Canadian National Population Health Survey Research Articles

Rating Health and Rating Change: How Canadians Rate Their Health and Its Changes.

Objectives: We investigated the contribution of five health domains to self-rated health (SRH) cross-sectionally and longitudinally and whether these contributions differ by gender or age. Methods: Employing dominance analyses, we quantified the contributions of functioning, diseases, pain, mental health, and behavior to both SRH at a point in time and for changes in SRH using data from the Canadian National Population Health Survey (NPHS, 1994-2011). Results: Cross-sectionally and longitudinally, functioning was the most important health domain, followed by diseases and pain. There were no meaningful differences in the ranking by gender while functioning, diseases, and pain were more relevant in older cohorts. Discussion: Functioning, diseases, and pain systematically were the most important health domains in both cross-sectional and longitudinal analyses. While these results held for women and men, they were more salient for older adults. This points to a gender-invariant but age-graded process, confirming previous research with European data.

Equity in the use of physician services in Canada's universal health system: A longitudinal analysis of older adults

This study presents longitudinal evidence on the trends and determinants of income-related inequities in general practitioner (GP), specialist, and any physician visits among older adults (aged 65+) in Canada. Using the Canadian National Population Health Survey between 1998/99 and 2010/11, random effect probit and negative binomial models were employed to model the probability of visit and the total number of visits, respectively. The concentration index-based horizontal inequity (HI) approach was used to measure income-related inequities in physician services. The decomposition technique was applied to explain the factors contributing to the observed inequities. The mobility index (MI) was also calculated to compare short-run and long-run estimates of inequities. The HI indices reveal significant pro-rich inequities in both the probability and the number of specialist visits. Inequities in the likelihood of GP visits and any physician visits were pro-rich but trivial in magnitude. The MI shows that upwardly income mobile individuals contribute to inequity in specialist visits in the long run. After income, education was the most important contributor to inequity in specialist visits, while unobserved heterogeneity explained most of the pro-rich inequity in the total number of GP and any physician visits. Although physician services are free at the point of the provision in Canada, this study demonstrates that poorer older adults utilized fewer specialist services than richer older adults for the same level of need. Specific policies are needed to ensure equity in specialist care use among the older adults in Canada.

Suboptimal baseline mental health associated with 4-month premature all-cause mortality: Findings from 18 years of follow-up of the Canadian National Population Health Survey

ObjectiveTo investigate: 1) whether baseline non-flourishing mental health is associated with a higher probability of all-cause mortality over 18-year follow-up after controlling for many risk factors for premature mortality; and 2) what other factors, independent of mental health status, are associated with all-cause mortality after adjustment for known risk factors. MethodsData were derived from waves 1 and 9 (1994/1995; 2010/2011) of the Canadian National Population Health Survey. An analytic sample of 12,424 participants 18 years and above was selected. Baseline information on flourishing and predictors of all-cause mortality was from wave 1 and mortality data was ascertained by the Canadian Vital Statistics-Death Database in wave 9. Mean time to all-cause mortality was estimated using Kaplan-Meir procedure. Cox proportional hazards models were used to assess the association of baseline non-flourishing mental health and potential predictors with time to all-cause mortality. ResultsAbout one in five participants was classified as non-flourishing at baseline. At the end of the study period 2317 deaths were observed. Baseline non-flourishing mental health was associated with a 19% higher probability of all-cause mortality during 18-year follow-up (HR = 1.19; 95% CI 1.08–1.32), corresponding to a 4.7-month shorter survival time. After controlling for baseline chronic health conditions, past-year depression, sociodemographics, health behaviors, social support, pain and functioning, baseline non-flourishing mental health status was associated with a 14% higher probability of death (HR = 1.14; 95% CI 1.02–1.27). ConclusionsSuboptimal mental health is associated with premature mortality even after accounting for many risk factors for early death. Future research should explore the physiological pathways through which non-flourishing influences mortality.

Blown off-course? Weight gain among the economically insecure during the great recession

Abstract This paper adds to the “costs of recessions” literature by examining whether the Great Recession caused an increase in body mass index (BMI) among economically insecure working age adults. Using a difference-in-differences (DiD) design and two panels of the Canadian National Population Health Survey, we compare the pre-recession era (2004–2005) with the Great Recession (2008–2009). In addition to stratifying by gender, quantile regressions examine BMI changes at different points along the outcome distribution, and we extend our DiD model to examine how effects vary across income, education, and age. Our results suggest that the increased economic stress of job insecurity or joblessness during the Great Recession caused a 2-point increase in BMI for females, and a 3-point increase for males aged 45–64. Results weakly suggest that lower educated males who were economically insecure during the Great Recession also gained 3 BMI points. For working age Canadians of average height, this translates to a 12 and 20 lb (5.44 and 9.07 kilogram) increase for vulnerable females and males respectively.

The role of education and other transition milestones in the progression of social inequalities in cigarette smoking between the ages of 18 and 25: Evidence from the Canadian National Population Health Survey

Young adulthood is now considered a sensitive period in the progression of health inequalities over the life-course. This age group experiences highly dynamic and socially patterned life-course events that require nuanced modelling choices compared to those commonly used in public health sciences. To illustrate this, we estimate changes in the risk of smoking according to student status, employment status, living arrangements, and relationship status at different ages across education categories. We used longitudinal data in 1,243 young adults followed every two years between the ages of 18–19 and 24–25 in the Canadian National Population Health Survey (1994–95 to 2010–11). We examined the age-graded associations of occasional and daily smoking with educational attainment and transition statuses using random-effects multinomial logistic regression models with interaction terms. Post-secondary education, living with parents, studying, and being in a relationship were associated with a lower risk of daily smoking in main models, with some of these associations significantly varying in magnitude by age. The risk associated with living without parents at ages 18–19 disappeared by ages 24–25. Being single was both a protective factor at ages 18–19 and a risk factor at ages 24–25. Finally, the risk associated with being single was also stronger among those who did not pursue post-secondary education. These findings support the argument that the simple conceptualization of young adults’ circumstances – independent from age and social context – provides a limited understanding of the progression of health inequalities over the life-course. Research needs to consider the dynamic and intersecting nature of transition milestones during this intensive life period.

Health Outcomes Before, During and After the Great Recession in Canada: A Longitudinal Analysis

Using panel data from Canadian National Population Health Survey (2006-2011), this study examined what happened to individuals’ self-reported health during and in the aftermath of great recession of 2008-2009. The study used different methods such as ordered probit method, ordinary least square method and panel fixed effects method. Once individual specific fixed effects are controlled for, the results show that great recession had no statistically significant detrimental impact on self-reported health status. The results further show that health status in the aftermath of great recession did not significantly differ from the health status before the great recession.

Body mass index trajectories among the Canadian workforce and their association with work environment trajectories over 17 years

ObjectiveTo determine the number of latent body mass index (BMI) trajectories from 1994 to 2010 among working Canadians and their association with concurrent trajectories in work environment exposures.MethodsData of employed...

Exploring unmet healthcare needs, healthcare access, and the use of practitioner based complementary and alternative medicine in adults with chronic pain

Background: Chronic pain is a complex condition frequently encountered in nursing practice, resulting in negative multidimensional effects on the individual and healthcare system. Increasingly, people with chronic pain are turning to Complementary and Alternative Medicine (CAM) to manage their pain. Objectives: To explore the relationship between healthcare access, unmet healthcare needs, and practitioner-based Complementary and Alternative Medicine use in adults with chronic pain. Design: A secondary analysis of 1688 individuals ≥18 years old self-reporting chronic pain from Cycle 9 of the Canadian National Population Health Survey. Methods: Multivariate logistic regression and descriptive statistics. Results: When controlling for demographics and health status indicators, the presence of unmet healthcare needs was found to predict CAM use (p < 0.001; OR 2.02; CI [1.45, 2.81]), along with sex, education, income, employment, and restriction of activities. Conclusion: People may be using CAM due to shortcomings of the conventional healthcare system, with implications for policymakers and healthcare professions to develop more integrative strategies to improve chronic pain management. Impact statement: Having unmet healthcare needs is associated with two-fold increased odds of using Complementary and Alternative Medicine in Canadian adults with chronic pain.

Changes in work factors and concurrent changes in leisure time physical activity: a 12-year longitudinal analysis

ObjectivesThere is a paucity of longitudinal population-based studies examining whether changes in work factors are associated with concurrent changes in leisure time physical activity (LTPA). This study examines this issue...

Shared and unique risk factors for depression and diabetes mellitus in a longitudinal study, implications for prevention: an analysis of a longitudinal population sample aged ⩾45 years.

Objective:The objective of this study was to examine shared and unique risk factors for incident depression and diabetes mellitus in a national longitudinal population-based survey.Methods:Canadian National Population Health Survey (NPHS) longitudinal study was used. A subsample of the initial NPHS sample (n = 4845), free of depression or diabetes mellitus at baseline was tracked over a 10-year period. Univariate and multivariate modified Poisson regression models were used to estimate the relative risk (RR). Stratified analyses by sex were conducted to measure its moderating role. The goodness-of-fit of the various models was tested.Results:The cumulative incidence rate of major depressive disorder and incident diabetes mellitus at 10-year follow-up were 4.1% and 10.1% respectively. Hypertension, daily smoking, physical inactivity and being overweight or obese were shared risk factors for major depressive episode and diabetes mellitus. Being female, family stress, traumatic events, having any chronic disease or heart disease were uniquely associated with depression while increasing age and ethnicity (non-white) were unique risk factors for diabetes mellitus. Also, underweight, family stress, chronic disease, and heart disease were risk factors for major depressive disorder in both sexes. Six risk factors, age, ethnicity (non-white), high blood pressure, daily smoking, physical inactivity, and body mass index were associated with incident diabetes mellitus in both sexes.Conclusion:We found common risk behaviors/conditions not specific to either diabetes mellitus or depression. These risks have also been implicated in the development of a variety of chronic diseases. These findings underline the importance of public health prevention programs targeting generic risk behaviors.

Association between dimensions of the psychosocial and physical work environment and latent smoking trajectories: a 16-year cohort study of the Canadian workforce

BackgroundThis study aimed to determine the number of latent smoking trajectories among Canadians employed in the workforce over a 16-year period, and if latent trajectories in dimensions of the physical...

Life expectancy and health-adjusted life expectancy are decreased in people living with inflammatory bowel disease: a population-based matched cohort study

IntroductionInflammatory bowel disease (IBD) is a chronic immune-mediated disease of the gastrointestinal tract. Significant improvements in treatments for IBD have occurred in the past two decades. However, the benefits of new treatments on mortality is uncertain and no prior study has evaluated the life expectancy (LE) of patients with IBD.&#x0D; Objectives and ApproachWe determined trends in the LE and health-adjusted life expectancy (HALE) in IBD. The Ontario Crohn’s and Colitis Cohort includes all patients in Ontario with IBD, identified from health administrative data using a previously validated algorithm. Cases were matched to five controls based on age, sex, rural/urban, and mean neighbourhood income quintile. Period life tables were used to calculate LE on July 1, 1996, 2000, and 2008. The Canadian National Population Health Survey (1996/97) and Canadian Community Health Survey (Cycles 1.1 and 2009/10) were used to estimate health utility index (HUI3). HALE was estimated using HUI3-weighted disability-free years lived.&#x0D; ResultsLE increased from 75.5 years (y) in 1996 to 78.0y in 2008 among women with IBD (∆2.5y, 95%CI 0.8 to 4.1) and from 72.2y in 1996 to 75.1y in 2008 among men with IBD (∆2.9y, 95%CI 1.8 to 4.0). HALE decreased among men with IBD (∆3.9y, 95%CI 1.2 to 6.6; 1996: 67.0y; 2008: 63.1y) but was stable among women with IBD (∆2.0y, 95%CI -1.6 to 5.7; 1996: 62.3y; 2008: 64.3y) and female controls (∆-0.4y, 95%CI -2.3 to 1.5; 1996: 74.3y; 2008: 73.9y) and male controls (∆0.2y, 95%CI -1.7 to 2.2; 1996: 69.6y; 2008: 69.8y). LE and HALE in both men and women with IBD were significantly decreased compared to controls (LE: women ∆6-8y, men ∆5y; HALE: women ∆10-14y, men ∆3-7y).&#x0D; Conclusion/ImplicationsAlthough patients with IBD experienced increases in LE at a pace similar to those without IBD, the gap in LE between cases and controls remains significant. Increases in LE have not been accompanied by increases in HALE. Treatments that increase both LE and HALE in patients with IBD are needed.

Changes in health but not in the general evaluation? The sensitivity of self-rated health to changes

Introduction Since many studies in epidemiology rely on self-rated health (SRH) as a generic measure of health status, studying this indicator is highly relevant for epidemiological research. Problematically, due to SRH's vagueness and the great room for interpretation for respondents, researchers usually do not know what exactly they measure when using this indicator. Firstly, if SRH, as studies suggest, is based on diverging aspects in different social groups (e.g., age-groups or cohorts), interpretations of respective group-differences are called into question. If, for example, younger respondents lay more weight on mental health than older respondents in rating their health, a comparison of SRH for these groups is disputable. Secondly, it is still unclear whether a (lack of) change in subjective health is due to real changes in health or changes in health aspirations. Accordingly, respondents might provide stable health-ratings despite deteriorating health because of lowered standards or changing frames of reference due to older age. For both reasons, more research on group-differences in response behavior and the sensitivity of SRH to changes in health is needed. Method In order to shed light on these issues, this paper analyzes data from the Canadian National Population Health Survey (NPHS). In the NPHS, around 17,000 people have been extensively surveyed biannually from 1994/1995 till 2012 regarding their health. This allows for a detailed analysis of which health-indicators and health-domains respondents use in rating their health and how reported changes in health over time affect changes in SRH. Utilizing dominance analyses, the contribution of five health-domains to R2 in explaining SRH are quantified: functioning, diseases, pain, depression, and risk-behavior. Employing both cross-sectional (OLS-regression models) and longitudinal methods (FE-regression models), this paper analyzes which health-domains are relevant for both SRH at a point in time as well as for their changes in SRH over time. Results Both cross-sectionally (R2 = 0.32 for women and 0.27 for men) and longitudinally (R2 = 0.12 for women and 0.11 for men), functioning was the most important health domain in explaining SRH, followed by diseases and pain. Depression and risk-behavior only played a minor role in evaluating one's current health status as well as changes. There were no meaningful differences in this ranking by gender. However, separate cross-sectional analyses by birth cohort show clear disparities in that functioning and diseases steadily increase in relevance for explaining SRH for older cohorts. The same is true, albeit to a lesser extent, for assessing changes in health. Conclusions This paper shows that there is a clear pattern in how respondents rate their health and that this pattern applies both to rating one's health at a point in time as well as to evaluating changes in health. However, the analyses also show that there are marked differences in how birth cohorts rate their health, highlighting the need to take these differences in rating behavior into account. The results are of great relevance to meaningfully measure generic health status via SRH and thus analyze health trajectories and health inequality.

Trajectories of body mass index among Canadian seniors and associated mortality risk

BackgroundThis study aims to characterize the heterogeneity in BMI trajectories and evaluate how different BMI trajectories predict mortality risk in Canadian seniors.MethodsData came from the Canadian National Population Health Survey (NPHS, 1994–2011) and 1480 individuals aged 65–79 years with at least four BMI records were included in this study. Group-based trajectory model was used to identify distinct subgroups of longitudinal trajectories of BMI measured over 19 years for men and women. Cox proportional hazards models were used to examine the association between BMI trajectories and mortality risks.ResultsDistinct trajectory patterns were found for men and women: ‘Normal Weight-Down’(N-D), ‘Overweight-Normal weight’ (OV-N), ‘Obese I-Down’ (OB I-D), and ‘Obese II- Down’ (OB II-D) for women; and ‘Normal Weight-Down’ (N-D), ‘Overweight-Normal weight’ (OV-N), ‘Overweight-Stable’ (OV-S), and ‘Obese-Stable’ (OB-S) for men. Comparing with OV-N, men in the OV-S group had the lowest mortality risk followed by the N-D (HR = 1.66) and OB-S (HR = 1.98) groups, after adjusting for covariates. Compared with OV-N, women in the OB II-D group with three or more chronic health conditions had higher mortality risk (HR = 1.61); however, women in OB II-D had lower risk (HR = 0.56) if they had less than three conditions.ConclusionThe course of BMI over time in Canadian seniors appears to follow one of four different patterns depending on gender. The findings suggest that men who were overweight at age 65 and lost weight over time had the lowest mortality risk. Interestingly, obese women with decreasing BMI have different mortality risks, depending on their chronic health conditions. The findings provide new insights concerning the associations between BMI and mortality risk.

Population-Based Study of Changes in Arthritis Prevalence and Arthritis Risk Factors Over Time: Generational Differences and the Role of Obesity.

To investigate cohort effects in arthritis prevalence across 4 birth cohorts: World War II (born 1935-1944), older and younger baby boomers (born 1945-1954 and 1955-1964, respectively), and Generation X (born 1965-1974), and to determine whether birth cohort effects in arthritis prevalence were associated with differences in risk factors over time or period effects. Analysis of biannually collected data from the longitudinal Canadian National Population Health Survey, 1994-2011 (n = 8,817 at baseline). Data included self-reported arthritis diagnosed by a health professional, risk factors (years of education, household income, smoking, physical activity, sedentary behavior, body mass index [BMI]), and survey year as an indicator of period. We used hierarchical age-period-cohort analyses to compare the age trajectory of arthritis by birth cohort and to examine the contribution of changes in risk factors and period to cohort differences. More recent cohorts had successively a greater prevalence of arthritis. Risk factors were significantly associated with arthritis prevalence independently of cohort differences. The effects of increasing education and income over time on potentially reducing the arthritis prevalence were almost counter-balanced by effects of increasing BMI. Significant cohort-BMI and age-BMI interactions indicated an earlier age of arthritis onset for obese individuals than those of normal weight. Projections that only take into account the changing age structure of the population may underestimate future trends. Our understanding of the impact of BMI on arthritis is likely an underestimate. Cohort differences focus attention on the need to target arthritis management education to young and middle-aged adults.

Pathway from poor self-rated health to mortality: Explanatory power of disease diagnosis

Poor self-rated health has been consistently demonstrated as a reliable predictor for mortality, often exceeding the predictive power of other “objective” medical factors. Drawing from a theoretical framework for the cognitive processes underlying the self-assessment of health, this study seeks to test the knowledge mechanisms that moderate the predictive power of poor self-rated health. Using nationally-representative longitudinal data from the Canadian National Population Health Survey (NPHS) from 1994 to 2010, this study tests the effects of physician-diagnosed disease for the life course trajectory of self-rated health, and as a moderator for the power of poor self-rated health to predict proximate mortality. Disruptions to self-rated health trajectories are measured using an interrupted time-series analysis. Predictive power is modelled using generalized estimating equation (GEE) logistic regression. Findings show that physician-diagnosed diseases cause a negative shock to self-rated health, even accounting for endogeneity. Furthermore, a major portion of the predictive power of poor self-rated health in the final years of life is explained by respondents' knowledge of the disease conditions which eventually cause their death. This novel finding supports one of the foremost theories putting cognition and knowledge at the root of why poor self-rated health is such a robust predictor of mortality.

Healing and/or breaking? The mental health implications of repeated economic insecurity

Current literature confirms the negative consequences of contemporaneous economic insecurity for mental health, but ignores possible implications of repeated insecurity. This paper asks how much a person's history of economic insecurity matters for psychological distress by contrasting the implications of two models. Consistent with the health capital literature, the Healing model suggests psychological distress is a stock variable affected by shocks from life events, with past events having less impact than more recent shocks. Alternatively, the Breaking Point model considers that high levels of distress represent a distinct shift in life state, which occurs if the accumulation of past life stresses exceeds some critical value. Using five cycles of Canadian National Population Health Survey data (2000–2009), we model the impact of past economic insecurity shocks on current psychological distress in a way that can distinguish between these hypotheses. In our sample of 1775 males and 1883 females aged 25 to 64, we find a robust healing effect for one-time economic insecurity shocks. For males, only a recent one-time occurrence of economic insecurity is predictive of higher current psychological distress (0.19 standard deviations). Moreover, working age adults tend to recover from past accumulated experiences of economic insecurity if they were recently economically secure. However, consistent with the Breaking Point hypothesis, males experiencing three or four cycles of recent insecurity are estimated to have a level of current psychological distress that is 0.26–0.29 standard deviations higher than those who were employed and job secure throughout the same time period. We also find, consistent with other literature, distinct gender differences - for working age females, all economic insecurity variables are statistically insignificant at conventional levels. Our results suggest that although Canadians are resilient to one-time insecurity shocks, males most vulnerable to repeated bouts suffer from elevated levels of psychological distress.

Changes in the use practitioner-based complementary and alternative medicine over time in Canada: Cohort and period effects.

BackgroundThe use of complementary and alternative medicine (CAM) is growing. However the factors contributing to changes over time and to birth cohort differences in CAM use are not well understood.SettingWe used data from 10186 participants, who were aged 20–69 years at the first cycle of data collection in the longitudinal component of the Canadian National Population Health Survey (1994/95-2010/11). We examined chiropractic and other practitioner-based CAM use with a focus on five birth cohorts: pre-World War II (born 1925–1934); World War II (born 1935–1944); older baby boomers (born 1945–1954); younger baby boomers (born 1955–1964); and Gen Xers (born 1965–1974). The survey collected data every two years on predisposing (e.g., sex, education), enabling (e.g., income), behavior-related factors (e.g., obesity), need (e.g., chronic conditions), and use of conventional care (primary care and specialists).ResultsThe findings suggest that, at corresponding ages, more recent cohorts reported greater CAM (OR = 25.9, 95% CI: 20.0; 33.6 for Gen Xers vs. pre-World War) and chiropractic use than their predecessors (OR = 2.2, 95% CI: 1.7; 2.8 for Gen Xers vs. pre-World War). There was also a secular trend of increasing CAM use, but not chiropractic use, over time (period effect) across all ages. Factors associated with cohort differences were different for CAM and chiropractic use. Cohort differences in CAM use were partially related to a period effect of increasing CAM use over time across all ages while cohort differences in chiropractic use were related to the higher prevalence of chronic conditions among recent cohorts. The use of conventional care was positively related to greater CAM use (OR = 1.8, 95% CI: 1.6; 2.0) and chiropractic use (OR = 1.2, 95% CI: 1.1; 1.4) but did not contribute to changes over time or to cohort differences in CAM and chiropractic use.ConclusionThe higher CAM use over time and in recent cohorts could reflect how recent generations are approaching their healthcare needs by expanding conventional care to include CAM therapies and practice for treatment and health promotion. The findings also underscore the importance of doctors discussing CAM use with their patients.

Longitudinal examination of temporality in the association between chronic disease diagnosis and changes in work status and hours worked

ObjectivesTo examine the longitudinal relationship between incidence of diagnosed chronic disease and work status and hours worked.MethodsA dynamic cohort approach was taken to construct our study sample using the Canadian...

Sex Variations in the Effects of Arthritis and Activity Limitation on First Heart Disease Event Occurrence in the Canadian General Population: Results From the Longitudinal National Population Health Survey.

To estimate sex-specific effects of arthritis and activity limitation on incident heart disease in a nationally representative, Canadian longitudinal population-based survey. Information on sociodemographic variables, self-reported physician-diagnosed chronic conditions (including arthritis and heart disease), activity limitations, and traditional risk factors was collected every 2 years from 1994-1995 through 2010-2011 as part of the longitudinal Canadian National Population Health Survey. Deaths due to ischemic heart disease (International Classification of Diseases, Tenth Revision [ICD-10] codes I20-I25) and heart failure (ICD-10 codes I50.0-I50.9) were confirmed against the Canadian Vital Statistics Database. Discrete-time survival analysis stratified by sex was used to estimate effects of arthritis and activity limitation on first heart disease event occurrence. The study included 12,591 participants with no prior history of heart disease and 1,783 incident heart disease events. After adjusting for common risk factors, arthritis was associated with a significant increased risk of incident heart disease in women (adjusted odds ratio [OR] 1.58, 95% confidence interval [95% CI] 1.23-2.02). Even higher risks were reported in women with arthritis and activity limitation (OR 2.19, 95% CI 1.61-2.97). Arthritis was not associated with incident heart disease in men, except for when also reported with activity limitation (OR 1.60, 95% CI 1.14-2.26). Women with arthritis, and men with arthritis and activity limitation, have significant excess risks for developing heart disease in the general population. These findings point to the need for improved access to arthritis care, cardiovascular prevention strategies, particularly in women with arthritis, and directed interventions toward prevention of activity limitation.