous system, which responds to the outside world
and transfers information to the immune system, is the biological pathway that links
external stimuli and the body. This link between the nervous system and the immune system
(which plays a central role in guarding health) is of major importance in understanding
how social and economic conditions can affect health.3
For example, we know that long-term, chronic stress in the environment has a
negative effect on the immune system and, in turn, on health status. While genetics may
play a role, the social environment, and more specifically, the extent of control over a life
situation largely determines how successful individuals will be at turning off the stress
response and protecting their immune systems from the effects of chronic stressors. People
who are lower on the social scale and have less control over their environment are likely
to experience more severe physiological consequences to adverse conditions than those
who are higher on the social scale and have more control over circumstances in their
environment.4
Biology and Birth Defects
In 1995, there were 13,629 anomalies or birth defects recorded, with a rate of 483.5
for every 10,000 births.5 This rate is the lowest recorded since monitoring began in
1989.6 The most common anomalies are musculoskeletal and congenital heart defects
(Exhibit 7.1). The most frequent musculoskeletal defects are congenital dislocation of
the hip and clubfoot, each of which is more common than anomalies of the digestive
system, the central nervous system and genital organs, and Down syndrome.
In this century, science has given
Birth Defects and Stillbirths, Canada
us numerous important findings
Exhibit 7.1
(Excluding NS and QC), 1995
about how to prevent health problems.
Nowhere is this research more
Musculoskeletal
important than in the birth of healthy
130.6
78.8
Congenital heart
babies. For example, research has shown
65.4
Stillbirths
that women who take supplementary
31.3
Digestive system
31.2
Circulatory system
folic acid (one of the B vitamins)
28.3
Central nervous system
around the time of conception can
26.8
Urinary system
greatly reduce the risk of neural tube
26
Genital organ
birth defects, including spina bifida
17.7
Cleft lip/palate
7
12.9
Down
syndrome
and anencephalus. Health Canada has
11.2
Ear, face and neck
recently published national guidelines
9.4
Respiratory system
for healthy eating throughout the
6.6
Integument
Eye 3.8
preconception and prenatal period in
light of a growing body of evidence
60
80 100 120 140
20
40
0
that suggests that preparing for
Cases/10,000 total births
pregnancy increases the chances of
a safe and successful birth outcome.
Source: Health Canada, Laboratory Centre for Disease Control, Canadian
Congenital Anomaly Surveillance System.
Surveys are needed to determine how
many women of childbearing age are
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Biology and Genetic Endowment
aware of the role of preconception nutrition in preventing birth defects and how many
women who are considering a pregnancy are taking steps to meet Health Canada’s
guidelines.
Other aspects of an expectant mother’s lifestyle practices affect the likelihood that
a child will be born with mental and physical disabilities. Maternal smoking and/or
considerable exposure to environmental tobacco smoke during pregnancy increases the
likelihood of a premature delivery and the birth of a low-weight baby who is at high risk
for disabilities. In 1996–97, about 36% of new mothers who were current or former smokers
acknowledged smoking during their most recent pregnancy and they smoked an average
of nine cigarettes each day while pregnant. This amounts to about 146,000 women who
smoked during their last pregnancy.8 As discussed in Chapter 3, women with lower levels
of education are much more likely to smoke during pregnancy than women who have
pursued a higher level of education.
Alcohol use during pregnancy can affect the health of the mother, the fetus and the
ability of the child to lead a healthy life from birth to adulthood. The most disturbing
results of alcohol use during pregnancy are fetal alcohol syndrome (FAS) and fetal alcohol
effects (FAE).
Definitions
◆ Fetal alcohol syndrome (FAS) is a set of alcohol-related disabilities characterized by
both physical and behavioural shortcomings, including prenatal and postnatal growth
restrictions, neurological abnormalities, developmental delays, behaviour dysfunction
and learning disabilities.
◆ Fetal alcohol effects (FAE) is the term used to describe children with only some of
the FAS characteristics in situations where prenatal alcohol use is a possible cause.
Although there is no national surveillance of FAS, conservative estimates suggest that
.33 cases of FAS occur in every 1,000 births in western countries.9 While the incidence of
FAE is about three times higher, the relative effects of alcohol use, poor nutrition and
impoverished conditions are hard to decipher.
Although some case studies in specific communities suggest that fetal alcohol
syndrome (FAS) is more common among Canadian Aboriginal children than nonAboriginal children, there is yet no good evidence to support this conclusion. For example,
researchers have studied FAS in Native communities without including a non-Native
comparison group. When a comparison group has been introduced, it is not clear that
criteria for FAS have been applied consistently to both groups. To date, a valid comparison
of the overall prevalence rates of FAS for Native individuals and non-Natives has not
been carried out.10
While binge drinking is the pattern associated with FAS, some women may be more
susceptible to the effects of alcohol because of differences in the way that their bodies
metabolize alcohol.11 Other risk factors point to the links between personal behaviour,
biology and socioeconomic factors. For example, women who drink heavily during
pregnancy are often poor, undernourished, depressed and abused, and many are unlikely
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Biology and Genetic Endowment
to receive prenatal care. Thus, reasons for drinking during pregnancy are based on a mix
of socioeconomic factors including the drinking patterns of family members and friends,
as well as other adverse situations that lead to heavy drinking.12
Virtually all women want to have healthy babies. Most who smoke or drink during
pregnancy do so as a consequence of addiction and/or high levels of stress caused by
poverty, abuse or other factors. Pregnant women need the support of their partners,
families and communities, as well as the recognition that their own health is as important
as that of the growing fetus.
More research on the effects of alcohol consumption and smoking by fathers on fetal
and infant development is required.
New Reproductive and Genetic Technologies (NRGTs)
Reproductive technologies are designed to overcome infertility or manipulate the
conventional conception process to produce a pregnancy. They include in vitro fertilization,
donor insemination, assisted insemination, preconception or “surrogacy” arrangements
and postmenopausal pregnancy. Applications of genetics-based technologies include sex
selection, embryo research, prenatal diagnosis and human embryo cloning. Recently, the
Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans stated
unequivocally that some of the practices mentioned in the paragraph above are both
unethical and problematic.13
The development and application of NRGTs in Canada have raised many profound
social, ethical, legal and health issues. While some NRGTs can enhance health and wellbeing, others threaten human dignity and treat women, children and the reproductive
process as commodities. Thus, the title of the 1992 report — Proceed With Care — from
the Royal Commission on New Reproductive Technologies, was both appropriate and
prescriptive.
The Royal Commission recommended a comprehensive, ethics-based approach to
regulation, licensing and prohibitions. The federal government responded with a voluntary
moratorium on certain procedures in 1995 and the introduction of the Human Reproductive
and Genetic Technologies Act to regulate NRGTs. This bill died on the order paper when a
federal election was called; a new replacement bill is currently being drafted, following a
round of strategic consultations. It is anticipated that the new bill will be comprehensive
in scope, addressing the issue of prohibitions of certain procedures, as well as proposing
regulatory and management structures.
New reproductive and genetic technologies concern the future of our society. They are
important to all Canadians, but particularly to women because they are practised almost
exclusively on women’s bodies. Women’s relative economic status also makes them more
susceptible to adverse consequences of these technologies such as the commercialization
of human gametes and embryos. Other vulnerable groups include the children born as
a result of these technologies who will be exposed to physical, emotional and legal risks.
Canadians with disabilities are concerned that the increasing use of prenatal diagnosis,
which is designed to detect genetic or other abnormalities in the embryo or fetus, may
heighten negative attitudes toward people with disabilities.14
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Biology and Genetic Endowment
New genetic discoveries related to diseases such as cystic fibrosis and Huntington’s
disease offer the hope of finding new drugs to treat and cure these conditions. But
presymptomatic testing and counselling for adults with a family history of disease raises
some profound questions for both individuals and the health-care system. What is a
young woman to do when she finds that she carries the gene for ovarian cancer? Should
she have her ovaries removed? Should she have children, knowing that there is a risk that
she will develop a serious illness and may pass on the gene to a daughter? Will monitoring
her health as a result of this knowledge be better for her? Or will the chronic anxiety
provoked by the test results make her health worse? An additional concern relates to
health and life insurance. Will persons who carry a gene for a particular disease be denied
insurance because of a disease they do not have now and may never have in the future?
These are all questions that must be addressed by policy-makers, consumers and healthcare practitioners on a one-on-one basis, in small focus groups and in public fora.
There is also a concern that a rush to expand high-tech solutions to infertility may
take away from low-tech, public health efforts to prevent sexually transmitted diseases
(STDs), which are a major cause of infertility. While there has been some decrease in
the rates of gonorrhea and syphilis between 1986 and 1996, the rate of chlamydia (an
infection that can cause sterility) remains high, particularly among women aged 15 to
24 (Exhibit 7.2). These high rates may be explained by a number of factors: the early onset
of unprotected sexual activity; the high “pool” of STD infection among young people;
the tendency of young people to change sex partners frequently; the symptomless nature
of some STDs; and the vulnerability of an adolescent woman’s immature genital tract to
invading micro-organisms.15 Since the only sensible approach to STDs is prevention, the
need to counsel young people on the use of abstinence and safe sex practices is clear.
Exhibit 7.2
Sexually Transmitted Diseases, by Selected Age Groups and Sex, 1996 (Rate per 100,000 Population)
Chlamydia
Gonorrhea
Syphilis
563.3
59.4
0.6
◆ Male
148.5
33.6
0.3
◆ Female
998.6
86.4
0.9
617.4
65.9
0.8
◆ Male
302.7
66.6
0.7
◆ Female
941.2
65.0
0.9
238.1
42.0
1.2
◆ Male
155.6
54.8
1.2
◆ Female
322.0
29.0
1.3
66.2
19.5
0.7
◆ Male
51.2
30.6
1.0
◆ Female
81.5
8.0
0.4
◆ Age 15 to 19, total
◆ Age 20 to 24, total
◆ Age 25 to 29, total
◆ Age 30 to 39, total
Source: Health Canada, Laboratory Centre for Disease Control, Bureau of HIV/AIDS, STD and TB, Division of STD Prevention and Control, 1998.
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163
Biology and Genetic Endowment
The Biology of Brain Development
In recent years, new knowledge from the science of neurobiology has expanded our
understanding of how the brain develops in the early years and how nature and nurture
interact to affect the short- and long-term development of emotions, thinking and
behaviour.
A newborn’s brain is complete with all of the brain areas and neurons, but only a
portion of the brain is “wired” to go. After birth, there is a frenzy of activity in which the
neurons connect with each other to form the neural networks that enable movement,
talking, feeling and thinking. This process is driven in large part by the flood of sensory
stimulation that a child receives from the outside world.
When an infant is cared for by a nurturing, sensitive, involved adult, a “secure
attachment” is formed. This attachment helps establish connections in the brain that
can reduce anxiety and allow the brain to take in and incorporate new stimuli.16 On
the other hand, neglecting or abusing an infant during this critical period may produce
wiring patterns in the brain that can lead to heightened sensitivity to stimuli and to
negative and abnormal behaviour in childhood and adulthood. In other words, the
environment around an infant has a major influence on the brain’s development and
subsequently on a person’s capacity for control over intense feelings, including anxiety
and aggression.17 This does not mean that a child who is maltreated cannot achieve
healthy development. It does mean, however, that it will be much more difficult for that
child to achieve success, and he or she will likely require more assistance in doing so.
One good example of the link between biology and the environment is language
development. Children are genetically programmed to learn to talk, but their ability to
communicate and the language they use depend on what they hear. Language that is part
of human caring and interaction activates the brain. As these pathways become well used, a
baby develops the ability to understand and use language. Pictures of the brain cortex show
that babies who are not exposed to a lot of verbal stimulation have fewer connections and
less activity in the brain. This translates into difficulties in communicating as a young child
and a reduced readiness for school.
Aging and Health
The biological effects of aging are fairly well known. As we age, there is a normal and
gradual decline in vision, nerve conduction velocity, muscular strength, bone mass and
kidney functions. These functions do not all decline at the same rate and there is marked
variation from person to person. Many older people develop a chronic disease (which
may or may not be related to heredity) that can have dramatic effects on normal body
functions. Other factors such as high stress levels associated with poverty or abuse and
the social roles assigned to gender in our society can also affect the aging process.
The question remains, however, as to how much of the decline associated with
aging is attributable to biological aging and how much of it is the result of other factors,
including socioeconomic status, social support, the physical environment and personal
health practices. It has been shown, for example, that an older person who is physically
active can maintain a level of general physiological functioning and energy that is 20%
higher than the majority of people in the same age category.18
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Biology and Genetic Endowment
Percentage
Information relating to the role of the various determinants of health in the aging
process is extremely important today and will be more so in the next century. By the year
2001, it is projected that one-quarter of Canada’s population will be over the age of 55.
Within that population, an increasing number of seniors will be over the age of 75. In
2011, seniors aged 75 and over will represent nearly 7% of the population of Canada and
more than 46% of the population aged 65 and over. The National Advisory Council on
Aging has called the growth in this age group one of the most striking socioeconomic
developments in recent years.19
Our understanding of the factors that influence biological changes associated with
aging is greatly complicated by the cohort factor, and the increasing racial and ethnic
diversity of Canada’s seniors. Those who are old now differ in many ways from those
who will be old in the new century. Most of tomorrow’s seniors will have enjoyed higher
incomes and higher levels of education than today’s seniors. They are likely to be more
knowledgeable about personal health practices. On the other hand, they may not have
learned the coping and resiliency skills of the current generation of older Canadians who
survived two world wars and the depression of the 1930s. The diversity we are seeing in
seniors who have come to Canada will continue to increase. The waves of new immigrants
and refugees from Asia, the Middle East and Africa that have arrived in the 1990s will be
an integral part of tomorrow’s population of seniors.
Clearly, aging is not synonymous with poor health. A large majority of older Canadians
report high levels of well-being on measures such as self-rated health and long-term
activity limitations. Older Canadians, however, report significantly lower levels of health
and higher rates of certain health problems than younger Canadians. This is particularly
true of older Canadians living on inadequate incomes.
Self-rated health status: Most older
Canadians enjoy good to excellent health
Percentage of Canadian Men and Women
status. In the 1996–97 NPHS, 80% of
Exhibit 7.3
Reporting Fair or Poor Health, by Selected Age
Canadians aged 65 to 74 and 73% of
Groups, 1996–97
Canadians aged 75 and over described their
30
health as good, very good, or excellent. The
28
percentage of older Canadians who described
25
25
their health as fair or poor declined from
23
24% of Canadians aged 65 to 74 and 31%
20
of those aged 75+ in 1994–95 to 20% and
17
27% respectively in 1996–97. Nevertheless,
15
Canadians aged 75 and over remained
10
nearly three times more likely to describe
9
10
their health as fair or poor than younger
Canadians (Exhibit 7.3).
5
Long-term activity limitations: In
0
1996–97, 28% of Canadians aged 65 to 74
Men
Women
and 44% of those aged 75 and over reported
a long-term activity limitation or disability
Age 75+
Age 65 to 74
All ages 12+
resulting from a health problem (Exhibit
7.4). This reflects an improvement from
Source: Statistics Canada. National Population Health Survey, 1996–97.
1994–95 when 36% of Canadians aged 65
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165
Biology and Genetic Endowment
Exhibit 7.4
Percentage of Canadian Men and Women with
Long-Term Activity Limitation or Disability
Resulting from a Health Problem, by Selected
Age Groups, 1996–97
50
45
44
40
Percentage
to 74 and 46% of those aged 75 and over
reported an activity limitation. In the age
group 65 to 74, men were more likely than
women to report an activity limitation;
after age 75, rates of long-term activity
limitations were slightly higher for women
(44% for men and 45% for women).
There are significant gender and age
category differences when the primary
condition responsible for the activity
limitation is identified. As Exhibit 7.5
shows, arthritis was the primary cause
of activity limitations for women over age
55 in all three age categories. In contrast,
the major causes of activity limitations
for men varied in each age category: back
problems for those aged 55 to 64, heart
problems in the age category 65 to 74, and
heart problems followed closely by nervous
system problems for men aged 75 and over.
29
30
20
26
17
15
10
0
Men
All ages 12+
Women
Age 75+
Age 65 to 74
Source: Statistics Canada. National Population Health Survey, 1996–97.
Exhibit 7.5
Primary Condition Responsible for Activity Limitation, Men and Women, by Age, Canada, 1996–97
Population
estimate
(’000)
Nervous
system
(%)
Back
problem
(%)
Limb
problem
(%)
Respiratory
problem
(%)
Arthritis
(%)
Heart
problem
(%)
663
13
18
10
6
17
11
◆ Male
319
11
23
11
7
9
16
◆ Female
344
14
14
9
6
24
7
578
10
9
6
8
21
16
◆ Male
272
10
10
6
10
10
20
◆ Female
306
10
9
7
6
32
14
◆ Age 75+, total
585
13
7
13
6
17
13
◆ Male
241
15
#
13
8
11
16
◆ Female
344
11
5
13
5
21
12
◆ Age 55 to 64, total
◆ Age 65 to 74, total
# Data suppressed because of high sampling variability.
Source: Statistics Canada. National Population Health Survey, 1996–97, special tabulations.
Toward a Healthy Future
166
Biology and Genetic Endowment
Rate per 100,000 population
Health service utilization: A wealth of research carried out over the last two
decades has shown that the vast majority of care given to older adults — at least threequarters of it — comes from their informal networks, such as family and friends. Most
of this informal care is provided by women, especially daughters and wives.20
At the same time, Canada’s older citizens understandably continue to rank at or
near the top of categories of certain health-care services, including visits to a physician,
admissions and lengths of stay in hospitals, use of medications and use of home-care
services. While there was a substantial reduction in hospital visits by Canadians over
the age of 65 from 1991 (35,233 per 100,000 Canadians) to 1995–96 (30,832 per 100,000
Canadians), reductions in length of stay were slight, probably due to the chronic nature
of most older people’s health problems.21
As Exhibit 7.6 shows, the rates of
Hospital Separations by Diagnostic Group,
hospital admissions for older Canadians
Exhibit
7.6
Rates per 100,000 Population, All Ages and
are substantially greater than those for all
Age 75+, 1995–96
Canadians in general, in each diagnostic
category except pregnancy (data not
12,000
shown). The largest differentials occur in
10,000
the categories for circulatory, respiratory
and digestive diseases, injuries and
8,000
neoplasms. Patterns of utilization also vary
substantially for men and women: men had
6,000
substantially greater numbers of hospital
admissions due to circulatory, respiratory
4,000
and genitourinary diseases, and neoplasms,
while women had higher admission rates
2,000
for injuries and musculoskeletal disorders.
Seniors are the largest consumers
0
Respiratory
Injury
Urinary
of publicly funded home-care services.
Circulatory
Digestive
Neoplasms
Musculoskeletal
In 1996–97, 5% of seniors aged 65 to 74
Diagnoses
and 17% of those aged 75 and over used
home-care services. Women aged 75 and
All ages
Age 75+
over were the largest consumers of publicly
funded home-care services: 20% reported
Source: Canadian Institute for Health Information. Hospital Morbidity
Database, 1995–96.
the use of such services. This is not
surprising as most women in this age
group either provide care to a spouse or live alone, without a partner to care for them.
There was a slight reduction in the proportion of seniors receiving publicly funded homecare services from 1994–95 to 1996–97.22 The extent to which the reduction translated
into increased demands on family members has not been determined.
Effects of Other Determinants of Health on Healthy Aging
Income: Data from the 1996–97 NPHS across all age groups show that all three of the
previously discussed health status indicators are related to income level: mean scores
increase with each successive income level.
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Biology and Genetic Endowment
Education: While education and income are highly correlated, education is also related
independently to health status. People with low levels of education tend to have more
disabilities and chronic illnesses, regardless of age. Recent research also suggests that a low
level of education is a significant predictor of having dementia in old age.23 While initially
this finding was not taken seriously, it is now receiving much attention. As discussed in
the previous section, learning and memory depend on connections between nerve cells
in various parts of the brain; dementia involves the loss of these connections. Education
and ongoing learning enriches these interconnections, creating reserve capacity that may
compensate for losses that occur with biological aging.24
Personal health practices: The potential of active living to prevent the declines
associated with biological aging has major implications for maintaining health, mobility
and independence in old age. Regular physical activity can reduce risk for back problems
and heart disease, which are the two major causes of disability in older men. It also has
an important role in the management of arthritis, the number one cause of disability
in older women; however, more research on the appropriate use of exercise to manage
arthritis is needed. The relationship between physiology and medication use is another
area that has received increasing attention in the past several years. Age, size and gender
can all affect how the body metabolizes medications. Yet as we saw in Chapter 6, seniors
are the most likely of any age group to be prescribed and to use multiple drugs.
Social support: There is both theoretical and empirical support for the notion that
social support and social ties positively influence health in old age. There is also evidence
that social support protects individuals from the negative effects of highly stressful situations
such as getting a serious illness. The positive effects of interaction are more apparent for
women and vary from one subculture to another.25 Based on the responses to the 1994–95
NPHS, Statistics Canada recently combined a number of indicators (social participation,
contacts with friends, relatives and neighbours, and perceived social support) to determine
which groups of Canadians were at increased risk for social isolation. They found that adults
over the age of 74 accounted for 74% of those at risk, although they account for only 5% of
the population as a whole. Other factors that contributed to a high risk for social isolation
included disability, widowhood, having a low level of education, being a newcomer to
Canada, and having a cultural background other than French or British.26 For this reason,
some writers consider foreign-born seniors to be victims of double jeopardy. Older ethnic
women who are widowed may be triply disadvantaged.27
Discussion
Interdisciplinary Research
This chapter is filled with the hope of what can be achieved by learning more about the
relationship between biology and genetics, health status and the other determinants of
health. This will require that researchers in social science, epidemiology and biology work
together and continue to explore how the findings from the various fields of science are
linked. Policy-makers and research-funding bodies need to support and encourage this
kind of collaborative work.
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Biology and Genetic Endowment
New Reproductive and Genetic Technologies
While a national consensus on how to handle new reproductive and genetic technologies
(NRGTs) has not yet emerged, Canadians are clearly looking to the federal, provincial and
territorial governments to legislate, regulate, monitor and manage these new technologies
in a way that protects and respects those most affected and reflects our collective values
and ethics. Thus, governments need to ensure that women of all income levels and races
and people with disabilities are fairly represented in consultations, focus groups and public
discussions related to the drafting and implementation of regulations, legislation and
standards. These groups will be joined by bioethicists and consumer advocates who want
to make sure that decisions about the use of NRGTs are grounded in ethics and public
health, not commercial interests.
Canada is well placed to play a leadership role in the further development of
biotechnology; however, ethical and economic considerations are unavoidable. Would
spending more to prevent the known causes of disabilities be a wiser investment than
devising more tests to detect fetal conditions and the presence of genes that carry a
particular disease? Would increased spending on public health efforts to prevent sexually
transmitted diseases and to determine the effects of environmental contaminants on
infertility be a wiser investment than rushing toward more high-tech, expensive treatments
for infertility? While no one denies the right and need of an infertile couple to seek a
solution to their problem, that same couple would have been happier if there had been
a way to prevent the problem in the first place.
Brain Development
Studies in neurobiology have now confirmed that what happens in the first few years of
life can have major, long-lasting effects on the capacity of a person to be healthy, to learn
and to cope with life’s challenges. When optimum conditions for a child’s development
are provided in the investment phase between conception and age 5, the brain develops
in a way that has positive outcomes for a lifetime. This points to the need to provide new
parents with adequate social supports during the neonatal and toddler periods, to provide
effective prenatal care and treatment for maternal depression, and to support mothers
and families who are faced with abandonment, abuse, chronic friction or the psychosocial
stresses that are often associated with poverty.28 It also speaks to the need to educate young
people and young parents about the importance of caregiving style and the value of early
stimulation, and to help them learn positive parenting skills.
Many children show remarkable resiliency despite exposure to high-risk conditions
in the early years. A supportive and stimulating environment combined with loving care
from adults in schools and communities can help children achieve positive development
outcomes. In the preschool years, opportunities to play with peers and to enjoy stimulating,
high-quality preschool or “head start” programs may be particularly important, especially
for children from disadvantaged communities (see Chapter 3).
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Biology and Genetic Endowment
Promoting Healthy Aging
When it comes to healthy aging, biology is not destiny. Promoting healthy aging means
taking action on the broad determinants of health, including socioeconomic status,
education and lifelong learning, social support and an active lifestyle. Gender differences
need to be taken into account when addressing these determinants and when looking for
ways to prevent and reduce activity limitations among seniors. Older women who are
poor and live alone, and older adults who are immigrants and refugees are particularly
vulnerable to social isolation. Community initiatives to involve and empower these
groups are especially important if health inequities are to be reduced.
Endnotes for Chapter 7
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Marmor, T., Mustard, F. “Coronary Heart Disease from a Population Perspective.” In Evans,
Barer and Marmor (eds.) Why Are Some People Healthy and Others Not? The Determinants
of Health of Populations. New York: Aldine de Gruyter, 1994: 201.
Evans. R., Hodge, M., Pless, I. “If Not Genetics, Then What? Biological Pathways and
Populations Health.” In Evans, Barer and Marmor (eds.) Why Are Some People Healthy and
Others Not? The Determinants of Health of Populations. New York: Aldine de Gruyter, 1994:
177.
Canadian Public Health Association. Health Impacts of Social and Economic Conditions:
Implications for Public Policy. Board of Directors Discussion Paper, 1997.
Ibid.
Health Canada, Laboratory Centre for Disease Control, Canadian Congenital Anomaly
Surveillance System. Birth Defect Prevalences in Canada, 1995.
Johnson, K., Rouseau, J. “Temporal Trends in Birth Defects Birth Prevalences, 1979–1993.”
Canadian Journal of Public Health 88 (1997): 169–76.
Cohen, F.L. “Neural Tube Defects: Epidemiology, Detection and Prevention.” Journal of
Obstetrical and Gynaecological Neonatal Nursing 16 (1987): 105–15.
Pederson, L. “Smoking.” In Health and Welfare Canada. Canada’s Health Promotion Survey
1990: Technical Report. Ottawa: Minister of Supply and Services Canada, 1993 (Cat. No.
H39-263/2-1990E).
Abel, E., Sokol, R. “A Revised Conservative Estimate of the Incidence of FAS and Its
Economic Impact.” Alcoholism: Clinical and Experimental Research 15, 3 (1991): 514–24.
First Nations and Inuit Regional Health Survey. Ottawa: First Nations and Inuit Regional
Health Survey Steering Committee, 1999.
Ashley, M.J. “Alcohol-Related Birth Defects.” In McKenzie, D. Aboriginal Substance Use:
Research Issues. Ottawa: Canadian Centre on Substance Abuse, 1994.
McKenzie, D. “Fetal Alcohol Syndrome.” 1997 Canadian Profile: Alcohol, Tobacco and Other
Drugs. Ottawa: Canadian Centre on Substance Abuse and Addiction Research Foundation
of Ontario, 1997: 193–205.
Medical Research Council of Canada, Natural Sciences and Engineering Research Council of
Canada, Social Sciences and Humanities Council. Tri-Council Policy Statement: Ethical Conduct
for Research Involving Humans. Ottawa: Medical Research Council of Canada, August 1998.
Health Canada. New Reproductive and Genetic Technologies: Setting Boundaries, Enhancing
Health. Ottawa: Health Canada, June 1996.
Engel, J. The Complete Canadian Health Guide. University of Toronto Faculty of Medicine,
Toronto: Key Porter Books (1993): 179.
Hertzman, C., Mustard, F. Based on two articles in Entropy 1, 1 (Spring 1997), reported in
Our Promise to Children, Kathleen Guy (ed.). Arnprior, ON: The HLR Publishing Group,
1997. Distributed by the Canadian Institute of Child Health.
Toward a Healthy Future
170
Biology and Genetic Endowment
17. Perry, B. “Incubated in Terror: Neurodevelopmental Factors in the Cycle of Violence.”
Children, Youth and Violence: Searching for Solutions. J. Osofsky (ed.). New York: Guilford
Press, in press, as discussed in Steinhauer, P. “Developing Resiliency in Children from
Disadvantaged Populations.” Determinants of Health: Children and Youth, Volume 1. Canada’s
Health Action: Building on the Legacy, Volume I. National Forum on Health. Sainte-Foy:
Éditions MultiMondes, 1998.
18. Orban, W. “Active Living for Older Adults: A Model for Optimal Active Living.” In Quinney,
A., Gauvin, L., Wall, T. (eds.) Toward Active Living: Proceedings of the International Conference
on Physical Activity, Fitness and Health. Champaign, IL: Human Kinetics Publishers, 1992:
153–61.
19. National Advisory Council on Aging. Aging Vignettes: A Quick Portrait of Canadians. Ottawa:
Supply and Services Canada, 1993.
20. Chappell, N. “Maintaining and Enhancing Independence in Old Age.” Determinants of Health:
Adults and Seniors. National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1997.
21. Canadian Institute for Health Information. Hospital Morbidity Database, 1991 to 1995–96.
22. Wilkins, K., Park E. “Home Care in Canada.” Health Reports 10, 1 (Summer 1998): 29–37
(Statistics Canada Cat. No. 82-003-XPB).
23. Katzman, R. “Education and the Prevalence of Dementia and Alzheimer’s Disease.” Neurology
43: 13–20. In Chappell, N. “Maintaining and Enhancing Independence in Old Age.”
24. Hertzman, C. “The Lifelong Impact of Childhood Experiences: A Population Health
Perspective.” Daedalus, Journal of the American Academy of Arts and Science 123, 4 (1994):
167–80. In Chappell, N. “Maintaining and Enhancing Independence in Old Age.”
25. Chappell, N. “Maintaining and Enhancing Independence in Old Age.”
26. Health Canada. Risk of Social Isolation. Prepared by Statistics Canada, Family and Community
Support Systems Division. In press.
27. Health Canada. The Broader Determinants of Healthy Aging: A Discussion Paper. Working
Paper. Ottawa: Health Canada, October 1996.
28. Garmezy, N. “Resiliency and Vulnerability to Adverse Developmental Outcomes Associated
with Poverty.” American Behavioural Scientist 34 (1991): 416–30. Discussed in Steinhauer, P.,
“Developing Resiliency in Children from Disadvantaged Populations.” Determinants of Health:
Children and Youth, Volume 1. Canada’s Health Action: Building on the Legacy, Volume I.
National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
Toward a Healthy Future
Part C:
Improving Health
8
Improving Health
Reason to Celebrate
This report has shown that Canada has much to celebrate. Many Canadians enjoy high
levels of health and Canada ranks well above other countries in most of the major indicators
of population health. Canada’s health-care system remains a source of pride for Canadians,
despite major restructuring efforts in all jurisdictions. With the exception of certain
population groups, health promotion and disease and injury prevention strategies have
shown positive results in areas such as immunization, mammography, breastfeeding and
car seatbelt usage.
At the same time, there is definitely room for improvement. The high standard of
health experienced by many Canadians is not shared by all sectors of society. There are
clearly disparities in health status associated with gender, age, socioeconomic status and
place of residence. Some Canadians (especially children living in low-income families)
are also more vulnerable to threats in the physical environment, including inadequate
housing and exposure to damaging toxins.
Achieving complete equality in health status among all Canadians is an unrealistic
goal. But achieving equitable or fair access to the opportunities and supportive
environments all citizens need to be healthy is both a laudable and achievable goal in a
civil, caring society. As this report has also shown, increased access to protective factors
in the environment such as social support, safe communities, employment opportunities
and advanced education can help to ameliorate some of the inequities in health status
associated with living in low socioeconomic circumstances.
The Use of a Population Health Approach
A population health approach uses both short- and long-term strategies to:
•
strengthen the underlying and interrelated conditions in the environment so that
all Canadians can enjoy optimum surroundings for healthy living
•
reduce inequities in the underlying conditions that put some Canadians at
a disadvantage for attaining and maintaining optimal health and well-being.
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Improving Health
The deceptively simple story that follows speaks to the complex set of factors or
conditions that determine health.
“Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut on his leg?
Because he was playing in the junk yard next to his apartment building and there was
some sharp, jagged steel there that he fell on.
But why was he playing in a junk yard?
Because his neighbourhood is kind of run down. A lot of kids play there and there is
no one to supervise them.
But why does he live in that neighbourhood?
Because his parents can’t afford a nicer place to live.
But why can’t his parents afford a nicer place to live?
Because his Dad is unemployed and his Mom is sick.
But why is his Dad unemployed?
Because he doesn’t have much education and he can’t find a job.
1
But why ...?”
Getting to the root cause of Jason’s illness and the other major health problems we
face in Canada today requires action on the broader determinants of health. It is also
important to continue to provide high-quality health services that will help Jason heal.
This is the essence of a population health approach.
In January 1997, the Federal, Provincial and Territorial Advisory Committee on
Population Health defined population health as follows:
Population health refers to the health of a population as measured by health
status indicators and as influenced by social, economic and physical environments,
personal health practices, individual capacity and coping skills, human biology,
early child development and health services.
As an approach, population health focuses on the interrelated conditions and
factors that influence the health of populations over the life course, identifies
systematic variations in the patterns of occurrence, and applies the resulting
knowledge to develop and implement policies and actions to improve the health
and well-being of these populations.2
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Improving Health
A population health approach studies these interrelated conditions and then uses
what is learned to suggest policies and actions that will improve the health and well-being
of all Canadians.
Priorities for Action
While there are many challenges to improving health, the Advisory Committee on
Population Health (ACPH) recognized the importance of highlighting three broad priority
areas for action. The selection of these priorities was based on the evidence contained in
this report as well as the collective experience and expertise of the committee members
and their partners. Additional references and further elaboration of the statements made
in this section can be found within the individual chapters noted in the text.
Within each of the following three priority areas, a number of specific challenges are
highlighted; both short- and long-term strategies are suggested.
1. Renewing and reorienting the health sector requires collaborative efforts to:
•
take action to meet emerging challenges in health promotion, disease and injury
prevention and health protection, as well as in treatment services,
•
increase the accountability of health services through improved reporting on the
quality of health services and increasing access to needed services,
•
increase our understanding of how the basic determinants of health influence
collective and personal well-being,
•
evaluate and identify policy and program strategies that work, and
•
influence sectors outside of health which can significantly affect health status.
2. Investing in the health and well-being of key population groups reflects recent trends
that have shown decreased opportunities for optimal well-being among three groups:
children, youth and Aboriginal people.
3. Improving health by reducing inequities in income distribution and in literacy and
education speaks to the findings in this report that show direct links between poor
health and early death, and low levels of education, literacy and income.
1. Renewing and Reorienting the Health Sector
Improving the health of all Canadians requires continuing efforts to reorient the health
sector. The achievement of sustainable, effective, health services requires renewal and
reorientation on five fronts:
Continue and broaden health promotion, protection and disease and injury
prevention strategies in key areas.
The public will continue to look to health professionals to work with citizens and
communities to coordinate health promotion, health protection and disease and injury
prevention strategies as outlined in the Ottawa Charter for Health Promotion.3
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Improving Health
This report suggests that there is a need to continue and broaden strategies in the
following areas:
◆ Reducing costs and suffering through comprehensive strategies on injury prevention.
◆ Continuing and improving upon successful initiatives in areas such as immunization,
breastfeeding, heart health, safe driving and prenatal health.
◆ Providing additional support to young families and parents.
◆ Continuing and improving upon successful initiatives in healthy aging, especially in
light of the aging of a substantial proportion of the population.
◆ Continuing and improving upon successful initiatives in healthy child development.
◆ Developing and implementing comprehensive, collaborative strategies to deal with timely
issues such as increased smoking among girls and young women, increases in asthma
among children, low levels of physical activity among some groups, increases in unsafe
sex practices and other risk-taking behaviours among Canada’s youth, as well as efforts
to reduce family violence and the harm associated with injection drug use.
◆ Developing and implementing comprehensive, collaborative strategies to increase
the mental and social well-being of young people and to reduce violent behaviour
and suicide.
Renew and modernize the health treatment system by making it more integrated,
sustainable, flexible and accountable.
The health sector is responsible for the delivery of high-quality, timely health services.
The evidence shows that, unlike the other determinants, access to insured health services
in Canada is not affected by income level; however, this is not the case for uninsured
services. Canadians who work part-time or in low-paying jobs without benefits are less
likely to have access to these services. This, plus other evidence on the fragmentation of
services (e.g. home-care, pharmacare) pose a number of challenges for the health sector.
Chapter 6 suggests that key strategies include:
◆ Increasing the accountability of health services through improved reporting on the
quality of health services in both the acute and community settings.
◆ Increasing access to essential, cost-effective health services such as dental care, eye care
and required medications which are not currently covered by Canada’s universal health
insurance plan. Whether this is done through universal access programs or through
specific support to Canadians without insurance or the ability to pay for needed
services is an important subject for debate and discussion.
◆ Ensuring equitable access to community care, home care, mental health services,
respite care and palliative care when needed.
◆ Continuing and improving upon successful, cost-effective preventive interventions
such as mammography, Pap tests and injury control measures.
◆ Adopting a rational, evidence-based approach to the complex challenge of containing
drug expenditures, while making necessary drug therapies accessible to all Canadians
who need them.
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177
Improving Health
Increase our understanding of how the basic determinants of health influence
collective and personal well-being.
Knowledge and information gaps in population health have been identified throughout
this report.
◆ Two priorities are the need for additional collective indices
of community and population health and the need for more
up-to-date, comprehensive and regionally relevant indicators
of health in the physical environment. Other gaps include the
he health sector can
need for more information on rural and urban differences.
T
◆ Data on the determinants of health (e.g. income, employment)
and on health status are often collected in the territories in ways
that do not allow for national comparisons. For example, some
national household and labour surveys are not carried out in
the territories and the information is sometimes collected in
different ways. This gap needs to be addressed.
initiate dialogue and act
as a catalyst for change.
◆ Enhanced analysis of the effect of gender, culture, age/stage of development and
socioeconomic status on measures of health is needed.
Initiate dialogue with other health-determining sectors about the health impacts
of policies in sectors outside health and about collective actions that can be taken.
Addressing the root causes of poor health will mean working with other sectors to ensure
that the general conditions within society support health. This report suggests that there is
a need to initiate dialogue with other health-determining sectors, particularly those in the
socioeconomic domain, about the health impacts of policies in sectors outside health and
collective strategies that can be adopted.
The ideal outcome of these collaborations will be healthy public policies in a variety
of health-determining sectors, particularly those in the socioeconomic domain. The health
sector cannot do it all, nor can it impose its agenda on other sectors. It can, however,
initiate dialogue and act as a catalyst for change.
The 1994 ACPH document Strategies for Population Health: Investing in the Health
of Canadians stressed the need for collaboration across all sectors in addressing the
major determinants of health discussed in this report. Since many of the determinants
of health are outside of the traditional health system, building alliances in pursuit of
policies in all sectors that affect health is a primary strategy for improving the health
of the population. Other sectors that need to be involved include the economic, justice,
housing, education, environmental, employment, transportation and social service sectors.
Collaboration can occur at all levels — neighbourhoods, communities, provincial/
territorial, regional and national. Partners need to include voluntary, professional, business,
consumer and labour organizations, governments and representatives of communities
of faith, various cultures, and population groups and disadvantaged groups.
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Improving Health
Generate and share knowledge about the health status of Canadians, the
determinants that influence health and the effectiveness of health services.
Knowledge development refers to a number of related activities including research
initiatives that utilize a variety of methodologies, the development of new indices to
measure health, program and policy evaluation, and the collection, analysis, synthesis
and sharing of information.
Advances in information technology hold great promise for enhancing our capacity to
share information with both professionals and the public. Governments and the private
sector need to invest in innovative ways of sharing knowledge about population health,
and in building the capacity for electronic communication among the voluntary sector,
community groups and the public.
This report suggests a number of priority areas for knowledge development:
◆ Harmonized standards in information collection are required if health information
is to be shared across local, regional, provincial, territorial, national and international
levels.
◆ Data gaps in health services exist and include a lack of national databases for some
chronic diseases (such as diabetes and arthritis), and national data sets for mental
health, home-care and community health services. More information on the quality
of health services and increased measures of accountability that track the outcomes
and cost effectiveness of health service interventions are needed.
◆ A better understanding of the quality of existing data (especially self-reports on
items with a high level of social desirability) is needed.
◆ Lastly, a population health approach requires that investigators in a number of
different disciplines increase their collaborative efforts. Interdisciplinary research
is particularly important in the exploration of the relationship between biology,
genetics and health.
2. Investing in the Health and Well-Being of Key Population Groups
The evidence in this report suggests that three population groups are particularly
vulnerable at this time to poor health outcomes. These three groups are children, youth
(and by extension, families with children and youth) and Aboriginal people. Investing
in activities to improve health among these groups and in the conditions that affect their
health will lead to important improvements in the health of the Canadian population
overall, as well as reducing the future suffering and costs that result from poor health.
This does not mean that efforts to support and improve the health of other
segments of the population should be abandoned or ignored. Findings in population
health increasingly point to the importance of developmental stages and transitions
throughout the life cycle. In particular, the aging of the population suggests that efforts
to support healthy aging need to continue and expand. At the same time, it is clear in
this report that the need to focus on the three groups identified here has increased in
recent years.
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Improving Health
Invest in early childhood.
Studies in neurobiology have now confirmed that when optimal conditions for a child’s
development are provided in the period between conception and age 5, the brain develops
in a way that has positive outcomes for a lifetime. When parents, caregivers and babies
have a loving, secure relationship in the first 18 months of the child’s life, the infant forms
a “secure attachment.” This attachment helps to establish positive connections in the
brain that allow the child to develop trust, self-esteem, emotional control and the ability
to have positive relationships with others later in life. Infants who are neglected or abused
or whose parents are unable to form this attachment due to illness or stress are at higher
risk for a number of behavioural, social and cognitive problems later in life (Chapters 1, 3
and 7). With nurturing and consistent support in later years, children can overcome these
early disadvantages. However, the preferred strategy is to prevent problems by providing all
children with the kinds of social and physical environments they need in order to thrive.
Studies have shown that children in low-income families
and neighbourhoods are at higher risk for infant death and low
birthweight. They are more likely to experience developmental
ll children in
delays, to be exposed to environmental contaminants that have
a negative effect on health and to experience higher rates of both
Canada deserve nurturing,
unintentional and intentional injuries than children who grow up
stimulating, caring and safe
in families with higher incomes. Some of these disadvantages may
be alleviated or overcome by positive parenting, loving caregivers,
environments, nutritious
early opportunities for learning and supportive communities
(Chapter 3).
food, safe, stable shelter, and
Despite a parliamentary resolution to eliminate child poverty
by the year 2000, we have seen the number of young children who
opportunities to participate
live in low-income families increase from one in five in 1990 to one
in community-based
in four in 1995. These proportions are higher in Aboriginal and
recently arrived immigrant communities, and in families headed
recreation and learning
by very young parents and female lone parents (Chapters 2 and 3).
Changes in family structure have contributed to the rise in
activities.
family poverty in Canada. In 1995, almost 50% of single-parent,
mother-led families lived below Statistics Canada’s low income
cut-off levels (LICOs). However, increases in poverty have not been restricted to singleparent families. Between 1990 and 1995, the percentage of married couples with children
in low-income situations rose from 9.5% to 13% — a total of almost 460,000 families
(Chapter 2).
Although the highest proportion of children not doing well live in low-income families,
there is no income cut-off above which all children do well. Therefore, policies and programs
for positive child development must apply to all sectors of society.
All children in Canada deserve nurturing, stimulating, caring and safe environments,
nutritious food, safe, stable shelter, and opportunities to participate in community-based
recreation and learning activities. Indeed, their rights to these basic prerequisites of health
are provided for in the United Nations Convention on the Rights of the Child, which was
ratified by Canada in 1991.
A
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180
Improving Health
Investing in early childhood begins before and after conception. Access to a healthy
diet in the preconception stage is important for a healthy birth outcome (Chapter 7).
Low birthweight (less than 2,500 grams or about 5.5 pounds) is linked to physical and
mental disabilities, and sometimes early death. Women who are most likely to have low
birthweight babies are those with lower levels of education, who live in highly stressful
environments, who do not have adequate nutrition and support, and who smoke during
pregnancy. Women who drink alcohol and/or use drugs during pregnancy are also more
likely to have babies with developmental problems. Fetal alcohol syndrome and fetal
alcohol effects are the most dramatic outcomes associated with heavy drinking and drug
use during pregnancy. Women who drink or use drugs during pregnancy are often victims
of addiction, abuse, poverty or neglect (Chapters 3 and 7).
In recent years, both the federal and provincial/territorial governments have begun
to invest in early childhood through a series of policies, programs and legislative changes.
It will be important to monitor the effects of these initiatives and to report to the public
on changes that result.
Efforts to maximize healthy child development in the early years will require direct
action by the health sector as well as collaboration with the other sectors (e.g. education,
social services, housing, taxation) and the many people and institutions that affect child
development (e.g. families, schools, communities, workplaces, governments, the media).
Key strategies include:
◆ Alleviating child poverty by increasing income security for all families in Canada.
In addition to strategies designed to increase and protect income security for all
families in Canada, there is a need to develop sustained, long-term strategies that
support lone parents of all ages (especially female lone parents) and enable them to
return to school or upgrade their working capacity, without compromising their own
health or the well-being of their children (Chapters 2 and 3).
◆ Continuing efforts to support healthy pregnancies by providing information and support
to young people and expectant parents about health in the prenatal and postnatal
periods. Providing outreach services (including social support, information, food
and protection) to pregnant women who are isolated, impoverished or distressed
in other ways, is an important part of this strategy.4
◆ Supporting families and positive parenting by providing workplace, labour and
government policies and programs that enhance parents’ (especially young parents)
capacities to support their families and still have time to spend with their children,
without compromising their own health. These policies may be particularly important
for women (Chapter 2). Many women who work outside the home suffer high stress
levels trying to balance work and family life. Alternatively, women who work inside
the home must deal with the stress of trying to parent well while living on one
income. Comprehensive school and community strategies can help provide young
people and parents with the information and support they need to build positive
parenting skills. Cohesive, safe neighbourhoods and access to high-quality childcare
when it is needed have also been shown to support families and parents (Chapter 3).
The role of taxation policies in supporting families is important and needs further
discussion (Chapter 3).5
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181
Improving Health
◆ Upholding the right of all children to a safe and secure environment, free from child abuse,
neglect and exploitation. Family violence is both an intergenerational and a systemic
issue. In the short term, infants and young children must be protected from abuse
and neglect. Zero tolerance for this behaviour is an important community norm.
In the long term, research suggests that broad policy efforts to increase employment,
relieve the stress of poverty and prepare young people for intimate, egalitarian
relationships are important strategies for reducing and eliminating child abuse
and neglect (Chapters 2 and 3).
◆ Providing preschool children with the stimulation and nurturing they need to arrive at
school ready to learn and to interact with other children in a positive way. Community
programs that support families and help parents create stimulating environments
for their preschoolers can help. Policies that increase access to both high-quality
childcare programs for families that need them and to junior
kindergartens and preschools need to be considered. Studies have
also shown that “Head Start” programs for toddlers who live in
oung people deserve
disadvantaged neighbourhoods may help some children arrive at
school with cognitive and behavioural scores that are similar to
love and respect for who they
children who come from more advantaged families. (Chapter 3).
Y
◆ Reducing and eliminating unintentional injuries among infants
and preschool children (e.g. poisoning, falls, motor vehicle
crashes) and exposure to environmental contaminants in both
the natural and built environments (e.g. environmental tobacco
smoke) (Chapters 2, 3, 4).
are. They are also central to
Canada’s investment in its
future as a caring and
productive nation.
Work with young people to improve their health.
Just as it is important to invest in early childhood, this report points to the immediate need
to invest in Canada’s youth. Young people deserve love and respect for who they are. They
are also central to Canada’s investment in its future as a caring and productive nation.
This report suggests that a number of things are going well with young people. For
example, youth voluntarism has increased dramatically and the number of young women
completing post-secondary levels of education is at its highest point ever.
At the same time, we are alerted to distressing trends in the health and psychosocial
well-being of Canada’s youth in virtually every chapter of this report. Among young men,
high rates of suicide (especially in Aboriginal communities) and unintentional injuries
contribute to early deaths (Chapter 1). Early school leaving and multiple risk-taking
behaviours (including drinking and driving, and drinking and unsafe sex) are symptoms
of despair that do not bode well for the current or future health of the young men who
engage in these behaviours (Chapters 2 and 5). While the incidence of violent youth
crime — a sign of anger and alienation — has decreased in recent years, it remains
much higher than it was a decade ago (Chapter 2).
Negative health predictors among young women include high levels of reported
stress and depression and low levels of psychological well-being (Chapter 1). Cancer
death rates have remained persistently stubborn among women, mainly due to increases
in lung cancer mortality. The increase in smoking among young women predicts that
this trend will continue and worsen in the new millennium. Many young women report
that they smoke to deal with stress (Chapters 1 and 5).
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Improving Health
Despite some recent improvements, unemployment and underemployment remain
pervasive problems for young people. These conditions are related to increases in the
number of young people who live in low-income situations and the number of young
low-income families in Canada (Chapter 2). The stresses of poverty tend to exacerbate
relationship problems and homelessness (Chapters 3 and 4). Some groups of young
people are at particularly high risk for poor health, including young people in care
and street youth (Chapter 3).
Most of the negative outcomes described above are preventable. A comprehensive
plan to invest in Canada’s young people is badly needed. Young people themselves must
be involved in identifying both problems and solutions, and in providing input to policy
and program decisions related to their well-being. This report also points to the need
to pay attention to how gender, culture and membership in various age cohorts and
population groups affects the behaviours, beliefs and opportunities available to young
people. Key strategies to address this challenge include:
S
chool and community
programs are needed
to help both young men
and women prepare
for parenting.
◆ Helping young people prepare for intimate relationships and family
life. Positive relationships with peers, family members and other
adults prepare young people for intimacy and family life. Young
people who are ready for intimate relationships respect each other
and share roles between the sexes. They are willing and able to
make an intimate commitment to another person. While family
life experience is critical in learning how to develop healthy
relationships, societal influences in education, media and sport
and recreation systems can also have a positive or negative effect
on how young people learn to form and maintain relationships.
At the same time, school and community programs are needed
to help both young men and women prepare for parenting
(Chapters 1 and 3).
◆ Helping young people make a successful transition from school to meaningful employment.
Educational achievement is an important factor in obtaining a good job. The following
conditions may help young people stay in school: stimulating environments in early
childhood, early success in school, nurturing school environments, involved parents
who value an education, community support for troubled young people, efforts to
prevent teen pregnancy, and increased support for adolescents who cannot afford to
stay in school (Chapter 2). Other studies have shown that mentoring, cooperative
education, apprenticeship programs and school curriculums that teach work-related
skills such as teamwork and problem solving can also help young people make a
smoother transition from school to work.6
◆ Helping young people prepare to participate in community life. Partnerships among
schools, community agencies, businesses and parents are increasingly seen as an
effective way to help young people learn the civic and social skills they need for
adulthood. Community service and volunteer work give youth opportunities to develop
meaningful roles, to apply academic learning in real life situations, to learn job skills
such as cooperation and decision making, to develop self-respect and to earn the respect
of the community.7 Remote, isolated communities and high-density urban housing
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183
Improving Health
areas face special challenges in supporting young adults. Sometimes, the whole
community needs to engage in a healing process that involves young people as
important contributors to the process.8
◆ Making the healthy choices the easy choices. This report has pointed to several disturbing
trends, including unsafe sex practices, which can lead to infection and unwanted
pregnancy, increased rates of smoking among young women and multiple drug use
by both sexes. Policies and programs to address and reverse these trends are needed.
At the same time, we need to recognize that personal lifestyle “choices” are linked to
the capacity of the home, school, community, workplaces and governments to make
“the healthy choices the easy choices.” Crowded housing, neighbourhoods in which there
is a lot of drug dealing, isolated living conditions with little to do, and threatening
school environments contribute to increased violence, youth misuse of alcohol,
tobacco and other drugs, and increased feelings of alienation and depression. Strategies
to support healthy development in adolescence need to focus on providing supportive
environments in the places where young people learn, work, recreate and live.
Improve the health of Canada’s Aboriginal people.
Despite major improvements in infant mortality rates and education levels, and reductions
in substance use in many Aboriginal communities, Aboriginal people remain at higher risk
for illness, infant mortality and earlier death than the Canadian population as a whole
(Chapters 1 and 3). Climate change and environmental hazards in the food supply may
have a particularly negative effect on Aboriginal cultures and their way of life (Chapter
4). Young men (particularly those in Inuit communities) are far more likely to commit
suicide than their peers in the rest of Canada (Chapter 1) and Aboriginal young people
are at higher risk for non-intentional injuries and early deaths from drowning and other
causes (Chapters 1 and 5). Aboriginal children in some communities are more likely than
children in the general population to engage in adult behaviours such as smoking, drinking
and drug use at a young age (Chapters 3 and 5).
A greater proportion of Aboriginal families are experiencing problems with housing
and food affordability than Canadian families as a whole (Chapter 4). This is clearly
linked to high levels of unemployment and pervasive low incomes. Aboriginal leaders
have identified low-income levels as a critical factor in their communities’ health status
and have called for a better understanding of the links between income, social factors
and the health of their people. Strategies to address this challenge should take into account
the following points:
◆ Aboriginal people have the lead role in finding ways to enable their people to take
control of and improve their health. However, meeting this goal will require the
support of all Canadians. Policy makers and practitioners who are non-Aboriginal
need to work with Aboriginal people to find culturally appropriate ways to improve
their health and well-being.
◆ The subpopulations within the Aboriginal population are diverse. Conditions vary
greatly from settlement to settlement and between Aboriginal people who live on
and off reserve. It is important to recognize this diversity and to involve specific
communities in developing strategies that will address their health challenges.
Toward a Healthy Future
184
Improving Health
◆ The creation of the new territory, Nunavut, offers an exciting opportunity to better
understand the health of Inuit peoples, who make up the majority of residents there.
Existing surveys and databases will need to be analyzed to separate information on
Nunavut from the Northwest Territories. Different research methodologies will need
to be applied to overcome the challenges of information collection and dissemination
in this far-reaching, diverse Northern area.
◆ The recent Royal Commission Report on Aboriginal Peoples identified numerous
strategies to address this challenge, including increased support for self-government,
improvements in the basic prerequisites for health such as access to safe, high-quality
and affordable housing, and the elimination of racial prejudice in mainstream society.
The recommendations from this report should be used to inform a collaborative
strategy to improve health in Aboriginal communities.
◆ Some of the strategies to improve the well-being of Aboriginal people in Canada’s North
are likely to benefit all people who live in the area. Compromised health among
Aboriginal people may sometimes be compounded by isolation and the high costs of
living in areas that are remote from food production, schools and health facilities —
factors that Aboriginal people share with non-Aboriginal residents of the North.
◆ Aboriginal and non-Aboriginal researchers, policy-makers and practitioners need to
involve local people in all aspects of their studies and to provide ownership of the
results to the communities that are involved.
◆ Future reports on health status and the determinants of health need to take into account
cultural differences in definitions when making provincial-territorial comparisons.
Definitions of “employment,” for example, may vary dramatically in West coast
communities and in Northern Inuit and First Nations communities, where, for
example, a major aspect of daily employment is hunting for food.
◆ Many of the strategies presented in the next section on reducing income inequities will
help to improve health status among Aboriginal people, as well as among other groups
in Canada.
3. Improving Health by Reducing Inequities in Income Distribution
and in Literacy and Education
The two priorities described in this section — achieving a more equitable distribution of
incomes in Canada, and increasing literacy levels and access to education — have a direct
effect on health status even though they are largely managed outside of the health sector.
Collaborative, multisectoral, long-term strategies with other sectors involved in these areas
are important for improving the health of the Canadian population.
Achieve a more equitable distribution of incomes in Canada.
Canadians with low incomes are more likely to have physical, social and mental health
problems than Canadians with higher incomes. They are also more likely to die earlier than
other Canadians, no matter which cause of death is considered. This is true, regardless of
race, age, gender or level of funding in the health care system (Chapters 1 and 2).
Toward a Healthy Future
185
Improving Health
Research suggests that in terms of the health of the population, the overall wealth
of a given society is less important than how evenly wealth is distributed within that
society. The more equally wealth is distributed, the better the health of the population.9
It is estimated that if all Canadians achieved the same death rates as the highest income
earners, over one-fifth of all potential years of life lost before age 65 could be prevented10
(Chapters 1 and 2).
An income gradient affects health at every rung of the socioeconomic ladder, not just
the health of the poor. It also affects the social cohesion that characterizes a neighbourhood
or community.11 Therefore, middle-income and high-income Canadians also stand to
benefit from increases in income equality (Chapter 2).
Wages are the major source of income for most Canadians. Despite some recent
improvements, high rates of unemployment and underemployment remain problematic
among young people, women, Aboriginal people and visible minority groups. The wage
gap between men and women persists and women continue to dominate in low-paying
jobs. Canada’s performance on the United Nations measure of gender empowerment
suggests that Canada can do a better job of enabling women to gain decision-making
roles in business, industry and government (Chapters 1 and 2).
Canada’s tax, transfer and social policies have played a key role in reducing
inequities in Canada in the past. Canada’s universal health insurance scheme, which
provides access to needed medical services, has also been effective in reducing inequities
(Chapter 2). However, many low- and moderate-income Canadians do not have equal
access to necessary services such as eye care, dentistry, mental health counselling and
prescription drugs, which are not covered by current universal health-care plans. This
challenge is addressed earlier in this chapter.
Social services and recreation are important complements to health services,
especially in support of the healthy development of children and youth.12 Reductions
in access to social services and recreation are particularly hard on families with children
that have low- and moderate-incomes and cannot afford to purchase these services
(Chapter 3). Providing equitable access to safe, affordable housing is also an important
way to reduce inequities (Chapter 4).
At the time of writing, Canada was in the throes of a housing affordability crisis.
Reductions in the availability of social housing combined with cyclical recessions and
reductions in family incomes have contributed to the increase in the number of families
that live in low-income situations, and sometimes are homeless. In 1996, 30% of families
with children that rented had housing affordability problems. This increased to 58%
among lone-parent families and to 76% among lone-parents under the age of 30 (Chapter
4). Homelessness has increased and homeless Canadians include increasing numbers of
women and children and other groups in special circumstances, including Aboriginal
people, adolescents and people with mental illness.
A report from the Canadian Association of Food Banks stated that, in 1998, more
than 250,000 children and young people under the age of 18 were recipients of food
banks. Data from the 1996–97 NLSCY suggested that children who went hungry came
from families that depended on social assistance and from families that reported having
wages as a source of income. Thus, it appears that poor working families are vulnerable
to hunger, as are families on social assistance (Chapter 3).
Toward a Healthy Future
186
Improving Health
This report suggests that there are several key strategies for achieving a more equitable
distribution of incomes in Canada.
◆ Increase earning capacities and employment opportunities among individuals and groups
that have been left behind. These include women, young people (especially young men
with low levels of education and skills and lone female parents), Aboriginal people,
members of visible minority communities, and workers in specific industries (e.g. cod
and salmon fishing). Policies that promote full-time work for those who want it, fair
wages, pay equity, access to employee health benefits, fair unemployment benefits and
job diversification are all important strategies to consider.13 Support for increased
opportunities in education, literacy and skills training (discussed later) that enable
Canadians to pursue meaningful careers in the higher wage-earning sectors is equally
important (Chapter 2).
◆ Continue to use tax and transfer/social policies to reduce inequities among different
levels of wage earners. These have played a key role in reducing inequities in Canada
in the past. Any changes in these policies must be looked at carefully because of their
potential to ameliorate or increase inequities in income (and therefore in health
status) (Chapter 2).
◆
Review the effectiveness of current programs that provide a safety
net for Canadians who require assistance at different times in their
lives. The trends described in this report suggest that this may
be especially important for older women who live alone (one
in five lives below Statistics Canada’s LICO) and for young families
that experience economic setbacks due to unemployment,
underemployment, elevated housing costs and changes in family
structure (Chapters 2 and 3).
◆
Recognize the importance of recreation and social services to health
and find ways to provide equitable access to these services, regardless
of an individual’s or family’s ability to pay (Chapter 3).
◆
Find ways to ensure that all Canadian individuals and families have
their essential needs for shelter, privacy and security met. Work with
Aboriginal people to ensure adequate, appropriate housing both
on and off reserve (Chapter 4).
P
eople with higher
levels of education tend to
embrace positive health
practices more so than
people with low levels
of education.
◆ Develop long-term strategies to prevent hunger in Canada, including increased access
to healthy, affordable foods in Northern and rural communities and in urban settings.
While food banks serve an important stop-gap role, they provide only short-term and
partial solutions (Chapter 4).
Increase literacy levels and access to education for all Canadians.
Canadians with low literacy skills are more likely to be unemployed and poor, to suffer
poorer health and to die earlier than Canadians with high levels of literacy (Chapters 1
and 2). The positive links between level of education and other major determinants of
health are also well documented. For example, people with higher levels of education
Toward a Healthy Future
187
Improving Health
tend to embrace positive health practices more so than people with low levels of
education (Chapter 5), to have better access to healthy physical environments (Chapter 4)
and to be better able to optimally prepare their children for school (Chapter 3).
In 1995, Canada had more than twice the number of citizens who lacked adequate
literacy skills as Sweden, the country ranked number one on the United Nation’s Human
Poverty Index for industrialized countries (Chapter 2). While higher numbers of
newcomers who do not speak English or French may account for part of this difference,
the reasons for this need further exploration.
Educational achievement and literacy are usually, but not always, linked. For
example, seniors with low levels of formal education who have pursued lifelong learning
opportunities score higher on literacy tests than would be expected. Chapter 7 supports
the notion that the provision of opportunities for lifelong learning may be particularly
important for maintaining mental health and cognitive capacity in old age.
There is a core of young people who drop out of high school early. They tend to be
young men who are having difficulty in school and have limited emotional and financial
support for staying in school. In 1996, more young Canadians (especially women) were
gaining advanced degrees than ever before. However, between 1992 and 1997, tuition fees
for post-secondary education rose 70%, compared to a 6% rise in the Consumer Price
Index. As a result of increased tuition costs and increases in family poverty, the average
debt load for the growing number of students who must seek financial assistance to
attend college or university tripled in the 1990s. This is a worrisome trend that may
deter future students from seeking a higher education and cause an increasing number
of students to default on their loans.14
As the demand for workers with knowledge-based skills increases in the new
millennium, the marginalization of Canadians with low literacy skills and low levels
of education will worsen. Addressing this challenge must be a priority for all sectors:
schools, workplaces, communities, governments and families. Key strategies to address
this challenge include:
◆ Providing support for literacy upgrading programs in workplaces and communities for
people of all ages. This includes helping newcomers to Canada learn English or French
(Chapter 2).
◆ Encouraging young people to stay in school and finding ways to decrease the debt burden
for students who pursue a post-secondary education (Chapter 2).
◆ Preventing adolescent pregnancies. The evidence in this report has shown a consistent
link between a mother’s level of education, her own well-being and several indicators
related to children’s opportunities for a healthy start in life. We need to provide young
women with the information and support they need to stay in school and delay
pregnancy beyond the teen years (Chapters 1 and 3). At the same time, there is a need
to develop a strategy for helping young men stay in school and use safe sex practices
that prevent pregnancy and sexually transmitted diseases (Chapters 2 and 5).
◆ Increasing support for lifelong learning. This report has shown that stimulation and
opportunities to learn are important throughout life, beginning in infancy and
extending into old age. As discussed in a previous section, preparing preschoolers
for a successful entrance to school is especially important for their future health
and development (Chapters 3 and 7).
Toward a Healthy Future
188
Improving Health
A Vision for the Future
A vision for health in the new millennium would see all Canadians enjoying improved
health and well-being. Maintaining and improving health by enhancing quality of life,
increasing the number of years lived in good health and reducing inequities in health
status will require collaborative efforts in pursuit of five major outcomes. These represent
a synthesis of the major strategic directions articulated by the ACPH.
1. Positive, supportive living and working conditions in all communities, including:
• a thriving and sustainable economy with meaningful work for all
•
an adequate income for all Canadians and a reduction in the number of families
living in poverty
•
a more equitable distribution of income
•
healthy working conditions
•
educational, literacy and lifelong learning opportunities for all
•
supportive friendships and social support networks in all communities.
2. A safe, high-quality physical environment, including:
• a healthy and sustainable environment for all with access to good quality air, water
and food, and freedom from exposure to harmful toxins
•
suitable, adequate and affordable housing for all
•
safe, well-designed communities.
3. Opportunities for healthy development and support for individual choices that
enhance health and foster independence, including:
• healthy child development
•
healthy life choice decisions
•
enhanced independence for those who require assistance with activities of daily living.
4. Appropriate and affordable health services that are accessible to all, including:
• a continued commitment to a health-service system based on the principles of
universality, accessibility, comprehensiveness, portability and public administration
•
improved access to services that have been proven cost-effective but are not
consistently or uniformly available
•
decreased utilization of services, technologies and medications which the evidence
indicates are inappropriate, ineffective or over-utilized
•
improved service integration and effectiveness, and increased accountability for
improving health outcomes.
Toward a Healthy Future
189
Improving Health
5. Reductions in preventable illness, injuries and premature death, including:
• reductions in health problems that take a significant toll on the health of Canadians
and for which effective prevention or intervention strategies are available
•
an initial focus on priorities currently being addressed by several provinces and
territories and the federal government.
Conclusion
Canadians are among the healthiest people in the world. However, this good health is not
enjoyed equally by everyone. This report points to some important trends and challenges
that need to be addressed. Trends, however, are not destiny. It is possible to achieve positive
population health outcomes through the implementation of a broad population health
strategy that has a role for all sectors: public, private and not-for-profit.
A major challenge facing those who design, implement and manage policies, programs
and research is finding the means to effectively tackle the underlying determinants of
health and their interactions. As we have seen in this report, these determinants are
complex and dynamic. Thus, interventions must include both short- and long-term
strategies, within the health sector and in other sectors that influence health status. It
is hoped that the evidence presented in this report (and ones to follow) will help initiate
dialogue between sectors and guide the development of initiatives designed to improve
and promote public health in the new millennium.
As we enter a new century, our country continues to grow in complexity. Canada
is a federation of 10 provinces and three territories that supports bilingualism and
multiculturalism. The geography of Canada is vast and varied, and the diversity of our
population continues to grow. This breadth, complexity and diversity is both a challenge
and a strength.
There is an expectation that our past achievements and collective commitment to
improving the well-being of all Canadians will provide us with some exciting opportunities
to address the challenges presented in this report.
Endnotes for Chapter 8
1.
2.
3.
4.
5.
6.
Adapted to a Canadian setting from D. Werner and B. Bower in Helping Health Workers
Learn. Palo Alto, CA: The Hesperian Foundation, 1982.
Federal, Provincial and Territorial Advisory Committee on Population Health. A Definition
of Population Health. Ottawa: Advisory Committee on Population Health, 1997.
Canadian Public Health Association, World Health Organization, National Department of
Health and Welfare. Ottawa Charter for Health Promotion. Ottawa: CPHA, 1986.
Steinhauer, P. “Developing Resiliency in Children from Disadvantaged Populations.”
Determinants of Health: Children and Youth, Volume 1. Canada’s Health Action: Building on
the Legacy, Volume I. National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
McDaniel, S. “Toward Healthy Families.” Determinants of Health: Settings and Issues, Volume 3.
Canada’s Health Action: Building on the Legacy, Volume I. National Forum on Health.
Sainte-Foy: Éditions MultiMondes, 1998.
Anisef, P. “Making the Transition from School to Employment.” Determinants of Health:
Children and Youth, Volume 1. Canada’s Health Action: Building on the Legacy, Volume I.
National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
Toward a Healthy Future
190
Improving Health
7.
8.
9.
10.
11.
12.
13.
14.
Gottlieb, B. “Strategies to Promote the Optimal Development of Canada’s Youth.”
Determinants of Health: Children and Youth, Volume 1. Canada’s Health Action: Building on
the Legacy, Volume I. National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
Fralick, P., Hyndman, B. “Youth, Substance Abuse and the Determinants of Health.”
Determinants of Health: Children and Youth, Volume 1. Canada’s Health Action: Building on
the Legacy, Volume I. National Forum on Health. Sainte-Foy: Éditions MultiMondes, 1998.
Wilkinson, R. Unhealthy Societies: The Afflictions of Inequality. New York: Routledge, 1996.
Wilkins, R. “Mortality by Neighbourhood Income in Canada, 1986 to 1991.” Presented at the
Conference of the Canadian Society for Epidemiology and Biostatistics, St. John’s, Newfoundland,
August 1995.
Wilkinson, R. Unhealthy Societies: The Afflictions of Inequality.
Health Canada. “Health Services and Social Services.” Healthy Development of Children
and Youth. Ottawa: Health Canada (in press).
Sullivan, T., Uneke, O., Lavis, J., et al. “Labour Adjustment Policy and Health: Considerations
for a Changing World.” Determinants of Health: Settings and Issues, Volume 3. Canada’s Health
Action: Building on the Legacy, Volume I. National Forum on Health. Sainte-Foy: Éditions
MultiMondes, 1998.
Canadian Council on Social Development. The Progress of Canada’s Children, 1997. Ottawa:
CCSD, 1997.
Toward a Healthy Future
Appendices
Appendix A
Members of the Federal, Provincial and Territorial
Advisory Committee on Population Health (ACPH),
Working Groups and Production Consultants
Federal, Provincial and Territorial Advisory
Committee on Population Health (ACPH)
Ms. Cecilie Lord (Chair)
Assistant Deputy Minister
Health Strategies Division
Alberta Health
10025 Jasper Avenue, 24th Floor
Edmonton, AB T5J 2N3
Mr. Ian Potter (Vice-Chair)
Assistant Deputy Minister
Health Promotion and Programs Branch
Health Canada
Jeanne Mance Building
Room A1614, 16th Floor
Tunney’s Pasture (AL1916A)
Ottawa, ON K1A 1B4
Ms. Beverly Clarke (Newfoundland)
Assistant Deputy Minister
of Community Health
Department of Health and
Community Services
Main Floor, West Block
Confederation Building
Prince Phillip Drive
P.O. Box 8700
St. John’s, NF A1B 4J6
Ms. Carole Dilworth (New Brunswick)
Director
Program Analysis and Evaluation
Department of Health and
Community Services
7th Floor, Carleton Place
520 King Street
P.O. Box 5100
Fredericton, NB E3B 5G8
Toward a Healthy Future
194
Appendix A
Ms. Debra Keays (Nova Scotia)
Director
Public Health and Health Promotion
Department of Health
Joseph Howe Building
1690 Hollis Street, 11th Floor
P.O. Box 488
Halifax, NS B3J 2R8
Ms. Teresa Hennebery (P.E.I)
Director, Public Health and Evaluation
Department of Health and Social Services
11 Kent Street
P.O. Box 2000
Charlottetown, PE C1A 7N8
Dr. Richard Massé (Quebec)
Assistant Deputy Minister
Ministère de la Santé et des
Services sociaux
1075 Ste-Foy Road, 2nd Floor
Quebec, QC G1S 2M1
Ms. Barbara Hansen (Alberta)
Senior Strategy Lead
Population Health Strategies Branch
Telus Plaza North Tower, 23rd Floor
P.O. Box 1360, Stn. Main
10025 Jasper Avenue
Edmonton, AB T5J 2N3
Dr. Perry Kendall (B.C.)
Provincial Health Officer
Ministry of Health
1810 Blanshard Street, 3rd Floor
Victoria, BC V8V 1X4
Mr. Ron Pearson (Yukon)
Director, Health Programs
Government of Yukon Territory
2 Hospital Road
Whitehorse, YK Y1A 3H8
Dr. André Corriveau (N.W.T.)
Director
Population Health
Northwest Territories Department
of Health and Social Services
5022-49th Street
Centre Square Tower, 6th Floor
P.O. Box 1320
Yellowknife, NT X1A 2L9
Dr. Colin D’Cunha (Ontario)
Chief Medical Officer of Health
and Director
Public Health Branch
Ontario Ministry of Health
5700 Yonge Street, 8th Floor
Toronto, ON M2M 4K5
Ms. Janet Braunstein-Moody (Nunavut)
Director of Policy and Planning
Nunavut Department of Health and
Social Services
P.O. Box 800
Iqualuit, Nunavut X0A 0H0
Ms. Sue Hicks (Manitoba)
Associate Deputy Minister
External Programs and Operations
Manitoba Health
599 Empress Street, 2nd Floor
Winnipeg, MB R3C 2T6
Ms. Marlene Smadu (Saskatchewan)
Assistant Deputy Minister
Saskatchewan Health
T.C. Douglas Building
3475 Albert Street
Regina, SK S4S 6X6
Dr. Clyde Hertzman
(Non-governmental representative)
Department of Health Care
and Epidemiology
University of British Columbia
Mather Building
5804 Fairview Avenue
Vancouver, BC V6T 1Z3
Toward a Healthy Future
195
Appendix A
Dr. David Kinloch
(Non-governmental representative)
Consultant and Policy Researcher
5018 49th Street, 1703 Northern Heights
Yellowknife, NT X1A 3R6
Dr. Ralph Nilson
(Non-governmental representative)
Dean
Faculty of Physical Activity Studies
Room 109.1 PAC
University of Regina
3737 Wascana Parkway
Regina, SK S4S 0A2
Mr. Craig Shields
(Non-governmental representative)
Consultant in Health and Social Services
Human Services Consultants
33 Cricklewood Crescent
Thornhill, ON L3T 4T8
Dr. Bryce Larke (Co-Chair F/P/T AIDS)
Provincial Medical Consultant,
HIV/AIDS/Hepatitis
Disease Control and Prevention
Alberta Health
Telus Plaza North Tower, 23rd Floor
10025 Jasper Avenue
P.O. Box 1360, Stn. Main
Edmonton, AB T5J 2N3
Dr. Tariq Bhatti (Health Canada)
Director
Population Health Development Division
Population Health Directorate
Health Canada
Jeanne Mance Building
Tunney’s Pasture (AL1908C1)
Ottawa, ON K1A 1B4
Observer
Mr. Gary Catlin
Director
Health Statistics Division
Statistics Canada
18th Floor, Section F
R.H. Coats Building
Tunney’s Pasture
Ottawa, ON K1A 0T6
Secretariat
Ms. Julie Pigeon
Program Manager
Development and Project
Management Section
Population Health Development Division
Population Health Directorate
Health Canada
Jeanne Mance Building
Tunney’s Pasture (AL1908C1)
Ottawa, ON K1A 1B4
Mr. Pierre Génier
Manager
Development and Project
Management Section
Population Health Development Division
Population Health Directorate
Health Canada
Jeanne Mance Building
Tunney’s Pasture (AL1908C1)
Ottawa, ON K1A 1B4
Toward a Healthy Future
196
Appendix A
ACPH Working Group on the Report on the Health of Canadians
Dr. Shaun Peck (Co-Chair,
as of December 1998)
Deputy Provincial Health Officer
Ministry of Health
1810 Blanshard Street, 3rd Floor
Victoria, BC V8V 1X4
Mr. Randy Passmore
Senior Policy Analyst
Policy and Planning Branch
Saskatchewan Health
3475 Albert Street
Regina, SK S4S 6X6
Ms. Kim Elmslie (Co-Chair,
as of December 1998)
A/Director
National Health Research and
Development Program
Information, Analysis and
Connectivity Branch
Health Canada
Jeanne Mance Building, Room A1513
Tunney’s Pasture (AL1915A)
Ottawa, ON K1A 1B4
Dr. Stephan Gabos
Senior Team Leader
Health Surveillance Branch
Alberta Health
10025 Jasper Avenue, 9th Floor
Edmonton, AB T5J 2N3
Ms. Hope Beanlands
Coordinator
Public Health Enhancement
Public Health and Health Promotion
Department of Health
Joseph Howe Building
1690 Hollis Street, 11th Floor
P.O. Box 488
Halifax, NS B3J 2R8
Ms. Madeleine Levasseur
Research Officer
Direction générale de la Santé publique
Ministère de la Santé et des
Services sociaux
201 Cremazie Street East, 3rd Floor
Montreal, QC H2M 1L2
Dr. Jamie Blanchard
Provincial Epidemiologist
Manitoba Health
800 Portage Avenue, 4th Floor
Winnipeg, MB R3G 0N4
Dr. Clyde Hertzman
Department of Health Care
and Epidemiology
University of British Columbia
Mather Building
5804 Fairview Avenue
Vancouver, BC V6T 1Z3
Mr. Craig Shields
Consultant in Health and Social Services
Human Services Consultants
33 Cricklewood Crescent
Thornhill, ON L3T 4T8
Dr. John Millar (Chair, until
December 1998)
Vice-President
Canadian Institute for Health
Information
377 Dalhousie Street, Suite 200
Ottawa, ON K1N 9N8
Mr. Serge Taillon
Director, Planning and Communications
Canadian Institute for Health
Information
377 Dalhousie Street, Suite 200
Ottawa, ON K1N 9N8
Toward a Healthy Future
197
Appendix A
Mr. Gary Catlin
Director
Health Statistics Division
Statistics Canada
18th Floor, Section F
R.H. Coats Building
Tunney’s Pasture
Ottawa, ON K1A 0T6
Dr. Gregory Sherman
Senior Scientific Advisor
Health Analysis Unit
First Nations and Inuit Health
Programs Directorate
Medical Services Branch
Health Canada
Jeanne Mance Building, Room 2099D
Tunney’s Pasture (AL1920D)
Ottawa, ON K1A 0L3
Ms. Rachel Moore
Head
Health Expenditures Surveillance Unit
Bureau of Operations, Planning and Policy
Laboratory Centre for Disease Control
Health Protection Branch
Health Canada
LCDC Building
Tunney’s Pasture (AL0602D)
Ottawa, ON K1A 0L2
Ms. Monique de Groot
Senior Program Manager
Population Health Directorate
Health Promotion and Programs Branch
Health Canada
Jeanne Mance Building
Tunney’s Pasture (AL1908C1)
Ottawa, ON K1A 1B4
Secretariat
Ms. Carol Silcoff
Manager, Research Development and Analysis Section
National Health Research and Development Program
Information, Analysis and Connectivity Branch
Health Canada
Jeanne Mance Building, Room D1596
Tunney’s Pasture (AL1915A)
Ottawa, ON K1A 1B4
Former Members
Dr. Peter Barss
Government of Northwest Territories
Dr. Hilary Robinson
Health Canada
Dr. Maureen Carew
Health Canada
Ms. Linda Senzilet
Health Canada
Dr. Paul Gully
Health Canada
Dr. Odette Laplante
Ministère de la Santé et des
Services sociaux
Toward a Healthy Future
198
Appendix A
Health Canada Working Group on the Report of the Health of Canadians
Carol Silcoff (Chair)
Information, Analysis and Connectivity
Branch
Nancy Hamilton
Information, Analysis and Connectivity
Branch
Bill Bradley
Policy and Consultation Branch
Glenn Irwin
Health Promotion and Programs Branch
Eric Jenkins
Health Promotion and Programs Branch
Tom Lips
Health Promotion and Programs Branch
William Murray
Health Promotion and Programs Branch
Margaret Moyston-Cumming
Policy and Consultation Branch
Eric Nicholls
Health Promotion and Programs Branch
Patricia Dunn-Erickson
Policy and Consultation Branch
Sylvain Paradis
Health Promotion and Programs Branch
Abby Hoffman
Office of the Deputy Minister
Jane Boswell-Purdy
Health Promotion and Programs Branch
Lynda Bottoms
Health Promotion and Programs Branch
Carmen Connolly
Health Promotion and Programs Branch
Monique de Groot
Health Promotion and Programs Branch
George Torrance
Health Promotion and Programs Branch
Gregory Sherman
Medical Services Branch
Rachel Moore
Health Protection Branch
Toward a Healthy Future
199
Appendix A
Centre for Health Promotion, University of Toronto
Peggy Edwards
Head Writer
Irving Rootman
Director, Centre for Health Promotion
Reg Warren
Data Analyst
Kathryn Joly
Word Processing
Rick Wilson
Project Manager
Design, Editing and Production
Allium Consulting Group Inc.
Translation
Communications Essema
Toward a Healthy Future
Appendix B
Selected Health Indicators —
Canada, the Provinces and Territories
Introductory Note
This appendix contains approximately 100 of the indicators most commonly used
to measure health, and the factors that determine the health of Canadians. All of the
indicators described in this Appendix are derived from and documented more fully
in the Statistical Report on the Health of Canadians.
The Statistical Report includes: discussion of each of these measures and their
derivation; applicable population boundaries (e.g. age groups); scope of coverage; time
frames; and sources. The Statistical Report also addresses the interpretation of interjurisdictional comparisons in light of factors such as the limitations of the data-sets
and their comparability.
In this section, estimates with high sampling variability have been replaced with
a pound sign (#), while those with moderate sampling variability have been identified
with an asterisk (*).
Unfortunately, comparative data from the Northwest Territories and the Yukon
Territory are sometimes missing, because analysis of the National Population Health
Survey was still under way in the Territories and a number of surveys are not carried
out in the Territories. Please note that data pertaining to Nunavut are reported under
Northwest Territories.
Caution should be used in drawing comparisons between jurisdictions as a result
of differing sample sizes and reporting conventions. Provincial and territorial estimates
reported in this appendix are not age-standardized, unless otherwise noted. While a
number of notes and some information about sources are included here, readers are
referred to the companion Statistical Report on the Health of Canadians for more details
on reporting methodologies.
Toward a Healthy Future
202
Appendix B
Indicator Data: Canada, Provinces and Territories
Indicator
Canada
NF
PEI
NS
NB
QC
ON
Excellent health (self-rated)
25%
26%
22%
20%
21%
27%
25%
High self-esteem
49%
35%
40%
37%
41%
62%
47%
High mastery
21%
13%
17%
19%
14%
22%
22%
High sense of coherence
28%
36%
33%
28%
27%
25%
30%
16%
16%
20%
25%
19%
15%
14%
Well-being
Function
Long-term activity limitation
Disability days (past 2 weeks)
0.85
0.81
0.80
1.05
1.02
0.64
0.80
Very good health (functional status)
88%
91%
89%
85%
87%
90%
88%
Injuries (admissions/10,000 pop.)
72.2
66.0
57.7
61.5
81.0
60.9
63.3
Work injuries (per 1,000 workers)
27.6
27.7
40.6
20.6
12.5
37.2
19.4
Traffic deaths (per 100,000 pop.)
10
8
14
12
12
12
8
Traffic injuries (per 100,000 pop.)
762
463
618
663
627
641
775
Low birthweight rate
5.8%
6.1%
5.3%
5.4%
5.1%
5.9%
6.0%
Stillbirths (per 10,000 births)
65.4
44.8
70.4
Overweight (age 20 to 64)
29%
39%
37%
38%
42%
27%
29%
4%
#
#
5%
5%
4%
4%
Injuries
Miscellaneous Conditions
35.3
65.8
Mental Health
Depression (probable)
High chronic stress
26%
17%
20%
27%
26%
24%
28%
Psychiatric hospitalization rate
709.1
749.9
1,181.9
749.0
857.0
706.7
676.9
4%
#
#
#
#
3%
5%
41,049
178
217
8,553
18,552
Gonorrhea (per 100,000 pop.)
16.8
0.4
0.7
10.3
5.4
6.5
20.5
Chlamydia (per 100,000 pop.)
114.8
48.8
95.8
113.9
109.3
90.1
94.2
Measles (per 100,000 pop.)
1.1
0.0
0.0
0.3
0.0
1.1
1.7
Pertussis (per 100,000 pop.)
18.0
10.7
24.9
24.3
16.4
17.9
6.4
High work stress
Sexually Transmitted Diseases
HIV positive tests
PEI+NS* = 531*
Vaccine-Preventable Diseases
Enteric, Foodborne and Waterborne Diseases
Campylobacter (per 100,000 pop.)
42.7
17.7
31.5
22.5
33.6
38.1
47.8
Salmonella (per 100,000 pop.)
22.0
8.9
11.0
15.6
21.0
21.8
23.7
Giardia (per 100,000 pop.)
20.3
7.3
6.6
15.8
14.6
12.6
22.5
Hepatitis A (per 100,000 pop.)
8.7
0.2
0.7
1.2
1.0
8.0
5.5
E. coli 0157 (per 100,000 pop.)
4.1
0.3
7.3
3.9
0.7
4.1
4.1
Toward a Healthy Future
203
Appendix B
Indicator Data: Canada, Provinces and Territories
MB
SK
AB
BC
YT
NT
Canada
Indicator
21%
17%
25%
25%
25%
Excellent health (self-rated)
34%
34%
44%
46%
49%
High self-esteem
13%
15%
22%
21%
21%
High mastery
31%
34%
28%
28%
28%
High sense of coherence
Well-being
Function
18%
22%
18%
21%
16%
Long-term activity limitation
1.02
0.93
1.00
1.05
0.85
Disability days (past 2 weeks)
87%
86%
88%
86%
88%
Very good health (functional status)
Injuries
89.1
106.3
93.6
91.7
32.8
29.2
22.5
39.7
111.3
8
13
12
10
22
914
664
728
1,022
1,081
136.3
72.2
Injuries (admissions/10,000 pop.)
27.6
Work injuries (per 1,000 workers)
22
10
Traffic deaths (per 100,000 pop.)
388
762
Traffic injuries (per 100,000 pop.)
Miscellaneous Conditions
5.5%
5.0%
6.1%
5.2%
4.3%
5.5%
5.8%
Low birthweight rate
78.2
60.6
66.9
69.5
0
31.3
65.4
Stillbirths (per 10,000 births)
35%
36%
30%
27%
29%
Overweight (age 20 to 64)
Mental Health
5%
5%
5%
5%
4%
29%
25%
24%
26%
857.0
797.2
647.3
721.7
5%
#
4%
4%
621
378
2,976
8,993
21
48.4
39.5
16.9
13.7
224.4
219.3
174.3
106.7
653.1
811.7
Depression (probable)
26%
High chronic stress
709.1
Psychiatric hospitalization rate
4%
High work stress
29
41,049
HIV positive tests
31.8
187.8
16.8
Gonorrhea (per 100,000 pop.)
458.6
1,344.9
114.8
Chlamydia (per 100,000 pop.)
Sexually Transmitted Diseases
Vaccine-Preventable Diseases
0.0
0.8
0.3
1.1
6.4
0.0
1.1
Measles (per 100,000 pop.)
17.4
52.2
36.9
25.4
421.7
72.0
18.0
Pertussis (per 100,000 pop.)
Enteric, Foodborne and Waterborne Diseases
17.5
24.4
32.0
67.9
28.7
29.9
42.7
Campylobacter (per 100,000 pop.)
18.9
25.5
21.2
21.7
25.5
41.9
22.0
Salmonella (per 100,000 pop.)
39.2
19.5
33.7
70.1
32.9
20.3
Giardia (per 100,000 pop.)
21.4
44.1
7.1
12.6
0.0
3.0
8.7
Hepatitis A (per 100,000 pop.)
9.1
3.0
5.1
3.6
0.0
0.0
4.1
E. coli 0157 (per 100,000 pop.)
Toward a Healthy Future
204
Appendix B
Indicator Data: Canada, Provinces and Territories
Indicator
Canada
NF
PEI
NS
NB
QC
ON
Cancer (new cases per 100,000 population)
Women
346
286
384
354
335
334
350
Men
501
390
563
478
532
511
493
Cancer (deaths per 100,000 population)
Women
151
149
168
167
158
157
151
Men
232
273
281
264
255
260
223
Arthritis/Rheumatism
14%
14%
18%
20%
16%
12%
14%
Asthma
7%
5%
6%
6%
6%
7%
7%
Back problems
14%
11%
12%
14%
13%
11%
15%
Chronic Conditions
Food allergies
7%
4%
7%
7%
9%
5%
7%
Non-food allergies
22%
15%
18%
25%
22%
22%
23%
Total
653
710
753
700
680
666
648
Cancer (all)
185
189
207
210
193
203
180
Lung cancer
49
50
57
58
55
61
45
Breast cancer (women only)
29
28
24
30
33
29
29
Deaths (per 100,000 population)
Cardiovascular disease
226
281
277
233
236
220
229
Coronary heart disease
133
165
165
134
127
135
140
Stroke
47
62
63
42
44
41
48
Respiratory (all)
58
50
76
68
59
56
55
Pneumonia/Influenza
22
18
41
28
18
16
23
Accidents (all)
43
36
45
46
42
49
38
Suicide (all)
13
7
9
12
12
19
9
Infant mortality (per 1,000 live births)
5.6
6.6
4.7
5.6
4.9
4.6
5.7
Perinatal mortality rate
(per 1,000 births)
6.7
6.9
7.7
6.2
6.2
5.7
7.2
Early neonatal mortality rate
(per 1,000 live births)
3.3
4.5
4.7
3.2
2.4
2.9
3.4
Therapeutic abortions (per 100 live births) 18.7
9.0
0.5
16.8
7.3
20.8
19.9
Toward a Healthy Future
205
Appendix B
Indicator Data: Canada, Provinces and Territories
MB
SK
AB
BC
YT
NT
Canada
Indicator
360
329
338
332
346
Women
549
451
453
447
501
Men
154
139
143
143
151
Women
228
217
211
201
232
Men
15%
19%
13%
14%
14%
Arthritis/Rheumatism
7%
7%
7%
8%
7%
Asthma
16%
17%
15%
16%
14%
Back problems
Cancer (new cases per 100,000 population)
Cancer (deaths per 100,000 population)
Chronic Conditions
7%
9%
7%
8%
7%
Food allergies
18%
23%
21%
25%
22%
Non-food allergies
Deaths (per 100,000 population)
668
640
639
623
887
1,005
653
Total
185
172
174
166
210
285
185
Cancer (all)
48
43
42
45
83
66
49
Lung cancer
30
25
29
26
12
11
29
Breast cancer (women only)
241
222
233
207
243
216
226
Cardiovascular disease
141
122
127
112
136
58
133
Coronary heart disease
51
45
49
48
11
45
47
Stroke
58
61
58
61
59
179
58
Respiratory (all)
27
28
22
26
20
78
22
Pneumonia/Influenza
45
50
53
41
126
128
43
Accidents (all)
11
14
16
10
35
32
13
Suicide (all)
6.7
8.4
6.2
5.1
#
12.2
5.6
Infant mortality (per 1,000 live births)
7.6
7.1
7.0
6.2
4.5
7.6
6.7
Perinatal mortality rate
(per 1,000 births)
3.8
4.5
3.4
2.9
#
2.6
3.3
Early neonatal mortality rate
(per 1,000 live births)
17.6
13.6
17.0
18.3
27.2
17.1
18.7
Therapeutic abortions (per 100 live births)
Toward a Healthy Future
206
Appendix B
Indicator Data: Canada, Provinces and Territories
Indicator
Canada
NF
PEI
NS
NB
QC
ON
Potential Years of Life Lost (per 100,000 population), age standardized
Total
3,804
3,721
3,687
3,983
3,736
4,032
3,453
Cancer
1,098
1,152
1,189
1,264
1,126
1,192
1,079
Accidents
746
759
829
860
758
735
601
Suicide
417
224
188
367
394
660
284
Respiratory
113
77
144
147
77
108
110
Heart disease
491
663
642
592
589
521
475
Stroke
91
110
138
64
82
98
93
Other
848
737
557
689
711
717
810
78.6
77.7
77.2
77.8
78.2
78.4
78.9
Life Expectancy at Birth
Total
Men
75.7
75.0
73.9
74.9
75.2
75.2
76.1
Women
81.4
80.5
80.7
80.7
81.2
81.5
81.4
Less than high school
35%
45%
42%
39%
40%
36%
33%
University completed
16%
10%
13%
15%
12%
15%
17%
25,196
19,710
20,527
21,552
20,755
23,198
27,309
20%
21%
15%
19%
19%
23%
18%
Labour force participation rate
64.8%
52.5%
66.3%
60.2%
60.1%
62.1%
65.9%
Unemployment rate
9.2%
18.8%
14.9%
12.2%
12.8%
11.4%
8.5%
Any
89%
85%
87%
87%
87%
88%
89%
60+ hours
5%
10%
5%
6%
6%
4%
5%
Unpaid child care (some)
38%
39%
40%
38%
38%
39%
38%
Unpaid senior care (some)
17%
16%
19%
17%
18%
16%
16%
Effective family functioning
92%
93%
94%
92%
93%
91%
92%
Consistent parenting
58%
54%
58%*
59%
53%
47%
61%
Positive interaction
51%
56%
47%*
50%
52%
52%
51%
Smoking bylaws (population covered) 63%
3%
13%
27%
30%
51%
81%
Smoke-free schools
65%
66%
66%
78%
59%
15%
93%
Smoke-free daycares
51%
55%
50%
48%
47%
35%
53%
Smoke-free health-care settings
29%
44%
18%
18%
31%
7%
30%
Education
Income
Average individual income ($)
Low-income persons (%)
Unpaid Household Activities
Smoking Bylaws/Bans
Toward a Healthy Future
207
Appendix B
Indicator Data: Canada, Provinces and Territories
MB
SK
AB
BC
YT
NT
Canada
Indicator
4,066
4,203
3,943
3,986
4,742
7,695
3,804
Total
1,147
1,086
1,009
960
775
1,479
1,098
Cancer
936
964
963
828
1,788
2,309
746
Accidents
351
508
529
279
457
1,480
417
Suicide
140
161
129
102
86
370
113
Respiratory
546
523
492
385
559
481
491
Heart disease
121
82
86
75
0
269
91
Stroke
824
879
735
1,357
1,078
1,308
848
Other
Potential Years of Life Lost (per 100,000 population), age standardized
Life Expectancy at Birth
78.2
78.4
78.7
79.0
76.1
72.7
78.6
Total
75.5
75.5
76.0
76.1
72.3
69.9
75.7
Men
80.8
81.4
81.3
81.9
84.7
75.8
81.4
Women
Education
41%
43%
34%
31%
28%
42%
35%
Less than high school
14%
13%
15%
16%
17%
12%
16%
University completed
Income
22,667
22,541
26,138
26,295
21%
18%
18%
20%
29,079
29,011
25,196
20%
Average individual income ($)
66.9%
66.4%
71.8%
64.9%
64.8%
Labour force participation rate
6.6%
6.0%
6.0%
8.7%
9.2%
Unemployment rate
Low-income persons
Unpaid Household Activities
89%
90%
90%
89%
89%
88%
89%
Any
6%
7%
5%
5%
6%
8%
5%
60+ hours
40%
41%
41%
36%
42%
57%
38%
Unpaid child care (some)
20%
21%
16%
15%
12%
21%
17%
Unpaid senior care (some)
92%
91%
91%
92%
92%
Effective family functioning
62%
64%
65%
63%
58%
Consistent parenting
49%
41%
51%
51%
51%
Positive interaction
Smoking Bylaws/Bans
62%
55%
70%
71%
72%
65%
49%
67%
55%
49%
53%
54%
47%
44%
28%
37%
63%
Smoking bylaws (population covered)
YT+NWT = 57%
65%
Smoke-free schools
YT+NWT = 24%
51%
Smoke-free daycares
YT+NWT = 81%
29%
Smoke-free health-care settings
Toward a Healthy Future
208
Appendix B
Indicator Data: Canada, Provinces and Territories
Indicator
Canada
NF
PEI
NS
NB
QC
ON
Current smoker
28%
31%
32%
31%
28%
32%
25%
Regular drinker
53%
48%
44%
47%
42%
57%
52%
14+ drinks per week
9%
11%
10%
12%
10%
9%
9%
5+ drinks per occasion
42%
53%
48%
51%
47%
39%
39%
Driving after drinking (1+ times)
10%
8%
9%
7%
7%
10%
7%
Currently use cannabis
7%
4%
#
8%
6%
9%
5%
1+ illicit drugs, lifetime
24%
16%
19%
25%
22%
25%
17%
Physically active
21%
18%
14%
18%
18%
17%
21%
Walk to work
7%
10%
7%
8%
7%
7%
6%
Always use bicycle helmet
29%
#
#
37%
21%
19%
33%
Always insist on seatbelt use
86%
88%
83%
82%
88%
87%
86%
Took actions to improve health
47%
41%
43%
46%
44%
44%
50%
Influenza vaccination, ever
26%
18%
27%
33%
24%
17%
32%
Pap smear test, ever (age 18+)
Personal Health Practices
Health-Care Services
87%
91%
87%
90%
89%
82%
88%
Screening mammogram, past 2 years
(age 50–69)
54%
29%
56%
40%
60%
49%
59%
Blood pressure test, past year
71%
73%
67%
75%
71%
68%
75%
HIV/AIDS test, ever
15%
8%
8%
11%
8%
14%
17%
Visits to health professional (1+)
93%
88%
92%
93%
90%
91%
94%
Visits to a physician (1+)
81%
80%
80%
82%
80%
76%
83%
Visits to a dentist, past year
62%
44%
58%
57%
52%
53%
71%
Dental insurance
55%
43%
48%
50%
53%
40%
63%
Eye examination, past year
42%
31%
39%
39%
34%
39%
48%
Insurance for corrective lenses
47%
47%
51%
52%
56%
34%
57%
1+ medications used, past two days
63%
63%
68%
69%
71%
62%
64%
Insurance for prescription meds.
61%
57%
58%
67%
63%
55%
66%
Unmet health-care needs
5%
3%
5%
5%
6%
3%
6%
433.1
180.3
332.4
380.3
190.9
449.1
465.3
Hospital (average days of stay)
11
8
8
8
8
13
10
Health expenditures (% of GDP)
9.2%
12.1%
11.8%
10.9%
10.8%
9.5%
8.9%
Emergency visits (per 1,000 pop.)
Per capita health expenditures ($)
2,512.72 2,266.86 2,465.77 2,273.71 2,371.39 2,309.01 2,624.27
Toward a Healthy Future
209
Appendix B
Indicator Data: Canada, Provinces and Territories
MB
SK
AB
BC
YT
NT
Canada
Indicator
26%
29%
28%
24%
28%
Current smoker
52%
54%
52%
56%
53%
Regular drinker
11%
8%
9%
10%
9%
14+ drinks per week
48%
48%
48%
44%
42%
5+ drinks per occasion
13%
21%
12%
11%
10%
Driving after drinking (1+ times)
9%
7%
8%
12%
7%
Currently use cannabis
26%
22%
30%
37%
24%
1+ illicit drugs, lifetime
20%
20%
26%
27%
21%
Physically active
9%
10%
7%
7%
7%
Walk to work
12%
#
26%
53%
29%
Always use bicycle helmet
77%
82%
78%
89%
86%
Always insist on seatbelt use
46%
39%
48%
49%
47%
Took action to improve health
Personal Health Practices
15%
42%
Health-Care Services
26%
23%
28%
29%
26%
Influenza vaccination, ever
90%
93%
90%
86%
87%
Pap smear test, ever (age 18+)
50%
50%
56%
54%
54%
Screening mammogram,
past 2 years (age 50–69)
72%
68%
69%
66%
71%
Blood pressure test, past year
11%
8%
15%
17%
15%
HIV/AIDS test, ever
93%
92%
91%
93%
93%
Visits to health professional (1+)
81%
81%
80%
83%
81%
Visits to a physician (1+)
60%
48%
59%
64%
62%
Visits to a dentist, past year
58%
50%
62%
59%
55%
Dental insurance
37%
43%
38%
36%
42%
Eye examination, past year
40%
26%
43%
49%
47%
Insurance for corrective lenses
62%
69%
62%
63%
63%
1+ medications used, past two days
47%
40%
67%
62%
61%
Insurance for prescription medications
7%
6%
8%
6%
502.1
151.7
479.2
433.5
527.8
280.7
433.1
5%
10
8
6
13
4
5
11
Hospital (average days of stay)
10.4%
9.0%
7.1%
9.9%
8.7%
12.9%
9.2%
Health expenditures (% of GDP)
2,579.30 2,477.06 2,380.35 2,728.32 3,267.22 5,563.87 2,512.72
Toward a Healthy Future
Unmet health-care needs
Emergency visits (per 1,000 pop.)
Per capita health expenditures ($)
210
Appendix B
Indicator Data: Notes and Sources
Indicator
Topic Number
(Statistical Report)†
Notes and Sources
Well-being
Excellent health (self-rated)
53
Age 12+, NPHS,** 1996–97. Percentage rating their
health as “excellent.”
High self-esteem
54
Age 12+, NPHS, 1994–95. “High” is a score of 20 or
more out of a possible 24 on the Self-esteem Scale.
High mastery
54
Age 12+, NPHS, 1994–95. “High” is a score of 23
or more out of 28 on the Mastery Scale.
High sense of coherence
54
Age 18+, NPHS, 1994–95. “High” is a score of 67 or
greater (the approximate 70th percentile)
on the Sense of Coherence Scale.
Long-term activity limitation
58
Age 12+, NPHS, 1996–97. Any limitation or disability
in normal activities, at home, school or work.
Disability days (in past 2 weeks)
57
All ages, NPHS, 1996–97.
Very good health (functional status)
56
Age 12+, NPHS, 1996–97. Percentage with very
good health, a score of 0.80–1.00, based on eight
attributes: vision, hearing, speech, mobility, dexterity,
cognition, emotion, and pain/discomfort.
Injuries (admissions per 10,000 pop.)
60
All ages, National Trauma Registry, 1995–96.
Acute care hospital admissions due to injury.
Work injuries (per 1,000 workers)
resulting in time off work
61
Age 15+, 1996, Statistics Canada,
Health Statistics Division. Calculated
with data from the National Work Injuries Section
and the Labour Force Survey Subdivision.
Traffic deaths (per 100,000 pop.)
63
All ages, 1996, Transport Canada, Motor Vehicle
Traffic Collision Statistics.
Traffic injuries (per 100,000 pop.)
63
All ages, 1996, Transport Canada, Motor Vehicle
Traffic Collision Statistics.
Low birthweight
64
Percentage of all live births less than 2,500 grams,
1996. Statistics Canada. The Daily, July 8, 1998.
Stillbirths (per 10,000 births)
65
Rate per 10,000 births, 1995. Health Canada,
Birth Defect Prevalences in Canada, 1995.
Overweight (age 20–64)
67
Age 20–64, NPHS, 1996–97. Body Mass Index
(weight in kilograms/[height in metres, squared])
27.0 or greater.
Function
Injuries
Miscellaneous Conditions
Toward a Healthy Future
211
Appendix B
Mental Health
Depression (probable)
75
Age 12+, NPHS, 1996–97. 90% probability of
suffering a major depressive episode.
High chronic stress
8
Age 18+, NPHS, 1994–95. Score of 5 or more
on 18-item scale.
Psychiatric hospitalization rate
76
All ages, 1995–96. Separations in psychiatric
hospitals and general hospitals per 100,000
population, Canadian Institute for Health Information,
Mental Health Database.
High work stress
9
Employed Canadians, age 15–74, NPHS, 1994–95.
Based on a score of 30 or more on a 12-item
(60 point) work stress scale.
HIV positive tests
71
All ages, cumulative total reported HIV positive tests
to December 31, 1997. (Note: excludes Quebec
results for 1997). Health Canada. HIV and AIDS in
Canada, Surveillance Report to December 31, 1997.
Gonorrhea (per 100,000 pop.)
70
All ages, 1996. Health Canada, Special tabulations.
Chlamydia (per 100,000 pop.)
70
All ages, 1996. Health Canada, Special tabulations.
Measles (per 100,000 pop.)
69
All ages, 1996. Health Canada. Canada Communicable
Diseases Report, 1997.
Pertussis (whooping cough,
per 100,000 pop.)
69
All ages, 1996. Health Canada. Canada Communicable
Diseases Report, 1997.
Sexually Transmitted Diseases
Vaccine-Preventable Diseases
Enteric, Foodborne and Waterborne Diseases
Campylobacter (per 100,000 pop.)
72
All ages, 1996. Health Canada. Notifiable diseases
annual summary, 1996. Canada Communicable
Diseases Report, 1998.
Salmonella (per 100,000 pop.)
72
All ages, 1996. Health Canada. Notifiable diseases
annual summary, 1996. Canada Communicable
Diseases Report, 1998.
Giardia (per 100,000 pop.)
72
All ages, 1996. Health Canada. Notifiable diseases
annual summary, 1996. Canada Communicable
Diseases Report, 1998.
Hepatitis A (per 100,000 pop.)
72
All ages, 1996. Health Canada. Notifiable diseases
annual summary, 1996. Canada Communicable
Diseases Report, 1998.
E-coli 0157 (per 100,000 pop.)
72
All ages, 1996. Health Canada. Notifiable diseases
annual summary, 1996. Canada Communicable
Diseases Report, 1998.
Cancer (new cases per 100,000 population)
Women
73
All ages, estimated rates, 1998. National Cancer
Institute of Canada. Canadian Cancer Statistics, 1998.
Men
73
All ages, estimated rates, 1998. National Cancer
Institute of Canada. Canadian Cancer Statistics, 1998.
Toward a Healthy Future
212
Appendix B
Cancer (deaths per 100,000 population)
Women
73
All ages, estimated rates, 1998. National Cancer
Institute of Canada. Canadian Cancer Statistics, 1998.
Men
73
All ages, estimated rates, 1998. National Cancer
Institute of Canada. Canadian Cancer Statistics, 1998.
Arthritis/Rheumatism
68
Age 12+, NPHS, 1996–97. Percentage reporting
chronic condition.
Asthma
68
Age 12+, NPHS, 1996–97. Percentage reporting
chronic condition.
Back problems
68
Age 12+, NPHS, 1996–97. Percentage reporting
chronic condition.
Food allergies
68
Age 12+, NPHS, 1996–97. Percentage reporting
chronic condition.
Non-food allergies
68
Age 12+, NPHS, 1996–97. Percentage reporting
chronic condition.
Total
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Cancer (all)
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Lung cancer
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Breast cancer (women only)
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Cardiovascular disease
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Coronary heart disease
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Stroke
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Respiratory (all)
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Pneumonia/Influenza
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Accidents (all)
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Suicide (all)
82
1996 (age standardized to the 1991 population).
Statistics Canada. Health Indicators, 1997.
Infant mortality (per 1,000 live births)
78
1996. Deaths (per 1,000 live births). Statistics
Canada, Compendium of Vital Statistics, 1996.
Perinatal mortality (per 1,000 births)
78
1996. Stillbirths and infant deaths under one week
of age (per 1,000 births). Statistics Canada,
Compendium of Vital Statistics, 1996.
Early neonatal mortality
(per 1,000 live births)
78
1996. Deaths (per 1,000 live births). Statistics
Canada, Compendium of Vital Statistics, 1996.
Therapeutic abortions
(per 100 live births)
66
All ages, 1995. Statistics Canada. Therapeutic
Abortions, 1995. Note: Nova Scotia serves the needs
of Prince Edward Island and New Brunswick.
Chronic Conditions
Deaths (per 100,000 population)
Toward a Healthy Future
213
Appendix B
Potential Years of Life Lost (per 100,000 population)
Total
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Cancer
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Accidents
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Suicide
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Respiratory
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Heart disease
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Stroke
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Other
83
1996. Years of Life Lost per 100,000 population (age
adjusted) based on deaths prior to age 70. Statistics
Canada. Health Indicators, 1997. Special tabulations.
Total
84
Total life expectancy at birth, 1996. Statistics
Canada. Compendium of Vital Statistics, 1996.
Men
84
Total life expectancy at birth, 1996. Statistics
Canada. Compendium of Vital Statistics, 1996.
Women
84
Total life expectancy at birth, 1996. Statistics
Canada. Compendium of Vital Statistics, 1996.
Less than high school
5
Age 15+, 1996. Statistics Canada, 1996 Census:
Education.
University completed
5
Age 15+, 1996. Statistics Canada, 1996 Census:
Education.
Average individual income
6
Age 15+, 1995. Statistics Canada, 1996 Census:
Sources of Income.
Low-income persons (%)
6
All ages, 1995. Statistics Canada, 1996 Census:
Sources of Income. “Low income” refers to
economic families and unattached individuals who
have income below Statistics Canada’s Low Income
Cut-Offs, 1992 base. Families and unattached
individuals with incomes below these limits usually
spend more than 54.7% of their income on food,
clothing and shelter.
Life Expectancy at Birth
Education
Income
Toward a Healthy Future
214
Appendix B
Labour force participation rate
7
Age 15+, 1997. Statistics Canada, Historical Labour
Force Statistics, 1997.
Unemployment rate
7
Age 15+, 1997. Statistics Canada, Historical Labour
Force Statistics, 1997.
Any
7
Age 15+, 1996. Statistics Canada, 1996 Census:
Unpaid Work. Time spent doing unpaid housework,
yard work or home maintenance during the previous
week, including preparing meals, shopping, laundry
and cutting the grass.
60+ hours per week
7
Age 15+, 1996. Statistics Canada, 1996 Census:
Unpaid Work. Time spent doing unpaid housework,
yard work or home maintenance during the previous
week, including preparing meals, shopping, laundry
and cutting the grass.
Unpaid child care
32
Age 15+, 1996. Statistics Canada. 1996 Census:
Unpaid Care. Percentage who report spending some
time during past week providing unpaid child care.
Unpaid senior care
32
Age 15+, 1996. Statistics Canada. 1996 Census:
Unpaid Care. Percentage who report spending some
time during past week providing unpaid care or
assistance to one or more seniors.
Effective family functioning
31
Parents of children aged 0–11, National Longitudinal
Survey of Children and Youth, 1994–95. Effective
family functioning was defined as a score of 0–14
on a 12-item scale, wherein 35 indicates major
dysfunction.
Consistent parenting
31
Parents of children aged 2–11, National Longitudinal
Survey of Children and Youth, 1994–95. Consistent
parenting measured as a score greater than 14.7 out
of a possible 20 for consistency.
Positive interaction
31
Parents of children aged 2–11, National Longitudinal
Survey of Children and Youth, 1994–95.
Positive/warm interaction measured as a score
greater than 13.5 out of 20 for interaction.
Unpaid Household Activities
Smoking Bylaws/Bans
Population protected by smoking bylaws 12
Percentage of population living in municipalities with
bylaws restricting smoking, 1995. Health Canada.
Smoking Bylaws in Canada, 1995.
Smoke-free schools
12
Percentage of schools with complete smoking bans
(indoor and out), 1995. Health Canada. Study of
Smoking Policies in Various Settings in Canada, 1995.
Smoke-free daycares
12
Percentage of daycare centres with complete
smoking bans (indoor and out), 1995. Health
Canada. Study of Smoking Policies in Various
Settings in Canada, 1995.
Smoke-free health-care settings
12
Percentage of health-care facilities with smoking bans
(indoor ban), 1995. Health Canada. Study of Smoking
Policies in Various Settings in Canada, 1995.
Toward a Healthy Future
215
Appendix B
Personal Health Practices
Current smoker (%)
40
Age 12+, NPHS, 1996–97. Smokes cigarettes daily
or occasionally.
Regular drinker (%)
42
Age 12+, NPHS, 1996–97. Persons who report
drinking alcohol at least once per month.
14+ drinks per week
42
Age 12+, NPHS, 1996–97. Percentage of regular
drinkers who report consuming 14 or more drinks
weekly.
5+ drinks per occasion
43
Age 12+, NPHS, 1996–97. Percentage of “current
drinkers” (at least one drink in the past year) who
report consuming at least five drinks on one or more
occasions during the past year.
Driving after drinking (1+ times)
44
Age 16+, NPHS, 1996–97. Persons who had a
driver’s licence and were current drinkers who
reported driving a motor vehicle after drinking
“too much” alcohol.
Currently use cannabis
45
Age 15+, 1994. Reported using cannabis at least
once during the previous year. Canada’s Alcohol
and Other Drugs Survey, 1994.
1+ illicit drugs used, lifetime
45
Age 15+, 1994. Reported using cannabis (excluding
one-time use only), cocaine/crack, LSD, amphetamines
(speed) or heroin at least once during their lifetime.
Canada’s Alcohol and Other Drugs Survey, 1994.
Physically active
46
Age 12+, NPHS, 1996–97. Estimated level of activity
equal to or greater than three kilocalories per kilogram
of body weight per day.
Walk to work
46
Employed Canadians, age 15+, 1996. Statistics
Canada, 1996 Census: Mode of Transportation.
Always use bicycle helmet
49
Cyclists age 12+, NPHS, 1996–97. Percentage who
say that they always use a helmet when riding a
bicycle.
Always insist on seatbelt use
49
Motorists age 16+, NPHS, 1996–97. Percentage
who say that they always insist that their passengers
wear a seatbelt.
Took actions to improve health
52
Age 12+, NPHS, 1996–97. Percentage who report
that they took some action to improve their health
during the past year.
Influenza vaccination, ever
15
Age 12+, NPHS, 1996–97. Percentage who report
ever having influenza shots.
Pap smear test, ever (age 18+)
16
Women age 18+, NPHS, 1996–97. Percentage who
report ever having had a Pap smear test.
Screening mammogram, past 2 years
(age 50–69)
17
NPHS, 1996–97. Note: Includes only women who
report reason for mammography as follows: a checkup, family history of breast cancer, age or hormone
replacement therapy. (Women who reported other
reasons were categorized as a non-screening
mammography.)
Health-Care Services
Toward a Healthy Future
216
Appendix B
Blood pressure test, past year
18
Age 12+, NPHS, 1996–97. Percentage who report
a blood pressure check-up within the previous
12 months.
HIV/AIDS test, ever
20
Age 18+, NPHS, 1996–97. Percentage who report
having been tested for HIV/AIDS.
Visits to a health professional (1+)
19
Age 12+, NPHS, 1996–97. Percentage who report
at least one visit to a health professional during the
past year.
Visits to a physician (1+)
19
Age 12+, NPHS, 1996–97. Percentage who report
at least one visit to a physician during the past year.
Visits to a dentist, past year
21
Age 12+, NPHS, 1996–97. Percentage who report
at least one dental visit during the past year.
Dental insurance
21
Age 12+, NPHS, 1996–97. Percentage who report
having dental insurance.
Eye examination, past year
23
Age 12+, NPHS, 1996–97. Percentage who report
at least one eye examination during the past year.
Insurance for corrective lenses
23
Age 12+, NPHS, 1996–97. Percentage who report
having insurance for corrective lenses.
1+ medications used, past two days
24
Age 12+, NPHS, 1996–97. Percentage reporting use
of one or more medications in the past two days.
Insurance for prescription medications 24
Age 12+, NPHS, 1996–97. Percentage reporting full
or partial coverage through government plans or
insurance.
Unmet health-care needs
25
Age 12+, NPHS, 1996–97. Percentage who required
some health care or advice on at least one occasion
and did not receive it.
Emergency visits (per 1,000 pop.)
26
All ages, 1995–96. Canadian Institute for Health
Information. Annual Hospital Survey Database,
1995–96.
Hospital (average days of stay)
27
All ages, 1995–96. Canadian Institute for Health
Information. Hospital Morbidity Database.
Health expenditure (% of GDP)
29
1996. Canadian Institute for Health Information.
National Health Expenditure Trends, 1975–1998.
Note: health-care spending only (not social services
spending).
Per capita health expenditures ($)
29
1996. Canadian Institute for Health Information.
National Health Expenditure Trends, 1975–1998.
Note: health-care spending only.
† The most closely related topic in the Statistical Report on the Health of Canadians (1999) is listed. Note
that definitions vary in some instances.
** NPHS: National Population Health Survey
Toward a Healthy Future
Appendix C
Selected Resource Documents
The reader is directed to the following key resource documents for more information.
More detailed materials are listed in the Endnotes.
Population Health and Determinants of Health: General
Evans, R., Barer, M., Marmor, T. (eds.) Why Are Some People Healthy and Others Not? The
Determinants of Health of Populations. New York: Aldine De Gruyter, 1994.
Federal, Provincial and Territorial Advisory Committee on Population Health. Strategies
for Population Health: Investing in the Health of Canadians. Ottawa: Minister of Supply
and Services Canada, 1994.
Health and Welfare Canada. A New Perspective on the Health of Canadians. Ottawa:
Health and Welfare Canada, 1974.
Health and Welfare Canada. Achieving Health for All: A Framework for Health Promotion.
Ottawa: Health and Welfare Canada, 1986.
National Forum on Health. Determinants of Health: Adults and Seniors. Sainte-Foy:
Éditions MultiMondes, 1998.
National Forum on Health. Determinants of Health: Settings and Issues. Sainte-Foy:
Éditions MultiMondes, 1998.
United Nations Development Program. Human Development Report 1998. New York:
Oxford University Press, 1998.
World Health Organization, Health and Welfare Canada, Canadian Public Health
Association. Ottawa Charter for Health Promotion. Ottawa: CPHA, 1986.
Socioeconomic Environment and Health (Chapter 2)
Canadian Public Health Association. The Health Impacts of Social and Economic
Conditions: Implications for Public Policy. Board of Directors Discussion Paper. Ottawa:
CPHA, 1997.
Statistics Canada. Family Violence in Canada: A Statistical Profile, 1998. Ottawa: Statistics
Canada, 1998. (Statistics Canada Cat. No. 85-224-XIE).
Wilkinson, R. Unhealthy Societies: The Afflictions of Inequality. New York: Routledge, 1996.
Toward a Healthy Future
218
Appendix C
Healthy Child and Youth Development (Chapter 3)
Canadian Council on Social Development. The Progress of Canada’s Children, 1997 and
1998. Ottawa: CCSD, 1997 and 1998.
Canadian Institute of Child Health. The Health of Canada’s Children: A CICH Profile.
Ottawa: CICH, 1994.
Guy, K. (ed.). Our Promise to Children. Arnprior, ON: The HLR Publishing Group, 1997.
Distributed by the Canadian Institute of Child Health.
Human Resources Development Canada and Statistics Canada. Growing Up in Canada.
National Longitudinal Survey of Children and Youth. Ottawa: 1996. (Cat. No. 89-550-MPE,
No. 1.)
National Crime Prevention Council. Preventing Crimes by Investing in Families (a series
of three publications). Ottawa: National Crime Prevention Council, 1996 and 1997.
National Forum on Health. Determinants of Health: Children and Youth. Sainte-Foy:
Éditions MultiMondes, 1998.
The Honourable McCain, M.N., Mustard, J.F. Early Years Study: Final Report. Toronto:
Reference Group on the Early Years, 1999.
Physical Environment and Health (Chapter 4)
Health Canada. Health and Environment: Partners for Life. Ottawa: Minister of Public
Works and Government Services Canada, 1997. (Cat. No. H49-112/1997E.)
Last, J., Guidotti, T., Hertzman, C., et al. Implications of Global Change for Human Health.
The Royal Society of Canada, 1995.
Last, J., Trouton, K., Pengally, D. Taking Our Breath Away. Vancouver: David Suzuki
Foundation, 1998.
World Health Organization. Health and Environment in Sustainable Development: Five
Years After the Earth Summit. Geneva: World Health Organization, 1997.
Environment Canada. Canada’s National Environmental Indicators Series.
http://www.ec.gc.ca/natural_f.html
Health Care and Health (Chapter 6)
National Forum on Health. Health Care Systems in Canada and Elsewhere. Sainte-Foy:
Éditions MultiMondes, 1998.
National Forum on Health. Evidence and Information. Sainte-Foy: Éditions
MultiMondes, 1998.
Biology and Genetics (Chapter 7)
Health Canada. New Reproductive and Genetic Technologies: Setting Boundaries,
Enhancing Health. June 1996.
Medical Research Council of Canada, Natural Sciences and Engineering Research
Council of Canada, Social Sciences and Humanities Council. Tri-Council Policy
Statement: Ethical Conduct for Research Involving Humans, August 1998.
Toward a Healthy Future
Appendix D
Key Word Index
This brief index is intended to supplement the detailed Table of Contents. Please note
that recommendations from Chapter 8, and highlights and summary sections from all
chapters are not covered by the index.
Aboriginal people
alcohol and drug use
education
fetal alcohol syndrome
food security
housing
health services
HIV
infant mortality
injuries
life expectancy
low income, poverty
PYLL
smoking
suicide
31
124
51, 57, 74
160
102, 103
105
149
19
25
23, 74
26
47, 50
27
119
24
Active living — see Physical activity
AIDS, HIV
18, 19, 123, 126, 127, 131
Alcohol and drug use
Aboriginal children
driving
HIV
pregnancy
trends and rates
youth
124
122, 129
19
77
121, 122, 131
122, 124, 129
Toward a Healthy Future
220
Toward a Healthy Future
Alternative health services
153
Arthritis, rheumatism
17
Abuse
85, 90
Biology and genetics
158, 159, 161, 162
Birth defects
159
Birthweight
Breastfeeding
Built environment
76, 77
78
104, 105, 106, 107, 108, 109, 158
Cancer
children
breast
lung
prostate
screening
21, 22, 27, 74
22
22, 32
22
146, 147
Children and youth
abuse
cancer
childcare
development
emotional and behavioural
competence
environment
injury
investment in
multiple risk behaviours
poverty, low income
pregnancy
psychological well-being
suicide
unemployment
109
19, 74, 80
88, 90
128, 129, 131
43, 44, 46, 64, 82, 84
78
83, 89
23, 24, 32
57
Chronic conditions and diseases
17, 32, 144
Death, causes of
cancer
cardiovascular disease
and stroke
infant mortality
motor vehicle crashes
85, 90
74
87
75, 79, 80, 82, 163, 168
81
21, 22, 27, 28, 32
21, 27, 28, 32
25, 28, 75
23, 121, 122
Toward a Healthy Future
221
Toward a Healthy Future
smoking
suicide
unintentional injuries
22, 25, 32
23, 24, 25, 27, 28, 32
23, 27, 28, 32
Depression
18, 79
Diabetes
17
Disability and activity limitations
low income
seniors
20, 43
164, 165
Education, literacy
and income
and gender
51, 52, 53, 54, 64, 65
54
Employment, unemployment
gender
54
55, 56, 64
Families
composition
income level
lone parents
investment in
48, 86
44, 47, 48, 49, 50, 85
45, 47, 58, 60, 87
89
Fetal alcohol syndrome (FAS) and effects 77, 160
Food security
102, 103
Gambling
126
Gender
24, 29, 31, 32, 53, 90, 146, 153
Gini Index or Coefficient
40, 49, 50
Government transfer payments
and income taxes
50, 64
Health services, social services
access and utilization
expenditures
need for integration
quality of health care
52, 86, 145, 146, 148, 149, 154, 166
138, 139, 140, 141
66, 87, 109
145, 154
Toward a Healthy Future
222
Toward a Healthy Future
Healthy eating — see Nutrition
Home care
144, 145, 154, 155, 166
Homicide
25
Hospital care
142, 143, 144
Housing, homelessness
105, 106, 107, 109, 131
Immigrants, immigration
26, 53, 85, 116, 120, 149
Income
43, 49, 63, 64, 65, 66, 116, 130, 144, 148, 149
Low income, poverty
16, 17, 18, 20, 26, 28, 29, 30, 31, 32, 40, 43,
44, 45, 47, 51, 52, 53, 54, 60, 63, 65, 75, 84,
85, 102, 146, 152, 161
Injuries, unintentional
19, 23, 32, 59, 74, 80
Life expectancy
12, 26, 27, 28
Literacy — see Education, literacy
Medication
150, 151, 155
Mental health services
150
Mental health — see Psychological well-being
Mortality — see Death, causes of
Natural environment
98, 99, 100, 101, 102, 103, 108, 158
Nutrition
117, 129
Parenting practices
87
Physical activity
115, 128, 130
Physical environment — see Built environment, Natural environment
Potential years of life lost (PYLL)
12, 21, 23, 26, 27, 28
Toward a Healthy Future
223
Toward a Healthy Future
Pregnancy, birth
smoking, alcohol use
youth
77, 104, 160
78
Psychological well-being
12, 15, 16, 32
Reproductive technologies
161, 168
Respiratory disease
101, 104
Safety equipment
124, 125, 129
School readiness
52, 72, 79
Secure attachment
72, 78, 163
Self-rated health
12, 14, 15, 164
Seniors, aging
biology
education
health-care services
income
injury
medication
personal health practices
social support
163, 164, 165
54, 167
146, 166
43, 44, 166
19, 23
151
167
60, 167
Sexual practices
126, 128, 129
Sexually transmitted diseases
126, 127, 162
Smoking
environmental tobacco smoke
gender
immigrants
pregnancy
youth
25
104, 160
22, 25, 32, 120, 129
120
7, 104, 160
22, 32, 120, 121, 129, 130
Social services — see Health services, social services
Social well-being
60, 64, 66
Toward a Healthy Future
224
Toward a Healthy Future
Socioeconomic environment
89
— See also Income, Low income, Education
Stress
57, 159, 161
Substance use and abuse — see Alcohol and drug
Sudden infant death syndrome (SIDS)
75, 104
Suicide
18, 23, 24, 25, 27
Sustainable development
97, 108
Tobacco use — see Smoking
Transportation
105
United Nations Human
Development Index
12, 29, 30, 31
Vaccines, immunization
79
Violence
60, 61, 66, 85
Volunteer, community action
61, 62, 63
Weight
117, 118, 129
Working conditions, work
5, 56, 57, 58, 59
Toward a Healthy Future
Reader Feedback
Reader Feedback
The Federal, Provincial and Territorial Advisory Committee on Population Health invites
you to answer a few questions about Toward a Healthy Future: Second Report on the Health of
Canadians. Your answers will provide feedback on the content and usefulness of this report.
Please return the completed questionnaire to:
Quantitative Analysis and Research Section
Policy Development and Coordination Division
Health Promotion and Programs Branch
Health Canada
Jeanne Mance Building
Tunney’s Pasture (AL 1917C1)
Ottawa, ON K1A 1B4
Alternately, you may return the questionnaire by e-mail to Serge Tanguay at
[email protected]
Overall Satisfaction with the Report
For each of the following questions, please place an X beside the most appropriate response.
1. How did you obtain your copy of the Report ?
It was mailed to me as part of the initial distribution
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Other (please specify) ___________________________________________________________________
2. To what extent have you read or browsed through the Report ?
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3. How satisfied are you with the following aspects of the Report ?
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Toward a Healthy Future
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Reader Feedback
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4. How can the Report be improved (e.g. content, format, etc.)?
____________________________________________________________________
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Usefulness of the Report
5. One of the goals of the Report is to increase awareness and understanding about the
health status of Canadians and the factors that influence health. Overall, how successful
do you think it was in achieving this goal?
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6. Have you used, or will you likely use, the information in the Report for any of the
following?
(Place an X beside all the appropriate responses.)
Policy development
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For information only
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Research and/or evaluation
Briefing notes
To support intersectoral collaboration
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Other (please specify)_____________________
7. How useful did you find each section of the Report? (For each, please place an X
beside the most appropriate response.)
Very useful
Executive Summary
Introduction
Health Status
Social/Economic Environment
Healthy Child Development
Physical Environment
Personal Health Practices
Toward a Healthy Future
Somewhat useful
Not useful
Reader Feedback
Health Services
Biology and Genetics
Conclusions
Appendix B
8. What (degree of) impact do you think the Report has had or will have among the
following groups? (Please place the appropriate number beside each item.)
1 = high impact (widely used)
3 = little impact (little use)
2 = some impact (some use)
4 = no impact (not read or used)
5 = unsure
___ Health policy makers within government
___ Government policy makers within other sectors
___ Local or regional health authorities
___ Non-governmental (e.g. voluntary) organizations
___ Service providers (e.g. clinicians, other health professionals, social workers)
___ Academic and/or policy researchers
___ Members of the general public
___ Media
9. Do you have a copy of the companion document, Statistical Report on the Health of
Canadians (1999)?
Yes
No
If yes, which document do you find to be the more useful?
Toward a Healthy Future
Both are useful
Statistical Report
Unsure (haven’t read the Statistical Report)
10. Do you have other comments about Toward a Healthy Future or suggestions for
future reports?
____________________________________________________________________
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Toward a Healthy Future
Reader Feedback
Reader Information
For each of the following questions, please place an X beside the most appropriate response.
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12. What sector are you most closely associated with?
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Other (please specify) _______________________________
13. What is your affiliation?
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organization
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Library
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Other (please specify)__________________
14. What is your position or role within your organization?
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Other (please specify)___________________________
Thank you for taking the time to complete this questionnaire.
Toward a Healthy Future

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