Summary of Key Messages and Recommendations

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Letter to the Speaker of the Legislative Assembly of Ontario

Dear Speaker,

I am pleased to provide the 2017 Annual Report of the Chief Medical Officer of Health of Ontario for submission to the Assembly in accordance with the provision of section 81.(4) of the Health Protection and Promotion Act.

Yours truly,

David C. Williams, MD, MHSc, FRCPC
Chief Medical Officer of Health

Executive summary

Being socially connected to family, friends and our communities — having a sense of belonging — is important to our well-being. People who are connected are happier. They enjoy better health and use fewer health services. They are more resilient in the face of adversity, and they live longer.

Communities where people feel connected have less crime and stronger economic growth. Their children perform better in school. Their citizens are more involved: they are more likely to co-operate to benefit all members of the community and to work together to address the social determinants of health, which leads to greater health equity.

How connected are Ontarians? There are worrying signs that many — particularly younger people — feel less connected than they did in the past. While most Ontarians have friends, they see them much less often. They are also much less likely to volunteer in their communities than they once did and, when they do volunteer, they give less time.

Our sense of community is threatened by large systemic pressures and changes. Changes to family and social structures, increasing work and time pressures, urbanization and sprawl, and growing income inequality all make it harder for people to feel connected. Technologies, including television, computers and smartphones, compete for our attention: a growing number of people have hundreds of friends online but few in-person contacts. Perhaps of greatest concern, a growing number of people have lost trust in governments, institutions and one another, which makes them less likely to actively participate in their communities.

These large systemic pressures require system-wide solutions.

The time to act is now. Loneliness and social isolation are serious public health problems that cost us all. They affect our productivity, health, well-being — even how long we live. It’s time to revitalize communities and create a healthier Ontario.

Helping people and communities (re)connect is everyone’s business. To (re)build a sense of belonging — create connected communities — individuals, organizations, businesses, communities and governments must work together to foster a society that values social connection.

This report recommends three key ways to create more connected communities:

  1. Invest in Community: Governments should shine a spotlight on the critical importance of connected communities by investing in collecting data on social connection and sense of community, assessing all government policies for their impact on community, creating built environments that make it easier for people to engage in their communities, and tackling the broader social and economic drivers of social isolation.
  2. Enable Community: Public health units — uniquely positioned between communities and different levels of government — should play a lead role in enabling community. Public health units can make people aware of the benefit of social connections, use data to develop targeted community-building programs, encourage organizations to partner to address systemic issues that drive social isolation, and champion effective frameworks for community development.
  3. Be Community-Centred and Community-Driven: We should challenge ourselves and each other to make community health and well-being a priority.

Community begins from the ground up. Individual actions make a big difference. At the local level, individuals and organizations — including businesses — can drive change. They can collaborate, pooling strengths and assets to build community. They can make community health and well-being a priority in all their decisions.

It’s time to make social connection and sense of community as important a measure of our health and well-being as blood pressure and economic output.

How do social connections affect health?

Human beings are hard wired to connect. Our need to be part of a group — a family, a network of friends, or a community — is part of our DNA.

The desire to belong and feel connected doesn’t just fulfill a primal urge, it affects our physical and mental health, our sense of well-being — even how long we live.

People who are isolated have a 50 per cent greater risk of dying early than those with strong social connections, about the same negative impact on health as smoking 15 cigarettes a day. Social isolation can be twice as deadly as obesity and as big a killer as diabetes.footnote 1,footnote 2 It also increases the risk of dementia by 64 timesfootnote 3.

On the other hand, being socially connected can help people overcome adversity and lead longer, happier lives:

  • In a 50-year study of 17,000 children born on the same day in Britain in 1958, those with strong family support were more likely to overcome social disadvantagesfootnote 4.
  • In a 75-year Harvard study of a highly privileged, educated group of men, the factor that contributed the most to healthy aging was strong, loving relationships. Men who had close family ties and good friendships were healthier and happier in old age than those who did notfootnote 5.

Even those at the top of the socio-economic scale experience dramatic differences in health depending on their connections with other people.

How does community belonging protect our health?

Strong social connections help people recover more quickly from stressful situations. Stress is part of life but when we can manage stress, we are more confident and less anxious. We are better able to calm the “fight or flight” response caused by cortisol, the stress hormone.

Left unchecked, high levels of cortisol threaten our health. They trigger inflammation, headaches, high blood pressure, high blood sugar levels, weight gain, depression, problems remembering or concentrating, and sleep problemsfootnote 6. Being isolated often translates into being inactive, which also increases the risk of obesity and diabetes. Not being connected — being isolated — is bad for the body, mind and soul.

On the other hand, people with strong social connections and a sense of community belonging have more emotional support and companionship as well as practical supports, such as financial assistance, in emergencies and other resources that help them succeed in life.

For example, when disaster strikes, people who are socially connected have others around them who will lend them money or provide supports, such as child care or a place to stay — while those who are isolated are less likely to receive help from othersfootnote 7,footnote 8. During Chicago’s 1995 heat wave, isolated elderly people were the most likely to die and not be found for daysfootnote 9. More deaths occurred in a poor, African American community that had less public space and social capital than an equally poor, neighbouring Hispanic communityfootnote 10.

Indigenous ways of knowing can help us understand the link between a sense of community and health.

Indigenous peoples recognize that “community is the natural context of human life and activity. We are, one and all, social beings living in relation to one another. Our physical and biological survival is intimately interwoven with the communities that we create and that create us. The community is a complex of physical, social, and psychical relationships that are ever-changing and evolving through time and the generations of people who identify with itfootnote 11.”

One of the most powerful expressions of the importance of connectedness comes from the Indigenous concept of health and well-being, which honours and celebrates not only the connections between people — and the importance of nurturing both the young and the old — but also, the connections between human beings and the earth, the natural world and the spiritual world.

Compared to those with a weak sense of connection, Canadians with a strong sense of community belonging — regardless of their income — experience significant health benefits. They feel better about themselves and are more likely to make healthy choices like exercising, eating well, drinking moderately and following their health care providers’ advice — all of which leads to better health. On the other hand, people who report feeling stressed say that social isolation is a factor in their stress.

People with a weak sense of community belonging are more likely to be in the top five per cent of users of health care services; this five per cent accounts for more than 50 per cent of total health care spending. Of the top one per cent of high resource users, 83.5 per cent use emergency department services and 92.5 per cent require acute hospital care compared to 7.8 per cent and zero per cent for the bottom 50 per cent of resource users. In 2018-19, these high resource users will cost Ontario’s health care system a projected $16.5 billionfootnote 17 — costs that could be reduced if these individuals were part of connected communities.

What is social capital?

The resources and associated benefits people have access to through their social networks and relationshipsfootnote 18.

Being socially connected and involved in our communities has benefits beyond individual health and well-being. A strong sense of community gives rise to shared values that benefit society as a whole. In communities where people feel connected (often known as a high level of social capital), people tend to trust one another — even if they do not know each other. These communities have less crime and stronger economic growth. Their children perform better in school and their citizens are more politically involvedfootnote 19.

People in communities with high levels of connection and social capital are more likely to co-operate to benefit all members of the community. They are more resilient in the face of disaster, and they are also more likely to work together to address the social determinants of health, which leads to greater equity.

How connected are Ontarians?

Over six in 10 Ontarians say they have a very or somewhat strong sense of community belonging.

However, only four in 10 know many or most of their neighbours.

According to Statistics Canada General Social Survey, Canadians have more friends but they see close friends or family less frequentlyfootnote 19. There is a growing loneliness gap that we must act now to fill.

When asked why they don’t have a stronger sense of belonging, Torontonians said: it wasn’t important or they were too busy. Ontarians may not understand how important social connections are to their health.

That being said, most Torontonians agree that people can make a real difference in their communities if they are willing to work together to solve problems.

How do people build a sense of community?

People build community in many different places and ways, such as:

  • Close relationships with family members — both biological family and family of choice
  • Friendships formed early in life that sustain people over time
  • Strong connections with neighbours
  • Supportive relationships with colleagues at work
  • Connections with others at the same stages of life, such as mothers of young children who meet at the park and provide both social and parenting support and seniors who gather for social activities
  • Being part of a supportive cultural, ethnic, religious or spiritual group
  • Through a common interest such as the arts or sports or a desire to protect the environment
  • Working with others who share common values or political beliefs through service clubs or community groups.

Some connect with others — face-to-face — in their neighbourhoods and communities. Some connect through online networks that bring people together regardless of distance.

What is fragmenting our sense of community?

Our society has changed significantly over the last few decades. Traditional support networks are weaker, and the ways we live and communicate make it harder to connect in meaningful ways.

Family and social structures have changed. Families are smaller and more spread out, so people are not necessarily surrounded by relatives. Fewer people are married. More are divorced. And the number of single person households continues to grow.

According to a recent Vanier Institute report on Canadian families, between 1981 and 2016footnote 21:

  • The proportion of families that included a married couple dropped from 83 per cent to 66 per cent
  • The number of lone-parent families increased from 11 per cent to 16 per cent
  • Families are getting smaller — from 3.9 to 2.4 persons per household.

Because people are living longer and family structures are changing, more seniors are isolated. The National Seniors Council estimates that up to 16 per cent of Canadians age 65 or older (950,000 seniors) experience loneliness and isolationfootnote 22. Isolation affects physical and mental health, which can lead to a loss of function and cognitive abilities, more emergency department visits and hospitalizations, and higher health and social services costs.

Work and time pressures have increased and work has become more precarious. Over the past 50 years, we have seen dramatic shifts in the workforce: more two-income families, greater concentration of jobs in a small number of urban centres, more contract work, more multiple part-time jobs and less economic certainty or stability. Over this same period, the cost of living — in particular, housing — has increased exponentially, particularly in urban areas. As a result, people feel more anxious and stressed, and are less likely to be involved in all forms of social and community lifefootnote 23. Changes that make businesses more efficient and productive are having a negative effect on employees.

It costs more to be socially connected. The general financial anxiety that many people feel is exacerbated by the fact that many social activities, such as adult education classes, fitness programs, music concerts and dancing, are expensive and increasingly out of reach for many people. It is much less expensive to stay home and watch TV than it is to be out in the community taking part in activities that could enhance both connection and health.

With urbanization and sprawl, people spend more time commuting and less time connecting. As jobs migrated to the cities, so did people. However, some communities were not designed with social connection in mind. Many are not walkable: in order to shop, people have to take the bus or drive and these communities often lack the parks and community gathering spots that bring people together.

Faced with rising housing costs in the city core, many people moved to suburban neighbourhoods where they could have larger homes with yards. As commute time increases, willingness to get involved in community activities drops: each additional 10 minutes in daily commuting time cuts involvement in community affairs by 10 per centfootnote 23. Urban sprawl means that people spend more time alone in the car or on public transport and less time with family, friends and neighbours. It also affects people’s sense of community as they are often living, working and shopping in different neighbourhoods and do not feel truly part of any of themfootnote 23.

Television, computers and smart phones increase isolation. In the mid-20th century, Canadians mainly went out into the community for entertainment. With television, low-cost entertainment and leisure came right into our homes, and we began to prefer “spending a quiet evening at home.” As the number of television sets per household grew, people spent less time watching TV together and more time watching entirely alonefootnote 23.

Television is a medium of entertainment which permits millions of people to listen to the same joke at the same time, and yet remain lonesome. — T.S. Eliot

At the turn of the 21st century, television was the single most consistent predictor of people being disconnected from their communities — more significant than education, age, gender, marriage, children, income, financial worries, work obligations and commuting timefootnote 23. Over the past 20 to 30 years, other technologies — computers, smartphones, online networks and streaming services — have competed to take more of our time and attention. A growing number of people have hundreds of friends online, but few in-person contacts. In some cases, these virtual connections are highly supportive. They allow children to “see” and talk to grandparents who live far away and develop a stronger sense of family. They also help people who live in rural and remote areas overcome geographic isolation.

But social media can also make the lonely more isolated. It can connect people who are socially disconnected with those who manipulate them. They may engage only with those who share or amplify their views so they have fewer opportunities to talk to or understand people with different perspectives.

Some social media platforms have taken steps to limit inaccurate and misleading information and reduce cyber bullying. Some platforms have simple nudges designed to help people reduce screen time — such as programs that tell people how much time they spend each day looking at their screens. However, more must be done to reduce the negative impact of technology on social connections.

Social media technologies also allow people to share information, which may or may not be accurate. Real harm can be done — both to individuals and society — when people spread inflammatory, unverified or false information.

If you were going to give advice for a happy adolescence based on this survey, it would be straightforward: Put down the phone, turn off the laptop, and do something — anything — that does not involve a screenfootnote 27.

People have lost trust in governments and institutions. According to the Edelman Trust Barometer, a survey of 28 countries, the world is facing a crisis of trust in its institutions. In 20 of the 28 countries, average trust in government, business, non-governmental organizations and media was below 50 per cent.

Trust is the “belief that someone or something is reliable, good, honest, effective.” High levels of trust promote healthy interactions, whereas low levels of trust undermine constructive relationshipsfootnote 28.

Compared to many other countries, Canada actually scored relatively well on the 2018 Edelman Trust Barometer. Between 2017 and 2018, Canadians’ trust in government and media increased (from 58 to 61 per cent and from 52 to 59 per cent respectively), while their confidence in non-governmental organizations dropped (from 74 to 65 per cent) and their trust in business remained relatively steady (63 per cent). In general, Canadians said they wanted to see all their institutions play a more active role in creating a stronger, fairer societyfootnote 29.

In Ontario, over three in four people have a great deal of confidence in police and about six in 10 have confidence in local businesses and the justice and school systems. On the other hand, fewer Ontarians have confidence in the media, the federal government and major corporations.

People have less trust in political systems when they are having money problems or are unemployedfootnote 30. On the other hand, people living in jurisdictions with stronger property rights and extensive labour market regulations have more trust in their institutions and governmentsfootnote 31.

When those with more resources or power have a disproportionate influence over economic opportunities, income gaps widen, more people become marginalized, inequities increase, and community connection and trust are brokenfootnote 32 Cotter, A. (2016). Canadians’ Perceptions of Neighbourhood Disorder. Statistics Canada.

Disconnection and lack of trust leads to more disconnection. Lack of connection to our communities and lack of trust in government can lead to public disorder. People who live in neighbourhoods with visible signs of disorder — such as people dealing drugs, vandalism, graffiti or property damage — feel more vulnerable and fearful of crimefootnote 33. They are more likely to report being afraid when walking alone after dark, using or taking public transportation or home alone in the evenings. They also report less life satisfactionfootnote 34

People who trust law enforcement are more likely to participate in activities designed to improve community safety. However, people who live in neighbourhoods with high crime rates — particularly members of racialized communities — report being more likely to be stopped and questioned, and more distrustful of police. These disparities create the sense of an unequal society where some feel comforted by the law and others feel suspicious and distrustfulfootnote 28.

What can we do to help Ontarians (re)build community?

The growing sense of social isolation Ontarians are experiencing can be slowed or stopped. Many factors driving isolation and loneliness are systemic so they require a system-wide approach. Individuals, organizations, businesses, communities and governments must work together to foster a society that values and invests in social connection and community.

Sound public policies can nurture well-being.

There are many relatively simple steps we all can take to (re)build community. Many people are already involved in innovative efforts to connect people and create supportive, connected communities.

Connecting people

Building community and social connections often happens informally. Sometimes it’s as simple as talking to your neighbours or inviting someone to join you at an event. Sometimes it’s part of more formal efforts by organizations to either bring people together or create spaces where people can gather.

Connecting newcomers to neighbours

Beginning in 2015, groups of Canadians came together to privately sponsor Syrian refugee families. A recent evaluation of the country’s refugee resettlement programs found that privately sponsored refugees had a significantly better chance of getting help settling in Canada, finding a job and having better health outcomes than government-assisted refugees. They were more likely to have received help learning key skills, such as speaking English or French, shopping for food and finding a doctor. Within nine months of arriving in Canada, over 50 per cent of privately sponsored refugees were working compared to 10 per cent of government-assisted refugeesfootnote 35.

Unlike government institutions, private sponsors provide emotional support. They introduce refugees to their social networks, give them a tour of the best places in town to shop and help them set up new businesses. The experience is also a positive one for the sponsors themselves. They gain a greater sense of connection from being involved and contributing to the welfare of othersfootnote 36.

Connecting people to culture

Most Indigenous peoples with life-limiting illnesses die in urban hospitals or long-term care homes. They do not have access to palliative care at home or in their First Nations or Aboriginal community, surrounded by family, friends, culture and spirituality.

To connect people to culturally safe end-of-life care, the South West Local Health Integration Network collaborated with the Southwest Ontario Aboriginal Health Access Centre (SOAHAC) and other partners — including Chippewas of the Thames First Nation, Munsee-Delaware Nation, Oneida Nation of the Thames and Cancer Care Ontario — to implement an Indigenous-led palliative model of care, including an Indigenous Palliative Care Team (IN-PaCT). The team includes physician support, a nurse practitioner, a registered nurse, a mental health counselor and a traditional Indigenous healer who supports the spiritual needs of patients and families.

Connecting health professionals

Certain parts of the province are designated to provide French language services. The Public Health en français Community of Practice started as a collaboration among health units to connect professionals delivering French language services so they could share resources and expertise.

With more than 100 members, the Community of Practice keeps professionals from feeling isolated in their work which, in turn, helps support and strengthen the Francophone community and improve access to equitable high quality public health services. Members are now more aware of resources and tools, and more likely to collaborate with one another to deliver consistent services.

Creating supportive, connected communities

Reaching and connecting isolated seniors

To help break the cycle of social isolation for seniors, seven organizations in Hamilton came together to develop the Hamilton Seniors Isolation Impact Plan (HSIIP). The goal is to have more seniors feel connected to family and friends, access support and participate in physical and social activities, and feel valued.

HSIIP has established three connector programs:

  • The Hospital Connector Program connects seniors being discharged from hospital to services and activities in the community.
  • The Community Connector Program connects isolated seniors in the community to services and activities.
  • The Peer Connector Program trains peers to provide friendly visiting services.

HSIIP strives to:

  • Find and work with seniors at risk for social isolation
  • Help reduce barriers to seniors’ engagement in activities and networks
  • Create opportunities for seniors to become involved in meaningful social activities and their communities
  • Build more sustainable and inclusive communities that value the contribution of all members, regardless of age.

The HSIIP and the ENRICHES Collaborative are funded in part by the Government of Canada’s New Horizons for Seniors Program. The Program provides grants and contributes funding for projects that make a difference in the lives of seniors and in their communities.

Between May 2016 and March 2018, the collaborative helped 1,014 seniors. Every senior was connected to some form of visiting and information-sharing, and most were anchored into other services and activities. The program was able to close gaps in services and relieve pressure on an overburdened health care system.

Connecting family caregivers to supports and resources

When seniors with complex health problems age at home, they often rely on a family or informal caregiver — who is also aging — to look after them. Family caregivers often struggle to provide this care. They can experience high levels of stress, financial hardship and isolation. Five organizations in Toronto — Alzheimer Society Toronto, Canadian Mental Health Association Ontario, North York Community House, WoodGreen Community Services and the Reitman Centre at Sinai Health System (the lead for the collective) — are part of the ENRICHES Collaborative. Together, they are trying to reduce social isolation in caregivers age 55 and older.

Using the collective impact model (see page 25), the ENRICHES Collaborative organizations identify caregivers in need of support, engage them in activities, connect them to programs and services, and build health system capacity to respond to caregiver needs.

ENRICHES has engaged over 12,000 caregivers and connected them to services, such as workshops and education sessions, social and recreational opportunities, as well as digital literacy and financial empowerment programs offered through the various ENRICHES partners. These services help caregivers build resilience and expand their social networks. They also empower them to navigate the health system and manage their own health and well-being.

Connecting and integrating newcomers

Rural communities often face demographic challenges such as youth out-migration and labour shortages. Many need newcomers to maintain their vibrancy and economic health. When newcomers are able to build social capital, they feel a sense of belonging in their new communities and are more likely to stay.

When residents in the host community use their influence to help newcomers, all benefit. When newcomers develop their networks, resources and assets, they build up the communityfootnote 18. It’s crucial for communities to provide opportunities for newcomers to become connected and develop social capital.

The Rural Ontario Institute has gathered and distilled information on effective ways to help newcomers integrate:

  • Strong intentional community leadership. Municipalities make a conscious effort to create welcoming communities.
  • A commitment to reduce system barriers. Successful communities work to address issues such as public transportation, social supports, affordable housing, language and settlement services. They also actively communicate positive messages about the importance and value of newcomers to the community.
  • Opportunities to build relationships. Communities create opportunities for newcomers to connect in meaningful ways with people in the community, which can have a profound effect on social capital. Newcomers and members of the community get to know each other and develop lasting bonds that benefit everyone.
  • Robust support systems. Rural communities that develop strong, accessible support systems for newcomers are more likely to retain their newfound residents.

Creating built environments that encourage connection

The physical spaces where people live, play, work and study — the built environment — affects their health.

In all types of communities — urban, suburban or rural — supportive built environments can promote mental and physical well-being, improve quality of life and foster social connections. The way that communities, neighbourhoods and housing complexes are physically laid out can affect social capital and sense of communityfootnote 11.

It is unreasonable to expect large proportions of the population to make individual behaviour changes that are discouraged by the existing environment and social normsfootnote 37.

It’s important to keep social connection and health goals in mind when designing streets and neighbourhoods by, for example:

  • providing wider, barrier-free streets that encourage social interaction and support different ways of moving, such as walking, cycling, roller blading and driving
  • building mixed use neighbourhoods that include homes, retail stores, services and cafes so people can walk to get the things they need
  • creating good quality public and green spaces with landscaping, lighting, facilities and pathways that invite people to gather.

When residents have more control over the areas around their homes, including lobbies, streets and grounds, they feel more connected to these community spaces and to their neighbours. These neighbourhoods have lower rates of crime and higher levels of social capitalfootnote 11

When residents have access to places to meet (often called “third places” because they are not private residences or work spaces), such as coffee shops, bookstores, bars, hair salons, public squares and libraries, there are opportunities for social interactions that build connected communitiesfootnote 37.

Making health part of city planning

Ontario’s Places to Grow Act, 2005 recognizes that, to provide a high quality of life, communities must be planned strategicallyfootnote 39.

Public health units in the Greater Golden Horseshoe have been working with municipal planners and community partners to encourage healthy community policies that:

  • encourage walking, cycling and other forms of active transportation
  • promote complete community design
  • advocate to preserve land and water to ensure a sustainable food system
  • improve the built environment to enhance social cohesion and well-being.

The Simcoe Muskoka District Health Unit (SMDHU) supported a series of active transportation workshops that led many municipalities to develop active transportation and trail plans. Some are now creating trails connecting to schools, way-find projects, cycling lanes, road diets, transit initiatives and more. Some have been designated age-friendly, youth-friendly, walk-friendly and bike-friendly communities. All this activity is the result of community engagement.

These communities are also leading the way in innovative community design:

  • Essa included waterways in its trails system
  • Wasaga Beach was the first municipality in Ontario to install portable roll-out mats on the beach so all residents and visitors — including those in wheelchairs and strollers — could enjoy the beach and feel more connected to the community
  • Collingwood, Essa and Wasaga Beach have established healthy community committees that focus on healthy community design, social cohesion and well-being.

Capitalizing on infrastructure projects to build community

Poverty and economics are strong drivers of social disconnection. Community benefits agreements are formal agreements between a private or public development and a coalition that reflects and represents people who are affected by a large development project. They help ensure that communities benefit — both economically and socially — from investments in infrastructure and purchases of goods and services.

Community benefits agreements are clauses added to contracts that require companies to, for example, improve public spaces, hire local workers and/or provide appropriate training. These agreements often require significant time and commitment to be successful, but can be a strategic tool for community wealth.

Community benefits agreements are usually negotiated collaboratively by government, businesses, labour, advocacy coalitions and local residents.

The Toronto Community Benefits Network is using this approach to influence the development process and deliver social benefits that help build connected communities. Here are a few successes from community benefits agreements:

  • Local people received jobs as part of the Regent Park redevelopment.
  • The contract for the Eglinton Crosstown LRT included a commitment to provide training and employment for local people and to procure supplies from local businesses.
  • As part of the Pan Am games, local suppliers and social enterprises were encouraged to bid on contracts.

Frameworks for measuring connectedness and building community

To reduce social isolation and build social capital, we need ways to measure connectedness and belonging as well as effective frameworks that help build community.

Measuring connectedness and community

A number of jurisdictions are trying to measure connectedness (social capital) and social isolation, and use the findings to build community and improve health.

Toronto Social Capital Study

The Toronto Social Capital Study is measuring the extent to which social capital contributes to outcomes, such as health, happiness and life satisfactionfootnote 20.

Asking about social networks helps assess how large people’s social networks are, how often they connect, how invested they are in these friendships and the extent to which they rely on their social networks for help and support.

Asking about civic connections helps assess how engaged people are in their community and the extent to which they volunteer or take part in activities that benefit their communities. For example, are they meeters, joiners and co-operators — all measures of connectedness — or are they less involved and more isolated?

To develop the Toronto Social Capital Study survey, researchers pulled questions from established surveys in Canada, such as the Canadian General Social Survey, the Equality, Security and Community Survey, and the Neighbourhood Effects on Health and Well-being Study.

Asking about neighbourhood support helps assess how people see their neighbourhood and how welcoming and resilient that neighbourhood is. Are there safe places for children to play? Are people willing to help their neighbours?

These measures of social capital — which were recently applied in the City of Toronto — help health and city planners understand how connected their communities are and the role that social capital plays in that sense of community belonging. The information can also be used to identify neighbourhoods that would benefit from community building.

Canadian Index of Wellbeing

The Canadian Index of Wellbeing at the University of Waterloo, developed by researchers from across Canada, is based on talking to Canadians about what is most important to their quality of life. From those consultations the researchers developed eight domains:

  • Community vitality looks at social relationships. Do people have a sense of belonging? Do they volunteer? Do they have close friends they can turn to and do they provide unpaid help for others? Do they trust others and feel safe in their community?
  • Democratic engagement looks at the extent to which people participate in the democratic process. Do they vote? Do they participate in political groups? Are they satisfied with the way democracy works in Canada?
  • Education looks at access to education across the lifespan. How many registered child care spaces does a community have? How much does it spend on educating students? How many young people complete high school? How many adults have university degrees? How many adults participate in ongoing education?
  • Environment looks at the availability and use of natural resources, and the impact of human activity on the environment. How clean is our air? How much energy do we use? What about our fresh water resources? What actions do we take to help protect the environment?
  • Healthy populations looks at health status, lifestyle and behaviour as well as health care system factors. How many Canadians rate their physical and mental health as good? What is our life expectancy? How many people have diabetes? How many smoke? How many have a doctor?
  • Leisure and culture assess the amount of time and money Canadians spend in social, physical or cultural activities. How many hours do they volunteer for recreation and cultural organizations? How much time do they spend on holidays? How often do they visit national parks and historic sites?
  • Living standards measures average income and wealth, as well as income gaps. How many Canadians have incomes below the low income cut-off? How many households are food insecure? What percentage of the labour force is employed? How many people are in high quality jobs? What about housing affordability?
  • Time use looks at how Canadians spend their time and how our time use affects our well-being. How many Canadians work more than 50 hours a week at a main job? How many minutes each day do we spend with friends? How long do we spend commuting? How many people have flexible work hours? How many report time pressure? How many people get seven to nine hours sleep a night?

Taken together, these domains paint a picture of Canadians’ well-being. Planners can use the results to understand trends and advocate for policies, programs and other changes that improve wellbeing. Findings can start a dialogue about what truly matters to Canadians and how communities, governments, organizations and businesses can enhance health and strengthen communities.

Jurisdictions can use the Canadian Index of Wellbeing to: create a community well-being profile; identify strengths and weakness, as well as inequities; and, using the insights gained, develop community plans.

Rio Declaration on social determinants of health

In 2011, member states of the World Health Organization (WHO) pledged to reduce health inequities — a key factor in the fragmentation of communities. A group established by the WHO, the Public Health Agency of Canada and the Canadian Institutes of Health Research (CIHR) Institute of Population and Public Health identified 36 indicators across five domains that jurisdictions could use to monitor their progress in reducing health inequitiesfootnote 41.

The domains include:

  • global governance
  • monitoring and accountability
  • national governance
  • participation
  • health sector reorientation

The focus on participation highlights the importance of involving civil society in creating equitable health policies. Governments can use these indicators to assess how well they are doing in addressing underlying systemic issues and social determinants of health that drive social isolation.

Building community

The Chief Medical Officer of Health’s 2016 report — Improving the Odds: Championing Health Equity in Ontario — highlighted the important role communities can play in reducing health inequitiesfootnote 42:

“Community development interventions can bring community members together to take collective action and solve common problems. They can also help build social cohesion which, in turn, improves health… Different players and levels of government have different levers... Working together as a system, they can reduce or eliminate health disparities.”

That report challenged government and organizations to champion community development and pursue partnerships within and beyond the health sector to improve health equity.

Here are three effective approaches to building community. All share a commitment to engaging people in solving complex problems that fragment community.

Collective impact model

Collective impact is based on the idea that organizations must work collectively — not in isolation — to create social change and solve complex dynamic problems like social isolation. Successful collective impact initiatives build on all partners strengths and share five criteria:

  • Common agenda: All participating organizations share a vision for social change: a common understanding of the problem and a joint approach to solving it.
  • Shared measurement system: Agreement on how success will be measured and reported, with key indicators.
  • Mutually reinforcing activities: A diverse set of stakeholders, typically in multiple sectors, coordinating activities through a plan of action.
  • Continuous communication: Frequent communications among key players within and between organizations to build trust and encourage ongoing learning and adaptation.
  • Backbone organization: Ongoing support provided by an independent staff that helps move the work forward.

The collective impact framework, developed in the U.S., has been adapted by the Tamarack Institute in Canada to shift it from a managerial to a movement-building paradigm (Collective Impact 3.0) that “opens up peoples’ hearts and minds to new possibilities” and “emboldens policymakers” and system leaders. Building a movement requires strong relationships based on a common vision, values and stories that can rally like-minded organizationsfootnote 43.

Connected community approach

The Connected Community Approach is a way of understanding how to work in a community using a community development lens. Its focus is on changing and strengthening local systems: the way people interact, access programs and services, and spend their time, energy and money. It includes the ways organizations conduct outreach, institutions engage community members and businesses hire.

The Connected Community Approach aims to change the community itself, which is quite different from services that offer support and knowledge. It draws inspiration from the collective impact modelfootnote 44 and uses its language to describe the work of supporting organizations, which is where the concept of a community backbone organization comes from. By focusing on strengthening social networks between and among people and organizations, a community backbone organization can be a catalyst that stimulates community-based social and economic improvement and mobilizes local assets, skills, aspirations, talents and resources.

The East Scarborough Storefront is an example of the Connected Community Approach. Originally a one-stop shop where agencies serving the community could provide a range of education, legal, employment and settlement services, the Storefront has evolved into an organization that supports resident agency and strategic engagement of other community players. Its goal is to: facilitate collaboration and help people learn and create together, live healthy lives, find meaningful work, play and thrive.

The community now works together to identify and solve problems. Solutions have included:

  • petitioning for better bus service
  • a community youth art project and community event to reclaim a bridge that was unpopular because of traffic speed, narrow sidewalks and a history of suicides
  • a skills-building project that involved youth in renovating a former police station to become the Storefront’s home
  • Residents Rising — volunteers working in the community to engage residents in neighbourhood issues
  • a business network that cross-promotes local businesses and helps them learn from one another, and helps new entrepreneurs with business planning.

The impact of empowering connected communities is impressive: more at-risk youth attending college, a stronger local economy and an increase in literacy and leadership.

Asset-Based Community Development

Asset-Based Community Development (ABCD) is a strengths-based approach to community developmentfootnote 46. It recognizes that communities are diverse and potent webs of gifts and assets — rather than complex masses of needs and problems. Each community has a unique set of skills and capacities that can be channeled for community development.

ABCD organizes resources and assets into six groups:

  1. Individuals: Every resident of the community has assets and gifts that need to be recognized. In community development, you cannot do anything with people’s needs, only their assets.
  2. Associations: Small informal volunteer groups of people working with a common interest, such as clubs, are critical to community mobilization. They don’t control anything; they just come together by individual choice around a common interest.
  3. Institutions: Paid groups of people — generally professionals — organized within a structure. They include government agencies, private business and schools. The assets of these institutions help the community capture valuable resources and establish a sense of civic responsibility.
  4. Built and Natural Environment: Physical assets include land, buildings, space and funds.
  5. Local Economy or Exchange: In the non-monetary world, there are three forms of exchange: 1) intangibles, 2) tangibles, and 3) alternative currencies. In the commercial world, there is a fourth form of exchange: money. There must be an exchange between people sharing assets by, for example, bartering. People who make these connections — normally through building relationships individual by individual — are connectors.
  6. Stories: Local culture or “the community way” often finds expression in the ways people have learned through time to survive and thrive within their home places. When we cooperate with our neighbours to create and exchange stories of a compelling future that respects our traditions, we ensure our culture or “way” prevails. Stories help us pass on important life lessons and are powerful connection points between generations.


For more information on tools, frameworks and initiatives, please go to:


Loneliness and social isolation are serious public health problems that cost us all. They affect our productivity, health and well-being — even how long we live.

Community begins from ground-up individual actions.

Because the impact of social isolation is so pervasive, helping people and communities (re)connect is everyone’s business. Individuals, organizations and businesses, communities and all levels of government must act — together — to build a sense of community.

It’s time to revitalize communities and create a healthier Ontario.

Key messages

Being connected to other people and part of a community are essential to our physical and mental health and well-being. Being socially connected can help people overcome adversity and lead longer, happier lives. People who have a sense of community belonging recover more quickly from stressful situations. They feel better about themselves and make healthy choices. They trust one another and co-operate to benefit all community members. Connected communities have less crime and stronger economic growth. Their children perform better in school and their citizens are more politically involved.

Complex systemic issues fragment community and threaten our sense of belonging. Over the past 50+ years, rapid changes in family structure, the workforce and technology have disrupted our sense of community belonging. Families are smaller. More people live alone. Work has become more precarious and life less certain. People now spend more time commuting and less time connecting. Technologies, such as televisions, computers and smart phones, compete for our attention. Attention is focused on economic goals at the expense of social and environmental goals. As income and opportunity gaps widen and more people feel socially and economically “left behind”, they lose trust in institutions, including government. People are less willing to be involved in their communities and become more isolated.

Strong resilient communities are an effective way to tackle social isolation. Efforts to (re)build community and (re)connect people reinforce the critical importance of engaging people in their communities and investing in activities that nurture and balance social, environmental and economic health. Social capital enhances people’s capacity to manage life stresses and leads to innovative policies that value families, friends, neighbours and other relationships that build connected communities. Organizations across Ontario are working to build community. There are highly successful approaches to measuring well-being as well as developing community that Ontario must leverage to improve health.


To stop the growing public health “epidemic” of social isolation, stress and loss of community, governments must be community-friendly, public health units must be community enablers and all organizations and individuals must be community-centred and community-driven.

  1. Invest in Community

    The provincial and municipal governments should actively invest in community:

    • Make measuring social connection and sense of community as important as measuring other indicators of well-being, such as blood pressure and economic output
    • Collect data on social well-being and social capital over time to establish a baseline and then measure/evaluate the impact of community-building initiatives
    • Assess all policies and initiatives for their impact on community
    • Tackle the broader social and economic drivers that fragment communities
    • Create built environments/infrastructure that make it easier for people to connect and be engaged in their communities.
  2. Enable Community

    Public health units should play a critical role in enabling community. They are uniquely positioned to assess, evaluate and address this serious public health issue:

    • Make communities aware of the benefits of social connections and social capital
    • Connect communities and governments to influence change
    • Leverage the new, less prescriptive Ontario Public Health Standards to develop targeted communitybuilding programs
    • Develop partnerships with municipalities and other organizations to (re)build community and address system barriers, policies and practices that drive social isolation
    • Use data on community well-being and social capital to work with communities to develop concrete action plans
    • Adopt effective evidence-based frameworks for community development that engage people in addressing social determinants of health, building healthy communities and increasing health equity.

    Public health has a long history of community development and should play a key role in building connected communities. Public health units can take the lead on measuring community connectedness and wellness, identifying strengths and resources, hosting connecting events, and using data to realign programs and services to focus on social connections. They can draw attention to the underlying social and economic drivers of social isolation and loss of community and the failure of institutions — governments, businesses and community organizations — to invest in people and services that reinforce a sense of belonging. They can draw attention to investments that promote community connections and social engagement, such as affordable daycare programs, programs for seniors and their caregivers, walkable communities and infrastructure projects that include community benefits agreements.

  3. Be Community-Centred and Community-Driven

    Community begins from the ground up. Individual actions make a big difference. At the local level, individuals and organizations — including businesses — can drive change by being community-centred and community-driven. They can collaborate, pooling strengths and assets to build community. They can make community health and well-being a priority in all their decisions:

    • Be aware of how their decisions affect people’s sense of belonging
    • Enhance their own social capital, connections and partnerships
    • Invest in community.

    Strong, resilient communities are an effective way to tackle these large social, economic and environmental issues. There are already many examples of community building underway in Ontario, including efforts to connect people, connect communities and create built environments that reduce social isolation. There are also frameworks for measuring connectedness and building community — described in this report — that we can use to create more connected and healthier communities.


Advisory Committee:
Dianne Alexander, Charles Gardner, Thelma Gee, Heather Mair, Heather Manson, Patricia O’Campo, Joanne Plaxton, Blake Poland, Suzanne Stewart

Lead Staff:
Elizabeth Choi, Daniel Warshafsky

Catherine Fraser, Fiona Kouyoumdjian, Gillian MacDonald, Laura Seeds

Jean Bacon

Leora Conway

Data and Analytics:
The data in figures I, II, III, VI and VII were provided by Dr. Laura Rosella, Meghan O’Neill and Kathy Kornas of the Population Health Analytics Lab, University of Toronto. Dr. Rosella is supported by a Canadian Institutes of Health Research Foundation Scheme Grant [FDN-148456] and by a Canada Research Chair in Population Health Analytics.

Alliance for Healthier Communities, Canadian Index of Wellbeing, Centre for Connected Communities, Engagement to Reduce Social Isolation in Caregivers at Home and Enhance Seniors Collaborative, Hamilton Social Isolation Impact Project, Indigenous Primary Health Care Council, Rural Ontario Institute, Southwest Ontario Aboriginal Health Access Centre, Simcoe Muskoka District Health Unit, Toronto Social Capital Project

Ministry of Health and Long-Term Care, Ministry of Municipal Affairs

Special thanks to Clayton Shirt, Suzanne Stewart and the Waakebiness-Bryce Institute for Indigenous Health


Ontario Health Units with Vacant Medical Officer of Health (MOH) Positions* Filled By Acting MOHs as of January 24, 2019

  • Huron County Health Unit
  • Niagara Region Health Unit
  • Renfrew County & District Health Unit

Total = 3 Health Units with MOH Vacancies

*Under 62. (1)(a) of the Health Protection and Promotion Act, every board of health shall appoint a full-time medical officer of health

Ontario Public Health Units with Vacant Associate Medical Officer of Health (AMOH) Positions* as of January 24, 2019

  • Durham Region Health Department
  • Grey Bruce Health Unit
  • Halton Region Health Unit**
  • Kingston, Frontenac and Lennox & Addington Health Unit
  • Niagara Region Health Unit**

Total = 5 Health Units with AMOH Vacancies

*Under 62. (1)(b) of the Health Protection and Promotion Act, every board of health may appoint one or more associate medical officers of health.

**Vacancies may include less than or more than one FTE position per health unit and include positions filled by qualified physicians awaiting appointment by boards of health and ministerial approval.

Summary of key messages and recommendations

The last three annual reports issued by Dr. David Williams, Ontario’s Chief Medical Officer of Health, are part of a series that sets out practical strategies to enhance community health and wellness.

The key messages in these reports are interdependent: better data will help us understand our communities’ health issues and identify people and populations facing health inequities, and investing in stronger, more connected communities can improve health and be a protective, sustainable way to enhance health equity.

Mapping Wellness: Ontario’s Route to Healthier Communities

The first in the series of reports talks about the importance of collecting good local data to understand people’s health and make informed, evidence-based decisions to improve health.

Key messages

  • Relevant, timely, consistent population health data is critical to be able to map community wellness, identify health issues at the neighbourhood level and target programs and services to those in greatest need
  • With good data, local health jurisdictions can empower their communities to take action on urgent health needs
  • When members of the community understand the complex social, economic and environmental factors that affect their health, they are more likely to mobilize and create partnerships to address issues that can range from low immunization rates to lack of affordable housing

Improving the odds: Championing Health Equity in Ontario

This was an urgent call to tackle the social, economic and environmental determinants of health and ensure all Ontarians — regardless of race, ethnicity, religion, gender, age, social class, geography, socioeconomic status or other social circumstances — have the opportunity to be as healthy as possible.

Key messages

  • All Ontarians should have the opportunity to be as healthy as possible, yet many face unfair disadvantages that threaten their health (e.g., low incomes, lack of education and employment opportunities, lack of access to stable housing and healthy food, violence and social isolation)
  • The public health sector should treat social inequities with the same urgency as managing outbreaks of infectious diseases
  • It’s time to champion health equity: to bring a wide range of partners together to develop policies and programs that reduce or eliminate social, economic and environmental barriers to good health
  • Community members should come together to implement community development interventions to solve common problems and improve health

Connected Communities: Healthier Together

This report highlights the growing problem of social isolation and asks us all to strengthen our social connections and build more connected and healthier communities.

Key messages

  • Being connected to other people is essential to our well-being, yet a growing number of Ontarians are feeling socially isolated
  • Our sense of belonging is being threatened by changes in family and social structures, work and time pressures, new technologies and economic pressures/income inequality
  • Individuals, organizations, businesses, communities and governments must work together to create a society that values and invests in social connection and community
  • Strong, resilient communities reduce social isolation