Assessing and reporting the health status of Toronto’s population is a foundational role for public health. Health status information provides vital evidence for responding to the city’s unique and emerging health needs using an evidence-informed approach.
Toronto’s Health Status 2019 provides a broad array of population health indicators that reflect health determinants, risk factors, behaviours and outcomes. Selected results are depicted over time or compared to other regions. Examples of health inequities are provided throughout the report to demonstrate that good health is not equally shared by everyone. Gaps in information are also identified to shine a light on the need for improved data and more efficient data collection processes.
Click on the boxes below to view the introduction and key messages for each chapter of the report. Links to the full chapter PDFs are also included.
TO Health Check Report 2019 Board of Health Report Population Health Status Indicators Dashboard
Toronto is Canada’s largest city, with one of the most diverse populations in the world. The structure of Toronto’s population has changed over time, influencing population health status and other social outcomes, and shaping the city in a dynamic fashion. Demographic information reflecting the city’s changing size and composition, helps public health and other service providers prepare to respond to issues and demands arising from population growth, aging, migration, and other changes.
Some of the demographic characteristics described in this chapter such as age and sex, influence health status directly through biology. Others including Indigenous identity, immigration, ethnicity, sexual orientation and others, are linked to social processes that influence health status. For example, people of some ethnic backgrounds may experience discrimination or racism which is harmful to their health. The demographic information in this chapter sets a foundation for the health inequities and differences between groups that are highlighted throughout this report.
Link to Chapter 1: Population Demographics
*“Aboriginal Peoples” is a collective name used for all of the original Peoples of Canada and their descendants. The Canadian Constitution Act of 1982 specifies that the Aboriginal Peoples in Canada consist of three groups: Indians (First Nations), Inuit and Métis. The term “Indigenous” is increasingly preferred in Canada over the term “Aboriginal”. Ontario’s current practice is to use the term “Indigenous” when referring to First Nations, Inuit and Métis Peoples as a group, and to refer to specific communities whenever possible.
The preceding chapters described how social determinants of health influence individual and population health. The natural and built environments in which people live, work, learn and play also influence healthy behaviours and create conditions for good health. Quality, affordable housing, an active transportation infrastructure, and an abundance of quality green space, encourage settings in which people can prosper, socialize and be physically active. In contrast, harmful environmental exposures including ultraviolet (UV) radiation, poor air and water quality, climate change and noise can be detrimental and result in injury, disease, and death.
Addressing local environmental determinants of health is one component of improving health equity and is a key approach for the future health of the entire population, not just in Toronto, but across the globe.
Link to Chapter 3: The Natural and Built Environments
The early years are an important time for rapid growth and development. A person’s future health status is heavily influenced by experiences, exposures, and relationships during the first few years of life. Even before birth, a child’s health is influenced by the preconception health of both of their parents and by their mother’s prenatal health and exposures while they are developing in utero. Positive physical, social, and emotional development in early childhood are the building blocks for favourable long-term educational, behavioural, and health outcomes.
Because the preconception and prenatal periods and the early years are such important times for setting the stage for a lifetime of health, they are key windows of opportunity for public health promotion and intervention to encourage the best possible beginnings for Toronto’s youngest residents and their families.
Link to Chapter 4: Reproductive and Early Child Health
Good oral health allows one to eat, drink, speak, smile, and socialize, and protects against pain and microbial infections. Poor oral health is associated with a variety of negative health outcomes, including the delivery of pre-term low birthweight babies, diabetes, and cardiovascular disease. Dental disease is a complex chronic disease that is heavily influenced by biomedical factors such as diet, bacteria and host. Social, economic, and behavioral determinants also play an important role.
Early childhood caries (ECC) is the most common childhood disease and is often accompanied by serious comorbidities affecting children, their families, the community and the health care system. Despite continued efforts to better understand the etiology of ECC and despite advances in prevention, the prevalence of ECC in Canadian preschool children is a growing concern. Dental surgery for ECC under general anesthesia is the most common day surgery procedure at most pediatric hospitals in Canada.
Children who have poor oral health often miss more school and receive lower grades than children who don’t. As with other areas of health, the early years are an important time to set the trajectory for a lifetime of good oral health and represents an opportunity for public health promotion and intervention to encourage good oral health behaviours and outcomes.
Link to Chapter 5: Oral Health
Assessing the state of mental health of the population involves examining two distinct but interrelated concepts: positive mental health and mental illness. A mental illness is a medically diagnosable condition where a person’s thinking, mood, and/or behaviours can negatively and sometimes severely impact functioning in life. Positive mental health describes a person’s ability to enjoy life, work productively, and manage life’s challenges. People living with mental illness can still experience high levels of emotional well-being and positive psychological and social functioning in life, while people not diagnosed with mental illness can experience lower levels of emotional and functional well-being.
Overlapping with those which influence physical health, the social determinants of mental health drive risk and protective factors for poor mental health and illness across the lifespan. Research suggests that social inclusion (supportive relationships, community and social connections, and civic engagement), freedom from violence and discrimination (physical security, living in a community that values diversity, self-determination), and access to economic resources (access to adequate housing, education, work, money and meaningful engagement) are important determinants of mental health.
Mental illness and poor mental health are associated with a range of negative physical health outcomes, increased health care use, work absenteeism, and lower quality of life. This chapter examines both positive mental health and mental illness, as well as related issues such as stress and coping.
Link to Chapter 6: Mental Health and Illness
The substances covered in this chapter include psychoactive drugs, which are chemical substances that alter brain function and result in temporary changes in perception, mood and behaviour. Psychoactive substances are used for both medical and non-medical reasons. They can be legal, and are widely available, such as alcohol. Some are available by prescription for pharmaceutical use, such as some opioids and stimulants. Other drugs are obtained in the illicit market, such as cocaine and heroin.
When used in moderation and in a safe environment, substance use can have a positive impact on life satisfaction. However, substance use can also have negative physical, social, and psychological impacts. It can lead to a higher risk of injury and chronic disease, can have a negative impact on mental health and relationships, and can interfere with employment and housing security. Behaviours such as driving under the influence of psychoactive substances, sharing intravenous needles and other equipment, and using drugs alone or in unsafe environments can increase the risk of harms. In addition, the unregulated nature of the illicit drug market can result in unintentional drug poisoning via product contamination and/or unknown potency.
Beyond mental and physical health impacts, the stigma, marginalization, and discrimination also impact the health of people who use drugs. The criminalization of some types of drug use contributes significantly to these harms. Addressing the related social determinants of health, such as housing, social inclusion, and income, is an important component of preventing harmful substance use.
Like other behaviours, substance use is challenging to reliably measure in the population. Many of the data sources used to estimate substance use in this chapter likely underestimate the magnitude of use and harms in Toronto. Surveys, in particular, under-represent many of the vulnerable populations that use drugs. In addition, social desirability bias, whereby survey respondents may not want to admit their use of drugs for fear of judgement or criminalization, could contribute to under-reporting. The stigmatizing and marginalization of people who use drugs compounds this problem. In this regard, caution should be exercised when interpreting the estimates presented in this section.
Link to Chapter 7: Substance Use
Sexual health is defined as a state of physical, mental and social well-being in relation to sexuality. Historically, indicators that have been used to track sexual health have had a biomedical focus primarily due to the fact that epidemiological measures of sexually transmitted infections (STIs), human immunodeficiency viruses (HIV) (Chapter 9) and pregnancy (Chapter 4) have been readily available. While these indicators are important to public health, sexual health promotion ideally balances the biomedical and the social dimensions of sexual health. Sexual health indicators should not only inform our understanding of observed changes in STIs, HIV, and unintended pregnancy, they should also form the basis of evidence-informed sexual health promotion programs aimed at improving sexual competence and creating healthy sexual relationships.
A sexual competence framework is used in this chapter as it captures both the emotional and social context around sex and protective behaviours taken to prevent unwanted and/or negative physical health outcomes. Sexual competence, in the context of first intercourse, is characterized by self-perceived autonomy, self-perceived consensual sex, self-perceived acceptable timing, and contraceptive protection. This framework acknowledges that sexual competence has a direct influence on sexual behaviours and outcomes.
The sexual health data presented in this chapter includes sexual health behaviours, knowledge, attitudes, and resources collected through two surveys, the Canadian Community Health Survey (CCHS) for 2015/2016 and Toronto Public Health’s 2014 Student Health Survey. Results from these two surveys are limited in their ability to be compared across geographies and over time. Comparisons between the two surveys are also limited, in part due to differences in terminology such as sexual orientation, sexual initiation and birth control. This chapter also includes reported STIs rates, which were calculated using data extracted from Ontario’s integrated Public Health Information System (iPHIS). While this chapter describes some important sexual health indicators, it also highlights the importance of developing, validating, and routinely and systematically collecting data to provide an inclusive report of sexual health and wellness.
Link to Chapter 8: Sexual Health
Successful public health interventions such as vaccination, pasteurization, food safety programs, improved sanitation, and education have greatly reduced the burden of illness associated with infectious diseases. Despite this, infectious diseases still circulate and can have a significant impact on health. New and accessible prevention and treatment options for infections such as bloodborne hepatitis and HIV have led to longer lifespans and a longer chronic state of illness for those infected.
Complex contributing factors can include sexual practices, travel patterns, housing status, immigration status, vaccination status, food handling practices, and access to health care for prevention, early diagnosis and treatment. New challenges to the control of infectious disease have been introduced by the growing threat of antimicrobial resistance. As more drugs become ineffective, the risk of disease transmission and associated morbidity and mortality are increased.
Link to Chapter 9: Infectious Disease
In Canada, the economic burden of injury is increasing, and costs more than heart disease and stroke combined. In Ontario, the total cost associated with unintentional injuries in 2010 was $7.4 billion of which $4.7 billion were direct health care costs, and the remainder were indirect. Daily, more than 10,000 Canadians are injured seriously enough to require medical attention. However, the majority of injuries can be prevented.
Injuries can be defined by whether they are intentional or unintentional. Intentional injuries can include violence (homicide and assault) (Chapter 2), and self-harm and suicide (Chapter 6). Unintentional injuries represent the majority of injuries and include injuries that are not purposely inflicted, such as those resulting from motor vehicle collisions, drowning, falls, and sports and recreation. Most unintentional injuries are predictable and can be prevented by recognizing and addressing unsafe environments, conditions, and behaviours. The rates and types of unintentional injuries are notably different among adults and seniors compared with children and youth and are important to understand for the development of effective prevention strategies. Unintentional injuries can also vary in their degree of seriousness. They can lead to emergency department visits, hospitalization, being partially or totally disabled, and sometimes death.
Link to Chapter 10: Unintentional Injury
Chronic diseases, such as cancer, diabetes, cardiovascular disease, and respiratory disease, are leading contributors to death and disability, both locally and nationally. With the aging population in Canada, most chronic diseases are increasing in burden, including dementia, which is emerging as a condition with growing public health importance. Like other population health outcomes, chronic conditions are influenced by complex interactions of biological, social and environmental determinants, and risk factors including individual behaviours. Chapters 2 and 3 of this report include some of the key social and environmental issues that influence the health of Torontonians. This chapter investigates important risk factors for chronic disease including cigarette smoking, physical inactivity, unhealthy eating. The majority of Canadians have at least one of these risk factors, which have a strong influence on several disease outcomes.
Health-related behaviours provide critical opportunities for chronic disease prevention and improved health. A lifestyle including healthy eating and physical activity directly contributes to positive health outcomes, and can also modify other risk factors, such as overweight status/obesity. Tobacco use is also a major contributor to disease and disability in Canada, associated with cancer, cardiovascular disease, and respiratory disease. Smoking prevention and cessation activities are essential to reducing the incidence and prevalence of chronic disease in Toronto. Although individual choice plays a role, the prevalence of chronic diseases will not be reduced one person at a time. Addressing determinants of health through healthy public policy and a comprehensive health promotion strategy at the population level is essential to reduce the burden of chronic disease.
The majority of the data on risk factors reported here are self-reported. Evidence shows that self-reports may over- or underestimate the true prevalence of many behaviours; for example, people tend to overestimate how much physical activity they are getting, and underestimate their weight.
Link to Chapter 11: Chronic Conditions and Risk Factors
Link to Appendix 1: Mortality
Link to Appendix 2: Terms and Definitions
Link to Appendix 3: Data Notes and Caveats
Link to Appendix 4: Data Sources