Health Equity Report - Social Determinants of Health for the Eastern Ontario Health Unit Population

Table of Contents

List of Tables

List of Figures

Executive Summary

Health is influenced by a broad range of factors beyond an individual’s biology and behaviours. Those that form the conditions in which people are born, grow up, live and work are known as the Social Determinants of Health (SDOHs). Any differences or variations in health status between groups are known as health inequalities. When health inequalities have the potential to be changed or decreased by social action, they are called health inequities.

Health inequities are health differences that are:

  • Systemic, meaning that health differences are patterned, where health generally improves as socioeconomic status improves.
  • Socially produced, and therefore could be avoided by ensuring that all people have the social and economic conditions that are needed for good health and well-being.
  • Unfair and/or unjust because opportunities for health and well-being are limited.

Health equity means that all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance.

The SDOHs are used to gain a deeper understanding of the health needs of communities. This information helps identify policy work aimed at reducing barriers to positive health outcomes, and activities that facilitate positive behaviour changes which in turn leads to positive health outcomes. Assessing the SDOHs gives a better understanding of the impact of various social constructs within communities and allows for better and more targeted planning for programs and services that can help address health inequities.

(adapted from OPHS 2018)

It is important to keep in mind that, although the SDOHs are divided in this report, they are always closely interrelated and often combined.

The social determinants of health include the following, but are not limited to:

  • Access to health services
  • Culture, race, and ethnicity
  • Disability
  • Early childhood development
  • Education, literacy, and skills
  • Employment, job security and working conditions
  • Food insecurity
  • Gender identity and expression
  • Housing
  • Income and income distribution
  • Indigenous status
  • Personal health practices and resiliency
  • Physical environments
  • Sexual orientation and attraction
  • Social inclusion/exclusion
  • Social support networks

Health and social problems present across the region are complex and cannot be resolved on an individual basis or by a single organization. There needs to be collaboration between all levels of the community; different professionals, services, sectors and with the community itself. Essentially, in addition to the programs and services, a focus on Systems Change needs to be present to achieve an equitable change.  A Systems Change framework concentrates on bringing about change at three different levels: structural, relational, and transformative. To advance health and social equity, there needs to be a shift in the conditions holding a problem or barrier in place.

The report demonstrates that over time, due to the employment landscape, the municipalities with the biggest inequities are also the poorest. Low income has a direct impact on poverty, mental and physical health, child development, and much more. The Town of Hawkesbury and the City of Cornwall show poorer health indicators due in part to the low median income of the residents. In addition, the top 3 employment sectors for growth in the near future all pay low wages. Lesser higher education levels and poorer child development outcomes are directly linked to the low-income levels. Likewise, less access to transportation, to specialized healthcare and to culturally appropriate food contributes to the poor health outcomes of our residents.

On a positive note, our social capital is quite strong. Social capital can be measured by the amount of trust and sharing in a community or between individuals. Higher social capital means a stronger sense of trust, higher civic engagement, more involvement in the community, and more connections across differences. Relationships are key.

By building social capital, we look to create vibrant neighborhoods with people of diverse backgrounds connecting across differences, leading to a community where everyone has an equal opportunity to thrive.

Looking at trends over the past several years, many of our health and social indicators have improved as well as the services that are in place to assist. As a community, we need to continue to strive to improve the quality of life in our communities.

Health Equity Report

This report was created to combine statistics through a Health Equity Lens to help better understand how the SDOHs affect the health of individuals. According to the Ministry of Health of Ontario (2021):

“Health is influenced by a broad range of factors beyond an individual’s biology and behaviours – those that form the conditions in which people are born, grow up, live and work – are known as the social determinants of health. Any differences or variations in health status between groups are known as health inequalities. When health inequalities have the potential to be changed or decreased by social action, they are called health inequities.

Health inequities are health differences that are:

  • Systemic, meaning that health differences are patterned, where health generally improves as socioeconomic status improves;
  • Socially produced, and therefore could be avoided by ensuring that all people have the social and economic conditions that are needed for good health and well-being; and
  • Unfair and/or unjust because opportunities for health and well-being are limited.

Health equity means that all people can reach their full health potential and are not disadvantaged from attaining it because of their race, ethnicity, religion, gender, age, social class, socioeconomic status or other socially determined circumstance.”1

This report is complementary to the Community Health Status report, which gives the current health status of the Eastern Ontario Health Unit’s population area compared to Ontario.

“Canadians are among the healthiest people in the world. However, the benefits of good health are not equally enjoyed by all. Many of these inequalities are the result of social, political, and economic disadvantages, which affect our chances of achieving and maintaining good health.”2

Data Sources

Data Sources for the Health Status Report commissioned by the Eastern Ontario Health Unit (2019) include a large set of national and regional data sources such as:

  • Census of Canada – Statistics Canada
  • IntelliHEALTH Database – Ontario Ministry of Health 
  • Integrated Public Health Information System (iPHIS) – Public Health Agency of Canada
  • Canadian Community Health Survey (CCHS) – Statistics Canada
  • Ontario Cancer Registry (OCR) – Cancer Care Ontario (CCO)
  • Rapid Risk Factors Surveillance System (RRFSS), Ontario – Institute for Social Research (ISR) at York University
  • PHO Snapshots – Public Health Ontario
  • Local Data – Eastern Ontario Health Unit – Population Mental Health Status (2023), Chronic Disease Prevention (2018)

A note to the reader: In some data tables, you may notice that adding up the value of individual cells in any column or row does not produce the expected total. Statistics Canada rounds the numbers to the nearest 0 or 5 in the individual cells of data tables. We appreciate your understanding and apologize for any inconvenience this may cause.

Eastern Ontario Health Unit Population

Presently, in the Eastern Ontario Health Unit (EOHU) catchment area, there are 210,275 citizens spread across 5,314 square kilometres. The EOHU boundaries begin at the east side of Ottawa stretching to the Quebec border while being flanked to the north by the Ottawa River and the St-Lawrence River to the south. It is a rural-urban mixture with the more densely populated areas being the City of Cornwall, the City of Clarence-Rockland, and the Town of Hawkesbury while most of the remaining municipalities are rural in nature. There are 15 municipalities grouped into the 5 counties of Stormont, Dundas & Glengarry (SD&G), Prescott and Russell (PR) plus Akwesasne.

Figure 1: The Location of the Catchment Area for the Eastern Ontario Health Unit

The population change from 2016 to 2021 is described in Table 1. From 2016 to 2021, the EOHU population change is 4.27%. Russell TP had the highest increase in population change with 15.71%, while Hawkesbury had the smallest increase with -0.68%.  All areas within the EOHU catchment had increases, except for Hawkesbury and Champlain.

Table 1: Population Change, EOHU and Ontario 2016 to 2021, Census 2021

Location Population 2016 Population 2021 Population change
Cornwall 46,589 47,845 2.63%
Hawkesbury 10,263 10,194 -0.68%
UC-SDG 111,961 114,637 2.33%
UC-PR 89,333 95,639 6.59%
EOHU 201,294 210,276 4.27%
Ontario 13,448,494 14,223,942 5.45%

Social Determinants of Health

The SDOHs are used to gain a deeper understanding of the health needs of communities. This information then helps identify policy work aimed at reducing barriers to positive health outcomes, and activities that facilitate positive behaviour changes which in turn lead to positive health outcomes. Assessing the SDOHs gives a better understanding of the impact of various social constructs within communities and allows for better and more targeted planning for programs and services that can help address health inequities. (Adapted from Ontario Public Health Standards, 2021)

The social determinants of health include, but are not limited to the following:

  • Access to health services
  • Culture, race and ethnicity
  • Disability
  • Early childhood development
  • Education, literacy and skills
  • Employment, job security and working conditions
  • Food insecurity
  • Gender identity and expression
  • Housing
  • Income and income distribution
  • Indigenous status
  • Personal health practices and resiliency
  • Physical environments
  • Sexual orientation and attraction
  • Social inclusion/exclusion
  • Social support networks

Depending on the source (World Health Organization, Public Health Agency of Canada, The Canadian Facts), SDOHs can be identified differently. For the purpose of this report, the data analysis will be done through a health equity lens. Some determinants will be described individually, while others regrouped. It is important to keep in mind, that even though they are divided in this report, they are always closely interrelated and often combined. SDOHs are under the bigger umbrella of the Determinants of Health which touch personal, social, economic, and environmental factors affecting health.

Early Childhood Development

Conception to the early years (school entry) is the period of life which has the largest influence on life trajectory. Different SDOHs can either enhance or undermine a child’s development and when a child’s life trajectory is impacted negatively by these determinants, the child’s outcome is often negatively influenced. Children raised in poverty tend to have lower levels of education attainment, less resources and support for school, frequent moves from residences and schools for affordable housing, affecting the stability and increasing stress. They are more likely to be exposed to air pollutants, residential crowding, and poor housing quality and to live in poverty as adults as they face many obstacles.

“The longer children live under conditions of material and social deprivation, the more likely they are to show adverse developmental and health outcomes. Accumulated disadvantage can lead to cognitive and emotional deficits that make coping difficult. In addition, adverse childhood experiences can create a sense of inefficacy – or learned helplessness – which is a strong determinant of poor health.”3

Early Development Instrument (EDI)

The EDI measures children’s ability to meet age-appropriate developmental expectations in five general domains when they enter school. It is a 103-item checklist administered by their Kindergarten teachers from participating school boards with a separate analysis for children who are identified as having special needs. It is not conducted with children who are home schooled or who attend private schools. The EDI scores for our communities gives us a general understanding of how well the children who grow up here are developing and provides evidence of the need for additional measures to ensure there are quality, accessible child and family supports in our community and that all children and families have equal access to programs and services that are offered in welcoming and inclusive environments.

There have been 5 cycles completed to date, the latest completed was in 2018. The EDI is divided into five domains and corresponding sub-domains. The five domains are the following: Physical Health and Well-Being; Social Competence; Emotional Maturity; Language and Cognitive Development; Communication Skills and General Knowledge. The score establishes how many children are considered vulnerable, at risk or on track to meet their age-appropriate milestones and to be ready to start school (Adapted form Early Development Instrument, 2019).

According to the Public Health Ontario - Early Development Instrument Snapshot of 2018, close to 27.9% of children in the EOHU area were in the vulnerable category for 1 or more domains, a slight improvement from the 2015 cycle results. From that, 14.1% are categorised as vulnerable in 2 or more domains, which is slightly higher than the Ontario average. The two domains that identify more vulnerability in the EOHU area are Language and Cognitive Development at 10.3% (7.5% ON), and Emotional Maturity at 12.9% (11.3% ON).

Education, Literacy and Skills

“Education is an important social determinant of health. People with higher education tend to be healthier than those with lower educational attainment. There are various pathways by which education leads to better health. First, the level of education is highly correlated with other social determinants of health such as the level of income, employment security, and working conditions. Viewed in this light, education helps people to move up the socioeconomic ladder and provides better access to economic and social resources. Finally, education increases overall literacy and understanding of how one can promote one’s own health through individual action. With higher education, people attain more sophisticated skills to evaluate how behaviours they adopt might be harmful or beneficial to their health. They achieve greater ability and more resources to allow attainment of healthier lifestyles.”4

Looking at the history of Hawkesbury and Cornwall being the two regions with the lowest income, similar patterns emerge. Both cities historically had large industries, not requiring a high education level to access well-paid employment with good benefits. When these industries closed, the workers did not have the education level to access similar salaries in other sectors. These industries were replaced by retail, call centers, distribution centers and smaller industries that paid minimum wage. Thus, despite a very low unemployment rate, overall residents and by consequence, these communities became poorer with a lesser skilled workforce.

On a positive note, according to Census 2020, there has been an increase in the highest education level achieved between 2016 and 2021 in both PR and SDG territories including Cornwall.

Table 2: Education Level – Population Aged 15 Years and Over in Private Households, Census 2021

Location No certificate, diploma or degree High (secondary) school diploma or equivalency certificate Post-secondary certificate, diploma or degree
Cornwall 22% 34.7% 43.3%
Hawkesbury 27.7% 34.1% 38.2%
UC-SDG 19.0% 32.9% 48.1%
UC-PR 16.9% 30.4% 52.8%
EOHU 18.0% 31.8% 50.2%
Ontario 15.3% 27.2% 57.5%

Employment, Job Security and Working Conditions

“Working conditions are an important social determinant of health because of the great amount of time we spend in our workplaces. People who are already most vulnerable to poor health outcomes due to their lower income and education are also the ones most likely to experience health threatening working conditions. Researchers have identified a host of work dimensions which shape health outcomes. The dimensions include factors such as: 1) employment security; 2) physical conditions at work; 3) work pace and stress; 4) working hours; and 5) opportunities for self-expression and individual development at work. Research evidence has also shown that imbalances between efforts to meet demands (e.g. time pressures, responsibility) and rewards (e.g. salary, respect from supervisors) often lead to significant health problems. Similarly, increased health problems are seen among workers who experience high demands but have little control over how to meet these demands. These high-stress jobs predispose individuals to high blood pressure, cardiovascular diseases, and development of physical and psychological difficulties such as depression and anxiety. High-strain jobs are especially common among low-income women working in the sales and service sector. Canadian women score higher than men in reporting high stress levels from ‘too many hours or too many demands’.”5

In the Eye on the Labour Market, 2023 prepared by the Eastern Ontario Training Board (EOTB), the unemployment rate in Eastern Ontario for November 2023 is at 5.2% which has increased since June 2023 when it stood at 3.8%. But looking at the Census 2021 data, the unemployment rate has decreased since, as the Prescott and Russell rate was at 6.5% and SDG at 7.7% and the highest rates were found in Cornwall at 12.4%, closely followed by Hawkesbury at 11.5%.

Although we have a very low unemployment rate, the EOTB identifies a 3% decrease in jobs availability in SDG and 6% in PR between 2019 and 2021, and 4% for Ontario. Despite this, employers are struggling with recruitment and retention. Unfortunately, the top occupations and job growth projections are for low paying jobs (nurses aides/orderlies, cashiers and food attendants).

Income and Income Distribution

“Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions that affect physiological and psychological functioning and the take-up of health-related behaviours such as quality of diet, extent of physical activity, tobacco use, and excessive alcohol use. In Canada, income determines the quality of other social determinants of health such as food security, housing, education, early child development, and other prerequisites of health.”6

The counties and/or cities with the highest prevalence of low income based on the LIM-AT (total) are the same as identified with the lowest median after-tax income.

Low-Income Measure; After Tax (LIM-AT)

Table 3: Prevalence of Low Income Based on the Low-Income Measure; After Tax (LIM-AT), Statistics Canada, Census 2021

Age Hawkesbury Cornwall UC-SDG UC-PR EOHU Ontario
Total 20.7% 18.1% 9.5% 7.7% 10.6% 10.1%
0 to 17 years 25.1% 22.5% 9.4% 7.0% 11.1% 11.5%
0 to 5 years 30.9% 25.3% 9.6% 7.6% 12.1% 12.4%
18 to 64 years 18.6% 16.2% 7.9% 6.4% 9.0% 9.1%
65 years and over 22.0% 18.9% 13.6% 12.9% 14.6% 12.1%

Median After-Tax Income ($)

Table 4: Median After-Tax Income for Recipients Aged 15 Years and Over in Private Households Compared for Family Income in Private Households, Statistics Canada, Census 2021

Median After-Tax Income Recipients Aged 15 and Over in Private Households Family Income in Private Households
Canada $36,800 $73,000
Ontario $37,200 $79,500
EOHU Counties/Cities with the Lowest Median After-Tax Income
Hawkesbury $31,000 $49,200
Cornwall $32,800 $55,200
North Glengarry $34,000 $63,200
South Dundas $36,000 $69,500
East Hawkesbury $36,000 $71,500

When looking at the after-tax income for males in comparison to females aged 15 years and over in private households, women are more present in the lower income range up to $40,000, while men are more present in the $50,000 and over income. Please refer to Table 5 and figure 2 below.

Table 5: After-Tax Income for Female and Male, Aged 15 Years and over in Private Household, Census 2021

Income Female % Male %
EOHU Ontario EOHU Ontario
No income 2.6 3.9 3.0 4.3
<$10,000 7.9 9.7 5.8 7.7
$10,000~ 14.7 13.5 10.4 10.9
$20,000~ 18.6 18.3 15.0 15.0
$30,000~ 15.4 14.7 14.2 12.8
$40,000~ 13.5 12.1 13.5 11.4
$50,000~ 9.7 8.8 11.8 9.3
$60,000~ 6.4 5.9 8.5 7.4
$70,000~ 4.2 4.1 6.1 5.7
$80,000~ 3.5 3.4 4.2 4.4
$90,000~ 1.5 1.8 2.7 3.0
$100,000~ 1.2 2.0 2.8 3.9
$125,000+ 0.7 1.8 1.9 4.3

Figure 2: After-Tax Income for Male and Female Aged 15 Years and over in Private Household, Census 2020

In order to measure the inequalities in the population, there is an indicator called the Gini index or coefficient. The index ranges from 0 to 1, 0 being complete equality and 1 complete inequality. When the index is 0.4 or higher it indicates a significant income or wealth inequality and 0.3 or less is relatively equal distribution of income. According to Census 2021, the Gini index for the EOHU catchment area is below 0.3 with the exception of East Hawkesbury which is below 0.4 for after tax household income. This demonstrates that the wealth across our area is evenly shared.

Family Structure

Family structure can impact the total and disposable family income as well as available resources and support system which in the end can have an impact on stress and be interlinked with SDOHs.

Lone-Parent Families

In the 2021 Census, 29% of all “census families with children” in the EOHU catchment area were single-parent families which is very similar to 28% for the province. These rates have remained fairly stable since 2011. However, there are geographical variations across the EOHU: in Hawkesbury, close to half of all families are headed by a lone parent with Cornwall second at 42%, whereas in Russell Township and Nation Municipality, just under 20% of households with children are headed by lone parents.

According to the 2021 Census, the difference between women and men as head of a lone parent household is split 75/25 in the EOHU area, which differs from Ontario where the split is closer to 80/20. Champlain Township has the highest number of lone parent households run by a man at 37%.

Housing

The type of housing and the quality of the living conditions impact health. “The presence of lead and mold, poor heating and drafts, inadequate ventilation, vermin, and overcrowding are all determinants of adverse health outcomes.”7

Housing Services (HS)

The HS offer different programs depending on need: the Rent Supplement to help bridge the gap to pay rent, the Ontario Renovates for urgent repairs as well as the Housing Assistance Fund to help low-income households to remain housed, and the Low-Income Energy Assistance Program (LEAP).

The HS within the United Counties of Prescott and Russell Social Services Department (UCPR) own and manage 311 family, senior, and single adult units within their service area. These units are a mix of semi-detached houses and apartments, ranging from 1 to 5 bedrooms. The wait time varies from 3 to 5 years, except for the "Special Priority Program." The longest wait time is for the 1 bedroom for adults.

The HS in PR also manage approximately 92 units with private sector landlords, and all rents are subsidized based on family income. Furthermore, the HS’s responsibilities include the administration of 12 non-profit housing corporations comprised of 500 units as well as the management of a centralized waiting list for Rent-Geared-to-Income (RGI) applicants.

The situation with the HS in the United Counties of Stormont, Dundas and Glengarry (UC-SDG) is similar. As of July 2023, there were close to 500 applicants on the social housing waitlist, with the 1-bedroom unit being the most in demand (64% of applicants). There is a wait time of up to 5 years for a 1-bedroom unit and 1 to 2 years for a 1-bedroom for seniors unit. The SDG has a total of 2005 units with a mix of affordable housing, and market rental supplements with social housing providers who have a contract with the city of Cornwall.

Homeless enumerations were completed for the PR and SDG areas. These are snapshots of the scope and nature of the homelessness in the different communities to help target resources for individuals that need them the most and help in the evaluation process of initiatives in place and their impacts to help with improvement in the delivery and design of services.

Homelessness in small rural areas is different than in urban areas. Almost half of the respondents spent the night in their home but considered themselves in danger. Others sleep at someone else’s home or at a shelter for victims of domestic violence, while a small percentage live outdoors. In PR and SDG, there are no large homeless shelters; the only type of shelters available are for women and their children who are victims of domestic violence and then the closest shelter to PR and SDG is in Ottawa. Also, the data doesn’t always tell the whole story as many of the homeless in our area are considered the “hidden homeless” which do not get counted in statistics: individuals in precarious housing, some suffering from abuse, some with health issues, others often moving or sleeping on friends’ couches (couch surfers).

In the United Counties of PR Homeless Enumeration report from 2018, the 3 main reasons why people are homeless or in danger of being homeless are job loss, eviction for non-financial reasons, and being victims of abuse. Other reasons identified were addiction, unable to pay the rent or mortgage, conflict with a parent/guardian or with spouse/partner and illness or health problems. Prescott and Russell Victim Services also did a survey called « Sondage sur le soutien à l’itinérance du réseau communautaire de Prescott-Russell » in August 2023. The top 3 challenges regarding homelessness were a lack of resources for housing and shelters, no methods of communication to reach potential clients, and clients’ mental health issues. Some other factors included too much bureaucracy, that the clients’ choices need to be respected and the need for coordination of services.

In the Human Services Department of Cornwall, Stormont, Dundas and Glengarry, 2021 Homeless Enumeration report, the top three living situations identified were living with friends or family, followed by homeless shelter, and then unsheltered in a public space, and treatment centre, equally. Most respondents had an income from ODSP (30%), then Ontario Works (16%), closely followed by no income (14%). The 3 main reasons for being in this living situation were not having enough income (29%), substance abuse issues (14%) and mental health issues (12%).

Core Housing

Core housing need refers to households that are experiencing housing affordability and adequacy challenges. The "In core need" means that residents are spending a significant portion of income on housing costs and thus are experiencing housing insecurity and/or affordability issues.

Cornwall has the highest percentage of residents in need of core housing at 12% while The Nation has the lowest at 3%.

Housing Affordability

Table 6:  Proportion of Households (Tenant and Owner, Combined) Spending More Than 30% of Income on Shelter Costs, Statistics Canada, Census 2021

Location Percent
Ontario 24.2
EOHU 16.2
UC-PR 14.9
UC-SDG 13.2
Hawkesbury 21.8
Cornwall 22.1
East Hawkesbury 17.3
Alfred & Plantagenet 17
North Glengarry 16.3
Casselman 15.6
Clarence-Rockland 14
South Dundas 13.9
The Nation Municipality 13.2
North Dundas 13
North Stormont 13
South Glengarry 12.8
Champlain 12.8
Russell TP 11.8
South Stormont 10.8

Figure 3: Proportion of Households (Tenant and Owner, Combined) Spending More Than 30% of Income on Shelter Costs, Statistics Canada, Census 2021

Food Insecurity

To remain housed and pay bills, people may need to forego purchasing enough food and may turn to charitable food programs to help make ends meet. It cannot be overemphasized, that for many Ontarians, this is not because food prices are too high, but because people with inadequate or unstable incomes do not have enough income to cover the costs of basic living, including enough food (Ontario Dietitians in Public Health, 2023).

“Food banks and other charitable food programs are doing their best to help those struggling with food insecurity in their communities; however, only 1 of 4 people living in food insecure households (or experiencing food insecurity) uses food banks, and research has shown there is no evidence that food charity is able to move households out of food insecurity.

According to research, there is no indication that increasing food skills or budgeting skills will reduce food insecurity. An analysis of national survey data from Statistics Canada found that adults in food-insecure households report having food preparation and cooking skills comparable to those in food-secure households.”8

“Linking data from the Canadian Community Health Survey to hospital records and health care expenditure data, we examined the association of food insecurity with acute care hospitalization, same-day surgery, and acute care costs among Canadian adults, adjusting for sociodemographic characteristics. Compared with fully food-secure adults, marginally, moderately, and severely food-insecure adults presented 26 percent, 41 percent, and 69 percent higher odds of acute care admission and 15 percent, 15 percent, and 24 percent higher odds of having same-day surgery, respectively. Conditional on acute care admission, food-insecure adults stayed from 1.48 to 2.08 more days in the hospital and incurred $400 to $565 more per person per year in acute care costs than their food-secure counterparts. Programs reducing food insecurity, such as child benefits and public pensions, and policies enhancing access to outpatient care may lower health care use and costs.”9

Other research from Ontario also shows that severely food insecure adults account for a disproportionately large amount of mental health care use, including emergency visits and hospitalization for mental health problems (Adapted from: Tarasuk V, Cheng J, Gundersen C, et al., 2018).

The following Figure was taken from PROOF.

Figure 4: Implications of Food Insecurity for Health and Health Care

The table below shows the total rate of food insecurity in the EOHU area. The total rate of food insecurity includes individuals who are marginally, moderately and severely food insecure.

Table 7: 2020, 3-Year Combined Estimates: PHO – Response to Scientific/Technical Request – Household Food Insecurity Estimates from Canadian Income Survey: Ontario 2018-2020

Location Totally Food Insecure Marginally Food Insecure Moderately Food Insecure Severely Food Insecure
EOHU 15.3% 3.2% 7.5% 4.7%
Ontario 16.7% 4.7% 7.8% 4.3%

Table 8: Cost of a Nutritious Food Basket (NFB) per Week - Family of Four Composed of: Male Adult, 31 to 50; Female Adult, 31 to 50; Female Child, 4 to 8 and Male Youth, 14 to 18. Source: EOHU NFB Costing Spreadsheets

Year Amount ($)/Week
2009 171.02
2010 173.19
2011 181.66
2012 190.38
2013 186.66
2014 195.85
2015 191.45
2016 194.16
2017 203.73
2018 194.47
2019 212.30
2020 -
2021 -
2022 254.05
2023 271.28

Figure 5: Cost of a Nutritious Food Basket (NFB) per Week - Family of Four Composed of: Male Adult, 31 to 50; Female Adult, 31 to 50; Female Child, 4 to 8 and Male Youth, 14 to 18. Source: EOHU NFB Costing Spreadsheets

Table 9: Cost of Inflation from the NFB Data in Previous Figure

Year Inflation (%)
2009 0
2010 1.27
2011 4.89
2012 4.80
2013 -1.95
2014 4.92
2015 -2.25
2016 1.42
2017 4.93
2018 -4.55
2019 9.17
2020 -
2021 -
2022 19.67
2023 6.78

Figure 6: Cost of Inflation from the NFB Data in Previous Figure

The following table, which was taken from the Eastern Ontario Health Unit’s website - Cost of Eating in Eastern Ontario, demonstrates the funds remaining after housing and food are deducted from different family structures and revenues.

Table 10: Monitoring Food Affordability Income Scenarios, EOHU Region, 2023

Scenarios Total Monthly Incomea Housingb Foodc Funds Remaining for Other Costs of Basic Living
Family of 4*
Ontario Works		 $2800 $1104 $1175 $521
Family of 4*
Full-Time Minimum Wage Earner		 $4166 $1104 $1175 $1887
Family of 4*
Median Income		 $9323 $1104 $1175 $7011
Single Parent 
with 2 Children
Ontario Works		 $2566 $906 $864 $796
1 Person
Ontario Works		 $868 $658 $422 $-212
1 Person
Ontario Disability Support Program		 $1372 $735 $422 $215
1 Person
Old Age Security/Guaranteed Income Supplement		 $1996 $735 $304 $957
Married Couple
Ontario Disability Support Program		 $2437 $735 $702 $1000
Single Pregnant Person
Ontario Disability Support Program		 $1412 $735 $399 $278
Single Parent with 2 Children
Full-Time Minimum Wage Earner		 $4308 $906 $714 $2688

*Reference family of four: 31 to 50 year-old male, 31 to 50 year-old female, 14 to 18 year-old male, and 4 to 8 year-old female. Other types of households may have different costs.
a. Total income sources vary by scenario and can include: income from employment; Basic Allowance; Maximum Shelter Allowance; Old Age Security/Guaranteed Income System; Canada Child Benefit; GST/HST credit; Ontario Trillium Benefit; Working Income Tax Benefit; Employment Insurance paid; Canada Pension Plan paid, Climate Action Incentive Payment.
b.Canada Mortgage and Housing Corporation. Rental Market Statistics by Metropolitan Areas, Census Agglomeration and Cities. Average cost of rent for Cornwall and Hawkesbury. Accessed October 19, 2023. [https://www03.cmhc-schl.gc.ca/hmip-pimh/en/TableMapChart/Table?TableId=2.1.31.2&GeographyId=35&GeographyTypeId=2&DisplayAs=Table&GeograghyName=Ontario#Bachelor%20]
c. Reference: Ontario Nutritious Food Basket Data Results 2023 for Eastern Ontario Health Unit – Includes family size adjustment factors.

In the Food Insecurity among Children using the Canadian Health Survey of Children and Youth, 3rd Edition of November 2023, it is highlighted that the highest prevalence of severe household food insecurity is found in rural or rural-urban mixed areas where population growth is low, which represent the EOHU communities.

Social Exclusion

“Social exclusion refers to specific groups being denied the opportunity to participate in Canadian life. In Canada, Indigenous Canadians, Canadians of colour, recent immigrants, low-income Canadians, women, and people with disabilities are especially likely to experience social exclusion. Many aspects of Canadian society marginalize people and limit their access to social, cultural and economic resources. Socially excluded Canadians are more likely to be unemployed and earn lower wages. They have less access to health and social services and means of furthering their education. These groups are increasingly being segregated into specific neighborhoods. Excluded groups have little influence upon decisions made by governments and other institutions. They lack power. Social exclusion creates a sense of powerlessness, hopelessness and depression that further diminish the possibilities of inclusion in society.”10

Sex

There are many societal situations that demonstrate the differences between men and women. When it comes to single parenting, the percentage of female lone parents is much higher across all 5 counties. In addition, when comparing after-tax income, you'll find more women with lower income and less women with higher income, which is the opposite of the situation for men.

Another major concern reflecting gender inequality is the lack of affordable and high-quality daycare services. Culturally, couples tend to make the decision that women stay home to take care of family responsibilities. When combined with the high number of single parent households run by women, a lack of daycare services forces many women out of the workforce.

“Women have a life expectancy of 84 years as compared to men’s 79.9 years. However, the higher mortality rate and lower life expectancy of men does not mean that women enjoy superior health. Women have more episodes of long-term disability and chronic diseases than men. On the other hand, men are more prone to accidents and extreme forms of social exclusion such as homelessness and severe substance abuse which reduce their overall life expectancy.”11

Disability

Given that disabilities are mostly seen as being related to physical or mental functioning, this lens is largely impacting how society supports individuals with a disability.

Over 40 percent of Canadians with disabilities are not in the labour force, many having to rely on social assistance benefits. These benefits are very low in Canada and do not bring individuals even close to the poverty line in most cities.12

Disabilities do not necessarily prevent individuals from working, but various situations, challenges, and barriers such as inaccessible workplaces, a lack of adapted transportation or accommodation, or outright discrimination reduce access to gainful employment.

Culture, Race and Ethnicity

“Racism in Canadian society is responsible for these phenomena. Racism takes three forms, all of which have an impact on health. Institutionalized racism is how racism is embedded in institutions of practice, law, and governmental inaction. Personally mediated racism is prejudice and discrimination and manifests as lack of respect, suspicion, devaluation, scapegoating, and de-humanization. In the healthcare system, personally mediated racism impacts quality of care for racialized persons. Internalized racism is when those who are stigmatized accept these messages about their abilities and lack of worth. This leads to resignation, helplessness, and lack of hope.”13

“Results indicate that young Black people were as likely as other young Canadians from the same cohort to obtain a high school diploma but were less likely to obtain a postsecondary degree – particularly among men.”14

Referring to the Food insecurity section, the Canadian Health Survey of Children and Youth, 3rd Edition of November 2023, indicates that the highest prevalence of household food insecurity for children was found in the Black population group, at 34.7%.

Immigration

The EOHU population is somewhat homogenous according to the 2021 Census, with only 6.8% being immigrants, versus Ontario at 44.6%. However, the immigrant population in the EOHU area has increased since 2016, when it stood at 5.7%.

When looking at the EOHU's territory, Cornwall has the highest proportion of immigrants, followed by UCSDG and then UCPR (9.3% versus 7.5% versus 6.1%).

Recent immigrants (i.e. those who have lived in Canada less than 10 years) may face language barriers, discrimination, difficulty having their educational and professional credentials recognized, a lack of Canadian work experience, and difficulty building social networks when they arrive in Canada.”15

“Non-European immigrants, especially those of colour, report higher levels of mental health problems the longer they are in Canada. These immigrants also become more likely to suffer from chronic illnesses such as adult-onset diabetes, arthritis, and heart disease. There are several explanations for immigrants’ transition to poorer health. Acculturation to a new environment and cultural norms impede access to health care, but more importantly, immigrants’ adverse health outcomes are due to a disproportionate exposure to health threatening social determinants of health that are a result of social exclusion and the racialization of poverty.”16

Indigenous Status

“Low-income data for First Nations on reserve and people living in the territories, including the Inuit in Nunavut, is not published on an annual basis by Statistics Canada. Further, incomes on reserve and in the territories are affected by the use of in-kind transfers such as band housing; products from hunting, trapping, fishing and harvesting; and the existence of bartering for goods and services. The spending patterns of First Nations on reserve and people living in the territories are also different from those of their peers living off reserve and in the provinces. First Nations on reserve have access to band housing and may not have to spend as much of their income on housing as their peers living off reserve. However, living conditions on reserve and statistics on educational and employment outcomes suggest that the poverty rate on reserve is higher than off reserve.”17

“The health of Indigenous peoples in Canada is inextricably tied up with their history of colonialization. This has taken the form of legislation such as the Indian Act of 1876, disregard for land claims of Metis peoples, relocation of Inuit communities, and the establishment of residential schools. The result has been the experience by Indigenous people in Canada of adverse social determinants of health and adverse health outcomes. The lower incomes of Indigenous Canadians and their higher poverty rates lead to their greater incidence of a range of afflictions and premature death from a variety of causes. While Canada’s overall life expectancy is 81.0 years, for Indigenous Canadians it is much lower (75.1 years for First Nations; 77.0 years for Métis; and 68.5 years for Inuit).”18

2SLGBTQI+

According to the highlights of Disaggregated trends in poverty from the 2021 Census of Population, more than one in five non-binary people live in poverty. Transgender and non-binary people were more likely to experience poverty than cisgender people. In 2020, the poverty rate among transgender women was 12.0%, while for transgender men the rate was 12.9%. These proportions are considerably higher than those for cisgender women (7.9%) and cisgender men (8.2%). However, non-binary people were most likely to experience poverty with a rate of 20.6%, more than twice the rates for cisgender women and men.

“There is also evidence that gay, lesbian, and transgendered Canadians experience discrimination that leads to stress that has adverse health effects. This is especially a problem during adolescence when gay and lesbian youth need to come to terms with their self-identity. Discrimination is also an ongoing problem when these Canadians enter the work world.”19

Colonisation impacted the stigma and shame around gender identity and sexual diversity in society. Looking at the system level, Canada does have marriage equality, a legal framework with human rights protection, but this does not necessarily mean positive health outcomes or a social acceptance of diversity.

“According to CCHS data from 2015 to 2018, heterosexual people had the highest median annual employment income ($58,000) among Canadian-born full-time workers aged 25 to 64. Gay or lesbian individuals earned lower median incomes ($50,100) than their heterosexual counterparts, while bisexual people had the lowest earnings ($38,800) among the Canadian-born population.”20

“Lesbian, gay and bisexual individuals are more likely to experience depression, anxiety, suicidality and substance abuse than their heterosexual counterparts. Social stresses experienced in sexual minority populations, such as stigma, prejudice and discrimination, in addition to internalized feelings of negativity and expectations of rejection, are thought to be part of the explanation for these differences in risk for mental disorders.”21

Environments

Physical Environments

“Geography most obviously influences our health through the air we breathe, the food and water we consume, and the environmental pollution and vectors of disease to which we are exposed. In addition, rural, remote, isolated, Northern and urban geographies determine not only physical aspects of the environment, but also other social determinants of health such as access to health care, food, education, employment and housing, among others, that directly shape our health.”22

Climate Change

Climate change also has an important role in the health and well-being of our young population.

According to a study from Galway and Field (2023), retrieved from the Top 10 Threats to Childhood in Canada, nearly half (48%) of Canadian youth aged 16 to 25 expressed feeling high levels of anxiety about air pollution and climate change, while three-quarters (73%) expressed fear for their future.

We cannot overlook the events that occurred in the summer of 2023, with various warnings of extreme weather, tornadoes, and pollution associated with climate change. The summer of 2023 was also marked by wildfires and poor air quality conditions, resulting in many individuals having to be relocated, or who had their routines disrupted due to the wildfires.

Social Capital

Social capital can be measured by the amount of trust and sharing in a community or between individuals. Higher social capital means a stronger sense of trust, higher civic engagement, more involvement in community, and more connections across differences. Relationships are key.

By building social capital, we look to create vibrant neighborhoods with people of diverse backgrounds connecting across differences, leading to a community where everyone has an equal opportunity to thrive.

From the EOHU Population Mental Health Survey, residents in the EOHU area feel that they have strong individual relationships with each other and to the community. Seventy-seven percent of the population stated that they enjoy warm and trusting relationships with others and over two-thirds have a strong sense of belonging to their local community. However, there are a few discrepancies when looking at the different areas within the EOHU's territory. The highest sense of belonging to the community (75%) is in the UCSDG, whereas only 59% of the population in Cornwall feel the same way. Likewise, the UCSDG leads the way with more people (81%) enjoying a warm and trusting relationship as opposed to Cornwall and Hawkesbury, where a lesser number of people (71% and 72% respectively) enjoy similar relationships.

Isolation

Referring back to the EOHU Population Mental Health Survey results, a third of EOHU residents have feelings of isolation or loneliness some of the time (23%) or often (11%). The prevalence of residents having feelings of isolation or loneliness some of the time or often was higher among residents living in Cornwall (28% and 18% respectively).23

Table 11: Percentage (%) of Residents Feeling Isolated or Lonely Some of the Time or Often, by Region, 2022

Frequency EOHU Cornwall Hawkesbury UCPR UCSDG
Some of the time 23% 28% 21% 21% 23%
Often 11% 18% 12% 8% 10%

In "The Great Disconnect" documentary, there is a quote saying that “our time has been called the age of loneliness” (The Huffington Post). Douglas Tindal, the writer and co-housing advocate, mentions that “social isolation is the medical equivalence of smoking 15 cigarettes a day, it has the same impact on health as diabetes.”24  In this documentary, they identify that the issues are not only impacting personal health and wellbeing, but impacting a much larger scale of communities. They express that “loneliness and social isolation are being labeled as epidemics - epidemics that may become one of society’s biggest challenges of the 21st century.”25

Transportation

Transportation is a key element in a rural environment to access services from organizations, health care facilities, having employment, getting groceries, all essential needs, and affecting isolation. When services are not at walkable distances, an individual without transportation is very limited and expenses are higher (cost of taxi, limited employment opportunities, and use of corner stores which are more expensive and have limited fresh fruits and vegetables, etc.).

According to the documentary called "The Great Disconnect," an additional difficulty is the lack of transportation to access care or to participate in community activities24. This is a major concern, because it results in significant risk factors, such as neglect, depression, and isolation. These issues can contribute to or coexist with the isolation of older Francophones (French Language Services Commissioner, 2018).

The United Counties of Prescott and Russell had introduced the Intermunicipal Transportation Network in the fall of 2019. It was a pilot project to provide support and enable residents of the eight municipalities in Prescott and Russell to benefit from a public transit service to travel across the region and access various services. It aimed at reducing transportation and accessibility barriers in a rural area while encouraging economic growth but was put on hold due to the COVID-19 pandemic. Then, in June 2023, the project was suspended as the current format was not meeting the needs of the community. Other more sustainable and responsible options will be looked at as a means to better serve the population.

Community Services of Prescott Russell also offer a personalized transportation service for medical appointments or other specific needs. They also offer special assistance for all transportation within the Prescott Russell area for any person aged 55 and over (https://servcompr.com/en/services/transportation/). Leduc Bus Lines offers commuter bus trips from Ottawa and the Eastern Ontario region, but they have been suspended since the COVID-19 pandemic (https://www.leducbus.com/).

Stormont, Dundas and Glengarry do not have a transportation service other than taxis. Within the SDG area, only Alexandria has a Via Rail train station. Cornwall on the other hand, has a public transit system which includes four conventional bus routes, a community bus service and several supplementary routes to the Cornwall Business Park. There is also an individual Handi-Transit public transit system for individuals who are unable to use the conventional transit system (https://www.cornwall.ca/en/live-here/transportation.aspx). In addition, train service is provided by Via Rail and out-of-town travel by bus is also available by Megabus and 417 Bus Line.

Access to Health Services

“The Canada Health Act (CHA) states that every Canadian must be provided uniform access to health services in a way that is free of financial barriers (accessibility). No one should be discriminated against on the basis of income, age or health status.”26

However, the CHA does not specify which services are covered, which explains the differences between provinces and territories. Consequently, this has an impact on health if the services needed are not covered and they come at a high cost. For example, some residents often skip dental or vision screenings, while others can’t pay for expensive medications. These decisions have a direct impact on health as these residents often end up at the hospital for emergency care.

Conclusion

As demonstrated in the report, the types of problems playing critical parts in inequity are complex and cannot be resolved on an individual basis or by a single organization. There must be collaboration between all levels of the community, different professionals, services, sectors, and within the community itself. Essentially, in addition to programs and services, a focus on Systems Change needs to be present to achieve an equitable change.

Equity, diversity and inclusion are essential and need to be at the centre of every approach. Identifying, addressing, and looking at the root causes of health inequities is part of an important process to improve health equity for all. When focusing on the cause, we are looking at the system of social oppression; how colonisation, dominance, exploitation, and assimilation influence the mainstream of society, and in result cause discrimination. Being part of the indigenous, 2SLGBTQI+ community or having a different culture or skin color are not what needs to be addressed. We need to address the underlying issues, the racism, sexism, and homophobia that is causing discrimination.

The "Water of Systems Change" model to help bring about an equitable change, concentrates on shifting the conditions holding a problem in place. This framework is an actionable model that uses 3 levels of change: structural, relational and transformative.

A low income remains one of the most important social determinants of health. The Ontario Living Wage network calculates the hourly salary needed to remain above the poverty line and meet the most basic living requirements for the different regions in Ontario. In the East region (which includes SDG and PR), the calculation as of November 2023 was $20.60 per hour. This wage includes basic costs such as food, clothing, shelter, hydro, cell service, insurance, internet, television, childcare, transportation, medical expenses, recreation, and a modest vacation. The calculation is completed on a yearly basis. When compared to the minimum wage in Ontario, which is currently at $16.55 per hour, it is obvious that our low-income populations are well below the poverty line.

The following quote is from INCOME SECURITY: A Roadmap for Change.

“When you do not have enough income to afford even the most necessary essentials of life, like a home or a meal or a way to get around in your community, it is almost impossible to improve your circumstances. You will likely find that your health worsens, you become increasingly detached from the world of work, and social isolation and stigma deepen.”27

In the Public Health Agency of Canada’s (PHAC) report on Key Health Inequalities in Canada, it was identified that:

“Significant health inequalities were observed for those with lower socioeconomic status, Indigenous peoples, sexual and racial/ethnic minorities, immigrants, and people living with functional limitations (such as physical or mental impairments).”28

A strong correlation between health and income, education levels, employment and occupational status confirm that health outcomes worsen with lower socioeconomic status. “Achieving health equity is a shared responsibility that requires creating and sustaining healthy living and working conditions and environments. When the conditions are in place for everyone to have the opportunity to be heathier, we all enjoy the benefits.”29

As identified, poverty affects an individual’s health, but on the other hand, poor health can also affect an individual’s productivity, increasing economic losses for individuals and society. Living in poverty has an impact on health due to obstacles and challenges emerging from various Social Determinants of Health (SDOH).

“The differences in health by income level were estimated to cost Canada’s health care system at least $6.2 billion annually, or over 14% of total expenditures on acute care inpatient hospitalizations, prescription medication and physician consultations.”30

It is important to follow the trends from one year to the next to get a clear understanding of the situation, as these changes can influence the data used to paint the portrait. In our area, we have seen some improvements since 2016, such as an increase in the overall education level, an increase in the young children population, and an improvement in the unemployment rate.

However, given “the rising price of shelter (+6.9%) and food (+8.9%) that were among the top three basic costs that saw the highest increase in 2021 from previous years,”31 our gains remain fragile.

In order for change to happen, there needs to be a collaboration at all levels, and appropriate funding to ensure equitable and culturally appropriate services to different populations.

“Courage my friends, ‘tis not too late to build a better world.”
 – Tommy Douglas, Founder of Medicare in Canada

References

1. Ministry of Health of Ontario (2021). The Ontario Public Health Standards: Requirements for Programs, Services, and Accountability. Retrieved from https://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Ontario_Public_Health_Standards_2021.pdf (p. 20-21)

2. Government of Canada (2019). Understanding the report on Key Health Inequalities in Canada. Public Health Agency of Canada. Retrieved from: https://www.canada.ca/en/public-health/services/publications/science-research-data/understanding-report-key-health-inequalities-canada.html

3. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 31)

4. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 21)

5. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 27)

6. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 17)

7. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 38)

8. PROOF (2019). Household Food Insecurity in Canada. Retrieved on 2019/03/20 from: https://proof.utoronto.ca/food-insecurity/

9. Men, F., Gunderson, C., Urquia, M.L. and Tarasuk, V. Food Insecurity Is Associated with Higher Health Care Use And Cost Among Canadian Adults. 2020 Aug;39(8):1377-1385. doi: 10.1377/hlthaff.2019.01637. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32744947/

10. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 42)

11. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 63-64)

12. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 55)

13. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 71)

14. Statistics Canada. (2020). A socioeconomic portrait of Canada’s Black population. https://www150.statcan.gc.ca/n1/daily-quotidien/200225/dq200225b-eng.htm?CMP=mstatcan

15. Government of Canada. (2022). Towards a Poverty Reduction Strategy – A backgrounder on poverty in Canada. https://www.canada.ca/en/employment-social-development/programs/poverty-reduction/backgrounder.html

16. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 67)

17. Government of Canada. (2022). Towards a Poverty Reduction Strategy – A backgrounder on poverty in Canada. https://www.canada.ca/en/employment-social-development/programs/poverty-reduction/backgrounder.html

18. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 59-60)

19. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 64)

20. Statistics Canada. (2023). Ethnocultural diversity among lesbian, gay and bisexual people in Canada: An overview of educational and economic outcomes. https://www150.statcan.gc.ca/n1/pub/89-28-0001/2022001/article/00005-eng.htm

21. Statistics Canada by Gilmour, H. (2019). Health Reports – Sexual orientation and complete mental health. https://www150.statcan.gc.ca/n1/pub/82-003-x/2019011/article/00001-eng.htm

22. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 52)

23. Eastern Ontario Health Unit. (2023). Local Data EOHU Population Mental Health Status. https://eohu.ca/en/my-health/mental-health-in-eastern-ontario

24. Soliman, T., Walton, J., Tyler, R., Douglas, S., Price, S., Whicker, C., and Hicks, N. (2020) The Great Disconnect. https://thegreatdisconnectfilm.com/

25. Soliman, T., Walton, J., Tyler, R., Douglas, S., Price, S., Whicker, C., and Hicks, N. (2020) The Great Disconnect. https://thegreatdisconnectfilm.com/

26. Raphael, D., Bryant, T., Mikkonen, J., and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts, 2nd Edition. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf (p. 48)

27. Government of Ontario (2017). Income Security: A Roadmap for Change. Retrieved from: https://files.ontario.ca/income_security_-_a_roadmap_for_change-english-accessible_0.pdf (p. 70)

28. Government of Canada (2019). Understanding the report on Key Health Inequalities in Canada. Retrieved from: https://www.canada.ca/en/public-health/services/publications/science-research-data/understanding-report-key-health-inequalities-canada.html

29. Government of Canada (2019). Understanding the report on Key Health Inequalities in Canada. Retrieved from: https://www.canada.ca/en/public-health/services/publications/science-research-data/understanding-report-key-health-inequalities-canada.html

30. Public Health Agency of Canada. 2016. The Direct Economic Burden of Socioeconomic Health Inequalities in Canada: An analysis of health care cost by income levels. Retrieved from: https://www.canada.ca/en/employment-social-development/programs/poverty-reduction/backgrounder.html

31. Statistics Canada. Consumer Price Index: Annual review, 2022. The Daily. May 8, 2023. Accessed May 8, 2023. https://www150.statcan.gc.ca/n1/daily-quotidien/230117/dq230117b-eng.htm. Retrieved from: https://childrenfirstcanada.org/wp-content/uploads/2023/08/Raising-Canada-2023_V1d.pdf

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