Assignment 3

Ace your studies with our custom writing services! We've got your back for top grades and timely submissions, so you can say goodbye to the stress. Trust us to get you there!


Order a Similar Paper Order a Different Paper

Although Canada is contiguous to the United States and has some cultural and historical similarities, Canada’s population enjoys a vastly superior health status. Reasons are many, can be traced historically, and are related to a different view of the role of government. The experience of Canada demonstrates that neither a heterogeneous population, nor a health system that has waiting lines for services, are reasons for poor health. By looking critically at what produces good health in Canada, much can be learned about steps the U.S. might need to take if population health is its goal.

The Canadian Best Practices Portal challenges Canadian public health practitioners and researchers to create upstream interventions aimed at the source of a population health problem or benefit. What is being done to address the influences on population health in Canada?

To prepare for this Assignment, review your Learning Resources. Search the Internet and scholarly research for examples of Canadian “upstream interventions” that can be put forth as examples of either effective or ineffective efforts to improve population health.

The Assignment (2–4 pages):

  • Provide a description of an existing intervention in Canada, intended to improve health inequities. Include an explanation of the inequity and how the intervention targets upstream determinants of health.
  • Describe the organizations involved and/or social policies enacted in the implementation of the intervention.
  • Explain whether or not the intervention was/is successful and what lessons public health practitioners can learn from that experience that might improve population health in the United States.
  • Expand on your insights utilizing the Learning Resources.

Use APA formatting for your Assignment and to cite your resources.

Resources..

https://www.canada.ca/en/public-health.html

https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-36-no-10-2016/describing-population-health-burden-depression-health-adjusted-life-expectancy-depression-status-canada.html

https://www.who.int/countries/can/

14 Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018 • Statistics Canada, Catalogue no. 82-003-X
Health-adjusted life expectancy in Canada • Research Article

Abstract
Background: Over the past century, life expectancy at birth in Canada has risen substantially. However, these gains in the quantity of life say little about gains
in the quality of life.
Methods: Health-adjusted life expectancy (HALE), an indicator of quality of life, was estimated for the household and institutional populations combined every
four years from 1994/1995 to 2015. Health status was measured by the Health Utilities Index Mark 3 instrument in two national population health surveys, and
was used to adjust life expectancy. The percentage of the population living in health-related institutions was estimated based on the Census of Population.
Attribute-deleted HALE was calculated to determine how various aspects of health status contributed to the differences between life expectancy and HALE.
Results: HALE has increased in Canada. Greater gains among males have narrowed the gap between males and females. The ratio of HALE to life
expectancy changed little for males, and a marginal improvement was observed for females aged 65 or older. Mobility problems and pain, the latter mainly
among females, accounted for an increased share of the burden of ill health over time. Exclusion of the institutional population significantly increased the
estimates of HALE and yielded higher ratios of HALE to life expectancy.
Interpretation: Although people are living longer, the share of years spent in good functional health has remained fairly constant. Data for both the household
and institutional populations are necessary for a complete picture of health expectancy in Canada.

Keywords: Gender differences, health expectancy, Health Utility Index, morbidity, mortality, summary measures of health

Authors: Tracey Bushnik ([email protected]) and Michael Tjepkema are with the Health Analysis Division and Laurent Martel is with the Demography
Division at Statistics Canada, Ottawa, Ontario.

Health-adjusted life expectancy in Canada
by Tracey Bushnik, Michael Tjepkema and Laurent Martel

Over the past century, life expectancy at birth in Canada has risen substantially to 79.8 years for males, and 83.9 years
for females.1,2 These increases in the quantity of life say little
about the quality of life. How quality of life is keeping pace
with the increase in life expectancy is an important health
indicator.3,4

Health expectancy is a summary indicator that incorporates
information on mortality (such as life expectancy) and health
status (such as morbidity) into a single estimate that can be
considered a measure of quality of life.5-7 Health expectancy rep-
resents the number of years of life lived in good health that could
be expected,4 based on the average experience in a population if
current patterns of mortality and health states persisted.3,7,8

Several Canadian studies have estimated health expectancy
using various measures of health status (such as health utility
indices, prevalence of disability, incidence of disease) and data
sources.3,9-15 The most recent study found that, in general, the
health expectancy of the population living in private households
was relatively stable from 1994 to 2010, and that absolute gains
in health expectancy were due mainly to a decrease in mortality
with little change in morbidity.14 However, a limitation of this
and many other studies is exclusion of the institutional popula-
tion, who are more likely to be in ill health; excluding them may
create an overly optimistic picture of population health.16

This study calculates health-adjusted life expectancy (HALE)
for the combined household and institutional population every
four years from 1994/1995 to 2015. Trends over time in health
status, life expectancy, and HALE are examined. Health status is
estimated using the Health Utilities Index Mark 3 (HUI3) instru-
ment,17 which has been used for previous estimates of HALE in
Canada.10,12-15 The study also discusses how HALE has changed
relative to life expectancy. To better understand how specific
aspects of health status contribute to differences between HALE
and life expectancy, attribute-deleted HALE is estimated and
assessed over time.

Methods
Data sources

National Population Health Survey and Canadian
Community Health Survey
Estimates for the HUI3 are derived from responses to the
1994/1995 and 1998/1999 National Population Health Survey
(NPHS), and the 2001, 2005, 2009/2010 and 2015 Canadian
Community Health Survey (CCHS). Information about the
NPHS and the CCHS is available at www.statcan.gc.ca, and is
summarized briefly here.

The target population of the NPHS Household component was
residents of private households in the ten provinces, excluding
residents of Indian Reserves, Crown Lands, some remote areas
in Ontario and Quebec and health institutions, and full-time
members of the Canadian Forces. The selected household/
selected person response rates for the 1994/1995 and 1998/1999
NPHS were 88.7%/96.1% and 87.6%/98.5%, respectively. The
target population of the 1994/1995 NPHS Institution component
consisted of residents of health institutions (long-term, at least
four beds, and residents not autonomous) sampled in five geo-
graphic regions (Atlantic Provinces, Quebec, Ontario, Prairie
Provinces, and British Columbia) from three types of institu-
tion: institutions for the aged; cognitive institutions; and other
rehabilitative institutions. The selected institution/selected resi-
dent response rates in 1994/1995 were 95.5%/93.6%.

The CCHS covers the population aged 12 or older in the ten
provinces and three territories. Residents of Indian Reserves,
Crown lands, certain remote regions and institutions and full-
time members of the Canadian Forces are excluded; together
these exclusions represent less than 3% of the target population.
The combined household/selected person response rates for the
2001, 2005, 2009/2010, and 2015 CCHS were: 84.7%; 78.9%;
72.3% and 57.5%.

15Statistics Canada, Catalogue no. 82-003-X • Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018
Health-adjusted life expectancy in Canada • Research Article

What is already
known on this
subject?

■ Life expectancy has increased
substantially in Canada over the past
century

■ Life expectancy describes quantity
of life, whereas health-adjusted life
expectancy (HALE) describes quality
of life

■ As of 2010, there has been little
evidence of a faster increase in
HALE than in life expectancy among
the household population.

What does this study
add?

■ Between 1994/1995 and 2015, HALE
increased in Canada.

■ The gap between males and females
in life expectancy and in HALE
narrowed because of greater gains
by males.

■ Males spent a larger share of their
years of life in good functional health,
compared with females.

■ The percentage of years in good
functional health was relatively
unchanged over time for males, with
a marginal improvement for females
aged 65 or older.

■ The importance of sensory problems
declined, while mobility problems
and pain accounted for an increased
share of the burden of ill health.

■ Excluding the institutional population
significantly increased estimates of
HALE, resulting in higher ratios of
HALE to life expectancy, particularly
for people aged 65 or older.

49,747 (2015 – excludes the territories).
As well, 2,283 out of 2,287 institu-
tional respondents had a valid HUI3
in 1994/1995, 713 of which had been
imputed.

Census of Population
The Census of Population enumerates
the entire population, which consists
of Canadian citizens (by birth and by
naturalization), landed immigrants and
non-permanent residents and their fam-
ilies living with them in Canada (detailed
information is available at www12.
statcan.gc.ca/census-recensement/2016/
ref/index-eng.cfm). The census collected
information on dwelling type (private or
collective); type of collective dwelling
was used to estimate the percentage of
the population living in health-related
institutions in 1996, 2001, 2006, 2011,
and 2016.

Life tables
Life tables use provincial and territorial
mortality data from the Vital Statistics–
Death Database and population estimates
to calculate life expectancy at birth and at
different ages, death probabilities, prob-
abilities of survival between two ages,
years of life lived, and the number of
survivors at different ages.18 Life expect-
ancy and HALE were estimated for each
survey year using complete (by single-
year-of-age) life table data for males and
females for 1993-to-1995, 1997-to-1999,
2000-to-2002, 2004-to-2006, 2009-to-
2011, and 2013-to-2015.2

Measures

Health Utilities Index Mark 3 (HUI3)
The Health Utilities Index Mark 3
(HUI3) measures eight attributes of
self-reported health status: vision,
hearing, speech, ambulation, dex-
terity, emotion, cognition, and pain.17
A respondent’s attribute levels—from
normal to highly impaired—are sum-
marized by a weighted scoring function
into a single value representing their
overall health state. The value can range
from -0.36 (state worse than death; death
represented by 0) to 1.00 (best possible
health state).

This study uses data from respondents
with a valid HUI3. In general, the
household non-response rate for HUI3
was less than 1% in any survey year,
resulting in the following sample sizes
for this analysis: 15,989 (1994/1995);
16,408 (1998/1999); 129,834 (2001);
30,809 (2005); 121,606 (2009/2010) and

Institutional population
For this study, the institutional popula-
tion was defined as individuals living in
the following types of health-related col-
lective dwellings on census day: general
and specialty hospitals (including
chronic care, short- or long-term care);
nursing homes; residences for senior cit-
izens; group homes or institutions for the
physically handicapped and treatment
centres; and group homes and institutions
or residential care facilities for people
with psychiatric disorders or develop-
mental disabilities. Individuals not living
in such dwellings were considered to be
in the household population.

Statistical analysis

Health-adjusted life expectancy
(HALE)
To estimate HALE, mean HUI3 scores
by sex and age group were tabulated
for the household population in each
survey year and the institutional popu-
lation in 1994/1995. Age groups were:
0 to 11 (for the household population
in 1994/1995 and 1998/1999, the mean
value for 4- to 11-year-olds was assigned
to the entire 0-to-11 age group, and the
mean value from 1998/1999 was carried
forward to all subsequent years), 12 to 14
(HUI3 is available in the CCHS starting
at age 12), 15 to 24, 25 to 34, 35 to 44,
45 to 54, 55 to 64, 65 to 74, 75 to 84, and
85 or older. Survey weights were applied
so that the mean HUI3 estimates were
representative of the health status of the
underlying target populations by sex and
age group, and bootstrap weights were
applied so that the standard errors were
estimated taking into account each sur-
vey’s complex design.19

The percentages of people living in
private households and in health-related
institutions were estimated by sex and
age group using census data. Mean HUI3
scores (by sex and age group) for the
household population (HUI3 household)
in each survey year were multiplied by the
percentage in households by sex and age
group estimated from each census year
as follows (survey year*census year):
1994/1995*1996; 1998/1999*1996;
2001*2001; 2005*2006; 2009/2010*2011

16 Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018 • Statistics Canada, Catalogue no. 82-003-X
Health-adjusted life expectancy in Canada • Research Article

and 2015*2016. For the institutional
population, the mean HUI3 scores (by
sex and age group) in 1994/1995 (HUI3
institution) were carried forward to all
subsequent survey years, multiplied by
the percentage by sex and age group in
health-related institutions estimated from
each census year as shown above. The
resulting two values—HUI3 household
and HUI3 institution—were summed to
provide overall HUI3 scores by sex and
age group for each survey year. The vari-
ance of the overall HUI3 score by sex
and age group was estimated from the
sum of the variance of HUI3 household
multiplied by the square of the percentage
in households and the variance of HUI3
institution multiplied by the square of the
percentage in institutions.

HALE was estimated for each survey
year using a modified version of the
Sullivan method.20 The life expectancy
information from each three-year set of
complete life tables by sex was weighted
by the number of life-years lived at a par-
ticular age x using the mean HUI3 for that
age. The sum of the adjusted life-years
beyond age x was then divided by the
number of survivors at that age to yield
HALE by age and sex.6 The variance of
HALE was estimated using the method
proposed by Mathers,21 which takes sto-
chastic fluctuations in the observed death
probabilities and the mean global HUI3
scores into account.

Attribute-deleted HALE
Attribute-deleted HALE for the house-
hold and institutional populations was
estimated for 1994/1995 and 2015 to
determine how much of the difference
between HALE and life expectancy
was ascribed to each HUI attribute. To
produce attribute-deleted HALE, the
overall HUI3 score was recalculated for
the household and institutional popu-
lations separately six times, each time
assigning a perfect score (1.0) to one
attribute but leaving the others at their
actual levels. Vision, hearing, and speech
were combined into “sensory.”

There were no missing values for the
household population in 1994/1995 or
2015, but for the 1994/1995 institutional
population, missing values for each

attribute—vision (n = 271), hearing (n =
117), speech (n = 60), ambulation (n =
20), dexterity (n = 50), emotion (n = 185),
cognition (n = 95), and pain (n = 137)—
were assigned the average score by sex
and age group from those with complete
data for that attribute. The HUI3 esti-
mates for the institutional population in
1994/1995 were carried forward to 2015.

The attribute-deleted HUI3 estimates
for the household and institutional popu-
lations in each survey year were summed
to provide an overall attribute-deleted
HUI3 score by sex and age group in
1994/1995 and 2015.

Sensitivity analyses
The estimates of HUI3 for the insti-
tutional population that were used to
calculate HALE in 2015 were adjusted to
reflect three scenarios: 0.03 added to each
institutional respondent’s HUI3 score
from 1994/1995; 0.03 subtracted from
each HUI3 score; and the score replaced
by HUI3 values derived from the 2012
interRAI assessments of the nursing
home population in Ontario.22 The
amount 0.03 was selected because it is the
smallest difference in HUI3 that reflects

a meaningful change.23 Adjusted mean
values of HUI3 (up, down, and replaced)
were estimated by sex and age group, and
then multiplied by the percentage of the
population living in institutions in 2016
and combined with the HUI3 values for
the CCHS household population in 2015
for an overall HUI3 estimate. HALE in
2015 was then recalculated. A second
sensitivity analysis excluded the HUI3
estimates for the institutional population
from the HALE estimated at each period,
thereby limiting the results to the house-
hold population.

Results
Health status of household and
institutional populations
In 2015, the average HUI3 of men and
women in the household population
who were younger than 65 was similar
to that in 1994/1995 (Table 1). For those
aged 65 or older, the average HUI3 in
2015 was higher than in 1994/1995.

Owing to the increased likelihood of
institutionalization with advancing age,
estimates for household residents are less
representative of the older population. In

Table 1
Mean HUI3 scores, by sex and age group, household and institutional population,
Canada, 1994/1995, 1998/1999, 2001, 2005, 2009/2010 and 2015

Sex/Age
group

Household population
Institutional
population

1994/1995 1998/1999 2001 2005 2009/2010 2015 1994/1995
Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE

Males
15 to 24 0.889 0.007 0.940 0.005 0.915 0.002 0.897 0.005 0.913 0.002 0.892 0.006 0.556 0.192
25 to 34 0.900 0.006 0.943 0.004 0.919 0.003 0.915 0.004 0.916 0.003 0.902 0.004 0.193 0.060
35 to 44 0.897 0.006 0.922 0.006 0.903 0.002 0.900 0.006 0.904 0.003 0.898 0.004 0.331 0.050
45 to 54 0.872 0.007 0.894 0.006 0.879 0.003 0.883 0.007 0.882 0.003 0.873 0.004 0.308 0.081
55 to 64 0.847 0.010 0.873 0.008 0.858 0.004 0.861 0.007 0.865 0.004 0.852 0.006 0.345 0.072
65 to 74 0.816 0.010 0.806 0.011 0.832 0.004 0.856 0.007 0.850 0.003 0.849 0.006 0.219 0.038
75 to 84 0.753 0.019 0.740 0.023 0.753 0.008 0.771 0.013 0.788 0.006 0.782 0.010 0.146 0.024
85 or older 0.592 0.053 0.644 0.056 0.591 0.019 0.619 0.042 0.627 0.024 0.614 0.033 0.170 0.030

Females
15 to 24 0.882 0.007 0.933 0.004 0.907 0.002 0.895 0.005 0.906 0.003 0.872 0.005 0.584 0.181
25 to 34 0.895 0.006 0.912 0.009 0.908 0.002 0.904 0.005 0.918 0.002 0.900 0.004 0.138 0.070
35 to 44 0.889 0.006 0.910 0.005 0.888 0.002 0.898 0.005 0.898 0.003 0.878 0.005 0.155 0.065
45 to 54 0.839 0.009 0.875 0.009 0.862 0.003 0.874 0.005 0.863 0.004 0.850 0.007 0.305 0.079
55 to 64 0.828 0.009 0.849 0.009 0.845 0.003 0.850 0.006 0.849 0.003 0.836 0.006 0.265 0.070
65 to 74 0.787 0.014 0.823 0.009 0.826 0.004 0.836 0.007 0.832 0.003 0.825 0.006 0.196 0.038
75 to 84 0.708 0.016 0.727 0.016 0.729 0.006 0.758 0.012 0.762 0.006 0.762 0.009 0.157 0.025
85 or older 0.571 0.036 0.572 0.033 0.588 0.014 0.584 0.028 0.629 0.012 0.620 0.019 0.097 0.016

HUI3 = Health Utility Index Mark 3
SE = standard error
Sources: 1994/1995 and 1998/1999 National Population Health Survey; 2001, 2005, 2009/2010 and 2015 Canadian Community
Health Survey.

17Statistics Canada, Catalogue no. 82-003-X • Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018
Health-adjusted life expectancy in Canada • Research Article

2016, 5.7% of men and 9.1% of women
aged 75 to 84, and 23.1% of men and
35.6% of women aged 85 or older lived
in health-related institutions.

According to the 1994/1995 NPHS,
the average HUI3 of the institutional
population was substantially lower
than that of the household population

(Table 1). For men aged 75 to 84, average
HUI3 was .146 for the institutional popu-
lation versus .753 for the household
population; for men aged 85 or older, the
figures were .170 versus .592. Similar
differences were observed for women in
these age groups: .157 versus .708, and
.097 versus .571.

Life expectancy and HALE
Between 1994/1995 and 2015, life
expectancy and HALE increased among
both sexes and at all ages (Appendix
Table A). Male life expectancy at birth
rose from 74.9 to 79.8 years, and HALE,
from 65.0 to 69.0 years (Figure 1).
Females’ life expectancy at birth

Figure 1
Life expectancy and health-adjusted life expectancy (HALE) at birth, by sex, household and institutional populations combined,
Canada, 1994/1995, 1998/1999, 2001, 2005, 2009/2010 and 2015

Sources: 1994/1995 and 1998/1999 National Population Health Survey; 2001, 2005, 2009/2010 and 2015 Canadian Community Health Survey; 1996, 2001, 2006, 2011 and 2016 Census
of Population; life tables for 1993-to-1995, 1997-to-1999, 2000-to-2002, 2004-to-2006, 2009-to-2011 and 2013-to-2015.

years
Males

years
Females

Life expectancy HALE

60

64

68

72

76

80

84

1994/1995 1998/1999 2001 2005 2009/2010 2015
60

64

68

72

76

80

84

1994/1995 1998/1999 2001 2005 2009/2010 2015

Figure 2
Increase in life expectancy and health-adjusted life expectancy (HALE) between 1994/1995 and 2015 at selected ages, by sex,
household and institutional populations combined, Canada

Sources: 1994/1995 National Population Health Survey; 2015 Canadian Community Health Survey; 1996 and 2016 Census of Population; life tables for 1993-to-1995 and 2013-to-2015.

age
Males

age
Females

Life expectancy HALE

Increase in years Increase in years
0 1 2 3 4 5

At birth

20

35

45

55

65

75

85

0 1 2 3 4 5

At birth

20

35

45

55

65

75

85

18 Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018 • Statistics Canada, Catalogue no. 82-003-X
Health-adjusted life expectancy in Canada • Research Article

increased from 80.9 to 83.9 years, and
HALE, from 67.8 to 70.5 years.

Among males, the absolute increase
was greater for life expectancy than for
HALE (Figure 2). For example, during
the past 20 years, at age 65, men gained
3.3 years of life expectancy and 2.7 years
of HALE. By contrast, among females,
the absolute increase in life expectancy
and HALE was similar but lower than for
males. Consequently, the gap between
males and females in years of life expect-
ancy and HALE has narrowed over time.

HALE relative to life expectancy
The ratio of HALE to life expectancy—
the percentage of years spent in good
functional health—changed marginally
between 1994/1995 and 2015 (Figure 3).
Change among males was negligible
at all ages, whereas among females, a
modest gain was apparent at age 65 or
older. Nevertheless, at all ages and at all
time points, a smaller share of females’
remaining years was spent in good health
compared with males. For example,
in 1994/1995 and in 2015, at age 20,
females could expect to spend 81% of
their remaining years in good health; the
percentage for males was 85%.

Attribute-deleted HALE
The HUI3 is comprised of six health
attributes: sensory, mobility, dexterity,
emotion, cognition, and pain. The rela-
tive importance of each in explaining
the difference between HALE and life
expectancy (years of ill health) varied by
age and sex, and over time. At age 20,
for both sexes, pain was a greater source
of diminished health in 2015 than it had
been in 1994/1995 (Table 2). The relative
importance of mobility also increased
slightly, while that of sensory problems
declined.

At age 65, mobility became a more
important source of diminished health for
males; mobility and pain became more
important for females (Table 2). Sensory
problems declined in relative importance
for seniors of both sexes.

When estimates of attribute-deleted
HALE were restricted to the household
population, in both periods (1994/1995
and 2015), the percentage of years in ill

health due to pain was higher at both ages
(at age 20 and at age 65), while the per-
centage assigned to the combined effect
of multiple attributes (the residual) was
lower (results not shown).

Sensitivity analyses
Recalculating HALE in 2015 by
assuming a 0.03 increase or a 0.03
decrease in individual HUI3 for the insti-
tutional population from 1994/1995, or
by using the HUI3 based on the 2012

interRAI assessments, had little effect on
HALE, even at the oldest ages (results not
shown). Recalculating HALE excluding
the institutional population, however,
resulted in increased values, particularly
among females (results not shown). It
also yielded higher ratios of HALE to
life expectancy for both sexes (Figure 4).
The exclusion had little effect on ratios
at birth or at age 20, but at older ages,
it resulted in a larger share of remaining
years in good functional health.

Figure 3
Ratio of health-adjusted life expectancy (HALE) to life expectancy (LE) at selected
ages, by sex, household and institutional populations combined, Canada, 1994/1995,
1998/1999, 2001, 2005, 2009/2010 and 2015
HALE/LE

Sources: 1994/1995 and 1998/1999 National Population Health Survey; 2001, 2005, 2009/2010 and 2015 Canadian
Community Health Survey; 1996, 2001, 2006, 2011 and 2016 Census of Population; life tables for 1993-to-1995, 1997-to-1999,
2000-to-2002, 2004-to-2006, 2009-to-2011 and 2013-to-2015.

Males

At birth

Age 20

Age 35

Age 45

Age 55

Age 65

Age 75

Age 85+

Females

At birth

Age 20

Age 35

Age 45

Age 55

Age 65

Age 75

Age 85+

0.35

0.45

0.55

0.65

0.75

0.85

1994/1995 1998/1999 2001 2005 2009/2010 2015

0.35

0.45

0.55

0.65

0.75

0.85

1994/1995 1998/1999 2001 2005 2009/2010 2015

19Statistics Canada, Catalogue no. 82-003-X • Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018
Health-adjusted life expectancy in Canada • Research Article

Table 2
Difference (years) between life expectancy and health-adjusted life expectancy at
ages 20 and 65, by sex and HUI3 attribute, household and institutional population
combined, Canada, 1994/1995 and 2015

Attribute
and sex

Age 20

Attribute
and sex

Age 65
1994/1995 2015 1994/1995 2015

Years % Years % Years % Years %

Males Males
Overall† 8.6 100.0 9.4 100.0 Overall† 4.1 100.0 4.7 100.0
Cognition 2.3 26.7 2.4 25.5 Sensory 1.0 24.4 1.0 21.3
Pain 1.8 20.9 2.2 23.4 Pain 0.8 19.5 0.9 19.1
Sensory 1.7 19.8 1.5 16.0 Cognition 0.8 19.5 0.9 19.1
Emotion 1.2 14.0 1.1 11.7 Mobility 0.4 9.8 0.6 12.8
Mobility 0.5 5.8 0.7 7.4 Emotion 0.3 7.3 0.3 6.4
Dexterity 0.1 1.2 0.1 1.1 Dexterity 0.1 2.4 0.1 2.1
Residual‡ 1.0 11.6 1.4 14.9 Residual‡ 0.7 17.1 0.9 19.1
Females Females
Overall† 11.9 100.0 12.1 100.0 Overall† 6.6 100.0 6.7 100.0
Cognition 2.7 22.7 2.8 23.1 Sensory 1.4 21.2 1.0 14.9
Pain 2.6 21.8 3.2 26.4 Pain 1.2 18.2 1.4 20.9
Sensory 2.2 18.5 1.7 14.0 Cognition 1.2 18.2 1.1 16.4
Emotion 1.3 10.9 1.1 9.1 Mobility 0.8 12.1 1.1 16.4
Mobility 0.9 7.6 1.2 9.9 Emotion 0.4 6.1 0.4 6.0
Dexterity 0.2 1.7 0.1 0.8 Dexterity 0.1 1.5 0.1 1.5
Residual‡ 1.9 16.8 2.0 16.5 Residual‡ 1.5 22.7 1.6 23.9
† sum of differences assigned to each attribute, plus residual
‡ contribution of combined effects of multiple attributes
HUI3 = Health Utilities Index Mark 3
Note: Percentages may not add up to 100 due to rounding.
Sources: 1994/1995 National Population Health Survey and 2015 Canadian Community Health Survey; 1996 and 2016 Census
of population; life tables for 1993-to-1995 and 2013-to-2015.

The present study measured health
expectancy using the Health Utilities
Index Mark 3 (HUI3) instrument, which
assigns an overall score to a respondent’s
self-reported level of impairment associ-
ated with sensory (vision, hearing, and
speech), ambulation, dexterity, emotion,
cognition, and pain. Over time, sensory
problems accounted for a smaller share
of the burden of ill health for both sexes,
while mobility problems increased in
relative importance. A decline in the
prevalence of sensory problems has also
been reported in the United States,31 as
has an increase in mobility disability.32
The present study found that pain
accounted for a greater share of ill health
among females, whereas Stewart et al.27
reported a decrease in pain prevalence
between 1987 and 2008. This differ-
ence might reflect how pain was defined.
The Stewart study pertained to pain that
interfered with normal work, but pain in
the present study prevented activities in
general.

If morbidity is compressed into a
shorter period before death, the impact
is less severe than if longer life involved
many years of costly care and treat-
ment of illness and disability.31 The
present study found that the ratio of
HALE to life expectancy remained rela-
tively stable for people younger than
65, which suggests neither compression
nor expansion of morbidity relative to
life expectancy. For females aged 65 or
older, the ratio increased marginally, as
their self-reported health status improved
slightly over time. Cutler et al. reported
an improvement in the ratio of disabil-
ity-free life expectancy to life expectancy
between 1991 and 2009 for men and
women aged 65 or older in the U.S., with
greater improvements among women.31
Findings from other studies are mixed.
Although it has been suggested that more
populations worldwide are spending
more time with functional health loss,5
Freedman et al. reported improvements
between 1982 and 2011 in the percentage
of years expected to be lived without a
disability for males in the United States
and little change for females.26 By con-
trast, in Canada, Steensma et al. found
little change for either sex in the per-
centage of life spent in an unhealthy state

Discussion
Over the past 20 years, life expectancy
and HALE increased in Canada, and the
gap between the sexes narrowed because
of greater gains by males. In 2015,
HALE at birth was 69.0 years for males
and 70.5 years for females, increases
of 4.0 and 2.7 years, respectively, since
1994/1995. Throughout the period, the
ratio of HALE to life expectancy—the
share of years in good functional health—
was higher for males than for females.
However, there was little change in this
ratio over time for males, but a marginal
improvement among women aged 65 or
older. The importance of sensory prob-
lems as a source of diminished health
declined for both sexes, while mobility
and pain, the latter among females,
accounted for a higher percentage of the
burden of ill health.

The well-documented increase in
life expectancy in Canada is due in
large part to a decline in late-life mor-
tality since the 1950s.24,25 That HALE
also increased has been reported in
Canada and elsewhere,14,26,27 although
how much of the improvement that can

be attributed to reductions in morbidity
versus mortality depends on the health
expectancy indicator. A study based on
the HUI3 reported that gains in HALE
came primarily through improvements in
mortality,14 whereas studies using other
measures found that declines in symp-
toms and impairments27 or in disability
prevalence26 accounted for some of the
improvement.

The present study found differences
in life expectancy and HALE between
males and females. Narrowing of the life
expectancy gap between the sexes has
been attributed to factors that include a
reduction in violent deaths among male
teenagers and young adults, better treat-
ment for cardiovascular diseases, and
increasing similarity in women’s and
men’s behaviour, notably, smoking,
drinking, and work-related stress.1 That
males spend a greater share of their lives
in good functional health compared with
females has been reported in many coun-
tries.26,28-30 Women may live longer with
illness because their health problems are
less lethal, whereas men may be more
likely to suffer from conditions that lead
to earlier death.29

20 Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018 • Statistics Canada, Catalogue no. 82-003-X
Health-adjusted life expectancy in Canada • Research Article

between 1994 and 2010.14 Data from the
Canadian Chronic Disease Surveillance
System, on the other hand, suggest that
from 2000 to 2011, a growing percentage
of people were living with diseases
including ischemic heart disease, chronic
obstructive pulmonary disorder, and dia-
betes, all of which decreased in incidence
among those 50 or older, but increased
in prevalence.33 These seemingly con-
tradictory findings point to the difficulty
of drawing definitive conclusions from
studies with different data sources, target

populations, reference periods, and indi-
cators of health expectancy.34

Strengths and limitations
This study has many strengths. HUI3 is
a continuous scale, which makes it less
sensitive to measurement error than
dichotomous estimates of health status
such as prevalence of disability. Data
were available over a 20-year period.
HALE was estimated not only for the
household population, but also incorpor-

ated the health status and the percentage
of people in health-related institutions,
thereby providing a more complete
picture of health expectancy. Without the
institutional population, HALE would
have been significantly higher, particu-
larly at age 65 or older.

At the same time, the lack of recent
estimates of the health status of the
institutional population is a limitation
and a major data gap. Although this
population is included in administrative
databases that collect information about
diseases and chronic conditions, national
information about their health-related
quality of life is not regularly collected.
Life expectancy and HALE for the year
2015 were based on life table data for the
2013-to-2015 period, which was the most
recent available. Variations in the collec-
tion modes of the NPHS and the CCHS,
and declining CCHS response rates
could affect health-related estimates over
time.35,36 Although applying the survey
weights ensured that the sample was rep-
resentative of the target population, bias
might exist if non-respondents differed
systematically from respondents.

Conclusion
Life expectancy and HALE have
increased over time in Canada. The gap
between males and females has narrowed
because of greater gains by males during
the past 20 years. The ratio of HALE
to life expectancy has remained stable,
which suggests neither a reduction nor
improvement in overall functional health
relative to life expectancy. Mobility prob-
lems and pain, the latter mainly among
females, now account for a greater per-
centage of the burden of ill health. Future
years of data for both the household and
institutional populations are necessary to
provide further insight into the compon-
ents of and trends in health expectancy.

Acknowledgements
The authors gratefully acknowledge the
help of Philippe Finès who provided the
syntax to produce the variance estimates
for HALE. ■

Figure 4
Ratio of health-adjusted life expectancy (HALE) to life expectancy (LE) at selected
ages, with and without institutional population, by sex, Canada, 1994/1995,
1998/1999, 2001, 2005, 2009/2010 and 2015
HALE/LE

Sources: 1994/1995 and 1998/1999 National Population Health Survey; 2001, 2005, 2009/2010 and 2015 Canadian
Community Health Survey; 1996, 2001, 2006, 2011 and 2016 Census of Population; life tables for 1993-to-1995, 1997-to-
1999, 2000-to-2002, 2004-to-2006, 2009-to-2011 and 2013-to-2015.

Males

Females

At birth
(household only)

At birth

Age 20
(household only)

Age 20

Age 65
(household only)

Age 65

Age 85+
(household only)

Age 85+

At birth
(household only)

At birth

Age 20
(household only)

Age 20

Age 65
(household only)

Age 65

Age 85+
(household only)

Age 85+

0.35

0.45

0.55

0.65

0.75

0.85

1994/1995 1998/1999 2001 2005 2009/2010 2015

0.35

0.45

0.55

0.65

0.75

0.85

1994/1995 1998/1999 2001 2005 2009/2010 2015

21Statistics Canada, Catalogue no. 82-003-X • Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018
Health-adjusted life expectancy in Canada • Research Article

References
1. Lebel A, Hallman S. Mortality: Overview,

2012 and 2013. Report on the Demographic
Situation in Canada (Catalogue 91-209-XPE)
Ottawa: Statistics Canada, 2017

2. Statistics Canada. Life tables, Canada,
provinces and territories: Complete set of life
tables for Canada, provinces and territories
(Excel) (Catalogue 84-537-X). Accessed
February 26, 2018.

3. Public Health Agency of Canada Steering
Committee on Health-Adjusted Life
Expectancy. Health-Adjusted Life Expectancy
in Canada: 2012 Report by the Public Health
Agency of Canada. Ottawa: Public Health
Agency of Canada, 2012.

4. Stiefel MC, Perla RJ, Zell BL. A healthy
bottom line: Healthy life expectancy as an
outcome measure for health improvement
efforts. The Milbank Quarterly 2010; 88(1):
30–53.

5. Global Burden of Disease 2015 DALYs
and HALE Collaborators. Global, regional,
and national disability-adjusted life-years
(DALYs) for 315 diseases and injuries and
healthy life expectancy (HALE), 1990–2015:
A systematic analysis for the Global Burden
of Disease Study 2015. Lancet 2016; 388:
1603-58.

6. Berthelot J-M. Health-adjusted life expectancy
(HALE). In: Robine J-M, Jagger C,
Mathers CD, et al., eds. Determining
Health Expectancies. Chichester, United
Kingdom: John Wiley & Sons, Ltd., 2003.
doi: 10.1002/0470858885.ch12.

7. Health Canada. Healthy Canadians: A Federal
Report on Comparable Health Indicators 2004
(Catalogue H21-206/2004) Ottawa: Health
Canada, 2004.

8. Porta MS, Greenland S, Hernán M, et al. A
Dictionary of Epidemiology. 2014.

9. Allin S, Graves E, Grigson M, et al.
Health-adjusted potential years of life lost
due to treatable causes of death and illness.
Health Reports 2014; 25(8): 3–9.

10. Martel L, Bélanger A. An analysis of the
change in dependence-free life expectancy
in Canada between 1986 and 1996. Report
on the Demographic Situation in Canada,
1998-1999 (Catalogue 91-209-XPE) Ottawa:
Statistics Canada, 2006.

11. Mayer F, Ross N, Berthelot J-M, et al.
Disability-free life expectancy by health
region. Health Reports 2002; 13(4): 49–60.

12. McIntosh CN, Finès P, Wilkins R et al. Income
disparities in health-adjusted life expectancy
for Canadian adults, 1991 to 2001. Health
Reports 2009; 20(4): 55–64.

13. Roberge R, Berthelot J-M, Cranswick K.
Adjusting life expectancy to account for
disability in a population: A comparison of
three techniques. Social Indicators Research
1999; 48: 217-43.

14. Steensma C, Loukine L, Choi BCK. Evaluating
compression or expansion of morbidity
in Canada: Trends in life expectancy and
health-adjusted life expectancy from 1994 to
2010. Health Promotion and Chronic Disease
Prevention in Canada 2017; 37(3): 68–76.

15. Wolfson MC. Health-adjusted life expectancy.
Health Reports 1996; 8(1): 41–6.

16. Orpana HM, Ross N, Feeny D et al. The
natural history of health-related quality of
life: A 10-year cohort study. Health Reports
2009; 20(1): 29-35.

17. Feeny D, Furlong W, Torrance GW, et al.
Multi-attribute and single-attribute utilities
functions for the Health Utilities Index Mark 3
system. Medical Care 2002; 40(2): 113-28.

18. Martel L, Provost M, Lebel A, et al. Methods
for Constructing Life Tables for Canada,
Provinces and Territories (Catalogue
84-538-X-001) Ottawa: Statistics Canada,
2016.

19. Rust KF, Rao JNK. Variance estimation for
complex surveys using replication techniques.
Statistical Methods in Medical Research 1996;
5: 281–310.

20. Sullivan DF. A single index of mortality and
morbidity. HSMHA Health Reports 1971;
86(4): 347–54.

21. Mathers C. Health Expectancies in Australia
1981 and 1988. Canberra, Australia:
Australian Institute of Health, 1991.

22. Hirdes JP, Bernier J, Garner R, et al. Measuring
Health Related Quality of Life (HRQoL) in
Community and Facility-based Care Settings
with the interRAI Assessment Instruments:
Development of a Crosswalk to HUI3. In
press.

23. Horsman J, Furlong W, Feeny D, et al. The
Health Utilities Index (HUI®): Concepts,
measurement properties and applications.
Health and Quality of Life Outcomes 2003;
1: 54.

24. Bergeron-Boucher M-P, Bourbeau R, Légaré J.
Changes in cause-specific mortality among
the elderly in Canada, 1979–2011. Canadian
Studies in Population 2016; 43(3–4): 215–33.

25. Dong X, Milholland B, Vijg J. Evidence for
a limit to human lifespan. Nature 2016; 538:
257–9.

26. Freedman VA, Wolf DA, Spillman BC.
Disability-free life expectancy over 30 years:
A growing female disadvantage in the US
population. American Journal of Public
Health 2016; 106: 1079-85.

27. Stewart ST, Cutler DM, Rosen AB. US trends
in quality-adjusted life expectancy from
1987 to 2008: Combining national surveys
to more broadly track the health of the nation.
American Journal of Public Health 2013; 103:
e78–87.

28. Bélanger A, Martel L, Berthelot J-M, et al.
Gender differences in disability-free life
expectancy for selected risk factors and
chronic conditions in Canada. Journal of
Women & Aging 2002; 14(1-2): 61–83.

29. Luy M, Minagawa Y. Gender gaps—Life
expectancy and proportion of life in poor
health. Health Reports 2014; 25(12): 12–9.

30. Organisation for Economic Cooperation and
Development/European Union. 2016. Health
at a Glance: Europe 2016 – State of Health
in the EU Cycle. Paris: OECD Publishing,
2016.

31. Cutler DM, Ghosh K, Landrum MB. Evidence
for Significant Compression of Morbidity
in the Elderly U.S. Population. National
Bureau of Economic Research Working
Paper no. 19268. Cambridge, Massachusetts:
National Bureau of Economic Research, 2013.

32. Crimmins EM, Beltrán-Sánchez H. Mortality
and morbidity trends: Is there compression
of morbidity? The Journals of Gerontology.
Series B, Psychological Sciences and Social
Sciences 2011; 66B: 75-86.

33. Public Health Agency of Canada. Canadian
Chronic Disease Surveillance System
Data. Available at https://open.canada.
ca/data/en/dataset/9525c8c0-554a-461b-
a763-f1657acb9c9d. Accessed May 26, 2017.

34. Howse K. Increasing life expectancy and the
compression of morbidity: A critical review
of the debate. Oxford Institute of Ageing
Working Papers. Working Paper no. 206.
Oxford: Oxford Institute of Ageing, 2006.

35. Baribeau B. Could nonresponse be biasing
trends of health estimates? In: JSM
Proceedings. Alexandria, Virginia: American
Statistical Association, 2014: 4285–93.

36. St-Pierre M, Béland Y. Mode Effects in
the Canadian Community Health Survey:
A Comparison of CAPI and CATI, 2004.
Proceedings of the American Statistical
Association Meeting, Survey Research
Methods. Toronto, Canada: American
Statistical Association, 2004.

22 Health Reports, Vol. 29, no. 4, pp. 14-22, April 2018 • Statistics Canada, Catalogue no. 82-003-X
Health-adjusted life expectancy in Canada • Research Article

Appendix

Table A
Life expectancy (LE) and health-adjusted life expectancy (HALE) at selected ages, by sex, Canada, 1994/1995, 1998/1999, 2001, 2005,
2009/2010 and 2015

1994/1995 1998/1999 2001 2005 2009/2010 2015
Years SE Years SE Years SE Years SE Years SE Years SE

Males

At birth LE 74.9 0.02 76.0 0.02 76.9 0.02 77.9 0.02 79.1 0.02 79.8 0.02
HALE 65.0 0.07 67.4 0.07 67.3 0.04 68.1 0.06 69.3 0.04 69.0 0.06

Age 20 LE 55.9 0.02 56.8 0.02 57.7 0.02 58.7 0.02 59.8 0.02 60.5 0.02
HALE 47.3 0.06 49.3 0.06 49.3 0.03 50.2 0.05 51.3 0.03 51.1 0.05

Age 35 LE 41.7 0.02 42.5 0.02 43.4 0.02 44.3 0.02 45.5 0.02 46.1 0.02
HALE 34.6 0.06 35.8 0.06 36.1 0.03 37.2 0.05 38.1 0.03 38.2 0.04

Age 45 LE 32.5 0.02 33.2 0.02 33.9 0.02 34.9 0.02 36.0 0.02 36.6 0.02
HALE 26.3 0.06 27.2 0.06 27.6 0.03 28.7 0.05 29.5 0.03 29.6 0.04

Age 55 LE 23.6 0.02 24.2 0.02 25.0 0.02 25.9 0.02 26.9 0.02 27.6 0.02
HALE 18.5 0.05 19.1 0.06 19.7 0.03 20.7 0.05 21.5 0.03 21.7 0.04

Age 65 LE 15.9 0.02 16.3 0.02 17.0 0.02 17.7 0.02 18.6 0.02 19.2 0.02
HALE 11.8 0.05 12.0 0.06 12.6 0.02 13.5 0.04 14.2 0.03 14.4 0.04

Age 75 LE 9.7 0.02 9.9 0.02 10.3 0.02 10.8 0.02 11.5 0.02 12.0 0.02
HALE 6.4 0.05 6.5 0.06 6.8 0.02 7.3 0.05 7.9 0.03 8.0 0.04

Age 85
or older

LE 5.4 0.02 5.3 0.02 5.5 0.02 5.7 0.02 6.1 0.02 6.4 0.02
HALE 2.7 0.07 2.8 0.08 2.7 0.03 3.0 0.06 3.2 0.04 3.3 0.05

Females

At birth LE 80.9 0.02 81.4 0.02 81.9 0.02 82.6 0.02 83.5 0.02 83.9 0.02
HALE 67.8 0.08 70.1 0.07 69.8 0.03 70.6 0.06 71.3 0.04 70.5 0.05

Age 20 LE 61.7 0.02 62.1 0.02 62.5 0.02 63.2 0.02 64.0 0.02 64.5 0.02
HALE 49.8 0.07 51.6 0.07 51.5 0.03 52.3 0.05 53.0 0.03 52.3 0.05

Age 35 LE 47.0 0.02 47.4 0.02 47.8 0.02 48.5 0.02 49.3 0.02 49.8 0.02
HALE 36.7 0.07 38.1 0.06 38.1 0.03 39.1 0.05 39.5 0.03 39.2 0.04

Age 45 LE 37.5 0.02 37.8 0.02 38.2 0.02 38.9 0.02 39.7 0.02 40.1 0.02
HALE 28.2 0.07 29.3 0.06 29.6 0.03 30.4 0.05 30.8 0.03 30.7 0.04

Age 55 LE 28.3 0.02 28.6 0.02 29.0 0.02 29.6 0.02 30.4 0.02 30.8 0.02
HALE 20.4 0.06 21.2 0.05 21.5 0.03 22.2 0.04 22.7 0.03 22.7 0.04

Age 65 LE 19.8 0.02 20.0 0.02 20.3 0.02 20.9 0.02 21.6 0.02 22.0 0.02
HALE 13.2 0.06 13.8 0.05 14.1 0.02 14.7 0.04 15.2 0.02 15.3 0.03

Age 75 LE 12.5 0.02 12.5 0.02 12.7 0.02 13.2 0.02 13.8 0.02 14.1 0.01
HALE 7.1 0.05 7.3 0.05 7.5 0.02 8.0 0.04 8.4 0.02 8.5 0.03

Age 85
or older

LE 6.8 0.02 6.7 0.02 6.8 0.01 7.0 0.01 7.4 0.01 7.6 0.01
HALE 2.7 0.05 2.7 0.04 2.8 0.02 3.0 0.04 3.3 0.02 3.3 0.03

SE = standard error
Sources: 1994/1995 and 1998/1999 National Population Health Survey; 2001, 2005, 2009/2010 and 2015 Canadian Community Health Survey; 1996, 2001, 2006, 2011 and 2016 Census of Population;
life tables for 1993-to-1995, 1997-to-1999, 2000-to-2002, 2004-to-2006, 2009-to-2011 and 2013-to-2015.

Statistics Canada information is reproduced with the permission of the Minister of Industry,
as Minister responsible for Statistics Canada. Information on the availability of data from
Statistics Canada can be obtained from Statistics Canada’s Regional Offices, www.statcan.ca,
or by calling 1-800-263-1136.

Writerbay.net

Looking for top-notch essay writing services? We've got you covered! Connect with our writing experts today. Placing your order is easy, taking less than 5 minutes. Click below to get started.


Order a Similar Paper Order a Different Paper