H u r o n C o u n t y H e a l t h U n i t Community Health Status Report

Transcription

1 H u r o n C o u n t y H e a l t h U n i t 2 9 Community Health Status Report

2 Message from the Huron County Health Unit In public health we are always striving to gain a better understanding of the needs of our community so that we can make evidence-informed decisions about the programs and services we provide. Evidence informed decision-making allows us to focus our limited resources where they will have the greatest impact in our rural setting. This Community Health Status Report is one important way the Huron County Health Unit builds the evidence to support the decisions we make. The report provides a snapshot of the health status of our community, allowing us to highlight where the health of our community is thriving and where it could use improvement. Monitoring the health status of Huron County over time will also be vital to ensure that we continue to be flexible in meeting the changing needs of our community. The report also examines how the social determinants of health are at play in our community, which is vital to describing community needs. Given that the social determinants of health are a guiding principle of our organizational structure and are embedded into our program and service delivery, it is a natural extension to use them as a framework for this report. The report details the impact of social and economic factors on health, and helps develop an understanding of those most at risk or who may have barriers to accessing good health. It also examines how social factors influence different health outcomes for Huron County residents. They will help us and other community groups provide services that are accessible to all, especially those who need these services the most. It is the vision of our health unit that we all work to create healthy communities together. As such, we hope this report will belong to the community, not only those who plan and provide community services, but also those who live, work and play in Huron County. This report is a reflection of the people who live in Huron County and brings a greater understanding of the community as a whole. Author: Rachel Savage, Epidemiologist Co-Authors: Dr. Beth Henning, Medical Offcer of Health and Penny Nelligan, Director. September 28 Huron County Community Health Status Report - 1

3 Table of Contents 1. Executive Summary A summary of the major findings and themes Introduction Describes the purpose and content Methods Identifies and describes the data sources, methods of analysis used and a summary of limitations Demographics Describes the population characteristics of Huron County such as population size, density, age distribution, ethnicity and immigration Social Determinants of Health Explains the impact of social and economic factors on health and describes the social and economic characteristics of Huron County Income and Cost of Living in Huron County Employment Education Housing Food Security Social Networks 6. Self-Reported Health Describes self-reported general health status of Huron County residents by various social and economic factors, such as income level and education Behavioural Risk Factors Measures and describes various health behaviours established to increase the risk of developing poor health outcomes, particularly chronic health conditions...23 Tobacco Smoking Status Smoke-Free Homes Secondhand Smoke Alcohol Alcohol Use Binge Drinking Drinking and Driving Physical Activity Fruit and Vegetable Consumption Body Mass Index (BMI) Sun Safety Self-Perceived Life Stress 8. Mortality Describes annual deaths rates in Huron County and ranks the leading causes of death and premature mortality....3 All Cause Mortality Leading Causes of Death Standardized Mortality Ratios (SMRs) Life Expectancy Potential Years Life Lost (PYLL) 2 - Huron County Community Health Status Report

4 9. Morbidity Describes annual hospitalization rates in Huron County and ranks the leading causes of hospitalization All Cause Hospitalization Leading Causes of Hospitalization Standardized Morbidity Ratios (SMRs) 1. Chronic Health Conditions Measures the self-reported prevalence of health conditions which develop and last over a long period of time and also describes hospitalization and death rates for chronic conditions of public health importance Prevalence of Chronic Health Conditions Morbidity and Mortality for Selected Chronic Conditions Ischemic Heart Disease Cerebrovascular Disease Diabetes Chronic Lower Respiratory Diseases Incidence and Mortality Rates for Cancers Overall Cancer Incidence and Mortality Breast Cancer Prostate Cancer Colorectal Cancer Lung Cancer Prevalence of Cancer Screening Breast Cancer Cervical Cancer Colorectal Cancer 11. Reproductive Health Describes the characteristics of Huron County parents which are known to affect birth outcomes and measures the number and rate of births and pregnancies in Huron County. Birth outcomes are also described and compared to the province Characteristics and Health Behaviours in Parents Maternal and Paternal Age Maternal Education Household Income Level of Support in the Household Smoking Status Alcohol Use Folic Acid Supplementation Prenatal Classes Breastfeeding Initiation and Duration Fertility and Pregnancy Crude Birth Rate Multiple Births Pregnancy Rate Fertility Rate Therapeutic Abortion Rate Birth Outcomes Birth Weight Low Birth Weight Rate High Birth Weight Rate Preterm Birth rate Stillbirth Rate Huron County Community Health Status Report - 3

5 Infant Mortality Rate Congenital Anomalies 12. Unintentional Injury and Injury Prevention Describes important risk factors for unintentional injuries with a focus on risk factors prevalent in rural environments. Emergency room visits, hospitalizations and deaths are measured to describe select unintentional injuries. Self-reported injury prevention behaviours are described Risk Factors for Unintentional Injuries Self-Report Injury All Unintentional Injuries (All Causes) Selected Causes of Injury Falls Land Transport Occurrences Injuries Occurring on Farms Unintentional Injuries in Children -6 years Injury Prevention Seat Belt and Booster or Car Seat Use Bike Helmet use 13. Communicable Disease Measures and describes the most common reportable diseases in Huron County caused by infectious bacteria, viruses and parasites Most Common Reportable Diseases Sexually Transmitted Infections (STIs) and Bloodborne Diseases Chlamydia Gonorrhea Hepatitis C Food and Waterborne Enteric Diseases Campylobacteriosis Salmonellosis Giardiasis Verotoxin-Producing Escherichia coli (VTEC) Cryptosporidiosis Vaccine Preventable Diseases Influenza Pertussis Rubella Zoonotic Diseases Rabies West Nile Virus Outbreaks 14. Environmental Health Describes the unique aspects of the rural physical environment that impact the health of Huron County residents Water in Huron County Rurality Private Drinking Water Wells Private Septic Systems Population Density and the Built Environment 4 - Huron County Community Health Status Report

6 Agricultural Land Use and Practices Outdoor Air Quality 15. Oral Health Measures self-reported dental health status of Huron County residents by social and economic factors and describes health behaviours established to influence oral health Self-Perceived Oral Health Regular Dental Check-ups Dental Insurance Teeth Brushing Oral Health of Children in Huron County 16. Discussion of Themes Summarizes major themes which emerged from the report as identified by health unit staff. The themes are labelled as important determinants of health for Huron County residents and their impact is briefly described Appendices Leading Causes of Death Groupings International Classification of Disease (ICD), 1th Revision, Chapters Unintentional Injury Classifications Reportable Disease List, 28 Huron County Community Health Status Report - 5

7 Sociodemographics Executive Summary Huron County is one of Ontario s most rural communities, with 6% of the population living in non-urban areas. Median and average household income is lower in Huron County than the province; however, there is a lower incidence of low income due to a lower cost of living. Almost one in five persons are employed in agriculture and other resource-based industries, which results in seasonal unemployment. Only half as many individuals report having university-level education compared to the province; yet a higher percentage has pursued trades certificates/diplomas. Huron County residents report a strong sense of belonging to their community. Behavioural Risk Factors Almost one in five Huron County adults reported being a current smoker in 26. While tobacco use prevalence has remained constant over the past few years, the percentage of smoke-free homes has increased significantly. More than half of Huron County adults consume alcohol in a high risk manner, which is similar to the province. Youth, however, are significantly more likely to binge drink than other youth in Ontario. In 25, over a quarter of Huron County residents were classified as active and just under half reported consuming the recommended daily intake of fruits and vegetables. Also in 25, 23% of Huron County adults were classified as obese, which was significantly higher than the province. 6 - Huron County Community Health Status Report With an aim to understand the unique health needs of our community, the 28 Community Health Status Report describes and measures the health of Huron County residents. A social determinants of health framework is used to examine the influence social and economic factors have on various health issues of public health importance. A summary of the major findings of the report is provided below. Huron County residents reported lower stress levels than the province. Mortality Between 2 and 23, there was a range of 574 to 628 deaths per year in Huron County. All cause, age-standardized mortality rates are similar for Huron County and Ontario. The leading causes of death in Huron County are ischemic heart disease, cerebrovascular disease (stroke) and lung cancer. These are also the leading causes of death in Ontario. Mortality due to land transport occurrences was significantly higher for both Huron County males and females than the province. Suicide mortality among Huron County males was also significantly higher than Ontario males. Ischemic heart disease and land transport occurrences are the leading causes of premature mortality in Huron County. Morbidity Between 22 and 26, there was a range of 6,251 to 7,129 hospitalizations in Huron County per year. All cause, age-standardized hospitalization rates have decreased during this time period; however, Huron County hospitalization rates remain higher than the province. Leading causes of hospitalization in Huron County are diseases of the circulatory system, diseases of the digestive system and factors influencing health status/contact with health services. Hospitalizations due to pregnancy and childbirth were lower than the province. Hospitalization rates were significantly higher for most diseases and injuries in Huron County than Ontario; this includes hospitalizations due to land transport

8 occurrences, attempted suicide and accidental falls for both sexes and chronic diseases such as breast cancer and prostate cancer. Chronic Health Conditions In 25, 75% of Huron County residents reported having at least one long-term chronic condition diagnosed by a health professional. Prevalence of chronic conditions increased with decreasing income. Arthritis/rheumatism was the most common self-reported chronic health condition in Huron County, followed by high blood pressure. Between 1995 and 24, there was an average of 337 new cancer cases diagnosed per year and 162 deaths per year. Among Huron County males, prostate cancer was the most commonly diagnosed cancer, while breast cancer was the most commonly diagnosed cancer among females. Lung cancer was the leading cause of cancer death for both sexes. All cause cancer incidence and mortality rates do not differ significantly from the province. Reproductive Health Huron County has younger first time mothers than the province. Between 2 and 24, there was an average of 561 births per year and 64 pregnancies per year in Huron County. Teenage pregnancy and abortion rates are significantly lower in Huron County than Ontario. Huron County birth outcomes are similar to the province. Unintentional Injuries and Injury Prevention Several themes emerge from this report which identify the key determinants of health for Huron County residents the physical environment, rural sociodemographics, and limited access to health services. While other factors make important contributions to the health of our community, these three determinants were identified by health unit staff as instrumental in understanding and describing the unique health outcomes experienced by Huron County residents. Recognizing and addressing the barriers and resources associated with these determinants of health in planning and service delivery will help ensure the provision of accessible, effective programs for Huron County residents. In 25, there were over 1, emergency room (ER) visits for unintentional injuries in Huron County. Youth aged 1-19 years old had the highest rate of ER visits. Age-standardized hospitalization and mortality rates for all unintentional injuries are higher in Huron County than the province. In 25, Huron County children aged -9 years and adults over the age of 75 years had the Huron County Community Health Status Report - 7

9 highest rate of ER visits for injuries caused by falls. Youth aged 1-19 years had the highest rate of ER visits for injuries caused by land transport occurrences. Over 2 ER visits were made in 25 for injuries that occurred on a farm. Fewer than 3% of all Huron County farm operators reported having been injured in 21. In a 23 survey, over 8% of Huron County adults reported they wear a seat belt all of the time when they drive, while 74% of households with a child aged 4-7 years reported that the child usually travels in booster seat and always in the back of the car. Less than 15% of Huron County residents aged 12 years and older who reported bicycle use reported that they always wear a helmet, which was significantly lower than the province. Oral Health Half of Huron County adults rated their dental health as excellent or very good when compared to others their age in 26. Self-reported oral health improved with increasing household income level. In 25, just over 4% of Huron County residents reported that they usually visit the dentist more than once a year for dental check-ups. Almost 2% reported only visiting the dentist for emergency care. Half of Huron County residents reported having dental insurance that covered all or part of their dental expenses in 25, which was significantly lower than the province. Communicable Disease Campylobacteriosis, influenza and clamydia were the most commonly reported diseases in Huron County, accounting for 5% of all reportable diseases between 1995 and 25. Huron County age-standardized chlamydia incidence rates are significantly lower than the province; however, rates have been increasing over time. Huron County campylobacteriosis and cryptosporidiosis incidence rates are significantly higher than Ontario. Environmental Health Over a third of Huron County households reported receiving their tap water from a private well in 26. Only 16% of these households reported testing their water for bacteria at least three times a year as recommended by the health unit. The majority of well water samples submitted for testing came back safe. Due to transboundary air pollution, Huron- Perth was issued 12 smog advisories spanning 27 days in 27. It was estimated that there will be 6 premature deaths due to smog in Huron County in Huron County Community Health Status Report

10 Introduction This report is the first comprehensive community health status report completed in Huron County. The overall aim of this report is to describe the health of Huron County residents so that needs may be identified. To accomplish this, a variety of data and information sources are used to report on key population health indicators for the following health topics: Demographics Social Determinants of Health Self-Reported Health Risk Factors Mortality Morbidity Chronic Health Conditions Reproductive Health Unintentional Injuries and Injury Prevention Communicable Disease Environmental Health Oral Health This report will be useful to health unit staff and others in the community who plan and evaluate services which support and promote the health of Huron County residents. The report will also serve as a baseline for future reporting of Huron County s health, allowing the health of the community to be monitored over time. Addressing the impact of social and economic factors, such as income, education, housing and employment, on the public s health has become an important priority in the field of public health. Canada s Chief Public Health Offcer recently released a report on the state of public health in Canada, which focused on these social determinants of health and discussed how they contribute to differences in health. Similarly, the Ontario Public Health Standards highlight the impact social and economic factors have on the health of the population and recognize that addressing determinants of health and reducing health inequities are fundamental to the work of public health in Ontario. In 25, the Huron County Health Unit underwent an organizational restructuring and central to this restructuring were the social determinants of health. Services were reviewed to ensure that programs and services addressed community need and determinants of health. Questions were asked to determine how equal access services could be provided. Where programs were more prescriptive in nature, strategies were sought to identify and deliver the program to those most at risk or to those for whom the program was potentially the least accessible. In addition, the health unit created four strategic directions (known as pillars ) rooted in the determinants of health poverty, water, e-health and primary health care. From this direction, a poverty strategy was created which included hiring community developers, describing poverty in Huron County, securing external funding to modify or create programs to address poverty in Huron County, collaborating with primary care and providing services through e-health to improve accessibility, and improving staff understanding of how poverty impacts health through education and training. Figure 1 visually outlines this restructuring. Huron County Community Health Status Report - 9

11 Given the health unit s dedication to addressing the social determinants of health in program planning and service delivery, this report has been created using a social determinants of health framework. To accomplish this, the report describes the impact of social factors on health throughout a lifetime using the board game Snakes and Ladders (with permission of the Interior Health Authority, British Columbia) and examines key social determinants in Huron County. Where possible, traditional health indicators such as self-reported health status are examined with a social determinants of health lens to provide a better understanding of how social factors influence the health of residents in Huron County. In the absence of local data linking social determinants with health outcomes, discussions are offered on the impact of the social determinants on particular health outcomes using available literature. Huron County Health Unit Protecting the Environment Building Community Capacities (Internal) Assuring Quality Services Social Determinants of Health - Program Planning, Community Assessment, Pathways Strengthening Families Surge Capacity Research Committee Special Projects Transition Team Best Practices Education Committee Supporting Healthy Communities (External) Figure 1. The restructuring process included reorganizing staff into five, interdisciplinary quads, shown by the orange circles, to improve efficiency and communication between staff. Central to this reorganization were the social determinants of health, which were addressed as part of a service review and as part of the health unit structure. Other projects integral to the restructuring process were: developing surge capacity for the organization, resurrecting Research and Education committees, ensuring programs and services were based upon best practice information and developing a Transition Team to guide this reorganization process. 1 - Huron County Community Health Status Report

12 Methods A variety of data and information sources were used to prepare this report. Data sources have been referenced at the end of each chapter in this report; however, a brief description is provided below. The following population health survey data was utilized in this report: 1 The Canadian Community Health Survey (CCHS) is a cross-sectional survey of all Canadians aged 12 years and older. It collects information related to health status, health care utilization and health determinants. Data collection prior to 27 occurred every two years; since 27, data collection is on an annual basis. The sample size for Huron County in the 25 survey was approximately 55. The Rapid Risk Factor Surveillance System (RRFSS) is an ongoing, monthly telephone survey conducted by the Institute of Social Research at York University on behalf of various health units in Ontario. Approximately 6 adults aged 18 years and older are randomly selected within Huron County each month to answer questions regarding risk factors, knowledge, attitudes and awareness about health related topics of importance to public health. Southern Ontario Infant Feeding Survey (SOIFS) is a cross-sectional telephone survey administered to mothers of newborn children at three and nine months postpartum between 22 and 24. Questions were asked on breastfeeding initiation and duration, key influences on mothers decision-making and infant feeding practices and evaluation of the infant feeding supports and interventions most frequently encountered by mothers. Eight health units, including Huron County, participated in this survey. The Provincial Health Planning Database (PHPDB), managed by the Ontario Ministry of Health and Long-Term Care, houses a variety of health information from numerous sources. Data is analyzed by place of residence, not where the event occurred and does not include records on procedures or events that occurred out of the province of Ontario. Data used in this report includes: 1 Vital statistics (i.e. births and deaths), provided by the Offce of the Ontario Registrar General. 1 Hospitalization (inpatient discharge) data, provided by the Canadian Institute for Health Information s (CIHI) Discharge Abstract Database and emergency room visits, provided by the National Ambulatory Care Reporting System (NACRS). 1 Inter-census population estimates (used in rate calculations), obtained through Statistics Canada and the Ontario Ministry of Finance. Other important data sources include: 1 Therapeutic abortion data was provided by the Ontario Therapeutic Abortion Database in the Health Planning System (HELPS), which is produced by the Ontario Ministry of Health Promotion. 1 Census data was provided by Statistics Canada. The census is conducted every five years in Canada and collects information on the population, dwellings and also demographic, social and economic characteristics. The most recent census took place in Communicable disease data was extracted from the integrated Public Health Information System (iphis). iphis is a database used by front-line public health professionals in Ontario for case and contact follow-up and outbreak management of reportable diseases. The database is used for local and provincial surveillance of communicable diseases. Immunization Huron County Community Health Status Report - 11

13 1 1 data was extracted from the Immunization Records Information System (IRIS), which is a database used to collect and maintain immunization data for all students and children attending schools and licensed day cares in Ontario. The Ontario Cancer Registry managed by Cancer Care Ontario provides cancer incidence and mortality data. This data is disseminated using SEERStat software. Records of new cancer diagnoses and deaths in Ontario are based on four sources of information: hospital discharge summaries, pathology reports, records from regional cancer centres and death records. Internal sources provided valuable information and data on: West Nile Virus surveillance, recreational water sampling; and well water testing, among others. Indicators This report describes the health of Huron County using commonly accepted and validated health indicators. A health indicator is a measure of the state of health among individuals in a defined population. Some examples of health indicators include hospitalization rates, birth rates and prevalence of diabetes. The use of indicators in measuring and reporting health status information allows for comparisons to be made with other geographic regions and over time within Huron County. This provides important context for the data and helps to identify health issues the community faces. Indicators used within this report have been developed by the Association of Public Health Epidemiologists in Ontario. 1 Explanations of various indicators are provided in sidebars throughout the report. Analysis Rates To measure the health status of the community, rates of health outcomes or behaviours are often calculated. A rate is a measure of how often an event occurs in a defined population in a specified period of time. 2 Incidence rates measure the frequency of new occurrences in a given time period, while prevalence rates measure the frequency of occurrences that exist in a given population at a particular time period. For example, a diabetes incidence rate measures the number of newly diagnosed diabetes cases in Huron County for 25, while a diabetes prevalence rate measures the number of individuals who have diabetes in Huron County in 25. A rate can be calculated as follows: Rate = (# of events in a specified period / population during the period) x 1 n Rates are usually multiplied by a power of 1 to convert a decimal or awkward fraction into a whole number. Rates are used instead of counts because they allow comparisons between populations at different times, different places or among different classes of persons. The process of agestandardization adjusts rates to minimize the effects of differences in age composition when comparing rates for different populations. Confidence Intervals Except when a full census is undertaken or all of the health outcomes are recorded accurately, data is collected on a sample from the population. This sample is used to describe what is happening in the larger, underlying population. Because different samples can produce different results, confidence intervals are calculated to describe how reliable the sample estimate is, with a wider interval indicating a less reliable estimate. 95% Confidence Intervals have been calculated for all survey estimates and selected rates. These intervals tell us that if there was repeated sampling, the true population value or rate would lie within this range 19 times out of 2 (i.e. 95% of the time). Process of Creating the Report A consultative process was used to create this report for several reasons: 1. to ensure staff and community needs for information were addressed; 2. to provide important context for the data (i.e. program staff identified if results reflected what they knew empirically to be happening in the community and also 12 - Huron County Community Health Status Report

14 identified possible explanations for the results); 3. 1 to widen the network of available resources for data; and 4. 1 to educate health unit staff on the health status of Huron County. This process was achieved by first creating a table of contents for management and staff to review. Staff and health unit information needs were identified and prioritized at this stage. Next, each chapter of the report, upon its completion, was reviewed by appropriate program staff and feedback was solicited and incorporated into the report. Chapters were also reviewed at management meetings to discuss the results and provide context for the information. Lastly, after all chapters were written, relevant results were presented to each health unit quad at their regular team meeting. At these meetings, staff was asked the following questions: 1. 1 did any of the results surprise you? 2. 1 what information do you think will be useful in your work? 3. 1 is there any information that you think is missing? Staff comments from these discussions were then used to enhance the report and to identify major themes of the report which are summarized in the discussion section. Limitations There are several limitations to the data which should be considered when interpreting the results. First, population health survey data is based on self-reported information and as a result, respondents may feel pressure to select the most socially desirable response. This may falsely underestimate the incidence or prevalence of risky health behaviours or poor social circumstances, such as food security. Self-reported data is also subject to recall bias. Additionally, because participation in surveys is rarely 1%, bias may be introduced as those who respond often differ systematically from those who do not. By drawing on a random sample this bias is minimized and helped to ensure a representative sample of Huron County residents was selected. Another limitation of population surveys used in this report is that they are administered by telephone, which excludes an estimated 2% of the population who live in households without active telephones. 3 Surveys, therefore, can underrepresent populations living in low income that may not have access to a phone. Also, as telephone surveys are based on landline phone numbers, a younger demographic may be excluded from participation due to increasing reliance on mobile phones. Other data limitations include under-reporting of actual cases for some infectious diseases in iphis as infected individuals that are asymptomatic or have only mild clinical symptoms may not seek medical care. Additionally, not all cases who visit physicians will submit a sample for laboratory testing. 4 Similarly, when using hospitalization data as a crude measure of the prevalence of an illness, precaution should be taken as individuals with mild clinical illness may not be hospitalized for a condition (or conversely, individuals may be hospitalized many times for the same condition). Lastly, the number of births may be underreported as registration fees initiated in 1996 may have reduced the number of births registered due to the associated cost. All additional limitations in the data have been addressed within the appropriate chapters. A final caution should be made to the interpretation of this report. Data on health topics absent from this report may be important to understanding the health of our community; however, this data may either not be available or is not considered to reflect an issue of public health importance. 1 Association of Public Health Epidemiologists in Ontario. Core Indicators and Resource List. Available online at: 2 Last J. A Dictionary of Epidemiology, Fourth Ed. New York, NY: Oxford University Press, Inc., Statistics Canada. Residential Telephone Service Survey, 24. Accessed on 18 August 26 from 4 Association of Public Health Epidemiologists in Ontario. Core Indicators Enteric Disease Incidence. Accessed on 29 August 28 from apheo.ca/index.php?pid=177. Huron County Community Health Status Report - 13

15 Demographics The County of Huron is not only one of Ontario's most productive farming communities, but also a summertime retreat for thousands of visitors. Located about three hours northwest of Toronto, Huron County covers 3,48 km 2 of mixed farming country in the lee of Lake Huron. Crossed by major rivers like the Maitland, the county boasts many scenic conservation areas and nature preserves. This link to water continues to have a profound influence on Huron's economy, social life and environment. Farming and small-scale manufacturing dominated the economy upon early settlement and continue to do so today, with about one in five residents still counting farming as their occupation. Service and retail sectors also comprise a large portion of the economy, driven by tourism generated from Huron s many public beaches and spectacular sunsets. Other popular tourist attractions include the Blyth Festival Theatre, the designated historic main street (and shopping district) of Bayfield, the County Museum and Historic Gaol, and an extensive trail network enjoyed by walkers, hikers and snowmobilers. In 26, Huron County s population was estimated at 59,325 people by the Canadian Census, down.6% from 59,71 in This decline is due to an aging population, a declining birth rate and the migration of younger people to larger cities. 2 The county includes nine local municipalities: Howick (population 3,882), North Huron (5,15), Morris-Turnberry (3,43), Huron East (9,31), Central Huron (7,641), Ashfield-Colborne-Wawanosh (5,49), Goderich (7,563), Bluewater (7,21) and South Huron (9,982). Bluewater, North Huron and Howick all experienced population growth between 21 and 26. The largest centre by population, and the county seat, is Goderich. Huron County is one of Ontario s most rural counties with 6.4% of the population living in a non-urban areas and an overall population density of 17.5 people/km 2 (1). 3 Typical of rural communities, Huron County exhibits a high dependency ratio. This means that the county has large populations of children, youth and seniors compared with a relatively smaller population of working-age persons. The age distribution, by gender, of Huron County is shown in Figure 2. As noted, almost half of the population is either 19 years (26%) or 65 years of age (18%). This higher proportion of children/ youth and seniors becomes apparent upon comparison to the age distribution of Ontario, shown in Figure 3. This figure also demonstrates the lower proportion of residents aged 2-39 years in Huron County compared to Ontario. The majority of Huron County residents are Map of the location of Huron County within Southwestern Ontario Huron County Community Health Status Report

16 Canadian-born (92%) (3). Foreign-born Huron County residents were mainly from either the United Kingdom (22%) or the Netherlands (33%). English is the predominant first language (91%) in Huron County; although there are also large German (4%) and Dutch (3%) speaking communities. 1 Statistics Canada. 26 Census. Accessed 1 July 28 from 2 Huron Business Development Corporation. 25. State of the Economy Report. Accessed 1 July 28 from StateofHuronCountyEconomy5.pdf. 3 Statistics Canada. 21 Census. Accessed 1 July 28 from Huron County Population Distribution, 26 Age Group (years) Male Female Figure 2. The age distribution of Huron County, by gender. Source: Statistics Canada, Census, Population (n) Ontario Population Distribution, 26 Figure 3. The age distribution of Ontario, by gender. Source: Statistics Canada, Census, 26. Age Group (years) Male Female Population (n) Huron County Community Health Status Report - 15

17 Social Determinants Of Health Economic and social conditions influence the extent to which a person has the resources to meet basic living requirements, satisfy personal aspirations and cope with the environment. 1 Income, employment status, type of employment, education, food security, and housing are all socioeconomic factors that contribute to the health of individuals and communities. A useful approach to understanding the complex interaction and impact of social factors on health and well-being is by using the board game Snakes and Ladders as a metaphor for health. 2 The goal of Snakes and Ladders is to reach the top of the board by climbing the ladders and avoiding the snakes. Applying this concept to the pursuit of good health, we try to achieve optimum wellness by using the resources available to us (the ladders), while trying to avoid obstacles that will result in set-backs and other negative consequences (the snakes). Education, employment, access to health services and community support act as ladders in achieving good health, while low income, poor environments and low social status act as snakes. Having a board with more ladders than snakes makes optimum wellness easier to achieve. For example, a child born into a high-income family is more likely to have access to nutritious food and recreational activities than a child born into a low-income family. However, like the game, with a roll of a die anyone can face the chance o f encountering more snakes than ladders. Rural communities can face additional snakes or barriers on the path to wellness when compare d to urban environments. 3 These barriers include fe wer people, which can translate into less employment opportunities, fewer educational or training programs and a lack of affordable transportation without access to a public transportation system. In rural communities, there are also fewer socia l supports and services and of those available, some families are hesitant to access them for fear of exposing their financial hardships in a community where everyone knows everyone. Given the impact of these factors on health, rural communities face particular barriers which must be addressed when planning and implementing health programs and support. Several social determinants of health are described in this chapter, including income and cost of living in Huron County, education, employment, affordable housing, food security and social networks. Income and Cost of Living in Huron County Many Canadian studies have shown that health increases with increasing income. 4 Income impacts the health of families and individuals by affecting access to resources required for healthy lifestyles. In Huron County, the average household income was $54,496 in 2, with a median income of $45,885. This income level is approximately $1, lower than the Ontario average of $66,836. Lower average and median income levels in Huron County can primarily be attributed to having almost half as many households earning over $1,/year, as shown in Figure 1. When comparing incomes across populations, variations in the cost of living must also be considered. One way this is done is by using Low Income Cut-offs (LICOs) to calculate the incidence of low income in a population. LICOs are income levels at which a family or individual will likely devote a larger share of its income to the necessities of food, shelter and clothing than the average family. 5 The cost of living, family size and place of residence (urban or rural) are all used to calculate LICOs. The incidence of low income in Huron County and Ontario is shown in Table 1. Huron County 16 - Huron County Community Health Status Report

18 has lower proportions of households, families and individuals that are living in low-income situations when compared to Ontario. As average income levels in Huron County are lower than Ontario, Huron County may also experience a lower cost of living. Within Huron County, Goderich has the highest percentage of persons with low income (11.58%), almost double that of Bluewater. In both Huron County and Ontario, female-led lone-parent families continue to be the most economically disadvantaged, with approximately one third of all female-led lone parent families living in low income. In Huron County, 1% of economic families are lone parent families and of those, 77% are female-led. 6 Figure 1. Household income of all private households in both Huron County and Ontario in 2. A private household is referred to as a person or a group of persons (other than foreign residents) who occupy the same private dwelling and do not have a usual place of residence elsewhere in Canada. Source: Statistics Canada, Percent (%) Household Income of all Private Households in Huron County and Ontario, Under $1, $1, - $2, - $3, - $4, - $19,999 $29,999 $39,999 $49,999 $5, - $6, - $7, - $8, - $9, - $1, $59,999 $69,999 $79,999 $89,999 $99,999 and over Huron County Ontario Income Level Table 1. Incidence of low income, by private household, economic family and unattached individuals over 15 years. An economic family refers to a group of two or more persons who live in the same dwelling and are related to each other by blood, marriage, common-law or adoption. Source: Statistics Canada, Census 21. Category Huron County % Ontario % All People in Private Households By municipality South Huron Bluewater Central Huron Goderich Huron East Morris-Turnberry North Huron Ashfield-Colborne-Wawanosh Howick Economic Family By family type Couple with no children Couple with children Lone Parent, male-led Lone Parent, female-led Unattached Individuals ( 15 years old) Huron County Community Health Status Report - 17

19 Employment Employment insecurity and job quality are known to be associated with physical and mental health. 1 In addition, individuals who have more control over their work circumstances and have fewer stress-related demands of the job are healthier. The unemployment rate for 25 in Huron County for persons aged 15 years and over remains at 5.%, below the provincial rate of 6.6%. 7 Since 21, unemployment rates have been increasing in Huron County, while decreasing in Ontario. In addition, Huron County sees a seasonal increase in unemployment because of strong reliance of resource-based industry. 8 The division of the labour force population by industry is shown in Figure 2 for both Huron County and Ontario. Huron County has a substantially higher proportion of persons employed in agriculture and other resource-based industries than Ontario (17.5% versus 3.2%), yet a much lower participation in the business services sector (11.1% versus 19.1%). Education Education is one of the most important determinants of health, given its impact on employment and on income. 1 Education contributes to health by equipping people with knowledge and skills for problem solving. Education helps provide a sense of control and mastery over life circumstances. It also improves people s ability to access and understand information needed to help them make healthy choices. Within Huron County, more than half (52%) of individuals aged 2 years or older have completed a Grade 13 education level or less, compared to 4% of Ontario. Also, Ontario has more than double the percentage of individuals with university-level education (Figure 3). Despite this, Huron has more individuals with trade certificates and diplomas, reflecting labour force divisions within the county. Industry Sector Labour Force Population, by Industry, Huron County and Ontario, 21 Manufacturing and construction industries Agriculture and other resource-based industries Wholesale and retail trade Other services Health and education Huron County Ontario Figure 2. The percentage of individuals employed within each industry out of the entire labour force population, both in Huron County and in Ontario for 21. Source: Statistics Canada, Census 21. Business services Finance and real estate Percent (%) of Labour Force Population Highest Level of Schooling (Population 2+ years), Huron County and Ontario, 21 Figure 3. Education levels of Huron County and Ontario among individuals aged 2 years and older in 21. Source: Statistics Canada, Census 21 Percent (%) Less than Grade 9 Grade 9 to 13 Trades certificates or diploma College with or without diploma University with or without degree Education Level Huron County Ontario 18 - Huron County Community Health Status Report

20 Housing Inadequate housing affects health in many ways. High housing costs impact available monetary resources necessary for living, while poor living conditions and stress induced by housing insecurity increases risk of morbidity and mortality. 1 In Huron County, adequate, affordable housing is a major issue. There are 627 social housing units in Huron County, all of which are occupied. As of October 31, 26, 251 households were on the waiting list for rent-geared-to-income units. Over half of applicants are adults without children who are requesting one-bedroom housing units (Table 2). In mid-october 26, provincial and federal governments announced funding for 15 affordable housing units in Huron County which could house 15 households. Three of the 15 units have been allocated for supportive housing for people with mental health disabilities and two for victims of domestic violence. In addition, money has been made available to make homeownership affordable for low-income households. Provision of emergency shelters help ensure safe places for women and families in crisis. For the 25/26 fiscal year, the emergency women s shelter housed 81 women and 45 children, giving an average occupancy rate of 89.3%. 9 In addition, rent-geared-to-income housing was provided for 41 women, with an average occupancy rate of 79.9%. 9 Household Type and Housing Number of Need Applicants Adult (without children) bedroom Seniors - 1 bedroom 39 Family - 3 bedroom 35 Family - 2 bedroom 29 Family - 4 bedroom 1 Total 251 Table 2. Number of households on the waiting list for rent-geared-to-income accommodation, by household type and housing need as of October 31, 26. Source: Housing Services, Social Services Department, County of Huron. Food Security Food insecurity is the inability or uncertainty of having adequate diet quality and quantity. 1 Families or households that experience food insecurity are more likely to report poor or fair self-rated health and chronic health conditions. 1 Food insecurity is most prevalent among single parent families, families with high number of siblings or families with poor maternal health. In 25, 96.1% (95% CI ) of persons in Huron County indicated that members of their household showed no or minimal evidence of food insecurity. 1 Therefore, less than 4% indicated food insecurity with or without hunger. Income also impacts food security, in the same survey, only 15% (95% CI ) of persons with household incomes of less than $2,/ year indicated evidence of food insecurity 1 compared to only 3.2% (95% CI ) of persons with household income above $2,/year. It is possible, however, that the sensitive nature of the question may have caused respondents to feel uncomfortable disclosing information relating food security and thus would under estimate the proportion experiencing food insecurity. This finding is supported by high attendance to the eight food banks in Huron County, where an estimated 6,5 to 7,1 families or individuals visited in 25. In 2, focus groups were conducted (n=45) among low income families in Huron County to determine barriers rural families faced surrounding food access. 11 Participants felt that social assistance cutbacks and unexpected expenses left them with little money to put towards food after housing and other essential costs. Several participants also responded they were unable to give their children essentials because of lack of money. Other identified barriers to accessing food included: high grocery costs in small towns; lack of appropriate food at the food banks (i.e. fresh fruit and vegetables, milk and meat); lack of transportation to access grocery stores or food banks; and Huron County Community Health Status Report - 19

21 stigma affecting participants comfort in acquiring food through the food bank in a small-town environment. Therefore, many barriers exist to accessing the quantity and quality of food desired in rural families which must be addressed, especially among households with low income and young children. Social Networks Strong social connections promote a sense of belonging and well-being. They also provide support and a sense of control in times of adversity. 12 There is an established causal link between social relationships and health, with those who are strongly connected to the community being less likely to be involved in risky health behaviours. 12 In Huron County, a quarter of the population (25.%, 95% CI ) report a very strong sense of belonging to their local community. 16 This is significantly higher than the Ontario average. 1 Raphael D. Social Determinants of Health: Canadian Perspectives. Toronto, ON: Canadian Scholars Press Inc, Concept used in Beyond Health Services and Lifestyle: A Social Determinants Approach to Health. Interior Health Authority, British Columbia. Permission granted by Dr. Ronald A. Dovell, November Canadian Institute for Health Information. How Healthy Are Rural Canadians? Ottawa, ON: Canadian Institute for Health Information, Wilkins R, Berthelot J-M and Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to Health Reports 22; 13 (Supplement :45-71). 5 Statistics Canada. Low Income Cut-offs for 25 and Low Income Measures for 24. Accessed 1 July 28 from bsolc?catno=75f2m Statistics Canada. 21 Census. Accessed 1 July 28 from 7 Statistics Canada. Unemployment rate, 15 years and over, Canada, provinces, health regions and peer groups, 24 to 25. Accessed 31 October 26 from statcan.ca/english/freepub/ xie/261/tables/t2g.htm. 8 Huron County Health Unit. Trust Before Change Report. Clinton, ON: Huron County Health Unit, Hanson M. Executive director s annual report women s shelter, second stage housing and counselling services of Huron for the year 25/26. Women s Shelter, Second Stage Housing and Counselling Service of Huron. 1 Canadian Community Health Survey, Cycle 3.1 (25). Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. 11 Huron County Health Unit. Building Bridges. Clinton, ON: Huron County Health Unit, Bryan H. (Ed: Vivien Bowers) Beyond Health Services and Lifestyle: A Social Determinants Approach to Health. Interior Health, Huron County Community Health Status Report

22 Self-Reported Health Self-reported health is one way of measuring an individual s current health status. This measure has been found to be predictive of future mortality 1 and of the development of chronic conditions. 2 In 26, 59.6% (95% CI ) of Huron County residents rated their health as excellent or very good (Figure 1). This is consistent with previous years. There were no significant differences in self-rated health between men and women in 26; however, self-rated health declined as age increased. In Huron County 72.7% (95% CI ) of year olds reported having excellent or very good self-reported health compared to just 36.5% (95% CI ) of adults aged 65 years and older. The impact of socioeconomic status on health becomes apparent when self-rated health is examined by education and income level (Figure 2). Self-reported health significantly improved as both education and income level increased. In 26, 74.8% (95%CI ) of Huron County college or university graduates reported excellent or very good health versus 37.2% (95% CI ) of individuals who did not complete high school (p<.1). Similarly, 76.1% (95% CI ) of individuals with a household income of $8, or more a year reported excellent or very good health, while just 37.2% (95% CI ) of individuals with a household income of $3, or less reported the same. 1 Idler EL and Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior. 1997;38: Kopec JA, Schultz SE, Goel V. and Williams JI. Can the Health Utilities Index measure change? Medical Care. 21;39(6): Huron County Community Health Status Report - 21

23 Self-Reported Health (18 years +), Huron County, Percent (%) Excellent / Very Good Good Fair / Poor Self-Reported Health Figure 1. Self-reported health status of Huron County residents aged 18 years and older from 22 to data was not collected. Source: Rapid Risk Factor Surveillance System, 22 (n=88), 23 (n=1211), 25 (n=62) and 26 (n=718). Percentage who Report Excellent or Very Good Health (18+ years), by Household Income Level, Huron County, Percent (%) < $3, $3-49,999 $5-79,999 $8,+ Income Level Figure 2. Percentage of Huron County adults (18 years and older) who reported excellent or very good health, by household income level, 26. Source: Rapid Risk Factor Surveillance System, 26 (n=574) Huron County Community Health Status Report

24 Behavioural Risk Factors The following chapter outlines the prevalence of various behavioural risk factors, such as tobacco and alcohol use, nutrition, physical activity and sun safety, in the Huron County population. All of the risk factors examined here have established associations with chronic disease. Typical prevention strategies often aim to reduce (or increase) the prevalence of these risk factors; however, we know that social and economic constraints influence health behaviour and dictate which choices are available. To be truly effective in preventing chronic disease caused by behavioural risk factors, the upstream socioeconomic factors which contribute to the adoption of these behaviours need to be understood and addressed. 1 Tobacco The harmful effects of smoking have been well established. In Canada, smoking is the number one preventable cause of death. 2 Active smoking significantly reduces life expectancy, with the majority of excess mortality attributable to lung cancer, chronic obstructive lung disease and ischemic heart disease. 2 3 Active smoking has also been implicated as a cause of many other cancers, including cancers of the oral and nasal cavity, pharynx, larynx, oesophagus, pancreas, stomach, liver, kidney, urinary bladder, renal pelvis and cervix. 4 Also of public health importance is exposure to secondhand smoke, which is associated with sudden infant death syndrome, reduced birth weight, middle ear disease, coughing, breathlessness and lower levels of lung function in children. In adults, secondhand smoke exposure increases the risk of lung cancer and coronary heart disease. 5 Smoking Status The prevalence of smoking has remained constan t over the past few years in Huron County. In 26, 2.3% (95% CI ) of adults aged 18 years and older reported being a current smoker compared to 21.3% (95% CI ) in 22 (Figure 1). While prevalence of smoking remained constant, it is encouraging to see that the proportion of former smokers is beginning to increase. Men were significantly more likely to be current smokers than women (24.4%, 95% CI compared to 17.4%, 95% CI in 26). Smoking status also varied by age and education level, with the proportion of current smokers decreasing with increasing age (X 2 =36.7, p<.1) and education level (X 2 =46.31, p<.1). In 26, the percentage of current smokers was more than doubled in individuals with less than a high school diploma when compared to individuals who were college or university graduates (28.5%, 95% CI versus 13.1%, 95% CI ). Smoke-Free Homes While the prevalence of smoking has remained constant, the proportion of smoke-free homes in Huron County has significantly increased from 22 to 26 (X 2 =59.9, p<.1) (Figure 2). Smoke-free homes are defined as homes where neither household members nor visitors are permitted to smoke in the home. In 26, 73.5% (95% CI ) of homes were completely smoke-free, up from 57.3% (95% CI ) in 22. Secondhand Smoke Less than 1% of non-smokers in Huron County (9.3%*, 95% CI ) reported being exposed to secondhand smoke in the past month in public places, such as bars, restaurants, bowling alleys, etc. 6 This does not differ significantly from Ontario. Huron County Community Health Status Report - 23

25 Reported Smoking Status (18+ years), Huron County, Percent (%) Current Smoker Former Smoker Nonsmoker Smoking Status Figure 1. The smoking status of Huron County residents aged 18+ years from Current smokers are defined as those who have smoked at least 1 cigarettes in their lifetime and currently smoke cigarettes daily or occasionally; former smokers have smoked at least 1 cigarettes in their life but currently do not smoke at all (RRFSS). Source: Rapid Risk Factor Surveillance System (RRFSS) 22 (n=888), 23 (n=127), 25 (n=622) and 26 (n=717). Percent (%) Percentage of Completely Smoke Free Homes, Huron County Figure 2. The percentage of completely smoke free homes in Huron County. Source: Rapid Risk Factor Surveillance System (RRFSS) 22 (n=886), 23 (n=1193), 25 (n=614) and 26 (n=75). Alcohol Like tobacco, alcohol is associated with a number of health problems, which include various cancers, hypertension, liver cirrhosis, congenital abnormalities and fetal alcohol spectrum disorders and depression. 7 Alcohol Use Alcohol consumption has been dichotomized into low risk and high risk consumption patterns by the Centre for Addiction and Mental Health (CAMH) and the University of Toronto. 8 Low Risk: Women who consume less than 9 drinks/week and no more than 2 per day Men who consume less than 14 drinks/week and no more than 2 per day Pregnant women who consume drinks/week High Risk: Women and men who consume more alcoholic drinks than outlined in the low risk classification Over half of Huron County residents aged 2+ years * High sampling variability. This estimate should be interpreted with caution Huron County Community Health Status Report

26 (52.5%, 95% CI ) were classified as having high risk alcohol consumption in This is consistent with the prevalence of high risk alcohol consumption in Ontario. Binge Drinking Binge drinking, also known as heavy drinking episodes, is classified as consuming 5 or more drinks on at least one occasion. 8 Heavy drinking occasions can increase the risk of coronary heart disease (CHD), sudden cardiac death and injury, particularly traffc injuries related to impaired driving. 9 In addition, because many alcohol-related deaths involve relatively young individuals, alcohol use contributes to significant potential years of life lost (PYLL). Higher volume of alcohol consumption is also associated with increased symptoms of depression. 1 In 25, 82.9% (95% CI ) of Huron County adults aged 2 years or older reported having at least one drink over the past 12 months. 6 Of those, 48.% (95% CI ) reported heavy drinking, which was not significantly different from Ontario. Among youth aged years, 49.1% * (95% CI ) reported having at least one drink over the past 12 months and of those, 78.9% (95% CI ) had participated in binge drinking over the past 12 months. This is significantly higher than the Ontario average. Drinking and Driving The Rapid Risk Factor Surveillance System defines drinking and driving as driving a motor vehicle (includes cars, vans, trucks and motorcycles) when two or more drinks have been consumed in the hour before driving. The largest number of alcohol-related deaths is due to impaired-driving collisions. 11 In 23, 4.9% (95% CI ) of Huron County residents aged 18 years and older reported drinking and driving. 12 Males were significantly more likely to drink and drive than females (X 2 =25.94, p<.1). Physical Activity Various methods are used to define and measure physical activity. The Canadian Community Health Survey (CCHS) uses estimated energy expenditures, based on the duration and frequency of various leisure activities within the past 3 months, to categorize individuals as active, moderately active and inactive. The energy expenditure cut-offs are shown below in Table 1. Physical activity reduces the risk of cardiovascular disease, some cancers (particularly breast, colon and rectal cancers) and type 2 diabetes. 13 In addition, participating in physical activity can improve musculoskeletal health (including osteoporosis and arthritis), control body weight and reduce symptoms of depression. 13 In 25, 47.1% (95% CI ) of Huron County residents were classified as inactive in their leisure time, which did not differ from the province as a whole. Just over a quarter were classified as active (27.9%, 95% CI ). Males typically tend to be more physically active than females; however, in Huron County, physical activity indices did not differ between genders, with 28.6% (95% CI ) of males being classified as active compared to 27.2% (95% CI ) of females (Figure 3). Table 1. Physical Activity Index derived from leisure-time activities (Source: Canadian Community Health Survey, Statistics Canada). Activity Index Active Moderately Active Inactive Energy Expenditure (kcal/kg/day) < 1.5 Health Outcome Cardiovascular health benefit May experience some health benefits but little cardiovascular benefit At highest risk for obesity and chronic disease * High sampling variability. This estimate should be interpreted with caution. Huron County Community Health Status Report - 25

27 Percent (%) Active Lesiure-Time Physical Activity (12+ years) Huron County and Ontario, 25 Moderately Active Huron County Inactive Active Moderately Active Ontario Inactive Male Female Figure 3. Percentage of respondents aged 12 and older who were classified as active, moderately active and inactive in both Huron County (n=562) and Ontario (n=38,759). Source: Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. Fruit and Vegetable Consumption As part of Canada s Food Guide to Healthy Eating, it is recommended that people aged 4 years and older eat 5 to 1 servings of fruits and vegetables each day. Fruit and vegetable consumption lowers blood pressure and the risk of cardiovascular disease, as well as some cancers. 14 It is estimated that one in ten cancers in western populations are due to an insuffcient intake of fruits and vegetables. 15 The proportion of Huron County residents consuming 5 or more servings of fruits and vegetables a day does not significantly differ from Ontario. In 25, 45.2% (95% CI ) of the Huron County population aged 12 years and older ate at least the daily recommended amount of fruit and vegetables (Figure 4). Youth (age years) were less likely to eat at least 5 servings of fruits and vegetables per day compared to adults, although this difference was not significant. Women, however, were significantly more likely to reach the recommended target, with 54.1% (95% CI ) consuming at least 5 servings of fruit and vegetables per day compared to 36.2% (95% CI ) of men. This finding is corroborated by prior research. 16 Figure 4. Percentage of respondents aged 12 and older who consumed less than or greater than or equal to 5 daily servings of fruits and vegetables by gender (n=576). Note: As not stated responses were greater than 5%, missing responses were included in the denominator. Source: Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. Percent (%) Daily Fruit and Vegetable Consumption (12+ years), by Gender, Huron County 25 < 5 servings 5 servings Daily Servings of Fruit and Vegetables Male Female 26 - Huron County Community Health Status Report

28 Body Mass Index (BMI) The Body Mass Index (BMI) is an index of body weight (kg) to height (m 2 ). Body Mass Index is an indicator of relative health risk associated with underweight, overweight and obesity compared to those classified as normal weight. The classifications and associated risks are shown below in Table 2. BMI as an indicator of risk may have limitations for adults aged 65 years and older as some research has shown that the risk of morbidity and mortality in seniors with BMIs in the overweight range is less than that for younger and middle-aged adults. 17 Limitations may also exist for young adults who have not attained full growth, adults with naturally very lean or Classification Underweight Normal Weight BMI Category (kg/m2) < Risk of Developing Increased Least Overweight Increased Obese > 3. High Table 2. BMI Classification for Adults (18+years). Note: The BMI classification is not for use with pregnant and lactating women. Source: Canadian Guidelines for Body Weight Classification in Adults. Health Canada, 23. very muscular body builds and certain ethnic or racial groups. In addition, caution should be paid as BMIs are based on self-reported height and weight which tends to underestimate BMI. This is because individuals are likely to underestimate their weight and overestimate their height. 18 The prevalence of overweight and obesity in Canada has increased over the past 2 years. 17 Underweight is associated with undernutrition, osteoporosis, respiratory disease and eating disorders, while overweight is associated with type II diabetes, hypertension, coronary heart disease, gallbladder disease, and certain cancers (among other health problems). 17 In Huron County, the prevalence of overweight and obesity has remained stable over the past 5 years (Figure 5). In 26, 36.5% (95% CI ) of respondents were classified as having a normal weight; 36.% (95% CI ) were classified as overweight; and 21.1% (95% CI ) as obese. Men were significantly more likely to be overweight and obese than women for all years of data collected. In 26, 46.9% of men were classified as overweight compared to 31.5% of women and 24.% obese compared to 2.8% (X 2 =25.11, p<.1). Compared to Ontario, Huron County has a significantly higher proportion of individuals classified as obese. 6 In a 25 Canada-wide survey, 22.5% (95% CI ) of Huron County residents were categorized as obese, compared to 15.5% of Ontarians (95% CI ). 6 Figure 5. Percentage of respondents classified as underweight, normal weight, overweight and obese in Huron County according to the Canadian Guidelines for Body Weight Classifications in adults (18+ years). All pregnant women were excluded from analysis. Proportions of individuals underweight could not be released for 22, 25 Percent (%) * BMI Classification (18+ years), Huron County Underweight Normal Weight Overweight Obese BMI Classification and 26 due to small numbers or extremely high variability. * Indicates high sampling variability - estimate should be interpreted with caution. Source: Rapid Risk Factor Surveillance System (RRFSS) 22 (n=586), 23 (n=1136), 25 (n=842) and 26 (n=711) Huron County Community Health Status Report - 27

29 Youth Obesity in children increases the risk of developing heart disease and other chronic diseases later in life. 19 International cut off points for BMI for overweight and obesity have been developed for children aged 2-18 years, which are currently used by Statistics Canada. In Huron County, 72.% (95% CI ) of youth aged years report a normal weight. 6 Sun Safety Ultraviolet radiation produced by the sun causes skin cancer. 2 Skin cancer is the most common cancer in Ontario, accounting for approximately a third of all diagnosed cancers. 21 Severe, repeated sunburns as children, and also as adults, can increase the risk of skin cancer. 22 In Huron County, 34.4% (95% CI ) of adults (18 years+) reported being sunburned in the past 12 months. 23 Reducing exposure to harmful ultraviolet radiation by avoiding the sun at peak hours during the summer months, wearing sunscreen and/or wearing protective clothing and sunglasses can reduce the risk of developing skin cancer. In the summer of 26 (May September), Huron County residents were asked about protective measures they take when in the sun. Only 33.8% (95% CI ) of adults responded that they always or often avoid sun during peak hours of the day and 3.6% (95% CI ) always or often wear sunscreen. 24 Over half of Huron County residents wear sunglasses with UV protection (57.6%, 95% CI ) and 47.4% (95% CI ) wear protective clothing when in the sun. Artificial tanning equipment (or tanning beds) also emits ultraviolet radiation. In 26, 8.5% (95% CI ) of Huron County residents reported using artificial tanning equipment over the past 12 months. Women were significantly more likely to use this equipment compared to men (X 2 =2.79, p<.1) and those years of age compared to all other age groups (X 2 =18.13, p<.1). Self-Perceived Life Stress Stress can be caused by acute stressors such as major life events or by chronic stressors which have less obvious beginnings and develop and persist subtly over time. 25 Taking on too many tasks, financial burdens and problems with relationships and children are common causes of stress. 25 Stress impacts health in a number of ways. Stress has been found to be related to psychological distress and negative changes in health behaviours in the short term and increased risk for developing chronic conditions, such as arthritis, back problems, chronic bronchitis, ulcers and heart disease, in the long term. 25 In 25, 18.% (95% CI ) of Huron County residents reported that most days were quite a bit or extremely stressful. 6 This was significantly lower than the provincial average of 22.7% (95% CI ). There was no significant difference in stress levels between genders, unlike Ontario as a whole, where women reported significantly more stressful days than men. While Huron County men appear to report similar stress levels to Ontario men, Huron County women report significantly lower stress level to Ontario women (17.1%, 95% compared to 23.8%, 95% CI ). This could be due to the strong sense of community and support that is typical of rural communities Huron County Community Health Status Report

30 Conclusions While the prevalence of current smokers has remained relatively constant over the past five years, the proportion of completely smokefree homes has increased in Huron County. Consumption patterns (number of cigarettes smoked per day) and changes in attitudes towards smoking and smoking restrictions should continue to be examined to monitor progress in tobacco use prevention. More than half of the Huron County population consumes alcohol in a high risk manner and youth in Huron County are much more likely to binge drink than the average Ontario youth. Alcohol use is an issue that continues to need to be addressed. Huron County also has a higher proportion of individuals classified as obese when compared to Ontario, with approximately one in five being obese. Despite this, physical activity levels and fruit consumption patterns appear to be similar to the province. Further research into factors which may be contributing to this higher level of obesity, which may include the rural built environment, should be explored. 1 Bryan H. (Ed. Vivien Bowers) Beyond Health Services and Lifestyle: A Social Determinants iarc.fr/eng/press_release/archives/pr144a.html. Approach to Health. Interior Health, Pérez CE. Fruit and vegetable consumption. Health Reports, 22;13(3): Makomaski EM and Kaiserman MJ. Mortality Attributable to Tobacco Use in Canada and its 17 Health Canada. Canadian Guidelines for Body Weight Classification in Adults. Ottawa, ON: Regions, Canadian Journal of Public Health 24;95: Office of Nutrition Policy and Promotion, Doll R, Peto R, Boreham J and Sutherland I. Mortality in relation to smoking: 5 years 18 Connor Gorber S et al. A comparison of direct vs. self-report measures for assessing observations on male British doctors. British Medical Journal 24;328: height, weight and body mass index: a systematic review. Obesity Reviews, 27;8(4):37 4 International Agency for Research on Cancer. IARC Monographs. Tobacco Smoke and 326. Involuntary Smoking, 22. Volume 83. Accessed 2 July 26 from 19 Cole TJ et al. Establishing a standard definition for child overweight and obesity worldwide: iarc.fr/eng/monographs/vol83/volume83.pdf#search=%22who%2-%2iarc%2c%2 international survey. British Medical Journal, 2;32:124. Monograph%283%22. 2 International Agency for Research on Cancer. IARC Monographs. Solar and Ultraviolet 5 U.S. Department of Health and Human Services. The Health Consequences of Involuntary Radiation,1992. Volume 55. Accessed 15 September 28 at Exposure to Tobacco Smoke: A Report of the Surgeon General Executive Summary. ENG/Monographs/vol55/volume55.pdf. Centers for Disease Control and Prevention, Office of Smoking and Health, Cancer Care Ontario. Ontario Cancer Fact: Skin cancer is the most common cancer, June 6 Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge 25. Accessed 15 September 28 at Management and Reporting Branch, Ontario MOHLTC. htm. 7 World Health Organization. Global Status Report on Alcohol 24. Geneva: Department of 22 Grodstein et al. Risk factors for melanoma. Harvard Center for Cancer Prevention, 1995, Mental Health and Substance Abuse, 24. retrieved 18 January 27 from 8 Rehm J. et al. Overview of positive and negative effects of alcohol consumption implications riskfactors/ydr_riskfac.htm. for preventive policies in Canada. Centre for Addiction and Mental Health, 26. Retrieved 23 Rapid Risk Factor Surveillance System, May-December May 28 from 24 Rapid Risk Factor Surveillance System, May-September 26. Winter%227/Alcohol_riskbenefits_Overview_english_final_%227.pdf. 25 Shields M. Stress, health and the benefit of social support. Health Reports, 24:15(1), 9 Murray RP et al. Alcohol Volume, Drinking Pattern, and Cardiovascular Disease Morbidity and Mortality: Is There a U-shaped Function? American Journal of Epidemiology 22;155(3 ): Tjepkema M. Alcohol and illicit drug dependence. Supplement to Health Reports, Statistics Canada, 24;15: Single E et al. The relative risks and etiologic fractions of different causes of death and disease attributable to alcohol, tobacco and illicit drug use in Canada. Canadian Medical Association Journal, 2;162(12): Rapid Risk Factor Surveillance System, January-December World Health Organization. The World Health Report 22 - Reducing Risks, Promoting Healthy Life. (Chapter 4: Quantifying Selected Major Risks to Health). Accessed on 15 September 28 at 14 Traynor MM. Vegetable and Fruit Food Frequency Questionnaire Serves as a Proxy for Quantifies Intake. Canadian Journal of Public Health, 26;97(4): International Agency for Research on Cancer. Fruits and Vegetables Protective Overall Against Cancer. 23. IARC Press Release 144. Accessed 5 January 27 from Huron County Community Health Status Report - 29

31 Mortality Mortality is commonly used to measure the overall health of a population. Examining patterns of death helps develop public health goals and guide program planning. There is evidence that these direct causes of death can be linked to socioeconomic status (SES). For example, individuals with lower SES are more vulnerable throughout their lifetime to developing cardiovascular disease. Social and economic deprivation influence the adoption of risk behaviours (such as smoking, poor eating habits or lack of physical activity), exposure to poor working conditions including stress at work, and limit the availability of resources for adequate care. 1 All of these factors influence health and subsequent mortality. As such, a key component for decreasing mortality rates is to minimize the risks subjected to those with lower SES. This chapter examines all-cause mortality rates and leading causes of death for Huron County. The report also makes comparison to Ontario through standardized mortality ratios. Life expectancy and potential years of life lost are also described. All deaths reported are for Huron County or Ontario residents whose death occurred in Ontario. All Cause Mortality Mortality due to all causes is a good indicator of the health status of the population. High mortality rates in a population can signal poor living conditions, low socioeconomic status or an aging population. Examining trends in mortality can shed light on changes in health status, living conditions, socioeconomic status, medical advancements, or changes in behavioural risks. The crude mortality rate is the number of deaths divided by the population at risk over a defined period of time. This rate gives the true picture of death in a community. Table 1 shows the crude mortality rates for Huron County for Between 2 and 23, a range of deaths occurred per year, giving an average crude death rate of 91.2 deaths per 1, population. Huron County s higher crude death is likely due to having a relatively higher proportion of individuals aged 65 years and older when compared to Ontario (17% compared to 13% for 2 to 23). Crude mortality rates are influenced by the age structure of a population and can be misleading when comparing mortality in populations with different age structures. Instead, age-specific mortality rates can be examined. Age-specific mortality rates for Huron County are shown in Figure 1. As expected, the mortality rate is highest in those over the age of 65 years. 3 - Huron County Community Health Status Report Year Deaths (Count) Crude Mortality Rate (per 1,) Male Female Total Male Female Overall Ontario , , ,26.3 1,1.9 1, Total/Average 1,171 1,221 2, Table 1. The number of deaths and crude mortality rates for Huron County (and Ontario) from 2 to 23. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 29/1/27, Health Planning Branch, Ontario MOHLTC.

32 Age Group <1 Age-Specific Mortality Rates - All Causes Huron County Figure 1. Age-specific mortality rates due to all causes in Huron County (2-23 combined). Note: The mortality rate for ages 1-9 years has been suppressed due to small numbers. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 29/1/27, Health Planning Branch, Ontario MOHLTC. Rate per 1, Another useful method to compare mortality between different populations or to look at mortality trends over time is to calculate agestandardized mortality rates. Age standardization is a procedure for adjusting rates designed to minimize the effects of differences in age composition when comparing rates from different populations. 2 Age standardization allows a summary mortality rate to be calculated based on the number of deaths that would be expected if the population had the same age structure as the 1991 Canadian standard population. The rates themselves do not give an accurate picture of mortality in the community. However, they allow comparisons between populations with differing age structures. The age-standardized mortality rates for Huron County and Ontario are shown in Figure 2. Over the past four years, Huron County s age-standardized mortality rate has remained fairly constant, with a slight increase over the past three years. Huron County s agestandardized mortality rate is similar to Ontario s. Age Standardized Mortality Rates, All Causes Huron County and Ontario Rate per 1, Figure 2. Age-standardized mortality rates for Huron County and Ontario from 2 to 23. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 3/1/27, Health Planning Branch, Ontario MOHLTC. Huron County Ontario Huron County Community Health Status Report - 31

33 Leading Causes of Death Mortality patterns in a population can be described by ranking causes of death in order of their frequency. Causes of death were grouped according to Becker et al 26 with some minor modifications as agreed on by the Association of Local Public Health Agencies Leading Causes of Death Working Group. 3 Figures are presented for the whole County, by sex and by age group. A glossary of the causes of deaths, their descriptions and their International Classification of Diseases ICD-1 codes are provided in Appendix 1. International Classification of Diseases (ICD) classifies diseases and other health problems recorded on many types of health and vital records including death certificates and health records using a numbering system. This system, which is currently in its 1 th revision, is maintained by the World Health Organization. From 2 to 23, the leading cause of death in Huron County was ischemic heart disease (Table 2). After ischemic heart disease, cerebrovascular diseases and lung cancer were the second and third leading causes of death. Huron County had similar leading causes of death as compared to Ontario, with some exceptions. Huron had a Rank Cause of Death Number Per Cent Ontario of Deaths (%) Rank 1 Ischemic Heart Disease Cerebrovascular Diseases Lung Cancer Chronic Lower Respiratory Diseases Diabetes Dementia and Alzheimer Disease Colorectal Cancer Heart Failure and complications Lymphoma and Leukemia Influenza and Pneumonia n=2,392 Table 2. Top Ten Leading Causes of Death in Huron County, Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 29/1/27, Health Planning Branch, Ontario MOHLTC. MALE FEMALE Rank Cause of Death Number Per Cent (%) 1 Ischemic Heart Disease Lung Cancer Chronic Lower Respiratory Diseases Cerebrovascular Diseases Colorectal Cancer Prostate Cancer Diabetes Lymphoma and Leukemia Land Transport Occurrences Suicide n=1,171 Rank Cause of Death Number Per Cent (%) 1 Ischemic Heart Disease Cerebrovascular Diseases Dementia and Alzheimer Disease Lung Cancer Heart Failure and complications Breast Cancer Diabetes Chronic Lower Respiratory Diseases Influenza and Pneumonia Colorectal Cancer n=1,221 Table 3. Top Ten Leading Causes of Death in Huron County, by sex, Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 29/1/27, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

34 higher percentage of deaths due to heart failure and land transport occurrences (ranked 11th with 49 deaths in Huron County compared to ranked 18 in Ontario). When looking at leading causes of death by sex, several differences were apparent (Table 3). In men, lung cancer and chronic lower respiratory diseases were among the top three leading causes of death. Colorectal cancer, land transport occurrences and suicide were also significant causes of death. In women, however, the top three included cerebrovascular diseases, dementia and Alzheimer disease, and heart failure. Influenza and pneumonia were also important causes of death. The sex differences in mortality observed in Huron County are consistent with those observed at the provincial level (data not shown). Leading causes of death by age group are shown in Table 4. Land transport occurrences were the leading cause of death for males and females from ages 7 to 44 years. Ischemic heart disease and lung cancer were the leading causes of death for both men and women ages 45 years and older. Land transport occurrences were also a leading cause of death in this age group among men, while pulmonary heart disease was a leading cause of death among women. Deaths in individuals aged 65 years or older mirrored the overall leading causes of death. to 6 years MALE Rank Cause of Death Number Per Cent (%) (n<5) Numbers too small to release n/a FEMALE Rank Cause of Death Number Per Cent (%) Certain Conditions Originating (n=9) Perinatally 7 to 19 years MALE Rank Cause of Death Number Per Cent (%) (n=17) 1 Land Transport Occurrences FEMALE Rank Cause of Death Number Per Cent (%) (n=6) Numbers too small to release n/a 2 to 44 years MALE Rank Cause of Death Number Per Cent (%) (n=58) 1 Land Transport Occurrences Ischemic Heart Disease Suicide Table 4. Leading Causes of Death in Huron County, by age and sex, Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 29/1/27, Health Planning Branch, Ontario MOHLTC. FEMALE Rank Cause of Death Number Per Cent (%) (n=24) 1 Land Transport Occurrences to 64 years MALE Rank Cause of Death Number Per Cent (%) (n=199) 1 Ischemic Heart Disease Lung Cancer Land Transport Occurrences Pancreatic Cancer Cirrhosis and other diseases of the liver Suicide Lymphoma and Leukemia Colorectal Cancer Chronic Lower Respiratory Diseases Diabetes 6 3. Huron County Community Health Status Report - 33

35 FEMALE Rank Cause of Death Number Per Cent (%) (n=131) 1 Lung Cancer Ischemic Heart Disease Breast Cancer Ovarian Cancer Cirrhosis and other diseases of the liver Pulmonary Heart Disease years and older MALE Rank Cause of Death Number Per Cent (%) (n=895) 1 Ischemic Heart Disease Lung Cancer Chronic Lower Respiratory Diseases Cerebrovascular Diseases Prostate Cancer Colorectal Cancer Diabetes Influenza and Pneumonia Lymphoma and Leukemia Diseases of the Urinary System FEMALE (n=151) Rank Cause of Death Number Per Cent (%) 1 Ischemic Heart Disease Cerebrovascular Diseases Dementia and Alzheimer Disease Heart Failure and complications Diabetes Chronic Lower Respiratory Diseases Lung Cancer Breast Cancer Influenza and Pneumonia Colorectal Cancer Standardized Mortality Ratios (SMRs) The age-standardized mortality ratio (SMR) is a ratio of the observed number of deaths in a specific population to the number of deaths that would be expected if the population had the same age-specific mortality rates as a reference population. This method is useful to compare mortality in two different populations when one of those populations has unstable agespecific rates due to small numbers. In this case, calculating an SMR for Huron County, using Ontario as a reference population, tells us the expected number of deaths in Huron County if Huron County had the same mortality experience as Ontario (i.e. the same age-specific death rates). An SMR greater than one indicates that the mortality rate in Huron County is higher than Ontario, while an SMR lower than one indicates that Huron County has a lower mortality rate than Ontario. Confidence intervals have been calculated to assess and report the precision of the agestandardized mortality ratios. When the SMR and its confidence interval overlap 1, the mortality rate for Huron County is not considered to be statistically significant from Ontario. SMRs for selected causes of death due to chronic and communicable diseases are shown in Figures 3 (male) and 4 (female). Huron County males had a significantly lower mortality rate due to dementia and Alzheimer disease than Ontario. Women in Huron County had a higher mortality rate due to heart failure and related complications, yet a lower mortality rate due to colorectal cancer when compared to Ontario Huron County Community Health Status Report

36 Standardized Mortality Ratios (SMRs) for Selected Causes of Death, Males, Huron County, SMR 1 Ischemic Heart Disease Cerebrovascular Diseases Lung Cancer Chronic Dementia Low er and Respiratory Alzheimer's Diabetes Heart Failure Influenza and Pneumonia Colorectal Cancer Upper CI Low er CI SMR Prostate Cancer Figure 3. Standardized Mortality Ratios (SMRs) for selected causes of death due to chronic and communicable diseases among men in Huron County, using 2-23 mortality data. The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for HuronCounty is significantly higher or lower than that of Ontario. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 23/2/27, Health Planning Branch, Ontario MOHLTC. Standardized Mortality Ratios (SMRs) for Selected Causes of Death, Females, Huron County, SMR 1 Ischemic Heart Disease Cerebrovascular Diseases Lung Cancer Chronic Dementia Low er and Respiratory Alzheimer's Diabetes Heart Failure Influenza and Pneumonia Colorectal Cancer Breast Cancer Upper CI Low er CI SMR Figure 4. Standardized Mortality Ratios (SMRs) for selected causes of death due to chronic and communicable diseases among women in Huron County, using 2-23 mortality data. The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron County is significantly higher or lower than that of Ontario. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 23/2/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 35

37 SMRs for selected causes of death due to injury are shown in Figure 5 (males) and 6 (females). Both Huron County males and females had a higher mortality rate due to land transport occurrences than Ontario. This is likely due to Huron County having a higher proportion of rural roads, with higher speed limits and subsequently increased risk of fatal collisions. Huron County men also had a higher mortality rate due to suicide when compared to Ontario. Standardized Mortality Ratios (SMRs) for Selected Causes of Death, Males, Huron County, SMR 2 1 Land Transport Occurrences Suicide Accidental Fall Upper CI Lower CI SMR Figure 5. Standardized Mortality Ratios (SMRs) for selected cause of death due to injury among men in Huron County, using 2-23 mortality data. The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron County is significantly higher or lower than that of Ontario. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 23/2/27, Health Planning Branch, Ontario MOHLTC. SMR Standardized Mortality Ratios (SMRs) for Selected Causes of Death, Females, Huron County, Land Transport Occurrences Suicide Accidental Fall Upper CI 4.34 small cell count 1.88 Lower CI SMR Figure 6. Standardized Mortality Ratios (SMRs) for selected cause of death due to injury among women in Huron County, using 2-23 mortality data. The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron County is signifi cantly higher or lower than that of Ontario. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 23/2/27, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

38 Life Expectancy Life expectancy is the average length of time that an individual will live (in years) if subjected to a given mortality experience unique to a specified population and time period. It is used to estimate population health. However, it should not be used as a predictor of population health, as mortality rates change over time. Life expectancy is significantly influenced by socioeconomic status and less so by behavioural factors. In a study conducted by Statistics Canada in 22, sociodemographic factors accounted for a 56% variation in life expectancy compared to only an 8% variation due to smoking. 4 Therefore, a key component to improving life expectancy is to improve the socioeconomic status of disadvantaged individuals in a population. In Huron County, at birth, men were expected to live years and women 81.2 years in This was slightly lower than the life expectancy in Ontario (77.67 years for men and years for women). Potential Years Life Lost (PYLL) Potential years life lost (PYLL) is an indicator of premature mortality and is calculated by dividing the total years of life lost before age 75 by the total population under 75 years. More weight is given to the deaths of younger individuals as a higher number of years of life are lost. For example, a person who dies at age 25 will have lost 5 potential years of life. Income differences have been shown to contribute to 24% of premature years of life lost, with heart disease, stroke, cancer and infectious diseases having the highest association with income. 6 Between 2 and 23, the two most important causes of premature mortality in Huron County among males and females were ischemic heart disease and land transport occurrences. Selected causes of PYLL for males in Huron County are shown in Figure 7 and for females in Figure 8. Among men, other important causes of PYLL included suicide, lung cancer and accidental injury. Among women, lung, breast and ovarian cancers were important causes of death among those under 75 years of age. In Huron County youth (1-25 years), land transport occurrences were the leading cause of PYLL, with 21.6 years lost per 1, youth for 2 to Potential Years Life Lost for Selected Causes of Death in Males, Huron County 2-23 Cause of Death Ischemic Heart Disease Land Transport Occurrences Suicide Lung Cancer Accidental Injury Cirrohosis and other diseases of the liver Lymphomas and Leukemia Colorectal Cancer Pancreatic Cancer Diabetes Chronic Lower Respiratory Diseases Melanoma Rate per 1, Figure 7. PYLL for selected causes of death among men in Huron County from 2 to 23. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 1/2/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 37

39 Cause of Death Potential Years Life Lost for Selected Causes of Death in Females, Huron County 2-23 Land Transport Occurrences 4.87 Ischemic Heart Disease 4.13 Lung Cancer 3.95 Breast Cancer 3.38 Ovarian Cancer 1.73 Cirrohosis and other diseases of the liver 1.26 Pancreatic Cancer.97 Lymphomas and Leukemia.94 Colorectal Cancer.86 Chronic Lower Respiratory Diseases.84 Melanoma.51 Heart Failure Rate per 1, Figure 8. PYLL for selected causes of death among women in Huron County from 2 to 23. Source: Ontario Mortality Data and Population Estimates [2-23], Provincial Health Planning Database (PHPDB) Extracted: 1/2/27, Health Planning Branch, Ontario MOHLTC. Conclusion From 2 to 23, Huron County has experienced an average crude mortality rate of 91.2 deaths per 1,, which is higher than the province. When standardized for age, however, Huron County mortality rates were similar to Ontario. Ischemic heart disease, cerebrovascular disease and lung cancer were the top three leading causes of death, as they were for Ontario. Huron County males have experienced significantly higher mortality rates than Ontario due to suicide, while females have experienced significantly higher mortality rates due to heart failure. In both sexes, mortality due to land transport accidents was significantly higher than Ontario and was a leading cause of premature mortality, especially in men and in youth. Many of the direct causes of death are linked to socioeconomic status, especially chronic diseases such as cardiovascular disease. Given that ischemic heart disease is the leading cause of death and a top cause of premature death in Huron, social and economic factors which influence the adoption of poor lifestyle behaviours must be addressed. In addition, attitudes toward safe driving practices should be explored in Huron County to help guide program planning and prevention efforts. 1 Bryan H. (Ed. Vivien Bowers) Beyond Health Services and Lifestyle: A Social Determinants Approach to Health. Interior Health, Last J. A Dictionary of Epidemiology, Fourth Ed. New York, NY: Oxford University Press, Becker R et al. A method for deriving leading causes of death. World Health Organization. 26;84(4): Shields M and Tremblay S. The Health of Canada s Communities. Health Reports (Supplement), 22;13: Ontario Mortality Data and Population Estimates 23, Provincial Health Planning Database. Extracted: 3/1/27, Health Planning Branch, Ontario Ministry of Health and Long-Term Care. 6 Wilkins R, Berthelot J-M and Ng E. Trends in Mortality by Neighbourhood Income in Urban Canada from 1971 to Health Reports (Supplement), 22;13: Ontario Mortality Data and Population Estimates 23, Provincial Health Planning Database. Extracted: 1/2/27, Health Planning Branch, Ontario Ministry of Health and Long-Term Care Huron County Community Health Status Report

40 Morbidity Morbidity, also known as sickness or illness, can be defined as a departure from a state of physiological or psychological well-being. 1 Many different factors can influence this departure from health, including environmental characteristics, health behaviours, and social and economic conditions. The impact of socioeconomic factors on chronic disease and injury are explored in more detail in the corresponding chapters. Hospitalization data is typically used to provide a crude measure of the prevalence of illness in the population. In this report, hospitalizations are measured by in-patient hospital separations, which refer to a separation from a health care facility because of death, discharge or transfer. Day procedures are not included in the hospitalizations reported here. Causes of hospitalization are based on the most responsible diagnosis (MRD) during a given hospital stay, where the MRD is the diagnosis associated with the longest duration of treatment. It is possible that patients may be hospitalized for more than one disease or condition (co-morbidity), which contributes uncertainty to classifying the MRD. An additional limitation of hospitalization data, particularly in its use as a crude measure of the prevalence of an illness, is that individuals may not be hospitalized for a condition or they may be hospitalized several times for the same illness or injury. Hospitalization data can also be influenced by the availability and accessibility of services and hospital policies and procedures. For the purposes of this report, healthy newborns (i.e. newborns born alive in hospital) have been excluded from all-cause hospitalization data to eliminate double-counting as the births have already been captured through the mothers under pregnancy and childbirth. It is important to note, however, that from a health-care utilization perspective newborns receive additional services and require additional resources, which is not reflected in these counts. In this chapter, all-cause hospitalization rates will be presented, along with the leading causes of hospitalization. Comparisons of hospitalization data with Ontario will be made through standardized morbidity ratios. All Cause Hospitalization The crude hospitalization rate is the total number of hospital separations (discharges, transfers, and deaths) during a given year (fiscal or calendar) per total population. The total number of hospitalizations, along with the crude hospitalization rate for Huron County and Ontario, is shown for in Table 1. Between 22-26, there was a range of 6,251 7,129 hospitalizations per year in Huron County, resulting in an average crude hospitalization rate of 11. hospital separations per 1, population. Females had a higher number and rate of hospitalizations than males, due in part to the high proportion of female hospitalizations resulting from pregnancy and childbirth. The crude hospitalization rate is higher for Huron County than Ontario, which could be the result of an older population. Examining crude hospitalization rates by age groups demonstrates how morbidity varies by age. Age-specific hospitalizations for all causes are shown in Figure 1 for Huron County. Hospitalization rates were highest for adults aged 65 years and older, followed by infants under the age of 1 year. To compare Huron County hospitalization rates with the province, age-standardized hospitalization rates were calculated and are shown in Figure 2. Age-standardized hospitalization rates have declined 12.% from 22 to 26 among Huron County residents. Ontario rates have also declined; however, Huron County continues to have higher age-standardized hospitalization rates than the province. Huron County Community Health Status Report - 39

41 Year Hospitalizations (Count) Male Female Total 22 3,163 3,965 7, ,993 3,862 6, ,114 3,78 6, ,87 3,739 6,828 26* 2,8 3,45 6,251 Total/Average 15,157 18,796 33,957 Crude Hospitalization Rate (per 1,) Male Female Overall Ontario Table 1. The number of hospital separations for both Huron County males and females, along with the crude hospitalization rates for both Huron County and Ontario, * Note: The reporting system for hospitalizations in psychiatric beds in acute care hospitals changed at the beginning of the 26 fiscal year. As a result, only approximately 5% of psychiatric hospitalizations for 26 are captured, resulting in an underestimate of the number of hospitalizations for all causes in this year. Source: Hospital In-Patient Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB). Extracted: 4/28, Health Planning Branch, Ontario MOHLTC. Age Group (years) < Age-Specific Hospitalizations - All Causes Huron County Combined Figure 1. Age-specific hospitalization rates for all causes in Huron County (22-26 combined). Source: Hospital In-Patient Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB). Extracted: 4/28, Health Planning Branch, Ontario MOHLTC Rate per 1, Age-Standardized All Cause Hospitalization Rates, Figure 2. Age- Huron County and Ontario standardized hospitalization rates 12 for Huron County and Ontario from 22 to 26. Source: Hospital In-Patient Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB) Extracted: 3/1/27, Health Planning Branch, Ontario MOHLTC. Huron Rate Ontario Rate Year Rate (per 1,) Huron County Community Health Status Report

42 Leading Causes of Hospitalization Causes of hospitalization, as indicated by the most responsible diagnosis, were grouped by ICD-1 chapter* and ranked to determine the most common causes of hospitalization in Huron County. Figures are presented for the community as a whole, by sex and by age group. A description of the contents of each ICD-1 chapter, along with the resulting ICD-1 codes, is provided in Appendix 2. Accounting for 13.8% of all hospitalizations between 23 and 26, the leading cause of hospitalization in Huron County was diseases of the circulatory system (Table 2). Following that, diseases of the digestive system and factors influencing health status and contact with health services were the second and third leading causes of hospitalization. Huron County has a higher proportion of hospital separations due to contact with the health services than Ontario, which could be due to the shortage of family physicians. Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) Ontario Rank 1 Diseases of the Circulatory System 3, Diseases of the Digestive System 2, Factors Influencing Health Status and Contact with Health Services 2, Injury, Poisoning and Certain Other Consequences of External Causes 2, Pregnancy, Childbirth and the Puerperium 2, Diseases of the Respiratory System 2, Neoplasms (Cancers) 1, Mental and Behavioural Disorders* 1, Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classified 1, elsewhere) 1 Diseases of the Musculoskeletal System 1, n=26,828 Table 2. Top ten leading causes of hospitalization in Huron County, * Note: The reporting system for hospitalizations in psychiatric beds in acute care hospitals changed at the beginning of the 26 fiscal year. As a result, only approximately 5% of psychiatric hospitalizations for 26 are captured, resulting in an underestimate of the number of hospitalizations for mental and behavioural disorders. Source: Hospital In-Patient Data [23-26], Provincial Health Planning Database (PHPDB). Extracted: 18/4/28, Health Planning Branch, Ontario MOHLTC. * The International Statistical Classification of Diseases and Related Health Problems, 1th Revision (ICD-1) is an international standard for reporting clinical diagnoses developed by the World Health Organization Huron County Community Health Status Report - 41

43 Leading causes of hospitalization are shown for different age groups in Table 4. For infants under the age of one year, the leading cause of hospitalization for both sexes was conditions originating in the perinatal period, accounting for almost a third of all hospitalizations in this age group. These conditions include infants affected by maternal factors and pregnancy complications; disorders related to gestation length and fetal growth; respiratory, cardiovascular and digestive system disorders, among others. For children aged 1-9 years, diseases of the respiratory system were the leading cause of hospitalization for both males and females. Among youth aged 1-19 years, the top cause of hospitalization was injuries, poisonings and certain other consequences of external causes among males while pregnancy, childbirth and the puerperium was the leading cause among females. Pregnancy was also the leading cause of hospitalization in women aged 2-44 years, whereas mental and behavioural disease was the leading cause among men in that age group. Diseases of the circulatory system were attributable for the highest number of hospitalizations among men aged 45 years and older and also among women aged 65 years and older. Diseases of the digestive system were the leading cause of hospitalization among women aged years. MALE FEMALE Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Diseases of the Circulatory System 2, Diseases of the Digestive System 1, Injury, Poisoning and Certain Other Consequences of External Causes 1, Diseases of the Respiratory System 1, Neoplasms (Cancers) Factors Influencing Health Status and Contact with Health Services Mental and Behavioural Disorders Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classified elsewhere) 9 Diseases of the Musculoskeletal System Diseases of the Genitourinary System n=11,994 Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Pregnancy, Childbirth and the Puerperium 2, Factors Influencing Health Status and Contact with Health Services 1, Diseases of the Circulatory System 1, Diseases of the Digestive System 1, Injury, Poisoning and Certain Other Consequences of External Causes 1, Neoplasms (Cancers) 1, Mental and Behavioural Disorders Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classified elsewhere) 9 Diseases of the Respiratory System Diseases of the Musculoskeletal System n=14,831 Table 3. Top ten leading causes of hospitalization in Huron County, by sex, Source: Hospital In-Patient Data [23-26], Provincial Health Planning Database (PHPDB). Extracted: 18/4/28, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

44 Table 4. Top five leading causes of hospitalization for various age groups in Huron County, by sex, Source: Hospital In-Patient Data [23-26], Provincial Health Planning Database (PHPDB). Extracted: 18/4/28, Health Planning Branch, Ontario MOHLTC. Under 1 year MALE (n=277) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Certain Conditions Originating in the Perinatal Period Diseases of the Respiratory System Factors Influencing Health Status and Contact with Health Services Congenital Malformations, Deformations and Chromosomal Abnormalities Diseases of the Digestive System FEMALE (n=159) Rank ICD-1 Chapter Certain Conditions Originating in the Perinatal Period Diseases of the Respiratory System Factors Influencing Health Status and Contact with Health Services Congenital Malformations, Deformations and Chromosomal Abnormalities Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classifi ed elsewhere) Number of Per Hospital Separations Cent (%) to 9 years Rank 1 2 MALE (n=355) ICD-1 Chapter Diseases of the Respiratory System Diseases of the Digestive System Injury, Poisoning and Certain Other Consequences of External Causes Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classifi ed elsewhere) Factors Influencing Health Status and Contact with Health Services Number of Hospital Separations Per Cent (%) FEMALE (n=224) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Diseases of the Respiratory System Injury, Poisoning and Certain Other Consequences of External Causes Diseases of the Digestive System Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classifi ed elsewhere) Endocrine, Nutritional and Metabolic Diseases Huron County Community Health Status Report - 43

45 1 to 19 years MALE (n=549) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Injury, Poisoning and Certain Other Consequences of External Causes Mental and Behavioural Disorders Diseases of the Digestive System Factors Influencing Health Status and Contact with Health Services Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classifi ed elsewhere) FEMALE (n=51) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Pregnancy, Childbirth and the Puerperium Mental and Behavioural Disorders Injury, Poisoning and Certain Other Consequences of External Causes Diseases of the Digestive System Factors Influencing Health Status and Contact with Health Services to 44 years MALE (n=15) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Mental and Behavioural Disorders Injury, Poisoning and Certain Other Consequences of External Causes Diseases of the Digestive System Symptoms, Signs and Abnormal Clinical and Laboratory Findings (not classifi ed elsewhere) Factors Influencing Health Status and Contact with Health Services FEMALE (n=4329) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Pregnancy, Childbirth and the Puerperium 2, Factors Influencing Health Status and Contact with Health Services Mental and Behavioural Disorders Diseases of the Genitourinary System Diseases of the Digestive System Huron County Community Health Status Report

46 45 to 64 years MALE (n=3211) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Diseases of the Circulatory System Diseases of the Digestive System Neoplasms (Cancers) Mental and Behavioural Disorders Diseases of the Musculoskeletal System Rank ICD-1 Chapter Number of Per Cent Hospital (%) Separations FEMALE 1 Diseases of the Digestive System (n=2797) 2 Neoplasms (Cancers) Mental and Behavioural Disorders Diseases of the Circulatory System Diseases of the Genitourinary System years and older MALE (n=612) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Diseases of the Circulatory System 1, Diseases of the Respiratory System Neoplasms (Cancers) Diseases of the Digestive System Factors Influencing Health Status and Contact with Health Services FEMALE (n=6812) Rank ICD-1 Chapter Number of Hospital Separations Per Cent (%) 1 Diseases of the Circulatory System 1, Factors Influencing Health Status and Contact with Health Services Injury, Poisoning and Certain Other Consequences of External Causes Diseases of the Digestive System Diseases of the Musculoskeletal System Huron County Community Health Status Report - 45

47 Standardized MorbidityRatio (SMR) Like the Standardized Mortality Ratio, the Standardized Morbidity Ratio is a useful method to compare morbidity in two different populations. The Standardized Morbidity Ratio is a ratio of the observed number of hospital separations in a specific population to the number of hospital separations that would be expected if the population had the same age-specific hospitalization rates as a reference population. Calculating Standardized Mortality Ratios for Huron County, using Ontario as the reference population, gives the expected number of hospitalizations in Huron County if Huron had the same age-specific hospitalization rates as Ontario. An SMR greater than 1. indicates that the hospitalization rate in Huron is higher than Ontario, while an SMR lower than 1. indicates that Huron has a lower hospitalization rate than Ontario. SMRs for selected causes of hospitalization between 23 and 26 are shown in Figure 3 for males and Figure 4 for females. Huron County males had a significantly higher hospitalization rate for chronic lower respiratory illness, influenza and pneumonia and prostate cancer than Ontario. Among females, by contrast, hospitalization rates were significantly higher for most causes of hospitalization when compared to Ontario, with the exception of chronic lower respiratory illness, cerebrovascular disease and lung cancer. SMRs were also calculated for external causes of hospitalization, including land transport occurrences, attempted suicide and accidental falls (Figure 5 for males and Figure 6 for females). Hospitalization rates were significantly higher in Huron County males and females for all three external causes when compared to Ontario. Standardized Morbidity Ratios (SMRs) for Selected Causes of Hospitalization, Males, Huron County SMR 1 Ischemic Heart Disease Cerebrovascular Diseases Lung Cancer Chronic Low er Respiratory Diabetes Influenza and Pneumonia Colorectal Cancer Prostate Cancer Upper CI Low er CI SMR Figure 3. Standardized Morbidity Ratios (SMRs) for selected causes of hospitalization among males in Huron County, The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron is significantly higher or lower than that of Ontario. Source: Hospital In-Patient Data and Population Estimates [23-26], Provincial Health Planning Database (PHPDB) Extracted: 4/28, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

48 Standardized Morbidity Ratios (SMRs) for Selected Causes of Hospitalization, Females, Huron County SMR 1 Ischemic Heart Disease Cerebrovascular Diseases Lung Cancer Chronic Low er Respiratory Diabetes Influenza and Pneumonia Colorectal Cancer Breast Cancer Upper CI Low er CI SMR Figure 4. Standardized Morbidity Ratios (SMRs) for selected causes of hospitalization among females in Huron County, The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron is significantly higher or lower than that of Ontario. Source: Hospital In-Patient Data and Population Estimates [23-26], Provincial Health Planning Database (PHPDB) Extracted: 4/28, Health Planning Branch, Ontario MOHLTC. Standardized Morbidity Ratios (SMRs) for Selected Causes of Hospitalization, Males, Huron County SMR 1 Land Transport Occurrences Attempted Suicide Accidental Fall Upper CI Lower CI SMR Figure 5. Standardized Morbidity Ratios (SMRs) for selected external causes of hospitalization among males in Huron County, The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron is significantly higher or lower than that of Ontario. Source: Hospital In-Patient Data and Population Estimates [23-26], Provincial Health Planning Database (PHPDB) Extracted: 4/28, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 47

49 Standardized Morbidity Ratios (SMRs) for Selected Causes of Hospitalization, Females, Huron County SMR 1 Land Transport Occurrences Attempted Suicide Accidental Fall Upper CI Lower CI SMR Figure 6. Standardized Morbidity Ratios (SMRs) for selected external causes of hospitalization among females in Huron County, The error bars represent the 95% Confidence Interval for the SMR. Intervals that do not include one indicate the SMR for Huron is significantly higher or lower than that of Ontario. Source: Hospital In-Patient Data and Population Estimates [23-26], Provincial Health Planning Database (PHPDB) Extracted: 4/28, Health Planning Branch, Ontario MOHLTC. Conclusions Between 22 and 26, there was a range of 6,251 to 7,129 hospitalizations per year in Huron County. Females experienced higher hospitalization rates compared to males, likely a result of the high proportion of hospitalizations due to pregnancy and childbirth. Leading causes of hospitalization for both sexes were diseases of the circulatory system, followed by diseases of the digestive system and factors influencing health status and contact with health services. The higher number of hospitalizations due to this latter category could be a result of the physician shortage in Huron County. When compared to the province, Huron County males had higher hospitalization rates for chronic lower respiratory illness, influenza and pneumonia and prostate cancer. Huron County women had significantly higher hospitalization rates than Ontario for most causes of hospitalization. 1 Last J. A dictionary of epidemiology, Fourth Edition. New York, NY: Oxford University Press, Inc., Huron County Community Health Status Report

50 Chronic Health Conditions Chronic health conditions typically develop over a long period of time, have a long duration and, in most cases, have no cure. 1 These conditions can have significant impacts on an individual s sense of well-being and also on their ability to continue their everyday activities. 1 Examples of chronic health conditions include: allergies, asthma, arthritis, high blood pressure, chronic respiratory diseases, diabetes, heart disease, cancer, mood disorders, among others. Social determinants of health, such as education levels, income and employment status, are major contributors to the development of chronic health conditions. These social characteristics directly impact health behaviours (i.e. tobacco and alcohol use, poor diet, physical inactivity, etc) and outcomes (i.e. high blood pressure and obesity) which can lead to chronic disease development. These risk factors, however, are not always present during adulthood when diagnosis of these chronic conditions occurs. Increasingly, research has shown that chronic health conditions may result from complex interactions of multiple risk factors which begin as early as in utero through to adolescence. For example, Figure 1 demonstrates biological and social exposures that can act across a life span to influence the development of respiratory disease. Low birth weight infants have been shown to have an increased risk of respiratory disease in later life, which could be due to poor lung development in utero. In addition, poor socioeconomic status (SES) as a child can result in increased exposure to air pollution, poor nutrition and/or adoption of smoking which can in turn lead to respiratory illness as a child and increased risk of developing chronic respiratory illness as an adult. Poor social status can also result in lower educational attainment as a child, leading to a lower adult socioeconomic position and increased risk of chronic respiratory disease. Figure 1. The biological and social exposures across a life course that influence the development of respiratory disease in adulthood. Source: Ben-Shlomo Y and Kuh D. 22. A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives. International Journal of Epidemiology. 31: Huron County Community Health Status Report - 49

51 In addition to social and behavioural risk factors, community characteristics, such as population density and built environment, have a major impact on the development of chronic conditions. 1 This section will detail the prevalence of selfreported chronic health conditions along with the morbidity and mortality for selected chronic health conditions of public health importance. In addition, incidence and mortality rates for selected cancers and prevalence of cancer screening will be reported. Prevalence of Chronic Health Conditions In 25, 74.7% (95% CI ) of Huron County residents aged 12 years or older reported having at least one long-term chronic condition diagnosed by a health professional. 2 Females were more likely to report having a chronic condition than men (79.1%, 95% CI compared to 7.3%, 95% CI ), although this difference was not statistically significant. The percentage of individuals reporting at least one chronic condition increased with age. Of individuals aged 65 years and older, 93.% (95% CI ) reported having at least one chronic condition. The prevalence of chronic conditions also varies inversely by income level. In Huron County, 87.7% (95% CI ) of individuals living in a household with an annual income of less than $3, reported having at least one longterm chronic condition diagnosed by a health professional (Figure 2). By contrast, 66.7% (95% CI ) of individuals living in a household with an annual income of $8, or more reported the same. The prevalence of selected chronic conditions - arthritis/rheumatism, high blood pressure, asthma, diabetes, heart disease and mood disorders - is presented in Figure 3. In 25, arthritis/rheumatism was one of the most commonly reported chronic illnesses in Huron County, with 23.3% (95% CI ) of individuals aged 12 years and older reporting a diagnosis from a health professional. This is significantly higher than the 17.2% (95% CI ) of Ontarians who report having been diagnosed with arthritis/rheumatism. Huron County also has a higher prevalence of self-reported high blood pressure (Figure 3). Prevalence of asthma, diabetes, heart disease and mood disorders was similar to Ontario. Percent (%) Prevalence of Self-Reported Chronic Health Conditions by Income Level (12+ years), Huron County, CCHS 25 < $3, $3-49,999 $5-79,999 $8,+ Huron Annual Household Income Level Figure 2. The prevalence of self-reported chronic health conditions by household income level for Huron County (12+ years), 25 (n=576). Error bars represent 95% confidence intervals. Source: Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. 5 - Huron County Community Health Status Report

52 Percent (%) Prevalence of Selected Self-Reported Chronic Health Conditions (12+ years), Huron County and Ontario, CCHS Arthritis or Rheumatism High Blood Pressure Asthma Diabetes Heart Disease Huron County Ontario Chronic Health Condition Mood Disorder * * * Figure 3. The prevalence of selected chronic health conditions among individuals aged 12 years and older, Huron County and Ontario, 25 (n=576). * Indicates that the estimate should be interpreted with caution due to high sampling variability. Error bars represent 95% confidence intervals. Source: Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. Ischemic Heart Disease Ischemic heart disease (International Classification of Diseases ICD-1-CA I2-I25) is any condition in which the heart muscle is damaged or works inefficiently because of a deficiency in blood supply. 3 Ischemic heart disease includes angina pectoris, acute myocardial infarction, chronic ischemic heart disease and sudden death. A common cause of ischemic heart disease is atherosclerosis, which is a slow, progressive condition where arteries lose their elasticity and narrow as they become clogged with fatty deposits (or plaque). Risk factors for atherosclerosis include diabetes, obesity, high blood cholesterol, consuming a high fat diet, or a family history of heart disease. 4 Hospitalization From 22 to 26 in Huron County, there were a total of 2,46 hospital separations for ischemic heart disease (annual average: 49) (Figure 4). Huron County males accounted for 62.8% of all hospital separations in this time period, with an average crude hospitalization rate almost double that of females (833.3 hospital separations per 1, population compared to hospital separations per 1, population). Ischemic heart disease age-standardized hospitalization rates have steadily declined from 22 to 26 for both Huron County and Ontario (Figure 4). In Huron County, the agestandardized hospitalization rate in 26 was hospitalizations per 1, population, a 33.8% reduction from 22. Age-standardized ischemic heart disease hospitalization rates were similar for Huron County and Ontario. Mortality Between 2 and 23, ischemic heart disease was the leading cause of death in Huron County, accounting for 21.7% of all deaths in that time period (see Mortality section, page 38). The annual number of deaths due to ischemic heart disease ranged from 112 to 152 deaths between 2 and 24, for a total of 641 deaths (Figure 5). Average crude mortality rates for these five years were higher among males than females Huron County Community Health Status Report - 51

53 Rate (per 1,) Age-Standardized Hospitalization Rates, Ischemic Heart Disease, Huron County and Ontario Huron Rate Ontario Rate # Hospital Separations Year Figure 4. Agestandardized hospitalization rates for ischemic heart disease in Huron County and Ontario (22-26). The annual number of hospital separations in Huron County is also listed. Source: Hospital [In-Patient] Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB) Extracted: 7/1/28, Health Planning Branch, Ontario MOHLTC. (225.5 deaths per 1, population compared to deaths per 1, population). The majority of deaths were among Huron County males (54.3%) and individuals aged 65 years and older (85.2%). When looking at age-standardized mortality rates for ischemic heart disease, slightly different trends emerge for Huron County and Ontario (Figure 5). In Ontario, age-standardized mortality rates have decreased 19.4%, from deaths per 1, population in 2 to 1.6 deaths per 1, population in 24. In Huron County, however, rates have increased 5.6%, from deaths per 1, population in 2 to deaths per 1, population in 24. Age-standardized mortality rates were similar for all years in Huron County compared to Ontario with the exception of 23. Rate (per 1,) Age-Standardized Mortality Rates, Ischemic Heart Disease, Huron County and Ontario Huron Rate Ontario Rate # deaths Year Figure 5. Agestandardized mortality rates for ischemic heart disease in Huron County and Ontario, The annual number of deaths in Huron County is also listed. Source: Ontario Mortality Data and Population Estimates [2-24], Provincial Health Planning Database (PHPDB) Extracted: 28/11/27, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

54 Cerebrovascular Disease Cerebrovascular disease (International Classification of Diseases ICD-1-CA I6-I69) is the label for diseases resulting from disturbances in blood supply to the brain, such as a stroke. In particular, strokes can be the result of a blockage (ischemic stroke) or a rupture of a blood vessel (hemorrhagic stroke). 5 Approximately 8 per cent of strokes in Canada are ischemic. High blood pressure and tobacco use are the two most important modifiable risk factors for stroke. 6 Hospitalization Hospital separations due to cerebrovascular disease are less common than ischemic heart disease, with an average of 117 hospital separations per year in Huron County from 22 to 26. Males accounted for over half (54.6%) of these hospitalizations. While age-standardized hospitalization rates for cerebrovascular disease have clearly declinedfrom 22 to 26 in Ontario, rates in Huron County have increased in 25 and 26 (Figure 6). Age-standardized cerebrovascular disease hospitalization rates did not significantly differ between Huron County and Ontario for this time period. Mortality Cerebrovascular disease was the second leading cause of death in Huron County, accounting for 6.7% of all deaths between 2 and 23 (see Mortality section, page 3). In total, 24 Huron County deaths have been attributable to cerebrovascular disease from 2 to 24, with an average of 41 deaths annually (Figure 7). Females in Huron County experienced higher crude mortality rates due to cerebrovascular disease than males, with an average crude mortality rate of 81.2 deaths per 1, population compared to 5.6 deaths per 1, population. From 2 to 24, 61.8% of all cerebrovascular disease deaths were in females and more than half (52.%) were in those aged 85 years and older. After adjustment for age, Huron County agestandardized mortality rates became more similar to the province (Figure 7). From 2 to 24, Ontario cerebrovascular mortality rates steadily decreased. In this same time period, Huron rates also decreased to 28.1 deaths per 1, population in 22, after which rates increased to 41.2 deaths per 1, in 24. Rates did not differ significantly between Huron County and Ontario. Rate (per 1,) Age-Standardized Hospitalization Rates, Cerebrovascular Disease, Huron County and Ontario Huron Rate Ontario Rate # Hospital Separations Year Figure 6. Agestandardized hospitalization rates for cerebrovascular disease in both Huron County and Ontario (22-26). The annual number of hospital separations in Huron County is also listed. Source: Hospital [In-Patient] Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB) Extracted: 7/1/28, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 53

55 Rate (per 1,) Age-Standardized Mortality Rates, Cerebrovascular Disease, Huron County and Ontario Huron Rate Ontario Rate # deaths Year Figure 7. Agestandardized mortality rates for cerebrovascular disease in Huron County and Ontario, The annual number of deaths in Huron County is also listed. Source: Ontario Mortality Data and Population Estimates [2-24], Provincial Health Planning Database (PHPDB) Extracted: 28/11/27, Health Planning Branch, Ontario MOHLTC. Diabetes Diabetes (International Classification of Diseases ICD-1-CA E1-14) is a chronic condition that results from the body's inability to sufficiently produce and/or properly use insulin. 7 There are several forms of diabetes: type 1; type 2; and gestational. Approximately 9 per cent of all diabetes cases are type 2, which is usually adult-onset and is associated with excess body weight. In most cases, this form of diabetes can be prevented through a healthy diet and regular physical activity. If not properly managed, diabetes can lead to serious complications, such as cardiovascular disease, kidney disease and/or blindness, and also premature death. Hospitalization In Huron County, there were, on average, 72 hospital separations per year due to diabetes from 22 to 26 (range: 61-86). 4 Males and females were equally hospitalized. Age-standardized diabetes hospitalization rates were calculated for 22 to 26 and are shown in Figure 8 for Huron County and Ontario. For all years, agestandardized diabetes hospitalization rates were similar for Huron County and the province. Since 23, Huron County age-standardized hospitalization rates have steadily increased 47.8% from 68.3 hospitalizations per 1, in 23 to 11. hospitalizations per 1, population in 26 (Figure 8). Ontario has also seen an increase in age-standardized hospitalization rates since 23, albeit a smaller and more gradual increase. Mortality Diabetes is one of the top ten leading causes of death in Huron County and has accounted for 3.8% of all deaths from 2 to 23 (see Mortality section, page 38). The annual number of deaths has ranged from 17 to 31 deaths between 2 and 24, with an average of 24 deaths annually. 8 Males and females had similar average crude mortality rates for this five year period (4.8 deaths per 1, population compared to 37.4 deaths per 1, population). Over 9 per cent (93.4%) of all diabetes deaths in Huron County were in individuals aged 65 years and older. Crude diabetes mortality rates were higher in Huron County than Ontario between 2 and 24 (data not shown); however, this difference disappeared after age-standardization. For 2 24 combined, the age-standardized mortality rate for diabetes in Huron County was 22.8 deaths per 1, population, which was similar to the Ontario rate of 21.6 deaths per 1, Huron County Community Health Status Report

56 Rate (per 1,) Age-Standardized Hospitalization Rates, Diabetes, Figure 8. Age- Huron County and Ontario standardized hospitalization rates for diabetes in 12. both Huron County and 1. Ontario (22-26). 8. The annual number of hospital separations in 6. Huron County is also 4. listed. Source: Hospital 2. [In-Patient] Data and Population Estimates [22-26], Provincial Huron Rate Health Planning Database Ontario Rate (PHPDB) Extracted: # Hospital Separations /1/28, Health Year Planning Branch, Ontario MOHLTC. Chronic Lower Respiratory Diseases Mortality Chronic lower respiratory diseases were the fourth leading cause of death in Huron County for Chronic lower respiratory diseases (International 2 to 23 (see Mortality section, page 38). Classification of Diseases ICD-1-CA J4-J47) are diseases affecting the lower respiratory tract and On average, chronic lower respiratory diseases include chronic bronchitis, emphysema, chronic have resulted in 3 deaths annually in Huron obstructive pulmonary disease and asthma. County from 2 to 24, for a total of 148 Tobacco smoke and air quality are the two most deaths. 11 The crude mortality rate for chronic important, preventable risk factors for chronic lower respiratory diseases in Huron County was respiratory diseases deaths per 1, population in 24. The majority of chronic lower respiratory diseases Hospitalization occurred in males (56.8%) and those aged 65 years and older (93.2%). Over 1, hospital separations due to chronic Age-standardized mortality rates for 2-24 lower respiratory disease occurred in Huron combined revealed a significantly higher mortality County between 22 and 26, with an average rate due to chronic lower respiratory disease of 21 hospitalizations per year (Figure 9). in Huron County compared to the province. In Males accounted for almost two thirds of all Huron County, the age-standardized mortality hospitalizations (6.2%). Of all chronic lower rate was 28.2 deaths per 1, population, while respiratory disease hospitalizations, 13.9% were the age-standardized mortality rate for Ontario due to asthma (annual average: 28 hospital was 23.3 deaths per 1, population for 2 separations), compared to 26.9% in Ontario. 24. Age-standardized hospitalization rates for both Huron County and Ontario have remained relatively stable from 22 to 26 (Figure 9). There were no significant differences in rates between the two regions for this time period. Huron County Community Health Status Report - 55

57 Rate (per 1,) Age-Standardized Hospitalization Rates, Chronic Lower Respiratory Diseases, Huron County and Ontario Huron Rate Ontario Rate # Hospital Separations Year Figure 9. Agestandardized hospitalization rates for all chronic lower respiratory diseases in both Huron County and Ontario (22-26). The annual number of hospital separations in Huron County is also listed. Source: Hospital [In-Patient] Data and Population Estimates [22-26], Provincial Health Planning Database (PHPDB) Extracted: 7/1/28, Health Planning Branch, Ontario MOHLTC. Incidence and Mortality Rates for Cancers in Huron County Cancers are characterized by the uncontrolled growth and spread of abnormal cells in some part of the body. 1 They are typically named after the part of the body where the cancer originates. Cancer takes many years to develop and is caused by the complex interaction of genetic, social, lifestyle and environmental factors. Common factors include, but are not limited, to: age tobacco use diets high in fat sun exposure (U.V. radiation) family history of cancer alcohol use reproductive factors sexual activity lack of physical activity In 26, over 15, new cancer cases and 7, cancer deaths were estimated to occur in Canada. 11 Overall Cancer Incidence and Mortality From 1995 to 24, the crude incidence rate (rate of new cases) of cancer has increased 12.1% in Huron County, from cases per 1, population in 1995 to 549. cases per 1, population in 24 (Figure 1). The number of new cancer cases diagnosed each year has ranged from 33 cases to 368 cases in this time period (average: 337 cases per year). The crude mortality rate of cancer has also gradually increased. From 1995 to 24, the number of cancer deaths increased from 15 deaths in 1997 to 181 deaths in 24 (average: 162 deaths per year from 1995 to 24) (Figure 1). Increases in cases and deaths are likely due in part to an aging population. The top ten diagnosed cancers between 2 and 24 in Huron County males and females are shown in Table 1. Among Huron County males, prostate cancer was the most frequently diagnosed cancer, accounting for almost one third (31.5%) of all male cancer cancers. Breast cancer was the most frequently diagnosed cancer among females, accounting for one quarter (25.1%) of all female cancer cases in Huron County. Breast and prostate cancers are also the most commonly diagnosed cancers in Canadian women and men. 11 Colorectal and lung cancer were the second and third most frequently diagnosed cancers for Huron County men and women Huron County Community Health Status Report

58 The top ten leading causes of cancer death between 2 and 24 in Huron County males and females are shown in Table 2. Like Canada, lung cancer was the leading cause of cancer death for both sexes. Among both males and females, colorectal cancer was within the top three causes of cancer deaths, along with prostate cancer in men and breast cancer in women. To make comparisons to the province, cancer incidence rates were standardized for age and Crude Cancer Incidence and Mortality Rates, Huron County are shown in Figure 11 for each gender. Agestandardized cancer incidence rates for 1995 to 24 were similar for Huron County and Ontario (confidence intervals not shown). In females, age-standardized cancer incidence rates have experienced a slight increase over this time period. Ontario males also experienced a slight increase in rates, while Huron County rates have gradually declined over this time period. In both Huron County and Ontario, males experienced a higher age-standardized cancer incidence rate than females. Rate (per 1,) Incidence Mortality # Cases # Deaths Year Figure 1. The number of cancer cases and number of deaths, for 1995 to 24, in Huron County. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. MALES All Cancers Prostate Cancer Colorectal Cancer Lung Cancer Bladder Cancer Melanoma of the skin Non-Hodgkin Lymphoma Kidney Cancer Leukemia Stomach Cancer Oral Cancer FEMALES # Cases # Cases 939 All Cancers Breast Cancer Colorectal Cancer Lung Cancer Uterine Cancer Thyroid Cancer Ovarian Cancer Melanoma of the skin Non-Hodgkin Lymphoma Pancreatic Cancer Bladder Cancer Table 1. Top ten diagnosed cancers (# Cases) in Huron County, by sex, for 2-24 combined. Note: The Ontario Cancer Registry excludes skin cancers other than melanoma. Source: Cancer Incidence [2-24], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 57

59 Age-standardized cancer mortality rates for Standardized incidence ratios (SIR) and Huron County and Ontario are shown in Figure standardized mortality ratios (SMR) were 12 for both genders. Age-standardized cancer calculated to compare if Huron County cancer mortality rates for 1995 to 24 were similar for incidence and mortality was significantly different Huron County and Ontario (confidence intervals from Ontario for (Figure 13). For both not shown). Both Ontario males and females males and females, there were no significant experienced gradual declines in age-standardized differences in cancer incidence and mortality for cancer mortality rates. The trends are less clear Huron County compared to the province. for Huron County due to fluctuating rates caused by a smaller number of deaths. Like incidence rates, mortality rates were higher among males compared to females for both Huron County and Ontario. MALES FEMALES # Deaths # Deaths Table 2. Ten leading All Malignant Cancers 458 All Malignant Cancers 37 causes of cancer death Lung Cancer 125 Lung Cancer 68 (# Deaths) in Huron Colorectal Cancer 67 Breast Cancer 58 County, by sex, 2- Prostate Cancer 64 Colorectal Cancer combined. Note: Pancreatic Cancer 21 Pancreatic Cancer 27 The Ontario Cancer Non-Hodgkin Registry excludes skin 19 Ovarian Cancer 19 Lymphoma cancers other than Leukemia 15 Esophageal Cancer 1 melanoma. Source: Esophageal Cancer 14 Non-Hodgkin Cancer Mortality [2-1 Lymphoma 24], Cancer Care Bladder Cancer 12 Leukemia 1 Ontario, Release: 6, July Stomach Cancer 12 Kidney Cancer Brain Cancer 11 Myeloma 8 Age-Standardized Cancer Incidence Rates, by Gender, Huron County and Ontario Figure 11. Agestandardized incidence rates for cancer (at all sites) both males and females in Huron County and Ontario ( ). Source: Cancer Incidence [ ], Cancer Care Ontario, Release: 6, July 27. Rate (per 1,) Year ICD9 to ICD1 conversion Huron Males Huron Females Ontario Males Ontario Females 58 - Huron County Community Health Status Report

60 Age-Standardized Cancer Mortality Rates, by Gender, Huron County and Ontario ICD9 to ICD1 conversion 25. Rate (per 1,) Year Huron Males Huron Females Ontario Males Ontario Females Figure 12. Age-standardized mortality rates for cancer (at all sites) for both males and females, in Huron County and Ontario ( ). Source: Cancer Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Standardized Incidence Ratio (SIR) and Standardized Mortality Ratio (SMR) for All Cancers by Gender, Huron County Combined Male Female Male Female SIR SMR Figure 13. Standardized incidence and mortality ratios for all cancers, by sex, comparing Huron County to Ontario ( data combined). Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 59

61 Selected Cancers The most frequently diagnosed cancers and leading causes of cancer death in Huron County breast, prostate, colorectal and lung cancer will be explored here in more detail. Breast Cancer Breast cancer begins in cells of the breast. While breast cancer can affect both men and women, less than one per cent of Canadian cases are male. 11 Risk factors for breast cancer include, but are not limited to: age; having a family history of breast or ovarian cancer; an above average exposure to estrogen; dense breast tissue; being obese; alcohol use; and taking birth control pills. 12 Recent studies have also shown that both vitamin D and physical activity are associated with a reduced breast cancer risk. 13 Like Canada, breast cancer is the most commonly diagnosed cancer among Huron County women. Crude breast cancer incidence and mortality rates are shown in Figure 14, along with the number of new cases and number of deaths annually. Between 1995 and 24, a range of 29 to 49 new cases were diagnosed per year (average: 39 cases per year). Almost 4 per cent (39.2%) of all cases were aged between years. The crude breast cancer incidence rate increased by 1.9% from 93.3 cases per 1, population in 1995 to 13.5 cases per 1, population in 24. An average of 12 deaths occurred per year from 1995 to 24 (range:1 to 16 deaths). Crude breast cancer mortality rates have remained relatively stable in Huron County, ranging from 32.1 deaths per 1, population to 51.4 deaths per 1, population. Age-standardized breast cancer incidence rates for Huron County and Ontario females are shown in Figure 15. Rates from 1995 to 24 were similar for Huron County and Ontario (confidence intervals not shown). In Ontario, age-standardized breast cancer incidence rates have remained around 1 new cases diagnosed per 1, population over this time period. By contrast, Huron County rates have fluctuated between 72.5 cases per 1, population in 1995 to 12.2 cases per 1, population in 23. Figure 14. Crude breast cancer incidence and mortality rates for Huron County females, including the number of breast cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Rate (per 1,) Crude Breast Cancer Incidence and Mortality, Huron County Incidence Mortality # Cases # Deaths Year 6 - Huron County Community Health Status Report

62 Because Huron County has a relatively small rates were not significantly different from Ontario number of deaths due to breast cancer each year, for this time period. In both regions, mortality age-specific mortality rates were calculated for rates were highest among females aged 75 years 1995 to 24 combined and compared to Ontario and older. (Figure 16). Huron County age-specific mortality Rate (per 1,) Age-Standardized Breast Cancer Incidence Rate in Females, Huron County and Ontario Year of Diagnosis ICD9 to ICD1 conversion Figure 15. Agestandardized incidence rates for breast cancer in females, for Huron County and Ontario ( ). Source: Cancer Incidence [ ], Cancer Care Ontario, Release: 6, July 27. Huron Rate Ontario Rate Age-Specific Breast Cancer Mortality Rates in Females, Huron County and Ontario, Combined 25 Rate (per 1,) Huron Ontario Age Group (Years) Figure 16. Age-specific breast cancer mortality rates for females in Huron County and Ontario, data combined. Error bars represent 95% confidence intervals for the rates. Source: Cancer Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 61

63 Prostate Cancer Beginning in the cells of the prostate gland, prostate cancer is the most common cancer in Canadian men. 14 Because prostate cancer takes many years to develop, being over the age of 65 years increases the risk of developing prostate cancer. High fat diets and a family history of prostate cancer can also increase the risk of developing prostate cancer. 15 Prostate cancer is the most commonly diagnosed cancer among Huron County men and is the third leading cause of cancer death. The crude prostate cancer incidence and mortality rates, along with the number of cases diagnosed and number of deaths annually, is shown in Figure 17 for Huron County. Between 1995 and 24, the crude prostate cancer incidence rate increased 11.5% from new cases diagnosed per 1, population in 1995 to cases per 1, population in 24. Annually, an average of 57 new cases of prostate cancer were diagnosed in Huron County (range: 48 to 65 cases). Almost half (44.1%) of all cases were aged years. The crude mortality rate for prostate cancer has remained relatively constant for this time period, hovering around 4 deaths per 1, population. On average, 12 deaths occurred each year in Huron County males due to prostate cancer. Prostate cancer incidence rates, adjusted for age, are shown in Figure 18 for Huron County and Ontario. For all years, the Huron County agestandardized prostate cancer incidence rates were similar to the province. Age-specific prostate cancer mortality rates for combined are shown below in Figure 19. There was no significant difference in agespecific prostate cancer mortality rates for Huron County and Ontario during this time period. In both regions, mortality rates were highest among males aged 75 years and older. This age group accounted for almost three-quarters of all prostate cancer deaths in Huron County (91 deaths or 73.4%). Crude Prostate Cancer Incidence and Mortality Rates, Huron County Rate (per 1,) Incidence Mortality # Cases # Deaths Year 62 - Huron County Community Health Status Report Figure 17. Crude prostate cancer incidence and mortality rates for Huron County males, including the number of prostate cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27.

64 Age-Standardized Prostate Cancer Incidence Rate, Huron County and Ontario Rate (per 1,) Year of Diagnosis ICD9 to ICD1 conversion Huron Rate Ontario Rate Figure 18. Age-standardized incidence rates for prostate cancer in Huron County and Ontario ( ). Source: Cancer Incidence [ ], Cancer Care Ontario, Release: 6, July 27. Age-Specific Prostate Cancer Mortality Rates, Huron County and Ontario Combined 6 Rate (per 1,) Huron rate suppressed Ontario Age Group (Years) Figure 19. Age-specific prostate cancer mortality rates for males in Huron County and Ontario, data combined. Error bars represent 95% confidence intervals for the rates. The rate was suppressed in the years age group for Huron due to <5 deaths. Source: Cancer Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 63

65 Colorectal Cancer Most colorectal cancers begin in the cells of the colon or rectum, which make up the large intestine. 16 While 7 to 75 per cent of all colorectal cancers develop in individuals with no specific risk factors, there are factors which may increase the risk of developing colorectal cancer. 17 These factors include: age; presence of polyps in the colon or rectum; personal and/or family history of colorectal cancer; inflammatory bowel disease; a diet high in fat; high intake of red meat and meats that have been cooked at high temperatures; alcohol and tobacco use; and physical inactivity; among others. 18 Crude colorectal cancer incidence and mortality rates are shown in Figure 2 (males) and Figure 21 (females) between 1995 and 24. Unlike mortality rates, which were relatively similar for Huron County males and females, crude colorectal cancer incidence rates were higher among males when compared to females. This difference, however, was not statistically significant. Among Huron County women, both crude incidence and mortality rates have somewhat increased from 1995 to 24, while in males, a trend is less clear. Age-standardized colorectal cancer incidence rates are shown in Figure 22 for Huron County and Ontario. For all years, with the exception of 21, the age-standardized colorectal cancer incidence rate for Huron County was similar to the province. Crude Colorectal Cancer Incidence and Mortality Rates in Males, Huron County Rate (per 1,) Incidence Mortality # Cases # Deaths Year Figure 2. Crude colorectal cancer incidence and mortality rates for Huron County males, including the number of colorectal cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July Huron County Community Health Status Report

66 Crude Colorectal Cancer Incidence and Mortality Rates in Females, Huron County Rate (per 1,) Incidence Mortality * # Cases # Deaths * Year Figure 21. Crude colorectal cancer incidence and mortality rates for Huron County females, including the number of colorectal cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. * indicates that the rate was suppressed due to <5 deaths. Note: The International Classifi cation of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Age-Standardized Colorectal Cancer Incidence Rates, Huron County and Ontario Rate (per 1,) Year of Diagnosis ICD9 to ICD1 conversion Huron Rate Ontario Rate Figure 22. Age-standardized incidence rates for colorectal cancer in Huron County and Ontario ( ). Source: Cancer Incidence [ ], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 65

67 Age-specific colorectal cancer mortality rates for combined are shown for males and females in Figure 23. There was no significant difference in age-specific colorectal cancer mortality rates for Huron County and Ontario during this time period. In both regions, mortality rates were higher among males aged 45 years and older when compared to females, although this difference was not statistically significant for Huron County. In Huron County, over half of all deaths in this time period were among males and females aged 75 years and older (52.3% and 58.4%). Age-Specific Colorectal Cancer Mortality Rates, by Sex, Huron County and Ontario Combined 5 Rate (per 1,) Male Female Huron * Ontario Figure 23. Age-specific colorectal cancer mortality rates for males and females in Huron County and Ontario, data combined. Error bars represent 95% confi dence intervals for the rates. * indicates that the rate was suppressed due to <5 deaths. Source: Cancer Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Lung Cancer Lung cancer begins in cells of the lung. There are two main types of lung cancer: non-small cell lung cancer, which is the most common and can originate anywhere in the lungs and small cell lung cancer, which usually begins in the cells of the bronchi, bronchioles or alveoli. 18 The major risk factor for lung cancer is smoking. Other risk factors include: exposure to second-hand smoke; working with materials such as asbestos, arsenic, nickel and petroleum products; and exposure to radon gas. 19 Lung cancer is the third most commonly diagnosed cancer and the leading cause of cancer death in Huron County. The crude incidence and mortality rates for lung cancer are shown in Figure 24 (males) and Figure 25 (females). Unlike other cancers presented here, crude incidence rates were similar to crude mortality rates for both sexes (i.e. the number of new cases diagnosed each year roughly matched the number of deaths each year). In Huron County males, there was an average of 25 new cases and 24 deaths each year between 1995 and 24. By contrast, there was an average of 16 Huron County women diagnosed with lung cancer and 13 deaths each year. Both crude lung cancer incidence and mortality rates were higher in Huron County males when compared to females between 1995 and 24. This difference, however, was not statistically significant for most years Huron County Community Health Status Report

68 Crude Lung Cancer Incidence and Mortality Rates in Males, Huron County Rate (per 1,) Incidence Mortality # Cases # Deaths Year Figure 24. Crude lung cancer incidence and mortality rates for Huron County males, including the number of lung cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Rate (per 1,) Crude Lung Cancer Incidence and Mortality Rates in Females, Huron County Incidence Mortality # Cases # Deaths Year Figure 25. Crude lung cancer incidence and mortality rates for Huron County females, including the number of lung cancer cases and deaths for 1995 to 24. Year refers to the year of diagnosis for incidence rates and new cases, and the year of death for mortality rates and deaths. Note: The International Classification of Disease (ICD) was revised in January 1, 2 for mortality data and April 1, 22 for hospitalization data. Caution should be used when interpreting trends over time periods which span this revision. Source: Cancer Incidence and Mortality [ ], Cancer Care Ontario, Release: 6, July 27. Huron County Community Health Status Report - 67

69 Lung cancer incidence rates, adjusted for age, are shown in Figure 26 for Huron County and Ontario. Age-standardized lung cancer incidence rates have declined 7.7% in Ontario from 1995 to 24. The trend is less clear in Huron County due to a smaller number of cases. For all years examined, age-standardized lung cancer incidence rates for Huron County were similar to the province. Age-specific lung cancer rates for males and females for 1995 to 24 combined and are shown in Figure 27 for Huron County and Ontario. Rates were significantly higher for males compared to females for those aged years and 75+ years in Huron County. While Huron County and Ontario mortality rates were similar for most age groups, Huron County women aged 75 years and older had a significantly lower mortality rate compared to the province. Rate (per 1,) Age-Standardized Lung Cancer Incidence Rates, Huron County and Ontario Year of Diagnosis ICD9 to ICD1 conversion Figure 26. Agestandardized incidence rates for lung cancer in Huron County and Ontario ( ). Source: Cancer Incidence [ ], Cancer Care Ontario, Release: 6, July 27. Huron Rate Ontario Rate Rate (per 1,) Age-Specific Lung Cancer Mortality Rates, by Sex, Huron County and Ontario Combined Male Female Huron * Ontario Figure 27. Agespecific lung cancer mortality rates for males and females in Huron County and Ontario, data combined. Error bars represent 95% confi dence intervals for the rates. * indicates that the rate was suppressed due to <5 deaths. Source: Cancer Mortality [ ], Cancer Care Ontario, Release: 6, July Huron County Community Health Status Report

70 Prevalence of Cancer Screening Cancer screening is used to identify early disease or precursors of disease in individuals who are not exhibiting any symptoms so that the disease can be treated early and result in a better outcome. 19 Breast Cancer Breast screening includes mammography and a physical examination of the breasts by a health care professional. A mammogram is a low dose X-ray of the breast, which can detect changes in the breast even when they are too small to feel or see. 2 Regular mammograms have been shown to reduce the risk of dying from breast cancer and allow women more treatment options if detected early. 21 In Ontario, the Canadian Cancer Society recommends women aged 5 to 74 years have a screening mammogram roughly every two years. In 25, 87.2% (95% CI ) of Huron County women aged 5-74 years reported ever having a mammogram, which was similar to Ontario. 2 This figure, however, drops to 68.6% (95% CI ) for women who report having a mammogram within the last two years as recommended. This percentage is also similar to the province (72.2%, 95% CI ). Cervical Cancer An effective way to control cervical cancer is through regular Pap test screening. Pap tests can identify precancerous lesions and cancers at an early stage, when treatments are most effective. 22 The Ontario Cervical Screening Program Practice Guidelines outlines that women of all ages who have been sexually active should be screened. 23 It is recommended that pap tests are conducted annually until 3 consecutive normal tests, after which screening is recommended to be continued every 2-3 years. Screening is discontinued after age 7 if there have been three or more normal pap tests within the previous ten years. In Huron County, in 25, 94.3% (95% CI ) of women aged 18 to 69 years reported ever having a pap test. 2 In addition, 72.9% (95% CI ) of women in this same age group reported having a pap test within the last 3 years as recommended. This percentage was similar to the province (74.6%, 95% CI ). The main cause of cervical cancer is infection with a high-risk form of human papillomavirus (HPV). In July 26, an HPV vaccine, Gardasil, was approved by Health Canada for females aged 9 to 26 years. If received before possible exposure to HPV through sexual contact, Gardasil protects against two of the many high-risk types of HPV, which are responsible for seventy per cent of cervical cancers. 24 In the fall of 27, the government of Ontario introduced the HPV vaccine as part of a voluntary schoolbased immunization program for females in Grade eight. 25 In Huron County, 42.5% (164/386) of Grade eight girls had started the series of vaccinations in Colorectal Cancer The primary method of screening for colorectal cancer is to administer a Fecal Occult Blood Test (FOBT). Regular screening using this test has been shown to reduce the risk of dying of colorectal cancer by a minimum of 16% in several large, randomized clinical trials Screening for colorectal cancer can be particularly effective, as there is a 9 per cent chance of curing colorectal cancer if it is detected early and only a ten per cent chance if it is detected at an advanced stage. 28 Individuals typically display no symptoms at first, so screening is the best way to detect this cancer early. 29 In January 27, a province-wide colorectal cancer screening program was launched by the Ministry of Health and Care and Long-Term Care and Cancer Care Ontario. This program provides funding to screen all average risk men and women 5 years and older using the FOBT every two years. 29 In 25, before the launch of this program, 43.6% (95% CI ) of Huron County residents aged 5 years and older reported ever having a FOBT. 2 However, just 2.5% (95% CI ) of all Huron County adults aged 5 years and older reported having a FOBT within the last two years as recommended by Cancer Care Ontario and the Canadian Cancer Society. This is similar to the Interpret with caution, high sampling variability. Huron County Community Health Status Report - 69

71 province (2.8%, 95% CI ). Colonoscopies are generally recommended to screen those at increased risk because of one or more first degree family members with colorectal cancer. It is also recommended as a follow-up procedure for those with positive FOBT results. 29 Use of colonoscopy procedures in Ontario has been reported by the Institute for Clinical Evaluative Sciences. 29 In 21, Huron County colonoscopy utilization rates were significantly higher than Ontario for adults aged 5-74 years and were also higher than all other counties within the South West region. Between 1992 and 21, 2.% of Huron County adults 5-74 years had at least one colonoscopy compared to 15.7% of Ontarians. Living in a rural area does not appear to be a barrier to accessing colonoscopy procedures. Conclusions Three quarters of Huron County residents report having at least one chronic health condition, with arthritis and rheumatism being the most commonly reported chronic health condition. Hospitalization and mortality rates for ischemic heart disease, cerebrovascular disease, diabetes and chronic lower respiratory diseases were generally similar between Huron County and Ontario. Cancer is another important chronic disease, with roughly just over 3 new cancer cases diagnosed among Huron County residents and over 15 deaths annually. The most commonly diagnosed cancers, and also the leading causes of cancer death in Huron County, are prostate, breast, colorectal and lung cancer. The percentage of Huron County residents reporting undergoing preventive cancer screening tests, including mammograms, pap tests and fecal occult blood testing, are similar to the province. 1 Health Council of Canada. Why Health Care Renewal Matters: Learning from Canadians with Chronic Health Conditions. Toronto, ON: Health Council, 27. Accessed at www healthcouncilcancada.ca. 2 Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. 3 Health Canada. The Growing Burden of Heart Disease and Stroke in Canada 23. Ottawa, ON: Heart and Stroke Foundation, Heart and Stroke Foundation. Atherosclerosis. Accessed 31 January 28 from wwwheartandstroke.com/site/c.iklqlcmwjte/b /apps/s/content.asp?ct= World Health Organisation. The Atlas of Heart Disease and Stroke - Types of cardiovascular disease. Accessed 2 January 28 from cvd_atlas_1_types.pdf. 6 Truelsen T, Begg S and Mathers C. Global Burden of Disease 2 - The global burden of cerebrovascular disease. Geneva: World Health Organisation, 2. Geneva. Accessed 2 January 28 from pdf. 7 Public Health Agency of Canada. National Diabetes Fact Sheet Canada 27. Accessed 2 June 28 from ndfs-fnrd7-eng.html. 8 Ontario Mortality Data and Population Estimates 2-24, Provincial Health Planning Database (PHPDB). Extracted 28/11/27, Health Planning Branch, Ontario MOHLTC. 9 Public Health Agency of Canada. Life and Breath: Respiratory Disease in Canada. Ottawa, ON: Public Health Agency of Canada, 27. Accessed 2 June 28 from 1 Health Canada. Diseases & Conditions - Cancer. Accessed 2 June 28 from hc-sc.gc.ca/dc-ma/cancer/index_e.html. 11 Canadian Cancer Society. About Cancer: Breast cancer in men. Accessed 15 September 28 from langid-en,.html. 12 Canadian Cancer Society. About Cancer: Causes of breast cancer. Accessed 22 January 28 from 13 Canadian Cancer Society. Canadian Cancer Encyclopedia: Breast Cancer, Noteworthy Developments, 26. Accessed 22 January 28 from HTML/1_254.html. 14 Canadian Cancer Society. About Cancer: What is prostate cancer?. Accessed 6 February 28 from 15 Canadian Cancer Society. About Cancer: Causes of prostate cancer. Accessed 6 February 28 from 16 Canadian Cancer Society. About Cancer: What is colorectal cancer? Accessed 6 February 28 from 17 Canadian Cancer Society. Canadian Cancer Encyclopedia: Colorectal Cancer, Risk Factors for Colorectal Cancer. Accessed 23 January 28 from cceexplorer.asp?tocid= Canadian Cancer Society. About Cancer: What causes lung cancer? Accessed 29 January 28 from 19 Oleckno WA. Essential Epidemiology principles and applications. Illinois: Waveland Press, Inc., Cancer Care Ontario. Breast Screening: Mammograms. Accessed 2 June 28 from Ibid. 22 Cancer Care Ontario and Canadian Cancer Society (Ontario Division). Insight on Cancer: News and Information on Cervical Cancer, Volume 5. Toronto, ON: Cancer Care Ontario and Canadian Cancer Society (Ontario Division), 25. Accessed 7 January 28 from Cancer Care Ontario. Ontario Cervical Screening Practice Guidelines Reference Card (25). Accessed 7 January 28 from CervicalScreeningGuidelines.pdf. 24 Cancer Care Ontario. Fact Sheet - Human Papillomavirus (HPV) Vaccine: Helping you make an informed decision. Accessed 15 September 28 from documents/hpvvaccinefactsheeteng.pdf. 25 Internal communication with Building Community Capacity (BCC) Quad, 8 January Cancer Care Ontario. Ontario Cancer News - Ontario launches ColonCancerCheck campaign to promote screening for colorectal cancer. March 28. Volume 6, No 1. Accessed 3 June 28 from htm. 27 Niv Y et al. Protective effect of faecal occult blood test screening for colorectal cancer: worse prognosis for screening refusers. British Medical Journal, 22;5: Ministry of Health and Long-Term Care with Cancer Care Ontario. Frequently Asked Questions About Colorectal Cancer. Accessed 3 June 28 from public_faq.html. 29 Tu JV, Pinfold SP, McColgan P and Laupacis A, eds. ICES Atlas - Access to Health Services in Ontario. Toronto, ON: Institute for Clinical Evaluative Sciences, Huron County Community Health Status Report

72 Reproductive Health Reproductive health refers to and addresses the reproductive process from fertility regulation to healthy pregnancies to healthy birth outcomes. The impact of social determinants of health on various reproductive health issues will be explored in more detail within this chapter. Maternal and paternal characteristics known to affect pregnancy outcomes, such as age, income, education level and health behaviours, are reported for Huron County parents. In addition, birth, fertility and pregnancy rates are presented and compared to the province. Lastly, birth outcomes, such as birth weight, preterm births, and infant mortality, are described. Maternal and Paternal Age at Mother s First Birth Adolescent mothers are at a significantly higher risk of preterm birth and small-for-gestational age infants. 1 In addition, young parents face financial stress and additional barriers, such as lack of transportation, isolation from peers and communities, and food security. By contrast, advanced maternal age has been shown to be a risk factor for the development of Down s Syndrome (among other congenital anomalies), multiple births, preterm birth and low birth weight. 2 In 24, the average age of new mothers and fathers in Huron County was 26.2 years and 28.9 years up.9 years and.5 years from 2. 3 Age at first birth, for both mothers and fathers, has gradually increased over the past 5 years in Huron County and Ontario (data not shown). Despite this, Huron County continues to have younger first-time mothers and fathers than Ontario. Maternal Education Low maternal education is related to poor perinatal health outcomes, such as preterm birth, small-for-gestational age, and increased rate of stillbirth and infant mortality. 4 Between June 22 and April 24, Huron County mothers of newborn children were surveyed as part of the Southern Ontario Infant Feeding Survey. 5 Of all mothers surveyed, 9% reported having less than high school diploma (Figure 1). Thirty-one per cent of mothers completed high school, while 61% went on to further education (trade certificate, college diploma or university degree). Household Income Poverty is a risk factor for poor perinatal health outcomes, such as preterm birth, low birth weight and infant mortality. In 1991, Ontario infant mortality rates were 1.6 times higher in the lowest income groups when compared to the highest income groups. 6 Also, women in the lowest socioeconomic group have been shown to be four times more likely to experience pregnancy related complications that require hospitalization than those in the highest income group. 7 More than a quarter of mothers (26%) reported an annual household income in 21 of $4,- $59,999, with another 22% reporting an income of $2,-$39,999. Five per cent of mothers surveyed had a household income of less than $2, (Figure 1). Huron County Community Health Status Report - 71

73 Level of Support in the Household Household support was determined by asking new mothers who else lived in the household with them. Overall, 94% of mothers reported living with a partner or a partner and other children, while 2% lived alone with their children (Figure 1). Smoking Status Smoking during pregnancy can result in adverse health effects on the fetus and child. These effects include preterm birth, spontaneous abortion, placental complications, stillbirth and sudden infant death syndrome. 4 Recent research has shown that active maternal smoking during pregnancy may also lower cognitive development in children at age four, although research has not been completed to determine what effects this would have for the child later in life. 8 Nineteen per cent of surveyed mothers reported that they smoked tobacco during their pregnancy and of these mothers, 78% continued to smoke after the birth of their baby. In comparison, the National Longitudinal Survey of Children and Youth found that 15.8% of Ontario mothers reported smoking during pregnancy in Alcohol Use No amount of alcohol use during pregnancy is considered safe. Fetal Alcohol Spectrum Disorder (FASD) describes the range of effects that can occur in an individual whose mother consumed alcohol during pregnancy. These effects range from severe growth restriction to intellectual disability to birth defects to lifelong deficits in brain function. 9 It is estimated that more than 3, babies are born each year in Canada with FASD. 1 In a national study, conducted in 26 for the Public Health Agency of Canada, perceptions of alcohol use during pregnancy were obtained from Canadian women aged 18-4 years and their male partners. 11 Seventy-six per cent of respondents agreed that any alcohol consumption during a pregnancy can harm the baby and 86% of respondents had heard of FASD. No local data is provided on reported use of alcohol during pregnancy or FASD due to small numbers of Huron County women who were surveyed about alcohol use during pregnancy. Characteristics of Huron County Mothers, Characteristics of At-risk Mothers Less than high school diploma Low Household Income (<$2,) Under 2 years of age No partner or family support Percent (%) Figure 1. Percentage of mothers who report characteristics that are risk factors for adverse pregnancy and birth outcomes, Huron County, Source: Southern Ontario Infant Feeding Survey, Huron County Community Health Status Report

74 Folic Acid Supplementation Maternal folate supplementation has been shown to reduce the rates of neural tube defects in North America. 12 Recently, a meta-analysis has shown that multivitamins containing folic acid are also associated with a protective effect against cardiovascular and limb defects. 13 In 25, 37.%* (95% CI ) of women who had given birth (live births only) within the past five years reported that they had taken a vitamin supplement containing folic acid before becoming pregnant. 14 This is significantly lower than 62.8% (95% CI ) reported for Ontario. Prenatal Classes Prenatal education classes provide expectant parents with information and skills needed to improve pregnancy and birth outcomes, to have a positive birth experience and to prepare parents for early parenting. 15 In Huron County, maternal age, education, income and smoking status are all associated with attendance of prenatal classes in any pregnancy. 5 In 26, 14 Huron County women attended at least one prenatal class (three classes in the first trimester and five classes in the final trimester are offered). 16 Of those, 58 (55.8%) attended both the early and late sessions. The majority of women attending at least one session were aged years (41.3%) and were either married or common law (91.3%). Breastfeeding Initiation and Duration To maximize the health benefits of breastfeeding for both infants and mothers, exclusive breastfeeding is recommended for the first six months after birth. 17 Specific benefits in babies include protection against gastrointestinal and respiratory infections and otis media. In mothers, breastfeeding reduces postpartum bleeding and the risk of ovarian cancer and increases the spacing between pregnancies. * High sampling variability. This estimate should be interpreted with caution. Of all mothers participating in the Infant Feeding Survey, 91% (95% CI 88-94) reported that they had initiated breastfeeding with their baby. 5 This is slightly higher than the 83.8% (95%CI ) of Huron County mothers who reported initiating breastfeeding in the Canadian Community Health Survey in In Ontario, 88.% (95% CI ) of mothers report initiating breastfeeding with their infant. 14 At three months postpartum, the percentage of Huron County mothers breastfeeding dropped to 58%. 5 Common reasons for stopping breastfeeding included not having enough milk (4%) and having sore nipples (11%). Breastfeeding status continued to decline with increasing time since birth with 48% of mothers reporting breastfeeding at six months and 27% at nine months postpartum. FERTILITY AND PREGNANCY Crude Birth Rate The crude birth rate is the total number of live births per 1, population. The number of live births over the past five years in Huron County has remained relatively stable, with an average of 561 births and a rate of 9.1 births per 1, population. 2 The number of live births and crude birth rates for 2-24 are shown in Table 1. For this time period, Huron County has a significantly lower average crude birth rate compared to Ontario (data not shown). This is likely a result of having a lower proportion of women of childbearing age (15-49 years). Huron County Ontario Year Rate (per Rate (per # Live Births 1,) 1,) Table 1. The number of live births and crude live birth rate for Huron County and Ontario, Source: Ontario Live Birth Data [2-24], Provincial Health Planning Database (PHPDB) Extracted: 15/8/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 73

75 Multiple Births Multiple births are at increased risk for preterm birth and low birth weight. 4 The rate of multiple births has increased in Ontario from 1991 to 24, which is likely due to an increase in births to older mothers and increased use of fertility treatments and assisted conception. 22 The multiple live birth rate is the ratio of the total number of live multiple births divided by the total number of live births. The multiple live birth rate has fluctuated in Huron County over the past five years from 1.8% in 21 to 4.3% in In 24, 1.9% (95% CI.8-3.1) of live births in Huron County were multiple births (i.e. twins, triplets, etc). From 2 to 24, a total of 2.6% (95% CI ) of all live Huron County births were multiple births, which is lower than the provincial percentage of 3.1% (95% CI ). Pregnancy Rate The number of pregnancies is calculated by summing the number of live births, therapeutic abortions and stillbirths. There were a total of 64 pregnancies in Huron County in 24, with an average of 634 pregnancies a year over the past five years (Table 2). When compared to the province, Huron County has statistically significant lower pregnancy rates (confidence intervals not shown). In 24, the pregnancy rate in Huron County was 46.8 pregnancies per 1, women aged years compared to 52.5 pregnancies per 1, women in Ontario. Teen pregnancy rates are also significantly lower in Huron County than Ontario. Despite having a significantly higher pregnancy rate in the year age group and a similar rate in the 2-24 year age group, Huron County pregnancy rates are lower than Ontario s for all other age groups (Figure 2). Year Pregnancy Rate (per 1,) Huron County Teen Pregnancy Rate (per 1,) Pregnancy Rate (per 1,) Ontario Teen Pregnancy Rate (per 1,) Table 2. Pregnancy rates for women aged years and for women aged years (teen) for both Huron County and Ontario, Sources: Ontario Live Birth Data [2-24], Provincial Health Planning Database (PHPDB) Extracted: 3/1/27, Health Planning Branch, Ontario MOHLTC. Source: Ontario Therapeutic Abortion Database 24, 21 and 2, HELPS (Health Planning Systems). Released January 27, Ministry of Health Promotion, Chronic Disease Prevention and Health Promotion Branch Huron County Community Health Status Report

76 Age-Specific Pregnancy Rates, Huron County and Ontario, 24 Rate (per 1,) Age Group (years) Huron County Ontario Figure 2. Age-specifi c pregnancy rates for Huron County and Ontario, 24. Error bars represent 95% confidence intervals for the rates. Sources: Ontario Live Birth Data [2-24], Provincial Health Planning Database (PHPDB) Extracted: 3/1/27, Health Planning Branch, Ontario MOHLTC. Source: Ontario Therapeutic Abortion Database 24, 21 and 2, HELPS (Health Planning Systems). Released January 27, Ministry of Health Promotion, Chronic Disease Prevention and Health Promotion Branch. Fertility Rate When looking at fertility rates for different age groups, specific trends emerge. Fertility rates for the year age group have decreased in The general fertility rate (number of live births per Huron County since 1994, but increased in the 3-1, women aged 15 to 49 years) is a more refined 44 year age group (Figure 3). The most marked measure of fertility than the crude birth rate as increase in fertility was in the 3-34 year age it is restricted to women of childbearing years. group, which increased by 29% from 1994 to 24. In Huron County, general fertility rates have When compared to Ontario, fertility rates were remained relatively stable over the past five years, significantly higher in the younger age groups (2- ranging from 38. to 41.9 live births per 1, 29 years), but lower in the older age groups (35-44 women aged years. These rates are similar years) in 24 (Figure 3). to Ontario. Year Huron County Fertility Rate (per 1,) Ontario Fertility Rate (per 1,) Table 3. The general fertility rate for Huron County and Ontario, Source: Ontario Live Birth Data [2-24], Provincial Health Planning Database (PHPDB) Extracted: 24/9/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 75

77 Rate (per 1,) Age-Specific Fertility Rates, Huron County and Ontario, Huron Huron Ontario Age Group (years) Figure 3. Age-specific fertility rates for Huron County in 1994 and 24, and Ontario 24. Error bars represent the 95% confi dence intervals for the rate. Source: Ontario Live Birth Data [2-24], Provincial Health Planning Database (PHPDB) Extracted: 24/9/27, Health Planning Branch, Ontario MOHLTC. Therapeutic Abortion Rate The rate of therapeutic abortions (the number of therapeutic abortions per 1, women aged years) is an indicator of unwanted pregnancy. The number of therapeutic abortions are usually underestimated as procedures performed out of province, pharmacologically terminated pregnancies and terminations performed in physician offices not designated as abortion clinics are not included in the total counts. 21 In 24, the rate of abortion in Huron County was less than half that of Ontario at 5.1 abortions per 1, women years (Figure 4). Teen abortion rates were higher, with 7.4 abortions per 1, women years in Huron County, but still lower than for Ontario. Figure 4. Therapeutic abortion rates for Huron County and Ontario in women of childbearing years (15-49 years) and in teens (15-19 years), 24. Error bars represent 95% confi dence intervals for the rates. Source: Ontario Therapeutic Abortion Database 24, HELPS (Health Planning Systems). Released January 27, Ministry of Health Promotion, Chronic Disease Prevention and Health Promotion Branch. Rate (per 1,) Therapeutic Abortion Rate, Huron County and Ontario, Total (women aged 15-49) Teen (women aged 15-19) Age Group (years) Huron County Ontario 76 - Huron County Community Health Status Report

78 BIRTH OUTCOMES Birth Weight Infants weighing less than 2,5 grams are classified as having a low birth weight while infants born weighing more than 4, grams at birth are classified as having a high birth weight. Low and high birth weight infants face increased health risks compared to infants born in the middle of the spectrum. Infant birth weight is affected by a multitude of factors including: mother s age, type of birth (single versus multiple), maternal lifestyle factors (such as smoking, alcohol use and diet), physical and social environment, genetic factors and parity (primaparous opposed to multiparous women). 22, 23 Low birth weight is associated with increased fetal and infant morbidity and mortality, along with lower cognitive development. 4 High birth weight is associated with low blood glucose levels and shoulder dystocia, along with other trauma to the head and neck during delivery. 23, 2 Low Birth Weight Rate In Huron County, 5.1% (95% CI ) of all live births occurring between 2 and 24 weighed less than 2,5 grams. 3 The proportion of low birth weight infants born in Ontario for that same time period was similar at 5.8% (95% CI ). When looking at singleton versus multiple births, the proportion of low birth weight singleton infants decreased to 3.7% (95% CI ). By contrast, 59.7% (95% CI ) of all live multiple births in Huron from 2 to 24 were low birth weight. Neither rate was significantly different from Ontario. High Birth Weight Rate Between 2 and 24, 16.9% (95% CI ) of all live births in Huron County weighed at least 4, grams at birth. 3 The proportion of high birth weight infants was significantly higher in Huron County than Ontario (13.1%, 95% CI ). Preterm Birth Rate A birth is considered preterm if the gestational age at birth is less than 37 completed weeks. Preterm birth is the most important cause of perinatal mortality and morbidity. 4 Risk factors for preterm birth include single marital status, younger or older mothers, smoking, low pre-pregnancy weight, low or high weight gain and multiple pregnancy. 4 On average, 42 births were delivered annually before 37 completed weeks of gestation in Huron County between 2 and In total, 7.4% (95% CI ) of all live births from 2 to 24 were delivered preterm, compared to 7.2% (95% CI ) in Ontario. Preterm births are more likely to occur with multiple gestations. From 2 to 24, 68.1% (95% CI ) of all multiple live births were delivered preterm, which was significantly higher than the provincial average (53.2%, 95% CI ). By comparison, just 5.8% (95% CI ) of all live singleton births were preterm. This rate is similar to Ontario. Stillbirth Rate The delivery of a fetus or infant that occurs after 2 weeks of gestation and that shows no signs of life upon delivery is considered a stillbirth. Congenital anomalies, prenatal infections and fetal growth restrictions can all cause stillbirths. 4 In Huron County, an average of three stillbirths occurred each year (range: 1-4) from 2 to In total, the rate of stillbirths was 4.6 stillbirths per 1, total births (live and still) for all five years combined. This is slightly lower than the Ontario rate of 6.5 stillbirths per 1, total births. Infant Mortality Rate Infant mortality is a death that occurs in a live born infant younger than 365 days old. Nine infant deaths have occurred in Huron County from 2 to 24 (average two deaths/year), resulting in an infant mortality rate of 3.2 deaths per 1, live births. 3 This is similar to the Huron County Community Health Status Report - 77

79 provincial rate of 5.4 deaths per 1, live births for the same time period. Congenital Anomalies A congenital anomaly (birth defect) includes any abnormality of structure, function or metabolism that is present at birth. 4 Neural tube defects, Down s Syndrome, congenital heart defects, oral facial clefts and limb reductions are all examples of congenital anomalies. Serious congenital anomalies are detected in 2-3% of births every year in Canada and are the leading cause of infant death. Recognized genetic conditions (such as inherited and chromosomal disorders) and environmental factors (such as maternal-related conditions or drug/chemical exposure) increase the risk of congenital anomalies. 24 In Huron County, there were 83 births with at least one congenital anomaly between 2 and 24 (range: 7-21). 25 This translates to a rate of 39.2 per 1, births (live and still), which is significantly lower than the provincial rate of per 1, births (confidence intervals not shown). Conclusions Huron County has a lower birth rate when compared to the province, which is likely due to having a lower percentage of women in their childbearing years. Despite following the provincial trend of increasing maternal age at first birth over time, first-time mothers in Huron still tend to be younger than Ontario, with a significantly higher pregnancy rate in women years of age. Huron, however, continues to have a lower teenage pregnancy rate than the province and lower reported therapeutic abortion rates for this age group. While adverse birth outcomes in Huron appear similar to the province, continued education on the benefits of folic acid, breastfeeding and cessation of smoking need to be promoted in order to ensure the health of babies born in Huron County. 1 Best Start. Reducing the Impact working with pregnant women who live in diffi cult life situations. Toronto, ON: Best Start Resource Centre, Coleman BL. Reproductive Health in Elgin-St. Thomas. St. Thomas, ON: Elgin-St. Thomas Health Unit, Ontario Live Birth Data 2-24, Provincial Health Planning Database. Extracted 8/27, Health Planning Branch, Ontario Ministry of Health and Long-Term Care. 4 Health Canada. Canadian Perinatal Health Report, 23. Ottawa, ON: Minister of Public Works and Government Services Canada, Compustat Consultants Inc. Huron County Health Unit Infant Feeding Summary Report Best Start. Socioeconomic Status and Pregnancy Fact Sheets - Stats and Facts About Poverty and Health During Pregnancy. Accessed 28 May 28 from resources/anti_poverty/pdf/ses_factsheets.pdf. 7 Best Start. Socioeconomic Status and Pregnancy Fact Sheets - Poverty, Pregnancy, and Culturally Diverse Women. Accessed 28 May 28 from anti_poverty/pdf/ses_factsheets.pdf. 8 Julvez J et al. Maternal smoking habits and cognitive development of children at age 4 years in a population-based birth cohort. International Journal of Epidemiology, 27;36(4): Chudley AE et al. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journal, 25;172(5 supp): S1-S2. 1 Health Canada. It s Your Health: Fetal Alcohol Spectrum Disorder. Accessed 28 May 28 from 11 Environics Research Group for the Public Health Agency of Canada. Alcohol Use during Pregnancy and Awareness of Fetal Alcohol Syndrome and Fetal Alcohol Spectrum Disorder. Toronto, ON: Environics Research Group, Mills JL and Signore C. Neural tube defect rates before and after food fortification with folic acid. Birth Defects Res A Clin Mol Teratol, 24;7(11): Goh YI et al. Prenatal Multivitamin Supplementation and Rates of Congenital Anomalies: A Meta-Analysis. JOGC, 26;28(8): Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario Ministry of Health and Long-Term Care. 15 Choquette L. Prenatal Education in Ontario Better Practices. Toronto, ON: Best Start Resources Centre, Internal communication with the Strengthening Families Quad, August World Health Organization. Global Strategy for Infant and Young Child Feeding. Geneva: World Health Organization, American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics 1997;1: Canadian Pediatric Society, Dieticians of Canada and Health Canada. Nutrition for Healthy Term Infants. Ottawa, ON: Minister of Public Works and Government Services, Ontario Live Birth Data 2-24, Provincial Health Planning Database. Extracted 15/8/27, Health Planning Branch, Ontario Ministry of Health and Long-Term Care. 21 Crosse E. Reproductive Health Status in Perth County Community Health Series, Vol. IV, 24. Stratford, ON: Perth District Health Unit, Malina RM, Bouchard C and Bar-Or O. Growth, Maturation, and Physical Activity, 5th ed. Windsor, ON: Human Kinetics, Association of Public Health Epidemiologists in Ontario. Core Indicators Family Health, Reproductive Health Birth Weights. Accessed 29 September 26 from 24 Health Canada. Congenital Anomalies in Canada A Perinatal Health Report 22. Ottawa, ON: Minister of Public Works and Government Services Canada, Health Canada. Canadian Congenital Anomalies Surveillance System (22-24). Obtained 17 September Huron County Community Health Status Report

80 Unintentional Injuries & Injury Prevention Injury is the leading cause of death and a major cause of morbidity among children and youth in Canada. 1 In Huron County, land transport occurrences and unintentional injuries account for significant potential years of life lost (Mortality section). Given the impact of injury on morbidity, mortality, and personal and economic cost, preventing injuries is an important public health challenge. In this section, unintentional injuries in Huron County will be examined for all causes, for injuries caused by falls and land transport occurrences, and for injuries that take place on a farm. In addition, unintentional injuries for children -6 years will be reported. The ICD-1 codes used to classify these injuries are shown in Appendix 3. For a complete picture of the impact of unintentional injuries in a population, data presented will include the number and rate of emergency room (ER) visits by age group, as well as crude and age-standardized hospitalization and mortality rates. Lastly, data on the proportion of preventive measures used in Huron County, such as seat belt, booster seat, and bike helmet use, will be reported. Risk Factors for Unintentional Injuries Injuries are often referred to as accidents ; however, approximately 9% of injuries are predictable and preventable. Many different factors can influence risk of injury. These include income and social status, education and living in a rural area, among others. The Canadian Institute for Health Information (CIHI) has shown that injury-related emergency room visits and hospitalizations are more common among individuals from lower income neighbourhoods. 2 For example, ER visits for year olds in households earning less than $39,5 were 35% higher when compared to those earning $74,51 or more. Likewise, Canadian studies have demonstrated that the risk of injury in children is higher in families that are economically disadvantaged. 3 Poverty can impact the risk of injury by limiting resources for supervised care or for implementing safety measures in the home. Also, poorer neighbourhoods can have fewer safe areas to play and are often in closer proximity to busier streets. Recently, it has also been shown that the overall injury-related mortality of Canadians increases with increasing rurality. 4 Specifically, mortality due to motor vehicle collisions represents the leading cause of injury among rural areas, due to the predominance of rural roads, with higher speed limits, increased distance of travel and poorer road conditions; more risky behaviours (such as alcohol use and not wearing a seat belt); and increased time for response of emergency medical services. 4 Farm-related injuries also increase the risk of injury in rural areas. It is important to understand the factors which contribute to injury occurrence and compliance in protective measures in order to produce effective injury prevention strategies. Self-Reported Injury In 25, 12.5% (95% CI ) of Huron County residents aged 12 years and older reported that they suffered an injury serious enough to limit normal activities within the last 12 months. 5 This is not significantly different from Ontario. Huron County Community Health Status Report - 79

81 All Unintentional Injuries (All Causes) Unintentional injuries are injuries that are neither self-directed nor directed at others and often result from motor vehicle collisions, falls, fires and poisonings. The majority of health care encounters for unintentional injuries take place in the emergency room (ER). In 25, there were 1,94 ER visits due to unintentional injuries in Huron County, giving a crude rate of ER visits per 1, population (Table 1). Of all age groups, 1-19 year olds had the highest rate of ER visits, with ER visits per 1, population. Almost two thirds (61.5%) of all ER visits were made by men (data not shown). More serious injuries can require hospitalization (i.e. admission to the hospital for more than 24 hours). In 25, 553 individuals were hospitalized for unintentional injuries (all causes) in Huron County, giving a crude hospitalization rate of hospitalizations per 1, population. 6 Of those hospitalized, 53.7% were female and 43.2% were 75 years and older. Age-standardized hospitalization rates from in Huron County are shown in Figure 1. From 24 to 25, hospitalization rates for unintentional injuries in Huron County decreased 11%. When compared to Ontario, age-standardized hospitalization rates due to unintentional injuries were higher for all four years examined in Huron County. Injuries can have fatal consequences. In Huron County, there were 33 deaths due to unintentional injuries (all causes) in 23, resulting in a crude mortality rate of 53.3 deaths per 1, population. 6 Over 7% (72.7%) of deaths were in men and 3.3% of all deaths occurred in individuals under the age of 25 years. When standardized for age, the Huron County mortality rate due to unintentional injuries was double that of Ontario, with 44.9 deaths per 1, compared to 22.7 deaths per 1, in 23. Possible explanations for higher hospitalization and mortality rates due to unintentional injuries in Huron County include: higher proportion of rural roads which lead to more serious land Age Group Rate # ER Visits (years) (per 1,) Total Table 1. The number and rate of emergency room (ER) visits due to unintentional injuries per 1,, by age group, Huron County, 25. Source: National Ambulatory Care Reporting System and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Rate per 1, Age-Standardized Hospitalization Rates for All Unintentional Injuries, Huron County and Ontario, Huron Rate Ontario Rate # Huron Hospitalizations Year Figure 1. Agestandardized hospitalization rates for unintentional injuries (all causes) in Huron County and Ontario (22-25). Source: Hospital [In-Patient Discharges] Data and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 26/4/27, Health Planning Branch, Ontario MOHLTC. 8 - Huron County Community Health Status Report

82 transport occurrences; higher proportion of farms and potential for farming-related injuries; and increased risky behaviours, such as increased alcohol use and decreased bicycle helmet and seat belt use (see Injury Prevention). Selected Causes of Injury Falls In Ontario, falls were the leading cause of ER visits and hospitalization for all age groups, with the exception of year olds, for 22/23. 2 Mortality due to an unintentional fall is most likely to occur in adults aged 65 years and older. Injuries can also lower the confidence and independence of seniors which can impact themselves and their family, friends, and caregivers. 7 In 26, 19.5% (95% CI ) of Huron County adults aged 18 years and older reported experiencing a fall in the last 12 months. 8 Of those, 37.9% (95% CI ) reported that their fall resulted in an injury that affected their daily activities. In adults 65 years and older, 16.8% (95% CI ) reported experiencing a fall in the last 12 months and 33.3%* (95% CI ) reported that the injury affected their daily activities. * High sampling variability. This estimate should be interpreted with caution. In 25, there were 2,747 ER visits in Huron County due to injuries caused by falls, resulting in a crude rate of 44.6 ER visits per 1, population (Table 2). Rates of ER visits were highest in those aged -9 years and 75 and older. In 25, there were 325 hospitalizations due to falls, for a crude hospitalization rate of hospitalizations per 1, population (Figure 2). Of those hospitalized, 7.5% were aged 65 years or older. Age-standardized hospitalization rates due to injuries caused by falls are shown for Huron County and Ontario in Figure 2. From 22 to 25, Huron County had higher rates of Age Group (years) # ER Visits Rate (per 1,) Total Table 2. The number and rate of emergency room (ER) visits due to injuries caused by falls per 1,, by age group, Huron County, 25. Source: National Ambulatory Care Reporting System and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Rate per 1, Age-Standardized Hospitalizations due to Land Transport Occurrences, Huron County and Ontario, Huron Rate Ontario Rate # Huron Hospitalizations Year Figure 2. Agestandardized hospitalization rates for unintentional injuries caused by falls in Huron County and Ontario (22-25). Source: Hospital [In-Patient Discharges] Data and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 26/4/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 81

83 hospitalization due to injuries caused by falls than Ontario, even once standardized for age. Mortality due to falls most often occurs in individuals aged 65 years and older. Between 2 and 23, 2 deaths occurred due to falls among those 65 years and older, giving an agespecific mortality rate of 47.5 deaths per 1, population. 6 Land Transport Occurrences While motor vehicle collisions are somewhat less common than falls in Ontario, the resulting injuries are more likely to result in hospitalization or death. 2 In Huron County, land transport occurrences are the 11 th leading cause of death (see Mortality chapter), which likely results from Huron County being predominantly rural. The Canadian Institute for Health Information (CIHI) has shown that increasing rurality increases the risk of mortality due to a motor vehicle collision, even after controlling for socioeconomic and demographic determinants of health. 4 In 25, Huron County had 878 ER visits due to injuries caused by land transport occurrences, resulting in a crude rate of 14.3 ER visits per 1, population (Table 3). Age-specific rates of ER visits shows that youth aged 1-19 years had the highest rate of visits, followed by those aged 2-44 years. Age-standardized hospitalization rates due to land transport occurrences have decreased 14% from 24 to 25 (Figure 3). Despite this, Huron County rates of hospitalization continue to be higher than Ontario. In 23, there were 18 deaths due to land transport occurrences, resulting in a crude death rate of 29.1 deaths per 1, population. 6 Overall, youth aged years contributed to 44% of those deaths. Injuries Occurring on Farms Age Group (years) # ER Visits Rate (per 1,) Total Table 3. The number and rate of emergency room (ER) visits due to injuries caused by land transport occurrences per 1,, by age group, Huron County, 25. Source: National Ambulatory Care Reporting System and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Rate per 1, Age-Standardized Hospitalizations due to Land Transport Occurrences, Huron County and Ontario, Huron Rate Ontario Rate # Huron Hospitalizations Year Figure 3. Agestandardized hospitalization rates for unintentional injuries caused by land transport occurrences in Huron County and Ontario (22-25). Source: Hospital [In-Patient Discharges] Data and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 26/4/27, Health Planning Branch, Ontario MOHLTC Huron County Community Health Status Report

84 Huron County has the highest proportion of individuals living in farming households of all counties in southwestern Ontario. 9 In 21, 16% of all Huron County residents lived in farming households compared to just 2% of Ontarians. In addition, 15% of the labour force in Huron County is engaged in agricultural work. 1 Agricultural workers face more hazards in the workplace than their counterparts from other occupations. In 2, there were 14 fatalities related to agricultural injuries and almost 1,5 hospitalizations in Canada. 11 Those at highest risk of injury include farm operators and children living on farms. The only local source of farm-related injuries (i.e. injuries sustained in the process of agricultural production) is the 21 Census of Agriculture. In the census, farmers were asked to report whether they had sustained any injuries in the previous 12 months that required medical attention or time off work. In Huron, 2.9% of all farm operators (n=3,955) reported having been injured compared to 2.7% of farm operators (n=85,15) in Ontario. 12 In this chapter, injuries that occurred on a farm are reported (ICD1-CA Code U987). This includes any injuries that were sustained on a farm, regardless of whether or not agricultural production was happening at the time of the injury. Over 2 ER visits were made in 25 in Huron County due to injuries that occurred on a farm (Table 4). The rate of ER visits was highest for those aged 2-44 years (5.8 visits per 1, population). In 25, 13 individuals were hospitalized due to unintentional injuries that occurred on a farm. When looking at age-specific hospitalization rates for combined, Huron County had higher rates of hospitalization for all age groups when compared to Ontario (Figure 4). This is expected as Huron County has a higher proportion of farms than Ontario. Age Group (years) # ER Visits Rate (per 1,) Total Rate per 1, Age-Specific Hosptialization Rates due to Injuries that Occurred on a Farm, Huron County and Ontario, Combined Age Group (Years) Huron Ontario Table 4. The number and rate of emergency room (ER) visits due to unintentional injuries that occurred on a farm per 1,, by age group, Huron County, 25. Source: National Ambulatory Care Reporting System and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Figure 4. Age-specific hospitalization rates due to unintentional injuries that occurred on a farm in Huron County and Ontario (22-25 combined). Source: Hospital [In-Patient Discharges] Data and Population Estimates [22-25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Huron County Community Health Status Report - 83

85 Unintentional Injuries in Children -6 years Unintentional injuries are the leading cause of death in children aged six years and younger. Most home injuries in children are caused by falls, burns and scalds, and poisonings, all of which are preventable through the removal of hazards in the home and close parental supervision. 13 In 23-24, Huron County individuals aged 18 years and older were asked about their beliefs and perceptions of childhood injuries. 14 Overall, 58.9% (95% CI ) correctly identified that childhood injuries were the leading cause of death among children 1-6 years of age in Ontario. Over 5% (54.4%, 95% CI ) thought that injuries to children were very or completely preventable and 84.8% (95% CI ) of individuals believed the best way to prevent injuries was by active supervision by an adult. More recently, a national survey by Safe Kids Canada has shown that 86% of Canadian parents believe that swimming lessons are the best way to protect a child from drowning. 15 However, active supervision of parents, adult training in CPR, First Aid and water rescue, fencing surrounding the pool and using lifejackets are also important steps that need to be taken in order to reduce mortality and hospitalization due to drowning. In 25, there were 843 visits to the ER by children -6 years and 11 hospitalizations (Table 5). Of all Huron County children aged -6 years, there were zero deaths due to unintentional injuries in 23. Of all ER visits reported in 25 for Huron County children -6 years, 38.3% of visits were due to falls (Figure 5). Falls are also the leading cause of ER visits among Ontario children. 2 Exposure to inanimate mechanical forces, such as contact with sharp objects or explosion of materials, also contributed to a large proportion of ER visits (11.3%). There was one ER visit due to drowning in Huron County in 25. Table 5. The number and rate of emergency room (ER) visits and hospitalizations per 1, due to unintentional injuries in children aged -6 years, Huron County, 25. The number of deaths and mortality rate is also reported for 23. Source: National Ambulatory Care Reporting System, Ontario Mortality Data and Population Estimates [23, 25], Provincial Health Planning Database (PHPDB) Extracted: 27/4/27, Health Planning Branch, Ontario MOHLTC. Number (#) Rate (per 1,) ER Visits Hospitalizations Deaths (23) 1% Leading Causes of ER Visits due to Unintentional Injuries in Children -6 years, Huron County, 25 8% 5% 4% 4% 3% 38% Falls Other Exposure to other inanimate mechanical forces Foreign Bodies Contact with Animals, Insects or Plants Struck by or against (object or person) Burns Figure 5. The leading causes of ER visits due to unintentional injures in children -6 years, Huron County, 25 (n=843). Source: National Ambulatory Care Reporting System and Population Estimates [25], Provincial Health Planning Database (PHPDB) Extracted: 3/4/27, Health Planning Branch, Ontario MOHLTC. 12% 16% Land Transport Occurrences Unintentional Poisoning 84 - Huron County Community Health Status Report

86 Injury Prevention Most injuries can be prevented. Education campaigns, legislative changes and product modifications have all worked to reduce injuries. 16 Seat Belt and Booster or Car Seat Use Using a seat belt is the single most effective way to reduce the risk of injury or death in a motor vehicle collision. 17 For every 1% increase in seat belt use, five lives in Canada are saved (Transport Canada). By law, all Ontario residents who occupy a seating position in a motor vehicle for which a seat belt is provided must wear a seat belt or use a child safety seat. 17 In addition, it is also mandatory for Ontario children who are under the age of eight, and who weigh between kg and are less than 145 cm tall, to be seated in a booster seat. 18 In 23, 81.2% (95% CI ) of Huron County adults aged 18 years and older reported that they wear a seat belt all of the time when they drive. 19 When a passenger in a vehicle, 81.7% (95% CI ) reported that they wore their seat belt all the time. When looking at seat belt use by gender, it is apparent that women drivers and passengers are significantly more likely to always wear a seat belt when compared to men (Figure 5). In Huron County, 92.5% (95% CI ) female drivers reported wearing a seat belt all the time versus only 69.9% (95% CI ) of male drivers (p<.1). In 25, 73.9% (95% CI ) of households with a child aged 4-7 years responded that the child usually travels in a booster (or car) seat and always in the back of the vehicle. 2 Among households with a child aged 8-11 years, 52.9% (95% ) report that the child usually uses a seat belt with a lap and shoulder belt combination (or a booster seat and seat belt) and always travels in the back of the vehicle. The health unit, along with other partners, checks car seats for incorrect installation and usage. The majority of car seats inspected are installed and used incorrectly. In 25, 9.% of car seats inspected in Huron County were used incorrectly and in 26, 77.5% were used incorrectly. 21 Percent (%) Pecentage who Report Wearing a Seat Belt "All the time" by Gender, Huron County, Drivers Passengers Male Female Figure 5. The frequency of reported seat belt use among those who drive vehicles (n=1117) or are passengers in vehicles (n=1212) in Huron County, by gender, 23. Source: Rapid Risk Factor Surveillance System, January- December 23. Position in Vehicle Huron County Community Health Status Report - 85

87 Bike Helmet Use Wearing a helmet can reduce risk of head injury by up to 85%. 22 In Ontario, every cyclist under the age of 18 years is required to wear an approved bicycle helmet. 22 Of all Huron County residents (12+ years) who reported bicycle use in 25, only 14.5%* (95% CI ) reported that they always wear a helmet compared to 78.1% (95% CI ) who rarely or never wear a helmet (Figure 6). By contrast, 31.4% (95% CI ) of Ontarians report that they always wear a helmet, which is significantly higher than Huron. When looking at bike helmet use by age group, 4.7%* (95% CI ) of year olds report always using a bike helmet compared to only 7.4%* (95% CI ) of adults aged 18 years and older. * High sampling variability. This estimate should be interpreted with caution. Conclusion Huron County experiences higher hospitalization and mortality rates for unintentional injuries than Ontario, even when standardized for age. Possible explanations include: higher proportion of rural roads which lead to more serious land transport occurrences, higher proportion of farms and potential for farming-related injuries, and increased risky behaviours. The highest rate of emergency room visits in Huron County is in the 1-19 years age group, both for all causes of unintentional injuries and for land transport occurrences. This is an important target group to share prevention messages and strategies with. While Huron County has higher rates of injuries that occur on farms than Ontario (likely due to the higher proportion of farms in Huron County), self-reported farm-related injuries were comparable in farm operators in Huron and Ontario. When it comes to preventing injuries, a lower percentage of males in Huron County report wearing a seat belt when compared to women. In addition, not all households with children under the age of 8 years report that the child travels in a booster seat in the back of the car as is required by law. Lastly, a lower percentage of individuals report wearing a bicycle helmet when cycling than Ontario and only 41% of those under the age of 18 years report that they always wear a bicycle helmet. Further education efforts must be made to increase awareness and promote behavioural changes in order to decrease the incidence of unintentional injuries in Huron County. Percent (%) Reported Bike Helmet Use, Huron County and Ontario, 25 * * Always Most of the time Rarely or never Frequency of Use Huron Ontario Figure 6. The frequency of reported bicycle helmet use among those who ride bicycles in Huron County (n=151) and Ontario (n=9,614), 25. * Indicates that there is high variability and that the estimate should be interpreted with caution. Source: Canadian Community Health Survey, Cycle 3.1 [25], Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC Huron County Community Health Status Report

88 1 Health Canada. Injury Surveillance in Canada: Current Realities, Challenges, 23. Accessed 26 May 28 from InjurySurveillanceinCanada.pdf. 2 Macpherson A et al. ICES Atlas - Injuries in Ontario. Toronto, ON: Institute for Clinical Evaluative Sciences, Faelker T, Pickett W and Brison RJ. Socioeconomic differences in childhood injury: a population based epidemiologic study in Ontario, Canada. Injury Prevention, 2;6: Canadian Institute for Health Information. How Healthy Are Rural Canadians? Ottawa, ON: Canadian Institute for Health Information, Canadian Community Health Survey 3.1 (25). Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario Ministry of Health and Long-Term Care. 6 Hospital In-Patient Discharges Data and Population Estimates 22-25, Provincial Health Planning Database, Extracted: 26/4/27, Health Planning Branch, Ontario Ministry of Health and Long-Term Care. 7 Ottawa Public Health. City of Ottawa 26 Health Status Report: Measuring health in Ottawa to build a stronger and healthier community. Ottawa, ON: Ottawa Public Health, Rapid Risk Factor Surveillance System, January December Turner L. & Gutmanis I. Rural Health Matters: A Look at Farming in Southwest Ontario Part 2. London, ON: Southwest Region Health Information Partnership, Turner L. Rural Health Matters: A Look at Farming in Southwest Ontario. London, ON: Southwest Region Health Information Partnership, Canadian Agricultural Injury Surveillance Program. Summary Report on Agriculture Injuries in Canada Accessed 29 April 27 from 12 Statistics Canada. 21 Census of Agriculture - Characteristics of Farm Operators. Accessed 24 July 28 from optab1.pdf. 13 LeBlanc JC et al. Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study. Canadian Medical Association Journal, 26;175(8): Rapid Risk Factor Surveillance System, October 23 - February Safe Kids Canada. Safe Kids Week 27: Drowning Prevention. Accessed 22 June 27 from 27&ssID=2584&sss=Safe+Kids+Week+27%3A+Drowning+prevention&sssID= D Cunha CO. 22 Chief Medical Officer of Health Report Injury: Predictable and Preventable. Toronto, ON: Ministry of Health and Long-Term Care, Ontario Ministry of Transportation. Seat Belts Stay safe and secure. Accessed 26 May 28 from 18 Ontario Ministry of Transportation. Safe and Secure: Choosing the Right Car Seat for Your Child. Accessed 24 July 28 from htm. 19 Rapid Risk Factor Surveillance System, January - December Rapid Risk Factor Surveillance System, March - December Internal communication with the Strengthening Families Quad, 7/6/ Ontario Ministry of Transportation. Young Cyclist s Guide. Accessed 26 May 28 from Huron County Community Health Status Report - 87

89 Communicable Diseases Communicable diseases are often thought of as diseases that are more prevalent in developing countries; however, recent outbreaks such as Walkerton, SARS and the listeriosis in meat products have shown the risk communicable disease can pose to developed countries like Canada. Communicable diseases are caused by living organisms, such as bacteria, viruses and parasites, or by toxins these organisms produce. They are spread directly through contact with an infected person or animal, or indirectly through contact with contaminated objects or consumption of contaminated food or water. This chapter will outline the most common communicable diseases in Huron County that are mandated by the government to be reported. In addition, the incidence of sexually transmitted infections and other blood-borne infections, food and waterborne enteric diseases, and vaccinepreventable diseases will be described. Agestandardized incidence rates are presented for the most reported diseases where there are a large number of cases per year, while crude incidence rates are presented for all other diseases. Standardized incidence ratios (SIRs) were also calculated to determine if the incidence of selected diseases in Huron County was significantly different from Ontario. Most Common Reportable Diseases Under the Health Protection and Promotion Act, physicians and other health care professionals, hospitals, laboratories, schools and child care facilities must report any person who may be infected with a reportable disease. A list of reportable diseases for 26 is shown in Appendix 4. The top 15 reportable diseases in Huron County from 1995 to 25 are shown in Figure 1. There were a total of 2,5 cases of communicable diseases reported in Huron County over this time period. Campylobacter enteritis, influenza and chlamydial infections were the most commonly reported communicable diseases, accounting for 5.% of all reported diseases. When looking at the most common reportable diseases for men and women separately, a Reportable Disease Top 15 Reportable Diseases in Huron County ( ) Campylobacter enteritis Influenza Chlamydial Infections Pertussis Salmonellosis Rubella Giardiasis Verotoxin-Producing E. coli Hepatitis C Cryptosporidiosis Gonorrhoea Yersiniosis Group A Streptococcal Infections Streptococcus pneumoniae Encephalitis Figure 1. The 15 most commonly reported diseases in Huron County ( data combined). Source: integrated Public Health Information System (iphis)., Extracted 7/3/ Number of Reported Cases 88 - Huron County Community Health Status Report

90 different pattern emerges (Figure 2 for males and Figure 3 for females). Campylobacter enteritis was the most commonly reported disease among men in Huron County, while chlamydial infections were more commonly reported for women. Reportable Disease Top Reportable Diseases in Huron County Males ( ) Campylobacter enteritis Influenza Salmonellosis Chlamydial Infections Pertussis Rubella Giardiasis Hepatitis C Cryptosporidiosis Verotoxin-Producing E. coli Gonorrhoea Yersiniosis Group A Streptococcal Infections Encephalitis Streptococcus pneumoniae Figure 2. The 15 most commonly reported diseases in Huron County among males ( data combined). Source: iphis, Extracted 7/3/ Number of Reported Cases Top Reportable Diseases in Huron County Females ( ) Reportable Disease Chlamydial Infections Influenza Campylobacter enteritis Pertussis Salmonellosis Rubella Giardiasis Verotoxin-Producing E. coli Cryptosporidiosis Hepatitis C Yersiniosis Group A Streptococcal Infections Gonorrhoea Streptococcus pneumoniae Figure 3. The 15 most commonly reported diseases in Huron County among females ( data combined). Source: iphis, Extracted 7/3/ Number of Reported Cases Huron County Community Health Status Report - 89

91 Sexually Transmitted Infections (STIs) and Bloodborne Diseases Sexually transmitted infections (STIs) are caused by bacteria and viruses in bodily fluids, such as blood, semen, vaginal secretions, breast milk and saliva, and are spread through sexual contact and other types of direct contact such as injections or cuts to the skin. Chlamydia The most common sexually transmitted infection in Canada, chlamydia is a bacterial infection spread by direct contact (usually sexual) with an infected individual. Symptoms include urinary pain and genital discharge; however, about 8% of women and 5% of men do not show symptoms. 1 If left untreated, chlamydia can cause pelvic inflammatory disease (PID) in women, which can lead to infertility, ectopic or tubal pregnancy and chronic pelvic pain. 1 In men, untreated chlamydia can cause pain of the testicles, penis or rectum. 1 In Huron County, chlamydia is the most commonly reported sexually transmitted infection, with 33 cases reported in 25. The number of cases reported per year, along with the age-standardized incidence rates are shown in Figure 4. Age-standardized rates increased overall by 49% from 1995 to 25, with the lowest number of cases reported in 1999 and a peak in 24. Huron County rates were significantly lower than Ontario (SIR=.35, 95% CI.32-.4). Chlamydia incidence rates in Huron County vary by age and sex (Figure 5). Chlamydia was most commonly reported in females and individuals aged years. Between 2 and 25, there was double the number of cases of chlamydia in women compared to men (128 cases versus 64 cases) and 78% of all chlamydia cases were between the ages of 15 and 24 years. Among females, chlamydia was most commonly reported in the 2-24 years age group, while in males, chlamydia incidence appeared relatively stable between the ages of Age Standardized Incidence Rates of Chlamydia in Huron County and Ontario, Rate (per 1,) Huron County Ontario # Huron Cases Year Figure 4. Age-standardized incidence rates of chlamydia for Huron County and Ontario from 1995 to data was not available for Ontario. Source: iphis, Extracted 8/3/ Huron County Community Health Status Report

92 Rate (per 1,) Incidence of Chlamydia by Age Group and Sex, Huron County, 2-25 Combined Male Female Age Group (years) Figure 5. Incidence rate of chlamydia by age and sex for 2-25 combined. Source: iphis, Extracted 8/3/27. Gonorrhea Gonorrhea is a bacterial infection that is also spread by sexual or direct contact with an infected individual. Like chlamydia, gonorrhea can be asymptomatic, although the majority of infected men have symptoms, while most women are asymptomatic. 2 If left untreated, females may acquire PID and both sexes may experience rectal and pharyngeal infections. 2 Infants born to infected mothers are at risk for developing sightthreatening eye infections, scalp abscessed or disseminated gonorrhea infection (extension of infection from genital site). 2 The incidence of gonorrhea in Huron County is low, with an average of approximately two cases per year and a peak of 5 cases in Between 1995 and 25, there were a total of 21 cases, 61.9% of which were male. The number of cases of gonorrhea has remained stable over this time period. nausea and vomiting, stomach pain, fatigue and jaundice, although most infected persons experience no or very mild symptoms. 4 Most persons infected with hepatitis C will remain infected for the rest of their lives and may experience complications such as cirrhosis of the liver and liver failure. 3 In Huron County, there have been 75 reported cases from 1995 to 25, with males accounting for 66.7% of all cases. 5 Age and sex-specific incidence rates were calculated for combined and are shown in Figure 6 for males and Figure 7 for females. Men aged 4-59 years had the highest incidence of hepatitis C at 33. cases per 1, population, which is over three times that of women in the same age group. In both males and females, age-specific incidence of hepatitis C was lower in Huron County than Ontario. Hepatitis C Hepatitis C is a viral infection of the liver and is acquired primarily through activities which involve the exchange of blood, such as sharing needles. Symptoms include loss of appetite, Huron County Community Health Status Report - 91

93 Age-Specific Incidence of Hepatitis C in Males, Huron County and Ontario, Combined Rate (per 1,) Huron Ontario Age Group (years) Figure 6. Age-specific incidence of hepatitis C for males in Huron County and Ontario, data combined. Source: iphis, Extracted 12/3/27. Age-Specific Incidence of Hepatitis C in Females, Huron County and Ontario, Combined Rate (per 1,) Huron Ontario Age Group (years) Figure 7. Agespecific incidence of hepatitis C for females in Huron County and Ontario, data combined. Source: iphis, Extracted 12/3/ Huron County Community Health Status Report

94 Food and Waterborne Enteric Diseases Food and waterborne enteric diseases are acquired mainly through consuming contaminated food or water and/or through direct fecal-oral contact. Common symptoms of enteric illness include nausea, vomiting, diarrhea, cramps, fatigue, fever, headache, chills and loss of appetite. While most infected individuals recover without antibiotics, some infections may cause long-term complications such as kidney failure, systemic infections and immune system problems. Food and waterborne enteric disease are most common in those under five years of age. Campylobacteriosis (Campylobacter enteritis) Campylobacteriosis, a bacterial infection that targets the digestive system, is the most common enteric disease in Canada. An individual can become infected through eating undercooked chicken or pork, drinking contaminated water or raw milk or through close contact with infected animals. 6 In Huron County, campylobacteriosis is the most commonly reported disease and also the most commonly reported enteric illness, accounting for 19.5% of all reportable diseases. 7 In 25, 28 cases were reported, resulting in a crude incidence rate of 45.5 cases per 1, population, down from 53.4 cases per 1, population in Agestandardized incidence rates from 1995 to 25 are presented in Figure 8 for both Huron County and Ontario. Huron County and Ontario rates remained similar until 2, at which time Huron County rates increased. A possible explanation for this peak in 2 was the contaminated municipal water in Walkerton which resulted in an outbreak of both campylobacteriosis and verotoxinproducing E. coli. The sustained increase in Huron since 2 is likely due to increased physician visits and testing resulting from heightened awareness and willingness to be tested. Overall, between 1995 and 24, Huron County had significantly higher rates of campylobacteriosis compared to Ontario (SIR=1.43, 95% CI ). Age-specific incidence of campylobacteriosis in Huron County is shown in Figure 9. Campylobacteriosis rates were highest among those under the age of five years and those aged years. In Huron County, children are most likely infected with Campylobacter enteritis through contact with farm animals and barn cats and through sharing baths with infected children and siblings. The higher incidence among the year age group may be due to a high proportion of individuals who work with chickens in Huron County. Rate (per 1,) Age-Standardized Incidence Rates of Campylobacteriosis, Huron County and Ontario, Huron County Ontario # Huron Cases Year Figure 8. Agestandardized incidence rates of campylobacteriosis for both Huron County and Ontario from 1995 to data was not available for Ontario. Source: iphis, Extracted 13/3/27. Huron County Community Health Status Report - 93

95 Rate (per 1,) Age-Specific Incidence of Campylobacteriosis, Huron County, 2-25 Combined Age Group (years) Figure 9. Age-specific incidence rates of campylobacteriosis in Huron County for 2-25 combined. Source: iphis, Extracted 13/3/27. Salmonellosis Salmonellosis is caused by different types of Salmonella bacteria and results from ingesting contaminated food (usually of animal origin such as beef, poultry, pork and eggs). 8 Salmonellosis can also be associated with pets, such as dogs, cats and turtles. Young children, seniors and those with weakened immune systems are the most vulnerable. 8 Salmonellosis is the second most commonly reported enteric illness in Huron County. The crude incidence rates of salmonellosis are shown in Figure 1. Incidence rates of salmonellosis have fluctuated between 14.6 to 32.5 cases per 1, population over the eleven-year period. The peak in cases in 1998 is likely due to the Canada-wide outbreak, while the increase in cases in 25 is due to a bean sprout-related outbreak. To compare incidence of salmonellosis in Huron County with that of Ontario, age-specific incidence rates were calculated (Figure 11). For most age groups, incidence of salmonellosis was higher in Huron County than Ontario, with the exception of those aged 6 years old and older. Figure 1. Crude incidence rates for salmonellosis in Huron County from 1995 to 25. Age-standardized rates were not calculated due to small number of cases. Source: iphis, Extracted 7/3/27. Crude Rate (per 1,) Crude Incidence Rates of Salmonellosis, Huron County, Rate # Cases Year 94 - Huron County Community Health Status Report

96 Overall, however, incidence of salmonellosis between 1999 and 24 in Huron County did not differ significantly from Ontario (SIR=1.21, 95% CI ). For both Huron County and Ontario, those under the age of five years were the most vulnerable to infection. Age-Specific Incidence of Salmonellosis, Huron County and Ontario, Combined Rate (per 1,) Huron Ontario Age Group (years) Figure 11. Age-specific incidence rates of salmonellosis in Huron County, combined. Source: iphis, Extracted 15/3/27. Giardiasis Giardiasis is a parasitic infection that can be spread person-to-person or through contaminated food or water. Common symptoms include chronic diarrhea, abdominal cramps and bloating and fatigue. Infections are more common in institutions and daycare centres where children are not yet toilet trained. Children under five years and their parents are at increased risk of infection. 9 From 1995 to 25, an average of 11 cases annually has been reported in Huron County. 1 Crude incidence rates for giardiasis are shown in Figure 12. The incidence of giardiasis has generally decreased since 1998, with six reported cases in 25 or a crude incidence rate of 9.8 cases per 1,. Crude Incidence Rates of Giardiasis, Huron County, Rate (per 1,) Rate Cases Year Figure 12. Crude incidence rates of giardiasis in Huron County from 1995 to 25. Agestandardized rates were not calculated due to small number of cases. Source: iphis, Extracted 15/3/27. Huron County Community Health Status Report - 95

97 Age-specific incidence rates were calculated for Huron County and Ontario and are shown in Figure 13. Huron County s age-specific incidence rates are similar to Ontario. Individuals under the age of five years and those aged 3-39 years had the highest incidence of giardiasis. Possible explanations for higher incidence rates among 3-39 year olds is that these individuals may be parents of young children and/or there are a high proportion of individuals in this age group who fish in Huron County. Age-Specific Incidence of Giardiasis, Huron County and Ontario, Combined Rate (per 1,) Huron Ontario Age Group (years) Figure 13. Agespecifi c incidence rates of giardiasis in Huron County, combined. Source: iphis, Extracted 16/3/27. Verotoxin-Producing Escherichia coli (VTEC) VTEC is a strain of Escherichia coli (E. coli) that can cause enteric illness. Individuals most commonly become infected by consuming contaminated hamburger or ground meat product. However, in 2, a contaminated municipal water supply caused a serious outbreak of VTEC in Walkerton, Ontario, resulting in seven deaths and approximately 2,3 infected. 11 VTEC causes diarrhea and can cause hemolytic uremic syndrome (HUS), a life-threatening condition in which the red blood cells are destoyed and the kidneys fail, among seniors or those under the age of five years. 12 in Huron County or 14.6 cases per 1, population. There was a peak in cases in Huron County in 2 likely due to increasing testing related to the major VTEC outbreak in Walkerton, Ontario. Fourteen cases were reported in 2 in Huron County, giving a crude incidence rate of 22.6 cases per 1,. The crude incidence of verotoxin-producing E. coli (VTEC) in Huron County from 1995 to 25 is shown in Figure 14. In 25, nine cases of verotoxin-producing E. coli (VTEC) were reported 96 - Huron County Community Health Status Report

98 Rate (per 1,) Crude Incidence Rates of Verotoxin-Producing E. coli, Huron County, Figure 14. Crude incidence rates of verotoxin-producing E. coli (VTEC) in Huron County from 1995 to 25. Age-standardized rates were not calculated due to small number of cases. Source: iphis, Extracted 16/3/ Rate Cases Year Cryptosporidiosis Like giardiasis, cryptosporidiosis is a parasitic infection that results in similar symptoms, most commonly watery diarrhoea, abdominal cramps, nausea, and headaches. Those at increased risk of infection are children under two years of age, parents of young children or child care workers, animal handlers, travellers, people who drink from untreated shallow, unprotected wells and men who have sex with multiple same sex partners. 13 Crude incidence rates of cryptosporidiosis are shown in Figure 15. Incidence has remained between 8.1 to 16.1 cases per 1, from 1996 to 25 in Huron County. Crude incidence of cryptosporidiosis in Ontario is lower than Huron County, with 2.4 cases per 1, population reported in Ontario for 25 compared to 13. cases per 1, population in Huron County. From 2 to 24, Huron County rates were significantly higher than Ontario (SIR=6.1, 95% CI ). Possible explanations for this include the predominance of agricultural industry in Huron County and the subsequently higher proportion of animal handlers. Figure 15. Crude incidence rates of cryptosporidiosis in Huron County from 1996 to 25. Ontario cases were not mandated to be reported until Source: iphis, Extracted 7/3/27. Rate (per 1,) Crude Incidence Rates of Cryptosporidiosis, Huron County, Rate # Cases Year Huron County Community Health Status Report - 97

99 Vaccine Preventable Diseases Vaccine preventable diseases are caused by viruses and bacteria which are highly contagious and can be spread through a cough or sneeze of an infected person. Outbreaks of vaccine preventable disease can occur in developed countries when immunization rates decline, in the case of influenza, or when the vaccine formula is insufficiently targeted to the season s pathogen. For the 25/26 school year, 76.6% of all students entering junior kindergarten in Huron County had been vaccinated with the mandatory vaccines (diphtheria-polio and measles-mumpsrubella). 14 Influenza Influenza, a viral infection, is a highly infectious respiratory illness. Common symptoms include fever, headache, cough and muscle aches. 15 These symptoms are similar to those of the common cold but are usually more severe and can result in complications like pneumonia. In 2, Ontario began to implement free, voluntary influenza vaccinations (flu shots) to those aged six months and older. 16 Immunization coverage rates are shown in Table 1 for the 25/26 season. For the 25/26 influenza season (July 1, 25 to June 3, 26), 44 positive cases were confirmed in Huron County. Age-standardized incidence rates of lab-confirmed influenza for Huron County and Ontario are shown in Figure 16. For most years, Huron County incidence rates were higher than Ontario, although they had similar trends. In general, young children and the elderly have the highest incidence rates of influenza. 14 In Huron County, individuals aged years and those aged 6 years and older had the highest incidence rates of influenza (Figure 17). The unusual peak in year olds is due to 11 reported cases of influenza B in this age group for the 25/26 season, which was a result of both a poor vaccine match for the influenza B virus and increased testing in this age group. When surveyed, 5.9% (95% CI ) of Huron County adults aged 18 years and older reported getting a flu shot during the 25/26 season (n=24). 17 Among those 65 years and older, 89.8% (95% CI ) reported receiving a flu shot. Immunization coverage was highest for the 25/26 season when compared to the previous three seasons. Huron County Health Unit also provided influenza vaccine to hospitals, retirement and nursing homes for the vaccination of staff and residents (in long-term care facilities). Coverage Location Staff Residents Hospitals 78% N/A Nursing Homes 74% 95% Retirement Homes 79% 92% Table 1. Influenza immunization coverage rates for staff and residents of 6 area hospitals, 9 area nursing homes and 6 area retirement homes for the 25/26 influenza season. Source: Internal communication with the Building Community Capacity Quad, Huron County Health Unit Huron County Community Health Status Report

100 Crude Incidence Rates of Cryptosporidiosis, Huron County, Rate (per 1,) Rate # Cases Figure 16. Age-standardized rates of lab-confirmed influenza cases for both Huron County and Ontario from 1995/1996 to 25/26. 24/5 and 25/6 data was not available for Ontario. Note: seasons are defi ned as July 1 to June 3. Source: iphis, Extracted 16/3/27. Year Figure 17. Age-specific incidence rates of infl uenza in Huron County, 2/21 to 25/26 combined. Source: iphis, Extracted 16/3/27. Age-Standardized Rates of Lab-confirmed Influenza Cases, Huron County and Ontario, 1995/ /26 1 Rate (per 1,) /96 96/97 97/98 98/99 99/ /1 1/2 2/3 3/4 4/5 5/6 Huron Ontario # Huron Cases Season (years) Huron County Community Health Status Report - 99

101 Pertussis Pertussis, or whooping cough, is a bacterial infection which can result in very severe coughing spells. 18 Complications from pertussis are more common among the very young and include pneumonia, brain damage and death. Pertussis is easily transmitted from one person to another through the discharges or droplets from an infected person's nose or mouth. In Huron County, pertussis is the fourth most commonly reported disease due to three outbreaks of pertussis that have occurred in Huron County between 1995 and In 1995, 84 cases were reported; in 1998, 5 cases; and in 22, 12 cases. These outbreaks are due to a largely unvaccinated pocket of the population in Huron County. For all other years, the average number of cases reported is just under four cases per year. These peaks match Ontario trends. Rubella Rubella, also called the German Measles, is a mild, viral illness that produces a rash, followed by a fever and upper respiratory symptoms. It is transmitted by direct contact with or inhalation of the secretions from an infected person's nose or mouth. If a pregnant woman becomes infected with rubella early in the pregnancy, serious consequences can result for the baby, such as congenital rubella syndrome or death. 2 In 1995, there was an outbreak of 144 rubella cases reported in Huron County. 21 This outbreak occurred in a largely unvaccinated pocket of population in Huron County. Only one other case of rubella has been reported since then, which is likely due to the introduction of the seconddose measles-mumps-rubella (MMR) vaccine introduced in Zoonotic Diseases Zoonotic diseases are any diseases or infections which are transmissible from animals to humans. 25 Rabies Rabies is a viral infection of animals, which attacks the central nervous system and eventually affects the brain. 23 The virus, usually found in the saliva of an infected animal, can be transmitted to humans through a bite or a scratch. Rabies is almost always fatal in humans once symptoms occur. The Huron County Health Unit investigates all reported human-animal exposures. In 26, 167 investigations were made, up from 158 in 25 (Table 2). Of all investigations made in 26, 14 individuals received rabies prophylaxis to prevent the development of rabies (Table 2) and three animals tested positive for rabies. To date, no human rabies cases have been reported in Huron County. To eliminate the potential incidence of rabies in humans, it is mandatory in Huron County that cats and dogs be vaccinated against rabies. In 26, Huron County households who had at least one cat or dog were questioned on whether or not their pet had received a rabies vaccine within the past 12 months. Of all Huron County households who had at least one dog, 76.7% (95% CI ) reported that all of their dogs had received the vaccine within the past 12 months (Figure 18). By contrast, only 47.5% (95% CI ) of households with at least one cat reported that all of their cats had been vaccinated against rabies (Figure 18). This is likely due to a high number of barn cats in Huron County, which present difficulties for vaccination. One barrier to vaccinating pets is cost. Huron County provides low-cost rabies vaccination clinics to help make rabies vaccination more accessible to individuals and households with lower income. In 26, 511 dogs and 264 cats were vaccinated at low-cost clinics in Huron County. 24 Year # Investigations Conducted # Individuals Receiving Rabies Vaccine Table 2. The number of human-animal exposure investigations conducted and the number of individuals put on prophylaxis for rabies in Huron County, Source: Internal communication with Protecting the Environment Quad, Huron County Health Unit Huron County Community Health Status Report

102 Percent (%) Animal Rabies Immunization Status Among Households who Report Having at Least One Dog or Cat, Huron County, 26 All are immunized Some are immunized None are immunized Immunization Status Dogs Cats Figure 18. The frequency of reported rabies vaccination status among households with at least one dog (n=266) or cat (n=22), Huron County, 26. Source: Rapid Risk Factor Surveillance System, January-December 26. West Nile Virus (WNV) West Nile virus belongs to the family of viruses entitled Flaviviridae and is closely related to the viruses that cause Dengue fever, Yellow fever, and St. Louis encephalitis. Generally the virus is spread to humans by mosquitoes that have fed on the blood of an infected bird. Many individuals that become infected with WNV show no symptoms and do not get sick. In mild cases, there may be flu like symptoms, including rash, fever, headache, and general malaise. In rare cases, some individuals with weakened immune systems can react quite severely to the infection and present symptoms such as severe headache, high fever, stiff neck, nausea, difficulty swallowing, vomiting, loss of consciousness, and even paralysis. 26 testing, based upon their susceptibility to WNV and the fact that they frequently die of the disease. Huron County Health Unit has been monitoring birds for WNV since 22. In that year, a total of 5 WNV positive birds were identified in Huron County. The total number of WNV positive birds in 23, 24, and 25 were two, four, and four, respectively. 27 Five positive birds were identified for 26, indicating viral activity has been consistent in Huron County s bird population. The number of dead bird sightings, along with the number of birds submitted for testing, is shown in Figure 19. Monitoring WNV in birds and mosquitoes helps to predict the risk of acquiring WNV in humans and determine appropriate control measures. Bird Surveillance The goal of bird surveillance is to use bird mortality to monitor the presence of WNV in the bird population. Data is collected on all species; however, only crows and blue jays are sent for Huron County Community Health Status Report - 11

103 Huron County 26 Breakdown of Reported Bird Sightings 25 Number of Speciments Sighted or Submitted WNV Positive Bird WNV Negative Bird Dead Bird Sightings Figure 19. The number of reported dead birds, along with the number of birds submitted for testing for West Nile Virus, in Huron County for 26. Source: Huron County Health Unit, May 21-May 28-May 4-Jun 11-Jun 18-Jun 25-Jun 2-Jul 9-Jul 16-Jul 23-Jul 3-Jul 6-Aug 13-Aug 2-Aug 27-Aug 3-Sep 1-Sep 17-Sep 24-Sep Week Mosquito Surveillance The purpose of mosquito surveillance is to determine if WNV is circulating in the area so that preventive measures (i.e. larviciding) can take place. Adult mosquitoes are trapped at fixed and flexible sites throughout Huron County. Female mosquitoes are submitted for testing in order to identify species types and infection with WNV. Species identification determines the prevalence of enzootic (mosquitoes that bite mainly birds and occasionally bite mammals) and bridge (mosquitoes that bite both birds and mammals) vectors in the county, while viral testing detects any mosquito pools infected with the virus. The total number of female adult mosquitoes trapped, along with a breakdown by vector type, for each municipality is shown in Figure 2. Both enzootic and bridge vector mosquitoes were detected in the county. In total, 261 (9%) female enzootic and 1,453 (49%) bridge vectors were trapped. The most prevalent mosquito species trapped in Huron County included: Oc. stimulans, Ae. vexans vexans and Cx. pipiens/restuans, as shown in Table 4. Of all mosquitoes submitting for viral testing, none were infected with WNV for the 26 surveillance season. Mosquito larvae are also monitored to determine the composition of container breeding mosquito populations in the area, to determine the prevalence of species of concern (i.e. species of the Culex genus), and to respond to standing water complaints. Larval surveillance is also used as a risk assessment tool to determine whether mosquito control measures are necessary. Species Name Vector Type Count % of Total Female Mosquitoes Oc. stimulans Bridge Ae. vexans vexans Bridge Cx. pipiens/restuans Enzootic Table 4. Number of female adult mosquitoes by vector type and species, Huron County, Huron County Community Health Status Report

104 Figure 2. The total number of adult mosquitoes, along with the number of mosquitoes that were classified as bridge or enzootic vectors, by municipality in Huron County, for the 26 surveillance season. Source: Huron County Health Unit, 27. Culex pipiens/restuans and Ochlerotatus triseriatus were the species identified by larval dipping. Cx. pipiens/restuans are enzootic vectors, which are active vectors in the WNV transmission cycle. Human Surveillance There have been no reported human cases of WNV in Huron County to date. Location Respiratory Enteric Long-term care facility Childcare facility 1 Hospital 1 1 Community 1 3 Other 1 Total Outbreaks An outbreak occurs when there is a greater incidence for a particular disease than what would normally be expected in a defined location. In 26, there were 36 confirmed outbreaks in Huron County (Table 5). Half of all outbreaks were related to respiratory infections. The majority of all outbreaks occurred in long-term care facilities, such as nursing and retirement homes. Table 5. The number of confirmed outbreaks in Huron County for 26 by location and outbreak type. Source: Huron County Health Unit, 27. Huron County Community Health Status Report - 13

105 Conclusion While Huron County has lower incidence of sexually transmitted infections and other bloodborne infections than Ontario, it has higher reported incidence for most food and waterborne infections, specifically campylobacteriosis and cryptosporidiosis. This is likely due to the predominance of the agricultural industry and farms in Huron County, leading to a higher proportion of individuals who come into contact with animals. Trends in lab-confirmed influenza cases mirror Ontario, while other vaccinepreventable diseases that have reports of a high number of cases, such as pertussis and rubella, were a result of a largely unvaccinated pocket of population in Huron County. 15 Health Canada. It s Your Health - Influenza. Accessed 2 September 28 from hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/flu-grippe-eng.php. 16 Ministry Health and Long-Term Care. Immunization: Influenza Vaccine. Accessed 9 July 28 from factsheets/flu_vaccine.html. 17 Rapid Risk Factor Surveillance System, January - April Health Canada. It s Your Health Whooping Cough (Pertussis). Accessed 2 September 28 from 19 iphis , Extracted 7/3/27. 2 Public Health Agency of Canada. Rubella Notifiable Diseases On-Line. Accessed 17 September 28 from html. 21 iphis 1995, Extracted 7/3/ Region of Peel Health Department. Communicable Disease 23. Peel Health Status Report. 23 Public Health Agency of Canada. Questions and Answers on Rabies. Accessed 9 July 28 from 24 Internal communication with Protecting the Environment Quad, Huron County Health Unit, World Health Organization. Zoonoses and veterinary public health (VPH). Accessed 9 July 28 from 26 Public Health Agency of Canada. West Nile Virus General Overview. Accessed 9 July 28 from 27 Internal communication with Building Community Capacity, Huron County Health Unit, Durham Region Health Department. Snapshot on Sexually Transmitted Diseases. December 24. Accessed 2 September 28 from health/health_statistics/snapshot/std.pdf. 2 Public Health Agency of Canada. Gonorrhea - Notifiable Diseases On-Line. Accessed 2 September 28 from html. 3 iphis , Extracted 8/3/27. 4 Public Health Agency of Canada. Hepatitis C - Notifiable Diseases On-Line. Accessed 2 September 28 from html. 5 iphis , Extracted 12/3/27. 6 Public Health Agency of Canada. Campylobacteriosis Notifiable Diseases On-Line. Accessed 14 March 27 from camp_e.html. 7 iphis , Extracted 13/3/27. 8 Public Health Agency of Canada. Salmonellosis Notifiable Diseases On-Line. Accessed 2 September 28 from html. 9 Public Health Agency of Canada. Giardiasis Notifiable Diseases On-Line. Accessed 2 September 28 from html. 1 iphis , Extracted 15/3/ O Connor D. Ontario Ministry of the Attorney General. Part One Report of the Walkerton Commission of Inquiry. Accessed 2 September 28 from gov.on.ca/english/about/pubs/walkerton/part1/. 12 Public Health Agency of Canada. Verotoxic E.coli Notifiable Diseases On-Line. Accessed 2 September 28 from html. 13 Centres for Disease Control and Prevention. Cryptosporidiosis: Epidemiology and Risk Factors. Accessed 17 September 28 from 14 Immunization Records Information System, Huron County Health Unit: 25/26, Extracted 2 March Huron County Community Health Status Report

106 Environmental Health The physical environment has a very important impact on a person's health. Encompassing both the natural and built environment, the physical environment includes (but is not limited to) water, soil and air quality, climate, land use, population density, physical infrastructure and design. For the purposes of this report, only select features of the physical environment unique to Huron County will be explored - the bordering of Huron County on Lake Huron and the predominance of recreational beaches; the rurality of the county; and air quality issues. Water in Huron County Huron County is privileged to border Lake Huron, providing 14 lakeshore public beaches for residents and visitors, as well as eight inland public dams (Figure 1). as safe or unsafe for swimming. The health unit posts a beach as unsafe to swim for the season if the five year geometric mean E.coli concentrations are 81/1mL or higher. Also, blue signs are posted at all times as a notice that water may be polluted with high levels of bacteria for up to two days following heavy rainfall and/or high winds both of which can make the water cloudy and possibly unsafe for swimming. The five year geometric means, along with three year and one year means, of the public beaches is shown in Table 1. All 14 lakeshore public beaches While this close proximity to water provides the community with enjoyment and a sense of well-being, it can also create potential health risks if water is contaminated. Beach water is subject to contamination by agricultural or urban run-off, storm sewers, sewer overflows, shoreline development, human waste (i.e. boats), swimmers, waterfowl, and wildlife wastes. Bacterial levels in beach water are influenced by adverse weather such as heavy rainfall and high winds, as well as water current and wind direction. High levels of bacteria can cause mild gastrointestinal infections, skin rashes, and throat and ear infections. Huron County uses a predictive model, based on a five year geometric mean of E.coli concentrations, to monitor beaches Figure 1. A map of the beaches and inland public dams of Huron County, 27. Huron County Community Health Status Report - 15

107 Lakeshore Public Beach Locations 5 Year 23 to 27 E. coli GM 3 Year 25 to 27 E. coli GM 1 Year 27 E. coli GM Amberley Beach Ashfield Township Park Beach 51* Bayfield Main Beach Bayfield South Beach Black's Point Beach Goderich - Main Beach Goderich - Rotary Cove Beach Goderich - St. Christopher's Beach Hay Township Park Beach Houston Heights Beach Port Albert Beach Port Blake Beach St. Joseph's Beach Sunset Beach Year E. coli Geometric Mean of 81 or greater 5 Year E. coli Geometric Mean between 61 and 8 5 Year E. coli Geometric Mean of 6 or lower Table 1. Five, three and one year geometric mean E.coli concentrations for the 14 lakeshore public beaches in Huron County. Source: Protecting the Environment Quad, Huron County Health Unit 28. in Huron County have a five year geometric mean E.coli levels below 81/1mL and are safe to swim in (except within 48 hours after a heavy rainfall or winds). Goderich Main Beach has a tendency to have higher E.coli levels compared to other beaches in Goderich, as it is subject to multiple sources of pollution, such as the break wall and freighter traffic. All inland public dams in Huron, with the exception of Morrison Dam, have been posted as being unsafe for the 28 swimming season based on high five year geometric means (data not shown). Huron County Is Predominantly Rural According to the 26 Census, 6% of Huron County is predominantly rural. 1 While little research exists on the physical environment as a determinant of health in rural settings 2 several physical attributes unique to rural environments are known to impact health. Private Drinking Water Wells Because Huron County is predominantly rural, there are a higher proportion of households whose water supply comes from a private well instead of a municipal supply when compared to other regions in Ontario. In Huron County, there are an estimated 8,934 private wells. 3 In 26, roughly a third (36.1%, 95% CI ) of households reported that they received their tap water from a private well (n=711). 4 Households receiving their tap water from a private well may be at increased risk for waterborne illness than those on municipal systems, especially if the well water is not tested on a regular basis for bacteria. Owners of unregulated or private water systems serving five or fewer residences can have water samples processed free of charge by the Public Health Lab in London, Ontario via the Huron County Health Unit, among other locations. Water results are compiled and analyzed daily to reveal trends in water quality and identify areas for concern. Of 16 - Huron County Community Health Status Report

108 households who use a private well, 28.7% (95% CI ) had not had their water tested for bacteria in the past 12 months, while only 3.6% (95% CI ) reported testing their water once over the past 12 months (Figure 2). Only 15.9% (95% CI ) of households reported testing their tap water at least three times in the past 12 months, as recommended by the health unit. The proportion of households who have their well water tested on a regular basis increased after the municipal water contamination in Walkerton, Ontario; however, these percentages have slowly declined over the past few years. Private well sample results for 25 to 27 are shown in Table 2. The total number of samples submitted to the health unit decreased from 3,237 samples in 25 to 2,761 samples in 27. Despite this, the percentage of safe water samples increased from 73.9% to 77.1%. As multiple samples can be submitted from single wells and participation is voluntary, these sample results are not meant to be indicative of the groundwater quality in Huron County. Although the results are not described here, a quality assessment of the groundwater of Huron County has occurred and research has been undertaken to understand regional aquifier characteristics, identify potential threats to groundwater and develop protection strategies. 5 Private Septic Systems Rural Huron County residents not connected to municipal water and sewage systems require a private septic system to process wastewater from the household. Wastewater is water that contains Percent (%) Reported Frequency of Well Water Testing among Households, Huron County times Not Stated Number of Tests over 12 months * Figure 2. Frequency of well water testing among Huron County households who report receiving their tap water from a private well. * indicates that the estimate should be interpreted with caution due to high sampling variability. Source: Rapid Risk Factor Surveillance System (RRFSS), January - December 26 (n=258). Table 2. Percentage of private well water samples submitted within Huron County that tested safe, not safe, adverse or other in Other indicates that the samples were not properly submitted. Note: Source: Protecting the Environment Quad, Huron County Health Unit 28, made available by the Public Health Lab, London, Ontario. Private Well Water Sample Result 27 (n=2761) 26 (n=2,863) 25 (n=3,237) % % % Safe Adverse Not Safe Other Huron County Community Health Status Report - 17

109 waste materials or pollutants and includes the water flushed down the toilet and the water drained from the sink, shower, washing machine, etc. In Huron County, 64% of households are on private septic systems. 6 Health hazards of septic systems which are not properly maintained include: potential contamination of well or surface water, impacting beach water quality, and also wastewater ponding can act as breeding grounds for mosquitos. Population Density and the Built Environment Population density measures the number of persons living in a defined area. Compared to urban areas, Huron County has a relatively low population density of 17.5 people per square kilometre. Population density impacts health in a variety of ways. Firstly, density affects the distance residents need to travel between destinations and the number of destinations that can be reached through active transportation, such as walking or cycling. Communities with a lower population density, such as Huron County, often have to travel further distances to reach their destinations. For example, only 11.2% of Huron County residents report walking or cycling to work, while 87.3% travel to work in a car, van or truck (either as a driver or passenger). 2 When motorized transport becomes necessary for everything from work to shopping to school, there are fewer opportunities to be physically active. Reduction in physical activity levels is an important risk factor for obesity. As shown in the Behavioural Risk Factors chapter, almost half of adults in Huron County are classified as inactive and a significantly higher proportion is classified as obese when compared to Ontario. Having farther distances to travel also increases the risk of motor vehicle collisions. In Canada, the overall injury-related mortality has been shown to increase with increasing rurality.2 This is likely a consequence of the predominance of rural roads, with higher speed limits and poorer road conditions, combined with increased time spent on the roads. 2 In Huron County, land transport occurrences are the 1 th leading cause of death in Huron County and the leading cause of death in adults 2-44 years (Mortality chapter). Low population density also influences the availability of public transit. In Huron County, no public transportation is currently available. Given the longer travel distances between destinations, taxi cabs are not always a financially viable transportation solution for individuals and families without access to a vehicle. Lack of affordable transportation creates barriers for Huron County residents to access health services and other resources necessary for good health. Lastly, the physical environment also influences accessibility to healthy food. As noted in Health Canada s report Nutrition for Health: An Agenda for Action, food is a part of the physical environment and the types of food available is a powerful influence on food choices. 8 Several studies have demonstrated a positive association between proximity to supermarkets/health food stores and dietary patterns, as well as weight status Recently, healthy food sources* were mapped in Huron County to describe how household access to these food sources varied across the county. 12 In total, 6% of Huron County households were farther than two kilometres from the nearest healthy food source. Proximity to these healthy food sources varied across the county, with over 77% of households in northern municipalities farther than two kilometres from the nearest healthy food source compared to 53% of households in southern municipalities. Northern municipalities in Huron County may, therefore, be disadvantaged when it comes to accessibility of healthy foods. There may be healthy food choices just outside of the boundaries of Huron County, but those were not mapped. * Healthy food sources were defined as equal in performance of grocery stores in terms of the number of Nutritious Food Basket (NFB) items carried Huron County Community Health Status Report

110 Agricultural Land Use and Practices Another aspect of the physical environment which dominates rural landscapes such as Huron County is the predominance of farmland. Southwest Ontario is a farming region; farmlands cover the largest proportion of land surface of any other health regions in Ontario. 13 In 26, 86% of the total land area in Huron County was designated for agricultural use (2,928 square kilometres). 14 This has important impacts on the economy and community of Huron County. Huron County leads all counties and regions in Ontario in total value of production. 15 In addition, farmers and agricultural workers (along with those employed in resource-based industries) make up an important part of Huron County s workforce; almost 1 in 5 persons (16.8%) persons in the labour force aged 15 years and older is employed in this sector. 16 Agriculture/farming is also one of the most hazardous professions. Outdoor Air Quality Free of high traffic volume and congestion, rural areas are often perceived as having pristine air quality given their lower population density and subsequent reduced energy consumption and emission of green house gases. Like other communities in Southwestern Ontario, however, Huron County s air quality is impacted by the long range transport of air pollution from sources within the United States. The Ministry of the Environment monitors the quality of the air on an hourly basis at 38 sites across Ontario. Six key air pollutants known to have adverse health effects on human health and the environment are measured - sulphur dioxide, ozone, nitrogen dioxide, total reduced sulphur compounds, carbon monoxide and fine particulate matter. In Huron County, elevated concentrations most often occur for ground-level ozone and fine particulate matter in the summer months, which is generally attributed to the long-range transport of these pollutants from the U.S. 17 By contrast, elevated concentrations of nitrogen dioxide, sulphur and carbon monoxide are more likely to occur in urban centres due to higher levels of vehicle and industrial facility emissions. Concentrations of each of these six pollutants are converted into a number ranging from zero upwards using a common scale to produce an Air Quality Index (AQI). The pollutant with the highest number at a given hour becomes the AQI reading. For example, if the value of ozone is highest at 54, then the AQI becomes 54. Because measurements are taken on an hourly basis, the AQI changes as the air quality changes. An AQI value below 32 indicates that the air quality is relatively good. An AQI between 32 and 49 indicates moderate quality at which adverse Smog Advisories for Huron-Perth and Ontario Figure 3. The number of smog advisories and the number of days advisories were in effect for Huron-Perth and Ontario, Source: Smog Advisory Statistics, Ministry of the Environment. Number Year Huron-Perth # Advisories Ontario # Advisories Huron-Perth # Days Ontario # Days Huron County Community Health Status Report - 19

111 health effects may be experienced by sensitive individuals, while an AQI of 5 or greater means poor air quality. If poor readings are predicted to be sustained over a period of time and over a wide area, then a Smog Alert is issued for that area. The number of smog advisories issued in Ontario and in Huron-Perth, along with the number of days those advisories were in effect, are shown in Figure 3. In 27, 13 smog advisories were issued for Ontario, spanning a total of 39 days; while in the Huron-Perth area, 12 smog advisories were issued which covered 27 days. 18 This is similar to the City of Toronto which had 11 smog advisories spanning 29 days in the same year. Over the past five years, Huron-Perth has experienced a similar number of advisories and span of advisories as the province and other regions in Southwestern Ontario (data not shown). Smog alerts come in the form of smog watches or smog advisories. Smog advisories are issued when there is a strong likelihood that widespread elevated and persistent smog levels are expected. (source: faq/cfm) In Huron County, elevated ozone and fine particulate matter levels that result in smog episodes are typically due to weather patterns that affect the lower Great Lakes region. 17 These weather patterns are associated with slow-moving high pressure systems across the region and result in the transport of smog pollutants from neighbouring industrialized and urbanized states in the U.S. during warm south to southwesterly air flow conditions (Figure 4). Monitoring air quality is important as poor air quality can cause short- and long-term adverse health effects. Air pollution is harmful to both the respiratory and cardiovascular systems and can cause eye and nose irritation; aggravate heart problems, bronchitis, asthma, and other lung problems; and reduce lung function. 19 Illness costs of air pollution have been estimated Figure 4. Transboundary flow of air pollution from the United States to Southwestern Ontario. Source: Used by permission by the Canadian Geographic using data from the Natural Resources Defense Council, Environment Canada, Health Canada, Ontario Power Generation, Nova Scotia Power and Pollution Probe. Note: The data upon which this fi gure was created is at least ten years old and may not accurately refl ect current air pollution patterns Huron County Community Health Status Report

112 by the Ontario Medical Association (OMA) using modelling techniques based on time-series and cohort epidemiological studies. 2 These costs are shown for Huron County in Table 3. For 25, an estimated 39 premature deaths occurred in Huron County due to short and long-term exposure to smog. 21 The majority of premature deaths were suffered by seniors because seniors are more likely to have a pre-existing respiratory or cardiovascular condition which increases their vulnerability to smog pollutants. Almost 4 emergency visits were estimated to occur, with most of these visits and hospital admissions likely due to cardiovascular illness. Minor illnesses associated with air pollution exposure are less severe but the most common, with 193,11 minor illness days estimated in Huron County. Recently, the OMA released new estimates for local premature smog deaths which reflect improving scientific evidence that allows the model to more accurately estimate smog-related health effects. For 28, there will be an estimated 6 premature deaths due to smog in Huron County. 22 Conclusion Many characteristics of Huron County s rural environment impact the health of its residents. While the rural landscape provides Huron County residents with access to beautiful beaches and profitable farmland, the reliance on private wells for drinking water and also the proximity of Huron County to the United States present possible health risks. Over a third of Huron County households report that private wells supply their tap water, yet only a small percentage of these households have their water tested for bacteria at least three times a year as recommended. While the majority of water sample submitted are tested as safe, this still leaves a large number of households vulnerable to poor water quality. In terms of air pollution, despite lower population density and reduced greenhouse gas emissions, Huron has comparable smog advisories as Toronto due to transboundary air pollution. These health risks should continue to be communicated with the public so that appropriate actions can be taken to protect their health. Outcome Number Premature Deaths 39 Hospital Admissions 17 Emergency Visits 362 Minor Illness Days 193,11 Table 3. Estimated health outcomes of outdoor air pollution in Huron County for 25. Source: Ontario Medical Association, June Statistics Canada. 26 Census. Accessed from index.cfm. 2 Canadian Institute for Health Information. How Healthy Are Rural Canadians? Ottawa, ON: Canadian Institute for Health Information, Communication with Ausable Bayfield Conservation Area, April Rapid Risk Factor Surveillance System, January - December Huron County Planning and Development Department. Huron County Groundwater Study Summary of Final Report, 21. Accessed from downloads/gw-study-summary.pdf. 6 Huron County Health Unit. Septic System Re-Inspection Program Statistics Canada. 26 Community Profiles. Accessed 4 February 28 from statcan.ca/english/census6/data/profiles/community/index.cfm?lang=e. 8 Health Canada. Nutrition for Health: An Agenda for Action. 22. Accessed 16 September 28 from virage_sante-eng.php. 9 Cheadle A, Psaty BM, Curry S, Wagner E, Diehr P, Koepsell T, et al. Community-level comparisons between the grocery store environment and individual dietary practices. Preventive Medicine 1991;2: Ransley JK, Donnelly JK, Botham H, Khara TN, Greenwood DC, Cade JE. Use of supermarket receipts to estimate energy and fat content of food purchased by lean and overweight families. Appetite 23;41: Laraia BA, Siega-Riz AM, Kaufman JS, Jones SJ. Proximity of supermarkets is positively associated with diet quality index for pregnancy. Preventive Medicine 24;39: Lankin M. Spatial Accessibility of Healthy Food Sources in Huron County a Contributor to the Prevalence of Overweight and Obesity in the Adult Population. Department of Family Relations and Applied Nutrition, University of Guelph, Turner L and Gutmanis I. Rural Health Matters: A Look at Farming in Southwest Ontario Part 2. London, ON: Southwest Region Health Information Partnership, Statistics Canada. 26 Census of Agriculture. Accessed from english/agcensus26/index.htm. 15 Huron County. Huron County Official Plan,1998. Accessed 2 June 28 from huroncounty.ca/plandev/downloads/huron_county_official_plan.pdf. 16 Statistics Canada. 26 Census. Accessed from index.cfm. 17 Ontario Ministry of the Environment. Air Quality in Ontario, 26 Report. Accessed 2 June 28 from 18 Ontario Ministry of the Environment. Smog Advisory Statistics. Accessed on 4 February 28 from 19 Ontario Ministry of the Environment. Smog. Accessed 19 June 28 from gov.on.ca/en/air/smog/index.php. 2 Ontario Medical Association. The Illness Costs of Air Pollution. Accessed 19 June 28 from 21 Ontario Medical Association. Illness Costs of Air Pollution (ICAP) Regional Data for 25. Accessed 2 June 28 from 22 Ontario Medical Association. Local Premature Smog Deaths in Ontario. Accessed 19 June 28 from Huron County Community Health Status Report - 111

113 Oral Health Good oral health is vital to general health and well-being. Poor oral health can lower self-esteem, cause pain and sleep deprivation, and affect the ability to chew and digest food properly. 1 Periodontal (gum) disease has been linked to various health problems including cardiovascular disease and preterm births. 2 One important risk factor for poor oral health is low socioeconomic status. Bacterial infection, consumption of foods high in sugar and individual susceptibility all contribute to the development of dental caries (cavities). 3 All of these factors are influenced by socioeconomic status. In the United States, the prevalence of reporting poorer oral health has been shown to be significantly higher at each lower level of education and poverty-income ratio, even after adjustment for education, income, ethnicity, age, sex, dental insurance and smoking. 4 In this section, self-reported oral health status, along with prevalence of dental check-ups, dental insurance, and frequency of teeth brushing will be reported. In addition, the oral health of children in Huron County will be described briefly. Figure 1. Self-perceived oral health of Huron County adults aged 18 years and older, 26. Error bars represent 95% confidence intervals. Source: Rapid Risk Factor Surveillance System (RRFSS), January- December 26, n=712. Percent (%) Self-Perceived Oral Health When asked to rate their dental health compared to people their age, 53.2% (95% CI ) of Huron County adults aged 18 years and older reported that their dental health was excellent or very good in 26 (Figure 1). Approximately one in seven adults (14.5%, 95% CI ) reported that their dental health was fair or poor. Reported excellent or very good dental health of Huron County adults increased significantly with both increasing education level and income level (data not shown). In addition to self-perceived oral health, adults were asked questions about the health of their natural teeth both the quantity of natural teeth remaining and causes of loss. Almost half of adults (49.3%, 95% CI ) reported that they had all of their natural teeth, while 7.9% (95% CI ) reported that they had none (Figure 2). Of all adults who reported that they had most, some or a few of their natural teeth, 61.9% (95% CI ) have had at least one tooth removed because of tooth decay or gum disease. Self-Perceived Oral Health, Huron County, 26 1 Excellent / Very Good Good Fair / Poor Response Huron County Community Health Status Report

114 Percent (%) Reported Frequency of Natural Teeth Remaining, Huron County, 26 All Most Some Few None Quantity of Natural Teeth * Figure 2. The reported frequency of natural teeth remaining in Huron County adults aged 18 years and older, 26. * indicates that this estimate should be interpreted with caution due to high sampling variability. Source: Rapid Risk Factor Surveillance System (RRFSS), January- December 26, n=715. Regular Dental Check-ups Visiting the dentist regularly is a key step in maintaining healthy teeth and a healthy mouth. While the frequency of check-ups depends on individual oral health needs, the Canadian Dental Association recommends preventive check ups every six months. 5 Just over 4% (4.6%, 95% CI ) of Huron County residents aged 12 years and older reported that they usually visit the dentist more than once a year for dental check-ups in 25 (n=553). 6 A slightly lower percentage reported visiting the dentist just once a year for check-ups (34.4%, 95% CI ). Only 6.1%* (95% CI ) of respondents reported that they visit the dentist less than once a year for check-ups; however, 18.9% (95% CI ) reported only visiting the dentist for emergency care. These percentages were similar to Ontario. Dental Insurance Barriers to regular dental check-ups include not having dental insurance to cover the costs of those visits or having insurance with low coverage of costs and services. Only 52.5% (95% CI ) of Huron County residents reported having dental insurance that covers all or part of their dental expenses (n=576). 6 By contrast, 64.8% (95% CI ) of Ontarians reported having dental insurance, which is significantly higher. Teeth Brushing Regular and thorough brushing is important in preventing tooth decay and gum disease. It is recommended to brush after every meal and at the very least, once a day before bed, in order to remove the bacteria that promotes tooth decay and the plaque that can cause periodontal disease. 7 As a general guideline, the Canadian Dental Association recommends brushing teeth twice a day with fluoride toothpaste. (source: cfyt/dental_care/prevention_plan.asp) In 25, Huron County residents were surveyed about their teeth cleaning habits. Overall, 71.% (95% CI ) of Huron County individuals aged 12 years and older reported that they brushed their teeth at least twice per day (Figure 3). This is significantly lower than the provincial percentage of 82.8% (95% CI ). Women were more likely to brush their teeth at least twice a day compared to men (8.8%, 95% CI versus 6.2%, 95% CI ). Huron County Community Health Status Report - 113

115 Percent (%) Reported Frequency of Teeth Brushing, Huron County and Ontario, 25 At least twice/day Once/day Less than once/day Frequency * Figure 3. The reported frequency of teeth brushing in Huron County (n=489) and Ontario (n=35,3), 25. * indicates that this estimate should be interpreted with caution due to high sampling variability. Source: Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario MOHLTC. Huron County Ontario Oral Health of Children in Huron Dental decay, caused by a bacteria infection, is one of the most common diseases in childhood. 8 Severe dental decay in children can result in pain, sleeping problems, trouble eating and behaviour problems. 9 Most of these problems, however, can be eliminated following dental treatment. Screening is necessary to identify children who may be experiencing dental decay, along with other dental problems. In Huron County, 3,656 kindergarten, Grade two, four, six and eight students were screened at the start of the 26/7 school year as part of the Ontario Dental Health Indices Survey (DIS). 1 A total of 3,42 primary teeth were visually identified to be decayed, lost or filled. In addition, a total of 1,497 secondary (permanent) teeth were visually identified to be decayed, lost or filled. The ratio of these two values (known as the deft/ DMFT index) is a general indicator of dental health status, with a deft/dmft index equal to zero indicating that all children screened were caries-free at the time of survey. In general, the lower the index, the better the dental health of the population, with a deft/dmft index of two or more considered high risk. 11 For Huron children screened, the deft/dmft index was Because each health unit uses different sampling strategies for the survey, this index is not comparable across health units. A short dental survey was administered to Huron County parents who had a three year old child that participated in the Calling All Three Year Olds developmental screening program in 26. Of 36 parents surveyed, 35% reported that their child had visited a dentist for a routine check-up, while 6% had not. The most common reason parents cited for not taking their child to the dentist was that the child was thought to be too young. Parents were also asked how often the child s teeth were brushed. The majority of children s teeth were brushed at least twice per day (6%); however, 32% of children s teeth were brushed just once per day. When asked about the health of the child s teeth, 6% of parents reported that the child had had a filling or a tooth removed. Conclusion Only half of Huron County adults rate their oral health as excellent or very good compared to others their age, with this percentage decreasing as education and income level decline. Over one third report visiting the dentist more than once per year; however, almost 2% report only visiting the dentist for emergency care. A barrier to regular dental check-ups may be lack of good dental coverage, as Huron County coverage rates are well below the provincial average. Given the impact of oral health on overall health, social barriers to accessing preventive dental services must be addressed in Huron County Huron County Community Health Status Report

116 1 Health Canada. It s Your Health The effects of oral health on overall health. Accessed 31 October 27 from 2 U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2. 3 Peres MA, Peres KG, Dornellas de Barros AJ and Victora CG. The relation between family socioeconomic trajectories from childhood to adolescence and dental caries and associated oral behaviours. Journal of Epidemiology and Community Health, 27;61: Sabbah W, Tsakos G, Chandola T, Sheiham A and Watt RG. Social Gradients in Oral and General Health. Journal of Dental Research, 27;86(1): The Canadian Dental Association. The Check Up. Accessed 5 November 28 from Canadian Community Health Survey 3.1 (25), Statistics Canada, Share File, Knowledge Management and Reporting Branch, Ontario Ministry of Health and Long-Term Care. 7 The Canadian Dental Association. Flossing & Brushing. Accessed 2 November 27 from 8 Locker D and Matear D. Oral disorders, systemic health, well-being and the quality of life: A summary of recent research evidence. Accessed 1 November 27 from utoronto.ca/dentistry/facultyresearch/dri/cdhsru/health_measurement/7.%2%2no%217. pdf. 9 Low W, Tan S and Schwartz S. The effect of severe caries on the quality of life in young children. Pediatric Dental Journal, 1999;21(6): Internal communication with the Supporting Healthy Communities Quad, Huron County Health Unit, Burt BA and Elund SA. Dentistry, Dental Practice and the Community. Philadelphia: W.B. Saunders Company, Huron County Community Health Status Report - 115

117 Discussion Of Themes In this report, the health status of Huron County residents has been described using a social determinants of health framework. Elements of this framework have included: describing how social factors impact health (using a snakes and ladders metaphor), understanding the sociodemographic characteristics of Huron County residents, and examining various health topics through a social determinants of health lens. Major findings of the report are highlighted in the Executive Summary. Several themes have emerged from this report. Themes were identified through focused discussions among health unit staff on the common elements linking unique health outcomes in Huron County (i.e. health outcomes that were significantly different in Huron County when compared to the province). Staff identified three major themes the physical environment, rural sociodemographics, and limited access to health services. In essence, these themes identify the major determinants of health of Huron County residents, as viewed by Huron County Health Unit staff. While other factors make important contributions to the health of this community, the determinants described here appear to play important roles in understanding and describing the health status of Huron County residents. In this section, these themes and their impact on health are briefly described. In addition, examples of several snakes and ladders associated with each determinant have been provided. Snakes are the barriers or obstacles that can be encountered on the path to wellness, while ladders are the resources available which help us achieve optimum wellness. Education, employment, access to health services and community support act as ladders in achieving good health, while low income, poor environments and low social status act as snakes. Identifying snakes helps to develop strategies to minimize or eliminate barriers to health in our community. Identifying ladders helps develop an understanding of how to further build on and extend these resources to our community. Minimizing barriers and increasing resources are important steps to take to make optimum wellness easier for Huron County residents to achieve. The Physical Environment Increasingly the physical environment has been recognized as a major determinant of health. However, the majority of research has focused on air, water and soil quality in urban environments 1 and additionally, on the impacts of the urban built environment on health. Rural environments have largely been understudied; yet, we know rural landscapes differ dramatically from urban landscapes. In Huron County, defining characteristics of our rural environment include: the predominance of recreational beaches; higher dependence on private drinking well water and private septic systems; low population density and geographic dispersion; rich agricultural land; and poor outdoor air quality due to transboundary air pollution. All of these characteristics directly and indirectly impact the health of Huron County residents. Geographic dispersion, for example, results in a higher number of rural roads which are known to be of poorer quality and have higher speed limits, contributing to increased motor vehicle collisions. In Huron County, land transport occurrence mortality and hospitalization rates are significantly higher than the province Huron County Community Health Status Report