CPHO Report on the State of Public Health in Canada, 2008: Addressing Health Inequalities Reference Deck

1. CPHO Report on the State of Public Health in Canada, 2008: Addressing Health InequalitiesReference Deck

2. Message from the CPHO • The majority of Canadians enjoy good to excellent physical and mental health and are living longer lives. • Over the past century, we have made significant strides in improving our collective health. • Not all health trends are improving and not all Canadians are benefiting to the same degree from these improvements over time. • Some groups experience lower life expectancy, higher rates of infant mortality, injury, disease and addiction.

3. Message from the CPHO • Evidence shows that Canadians who meet their basic needs for adequate shelter, a safe and secure food supply, access to education, employment and sufficient income adopt healthier behaviours and have better health. • Other important underlying factors that influence our health are: • Having a sense of control or influence over our own lives and future; and • Loving, being loved and having family, friends and other social connections that give us a sense of being part of something larger than ourselves. • All sectors of society are touched by health inequalities, and each individual or organization can make a positive contribution to their resolution.

4. Chapter 1:Introduction

5. Goals of the report • Shed light on public health in Canada, the state of Canadians’ health and highlight Canada’s successes and on-going challenges. • Inform all Canadians and stimulate dialogue on factors that contribute to good health, and how we can individually and collectively advance public health in Canada. • Inspire action to help create opportunities for all Canadians to be as healthy as they can be – mentally, physically and socially. • Hope to inspire increased collaboration among Canada’s leaders, public health practitioners, employers, educators, researchers, community groups, the media and individuals to improve Canadian’s health and overall well-being.

6. What the report covers Chapter 2: Public Health in Canada • Overview of public health approach and public health system • Examples of success stories and ongoing challenges Chapter 3: Our Population, Our Health and the Distribution of Our Health • Health of Canadians - leading causes of death, prevalence of disease and injury • Worrying trends Chapter 4: Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities • Social and economic determinants of health, behaviours and health inequalities • Promising interventions Chapter 5: Addressing inequalities – Where are we in Canada • Priority areas for action Chapter 6: Moving Forward

7. Chapter 2:Public Health in Canada

8. Public health in Canada The key activities of public health include: • Health protection – Health surveillance • Disease and injury prevention – Population health assessment • Health promotion – Emergency preparedness and response • Public health challenges Canadians to recognize that physical and mental health are intricately connected to the environment and society. • Public health success stories - mass immunization, decline in smoking rates, advances in water treatment and sanitation, increased seatbelt use. • Public health challenges - escalating obesity rates, mental health issues, poverty’s influence on health, changing environments and building healthy communities.

9. Public health in Canada Factors that influence our health Source:Dahlgreen, G. & Whitehead, M. (2006). European strategies for tackling social inequities in health: Levelling up Part 2. World Health Organization.

10. Chapter 3:Our Population, Our Health and the Distribution of Our Health

11. Our population • Canada’s Population is over 31.6 million people. • 1.17 million people (4%) are Aboriginal Peoples: • First Nations (60%), Métis (33%), Inuit (4%) and Other (3%) • 6.2 million people (20%) are Immigrants. • Canada’s population growth (1997-2005) is attributable to: • 3 million births, 2 million deaths and over 2 million new immigrants. • Most Canadians live in urban settings - over 80% reside in towns and cities.

12. Our population Population distribution by age, Canada, 1971-2006 Source: Public Health Agency of Canada using Health Canada’s Data Analysis and Information System (DAIS), Statistic Canada, CANSIM Table 051-0001.

13. Our health – Life expectancy * Denotes self-reported data

14. Our health – Life expectancy Life expectancy at birth, select OECD countries, 1980-2004 Source: Public Health Agency of Canada using Health Canada’s Data Analysis and Information System (DAIS), Organisation for Economic Co-operation and Development (OECD) Health Data, 2007.

15. Our health – Life expectancy Life expectancy at birth by neighbourhood income and sex, urban Canada, 2001 Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.Source: Wilkins et al. (2007), Statistics Canada.

16. Our health – Life expectancy Life expectancy at birth by sex, Registered Indian and general population, Canada, 1980-2001 Source: Indian and Northern Affairs Canada, Basic Departmental Data, 2004.

17. Our health – Infant mortality * Denotes self-reported data

18. Our health – Infant mortality Infant mortality rate, select OECD countries, 1980-2004 Source: Public Health Agency of Canada using Health Canada’s Data Analysis and Information System (DAIS), Organisation for Economic Co-operation and Development (OECD) Health Data, 2007.

19. Our health – Infant mortality Infant mortality rate by neighbourhood income, urban Canada, 1971-2001 Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs. Source: Wilkins et al. (2007), Statistics Canada.

20. Our health – Self-reported health * Denotes self-reported data

21. Our health – Self-reported health Proportion of Canadians* with excellent or very good perceived health by highest household level of education, Canada, 2005 * Population aged 12+ years.Source: Public Health Agency of Canada using Health Canada’s Data Analysis and Information System (DAIS), Statistics Canada, Canadian Community Health Survey (CCHS-SHR) 2005.

22. Our health – Causes of death

23. Our health – Causes of death (by age) Mortality by select causes and age groups, Canada, 2004 Source: Public Health Agency of Canada using Statistics Canada, CANSIM Tables.

24. Our health – Causes of death Age-standardized mortality rates for lung cancer by neighbourhood income, female, urban Canada, 1971-2001 Age-standardized mortality rates for ischemic heart disease by neighbourhood income, male, urban Canada, 1971-2001 ASMR – Age-standardized mortality rate.Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs. Source: Wilkins et al. (2007), Statistics Canada.

25. Our health – Premature death • In Canada, the overall Potential Years of Life Lost (PYLL) has been decreasing over time • Certain populations, however, experience differences in years lost to early death • For example, if the age- and sex-specific mortality rates in the highest-income quintile were applied to the entire population, the total PYLL for all urban neighbourhoods would be reduced by 20% • equivalent of eliminating all premature deaths due to injuries in those neighbourhoods.

26. Our health – Patterns of ill health and disability * Denotes self-reported data

27. Our health – Patterns of ill health and disability * Denotes self-reported data

28. Our health – Patterns of ill health and disability Age-adjusted prevalence of chronic conditions among First Nations adults compared to the general Canadian adult population Source: First Nations Regional Longitudinal Health Survey (RHS).

29. Our health – Patterns of ill health and disability Measured obesity by educational attainment and sex, household population age 19-45 years, Canada (excluding territories), 2004 Source: Public Health Agency of Canada using Health Canada’s Data Analysis and Information System (DAIS), Statistics Canada, Canadian Community Health Survey (CCHS) 2004.

30. Chapter 4: Social and Economic Factors that Influence our Health and Contribute to Health Inequalities

31. What makes - and keeps - us healthy • If good health is not shared equally by Canadians, then understanding the many factors – or determinants – that contribute to health is essential to identifying solutions • Health inequalities can be the result of genetic and biological factors, choices made or by chance, but often they are because of differences in key factors that influence our health, such as: - Income - Education and literacy - Employment and working conditions - Social support and connectedness - Food Security - Health behaviours - Environment and housing - Access to health care - Early childhood development • Socio-economic determinants interact to influence health - an improvement in any of these determinants can improve health behaviours and outcomes. • The structure of society influences health through the distribution of public goods and resources. • Factors that influence our health can be positively impacted by the different sectors of society working together to address health and social inequalities through interventions.

32. Income • Income is a significant contributor to health and, consequently, health inequalities • Individuals with low incomes often lack resources and access to nutritious food, adequate housing, safe environments and working conditions, which can negatively impact their health. • While Canadians’ overall personal income has increased over time, the poverty rate has not decreased proportionately. • 11% of Canadians currently live in poverty • Poverty rates among certain groups are estimated to be significantly higher than the national average: 26% for lone parents; 21% for work limited persons; 9% for recent immigrants;17% for off-reserve Aboriginal Peoples • There is a significant difference in disease prevalence and years of life lost to early death between the highest-income quintile and each subsequent lower quintile.

33. Income Children aged 0-17 years living in low-income families (after tax), Canada, 1996-2005 Child low-income rates in OECD countries based on market sources and disposable income: late 1990s and early 2000s Source: Adapted from Corak, M. (provided by Canadian Population Health Initiative, 2007).Source: Public Health Agency of Canada using Statistics Canada, CANSIM Table 202-0802.

34. Income interventions National Public Pensions for Seniors • Introduced in 1952, Old Age Security (OAS) was Canada’s first universal pension • Followed by the Canada Pension Plan, Quebec Pension Plan, Guaranteed Income Supplement (GIS), Spouse’s Allowance (SPA), Widowed Spouse’s Allowance and Provincial/Territorial income supplements • As Canada’s public pension system has matured, more seniors became eligible and their after-tax income has increased. Today, 95% of seniors receive their income from OAS, GIS or SPA Quebec’s Family Policy • Introduced in 1997 to offer an integrated child allowance, enhanced maternity and parental leave, extended benefits for self-employed women, and subsidized early childhood education and child care services • Over the last 10 years, Quebec has experienced a steady decline in its poverty rate which is below the national average Saskatchewan’s Initiative • Introduced in 1997 to offer employment supplements, child and family health benefits that have helped low-income people achieve financial independence • By 2004, the province had seen 41% fewer families dependent on social assistance and a substantial increase in after-tax disposable income among families working for minimum wage

35. Employment and working conditions • Employment provides Canadians with economic opportunities which can influence individual and family health. Working environments can directly impact physical and mental health • In 2006, Canada’s unemployment rate was at a 30-year low (6.3%) • Recent immigrants have a higher rate of unemployment (11.5%) although they are more likely to hold a university degree • Regulations and policies protect Canadian employees, however work-related injury, disability and death still occur • Blue collar workers experience over 4 times the injury rates of white collar workers • Men experience over twice the rate of work-related injuries as women • Since Canada extended its parental leave benefits, the number of parents taking leave and the length of leave have increased • Some mothers still do not take extended leave due to choice, eligibility or inability to live on non-supplemented employment insurance benefits

36. Food security • Healthy eating requires being food secure • 9% of Canadian households report being food insecure due to financial challenges at some point in the previous year • 1 in 10 households with children report not always having enough food • 48% of households at the lowest income level reported being food insecure compared to 1% of households at the highest income level • Households with the lowest education attainment (13.8%) reported some form of income-related food insecurity compared to households with the highest (6.9%). • When children go to school hungry or poorly nourished, their energy levels, memory, problem-solving skills, creativity, concentration and behaviour are all negatively impacted • 31% of elementary students and 62% of secondary school student do not eat breakfast • Almost 50% of Grade 8 girls do not eat breakfast. • The growth in the number of food banks and school breakfast programs reflects the increasing recognition of food insecurity in Canada.

37. Food security interventions Breakfast for Learning • Initiated in1992, this program has been providing funding, nutrition education and other resources to community based student nutrition programs across the country • With a network of over 30,000 volunteers, healthy breakfasts, lunches and snacks were served to over 1.5 million Canadian school children • Schools have reported improvements in scholastic performance, behaviour and attentiveness Food Banks • Canada’s first food bank opened in Edmonton, AB in 1981 • Over the last 18 years, reliance on food banks has increased 91% • As of March 2007 there were: • 673 food banks and 2,867 affiliated agencies across Canada • 2 million meals served and 720,000 individuals provided with groceries

38. Environment and housing • Where a person lives matters - both natural and built environments influence health • Physical environment can place increased burdens on health • Air pollution is responsible for 5,900 annual excess deaths in 8 Canadian cities • Ground-level ozone concentration has increased in southern Ontario/Québec • Water quality issues exist in small communities and on First Nations reserves • Built environments can influence physical and mental health through community design, adequate housing and access to public services • Urban sprawl has increased suburban vehicle use resulting in higher incidences of injury, heart and respiratory diseases, obesity, and stress • Residents of walkable neighbourhoods tend to have increased activity levels with lower rates of obesity • Access to affordable and nutritious foods contribute to healthier eating • Urban centres are less culturally and socially homogenous

39. Environment and housing • Health outcomes related to housing are complex, as housing can directly and indirectly impact health • 13.7% of Canadians report being unable to access acceptable housing • Overcrowding and poorly ventilated houses can increase susceptibility to disease and impact mental health. • There are an estimated 150,000 homeless people in Canada (underestimate) • About one-third are between 16-24 years • Street youth have higher rates of STIs and blood-borne infections • About one-half of street youth have been involved with the child welfare system • A lack of housing contributes to a vicious cycle influencing eligibility for income supports, community benefits, voter registration and employment options that could bring about changes in living conditions

40. Environment and housing interventions Vancouver Agreement • Tripartite agreement that combines government services and expertise to reduce crime, drug trafficking/use and rates of HIV infection • Results include lower death rates due to alcohol and drug use, HIV-AIDS and suicide; greater access to health services, expanded addiction treatment services and after-hours youth crisis response programs Healthy Cities • Internationally led initiative to build stronger movement at the urban level to promote application of public health criteria to community design and land use • Age-friendly cities project aims to better support the involvement of older citizens in making choices that enhance their health and well-being Habitat for Humanity Canada • Non-profit organization working to break the cycle of poverty for low-income families by providing safe and affordable housing and promoting home ownership • Since 1985, more than 1,200 homes have been built across the country resulting in • Improved finances; less reliance on social services and chance to build equity • Improvements in children’s grades (40%) and behaviour (50%) and well-being (60%)

41. Early childhood development (ECD) Receptive vocabulary scores* of children, age 5, by household income levels, who were or were not read to daily, Canada, 2002-2003 LICO – Low-income cut off* A score of 75 corresponds to the lower 5th percentile of the receptive vocabulary score distribution. Source: Public Health Agency of Canada using Statistics Canada, National Longitudinal Survey of Children and Youth, 2002/2003.

42. ECD interventions Community Action Program for Children (CAPC) • Provides long-term funding to community programs for at risk children aged 0 to 6 years • Through inter-sectoral partnership, CAPC funds approximately 450 projects to over 3,000 communities; delivering 1,800 programs for 110,000 participants across Canada per month • Program evaluations have found benefits that include: lower rates of maternal depression and isolation, and less emotional and behavioural issues among children Aboriginal Head Start in Urban and Northern Communities/Aboriginal Head Start On Reserve • Programs for preschoolers, parents and caregivers to provide opportunities to learn traditional languages, culture and values, along with school readiness skills and healthy living habits • Recent evaluations report that more than 13,600 children and their families continue to benefit in terms of their physical, personal and social development and health Healthy Child Manitoba • Long-term cross-departmental strategy promoting and supporting community-based programs for each community’s diverse and unique needs • Results range from improved parenting skills, and better community connectedness, to an 80% enrolment rate in Stop FAS program by women who are using/have used alcohol or drugs during pregnancy

43. Education and literacy • Generally, being well-educated equates to a better job, higher income, greater health literacy, a wider understanding of the implications of unhealthy behaviour and an increased ability to navigate the health care system • About 80% of Canadian adults over the age of 25 are high-school graduates • High school dropout rate has decreased since the 1990s to 10% among 20-24 year-olds • Women holding university degrees has increased at a higher rate than men • Those with post-secondary education earn almost twice the income of those who have not completed high school • Canadians with lower levels of education often experience poorer health outcomes, including reduced life expectancy and higher rates of infant mortality • First Nation populations have lower rates of high school completion than the Canadian average • About 42% of Canadians aged 16-65 perform below the literacy level needed to succeed, including the ability to correctly use medication or understand safety risks

44. Education and literacy interventions Pathways to Education • Program introduced in 2001 to work towards breaking the cycle of poverty by increasing the chances of youth completing secondary and possibly post-secondary school • Provides academic, social, financial and advocacy supports to at-risk and economically disadvantaged youth • Toronto’s Regent Park results include: • Over 90% of high school students enrolled • Decrease in dropout (56% to 10%) and absenteeism rates (decreased by 50%) • Quadrupled the number of youth attending college or university • Teen pregnancy rates fell 75% • The Pathways to Education program is now expanding to 5 other communities with plans to reach more than 20 across Canada

45. Social support and connectedness • Having family, friends and a sense of community belonging – being a part of something larger than self - positively contribute to physical and mental health • 62% of Canadians report feeling a sense of community belonging • 80% of Canadians report relying on a confidante for advice and caring during crisis • Seniors who report having no friends are less likely to report having excellent or very good health. • Young people do not vote as much as their elders, however they more often participate in politically related activities • First Nations actively vote in community elections, but participate less in national/provincial elections. • Social exclusion is experienced when individuals/groups have limited control, or access to social, political and cultural resources • Almost 50% of First Nations residential school survivors report that the experience negatively affected their mental and physical health • High rates of suicide among some First Nations communities, particularly among youth, are linked to social exclusion and disconnect from their traditions and culture

46. Social support and connectedness • Social connectedness is influenced by an individual’s actual and perceived safety – which may also impact mental and physical health • Although Canada’s crime rate has been decreasing, most Canadians believe it is increasing • Violent crimes occur more frequently in rural and remote areas • Women are more likely to incur injuries as a result of violence • Reported spousal abuse among Aboriginal women and men off reserve is higher than the national average (21% compared to 7% in 2004). • Survivors of child abuse are also more likely to become dependent on substances and more likely to commit suicide • During 2003, there were over 235,000 investigations of maltreatment involving children (in 82% of cases a parent was the alleged perpetrator ) • 50% of youth (14-17 years) who reported being assaulted were assaulted by either a close friend/co-worker/acquaintance; 20% by a stranger; and 16% by family • 25% of males and 21% of females (11-15 years) reported being bullied as a result of their race, ethnicity or religion. • Children who witness family violence often exhibit negative behaviours, physical aggression, emotional disorders, hyperactivity and destructive behaviours.

47. Social support interventions Montreal’s Santropol Roulant • Founded in 1995 to provide meaningful youth employment through preparing and delivering nutritious meals to seniors in isolated or vulnerable situations • Over 100 youth volunteers provide unique intergenerational and cultural connections, as well as inexpensive and nutritious meals • Other activities, such as roof-top gardening, attempt to reconnect people to healthy foods, the environment and their community Nova Scotia’s Eskasoni Primary Care Project • Eskasoni, a Mi’kmaq community, decided to manage their health care with the collaborative efforts of a Tripartite Steering Committee • To improve accessibility to health care, a new community health centre was built and involved community members in planning, execution, and evaluation as well as revamped services. • Positive results include: 96% of pregnancies are followed pre-to-post-natal; costs of prescriptions have decreased; annual number of physician visits has decreased, and outpatient/emergency trips have decreased by 40%. • In 2004, five Cape Breton Bands came together to build upon and expand the model to all Cape Breton First Nations communities - Tui’kn Initiative.

48. Health behaviours Age-standardized mortality rates for alcohol dependence, by sex and income quintile, urban Canada, 1971-2001 Smoking and education, aged 15+ years, Canada, 1999-2006 Source: Public Health Agency of Canada using Health Canada, Canadian Tobacco Use Monitoring System 1999-2006.ASMR – Age-standardized mortality rate.Q – population divided into fifths based on the percentage of the population in their neighbourhood below the low-income cut-offs.Source: Wilkins et al. (2007), Statistics Canada.

49. Health behaviours Percentage of the general population aged 12+ years who were physically active by income, Canada, 2005 Source: Statistics Canada, Physically Active Canadians.

50. Health behaviours interventions ActNow BC • Launched in 2005 as a program that champions healthy eating, physical activity, smoking cessation and healthy choices during pregnancy across British Columbia. • Over 130 towns and First Nations communities have registered as “Active Communities”; 360,000 students engage in physical activity through “Action Schools! BC”. • BC Health is partnering with Aboriginal Organizations as well as workplaces to extend the reach and uptake of the program. Canada Prenatal Nutrition Program (CPNP) • For over a decade, CPNP has provided long-term funding to community groups to develop or enhance programs for at-risk pregnant women and their children. • Initial results indicate that compared to similar high risk populations, CPNP participants had: higher birth weights, higher breastfeeding rates, reported improved access to services, better information on nutrition/parenting and felt less stressed/isolated during pregnancy.