Health and Wellness

Why is this important?

Good physical and mental health are vitally linked to, and affected by, virtually all the issues raised in the Toronto’s Vital Signs Report. Adequate income, stable and appropriate housing, a safe and walkable neighbourhood, strong social networks, and a high level of education all enhance the health of Torontonians. The absence of some or all of those factors contributes to the likelihood of a city resident experiencing, for example, diabetes, depression, or obesity.

 

What are the trends?

The percentage of Toronto residents reporting good health remains relatively stable, but it isn’ t improving (four in 10 don’ t report good health). Diabetes rates continue to be a major concern, and 15.6% of adult Torontonians now report being obese. The level of youth obesity is troubling (and likely even worse than the data show, because the figures are self-reported and therefore generally under-reported). And while most Torontonians are satisfied with life and believe their mental health is good, numbers are decreasing over time, and almost a quarter of the population experiences high levels of stress.

What’s new?

Torontonians’ health compares favourably or are on par with the rest of Ontario, except when it comes to physical activity, diabetes prevalence, and low birth weight infants. Almost one in five babies born in the city in 2015 was outside the healthy birth weight range. Drug overdose has become a significant public health issue—accidental deaths have increased by 82% in less than a decade. Inequities continue to affect health: youth accessing addiction services do not feel safe disclosing if they are queer or trans, residents who are low-income or who need cultural-specific services wait longer for long-term care, and parts of the city are “food deserts” lacking healthy food access. There is, however, a new City action plan to improve outcomes for women experiencing intimate partner violence.

 

How healthy are Torontonians?

Data from Toronto Public Health’s 2015 annual report shows that Torontonians’ health indicators compare favourably or are on par with the rest of Ontarians, except for rates for physical activity, diabetes prevalence, and low birth weight infants:

  • 49.5% of Torontonians were physically active during their leisure time in 2013-14, compared to 52.3% of other Ontarians, and 11.2% of were diabetic in 2013 versus 9.9% of other Ontarians. Toronto’s low birth weight rate in 2014 was 5.6%, higher than the 4.8% for the rest of Ontario.
  • The report notes that indicators vary across the city, as health is associated with social determinants of health including income, race, immigration status, and sexual orientation.[1]

 

Comparison of Selected Health Status Indicators, Toronto versus Health Units in Ontario [2]

Screen Shot 2016-09-07 at 3.25.50 PM

Torontonians are less likely to be obese than our provincial and national counterparts, but obesity rates are increasing. Our youth are more likely to be overweight or obese, and the long-term trend is troubling—over a quarter are now overweight or obese:

  • The adult (18+) obesity rate increased 32.2% between 2003 and 2014, from 11.8% to 15.6%, but remains lower than the national (20.2%) and provincial (20.4%) averages. (Adult obesity refers to a self-reported body mass index of 30.0 or higher).[3]
  • Youth (aged 12 to 17) are also getting fatter. Since data started to be collected in 2005, the rate of youth obesity in Toronto has increased from 19.5% to 27.0% in 2014, higher than the national (23.1%) and provincial (23.3%) averages. (Note that data are unavailable for 2011 as Statistics Canada considered it too unreliable to be published).[4]
  • Nonetheless, 66.8% of youth (12 to 19) reported good or excellent physical health in 2014, down from 68.9% in 2003, and below the national and provincial averages of 69.4% and 69.9% respectively. [5]

 

Diabetes rates increased more than 40% between 2003 and 2014:

  • 7.0% of Toronto’s population 12 and over reported in 2014 that they had been diagnosed with Type 1 or Type 2 diabetes, up from 4.9% in 2003 and higher than the national average of 6.7% (but lower than the provincial average of 7.4%).
    • The diabetes rate includes females 15 and over who reported being diagnosed with gestational diabetes.[6]

A diabetes prevention program is building community capacity while teaching healthy behaviours:Ideas-and-Innovations

  • Toronto Public Health’s Diabetes Prevention Peer Leadership Program funds agencies to recruit peer leads to implement diabetes prevention programs. In 2014, 19 agencies trained 220 leaders, and 9,935 community members participated in their prevention programs.
  •  Peer leaders have reported that participating in the program improved their own families’ wellness and often led to educational or job opportunities.[7]

 

Compared to our provincial and national counterparts, Torontonians are less likely to drink heavily (although our heavy drinking is increasing). However, we smoke more, are less active, and (except for seniors) are less likely to eat enough fruits and vegetables:

  • 14.0% of the population 12 and over were heavy drinkers in 2014, an 18.6% increase since 2003 (when 11.4% of the population were heavy drinkers), but lower than the national (17.9%) and provincial (16.2%) averages.
    • Heavy drinking is defined as having consumed five or more drinks on one occasion at least once a month in the last year for men, four or more for women.[8]
  • 15.6% of the population 12 and over were smokers in 2014, 14.4% higher than the national average (18.1%) and 14.5% higher than the provincial average (17.4%). The rate of smokers has dropped from 19.9% in 2003. The lowest rate recorded between 2003 and 2014 was 13.9% in 2009.[9]
  •  46.1% of the population 12 and over spent some leisure time being active or moderately active in 2014, up slightly from 45.3% in 2003 but lower than the high of 52.6% recorded in 2013. Toronto ranks below both the national (53.7%) and provincial (52.7%) averages.[10]
  • 61.7% of the population 12 and over consumed less than the recommended daily intake of fruits and vegetables in 2014, up from 56.3% in 2003 and higher than both the provincial (56.3%) and national (57.1%) averages.[11]
    • Seniors are faring slightly better. 52.0% of them are not eating enough produce, lower than the provincial and national averages (61.9% and 60.5% respectively), and the percentage has decreased 6.3% since 2003.[12]

 

Life expectancy for Torontonians is relatively high, when compared to other global cities:

  • Average life expectancy for Torontonians stands at 83 years (as reported to the global World Council on City Data or WCCD in 2015), slightly lower than the 83.5 in Melbourne.
  • People in Vaughan, however, have an average additional three years of life over Torontonians (their life expectancy sits at 85 years).
  • Toronto’s life expectancy age is only slightly higher than those of London (82.05), Los Angeles (80.3, Amsterdam (80.2), and Boston (80).[13]

Life Expectancy in Years, as Reported to WCCD in 2015 [14]

life-expectancy

 

In the Toronto Central LHIN (Local Health Integration Network) unit (which serves approximately 1.2 million Torontonians[15]), for every 100,000 residents there is more than double the number of physicians than there are nationally and provincially:

  • The total number of physicians per 100,000 residents was 496 per 100,000 residents in 2014, up 17.5% from 422 in 2002. Comparatively, there were only 224 physicians per 100,000 nationally, and 214 provincially.[16]
  • The number of family physicians per 100,000 residents increased by 27.8% between 2002 and 2014, reaching 184 (up from 144). Comparatively, there were only 114 family physicians per 100,000 nationally, and 118 provincially.[17]
  • There were 312 specialists per 100,000 residents in 2014 (an increase of 12.2% from 278 in 2002). In Ontario as a whole there were 107 specialists per 100,000 and in Canada, 110.[18]
  • Nonetheless, 10.8% of the population 12 and over was without a regular medical doctor in 2014, which was lower than the 12.2% rate in 2005, above the 2014 provincial rate of 7.5%, and below the 2014 national rate of 14.9%.[19]

Most Torontonians are satisfied with life and believe their mental health is good. But numbers are decreasing over time, and almost a quarter of the population experiences high levels of stress:

  • Almost nine in 10 Torontonians aged 12 and over (88.7%) self-reported in 2014 that they are satisfied or very satisfied with life.[20] This is lower than the national (92.2%) and provincial (91.2%) averages, and not much higher than a decade ago (it was 87.8% in 2003).[21]
  • Seven in 10 (70.5%) said in 2014 they are in very good or excellent mental health.
    • Over time, however, Torontonians’ self-rated mental health has decreased, by 1.2 percentage points between 2003 and 2014. It was at its highest in 2008 at 77.5% and lowest in 2013 at 67.4%.
    • Nonetheless, only 7.3% report fair or poor mental health.[22]
  • The mental health of Toronto’s youth (12-19) has also declined. 70.9% perceived their mental health as being very good or excellent in 2014, a decrease of 6.4 percentage points since 2003 and lower than the national (73.9%) and provincial (72.3%) averages.[23]
  • 22.8% of the population (15 years and over) reported in 2014 that most days in their life were quite a bit or extremely stressful, down from 26.8% in 2005.[24]

A study of suicide deaths in the city has found that nine out of 10 had some type of health care contact in the year prior:

  • The study analyzed 2,835 suicide deaths in the city from 1998 to 2011 to determine the relationship between mental health care contact and suicide.
  • 91.7% of those who died had health care contact within a year of their death, 66.4% had mental health care contact, and 25.3% had only non-mental health care contact (i.e., any contact with health care professionals that was not related to mental health).
    • Of those who had mental health care contact, 54% had an outpatient primary care visit, 39.8% had an outpatient psychiatric visit, 31.1% had contact with a mental health emergency department, and 21% had a mental health hospitalization.[25]

 

The City has a new action plan to improve outcomes for women experiencing intimate partner violence:

  • Intimate partner violence (IPV) is pervasive. The Department of Justice has estimated its cost nationally (in healthcare and other related costs) at $7.4B annually.[26]
  • In December 2015, City Council adopted Toronto Public Health’s recommendations for action to deal with IPV.[27]
  • The action plan outlines 10 goals for prevention, early identification, and response to IPV.[28]

TPH Action Plan on Intimate Partner Violence Against Women [29]
hpv

  • With respect to Goal 4, City staff cited research showing that healthcare settings provide a great avenue for screening women for IPV, substantially increasing identification.[30] But earlier in 2015, the Centre for Research on Inner City Health (CRICH) at St. Michael’s Hospital released a study that found screening practices varied widely between Toronto hospitals and departments.
    • The study found a number of barriers to IPV screening, including lack of knowledge of IPV or training on how to screen for it, lack of time or prioritization compared to other aspects of patient treatment, and a fear of harming patients further (by not being tactful) or violating their privacy.
    • Respondents named institutional support, IPV training, and personal motivation as things that enabled IPV screening in their work.
    • The researchers concluded that policy makers should make IPV screening a public health priority to improve health outcomes for women and to lessen the burden on the healthcare system through earlier identification and intervention.
  • Universal screening, in which healthcare providers routinely ask women about their experiences with IPV, has proven more effective at uncovering it than case-finding, in which healthcare workers ask women only if they see signs of abuse.[31]

 

What new public health challenges have emerged?

Accidental drug-induced deaths in Toronto increased by 82% in less than a decade, making drug overdose a significant public health issue:

  •  Toronto Public Health analyzed data from annual reports of the Office of the Chief Coroner for Ontario. Its findings show that deaths due to drug overdose increased dramatically (by 41%) in Toronto between 2004 and 2013 (the latest year for which data is available)—from 146 to 206. Deaths from opioids in particular have raised concern (between 2009 and 2013 alone, fentanyl deaths increased 76% in Ontario).
    • Deaths indirectly caused by drug use (such as accidents or disease as a result of substance use) were excluded—only overdoses (drug-induced deaths in which the person died directly from drug toxicity) were counted. Overdose deaths can be classed as accidental, intentional, or undetermined.
  • In every year analyzed, the majority of overdose deaths were accidental, and over time accidental overdose has increased as a percentage of total overdose deaths, reaching 72% in 2013. Accidental drug-induced deaths increased by 82% between 2004 and 2013, while both the suicide and undetermined categories of overdoses declined.[32]

Drug-Induced Deaths, Toronto, 2004-2013 [33]

 

drug-deaths

  • Males were more likely than females to die of overdose: 65% of all deaths by overdose were males, as were 71% of accidental overdoses.
  • 64% of overdose deaths were among people between 40 and 64 years old.
  • Data comparing substance use within the previous year shows higher rates of use among both adults and youth who are homeless or otherwise “street-involved” or incarcerated.
    • Of Toronto students in grades 7-12 surveyed, 29% consumed alcohol in the past year, and 13% used cannabis. Of street-involved youth surveyed, the rates were 99% and 96% respectively.
    • 75% of “street-entrenched adults” reported using cocaine (crack).[34]

Substance Use in the Past Year Among Various Groups, Toronto, 2002-2013 [35]
drug-use

  • The report recommends actions including development by the Province of a comprehensive overdose prevention strategy (informed by the 2015 Prescription for Life report by the Municipal Drug Strategy Coordinators Network of Ontario).[36]

Ideas-and-InnovationsAfter many public meetings, a recommendation from the medical officer of health Dr. David McKeown and the Toronto Drug Strategy implementation panel[37], the City of Toronto approved three safe injection sites on July 14, 2016.

  • Both Mayor John Tory and Chief of Police Mark Saunders have supported the sites as a key to saving lives and preventing overdoses.[38]

 

 

How are inequities impacting health and wellbeing?

 

Many Toronto youth who identify as queer and trans do not feel safe disclosing this identity when accessing addiction services:

  • In an early 2015 study (conducted by Breakaway Addiction Services and funded by the Toronto Central LHIN) of LGBTTQQITSA-identified youth and substance use, 58.5% of 183 “queer/trans” respondents who had accessed formal support services for substance use reported that they did not feel safe disclosing their queer/trans identity when doing so. 65.1% of those who accessed formal support services indicated that provider and/or client orientation towards their queer/trans identity negatively impacted their experiences.
  • 25.7% of 343 respondents who had not accessed support services were uncertain if staff would understand them as a queer/trans person, and 50.1% reported that not knowing what was available was a barrier to access.
  • Of 281 youth reporting previous experiences of service access, 65.5% had used individual counselling, 21.4% group counselling, 20.6% a 12-step program, and 37.4% harm reduction.[39]

 

A third of “street-involved youth” surveyed in a one study have attempted suicide:

  • In Fall 2015 193 street-involved youth from various organizations—Eva’s Satellite, Eva’s Place, Turning Point, Covenant House, Justice for Children and Youth, and Yonge Street Mission-Evergreen—were surveyed.
  • One in three respondents (36%) reported that they had attempted suicide, and that they were often bullied in school.[40]

 

Low-income Torontonians and those needing cultural-specific services wait longer for long-term care:

  • A 2016 Wellesley Institute report examined wait lists for long-term care (LTC) homes managed by the Toronto Central Community Care Access Centre (CCAC) — which manages 36 homes in the Toronto Central LHIN (TCLHIN)—and other CCACs serving GTA populations.
    • Wait time data gathered for the 90th percentile, or they reflect the experience of nine out of 10 residents, was as follows:
    • Those who can afford private accommodations get care faster.
  • Monthly rates, set by the Ministry of Health and Long-Term Care, are $1,774.81 for basic accommodation with two to four beds in a room and $2,535.23 for private accommodation. Low-income applicants opt for basic accommodation because of the lower cost and because government subsidies are available only for basic rooms.
  • Wait times are 86 days (28%) longer for basic accommodations (397 days versus 311 for private).
    • Those who want services specific to ethnic groups (for example, ethnic programming and food, and staff who speak their first language) wait longer for care.
  • Eight long-term care homes in the TCLHIN and at least 10 around the GTA provide “ethno-specific” services. Residents waited about 18 months for basic accommodations, about six months longer than at “mainstream” homes. The wait time for private accommodations was shorter at 15.5 months.[41]
  • There appears to be a greater demand for cultural-specific services than is currently available. Chinese-specific LTC homes in Scarborough, Richmond Hill, Markham, and Mississauga have wait lists for basic accommodations as long as eight years.[42]

Wait Times for Ethno-Specific LTC Homes, GTA, 2016 [43]

Toronto Public Health says parts of the city are “food deserts” with an under-abundance of healthy food sources:

  • A 2015 Toronto Public Health report mapped healthy food access across the city using the modified food retail environment index (MFREI), which represents a ratio of healthier to less-healthy food retail locations within a one-km walk of each city block. (Less-healthy outlets are typically convenience stores or fast food restaurants.)
  • Across Toronto the ratio of less healthy to healthier food outlets is four to one.
  • In the lowest-income areas (the bottom 20%), there are 15 less-healthy outlets for every healthier one.
  • Mapping low MRFEI scores with low income shows several areas where lower-income households may spend their limited resources at unhealthier, but more accessible, food outlets.
  • A lower-income area with relatively few supermarkets nearby is a “food desert.” Toronto Public Health’s analysis found that almost 31,000 households in Toronto’s lowest-income areas are more than a one-km walk from a supermarket. Over 9,000 of those households are more than a one-km walk from any food outlet.[44]

 

A “food swamp” on the other hand, is a place where there is an overabundance of unhealthy food options, which like food deserts, is also a problem facing many communities in Toronto:

  • According to a 2015 Toronto Public Health study, most of Toronto’s food swamps are in the inner suburbs.
  • Food swamps are seen in communities with both high and lower incomes. However, the trend becomes especially problematic if residents do not have access to healthy food options, and cannot travel easily to reach them due to economic barriers.[45]

Ideas-and-Innovations

 

Food by Ward project from the Toronto Food Policy Council has extensively researched and mapped food assets by ward across the entire city:

  • The objective is to assist City officials in their planning and to empowering community leaders in their advocacy.
  • The resource pays particular attention to unequal distribution of food assets as well as barriers that residents may encounter when beginning food security programs.
  • To goal is to have a holistic look at the city’s food system.[46]

Example of Ward 2, Etobicoke North at a glance, 2016 [47]

ward-2-food

Ideas-and-Innovations

In one Toronto neighbourhood, residents and an urban agriculture initiative have taken action to turn a food desert into an oasis, implementing a solution that could be replicated in other communities:

  • Since June, a market housed in a retrofitted shipping container has been offering residents of the Moss Park community fresh produce, saving them a 15-minute walk to the closest grocery store.
  • snapshotThe Moss Park Market will operate three days a week, year round, on the grounds of a Toronto Community Housing apartment complex, allowing local vendor Wali Barak to sell a diversity of culturally appropriate foods at lower costs despite Toronto’s high rents.
  • TCHC residents are collaborating on the two-year pilot project with Building Roots, a social venture addressing food security and food literacy.[48]

Ideas-and-Innovations

A “store on wheels” is increasing access to fresh, affordable, and culturally appropriate produce to places where there are less healthy food options within close proximity:

  • The Mobile Good Food Market is a collaboration between Toronto Public Health and FoodShare. In 2015 it travelled to 18 locations in low-income communities across the city.
  • The mobile market is housed in a retrofitted WheelTrans bus donated by the Toronto Transit Commission. In March 2015, City Council approved funding for a second vehicle.[49]

Ideas-and-Innovations

 

The Bowery Project uses milk crates to create mobile farms in vacant lots and community spaces to help grow healthy, accessible food:

  • A proportion of the vegetables grown are donated to community groups in the area and the rest is sold to local restaurants to fund more mobile farms.[50]

Ideas-and-Innovations

 

FoodShare has partnered with Toronto Public Health and the TTC to launch “Grab Some Good”, pop-up food markets with fresh produce and healthy snacks:

  • Downsview, Kipling and Victoria Park subway stations are the first stations for the project roll-out.
  • In its pilot phase in 2016, FoodShare hopes to open more across the subway system.[51]

 

The launch of Grab Some Good popup produce stand at the Downsview TTC station.

Photo credit: FoodShare Toronto

 

Almost one in five babies born in Toronto in 2015 was outside the healthy range for birth weight, putting them at risk of poverty later in life:

  • Babies born at weights below or above normal (for their gestational age) may face risk factors that increase their likelihood of experiencing poverty during their lifetimes.
  • The percentage of babies born at a healthy weight in Ontario has remained steady over the past five years, but data are revealing regional differences.
  • While 81.8% of babies born in Toronto in 2015 were a healthy weight—higher than the 80.5% province wide—10.1% were small (compared to 9.4% province wide) and 8.1% were large (versus 10.1% for Ontario).[52]

 

Percentage of Small and Large Birth Weights By Region, Ontario, 2015 [53]

birth-weight

  • Babies born to low-income families are more likely to be outside the normal range.
  • Extensive evidence has shown a clear link between income and health. Socio-economic circumstances account for 50% of a person’s health.[54]

What Shapes Canadians’ Health, 2015 [55]

what-shapes-health

Ideas-and-Innovations
To keep our city healthy in 2015, one area of focus for Toronto Public Health was preventing and controlling the spread of communicable disease:

  • According to its annual report, in 2015 Toronto Public Health (TPH):
    • investigated 140 suspected cases of communicable diseases, contacted 1,548 people potentially exposed to 10 confirmed cases, and vaccinated 132 people during an Ontario-wide measles outbreak, and monitored 300 returning travellers during the Ebola outbreak;
    • assessed the immunization records of 225,000 children in the 2014/15 school year and sent 113,981 letters to those whose shots were not up to date;
    • administered 29,139 HPV vaccine doses (three are required for full protection) to girls from Grade 8 and up at 1,242 clinics in 414 schools and at 43 community clinics; and
    • established the Communicable Disease Surveillance Unit to monitor public health threats throughout the Pan Am Games. While it detected no significant threats, the unit produced 121 reports and updates during the Games.
  • In addition, TPH inspected over 30 Game venues, eight swimming pools, and over 100 food premises serving 850,00 meals.[56]
  • 35.7% of the population aged 12 and over were immunized against influenza in 2014, up from 33.6% in 2003. The rate is close to the provincial average (35.4%) but slightly higher than the national average (32.5%). Toronto’s influenza immunization rates were at their highest at 42.6% in 2005.[57]

 


 

To learn more about innovative community-based organizations and programs working to address issues relating to health and wellness, check out ckc.torontofoundation.ca.

 

 


 

 

[1] Toronto Public Health (2016). 2015 Annual Report: A Healthy City for All. Last accessed June 1, 2016 from www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-92057.pdf

[2] Toronto Public Health (2016). 2015 Annual Report: A Healthy City for All. Last accessed June 1, 2016 from www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-92057.pdf

[3] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-3: Obesity Rates (Percent) of the Population 18 and Over

[4] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-14: Self-reported Overweight and Obesity Rate (percent) for Youth (12 to 17 years)

[5] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-17: Self-reported Physical Health (percent) for Youth (12 to 19 years)

[6] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-11: Diabetes Rate (Percent of Population 12 and over)

[7] Toronto Public Health (2016). 2015 Annual Report: A Healthy City for All. Last accessed June 1, 2016 from www.toronto.ca/legdocs/mmis/2016/hl/bgrd/backgroundfile-92057.pdf

[8] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-9: Heavy Drinking (Percent of Population, 12 and over)

[9] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-4: Smoking Rates (Percent) for Current Smokers (Population 12 and over)

[10] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-5: Leisure Time Spent Being Physically Active or Moderately Active (Population 12 and over)

[11] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-16-a: Fruit and Vegetable Consumption: population who do not eat recommended fruits and vegetables (percent, population 12 years and over)

[12] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-16-b: Fruit and Vegetable Consumption: Seniors who do not eat recommended fruits and vegetables (percent, population 65 years and over)

[13] World Council on City Data: WCCD Open City Data Portal. (2015). Last accessed August 26, 2016, from http://open.dataforcities.org/. Visit this portal to find further data on this and other subjects for these and other cities.

[14] World Council on City Data: WCCD Open City Data Portal. (2015). Last accessed August 26, 2016, from http://open.dataforcities.org/. Visit this portal to find further data on this and other subjects for these and other cities.

[15] Toronto Central LHIN. (2016). Webpage. Last accessed August 26, 2016 from http://www.torontocentrallhin.on.ca/.

[17] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-2-a: Total Physicians per 100,000 Population.

[17] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-2-b: Family Physicians per 100,000 Population.

[18] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-2-c: Specialist Physicians per 100,000 Population.

[19] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-7: Proportion of the Population (Percent) 12 years and over without a Regular Medical Doctor.

[20] Government of Canada, Statistics Canada. CANSIM Table 105-0501. Geography limited to “City of Toronto Health Unit, Ontario [3595-G],” and Characteristics limited to “Percent.” http://www5.statcan.gc.ca/cansim/a26?lang=eng&retrLang=eng&id=1050501&paSer=&pattern=&stByVal=1&p1=1&p2=-1&tabMode=dataTable&csid=.

[21] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table X-7: Percentage of Population 12 and Over Satisfied or Very Satisfied with Life.

[22] Government of Canada, Statistics Canada. CANSIM Table 105-0501. Geography limited to “City of Toronto Health Unit, Ontario [3595-G],” and Characteristics limited to “Percent.” http://www5.statcan.gc.ca/cansim/a26?lang=eng&retrLang=eng&id=1050501&paSer=&pattern=&stByVal=1&p1=1&p2=-1&tabMode=dataTable&csid=.

[23] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-6-a: Self-rated Mental Health (Population 12 and over).

[24] Special request from Community Foundations of Canada, Toronto Foundation’s national research partner. (2016). NVS Table III-8: Percentage of People with Perceived Life Stress, Quite a Lot (15 years and over).

[25] Ayal Schaffer et al. (2016). Population-based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies. Last accessed July 8, 2016 from: http://onlinelibrary.wiley.com/doi/10.1002/wps.20321/epdf.

[26] Centre for Research on Inner City Health. (February 2015). Reaching Out: Asking about Partner Violence in Toronto Teaching Hospitals. Last accessed September 2, 2016 from http://www.stmichaelshospital.com/crich/wp-content/uploads/finalipvscreeningreportfeb15.pdf.

[27] City of Toronto. (December 9, 2015). City Council Decision. Action on Intimate Partner Violence against Women. Last accessed July 19, 2016 from http://app.toronto.ca/tmmis/viewAgendaItemHistory.do?item=2015.HL8.1.

[28] City of Toronto. (November 16, 2015) Report from the Medical Officer of Health on Action on Intimate Partner Violence against Women. http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-85930.pdf.

[29] City of Toronto. (November 16, 2015) Report from the Medical Officer of Health on Action on Intimate Partner Violence against Women. http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-85930.pdf.

[30] City of Toronto. (November 16, 2015) Report from the Medical Officer of Health on Action on Intimate Partner Violence against Women. http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-85930.pdf.

[31] Centre for Research on Inner City Health. (February 2015). Reaching Out: Asking about Partner Violence in Toronto Teaching Hospitals. Last accessed September 2, 2016 from http://www.stmichaelshospital.com/crich/wp-content/uploads/finalipvscreeningreportfeb15.pdf.

[32] McKeown, David. (September 1, 2015). Overdose in Toronto: Trends, Prevention and Response. Medical Officer of Health: City of Toronto. Last accessed February 29, 2016 from http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-83429.pdf.

[33] McKeown, David. (September 1, 2015). Overdose in Toronto: Trends, Prevention and Response. Medical Officer of Health: City of Toronto. Last accessed February 29, 2016 from http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-83429.pdf.

[34] McKeown, David. (September 1, 2015). Overdose in Toronto: Trends, Prevention and Response. Medical Officer of Health: City of Toronto. Last accessed February 29, 2016 from http://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-83429.pdf.

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