Executive Summary: The Chief Public Health Officer's Report on The State of Public Health in Canada 2009

Executive Summary

This report is the Chief Public Health Officer of Canada's second annual report to Parliament on the state of public health in Canada. It considers the lifecourse approach to health – focusing on the lifelong impact of exposures and influences that occur early in life – and explores the current state of children's health in Canada up to and including age 11 years.

From this information, a number of worrying trends emerge that are either persistent or are increasing in prevalence, especially among certain sub-populations of children. Efforts to address these negative trends and reduce their impacts on children's health and development vary in approach and magnitude, from targeted community-level interventions to nationwide universal programs. Evidence suggests that, in some cases, broad multi-pronged approaches need to be developed, while in others current efforts should be supplemented in order to reach all those in need. Examples of successful and promising initiatives and research, both within Canada and abroad, provide guidance on optimal conditions and priorities to help children start and continue on the path to good health.

The role of public health in influencing the lifecourse trajectory

To fully understand the lifecourse approach to health, a discussion of trajectories is important. Lifecourse trajectories are pathways that are followed from the beginning of life to the end. Experiences and exposures over the course of a lifetime can influence health trajectories, both positively and negatively. Events in childhood, however, are particularly critical to lifelong health given the degree to which physical, neurological and emotional growth occurs at this early stage.

From a public health perspective, consideration of the lifecourse trajectory model can help with the identification of health trends and the links that can be made between exposures and outcomes. Interventions, including public policies, can then be targeted to address these trends and links by working to establish optimal conditions for health and wellness at critical points across the lifecourse. Evidence shows that efforts to reduce or mitigate negative influences on health made at the earliest stages in life – prenatally and in early childhood – provide the greatest returns. A brief overview of the history of children's health in Canada shows that past efforts to improve conditions and outcomes for children and families have had lasting positive effects in areas such as infant mortality, infectious disease mortality and life expectancy.

The health of Canadian children

Overall, most children in Canada are healthy. Life expectancy for Canada's children has reached one of the highest in the world at just over 80 years. During the last century, incidences of infant mortality dropped substantially to a rate of 5 per 1,000 live births; however, further progress on this front has slowed over the last decade relative to other similarly developed countries.

In the first year of life the main causes of death are related to congenital malformations, deformations and abnormalities such as spina bifida and Down Syndrome, followed by those who suffer disorders due to premature birth or low birth weight. From age 1 to 11 years, the leading cause of death shifts to unintentional injuries with the main cause being transport accidents.

Chronic conditions seen in this age group include asthma, diabetes and cancer. Health issues of particular concern include obesity and mental and behavioural disorders. Obesity rates among children and adults are on the rise in Canada as they are in many other similarly developed countries. Between 1978 and 2004, rates of measured obesity almost tripled among Canadian children and youth aged 2 to 17 years. While there is limited information on how many children are affected by behavioural disorders, it is estimated that 15% of children and youth in this country experience a mental health disorder at any given time.

Although rates of illness and disease among young children are relatively low in Canada, some — including Aboriginal children and those from low-income households — appear to be more vulnerable than others to certain adverse health outcomes.

Social and physical influences on health

Many factors influence children's health and development, including those that are social and physical in nature. This includes socio-economic status (SES), with inequalities in status linked to inequalities in health outcomes. Children living in families with low SES are less likely to have their basic needs met (sufficient family income, adequate food and shelter) and are more likely to experience ill health. In Canada, 12% of children under the age of 12 live in poverty – a level that has declined over time but remains higher than in some other countries. In addition, 10% of families with children report experiencing higher rates of income-related food insecurity and 13% of all Canadian households report being unable to access acceptable housing. These rates are higher among some populations; in particular Aboriginal households.

Developmental opportunities can influence health and social outcomes. School readiness is one measure of child development showing a child's level of knowledge, skills, language, maturity and cognitive development by kindergarten. Approximately 28% of kindergarten children (at age five) are considered vulnerable in terms of school readiness as a result of low scores on one or more of five measures of child development. Children who are not developmentally school ready may experience poorer educational and social outcomes.

Situations of family dysfunction, abuse and neglect, poor quality care arrangements, unsafe neighbourhoods and adverse environmental exposures (e.g. tobacco smoke, mould and prenatal risks) can amplify the likelihood of poor health outcomes. Abuse and neglect is an ongoing issue. In 2003 there were more than 75,000 substantiated maltreatment cases in Canada involving children (aged 0 to 11 years) and evidence suggests it is on the rise. Whether experienced at home, at school or among peers, abuse has a detrimental effect on health that can persist into adulthood and even carry over to the next generation.

Alternatively, environments that include nurturing caregivers, positive learning, access to health care, good nutrition, social interaction with other children, safe neighbourhoods and positive environmental exposures (e.g. good air quality) can all contribute positively to early physical and social development and can even help to mitigate the effects of low SES.

Through their actions and choices, parents influence children's health and behaviours. For example, while Canada reports recent reductions in smoking during pregnancy, 11% of women still smoked in the last three months of their pregnancy and nearly 17% smoked in the first year after birth. Breastfeeding is increasing in Canada, with 90% of mothers initiating breastfeeding and about 50% reporting breastfeeding for six months or more. Still, breastfeeding rates are lower among certain populations including Aboriginal, low-income and young mothers.

As children get older, their own behaviour also comes into play. Those who engage in regular physical exercise, adopt healthy eating habits, and develop strong resilience and risk-assessment skills are more likely to experience positive health outcomes and well-being and to carry these behaviours into adulthood with similar results. For example, among Canadian children (aged 6 to 11 years), 84% are physically active more than 7 hours per week. In addition, the majority of children consume the daily recommended servings of grains (73%) and milk and milk products (63%). Fewer children meet the recommendations for fruits and vegetables (30%).

Setting trajectories for a healthy life

As a result of ongoing efforts over the course of Canada's history, today's generation of children are generally healthy and socially well-developed. However, six issues warrant further examination because they are either having a substantial negative impact on the health of Canadian children or they are persistent or worsening, and there is evidence that they are preventable. They are:

• Socio-economic status and developmental opportunities;
• Abuse and neglect;
• Prenatal risks;
• Mental health and disorders;
• Obesity; and
• Unintentional injuries.

In each of the six areas, efforts are being made to reduce their occurrence or mitigate their negative effects by establishing or improving the conditions required for optimal health and well-being.

SES and developmental opportunities play an important role in children's health. Those children whose basic needs are not being met are at risk of immediate and longterm negative health outcomes. They are also more apt to miss opportunities to develop, grow and participate at school and in their communities if environments conducive to those opportunities are lacking. The best returns on investments are the ones contributing to the well-being of children, as dollars spent in the early years create savings in future spending on health, social and justice services. However, while broad social investments have contributed to a decline in child poverty in Canada, poverty reduction appears to have stalled. Some jurisdictions have either developed or are developing broad strategies to address this important issue. In terms of developmental opportunities, programs to enhance early child development and after-school programs exist but are not consistently available or affordable.

The potential for long-term and even intergenerational affects associated with abuse and neglect make efforts to understand and alleviate this issue critical. To date, there has been some progress in data collection efforts and public awareness initiatives across sectors and on different levels. The value of early intervention in this area is most evident, with those targeting women in the prenatal period showing high potential. Protective care is also important to ensure that children are removed from unsafe and unhealthy environments and placed in ones that are healthy and supportive. Placing children with extended family members in order to keep them in their home communities is showing signs of promise. However, further investigation into care options is needed and warranted.

As highlighted throughout the report, the prenatal period offers an unprecedented opportunity to set a child's health trajectory on the path to lifelong good health. Canada has done well in ensuring comprehensive prenatal care for mothers and in creating awareness of the connection between positive prenatal behaviours and good health outcomes for children. However, not all women are able to benefit from these efforts. For those more apt to engage in risky behaviours or who live within environments that can result in prenatal risk, studies show that bringing non-threatening, non-judgmental support directly to these women may be most effective. Additionally, efforts that encourage support from partners and close family members, and those involving early education and awareness (preferably prior to pregnancy), can also lessen prenatal risks.

About 15% of children and youth are affected by a mental health disorder at any given time. Educational programs which dispel myths and raise awareness about mental health can reduce stigmatization and support children and their families. Increasing specialized services for children as well as community factors such as culturally relevant resources, activities for social inclusion and parental skills/training can also build resiliency, coping mechanisms and strengthen relationships. In addition, evidence shows that co-ordinated strategies and investments in mental health are needed, and Canada is making progress on creating a national mental health strategy through the work of the Mental Health Commission. A broad co-ordinated strategy is expected to address childhood mental health issues, promote healthy development, and monitor mental health outcomes among Canadian children.

Rising rates of child obesity are related to lower rates of physical activity and poor eating habits due to a shift to more sedentary lifestyles and consumption of processed “convenience” foods. Neighbourhoods with less access to grocery stores, fewer options for pedestrians and less recreational space may also contribute to this problem. Efforts to create more awareness of the issue and educate parents and children include national guidelines for healthy food choices and physical activity levels. A multi-governmental initiative to increase physical activity, which incorporates data collection of current and future levels, is also underway. Other initiatives that are being explored as a means of reducing obesity rates include more restrictive advertising rules to minors (e.g. food advertising), increased taxation of “junk” foods and subsidies of “healthy” foods, better neighbourhood planning, and supportive environments at home, school and in the greater community.

While unintentional injury is still the leading cause of death and a common cause of ill health and disability for young children, Canada has been successful in lowering rates of injury during childhood. Interventions that have shown success in reducing negative health outcomes in this area include education and awareness initiatives, safety legislation, and product standards and guidelines. Teaching children to assess risk is also important. Countries such as Sweden have put in place a national injury prevention strategy and have lowered their rates of childhood injury deaths.

Growing up well – conditions and priorities for a healthy future

The fact that the majority of Canadian children today enjoy good health and can expect to live longer than those in most other countries is a result of efforts to improve children's health and well-being over the last century. Unfortunately, not all children share in this progress, and certain health risks are emerging that may prevent children from benefiting from the positive outcomes associated with these gains. The evidence profiled in this report highlights the optimal conditions for childhood health and development which, if in place, can help all children to benefit from this progress: strong, healthy and sustainable communities; access to high-quality early learning, education and primary care; caring and safe environments; the ability to develop a sense of control, connectedness and responsibility; and opportunities to make healthy choices.

Four priority areas for action where Canada can foster these conditions include:  better collection and sharing of data and information; improved and ongoing education and awareness; healthy and supportive environments; and co-ordinated, multi-pronged and sustained strategies. Moving forward, however, requires participation from all sectors and levels. This will allow children the opportunity to achieve the highest attainable standard of health, and to lead healthier and more productive lives across the lifecourse – from birth through to old age.