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IMPROVING THE HEALTH OF CANADIANS: AN INTRODUCTION TO HEALTH IN URBAN PLACES Released: November 21, 2006
IMPROVING THE HEALTH OF
CANADIANS:AN INTRODUCTION TO
HEALTH IN URBAN PLACES
Released: November 21, 2006
About the Canadian Institute for Health Information (CIHI)
HealthInformation
Research and Analysis
Health Indicators
Data Holdings
StandardsLaying a foundation for health information
Capturing the portrait of health care
Building new health knowledge
Taking health information further
Priva
cy, C
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Canadian Population Health Initiative (CPHI)
CPHI�s Mission:
� To foster a better understanding of factors that affect the health of individuals and communities; and
� To contribute to the development of policies that reduce inequities and improve the health and well-being of Canadians.
CPHI�s Strategic Functions
Knowledge Generation Policy Synthesis
Knowledge Transfer Knowledge Exchange
CPHI�s Key Strategic Areas 2004�2007
Place and HealthHealthy Transitions to
Adulthood Healthy Weights♦ ♦
CPHI Council Members(as of August 2006)
Cordell Neudorf (Interim Chair)
Richard Lessard (Chair � On Sabbatical)
Monique Bégin John Millar
André Corriveau Ian Potter
Lynn McIntyre Elinor Wilson
Deborah Schwartz Michael Wolfson (ex-officio)
Gerry Predy Gregory Taylor (ex-officio)
Judy Guernsey
PH Expert Advisory Group MembersCordell Neudorf (Chair), Saskatoon Health Region
Marie DesMeules, Evidence and Risk Assessment Division, Public Health Agency of Canada
Karen Dufton, Communications, Infrastructure Canada
James Dunn, Centre for Research on Inner City Health
Trevor Hancock, BC Ministry of Health
Michael Hayes, Simon Fraser University
Russell Mawby, Housing, Community and Protective Services Department, City of Ottawa
Michael Wolfson, Statistics Canada
WHY LOOK AT HEALTH IN URBAN PLACES?
Health and the Urban Environment
� 80% of Canada�s population (24 million Canadians) lives in urban areas with populations over 10,000
� Urban environments can influence many aspects of health and well-being:� Access to food and nutrition habits� Environmental exposure (air, water, noise)� Employment� Housing� Access to health services� Exposure to potentially dangerous situations� Social support networks
Comparisons Between Countries
Comparisons Within Neighbourhoods:Housing
Comparisons Between Provinces And Territories
Comparisons Between Cities
Comparisons Between Neighbourhoods
UNDERSTANDING HEALTH IN THE URBAN SETTING
Goals of the Report
1. To promote discussion about the link between various aspects of place and health
2. To provide a foundation for future CPHI reports on place and health through an initial focus on specific health-related outcomes and aspects of urban areas
3. To provide a preliminary assessment of policy and intervention options to improve health among Canadians in urban areas
4. To complement the work CPHI is also doing on health among Canadians in rural areas
What�s New about this Report? (1)
This report looks at the link between health and the social and physical aspects of neighbourhoods and housing in urban areas
Space: The physical or geographical characteristics of a location�where it is (for example, a house)
Place: The social aspects of a location�what a space represents or what meaning it has for people (for example, a home)
What�s New about this Report? (2)
This report presents new CPHI analyses of health outcomes and behaviours between Canada�s urban areas
It also presents new CPHI analyses of health outcomes and behaviours between neighbourhoods within Canada�s three most populated cities, as well as the next most populated cities in the Prairies and Eastern Canada
� Vancouver� Toronto� Montréal� Calgary� Halifax
Report�s Data Sources and Outcomes
Outcomes of Interest� Self-rated health, perceived stress, injuries, overweight
and obesity, tobacco use, physical activity, self-perceived unmet health care needs, alcohol use
Data Sources1. Statistics Canada
� CCHS 2.1 (2003)� Census (2001)
2. CIHI� National Trauma Registry (2003-2004)� Nursing Databases� Scott�s Medical Database
HEALTH STATUS IN DIFFERENT URBAN AREAS:
PATTERNS OF HEALTH OUTCOMES AND BEHAVIOURS BETWEEN CANADIAN CITIES
Excellent or Very Good Self-Rated Health
67* 67*63* 63*
59 56* 53* 53* 53* 53* 53*
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Victoria, Vancouver, Abbotsford, Saskatoon, Regina, London, Oshawa, Hamilton, St. Catharines/Niagara, Kitchener, Ottawa/Gatineau, Sherbrooke, Trois-Rivières, Québec, Montréal, Saint John and Halifax were not statistically significantly different from CMA average, p<.05.
Life as Extremely or Quite a Bit Stressful
30* 30* 29* 25 22* 21* 21* 20* 19* 19*
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Abbotsford, Edmonton, Calgary, Regina, Thunder Bay, Greater Sudbury, Windsor, London, Kitchener, St.Catharines/Niagara, Hamilton, Toronto, Oshawa, Kingston, Ottawa/Gatineau, Trois-Rivières, Saguenay and Saint John were not statistically significantly different from CMA average, p<.05.
URBAN LIVING: NEIGHBOURHOODS AND HEALTH
A SAMPLE OF THE LITERATURE
Why Look at Health Outcomes at Different Levels of Geography?
Looking at data only at the CMA level may mask various inequalities within a CMA
� Individual-level factors, such as education, income and health-related behaviours, tend to be strongly associated with differences in health
� Research suggests there is an additional, potentially important, association between some aspects of health and characteristics of the neighbourhoods in which people live
Neighbourhood Social Characteristics (1)Social Support Networks and Resources
Social cohesion: the extent of connectedness and solidarity among groups in society
� Research shows that lack of neighbourhood cohesion and perceived local problems have been associated with self-reported physical and mental health problems
Collective efficacy: a measure of mutual trust and willingness to help out for the common good
� Evidence indicates that youth living in neighbourhoods with highlevels of collective efficacy had lower body mass indices than youth living in neighbourhoods with average levels of collective
Neighbourhood Social Characteristics (2)Cultural Diversity
In 2001, 73% of immigrants settled in Toronto, Montréal and Vancouver
Evidence regarding ethnic concentration is inconclusive� Some Canadian researchers have emphasized the positive role
of ethnic concentration in enhancing integration of immigrant communities
� Other research suggests that these areas reinforce the persistence of social inequalities, in terms of labour market integration, poor language acquisition and educational achievement
Socio-Economic InfluencesResearch shows an association between neighbourhood affluence and positive health effects over and above individual income, demographic and health-related background factors
Socio-economic influences on neighbourhood variations in health have been observed for a number of health outcomes
� Poor mental health� Behavioural problems in children� Heart attacks� Levels of health care access and use� Height and weight in children
Physical Characteristics: SafetyThere can be a link between health and the availability of safe and secure housing, work and play environments
� Playgrounds in neighbourhoods identified as having �high social needs� often do not meet safety standards
� Neighbourhood appearance is linked to increased physical activity and reduced overweight/obesity
� Low perceived neighbourhood safety is linked to decreased physical activity
� Residents who report liking their neighbourhood�s physical characteristics are less likely to rate their health as fair or poor compared to those who dislike their neighbourhood
Physical Characteristics: TrafficLeading Cause of InjuryIn 2003, motor vehicle collisions were the second leading cause of injuries serious enough to require hospitalization among Canadians in urban areas
SpeedFatalities are higher in rural areas where speed limits are higher (1,539 versus 936); personal injuries are higher in urban areas (110,511 versus 41,639)
Population DensityA U.S. study found that counties with the lowest traffic fatality rates were those that were most densely populated and that had the most street-accessible destinations
Moving Between and Within Neighbourhoods: Personal Vehicle Use
Research shows a link between the expansion of work into the suburbs and an increased likelihood of commuting by car
� 2001 Census data show that of commuters in Canada�s 27 CMAs, 71% drove a car to work
� Almost 6% of commuters walked to work and just over 1% commuted by bicycle
� In 2001, three of Canada�s largest CMAs (Montréal, Ottawa�Gatineau, Toronto) had the lowest proportion of drivers to work;despite this, nearly two-thirds of commuters still drove to work in these cities
Access to Health and Food Services
In 2001, a higher number of active physicians within a CMA was linked to a higher proportion of residents reporting good or better health status, but not to longer life expectancy
� New CPHI analyses show that in 2003, there were differences in self-reported unmet health care needs between CMAs and in some cases, differences between CMAs in the same province
Features specific to the nutrition environment, such as proximity of local grocery shopping facilities and cost of food, may be linked to healthy eating
Moving Between and Within Neighbourhoods: Mode of Transport
Of those whose commuting distance was less than five kilometres, 57% drove to work. Factors influencing modes of transport other than car:
� Ease of movement and distance between trip origin and destination
� Perceived flexibility by having one�s personal vehicle
� Income
� Gender
� Age
� Length of time since immigration
Moving Between and Within Neighbourhoods: Traffic Pollution
Transportation is a producer of air pollution in Canada � In 1999, cars and light trucks made up almost 50% of
transportation�s total greenhouse gas emissions
� Public transit produces fewer greenhouse gas emissions
� Internal combustion engines that power vehicles and equipment contribute to the formation of smog, which can have adverse effects on both the environment and people�s health
� Health outcomes linked to air pollution include post-neonatal respiratory deaths and, in some cases, respiratory problems
Drinking water and noise levels can also be affected by a number of traffic-related sources in the urban environment
URBAN LIVING: NEIGHBOURHOODS AND HEALTH
NEW CPHI ANALYSES OF PATTERNS OF HEALTH BETWEEN FIVE CANADIAN CITIES
New CPHI Analyses: Patterns of HealthBetween Different Neighbourhood Types
Vancouver, Calgary, Toronto, Montréal and Halifax
Neighbourhoods within each city were grouped along five socio-demographic variables to create relatively homogeneous types of neighbourhoods
� % of postsecondary graduates� Median income� % of recent immigrants (5 years)� % of lone-parent families� % of persons living alone
CPHI Neighbourhood-Level AnalysesNew analyses show that patterns of health outcomes and behaviours vary depending on the neighbourhood in which people live
Rates varied by neighbourhood type in Toronto and Vancouver only
� Injury in the Last 12 Months
Rates were lower in neighbourhoods mostly situated closest to downtown areas
� Self-Reported Overweight/Obesity (BMI >25)
In general, rates were higher among residents in neighbourhoods with higher-than-average median income and percentage of postsecondary graduates
� Self-Rated Excellent or Very Good Health� Active or Moderately Active Physical Activity� Non-Smokers
Neighbourhood TypeOutcome or Behaviour
Vancouver CMA
Vancouver Neighbourhoods: Differences in Health-related Behaviours and OutcomesEXCELLENT/VERY GOOD HEALTH, ACTIVE/MODERATELY ACTIVE PHYSICAL ACTIVITY
Residents in neighbourhoods with higher-than-average median income and/or a higher-than-average percentage of postsecondary graduates were more likely to report excellent or very good health and active/moderate physical activity than residents of other neighbourhood types.
SMOKERS
People living in Vancouver�s most affluent neighbourhoods were less likely to report being smokers than other residents of Vancouver.
INJURIES
The proportion of people reporting an injury in the last year was lower among residents in neighbourhoods with a high percentage of recent immigrants and neighbourhoods with low median income compared to other neighbourhood types.
OVERWEIGHT/OBESITY
Rates of overweight and obesity were higher in neighbourhoods with high median income and lower-than-average percentage of postsecondary graduates compared to neighbourhoods that have a high percentage of recent immigrants or a high percentage of persons living alone.
Calgary CMA
Calgary Neighbourhoods: Differences in Health-related Behaviours and OutcomesEXCELLENT/VERY GOOD HEALTH, SMOKERS
Residents of neighbourhoods with higher-than-average median income and a higher-than-average percentage of postsecondary graduates were more likely to report excellent or very good health and less likely to report being smokers than residents of other neighbourhood types.
ACTIVE/MODERATELY ACTIVE PHYSICAL ACTIVITY
Residents of neighbourhoods with higher-than-average median income and a higher-than-average percentage of postsecondary graduates are more likely to participate in physical activity than residents of neighbourhoods with lower-than-average median income and percentage of postsecondary graduates.
INJURIES
The proportion of people reporting an injury in the last year did not vary significantly among Calgary�s neighbourhood types
OVERWEIGHT/OBESITY
Residents of neighbourhoods with lower-than-average median income and percentage of postsecondary graduates were more likely to report being overweight or obese than residents of neighbourhoods with higher-than-average percentage of postsecondary graduates and lower-than-average median income.
Toronto CMA
Toronto Neighbourhoods: Differences in Health-related Behaviours and OutcomesEXCELLENT/VERY GOOD HEALTH
Residents of neighbourhoods with higher-than-average income and a higher-than-average percentage of postsecondary graduates were more likely to report excellent or very good health than residents of neighbourhoods with lower-than-average income and percentage of postsecondary graduates, as well as those in neighbourhoods with a higher-than-average percentage of recent immigrants
INJURIES, ACTIVE/MODERATELY ACTIVE PHYSICAL ACTIVITY
Residents of Toronto�s least affluent areas and which have twice the percentage of recent immigrants compared to Toronto on average, are less likely to report being physically active and less likely to report being injured in the previous 12 months than those living in other neighbourhoods.
SMOKERS
The proportion of residents that reports being smokers did not vary significantly among Toronto�s neighbourhood types.
OVERWEIGHT/OBESITY
Rates of overweight and obesity are lower in neighbourhoods located primarily in the inner city or the outer suburbs, compared to neighbourhood areas lying on the east and west sides of the downtown area.
Montréal CMA
Montréal Neighbourhoods: Differences in Health-related Behaviours and OutcomesEXCELLENT/VERY GOOD HEALTH, ACTIVE/MODERATELY ACTIVE PHYSICAL ACTIVITY
People living in neighbourhoods with higher-than-average income and percentage of postsecondary graduates were more likely than those living in most or all other neighbourhood types to report excellent or very good health and active/moderately active physical activity.
SMOKERS
The proportion of residents who reported being smokers was lower in neighbourhoods with higher-than-average income and percentage of postsecondary graduates than in other neighbourhoods.
INJURIES
The proportion of residents who reported injuries in the last year did not vary significantly from one Montréal neighbourhood to another.
OVERWEIGHT/OBESITY
Compared to other neighbourhoods, residents of neighbourhoods with higher-than-average percentage of postsecondary graduates and lower-than-average median income were the least likely to report being overweight or obese. This type of neighbourhood is largely situated on the island of Montréal, just east of the downtown core.
Halifax CMA
Halifax Neighbourhoods: Differences in Health-related Behaviours and OutcomesEXCELLENT/VERY GOOD HEALTHResidents of neighbourhoods with lower-than-average income but higher-than-average percentage of postsecondary graduates were more likely than those living in other neighbourhood types to rate their health as excellent or very good.
SMOKERSResidents of neighbourhoods living in Halifax�s least affluent areas (lowest percentage of postsecondary graduates and median income, and highest percentage of lone-parent families) were more likely to report being smokers than those living in the other types of neighbourhoods.
INJURIES, OVERWEIGHT/OBESITY, ACTIVE/MODERATELY ACTIVE PHYSICAL ACTIVITYThe proportion of residents who reported being injured in the previous 12 months, active or moderately active, or overweight/obese, did not vary significantly from one Halifax neighbourhood to another.
URBAN LIVING: HOUSING AND HEALTH
Home as Place, House as SpaceCanadian research reports linkages between self-rated health and mental health with:
� The meaning people attribute to their homes
� The level of satisfaction they feel with their homes
� The control they feel they have over their home lives
Qualitative international research reports that people associated their homes with:
� The rituals and celebrations of family life
� Feelings of control, privacy, refuge and familiarity
Housing AdequacyThe Canada Mortgage and Housing Corporation (CMHC) defines adequate housing as dwellings that occupants report do not require major repairs
� Housing that is in need of major repair tends to be found in low-income households or highest-need neighbourhoods
� Various biological, chemical and physical housing exposures can increase the risk of adverse health outcomes
� Lead
� Environmental Tobacco Smoke (ETS)
� Dust Mites and Dampness/Mould
� Smoke/Fire
� Home Safety/Stairs
Housing SuitabilityThe CMHC defines suitable housing as dwelling units that �have enough bedrooms for the size and make-up of resident households according to National Occupancy Standard requirements�
� Research shows a link between overcrowded or unsuitable housing and poor physical health outcomes (for example, tuberculosis) and mental health outcomes
� Various factors may influence whether people live in overcrowded housing:
� Arrival of unanticipated family members� Immigration� Cultural preferences� Financial need
Housing AffordabilityThe CMHC defines affordable housing as that which costs less than 30% of one�s household income before taxes
Research shows that people who own their home generally report being healthier than those who rent
� Health issues linked to owning and renting in urban areas include depression, stress, psychological distress and inadequate nutrition
2001 Census data show that almost two-thirds of Canadians own their own homes and about one-third rent
� In 2001, nine out of 10 Canadian households with the highest incomes owned their homes and spent about 10% of their income on housing
� Among households with lower incomes (under $20,000) almost two-thirds rented, many of which earned so little that they were considered to be in core housing need
CONCLUSION:PUTTING POLICIES AND PROGRAMS
IN PLACE
Policies and Health in Urban Places: Neighbourhood SafetyWe know that �
� a number of evaluated policies, guidelines and regulations affecting neighbourhood design and urban planning have been linked to improved health outcomes. For example:
� improved visibility of pedestrians and cyclists through increased lighting intensity in neighbourhoods can lead to a statisticallysignificant decrease in the number of night-time pedestrian/vehicle crashes
� injuries and crash rates in urban neighbourhoods have been reduced through traffic-calming measures, such as speed reductions and separating pedestrians and vehicles (for example,sidewalks, refuge islands, pedestrian barriers)
Policies and Health in Urban Places: Urban Design and HealthWe know that �
� policies ranging from emission standards to the availability of public transportation to urban design legislation may affect the quality of the air we breathe
� people living in high-walkability neighbourhoods are more likely to engage in at least 30 minutes of moderate-intense physical activity on a given day
� public transit users can achieve at least 30 minutes of daily physical activity by walking to and from pick-up points
Policies and Health in Urban Places:Neighbourhoods and Urban DesignWe do not know �
� a great deal about how neighbourhood-level strategies specific to health behaviours translate into health outcomes
� a great deal about the effectiveness of interventions and strategies to modify social characteristics
� Interventions intended to improve the quality of social relationships are not easily designed nor easily evaluated for their effectiveness in improving health outcomes
� the impact of full implementation of approaches such as Smart Growth and the resulting impacts, if any, on the health of communities
Policies and Health in Urban Places: Housing and Health (1)We know that �
� federal guidelines, codes and standards exist to ensure housing is suitable, adequate and affordable (for example, National Building Codes, National Occupancy Standard)
� a number of evaluated initiatives and interventions exist providing evidence on ways in which housing can be made safer and healthier
� Prevention programs to reduce blood lead level concentrations
� Provincial �Smoke-Free� by-laws
� Legislated installation of smoke detectors
� Installation of grab bars in housing
Policies and Health in Urban Places:Housing and Health (2)We do not know �
� the extent to which the psychosocial aspects of home are linked to health
� of the existence of research or policy initiatives designed to address overcrowding where associated health consequences among populations that may be more at risk have been evaluated
� the relationship between variations in provincial building codes and health outcomes across the provinces
� the full extent of the relationship and possible interactions between individual- and neighbourhood-level factors and their links to health
Conclusion� Patterns of health can vary between cities and between
neighbourhoods in urban areas
� Various social and physical (place and space) aspects of both a neighbourhood itself and the housing within it can shape these differences
� Both the place and space aspects of urban areas can in turn shape people�s daily lives and health
� There are a number of programs and policies related to place-specific aspects of neighbourhood characteristics, housing and the environment that have been implemented across Canada and around the world - some have been evaluated, but many have not
� There is a role for everyone to play, both in the health and non-health sectors, in creating places and spaces throughout Canada�s urban areas that are healthy and enable Canadians to support each other where they live, learn, work and play
