Executive Summary: The Chief Public Health Officer's Report on the State of Public Health in Canada 2011

Executive Summary

This is the Chief Public Health Officer's fourth annual report on the state of public health in Canada. It examines the state of health and well-being of Canadian youth (aged 12 to 19 years) and young adults (aged 20 to 29 years). The report considers many health issues affecting this population such as physical and mental health, injury, sexual and reproductive health and substance use and abuse. By discussing these issues and how they are addressed, the report identifies priority areas for action to maintain healthy transitions of young Canadians into adulthood.

Setting the Stage for Healthy Life Transitions

Over time and in part due to investments in public health and improving socio-economic conditions, Canada has set the stage for young Canadians to make a healthy and mature transition into adulthood. However, efforts to promote, improve and enhance healthy life transitions are an ongoing process and optimizing opportunities for good health and well-being must exist throughout the lifecourse. Given the diversity in the sequencing, timing and success of youth transitions into adulthood, this is even more apparent today. Young Canadians represent an increasingly diverse sub-population and the life transition patterns of youth and young adults have changed significantly over the last century. For most youth and young adults, this is still a time of positive life experiences and challenges as they progress and learn and develop into healthy adult roles and responsibilities. However, there are sub-populations of young Canadians that are more vulnerable to particular health issues and may face greater challenges, obstacles or interruptions that can affect their ability to transition into adulthood.

At every stage of life, health is directly or indirectly influenced by key determinants of health such as education and literacy, income and social status, employment and working conditions and social environments. The complex interaction between these key determinants of health can influence health outcomes – both positively and negatively – and, depending on the individual, can result in the individual beginning and progressing through life stages at different times and rates. For this reason, the life stages experienced by youth and young adults continue to be fluid and the boundaries between childhood and adolescence or between adolescence and adulthood vary from person to person. From a public health perspective, consideration of the lifecourse approach and the broader determinants of health can help to examine and evaluate how certain factors or experiences affect health outcomes and the ability for individuals to make healthy transitions from one life stage to the next.

A brief public health history of Canada's experience in setting the stage for healthy life transitions shows that past efforts have positively influenced the health outcomes of youth and young adults. Programs, policies and legislation have been put into place to establish the foundation for optimal health and well-being throughout an individual's life, including adolescence and young adulthood. It also points to some broad challenges that lie ahead. There are areas where Canada, as a society, can make a difference in the current and future health and well-being of our youth and young adults. These include education, employment, sexual and reproductive health, injuries, risk-taking behaviours and healthy living. In order to ensure that all young Canadians are making healthy transitions into adulthood, opportunities to identify and address these challenges and to promote healthy life transitions must exist.

The Health and Well-being of Canadian Youth and Young Adults

The 2006 Census reported that there are 7.5 million youth and young adults in Canada. Of these, 46% were youth between the ages of 12 and 19 years and 54% were young adults between the ages of 20 and 29 years. Together they represent 24% of the total population. This compares to 35 years ago when they made up 33% of the Canadian population. While most youth live with their families, some are living with a spouse or common-law partner, while others are living alone or may be parents themselves. However, more young adults lived with their parents in 2006 than five years earlier – 42% compared to 39% in 2001.

Education is an important determinant of health for all Canadians. In 2009, nine out of ten young adults were high school graduates, and the dropout rate was 8.5%, with more young men more likely to drop out than young women. However, the rate was much higher – 23% – among off-reserve Aboriginal youth. The number of young adults pursuing and completing post-secondary education has increased over time and in 2008 more than half of Canadians aged 25 to 34 years had completed post-secondary studies. In addition to being in school, many youth and young adults were working. In 2008, two-thirds of Canadians aged 15 to 29 years were employed, making up one-quarter of the total employed population in Canada. The majority of youth aged 15 to 19 years held part-time jobs, while most young adults were employed in full-time positions.

Mental health is an important aspect of the overall health and well-being of youth and young adults. Of particular concern for young Canadians are mental health problems and illnesses such as depression, panic disorder, eating disorders, intentional self-harm including suicidal behaviour and aggressive or anti-social behaviour such as bullying. More than three-quarters of young Canadians describe their mental health as "very good" or "excellent," and most report being "satisfied" or "very satisfied" with life. Despite this, 14% of youth and 24% of young adults perceived themselves as having quite a lot of life stress. Young Canadians living in low-income households, among whom Aboriginal, recent immigrant and homeless youth and young adults are over-represented, are more likely to experience stressors such as job strain, relationship problems and financial problems. Along with sexual minority youth and young adults, these sub-populations may also experience discrimination, which can increase levels of stress that can lead to mental health problems. Sexual minority youth and young adults also experience stigmatization and harassment, which can put them at higher risk of mental health issues.

Bullying takes many forms and can have a serious impact on the emotional health of those who are victimized. In 2006, 36% of students in Grades 6 to 10 reported being victims of bullying, 39% reported being bullies and 20% reported being both. The most common forms of bullying are teasing and indirect bullying (e.g. spreading lies about a victim). Other forms include physical and electronic bullying and sexual harassment. Data suggest that young people aged 15 to 24 years are at the highest risk of being victims of dating violence. Sexual minority youth are at a much higher risk of experiencing harassment, victimization and physical or sexual violence, both in school and in the community.

Intentional self-harm is an issue of concern for youth and young adults. This frequently hidden behaviour usually begins and is most common among youth and young adults. Compared to 22% for males, 36% of injury hospitalizations among females were for intentional injuries, including self-harm. Suicide is among the top causes of death in youth and young adults in Canada, second only to unintentional injuries. In 2007, nearly 800 young Canadians committed suicide, 76% of whom were young men. Although current data are not available, historical data and research suggest that the suicide rate among youth and young adults of certain Aboriginal peoples may be much higher than that of the general population. Lesbian, gay, bisexual, transgender or questioning (LGBTQ) youth and young adults are also more likely to commit suicide.

Compared to older populations, youth and young adults experience fewer chronic conditions and lower mortality and most – 68% of youth and 70% of young adults – perceive their health as "very good" or "excellent." Young Canadians are, however, prone to injuries and death due to injuries, many of which are preventable. Overall, injuries and poisonings are the leading cause of death among youth and young adults. They account for a much higher proportion (75%) of deaths among adolescent boys and young men however, than among adolescent girls and young women (56%). Males also account for the majority of injury-related hospitalizations in these age groups (66% among youth, 68% among young adults). Transport incidents are the most common cause of death due to injury, with male drivers involved in more automobile collisions than female drivers. In 2005/2006, more than 35,000 youth and young adults were hospitalized for injuries. Just over two-thirds (70%) of those hospitalizations were due to unintentional injuries, one-third of which were the result of transport incidents.

Canadian youth and young adults are experiencing higher rates of obesity than in the past. Between 1978/1979 and 2007-2009, rates of measured obesity rose from 3% to 11% among youth and from 6% to 15% among young adults. Survey data indicate higher rates among Aboriginal youth and young adults and lower rates among immigrant youth and young adults. Low socio-economic status is a factor in the likelihood of obesity; young people from more affluent families have greater opportunities to be physically active and consume healthier food. Being overweight or obese when young increases the risk of certain chronic health conditions such as type 2 diabetes and cardiovascular diseases in adulthood.

Between 1994 and 2009, the reported rates of sexually transmitted infections (STIs) increased in Canada. Young Canadians under the age of 30 years continue to experience the highest reported rates of chlamydia, gonorrhea and infectious syphilis. Survey data showed higher rates of chlamydia among First Nation adolescent girls and young women, and higher rates of chlamydia and gonorrhea in street-involved youth than among the general population. In 2009, more than one-fifth (22%) of all new positive human immunodeficiency virus (HIV) tests were in young adults aged 20 to 29 years.

Although it is normal for youth and young adults to engage in risk-taking behaviours some partake in riskier behaviours linked to negative health outcomes such as smoking, consuming alcohol, drug use and risky sexual behaviours. In 2009, almost half of all youth aged 15 to 19 years and nine out of ten young adults reported that they had had sexual intercourse at least once in their lives. More than two-thirds of those 15- to 19-year-olds and one-quarter of young adults reported having had more than one sexual partner in the previous year. Sexual minority and street-involved youth reported higher rates of risky sexual behaviours including early first sexual experience, multiple partners and lower rates of condom use.

Tobacco, alcohol and cannabis are the substances most frequently used by youth and young adults, and most Canadians are first exposed to these in adolescence. Although smoking rates have declined over the past decade, young adults have the highest smoking rate of all age groups in Canada – 23% are smokers. In 2009, more than two-thirds of youth aged 15 to 19 years had consumed alcohol in the previous 12 months and nearly half had consumed it at least two to three times a month. Cannabis use has decreased among young Canadians in recent years, yet continues to be the most commonly used illicit drug among youth and young adults with approximately one-quarter reporting using it in 2009. Certain populations are at greater risk of substance use and abuse. Young males are typically more likely to use substances and be heavy users; however, recent survey data suggest that the sex gap may be narrowing. Survey data indicate that alcohol consumption and cannabis use are more prevalent among youth who smoke tobacco than among youth who do not smoke. Street-involved youth, sexual minority youth and Aboriginal youth are all at greater risk of substance abuse.

Creating Healthy Transitions

To create conditions for youth and young adults to transition into healthy adulthood, Canada must continue to address complex and interconnected factors that influence health and well-being. Particular health issues examined in this report include mental health and illness, suicide, injuries, bullying, risky sexual behaviours, healthy weights, and substance use and abuse. Various approaches exist to address these issues including efforts to build resilience and reduce stigma; promote health and prevent and manage risk; target specific populations; educate and increase awareness; and develop healthy public policy and protection legislation. Examples of effective, promising and/or supportive approaches and interventions as well as research demonstrate what can be accomplished in creating healthy transitions for youth and young adults.

Social determinants are closely related to the health outcomes during youth and young adulthood. Also beneficial to health are the supportive environments of family and friends, school, the workplace and communities. For example, a positive living environment (home and family) can mitigate the direct outcomes of social, physical and economic exclusion. On the other hand, young Canadians experiencing abuse or neglect in a home setting may be at risk for adverse outcomes. 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. Addressing homelessness among youth and young adults is complex; to be most effective, interventions targeting youth should be delivered earlier in life, include the determinants of health, and provide children and youth with residential stability and support. School environments also offer supportive settings to youth, fostering academic, social and life skills. As well, schools provide an opportunity to disseminate health information by raising health issues, suggesting prevention tactics and helping students develop healthy skills. The comprehensive health promoting schools approach entails teaching skills in the classroom, addressing the social and physical environment and connecting with the community. A number of broad population-based programs that have increased access and financial support have also contributed to increasing the number of young Canadians who seek and complete post-secondary education. Canada has had some success with youth and young adult programs that build experience and gain the insight and skills necessary for full-time work.

Resilience is an individual's ability to cope with adversity, face challenges and navigate health and social resources. A range of biological, psychological and social factors influence resilience. It is important for a healthy transition into adulthood, affecting the ability to deal with mental and emotional trauma, develop self-confidence and self-respect, set realistic goals and build supportive relationships. Resilience develops differently in adolescent boys and girls, and interventions to address its promotion should be appropriately tailored.

Mental and emotional health problems experienced in childhood and adolescence can affect young Canadians across the lifecourse, and many mental illnesses manifest in adolescence. As such, it is crucial to address mental disorders and illnesses as early as possible, and programs targeted to youth are more effective in preventing mental health issues, managing illness and promoting positive mental health. Schools can be effective in early identification and education. Early education can increase awareness of mental health illnesses and prevent stigma by exposing children and youth to individuals with mental illnesses before negative attitudes emerge and by promoting empathy and tolerance. Stigma may negatively affect an individual's ability to develop and may act as a barrier to seeking treatment. Youth and young adults may also avoid programs and services they perceive as too adult-oriented or disconnected from their needs and culture. Greater consideration should be given to providing age-appropriate programs and services in a school setting. Overall, the most effective mental health interventions involve implementing sustainable multi-faceted programs that consider the many components of mental health and that target individuals, families and communities in an age-appropriate, gender- and culturally relevant approach. As well, broad initiatives or strategies can also offer co-ordinated integrated approaches that can result in significant improvements in overall mental health.

Suicide is a large but preventable public health problem, with emotional, social and economic impacts. Both the lack of awareness that suicide is a major public health problem and the assumption that it is a population-specific problem hinders the effectiveness of many suicide prevention programs. However, some population-specific issues have been noted. While restricting access to common tools used to assist suicide (e.g. firearms or toxic substances) can be effective, this does not address the underlying causes. Canada can address suicide as part of a broad wellness strategy that also promotes mental health. Among at-risk Aboriginal peoples, suicide prevention involves raising awareness and addressing community factors such as social exclusion and disconnection from traditions and culture, which are often deeply entrenched, possibly spanning generations. Promising practices come from within communities. Early research suggests that social media and online resources can be a tool for suicide prevention, for example, among LGBTQ youth and young adults. However, the dynamic environment, a lack of evaluation, the isolating potential of the medium and the possibility of using social networking to bully at-risk individuals or encourage suicide may challenge the effectiveness of such programs.

The majority of injuries that youth and young adults experience are preventable. In many cases, raising awareness is a common strategy for injury prevention. Workplace safety programs introduced in school create a culture of safety for young people entering the workforce. They provide information about workplace risks and employee rights and responsibilities regarding occupational health and safety. Broad awareness programs have been successful in changing the attitudes of young Canadians towards risky behaviours such as impaired driving. However, still more work is required to ensure the messages reach those who are most at risk. These messages should be expanded beyond roadways to include the use of boats, all-terrain vehicles and snowmobiles. Overall, multi-faceted approaches to injury prevention are most effective when combining enforcement of regulation and policies, control of environmental hazards and education.

Bullying is a problem that influences both current and long-term health and well-being. It occurs in a variety of social settings including school, the workplace and online; no matter the setting, everyone has a role to play in its prevention. Bullying is a relationship problem and is marked by an imbalance of power. Addressing bullying is about promoting healthy relationships and building social skills such as assertiveness, empathy, conflict resolution and other interpersonal skills. As bullying often occurs in schools, approaches are most frequently school-based, though evaluations report mixed results. Whole-school approaches involve the development of anti-bullying policies outlining both staff and student responsibilities. Adult involvement and presence in schools can positively influence outcomes. Addressing workplace bullying involves collaboration between employers and employees to clearly define what constitutes bullying and how protective measures are developed and enforced.

Sexual health is a major part of personal health, healthy living and healthy transitions. Healthy sexuality involves much more than avoiding negative outcomes, such as STIs and unplanned pregnancies. Most Canadians become sexually active during their teens. Because sexual attitudes and behaviours are established early, it is important to provide youth with the knowledge and skills necessary to develop healthy relationships and establish healthy sexual behaviours. School-based interventions are an opportunity to reach a large number of youth. Research indicates 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. Nevertheless, for the most part, school-based sexual health education is limited in effectiveness. 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. Programs should also address the diversity among students to address a range of needs and perspectives. In addressing issues such as teen pregnancy and risky sexual behaviours among street-involved youth, a comprehensive approach is required to address broader health determinants and the root causes of these issues. Addressing teen pregnancy involves both prevention measures and support services to ensure positive health for both young parents and their children, while avoiding the stigmatization of young mothers. Overall, the most effective sexual health interventions are those that are sensitive to a variety of backgrounds, experiences, cultures and sexual orientations and are implemented early on in the lifecourse.

Though overweight and obesity is a growing public health problem across all age groups, it is a critical issue for youth and young adults because of current and future adverse health outcomes. Unhealthy weight is linked to several factors including economic status, education, genetics, social factors, the built environment and culture. Addressing overweight and obesity is about promoting physical activity and healthy eating as well as their underlying socio-cultural and environmental determinants. For example, the built environment plays a role in the healthy lifestyle patterns of young Canadians by supporting active transportation, leisure-time physical activity, walking environments, recreational facilities and accessibility to affordable and nutritious foods. Broad initiatives with recommendations on nutrition and physical activity are one step to addressing unhealthy weights across the general population. Another approach provides increased opportunities and access to foods and programs to at-risk populations (e.g. in rural and remote communities). In addressing eating disorders, early detection is the key to increasing the likelihood of treatment. This is done by training families and teachers to identify behaviours and symptoms of disordered eating and recognizing the role of communities in developing healthy body image. More effort is required to reduce the negative stereotyping of those who are overweight or obese and emphasize that self-worth is not related to physical appearance.

Compared to other age groups, young Canadians are the most likely to engage in substance use and abuse. Substance use and abuse are complex issues, often resulting from the interaction of various influencing factors such as family, peers and school as well as broader factors related to socio-economic environments. A public health approach often involves prevention, treatment and rehabilitation, enforcement, and reducing the harm associated with substance use. Prevention is most effective when initiatives are introduced early in the lifecourse, before substance use occurs. Early interventions provide children with the tools necessary to make healthy life choices and can address risk factors earlier on in life. Youth programs must be relevant to the population and the substances most frequently used, as well as target youth interests, activities and values. The most effective health promotion interventions for alcohol use and abuse are broad population-level interventions such as adhering to a minimum drinking age, restricting alcohol sales to minors, taxing alcohol purchases, lowering legal blood alcohol limits and graduated licensing. Similarly, broad approaches such as regulation of tobacco products play an important role in the reduction of smoking prevalence.

Canada has made great progress in developing proven and promising program and policy interventions to address the current and future health of Canadian youth and young adults. However, the health and well-being of some Canadians is still compromised and gaps exist in knowledge, information and best practices. Existing programs and policies offer a starting point for all Canadians, communities and sectors of society to make a difference.

Moving Forward

Over the past century, through planning and research, Canada has made improvements to the health and quality of life of its population. As a result of these successes, Canadian youth and young adults can expect vibrant and healthy lives. However, there are negative influences on the current and future health of young Canadians. Of particular concern are certain groups who suffer higher rates of adverse health problems than the rest of the population.

It is important that Canada deal with these issues to ensure that vulnerable youth and young adults are able to live healthy and productive lives. Many efforts are already in place to tackle various health issues; some can be replicated, adapted or scaled up, while certain communities may require a unique approach. Evaluation of programs is crucial to establishing effective interventions.

To facilitate the best possible outcomes for youth and young adults, Canada must focus effort in the following key 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.

As a society, we can learn, adapt and build on successes to create environments that support the health and well-being of young Canadians. By doing so, we can support youth and young adults through this crucial period of development so they can better deal with adversity and reach their full potential.