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::: {#MathJax_Message style="display: none;"} ::: {#data-uuid-4f4e2a566725438a97ec8728ee4420e7.section.mhhe-blk-header} Wellness: The New Health Goal {#data-uuid-54f7e697b9d745f9953f3ae9eb7fe7a8} ============================= Generations of people have viewed health simply as the absence of disease...

::: {#MathJax_Message style="display: none;"} ::: {#data-uuid-4f4e2a566725438a97ec8728ee4420e7.section.mhhe-blk-header} Wellness: The New Health Goal {#data-uuid-54f7e697b9d745f9953f3ae9eb7fe7a8} ============================= Generations of people have viewed health simply as the absence of disease. That view largely prevails today; the word [health](javascript:void(0);) typically refers to the overall condition of a person's body or mind and to the presence or absence of illness or injury. It's important not to become obsessed with our health as that, in itself, can be unhealthy. In fact, the Ottawa Charter for Health Promotion underscores the important distinction that health is a resource for living, not the objective of living. [Wellness](javascript:void(0);) is a relatively new concept that expands our idea of health. Beyond the simple presence or absence of disease, wellness refers to optimal health and vitality---to living life to its fullest. Although we use the words *health* and *wellness* interchangeably in this text, two important differences exist between them: - ::: {#data-uuid-31fdd849d48a4281b98a543dcda63ba0} Health---or some aspects of it---can be determined or influenced by factors beyond your control, such as your genes, your age, the health care system, and the care you received as a young child (i.e., by some of the [social determinants of health](javascript:void(0);), see [Table 1.1](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). For example, consider a 60-year-old man with a strong family history of prostate cancer who lives in a rural community in the Northwest Territories and has limited access to cancer screening services. These factors place this man at a higher-than-average risk for developing prostate cancer himself. ::: - ::: {#data-uuid-babff2710e234adca4e752711db38a16} Wellness is largely determined by the decisions you make about how you live. That same 60-year-old man can reduce his risk of cancer by eating sensibly, exercising, and having screening tests when they are available. Even if he develops the disease, he may still live a rich, meaningful life. This means choosing not only to care for himself physically but also to maintain a positive outlook, keep up his relationships with others, challenge himself intellectually, honour his faith or spirituality, and nurture other aspects of his life. [Page 3]{#Page+3.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} ::: ::: {#data-uuid-12bbada76a8c4e67962ac7518d550717.scrobile_container} ::: {#data-uuid-f4883db60b2c4a14b4a7e1bf7bfed112.enumeration} Table 1.1 ::: Social Determinants of Health The Canadian Public Health Association identifies 14 key social determinants of health for both populations and individuals, the latter of which are the focus of this text. Some determinants are discussed throughout this chapter, and others are highlighted in the Dimensions of Diversity boxes throughout this text. ::: ::: - ::: {#data-uuid-399f940ab7cd489281507b3b3f3da066} **Income and income distribution** - ::: {#data-uuid-35294d126ad546bf9438662998f8c958} *Finances shape overall living conditions, affecting psychological functioning and health-related behaviours. More equal distribution of income among a population is a strong predictor of the better overall health of a society.* ::: ::: - ::: {#data-uuid-ba548d2ba7a64eb8ac4006d15da0596f} **Education** - ::: {#data-uuid-d4fb602e9c96468fa7ee75a80182d036} *People with more education tend to be healthier than those with lower educational attainment.* ::: ::: - ::: {#data-uuid-2ce418c117234326ac554d906ebc656a} **Unemployment and job security** - ::: {#data-uuid-8f545c243c4a483ab5bf698119b30f7f} *Being without a job often leads to material and social deprivation, psychological stress, and unhealthy coping behaviours; insecure employment is associated with high levels of stress, body pains, and risk of injury.* ::: ::: - ::: {#data-uuid-24266d3750574d4d9dfde55e49face49} **Employment and working conditions** - ::: {#data-uuid-1e4f1f43b6114498aebdce40fdbd6872} *People spend a substantial amount of time at work, making the physical, emotional, and other influences imposed by a work setting important contributors to health.* ::: ::: - ::: {#data-uuid-d671ecbc901a436aa8b2c1c2b1286d59} **Early childhood development** - ::: {#data-uuid-16c762ff837f4b3f8f7bb1fdd3c6bb3b} *Early childhood experiences have strong, immediate, long-lasting biological, psychological, and social impacts on health.* ::: ::: - ::: {#data-uuid-137ca4a7c9de4cac8c6b8d40050dc52d} **Food insecurity** - ::: {#data-uuid-63981e6666b54d2d9edaafd849213a68} *People who are unable to have an adequate diet in terms of quality or quantity are at high risk for inadequate nutritional intake.* ::: ::: - ::: {#data-uuid-9dfacc4be1b545f99fe5e9cf60be8e6a} **Housing** - ::: {#data-uuid-efe6842efe0e4fe380b6aa77e0cc3a96} *Poor quality housing and homelessness increase the risk for many health problems, including those associated with overcrowding, unclean water, and lack of a safe shelter.* ::: ::: - ::: {#data-uuid-88df3abe346e47138ea6d6f0fb6727db} **Social exclusion** - ::: {#data-uuid-08cd154245934e77b8c7880e28bd2dad} *Individuals or groups who are denied the opportunity to participate fully in mainstream society are less likely to have access to social, cultural, and economic resources, all of which impact health.* ::: ::: - ::: {#data-uuid-d5a58c908f884b91b238a39400ef83e6} **Social safety net and network** - ::: {#data-uuid-851c71dfd2ef4c20a796e61f60fd20ae} *There are a range of benefits, programs, and supports that protect citizens during various life changes that can affect their health.* ::: ::: - ::: {#data-uuid-59ba0a6dc48b40fa87c127b45710c082} **Health services** - ::: {#data-uuid-8be6c8a705e149be8102894b5edaf909} *High-quality health care services are considered both a social determinant of health and a basic human right.* ::: ::: - ::: {#data-uuid-003ea7f8b2b540829da76c13a770abde} **Indigenous status** - ::: {#data-uuid-087076b4e5754b18b49f1e3cb5ec5840} *The health of Indigenous peoples in Canada is inextricably linked to the history of colonization. This has taken the form of disregard for land claims of Métis people, relocation of Inuit communities, and the establishment of residential schools. Adverse health outcomes experienced by Indigenous people are one of the many negative effects of colonization.* ::: ::: - ::: {#data-uuid-8a57b7ec7e864dd28b1060cd841d1548} **Gender** - ::: {#data-uuid-531cc8975a53413eaedbd2d7c3ce016e} *Some people are at higher risk for adverse health outcomes due to gender-related discrimination, social exclusion, and society-influenced gender roles. * ::: - ::: {#data-uuid-b814f0fba6a24eb784ada52f5e8a2704} *Some academics believe that gender identity ought to be its own social determinant of health, given the discrimination and stigma associated with being a person who identifies as trans or gender-diverse.* ::: ::: - ::: {#data-uuid-b712c137a3fc4e3b9ccf11bf6a64bd5f} **Race** - ::: {#data-uuid-69631ea36aa14ffba8331ebd2024551d} *Racialized or non-white Canadians experience a range of adverse living circumstances that threaten their health. Because our country prides itself on being a multicultural society, these adverse circumstances also threaten overall health and well-being of *Canadian society*.* ::: ::: - ::: {#data-uuid-e55a0715ac344704bf014ac7da055e30} **Disability** - ::: {#data-uuid-d5853bc517d74ee8b22587aee794e9c5} *While disability tends to be related to physical and mental functions, it is important to consider whether society is willing to provide persons with disabilities with supports and opportunities necessary to participate in mainstream society.* ::: ::: Source: Canadian Public Health Association. (n.d.). What are the social determinants of health? Retrieved July 19, 2021, from https://www.cpha.ca/what-are-social-determinants-health; Raphael, D. (2009). *Social determinants of health: Canadian perspectives* (2nd ed.). (Toronto: Canada Scholars' Press); [Raphael, D., Bryant, T., Mikkonen, J., & Raphael, A. (2020). *Social Determinants of Health: The Canadian* ]{dir="ltr"}[*Facts.* (Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of ]{dir="ltr"}[Health Policy and Management)]{dir="ltr"}. Retrieved July 19, 2021, from https://thecanadianfacts.org/The\_Canadian\_Facts-2nd\_ed.pdf; Ross, L.E., Kinitz, D.J. & Kia, H. (2022). Pronouns Are a Public Health Issue, American Journal of Public Health, 112 (3), 360-362. https://doi.org/10.2105/AJPH.2021.306678. Enhanced wellness, therefore, involves making conscious decisions to control [risk factors](javascript:void(0);) that contribute to disease or injury. Age and family history are non-modifiable risk factors that you cannot control. Some behaviours, such as smoking, exercising, and eating a healthy diet, are modifiable factors. The Ottawa Charter for Health Promotion describes [health promotion](javascript:void(0);) as a vehicle for achieving wellness; you must play an active role in the decisions related to each dimension of your wellness rather than deciding simply that your health status happens to you. It is also important to recognize that different people define their level of wellness differently. ::: {#data-uuid-dfc490f89e5a4edcbd8743642077d639.section.mhhe-blk-header} Dimensions of Wellness {#data-uuid-1047caa7b89742a2be56605a4d43354d} ---------------------- The process of achieving wellness is continual and dynamic, involving change and growth. The encouraging aspect of wellness is that you can actively pursue it. Here are nine dimensions of wellness: - ::: {#data-uuid-f9f7190f57b6468b91ada04d200b3ede} Physical ::: - ::: {#data-uuid-32226467d5f744fcb97b36a536c71c7d} Emotional ::: - ::: {#data-uuid-20654322e4f74d938a9436786fb7674c} Intellectual ::: - ::: {#data-uuid-a9a8303d67314bed99ba87702702a4bb} Interpersonal ::: - ::: {#data-uuid-2787b7b45b254790990a42a47942b2cc} Cultural ::: - ::: {#data-uuid-79054519bd024582b6916db5b5e9aa10} Spiritual ::: - ::: {#data-uuid-1e7e3264d01a4a7c9989bd153d2f887d} Environmental ::: - ::: {#data-uuid-afcfeb0a4e0b4fe7986f26ec625689e2} Financial ::: - ::: {#data-uuid-a579f029bc9849a19422c8a93b384192} Occupational ::: [Page 4]{#Page+4.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} These dimensions are interrelated; each has an effect on the others, and researchers have found important connections between the wellness of the mind and that of the body (see [Chapter 19](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). [Figure 1.1](javascript:void(0);){.mhhe-link.dpg-bar--non_break} lists specific qualities and behaviours associated with each dimension. The following sections briefly introduce the dimensions of wellness. Figure 1.1 **[Figure 1.1]{.number.custom-figure-num.dpg-bar--uppercase}** [{#data-uuid-d55cce7f67e64c97810d790d5f45f014.longdesc-icon}](javascript:void(0);) ::: {#data-uuid-9b732cc50188474485ec01029767061b.section.mhhe-blk-header} ### Physical Wellness {#data-uuid-c432e1477ef64ab28670e2c3ff1a633d} Your physical wellness includes not just your body's overall condition and the absence of disease but also your fitness level and your ability to care for yourself. The higher your fitness level, the higher your level of physical wellness will be. Similarly, as you develop the ability to take care of your own physical needs, you ensure greater physical wellness. To achieve optimum physical wellness, you need to make choices that will help you avoid illnesses and injuries. The decisions you make now, and the habits you develop over your lifetime, will largely determine the length and quality of your life. ::: ::: {#data-uuid-a5cad9ca05d9433e82d3b4554dd75523.section.mhhe-blk-header} ### Emotional Wellness {#data-uuid-46b20f4aae63453a98868f3d6ebfa23f} Trust, self-confidence, optimism, satisfying relationships, and self-esteem are some qualities of emotional wellness. Emotional wellness is dynamic and involves the ups and downs of living. It fluctuates with your intellectual, physical, spiritual, cultural, and interpersonal health. Maintaining emotional wellness requires exploring thoughts and feelings. Self-acceptance is your personal satisfaction with yourself---it might exclude society's expectations---whereas self-esteem relates to the way you think others perceive you; self-confidence can be a part of both acceptance and esteem. Achieving emotional wellness includes finding solutions to emotional problems, with professional help if necessary. ::: [Page 5]{#Page+5.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} ::: {#data-uuid-b9b7027a21644f52864e68730e5e9226.section.mhhe-blk-header} ### Intellectual Wellness {#data-uuid-b0af1424c8f7443b8cb70bf9c97ef3dc} Those who enjoy intellectual (or mental) wellness constantly challenge their minds. An active mind is essential to wellness because it detects problems, finds solutions, and directs behaviour. People who enjoy intellectual wellness never stop learning; they continue trying to learn new things throughout their lifetime. ::: ::: {#data-uuid-b06580c2bb94480695b437a5de65f1a6.section.mhhe-blk-header} ### Interpersonal Wellness {#data-uuid-1d640701c4404ecf9b1b97b459ea6804} Your interpersonal (or social) wellness is defined by your ability to develop and maintain satisfying and supportive relationships. Such relationships are essential to physical and emotional health. Social wellness requires participating in and contributing to your community and to society. ### Cultural Wellness {#data-uuid-6a2dadba05ea4c74b0f485f1747cfbce} Cultural wellness refers to the way you interact with others who are different from you in terms of ethnicity, religion, gender, sexual orientation, age, and customs. It involves creating relationships with others and suspending judgment of others. It also includes accepting and valuing the different cultural ways people interact in the world. One measure of cultural wellness is the extent to which you maintain and value cultural identities. ::: ::: {#data-uuid-3b1c329d7d624072986dc0c2d29576e9.section.mhhe-blk-header} ### Spiritual Wellness {#data-uuid-31b5053e8e374e1c93b40836fda19bcd} To enjoy spiritual wellness is to possess a set of guiding beliefs, principles, or values that give meaning and purpose to your life, especially in difficult times. The spiritually well person focuses on the positive aspects of life and finds spirituality to be an antidote for negative feelings, such as cynicism, anger, and pessimism. Organized religions help many people develop spiritual health. Religion, however, is not the only source or form of spiritual wellness. Many people find meaning and purpose in their lives on their own---through nature, art, meditation, or good works---or with their loved ones. ::: ::: {#data-uuid-851f79e6274e4ccbac6aa0b014f8297a.section.mhhe-blk-header} ### Environmental Wellness {#data-uuid-9e8ec89ccdbe4d639c1fcc89422662d4} Your environmental wellness is defined by the livability of your surroundings. Personal health depends on the health of the planet---from the safety of the food supply to the degree of violence in society. Your physical environment either supports your wellness or diminishes it. To improve your environmental wellness, you can learn about and protect yourself against hazards in your surroundings and work to make your world a cleaner and safer place. See [[Chapter 18](javascript:void(0);)]{.mhhe-link} for more information on environmental health. ::: {#data-uuid-3faa2a50a2744d6a9c6723b8ea2ad85f.section} ::: {#data-uuid-4793376eaa1d4c10bf21497c14ee56ab.section} ### Financial Wellness {#data-uuid-b7dee06f6dae4a8692861a8b64cedfaa} Financial wellness refers to your ability to live within your means and manage your money in a way that gives you peace of mind. It includes balancing your income and expenses, staying out of debt, saving for the future, and understanding your emotions about money. ::: ::: {#data-uuid-fc45501b2c6b42dc9270852dbed35313.section} ### Occupational Wellness {#data-uuid-03127a48cb4a4ee4a97bbaa049932602} Occupational wellness refers to the level of happiness and fulfillment you gain through your work and employment. Although high salaries and prestigious titles are gratifying, they alone may not bring about occupational wellness. An occupationally well person enjoys their work, feels a connection with others in the workplace, and takes advantage of the opportunities to learn and be challenged. Another important aspect of occupational wellness is recognition from managers and colleagues. An ideal job draws on your interests and passions, as well as your vocational skills, and allows you to feel that you are making a contribution to your everyday work. The Long and the Short of Life Expectancy {#data-uuid-10d70127cdd44c17ae051b895efc606d} ----------------------------------------- Can we control how long we will live, or is our life span determined by our genes? Studies suggest that our genes can determine up to 25 percent of the variability in life span. Some genes influence lifestyle factors, such as alcohol consumption and addiction. A new study found correlations among genes, behaviour, and how long we might expect to live. [Page 6]{#Page+6.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} Researchers at the University of Edinburgh looked at the genomes of over 600 000 people in Europe, Australia, and North America and their parents' life spans. They found that the strongest correlations between genes and mortality are susceptibility to coronary artery disease and modifiable behaviours such as cigarette smoking. Also correlated to a shorter life span are obesity, susceptibility to lung cancer, and insulin resistance. Greater longevity can happen for people who give up smoking, maintain their high-density lipoprotein cholesterol levels, attain more education, and cope well with stress. ::: ::: ::: ::: ::: {#data-uuid-7af78677889a467687b423704e5348f2.section.mhhe-blk-header} New Opportunities, New Responsibilities {#data-uuid-21b44bdecccb41a4a73eb44ab57f30bc} --------------------------------------- Wellness is a fairly new concept. A century ago, North Americans considered themselves lucky just to survive to adulthood (see [Figure 1.2](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). Approximately one in ten Canadian babies born in 1921 died within their first year of birth. Those who did survive childhood were expected to live only 47 years. Many people died from common [infectious diseases](javascript:void(0);) (such as pneumonia, tuberculosis, or diarrhea) and poor environmental conditions (such as water pollution and poor sanitation). Figure 1.2 Public Health Achievements of the Twentieth and Twenty-First Centuries ¶ During the twentieth century, public health achievements greatly improved the quality of life for North Americans. A shift in the leading causes of death also occurred, with deaths from infectious diseases declining from 33 percent of all deaths to just 2 percent. Heart disease, cancer, and stroke are responsible for more than half of all deaths among North Americans. **[[Figure 1.2]{.custom-sans}]{.number.custom-figure-num.dpg-bar--uppercase}** [Public Health Achievements of the Twentieth and Twenty-First Centuries ]{.label} ¶ During the twentieth century, public health achievements greatly improved the quality of life for North Americans. A shift in the leading causes of death also occurred, with deaths from infectious diseases declining from 33 percent of all deaths to just 2 percent. Heart disease, cancer, and stroke are responsible for more than half of all deaths among North Americans. [{#data-uuid-89f067e8f335473c8a8d55ffcd55366e.longdesc-icon}](javascript:void(0);) Since 1900, life expectancy has nearly doubled, largely because of the development of vaccines and antibiotics to fight infections and public health measures to improve living conditions. Despite these improvements, infectious diseases are not only challenges presented in the past, as demonstrated by the COVID-19 pandemic, which resulted in a 7.7 percent increase in deaths between 2019 and 2020. The COVID-19 pandemic reflects the devastation of a highly contagious and uncontrolled infectious disease, especially among individuals whose determinants of health make them particularly vulnerable. Vaccines, masks, ventilation, physical distancing, and policies mandating their uses are among the tools that have been crucial to help reduce the spread of the world's most recent infectious disease pandemic. [Page 7]{#Page+7.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} While we remain acutely aware of the challenges that infectious diseases pose, during the twenty-first century, a different set of diseases emerged as our major health threat: cancer. [In most years in recent history, with the exception of 2020, which was the first year COVID‐19 was identified among the top three leading causes of death in Canada, cancer,]{lang="EN-US"} heart disease, and stroke are the typical three leading causes of death for Canadians (see [Table 1.2](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). Treating such [chronic diseases](javascript:void(0);) is costly and difficult. ::: {#data-uuid-249ddf4542dd4c3685e00f7ee1964164.scrobile_container} ::: {#data-uuid-b7651845928343aca2f1df38ce847203.enumeration} Table 1.2 ::: Ten Leading Causes of Death in Canada, 2020 ::: {#data-uuid-f8c7939d80e74948a62317fd6909e47f.hiddentext} Table Summary: A table summarizes the ten leading causes of death in Canada in 2020. The column headers are Rank, Cause of Death, Number of Deaths, Percentage of Total Deaths, and Lifestyle Factors. ::: **Rank** ::: ::: **Cause of Death** **Number of[ Deaths]{.newline}** **Percentage of[ Total Deaths]{.newline}** **Lifestyle[ Factors]{.newline}** All causes 307 205 100.0 Total, ten leading causes of death 215 166 70.0 1 Cancer  80 973   26.4 D I S A O 2 Heart disease  53 704 17.5 D I S A O 3 COVID-19 16 151 5.3 4 Unintentional injuries (accidents) 15 508    5.0 I S A 5 Cerebrovascular diseases (stroke)   13 695     4.5 D I S A O 6 Chronic lower respiratory diseases   11 722     3.6 S O 7 Diabetes mellitus   7 566     2.5 D I S O 8 Influenza and pneumonia  5 931   1.9 D I S A 9 Alzheimer's disease  5 743     1.9 10 Chronic liver disease and cirrhosis  4 173      1.6 D S A O Notes**:** **D** Diet plays a part; **I** Inactive lifestyle plays a part; **S** Smoking plays a part; **A** Excessive alcohol use plays a part; **O** Obesity plays a part. Source: Adapted from Statistics Canada. (2020). Leading causes of death, total population, by age group \[Table 13-10-0394-01\]. Retrieved June 25, 2021, from [](https://www150.statcan.gc.ca/t1/tbl1/en/cv!recreate.action?pid=1310039401&selectedNodeIds=5D1,5D2&checkedLevels=0D1,1D1,2D1,3D1,3D2&refPeriods=20200101,20200101&dimensionLayouts=layout2,layout2,layout2,layout3,layout3,layout2&vectorDisplay=false)[[https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1310039401.]{lang="EN-US"}]{lang="EN-CA"} [](https://www150.statcan.gc.ca/t1/tbl1/en/cv!recreate.action?pid=1310039401&selectedNodeIds=5D1,5D2&checkedLevels=0D1,1D1,2D1,3D1,3D2&refPeriods=20200101,20200101&dimensionLayouts=layout2,layout2,layout2,layout3,layout3,layout2&vectorDisplay=false)[[[]{lang="EN-US"}](https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1310039401)]{lang="EN-CA"} The good news is that people have some control over whether they develop chronic diseases. People make choices every day that increase or decrease their risks for such diseases. These [lifestyle choices](javascript:void(0);) include many different behaviours, such as smoking, diet, exercise, and alcohol use. As [Table 1.2](javascript:void(0);){.mhhe-link.dpg-bar--non_break} makes clear, lifestyle factors contribute to many deaths in Canada, and people can influence their own health risks. The need to make good choices is especially true for teens and young adults. For Canadians aged 15 to 24, the top three causes of death are unintentional injuries (accidents), suicide, and cancer, as shown in [Table 1.3](javascript:void(0);){.mhhe-link.dpg-bar--non_break}. [Page 8]{#Page+8.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} ::: {#data-uuid-38911e4b28724966b83c87716ce87631.scrobile_container} ::: {#data-uuid-8fb7ac13311e402f8952fe4fb85fb7b5.enumeration} Table 1.3 ::: Five Leading Causes of Death among Canadians Aged 15 to 24, 2019 ::: {#data-uuid-3cfe2cdbdb564b4a89ac5f521610e5be.hiddentext} Table Summary: A table summarizes the five leading causes of death among Canadians between the ages of 15 to 24 in 2019. The column headers are Rank, Cause of Death, Number of Deaths, and Percentage of Total Deaths. ::: **Rank** ::: **Cause of[ Death]{.newline}** **Number of[ Deaths]{.newline}** **Percentage[ of Total]{.newline}[ Deaths]{.newline}** All causes 2023 1 Accidents (unintentional injuries) 629 31.1 2 Intentional self-harm (death by suicide) 506 25.0 3 Cancer 147   7.3 4 Assault (homicide)  89  4.4 5 Heart disease  47  2.3 Source: Adapted from Statistics Canada. (2020). Leading causes of death, total population, by age group \[Table 13-10-0394-01\]. Retrieved June 25, 2021, from [[https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1310039401]{lang="EN-US"}]{lang="EN-CA"}. ::: {#data-uuid-d9bb0e50182c49a58a2735421848d0e4.section.mhhe-blk-header} The Integrated Pan-Canadian Healthy Living Strategy {#data-uuid-0e157b42368341b0b1108770cfb50248} --------------------------------------------------- Wellness is a personal concern, but the Canadian government has humanitarian and financial interests in it, too. In addition to the enormous human suffering caused by our nation's leading chronic diseases, the estimated cost in Canada of illness, disability, and death attributable to chronic diseases is more than \$190 billion annually, with \$68 billion going toward treatment and the rest to lost productivity. The Integrated Pan-Canadian Healthy Living Strategy was created in 2002 when the federal, provincial, and territorial ministers of health sought a collaborative and coordinated approach to curbing our nation's non-communicable diseases. The goal was to address the diseases' common, preventable risk factors (physical inactivity, unhealthy diet, and tobacco use) and the underlying conditions in society that contribute to them, including income, employment, education, geographic isolation, social exclusion, and other factors. In 2010, the strategy was strengthened through two initiatives focused on (a) making the prevention of disease, disability, and injury and health promotion priorities; and (b) decreasing the prevalence of childhood obesity. #### Quick Stats {#data-uuid-6be1e48e830c4dfda08ad42690a8b2b7} - ::: {#data-uuid-2a63ce1da31845619d82f82628d246cd} Canadian adults aged 20 to 25 have the highest impaired driving rates in Canada, and more than 41 percent of Canadians who die in alcohol-related vehicle accidents are between the ages of 20 and 25. Moreover, testing positive for marijuana is most likely in drivers aged 16 to 34. ::: - ::: {#data-uuid-c979491212034cfe98cff5cb0f8193c1} ---Lyon & Robertson, Traffic Injury Research Foundation, 2020;^[a](javascript:void(0); "Opens in a modal")^ Brown, Robertson & Vanlaar, Traffic Injury Research Foundation, 2021^[b](javascript:void(0); "Opens in a modal")^ ::: The strategy's vision is a healthy nation in which all Canadians experience the conditions that support the attainment of good health. Its goals were to improve overall health outcomes and reduce health disparities in meaningful ways by 2015. Although that date has passed, the vision and goals remain relevant today as we still have much work to do to improve our citizens' health. More specifically, the strategy's aim to increase healthy eating, physical activity, and healthy weights remain suitable targets: - ::: {#data-uuid-d3ed49dac51446de9085d37bb28043b8} *Healthy eating objective:* Increase by 20 percent the proportion of Canadians who make healthy food choices. ::: - ::: {#data-uuid-1f11e38095af4133bf23d1e6806ac338} *Physical activity objective:* Increase by 20 percent the proportion of Canadians who participate in regular physical activity based on 30 minutes/day of moderate to vigorous activity (the amount needed for health benefits). ::: - ::: {#data-uuid-01faf3fe78d141d5a2811b5b73168fa5} *Healthy weights objective:* Increase by 20 percent the proportion of Canadians at a healthy body weight based on a body mass index (BMI) of 18.5 to 24.9. ::: Information is collected for each objective to see if/when the targets are being met. If all Canadians improve these three areas of their lives, they will be better able to achieve their ideal level of wellness, and the nation as a whole will be much healthier. [Table 1.4](javascript:void(0);){.mhhe-link.dpg-bar--non_break} summarizes the current eating and physical activity habits and smoking and vaping rates of each province's and territory's population. Although Canadians have work to do to meet our health-related goals, when our country and its individual provinces are compared to 13 peer countries, our self-reported health status is greater than all of our international peers except the U.S. [Figure 1.3](javascript:void(0);){.mhhe-link.dpg-bar--non_break} illustrates this comparison. [Page 9]{#Page+9.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} ::: {#data-uuid-7d6e33ff489a4a4bac0c64765bb8fce6.scrobile_container} ::: {#data-uuid-17bdb5d3bdb04cdd9995e2785fd71684.enumeration} Table 1.4 ::: Eating Habits and Physical Activity and Smoking Levels among Canadians ::: {#data-uuid-0025af037ee04b4fafe1c70a5f1bac1f.hiddentext} Table Summary: \"A table summarizes Eating Habits and Physical Activity and Smoking Levels among Canadians. The column headers show the first cell blank. The second column header shows Smoking superscript 1 (percentage) - 2019 (daily or occasional), the third header shows Smoking (percentage) - 2019 (daily), Vaping (percentage) - 2017 (had ever used), Vaping (percentage) - 2017 (past 30-day use), Healthy Eating Habits superscript 2 (percentage), Physically Active superscript 3, 4 (percentage).\" ::: ::: ::: [Smoking^1 ^]{.mhhe-color--text-white}(%) - 2019 (daily or occasional) Smoking (%) - 2019 (daily) Vaping (%) - 2017 (had ever used) Vaping (%) - 2017 (past 30-day use) **Healthy[ Eating]{.newline}[ Habits^2^ (%)]{.newline}** **Physically[ Active^3,4^ (%)]{.newline}** British Columbia 11.1 6.7 17.6 5.4 28.8 64.7 Alberta 15.5 10.7 14.9 2.8 27.4 57.8 Saskatchewan 16.7 12.4 15.7 3.5 26.0 52.7 Manitoba 14.8 10.0 18.2 3.3 25.0 53.1 Ontario 13.8 9.3 12.9 1.9 26.7 53.4 Quebec 17.0 11.4 17.1 2.5 34.5 50.6 New Brunswick 16.3 11.4 16.7 5.7 25.3 49.4 Nova Scotia 18.3 13.3 19.9 4.7 25.5 54.7 Prince Edward Island 16.4 11.0 15.7 3.0 25.9 47.0 Newfoundland and Labrador 19.5 14.0 17.5 2.3 18.3 46.8 Yukon^5^ Northwest Territories^5^ Nunavut^5^ ^1^ The information was provided for those "aged 12 and over who reported being a current smoker." ^2^ Refers to consumption of five or more fruit or vegetable servings a day. ^3^ Refers to leisure-time activity level. ^4^ Physically active is defined as "self-reported physical activity, 150 minutes per week, adult (18 years and over)." ^5^ Information was not available for the territories. Sources: Adapted from Statistics Canada. (2017). Health characteristics, annual estimates \[Table 13-10-0096-01\]. Retrieved June 26, 2021, from [[https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1310009601]{lang="EN-US"}]{lang="EN-CA"}; adapted from University of Waterloo (2019). Tobacco use in Canada \| E-cigarette prevalence by province \[Figure 12.7\]. Retrieved July 21, 2021, from [[https://uwaterloo.ca/tobacco-use-canada/e-cigarette-use-canada/prevalence-e-cigarette-use/e-cigarette-prevalence-province]{lang="EN-US"}]{lang="EN-CA"}. [Page 10]{#Page+10.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} Figure 1.3 Self-Reported Health Status, 2012 or Most Recent Year **[Figure 1.3]{.number.custom-figure-num.dpg-bar--uppercase}** [Self-Reported Health Status, 2012 or Most Recent Year]{.label} [{#data-uuid-befce75773c540a1a0a28e23a6816915.longdesc-icon}](javascript:void(0);) ::: {#data-uuid-46e8785a7fb54e71b286f5296e7d4c22.section.mhhe-blk-header} Health Issues for Diverse Populations {#data-uuid-0529623a485e4d8ea119fd39f5492c62} ------------------------------------- Canadians are a diverse people. Over 250 ethnic origins were identified by those who completed the 2016 Canadian Census of Population, and about 40 percent reported multiple origins. Nearly one-third of the population reported at least one origin from the British Isles, and almost 14 percent reported at least one French origin (see [Figure 1.4](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). We live in cities, suburbs, and rural areas and work in every imaginable occupation. [Page 11]{#Page+11.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} Figure 1.4 Top 20 Ethnic Origins Reported Alone or in Combination with Other Origins, Canada, 2016 **[Figure 1.4]{.number.custom-figure-num.dpg-bar--uppercase}** [Top 20 Ethnic Origins Reported Alone or in Combination with Other Origins, Canada, 2016]{.label} [{#data-uuid-04c6b4cad85c44b0ab3708ffc2760065.longdesc-icon}](javascript:void(0);) When it comes to health, most differences among people are insignificant; most health issues concern us all equally. We all need to eat well, exercise, manage stress, and cultivate satisfying personal relationships. We need to know how to protect ourselves from heart disease, cancer, sexually transmitted infections (STIs), and injuries. We need to know how to use and access the health care system. But some of our differences, as individuals and as members of groups, have important implications for health. Some of us, for example, have a genetic predisposition for developing certain health problems, such as high cholesterol. Some of us have grown up eating foods that raise our risk of heart disease or obesity. Some of us live in environments that increase the chance that we will smoke cigarettes or abuse alcohol. These health-related differences among individuals and groups can be biological---determined genetically---or cultural---acquired as patterns of behaviour through daily interactions with our families, communities, and society. Many health conditions are a function of biology and culture combined. A person can have a genetic predisposition for a disease, for example, but won't actually develop the disease unless certain lifestyle factors, such as stress or a poor diet, are present. #### Quick Stats {#data-uuid-cca465581fd149498a48381c3b6fc56e} - ::: {#data-uuid-58c9e81d91f74290ba102b53b3deb2b8} 63.1 percent of Canadians aged 18 and older have either overweight or obesity. ::: - ::: {#data-uuid-a11e4355dfc2471797a0ffd16a21a6f7} ---Statistics Canada, 2018[^c^](javascript:void(0); "Opens in a modal") ::: When we talk about health issues for diverse populations, we face two related dangers. The first is the danger of *stereotyping*, or talking about people as groups rather than individuals. It is true that every person is an individual with a unique genetic endowment and unique life experiences. But many of these influences are shared with others of similar genetic and cultural backgrounds. Statements about these group similarities can be useful; for example, they can alert people to areas that may be of special concern for them and their families. The second danger is *overgeneralizing*, or ignoring the extensive biological and cultural diversity among peoples who are grouped together. Groups labelled Latinx, for example, include Mexican Canadians, Puerto Ricans, people from South and Central America, and other Spanish-speaking people. Similarly, the population referred to as Indigenous peoples of Canada includes First Nations, Métis, and Inuit, each with its own genetic and cultural heritage. Health-related differences among groups can be identified and described in the context of several different dimensions. Well-accepted dimensions are sex, gender, ethnicity, income, education, disability, geographic location, and sexual orientation. ::: {#data-uuid-acdfe0be5c36409fbfc064d10b43a6f8.section.mhhe-blk-header} ### Sex and Gender {#data-uuid-b12e497a5f654ccdbb4c915096391c40} Sex and gender profoundly influence wellness. The World Health Organization (WHO) defines [sex](javascript:void(0);) as the biological and physiological characteristics that define men, women, and [intersex](javascript:void(0);) people; these characteristics are related to chromosomes and their effects on reproductive organs and the functioning of the body. Menstruation in women and the presence of testicles in men are examples of sex-related characteristics. [Gender](javascript:void(0);) is defined as roles, behaviours, activities, and attributes that a given society expects of men, women, and gender-diverse people. A person's gender and **[gender identity](javascript:void(0);)** are influenced by biology and physiology, shaped by socio-cultural, psychological, and environmental factors, including how society responds to individuals based on their sex. Part of embracing one's gender identity comes through using preferred gender pronouns, such as but not limited to she/her/hers, he/him/his, and they/them/theirs. Using an individual's preferred pronouns can be an empowering way to promote inclusivity. Examples of gender-related characteristics that affect wellness include a higher risk of mental health problems for gender-diverse individuals, drinking among men compared to women, and lower earnings among women (compared with earnings for men doing similar work). [Page 12]{#Page+12.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} Both sex and gender have important effects on wellness, but they can be difficult to separate (see the [Sex and Gender Matters](javascript:void(0);){.mhhe-link.dpg-bar--non_break} box). For example, more women began smoking with changes in culturally defined ideas about women's behaviour (a gender issue). Because women are more vulnerable to the toxins in tobacco smoke (a sex issue), cancer rates also increased. A recent study shows that although men are more biologically likely than women to suffer from certain diseases (a sex issue), men are less likely to visit their physician for regular exams (a gender issue). As a result, only 70 percent of Canadian men, compared to almost 85 percent of Canadian women, were in contact with their doctor in the past year, and many say they wait as long as possible before seeing a doctor---even when they are sick. Some of the research that has been summarized in each chapter used only the man/woman and male/female binaries and so no additional information is available on gender and sex identities that are not of these binaries. However, the authors acknowledge the importance of including considerations for all gender and sex identities in this work. [Page 13]{#Page+13.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} \ #### Icon: Gender Matters.Sex and Gender [MATTERS]{.dpg-bar--uppercase} {#data-uuid-7ac1a87046db401ba9f2e8a210147d55} ##### Women's Health/Men's Health {#data-uuid-a2abd9c7385a4612b72718e59c15e3a6} In terms of their health, women and men differ in many ways. They have different life expectancies, for one thing, and suffer from various diseases at different rates. Men and women tend to differ in some health-related behaviours and respond in dissimilar ways to some medications and medical treatments. The following table highlights some sex and gender differences that can affect wellness. {#data-uuid-e1aec342fe3e441ab644c0248a6c5e26} ::: {#data-uuid-363f8d5e7d6b44f0a939e04acffc907f.scrobile_container} +----------------------+----------------------+----------------------+ | **[Health | **Women** | **Men** | | Issues]{.dpg-bar--no | | | | n_break}** | | | +======================+======================+======================+ | [**Life | On average, live | Shorter life | | expectancy**]{.dpg-b | about four years | expectancy but lower | | ar--non_break} | longer but have | rates of disabling | | | higher rates of | health problems | | | disabling health | | | | problems, such as | | | | arthritis, | | | | osteoporosis, and | | | | Alzheimer's disease | | +----------------------+----------------------+----------------------+ | [**Height and | Shorter on average, | Taller on average, | | weight**]{.dpg-bar-- | with a lower | with a higher | | non_break} | proportion of | proportion of | | | muscle; tend to have | muscle; tend to have | | | a pear shape with | an apple shape with | | | excess body fat | excess body fat | | | stored in the hips; | stored in the | | | obesity is more | abdomen | | | common in women than | | | | men | | +----------------------+----------------------+----------------------+ | **Skills and | Score better on | Score better on | | fluencies** | tests of verbal | tests of | | | fluency, speech | visual-spatial | | | production, fine | ability (such as the | | | motor skills, and | ability to imagine | | | visual and working | the relationships | | | memory | between shapes and | | | | objects when rotated | | | | in space) | +----------------------+----------------------+----------------------+ | **Heart attacks** | Experience heart | Experience heart | | | attacks about ten | attacks about ten | | | years later than | years earlier than | | | men, on average, | women, on average, | | | with a poorer | with a better | | | one-year survival | one-year survival | | | rate; more likely to | rate; more likely to | | | experience atypical | have classic heart | | | heart attack | attack symptoms | | | symptoms (such as | (such as chest pain) | | | fatigue, arm and | | | | back pain, and | | | | difficulty | | | | breathing) or silent | | | | heart attacks that | | | | occur without chest | | | | pain | | +----------------------+----------------------+----------------------+ | **Stroke** | More likely to have | Less likely to die | | | a stroke or die from | from a stroke, but | | | one, but more likely | more likely to | | | to recover language | suffer permanent | | | ability after a | loss of language | | | stroke that affects | ability after a | | | the left side of the | stroke that affects | | | brain | the left side of the | | | | brain | +----------------------+----------------------+----------------------+ | [**Immune | Stronger immune | Weaker immune | | response**]{.dpg-bar | systems; less | systems; more | | --non_break} | susceptible to | susceptible to | | | infection by certain | infection by certain | | | bacteria and | bacteria and | | | viruses, but more | viruses, but less | | | likely to develop | likely to develop | | | autoimmune diseases, | autoimmune diseases | | | such as lupus | | +----------------------+----------------------+----------------------+ | **Smoking** | Lower rates of | Higher rates of | | | smoking than men, | smoking and chewing | | | but higher risk of | tobacco use | | | lung cancer at a | | | | given level of | | | | exposure to smoke | | +----------------------+----------------------+----------------------+ | **Alcohol** | Become more | Become less | | | intoxicated at a | intoxicated at a | | | given level of | given level of | | | alcohol intake | alcohol intake but | | | | are more likely to | | | | use or abuse alcohol | | | | or to develop | | | | alcoholism | +----------------------+----------------------+----------------------+ | **Stress** | More likely to react | More likely to react | | | to stress with a | to stress with | | | tend-and-befriend | aggression or | | | response that | hostility, which may | | | involves social | increase the rate of | | | support; may have a | stress-related | | | longevity advantage | disorders | | | because of a reduced | | | | risk of | | | | stress-related | | | | disorders | | +----------------------+----------------------+----------------------+ | **Depression** | More likely to | Lower rates of | | | suffer from | depression than | | | depression and to | women and less | | | attempt death by | likely to attempt | | | suicide | death by suicide, | | | | but four times as | | | | likely to die by | | | | suicide | +----------------------+----------------------+----------------------+ | **Headaches** | More likely to | More likely to | | | suffer from migraine | suffer from cluster | | | and chronic tension | headaches | | | headaches | | +----------------------+----------------------+----------------------+ | **Sexually | More likely to be | Less likely to be | | transmitted | infected with an STI | infected with an STI | | infections (STIs)** | during a | during a | | | heterosexual | heterosexual | | | encounter; more | encounter | | | likely to suffer | | | | severe, long-term | | | | effects from STIs, | | | | such as chronic | | | | infection and | | | | infertility | | +----------------------+----------------------+----------------------+ ::: \ ::: ::: {#data-uuid-dba517279f6340838735709a20128124.section.mhhe-blk-header} ### Ethnicity {#data-uuid-caf38d8cae874c55afddf59828fc2e4c} Although Canada is recognized for its diversity, little research has been done here about the specific health differences among the various ethnic groups. However, research from elsewhere in North America is relevant and shows various health disparities among ethnic groups. These disparities result from a complex mix of genetic variations, environmental and systemic factors, and health behaviours. Some diseases are concentrated in certain gene pools, the result of each ethnic group's relatively distinct history. For example, sickle-cell disease is most common among people of African ancestry. Tay-Sachs disease affects people of Eastern European Jewish heritage and French-Canadian heritage. Cystic fibrosis is more common among people of Northern European descent. In addition to biological differences, many cultural differences occur along ethnic lines. Ethnic groups may vary in their traditional diets; family and interpersonal relationships; attitudes toward tobacco, alcohol, and other drugs; and health beliefs and practices. All these factors have implications for wellness. (See the [Dimensions of Diversity](javascript:void(0);){.mhhe-link.dpg-bar--non_break} box for more information.) Within Canada, Indigenous peoples represent an important portion of the population in many ways, including cultural richness and historical prominence. Currently, about 4.9 percent (about 1.67 million) of the Canadian population identifies as Indigenous, and approximately one in six (260 550) speak fluently in their Indigenous language. Statistics Canada lists 12 different Indigenous languages spoken in Canada, with over 70 different dialects. No single correct definition exists for the term *Indigenous*. Statistics Canada uses questions about ethnic origin (including ancestry), Aboriginal identity, Registered or Treaty Indian, and Band or First Nation membership to establish its definitions.  Compared with the non-Indigenous population, Indigenous people face additional health challenges. This population is the youngest in Canada, with 44 percent of Indigenous people being 25 years of age or younger. This is because of higher birth rates; however, those living on reserves have a dramatically higher infant mortality rate than the general population and, even in adulthood, tend to have a shorter life expectancy. Additional serious and intersecting health challenges affect First Nations, Inuit, and Métis peoples more than non-Indigenous Canadians, such as: [Page 14]{#Page+14.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} - ::: {#data-uuid-4263e83aef7b4ebbba8e1e8872a3cb34} About one-and-a-half to two times the rate of heart disease ::: - ::: {#data-uuid-4e8f3502c6aa437aa0d4fd4d39ef75e0} Three to five times the rate of type 2 diabetes mellitus among First Nations people (which is associated with overweight and obesity, a condition affecting about 17 percent of First Nations people living on-reserve, compared to 5 percent of non-Indigenous people) and a rising rate among Inuit ::: - ::: {#data-uuid-3c9f643fd0ea4a6ba29e7e23a38ab27a} Forty times the rate of infection from tuberculosis (which is caused by a bacteria that is spread through the air) when living on reserve due to overcrowding and multigenerational living arrangements ::: Lifestyle factors can affect these chronic diseases, including sedentary lifestyle, alcohol consumption, and inadequate nutritional intake. For example, [Figure 1.5a](javascript:void(0);){.mhhe-link.dpg-bar--non_break} shows that First Nations people living in First Nations communities struggle to achieve healthy levels of physical activity. It is important to consider the role of alcohol and substance abuse in Indigenous populations in a broader cultural, social, and economic manner. The roots of this epidemic are in the days of European arrival when alcohol was introduced and often used as a profitable trade good. Today, many Indigenous populations suffer from a disproportionate burden of alcohol and other substance abuse issues, often as a method to cope with the traumas left by the Residential School System and other factors related to colonialization (see [Figure 1.5b](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). Figure 1.5A Physical Activity among First Nations People Living on Reserve **[Figure 1.5A]{.number.custom-figure-num.dpg-bar--uppercase}** [Physical Activity among First Nations People Living on Reserve]{.label} [{#data-uuid-7f043afc218845b184f8307b5adabed6.longdesc-icon}](javascript:void(0);) [Page 15]{#Page+15.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} Figure 1.5B Heavy Drinking1 among First Nations People Living on Reserve **[[Figure 1.5B]{.custom-sans}]{.number.custom-figure-num.dpg-bar--uppercase}** [Heavy Drinking^1^ among First Nations People Living on Reserve]{.label} [{#data-uuid-01efe9fcf5a647d986390e6d3b0fb34f.longdesc-icon}](javascript:void(0);) First Nations people on reserve are also four times as likely to be unemployed and earn less than half the income of non-Indigenous Canadians. And when gender is considered, the discrepancy in median incomes is further magnified (see [Figure 1.6](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). In the next section, we will highlight why the determinants of income and education are so vital to all Canadians' health status. Figure 1.6Median income, 2015, Indigenous and non-Indigenous populations, Aged 25-64, by Gender, Canada **[Figure 1.6]{.number.custom-figure-num.dpg-bar--uppercase}**[Median income, 2015, Indigenous and non-Indigenous populations, Aged 25-64, by Gender, Canada]{.label} [{#data-uuid-bb6f501f2b3444b68a63a5ab2be50fc1.longdesc-icon}](javascript:void(0);) Recognizing the importance of reducing the health disparities among various groups of Canadians, Health Canada's website states that the organization "supports First Nations and Inuit in achieving their health and wellness goals, by working with First Nations, Inuit, provinces and territories to advance collaborative models of health and health care that support individuals, families and communities from a holistic perspective, while respecting jurisdictional roles and responsibilities." [Page 16]{#Page+16.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} #### Icon: Dimensions of Diversity.Dimensions *of* DIVERSITY {#data-uuid-90eb5b914fa142de86477b85d52c678e} ##### Health Disparities among Ethnic Minorities[^d^](javascript:void(0); "Opens in a modal") {#data-uuid-9a4feebdebb044f4a0b9ca07f640d9ef} In studying the underlying causes of health disparities, it is often difficult to separate the many potential determinants or contributing factors. ::: {#data-uuid-56edbbd48dfe4c56aa7f6e0c865158e6.section.mhhe-blk-header} ###### **Income and Education** {#data-uuid-b1eef86d17474d72a986e5abd86020b5} Poverty and low educational attainment are the most important factors underlying health disparities. People with low incomes and less education have higher rates of death from all causes, especially chronic disease and injury, and are less likely to access preventive health services, such as vaccinations and Pap tests. They are more likely to live in an area with a high rate of violence and many other environmental stressors.  Although ethnic disparities in health are significantly reduced when comparing groups with similar incomes and levels of education, they are not eliminated. For example, people living in poverty report worse health than people with higher incomes; however, within the latter group, visible minority populations often rate their health as worse in comparison to non-visible minorities. Infant mortality rates are reduced as the education level of mothers increases. Still, among mothers who have access to higher education, Indigenous peoples in Canada continue to experience significantly higher rates of infant mortality than non-Indigenous Canadians. These variations point to the complexity of health disparities that exist for equity-deserving groups. ::: ::: {#data-uuid-898ff3982ef94ac48c6d649d33010d37.section.mhhe-blk-header} ###### **Access to Appropriate Health Care** {#data-uuid-a3957bf231cb49db92a76c0b8420e17a} Those with low incomes are more likely to encounter issues arranging transportation to access health care. They are also more likely to experience decreased access to services and preventive care information. Ongoing studies continually find visible minorities have less access to better health care (such as complex surgery at high-volume hospitals) and receive lower quality care than non-visible minorities. Factors affecting such disparities may include the following: - ::: {#data-uuid-cd7f360c1e5d482eb4167ed4e3de1492} *Local differences in the availability of high-tech health care and specialists:* Ethnic minorities, regardless of income, may be more likely to live in medically underserved areas (i.e., rural and remote communities). ::: - ::: {#data-uuid-e91f57fbcccc4a85be5124d0c4d3bd0c} *Problems with communication and trust:* People whose primary language is not English or French are more likely to have trouble communicating with health care providers; they may also have problems interpreting health information from public health education campaigns. Language and cultural barriers may be exacerbated by an underrepresentation of visible minorities in the health professions and a general mistrust of health care systems. ::: - ::: {#data-uuid-bb8ce753124c424e93d79cfaff9f7ee5} *Cultural preferences relating to health care:* Groups may vary in their assessment of when it is appropriate to seek medical care and what types of treatments are acceptable (e.g., Jehovah's Witnesses do not accept blood transfusions). ::: ::: ::: {#data-uuid-73b1487828cb4476871801ba86efd044.section.mhhe-blk-header} ###### **Culture and Lifestyle** {#data-uuid-86090a6c90a54846b531a00834faba90} As described earlier, ethnic groups may vary in health-related behaviours, such as diet, tobacco and alcohol use, coping strategies, and health practices. These behaviours can have important positive and negative implications for wellness. For example, nutrition can be influenced by an individual's cultural beliefs and practices, and this must be honoured and respected when helping groups engage in healthy eating practices. For instance, the Canadian Aboriginal Nutrition Network---a practice group of the Dietitians of Canada---focuses specifically on supporting Indigenous nutrition. Being sensitive to traditional food preferences, cultural values, and peoples' spiritual connection with food is essential to facilitating healthy choices among the various cultures in Canada. ::: ::: {#data-uuid-e7e9d9b31aa0484a9ff7566c4ff236bc.section.mhhe-blk-header} ###### **Discrimination** {#data-uuid-0699d0267f9745818e975148c6db3672} Racism and discrimination are stressful events that can cause psychological distress and increase the risk of physical and psychological problems. Discrimination can contribute to lower socioeconomic status and its associated risks. Bias and racism in health care can directly affect treatment and health outcomes. Conversely, recent research shows better health care results when doctors ask patients detailed questions about their ethnicity. (Most medical questionnaires ask patients to put themselves in a vague racial or ethnic category, such as Asian or Caucasian.) Armed with more information on patients' backgrounds, medical professionals may find it easier to appropriately diagnose, refer patients to culturally appropriate services, and to overcome language or cultural barriers. ::: ::: [Page 17]{#Page+17.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} #### Quick Stats {#data-uuid-375a2482b0ad4d81b2bfc82fc58a4cf3} - ::: {#data-uuid-9b0ed8a34f4b4203b9b6f7c210f8ed32} In May 2020, the rate of COVID-19 infections in the most ethnically diverse neighbourhoods in Ontario was three times higher than the rate in less diverse neighbourhoods. Hospitalization rates were four times as high, and death rates were twice as high. ::: - ::: {#data-uuid-3772bb648ec24048a07ea4620188fc81} ---Public Health Ontario, 2020[^e^](javascript:void(0); "Opens in a modal") ::: ::: {#data-uuid-9351403cf5a741df95e6c2528014eb1d.section.mhhe-blk-header} ### Income and Education {#data-uuid-f64cd3be40a44adc8c23cedfa91135fe} Inequalities in income and education underlie many of the health disparities among Canadians. In fact, poverty and low educational attainment are far more important predictors of poor health than any ethnic factor. Income and education are closely related, and groups with the highest poverty rates and least education have the worst health status. These Canadians have higher rates of infant mortality, traumatic injury, and violent death, as well as many diseases, including heart disease, diabetes, tuberculosis, HIV infection, and some cancers. They are more likely to eat poorly, be overweight, smoke, drink, and suffer from substance abuse. They are also exposed to more day-to-day stressors, such as juggling multiple jobs or dealing with unreliable transportation. A surprising finding from a recent study was that people living in poverty in wealthy neighbourhoods had higher mortality rates than people living in poverty in lower-income areas, perhaps because of the higher cost of living or psychosocial stressors. ::: ::: {#data-uuid-db118ad0898b4db4a78dbca933c61357.section.mhhe-blk-header} ### Disability {#data-uuid-d2921c9953b140858926051291ba0734} People with disabilities often have activity limitations and/or need assistance. Also, perceptions of disability can disempower individuals through negative attitudes. About 22 percent of Canadians aged 15 years and older, as well as a third of Canadian seniors, have some level of disability, and the rate is rising, especially among younger segments of the population. People with disabilities are more likely to be inactive and overweight. They also report a higher incidence of depressive episodes than those without disabilities. ::: ::: {#data-uuid-a11bb5260f904aa0a19469cde8fb36ee.section.mhhe-blk-header} ### Geographic Location {#data-uuid-ec3d7281bef7484bb7810a8d203bfb8f} Less than one in five Canadians currently lives in a rural or remote area with fewer than 1000 residents and less than 400 people per square kilometre. People living in rural areas have higher death rates and are less likely to be physically active, use seat belts, or obtain screening tests for preventive health care than their urban counterparts. They are less likely to complete high school, have less access to timely emergency services, and experience much higher disease and injury-related death rates. In fact, there is a clear association between the level of the remoteness of an individual's home and their risk of death from a preventable cause (see [Figure 1.7](javascript:void(0);){.mhhe-link.dpg-bar--non_break}). Conversely, rural Canadians are less likely to be diagnosed with cancer, report feeling less stressed, and have a stronger sense of community belonging than urban dwellers. It is clear that our neighbourhoods matter. [Page 18]{#Page+18.page-number data-epub="http://www.idpf.org/2007/ops" type="pagebreak" data-role="doc-pagebreak"} ![**[[Figure 1.7]{.custom-sans}]{.number.custom-figure-num.dpg-bar--uppercase}**[Preventable Mortality Rate by Sex and Relative Remoteness]{.label}](https://epub-factory-cdn.mheducation.com/publish/sn_abe6/15/1080mp4/OPS/img/chapter001/ins81318_f0107.png){#data-uuid-4a772ac5af2b4beab9c078b25d78fab9.mhe-center-container.mhe-ninetyfive-container} [Access the text alternative for Figure 1.7](javascript:void(0);) ::: ::: {#data-uuid-210d264355254bd381e4c05ceadd7ec2.section.mhhe-blk-header} ### Sexual Orientation {#data-uuid-0beca31af9444ee28ddf7a654c810ea1} The 3.3 percent of Canadians aged 15 years and older who identify themselves as gay, lesbian, or bisexual make up a diverse community with varied health concerns. Their emotional wellness and personal safety are affected by factors relating to personal, family, and social acceptance of their sexual orientation. Gay, lesbian, and bisexual teens tend to experience increased social pressures, which may help to explain why research has found them to be more likely to engage in risky behaviours, such as unsafe sex and substance abuse; they are also more likely to experience depression and anxiety and to attempt suicide. Individuals who are gay, lesbian, or bisexual may have higher rates of substance abuse, depression, and suicide. ::: ::: ::: {#data-uuid-e6cf3d8da2a5afa59a0aabb938ac1f92.section.mhe-image-long-desc-group.mhe-intent-screen-reader} ::: :::