Chapter 5: The Chief Public Health Officer's Report on the State of Public Health in Canada 2011 – Moving forward – priority areas for action

Chapter 5: Moving Forward – Priority Areas for Action

Over the past century, improvements in health and quality of life have made Canada one of the healthiest nations in the world.^{Footnote 830} Through research, planning and action, Canada has established a strong foundation for the health of all Canadians. This success means that today's youth and young adults can, for the most part, expect to live long, vibrant and healthy lives.

Still, some persistent, worrying and emerging issues are negatively influencing the health of Canada's youth and young adults. As well, certain segments of the population are particularly affected with poorer health outcomes.^{Footnote 10, Footnote 23, Footnote 319, Footnote 831-833} Canada can create and implement more effective programs, interventions and policies that make a difference in tackling all serious health issues facing young people.

For the most part, the issues identified in this report can be improved. In fact, successful efforts that make a difference already exist and can be replicated and expanded. Based on what we know about the health of youth and young adults, action in the priority areas identified in this chapter can improve the health of young Canadians. Solutions are not easy – what works for one community or individual may not work for another. Understanding this and identifying what does and does not work are important first steps towards finding the right solutions.

Priority areas for action

To facilitate the best possible outcomes for youth and young adults as they transition to adulthood, Canada could benefit from better evidence and awareness, more supportive environments and improved collective leadership for this key population. In particular, efforts need to focus on the following areas:

• Improving and making better use of population and program evidence;
• Increasing education and awareness;
• building and maintaining supportive and caring environments; and
• approaching problems from all sides with co-ordinated, multi-pronged, inter-sectoral action.

While each of these areas is important to achieve the best results, greater engagement of youth and young adults is necessary. As a society, Canada must recognize the importance of having youth and young adults participate in identifying problems and realistic solutions for, among others, their health outcomes. It is crucial that Canadians are respected and given the opportunity to participate in society at all stages of life.

Improving and making better use of population and program evidence

This report has identified several areas where data on youth and young adults is limited. Having better information will allow for better identification of long-term trends and areas where efforts should be focused. It can also identify areas where programs are not working and where new approaches should be explored so that efforts continue to improve to meet the needs of youth and young adults in Canada.

While some health data exists, there are still challenges – small studies may be scaled up or generalized and not be applicable to the larger population or the data collected may not be comparable.^{Footnote 834} As well, national studies may not capture local issues. Having appropriate, sophisticated, public health data and evidence is important for policy-makers, public health practitioners and communities planning health interventions and programs, which is why looking broadly and finding applicable results from studies is an ongoing challenge.^{Footnote 834, Footnote 835}

Canada has made some progress in collecting data. For example, the Health Behaviour in School-aged Children (HBSC) studies have provided valuable information on the health, well-being and social context of health behaviours and outcomes.^{Footnote 836} The studies have also been influential in developing effective health promotion and health education policies that target young people. However, they only provide information on children and youth aged 11, 13 and 15 years who are attending school.^{Footnote 836} Other valuable information on Canadian youth and young adults comes from survey data such as the Canadian Community Health Survey (CCHS), the Canadian Alcohol and Drug Use Monitoring Survey (CADUMS), the National Population Health Survey (NPHS), the Youth in Transition Survey (YITS) and the National Longitudinal Survey of Children and Youth (NLSCY).^{Footnote 837-842}

There is limited socio-economic, physical and mental health data for the 12- to 29- year age group, and in particular for certain sub-populations (First Nation, Inuit and Métis, immigrants and street-involved youth). However, certain mental health information gaps might be addressed with the CCHS 2012 as its focus will be on mental health. In addition, the CCHS 2012 should be able to address some gaps related to socio-economic data for certain sub-populations.^{Footnote 843} Nevertheless, researchers, policy-makers, community leaders and schools could benefit from additional information to help understand why some young people engage in unhealthy risk-taking behaviours and others do not, allowing for more informed program design.

New longitudinal studies that follow a cohort of individuals from birth to early adulthood would also be beneficial. Such studies would help to examine the determinants of health that affect the lifecourse and identify certain trends over time including valuable information on the limitations of interventions directed towards young people. They could be designed to include data from all areas of Canada especially sub-populations. Cross-sectional data from these studies would provide a snapshot of the health of the population at a particular point in time.

Also important to note are the difficulties associated with comparing the health data on the Aboriginal population and the overall Canadian population. Data gathered on the health of Aboriginal peoples may not necessarily reflect each unique Aboriginal group's health circumstances because the data are often generalized as part of the entire Aboriginal population.^{Footnote 844} Comparable health data on the overall Canadian population and Aboriginal groups of First Nations living on a reserve, First Nations living off a reserve, Inuit and Métis are needed.

Since 1991, the Aboriginal Peoples Survey (APS), which is conducted every five years, has provided valuable health and socio-economic data on First Nation, Inuit and Métis youth and young adults. However, it does not contain any information for First Nations living on a reserve, and only certain data elements of the survey are comparable with other national surveys focussing on the overall Canadian population such as the annual CCHS.

While having improved health and social data is important, there is also a need for evidence of what programs and interventions work and where improvements can be made. In Canada, there are many programs aimed at improving the health of youth and young adults; however, evaluations for effectiveness are limited. Broadly speaking, there are challenges to conducting evaluations such as leadership, collaboration and having the appropriate resources in place.Footnote 845 Still, having robust evaluations can contribute to overall knowledge by providing important information to determine if the programs are reaching their targeted goals, reaching the targeted population and are applicable to other populations and jurisdictions. Evaluation should not only occur upon completion of a program, but should occur at varying points in program delivery to allow for ongoing adjustments. Engaging youth and young adults who participate in these programs would provide valuable information on the effectiveness of the intervention. While standard evaluation practices have been established for common types of program delivery, clear and consistent mechanisms are needed to measure the effectiveness of programs that are being delivered through new tools such as social media (e.g. Facebook, YouTube and Twitter).

Of those programs or interventions that have been evaluated, more effort is required to ensure that the targeted population is fully described; many of them do not indicate how the outcomes varied across sub-populations or by gender, race, culture and sexual orientation. This information is critical in effectively influencing healthy behaviours. By effectively capturing the demography of participants, programs can be better customized to help ensure that targeted populations are being reached.

With better data and evidence from intervention evaluations, it will be easier to assess current and long-term health trends and determine appropriate actions to improve the health and well-being of Canada's youth and young adults.

Increasing education and awareness

Combined with training, education and awareness programs play an important role in establishing healthy behaviours. Mitigation of negative behaviours and choices during adolescence and young adulthood can have a lasting impact on health. To be effective, there is a need to educate often, across the lifecourse, with the optimal approach being a combination of both formal education and social marketing practices. Education and training extends beyond youth and young adults to include all Canadians that support this age group (parents, teachers, mentors, community members, health- and social-care professionals).

Education allows for the development of healthy practices through knowledge that is acquired before the need for information arises.^{Footnote 507, Footnote 656} For example, learning about mental health or balancing nutrition and physical activity should start early when children are just beginning to learn about choices and healthy practices.^{Footnote 452, Footnote 507, Footnote 751} Similarly the time to learn about healthy sexual behaviours is before becoming sexually active.^{Footnote 655, Footnote 656} However, education and awareness activities should be ongoing and sustained across the lifecourse.

Canada has taken action by setting and promoting guidelines, recommendations and advisories on a number of key issues including injury prevention and sexual health education. The Mental Health Commission of Canada (MHCC) is working towards the development of a broad strategy for mental health that could include goals such as improving conditions for those experiencing mental disorders and illnesses, creating multi-pronged programs and continuing anti-stigma awareness campaigns. Education and awareness could also be a key component of a mental health strategy as raising awareness can help to break down barriers and stigma associated with mental health disorders and addressing mental health problems.^{Footnote 507}

As young Canadians grow increasingly comfortable with today's technology, they have quick access to all types of information via the Internet and social networking sites.^{Footnote 846} Messages can be delivered to young people through social media, targeted to change behaviour, create culture shifts and establish support networks. For instance, social media can be used to support and educate lesbian, gay, bisexual, transgender or questioning (LGBTQ) youth and young adults on how to seek support. Social media can also have negative consequences by further isolating and marginalizing individuals and being a tool for bullying. More applied research is needed to explore how social media can be used to support education and awareness as well as identify the challenges and risks associated with specific health issues, particularly for young Canadians.

Youth and young adults need to be engaged and involved in consulting, developing, implementing and disseminating information on programs that impact them.^{Footnote 847} Doing so provides valuable insight on issues that are relevant to youth and young adults, and in particular the programs and interventions that are most likely to be effective in reaching the intended audience.^{Footnote 847, Footnote 848} It is important to remember, however, that youth and young adults are a diverse population and that education and awareness programs may need to be tailored to the needs of different sub-populations. Active and ongoing engagement from youth and young adults will work towards reaching diverse populations.

Building and maintaining supportive and caring environments

The environments where youth and young adults live play a significant role in their health and well-being. Governments at all levels have a role in building and sustaining supportive and caring environments. But, as with most public health issues, close collaboration across sectors, jurisdictions and levels is essential. To be successful, governments, communities, individuals and families must work together. As a society, Canada must ensure there are opportunities for recreation, physical activity, employment, health care and social engagement for all Canadians.

In most cases, strong and supportive environments encourage youth and young adults to develop positive relationships with others (e.g. parents, peers, mentors, etc.) so that resilience and competence can be developed to overcome adversity and challenges.^{Footnote 456, Footnote 849} Programs that strengthen positive and supportive relationships between parents or adults and teens are important in bridging the gap between youth and adults.^{Footnote 456}

Interventions need to create environments that support and recognize the unique needs of all youth and young adults. For example, among Aboriginal youth and young adults, living in communities with cultural continuity (traditional teaching, language training, etc.) has been associated with lower levels of substance abuse and suicide.^{Footnote 58, Footnote 850, Footnote 851} In addition, interventions must offer appropriate services to meet specific needs (e.g. those that are culturally, LGBTQ, and gender appropriate). Supportive environments help create assets that enable individuals to overcome adversity (e.g. discrimination and bullying) often faced by those who are marginalized.

The education sector can play a vital role in creating caring and supportive environments. Schools and post-secondary institutions provide an environment to promote health, guide our young people to various career paths and develop their social skills. As mentioned in Chapter 4, a variety of effective school-based programs have provided information and influenced behaviours and health outcomes in the areas of sexually transmitted infections (STIs), mental health and social relationships. Continuing to strengthen the relationship between the health and education sector is an important and powerful partnership that can support healthy transitions into the future.

Supportive and caring environments involve the active and ongoing engagement of youth and young adults. It is through such engagement that young people can gain a sense of empowerment, support their leadership capabilities, make healthy connections with others and their community, and reduce the risk of negative behaviour. More importantly, youth engagement provides realistic and plausible solutions to issues that affect youth and young adults.^{Footnote 10, Footnote 848, Footnote 852, Footnote 853} Engaging youth and young adults allows them to take charge of their future.

Society as a whole can influence the success – and hence health and well-being – of youth and young adults by setting clear limits, providing good examples and trusting that they will use the knowledge and the tools provided to make appropriate healthy choices. Creating healthy and supportive environments is an enormous task that involves a whole-of-society approach. However, the range of community-based programs presented in this report is evidence of the impact that can be made. The key will be building on these successes as we move forward to foster and strengthen supportive environments for Canadian youth and young adults.

Approaching problems from all sides with co-ordinated, multi-pronged, inter-sectoral action

Public health issues are generally not overcome by simple means or singular approaches – nor by the action of a single jurisdiction or community acting alone. Increasingly, the role of the public health sector includes being a knowledge broker and advocate for all sectors working together. Addressing public health issues for youth and young adults should involve many approaches, from broad strategies to targeted initiatives. All sectors must act together on different fronts (e.g. community action, education, campaigns and legislation) to prevent or mitigate negative health outcomes. Strategies that combine several approaches have been effective, especially when sustained over a significant period. For example, Canada has been successful in reducing smoking rates and in dissuading young people from starting smoking. Legislation preventing the advertising and sale of tobacco products to youth along with the banning of smoking in public places has most likely contributed to the reduction in smoking among youth and young adults.^{Footnote 154, Footnote 854, Footnote 855} School-based programs, the financial cost of smoking, cigarette taxes and social marketing campaigns have also made large contributions.^{Footnote 818, Footnote 823, Footnote 855, Footnote 856}

Federal and provincial/territorial governments are using a similar approach to address the growing concern over unhealthy weights among youth and young adults, many of whom are either overweight, obese or at risk of developing an unhealthy weight. Our Health Our Future: A National Dialogue on Healthy Weights is a federal/ provincial/territorial initiative recently launched to engage Canadians and stakeholders in an open dialogue on healthy weights through marketing and social networking and engaging young Canadians.^{Footnote 857}

Canadian youth and young adults are a diverse population and as such, programs and interventions must be specifically designed to meet their needs and circumstances. Multi-pronged approaches are important as they can tackle issues on different fronts. Using different tactics can increase the reach of a strategy, allowing it to resonate with different groups of youth and young adults. Although there are effective programs and initiatives in place, we need to supplement these efforts. Interventions must be appropriately balanced between targeted and universal programs and must address Canada's geography, diversity and the needs of those most vulnerable to particular public health issues.

Making progress

Canada has had success in developing the conditions necessary for people to be healthy. Nevertheless, there are still persistent, worrying and emerging issues that underline the need for additional efforts to ensure a better future for Canada's youth and young adults. The priority areas for action outlined above will do much for improving the health and well-being of young Canadians.

Taking action requires time, effort and resources. These efforts, if made today, will have a positive impact not only on the current health of youth and young adults but also their future health. Better evidence and supportive environments are essential components to ensuring the healthy transitions of youth and young adults. In addition, Canada can learn, adapt and build on successes to ensure that no one is left behind. Adolescence and young adulthood are times of significant growth, risk-taking and experimentation. Those who grow up in a supportive environment tend to fare better when faced with adversities. As a society, we can foster a supportive environment that enhances health and well-being for all young people.

Canada needs to continue to support long-term, multi-pronged and multi-sectoral approaches that address key public health issues – often beginning in adolescence and young adulthood – and can significantly impact the lifecourse. Evidence from Canada and other countries has shown that negative outcomes related to youth and young adults can be successfully reduced or mitigated. Supporting young Canadians makes good sense because their positive development will lead to a healthier, happier and more productive society.

- From Words to Action -

In this report, I have tried to emphasize the state of health of Canada's youth and young adults and point to the important role of supportive environments and positive influences in preparing young people for the responsibility of adulthood.

We have made significant progress in helping youth and young adults transition, but there are some troubling and persistent, worrying and emerging issues over which we will need to triumph. I wanted this report to show that it is never too late to make a positive change to the lifecourse and supporting programs that strengthen the health and well-being of youth and young adults can have an impact that lasts well into their old age.

Generally, adolescence and young adulthood is a period equated with good health, but also with experimentation and risk-taking. In Canada, we have been successful in creating the conditions for young people to thrive. We need to continue to build on our successes and be attuned to the diversity that exists within this group and the many interconnecting influences of gender, culture and race. We must step up our efforts in areas where there is danger of losing ground so that no one is left behind.

The priorities identified in this report will require a collaborative approach. To advance the work needed to improve the health and well-being of youth and young adults, as Canada's Chief Public Health Officer, I will:

• work with my counterparts to create and foster initiatives that provide supportive environments for our youth and young adults;
• work with my colleagues and with those in other sectors to promote and develop policies that support healthy physical and emotional development;
• monitor the health and development of Canada's young people and work to improve data and knowledge sharing;
• work with my counterparts to promote positive mental health to youth and young adults;
• continue to support public health initiatives that show promise in successfully helping transitions into adulthood; and
• engage youth in efforts that promote and enhance their health and well-being.

— Dr. David Butler-Jones

Unite and Ignite Youth Engagement Conference

The Public Health Agency of Canada had the opportunity to engage youth and young adult representatives at the 2011 Unite and Ignite Conference held in Ottawa. It was gratifying to see youth and young adults engage in discussions and that they reported that the issues presented in this report resonate with their age group.

In fact, they expressed their desire to be more engaged in future discussions to bridge the gap between youth and adults. They explained that young people wanted to build relationships with adults by creating opportunities for communication, respect and a chance to be valued. Rather than being told what to do, they wanted to participate in creating cultural shifts and changing negative behaviours. The youth at the conference were also concerned with how to engage other young people.

Conference participants indicated that there is a need for more support groups at a community level for suicide survivors (those who have attempted suicide or lost a loved one to suicide). They suggested that developing a safe space for healing and moving through the stages of grief is important. As well, youth suggested that prevention of youth suicide can be achieved through education and building emotional intelligence. They envisioned support for community programs that could be led by young adult leaders.

In terms of substance abuse, many said that they would like someone with first-hand experience to discuss "honest" solution-based education that is non-judgmental and stigma-free. Youth believe that government support for youth-led programming will help reduce risks and create effective engagement strategies. They believe that by supporting positive alternatives, risky behaviours will be reduced and benefits will be seen in mental and physical health.

The conference participants indicated that greater awareness about the factors leading to homelessness would be useful. They believe that all Canadians should be concerned about the issue of street-involved youth and homelessness. Suggested solutions included additional investments for new facilities and improvements to existing ones so that basic needs are met and rehabilitation services are available to those who need them. Resources should be made available for qualified and dedicated staff to mentor and support the youth.

In response to the growing concern around bullying, young people at the conference said they would like to see both urban and rural communities across Canada receive professional medical and community support for promoting mental health and providing treatment. Since cyber-bullying is on the rise, they also encouraged additional training in the responsible use of social media for both users and social media providers.

Participants, including Aboriginal youth and young adults, also stated that they would like to see more opportunities for Aboriginal and non-Aboriginal people to gain a greater awareness of each other's culture. They suggested that to raise awareness about Aboriginal culture, classes on drum-making and on Aboriginal history and languages could be include in both mainstream and Aboriginal school curricula.²⁹

Many participants observed that there are obvious opportunities to work with youth and young adults to create better health outcomes. Decision-makers need to develop these important relationships to engage youth and to obtain their valuable insight into improving the health and well-being of youth and young adults.^{Footnote 29}

— Youth conference participant (2011)