T.O. Health Check: An Overview of Toronto’s Population Health Status
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.
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.
- Toronto’s population is growing and at the same time, aging. In 2016, seniors (aged 65 years and over) comprised a slightly larger proportion of the population than children (aged 14 years and under). The proportion of seniors is expected to continue growing, driving higher rates of certain chronic health conditions, the amount and type of health resources and urban design features required to respond to these changes, as well as dependencies on the working-age population.
- Lone-parent families represent one-third of all Toronto families with children. The majority of these families are led by female parents.
- There are many more Indigenous people living in Toronto than previously reported. According to the 2016 Census, there were 23,065 people living in Toronto who identified as Aboriginal*. More recent research shows that the actual Aboriginal population that year was between 34,000 and 69,000.
- The “visible minority” is now the majority. More than half (52%) of Toronto’s population identified as belonging to a visible minority (i.e. racialized group) in 2016, up from 47% in 2006. Some racialized groups are more likely to experience negative health outcomes compared to non-racialized groups.
- The proportion of immigrants dropped slightly, representing just under half of all Torontonians. In 2006, 50% of the population were immigrants; by 2016 this figure declined to 47%. Of these, 15% had immigrated within the last five years.
- Lesbian, gay or bisexual was identified as the sexual orientation of about five percent of Toronto adults in 2015/16. Among Indigenous people in Toronto (15 years of age and over) in 2016, the corresponding figure was nine percent.
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.
- Adequate, affordable and suitable housing is out of reach for many Torontonians. Almost four in ten households in Toronto (37%) were experiencing housing affordability issues in 2016 while 23% fell below at least one of the standards for adequacy, affordability or suitability (i.e. categorized as being in “Core Housing Need”).
- Active transportation such as walking or cycling, is used by about one in ten (11%) individuals, aged 15 years and over, as their main mode of commuting. Among grade 7 to 12 students, 44% used active transportation to and/or from school in 2014.
- Air pollution contributes to about 1,300 premature deaths and 3,550 hospitalizations in Toronto each year with traffic being a major contributor (2014 estimate). While Toronto’s air quality has been improving and the associated negative health impacts decreasing, climate change may create conditions for increasing secondary pollutants such as ozone.
- Extreme heat contributes to an estimated average of 120 deaths per year in Toronto. This figure could increase with climate change; the mean maximum summer temperature has increased from an average of less than 24 degrees Celsius in 1840, to over 26 degrees in 2017.
- Noise levels with the potential to harm health affect almost nine in ten (89%) Toronto residents (2016 estimate). The lowest income areas were almost eleven times more likely to have half of their residents exposed to night noise levels above the recommended level, compared to residents of areas in the highest income group.
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.
- There is a trend in Toronto to delay childbearing. Between 2007 and 2016, the average age of women giving birth increased and fertility rates in all age groups under the age of 35 decreased.
- About 4 in 10 (41%) of Toronto women gained more weight during pregnancy than recommended. Nine percent have been diagnosed with gestational diabetes. Both of these rates increase according to increases in pre-pregnancy body mass index.
- Mental health concerns during pregnancy are experienced by one in ten Toronto women. The most common are anxiety and depression.
- Singleton babies that are small for gestational age are born at a significantly higher rate in Toronto (12%) than the rest of Ontario (9.1%). Rates for low birth weight (8%) and preterm birth (9%) are also higher in Toronto; all three rates have been stable over time (2007 to 2016).
- At six months of age, three quarters (75%) of Toronto babies are receiving breastmilk. Almost all Toronto women (98%) initiate breastfeeding.
- Fourteen percent of Toronto kindergarten students are considered vulnerable for age-appropriate developmental expectations. Compared to the province, Toronto children are more likely to be vulnerable in communication skills and general knowledge.
- Health inequities exist even in these early stages. Lower income areas of the city have higher rates of unfavourable health outcomes for a number of reproductive and early child health indicators including gestational diabetes, small for gestational age, low birth weight and vulnerability in early child development.
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.
- The rate of suspected dental caries for children from schools in the lowest income areas is more than twice that for children from schools in the highest income areas (19% vs. 8%). Socio-economic status is an important determinant of a student’s ability to see the dentist.
- Nearly one-third (32%) of Toronto adults had not seen a dentist in the past year. Of those, nearly four in ten (38%) cited cost as a barrier in 2013/14. Separate estimates show that recent immigrants and Indigenous people are less likely to visit a dentist compared to the general population in Toronto.
- More Toronto adults lack dental insurance compared to adults in the rest of the province (38% vs. 28%). Seniors and lower income adults had higher rates of being uninsured compared to the general population in Toronto in 2013/14.
- Water fluoridation has contributed to lower rates of cavities in children. Before the introduction of community water fluoridation in 1963, children in Toronto had an average of five to seven cavities. In 2011, the estimate was an average of one to two.
- Data on the oral health of Toronto children and youth are limited. The data that do exist are not comparable between regions or over time.
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.
- While the majority of Toronto residents have positive mental health, there is a large gap between some groups. For example, 71% of Toronto adults rate their mental health as being ‘excellent’ or ‘very good’, compared to just 31% of Indigenous adults.
- More than two-thirds (68%) of Toronto adults report a “very strong” or “somewhat strong” sense of belonging to their local community. Younger adults (18 to 34 years of age) are less likely and older adults (65 years of age and over) more likely to report strong levels of belonging.
- Nearly one-quarter (22%) of Toronto adults report that most of their days are “quite a bit stressful” or “extremely stressful”. One-quarter (25%) rate their ability to handle unexpected and difficult problems or the day-to-day demands of life as ‘fair’ or ‘poor’.
- There are seven visits to a physician for a mental health or addiction-related issue per year for every 100 Toronto residents. The rate is 30% higher for females than males.
- Substance-related disorders are the most common diagnosis for a mental health- or addiction-related issue in emergency departments, with a rate of 6.6 per 100 people. Mood/affective disorders, such as depression, are the most common diagnosis for a mental-health related hospitalization, with a rate of 0.7 cases per 1,000 people.
- Just over one in ten (11%) Toronto students report hurting themselves on purpose, for example, by self-cutting or burning, in the past year. Among the general population in Toronto, rates of emergency department visits for self-harm increased from 9.0 per 10,000 in 2015 to 10.8 in 2017.
- There are on average 9 suicide deaths per 100,000 persons per year in Toronto. Twelve percent (12%) of Toronto students report they have seriously considered suicide in the past year. An Ontario-wide study found that 35% of transgendered persons considered suicide in the past year.
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.
- Alcohol is the most commonly used substance in Toronto, with three in four adults (76%), and one in three grade 7 to 12 students (29%) having consumed alcohol in the past year. One in four adults (25%) exceed the Low-Risk Alcohol Drinking Guidelines, and one in seven grade 7 to 12 students (15%) report heavy drinking (5 or more drinks on one occasion) in the past year. Alcohol was the most common drug for which Toronto residents attended substance use treatment programs in 2017.
- One in seven adults reported using cannabis in the past year in 2015/16. Cannabis was more commonly consumed in Toronto than in the rest of the Greater Toronto Area.
- The number of opioid poisonings has increased dramatically over the past five years. There were 308 Toronto deaths from opioid toxicity in 2017, and over 3,000 calls attended by Toronto paramedics for suspected opioid overdoses in 2018. Fentanyl and its analogues directly contributed to almost 80% of opioid poisoning deaths in 2017/2018.
- The proportion of adults reporting drinking alcohol and driving has decreased over the past 20 years. Driving and other psychoactive substance use is however, a growing concern with 6% of students in grade 7 to 12 reporting riding in a car in the past 30 days that was driven by someone who had used drugs.
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.
- Most students in grade 9 to 12 (85%) are extremely or very confident in their ability to refuse sexual activity. Confidence in refusing sexual activity is higher in females than in males.
- One in five (20%) students in grades 9 to 12 are sexually active. Of these, 84% feel confident in their ability to use protection against sexually transmitted infections, while rates of actual use are 61%.
- More than one-third (35%) of all sexually active students in grades 9 to 12 have had two or more partners in the past year. Compared to those with one partner, they are equally likely to use a condom, and over three times more likely to have been tested for sexually transmitted infections.
- Students identifying as lesbian, gay, bisexual, pansexual, other sexual orientation or not sure are almost twice as likely to be sexually active. They also indicate feeling significantly less confident in their ability to use protection against sexually transmitted infections.
- About one in five (19%) sexually active students report having been to a doctor or a clinic to be tested for a sexually transmitted infection (STI). Females are twice as likely (28%) to undergo STI testing compared to males (12%). Students identifying as lesbian, gay, bisexual, pansexual, other sexual orientation or not sure are twice as likely as heterosexual students to have been tested for STIs.
- The overall STI rates have increased by 58% over the last 10 years. The highest rates of chlamydia and gonorrhea were reported among those aged 15 to 29 years old, comprising 52% and 67% of reported cases, respectively.
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.
- Immunization coverage of school-age children in Toronto is nearing national target levels. The overall coverage rate in 2018 to 2019 school year was 89% for diphtheria, tetanus, polio vaccine and 94 % for measles, mumps, rubella (MMR) vaccine.
- HIV infection rates in Toronto continue to exceed the rest of Ontario and Canada. This reflects local population characteristics and is evidence of the need for improved diagnosis and treatment of new HIV infections to meet provincial and international targets for care.
- Cases of chronic viral bloodborne infections (e.g., hepatitis B and C) remain high in Toronto. Despite improved treatment and prevention strategies, these long-lasting infections still contribute significantly to the burden of illness in Toronto.
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.
- Emergency department visits for unintentional injuries are highest for males 10 to 19 years of age. The ED rate has increased over time for children 5 to 14 years of age.
- Hospitalization for unintentional injury is highest among females 65 years of age and over. There has been a recent increase in both hospitalizations and ED visits for unintentional injuries among adults 75 years of age and over.
- Falls are the leading cause for emergency department visits and hospitalization for unintentional injuries in Toronto and are the ninth leading cause of death. Falls are most common among seniors.
- One-third (33%) of Toronto adults 18 years of age and over with a valid driver’s license reported texting while driving in the past twelve months. Inattentive driving is the leading cause of traffic fatalities in Ontario.
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.
- The majority of Toronto adults and youth are not consuming enough vegetables and fruits. Only one in four (25%) adults consume vegetables and fruits five or more times per day, and only one in eight (13%) grade 7 to 12 students are meeting recommended vegetable and fruit consumption targets.
- The vast majority of Toronto youth are not getting enough exercise. Only one in 14 (7%) grade 7 to 12 students are meeting the Canadian Physical Activity Guidelines. Almost three in four (73%) students exceed the maximum amount of screen time recommended by the 24-Hour Movement Guidelines (less than two hours per day).
- Over half (52%) of adults and almost a third (29%) of youth in Toronto have overweight status/obesity. Toronto youth with lower socio-economic access are more likely to have overweight status/obesity.
- Youth in Toronto are not getting enough sleep. Two in five (40%) Toronto students in grades 7 to 12 report sleeping the recommended eight or more hours on an average school night. Sleep and screen time are closely linked.
- Approximately one in seven (16%) Toronto adults are current smokers. Health inequities persist, with 63% of Toronto Indigenous adults smoking currently. Disparities in smoking status by sexual orientation also exist.
- About one in five (21%) adult non-smokers are regularly exposed to second-hand smoke in public places. Exposure to second-hand smoke in public places is significantly higher in Toronto than in the rest of Ontario (13%).
- Breast cancer (in females), prostate, lung, and colorectal are the most common cancers in Toronto. Lung and colorectal cancers are the most likely to lead to death.
- It is becoming more common for people to live with some chronic diseases. The prevalence of diabetes, chronic obstructive pulmonary disease, and dementia is increasing in the population.
- Ischemic Heart Disease (IHD) is the leading cause of death. However, the mortality rate for IHD and other cardiovascular diseases is decreasing.
- People with lower income are at greater risk for chronic conditions. People in the lowest income quintile are more likely than those in higher income quintiles to have diabetes and chronic obstructive pulmonary disease, and are more likely to be hospitalized for cardiovascular disease.
- Dementia is becoming more common among seniors in Toronto. 16% of seniors between 75 and 84 years of age live with dementia. This figure increases to 45% for those over the age of 84. Dementia is the second leading cause of death among Torontonians.
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