Rethinking Women and Healthy Living in Canada A. Pederson M. J. Haworth-Brockman B. Clow H. Isfeld A. Liwander Editors Rethinking Women and Healthy Living in Canada A. Pederson, M. J. Haworth-Brockman, B. Clow, H. Isfeld and A. Liwander Editors British Columbia Centre of Excellence for Women’s Health Prairie Women’s Health Centre of Excellence Atlantic Centre of Excellence for Women’s Health February, 2013 Production of this manuscript has been made possible through a financial contribution from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada. Suggested citation: Pederson, A., Haworth-Brockman, M.J., Clow B., Isfeld, H. and Liwander, A. (eds). (2013). Rethinking women and healthy living in Canada. Vancouver: British Columbia Centre of Excellence for Women’s Health British Columbia Centre of Excellence for Women’s Health E311-4500 Oak Street, Box 48 Vancouver, British Columbia V6H 3N1 Telephone: (604) 875-2633 Fax: (604) 875-3716 Email: Rethinking Women and Healthy Living in Canada A. Pederson, M. J. Haworth-Brockman, B. Clow, H. Isfeld and A. Liwander Editors British Columbia Centre of Excellence for Women’s Health Prairie Women’s Health Centre of Excellence Atlantic Centre of Excellence for Women’s Health February, 2013 Table of Contents Acknowledgements ............................................................................ i Executive Summary ......................................................................... iii Résumé ............................................................................................... v Part One: Overview .......................................................................... 1 Introduction Ann Pederson, Anna Liwander, Barbara Clow and Margaret Haworth-Brockman .......................... 5 The Status of Women in Canada Anna Liwander, Margaret Haworth-Brockman and Ann Pederson .................................................... 13 The Meaning of the Healthy Living Discourse Barbara Clow .................................................................................................................................................. 33 Part Two: A Profile of Women & Healthy Living ........................ 51 Measures of Women and Healthy Living Margaret Haworth-Brockman ..................................................................................................................... 59 Data Sources and Methods Harpa Isfeld ...................................................................................................................................................... 67 Body Weights Meredith Evans and Barbara Clow ............................................................................................................. 73 Eating Well Margaret Haworth-Brockman ..................................................................................................................... 93 Food Insecurity Meredith Evans .............................................................................................................................................. 117 Physical Activity Ann Pederson, Anna Liwander and Wendy Rice .................................................................................. 143 Sedentary Behaviour Anna Liwander, Ann Pederson and Wendy Rice .................................................................................. 165 Smoking Tobacco Anna Liwander, Ann Pederson and Wendy Rice .................................................................................. 187 Drinking Alcohol Anna Liwander, Ann Pederson and Wendy Rice .................................................................................. 205 Sexual Behaviour Margaret Haworth-Brockman ................................................................................................................... 225 Injuries Harpa Isfeld, Margaret Haworth-Brockman and Nicola Schaefer ..................................................... 251 Gender-based Violence and Self-Injury Harpa Isfeld, Margaret Haworth-Brockman and Nicola Schaefer ..................................................... 305 Part Three: Addressing Healthy Living ....................................... 325 Strategies for Healthy Living Barbara Clow, Linda Snyder and Liz Sajdak ........................................................................................... 329 Promising Gender-sensitive Healthy Living Interventions for Women Ann Pederson and Anna Liwander ........................................................................................................... 385 Part Four: Conclusions .................................................................. 409 Conclusions Ann Pederson, Margaret Haworth-Brockman, Barbara Clow and Anna Liwander ...................... 411 Acknowledgements Many individuals have contributed to the development of this report. First and foremost, we want to acknowledge the dedicated team that worked tirelessly on this project, from its inception in 2011 to its launch in 2013: Ann Pederson, Margaret Haworth-Brockman, Barbara Clow, Harpa Isfeld, Anna Liwander and Linda Snyder. Each brought varied skills and insights to the design and execution of the project, which have made the work intellectually challenging, methodologically rigorous, and deeply satisfying. These acknowledgements would not be complete without a note of thanks to Pamela Chalmers at Prairie Women’s Health Centre of Excellence who worked tirelessly to tight deadlines in the design and layout of the final report. We are also deeply indebted to Depeng Jiang, PhD, Assistant Professor, Community Health Sciences, and Director of the Biostatistical Consulting Unit at the University of Manitoba. Depeng worked closely with Harpa Isfeld to ensure that the statistical manipulations of Canadian Community Health Survey (CCHS) data were appropriate for our analyses of female-specific survey data. Thanks also go to Brooke Kinniburgh, Epidemiologist at Perinatal Services BC, for her early input on our analysis plan, and for readily responding to calls for advice on the project. Interpretations of the data were made by the authors and the opinions expressed are not necessarily those of Statistics Canada or Health Canada. We appreciate as well the support of staff at Statistics Canada, including Janet Pantalone and Catherine Dick from Client Services at the Health Statistics Division; Chantale Lamarche from the Physical Health Measures Division; Granda Kopytko from the Agriculture Division; Lisa Adams, Manager - Products and Dissemination for the Canadian Community Health Survey; Edith Préfontaine, Analyst, Canadian Community Health Survey; and staff members of Health Canada, including Susanna Keller, Acting Senior Research Analyst (CADUMS). Thanks are extended to Lisa Smylie and Barbara Clarke at the Public Health Agency of Canada. Ian Fraser at the University of Winnipeg Library provided assistance with the Uniform Crime Reporting Survey and the 2006 Census of Agriculture, and Ray Outair at the Association of Workers’ Compensation Boards of Canada advised us on structuring our request for their program data. Staff at the British Columbia Centre of Excellence for Women’s Health provided invaluable support and administrative assistance. In particular, we thank Wendy Rice for her work on the data analysis of several healthy living topics in this report, Nancy Poole and Lorraine Greaves for their contributions to the chapters on alcohol and tobacco use respectively, and Pamela Ponic for her contribution to the section on trauma- informed physical activity. We also thank Marie Dussault for her work on the résumé, report cover and other work related to this project, Katherine Nichol for her review of the literature on gender-sensitive promising practices, and Jen Dewar for her work on the references. Nancy Poole, Ginny Gonneau and Tasnim Nathoo ACKNOWLEDGEMENT S i have also been most helpful with the chapter on promising gender-sensitive interventions in healthy living and Jocelyn Wentland has contributed to various aspects of this project. We would also like to acknowledge the tremendous support of Elaine Littmann from Working Design for her creative design work and for remaining flexible about the cover throughout the project and to thank Annie Bourret for her translation of the Executive Summary. In addition, we would like to acknowledge Michael Pennock, Epidemiologist with Population and Public Health at the Provincial Health Services Authority for providing public use microdata files from CTUMS. Additional thanks to research staff at Prairie Women’s Health Centre of Excellence for this project include our appreciation to Nicola Schaefer for her literature reviews and analysis, Aynslie Hinds for contributions to analyses of some data sets and Alexandria O’Toole for her assistance while at PWHCE as a student intern. At the Atlantic Centre of Excellence for Women’s Health, Meredith Evans led the research on and writing of the body weights and food security chapters and Andrea Papan contributed her expertise in food security to the analysis. Linda Snyder worked closely with Liz Sajdak, consultant from The Quaich, Inc., to review policies and programs related to healthy living and to undertake consultations with key stakeholders. We would also like to acknowledge the First Nations Information Governance Centre for their interest in the project and their efforts to support collaboration and data access, which unfortunately could not be pursued within the time frame and budget available. The Centres of Excellence for Women's Health received funding for this project from Health Canada. The views expressed herein do not necessarily represent the views of Health Canada. Layout and design by Pamela Chalmers. Cover design by Working Design. i i RETHINKING WOMEN AND HEALTHY LIVING IN CANAD A Executive Summary In 2005, Canada’s Federal, Provincial and Territorial governments released the Integrated Pan-Canadian Healthy Living Strategy (Strategy). The aim of the Strategy is to demonstrate and affirm a consensus across jurisdictions on the need for action on common chronic disease risk factors and the underlying conditions in society that contribute to them. The Strategy emerged largely because of concerns over reported increases in rates of overweight and obesity among the Canadian population and their association with chronic disease. The emphasis of the Strategy is on physical activity, healthy eating and healthy weights, and governments have established benchmarks within the three areas explicitly aimed at increasing the proportion of Canadian adults who engage in regular physical activity and report eating fruits and vegetables five or more times per day. Although all provinces and territories in the country, with the exception of Quebec, signed on to the Strategy, no single approach to addressing the goals was adopted and jurisdictions have responded differently to the challenge of meeting these benchmarks. Since the endorsement of the Strategy, two progress reports have been published indicating that there has been slight, if any, improvement in the target behaviours. Three Centres of Excellence – the BC Centre of Excellence for Women’s Health, Prairie Women’s Health Centre of Excellence, and the Atlantic Centre of Excellence for Women’s Health – have followed the developments of the healthy living discourse and federal and provincial healthy living strategies to examine current efforts to promote healthy living in Canada from the perspective of women. This project was inspired by a decade and a half of work on women’s health that has been conducted by our three Centres. During these years we saw relatively little critical discussion of women’s health built upon a comprehensive sex- and gender-based analysis (SGBA), despite mounting evidence of the value of SGBA. In response, we have championed the theory and practice of SGBA and developed resources, learning tools and myriad analyses of health topics and issues to illustrate its value. This particular report is another element of that legacy of research for action and change. In this report, we analyze the sex, gender, diversity and equity dimensions of healthy living among women in Canada, looking at the healthy living discourse, key healthy living topics and selected healthy living strategies. The report consists of four parts; (1) the status of women in Canada and the discourse of healthy living; (2) a profile of healthy living among women in Canada; (3) an examination of selected healthy living strategies and practices in Canada and promising gender-sensitive interventions in healthy living for women; and (4) recommendations for future directions in research, policy development, program design and delivery for women in Canada. EXECUTIVE SUMMARY i i i We begin with a look at international measures of gender equality and a demographic profile of women in Canada to provide context for our analyses. We describe the key features of the healthy living discourse, a history of its emergence in Canada, and examine the extent to which it can or does address the needs and experiences of diverse populations of women. Profiles of women and healthy living are provided for ten topic areas in the second section, three of which are conventionally understood as the core of healthy living—body weights, healthy eating and physical activity. Seven additional topics are discussed as they are important to a fuller understanding of women’s health: food insecurity, sedentary behaviour, alcohol use, tobacco use, sexual behaviour, injuries and gender-based violence. Drawing on national survey data, key reports and published literature, we present the current evidence about women in Canada for each of the topics. The third section of the report examines selected healthy living strategies including the federal strategy and strategies from Ontario, Manitoba, Prince Edward Island and British Columbia. While several strategies note the importance of factoring in the determinants of health – which include sex and gender – many do not, and it appears that there is limited attention to women and the particular challenges and opportunities they encounter in their efforts to engage in many aspects of healthy living. Finally, we provide a description of some interventions that may offer direction for new approaches to healthy living programming for women, including promising gender-sensitive practices such as trauma-informed physical activity. The evidence presented in this report suggests that there are enormous challenges to achieving the targets established by provincial and federal healthy living policies. Our review of several healthy living strategies confirms that they have not typically embraced women as a distinct population of interest although women are often implicitly – and negatively – the targets of such strategies. In addition, many strategies do not address the root causes of health problems that arise from the physical, social and environmental conditions in which women in Canada live, work and play. By ignoring salient differences between women and men as well as among women, healthy living policies run the risk of deepening inequity and causing harm to women. Thus “healthy living” needs to be reframed, to embrace a broader understanding of health and health issues. iv RETHINKING WOMEN AND HEALTHY LIVING IN CANAD A