The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2012Friday, January 18 2013
This is the Chief Public Health Officer’s fifth annual report on the state of public health in Canada. The report explores sex (i.e. biological characteristics) and gender (i.e. socio-cultural factors) and their connections with public health and the health status of Canadians. It examines how sex and gender interact with each other and with other determinants of health to influence health behaviours and symptoms, treatment effects and access to care. From this examination, the report outlines interventions, programs and policies that have maintained and improved the current and future health and well-being of Canadians. It also identifies priority areas for action where Canada as a society can better incorporate sex- and gender-related issues in public health resulting in reduced health inequalities.
The State of Public Health in Canada
In 2011, the Canadian population was about 33.5 million, almost equally divided between males and females. While the proportion of males to females varies somewhat by age group, from the age of 65 years onward the proportion of females exceeds that of males.
The life expectancy of Canadians has increased dramatically over the past century. A male born in Canada today can expect to live about 79 years and a female about 83 years. While Canadian women have historically experienced greater longevity, the gap in life expectancy at birth between Canadian men and women has decreased.
Many Canadians at every age consider themselves healthy. The majority of Canadians 12 years and older reported their health as either excellent (22%) or very good (38%), while even more reported their mental health as excellent (37%) or very good (37%). However, not all years are spent in good health. The health-adjusted life expectancy (HALE) from 2004 to 2006 shows that males spent approximately 69.6 years in good health whereas women spent about 72.1 years in good health.
In 2010, 55% of Canadians aged 12 years and older reported living with at least one chronic health condition, the most common being back problems (19%), high blood pressure (18%) and arthritis (16%). Back problems, including scoliosis, sciatica and herniated discs, can result in physical pain and in some cases be disabling. This can also be the case for any one of the 100 or so different types of arthritis that affect mainly women (61%). Almost one-quarter (24%) of Canadians 30 years and older reported having high blood pressure, a major contributor to heart disease and stroke, and the proportions increased with age to 51% among those 65 years and older.
Some Canadians also live with some form of mental illness. In 2010, mood disorders, such as depression and bipolar disorder, were the most commonly reported mental health conditions affecting 6.9% of Canadians 15 years and older (8.2% of women and 5.0% of men). The highest reported rates of mood disorder were among older adults aged 55 to 64 years (8.3%) and Aboriginal people not living on a reserve (11.7%).
Economic and social factors such as education, employment and income have a direct bearing on health. Between the 1990/1991 and 2010/2011 school years, the percentage of Canadians between 20 and 24 years who had completed high school increased from 81% to 90% (92% of women and 89% of men). The percentage of Canadians between 25 and 34 years who completed a post-secondary education also increased during the same period, from 44% to 72% for women and from 45% to 64% for men. In 2011, the unemployment rate for young Canadians between 15 and 24 years was 14.2%, with a difference between males (15.9%) and females (12.4%). Among Canadians aged 25 to 54 years, 6.2% were unemployed with little difference between men and women. In 2010, 32% of the working population between 30 and 54 years self-reported having work-related stress, with similar rates among both men and women.
Tobacco, alcohol and cannabis are the substances most frequently used by Canadians 15 years and older. While the overall smoking rate in Canada has been declining, 17% of Canadians reported smoking in 2010 with males in all age groups consistently reporting higher rates of smoking compared to females. In the same year, 77% had consumed alcohol (47% of whom consumed it once a week or more – 54% of males and 40% of females), whereas one-in-ten reported using cannabis in the past year (15% of males and 7% of females). Young adults between 20 and 29 years have the highest smoking, drinking and cannabis rates of all age groups in Canada.
Over the past 15 years, reported rates of sexually transmitted infections (STIs) have increased among the overall population. Young Canadians under the age of 30 years continue to experience the highest reported rates of chlamydia, gonorrhea and infectious syphilis. In 2008, 74% of all new positive cases of HIV reported were among men, with the highest rates among men between 40 and 49 years of age (32%). Women represent an increasing proportion of those with positive HIV test reports in Canada, and represented 26% of all new cases reported in 2008. Women between 30 and 39 years account for 35% of reported HIV infections among all females.
People who are physically active are at a lower risk of poor health. Less than one-fifth of adults and one-tenth of children met the World Health Organization and Canadian guidelines for physical activity in 2007–2009. Less healthy eating, including over-consumption, combined with inadequate physical activity, can lead to increased body weights, and Canadians are experiencing increasingly high rates of obesity and overweight. In 2007–2009, 24% of Canadian adults were considered to be obese and 37% overweight, an increase from the reported 12% and 32%, respectively, in 1978–1979. For both adults and children, a larger percentage of males than females are either overweight or obese.
Sex, Gender and Public Health
While there are no single agreed-upon definitions, “sex” typically refers to the biological and physiological characteristics that distinguish females and males, and “gender” is associated with the socio-cultural factors that societies ascribe to females and males. However, as opposed to the traditional binary view of men/women and male/female, many of the attributes of sex and gender can be described on continuums to account for the ranges of characteristics and behaviours that exist.
Public health serves to support, promote and protect the health of all Canadians. Sex and gender are critically important to all areas of public health – research, programs and policies. The interrelationships between sex, gender and the broader determinants of health influence risks, opportunities, behaviours and outcomes of men, women, boys and girls differently across the lifecourse.
Applying a sex and gender lens to health identifies patterns and gaps in how both can influence health status. Sex- and gender-based analysis (SGBA) is a systematic approach to research, policies and programs that explores biological (sex-based) and socio-cultural (gender-based) similarities and differences between women and men, boys and girls. Doing so helps to ensure that interventions are effective and inclusive.
Sex, Gender and Health Outcomes
Biological and socially constructed differences between men and women interact to affect individual susceptibility to particular health risks, health-seeking behaviours, outcomes and treatments. By examining health outcomes in the areas of physical health (e.g. hypertension), mental health (e.g. depression) and sexual health (e.g. STIs), it can be seen how and why these differences occur in terms of the influence of sex and gender.
Physiological and biological changes that occur across the lifecourse affect an individual’s likelihood of particular health outcomes as well as their responses to developmental stages and life events. Differences in rates of hypertension (high blood pressure) and depression in men and women suggest that sex hormones may play a significant role in these rates. With increasing androgen levels (i.e. testosterone) during puberty, blood pressure is higher in boys than in girls. Conversely, women may be protected from high blood pressure by female sex hormones (i.e. estrogens). Between puberty and menopause, rates of depression in women are two to three times higher than in men. When levels of estrogens decrease after menopause, hypertension prevalence increases in women while rates of depression begin to decrease. Dramatic hormone changes during pregnancy and postnatally can also cause forms of hypertension and can increase the risk of depression among women.
Biological differences between men and women can also mean that their bodies respond differently to various bacteria and organisms. For example, women’s anatomy makes them more susceptible to acquiring STIs through some forms of sexual contact. Sex also influences treatment and medication responses (e.g. antihypertensive medications are significantly less likely to control women’s blood pressure) as well as self-reported signs and symptoms (e.g. depressed women experience more feelings of helplessness, worthlessness and persistent sad moods whereas men experience discouragement, anger and irritability).
Gender plays a key role in the health-seeking behaviours of men and women. Women generally access the health care system more often than do men and therefore are more likely to be routinely screened, tested and treated for health conditions such as hypertension, depression and STIs. Attitudes and misinformation surrounding STI testing procedures, the non-detection of symptoms, questions of confidentiality, and stigma can act as deterrents to testing for both males and females of all ages. The socially constructed concept that men must be tough and strong can foster silence among some men which may prevent accurate diagnosis and treatment of depression. Socially constructed gender roles may also influence different sources of stress among women and men, increasing their risk for hypertension or poor mental health (i.e. depression). In addition, power relations within sexual encounters may affect decisions and the ability to negotiate the use of protection (e.g. refusal to use condoms) influencing the risk, incidence and outcomes of STIs.
Incorporating Sex and Gender into Health Interventions
Broad and targeted Canadian and international interventions – research, programs, initiatives and policies – that have addressed health issues and/or risk factors and consider and/or incorporate sex and gender into their design or execution can make a difference to health. A sex- and gender-based approach is part of systematically planned interventions that are consistent with population health approaches.
Canada embarked on its commitment to sex- and gender-based work when evidence surfaced that pointed to gaps and inequalities created by not addressing research, programs and policies in the context of sex and gender. By ratifying the Beijing Declaration, Canada agreed to promote gender mainstreaming in all relevant policies and programs such as the Health Portfolio’s Sex and Gender-Based Analysis Policy. Embracing the inter-relationships between sex, gender and the broader determinants of health needs to become part of mainstream practice in public health.
Sex, gender and physical health
Approaches to preventing and managing the onset of chronic disease must reflect differences among men, women, boys and girls so as to most effectively address and/or avoid adverse health outcomes. Being overweight and/or obese can influence the development of many chronic diseases. As such, it is important to address unhealthy weights as early as possible, and school-based, gender-focused health promotion interventions are ideally positioned to address the gender differences that occur in the physical activity and food and beverage consumption behaviours of boys and girls. Gendered experiences, stereotypes and societal expectations can influence approaches to physical activity. Perceptions of girls’ and boys’ sports and activities can influence participation across the lifecourse. Communities across Canada offer programs that educate and encourage women and girls in sports and challenge gender stereotypes and homophobia.
The perception of cardiovascular disease (CVD) as a “man’s disease” has affected the cardiac health of women, who have been under-represented in cardiovascular research, treatment and health prevention practices. CVD has only recently been recognized as one of the leading causes of death and ill health among Canadian women. Whereas factors such as sex affect symptom presentation and disease identification, gender can influence health care seeking behaviours as well as health practitioners’ reactions to symptoms. Heart health organizations in Canada are targeting women in social marketing, public awareness and health promotion campaigns to encourage them to learn about cardiac health.
Sex, gender and mental health
In Canada’s first mental health strategy, gender and sexuality are considered priority areas in addressing mental health disparities. Addressing mental health with a sex and gender lens requires increasing understanding, providing sex and gender sensitive services, reducing women’s risk factors and improving capacity of LGBTQ organizations to address stigma and offer support. Gender roles, life experiences and event-specific risk factors are often cited as contributors to common mental disorders that disproportionately affect women. The reproductive health of women, particularly postpartum depression (PPD), may have long-term health outcomes for mothers and their children. Addressing the outcomes of maternal depression involves a greater understanding of the complex interactions between mental health and other factors. Efforts to increase community awareness and understanding of PPD as well as supports to help manage it are underway. Systematic reviews and evaluations show that positive outcomes for a mother’s well-being and infant care are achieved through programs that offer individual support to help parents make the transition into parenthood. Also increasingly programs are recognizing the importance of men’s experiences on their partners’ pregnancies and mental health, as well as men’s own experiences influence their own mental health during fatherhood. Identifying paternal postpartum is lagging due to the tools used to routinely measure effects in women need to adapt to better reflect men’s symptomatic criteria. Additional research is needed to expand the focus of postpartum to new fathers from various cultural and socio-economic backgrounds.
Recent research and programs reveal that men are at risk for a range of mental health problems, which are often underdiagnosed and under-reported. Four out of five suicides are completed by men. Addressing issues such as suicide through prevention practices is challenged by a number of factors including gender differences in suicide and suicide ideation. Factors to consider when addressing the mental health of men and boys include the non-detection of male clinical depressive symptoms, a social inability to show weakness, low mental health literacy and the use of risky behaviours such as substance use and violence that can mask mental health problems. Health-promoting strategies for men in community settings are growing. The strategies and programs such as Men’s Sheds have been shown to be effective in addressing men’s health issues, while allowing social networking and the development of practical skills. Mental health practices found that more men would seek help for mental health issues if the programs suited those with traditional male gender roles. Broad-based media campaigns that challenge male norms must be intensive and target at-risk populations. In addition, some jurisdictions have developed suicide prevention strategies that include broad to targeted initiatives.
Mental health stigma continues to be a barrier to how people seek and acquire treatment for mental health disorders. A population health approach is necessary to address gender-specific risk factors as well as to improve access and delivery of mental health policies and programs. Early education and increasing awareness of mental health disorders is important in challenging misconceptions about mental illness.
Sex, gender, healthy relationships and sexual health
Healthy sexuality involves acquiring knowledge, skills and behaviours for positive sexual and reproductive health as well as options to avoid negative outcomes (e.g. STIs and unplanned pregnancies). Interventions that promote healthy relationships should be delivered as early as possible so that young men and women learn to value and understand the importance of respect, equality and harmony with relationships. To be effective, programs that target at-risk youth need to address a range of individual experiences as well as account for other factors such as gender, culture and sexual orientation. Communities and schools also play an important role in integrating and increasing the scope of interventions that help young people develop healthy relationships including sexual relationships. Interventions that have shown promise in supporting the prevention of intimate partner violence are those that provide the tools to ensure the safety of victims and potential victims and that address violence in a broader context of equality, rights and responsibility. Healthy relationships focused on the concerns of sexual and gender minorities can also challenge heteronormative (the view of heterosexuality as the normal or preferred sexual orientation) understandings of relationships, opening up possibilities for expanding sexual health education to address what constitutes healthy relationships for sexual and gender minority youth and adults.
Healthy relationships rely on having positive perceptions of self-image and sexual health. Repeated exposure to sexualized images can have negative effects on the cognitive and emotional development of girls and boys leading to poor body image, low self-esteem, eating disorders and depression. School-based interventions can reach a large number of children and youth; they have been shown to reduce risks of HIV and AIDS, other STIs and unplanned pregnancies over the long term. However, barriers to effective school-based sexual health education programs include allotted time or teaching materials as well as the comfort level of students, teachers, families and the community at large. Practices that show promise include those that address sexual risk and protective factors as well as non-sexual factors, programs that increase the knowledge and skills of parents and community members who interact with youth, and programs that provide access to health services for all youth and include diversity.
One area often overlooked is the sexual health practices of older adults. Despite an increase in cases of STIs among older adults, interventions designed to prevent STIs among this population are limited. Practicing safer sexual behaviours can depend on having access to relevant health care and information or being able to comfortably discuss practices with an available health care practitioner. Stigma associated with sexual health topics, in particular STIs, is a significant barrier to testing, early diagnosis, accessing treatment and support for all ages, genders and sexual orientations. Social marketing campaigns and sexual educational programs can be used to proactively address negative perceptions of sexual health, gender and age and the changing social trends and sexual practices of older adults.
Sex, gender and socio-economic determinants
Looking at sex and gender by selected health outcomes is only part of the broader story, as there are many cumulative socio-economic factors that directly or indirectly influence health across the lifecourse. Examples of socio-economic determinants, work, education and parenting were selected for this report because they influence other factors such as income. The effect of gender on how occupational health issues are experienced, expressed, defined and addressed can help identify risk factors for both women and men. Gender-based stereotyping (e.g. who does what job, the societal value attached to particular jobs, and associated risks of the work) can increase health risks for both men and women. Risk of injury and disease can be further confounded by biology, workplace seniority, social status, age, tasks, techniques and external life experiences. Being able to identify and track workplace injuries, illness and pain relies on having a health and safety program in place that monitors activities. The lack of such a program and other factors (e.g. reluctance of the employee or employer to report problems) means that workplace health outcomes are un- or under-reported. Workplace interventions need to acknowledge the realities of work such as risk, location and the role of confounding factors (e.g. environment, assumptions). Challenging gender stereotypes and addressing gender bias is necessary to attract and retain individuals in non-traditional fields such as nursing. A comprehensive gender analysis of workplace experiences is necessary to address the work-life issues relevant to retaining male and female workers.
Many Canadians also participate in unpaid and informal work such as informal care. More women than men provide some type of informal care, and women spend more than double the number of hours providing informal care. The proportion of male caregivers has been increasing, with men often caring more for partners with mental health issues and dementia than they had in the past. Men in caregiving roles have fewer opportunities for community support and less social services. Research on programs to support male caregivers is limited given their lack of recognition in this role. Several programs in Canada that support caregivers vary from financial support (e.g. wages, tax relief, and labour policies) to community supports and services. Results of a meta-analysis of caregiver interventions determined that supportive interventions were effective but that the effectiveness was dependent on other factors including gender and ethnicity as well as program deliverables (e.g. duration, setting).
Education is an underlying determinant for many health outcomes. As with other social determinants, sex and gender make a difference in how education is approached and used and on the resulting health effects over the long term. The number of Canadians who successfully complete high school and seek some level of post-secondary education, training or certification has increased over the last two decades. Despite overall educational successes, questions remain as to why boys are not faring as well as girls in school. Applying a sex and gender lens to educational attainment suggests looking at the criteria used to measure success and checking for possible gender bias in this measurement; the factors that encourage in-school participation and academic practices and the suitability of activities for gender and diversity; gender roles and expectations after graduation; perceptions of success; and teaching methods and suitability to learning styles by gender and behaviour and management. Strong role models at home are important for all children to achieve academically and socially, and for boys in particular male role models can positively influence their academic performance.
The role that fathers play in parenting and building healthy relationships should not be under-estimated. Where fathers are positively involved, outcomes in their children’s cognitive, emotional, relational and physical well-being have been reported. Canada, as a society, has made some progress in supporting research and/or programs on fatherhood. Interventions that target fathers are continuing to grow and recognize the importance of fathers to the health and well-being of Canadians. However, more can be done to see that knowledge about father involvement is disseminated to professionals and policymakers who wish to support families and healthy child development.
Sex, Gender and Public Health – A Path Forward
The majority of Canadians enjoy good to excellent physical and mental health, and are living longer, healthier lives. However, disparities do exist in the health of Canadian women, men, girls and boys. These require a better understanding of the many factors that contribute to this difference. Since an individual’s sex and gender play such a complex and crucial role in influencing health behaviours, health outcomes and well-being, it is essential that they be considered in the development, implementation and evaluation of research, programs and policies.
Given their extensive impact on every individual, there is no “one size fits all” solution to address sex- and gender-related health issues. Therefore, a broad, constantly evolving understanding of sex and gender as key determinants of health is essential.
Public health in Canada is a shared responsibility. As a society, we must continue to understand the importance of efforts to promote health and well-being, and where possible, prevent disease and illness. Actions to address the health and well-being of Canadians must be co-ordinated and multi-pronged and take into account Canada’s extensive geography and diversity. Actions must also be sustainable and not limited to one-time efforts with short-term impacts. Moving forward requires building on existing initiatives and measuring their impact so we are better able to effect change. Understanding what makes some programs and initiatives work and adapting them to fit the diversity of Canadians is the challenge we must face if we want to continue to improve the health of Canadians. Collectively, Canada has the capacity to understand and address the specific issues of our diverse population to ensure that all Canadians have the opportunity to live as healthy a life as possible.