HL9.1 Attachment 1
T.O. Health Check An Overview of Toronto's Population Health Status Reference Toronto Public Health. T.O. Health Check. August, 2019.
Lead Author Paul Fleiszer
Project Lead Dina Tsirlin
Chapter Leads and Contributing Authors Sarah Ahmed, Donna Ansara, Anne Arthur, Soraya Blot, Sarah Collier, Liz Corson, Effie Gournis, Janet Heng, Kelsie Near, Heather Rilkoff, Dina Tsirlin
Acknowledgements This report is the result of a true team effort. Subject matter and other technical experts from Toronto Public Health contributed their knowledge, experience and skills to help identify key issues, provide a “ground-level” perspective, and ensure quality. The support provided by Gary Baker and Jamie McEachern (design), Jill MacLachlan and Lauren Junkin (editing), Dr. Eileen de Villa (review), and Shusmita Rahman and Catalina Yokingco (data analysis) is particularly appreciated.
Vital input was also provided by our external advisors and partners including: Susan Barrass and Devon MacFarlane (Rainbow Health Ontario), Dr. Raglan Maddox (Well Living House, St. Michael’s Hospital), Dr. David Mowat, Selina Young (Indigenous Affairs Office, City of Toronto).
Indigenous Acknowledgement Toronto Public Health (TPH) acknowledges that the land on which it operates is the traditional territory of many nations including the Mississaugas of the Credit, the Anishnabeg, the Chippewa, the Haudenosaunee and the Wendat peoples and is now home to many diverse First Nations, Inuit and Métis peoples. TPH also acknowledges that Toronto is covered by Treaty 13 signed with the Mississaugas of the Credit, and the Williams Treaties signed with multiple Mississaugas and Chippewa bands.
Access Copies of this report are available on the Toronto Public Health website: toronto.ca/health or by: Phone: 416-338-7600 TTY: 416-392-0658 Email: [email protected] TABLE OF CONTENTS
Message from Toronto’s Medical Officer of Health 2
Introduction 3
1 Population Demographics 5
2 The Social Environment 19
3 The Natural and Built Environments 37
4 Reproductive and Early Child Health 49
5 Oral Health 67
6 Mental Health and Illness 75
7 Substance Use 87
8 Sexual Health 101
9 Infectious Disease 113
10 Unintentional Injury 129
11 Chronic Conditions and Risk Factors 137
1 Appendix 1: Mortality 157
2 Appendix 2: Terms and Definitions 162
3 Appendix 3: Data Notes and Caveats 177
4 Appendix 4: Data Sources 204
T.O. HEALTH CHECK 1 MESSAGE FROM TORONTO'S MEDICAL OFFICER OF HEALTH
On behalf of Toronto Public Health (TPH), I am This report provides a range of population health pleased to present T.O. Health Check. TPH is indicators on health determinants, risk factors and responsible for the health and well-being of three outcomes. It is also an example of how TPH fulfills its million Toronto residents and together with our vital role of assessing and reporting on the health of partners, delivers the programs and services to Toronto’s population. protect and promote the health of all people in the In a dynamic and growing city like Toronto, change is city. Since 1883, TPH has met this mandate by: constant and TPH must be agile and responsive to Preventing the spread of disease, promoting the evolving needs of its residents. The information in healthy living and advocating for conditions that this report will help to inform our upstream efforts to improve the health of Toronto’s residents. keep Toronto a healthy city for all of our residents. Developing and implementing public policy and practices that enhance the health of individuals, communities and the entire city. Monitoring the health status of the population to respond to the city’s unique and emerging health needs using an evidence-informed approach.
Dr. Eileen de Villa Medical Officer of Health
2 T.O. HEALTH CHECK INTRODUCTION
Public health epidemiologists assess and report on together in this report provides a comprehensive the health status of the local population. Similar to picture of our population’s health and the context in how a clinician uses a diagnosis to develop a which people live that directly and indirectly affects it. treatment plan, a health status assessment The following criteria were used to select the contributes to a body of information that Toronto indicators included in this report: Public Health uses to develop strategic goals that support its mandate to improve the health of our Public health relevance: indicators that reflect community and reduce health disparities. issues of importance to the residents of Toronto and are consistent with the mandate of Toronto Collectively, Toronto is doing relatively well in terms Public Health. of health and wellness. Over half of Toronto adults Actionability: indicators that can help inform public rate their health as excellent or very good. However, health practice and policy. health inequities exist in the city and certain populations fare worse in a number of areas of health. Clarity: indicators that are well defined, measure A complexity of biological, social, psychological, their intended purpose, and can easily be environmental, and economic factors influence interpreted by a range of audiences. health. Understanding the distribution of these Data availability: appropriate data exist and the determinants of health in the population and how indicator is calculable. they relate to health outcomes can provide direction Data Quality: the data are valid, reliable, and were for public health initiatives. T.O Health Check reports collected using sound methodological principles. on key population health status indictors grouped into broad themes that cover the many facets of How to read this report population health, demonstrating the breadth of To tell the story of the health status of Torontonians, health issues in Toronto. selected health indicators have been grouped into 11 This report is intended to guide discussion on sections and include population demographics, social population health concerns specific to Torontonians determinants of health, health outcomes, and risk that will identify emerging issues and priorities for and protective behaviours. Where possible, local level where more information is needed. These discussions data for Toronto were used. Where local data were will lead to a strategy for supporting the information not available, general findings from the literature or needs of Toronto Public Heath as well as stakeholders data from other areas were used. A list of literature who have potential to impact the health of the city. references can be found at the end of each chapter. Despite the depth of this report, further data analysis that dives deeper into specific issues can help us to Key Themes better understand our population’s health and inform Key themes throughout the report are identified by the work that is needed to reduce health inequities their respective icons: and improve the health of the whole population. Health Inequities Health Indicators Health inequities are the systematic, unjust and avoidable differences in the Population health status indicators are used to distribution of health status between measure risk factors and outcomes at a population different populations. Health inequities that are level. They can provide a snapshot of health and captured throughout the report include disparities by wellbeing over time and across populations and income, immigrant status, sexual orientation and geographies. The suite of indicators presented indigenous identity.
T.O. HEALTH CHECK 3 INTRODUCTION
Geographical Comparison This report is intended to To contextualize the health status of complement ongoing reporting. Torontonians, it is useful to compare it Additional demographic and to the health status of other populations, such as health status information is other large cities and the rest of Ontario (Ontario available on the City of Toronto excluding Toronto). and Toronto Public Health websites. Data Gaps In some cases, indicators on topics of public health importance are not covered in the report due to gaps in data. Challenges in obtaining robust data include declining survey response rates, increasing costs for data gathering, and uncoordinated systems. Data gaps can also exist for certain sub-populations, especially those that are small and/or less likely to participate in data collection initiatives. While it is important to promote and use our existing information and evidence wisely, there is important work to do to strengthen our statistical resources and the ways in which data are collected.
More Information Health is complex and often intertwined. The report provides links to where other indicators or information of interest relevant to a particular topic can be found.
Appendices A comprehensive list of terms and definitions used throughout the report, including statistical definitions, can be found in Appendix 2. Indicators can have limitations of what they can tell us, including how they may or may not be compared. A list of data notes and caveats can be found in Appendix 3. A wide variety of data sources were used in this report. And a chapter specific list of data sources can be found in Appendix 4.
4 T.O. HEALTH CHECK POPULATION DEMOGRAPHICS
Introduction Toronto is Canada’s largest city, with one of the most diverse populations in the world. The structure of Toronto’s population has changed over time, influencing population health status and other social outcomes, and shaping the city in a dynamic fashion. Demographic information reflecting the city’s changing size and composition, helps public health and other service providers prepare to respond to issues and demands arising from population growth, aging, migration, and other changes.
Some of the demographic characteristics described in this chapter such as age and sex, influence health status directly through biology. Others including Indigenous identity, immigration, ethnicity, sexual orientation and others, are linked to social processes that influence health status. For example, people of some ethnic backgrounds may experience discrimination or racism which is harmful to their health. The demographic information in this chapter sets a foundation for the health inequities and differences between groups that are highlighted throughout this report.
T.O. HEALTH CHECK 5 POPULATION DEMOGRAPHICS
3 million residents growing to 3.5 million by 2030
p. 7
Senior population to 19% by 2030 expected to grow from 16% p. 7
Dependents (seniors & kids) are to 64 dependents per 100 expected to increase from 55 working-age Torontonians by 2030.
p. 8
52% Just under half of all Torontonians identify as visible minorities are immigrants
p. 13 p. 11
6 T.O. HEALTH CHECK POPULATION DEMOGRAPHICS
Population Size and Growth Sex, Age and Age-Related Dependency Population growth is a function of birth and death The sex and age composition of the population rates, as well as immigration and emigration. Given also affects population growth and health status. the relationship between each factor and the social Forecasted changes in population structure are vital and physical environments, population growth can for understanding future population health needs and be viewed as both a health outcome and determinant ensuring that today’s planning is effective in meeting of health. the population health needs of tomorrow’s city.
Toronto’s population: Age and Sex Was approximately 2,731,570 according to the 2016 In Toronto: Census of Population. There were slightly more females (52%) than males Increased by 9% between 2006 and 2016. This (48%) in 2016. This is the equivalent of 93 males for translates to on average, 63 more people each day, every 100 females. or 22,830 each year during this ten year period. 2016 marked the first time that there were more Was more recently estimated for 2019 at over people aged 65 years and over, than 14 and under. 3,060,000 people. This is predicted to increase to The share of seniors aged 65 years and over 3,109,676 in the following year (2020). increased over the ten years from 2006 (14%) to Is estimated to grow to almost 3,500,000 by 2030 2016 (16%). By 2030, this figure is projected to which is an increase of 13% from 2020 (Figure 1.1). increase and represent about 19% of the population, or more than 678,000 individuals. Figure 1.1: Population Growth, Toronto, 2006 to 2016 and 2020 to 2030 Life expectancy is 86.6 years for females and 82.0 years for males, figures that are higher than those 13% for Ontario (Ontario females: 84.2 years, Ontario 4,000,000 increase 9% males: 80.3 years). increase 3,000,000 The aging population is a result of decreasing fertility rates (described in Chapter 4) and increases 2,000,000 in life expectancy. This affects the incidence of
Number of People certain chronic health conditions or events (eg. 1,000,000 cancer, dementia, falls, obesity, and diabetes) and by extension, the amount and type of health 0 2006 2016 2020 2030 resources and other urban design features required Census Estimates Projected Estimates to respond to these emerging issues.
Data Sources: Statistics Canada, Census of Population, 2006. Toronto’s changing age and sex distribution is Population Projections 2019 & 2030, Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: June 8, 2018 . depicted in Figure 1.2.
T.O. HEALTH CHECK 7 POPULATION DEMOGRAPHICS
Figure 1.2: Population by Age and Sex, Toronto, 2016 and 2030
Data Sources: Statistics Canada, Census of Population, 2016. Population Projections 2030, Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: June 8, 2018.
Dependency on the Working-Age Population In 2016: The proportion of non-working age people compared There were 24 senior dependents per 100 working- to those who are working (known as the dependency age Torontonians. ratio) is one way to assess the age structure of the There were 55 total dependents (including both population. A low dependency ratio is desirable seniors and children/youth) per 100 working-age because there are proportionally more working-age Torontonians. adults who can support the young and the elderly. The growth of Toronto’s senior population has led to In 2030: an increasing dependency ratio. This is a signal for There will be 32 senior dependants per 100 greater social and economic burdens on the working- working-age Torontonians. age population and additional demands on There will be 64 total dependents (including both government support programs and the health care seniors and children/youth) per 100 working-age system [1] [2]. These can have negative impacts on Torontonians. the growth of the economy and financing the pensions of retirees [1] [2].
8 T.O. HEALTH CHECK POPULATION DEMOGRAPHICS
Living Arrangements, Marital Status, Marital Status2 and Family Type For Torontonians aged 20 years and over, in 2016: Living arrangements, marital status, and household 54% were married or living common-law3. composition can impact the amount of social, 30% were single (never married). physical, and economic support an individual receives, and can also affect stress levels, feelings of 16% were divorced, separated or widowed. Females loneliness, and isolation [3] [4]. Each of these is were twice as likely (21%) to be in this category considered an important social determinant of compared to males (10%). This is due in part to health. Living alone has been associated with longer life expectancies for females who often increased hospitalization, poorer health, and outlive their male partners. increased mortality, particularly in men and older Family Type adults [5] [6]. People with spouses, friends, and family In Toronto in 2016: members who provide psychological, social, and material resources are in better health than those 33% of families with children were lone-parent with fewer social contacts [3] [7]. The absence of a families, an increase from 30% in 2006. Most second parent can leave single-parent families more lone-parents were female (84%). vulnerable to socio-economic strain and higher levels 22% of children4 (14 years and under) were living in of stress, possibly leading to various health a lone-parent family. disadvantages than two-parent families [8].
Living Arrangements In Toronto in 2016: 16% of people aged 15 years and over were living alone, an increase from 14% in 2006. This was slightly higher than Ontario (12%). Females were slightly more likely to be living alone (17%) compared to males (15%). 27% of seniors (aged 65 years and over) were living alone, unchanged from 2006. Seniors were twice as likely to be living alone as people aged 15 to 64 (13%). Female seniors were almost twice as likely to live alone (33%) compared to male seniors (18%), largely due to having a longer life expectancy [9].
2 The 2006 and 2011 Census reported on 'legal marital status' for people aged 20 years and older whereas the 2016 Census reported on 'marital status' (see Appendix 3 for clarification on these terms). As such, no temporal comparisons are made for this section. 3 "Includes same-sex common-law and married couples. 4 This indicator is calculated using the number of children from birth to age 14 years that were living in a lone-parent census family relative to the total number of children from birth to age 14 years living in all census families. Children living in a census family may be living with one or two biological parents, adoptive parents, step-parents, and/or grandparents. One or more grandparents may also be present in the household for children living with one or both parents.
T.O. HEALTH CHECK 9 POPULATION DEMOGRAPHICS
Indigenous People5 More information on sexual 6 Many Indigenous people living in Toronto face orientation and gender identity for multiple health challenges and have been largely Indigenous people is included in under-represented in national surveys and other the corresponding sections of this health data sources available at the local and chapter. Information on education, employment provincial level. Recently however, a local survey of and low income is included in Chapter 2. Toronto’s Indigenous population, Our Health Counts (OHC) Toronto, produced a comprehensive health status and health care utilization dataset. Due to A history of colonialism resulting in concerns about the reliability of the 2016 Census economic, social, and cultural estimates and potential under-counting (see first marginalization has had a strong bullet point below), the OHC results are used for negative impact on the health of demographic indicators related to Indigenous people Indigenous people in Canada [10]. in this and the following chapter, and for other Through colonization, systematic racism and health-related findings in the rest of this report7. discrimination, Indigenous people have been denied the resources necessary to maximize their According to the 2016 Census, there were 23,065 socio-economic status, leading to both social and people living in Toronto who identified as economic inequities such as reduced opportunities Aboriginal8, representing less than 1% of the total for education, unemployment, food insecurities, 2016 Toronto population. The OHC Toronto study lack of appropriate housing, and lack of access to provided a much larger estimate of between 54,000 quality health care [11]. As a result of these and 87,000 for the same year. conditions, Indigenous people face health inequities The majority of Indigenous adults living in Toronto related to behavioural risk factors, nutrition, in 2016 identified as First Nations (86%), followed mental health, and morbidity and mortality [10] by Métis (14%). [12] [13]. Toronto-specific examples are provided The Indigenous population tended to be younger in the following chapters of this report. than the general population in Toronto. Of those aged 15 years and over, 62% of the Indigenous population was between 15 and 45 years of age compared to 50% of the overall Toronto population. Three percent were 65 years and over compared to 16% for Toronto overall. In 2016, approximately 65% of Indigenous people (aged 15 years and older) in Toronto were single, almost twice as high as the percent observed for Toronto overall (35%).
5 Toronto comparisons in this section use the 2016 Census of Population data. Caveats related to comparing results from different surveys are provided in Appendix 3. 6 “Indigenous” means ‘native to the area. It is the preferred collective name for the original people of Canada and their descendants. This includes First Nations (status and nonstatus), Métis and Inuit. It is important to remember that each Indigenous nation in the larger category of “Indigenous” has its own unique name for its community (e.g., Cree, Ojibwa, Inuit). 7 More information about the Toronto Our Health Counts study and its findings can be found at: http://www.welllivinghouse.com/what-we-do/projects/our-health-counts-toronto/. 8 The 2018 Relationship with Indigenous Community Guidelines under the Ontario Public Health Standards state that the term 'Indigenous' is increasingly preferred in Canada over the term 'Aboriginal'. Ontario's current practice is to use the term Indigenous when referring to First Nations, Métis, and Inuit as a group, and to refer to specific communities whenever possible. The term 'Aboriginal' is used in certain instances in this report to be consistent with the 2016 Census of Population. The term 'Indigenous' is used otherwise for consistency with the Our Health Counts study and the Ontario Public Health Standards.
10 T.O. HEALTH CHECK POPULATION DEMOGRAPHICS
Immigration, Residency, Ethnicity In Toronto in 2016: and Language Immigrants comprised a slightly smaller proportion Toronto has become one of the most ethnically of the population (47%) compared to Canadian- diverse cities in the world due largely to immigration. born people (49%). Non-permanent residents Newcomers to Toronto bring many strengths and (e.g. temporary residents, refugee claimants, etc.) assets that make Toronto vibrant and prosperous. made up approximately 3% of the population. These include good health, education, professional These figures have changed slightly from 2006 experience and skills, new perspectives, and cultural, when immigrants comprised 50% of the ethnic and linguistic diversity. Toronto’s global population, Canadian-born people 48%, and community also poses ever changing health needs non-permanent residents 2%. that must be met through culturally competent Most immigrants were longer-term immigrants programs, translated materials, language (85%) who first obtained landed immigrant or interpretation, partnerships with community agencies permanent resident status before 2011. Recent and continuous community engagement. immigrants, who first obtained landed immigrant or permanent resident status between 2011 and 2016, Immigrant Status represented the remainder (15%). Immigration compensates for an aging population, 83% of recent immigrants in Toronto belonged to a lower fertility rates, and a shrinking working-age racialized group, higher than the percent observed population. It also has a positive effect on overall for Canadian-born individuals (31%) and longer- population health status in Toronto as recent term immigrants (69%). This demonstrates how immigrants tend to be healthier than their Canadian- immigration has shaped racial and ethnic diversity born counterparts, a phenomenon known as the in Toronto [39]. “Healthy Immigrant Effect” [14] [15] [16] [17]. Over time however, their health begins to deteriorate, resembling The top three countries of birth for recent the rest of the population [16] [17]. Racialization9 is one immigrants were the Philippines, China, and India. of the factors impacting the health of many newcomers, The top three for all immigrants were China, the as they establish themselves in Toronto and embark Philippines, and India (Table 1.1). on their journey towards successful integration into Canadian society (see section on Ethnicity).
9 Racialization refers to the social processes that construct racial categories as “real, different and unequal in ways that matter to economic, political and social life”. Racialization is often based on perceived differences in anatomical, cultural, ethnic, genetic, geographical, historical, linguistic, religious, and/or social characteristics and affiliations [35]. The use of the term in this section of the report acknowledges that health inequities often exist for people as a result of racialization, based in part, on their ethno-racial identity.
T.O. HEALTH CHECK 11 POPULATION DEMOGRAPHICS
Table 1.1: Top Ten Countries of Birth for Immigrants, Toronto, 2016
All Immigrants Recent Immigrants* Percent of Total Percent of Total Rank Country of Birth Country of Birth Immigrant Population** Immigrant Population** 1 China 10% Philippines 17% 2 Philippines 9% China 12% 3 India 6% India 11% 4 Sri Lanka 4% Iran 6% 5 Italy 4% Pakistan 4% 6 Jamaica 4% Bangladesh 3% 7 United Kingdom 3% Sri Lanka 2% 8 Hong Kong 3% United States 2% 9 Portugal 3% Iraq 2% 10 Guyana 3% Jamaica 2%
Data Source: Statistics Canada, Census of Population, 2016 *Recent immigrants first obtained landed immigrant or permanent resident status between 2011 and 2016. **Percentages do not total 100% as only the top tean countries are shown.
Figure 1.3: Number of Immigrants by Admission Category, Toronto as Intended Destination, 2008 to 2017
60,000
50,000
40,000
30,000
20,000 Number of Immigrants
10,000
0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Total 50,725 46,975 50,630 44,400 42,890 42,420 43,450 59,765 57,560 58,620 Economic 27,175 24,680 29,670 22,795 21,580 19,835 24,280 38,250 30,695 33,420 Sponsored Family Member 15,725 15,155 13,215 12,240 13,565 15,320 12,105 12,730 14,710 14,960 Resettled Refugee & Protected Person 6,670 5,940 6,745 8,260 6,405 6,415 6,215 7,890 11,405 9,360 Other 1,155 1,205 995 1,110 1,345 855 850 890 750 880
Data Source: Immigration, Refugees and Citizenship Canada (IRCC), Permanent Residents.
12 T.O. HEALTH CHECK POPULATION DEMOGRAPHICS
During the ten-year period from 2008 to 2017 in Health disparities among Toronto: immigrant sub-groups exist due There was a 16% increase in immigrants arriving in to the circumstances of their the city (50,725 to 58,620) (Figure 1.3). immigration. For example, 55% of all immigrants10 arriving in the city during stressors experienced due to war this period were economic immigrants, 28% were and violence may be worsened after immigration sponsored family members, 15% were resettled for refugees and asylum-seekers [15] [20] [21]. refugees or protected persons, and the remaining Medically uninsured immigrants such as 2% were other types of immigrants. temporary residents, refugees, asylum-seekers, Approximately 7,500 resettled refugees or protected and undocumented people may also suffer persons arrived annually. The number of resettled poorer health outcomes due to limited options refugees and protected persons peaked in 2016 to to access healthcare [21] [22]. 11,405.