Chapter 4: The Chief Public Health Officer's Report on the State of Public Health in Canada 2011 – Creating healthy transitions

Chapter 4: Creating Healthy Transitions

While most youth and young adults in Canada are healthy and transitioning effectively, some young Canadians are not faring as well. Creating conditions for healthy transitions for all youth and young adults will require Canada to address complex and interconnected factors that influence, interrupt or create obstacles to health and well-being. The successful approach will grant returns on investment in terms of lifelong health, improved quality of life and increased productivity.

This chapter examines effective, promising and/or supportive Canadian and international approaches addressing current and emerging health challenges, such as mental health and mental illness, suicide, injuries, bullying, risky sexual behaviours, healthy weights, and substance use and abuse. These approaches include efforts to build resilience; reduce stigma; prevent and manage risk; target specific populations; promote health, increase awareness and education; and develop healthy public policy and protection legislation. In this chapter, examples of best practices from interventions and well as research demonstrate what can be accomplished to create healthy transitions. While there are many examples of proven and promising actions, only some are profiled here. These examples highlight the progress that has been made as well as how to move forward in making further progress in these areas. This chapter also highlights areas where challenges remain.

The approach

This chapter looks at how the underlying determinants of health make important contributions to long-term health and well-being, which can interact, cumulate and cultivate across the lifecourse. While physical and social environments – home, school, work – are important, if basic needs are not met, health issues cannot be adequately addressed. For youth and young adults, meeting these basic needs requires addressing factors that many Canadians take for granted, such as having somewhere to live, having an income, a family, a social network and/or community and access to appropriate services.

This chapter also looks at resilience as a factor that allows individuals to have healthy relationships and develop skills, independence and decisiveness. A broad range of factors that can evolve over time can influence resilience.^{Footnote 384-386} Risks and risk-taking are a part of daily life but these are often elevated during youth and young adulthood. During transition periods across the lifecourse, there are changes to roles, relationships, experiences and expectations for which specific skills and experimenting may be beneficial or harmful to health.^{Footnote 10} Early established healthy behaviours can potentially endure over the lifecourse and influence health outcomes.

Finally, for some of the health issues identified in Chapter 3, there are interventions or approaches that can make a difference. Examples highlighted below show that efforts are widespread. Federal and provincial/territorial governments and other jurisdictions, communities and individuals are making a difference towards improving the health of youth and young adults in Canada. As reported in Chapter 3, most young Canadians are healthy; examination of these issues therefore uses a health inequalities lens and identifies efforts that focus on reducing health gaps and gradients.

Creating supportive environments for transition

As shown in earlier chapters, a close relationship exists between the social determinants of health and the health and behavioural outcomes experienced during youth and young adulthood. Moreover, those who feel nurtured by family members or adult mentors, who feel a sense of connectedness to and/or are engaged with school, community and friends report better health and a greater sense of self-worth and are less likely to participate in unsafe behaviours.^{Footnote 10} The protective effects of these supportive environments are clear in responding to the issues and through the interventions profiled.

Home, living environment and family

Family characteristics (parental income, education and family status); parenting style and participation in a child's activities; parental stress as well as level of family conflict can influence child and youth development. The more connected and positive the relationship youth have with their parents and family, the less likely they are to engage in risk-taking behaviours, anti-social behaviour and delinquency or to report experiencing distress. They are also more likely to have positive social relationships, complete secondary school or pursue post-secondary education and to report good overall health.^{Footnote 10}, ^{Footnote 47}, ^{Footnote 53}, ^{Footnote 383} As children transition into youth and young adults, they gradually relinquish their connections to their families and increase their connections to peers.^{Footnote 47}

Factors such as living in low-income households can limit the ability of families to provide the necessary support for the healthy development of children and youth.^{Footnote 9, Footnote 10, Footnote 398} However, these direct outcomes of social, physical and economic exclusion can be mitigated through positive home and family attributes that include positive parenting.^{Footnote 10} Community-based programs that support families and create opportunities to overcome disadvantage by building social networks and positive parental relationships have had some success (see the textbox "Creating strong families: the Triple P-Positive Parenting Program and Strengthening Families for the Future"). Some communities are also making a difference for sub-populations such as immigrants through policies that reduce financial and systemic barriers to services associated with recreational, information and health resources.^{Footnote 59}

Addressing homelessness

Some youth and young adults become homeless as a result of abuse and neglect; a mental illness; inadequate income or housing; or lack of employment, parental support or income.^{Footnote 23} Youth who are living independently and with limited resources face many challenges. Among these are age cut-offs and eligibility criteria for income supports and social supports that are dependent on having an address.^{Footnote 402} Homelessness affects a broad range of people; however, almost one-third of all homeless people are aged 15 to 24 years, making it a particular concern for youth and young adults.^{Footnote 23}, ^{Footnote 403}

About half of the youth living on the street have been involved with the child welfare system at some point; about the same percentage were sexually and physically abused as children and left home as a result.^{Footnote 23} Given the many paths that lead to it, addressing homelessness is complex. As a result, many approaches exist that work with a young homeless population, three of which are discussed here: targeting street-involved youth; targeting a health-related risk factor (e.g. mental illness or a chronic condition); and initiatives that broadly address poverty and homelessness.

Focusing on at-risk and homeless youth

To be most effective, youth-based interventions should consider the broader determinants of health.^{Footnote 23}, ^{Footnote 400} Targeting specific issues may not address the causes of some risk behaviours and environments that impact decisions. It is also important to acknowledge that the experience of a street-involved youth differs from that of a homeless adult.^{Footnote 225} Street-involved youth are vulnerable to exploitation by adults and peers; are more likely to experiment and take risks; and have different coping strategies.^{Footnote 225} Evidence shows that programs should be delivered earlier, for example, Strengthening Families for the Future (profiled in the textbox "Creating strong families") which targets families with children.^{Footnote 23}, ^{Footnote 225}, ^{Footnote 395} This provides youth with residential stability and support early in their lifecourse. While evaluations and follow-up research on programs directed at street-involved youth are limited, it is known that investing in early-life programs for children and families can positively influence outcomes for youth, and therefore programs for street-involved youth that focus on education, employment and opportunities to get housing and develop life skills will also have positive outcomes.^{Footnote 225}, ^{Footnote 400} Such programs focus on three main areas: prevention, crisis response and integrated support for transitioning out of homelessness.

• to be effective, prevention initiatives should be sustained over a period of time and address key risk factors.^{Footnote 225} Family is a key component in evidence-based prevention practices; and supports and services that promote healthy family relationships allow youth to live at home (or in a safe environment if home is deemed unsafe).^{Footnote 225} Schools and learning environments can also offer a range of traditional and non-traditional approaches to learning that may keep youth from leaving school before completing high school. Some sub-populations, such as lesbian, gay, bisexual, transgendered or questioning (LGBTQ) and Aboriginal youth, are disproportionately represented among the street-involved youth population as a result of a prior history of victimization.^{Footnote 404} Since many street-involved youth have experienced child protection or justice services and abuse and/or have an identified mental illness, there is a window of opportunity to offer support services to children before they become at-risk youth.
• crisis response – shelter, food and emergency support and services – is about enacting immediate services to assist youth in overcoming immediate challenges.^{Footnote 225} These basic needs must be met to address long-term goals of independence, stability and addiction management.^{Footnote 225} Crisis response has an outreach component that is important for identifying needs, increasing access and offering appropriate services to meet specific needs (e.g. those that are culturally, LGBTQ- (lesbian, gay, bisexual, transgendered and questioning) and gender-appropriate) as well as reducing negative outcomes associated with illness, disease and addiction.^{Footnote 225, Footnote 404}
• to make a transition, steps to find adequate and affordable housing need to be facilitated to help youth and young adults exit a cycle of homeless. Difficulties in breaking the cycle may be due to barriers such as not having access to money for down payments, credit checks and discrimination.^{Footnote 404, Footnote 405} Support for education and training including pre-employment skills such as problem-solving, financial management, leadership training and coping strategies must also be available to help secure stability for the future.^{Footnote 225} Support for services that overcome barriers to accessing health and social services (such as age cut-offs) must also be available. Addiction and drug/alcohol management and mental health services and supports should be included throughout the process.^{Footnote 404} Finally, follow-up and long-term support is important to complete the cycle.^{Footnote 225} Promising programs are those that use an integrated approach to addressing homelessness among youth and young adults (see the textbox "Integrated approaches to addressing homelessness").

Addressing mental health problems and homelessness

Recovery for those who have a mental health problem can be further complicated by homelessness. Programs that address mental health problems (particularly a mental illness) and homelessness focus on rehabilitation and treatments through supported housing.^{Footnote 400} Two models of supported housing include:

• the treatment first model – also known as the continuum of care model – identifies individuals through outreach and follows up with referrals for shelter and treatment and ultimately permanent housing.^{Footnote 400, Footnote 414} The effectiveness of the treatment-first model in four communities in the United States was reviewed to determine its applicability in Canadian cities. Strengths cited included the community-driven approach and collaborative and co-ordination of local services. The model showed an increase in supportive housing services and local awareness, as well as an increase in funding for long-term action plans. However, challenges in terms of length of the planning process, inflexibility, fragmentation of services and a lack of permanent housing may impede its applicability in Canada.^{Footnote 414}
• the housing first model focuses on providing access to housing independent of treatment.^{Footnote 400} New York City's Pathways to Housing project was the first to adopt this model of housing in the United States. Now in use in many urban areas, this model has shown some success in terms of housing and wellness. The program has shown a decrease in the number of homeless, the time spent in institutional settings and in community-provided housing for those with a mental illness; however, evaluations of the longer-term health outcomes (if wellness is sustained) will require more research.^{Footnote 415} Using the housing first model, another promising project, the Mental Health Commission of Canada's At Home/Chez-Soi is assisting over 2,200 homeless people living with a mental illness in five Canadian cities (Vancouver (British Columbia), Winnipeg (Manitoba), Toronto (Ontario), Montreal (Quebec) and Moncton (New Brunswick)). As of March 2011, over 1,800 project participants in these five cities have been offered places to live and services to assist them over the course of the programs (770 participants now have homes) or they receive the regular services available to them.^{Footnote 416} While it is early in this program's development, some positive initial indications are notable.

Some programs address the specific needs of a homeless population by providing culturally relevant treatment and outreach options that offer traditional as well as mainstream opportunities (e.g. see the textbox "Addressing mental health problems and addictions among the homeless: Ottawa's Wabano Centre").

Developing broad strategies that address poverty and homelessness

Communities and organizations across all regions can partner with Canada's Homelessness Partnering Strategy (HPS) to develop programs that are relevant and appropriate to local needs.^{Footnote 421, Footnote 422} HPS supports communities to find solutions for local people who are homeless or at-risk of being homeless by:

• investing in transitional and supportive housing to help individuals while they work towards accessing longer-term housing;
• supporting community-based efforts to prevent or reduce homelessness;
• building partnerships across jurisdictions and sectors; and
• working in collaboration with a range of stakeholders.^{Footnote 421, Footnote 422}

Currently, HPS supports 61 designated communities.^{Footnote 422} These are primarily in larger urban areas that have significant problems with homelessness as well as a plan that outlines how homelessness can be addressed.^{Footnote 423, Footnote 424} The outreach component of the strategy supports smaller, rural and northern communities in collaboration with partners across the public and private sectors to fill in gaps in the infrastructure.^{Footnote 425} HPS also partners with Aboriginal groups and funds programs that address the specific needs of off-reserve homeless Aboriginal peoples in cities and rural areas.^{Footnote 426}

Some provinces/territories have successfully implemented broad strategies to address homelessness. For example, in 2009, Alberta implemented its broad strategy entitled A Plan for Alberta: Ending Homelessness in 10 Years. Moving away from managing the problem with emergency shelters, the plan has adopted a vision of eliminating homelessness in 10 years by placing individuals/families into permanent housing while also connecting them with the supports they need to maintain housing. These supports include employment opportunities, health and addiction treatment, education in household management, and family and cultural reconnection. As a result of this inter-sectoral approach and community-led action, 1,779 formerly homeless Albertans are now in permanent housing, far surpassing the target of 1,000 individuals for 2009/2010.^{Footnote 405, Footnote 427}

Being better able to address homelessness and/or risk factors during youth and young adulthood requires a greater understanding of who becomes homeless as well as why and how. As a society, Canada needs to be able to identify risk factors and health outcomes as well as be able to implement best practices. Developed to better understand and disseminate information about homelessness, the Homeless Individuals and Families Information System (HIFIS) was created to help facilities (e.g. shelters) with their operation and planning while collecting comprehensive data on local-risk populations to contribute to a national information system on homelessness.^{Footnote 428, Footnote 429} Currently in use in half of the homeless shelters in Canada, HIFIS will allow for a greater capacity to document and service homeless people and their needs.^{Footnote 429}

Healthy schools

Most youth spend a significant amount of their time in a school setting. These settings can help foster academic, social and life skills that are critical to healthy transitions.^{Footnote 10} The more youth are engaged in school and extracurricular activities, the more likely they will succeed in their careers and have better socio-economic outcomes later in life.^{Footnote 53} Students who are engaged in learning are more likely to challenge themselves and set long-term career-building goals. Further, youth who report feeling safe and connected at school and during extracurricular school-related activities (team sports, clubs, etc.) are less likely to report engaging in risk-taking behaviours and more likely to have emotional well-being and a greater sense of self-worth and self-rated health.^{Footnote 10} Since school environments play a critical role in the current and future well-being of young Canadians, initiatives that support healthy schools, encourage engagement and foster academic success are necessary to support and sustain healthy transitions.

Schools can effectively disseminate health information (through health promotion and health education programs) because they have the opportunity to influence a broad population of youth. They can raise health issues, suggest prevention tactics and help students acquire healthy skills. The World Health Organization (WHO) and other organizations, such as the European Commission, have advocated for the introduction of health promoting initiatives in schools across their member countries. The WHO produced a set of guidelines for health promoting schools:

• school health policies, including regulations and practices that influence healthy choices such as the availability of healthy foods, smoke- and drug-free environments, equality among students and emergency-preparedness plans;
• healthy physical environments (including the built environment and its surroundings) that support indoor and outdoor activities, are safe (have regular safety audits, use sports equipment that meet standards, etc.), are conducive to learning; and use environmentally sustainable practices where possible (e.g. have quality standards for air and water);
• healthy social environments that depend on quality relationships between and among students, staff, parents and the community. Factors that can improve school relationships include levels of support, met needs, engagement and involvement of adults;
• connection with the broader community including parents and a range of external stakeholders;
• opportunities to develop personal health skills; and
• school health services that are available, accessible and relevant to all students.^{Footnote 430, Footnote 431}

Health promoting schools can positively influence students' knowledge of and attitudes towards a range of health and social issues.^{Footnote 430, Footnote 431} More directly, when health services are provided in schools, students' health improves and academic outcomes are evident.^{Footnote 431, Footnote 434}

In Canada, the health promoting school approach is referred to as comprehensive school health (CSH), a framework for supporting improvements in students' educational outcomes, while addressing school health in a planned, integrated and holistic way. Students attending CSH schools have been shown to have more healthy eating habits, to be more active and less likely to be overweight.^{Footnote 435} The Joint Consortium for School Health (JCSH) is an example of a partnership between federal and provincial/territorial ministries of health and education to provide leadership and facilitate a comprehensive approach to school-based health promotion. The premise of the Consortium is simple: health and learning are interrelated. The Consortium works across jurisdictions and sectors to share information and experiences, identify best practices, leverage resources, minimize duplication, foster partnerships and conduct further research in promising areas.^{Footnote 436} More recently, the Consortium has also committed to including promotion of positive mental health.^{Footnote 437}

Systematic reviews of comprehensive school health approaches have found that mental health promotion and behaviour programs (e.g. classroom skills, emotional literacy, self-esteem) – especially those that are all encompassing, intensive and long – were effective in promoting mental health and reducing risky behaviours.^{Footnote 431} However, school health programs that focused on substance use and abuse were more effective at preventing behaviours if they were targeted, shorter in duration, and focused on factors such as self-esteem.^{Footnote 431} Generally, health promotion strategies in a whole-school approach were more effective than individual teacher-led interventions.^{Footnote 431} However, further evaluation is needed to assess the effectiveness of all whole-school programs and approaches rather than individual ones focused on mental health problems or substance use and abuse.^{Footnote 431} Programs have to be evaluated according to how well they respond to the unique communities they serve.

Efforts have been made to reduce the effects of living in low-income households by lowering the high school dropout rates and increasing access to post-secondary education for disadvantaged youth in Canada.^{Footnote 438} For example, the Pathways to Education program adopts a community holistic approach along four support areas: academic; social (includes group and career mentoring); financial (for transportation to schools, bursaries, etc.) and advocacy (fostering student, parent and community connections). The program's first site was in Regent Park, considered to contain the highest concentration of low incomes and school dropouts in Toronto (Ontario).^{Footnote 438}-441 An independent evaluation found that with a 93% youth program enrolment, school dropout rates had decreased from 56% to 12% and absenteeism had decreased by 50%; the number of young people from this community attending college or university quadrupled from 20% to 80%; and teen birth rates fell by 75%.^{Footnote 440}, ^{Footnote 442} As a result of the success in Regent Park, Pathways to Education has been expanded to other locations – Hamilton, Ottawa, Kitchener and Kingston (all in Ontario), Montreal-Verdun (Quebec), Halifax-Spryfield (Nova Scotia) and Winnipeg (Manitoba).^{Footnote 440} See The CPHO's Report on the State of Public Health in Canada, 2008 for more detail on Pathways to Education and Regent Park.^{Footnote 49} Further research is examining the in- and out-of-school factors that influence educational outcomes, and the extent to which the pathways program responds to the needs of at-risk youth.^{Footnote 441}

Supporting post-secondary education

The commitment of youth to stay in school has long-term benefits that are realised well into adulthood. Generally, being well-educated equates to a better job, higher income, greater health literacy, a wider understanding of the implications of unhealthy behaviour and an increased ability to navigate the health-care system – all of which lead to better health.^{Footnote 53} In the last three decades, there has been a notable increase in all post-secondary enrolment in Canada.^{Footnote 443} A number of broad programs have contributed to this success by increasing opportunities and access through financial support. Nine provinces/territories participate in the Canada Student Loans Program, determining eligibility, assessing needs and designating eligible educational institutions (Quebec, the Northwest Territories and Nunavut do not participate, but each offers a similar approach to assistance).^{Footnote 71} The program has assisted over 3.8 million students with over $28.1 billion in loans.^{Footnote 71} The recently enhanced and expanded Canada Student Loans Program and Canada Student Grants Program consolidates federal student assistance into a single application window. The programs' key targets are people from low- and middle-income families, with permanent disabilities (additional funds are available for those who require additional education-related support) and/or with dependents (full- and part-time) as well as those who will continue their studies part-time.^{Footnote 120, Footnote 122} Provinces/territories also offer additional financial aid programs.^{Footnote 120, Footnote 122} Further investments have expanded the Canada Student Loans Program and Canada Student Grants Program to extend eligibility and include measures such as: expanded adult basic education programming in the territories to increase northern employment opportunities, increased assistance to study abroad and tax relief on fees for skills certification (for occupations, trade and professional examination).^{Footnote 444}

The success of these programs includes creating better educational outcomes, measured in terms of the increased number of student opportunities (enrolment) and in program completions (graduation). However, the debt load that young Canadians have upon entering the job market is a concern. Many young adults who could not afford post-secondary education without aid face considerable debt at graduation.^{Footnote 208, Footnote 209} While grants and loans programs break down economic barriers to post-secondary education, other barriers impede some young Canadians from furthering their education.^{Footnote 383, Footnote 445} In particular, those who live in rural and remote communities may face non-economic barriers such as distance that affects access while those who have particular cultural traditions may face community perceptions that place a low value on academics.

Returning to school

While Canada has successfully reduced the high school drop out rate, some young Canadians nevertheless still do not complete this level of education. Interventions can encourage these young Canadians to return to school and/or seek training to increase their employment opportunities. Many who drop out of high school intend to – and often do – return to school later in life.^{Footnote 193, Footnote 194}

For example, Aboriginal youth, who are more likely to leave school earlier than the overall population, are also more likely to return to school later in life.^{Footnote 123} Overall, more young women than men return to school. However, not all the young men and women who return to school graduate successfully.^{Footnote 194} Programs that encourage young Canadians to return to school need to consider some critical factors including motivation and timing in relation to other responsibilities such as being a parent (particularly for young women). For young men, returning to school is driven by experiences in the labour market, past positive academic performance and the desire to fulfill aspirations of a different job or higher income.^{Footnote 194} More work needs to be done to understand the barriers to completing school and the supports needed to counteract dropping out for diverse groups of young men and women.

The Centre for Aboriginal Human Resource Development Inc. (CAHRD) is a community-driven organization located in Winnipeg (Manitoba) that has helped young Aboriginal adults obtain their high school diplomas, trades training and employment services. The centre provides financial support, transitional housing and daycare services to help with the needs of young parents who are students at one of CAHRD's programs. For each year of its 30 years of existence, the centre has helped about 1,200 students find meaningful employment.^{Footnote 446, Footnote 447}

Workplace

For many young Canadians, full-time work marks the end of the transitional period from youth to adulthood. In general, employment provides Canadians with the economic opportunities that can influence individual and family health. Research indicates that there is a significant gradient in disease prevalence and in years of life lost between the highest-income and each successive lower income quintile.^{Footnote 448, Footnote 449} While employment provides income and potentially a sense of connection – both of which are related to health – the working environment can also significantly affect physical and mental health (see the sections "Workplace initiatives" and "Preventing workplace injury" later in this chapter).

As seen in Chapters 2 and 3, entering the workplace for the first time is challenging. Economic recession, depression or otherwise strained economic conditions can further exacerbate this challenge.^{Footnote 72, Footnote 73} One obstacle to entering the workforce is a lack of experience and applied skills. Experience-building programs have had some success in helping young Canadians gain the insight and skills necessary for full-time work.^{Footnote 72, Footnote 126} Several programs to assist Canadians with job searches, placements and apprenticeships have been created such as the Youth Employment Strategy (YES). YES offers a range of initiatives:

• Skills Link, which helps young people aged 15 to 30 years who face employment barriers (high school dropouts, lone parents, Aboriginal youth, recent immigrants, youth in rural areas or with disabilities) find employment and help them gain valuable work skills;
• Career Focus, which helps post-secondary graduates develop skills and find work in their field of study; and
• Summer Work Experience, which provides wage subsidies to employers to create summer employment for secondary and post-secondary students.^{Footnote 72}

A recently initiated program, the Youth Eco Internship Program, offers young Canadians three- to twelve-month-long paid internships at not-for-profit, charitable, co-operative and/or voluntary organizations to provide on-the-job experience while simultaneously supporting environmental and community employment.^{Footnote 450} Job creation initiatives that encourage employers in specific fields to provide short- and long-term positions for students and recent graduates are important in developing the skills, confidence and experience of young Canadians. For example, Young Canada Works (YCW) helps employers create opportunities for young Canadians to learn and work in the field of heritage and cultural preservation while supporting their education. YCW partners with the Heritage Canada Foundation, Heritage Canada and the YES to offer summer employment and create internship programs for recent graduates.^{Footnote 126}

Healthy communities

School and work environments can influence current and long-term health. The built environment is the physical surroundings that include the buildings, parks, schools, road systems and other infrastructure. The land-use patterns, transportation systems and design features of the built environment influence the health of the population by affecting the convenience, accessibility and amount of recreational and utilitarian physical activity. Residents in communities characterized by mixed land use (i.e. with stores, schools and/or employment centres within walking distance of homes) are more active than in those neighbourhoods designed for automobile-dependent transportation. An association exists between sprawling single-use residential neighbourhoods and higher levels of obesity.^{Footnote 451} Walking and cycling as a means of active transportation can provide a significant portion of a person's daily physical activity as recommended by The Canadian Society for Exercise Physiology.^{Footnote 131} Access to recreational pathways and facilities, along with pleasing aesthetics and perceived safety, can also increase recreational physical activity. Location can also influence access and affordability of nutritious foods.^{Footnote 452}

The CPHO's Report on the State of Public Health in Canada, 2009 also highlighted the built environment as a key area of action that could contribute to decreasing the number of overweight and obese children.^{Footnote 30} Physical activity levels are significantly higher and obesity rates lower in more walkable environments.^{Footnote 9, Footnote 451} More children and youth are obese and overweight in disadvantaged neighbourhoods where there is less access to healthy foods and to recreational facilities and where there may be increased safety concerns.^{Footnote 30} Similarly, neighbourhoods in areas of high crime or that have high volume and/or fast-moving traffic discourage outdoor activity. (For more information on youth overweight and obesity, see the section "Healthy weights and healthy living" later in this chapter). The environment can also have direct and indirect influences on mental health and well-being in the form of distress, depressive symptoms and behavioural issues. Evidence shows a strong relationship between natural environment experiences and a young person's ability to learn, as well as greater overall health and well-being (including stress levels, attention-deficit hyperactivity disorder as well as cognitive functioning).^{Footnote 453}

Young Canadians have a role to play in developing policies and programs that impact their health and well-being and the broader social environment. For example, Communities That Care (CTC) is a system that enables communities to engage in prevention planning and implement evidence-based programs for youth aged 13 to 17 years. CTC supports decision-makers in selecting and implementing evidence-based programs that fit the needs of a specific community. Its aim is to promote healthy development and implement interventions that address problems such as substance abuse, delinquency, violence, teen pregnancy, dropping out of school, absenteeism and mental health problems. Evaluations of communities in the United States that have implemented the CTC system showed a lower level of risk factors and a decrease in crime and substance use among program participants.^{Footnote 454, Footnote 455} Cities in British Columbia and Ontario that have used the CTC system have seen some positive results, but further evaluation is needed to determine its potential for success in Canada.^{Footnote 454}

Developing resilience

Resilience is central to the issues discussed in this report, because of its role in successful transition into adulthood and in determining long-term health and well-being. Resilience is traditionally that which is needed in the face of adversity and requires positive assets and skills to address negative experiences. Building resilience is necessary for all individuals to develop positive skills, competencies and protective factors for situations that arise across the lifecourse. Promoting healthy development and positive assets in children and youth can create conditions for healthy transitions. Resilience can be negatively influenced by childhood factors such as abuse and neglect.^{Footnote 461}

There are many definitions of resilience and opinions on the extent that resilience matters to health and the individual and broader factors that influence it.^{Footnote 462} Resilience research has expanded over the last two decades as a result of evidence showing that, while more youth are experiencing adversity (e.g. disadvantage, poverty, abuse), interventions can build resilience.^{Footnote 461} Longitudinal studies, such as the classic Kauai Longitudinal Study (see the textbox "Longitudinal research on resilience: The Kauai Longitudinal Study"), have made significant contributions to resilience research. These studies have identified the factors that predict resilience and are protective.^{Footnote 386, Footnote 461} They have illustrated how protective factors can promote adaptation, and how processes such as a range of biological, psychological and social factors can, over time, influence an individual's ability to cope in many ways.^{Footnote 461}

Resilience affects how people cope with life challenges at different life stages. This ability to cope is often influenced by a sense of self and by how an individual relates to others and manages the various parts of their life.^{Footnote 384} Resilience can be cultivated by building relationships, successful problem-solving and being independent and decisive.^{Footnote 384}, ^{Footnote 385} For most young Canadians, resilience is born from what resilience researcher A.S. Masten calls "the magic of ordinary everyday" found within individuals, their families, their relationships and their communities.^{Footnote 385} Of concern are those who do not have the basic protective systems in place (e.g. social support) and who are unable to overcome adversity to deal with mental and emotional trauma and interruptions to development; become self-confident and gain self-respect; set realistic goals and engage in problem-solving to survive, thrive and build supportive and collaborative relationships.^{Footnote 463}

The most effective programs are those that focus on building resilience in young children so that it will grow with them across the lifecourse.^{Footnote 384} More research is needed on how parents, teachers and front-line workers can foster resilience in children and youth, as well as how resilience can be developed, protected, restored, facilitated and nurtured.^{Footnote 464} While most young Canadians are healthy, assumptions about homogeneity across populations overlook the diversity among youth and young adults and ignore lenses of gender, culture, sexuality, and race. Resilience research is ongoing in Canada and internationally, for example, with the work of Canada's Resilience Research Centre (see the textbox "Researching resilience – Canada's Resilience Research Centre").

There are clear differences in how resilience develops in adolescent boys and girls. For adolescent boys, traditional notions of the "boy code" have been built upon courage, strength, shame and low emotional attachment. These often mask genuine resilience and can interfere with building healthy relationships and better outcomes for mental health and well-being.^{Footnote 469}, ^{Footnote 470} For most adolescent boys, being strong is often achieved at the cost of building relationships with others. Building resilience in adolescent boys can include developing opportunities to build long-term and trust-based friendships (these types of friendships are found more often among girls); developing platonic friendships with girls (as girls often play more empathetic roles and allow more open emotional expression); learning to express a range of emotions; and having strong mentors, particularly among male family members.^{Footnote 469} Resilience can be one of the factors that contributes to gaps between adolescent boys and girls in their school work and their decision to stay in school, which affects their health and well-being in the long-term.^{Footnote 469}

During adolescence, many girls face a decrease in self-esteem and self-confidence. Compared to adolescent boys, adolescent girls are more likely to develop pessimistic views of self and society, expect future failure based on experience and engage in self-blame and self-criticism. As a result, adolescent girls are more likely to become depressed, have a poor self-image and begin to lose authentic relationships and relational intelligence.^{Footnote 470} However, compared to adolescent boys, adolescent girls are more likely to find support among social networks and opportunities to express emotion. Building positive skills, assets and relationships in girls involves education and skills training so that they learn to understand issues in a broader social context (outside of self), identify and know where to seek support, and oppose and replace negative forces. Developing resilience among adolescent girls develops the courage to resist disempowerment.^{Footnote 470}

Similarly, resilience for LGBTQ youth involves encouraging the development of resilience within the context of family, school and community.^{Footnote 249} Expected to conform to heterosexual and gender norms around individual development and socialization, sexual- and gender-minority youth are at increased risk for isolation, stigmatization and lower resilience. Building resilience in marginalized youth focuses on creating assets that enable individuals to address adversity with self confidence, rise above discrimination and bullying and engage with broad society to build supportive and collaborative relationships.^{Footnote 21} The Institute for Sexual Minority Studies and Services at the University of Alberta (Edmonton, Alberta) is conducting research on assets needed to grow into resilience. It uses research findings to develop and deliver two promising youth programs: the Youth Intervention and Community Outreach Worker program which provides one-to-one and social supports for Edmonton area youth year-round, and Camp fYrefly, a national leadership camp for sexual minority and gender-variant youth.^{Footnote 20} Both programs emphasize an arts-informed, community-based approach to education to help youth focus on building and nurturing their personal resilience and leadership potential within an environment that fosters individual development, positive socialization and enhanced self-esteem.^{Footnote 20, Footnote 21} The goal of both programs is to help youth learn how to make significant contributions to their own lives and within their learning environments, home/group home environments and communities.^{Footnote 20, Footnote 473}

Addressing risky behaviours

Risks are ever present and exist in countless daily activities.^{Footnote 149} Taking risks is a part of life at every age, and for youth and young adults, risk-taking is integral to learning and developing. However, during transition periods, there are changes to roles, relationships, experiences and expectations for which developing skills and experimenting may be beneficial or harmful to health.^{Footnote 10} Early established behaviours can potentially endure over the lifecourse. Some of these behaviours can become protective factors or long-term risk factors for many chronic health conditions.^{Footnote 10, Footnote 386} For example, smoking – a risk factor for a number of chronic conditions – is a behaviour that 87% of Canadian adults who have smoked reported initiating in their youth (before age 20 years) (see Chapter 3 for further information).^{Footnote 355}

Risk-taking behaviours are complex. While behaviours are ultimately individual choices, they are influenced by the social and economic environments where individuals work, learn, live and play. When these environments are unsupportive, making healthy choices is more difficult. As a result, some individuals are more likely to engage in adverse risk-taking behaviours that may result in higher rates of illness or injury. Therefore, when addressing risky behaviours, consideration must be given to the determinants of health and conditions in which some youth and young adults are making the transition. This includes biological processes as well as social determinants and behaviours.^{Footnote 10} For the most part, evidence shows that among young people, risk-taking behaviours cluster together.^{Footnote 10, Footnote 474} For example, generally regular users of tobacco are also more likely to use alcohol and/or illicit drugs.^{Footnote 10, Footnote 474}

Initiatives also use education to help young Canadians see and manage risks as well as apply these skills across the lifecourse (see the SMARTRISK example in the section "Preventing unintentional injury" further in this chapter). This approach aims to educate youth about making good choices – options for lowering risk – when they are making decisions where injuries may result.^{Footnote 149} However, more targeted programming needs to be developed to address sub-populations that have little support (low income, low education and low social support) or poor role models. Without addressing the unique needs of these sub-populations, there is a risk that the health gaps will increase.

Evidence from a Scottish study shows that substance use and sexual risk behaviour among young people do cluster (and among males and females).^{Footnote 474} While these risk clusters exist, there are limited data and evaluations of interventions that address both substance use and risky sexual behaviours.^{Footnote 474} Reviews showed that interventions that addressed single risk behaviours were promising. For example, policy based interventions on tobacco and alcohol control and access were found to be effective approaches in addressing these specific risk behaviours.^{Footnote 474} Difficulties remain in finding effective interventions across risk behaviours. Interventions that addressed a range of risky behaviours through in-class social and life skills training were limited in terms of long-term positive outcomes. Interventions that targeted four key domains of risk (individual, family, school and community) showed more promise.^{Footnote 474} Programs such as Strengthening Families Program (Canadian version profiled in the textbox "Creating strong families" in this chapter) had some success in reducing risky substance use behaviours. Interventions that address domains of risk must consider the dynamic nature of influence, social context and social change as well as the importance of transition points to find opportunities to strengthen protective factors and minimize risk.^{Footnote 474} Consideration must also be given to the role of broad networking and social media on the health of today's youth and young adults. Further research is needed to identify, develop, tailor and evaluate interventions for preventing single and clustering risky behaviours, as well as address differences in risk behaviours for sub-populations and address ways to reduce marginalization and exclusion.^{Footnote 474}

Enhancing positive mental health and protective factors

Many childhood experiences and factors can influence the risk of mental illness and mental health problems in youth and young adulthood that, in turn, can have an impact across the lifecourse. These include deprivation, abuse and neglect, and low-birth weight as well as parents' employment status, education, mental health and parenting skills.^{Footnote 210, Footnote 475, Footnote 476} The Standing Senate Committee on Social Affairs, Science and Technology report Out of the Shadows at Last: Transforming Mental Health, Mental Illness and Addictions Services in Canada highlighted the importance of upstream efforts to promote social and emotional well-being, and where possible, to prevent mental illness and promote mental health and well-being as early as possible in the lifecourse.^{Footnote 477} For young children, programs that strengthen families and combine home and community interventions have been shown to be effective at improving the well-being of young parents and children by creating more supportive environments, increasing access to care and breaking down barriers to seeking help when needed.^{Footnote 47, Footnote 478} Workplace interventions can also enhance the well-being of parents by promoting health and addressing mental health issues. By being flexible, workplaces allow families to address health issues and encourage parents to be engaged in the lives of their children.^{Footnote 479} Community programs may also contribute to the development of social capital and may increase social inclusion, factors that are known determinants of mental health status.^{Footnote 478} Interventions that promote mental health and well-being must recognize and address the underlying socio-economic determinants of health and other factors that build resilience among children and youth (see the section "Developing resilience" earlier in this chapter).

The most effective mental health interventions, especially among at-risk populations:

• are sustainable over time;^{Footnote 480}, ^{Footnote 481}
• are age-appropriate, culturally and gender-sensitive;
• are multi-faceted as to target multiple components;
• start early, and focus on cognition and relationships; and
• target individuals, families and communities.^{Footnote 482}

This section examines:

• interventions that target youth;
• school-based mental health services;
• access to mental health services;
• promotion of mental health and mental health literacy;
• reduction of mental health stigma; and
• development of broad strategies for mental health and well-being.

Interventions targeting youth

Many mental illnesses first manifest in adolescence. Focusing interventions on youth can therefore be effective in addressing mental health issues and promoting mental well-being.^{Footnote 210, Footnote 478, Footnote 482} Although broad population-based programs are the more cost-effective, targeted programs are more effective among youth, particularly those focused on preventing depression.^{Footnote 482, Footnote 483} Programs that specifically target at-risk youth include cognitive behavioural therapy (CBT), prevention practices and school-based education interventions (see the section "School-based mental health interventions").

CBT interventions focus on building social and problem-solving skills that, over time, develop resilience and reduce the likelihood of social withdrawal and poor academic performance among at-risk youth.^{Footnote 478} In randomized controlled trials, CBT interventions have shown a positive impact on mental health, such as a reduction in depressive symptoms during post-therapy and follow-up intervals. Longer interventions, lasting 10 or more sessions, were most effective.^{Footnote 478, Footnote 484} Although international studies show that CBT can improve clinical and economic outcomes, there is limited availability of CBT in Canada and more research would be required to determine its cost relevance and effectiveness in Canada.^{Footnote 478, Footnote 482, Footnote 485}

Intervention programs that target depression in youth were found to significantly reduce depressive symptoms.^{Footnote 483} In particular, interventions were found to be more successful among girls in later adolescence and among racial minorities who had higher rates of reported depression. Overall, prevention programs that were delivered by a program-specific professional (rather than a teacher, for example), that were short (duration) and that offered a homework or take-away assignment had the greatest effects on these target youth groups.^{Footnote 478, Footnote 482, Footnote 483}

Alcohol, tobacco and drug use prevention programs that address gender issues were more effective than programs for both sexes.^{Footnote 486} For adolescent girls and young women, programs that fostered gender identity tended to offer the greatest support during transitions and developed the skills necessary to build resilience and foster healthier relationships.^{Footnote 486} Based on a critical analysis, the Centre for Addiction and Mental Health (CAMH) has outlined several best practice guidelines for the development of mental health promotion interventions for youth regarding substance use and abuse. Those that are specifically relevant to this age group include:

• addressing and modifying risk and protective factors that pose mental health concerns;
• intervening in many settings with a focus on schools and adopting many intervention approaches;
• focusing on skills building, empowerment, self-efficacy and individual resilience;
• training non-professionals to establish caring and trusting relationships;
• providing comprehensive support systems that focus on peer and parent-child relations and academic performance; and
• providing information and services that are culturally appropriate, equitable and holistic.^{Footnote 487}

School-based mental health interventions

While early interventions – such as those aimed at preschool and early school-aged children – are outside the scope of this report, the benefits of these early interventions cannot be underestimated.^{Footnote 477, Footnote 478} Identifying at-risk youth and young adults and providing early intervention reduces the prevalence of mental health problems later in life. Since 69% of youth and young adults diagnosed with mood or anxiety disorder reported that their symptoms first developed before the age of 15 years, schools could be effective in early identification, reducing stigma and promoting effective strategies.^{Footnote 210, Footnote 488} Early interventions empower and encourage social connectedness and emotional learning.^{Footnote 489} Schools are the places where youth interact socially and where they can be influenced over an extended period of time.^{Footnote 481}

School-based teams of professionals are traditionally made up of social workers, child/youth workers and teachers who all have a role to play in identifying mental health issues and assisting in accessing and navigating mental health services.^{Footnote 490} Given the importance of school-based programs in reaching youth, the changing composition and access of in-school support teams may become a cause for concern. Recently there has been an increased reliance on training teachers to identify mental health issues and execute in-class programs, to enhance the work of health and social-care professionals.^{Footnote 490}

Accessing mental health services

The Mental Health Commission of Canada (MHCC) framework for broad mental health strategy (see the section "Developing broad strategies for mental health and well-being") identifies the importance of youth and young adults having access to mental health services that are appropriate to the needs of these age groups.^{Footnote 226, Footnote 477} Finding the right "fit" for youth and young adults is a challenge for mental health services given the potential for substance use, addiction, sexual health problems and aggressive behaviours that co-exist with mental health issues.^{Footnote 226, Footnote 491}

For many youth and young adults, seeking help in a primary care facility implies illness and raises feelings of uncertainty and concern for confidentiality.^{Footnote 491} Typical mental health services are also generally perceived as intended for adults, and they can appear disconnected from the needs and culture of youth and young adults. With adequate resources, schools could be effective in providing some mental health services.^{Footnote 491, Footnote 492} Teachers and social workers are the adults most likely to witness symptoms and identify problems, and youth often confide in them. Professionals can identify behaviours and symptoms to initiate referral for the right treatment, at the right time, by the right person.^{Footnote 490, Footnote 493} Addressing mental health issues and integrating programs in schools can begin to address stigma, build resilience and break down barriers associated with service relevance.

As a result of age-limits and cut-offs, upon turning 18 or 19 years old, often young adults can no longer access the health and social services.^{Footnote 477, Footnote 494} Such a separation of services based on age may not reflect the individual's state of health or stage of maturity. Services targeted for adults may feel unknown and uncertain or culturally irrelevant.^{Footnote 225, Footnote 494} Ideally, services would be seamless to ensure continuity in treatment. Organizations need to look towards broad programs that are fully integrated across sectors with a systemic approach to health to address issues facing individuals as they transition between childhood and adulthood.^{Footnote 495} As well, co-ordination across services can ensure that age limits are consistent between the range of health, social and criminal services as well as across provinces/territories and municipalities.^{Footnote 494}

Interventions promoting mental health and mental health literacy

The WHO states that implementing policies that promote mental health across the population and target people with mental health problems can lead to substantial gains in mental health and improve the social and economic development of the population.^{Footnote 477} Mental health can be influenced by the broader determinants of health. In particular, social connectedness and healthy behaviours (e.g. eating well) can positively affect and influence an individual's overall well-being and ability to cope with stress and life changes.^{Footnote 477}

Promotion of mental health at work can reduce the risks of anxiety, depression and stress-related problems that are a result of increased work pressure, time constraints, job insecurity, mundane tasks, noise, and work relationships among employees and between employers and employees.^{Footnote 496, Footnote 497} Employees at workplaces with programs or strategies including job training, workload reduction and healthy environments generally experience better overall well-being.^{Footnote 497} Broad policies and strategies can be implemented to reduce and manage workplace risks by preventing negative mental health and well-being issues. Equally, job-seeking initiatives that help young unemployed individuals find work were found to create positive outcomes such as an increased ability to cope with stress and self-motivate, aside from the resulting stability of employment and support networks.^{Footnote 477} With federal funding, the MHCC is developing a National Standard of Canada for Psychological Health and Safety in the Workplace with the long-term goal of creating a sustainable, systematic approach to managing psychological health and safety in the workplace.^{Footnote 498}

In May 2005, the Federal, Provincial and Territorial Ministers Responsible for Seniors endorsed Healthy Ageing in Canada: A New Vision, A Vital Investment. The report focuses on five priority areas for action: social connectedness, physical activity, healthy eating, falls prevention, and tobacco control.^{Footnote 7, Footnote 12} Although two of the priority areas (falls prevention and social connectedness) are discussed in other sections of this chapter, all areas are considered interconnected, and programs and interventions that address each priority area can have an impact on others. For example, participating in regular physical activity can reduce the risk of falling and of developing certain health conditions, and can also increase social interaction.

Healthy living practices are about creating conditions for individuals to make choices and engage in behaviours that support healthy aging, such as staying physically active and eating well, and to avoid choices and behaviours that are detrimental to health, such as smoking and excessive drinking. Although these behaviours are based on individual decisions, it is important to note that these decisions are influenced by physical, social and economic factors experienced over the lifecourse.

This section highlights six areas where programs and interventions are making progress in creating conditions for healthy aging:

• providing community support and infrastructure;
• raising awareness about physical activity;
• encouraging healthy eating;
• addressing smoking, alcohol and drug use;
• ensuring health literacy for seniors; and
• supporting opportunities for lifelong learning.

Each of these areas has either shown evidence of success and could be applied more broadly, or is an area of promise where further work and investigation is required.

Providing community support and infrastructure

Seniors who have been involved in their community, and/or who have been physically active over the lifecourse, generally continue these practices as they age. Supporting seniors in continuing healthy habits, as well as encouraging them to become more active in their communities, requires a safe and vibrant community and surrounding environment.^{Footnote 7, Footnote 12} Safe pedestrian crossings, well-maintained sidewalks, recreational pathways, and access to indoor walking programs and community centres offer opportunities for daily physical activity. Indoor mall walking programs, for example, have adopted existing infrastructure to create a no-cost environment for seniors to interact socially and stay fit in safe, barrier-free spaces.^{Footnote 488} Programs such as Active Living BC support seniors engaging in physical and social activities by providing discounts to art galleries, provincial parks, museums and theatres, and for buses and ferries.^{Footnote 489} As well, all age groups benefit from infrastructural development that facilitates activity and engages those with mobility-limiting disabilities.^{Footnote 327}

Generally, seniors spend much more time at home and in their own neighbourhoods than other age groups. Limited mobility may further localize the activities of some seniors. As a result, being able to get outside and having access to green space and community spaces close to home are important determinants of positive health for seniors. The design and overall attractiveness of the outdoor and community spaces are also important to attracting usage.^{Footnote 490}

A review of international studies of seniors' participation found that a number of adverse community factors such as a lack of attractiveness, and a perception of poor safety due to unattended pets and poor lighting, led to an overall decrease in physical activity.^{Footnote 491} The challenge for communities and organizations is to make physical activity more accessible and attractive to senior Canadians regardless of age, ability and interest. Creating and adapting environments for physical activity is also important in regions of Canada where winters are severe and may limit seniors' activities. For example, the Elders in Motion Fitness Program, a collaborative program of the Dene Nation, the Northwest Territories Recreation and Parks Association and the Canadian Centre for Activity and Aging, encourages elders' participation in physical activity in their local recreational centres, as well as trains elders to be fitness leaders in their communities. Communities incorporating age-friendly designs and adaptations that encourage seniors to get active and involved in local programs have had success in creating neighbourhoods conducive to healthy aging.^{Footnote 492}

In long-term care facilities as well as independent seniors' residences, creating environments that encourage physical activity and recreation among residents can be challenging given their range of functions, capacities and interests.^{Footnote 176} Facility limitations are also a consideration, including lack of space, specialized equipment and staff – especially staff trained in this area. There has been much media attention on the use of video exercise games to increase the physical activity of seniors, particularly those who are living in institutional settings or who face barriers to participating in physical activity outside the home/community centres.^{Footnote 493} Mental health benefits were found to be associated with use of video exercise games among residents with depression who engaged in a 12-week "gaming" program. The use of games that coach people (of all ages) into fitness programs has been shown to increase confidence, interest and physical performance. Seniors involved in the study were found to respond better to a human coach than to a simulated character.^{Footnote 494, Footnote 495} Supporting this finding is additional research that shows physical activity interventions that are led and guided and/or managed by a coach, health care professional or therapist have been effective in maintaining seniors' commitment and interest in such programs.^{Footnote 495}

Raising awareness about physical activity

The Special Senate Committee on Aging reports that despite the known benefits of being physically and mentally active during the senior years, some Canadians still do not recognize the importance of remaining active across the lifecourse and into senior adulthood. While many assume that slowing down is protective of health, evidence shows that living an active lifestyle can prolong the number of years in good health. A comprehensive seniors' health strategy would help to create conditions for healthy aging; however, many current strategies are broad, and do not specifically address the needs of seniors.^{Footnote 274}

Promising efforts to encourage health over the lifecourse include Canada's Physical Activity Guide to Healthy Active Living, which highlights how Canadians can build physical activity into their daily lives.^{Footnote 496} Canada's Physical Activity Guide to Healthy Active Living for Older Adults is designed specifically for seniors and includes the key messages "it is never too late to benefit from physical activity" and "being active promotes health and independence and can lessen the impacts of aging".^{Footnote 178} The guide also outlines how seniors can choose activities that are of interest to them and that may be done in a variety of settings. It also recommends lesser-impact and lower-risk activities for those who have certain health issues such as heart conditions, osteoporosis and arthritis, as well as for those who are concerned about falling, being unsteady and exercising in various weather conditions.^{Footnote 497}

Education and awareness around the benefits of active living for seniors can also help to challenge assumptions about age and capacity (see the section "Addressing ageism" earlier in this chapter). Despite broad national physical activity promotion programs, the number of seniors engaging in physical activity has not been increasing. This may be the result of assumptions about age and what seniors can/should do, as well as the fact that many seniors assume that, if they are in good health, they do not need to participate in physical activity programs or initiatives. Others may feel self-conscious about engaging in certain activities in a public setting where they may not have the same abilities as younger participants.^{Footnote 12} There are also barriers to behavioural change among disadvantaged communities where there are costs associated with physical activity programs as well as other social factors at play. Factors, such as living in a disadvantaged community, can have impacts outside of the addressing capacity of local public health and social services. Individual factors such changing/ transitioning income (e.g. living on retirement income) and physical ability may increase a need to develop new, less costly or less physically intense activities. Free or low-cost initiatives targeted to low-income seniors can be offered in specific communities and participation can be encouraged. Affordable activities such as walking and biking can also be promoted.

Interventions that offer incentives, such as tax credits, provide leadership options, and increase the visibility of active and healthy seniors have had some success, such as Canada's ParticipAction, which highlights and profiles examples of Canadians of all ages who have challenged themselves and social norms.^{Footnote 498} Also, there is no reason to believe that tax incentives for encouraging physical activity similar to the Canada Children's Fitness Tax Credit could not also be effective for seniors.^{Footnote 471}

Some seniors are less active than others, including women, minority groups, those with lower levels of education, people who are isolated or live in an isolated community, those living with one or more chronic conditions (including cognitive impairment), and individuals without family or friends to assist them.^{Footnote 7, Footnote 176} A targeted approach should be used to encourage physical activity in these less active groups. As well, consideration should be given to the location of services, the ease of access through transportation networks, as well as affordability. For those with mobility or other limitations, initiatives can be undertaken to encourage engagement in physical activity through home-based programs where success can be measured in terms of the development of strength, flexibility, interest and motivation (see Textbox 4.9 VON SMART Program).^{Footnote 499}

Textbox 4.9 VON SMART program

The Victorian Order of Nurses (VON) is a national, non-profit organization that has provided community-based health care across Canada since 1897. Among their many programs, SMART (Seniors Maintaining Active Roles Together)® was created to help seniors become more physically active. The goal of SMART is to promote health and maintain seniors' independence through home-based and group exercise programs.^{Footnote 499, Footnote 500} SMART addresses several age-related health determinants by creating social support networks, providing exercise and educational development, improving personal health practices and increasing access to health services.^{Footnote 499}

The SMART initiative includes an in-home program that provides individuals aged 55 years and older with supervised exercise in their home as well as a group exercise program available within the community. Programs are delivered by trained volunteers between 31 and 76 years old, with the majority being peers.^{Footnote 499, Footnote 500} SMART targets seniors living independently in the community, especially those with health risks and who may also be restricted by cost, transportation or limited abilities.^{Footnote 499}

Since its inception in the mid-1990s, the SMART program has contributed positively to improving the health and attitude of its participants. An evaluation done in 2004 reported that since joining SMART, 34% of its participants became more physically active outside of their regular SMART class. Statistically significant fitness measurement results were also observed during the 16-week monitoring period and participants improved their physical endurance, strength, flexibility, balance and agility.^{Footnote 499}

Furthermore, an evaluation completed in 2008 demonstrated that 50% of the participants of both programs reported their health improved after completing the VON SMART program. More than 90% of the seniors participating in the in-home program stated they were able to maintain or improve their function and mobility, while all the group program participants indicated they maintained and improved their function and mobility. It was also reported that the social aspect of both VON SMART programs was a significant reason for participation and was listed as a primary benefit of both programs.^{Footnote 500} By September 2008, 18 communities across Canada had developed one, or both VON SMART programs.^{Footnote 500}

 

Encouraging healthy eating

Addressing issues with seniors eating practices and nutrition often involve creating positive attitudes toward food, addressing issues of social connectedness and health conditions, as well as preventing food insecurity (including among seniors living in northern and remote communities). There is limited information on the effectiveness of nutrition interventions targeted at seniors. Broad upstream population interventions, such as food fortification to address nutritional deficiencies can potentially increase nutrients for the whole population. However, many food fortification interventions have been primarily intended to improve prenatal health and are not targeted to seniors.^{Footnote 501}

Broad programs work to ensure food security among the population as a whole and strive to ensure physical and economic access to sufficient, safe and nutritious foods to meet dietary needs and food preferences for an active and healthy life. Canada's Action Plan for Food Security is one example of this type of broad program and addresses a wide range of issues related to foods and production including right to access, reduction in poverty, food safety, access to traditional foods and an appropriate monitoring system.^{Footnote 502} Broad programs such as Nutrition North (building on the previous Food Mail Programs) were established to reduce the cost, increase access and promotion of healthy foods (nutritious perishable foods and traditional, northern foods) to eligible communities in the Yukon, Northwest Territories, Nunavut, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, and Newfoundland and Labrador.^{Footnote 503} During the Food Mail program pilot (2009), key project informants reported that nutritious perishable foods were more readily available, inexpensive and of a higher quality than before the pilot; however, levels of food insecurity and progress with changing behaviours varied between communities, and among subpopulations of all ages.^{Footnote 503} Although such programs improve food access across the population, they do not address the unique conditions and factors associated with food issues for seniors such as isolation and mobility issues.^{Footnote 502} The report Healthy Aging in Canada: A New Vision, A Vital Investment, discussed at the beginning of this section, calls for greater nutrition interventions that directly target seniors; these interventions are scarce and their evaluations are rare.^{Footnote 7,Footnote 12}

For seniors, nutrition and social relationships can be linked. For example, those who report being lonely, isolated or depressed often lose interest in eating. As well, many seniors question the need to prepare food for one person as the effort may outweigh the perceived benefits. Programs that encourage seniors to cook for themselves, or for friends and groups, encourage better eating practices and simultaneously contribute to being socially connected and enhancing positive mental health.^{Footnote 7, Footnote 12} Seniors' groups that teach cooking and meet for dinner or lunch regularly encourage healthy eating among those who may be undernourished due to inadequate food consumption and/or skipping meals.^{Footnote 504}

Poor oral health, including tooth loss, among seniors can influence food choices and lead to poor nutritional outcomes.^{Footnote 268,Footnote 505,Footnote 506} These factors are often more prevalent in long-term care facilities where other conditions such as functional difficulties that limit teeth cleaning and self-feeding, as well as medications, can increase tooth decay and impact eating habits. While many seniors may have received good dental care earlier in the lifecourse due to employer health insurance plans and greater access to services, management of oral health care declines with age due to access and affordability.^{Footnote 270,Footnote 505,Footnote 506} In a review of the Oral Health of Seniors in Nova Scotia, it was reported that seniors' oral health issues should be integrated into public health frameworks, including: regular reporting on indicators related to seniors' oral health; developing, implementing, monitoring and evaluating oral health care of seniors; and developing oral health awareness campaigns that specifically target seniors.^{Footnote 507} The Canadian Oral Health Strategy recommended a national standardized method of monitoring oral health indicators in Canada.^{Footnote 508} In response, an oral health component was included in the Canadian Health Measures Survey, 2007 to 2009.^{Footnote 269}

As noted in Chapter 3, poor nutrition can have adverse health impacts.^{Footnote 7, Footnote 180, Footnote 181, Footnote 190} There has been some success with nutrition awareness programs targeted to seniors, as well as nutrition screening among at-risk seniors to identify problems and assess solutions (see Textbox 4.10 Seniors in the Community Risk Evaluation for Eating and Nutrition) but these efforts and their evaluation are limited. Practices that encourage healthy eating among seniors need to address the broad range of factors that influence nutrition, including food choice, oral health and health, social and economic vulnerability.^{Footnote 7, Footnote 509} As well, education programs are needed that provide information and that challenge assumptions about healthy weights and eating practices for seniors.^{Footnote 7} Further research and knowledge is also needed to better understand the determinants of seniors eating habits, as well as increased evaluation of interventions.

Addressing smoking, alcohol and drug use

While about 9% of seniors (65 years and over) currently smoke (see Chapter 3), there are few seniors' smoking cessation programs, limited successes associated with these programs, and very few program evaluations and compilation of best practices.^{Footnote 7, Footnote 192-Footnote 194} Also, while there are positive health outcomes for seniors who quit smoking, there is still little research regarding seniors' motivations and barriers. More work needs to be done to increase the knowledge, awareness and effectiveness of seniors' smoking cessation programs.

Smoking cessation interventions primarily targeting youth have not been as effective with seniors.^{Footnote 516, Footnote 517} These two groups have very different attitudes and experiences related to smoking. For seniors, awareness campaigns that depict a loss of independence or quality of life or highlight the impact of smoking on the health of a loved one have been most effective in encouraging seniors to quit.^{Footnote 516-Footnote 518} Peer support for smoking cessation has had some success, especially when former senior smokers testify they were able to stay smoke free and saw improvement in their lives. Seniors need to be able to relate to other seniors and be aware that it is never too late to quit. Broad smoking cessation for all age groups is rarely achieved using a single point of entry or one single intervention.^{Footnote 517}

As with smoking, programs targeted at seniors and/or risk factors for seniors in terms of alcohol and drug use are limited. A variety of treatment approaches can be used or combined to address seniors with substance abuse issues. Peer-led self-help groups, such as Alcoholics Anonymous, have had some success with seniors in building social relations and mentoring among people of a similar age.^{Footnote 517} Brief interventions, as well as cognitive-behavioural treatment approaches, address the individual's motivations, thoughts and beliefs that underlie substance use problems. Similarly, outreach services provide treatment in the senior's home and overcome barriers inherent in requiring the senior to travel to receive services. Many intervention techniques that involve targeted programs to seniors and seniors helping seniors through support have had some success.^{Footnote 12}

It is also important to note that alcohol and drugs may be used by seniors to address chronic pain issues and/or insomnia. Interactions with prescription or over-the-counter medications can cause further health impacts, including decreased medication effectiveness, disorientation that may lead to falls or an increased risk of overdose.^{Footnote 205} Drug and alcohol cessation programs targeted to seniors should consider these issues, as well as other causes of substance use (e.g. loneliness, depression) to increase their effectiveness.

Ensuring health literacy for seniors

Health literacy is influenced by a number of factors including education, income, cognition, health and functional conditions.^{Footnote 73,Footnote 277,Footnote 279} Among seniors, health literacy is specifically influenced by aging; as a decline in health literacy skills may occur as people age, and by the fact that the current cohort of seniors generally has a lower level of education than younger age groups. Compounding this issue is the fact that as people age they are more likely to require health care services, information and treatments. This is a concerning issue in regards to seniors who lack the health literacy skills necessary to make basic health decisions and to access and accurately assess relevant health information.^{Footnote 276} The ability to acquire information can be further compromised by challenges with mobility, access to service, language, and level of technological skills and social engagement. Addressing health literacy among seniors will require better recognition of the issue and widespread action to engage individuals, communities and policy-makers to manage and improve health literacy levels among seniors as well as all other age groups.^{Footnote 280}

A low level of health literacy often results in the inability of seniors to access programs and services and to adhere to treatment regimes or disease management protocols.^{Footnote 280} These activities often require that an individual manoeuvre through systems of paperwork and information, which are often a barrier to receiving appropriate care. Awareness campaigns should encourage seniors to keep abreast of their own health and care issues (if possible). As well, seniors can work toward improved health literacy through daily reading, which evidence shows can improve health literacy scores by 52%.^{Footnote 280} Health literacy campaigns should also reinforce the benefits of posing questions to health care providers and pharmacists, and help to identify various sources and means of accessing additional health information, including the identification of a trusted individual to act as a health champion.^{Footnote 280}

All levels of government have a responsibility to address health-literacy challenges. Governments can apply plain-language principles to all health information and related services (such as medical insurance forms and medication labels) and support the translation of health-related materials in various languages in areas with populations of linguistic minorities. Communities can offer outreach programs to vulnerable populations, such as seniors who are immigrants, have low levels of education, have mobility issues or live in underserviced areas.^{Footnote 280}

Further, educating health care professionals about health literacy issues can enable them to better serve a diverse group of seniors who may otherwise have difficulties making informed decisions about their health and their options for care. The use of medical interpreters, for example, can assist health care professionals in ensuring that at-risk seniors receive and understand accurate information and instruction. Interpreters can, in turn, provide assurance to seniors with language barriers that their concerns and any issues they may have are properly communicated to their health care provider and/or pharmacist.^{Footnote 519}

In providing revised or targeted health information materials and services, there is also a responsibility to monitor effectiveness of these actions to ensure needs are being met. Gathering information on health literacy trends and issues is necessary to continue providing effective support for those in need.

Supporting opportunities for lifelong learning

Efforts to become more socially engaged can be enhanced through educational and/or lifelong learning opportunities. Seniors who participate in these activities can create and foster new interests and knowledge and maintain or increase their involvement in their communities. Participating in a learning activity can increase quality of life, prevent loss of brain function and improve cognitive skills, which may include improving or maintaining literacy skills.^{Footnote 280}

It is important for seniors to recognize the mental health benefits of continued learning and the educational opportunities available to them. Communities need broad approaches and guidelines to find collective ways of overcoming barriers to participation, developing learning programs and sharing best practices. A number of approaches can be used to improve access to lifelong learning:

• awareness efforts that encourage the participation of seniors;
• better information exchange on activities, programs and opportunities for and among seniors and across communities; and
• incentives for seniors to engage in learning (e.g. tax credits, reduced rates).

Educational programs are available to seniors within many settings. Local school boards offer continuing education programs, with courses ranging from adult high school curriculum to general interest courses. Many of Canada's universities and colleges support seniors who are interested in enrolling in degree/diploma courses by offering low or no-cost tuition as an incentive. Some seniors may be interested in learning at a post-secondary institution but may be deterred by the added responsibility and potential stress of exams and schoolwork. For these individuals, the option to audit courses and/or tailor programs to seniors has had success in encouraging their participation (see Textbox 4.11 Opportunities for lifelong learning: University of the Third Age). For example, the Seniors College of Prince Edward Island, an affiliation of the University of Prince Edward Island Centre for Life Long Learning, provides learning opportunities for seniors with a range of interest courses across three regions of the province.^{Footnote 520}

A seniors' knowledge network can serve as a communication mechanism for creating awareness of learning opportunities within various communities and providing an information exchange among network members. However, seniors who are educated or who participated in learning activities across the lifecourse are more likely to continue to participate in lifelong learning.^{Footnote 274} More work needs to be done to encourage those who are less likely to uptake learning programs to participate.

Care and services

For generations, Canadians have provided care for family members/peers who are sick and/or aging inside and outside the home. The majority of seniors' care (about 72%) is provided through informal sources – both family members and friends.^{Footnote 73} However, although demographic patterns have evolved and more individuals (particularly women) are participating in the workforce, care often coincides with other responsibilities such as formal working arrangements and child care.^{Footnote 529, Footnote 530} For a number of seniors, formal care providers can help them maintain independence at home by offering support for acute/ chronic health conditions and with meal preparation and daily activities.

The various levels and services of seniors' care can be complex. As well, the transitions between levels of care are not often smooth.^{Footnote 274} Seniors can experience difficulties in accessing, affording and deciding on the right care. In addition, decisions on care can impact the individual requiring care, the individual's family members and caregivers, as well as health care providers. The question for public health, health care and social services is how to best meet the needs of Canada's seniors now and in the future. What can be done to support individuals and their caregivers to ensure the best care in their place of choice?

Much research exists on the range of care opportunities that are or could be options for Canadian seniors. The following section highlights five areas of care that play important roles in aging:

• home and community care;
• assisted living and support;
• long-term care;
• palliative and end-of-life care; and
• integrated care.

While each addresses some of the needs of seniors, it is clear that Canada can do more to ensure a broader range of needs are met and to create a continuum of care in the future.

Home and community care

Home and community care services are received primarily at home or in the community, rather than in a hospital, supportive housing or long-term care facility setting.^{Footnote 531} Home care can bridge the gap between independent living and living in a residential care facility, as well as provide opportunities for seniors to continue to live at home if this is their place of choice.^{Footnote 531} A range of care is delivered by various individuals including regulated health care professionals (e.g. nurses, occupational therapists), non-regulated workers, volunteers, friends and family.^{Footnote 531, Footnote 532} Programs can offer an array of social services including homemaking and assistance with bathing, meal preparation and recreational activities. For many individuals, assistance with living at home can decrease and/or delay care in a hospital or long-term care facility.^{Footnote 531, Footnote 533} For the most part, evidence shows that home care can be a lower cost alternative to residential care among recipients with similar care needs (even when informal care time is valued at replacement wage).^{Footnote 534, Footnote 535} Differences in cost arise when type and level of care changes, which underlines the need for a planned and targeted approach to home care to ensure cost efficiencies.^{Footnote 534, Footnote 535}

Being able to provide home care across a variety of populations and communities can be difficult. While many seniors with care needs prefer to live independently, being able to access culturally and care-appropriate services in their community can be challenging (e.g. for those who live in rural and remote communities or those who are part of a vulnerable population). Some programs, such as Health Canada's First Nations and Inuit Home and Community Care (FNIHCC) Program, have been developed to provide comprehensive, culturally sensitive, accessible, effective and equitable services that respond to the health and social needs of First Nations and Inuit communities.^{Footnote 536, Footnote 537} FNIHCC funds essential services such as care assessment and management, home nursing services, in-home respite care, personal care, and linkages with other professional and social services. Evaluations show that since its inception 10 years ago, FNIHCC has built community health capacity by developing home and community services where there were no such services before. Also, the participation of First Nations and Inuit peoples in all stages of development has directly resulted in a strong sense of program ownership.^{Footnote 537} FNIHCC has been able to provide services to individuals within their own communities who would otherwise have had to seek these services elsewhere.^{Footnote 537, Footnote 538} Complementing the FNIHCC is Indian and Northern Affairs Canada's Assisted Living Program, which provides services that are specifically directed at First Nations seniors with functional limitations who may require assistance to maintain their independence.^{Footnote 539} Programs such as FNIHCC have been effective addressing home care issues of First Nations on-reserve and Inuit communities, however, similar programs could be adapted to address the home care needs of Aboriginal communities in other jurisdictions.

Canada's Veterans Independence Program is a national home care program that helps eligible veterans remain in their homes or communities for as long as possible.^{Footnote 60, Footnote 540} In 2005-2006, the VIP provided support to approximately 97,000 veterans.^{Footnote 541} It works with existing services and programs in the local community to meet veterans' unique care needs.^{Footnote 60} Those who qualify for the VIP can receive a range of health, personal and household services. Further, additional services are available to eligible veterans for such things as ambulatory health care, transportation expenses for activities that foster independence, nursing home care, and home adaptations that improve an individual's capacity to make a meal, bathe and sleep. The VIP has also been expanded to extend services to low-income and/or disabled survivors of veterans and civilians who served during World War I, II or the Korean War. In addition to assisting participants with care needs while living at home, the VIP participants have reported good levels of satisfaction with the program.^{Footnote 60, Footnote 540, Footnote 541} Another successful initiative for Canada's veterans, the Overseas Service Veterans "at Home" Project, has demonstrated the benefit of providing at home options for veterans who are waiting for long-term care placement (see Textbox 4.12 Overseas Service Veterans "at Home" Project). The VIP has been recommended as a model for broader home care programs and is being adopted more broadly.^{Footnote 542}

The success of programs such as VIP are based on the provisional policy of a continuum of service or graduated care model, emphasizing the need for early identification, assessment and intervention to prevent undue health system dependency. Providing a wide variety of service options is also important to be able to respond to changing needs and differences in need among individuals and the communities that support them. As well, initiatives should include provisions for working with provincial, territorial and community programs (such as VIP) to complement existing services rather than duplicate efforts.^{Footnote 274}

In Alberta, the Continuing Care Strategy is intended to deliver services that provide Alberta seniors with options to stay in their homes and communities for as long as possible. This client-focused strategy prioritizes the health and personal care required for seniors to "age in the right place." Alberta is working on an evaluation and assessment of the strategy in order to examine if the right level of service is being provided in the appropriate setting.^{Footnote 544} Internationally, Australia's Home and Community Care aligns domestic, health and personal care services with the goal of meeting the needs of individuals who require assistance with daily living (including seniors) to help them maintain independence and reduce unnecessary admissions into residential care.^{Footnote 545}

Over ten years ago, the National Forum on Health (1997) offered a number of recommendations, including one on home care that launched broad discussion about home care delivery in Canada. These recommendations also highlighted three areas for action to move toward a more integrated system of health care: providing options that ensure quality of life and reduce the risk of institutionalization; care that is appropriate to patient needs, cost-effective and support to caregivers; and, a system with a single point of entry that assesses needs on a case-by-case basis.^{Footnote 546} Since the release of the findings of the National Forum on Health, other debates have focused on integrating home care services; however, questions still remain and more work needs to be done in this area.

Supporting caregivers

Informal care providers play a vital role helping seniors to live at home. These efforts can reduce impacts on long-term care facilities and hospitals as well as help to maintain seniors' independence and capacity to live in their homes and communities.^{Footnote 274, Footnote 532}

While most caregivers report that they are generally coping or coping very well with their caregiving responsibilities, some may experience adverse health and social outcomes.^{Footnote 260} Caregivers, themselves – especially family caregivers – may be prevented from working outside of the home, or have to reduce/change hours of work, may incur unreimbursed expenses, and may experience social isolation, and/or mental and physical fatigue with longer-term health outcomes.^{Footnote 73} For some caregivers, this unpaid work can go unrecognized by the care recipient, family, co-workers and communities.^{Footnote 547} Canada, as a society, values caregivers and all Canadians have a role to play to support caregivers in their daily activities.

Supporting caregivers is complex as individual and situational needs vary. Many players need to be involved, including governments, employers, stakeholders, communities, and individual Canadians. In Canada, there are several programs to support caregivers which vary from financial support (including wages, tax relief, and labour policies) to community supports and services.^{Footnote 530}

The federal government provides a range of supports, including the Caregiver Tax Credit, the Eligible Dependant Tax Credit and Infirm Dependant Tax Credit, and the transfer of the unused amount of the Disability Tax Credit, which recognize the reduced ability of caregivers to earn and consequently pay income tax as a result of supporting a dependent.^{Footnote 305, Footnote 548-Footnote 552} Tax recognition for a dependent spouse is also provided through the Spousal Credit.^{Footnote 553} Under the Medical Expense Tax Credit, caregivers can claim on behalf of a dependent relative, up to $10,000 in eligible medical expenses.^{Footnote 554, Footnote 555} The federal government also offers targeted programs for caregivers of populations under federal responsibility. The Canada Pension Plan General Drop Out provision automatically exempts from a person's pension calculations up to 15% of his or her years of low- or no-income for a variety of reasons, including caregiving responsibilities.^{Footnote 556} Labour policies such as expanded and flexible paid leave for caregiving, are believed to be beneficial in helping to balance work and caregiver tasks. Canada's Employment Insurance Compassionate Care Benefit provides financial support to caregivers who require time away from their jobs to take care of gravely ill family members or friends.^{Footnote 305, Footnote 557} In addition, the Government of Canada is investing in research over the next three years to fill knowledge gaps on key caregiver issues.^{Footnote 305}

While each province and territory organizes health services differently, most provide provincial tax credits for caregivers, home and continuing care supports and services, along with important resources for caregivers such as respite programs, counselling and support groups. Some Canadian employers also offer a variety of flexible work arrangements for employees with family and caregiving responsibilities (e.g. telework, flexible work hours, provide on-site adult day care centers) so that employees can better balance work and care responsibilities. These kinds of initiatives can be mutually beneficial to employers by reducing costs incurred due to absenteeism, higher rates of illness for working caregivers, and the loss of skilled employees who leave work for caregiving responsibilities because of a lack of flexibility.

During national caregiving consultations for the Special Senate Committee on Aging, many participants emphasized that support for caregivers and care receivers are interrelated and issues span jurisdictions.^{Footnote 274} When seniors caring for seniors were asked about the types of assistance that would be useful to them in order to continue to provide care, 40% reported occasional relief or sharing of responsibilities, 30% reported financial assistance, 25% reported requiring more information about the nature of the long-term illness and how to be an effective caregiver, and 16% reported wanting counselling.^{Footnote 214, Footnote 262} While care receivers' access to home care and related supports can have positive impacts, it is difficult to assess the quality of benefits and challenges associated with these impacts. In order to better support informal care, more needs to be known about caregivers (e.g. the short- and long-term health and social outcomes of providing care).

With the aging of the population, an increase in the incidence of disability, more women in the workforce, and the emergence of smaller, less traditional, more dispersed families, it is anticipated that the number of informal caregivers needed in the future is likely to increase. Consequently, how to support caregivers is a topic of much debate in Canada and other countries. The debate centres on issues of what is appropriate, ethical, meets needs of caregivers and care-receivers, and considers policy priorities. The need increases as the demand for caregivers increases and the supply simultaneously decreases as a result of demographic changes, workforce participation and patient health conditions.^{Footnote 530} Considering the future needs of caregiving in Canada, more can be done to improve conditions for caregivers.

Other countries also have programs in place to support caregivers that include tax relief, paid leave, wages and broad community supports. Australia's National Respite for Carers Program offers community-based respite services in a variety of settings (home, residential and away) as well as a network of caregivers who can provide counselling, information and advice. Australia also provides a Carer Payment (a bi-weekly payment to those providing eligible care) and a Carer Allowance (a non-taxable supplementary payment available to caregivers who provide daily care to those with a severe disability or medical condition).^{Footnote 558, Footnote 559} Norway's health and social service policies cover a broad range of supports and services for caregivers, including its Social Services Act and Action Plan for the Elderly that support caregivers with respite care and caregiving wages.^{Footnote 560} Sweden has national measures to support family based caregivers such as its Care Leave Act, which provides caregivers opportunities to receive paid leave to support seriously ill family members and its Social Service Act, which encourages communities to support local caregivers.^{Footnote 561}

Assistance for caregivers can also come from the private sector by providing support to employees with caregiving responsibilities. Companies such as the United Kingdom's BT Global Service (a telecommunications company) supports employees, who are also caregivers, with flexible work hours, remote access or work-from-home arrangements.^{Footnote 562-Footnote 565} As a result of these arrangements, BT reports higher productivity and job satisfaction among these employees.^{Footnote 566-Footnote 569} By providing opportunities for family to care for other family members, the capacity of caregivers is increased, the ability of seniors to age in place of choice is maintained and the number of people relying on residential care is reduced.

Broad home care strategies

Canada does not have a home care strategy that addresses issues for both caregivers and care recipients. A national strategy would include several key components:

• education and training of caregivers to determine best practices for care;
• efforts to support and communicate across provinces/ territories and all communities in Canada;
• efforts to raise awareness of the critical role caretakers play in the lives of many Canadians; and
• efforts to develop of working options for people who work and are also caregivers.^{Footnote 570}

A greater understanding of home care and the role it plays for individuals, families and communities is required. So, too, is better knowledge around the relationship of home care to public health and health care activities. Additionally, more needs to be done to raise awareness of home care practices and the role they play in care provision, share best practices, support caregivers and identify issues and barriers to moving forward.^{Footnote 570}

Assisted living and support

Assisted living can address transition periods when individuals' needs for care exceed what is available in their own homes but do not require the attention and intensity of the service found in a long-term care facility.^{Footnote 571} Filling this gap is addressed through a range of both private and public-style housing options that offer services ranging from housekeeping and meal preparation to transportation and social activities.

Generally, in Canada, work still needs to be done to ensure that seniors have access to affordable supportive housing offering appropriate levels of services in places of choice. Regulations for supportive living vary by jurisdiction – in some areas there is a landlord-tenant relationship and in other jurisdictions it is classified as health services.^{Footnote 274} Services need to be regulated to ensure standards are met, costs are managed, and health and safety concerns are addressed.

It is important to ensure that needs are met for all seniors and that gaps in basic service are not determined by income.^{Footnote 274} In general, those with higher incomes have access to a greater range of supportive housing opportunities, whereas those with lower incomes can face a housing shortage based on access, availability and affordability.^{Footnote 572} Facilities that offer specific services or tailor to needs can be expensive and uninsured. Often too, there are increased costs associated with providing services at times of greatest need and vulnerability. Ideally, supportive housing fills the needs associated with transitional care and minimizes health impacts such as isolation and discomfort as seniors move between levels of care. Some jurisdictions are beginning to manage access to assisted living and support through a single entry point in order to provide appropriate and timely care. While this approach is successful in some areas, difficulties exist in the creation of systems that are too complex to navigate.

In smaller, rural and remote communities, seniors may experience barriers to accessing assisted living and support that can result in displacement to larger urban centres and/or accepting service gaps and facing adjustments in their needs/housing type.^{Footnote 82} Making do with fewer services because needed services are not available in the local community can result in extended hospital stays and/or living in a long-term care facility before it is necessary or beneficial, or remaining at home and at risk with no support.

The housing sector can play a key role in addressing individual and community needs with its knowledge of available options. For example, Independent Living B.C. helps low-income seniors who require support to remain independent by working with British Columbia Housing – in partnership with CMHC, housing providers and health authorities – to deliver a program to eligible participants who require personal care but not long-term care.^{Footnote 573} In remote areas, where access to care is limited, some progress is being made with federal investment in housing for low-income seniors, and renovation and retrofits in Canada's North and on-reserve in First Nations communities. For example, the On-Reserve Non-Profit Housing Program (section 95) assists First Nations community members, including seniors, in acquiring suitable, adequate and affordable rental housing on reserve. The program supports First Nations in the construction, purchase, rehabilitation and administration of affordable housing in communities such as Michipicoten (Ontario) where a high proportion of the population is older, and there is a growing need for affordable housing for seniors.^{Footnote 574, Footnote 575}

Long-term care

Long-term care services provide residential supervised care that includes professional health services, personal care, and services such as meals and laundry.^{Footnote 576} The range of services in long-term care varies and most facilities are provincially/territorially monitored (with the exception of services to on-reserve First Nations communities, veterans and offenders, which are federally addressed).^{Footnote 576} Long-term care is also complex and there is no consistency in the terms used across Canada to describe this type of care and the services offered.^{Footnote 576}

Although extended health care services are covered under the Canada Health Act, long-term care is non-insured and often requires user fees. Not understanding the distinction between insured and non-insured care can cause individuals to experience challenges in navigating, paying for and waiting to access long-term care facilities.^{Footnote 274} Costs and care vary across Canada, with different levels of care and sources of funding. Variation is due, in part, to differences in private and publically funded beds (and the care associated with those beds). A majority of long-term care facilities are privately owned and care can often be costly. For publicly funded facilities, significant waiting periods for a placement is typical. Waiting periods can cause gaps in care as well as displacement. Additionally, long-term care is not portable across provinces/territories such that subsidies, waiting periods and fee-for-services vary and can present barriers to seniors who are trying to move across provincial/ territorial borders.^{Footnote 274} This is often a difficulty for seniors who wish to move into the same community as other family members or live in the same facility as a partner, relative or friend.

In general, individuals entering long-term care facilities are older and have greater health care needs than in previous generations. In particular, there is an increase in those who are frail, have severe dementia and/or have multiple health conditions. In order to provide care to this vulnerable population, there is a need for specialized care and special care units within long-term care facilities that requires higher staff numbers and better training in key geriatric fields.^{Footnote 8, Footnote 274} Shortages of trained staff and accommodations within facilities contribute to difficulties in access. It is important that governments and communities work now to ensure that appropriate facilities and services are in place to meet the long-term care needs of Canada's current and future seniors population.

Palliative and end-of-life care

In recent decades, palliative and end-of-life care has gained increased recognition by health care providers, educators, governments and the general public as being an important and valued component of care that requires appropriate and compassionate support to individuals and their families/friends.^{Footnote 577} The purpose of palliative and end-of-life care is to provide services such as pain and symptom management, psychological, social, emotional, and spiritual support, as well as bereavement support for caregivers and families. Palliative and end-of-life care can occur in a range of settings such as hospitals, long-term care facilities, hospices, and private homes. Funding may come from a range of sources, including various levels of government, private sources and charitable donations.^{Footnote 577, Footnote 578} Ideally, care is provided by an interdisciplinary team that may include nurses, physicians, social workers, various therapists, spiritual advisors, bereavement support workers, volunteers and informal caregivers.^{Footnote 577} Each year, palliative and end-of-life care impacts the well-being of many Canadians. The Canadian Hospice Palliative Care Association estimates that for each death in Canada, an average of five additional Canadians are impacted.^{Footnote 578, Footnote 579}

Access to palliative care is a concern in Canada. It is estimated that only 16% to 30% of Canadians who die have access to, or receive needed hospice palliative and end-of-life services, and even fewer receive grief and bereavement services.^{Footnote 578} While many individuals are dying in hospitals, few are receiving care designated as inpatient palliative that may be required. Despite findings that about 70% of individuals report a preference to die at home, most individuals are dying in hospitals, few of which offer in-patient palliative care services.^{Footnote 578-Footnote 580}

As aging in place of choice is critical to healthy aging, so too is dying in one's place of choice. Addressing the discrepancy between what is preferred and what is possible is an issue requiring further consideration in palliative and end-of-life care planning. Establishing options for end-of-life care depend on the capacity of health care professionals, families, caregivers and volunteers and the overall ability to provide adequate end-of-life care that are also consistent with the individual's wishes. Additional training for health care professionals and support of palliative and end-of-life research may be necessary to provide the proper tools to assess and support individual and family needs, raise awareness and achieve effective practices.^{Footnote 577} There is a need for an integrated system that can effectively coordinate transitions between home, palliative, long-term and hospital-based care in order to provide the highest quality and most cost-effective care possible.

Not enough is known about the demand for, supply, quality or costs of palliative and end-of-life care in Canada. At the population level, it is difficult to assess the extent to which the needs of individuals and their families are met.^{Footnote 580} Health system data as well as differences in perception of the services available and how needs have been met vary across the country. More information is also needed about the type, amount and appropriateness of care to address and manage pain, bereavement and other support, as well as the effectiveness of end-of-life care programs.^{Footnote 580} In addition, more information is needed the effectiveness of end-of-life care programs. As Canada plans for future palliative and end-of-life needs, improvements to data and information systems will be required.

Canada has made progress in addressing palliative and end-of-life care. From 2004 to 2009, CIHR funded $16.^{Footnote 5} million for palliative and end-of-life care research, primarily for teams in areas such as care transitions, caregiving, pain management, care for vulnerable populations and program evaluation.^{Footnote 579, Footnote 581} Furthermore, through the 10-Year Plan to Strengthen Health Care, the Government of Canada has provided support to provinces and territories to improve the quality and accessibility of home palliative care.^{Footnote 305} The Employment Insurance Compassionate Care Benefit is a key support for people who need a temporary leave from work to care for someone who is gravely ill. This program was recently extended to self-employed Canadians.^{Footnote 305, Footnote 582}

From 2002 to 2008, Health Canada supported the work of the Canadian Strategy on Palliative End-of-Life Care.^{Footnote 577} Under the strategy, five collaborative working groups focussed on initiatives around best practices and quality care, education for formal caregivers, public information and awareness, research, and surveillance. Key accomplishments included a core set of performance measures for accreditation and guiding principles of palliative and end-of-life care; a palliative and end-of-life framework to promote awareness and increased dialogue on palliative and end-of-life care; tools for knowledge translation to move from research to practice and policy; and the development of electronic networks to share information, research and best practices.^{Footnote 577} While the strategy has come to an end, the Government of Canada continues to support a variety of initiatives.

Other organizations are also looking at palliative and end-of-life health issues. The Canadian Coalition for Seniors' Mental Health, in collaboration has developed the adapted National Guidelines on the Assessment and Treatment of Delirium in Older Adults to end-oflife settings.^{Footnote 583} The Canadian Hospice Palliative Care Association and the Quality End of Life Care Coalition are concerned with improving access to quality end-of- life care, promoting research, raising awareness and supporting caregivers and families.^{Footnote 581}

As Canada's population grows older and lives longer, (in many cases with chronic illnesses and functional limitations), palliative and end-of-life care will need to be coordinated to manage complex service issues.^{Footnote 580} Palliative and end-of-life care must best reflect the right kind of care, at the right time and in the most appropriate settings. This growing need is a call to action to work together to achieve the best care possible for all Canadians.

Integrated care

Mental health literacy includes preventing mental health illness, recognizing symptoms and interventions and reducing stigma. Overall, Canadians have good mental health literacy – being knowledgeable about the prevalence of mental disorders, warning signs and being able to identify a mental disorder.^{Footnote 499} Nevertheless, many reported that they believe mental health problems to be rare, consider disorders such as depression and anxiety to be environmental and are less able to distinguish between schizophrenia or anxiety and depression (particularly among youth) and mistake mental health problems with other health disorders.^{Footnote 499} While many Canadians reported that they would recommend medical attention for those with disorders, evidence shows that individuals would prefer to self-treat or seek lay-support and lifestyle interventions, and that they would be uncomfortable revealing that they have a mental health disorder for fear of jeopardizing job security and social relationships.^{Footnote 499}

To further develop mental health literacy, the Canadian Alliance on Mental Illness and Mental Health (CAMIMH), has developed a National Integrated Framework for Enhancing Mental Health Literacy in Canada. ^{Footnote 499} The framework established a list of expected outcomes for mental health literacy, including increased knowledge and reduced stigma and discrimination; improved systems capacity to promote and support individuals; improved mental health literacy for care providers; increased access to services and information for Aboriginal peoples regardless of region; and an increase in implementation, public engagement and support initiatives across the lifecourse.^{Footnote 499}

The key to successfully developing mental health literacy is the ability and capacity to understand and subsequently identify mental health problems which can result in better treatment outcomes.^{Footnote 499, Footnote 500} Following the Australian approach (developed by Australian National University's Centre for Mental Health Research and further sponsored by the University of Melbourne's ORYGEN Research Centre) is Mental Health First Aid (MHFA) which was adapted/implemented by the MHCC in 2010 and is now available in many communities across the Canada.^{Footnote 500, Footnote 501} By improving mental health literacy, the MHFA Canada program aims to provide the skills and knowledge to help people better recognize and manage mental health problems in themselves, family or a friend/colleague.^{Footnote 500}

Generally, the premise of mental health first aid is based on a traditional first aid approach. Help is provided until appropriate treatment is found or the crisis is resolved. Those who may be a danger to themselves are protected, and a mental health problem is prevented from developing into a more serious state. The recovery of good mental health is promoted, and comfort is provided to an individual experiencing a crisis (see the textbox "Mental Health First Aid Canada: The Jack Project example"). Evaluations have reported that MHFA increases knowledge, decreases stigma and increases helping behaviours. MHFA training increases participants' ability to recognize signs of a mental health problem and provide initial first aid support while guiding the person to appropriate professional help.^{Footnote 502, Footnote 503} Evaluations also found that an MHFA training course improved mental health literacy in the community and that it could be adapted broadly and across jurisdictions.^{Footnote 501, Footnote 504} However, evaluations of the long-term effects on the recipients of mental health first aid are limited and more research in this area would be beneficial.^{Footnote 503}

Interventions that reduce mental health stigma

Stigma for any reason (such as a health issue, culture, gender, sexual orientation) can affect many individuals and can occur in a variety of settings.^{Footnote 507} In general, stigma is the result of poor understanding of an issue, leading to prejudice and discrimination, and many individuals who have a mental illness or a mental health problem have also experienced stigma. Stigma can negatively affect an individual's ability to develop holistically, socialize, go to school, work and volunteer, and seek help and treatment.^{Footnote 507} There are several approaches to breaking down mental health-related stigma. Early education (focusing on primary school and then high school) and increasing awareness of mental health disorders generally challenge misconceptions about mental illness and reduce associated stigma.^{Footnote 507, Footnote 508} Targeting young Canadians is an effective method of teaching children and youth about mental illnesses and promoting empathy and tolerance before negative attitudes emerge. Early education interventions also have been shown to have greater benefits in reducing stigma than broad population-based initiatives.^{Footnote 507} Destigmatization approaches among those who are younger can carry through the lifecourse, providing opportunities to create the greatest impact across the population over time.

Stigma related to mental health issues not only has an impact on the well-being of Canadians but also acts as a barrier to seeking treatment.^{Footnote 509} In the Canadian Youth Mental Health and Illness Survey, 63% of respondents indicated that embarrassment, fear, negative peer response and stigma were barriers to young people seeking the help they needed.^{Footnote 510} Although approaches to combat stigma have had limited success, some success or promise has been found by:

• increasing education and awareness to dispel commonly held myths about mental illness among youth and young adults;
• challenging commonly held discriminatory attitudes through increased information; and
• providing a context for mental illness that makes it familiar and not unknown.^{Footnote 507}

Generally, providing some context to the illness, disorder or state of well-being is the most effective method of countering stigma and discrimination.^{Footnote 507} In 2009, MHCC launched a 10-year anti-stigma/anti-discrimination initiative called Opening Minds. This initiative is the largest systematic effort to reduce the stigma of mental illness in Canada, and the Commission will work with communities, stakeholders and specific at-risk groups.^{Footnote 509, Footnote 511} Evaluations of a number of these programs will occur in 2011. An earlier evaluation of Partners for Life, a project in Montreal (Quebec) that has since become part of Opening Minds, found that high-school presentations increased knowledge about depression and modified attitudes about illness and seeking help among participants.^{Footnote 512} Other countries, such as Australia, New Zealand, the United Kingdom and the United States, have also developed anti-stigma initiatives that share the vision of shifting attitudes and behaviours about mental health disorders and illnesses.^{Footnote 513}

Developing broad strategies for mental health and well-being

Broad integrated policies both inside and outside of the health sector can significantly improve overall community mental health. Hence, an integrated and inter-sectoral approach to mental health prevention and promotion is ideal. Organizations and jurisdictions have been making strides in creating frameworks for mental health. A significant advancement was the development of the European Commission's Green Paper on mental health in 2005. This set out a framework and guidelines for preventing and promoting mental health action plans for member states.^{Footnote 514} This led to the development of Mental Health Promotion and Mental Disorder Prevention: A Policy for Europe, which identifies evidence-based options for action and calls for an integrated and inter-sectoral approach to mental health initiatives.^{Footnote 515, Footnote 516} This includes programs and initiatives that target behaviours as well as other determinants of health.^{Footnote 516} Healthier communities can also contribute to good mental health through community design (e.g. green spaces, etc.) and other considerations, such as supportive networks that encourage inclusion of all members regardless of age or ability.^{Footnote 516} While the direct effectiveness of these policies and frameworks is often difficult to measure, they are critical to raising awareness and securing the resources necessary for delivering effective programs. A framework can co-ordinate actions across sectors and jurisdictions to ensure multi-faceted approaches.^{Footnote 517}

In 2009, MHCC developed a framework, Toward Recovery and Well-Being: A Framework for a Mental Health Strategy in Canada, to establish ground work for addressing the current and future mental health needs of all Canadians.^{Footnote 226} One of the areas focuses on children and youth so as to bring a lifecourse perspective to their work.^{Footnote 226} Similarly, a First Nation, Inuit and Métis focus will be concerned with promoting the overall mental health of Aboriginal peoples in Canada, and helping to increase knowledge and understanding of mental health with respect to cultural beliefs, social justice, ethical practices and diversity.^{Footnote 226, Footnote 518} As part of this work, MHCC will develop ethical guidelines on the delivery of front line mental health and addictions programming in Aboriginal communities.^{Footnote 226, Footnote 518}

The MHCC framework recognizes that programs and strategies will need to be adaptive and take into account family and community wellness as well as individual wellness. Community involvement and decision-making are necessary to provide effective, culturally relevant programs and a co-ordinated continuum of services.^{Footnote 226} Health Canada implemented the First Nations and Inuit Mental Wellness Advisory Committee (MWAC) Strategic Action Plan to address the mental health, mental illness and addiction needs of First Nations and Inuit in Canada by providing strategic advice on issues related to mental wellness.^{Footnote 519} MWAC has identified five priority goals within its action plan, including:

• supporting the development of a co-ordinated continuum of mental wellness services for and by First Nations and Inuit that includes traditional, cultural and mainstream approaches;
• disseminating and sharing knowledge about promising traditional, cultural and mainstream approaches to mental wellness;
• supporting and recognizing the community as its own best resource by acknowledging diversity of knowledge and by developing community capacity to improve mental wellness;
• enhancing the knowledge, skills, recruitment and retention of a workforce able to provide effective and culturally safe mental wellness and allied services and supports for First Nations and Inuit; and
• clarifying and strengthening collaborative relationships between mental health, addictions and other related services and between federal, provincial/territorial and First Nations and Inuit programs and services.^{Footnote 519}

The Alianait Task Group developed an Inuit-specific strategy, Alianait Inuit Mental Wellness Action Plan, to take a broad determinants approach and facilitate collaboration and information-sharing between key organizations, provide Inuit-specific recommendations, and provide ongoing strategic advice on program development and evaluation.^{Footnote 519, Footnote 520} These action plans also acknowledge the need to address youth health and wellness and the importance of youth involvement in the community. The inclusion, involvement and engagement of youth in the planning of long-term mental health is fundamental.^{Footnote 520}

In 2005, the WHO's Child and Adolescent Mental Health Policies and Plans identified a number of child- and youth-specific programs that address the unique mental health concerns of this age group.^{Footnote 521} The Child and Youth Advisory Committee of the MHCC, in consultation with stakeholders/partners, developed Evergreen, a national child and youth mental health framework intended for use by governments, institutions and organizations to help in the development of mental health policies, initiatives and services (see the textbox "Evergreen: A national framework for child and youth mental health").^{Footnote 522} This broad, nationally scoped framework aims to help provinces/territories and non-governmental organizations create, adopt or modify their strategies, raise public awareness and disseminate information.^{Footnote 522} While Evergreen is still in its early stages, it is intended to be an "ever-evolving framework."^{Footnote 522, Footnote 523} Recent investments will work toward addressing child and youth mental health issues such as bullying, resilience, healthy relationships and substance abuse.^{Footnote 524}

Evergreen: A national framework for child and youth mental health

The Evergreen framework has four strategic directions: promotion, prevention, intervention and ongoing care, and research and evaluation.^{Footnote 522} Strategic directions for promotion include developing mental health awareness and literacy and anti-stigma campaigns. Promotion activities will also include the development of stakeholder models and networks with Evergreen acting as a resource hub to disseminate information. Strategic directions for prevention will be holistic in approach to provide educational and training programming in all settings to a range of stakeholders including parents and educators.^{Footnote 522} Programs will range from prenatal health to mental and physical health issues. Strategic directions also include:

• enhancing the development of school-based programs that provide well-established, proven and cost-effective programs to at-risk populations;
• ensuring that youth do not experience policy, regulatory and programmatic barriers to receiving age- and culturally appropriate care and support;
• providing urgent 24/7 care, safe houses and continued electronic access; and
• providing youth-, family- and community-friendly programs that are a single-point access to addressing both mental and physical health problems as well as the social determinants (such as housing, education, etc.).^{Footnote 525}

Investments in effective delivery of programs, including the development of new mental health human resources, can enhance Canada's capacity to identify, diagnose and treat common child and youth mental health disorders. Strategic directions for research and evaluations are intended to support the areas of promotion, prevention and intervention to increase effectiveness and use of mental health services.^{Footnote 522}

In June 2011, the Government of Canada, with provinces/territories and community organizations, announced funding to promote positive mental health in children and youth. Through PHAC's Innovation Strategy, over $27 million will be invested in community-based education and family programs that directly promote mental health.^{Footnote 526} In particular, investment will focus on programs that overcome factors such as poor economic circumstances, education and living conditions, as well as living in rural and remote communities that often prevent children, youth and families from achieving optimal mental health and well-being.^{Footnote 526} Several identified programs specifically address factors that are also discussed in this report.

• Connecting the Dots is a community-based program (projects to take place in the Yukon, British Columbia, Manitoba) that prevents mental health and behavioural problems from emerging by reducing risk factors and strengthening protective factors during adolescence.
• Nunavut's Qaujigiartiit Health Resource Centre is researching youth mental health and wellness by documenting the experiences of northern youth that include factors such as living in a remote community, accessing community and health-care professionals and engaging parents. The resource centre also offers wellness and empowerment summer camps to local youth.
• Community Partnerships for Youth Health (Toronto, Ontario) is establishing a resource toolkit to promote mental health in schools to engage immigrant, refugee and racial minority youth.
• Creating Responsive Communities to Promote Healthy Relationships in Young Children encourages children as well as adults in British Columbia, Alberta, New Brunswick and Ontario to learn to respond effectively to bullying through a comprehensive approach that targets family, school and community.
• Handle with Care in At-Risk Communities is a training program for parents and caregivers in the Yukon, Manitoba, Ontario and Prince Edward Island on creating supportive environments for children to grow and develop.^{Footnote 526}

The Innovation Strategy requires that funded initiatives build practice-based evidence. The information gathered from these programs will contribute to the broader knowledge of mental health promotion that can be shared, adapted and implemented across many Canadian communities.

Approaches to preventing suicide

Suicide is a large but preventable public health problem.^{Footnote 527} Suicide is the cause of almost half of all violent deaths and represents 1.4% of the global burden of disease.^{Footnote 527} This burden measures only a portion of the impact; for every suicide death, there are also emotional, social and economic impacts on friends, families and communities. The effect of suicide is far reaching and impacts communities and ultimately concerns Canadians.^{Footnote 528} As seen in Chapter 3, certain sub-populations have higher than average rates of suicide as well as suicide ideation.^{Footnote 58}, ^{Footnote 249}, ^{Footnote 254}, ^{Footnote 271}-275, ^{Footnote 277}, ^{Footnote 529} Because of this, the suicide prevention interventions profiled in this report focus on examples from populations that are at-risk. The principles are, however, relevant to all youth and young adult programs.

The success of interventions that prevent suicide is hindered by a number of challenges and assumptions, such as a lack of awareness of suicide as a major public health problem, a belief that prevention is in isolation and the assumption that it is a population-specific issue. Further, suicide remains a taboo topic.^{Footnote 530} Broadly, some intervention approaches have been successful. Those approaches that restrict access to the more common tools for assisting suicide, such as firearms or toxic substances, have been effective in reducing suicide rates.^{Footnote 530}, ^{Footnote 531} However, restricting access to tools does not address the underlying problems that lead youth and young adults to suicide.^{Footnote 531} Media too has been attributed as playing a role in sensationalising and inciting imitation and/or encourage suicidal and self-harm actions.^{Footnote 528}, ^{Footnote 531} The WHO has developed guidelines for media on responsible suicide reporting.^{Footnote 528} The existence of some interventions has also been cited as promoting suicide through increased information. However, research shows that responsible depictions and opening dialogues can decrease suicide outcomes.^{Footnote 531} Some jurisdictions and organizations have developed and implemented policies to manage information and messages that may encourage suicidal behaviour.^{Footnote 532} The Canadian Mental Health Association have media guidelines for safe and sensitive reporting that recommend factors that reduce risk such as: use reliable sources; describe consequences; balance with positive (such as those who survived a crisis) and present alternatives, identify signs and where to seek help.^{Footnote 533}

Many individuals who reported having attempted suicide or having suicidal thoughts also reported having experienced a mental health problem and/or distress.^{Footnote 534} Interventions that prevent and treat these root causes have been successful at reducing rates of suicide and suicide ideation.^{Footnote 530} Addressing suicide and suicide ideation among youth and young adults is complicated, and needs to go beyond prevention practices. Periods of transition can be periods of increased vulnerability. During these times, peers, family and community play an important role in providing young people with the support they need through individual attention, family/community rituals, activities or structured experiences.^{Footnote 10, Footnote 123} Communities that offer physical, psychological, intellectual and spiritual resources are better equipped to support youth and young adults during the vulnerable periods of transition. However, young Canadians in communities of disadvantage – those with fewer family and community resources, high rates of substance use and abuse, violence and suicide – are less likely to have protective factors and prevention interventions and ultimately have poorer outcomes.^{Footnote 10, Footnote 123}

Suicide prevention among at-risk Aboriginal peoples requires a multi-faceted approach that includes raising awareness and challenging assumptions about Aboriginal youth suicide. It involves addressing the underlying factors including entrenched influences of history and colonization and broader community factors. Raising awareness involves challenging perceptions that all Aboriginal communities are unhealthy. Generalized suicide statistics create assumptions about the health and well-being of Aboriginal communities. However, evidence shows that youth suicide is not systemic within all Aboriginal communities.^{Footnote 58, Footnote 272} As with all Canadian communities, youth and young adults without connections to family, community and services are at greater risk.^{Footnote 10} In a random sample of American Indian youths, a United States study of successful functioning created a "success index" based on indicators such as good mental health, being substance-free, minimal misbehaviour, no criminal activity, good grades, positive psychosocial functioning and positive behaviour and emotions. The study found that family satisfaction was positively related to overall successful functioning. Whereas living in a dysfunctional family and/or neighbourhood and experiencing abuse were found to be inversely related to successful functioning.^{Footnote 535}

Higher rates of suicide among certain Aboriginal populations are linked to community factors of social exclusion and disconnection from their traditions and culture. These factors are often deeply entrenched within communities and can span generations.^{Footnote 58, Footnote 272, Footnote 536} Youth with a parent who attended a residential school – shown to have critically affected well-being, mental health and parenting style – are more likely to have contemplated suicide than those whose parents were not residential school survivors.^{Footnote 537} Addressing intergenerational effects of residential schools requires a wide range of approaches that blend traditional, western and alternative healing practices.^{Footnote 538} Healing programs, such as that of Resolution Health Support Program, provide mental health services as well as emotional and cultural support (dialogues, prayers and traditional healing) to former students and family members who have experienced inter-generational trauma associated with an Indian Residential School.^{Footnote 539} The lowest rates of suicide have been reported in communities where cultural preservation and continuity, some level of self-government, settled land claims and access to self-managed education, health and cultural services, as well as policing services have reported positive influences on overall health and well-being of communities.^{Footnote 58, Footnote 272, Footnote 536}

Implementing new policies is complicated by a history of unsuccessful policies, intrusive practices and the determination not to repeat past patterns.^{Footnote 123} Promising practices come from within those communities that are working well and building upon success. Several communities are working to provide opportunities for youth and young adults. Some Inuit communities with a history of youth and young adult suicide are now working with the Nunavut government and with non-governmental organizations to build resilience and other protective factors and raise awareness about what help is available for young at-risk Inuit (see the textbox "Suicide prevention with community programs").

Suicide prevention and the role of social media

Much media attention has focused on the connections between bullying and suicide, and individuals' reports that bullying was part of the decision to end their lives. Among marginalized sub-populations, LGBTQ youth and young adults report higher rates of suicide ideation and attempts than the overall population.^{Footnote 544, Footnote 545} Addressing this increased suicide risk has had limited success. However, uptake of emerging technologies, social networks and other online resources is high among youth and young adults and preliminary research in this area demonstrates that using the Internet and social media can also be a vehicle for suicide prevention (see the textbox "Social networks preventing LGBTQ suicide – It Gets Better Project").^{Footnote 274, Footnote 545} The effectiveness of such programs is complicated by an evolving environment, the ethics of addressing issues online and the lack of overall evaluation. Moreover, it is important to note that negative outcomes are also possible especially when social networking becomes a vehicle for additional isolation and bullying (see the section "Bullying and aggression"). More work and research is needed to understand the development of virtual communities, the levels of support and the effectiveness of programs.

Suicide prevention with community programs

The Isaksimagit Inuusirmi Katujjiqatigiit, the Embrace Life Council, developed and funded community events and created a day to "Celebrate Life" every September 10th. Celebrate Life relies on partnerships among communities and governments to develop and co-ordinate culturally relevant information, support training and raise awareness for suicide prevention.^{Footnote 540} In collaboration with similar initiatives, Tuktoyaktuk (Northwest Territories) participates in the international "Yellow Ribbon" campaign that allows young people to select a trusted adult, identified with a yellow card, to stay with until they are safe.^{Footnote 540} An evaluation of the Yellow Ribbon program in Alberta found that post-intervention there were a number of shifts in attitudes on seeking help. There was nearly a 6% increase in the number of participants indicating they would seek assistance in the future.^{Footnote 541} There was also a reported shift in the priority of seeking professional help when needed.^{Footnote 541}

Community-initiated programs such as Artcirq (Arctic Circus) gives young Inuit of Igloolik (Nunavut) the opportunity to express themselves through the arts, communicate across generations, incorporate traditional practices, promote spiritual and bodily self-expression and enhance self-esteem. A joint initiative of Isuma Productions and Cirque Eloize (originally founded to help the development of underprivileged youth training them in the circus and performing arts), Artcirq provides opportunities for Igloolik youth to interact, learn skills and express themselves. Artcirq also raises awareness about suicide in northern communities (such as Igloolik) through multimedia productions. A film initiative (following the success of Atanarjuat, the Fast Runner), uses a group of eight young people who intend to prevent suicide in this small community.^{Footnote 542, Footnote 543} While suicide reduction cannot be directly attributed to such a program, over the 12 years since its initiation, Artcirq has provided many opportunities for youth to creatively express themselves and to bridge and share artistic practices and experiences between northern and southern artists.^{Footnote 542, Footnote 543}

Social networks preventing LGBTQ suicide – It Gets Better Project

Recent developments in bullying prevention include the It Gets Better Project, which encourages communication and networking among LGBTQ youth and young adults struggling to see a future for themselves.^{Footnote 546} The It Gets Better Project profiles videos and stories of adults from various cultures and ranges of experiences. The videos and blogs demonstrate that there is a future for distressed youth and point to sources of help.^{Footnote 546}

Similarly, The Trevor Project, which originated as a television film about the struggles of a gay youth who attempted suicide, has grown to become the first twenty-four hour crisis and suicide prevention lifeline for LGBTQ youth in the United States.^{Footnote 547} The project works to provide online support, guidance and resources for educators and parents.^{Footnote 546, Footnote 547}

Broad suicide prevention strategies

Some jurisdictions have developed suicide prevention strategies that include a range of initiatives from broad to targeted activities. Countries such as Australia, Finland, Sweden and the United States have developed national suicide prevention strategies. The Australian government attributes its reduction in the rate of suicide over a 10-year period in part to its prevention strategy.^{Footnote 548} Australia launched the LIFE (Living is for Everyone) Framework based on the premise that all Australians have a role to play in suicide prevention; that reduction requires action across eight areas of care and support (broad population interventions, selective targeted interventions, indicated interventions, symptom identification, identifying and accessing early care and support, standard treatments, long-term support and ongoing support); and that there are safety nets provided for people moving between pre- and post-treatment and community.^{Footnote 548}

Some provinces/territories, such as New Brunswick and British Columbia, have broad suicide prevention strategies. New Brunswick was the first province in Canada to develop a suicide prevention strategy, since acknowledged for successfully identifying and targeting those at risk for suicide in that province.^{Footnote 549} New Brunswick's program builds on existing community-based resources and upon the capacity of local partners to know how best to respond to local needs.^{Footnote 549, Footnote 550} The New Brunswick Suicide Prevention Program has three guiding principles:

• community action – prevention is a shared responsibility, and communities as well as networks of family and friends play critical roles in support and raising awareness. Communities are involved in identifying needs and allocating resources and have the capacity to encourage participation. In essence, effective suicide prevention cannot occur without engaged communities.
• continuous education – education increases effectiveness of prevention. For example, the Applied Suicide Intervention Skills Training (ASIST) workshops, offered through LivingWorks Education, are designed to train all caregivers (formal and informal) to improve their capacity to help those at risk.^{Footnote 551} ASIST has delivered training to over one million caregivers in more than 10 countries for over 25 years. There have been over 15 independent evaluations that document its success in terms of numbers trained and caregivers applying skills in practice, to knowledge dissemination and skills development among community workers.^{Footnote 552}
• inter-agency collaboration – interdisciplinary teams of stakeholders provide a range of services from clinical to social.^{Footnote 550}

Canada can address suicide prevention as part of a broader wellness strategy that promotes mental health, prevents mental illness and also includes the broader determinants of health. A comprehensive and holistic approach can enable communities to allocate resources and offer support in areas where broader social determinants of health can directly impact mental health outcomes (such as housing).

Approaches should reflect cultural contexts such as traditional knowledge and practices of First Nation, Inuit and Métis communities. The National Aboriginal Youth Suicide Prevention Strategy has the goal of increasing resilience and protective factors and reducing risk factors for Aboriginal youth. This strategy acknowledges the impact of suicide on communities, including on other youth in the community, and the broader socio-economic factors influencing suicide in some communities.^{Footnote 553} An example of an initiative that uses this strategy is a project run by the National Aboriginal Health Organization, the Honouring Life Network. The network offers a website with culturally relevant information and resources on suicide prevention to help Aboriginal youth and youth workers. It also allows those working with Aboriginal youth to connect, discuss and share suicide prevention resources and strategies. Online resources that provide social and medical support for individuals by enabling culturally relevant communication and collaboration between peers, health-care professionals and individuals have shown promise, not least for those in rural or remote communities.^{Footnote 554-556} More work needs to done however, to better understand the challenges and outcomes of virtual networks.

Preventing unintentional injury

The majority of injuries and deaths due to injuries are preventable. Experience indicates that approaches involving a combination of the "3 'Es'" are the most efficient means of prevention: engineering (including the safe design of consumer products and the built environment); enforcement of regulation, legislation and policies; and education (education and behaviour changing approaches).^{Footnote 557} The "3 'Es'" have a role in the interventions discussed in this report:

• preventing workplace injury;
• driving safely; and
• broad injury prevention initiatives.

Preventing workplace injury

Young working adults are at greater risk than other age groups for workplace health and safety issues.^{Footnote 314} One-quarter of all workplace injuries are among those aged 15 to 29 years, and the majority of these are among young men.^{Footnote 279} Most youth and young adults injured at work are in manufacturing, construction and retail.^{Footnote 279} Like most injuries, workplace injuries are preventable.

Addressing workplace injuries benefits all Canadians as injuries impact individuals' lives and livelihood, as well as increase costs in terms of job and loss of time and productivity.^{Footnote 314} Many initiatives are in place, but more can be done to advance current workplace safety practices and initiatives.^{Footnote 314} Reducing the number and impact of injuries at work can be achieved through education, raising awareness, and legislation and regulations. Canada continues to investigate the well-being of young workers and promotion of healthy workplaces through research, such as the studies conducted by the Institute for Work & Health (IWH) at the University of Toronto (Ontario). The Institute works to study the prevention of work-related injury and illness, examining workplace programs, prevention policies and the health of workers.^{Footnote 558}

Raising awareness about the risks in the workplace is a common means of preventing injuries and promoting health. Early interventions have had some success. Programs introduced in schools to children and youth as part of the curriculum create a culture of safety for young people entering the workforce.^{Footnote 314} For example, British Columbia introduced workplace health and safety in the school curriculum through Planning 10, which targets youth in school just as they embark on summer jobs and more permanent employment. In school, educational initiatives through WorkSafeBC include a toolkit of lesson plans that support the learning outcomes of Planning 10. These include rights and responsibilities, causes of injury, recognizing hazards, protective equipment, occupational health practices and addressing violence in the workplace.^{Footnote 559}

Awareness-raising programs have also made a difference by providing information about rights and responsibilities regarding safe work environments. Occupational safety and health organizations provide information and skills training programs. Research shows that educating younger workers is more effective than older workers, as this age group is more likely to internalize the message and thus follow advice.^{Footnote 559} However, evidence also shows that, while information may be learned, translating that information into safer practices can be limited by the fact that young workers neither know their rights nor have the confidence to raise safety concerns with management or a worker protection organization.^{Footnote 560} In addition, for some sub-populations such as recent immigrants, culturally sensitive information in various languages would be necessary to ensure the uptake of the information as well empower those who may have less experience with protection of workers rights.^{Footnote 561}

Broad awareness campaigns have affected public perception of workplace health and safety. Many Canadians are familiar with a range of television and newspaper/magazine advertisements highlighting the importance of workplace safety.^{Footnote 562, Footnote 563} Workplace Safety and Insurance Board of Ontario (WSIB) has marketing campaigns that rely on graphic images to communicate the simple message: "There really are no accidents." Familiar to Ontarians since 1999 (and viewed across Canada and internationally), these advertisements educate by showing how key interventions would have changed the outcome.^{Footnote 564, Footnote 565} As well, print advertisements use humour by showing typical workplace scenes where people are taking exaggerated precautions.^{Footnote 398} The messages are intended to shock into action.^{Footnote 314} Research shows that exposure to sustained marketing campaigns has been found to change behaviours.^{Footnote 562, Footnote 563} While advertisements can be memorable and poignant, the direct contribution to prevention is difficult to measure and the message may be stronger than the actual change in behaviour that would be preventative.^{Footnote 314}

It is also difficult to measure the effectiveness of changes in legislation and compensation requirements. Saskatchewan was the first province to pass workplace health legislation that considered the rights of workers (as well as the safety concerns listed in earlier legislation) with its Occupational Health Act.^{Footnote 64} Soon after, the Canadian Centre for Occupational Health and Safety was created to promote health and safety in workplaces across Canada.^{Footnote 64} A range of legislation protects the health and safety of workers whether under federal jurisdiction (under Canada Labour Code for mining, transport and federal activities) or provincial/territorial jurisdiction. Health Canada's Workplace Health and Public Safety Programme develops healthy workplace policy, advances best practices and co-ordinates the national management of workplace hazardous materials. All these policies have, in part, contributed to the declining rates of work-related injury over time.^{Footnote 64} While individual or combined legislation across jurisdictions protects workers, workers themselves also have to play a role in knowing their rights and responsibilities and how to keep safe. Within Canada, employers are required to protect their employees by providing adequate training, information and supervision. Some provinces, such as British Columbia, have set provisions to ensure that employers provide necessary training and orientation to all new employees, especially those who are young and inexperienced. Despite this, the impact of efforts is limited.^{Footnote 314} Focus group research with new young workers found that many employees felt that communicating their concerns was dependent on the management and the culture of the work environment.^{Footnote 566}

Driving safely

Driving can be a high-risk activity for youth and young adults. As seen in Chapter 3, this population has high rates of fatality and injury.^{Footnote 100}, ^{Footnote 101} Inexperience can play a role in the risk; however, interventions such as graduated licensing have improved new driver safety by reducing their exposure to some well-established risks such as night-time driving, carrying multiple passengers, and drinking and driving.^{Footnote 567}, ^{Footnote 568} Research shows that crash risks increase in the first few weeks of youths receiving new and full-access licences; however, this period of reckless new freedom is short.^{Footnote 567} In addition, insurance companies offer financial incentives for taking drivers' education programs which have been shown to reduce injuries.^{Footnote 569} While speed is a concern for this age group, for discussion purposes this section focuses on addressing young Canadian drivers and driving distracted or under the influence.

Although the overall occurrence of drinking and driving has decreased over time, driving impaired (as a result of using alcohol and drugs) continues to be an issue among young Canadian drivers. Behaviour change has been most effective through the combination of regulation, enforcement, social marketing and taxation.^{Footnote 366} Broad awareness programs have successfully changed attitudes about sobriety and driving, and the numbers of young Canadians who drink and then drive has decreased over time (see the textbox "Raising awareness about drinking and driving").^{Footnote 570} More work needs to be done to ensure the messages continue to reach young at-risk Canadians. In addition, these messages need to be expanded beyond roadways to include the use of all motorized vehicles including boats, all-terrain vehicles and snowmobiles which are particular issues in rural and remote communities.

Targeted prevention programs have also contributed to preventing and reducing repeat drunk-driving offences. Alberta's Alcohol Ignition Interlocks (AII) is a prevention program that uses a breath-alcohol measurement device to prevent a driver from operating a vehicle if his/her blood alcohol concentration exceeds the specified threshold value.^{Footnote 575, Footnote 576} Attempts to circumvent the device are also addressed by using temperature and pressure sensors (driver identification), a running retest feature, and a data recorder (to log all driver activities).^{Footnote 576} In combination with licence suspension legislation, evaluations show that AII has been effective with repeat drunk drivers by creating barriers to driving under the influence. Whether short-term use of the AII can impact long-term independent decision-making regarding drinking and driving is less clear at this stage.^{Footnote 577}

Raising awareness about drinking and driving

MADD Canada (Mothers Against Drunk Driving)

MADD Canada (Mothers Against Drunk Driving) is a grassroots advocacy organization that is considered one of the most successful at reducing alcohol-related driving injuries and deaths. Initiated in the United States, the idea became global as it drew broad attention to victims of drunk driving.^{Footnote 570} MADD Canada runs national public awareness campaigns that include radio and television messages and runs a School Assembly Program. Generally, most Canadians recall and recognize the car antennae red ribbon as a campaign feature.^{Footnote 571} MADD Canada's School Assembly Program also works to reduce risks by raising awareness through youth appropriate (language and culture) and energetic school assemblies. Since 1994, the School Assembly Program exposes close to 1 million Grades 7 – 12 students each school year with messages of the risks associated with drugs and alcohol.^{Footnote 572}

arrive alive DRIVE SOBER – Canadian youth against impaired driving and Ontario Students Against Impaired Driving

For over 23 years, arrive alive DRIVE SOBER has been successfully increasing awareness about injury and death due to impaired driving while also promoting prevention strategies using typical marketing materials, public service announcements and social networking avenues.^{Footnote 97} arrive alive DRIVE SOBER collaborates on campaigns and education with both provincial and national groups, most notably partnering on public service announcements, iDRIVE: Road Stories and changetheconversation.ca. Most recent arrive alive DRIVE SOBER impaired driving solutions include a smartphone application to "Choose Your Ride"; the application presents alternatives such as calling a taxi or a friend or finding public transit.^{Footnote 573}

Canadian Youth Against Impaired Driving and Ontario Students Against Impaired Driving have been integral in reaching youth with a social norming approach via their annual conferences, regional workshops and peer mentoring for decades. Their efforts equip youth with programs and awareness to carry out locally and motivate them to be leaders in their schools and communities.^{Footnote 574}

An increasing problem, particularly among young Canadians, is the number who drive distracted, primarily as a result of using of a mobile device for talking, texting and other activities.^{Footnote 100} British Columbia, Saskatchewan, Manitoba, Ontario, Quebec, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador as well as some municipalities have banned the use of hand-held cellphones while driving.^{Footnote 102, Footnote 578} While these laws send strong messages about the risks associated with cellphone use and driving, there is an underlying misconception that hands-free devices are safe alternatives. Reports conducted in Quebec on driving performance and cellphones – both hands-free and hand-held devices – concluded that cellphone activity negatively affects performance and increases the risk of collision. The risks are not just manipulation and management of a device – conversation itself is also a risk.^{Footnote 579, Footnote 580}

The American Automobile Association Foundation for Traffic Safety found that cellphones have a greater risk than other devices especially during stressful, emotional or otherwise engaging conversations.^{Footnote 581} Nevertheless, many other activities such as conversations, eating and grooming are also distracting.^{Footnote 582, Footnote 583} Other in-vehicle devices such as global positioning systems (GPS) and DVD players – present in more vehicles across Canada than ever before – are also a risk for distraction. More research is needed on collisions involving mobile devices and related technologies including who uses them and in what capacity. Also, future research will need to include information on co-existing distractions as well as time, speed and external conditions of collisions to fully understand risk associated with mobile devices and related technologies.

Broad injury prevention initiatives

Broad injury prevention initiatives include the development of standards and consumer and environmental regulations; broad social marketing, education and advertising campaigns; development of toolkits for organizations and communities; effective data collection (including national indicators and surveillance) and knowledge translation.^{Footnote 584} Canada has made progress in reducing injuries through a number of initiatives, particularly those related to traffic and automobiles.^{Footnote 585} Similarly, Canadians are protected from injuries and premature death as a result of provincial/territorial legislation on equipment use such as helmets and personal floatation devices (PFDs); associations implementing membership requirements (such as helmet use in amateur hockey leagues); and increased safety standards on equipment and its proper use. Nevertheless, young Canadians are still being injured, and many youth are reporting not using safety equipment for their activities (see Chapter 3).

While sport and recreational activity injuries are preventable, programs must be careful that injury-preventing approaches do not inadvertently decrease participation in physical activity and healthy risk taking. Injury prevention initiatives must create conditions that are both enjoyable and safe. As such, injury prevention is a priority reflected in the federal-, and provincial/territorial-strengthened Integrated Pan-Canadian Healthy Living Strategy and Declaration on Prevention and Promotion.^{Footnote 142} In 2011, the Government of Canada invested $5 million over two years in the Initiative to tackle head injury risks to children and youth in sports that supports community-based activities that empower Canadians to make safe choices in amateur sport.^{Footnote 143} This initiative will focus on injuries such as concussions, drowning and fractures and will build upon initiatives and practices in communities to reach children and youth where they live and play. The Government of Canada will work with non-governmental organizations to encourage safe behaviours that prevent injuries by increasing awareness and understanding of the injury risks in sports and recreational activities and high participation sports such as hockey and snow sports, cycling, swimming and other water sports.^{Footnote 143}

Several Organisation for Economic Co-operation and Development (OECD) countries with injury prevention initiatives in place have had some success in reducing injury rates.^{Footnote 584, Footnote 586} For example, Sweden has progressed from having one of the highest rates of child and youth unintentional injuries in 1950 to one of the lowest.^{Footnote 586-588} Based on recommendations from the WHO, Sweden's approach to injury prevention recognizes injury prevention is based on a "healthy public policy" approach. This recognizes that public health problems require the involvement of all in their solutions.^{Footnote 586-589} In addition, their approach requires prioritizing safety in new policy, infrastructure design and public awareness. Evaluations have attributed Sweden's success to factors such as:

• being committed to research and investments in epidemiological evidence;
• creating a comprehensive national surveillance system of injury that includes interventions and their evaluations;
• developing legislation and policies that prioritize safer environments;
• having broad-based education and awareness campaigns and risk management programs to support the "preventability" of most injuries;
• encouraging social values that recognize the importance of prevention; and
• increasing multi-sectoral involvement and a shared sense of communal responsibility.^{Footnote 586-590}

A co-ordinated initiative of multi-sectoral efforts, strong leadership, ongoing surveillance, research and evaluation, broad-based awareness and education as well as public support have all contributed to Sweden's success in reducing the injury rate, especially among children and youth.^{Footnote 586-590}

Other initiatives for injury prevention exist. Canada has surveillance practices in place to better track and understand injuries through the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) and the National Trauma Registry, the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), and the Canadian Coroner and Medical Examiner Database (CCMED).^{Footnote 591}-594 As well, legislation and regulations (such as safety requirements and the proper use of equipment) exist, but these elements would benefit from further co-ordination. Provinces and territories have implemented injury prevention initiatives, such as Ontario's Injury Prevention Strategy, which has four main principles: shared responsibility and leadership; evidence-based approach; integrated practice; and recognizing diversity.^{Footnote 141}

Broad injury prevention initiatives are not implemented in isolation. Strong leadership is necessary as these integrated initiatives involve the collaboration of many sectors, organizations, communities and individuals. National non-governmental organizations such as ThinkFirst Foundation of Canada, Safe Communities Canada, SafeKids Canada, and SMARTRISK continue to play an integral part in addressing issues concerning injuries to young Canadians (see the textbox "Learning about risks: the SMARTRISK example").^{Footnote 149-151, Footnote 595}

Learning about risks: the SMARTRISK example

SMARTRISK is a national organization committed to preventing injuries by helping young Canadians identify and manage risks now and in the future. The program is based on the principle that reaching Canadians with smart risk messages when they are young will help turn them into smart risk-takers for life, and that working with youth in schools where they are already gathered is the easiest and most efficient way to connect with them.^{Footnote 149, Footnote 596} SMARTRISK helps young people learn to take smart risks through five positive choices: buckling up, looking first, wearing the gear, getting trained and driving sober.^{Footnote 149, Footnote 597} To promote these messages, SMARTRISK has two educational programs for youth:

• SMARTRISK No Regrets, a peer leadership program available in high schools across Canada that trains students and teachers to run injury prevention activities and events in their schools; and
• SMARTRISK No Regrets Live, a one-hour live presentation by an injury survivor that combines a discussion and video to profile how to make smart risk choices and illustrates the results of poor choices.^{Footnote 596, Footnote 598}

Initial evaluations showed that students gained significant knowledge around injury prevention and that the message and mode of delivery influenced their attitudes and behaviours around injury and risk. One year after exposure to the program's messages, students reported fewer injuries requiring medical care.^{Footnote 596} Additional benefits have been the number of students engaging in these issues.^{Footnote 596} Currently, over 100 high schools across Canada (including in the Yukon, British Columbia, Alberta, Saskatchewan, Ontario, New Brunswick, Nova Scotia, Prince Edward Island, Newfoundland and Labrador) have participated in SMARTRISK No Regrets. SMARTRISK aims to expand to reach more young Canadians through social networking sites such as Facebook, YouTube and Twitter and through online training. The organization is also working with parents on talking to teens about choosing risks wisely.^{Footnote 596, Footnote 599}

Bullying and aggression

Bullying is a health problem that influences not only the current state of health and well-being but also long-term behaviours, health and well-being.^{Footnote 604, Footnote 605} As reported in Chapter 3, the prevalence of bullying and victimization is of concern. As reported in the 2005/2006 Health Behaviour in School-aged Children survey, 13-year-old Canadians ranked 20th and 27th of 39 countries in bullying and victimization respectively.^{Footnote 606} As a society, Canada has considerable work to do to address this problem. All Canadians can play a role in addressing bullying in a variety of settings – schools, playgrounds, workplaces and online. While media attention given to the issue has raised Canadians' awareness, more work needs to be done to address and prevent this issue.^{Footnote 247}

Bullying is a relationship problem, and addressing bullying is about addressing relationships (see the section "Building healthy relationships").^{Footnote 607} As defined, a bullying relationship is marked by an imbalance of power between an individual who bullies and an individual who is victimized by bullying (and often marginalized).^{Footnote 600, Footnote 601} Some individuals are more vulnerable to being bullied due to factors such as race, religion, sexual orientation, gender identity, appearance (including weight) socio-economic status and disability. Bullying often further marginalizes these individuals, and the health and social outcomes of bullying can persist over time.^{Footnote 600} The most effective strategy to prevent bullying is to promote healthy relationships.^{Footnote 607} Many factors can play a role in bullying and addressing the problem requires a systemic approach that supports the individuals involved (i.e. the individual bullying others and the individual who is being victimized) as well as the larger social system including peers, educators, and parents.^{Footnote 607} Further, successful interventions can be implemented in many different contexts: the classroom, school, and the community.

Addressing school-based bullying

Most bullying takes place in school, and therefore many interventions are school-based.^{Footnote 608, Footnote 609} There is a breadth of school-based anti-bullying programs, but evaluations have reported mixed results.^{Footnote 607, Footnote 609} The most notable and successful of the anti-bullying interventions is the Olweus Bullying Prevention Program, developed by Dr. D. Olweus, a Norwegian psychology professor, whose landmark research and interventions are applied in Norwegian and American schools (see the textbox "The Olweus Bullying Prevention Program").^{Footnote 610}

Generally, whole-school approaches have become the focus of anti-bullying best practices. The whole-school approach involves the development of anti-bullying policies and initiatives that clearly outline the roles and responsibilities of staff and students and establish how bullying is handled in the school and what actions are needed to make improvements to current situations. Successful whole-school bullying prevention builds on the premise that bullying behaviour can be positively redirected through a systematic restructuring of the school's social environment.^{Footnote 614} Successful whole-school approaches include:

• strong teacher and adult leadership and involvement;
• clear and consistent behavioural rules and values;
• youth involvement in program development and delivery;
• multiple stakeholder involvement;
• targeting of multiple risk and protective factors; and
• focus on early and long-term intervention.^{Footnote 614}

Anti-bullying policies are likely to be more successful if students are involved in their schools' policies and use positive rewards and negative consequences to influence behaviour and influence peers. Students who are academically engaged and socially connected at school feel safer, experience fewer emotional and behavioural problems and have better educational outcomes.^{Footnote 615} In contrast, students reported feeling unhappy and unsafe in schools where adults – teachers, staff and parents – are only involved in the classroom and not present where bullying may occur.^{Footnote 615} Interventions intended to change behaviours need to recognize that bullying behaviour develops over a long period of time and as a result of many contexts. To address this, interventions need to have longevity and apply multiple approaches and messages.^{Footnote 247, Footnote 607} Intervention components need to build social skills such as interpersonal skills, assertiveness, empathy and conflict resolution.^{Footnote 616}

The Olweus Bullying Prevention Program

The Olweus Bullying Prevention Program is a system-wide approach that involves four component levels: individual, classroom, school and community.^{Footnote 611, Footnote 612} Various activities occur across levels, such as increasing student supervision in schools/classrooms, establishing school-wide rules and policies, training staff to better identify signs of bullying, involving students and parents across programs, and developing partnerships and broad awareness in the community.^{Footnote 611} The initial prevention program involved 2,500 Norwegian students from 42 schools over two-and-a-half years. Students reported a 50% decrease in bullying of others and of being bullied, reductions in antisocial behaviours and improvements in classroom social environments. By 2001, elementary and lower secondary schools throughout Norway had implemented the Olweus Bullying Prevention Program.^{Footnote 610} In the United States, three case study schools, in Virginia, Pennsylvania and California, have reported success with reduced reports of bullying from students and teachers/adults. Also, students reported they perceived their schools to be safer because they could see that adults were trying to stop the bullying at school.^{Footnote 610, Footnote 613}

Programs such as Roots of Empathy aim to reduce aggression by raising social/emotional competence and increasing empathy. Roots of Empathy is an in-class program that involves a trained instructor and neighbourhood infant and parent visiting the classroom. The students observe and describe the baby's feelings.^{Footnote 617}

This emotional literacy lays the foundations for safer and empathic classrooms (for more information see The CPHO's Report on the State of Public Health in Canada, 2009).^{Footnote 30, Footnote 618} Addressing bullying requires a whole-community approach and involves sharing knowledge about research, where to get help and the effective approaches. Although school-based programs are most effective, everyone has a role to play in raising awareness of the dangers and effects of bullying. A whole-community strategy is necessary to address the many facets of bullying and the impact these have on individuals across the lifecourse.^{Footnote 619}

Promoting Relationships and Eliminating Violence Network (PREVNet) is a national network of Canadian researchers, non-governmental organizations and governments across jurisdictions that are committed to addressing bullying.^{Footnote 620} Supported by Canada's National Networks of Centres of Excellence, PREVNet builds multi-sectoral partnerships to disseminate research-based resources, build awareness, change attitudes, assess the prevalence of bullying, implement and evaluate evidence-based strategies to reduce bullying, and develop policies that promote and support these activities.^{Footnote 620, Footnote 621} PREVNet has four strategy pillars that guide research and development:

• an education pillar focuses on changing attitudes and building commitment;
• an assessment pillar focuses on universal assessment tools to evaluate problems and impacts;
• an intervention pillar provides guidelines and tools to address bullying and victimization; and
• a policy pillar stimulates creation of policies and guidelines across jurisdictions.^{Footnote 621}

Workplace initiatives

Bullying is not just a school issue. As this report includes Canadians up to the age of 29, bullying also occurs in the workplace, and can affect many young Canadians who are newly employed and less experienced. Workplace bullying includes acts or verbal comments that can impact well-being and isolate an individual in the workplace..^{Footnote 622} Examples include spreading rumours; excluding a person or group; undermining an individual's work and removing work responsibilities; withholding work information and threatening physical and sexual abuse. Individuals who are victims of bullying have low morale and can feel angry, anxious and stressed. As a result of bullying, some workplaces suffer high absenteeism and employee turnover as well as costs related to employee assistance and low productivity and morale.^{Footnote 622}

Addressing workplace bullying is a challenge for employers given the differences of opinion on what constitutes workplace bullying and what employers may view as the fine line between bullying and aggressive management style. Nevertheless, bullying should be addressed in workplace health and safety plans and/or initiated through violence prevention programs. The organization (employer) and employee representatives must agree upon a definition of bullying, with examples to explain acceptable behaviours and conditions, if necessary. The definition must then apply to all employees, clients and others who have a relationship with the organization. Employers and employees should collaborate on a prevention program and agree on how preventive measures are to be developed and enforced and how incidences are to be reported and dealt with. Evidence shows that successful programs are the ones where both management and employees are committed to eradicating or reducing workplace bullying and where prevention strategies or programs are updated with regulatory requirements, as necessary.^{Footnote 622}

In Canada, legislation and acts that address bullying in the workplace are limited. The Canada Labour Code and the Canadian Human Rights Act outline protection for employees from some forms of harassment (particularly related to work).^{Footnote 80, Footnote 623} However, employers are ultimately responsible for work-related harassment and are expected to make reasonable efforts to ensure that no employee becomes a victim. As such, employers retain responsibility for preparing appropriate policies, monitoring their effectiveness, updating them as required, ensuring all employees are aware of the policies and providing anti-harassment training.^{Footnote 622} Some jurisdictions have legislation on workplace violence, harassment and bullying. For example, effective February 2011, Manitoba introduced changes to that province's Workplace, Safety and Health Regulation to protect workers from psychological harassment in the workplace. These new provisions will require all employers in that province to put in place harassment prevention policies and to educate employees on their right to a healthy workplace and their role in contributing to the health of a workplace.^{Footnote 624, Footnote 625} Employers are assisted in implementing policies that are suited to the environment, organization and line of work. Saskatchewan, Ontario, and Quebec have similar harassment protection legislation and policies in place.^{Footnote 525, Footnote 626, Footnote 627} As part of Saskatchewan's harassment prevention strategy, the province has developed "working well" tools to assist workers and employers to recognize and stop harassment and promote healthy and safe work environments.^{Footnote 627, Footnote 628}

Sexual and reproductive health issues

Sexual health is an important part of personal health, healthy living and healthy transitions. Healthy sexuality involves much more than avoiding negative outcomes, such as sexually transmitted infections (STIs) and unplanned pregnancies. Healthy sexuality involves acquiring knowledge, skills and behaviours for positive sexual and reproductive health and experiences across the lifecourse. Attitudes and ability to understand and accept sexuality affect an individual's ability to make healthy choices and respect the choices of others.^{Footnote 630}

Sexual health is particularly important to youth and young adults as most Canadians become sexually active during their teens and have had intercourse by the time they reach young adulthood.^{Footnote 219} Reported rates of notifiable STIs are higher among those aged 15 to 24 years compared to any of the older age groups.^{Footnote 161-163} The key areas that positively promote sexual health and address adverse health issues for youth and young adults are discussed next:

• building healthy relationships;
• developing sexual health education;
• reducing risky sexual behaviours;
• promoting healthy reproduction; and
• using broad strategies to address sexual health issues.

Building healthy relationships

Throughout this chapter, the premise is that healthy relationships – with parents, other adults and mentors as well as those with peers and partners – help build resilience and reduce risks for a variety of negative health outcomes. The topic of healthy relationships was identified by the Toronto Teen Survey respondents as one of three sexual health topics that they wanted to learn more about (the others were human immunodeficiency virus [HIV] and acquired immunodeficiency syndrome [AIDS] and sexual pleasure).^{Footnote 631} Building relationships is important for this age group because it marks a transition- young Canadians become more involved with peers, initiate sexual relationships and may become parents themselves. As a result, it is important for all youth to develop the skills, knowledge and attitudes to facilitate the development of respectful, healthy and supportive relationships in adolescence.

Dating relationships are particularly important for the transition into adulthood. During adolescence, individuals will experience and experiment with new behaviours that will bring a range of outcomes.^{Footnote 632} This is a time when individuals can be most vulnerable and can intentionally or unintentionally commit acts that jeopardize healthy relationships. These acts can range from subtle to violent, can be perceived as signs of commitment and love, and are related to a number of factors including control; however, the outcomes can be negative and long-lasting.^{Footnote 632}, ^{Footnote 633} Although it can occur at any age, youth and young adults may be at higher risk for dating violence.^{Footnote 253} Most victims of police-reported dating violence are female.^{Footnote 253} Developing programs that help youth to develop skills for building healthy relationships and creating conditions of equality are necessary to support youth transition into young adults.^{Footnote 632} Healthy relationships can challenge traditional gender roles, look towards balancing power in relationships and supporting gender equity.

Interventions that prevent violence and promote healthy relationships should be delivered as early as possible. Early promotion of interventions – at home, school and community – can encourage children and youth to value relationships and understand the importance of respect, equality and harmony within all relationships.^{Footnote 634} Programs such as Roots of Empathy (mentioned in the section "Bullying and aggression") teach youth to be empathetic towards others so as to understand the impact of their behaviours and actions.^{Footnote 617, Footnote 635} As well, systematic reviews have reported that programs that target those at risk, such as those with a history of childhood maltreatment, also show promise in reducing relationship violence (see the textbox "Preventing dating violence: Youth Relationships Project").^{Footnote 636-638}

Successful interventions involve many players. Communities play an important role in integrating and collaborating with schools offering interventions. Collaboration reduces overlap in programs, increases the scope to identify those who are in volatile relationships and addresses the issues from several perspectives. Interventions in schools reach a greater number of youth and can involve small- to medium-sized discussion-based and role-playing programs. To have promise, programs need to address a range of individual experiences and consider gender differences, culture, race and sexual orientation. Those interventions that are successful at preventing dating 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 (see the textbox "Building healthy relationships: The Fourth R").^{Footnote 638, Footnote 639}

Preventing dating violence: Youth Relationships Project

The Youth Relationships Project (YRP) is a study of an intervention that targets at-risk youth to help them develop healthy, non-abusive relationships with their current and future dating partners. This Ontario-based project targets youth with a history of family disruption and violence. These youth are at greatest risk of becoming either victims or perpetrators of violence. This project is based on the premise that future victimization and violent offences can be reduced when well-planned alternative sources of information and experiences are provided to at-risk youth.^{Footnote 636} The study component of the project assigned 400 youths (aged 14 to 16 years) from child protection services either to the intervention (YRP) or to a control condition (standard services). Those in the intervention groups were placed in small, co-ed groups that met for two-hour sessions over 18 weeks. The meetings were meant to increase understanding and awareness of gender-based violence and develop skills and social actions that encourage responsibility, communication and community participation.^{Footnote 636} Evaluations showed that, over time, participants reported a significant reduction in perpetration of physical and emotional abuse and of victimization compared to those in the control group. Participants also reported a decrease in interpersonal hostility and trauma symptoms compared to control participants. Although the evaluation relied on self-reported information to measure distress and abusive behaviour, the YRP demonstrated changes in violent behaviours among at-risk youth and has led the way for the developing of other successful programs such as the Fourth R (see the textbox "Building healthy relationships: The Fourth R").^{Footnote 637, Footnote 638} More high-quality research is needed to confirm these results.

Developing sexual health and education

Sexual health education is an integral part of a public health education. Comprehensive sexual health education increases the knowledge, understanding, personal insight, motivation and skills needed to achieve sexual health.^{Footnote 640} To be effective, sexual health education should be relevant and sensitive to the needs, experiences and circumstances of individuals, communities and populations.^{Footnote 22} Since there is a wide definition of sexual health and different perceptions of sexual health, the Canadian Guidelines for Sexual Health Education state that educational programs are most effective when broad in scope to help individuals achieve positive outcomes (e.g. respect for self and others, self-esteem, non-exploitive sexual relations and making informed reproductive choices) and avoid negative outcomes (e.g. STIs and HIV, sexual coercion, unplanned pregnancies, etc.).^{Footnote 22}

As mentioned earlier, school-based programs are important vehicles for sexual health information because schools are in contact with most young Canadians regularly and can formally integrate information into the curriculum. Apart from providing overall information about sexual health, comprehensive sexual health education programs play an important role in preventing STIs and reducing abusive relationships.

Research shows that the more children and youth learn about sexual health, the more likely they are to postpone sexual activity and/or engage in safer sexual practices (such as using condoms).^{Footnote 644} Evidence also shows that, over the long term, school-based interventions can be cost-effective especially considering the high economic and social impact of negative sexual health outcomes such as HIV and AIDS, other STIs and unplanned pregnancies.^{Footnote 644} Initiatives that result in small behavioural changes may result in community and social cost savings. For example, negative economic and social outcomes for unplanned teen pregnancies may disproportionately impact young women and their families.^{Footnote 339, Footnote 645}

Building healthy relationships: The Fourth R

Developed in Ontario, the Fourth R is a comprehensive school-based intervention to address violence, substance use, and unsafe sex.^{Footnote 641}, ^{Footnote 642} The Fourth R program is based on the premise that "relationship skills" coincide with "three Rs" of school lessons (Reading, 'Riting and 'Rithmetic). The program involves a 21-lesson skills-based program and aligns with requirements for Grade 9 Health and Physical Education in the Ontario public school curriculum. With three main units, the Fourth R curriculum focuses on healthy and non-violent attitudes including personal safety and injury prevention; healthy growth and sexuality; and substance use and abuse.^{Footnote 641}

Evaluation of this intervention showed that, compared to students in control schools (who had participated in regular health class lessons), program participants showed gains in knowledge, skills and attitudes.^{Footnote 643} Program participants also had lower reported dating violence two years following the Grade 9 program.^{Footnote 641} The Fourth R has since been expanded and has been implemented in more than 800 Ontario schools and has been adapted in 9 other provinces across Canada.^{Footnote 643}

Nevertheless, for the most part, school-based sexual health education has had limited success. Barriers to effective school-based sexual health education programs include allotted time or teaching materials; some level of community resistance; and some teachers' reported uneasiness with the topic.^{Footnote 640} As well, greater co-ordination is required across the community and across jurisdictions to ensure that sexual health education is available, accessible and meets diverse needs.^{Footnote 22}

Sexual health education programs should also address the diversity among students in order to meet a range of needs and perspectives. The Toronto Teen Survey found that African, Black and Caribbean survey participants were less likely to access and seek out information about sex.^{Footnote 631, Footnote 646} In addition, youth from certain cultural backgrounds face additional barriers (including practices considered culturally acceptable and unacceptable) that prevent access to sex education that may negatively impact their sexual and reproductive health.^{Footnote 647, Footnote 648} A lack of information and invisibility of sexual minorities can further manifest marginalization in the broader community.

Providing information and education about sexual orientation can meet some of the needs of LGBTQ youth and young adults. Through the Toronto Teen Survey, LGBTQ youth reported that LGBTQ issues were invisible in their school sexual health education. They also reported having encountered problems accessing sexual health services.^{Footnote 631, Footnote 649} There is limited research focused on sexual minorities and gender-variant adolescents due in large part to a heterosexual focus of adolescent sexuality research. However, research on sexual minorities and gender-variant adolescents demonstrates the complexity of identity, behaviour, and attraction and shows that youth sexuality is complex, diverse, and heterogeneous.^{Footnote 337, Footnote 650} Working towards meeting the sexual education needs of youth, will also work towards minimizing stigmata to break down fears and reduce stereotypes and discrimination.^{Footnote 644, Footnote 651}

Programs such as the Girls Chat Project (Ontario) increase awareness about healthy body image, self-esteem, healthy sexuality and sexual violence among young women from immigrant and refugee backgrounds in high schools. Weekly at-school discussion groups for adolescent girls allow them to express themselves in a supportive environment with peers who are facing similar challenges and similar experiences.^{Footnote 652, Footnote 653} Information sessions for teachers, school administrators and other community practitioners are provided to discuss the many needs of these young women and how to increase their access to available services.^{Footnote 653, Footnote 654} The Girls Chat Project is in its seventh year of operation and currently runs out of six Ottawa high schools with over 100 young women participating weekly.^{Footnote 653, Footnote 654} Reviews of this project show promise in building leadership skills among young women, fostering positive relationships between school personnel and students promoting positive emotional and social integration.

Reducing risky sexual behaviours

For youth and young adults, making responsible and informed sexual choices is essential to their development and transition into adulthood. Sexual attitudes and behaviours are established early and often carry across the lifecourse.^{Footnote 655, Footnote 656} Some risky sexual behaviours – including early sexual activity, infrequent use of condoms and multiple and/or concurrent partners – increase the risk of STIs as well as of unplanned pregnancies.^{Footnote 657} Risky sexual behaviours also increase the risk of developing long-term health problems.^{Footnote 655, Footnote 656} The more knowledge, skills and information provided to youth and young adults, the better control individuals have over their own sexuality and choices.

For some youth, knowledge and awareness of negative sexual health outcomes may be underdeveloped.^{Footnote 656} A contributing reason for the recent increase in officially reported STI cases may be due to lack of awareness about these infections (see Chapter 3). Self-reported data shows that most 14- to 17-year-olds believe they are knowledgeable about sexual health; however, one-quarter of Grade 9 and 10 students who reported being sexually active also reported not using contraceptives.^{Footnote 658} Although broad awareness campaigns have been used to provide information about sexual health risks across the population, it is likely targeted programs are most effective among youth.^{Footnote 659}, ^{Footnote 660}

Addressing risky sexual behaviours among street-involved youth is about addressing their broader determinants of health. Generally, single-issue public health interventions cannot address the root causes of risk-taking behaviours of street-involved youth. Most street-involved youth have left home because of family problems; conflict, violence and/or abuse; and substance use and abuse. Prevention programs that identify and build on positive social networks, including home, school and community, can reduce integration into street networks.^{Footnote 23} Chapter 3 reports that, compared to the overall population, street-involved youth are particularly vulnerable to sexual health risks such as higher rates of STIs and greater susceptibility to hepatitis B virus (HBV) and hepatitis C virus (HCV) infections.^{Footnote 661}-663 Although publicly funded HBV vaccination programs are school-based, many street-involved youth attend school erratically.^{Footnote 23}, ^{Footnote 664}, ^{Footnote 665}

Public health interventions that encourage condom use as well as fewer sexual partners are more effective at reducing the spread of STIs and blood-borne infections when enhanced via inter-sectoral collaborations.^{Footnote 23} As well, innovative outreach approaches may be needed to ensure that at-risk populations have access to health care and various immunization programs.^{Footnote 664} A systematic review of youth STI and HIV prevention programs indicates four key areas for reducing risky sexual behaviours:

• target those behaviours that youth perceive as manageable and attainable, for example, encouraging the use of condoms during sex. Research shows that these interventions reduce short- and long-term risky sexual behaviours which, in turn, can potentially reduce STIs and HIV rates.^{Footnote 666, Footnote 667}
• tailor programs for the target population. As a population, young Canadians are not homogeneous; what works as an intervention for one sub-population, may not work for another. Interventions must consider different racial and cultural practices, behavioural risks, developmental levels, sexual orientations and gender identities.^{Footnote 666}, ^{Footnote 667}
• adapt learning and cognitive theories to guide practices. Interventions that include skill-building and that increase awareness and self-efficacy have had some success in helping youth make choices, learn how to use contraception correctly, learn how to communicate with partners through role playing and learn how to articulate safer sex intentions.^{Footnote 667}
• address more than sexual risk. Interventions that also address broader factors – problem solving, decision-making and social skills, capacity building, and understanding influenced by gender and cultural beliefs – have successfully reduced risky sexual behaviours. Interventions that focus on building resilience and competencies are showing much promise.^{Footnote 667}

Promoting healthy reproduction

For some young Canadians, becoming a parent can mark the transition point into adulthood with all its responsibilities. Promoting positive reproductive health involves the delivering of programs that support positive outcomes for parents and children. For those most at risk for poor health outcomes due to a variety of individual and broader socio-economic factors, effective programs can be in place to ensure healthy starts for children.

Canada has been successful in increasing prenatal care and improving maternal and infant health. However, maintaining this level of success requires that delivery of these practices be continued and built upon where possible. Women who reported inadequate prenatal care during their pregnancies cited reasons such as having no fixed address; having poor access to health care; lacking transportation; having child care issues; fearing repercussions for substance use and/or disease screening.^{Footnote 668} It is among this group that risky prenatal behaviours and circumstances may go unrecognized and unaddressed. Barriers to care can also be compounded in distressed communities where broad social problems do not offer ideal environments for supporting and managing healthy pregnancies. Providing prenatal care through community outreach has shown some success by targeting distressed communities and individuals. For example, the Canada Prenatal Nutrition Program currently provides support for at-risk pregnant women and their children in over 2,000 communities in Canada.^{Footnote 669}, ^{Footnote 670} Evaluations reported better health behaviours and outcomes for participants and their children, for example, decreased prenatal substance use, better birth outcomes and an increased in breastfeeding initiation.^{Footnote 669} As well, culturally- and community-relevant programs that address sexual and reproductive health are being implemented in remote communities, for example, the Maternal Child Health Program (see the textbox "The Maternal Child Health Program").^{Footnote 671}

The teen pregnancy rate in Canada has declined over time, and Canadians are generally becoming parents later in life.^{Footnote 107, Footnote 108} Teenage pregnancy is a largely preventable public health issue that is often associated with negative outcomes for both the teen parents and for their children.^{Footnote 645, Footnote 675} Compared to older mothers, teen mothers are more likely to experience anemia, hypertension, pre-eclampsia, renal disease and depressive disorders, and their children may have higher perinatal mortality rate, higher preterm birth rates and lower birth weights.^{Footnote 111} There are also long-term socio-economic risks for the teen mother and her children such as lower educational attainment, reduced employment opportunities and the lack of a contributing partner to the household income.^{Footnote 675} Research shows that women with high socio-economic status are more likely to complete their post-secondary education before motherhood, while those with lower socio-economic status often become mothers at a younger age and often do not acquire post-secondary education, work and marry or cohabitate with a partner prior to childbirth.^{Footnote 37, Footnote 676, Footnote 677} As well, women with a higher socio-economic status have greater health literacy and access to contraception and abortion.^{Footnote 675} Often it is those who are the most vulnerable to the pressures of motherhood that are also vulnerable to external factors influencing health such as other risky behaviours, health conditions and access to health care.^{Footnote 675} Public health programs can influence young parents' health and ensure that there are initiatives in place to support young parents and create healthy beginnings for their children.^{Footnote 675}

Many factors contribute to teen pregnancy including choice, opportunities, support and broader socio-economic factors, and preventing teen pregnancy is complex and requires a holistic and comprehensive prevention strategy. Most jurisdictions have school-based strategies that offer sexual health education and contraception.^{Footnote 678} While these programs have had some success, they seldom address the root causes of teen pregnancy such as socio-economic conditions, low parental educational attainment, violence and mental health conditions.^{Footnote 678, Footnote 679} Teen pregnancy can be an outcome of many different situations such as limited access to health care and contraception (especially in rural and remote regions), stigma (especially in smaller communities), limited knowledge about reproduction, lack of skills to properly use contraception, difficulty negotiating condom use and the pressure to have sex.^{Footnote 679, Footnote 680}

The Maternal Child Health Program

The long-term goal of the Maternal Child Health (MCH) Program is to support pregnant First Nation women and families with infants and young children, who live on-reserve, to reach their full developmental and lifetime potential.^{Footnote 671} This is achieved by providing access to a local, integrated and effective MCH Program grounded in First Nations culture that responds to individual, family and community needs in identified First Nation communities.^{Footnote 672} The program supports a comprehensive approach to MCH services in First Nation communities that builds on community strengths including support from Elders, Canada Prenatal Nutrition Program, Fetal Alcohol Spectrum Disorder, nursing services, Home and Community Care, oral health and other community-based programs.^{Footnote 672} Services through the MCH program include reproductive health, screening and assessment of pregnant women and new parents to assess family needs as well as home visiting to provide follow-up, referrals, and case management as required.^{Footnote 672} Overall, home visitation programs, such as those applied through the Olds model in the United States, have had some success in improving health outcomes for parents and children.^{Footnote 673} A report of the Assembly of First Nations documented that the MCH home visits have identified and helped manage post-partum depression and enhanced mothers' support networks.^{Footnote 674} Home visiting also provides an opportunity to address sexual and reproductive health. In some communities, home visitors will provide reproductive health education in schools and preconception health programs among young adults to promote a healthy start to pregnancy.^{Footnote 674}

Among the variety of interventions designed to prevent teen pregnancy and prevent STIs, some evaluations report inconsistent results while others remain unevaluated, have not been reproduced across various populations and/or are limited in scope. Regardless of these limitations, several practices in teen pregnancy prevention have some promise:

• in-school educational programs that combine addressing teen pregnancy with preventing STIs have been effective in contributing to the decline in teen pregnancies.^{Footnote 678} Programs range from those that promote abstinence to those that support both abstinence and the use of contraception and condoms for sexually active teens. Efforts that address sexual risk and protective factors (as do sex and STI/HIV education programs) as well as non-sexual factors in combination are more likely to positively influence behaviours.^{Footnote 678} Evaluations show that adolescents who received comprehensive sex education had a lower risk of pregnancy than those who received abstinence-only or no sex education.^{Footnote 681}
• programs that increase knowledge and skills of parents and community members (that interact with youth) have also increased youths' knowledge and information about sexual health.^{Footnote 682} These programs develop skills on how to discuss issues such as contraception, sexual behaviours, building relationships and preventing STIs and pregnancies.^{Footnote 678}
• programs that provide access to reproductive health services for all youth and provide services that are relevant and applicable to location, age, gender, sexual orientation and culture are more effective. Programs can provide youth with the opportunity to apply what they learned about and set practical activities that are relevant to them.
  • programs that include adolescent boys and young men in initiatives and encourage open discussions about sexual health are effective.^{Footnote 679, Footnote 683} Too often, prevention programs do not focus on the sexual education of males and their skills with contraception and negotiation. This issue is further complicated by the fact that traditionally young women have been less empowered to negotiate safe sex, even if they have the knowledge of the positive outcomes. Building healthy relationships may go towards addressing this issue.^{Footnote 679, Footnote 683, Footnote 684}
  • programs that improve opportunities for youth in terms of education, career and skills development can address situations of boredom and risky behaviour, as well as address the sense of a lack of future.^{Footnote 679, Footnote 684}
  • sexual health is part of life and sexual health programs need to reflect that issues extend beyond school and youth. Evaluations show that community-based programs involving many organizations and individuals including parents and mentoring adults have been effective.^{Footnote 683}

Prevention programs must consider different views and perceptions to be effective. More research is needed to understand young women's perceptions and experiences concerning early pregnancy and follow-up pregnancies, contraceptive practices and access to services.^{Footnote 685} As well, little is known about young men and their perspectives on women, pregnancy and their role in the family. More male-based prevention programs can help to develop skills, understanding and relationships. This can have a significant impact on reproductive health.^{Footnote 684}

A challenge for public health is creating a balance between prevention and positive messages related to motherhood and outcomes of pregnancy. While delaying childbearing is becoming more frequent, for some young Canadians the choice to have children younger is preferable.^{Footnote 684, Footnote 686, Footnote 687} For example, some cultures support earlier pregnancies and in these cases, delaying childbearing could alienate these Canadians from their culture.^{Footnote 684, Footnote 686, Footnote 687}

Addressing teen pregnancy is a two-fold process: interventions that focus on prevention (discussed above) and interventions that address health outcomes for young parents to provide relevant support and services for effective and positive health outcomes for parents and their children. Some teen mothers report that they saw their pregnancy as a positive alternative to the path of alcohol and drugs taken by their peers, and the direction in which they felt they were heading in their pre-pregnancy life. Some young mothers also reported that motherhood was the motivating reason to get a job or go to school.^{Footnote 688} Prevention programs and policy efforts can often inadvertently cite blame and individual failure by portraying early pregnancy as negative. More interventions must be put in place to support young families and prevent subsequent pregnancies without marginalizing young mothers. While evidence supports that economic and educational outcomes for teen mothers are poorer than for adolescent girls of the same age, public health has a role to play in developing healthy futures for all mothers and children.

Broad strategies to address sexual health issues

Governmental and non-governmental agencies and institutions, including the public health sector, have a role to play in promoting sexual health. Over the last two decades, much progress has been made to transfer knowledge and understanding of human sexuality through interventions; however, even with higher public profile issues such as HIV and AIDS among youth and young adults, it has become apparent that more work needs to be done to raise awareness and identify effective interventions to address sexual health issues in the future.

Canada has set guidelines and created opportunities for education, promoted sexual health research and taken action on HIV and AIDS. Guidelines on Sexually Transmitted Infections is a resource for clinical and public health professionals in the prevention, diagnosis, treatment and management of STIs. Experts from the fields of medicine, nursing and public health volunteer to maintain updated, evidence-based recommendations on STIs. Ongoing updates reflect emerging issues and highlight changes in STI literature.^{Footnote 168} Similarly, the Canadian Guidelines for Sexual Health Education (see the section "Developing sexual health and education") provides information on new and effective program evaluations that guide and increase the understanding among professionals working within the sexual health education and promotion field.^{Footnote 22}

Surveillance on notifiable diseases including STIs such as chlamydia, gonorrhea and syphilis are collected through the Canadian Notifiable Disease Surveillance System (CNDSS).^{Footnote 689} Provinces and territories also have their own systems for case-management and evaluation.^{Footnote 689} Data are based on the results of individuals who have positive laboratory tests and have used a public health or health-care service.

The programs that are part of or align with Canada's National Immunization Strategy (NIS) – a comprehensive strategy to meet the current and future immunization needs of all Canadians – have had a significant impact on population health and prevented many diseases including those that can be sexually transmitted.^{Footnote 691, Footnote 692} While a number of vaccines have been part of routine immunization schedules for years (e.g. measles, mumps, rubella [MMR]), access and coverage for some recommended vaccines varies across the country.^{Footnote 693} Currently, all of Canada's provinces/territories have developed publicly funded immunization strategies for human papillomavirus (HPV) and HBV, targeting children and youth to ensure they are protected before they are at risk of exposure.^{Footnote 167, Footnote 694} As of 2007, girls in Grades 4 to 9 (depending on the province/territory) can receive the HPV vaccine.^{Footnote 167} HBV vaccination was also originally administered as a universal school-based vaccination program, but is now given to infants in their first year of life in some provinces/territories.^{Footnote 692, Footnote 693} School-based immunization programs give all students the chance to receive the vaccine, which generally results in higher numbers of students completing the immunization.^{Footnote 695}

HIV and AIDS continue to be an enormous challenge around the world. While the numbers in Canada are smaller than that in other similarly developed nations, data on sexual behaviour and STIs demonstrate the potential for the spread of HIV among young Canadians.^{Footnote 696} The youth and young adults most at-risk are males who have unprotected sex with males and those who are street-involved, engaged in the sex trade and use drugs intravenously.^{Footnote 697}

The Federal Initiative to Address HIV/AIDS in Canada supports Canada-wide action while remaining responsive to global shifts in the pandemic and forging new and collaborative relationships to address emerging issues.^{Footnote 104} The initiative, a partnership of PHAC, Health Canada, the Canadian Institutes of Health Research (CIHR) and Correctional Service of Canada, is a primary element of the Government of Canada's comprehensive approach to HIV and AIDS.^{Footnote 104} It outlines Canada's commitment and contribution to the national framework for HIV and AIDS, embodied in Leading Together: Canada Takes Action on HIV/AIDS.^{Footnote 104, Footnote 170} The initiative identifies youth as one of eight key populations most affected by HIV and those requiring specific, targeted approaches.^{Footnote 170}

Canada actively participates in the global response to address HIV and AIDS. Through the Global Engagement Component of the Federal Initiative to Address HIV/AIDS, Canada provides policy guidance and technical support, shares health sector experience and knowledge, promotes knowledge transfer between domestic and international responses and ensures policy coherence of Canada's international HIV and AIDS activities.^{Footnote 169, Footnote 698} Through the Canadian HIV Vaccine Initiative (CHVI), Canada contributes to global efforts by working to develop a safe, effective, affordable and globally accessible HIV vaccine.^{Footnote 105}

Canada has committed to championing the needs and rights of people living with HIV and AIDS and those at risk; to work collaboratively with international partners; and to act towards bringing an end to the HIV and AIDS pandemic. Canada has endorsed the 10-year action plan in the United Nations General Assembly Special Session Declaration of Commitment on HIV/AIDS, through which countries agreed to work together to achieve significant targets in prevention, care, treatment and support, human rights, and research and development.^{Footnote 170} Canada has also endorsed the United Nations Millennium Development Goal to halt and begin to reverse the spread of HIV and AIDS by 2015.^{Footnote 170} Addressing HIV and AIDS is about addressing the broader determinants of health, preventing the spread of disease, providing timely effective treatment and care, and contributing to research.^{Footnote 170}

Healthy weights and healthy living

A growing public health problem that spans all age groups, overweight and obesity is a critical issue for youth and young adults because of the current and future adverse health outcomes. Addressing the issue of overweight and obesity is complex and requires a healthy living approach driven by health behaviours such as being physically active and eating well. Two additional topics: body image and eating disorders are relevant to this discussion of healthy weights and healthy living. While the differences in the problems and their solutions are vast, the long-term goals in addressing these issues are the same – achieving healthy bodies. Achieving a healthy weight is also complicated by the fact that some young Canadians look to achieve a perceived "ideal" body image. As well, there are those who have eating disorders. This section is about working towards a healthy balance for Canada's youth and young adults.

Overweight and obesity

Overweight and obesity is a major public health challenge that affects Canadians across the country and from diverse populations. Generally, those who have lower levels of daily physical activity and poor nutrition are most likely to have excess body weight and an increased risk of developing related disease and adverse health outcomes over the lifecourse.^{Footnote 290}, ^{Footnote 699} However, the issue is more complex than the balance of caloric intake/outtake; for example, genetic predispositions, as well as an individual's broader physical and social environments, can provide opportunities or present barriers to achieving a healthy weight.^{Footnote 287}, ^{Footnote 452}, ^{Footnote 700} Changes in our food environment, including larger portion sizes and the availability of a wide variety of inexpensive and processed and fast food (containing high amounts of sugars and fats), have made it more challenging to maintain a healthy weight.^{Footnote 297}, ^{Footnote 452} In addition, profound changes have occurred in the physical and social environments in which Canadians live, learn, work and play – from the "walkability" of neighbourhoods and the marketing of foods, to the proximity and accessibility of grocery stores, and the increase in sedentary lifestyles.

Overweight and obesity is also a risk factor for many chronic diseases, including type 2 diabetes, cancer and cardiovascular disease.^{Footnote 292} As described in Chapter 3, the prevalence of diabetes among Aboriginal youth and young adults is higher than that of the overall Canadian population.^{Footnote 304, Footnote 308} Health Canada's Aboriginal Diabetes Initiative (ADI) aims to reduce the prevalence of diabetes among Aboriginal people in over 600 communities. ADI supports a range of health promotion, prevention, and screening and treatment services that are community-based and culturally appropriate to Inuit and on-reserve First Nations. There is also a prevention component for Métis and for First Nation and Inuit living outside of their traditional communities.^{Footnote 701}

Economic and social circumstances, combined with individual practices and capacities, influence what food is available and how it is chosen.^{Footnote 702, Footnote 703} Compared with those living in higher income, families and individuals living in low-income households are less likely to consume the nutrients needed for proper health and well-being.^{Footnote 452} Studies have also linked food insecurity to the prevalence of unhealthy weights.^{Footnote 452, Footnote 704} Living in a low-income household can exacerbate existing food security issues caused by the already high cost of nutritious food in many northern and remote areas in which these families live. Programs such as Nutrition North Canada, which launched in April 2011, intends to make nutritious perishable food available to northern and remote communities by expanding the list of subsidized perishable foods and encouraging retailers to order and stock these items.^{Footnote 705}

The eating styles of parents can often influence the dietary habits of youth. Research demonstrates that youth who regularly eat with their families are less likely to be overweight as they are more likely to consume a healthier diet and have better family support, communication and relationships.^{Footnote 699} However, youth living in the family home are not always in a position to choose or purchase their own food. Other factors that influence family meals and eating patterns include food preparation skills, time to prepare meals, and an understanding of information provided by sources such as food labels and Canada's Food Guide to Healthy Eating. ^{Footnote 706}

Advertising unhealthy foods and beverages to youth and young adults may well be contributing to unhealthy weights.^{Footnote 452} An American study showed that children consumed 45% more food when exposed to food advertisements on television.^{Footnote 707} Adults also consumed more snack food after watching a snack food advertisement.^{Footnote 707} Television programming in Quebec does not allow any type of food advertising to children aged under 13 years. In other regions of Canada, regulations protect children aged under 12 years from advertisements that do not depict balanced diet and/or portray snack foods as meals.^{Footnote 708, Footnote 709} Nevertheless, youth and young adults are still targeted by food marketing and advertising via international satellite, cable television and the Internet.^{Footnote 710} Canadian researchers are looking further at the influence of television and Internet advertisements on the food choices of youth to measure the effects across Canada.^{Footnote 711}

Eating Well with Canada's Food Guide provides recommendations on the quality and quantity of food that promote health and reduce the risk of obesity and nutrition-related chronic diseases.^{Footnote 712, Footnote 713} More recently, the Government of Canada launched the Eat Well Be Active Educational Toolkit to help teach children, youth, and young adults about healthy eating and physical activity and making healthy choices.^{Footnote 714} As well, the Government of Canada has been actively engaged in increasing nutrition labelling awareness. The Nutrition Facts Education Campaign, helps Canadians understand and use the information on the Nutrition Facts tables and the percentage daily value, to make informed food choices to maintain and improve their health.^{Footnote 715} In addition, Eating Well with Canada's Food Guide – First Nations, Inuit and Métis is a version of the guide tailored to meet the needs of Aboriginal peoples. It also emphasizes the importance of combining regular physical activity with healthy eating.^{Footnote 139}

Physical activity also plays a role in healthy weights. A number of initiatives promote physical activity, healthy eating, and healthy weights.^{Footnote 716} Initiated in 2005, the federal and provincial/territorial Integrated Pan-Canadian Healthy Living Strategy partnered with non-governmental, private sector and Aboriginal organizations to improve overall health outcomes and reduce disparities in health among Canadians.^{Footnote 142}, ^{Footnote 717} The strategy is aimed at the entire population but also includes elements to address those at risk; those among whom there is an expected high return on investments such as children and youth; and those in isolated, remote and rural areas and Aboriginal communities.^{Footnote 142} The strategy is aiming for a 20% increase in the proportion of Canadians who are physically active, eating healthily and are at healthy body weights by 2015.^{Footnote 142} In September 2010, Federal, Provincial and Territorial Ministers of Health Promotion/Healthy Living (excluding Quebec) endorsed Creating a Healthier Canada: Making Prevention a Priority, A Declaration on Prevention and Promotion, and Curbing Childhood Obesity: A Federal, Provincial, Territorial Framework for Action to Promote Healthy Weights ("the Framework for Action").^{Footnote 142}, ^{Footnote 452}, ^{Footnote 718} The framework focuses on addressing childhood obesity in Canada by shaping programs and prevention efforts for children and youth under 18 years old for the next 10 years.^{Footnote 452} These strategies will work in conjunction with the now strengthened Integrated Pan-Canadian Healthy Living Strategy and Declaration on Prevention and Promotion.^{Footnote 142} To further help Canadians adopt healthier lifestyles, PHAC supports the new physical activity guidelines developed by the Canadian Society for Exercise Physiology (CSEP).^{Footnote 719} These guidelines, released in January 2011, give Canadians basic information about the types, intensity and frequency of physical activity needed to promote good health.^{Footnote 719} For example, to achieve measurable health benefits, the guidelines suggest 150 minutes (2.5 hours) of moderate to vigorous physical activity a week for young adults aged 18 years and over and 60 minutes of moderate to vigorous physical activity a day for children and youth aged 5 to 17 years.^{Footnote 720}

Additionally, Sport Canada works with provincial/territorial governments, National Sport Organizations, Multisport Services Organizations, Canadian Sport Centres and other organizations to help Canadians participate in sports. It has provided funds to increase sport participation through a variety of initiatives for children and youth as well as targeted groups such as girls and women, persons with disabilities, low-income families, at-risk youth, visible minorities and Aboriginal peoples.^{Footnote 136, Footnote 721} Sport Canada has also provided support for projects undertaken by non-governmental organizations such as the such as Canadian Tire Jumpstart Charities through its signature program, Canadian Tire Jumpstart.^{Footnote 722} The program's goal is to remove financial barriers by helping to cover registration, equipment and/or transportation costs so that children and youth can participate in organized sport and recreation. Since 2005, this program has helped over 330,000 children in financial need to participate in organized sports.^{Footnote 723} ParticipACTION, a not-for-profit organization jointly funded by Sport Canada and PHAC, is the voice for physical activity and sport participation in Canada. Through communications, capacity building and knowledge exchange, ParticipACTION encourages youth to commit to healthy, active living.^{Footnote 135, Footnote 722}

Since January 2007, the Children's Fitness Tax Credit has enabled parents to claim a tax credit of up to $500 per year for eligible expenses from sport and physical activity programs for each child under the age of 16.^{Footnote 133, Footnote 134} While the tax credit supports families, it has difficulty helping those in the lowest income groups who cannot afford the costs associated with organized activities, making them less likely to be able to take advantage.^{Footnote 724} Although the Children's Fitness Tax Credit is not designed to address the full complexities of obesity issues, it serves as a positive reinforcement to encourage children and youth to become more active and to promote healthy weights.^{Footnote 134, Footnote 724, Footnote 725}

Negative stereotyping of those who are overweight or obese can affect their mental health (i.e. through poor self-esteem) both in the short and the long-term.^{Footnote 726} Because of the importance placed on physical appearance in our society, all Canadians, including youth and young adults, can feel pressured to conform to an "ideal" body image – and take extreme measures to fit this ideal – or be dissatisfied with their appearance. Efforts to treat overweight and obesity must continue to shift away from weight and appearance and towards healthy attitudes and balance. Most surprisingly, the source of the negative stereotypes are often from health-care professionals and family members.^{Footnote 726, Footnote 727} As a result, addressing healthy body image and healthy weight is a major public health challenge that crosses cultural, racial, socio-economic and gender boundaries.^{Footnote 452, Footnote 728} For many, weight-based stigmatization and negative stereotyping may have contributed to unhealthy weight.^{Footnote 726, Footnote 727} (See the section "Body image and eating disorders").

Health at Every Size (HAES) is a health-centered initiative that is challenging society's fixation with weight loss and dieting behaviours and shifting the focus to promoting health and healthy lifestyles through respect for one's body.^{Footnote 729}, ^{Footnote 730} The aim is to encourage acceptance and respect body size and shape diversity; to encourage eating to address hunger cues and satisfy appetite.^{Footnote 729}, ^{Footnote 731}, ^{Footnote 732} The main concept behind HAES is that weight is not a determinant of health, as people of different sizes can be healthy. The HAES approach, advocated by researchers and health-care professionals worldwide, has been associated with improvements in physiological measures (e.g. blood pressure), health behaviours (e.g. physical activity and eating behaviours) and psychological outcomes (e.g. mood, self-esteem and body image) and has achieved these health outcomes more successfully than traditional weight loss treatments.^{Footnote 731}, ^{Footnote 733}, ^{Footnote 734}

The built environment can also affect the healthy lifestyle patterns of youth and young adults.^{Footnote 735} As discussed in the section "Healthy communities" in this chapter, environments that support active transportation, leisure time physical activity, recreational facilities and accessibility to affordable and nutritious foods can all have a positive impact on the health of Canadians.^{Footnote 736} Since not everyone wants to participate in organized sporting events, other physical activity options should be made available, such as walking, cycling, playing or using trail systems.^{Footnote 735}

Across Canada, broad investments are being made to improve the physical environment to promote healthy lifestyles. The Building Canada plan provides long-term and reliable funding to provinces/territories and communities so that they can build indoor and outdoor sports facilities and active transportation projects to encourage walking, rollerblading and biking.^{Footnote 737, Footnote 738} Governments at all levels play an important role in addressing the problems of unhealthy weights among youth and young adults. Stakeholders need to collaborate with each other to promote healthy eating, physical activity and healthy weights. Additionally, more research is needed to understand the effects of the determinants of health on healthy/unhealthy weights in Canada so that stakeholders can apply evidence-based information to their programs and/or interventions. Although there are initiatives in place, more work needs to be done to address the challenges of unhealthy weights especially among at-risk populations such as First Nations and Inuit and those from low socio-economic households.^{Footnote 452, Footnote 725}

Body image and eating disorders

Healthy eating habits contribute to the physical health and well-being of youth and young adults by lowering the risk of disease, strengthening muscles and bones, increasing energy and maintaining healthy body weight.^{Footnote 713, Footnote 739} Also, society sends a range of messages about food and weight.^{Footnote 740, Footnote 741} Because of the importance placed on physical appearance in society, adolescent girls in particular, can feel pressured to conform to this perceived ideal body image or become dissatisfied with their appearance.^{Footnote 728, Footnote 740, Footnote 741} Some adolescent girls have reported familial pressure to lose weight or have been exposed to body preoccupations and disordered eating behaviours within their households.^{Footnote 740-742}

While importance of appearance is often associated with females, males are also being exposed to unrealistic images and are increasingly feeling pressured to conform to an ideal body image.^{Footnote 743} Males tend to associate their attractiveness with increased muscle definition, mass and body shape.^{Footnote 743, Footnote 744} Research shows that body dissatisfaction among males can lead to poor psychological adjustment, disordered eating behaviours (binge eating disorder, bulimia, anorexia and dysmorphia), steroid use and exercise dependence.^{Footnote 743, Footnote 745} Eating disorders and exercise dependence among young males can often go unnoticed because going to the gym and exercising is a culturally acceptable practice.^{Footnote 745} Much more research is required to determine the prevalence and patterns of eating disorders among adolescent boys and young men to recognize the symptoms and develop targeted treatment programs.^{Footnote 746, Footnote 747}

Both television and print media expose young women and men to an unrealistic body shape and look. In an era of lighting, make-up and digital manipulation, many desired features are enhanced or created. Research has shown that media does play a role in developing body dissatisfaction in young people, which for some can lead to unhealthy dieting practices and lower self-esteem.^{Footnote 748-751} Media literacy programs targeted at youth and young adults could benefit by helping young Canadians develop a more positive body image.^{Footnote 751}

Youth and young adults place high importance on friendships. These relationships can often influence an individual's self-perception and affect dieting practices. Communications with peers often model and reinforce the negative message that thinness and low body weight are associated with beauty.^{Footnote 752, Footnote 753} The family dieting environment can also increase the risk of negative body image. Parents' attitudes and behaviours on eating habits, body image and weight appear to influence adolescents' thinking regarding body image.^{Footnote 754, Footnote 755}

While eating disorders are a mental health issue, genetics and biological factors may predispose some individuals to unhealthy dieting practices. Risk factors such as personality and/or environment (social and cultural) can also lead to eating disorders.^{Footnote 240, Footnote 728, Footnote 756} Other risk factors include body dissatisfaction, dieting and using food to deal with stress. These risk factors have become well-known features of adolescent behaviour as a means of achieving the "perfect" body.^{Footnote 728, Footnote 742, Footnote 756} Disordered eating can mean eating too little or too much (e.g. restrictive diets, binge eating and purging), whereas normal eating involves eating to satisfy hunger.^{Footnote 728} Disordered eating patterns and unhealthy dieting practices are linked to the development of eating disorders.^{Footnote 728} Eating disorders are complex conditions characterized by abnormal perceptions of one's body image, signalling difficulties with identity, self-concept and self-esteem. Among some women, these perceptions are expressed with obsessive preoccupations with food and self-critical, negative thoughts and feelings about body weight, shape and size.^{Footnote 240, Footnote 728, Footnote 742}

Eating disorders can be difficult to detect and diagnose particularly in the current societal context in which experiences such as dieting, sports and performance are viewed as normal, and thinness and underweight may be difficult to conceptualize as a health concern.^{Footnote 756-758} Early detection is important for eating disorder treatment and recovery.^{Footnote 728} Eating disorders can be effectively treated using psychological and medicinal treatment plans tailored to the patient's individual needs. Treatment plans often include individual medical care, medication, and nutritional counselling as well as individual and group (family) psychotherapy.^{Footnote 759}

Promoting healthy weights requires co-operative action across all sectors and levels of government.^{Footnote 452} Many factors contribute to young people developing eating disorders, and these factors cannot all be changed immediately. More research is needed on the long-term outcomes of eating disorders in adolescents, and more research is needed to better understand the consequences of dieting on adolescent growth patterns. As well, social, economic, physical and environmental factors must be addressed to create environments that will support Canadians in making healthy choices.^{Footnote 452}

There is a need to train those who regularly interact with young Canadians, such as families and teachers, to identify behaviours and symptoms of disordered eating before eating disorders develop. Greater recognition of the role of the community in the development of healthy body images is also necessary. Society needs to do more to emphasize that self-worth is not related to physical appearance. Young Canadians should be given healthy food choices and taught to make informed decisions about the food they eat, focusing on healthy eating instead of food and weight. Media literacy programs targeted at youth and young adults could also be of benefit in helping young Canadians develop a more positive body image.^{Footnote 728, Footnote 751}

Substance use and abuse

Canada has successfully reduced smoking and the associated impact on health and while many Canadians aged 15 years and over drink alcohol most do so moderately (see Chapter 3).^{Footnote 364, Footnote 760, Footnote 761} Compared to other age groups, however, young Canadians are more likely to engage in substance use and abuse.^{Footnote 343, Footnote 364, Footnote 762}

It is often assumed that substance use and abuse is based on a lack of information and/or understanding of the short- and long-term impacts. Research shows that substance use behaviour is more complex; it is often as a result of an accumulation of interconnected and influential risk factors including familial situation, peer group, school and broader systemic factors related to socio-economic environments.^{Footnote 763} The transition from use to abuse (i.e. over-consumption and dependence) is often the result of the interrelation between a range of factors:

• individual risk factors: while previously more males than females participated in substance use and abuse, recent studies have found more women now binge drink, drink to excess, smoke and use licit and illicit drugs, compared to past generations.
• families: a history of inadequate parenting, low parental monitoring, poor parental-child relationships, family conflict, abuse, and family history and attitudes toward substance use can all be contributing factors.
• peers: while some youth use substances as a result of peer pressure, others choose to associate with peers that use substances and share similar values. A collective of peers can establish practices around substance use that in certain environments become normative within those peer groups.
• school: early negative school outcomes (e.g. poor academic performance, lack of reading skills, problem-solving abilities, participation and connectedness), as well as an inability to equate personal behaviours with the information being provided, can become processes that influence behaviours and choices.
• communities: the environment can create conditions for substance use through factors such as availability and easy access to licit and illicit substances as well as conditions for social acceptance, values and norms.^{Footnote 343, Footnote 763}

Both schools and communities have taken active roles in addressing substance use and abuse issues; however, success is limited and greater co-operation is necessary.^{Footnote 343} From a public health perspective, a four-pillar approach is often used when addressing substance use and abuse: prevention; treatment and rehabilitation; enforcement; and reducing the harms associated with substance use:^{Footnote 343}

• prevention efforts are intended to prevent – or at least delay or reduce – substance use.^{Footnote 343} Meta-analyses show that these efforts are most effective when they are introduced early in the lifecourse before use takes place. Many broad programs adapt a common prevention approach called Drug Abuse Resistance Education (DARE) that relies on the police providing credible information to youth and young adults to help them resist drug use.^{Footnote 343, Footnote 431} However, evaluations of the approach show that while the program provides information that participants retain, knowing this information does not necessarily prevent use. Prevention efforts are more promising when they focus on healthy development and building resilience (asset building). Protective factors include having supportive parents who are actively engaged in school and/or community.^{Footnote 343}
• while the ideal goal is to eliminate the risk, treatment and rehabilitation can redirect those who have adopted a risky behaviour. The success of treatment programs depends on having supportive and coordinated efforts. Evidence shows that the most effective interventions are those that target a young person's needs and motivations, support and integrate families and communities into the treatment, and provide a range of post-treatment options.^{Footnote 343} Treatment initiatives are complicated by the type of substance used as well as the range of organizations and institutions involved, in addition to the competing legal issues and values that may also be involved. The effectiveness of various treatment options is often challenged by the inability of those involved to agree on similar goals. As well, the nature of what is effective and acceptable varies across populations. For example, treatment and rehabilitation programs that integrate traditional practices and healing circles have shown promise with Aboriginal youth who are using drugs.^{Footnote 343}
• enforcement is one of the multi-sectoral issues where ultimately the goals are healthy and safe environment for society as a whole. Enforcement and regulatory practices are intended not only to address criminal activities and behaviours but also to set standards of zero tolerance, especially within schools and public environments.^{Footnote 343, Footnote 764}
• harm reduction is a public health approach used to prevent secondary consequences (disease, overdose, death) of risky behaviours that include alcohol and other drug use in individuals who have been unsuccessful in achieving abstinence or who are waiting for drug rehabilitation services.^{Footnote 765-768} In regards to substance use, these strategies are based on the premise that drug use exists, that some of the people using drugs are unable or unwilling to stop using drugs at a particular time, and that practices should be put in place to reduce the risk of harm to the person using drugs as well as the community in the interim.^{Footnote 343, Footnote 766, Footnote 767, Footnote 769, Footnote 770} Internationally, the focus of harm reduction has been primarily on the prevention of HIV and AIDS in relation to illegal drugs, and various bodies, including the WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Office on Drugs and Crime (UNODC) and United Nations Children's Fund (UNICEF), recognize the importance of reducing harm as part of a comprehensive response to addressing drug use and infectious diseases.^{Footnote 768, Footnote 771-773} Such a comprehensive response also includes efforts directed at abstinence, enforcement, education, illness prevention, condom distribution, infection control, disease surveillance, testing and treatment.^{Footnote 774}

Canadians have a vested interest in addressing problems with substance abuse. In 2002, the cost (including health, enforcement and lost productivity) of substance abuse in Canada was estimated at $39.8 billion (of which tobacco represented 43%, alcohol 37% and illegal drugs 21%).^{Footnote 775} The benefits of encouraging and offering treatment are immense. The United Kingdom's National Treatment Outcome Research Study reported that for every British pound spent on drug prevention interventions there was an estimated three British pounds saved on criminal justice costs.^{Footnote 776}

While there is much overlap between substance, alcohol and drug use and abuse, they are discussed separately in order to profile an example for each and to address the complexities in comparing behaviours that can range from legally and socially normative to illegal. For example, while in most provinces and territories, alcohol use is legal for those aged 19 years and older, illicit drug use is illegal and the context for addressing these situations is different, even if some of the approaches are similar. The following discussion highlights intervention examples for the following issues:

• drug use and abuse;
• alcohol use and abuse and prenatal alcohol use; and
• tobacco control initiatives.

Approaches to addressing drug use and abuse

The National Anti-Drug Strategy (NADS) is the Government of Canada's comprehensive response to addressing illicit drug use across the country. Launched in 2007, the strategy is a collaborative effort involving the Department of Justice, Public Safety Canada and Health Canada. Its goal is to contribute to safer and healthier communities by reducing and contributing to the elimination of illicit drug use in Canada. The NADS includes three action plans: preventing illicit drug use, treating those with illicit drug dependencies, and combating the production and distribution of illicit drugs.^{Footnote 764, Footnote 774, Footnote 777, Footnote 778}

• the Prevention Action Plan focuses on youth by supporting communities to address future challenges; providing information for parents, educators and health professionals, and developing school-based awareness tools and a national awareness campaign aimed at elementary and secondary school students and their parents;^{Footnote 764}, ^{Footnote 777}, ^{Footnote 779}
• the Treatment Action Plan supports new and innovative approaches to treatment and rehabilitation, enhances treatment for First Nations and Inuit, provides treatment for young offenders, and enables the RCMP to refer youth with drug problems for treatment; ^{Footnote 764}, ^{Footnote 777}, ^{Footnote 780} and
• the Enforcement Action Plan provides resources for combating, enforcing, investigating and prosecuting drug-related crimes, supporting and expanding RCMP anti-drug investigations, and increases inspection and investigation capacity across jurisdictions.^{Footnote 764, Footnote 777, Footnote 781}

The strategy's youth campaign, DrugsNot4Me, uses Internet channels (such as Facebook and YouTube), cinema and TV to help youth learn the effects of drugs and how they can avoid taking them ("say no"). There have been over 791,000 visits to the DrugsNot4Me website and more than 208,000 unique views of the TV ads on YouTube in a little over a year, as well as over 67,000 Facebook fans. DrugsNot4Me has capitalized on the popularity of social media and, through the implementation of original ideas and the unique adaptation of communications tools, has engaged youth on an important health issue.^{Footnote 782} Again, more research into and evaluation of the effectiveness of social media for reaching youth and young adults is required.

The NADS also supports communities and provinces/territories with targeting at-risk populations:

• funding health promotion and prevention initiatives aimed at reducing illicit drug use among young Canadians aged 10 to 24 years through the Drug Strategy Community Initiatives Fund;^{Footnote 783}
• supporting the National Native Alcohol and Drug Abuse Program, aimed at enhancing treatment and support for Aboriginal populations;^{Footnote 784} and
• collaborating with the provinces and territories to support drug treatment systems and services where gaps exist through the Drug Treatment Funding Program.^{Footnote 785}

Harm reduction is no longer a formal pillar to the Government of Canada approach.^{Footnote 774, Footnote 786} Rather, harm reduction is represented in NADS within the other three pillars of enforcement, prevention and treatment. The Government of Canada has made treatment for people addicted to drugs and helping them get off drugs a priority.^{Footnote 764, Footnote 774, Footnote 786} From a public health perspective, the goals of promoting abstinence, as well as facilitating and increasing access to drug treatment for those with addictions, aligns with NADS.^{Footnote 774, Footnote 786} In particular, PHAC plays a role in:

• helping address the health needs of at-risk populations;
• identifying and understanding patterns of infection and risk behaviours through routine epidemiology and surveillance (Enhanced Surveillance of Canadian Street Youth [E-SYS], hepatitis B vaccines, hepatitis C and HIV);
• exchanging and translating knowledge to build evidence that can guide policy and programs; and
• supporting community capacity to enable communities to find solutions (such as the AIDS Community Action Program, the National Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund and the Hepatitis C Prevention, Support and Research Program ).^{Footnote 774, Footnote 786}

Some jurisdictions extend further concepts in harm reduction practices within their anti-drug strategies. For example, the City of Vancouver specifies harm reduction in their drug strategy, which also includes prevention, treatment and enforcement.^{Footnote 787} A recent retrospective study by the British Columbia Centre for Excellence in HIV/AIDS that examined overdose mortality before and after the opening of Vancouver's supervised injection facility, reported a 35% decrease in mortality for the region served by the facility.^{Footnote 788}

Research on existing programs outlines the gaps in addressing substance abuse and shows where investments may improve outcomes for individuals, communities and families. Investments include age-relevant programs, increasing the knowledge and skills of those who work with youth and young adults who have been or are at risk for substance use and abuse, and increasing research knowledge and evaluation of current and future initiatives.^{Footnote 343}

Age-relevant programs include two main approaches: targeting children with early interventions and information, and addressing youth with age-appropriate initiatives.^{Footnote 789} Early interventions provide children with the tools necessary to make healthy lifestyle choices. They can also target and address risk factors such as early academic and social difficulties, abuse and psychological disorders, as well as preventing early initiation of substance use. To be effective, youth programs need to be relevant to the population and target the interests, activities and values of youth, as well as be informed about the substances most frequently used by youth.^{Footnote 343, Footnote 789} Programs for adults are neither youth-relevant nor in tune with young adults who have experienced a delayed transition. As a result, anti-substance initiatives that are oriented towards youth and young adults may need to expand the boundaries of what is considered youth programming.^{Footnote 343, Footnote 789}

While school-based programs may be effective for some, higher-risk users are less likely to attend school regularly and are also less likely to respond positively to mainstream messaging.^{Footnote 343} School-based best practices involve several factors:

• timing and program relevance: lessons need to be co-ordinated and relevant. Interventions are most effective if offered immediately prior to students initiating behaviour with additional follow-up to reinforce healthy behaviours.
• contextual content: youth and young adults are involved in developing prevention practices and provide context from their perspective by participating. This approach offers accurate experiential information that provides realistic understanding of substance use and how to address it. A youth context supports an approach that is skill-, activity- and knowledge-based for the age group. This approach has been shown to be more effective than relying solely on non-use goals.
• training: increased professional training in areas of drug education and interactive programming.^{Footnote 343, Footnote 789}

Interventions such as the School Health and Alcohol Harm Reduction Project (SHAHRP), which deals specifically with alcohol use, have had some success with a school-based health intervention (see the textbox "School Health and Alcohol Harm Reduction Project (SHAHRP)").

Professionals who work specifically with youth or with youth initiatives are often their first point of contact and may have the opportunity to identify who are at risk at an earlier age.^{Footnote 343} Young people come into contact with a number of health and social service providers who can promote healthy options, recommend interventions and refer them to other professionals. Thus, education programs for adults working with youth should be broadly disseminated and include modules that address risk factors for substance use, assessment and intervention strategies as well as resources for youth, their families and other significant adults in their lives. The knowledge of risk and protective factors is necessary to anticipate emerging needs or potential problems in the future.^{Footnote 343}

Addressing alcohol use

Many young Canadians engage in risky alcohol consumption, resulting in immediate and long-term effects on health and well-being. Binge drinking or heavy drinking can cause impaired judgement leading to further risk-taking behaviours (see Chapter 3 for more information). Excessive alcohol consumption over the short and long term can cause poisoning, illness, disease and injury as well as lead to risky sexual behaviours, assault and death.^{Footnote 343, Footnote 365, Footnote 366, Footnote 793, Footnote 794}

The most effective health promotion interventions for alcohol use and abuse are broad population-level interventions where outcomes focus on improving access to programs, providing information and developing healthy behaviours. A systematic review of 32 alcohol interventions measured these along four criteria: effectiveness, quality of the evidence, cultural relevance and costs of implementing and sustaining interventions over time.^{Footnote 795} The most effective interventions included adherence to a minimum drinking age, controlling and restricting alcohol sales to minors, taxing alcohol purchases, lowering legal blood alcohol limits and having graduated driver's licensing as well as licence suspensions.^{Footnote 789, Footnote 795, Footnote 796} The majority of these practices target youth and young adults rather than the remainder of the population. One approach to addressing issues of excessive alcohol consumption such as binge drinking is to target these age groups with education and broad awareness campaigns.^{Footnote 789, Footnote 795} Ensuring that youth and young adults understand the risks of excessive alcohol use and harm to oneself as well as the importance of recognizing and acting upon situations where a peer may need help (e.g. recognizing signs of alcohol poisoning) is critical.^{Footnote 795, Footnote 797}

School Health and Alcohol Harm Reduction Project (SHAHRP)

The School Health and Alcohol Harm Reduction Project (SHAHRP), a longitudinal intervention research study, used evidence-based classroom lessons on alcohol to reduce alcohol-related health impacts.^{Footnote 790} Over four years, the National Drug Research Institute of Australia targeted students aged 13 to 14 years in 14 schools in Perth, Australia. The goal of the study was to reduce the level of alcohol-related health impacts in students who drink alcohol and to reduce the negative impacts on those students who do not drink but are influenced by those who do.^{Footnote 790, Footnote 791} The lessons ran in three phases – eight lessons in the first year, five booster lessons in the following year and four additional booster lessons two years later.^{Footnote 790} The lessons included various activities to incorporate delivery of information, rehearse skills, develop individual and small group decision-making skills and encourage discussions based on scenarios.^{Footnote 791}

A one-year follow-up study showed that SHAHRP had a statistically significant impact on alcohol-related knowledge, attitudes and behaviours. After completion of the study, SHAHRP students had decreased risky behaviours associated with alcohol use.^{Footnote 791} The results of the SHAHRP evaluation showed a positive uptake of the messages when these were developed and presented within the context of the students' experiences.^{Footnote 791} This was particularly true for students who had previous experience with alcohol use and who were rarely affected by interventions that advocate for non-use or the delayed use of alcohol.^{Footnote 791} The study found that the project, which does not solely advocate for non-use or delayed use, nevertheless produced larger reductions in alcohol consumption than either classroom-based or comprehensive programmes that promote abstinence and delayed use. The findings of the study resulted in a wider application of the program throughout Australia.^{Footnote 792}

In 2010, the WHO adopted a Global Strategy to Reduce the Harmful Use of Alcohol after all member states identified the use of alcohol as a significant and global public health issue. The strategy recognizes the interconnection between all factors that influence health and alcohol behaviours in particular. The strategy highlights the importance of reducing health inequalities by addressing risky alcohol behaviours.^{Footnote 796} Actions include co-ordination and synergy across jurisdictions (including international jurisdictions), providing leadership, identifying at-risk populations (including youth), strengthening partnerships and networks, co-ordinated monitoring of alcohol-related harm and evaluating and disseminating results.^{Footnote 796}

Preventing prenatal alcohol use

Prenatal care and support continues to positively influence the health of pregnant women and infants in Canada by enabling healthy choices, including avoiding risk behaviours such as alcohol consumption during pregnancy and breastfeeding.^{Footnote 50, Footnote 368, Footnote 798-800} Much of this success can be attributed to prenatal care and screening, healthy pregnancy campaigns and other early education initiatives.^{Footnote 798-801} However, there are still pregnant women who are not receiving the support and care required for healthy fetal development as a result of socio-economic conditions, lack of general information, unavailability and inaccessibility of health information and support services, and interactions with other risk behaviours through individual or partner choices (e.g. smoking and second-hand smoke).^{Footnote 802} Those who are most vulnerable to unhealthy behaviours remain difficult to reach. Addressing the conditions and environments in which at-risk pregnant women live is critical.

Fetal Alcohol Spectrum Disorder (FASD) describes a range of health outcomes that may affect people whose mothers consumed alcohol while pregnant. While it is difficult to determine the prevalence of FASD, prenatal exposure to alcohol may be a significant cause of developmental and cognitive childhood disabilities in Canada.^{Footnote 368, Footnote 800} Prevention of FASD is complex and requires a holistic and multi-factorial approach that includes a variety of intervention tactics and a mix of service providers.^{Footnote 800} Broad awareness has had some success, though research shows that many factors influence alcohol use in general (e.g. addiction) and during pregnancy in particular (e.g. access to care, nutrition and violence).^{Footnote 800} PHAC has developed a four-part framework for prevention that includes:

• raising public awareness through campaigns and other broad strategies, which involve a range of promotion and awareness activities as well as a range of people at the community level to help offer social support and incite social change;
• counselling, so that adolescent girls and young women can openly and safely discuss pregnancy, alcohol use and related issues with their support networks and health-care providers;
• making available prenatal support that is accessible and culturally and gender-relevant and addresses a range of health issues including alcohol problems and related mental health concerns; and
• providing postnatal support to help mothers and families maintain the healthy changes made during pregnancy and adapt to new changes after pregnancy and birth. This is also an important stage to launch early interventions for children identified as having FASD.^{Footnote 800}

Raising public awareness and developing social policies to address the dangers associated with alcohol and pregnancy has had some success in advancing social support and social change.^{Footnote 368} Most Canadians are familiar with posters, television advertisements and label warnings on the possible effect of alcohol use on the fetus.^{Footnote 803} Broad campaigns against alcohol use during pregnancy have achieved good message recall and increased awareness of these issues in the short and long term and have contributed to positive changes in behaviours.^{Footnote 799} However, warning label messages (e.g. health warnings on product packages) in the United States have shown only modest benefits through increased knowledge and behavioural change. As well, knowledge and behavioural change success is most often reported among sub-populations that are at lowest risk for prenatal alcohol use.^{Footnote 368} Evidence demonstrates that warning labels on alcohol beverage containers alone are not effective in changing behaviour nor in reducing alcohol-related harm.^{Footnote 799} In a framework for action, Canada set goals that included improved awareness through a multifaceted approach with better information, greater dissemination as well as creation of information that is culturally relevant and compassionate. The framework also recognised that awareness practices do not act alone, as action on FASD must also include the development of effective tools for prevention, early identification, referral and diagnosis, as well as targeted initiatives and community-based programs which combined could achieve greater health and social outcomes.^{Footnote 804}

While these efforts are important for reaching the general population, they are often less effective in getting through to higher-risk sub-populations.^{Footnote 368} Programs that work to breakdown barriers to prenatal care through community outreach have had some success in addressing prenatal health risks in distressed communities. Programs such as the Canada Prenatal Nutrition Program (CPNP) and the Canada Prenatal Nutrition Program-First Nations and Inuit Component (CPNP-FNIC) use successful evidence-based approaches on maternal/child health that involve community workers.^{Footnote 669, Footnote 670, Footnote 672} The goal of CPNP and CPNP-FNIC is to provide program activities that reflect the priorities and culture of the communities the programs serve.^{Footnote 669, Footnote 672} While prenatal alcohol use was higher among CPNP participants than the overall population, evaluations show that those who received CPNP support including alcohol cessation and group nutritional counselling, were the most likely to quit drinking alcohol during their pregnancy.^{Footnote 805}

Evidence indicates that interventions that have been successful in helping young women reduce risk behaviours during pregnancy include targeted efforts to support minimizing risk factors; counselling; professional persistence (such as those supporting smoking cessation tactics); addressing isolation/depression issues; and creating safe opportunities for women to express themselves openly.^{Footnote 801}, ^{Footnote 806} These interventions have also been successfully extended to include broader groups within communities, such as partners and other family members who can support pregnant women who may be tempted to drink or smoke.^{Footnote 806}, ^{Footnote 807} At-risk women are more likely to positively respond to family members and/or health and social workers that they trust.^{Footnote 808} As well, some physician-led alcohol interventions during pregnancy have had some success in reducing alcohol consumption among women from a range of socio-economic backgrounds and various risk profiles.^{Footnote 809} Evidence suggests these programs could be beneficial when targeted at high-risk populations, especially if they are combined with home visitation over a significant period of time (two to five years following the pregnancy) (see the textbox "Addressing FASD – Manitoba's STOP FAS Initiative").^{Footnote 810}-812 However, barriers to accessing prenatal care can exist especially among certain sub-populations.^{Footnote 668}, ^{Footnote 808}, ^{Footnote 813}

Developing knowledge and providing proven and relevant services to pregnant women is key to addressing prenatal substance use. The Canadian Perinatal Surveillance System (CPSS) is an ongoing national health surveillance program aimed at improving the health of pregnant women, mothers and infants by systematically collecting and analyzing timely and relevant information about their health status and the factors that influence their health (including alcohol consumption during pregnancy).^{Footnote 814} The CPSS works with provincial/territorial partners and stakeholders to establish standardized indicators and variables on which to report.^{Footnote 814} In particular, the Maternity Experiences Survey (MES), a CPSS project, reports on women's knowledge, perspectives, practices and experiences related to pregnancy, birth and parenthood.^{Footnote 815} Regardless of these efforts, information gaps remain. Women who are at greatest risk for unhealthy prenatal behaviours do not seek some form of prenatal care and therefore information on their outcomes and experiences remain underrepresented.

Addressing FASD – Manitoba's STOP FAS Initiative

Manitoba's STOP FAS was developed to address the problem of the increasing numbers of children diagnosed with FASD during the 1990s.^{Footnote 812} The initiative (based on the American Parent-Child Assistance Program) is an outreach program that offers support, through mentorship, to women who are pregnant or have recently had a baby and are struggling with alcohol or drug use.^{Footnote 810}-812, ^{Footnote 812} The approach aims to provide a personalized program that gradually brings about behavioural change. A mentor is assigned to each woman, and they work one-on-one for three years with the woman and her family at home to help her identify personal goals; address socio-economic issues such as housing, family violence, access to health care and community services; access to drug/alcohol treatment and choose family planning practices.^{Footnote 810} Outcome evaluations found that 60% of women had a lower risk of delivering a child with FASD as a result of either being abstinent from alcohol (and drugs) for at least six months or as a result of using a family planning method regularly. About 65% had completed an addictions treatment program, and 28% had completed an educational/training program. As well, 63% of children of at-risk mothers were living with their own families (23% with their mothers and 40% with fathers and/or extended family).^{Footnote 812}

Tobacco control initiatives

Canada reports an overall significant and sustained decline in the prevalence of tobacco use. This progress can be credited to shifts in attitudes towards tobacco and to Canada's comprehensive initiatives to reduce smoking prevalence through, for example, the Federal Tobacco Control Strategy. ^{Footnote 152} Despite this success, youth and young adults continue to smoke – a behaviour that can have serious health outcomes over the lifecourse.^{Footnote 355, Footnote 356, Footnote 760, Footnote 816}

Most Canadians have directly or indirectly (through family and friends) experienced the health impacts of tobacco. Canada's Tobacco Act regulates the manufacture, sale, labelling and promotion of tobacco products.^{Footnote 154} Canada's Federal Tobacco Control Strategy is a collaborative effort across sectors to prevent people, and in particular youth, from starting or continuing to smoke, to protect people from second-hand smoke and to regulate tobacco products across Canada.^{Footnote 153} Provinces and territories are also developing programs to support individuals who wish to stop smoking. Programs such as Saskatchewan's Partnership to Assist with Cessation of Tobacco (PACT) trains health-care professionals in cessation principles and practices and building relationships of trust for individuals seeking smoking cessation.^{Footnote 817}

Since 2001, federal and provincial/territorial efforts in tobacco control have created a strong tobacco control environment in Canada. The success of Canada's tobacco control initiatives is in part due to compliance with existing laws and policies. Analysis of the Retailers' Behaviour Toward Certain Youth Access-to-Tobacco Restrictions Survey in 2009 shows an increase in compliance with youth purchase laws approaching 90%.^{Footnote 818} In addition, the Tobacco Act effectively bans advertising of tobacco products, and there is a high compliance with provincial/territorial legislation restricting tobacco displays in retail establishments. Retailer compliance is considered a contributing factor to the decrease in the prevalence of smoking among youth and the decrease in the percentage of youth buying cigarettes.^{Footnote 818}

Smoking rates among Aboriginal peoples are higher than the overall Canadian average.^{Footnote 176} While consideration must be given to the traditional use of tobacco for healing, prayer and giving thanks, First Nation Elders state that there is a difference between the traditional and modern use of tobacco and that addiction to commercial tobacco is non-traditional.^{Footnote 819}

Communities have a role to play in reducing the use of tobacco among youth and young adults by challenging social practices, raising awareness about the health risks associated with smoking and creating laws banning smoking in public spaces.^{Footnote 153}, ^{Footnote 820} Change has been gradual; nevertheless, more than 300 communities across Canada currently have by-laws or policies restricting smoking in public places.^{Footnote 821} The Municipal Bylaw Toolkit is a resource developed by Health Canada to help communities implement and evaluate smoking policies in public spaces.^{Footnote 820}, ^{Footnote 821} Provincial/territorial governments are also implementing broader control of smoking in public spaces. In 2006, Ontario introduced the Smoke-Free Ontario Act to prohibit smoking in enclosed workplaces and enclosed public places (such as shops, restaurants, bars, taxicabs, etc.).^{Footnote 822} Today, all provinces/territories have tobacco control legislation or strategies in place. Moreover, provinces/territories have implemented second-hand smoke bans that now cover many public spaces.^{Footnote 820}

The Students Commission of Canada develops initiatives to engage youth to reduce tobacco use among other young Canadians. Through the Youth Action Committee and the development of a Young Adult Advisory Committee, a network of youth and young adults provides ongoing advice and feedback on tobacco-related policies.^{Footnote 823} Engaging young Canadians in the decision-making process will help in developing relevant youth-oriented tobacco reduction initiatives. New programs are being developed to maintain and enhance the effectiveness of tobacco control measures.^{Footnote 824} For example, the amendment to the Tobacco Act, Cracking Down on Tobacco Marketing Aimed at Youth Act banned the use of certain additives, including flavours (excluding menthol) in cigarettes, little cigars and blunt wraps that contributed to making such products more appealing to youth.^{Footnote 824, Footnote 825} The Act also added further restrictions on tobacco advertising as well as minimum packaging requirements on some products.^{Footnote 824-826}

Targeting young adults with smoking cessation programs can be successful in terms of effective cessation outcome and benefits to current and long-term health. Targeted programs for young adults can have a good return on investment in terms of effectiveness and long-term benefits.^{Footnote 827} However, many smoking cessation programs are primarily used by older smokers.^{Footnote 828, Footnote 829}

Summary

The areas of concern highlighted in this chapter are ones where Canada, as a society, can make a difference in the current and future health and well-being of Canada's youth and young adults. While there are proven and promising interventions, there are also many gaps in knowledge, information and best practices.

Addressing the social determinants of health is critical to making the transition from childhood to adulthood. Initiatives that support home and family, healthy schools, work and community have been effective in improving the health and well-being of young Canadians. Programs that focus on strengthening families can also make a difference. Positive relationships with family have been shown to discourage risk-taking and anti-social behaviours and increase positive social relationships and the pursuit of academic goals. Broad programs that encourage youth to attend and stay in school as well as those that provide job search and workplace skills training make effective contributions to support populations. The most effective programs are those that target the young and build trusting and respectful relationships with adults. While the importance of resilience is known, more work needs to be done to increase knowledge, provide targeted programs that are appropriate and relevant, increase access and availability, inform decision-making and evaluate interventions for effectiveness and relevance to youth and young adults and the contexts in which they live, learn, work and play.

Investments in youth and young adult programs that promote social and emotional health and well-being and prevent mental health disorders and illnesses are important to mental health across the lifecourse. Targeted programs such as school-based programs or cognitive behaviour therapies are particularly effective among young Canadians. Youth and young adults still experience significant barriers in terms of accessing relevant and appropriate care and addressing the impacts of lack of information and stigma. Reducing stigma and raising awareness and mental health literacy are important to creating and increasing opportunities for prevention, treatment and support within communities and families. The latter can be best achieved by acquiring a better understanding of the effectiveness of current interventions. These efforts will require a co-ordinated and collaborative approach that may be facilitated through broad mental health strategies such as those being developed by the Mental Health Commission of Canada.

Suicide prevention is complex and requires many tactics that involve individuals, families, communities and governments. Targeting those most at-risk may involve addressing underlying factors such as social stigmatization and intergenerational histories as well as community and neighbourhood factors (as is seen among some Aboriginal populations). Social media can play a significant role in suicide prevention as a support for finding help; however, it can be a medium for bullying and isolation. More work needs to be done to better understand the role of social media and its influence on youth. Broad-based initiatives for suicide prevention can make a difference if they are multi-pronged and incite community action, offer continuous education and inter-sectoral collaboration.

Since preventable injuries are a significant cause of death and hospitalization for youth and young adults, interventions to raise awareness, modify risky behaviours and reduce or mitigate injuries are important practices, as are policies and legislation for safety. Workplaces are becoming safer as young Canadians, their employers and other organizations work to reduce risks by providing training, creating workplace safety policies and applying jurisdictional guidelines; nevertheless still more can be done. Youth-targeted educational programs have been instrumental in increasing awareness of risk and empowering young Canadians to make safer choices in activities and sports. Legislation and regulation have also helped encourage safer practices and provide safer products, equipment and vehicles. Broad initiatives that offer leadership and co-ordinated surveillance, regulation, education, prevention, community support and infrastructure have had some success in those areas.

Bullying is a relationship problem and addressing this involves developing healthy and respectful relationships among young Canadians. Addressing bullying at school is the most common anti-bullying approach. Whole-of-school approaches that encourage responsibility, empathy and leadership, involve adults and are focused on long-term interventions that start early have had the most success. Addressing workplace bullying requires employer/employee relationships and broad anti-harassment policies.

Most Canadians will experience sexual relationships during youth and young adulthood. Sexual health interventions are intended to promote sexual health and prevent risky sexual behaviours. Building strong and healthy relationships requires interventions that work to minimize unhealthy relationships by encouraging respect, responsibility and empathy. In-school programs have been effective in providing messages around reducing unplanned pregnancies and STIs.

Promoting reproductive health is an important component of sexual health. Creating opportunities for choices about reproduction as well as support for young parents is necessary. By supporting parents, there are opportunities to make a difference in prenatal nutrition and screening for current and subsequent pregnancies. Canada is also making progress in implementing broad population-based programs that are reducing and tracking STIs and HIV and continues to play a role in the global fight against HIV and AIDS.

Healthy living is important for all Canadians, not least youth and young adults. While the negative health outcomes of living with overweight and obesity are well known, information about risk factors, including nutrition and physical activity practices, is limited, as are data related to the effectiveness of interventions. Home and community environments are critical to establishing lifelong healthy behaviours, as are infrastructure and strategies that support and promote access to affordable recreation, foods that are more nutritious and other supportive resources. Eating disorders and unrealistic body images also impact the health and well-being of young adults and addressing these problems requires a multi-pronged approach including programs that raise awareness and challenge popular images, identify disorders early to seek treatment and train mentors and adults to recognize unhealthy behaviours and symptoms.

While Canada has had some success in reducing the effects of some substances (e.g. tobacco smoking), many young Canadians are at risk for substance use and abuse. Addressing substance use is complex and requires an understanding of both individual and broader socio-economic factors. In-school programs are important for outreach and to identify, use and implement target strategies. Legislation and regulations that establish age of use, bans and controls of use have made a difference. Broad strategies are using multi-pronged tactics to prevent use, treat dependencies and minimize distribution of and access to substances. Broad awareness programs have looked towards effectively engaging youth in the discussion to disseminate information and educate the population.

The promising and successful interventions and initiatives profiled in this chapter are making a difference in creating conditions for healthy transitions. Together, they illustrate and confirm that all Canadians and sectors of society can make a difference in identifying and implementing effective programs with measurable outcomes. These efforts provide a starting point from which to draw inspiration, think, plan and act; however, the health and well-being of some Canadians is still compromised and some still fall through the cracks. More can be done. Chapter 5 highlights the priorities for action to move forward towards a healthy future.