1 Health indicators are foundational statistics that provide a basis for comparing the factors that affect the health of a population (Wolfson; Parrish). They allow for the measurement, monitoring, and comparison of key factors that influence the health of a population and the health care system. Using health indicators, it is possible to compare geographic areas, population groups, time periods, and the quality of health services. Indicators are tools that can show communities, governments, health care organizations, and providers where they’ve been, where they’re headed, and where they need to improve. At the national level, a core set of health indicators has been produced since 2003 by Statistics Canada and the Canadian Institute for Health Information (Statistics Canada, “Health Indicators”; Canadian Institute for Health Information). Provincially, the New Brunswick Health Council (NBHC) produces a collection of health indicators that are roughly comparable at the health region and health council community level (New Brunswick Health Council, Recognizing and Focusing). This paper uses select health indicators to examine the nature of population health and population change in New Brunswick at multiple geographic levels. While data on population health and population change are presented regularly by Statistics Canada and by the New Brunswick Health Council, they have not yet been compiled and analysed in depth across multiple periods.

2 The population of New Brunswick has the dubious distinction of being one of the unhealthiest in Canada compared to other provinces (New Brunswick Health Council, Recognizing and Focusing; Office of the Chief Medical Officer of Health). The overall view of health within New Brunswick is low, with only 52 per cent of the population perceiving their overall health as very good or excellent, compared to 59 per cent in all of Canada (Statistics Canada, “Health Indicator Profile”). For mental health, only 64 per cent of New Brunswickers indicate that their mental health is very good or excellent, compared to 71 per cent overall in Canada. These differences are also evident for health status indicators, where 61 per cent of the New Brunswick population is overweight or obese compared to 52 per cent in Canada. Similar differences are present in non-medical determinants of health, health system performance, and community and health system characteristics.

3 Concurrently, the population of New Brunswick has been undergoing profound demographic shifts over the past decades (Peters, New Brunswick Population Snapshot). Much of the province has experienced prolonged real decline in total population numbers, with high levels of out-migration in the younger age groups and negligible in-migration. This has resulted in an aging population that is declining below the rate of replacement across most of the province. Population growth in New Brunswick is concentrated in only a few core areas, namely, the cities of Fredericton, Moncton, and the communities outside of Saint John. Growth in these areas has been largely due to internal migration, with low rates of interprovincial in-migration and immigration. In recent years, the rate of international immigration has begun to increase, with new arrivals focused in and around the three primary cities. The objective of this paper is to use a community-level population health approach to examine health indicators for New Brunswick communities alongside processes of population change and scenarios for future population growth. In this approach, health is a capacity or resource rather than a state of being, akin to being able to pursue one’s goals, to acquire skills and education, and to grow. This generalized definition recognizes a range of social, economic, and environmental factors that contribute to health (Public Health Agency of Canada). This concept of health has been articulated as “the capacity of people to adapt to, respond to, or control life’s challenges and changes” (Frankish et al. 6). Furthermore, a population health perspective is concerned with the social structural nature of health influences and, although health outcomes are ultimately experienced by individuals, the sphere of influence that shapes health experiences goes beyond the characteristics of the individual (Dunn and Hayes).

4 The geographic patterns of health inequalities and demographic change in New Brunswick are similar, with regions measuring lowest in key population health indicators also experiencing the largest population decreases. The observed combination of lower health measures in a context of regional population decline in many areas of the province points to the potential need for policy intervention, whether it be in terms of population growth or community health. While the causal relationship between health outcomes and demographic change are complex, the correlation of these elements can provide insight for communities and policy-makers to support local populations in areas undergoing negative population change in the face of lower health outcomes.

5 A community-based population health approach is useful for linking the overall well-being of a population and population change. At a basic level, the definition of population health combines the concept of population (groups of individuals, organized into different units of analysis, including common characteristics or geographies) and health (the state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity) (Kindig). Communities can be thought of similarly to populations, as a group of people that can be defined by location, race, ethnicity, or other common bonds, particularly those with shared geography (Turnock). Thus population health is a framework for thinking about why some populations are healthier than others, as well as the policy development, research agenda, and resource allocation that flow from it (Young). Approaching the health of communities in this manner allows for the study of how policies and interventions at the individual and social level could be related to patterns of health determinants over the life course and health outcomes and distribution within a population (Kindig and Stoddart). A goal for this paper is to examine the inequalities of health indicators at the community level in relation to historic and forecasted population change.

6 Health inequalities simply refer to measurable differences between individuals, groups, or communities. In contrast, health inequities are systematic differences in health status and outcomes between groups, where in general the more socially disadvantaged experience poorer health (Kindig). Inequities are rooted in economic and social structures and are persistent throughout the life course and across generations. Inequities affect people from all social groups and profoundly shape the public health and health-care system. The selected health indicators presented here provide a community-level view of health inequalities, where the spatial variation of selected indicators is presented across New Brunswick. Given the descriptive nature of this paper, it is not possible to determine to what extent observed differences are systematic and linked to economic and social structures. However, identification of geographic areas where observed values are low across multiple indicators can help target policies and community-based interventions.

7 New Brunswick’s changing population is often the focus of public debate in the province. The last decades have seen a variety of studies, policies, and workshops to discuss the rate of population growth, levels of out-migration, population aging, labour force change, skills shortages, and rising immigration, among others (Population Growth Secretariat, It’s Time to Act; Be Our Future; Government of New Brunswick, New Brunswick Population Growth Strategy 2014–2017; We Are All in This Together; Be Independent; Economic and Social Inclusion Corporation). The population growth rate in New Brunswick has been one of the lowest in Canada, with the population increasing from 516,000 in 1951 to 751,000 in 2011. Since 1971, the growth rate has been high variable, with a peak of 1.85 per cent per annum in 1975 to a low of -0.33 per cent per annum in 2006. Growth years occurred in 1975, 1983, 1991, and 2009. Times of lowest growth were in 1981, 1986, 1998, 2006, and 2013.

8 The population shifts were largely due to changing interprovincial migration rates, which are highly variable in New Brunswick. Interprovincial migration rates in New Brunswick have been shown to be correlated with labour market changes elsewhere in Canada (Peters, Population Forecasts). New Brunswick’s declining population growth rate has been identified as a key challenge to sustaining and growing the province and its economy, and has been identified as being linked to changing requirements for health services (Peters, Small Area Population Forecasts). New Brunswick has one of the fastest aging populations, lowest number of youths settling in the province, and lowest immigration rates in Canada (Government of New Brunswick, New Brunswick Population Growth Strategy 2013–2018). Given the small size of the province, even a moderate fertility rate does little to increase the total population, as deaths now outnumber births, resulting in population decline, not considering migration. These demographic shifts have significant implications for the labour force, the tax base, health care, long-term care, and social support (Post-Secondary Education, Training, and Labour).

9 Population change and population health are interrelated through a variety of mechanisms. At the most basic level, population change is a function of births, deaths, and migration. The number of births in a region is determined by the age-specific fertility rate, or the number of births that occur in each age group and the number of children born to each individual. The timing, frequency, and fecundity are in turn related to the income, education, and marital status of women. The number of deaths is related to overall health, availability of health services, and age profile. These two components are influenced by migration, with out-migration, in-migration, immigration, and emigration of individuals within the province, between provinces, and internationally.

10 Within a population health framework, however, population change is related to health outcomes through upstream patterns of health determinants over the life course. This is most evident in New Brunswick at the community level, where long-term population decreases and continued out-migration of the working-age population have left communities struggling to provide basic services and maintain existing infrastructure with a smaller tax base. These same communities that are in decline often measure lower across a range of population health indicators, further illustrating inequalities between New Brunswick communities. The Results section of this paper highlights the differences between communities across the province within a context of low or negative population growth, and provides some options for how these inequalities could be addressed by a population health approach.

11 The analysis presented here combines population health, census, and demographic indicators from multiple sources, for multiple time periods, and at multiple levels of geographic aggregation. The objective is to provide a comprehensive view of population health and population change for New Brunswick communities. To accomplish this, data from several comparable sources were combined: census information, health indicators from Statistics Canada, health indicators from the New Brunswick Health Council, and small-area population forecasts.

34 There are persistent and marked health inequalities in New Brunswick: between geographic regions, between socioeconomic groups, and between age groups. The results presented here have illustrated these inequalities across multiple dimensions, and highlighted spatial inequalities for several key population health indicators. Provincially, New Brunswick fares poorer than the national average on several key population and health indicators: post-secondary graduates, long-term unemployment, reliance on government transfers, high and growing old-age dependency, total age-standardized mortality rate, self-perceived health, proportion of overweight and obese, diabetes, and ACS conditions. However, New Brunswick fares better than Canada as a whole in terms of children in low-income families, the proportion of renters spending more than 30 per cent of income on shelter, lone-parent families, and community belonging. Of these, community belonging is worth highlighting, especially given the context of high local out-migration and low population growth. In most circumstances, these features would indicate communities “in decline.” However, given higher than expected rates of community belonging, it shows that a sense of belonging to place can transcend in population decreases.

35 At the community level, the results presented here point to mixed vulnerabilities and potential opportunities across the province. In particular, communities that have lower health measures across several indicators and persistently lower values for census indicators—combined with negative historic population growth and negative forecasted growth—there is a high potential for community vulnerability. In contrast, communities that measure higher in health and census indicators and have the potential for population growth have the opportunity to attract growth within the region and provide services for communities in decline.

36 The population forecasts presented here point to only a few areas for growth: Moncton (including Riverview and Dieppe), Fredericton (New Maryland and Oromocto), and the greater Saint John area (Quispamsis). Outside of these regions, little or negative population growth over the next thirty years is forecast. Within this context, the prospect for improvements in population health are questionable. As the resident population of many communities continues to age, and high youth out-migration continues, the provision of health services and public health programs will become even more difficult.

37 Without population growth at the provincial level, there will be a smaller proportion of working-age population contributing to the tax base required to support continued aging. Over the past decade there has been little population increase, with out-migration of working-age individuals. This leaves a greater proportion of older adults who may not be working full-time and are entering a time where they may have additional health needs. As such, it is imperative that provincial health strategies include a defined strategy for population growth, recognizing that most communities will likely continue to face population decline. The results above point to some opportunities to focus population growth within the three larger urban centres. Smaller communities across the province have maintained high levels of community belonging, despite continued population decreases. In this sense, population decreases do not equate to community decline (Taylor et al.). The prospect of these areas “disappearing” or “failing” is minimal, and experiences elsewhere have shown that even with large decreases in population, communities change and persist (Robinson and Carson).

38 At the same time, the high levels of out-migration from rural and small-town areas of the province have not resulted in an equivalent growth in the three urban centres. With most of out-migrants leaving New Brunswick, at least in the medium term, there is a missed opportunity to retain these individuals within the province. The gains of retaining even some out-migrants would extend across many of the indicators presented in this paper. Strategies to promote retention, however, would need to address the realities of health inequalities, economic activities, as well as forecasted population growth (Carson and Carson).

39 The consideration of population health alongside population change is an important next step for provincial planners and policy-makers (Carson). Over the past decades, there have been sustained population decreases across much of the province. Using small-area forecasting techniques, these decreases are projected to continue in all but a few areas. At the same time, these areas of population decrease are correlated with lower population health status, suggesting that if populations continue to decline, there may be a widening of health inequalities between regions of the province.