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Abstract

Introduction:

Individuals with participation and activity limitations face important healthcare challenges.

Objectives:

We investigated healthcare utilization and characteristics of Canadians living with participation and activity limitations between 2001 and 2010.

Methods:

We pooled data from 5 cycles of the Canadian Community Health Survey (2001-2010 CCHS). The multistage stratified cluster-sampling method used covered approximately 98% of Canadians, aged 12 years and older residing in private dwellings. We described sociodemographic, behavioral, and health-related characteristics of participants with participation and activity limitations and reported their annual utilization (prevalence; 95% CI) of 7 healthcare providers. Multivariable modified Poisson regression identified individual characteristics associated with healthcare utilization and examined the trends over time.

Results:

Annually, 8.1 million Canadians aged 12 years and older (29.8%) reported participation and activity limitations. Most common health conditions were back problems (37%) and arthritis (34%). Predominant healthcare providers were medical doctors (88.8%; 95% CI = 88.6-89.0), nurses (16.3%; 95% CI = 16.1-16.6), physiotherapists (15.0%; 95% CI = 14.7-15.2), and chiropractors (14.4%; 95% CI = 14.2-14.7). Overall, males, older adults, immigrants, those with lower education, lower income, recent employment, and better general health were less likely to consult providers. Over time, utilization of most non-medical providers increased.

Conclusion:

Participation and activity limitations are prevalent in Canada, and most consulted medical doctors. Disadvantaged groups reported lower utilization of most providers, emphasizing access challenges and the need for equitable and integrated healthcare policies. Improving access to rehabilitation services and their inclusion within universal healthcare coverage should be a priority.

Keywords

disability limitation of activity functional status health care Canada

Highlights

8.1 million Canadians (29.8%) experienced participation and activity limitations annually (2001-2010); back problems (37.0%) and arthritis (34.1%) were most prevalent conditions.

29.2% of Canadians with limitations attributed their limitations to causes other than injury, disease, or aging.

Most healthcare consultations were with medical doctors (88.8%), followed by nurses (16.3%), physiotherapists (15.0%), chiropractors (14.4%), and other providers (<10%).

Lower education and better general health were associated with lower healthcare utilization.

Biennially (2001-2010), healthcare utilization increased for nurses (7%), physiotherapists (5%), chiropractors (3%), psychologists (9%), and speech/audiology/occupational therapists (18%). Social worker consultations decreased by 4%, while medical doctor consultations remained stable.

Introduction

Human functioning encompasses biological health and lived experiences within the environment.¹ The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) defines functioning as the interaction of personal and environmental factors with body functions, activities, and participation.² According to the ICF, activities involve tasks executed at the level of the person, while participation involves engagement with life situations and societal activities.²

Participation and activity limitations are important health outcomes, extending beyond disease management to encompass overall functioning and quality of life.^1,3
-5 In 2017, WHO identified functioning as the third key health indicator, alongside mortality and morbidity, to better monitor the effectiveness of health strategies within health systems.⁶ Given the aging global population, the rise of multimorbidity, changing lifestyles, and the evolving concept of wellness, measuring participation and activity limitations is critical for understanding population health and furthering healthcare systems.^3,7

Despite growing methodological support for measuring these limitations as health outcomes,^8
-11 research remains in its early stages. Studies have thus far focused primarily on diseases and risk factors associated with participation and activity limitations within specific populations, such as those with cancer,¹² stroke,¹³ cerebral palsy,¹⁴ HIV,¹⁵ leprosy,¹⁶ arthritis,¹⁷ dysmenorrhea,¹⁸ spinal cord injury,¹⁹ and COPD.²⁰ While recent studies have explored the impact of sociodemographic and environmental factors on participation and activity limitations,^12,21
-23 there remains a significant gap in population-based evidence regarding the burden these limitations place on healthcare systems and the associated healthcare needs in most countries.^5,24
-27

The United Nations’ Sustainable Development Goals focus on promoting healthy lives and well-being for all ages, prompting the need for public health measures and health system strengthening. However, health system reforms are progressing slowly.³ In fact, most healthcare systems struggle to effectively address the multifaceted needs of people with participation and activity limitations, particularly limitations without a specific medical diagnosis or disease impairment.^5,26,28 Consequently, poor physical and mental health, participation limitations, and activity restrictions all lead to complex health issues, high-risk health behaviors, and diminished quality of life.^5,29
-31 In Canada, the universal health system covers visits to medical doctors, essential prevention and rehabilitation services often require additional funding.^26,32 Historically, Canada has allocated fewer resources to community and long-term care compared to peers in the Organization for Economic Co-operation and Development (OECD).³³ The COVID-19 pandemic further exacerbated unmet healthcare needs among Canadians with long-term conditions and disabilities.³⁴ However, the absence of comprehensive pre-pandemic population-based evidence on healthcare utilization of the population with limitations and the associated characteristics hinders healthcare system improvements.³

Our study provides a historical and national overview of healthcare utilization among Canadians with participation and activity limitations using 2001 to 2010 data. Specifically, we aimed to: (1) describe the characteristics of Canadians living with participation and activity limitations from 2001 to 2010; (2) determine the prevalence of healthcare utilization in this population; (3) identify factors associated with utilization of 7 different healthcare professionals (medical doctor, nurse, chiropractor, physiotherapist, psychologist, social worker/counselor, and speech/audiology/occupational therapist); and (4) examine trends in healthcare utilization from 2001 to 2010. This investigation aims to shed light on evolving healthcare needs and barriers faced by this population within the Canadian healthcare system.

Methods

Data Source

We used population-based cross-sectional data from Canadian Community Health Survey (CCHS) collected by Statistics Canada biennially from 2001 to 2007 and annually thereafter.³⁵ Through a multistage stratified cluster-sampling strategy, the CCHS achieved representation of approximately 98% of the target population (ie, Canadians aged 12 years and older residing in private dwellings of the 10 provinces and 3 territories).³⁵ Further details on the survey methodology are described by Statistics Canada.³⁶

We accessed CCHS Public Use Microdata Files via the secure Ontario Data Documentation, Extraction Services and Infrastructure (ODESI) digital data service.³⁷

Study Sample

All CCHS participants identified as having participation and activity limitations related to long-term condition(s) or problem(s) that lasted or were expected to last at least 6 months were eligible for inclusion. To assess these limitations, Statistics Canada developed the “Restriction of Activities” survey module for the CCHS using the WHO ICF framework. This module included 5 questions on the frequency of restrictions (ie, sometimes, often, never) in daily activities and participation across various settings, including hearing, seeing, communicating, walking, climbing stairs, bending, learning, and activities performed at home, school, work, and other settings (Supplemental Appendix 1).^38
-43 We classified individuals reporting “sometimes” or “often” to any of these questions as having participation and activity limitations.

We pooled 5 CCHS cycles from 2001 to 2010 to enhance sample size and statistical power, offering a comprehensive historical overview.⁴⁴ Cycle selection for pooled analysis prioritized data availability across all provinces and territories of Canada and consistency in survey frames and content, particularly regarding participation and activity limitations (study population) and consultations with healthcare providers (outcome variable).^39
-43

Measures

We used 8 questions from the “Healthcare Utilization” survey module to capture the self-reported utilization of healthcare services in the past 12 months from 7 professionals: medical doctor (including family physician and specialist), nurse, chiropractor, physiotherapist, psychologist, social worker/counselor, and speech/audiology/occupational therapist.^39
-43 Responding “yes” to each question indicated consultation with the respective professional.

Based on previous literature,⁴⁵ we used all relevant variables available (sociodemographic, behavioral, health-related) across all 5 CCHS cycles to explore characteristics associated with healthcare utilization. Sociodemographic variables included age, sex, residential province, cultural/racial background, immigration status, education level, household income level, marital status, and working status last week. Behavioral variables included type of smoker, type of drinker, and physical activity. Health-related characteristics included BMI, self-perceived general health, cause of the health problem that limits daily activity and participation, and self-reported chronic health conditions (Supplemental Appendix 2)

For variables with inconsistent categorization across 5 cycles (ie, cause of participation and activity limitations), we retained the relatively consistent and broader categories in most cycles, and regrouped them accordingly in the remaining cycles. Further details on variable categories are provided in Supplemental Appendix 2.

Statistical Analysis

We pooled 5 cycles of CCHS 2001 to 2010 data using rescaled sampling weights to ensure representativeness of the study population on an annual basis. Original sampling weights were divided by 5 for the pooled average population, yielding new weights for the pooled average population.⁴⁴

We described the study sample’s characteristics and healthcare provider consultation using weighted frequencies and proportions. To determine healthcare utilization prevalence, we divided the weighted number of users (respondents with participation and activity limitations reporting consultations with a certain healthcare professional) by the weighted number of Canadians with participation and activity limitations.

We studied the association between personal characteristics (explanatory variable) and utilization of each healthcare professional (outcome variable) using univariable and multivariable modified Poisson regression models with robust variance estimation.⁴⁶ We used modified Poisson regression to obtain direct and robust estimates of relative risk for binary outcomes, which is particularly advantageous for its interpretability compared to odds ratios when the outcome is common.⁴⁶ In the model for a particular healthcare professional, each personal characteristic was initially modeled individually to estimate its bivariable association with the healthcare utilization (crude Prevalence Ratio (cPR) with 95% CI). Subsequently, we built a multivariable model with all characteristics (including the survey cycle as a continuous variable representing the 5 CCHS cycles) to obtain adjusted Prevalence Ratios (aPR) with 95% CI. Chronic health conditions were not included in the models due to their high correlation with the self-reported causes of participation and activity limitations. Participants with missing data for any variables in the multivariable models were excluded from the analysis. However, response of “not applicable” due to the restricted universe was treated as a valid category to preserve sample size and the information they convey. The analyses for this study were generated using SAS software v9.4 (Copyright© 2012-2018, SAS Institute Inc., Cary, NC, USA. SAS and all other SAS Institute Inc. product or service names are registered trademarks or trademarks of SAS Institute Inc., Cary, NC, USA.)

Results

Sample Characteristics of Canadians Living With Participation and Activity Limitation

Annually between 2001 and 2010, 29.8% of community-dwelling Canadians aged 12 years or older (representing an estimated 8.1 million persons) reported limitations in daily activity and participation (Figure 1). The most common self-ascribed cause of participation and activity limitations was disease (31.3%), injury (20.9%), aging (18.6%), and other causes (eg, existed from birth or related to work, 27.5%). The most prevalent chronic health conditions were back problems (37%) and arthritis (34.1%), followed by high blood pressure (25.1%), mood disorder (12.7%), asthma (12.3%), and heart disease (10.9%), with prevalence lower than 10% for all other conditions. Notably, 20.6% of the population with participation and activity limitations did not report any of the twelve common health conditions covered by CCHS. (Table 1)

Figure 1.

Flow diagram for study sample of Canadian Community Health Survey (CCHS) respondents from 2001 to 2010.

Table 1.

Characteristics of Canadians Living With Participation and Activity Limitations and Those Who Consulted Health Professionals: Pooled Analysis of Canadian Community Health Survey 2001 to 2010.

Characteristics	Canadians living with participation and activity limitations	Canadians living with participation and activity limitations who consulted healthcare professionals
Characteristics		Medical doctor (incl. specialist)	Nurse	Physiotherapist	Chiropractor	Social worker/counselor	Psychologist	Speech/audiology/occupational therapist
Weighted sample, N (%)	8 123 871 (100.0)	7 216 193 (100.0)	1 325 780 (100.0)	1 217 319 (100.0)	1 172 069 (100.0)	666 019 (100.0)	415 262 (100.0)	357 756 (100.0)
Age group (years)
12-19	7.3%	6.5%	8.0%	5.9%	5.8%	16.9%	13.4%	8.7%
20-34	15.2%	14.5%	18.1%	15.7%	17.8%	21.9%	22.7%	12.1%
35-49	24.6%	24.2%	23.5%	29.7%	31.5%	29.8%	35.6%	20.5%
50-64	26.6%	27.3%	23.6%	28.8%	28.4%	18.6%	22.3%	24.7%
65-79	18.8%	19.7%	17.3%	15.0%	13.3%	7.4%	4.9%	22.0%
80+	7.5%	7.8%	9.5%	4.9%	3.2%	5.4%	1.2%	12.1%
Sex
Male	46.7%	44.9%	40.6%	42.6%	44.7%	39.9%	39.3%	53.5%
Female	53.3%	55.1%	59.4%	57.4%	55.3%	60.1%	60.7%	46.5%
Province of residence
Newfoundland	1.7%	1.8%	1.6%	1.2%	0.8%	1.4%	1.2%	1.7%
Prince Edward Island	0.4%	0.5%	0.5%	0.4%	0.2%	0.5%	0.2%	0.4%
Nova Scotia	3.7%	3.8%	3.2%	3.7%	1.5%	3.2%	3.3%	3.5%
New Brunswick	2.6%	2.6%	2.7%	2.2%	1.2%	2.7%	2.1%	2.8%
Quebec	20.5%	20.1%	28.2%	18.1%	14.9%	19.0%	33.3%	28.3%
Ontario	39.4%	39.7%	35.8%	39.0%	38.7%	39.2%	31.6%	33.8%
Manitoba	3.7%	3.7%	3.3%	4.1%	5.3%	3.6%	2.5%	3.7%
Saskatchewan	3.2%	3.2%	2.9%	2.9%	4.3%	3.2%	2.1%	3.0%
Alberta	10.5%	10.4%	10.1%	11.6%	15.9%	10.3%	12.0%	9.6%
British Columbia	13.9%	14.1%	11.1%	16.4%	17.0%	16.5%	11.5%	12.9%
Yukon, Northwest Territories and Nunavut	0.3%	0.2%	0.6%	0.2%	0.2%	0.5%	0.2%	0.3%
Cultural/racial background
White	84.8%	85.1%	87.3%	84.2%	88.1%	81.5%	84.4%	88.7%
Non-white	12.6%	12.4%	10.2%	13.3%	9.8%	15.7%	12.8%	8.7%
Unknown	2.6%	2.5%	2.5%	2.5%	2.1%	2.8%	2.8%	2.6%
Immigrant status
Non-immigrant	79.0%	78.7%	84.0%	77.8%	82.8%	84.6%	84.5%	83.4%
Immigrant (0-9 years)	2.8%	2.7%	1.8%	3.3%	2.5%	3.0%	2.6%	1.6%
Immigrant (10+ years)	16.0%	16.5%	12.1%	16.9%	13.0%	10.3%	10.7%	12.9%
Unknown	2.2%	2.1%	2.1%	2.1%	1.7%	2.1%	2.2%	2.1%
Highest level of education—respondents
<Secondary school	28.3%	27.8%	27.8%	19.7%	19.1%	34.3%	22.8%	28.0%
Secondary school graduate	15.7%	15.6%	13.8%	14.9%	16.4%	14.2%	13.5%	12.9%
Some post-secondary education	7.7%	7.7%	8.4%	7.7%	8.8%	10.0%	10.1%	7.7%
Post-secondary grad/university degree	45.8%	46.5%	47.7%	55.6%	53.9%	38.5%	51.2%	48.6%
Unknown	2.4%	2.3%	2.3%	2.2%	1.7%	2.9%	2.6%	2.7%
Total household income
1st quintile	14.6%	14.7%	17.1%	10.7%	9.3%	26.0%	17.6%	15.2%
2nd quintile	14.1%	14.1%	14.6%	12.5%	12.3%	15.1%	13.7%	15.8%
3rd quintile	18.3%	18.4%	18.2%	17.0%	18.1%	17.8%	18.0%	18.5%
4th quintile	20.6%	20.6%	19.6%	23.0%	23.9%	15.6%	20.8%	21.0%
5th quintile	17.7%	17.8%	16.3%	23.3%	23.4%	11.2%	17.2%	16.2%
Unknown/NS^b	14.7%	14.4%	14.2%	13.6%	13.0%	14.3%	12.7%	13.3%
Working status last week
Working	43.5%	42.3%	37.1%	47.4%	57.0%	33.1%	42.8%	31.8%
Absent	4.7%	4.9%	6.9%	8.1%	6.3%	5.5%	9.8%	5.5%
No job	28.4%	28.9%	28.6%	25.8%	23.3%	33.1%	29.6%	27.2%
Unable/permanent	6.0%	6.4%	8.4%	6.3%	3.6%	13.1%	9.0%	9.9%
NA^b (age <15 or >75 years)	15.7%	16.0%	17.5%	10.8%	8.3%	13.5%	6.9%	24.0%
Unknown	1.6%	1.5%	1.6%	1.7%	1.5%	1.7%	1.9%	1.6%
Marital status
Married	51.1%	52.3%	45.2%	54.6%	56.5%	27.7%	34.9%	49.0%
Common-law	8.2%	7.9%	9.3%	8.6%	9.4%	7.8%	11.5%	7.8%
Widowed/divorced/separated	18.2%	18.7%	20.5%	16.0%	14.3%	22.1%	16.6%	20.1%
Single	22.3%	20.8%	24.9%	20.5%	19.7%	42.1%	36.8%	23.0%
Unknown	0.2%	0.1%	0.2%	0.2%	0.1%	0.2%	0.2%	0.1%
Type of smoker
Daily	20.8%	20.0%	20.6%	17.3%	17.7%	28.8%	26.6%	16.2%
Occasional	4.3%	4.2%	4.6%	4.1%	4.6%	6.1%	6.5%	3.8%
Not at all	74.6%	75.5%	74.6%	78.3%	77.4%	64.8%	66.7%	79.8%
Unknown	0.2%	0.2%	0.2%	0.3%	0.3%	0.3%	0.2%	0.2%
Type of drinker
Regular	54.2%	53.9%	50.1%	59.2%	61.9%	44.2%	55.1%	50.8%
Occasional	19.2%	19.5%	21.1%	17.8%	18.3%	22.9%	19.0%	18.0%
Did not drink	25.3%	25.4%	27.4%	21.8%	18.6%	31.1%	24.5%	29.5%
Unknown	1.4%	1.3%	1.4%	1.3%	1.2%	1.7%	1.4%	1.7%
Physical activity
Active	19.3%	18.8%	18.5%	22.2%	22.9%	21.0%	20.5%	17.1%
Moderate active	21.5%	21.5%	20.9%	23.2%	24.4%	19.4%	21.7%	18.9%
Inactive	53.7%	54.2%	54.0%	50.4%	49.7%	48.9%	51.5%	50.4%
Unknown	5.6%	5.6%	6.5%	4.2%	3.0%	10.7%	6.3%	13.6%
BMI classification—International standard^c
Underweight	2.7%	2.7%	3.2%	2.6%	2.1%	4.0%	3.3%	2.8%
Normal weight	32.7%	32.5%	32.2%	35.1%	34.4%	32.2%	37.3%	29.5%
Overweight (incl. obese)	48.7%	49.4%	47.6%	50.3%	52.2%	39.7%	42.4%	46.8%
NA	11.4%	11.0%	11.7%	8.7%	8.0%	17.3%	12.5%	12.7%
Unknown	4.4%	4.4%	5.3%	3.3%	3.4%	6.8%	4.4%	8.2%
Perceived general health
Poor	8.2%	8.7%	13.3%	8.9%	5.5%	15.4%	12.4%	10.8%
Fair	19.4%	20.4%	23.7%	19.3%	16.1%	23.5%	22.6%	22.9%
Good	35.4%	35.5%	33.8%	34.3%	36.6%	32.5%	34.3%	33.3%
Very good	27.5%	26.8%	22.8%	27.8%	31.5%	21.4%	23.1%	22.8%
Excellent	9.3%	8.5%	6.3%	9.6%	10.2%	7.1%	7.5%	10.1%
Unknown	0.1%	0.1%	0.2%	0.2%	0.1%	0.1%	0.1%	0.1%
Cause of difficulty with activities
Injury	20.9%	20.7%	20.3%	36.7%	29.6%	18.8%	23.2%	20.7%
Disease	31.3%	32.8%	38.3%	28.4%	26.4%	32.6%	30.2%	30.4%
Aging	18.6%	18.6%	14.4%	12.9%	14.4%	8.3%	5.9%	16.5%
Other (existed at birth/work conditions/other)	27.5%	26.3%	25.6%	20.7%	27.8%	38.8%	39.7%	31.3%
Unknown	1.7%	1.5%	1.5%	1.3%	1.8%	1.5%	1.0%	1.1%
CCHS survey cycle
2001	19.3%	19.5%	17.2%	19.0%	18.9%	20.5%	17.6%	16.0%
2003	20.4%	20.2%	19.1%	19.9%	20.3%	19.3%	18.6%	16.0%
2005	19.8%	19.7%	20.1%	18.8%	19.7%	19.3%	18.2%	16.7%
2007	20.7%	20.7%	20.7%	20.9%	20.5%	20.6%	21.4%	21.6%
2009	19.8%	20.0%	22.9%	21.4%	20.6%	20.3%	24.1%	29.6%
Chronic health conditions (CHC)^a
Number of CHC
0	20.6%	15.3%	14.4%	16.2%	18.1%	14.2%	16.5%	18.8%
1	28.1%	28.9%	31.5%	24.0%	27.6%	23.1%	22.9%	24.5%
2	23.5%	26.0%	25.7%	23.3%	24.5%	23.7%	21.9%	23.3%
3	14.6%	15.3%	16.2%	17.1%	15.6%	17.0%	16.4%	15.8%
4	7.6%	8.1%	7.2%	10.5%	8.2%	10.8%	10.6%	8.5%
5	3.5%	3.7%	3.3%	5.0%	3.8%	6.0%	6.2%	4.8%
6	1.4%	1.6%	1.1%	2.4%	1.5%	3.3%	3.3%	2.5%
7	0.5%	0.7%	0.3%	1.0%	0.5%	1.1%	1.2%	1.1%
8	0.1%	0.1%	0.1%	0.3%	0.2%	0.4%	0.5%	0.5%
9	0.1%	0.1%	0.0%	0.1%	0.1%	0.2%	0.2%	0.1%
10	0.0%	0.0%	0.0%	0.1%	0.0%	0.1%	0.1%	0.1%
11	0.0%	0.0%	. %	0.0%	0.0%	0.1%	0.1%	. %
CHC—Back problems	37.0%	37.9%	37.3%	51.6%	59.2%	38.7%	41.5%	38.0%
CHC—Arthritis	34.1%	36.1%	35.6%	39.2%	32.7%	27.9%	23.5%	37.1%
CHC—High blood pressure	25.1%	26.8%	27.7%	22.5%	19.4%	19.0%	16.2%	28.1%
CHC—Migraine headache	15.0%	15.4%	18.8%	17.8%	18.1%	22.8%	25.4%	16.0%
CHC—Mood disorder	12.7%	12.6%	12.6%	18.2%	13.6%	45.0%	36.3%	16.7%
CHC—Asthma	12.3%	12.8%	15.5%	12.5%	12.3%	17.7%	16.1%	12.5%
CHC—Heart disease	10.9%	11.8%	14.8%	8.5%	6.7%	9.6%	7.3%	14.0%
CHC—Diabetes	9.4%	10.1%	14.0%	8.1%	6.4%	8.6%	6.4%	10.5%
CHC—Anxiety disorder	9.4%	8.9%	8.6%	13.4%	9.9%	32.4%	26.1%	12.0%
CHC—Intestinal/stomach ulcers	5.7%	6.0%	7.3%	5.7%	5.4%	7.8%	7.4%	6.4%
CHC—Cancer	3.5%	3.8%	6.7%	3.4%	2.7%	4.4%	3.6%	5.3%
CHC—Stroke	2.9%	3.1%	4.5%	3.2%	1.5%	4.7%	2.5%	6.6%
Health care utilization (HCU)
Number of health professionals consulted in the past 12 months
0	7.9%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%	0.0%
1	49.9%	53.2%	4.0%	2.5%	7.0%	4.4%	2.2%	3.0%
2	28.7%	31.7%	50.9%	48.4%	50.9%	36.8%	30.7%	37.8%
3	10.1%	11.2%	30.0%	33.3%	30.0%	34.7%	35.2%	32.1%
4	2.6%	2.9%	11.2%	11.2%	8.8%	16.3%	20.6%	16.8%
5	0.6%	0.7%	3.0%	3.2%	2.4%	5.6%	7.7%	6.5%
6	0.1%	0.2%	0.7%	0.9%	0.7%	1.5%	2.5%	2.6%
7	0.0%	0.1%	0.3%	0.3%	0.3%	0.6%	1.0%	1.1%
HCU—Medical doctors	88.8%	—	94.1%	95.6%	90.9%	92.4%	94.4%	94.3%
HCU—Nurse	16.3%	17.3%	—	21.4%	16.5%	32.4%	30.7%	27.6%
HCU—Chiropractor	14.4%	14.8%	14.6%	23.3%	—	15.2%	20.1%	16.1%
HCU—Physiotherapist	15.0%	16.1%	19.6%	—	24.2%	19.7%	24.9%	29.4%
HCU—Psychologist	5.1%	5.4%	9.6%	8.5%	7.1%	19.4%	—	12.8%
HCU—Social worker or counselor	8.2%	8.5%	16.3%	10.8%	8.7%	—	31.1%	18.1%
HCU—Speech/audiology/occupational therapist	4.4%	4.7%	7.5%	8.6%	4.9%	9.7%	11.0%	—

Data source: Public Use Microdata File of Canadian Community Health Survey produced by Statistics Canada and accessed via the Ontario Data Documentation, Extraction Services, and Infrastructure (ODESI) digital data service. The results or views expressed are those of the authors and are not those of Statistics Canada.

Data processing: 5 cycles from Canadian Community Health Survey 2001 to 2010 were pooled to obtain a single sample representing an average annual population from 2001 to 2010; Original sampling weights within each cycle were rescaled by dividing 5 (the number of survey cycles) to obtain a new weight in the newly pooled average population. All statistics are based on the rescaled sampling weights.

A total of 12 chronic health conditions was included in our analysis. Estimates for mood disorder (eg, depression, bipolar disorder, mania, or dysthymia) and anxiety disorder (eg, phobia, obsessive-compulsive disorder, or a panic disorder) were based on 4 CCHS cycles from 2003 to 2010 due to their unavailability in 2001 CCHS.

NA = not applicable according to population exclusions; NS = not stated or responses without enough information for classification.

BMI = Weight (kg)/squared height (m), weight and height are self reported. The BMI categories are adopted from a body weight classification system recommended by Health Canada and the World Health Organization (WHO) which has been widely used internationally. In CCHS 2001, NA: age <20 or age >64 years or pregnant; In CCHS 2004, NA: age <20 years or pregnant; in CCHS 2005 to 2010, NA: age <18 years or pregnant.

Most participants with participation and activity limitations consulted 1 (50%) or 2 (28.7%) healthcare professionals in the previous 12 months (Table 1). Medical doctors were the most commonly consulted (88.8%, 95% CI = 88.6-89.0), followed by nurses (16.3%, 95% CI = 16.1-16.6), physiotherapists (15.0%, 95% CI = 14.7-15.2), chiropractors (14.4%, 95% CI = 14.2-14.7), social workers/counselors (8.2%, 95% CI = 8.0-8.4), psychologists (5.1%, 95% CI = 5.0-5.3), and speech/audiology/occupational therapists (4.4%, 95% CI = 4.3-4.5).

Over 50% of Canadians with participation and activity limitations were aged 35 to 64 years, white, non-immigrant, resides of Ontario and Quebec, with at least average household income, non-smokers, regular alcohol drinkers, married, and physically inactive. A significant portion had a post-secondary education (45.8%), were working (43.5%) in the past week, overweight (48.7%), and reported good general health (35.4%).

Sociodemographic Characteristics and Healthcare Utilization Among Canadians With Participation and Activity Limitations

Our multivariable regression analyses suggest that individuals with less than a secondary school education were less likely to consult all healthcare providers than those who completed post-secondary education. Older participants were less likely than those 12 to 19 years to consult chiropractors, social workers/counselors, or psychologists. Females were more likely than males to consult every type of healthcare provider except for speech/audiology/occupational therapists (Table 2).

Table 2.

Regression Analysis of the Association Between Personal Characteristics and Self-reported Consultations With Health Professionals Among Canadians Living With Participation and Activity Limitations: Pooled Analysis of Canadian Community Health Survey 2001 to 2010.

Characteristics	Medical doctor (including specialist)	Nurse	Physiotherapist	Chiropractor	Social worker /counselor	Psychologist	Speech/audiology/occupational therapist
	PR (95%CI)^a	PR (95%CI)	PR (95%CI)	PR (95%CI)	PR (95%CI)	PR (95%CI)	PR (95%CI)
Age group (years)
12-19	1	1	1	1	1	1	1
20-34	1.03 (1.01-1.05)	1.04 (0.94-1.15)	0.91 (0.82-1.02)	1.05 (0.94-1.18)	0.82 (0.72-0.93)	0.84 (0.69-1.02)	0.98 (0.77-1.25)
35-49	1.04 (1.02-1.06)	0.81 (0.73-0.90)	1.01 (0.90-1.14)	1.09 (0.97-1.23)	0.78 (0.69-0.89)	0.87 (0.71-1.07)	1.05 (0.82-1.35)
50-64	1.07 (1.05-1.09)	0.68 (0.61-0.75)	0.96 (0.86-1.08)	0.99 (0.88-1.12)	0.41 (0.36-0.47)	0.49 (0.40-0.61)	1.08 (0.84-1.38)
65-79	1.09 (1.07-1.11)	0.70 (0.64-0.78)	0.90 (0.81-1.00)	0.85 (0.76-0.95)	0.19 (0.16-0.22)	0.15 (0.12-0.19)	1.30 (1.02-1.65)
80+	1.11 (1.09-1.13)	0.98 (0.88-1.10)	0.89 (0.78-1.02)	0.61 (0.52-0.70)	0.30 (0.25-0.36)	0.11 (0.08-0.15)	1.61 (1.25-2.08)
Sex
Male	1	1	1	1	1	1	1
Female	1.07 (1.07-1.08)	1.22 (1.18-1.26)	1.33 (1.28-1.38)	1.22 (1.17-1.26)	1.27 (1.21-1.33)	1.39 (1.29-1.49)	0.78 (0.73-0.83)
Province of residence
Newfoundland	1.02 (1.01-1.03)	0.95 (0.87-1.04)	0.83 (0.75-0.92)	0.46 (0.40-0.52)	0.64 (0.55-0.74)	0.83 (0.67-1.04)	1.14 (0.95-1.36)
Prince Edward Island	1.02 (1.00-1.03)	1.03 (0.93-1.14)	1.10 (0.98-1.23)	0.42 (0.34-0.51)	0.98 (0.84-1.14)	0.56 (0.40-0.79)	1.07 (0.84-1.35)
Nova Scotia	1.02 (1.01-1.03)	0.85 (0.79-0.92)	1.06 (0.98-1.14)	0.42 (0.37-0.48)	0.81 (0.73-0.90)	1.05 (0.89-1.23)	1.08 (0.94-1.25)
New Brunswick	1.00 (0.99-1.01)	1.05 (0.98-1.13)	0.97 (0.89-1.05)	0.48 (0.43-0.54)	0.89 (0.80-0.99)	1.01 (0.86-1.18)	1.25 (1.08-1.44)
Quebec	0.97 (0.97-0.98)	1.43 (1.37-1.49)	0.96 (0.91-1.01)	0.76 (0.71-0.81)	0.79 (0.73-0.85)	1.95 (1.78-2.13)	1.59 (1.44-1.75)
Ontario	1	1	1	1	1	1	1
Manitoba	0.98 (0.97-0.99)	0.96 (0.88-1.03)	1.20 (1.11-1.29)	1.40 (1.31-1.49)	0.96 (0.86-1.06)	0.85 (0.71-1.03)	1.14 (0.96-1.36)
Saskatchewan	1.00 (0.99-1.01)	0.94 (0.89-1.01)	0.99 (0.91-1.06)	1.33 (1.25-1.41)	1.06 (0.96-1.17)	0.88 (0.75-1.03)	1.04 (0.90-1.19)
Alberta	0.99 (0.98-1.00)	1.05 (0.99-1.11)	1.11 (1.04-1.18)	1.43 (1.36-1.51)	1.02 (0.94-1.10)	1.35 (1.20-1.52)	1.10 (0.97-1.24)
British Columbia	1.01 (1.00-1.02)	0.89 (0.84-0.94)	1.15 (1.09-1.21)	1.20 (1.15-1.26)	1.23 (1.15-1.31)	1.03 (0.92-1.15)	1.09 (0.99-1.21)
Yukon, Northwest Territories, and Nunavut	0.93 (0.91-0.95)	2.66 (2.47-2.87)	1.03 (0.92-1.15)	0.69 (0.60-0.80)	1.62 (1.44-1.83)	0.96 (0.76-1.21)	2.09 (1.69-2.58)
Cultural/racial background
White	1	1	1	1	1	1	1
Non-white	1.00 (0.99-1.01)	0.87 (0.82-0.93)	1.02 (0.96-1.10)	0.76 (0.70-0.82)	1.06 (0.98-1.15)	0.98 (0.86-1.11)	0.73 (0.62-0.85)
Immigrant status
Non-immigrant	1	1	1	1	1	1	1
Immigrant(0-9 years)	0.98 (0.96-1.01)	0.64 (0.54-0.77)	1.21 (1.06-1.39)	0.93 (0.78-1.10)	0.80 (0.66-0.96)	0.78 (0.57-1.06)	0.69 (0.47-1.02)
Immigrant(10+ years)	1.01 (1.00-1.01)	0.77 (0.72-0.83)	1.07 (1.01-1.13)	0.85 (0.80-0.91)	0.75 (0.68-0.83)	0.89 (0.77-1.02)	0.84 (0.75-0.94)
Highest level of education-respondents
<Secondary	0.97 (0.96-0.97)	0.79 (0.76-0.82)	0.72 (0.69-0.76)	0.86 (0.81-0.90)	0.88 (0.82-0.94)	0.64 (0.58-0.70)	0.65 (0.60-0.72)
Secondary grad	0.98 (0.97-0.98)	0.82 (0.79-0.86)	0.85 (0.81-0.89)	0.96 (0.91-1.01)	0.83 (0.78-0.90)	0.74 (0.67-0.82)	0.77 (0.70-0.85)
Some post-secondary education	0.99 (0.98-1.00)	0.94 (0.89-1.00)	0.86 (0.81-0.92)	1.03 (0.96-1.10)	1.01 (0.93-1.10)	0.94 (0.83-1.06)	0.96 (0.85-1.09)
Post-secondary grad/university degree	1	1	1	1	1	1	1
Total household income
First quintile	0.97 (0.96-0.98)	0.95 (0.89-1.01)	0.60 (0.56-0.65)	0.74 (0.69-0.80)	1.91 (1.73-2.11)	0.86 (0.76-0.97)	0.81 (0.70-0.92)
Second quintile	0.97 (0.96-0.98)	0.93 (0.87-0.98)	0.74 (0.69-0.80)	0.92 (0.86-0.99)	1.42 (1.28-1.57)	0.86 (0.76-0.97)	0.91 (0.81-1.03)
Third quintile	0.98 (0.97-0.99)	0.97 (0.91-1.02)	0.79 (0.75-0.84)	0.97 (0.92-1.03)	1.36 (1.24-1.50)	0.96 (0.85-1.08)	0.95 (0.85-1.07)
Fourth quintile	0.99 (0.98-1.00)	0.98 (0.93-1.04)	0.92 (0.88-0.97)	1.02 (0.97-1.07)	1.11 (1.01-1.22)	0.99 (0.89-1.10)	1.08 (0.97-1.20)
Fifth quintile	1	1	1	1	1	1	1
NA/NS^b	0.97 (0.96-0.98)	0.89 (0.83-0.95)	0.78 (0.73-0.84)	0.94 (0.88-1.00)	1.22 (1.10-1.36)	0.82 (0.72-0.95)	0.79 (0.69-0.91)
Working status last week
Working	1	1	1	1	1	1	1
Absent	1.05 (1.04-1.06)	1.53 (1.43-1.64)	1.46 (1.37-1.55)	1.02 (0.95-1.10)	1.51 (1.36-1.67)	1.88 (1.68-2.11)	1.55 (1.35-1.79)
No job	1.02 (1.01-1.03)	1.14 (1.09-1.19)	1.01 (0.96-1.06)	0.81 (0.77-0.85)	1.56 (1.46-1.67)	1.33 (1.21-1.45)	1.32 (1.20-1.46)
Unable/permanent	1.06 (1.05-1.06)	1.33 (1.25-1.42)	1.15 (1.06-1.25)	0.69 (0.62-0.76)	1.91 (1.75-2.09)	1.55 (1.35-1.77)	1.90 (1.63-2.21)
NA(age <15 or >75 years)	1.03 (1.01-1.04)	1.13 (1.05-1.21)	0.93 (0.85-1.01)	0.75 (0.68-0.81)	1.41 (1.27-1.58)	1.19 (1.00-1.41)	1.71 (1.47-1.99)
Marital status
Married	1	1	1	1	1	1	1
Common-law	0.97 (0.96-0.98)	1.04 (0.98-1.11)	0.96 (0.90-1.02)	0.96 (0.90-1.02)	1.29 (1.17-1.43)	1.18 (1.04-1.35)	0.97 (0.84-1.12)
Widowed/divorced/separated	0.99 (0.98-0.99)	1.12 (1.08-1.17)	0.99 (0.94-1.04)	0.93 (0.88-0.97)	1.93 (1.80-2.08)	1.61 (1.46-1.77)	1.10 (1.00-1.19)
Single	0.97 (0.96-0.98)	1.09 (1.04-1.15)	0.99 (0.93-1.04)	0.81 (0.77-0.86)	1.70 (1.58-1.83)	1.47 (1.34-1.62)	1.00 (0.89-1.13)
Type of smoker
Daily	0.96 (0.96-0.97)	0.92 (0.88-0.96)	0.77 (0.73-0.81)	0.77 (0.73-0.80)	1.17 (1.11-1.24)	1.01 (0.93-1.09)	0.82 (0.75-0.90)
Occasional	0.98 (0.97-1.00)	1.01 (0.93-1.09)	0.84 (0.77-0.92)	0.88 (0.81-0.97)	1.19 (1.08-1.31)	1.17 (1.03-1.33)	0.97 (0.79-1.20)
Not at all	1	1	1	1	1	1	1
Type of drinker
Regular	1.01 (1.01-1.02)	0.94 (0.90-0.98)	1.12 (1.07-1.17)	1.11 (1.05-1.17)	0.96 (0.90-1.03)	1.00 (0.92-1.10)	0.93 (0.86-1.01)
Occasional	1.01 (1.01-1.02)	1.03 (0.98-1.08)	1.00 (0.95-1.06)	1.05 (1.00-1.12)	1.09 (1.02-1.16)	0.94 (0.85-1.03)	1.02 (0.92-1.12)
Did not drink	1	1	1	1	1	1	1
Physical activity
Active	1	1	1	1	1	1	1
Moderate active	1.00 (0.99-1.01)	0.98 (0.94-1.03)	0.94 (0.90-0.99)	0.96 (0.92-1.01)	0.93 (0.87-0.99)	1.02 (0.92-1.12)	0.98 (0.89-1.09)
Inactive	1.00 (0.99-1.00)	0.93 (0.89-0.97)	0.87 (0.83-0.91)	0.90 (0.86-0.95)	0.91 (0.86-0.96)	0.98 (0.90-1.07)	1.01 (0.92-1.11)
BMI classification—International standard
Underweight	1.01 (1.00-1.02)	1.05 (0.96-1.15)	0.94 (0.84-1.04)	0.86 (0.76-0.96)	0.97 (0.86-1.09)	0.85 (0.73-0.99)	1.10 (0.89-1.37)
Normal weight	1	1	1	1	1	1	1
Overweight (incl. obese)	1.01 (1.00-1.01)	1.01 (0.98-1.05)	0.97 (0.93-1.00)	1.00 (0.96-1.04)	0.94 (0.89-0.99)	0.86 (0.80-0.92)	1.01 (0.94-1.09)
NA (age <18 years or pregnant)^c	1.00 (0.99-1.01)	1.06 (0.99-1.14)	0.94 (0.86-1.03)	0.97 (0.89-1.06)	1.04 (0.92-1.17)	1.01 (0.83-1.22)	1.17 (0.99-1.38)
Perceived general health
Poor	1.15 (1.13-1.16)	2.42 (2.23-2.62)	1.45 (1.32-1.58)	1.06 (0.96-1.17)	2.41 (2.12-2.74)	2.80 (2.36-3.32)	1.12 (0.94-1.33)
Fair	1.13 (1.12-1.14)	1.87 (1.73-2.01)	1.25 (1.16-1.34)	1.08 (1.01-1.17)	1.75 (1.56-1.98)	2.15 (1.84-2.52)	1.04 (0.89-1.21)
Good	1.09 (1.07-1.10)	1.46 (1.36-1.56)	1.07 (1.01-1.15)	1.12 (1.05-1.19)	1.27 (1.13-1.43)	1.45 (1.25-1.68)	0.86 (0.75-0.99)
Very good	1.06 (1.05-1.08)	1.26 (1.17-1.36)	1.01 (0.95-1.08)	1.08 (1.01-1.15)	1.08 (0.96-1.21)	1.13 (0.97-1.31)	0.78 (0.68-0.90)
Excellent	1	1	1	1	1	1	1
Cause of difficulty with activities
Injury	1	1	1	1	1	1	1
Disease	1.01 (1.00-1.02)	1.13 (1.08-1.18)	0.50 (0.48-0.52)	0.66 (0.63-0.69)	1.10 (1.03-1.18)	0.90 (0.82-1.00)	0.82 (0.74-0.90)
Aging	0.97 (0.96-0.97)	0.83 (0.78-0.88)	0.43 (0.40-0.46)	0.66 (0.62-0.70)	0.82 (0.73-0.91)	0.61 (0.52-0.71)	0.70 (0.63-0.78)
Other(existed at birth/work conditions/other)	0.97 (0.96-0.98)	0.94 (0.89-0.98)	0.44 (0.42-0.46)	0.74 (0.70-0.77)	1.35 (1.26-1.44)	1.21 (1.11-1.33)	1.03 (0.93-1.14)
CCHS survey cycle
Every 2-year increase	1.00 (1.00-1.00)	1.07 (1.06-1.09)	1.05 (1.03-1.06)	1.03 (1.01-1.04)	0.96 (0.94-0.98)	1.09 (1.06-1.12)	1.18 (1.15-1.22)

Data source: Public Use Microdata File of Canadian Community Health Survey produced by Statistics Canada and accessed via the Ontario Data Documentation, Extraction Services and Infrastructure (ODESI) digital data service. The results or views expressed are those of the authors and are not those of Statistics Canada.

PR (95%CI): adjusted prevalence ratio and 95% confidence interval were obtained from multivariable Poisson regression (with robust error variance estimate). All of the 14 personal characteristics listed in the table were entered in the multivariable regression model. Crude prevalence ratio and 95% confidence interval obtained from bivariate Poisson regression (with robust error variance estimate) between the consultation with a specific health care provider (yes or no) and each of the personal characteristics can be found in Supplemental Appendix 3.

NA = not applicable according to population exclusions. NS = not stated or responses without enough information for classification. For Total Household Income, Not Stated was merged with Not Applicable and treated as 1 category together.

In CCHS 2001, NA: age <20 or age >64 years or pregnant; In CCHS 2004, NA: age <20 years or pregnant; in CCHS 2005 to 2010, NA: age <18 years or pregnant.

Non-white individuals and immigrants were less likely to consult nurses, chiropractors, and speech/audiology/occupational therapists. In addition, immigrants were less likely to consult social workers/counselors but more likely to consult physiotherapists. Lower household income was associated with a decreased likelihood of consulting most healthcare providers but an increased likelihood of consulting social workers/counselors. Married individuals were less likely to consult nurses, social workers/counselors, and psychologists, but more likely to consult medical doctors and chiropractors compared to those with other marital statuses. Individuals not currently working, in comparison to those employed in the past week, showed a higher likelihood of utilizing most healthcare services, except for a lower likelihood of consulting chiropractors.

Across the 10 provinces and 3 territories of Canada, individuals from Quebec or the territories were least likely to consult medical doctors but most likely to consult nurses and speech/audiology/occupational therapists. In contrast, those from Nova Scotia and British Columbia were least likely to consult nurses. Following Quebec and the territories, residents of New Brunswick also showed greater likelihood of consulting speech/audiology/occupational therapists than those from other provinces. Psychologists were least likely to be consulted by those from Prince Edward Island but more likely consulted by those from Quebec and Alberta.

For physiotherapists, chiropractors, and social worker/counselor consultations, individuals from eastern provinces, including Newfoundland and Labrador, Prince Edward Island, Nova Scotia, and Quebec showed lower likelihood of consultation, with Newfoundland and Labrador exhibiting the lowest likelihood of consulting physiotherapists and social workers/counselors. In addition to these eastern provinces, chiropractors were also less likely to be consulted by those from the territories. (Table 2)

Behavioral Factors Associated With Healthcare Utilization Among Canadians Living With Participation and Activity Limitations

Daily smokers compared to non-smokers were more likely to consult social workers/counselors and psychologists but less likely to consult the other 5 healthcare providers. Regular alcohol drinkers compared to non-drinkers were more likely to consult medical doctors, physiotherapists, and chiropractors but less likely to consult nurses. Physically inactive individuals compared to physically active individuals were less likely to consult nurses, physiotherapists, chiropractors, and social workers/counselors (Table 2).

Health-Related Characteristics Associated With Healthcare Utilization Among Canadians With Participation and Activity Limitations

Self-rated poorer general health was associated with a higher likelihood of consulting all healthcare providers. Compared to those with self-ascribed injury-caused participation restrictions and activity limitations, those attributing limitations to aging were less likely to consult any healthcare provider, while disease-caused limitations were associated with higher likelihood of consulting nurses and social workers/counselors. Individuals with other causes of limitations were more likely to consult social workers/counselors and psychologists (Table 2).

Healthcare Utilization Over Time

The results of our multivariable regression analyses suggest trends in healthcare utilization varied from 2001 to 2010. Utilization of medical doctors remained stable while consultations with nurses, physiotherapists, chiropractors, psychologists, and speech/audiology/occupational therapists increased, with increases ranging from 3% to 18% every 2 years. Consultations with social workers/counselors decreased by 4% every 2 years (Table 2).

Discussion

Our study provides a historical overview of the characteristics and healthcare utilization of Canadians with participation and activity limitations from 2001 to 2010, representing an annual population of 8.1 million individuals (30% of the national population). We observed an increasing consultation trend with most healthcare providers from 2001 to 2010. While most consulted medical doctors, disadvantaged groups exhibit lower utilization rates across most healthcare providers. Notably, 20.6% did not report any of the 12 common conditions covered by the CCHS, and 29.2% did not attribute their limitations to injury, disease, or aging-related conditions, suggesting potential unaccounted limiting conditions in the current healthcare system metrics.³ Musculoskeletal conditions, notably back pain (37.0%) and arthritis (34.1%), were prevalent among this population. However, only 14% to 15% sought consultation with rehabilitation professionals like physiotherapists and chiropractors, revealing a crucial gap in access to rehabilitation services.

Factors Associated With Healthcare Utilization

Factors associated with healthcare utilization showed variations by provider, highlighting the complexity of healthcare-seeking behaviors and disparities in access to different services. Lower education levels were consistently associated with reduced healthcare utilization across all providers, possibly due to limited health literacy,⁴⁷ cultural influences favoring self-care,⁴⁸ and systemic barriers related to socioeconomic status.^49,50

Older individuals were more likely to consult medical doctors than younger individuals, potentially due to trust and familiarity with medical doctors,^51
-54 while facing limited acceptability and accessibility to alternative health providers.^49,50 Males showed lower healthcare utilization overall, possibly attributed to their lower perceived needs and reluctance for non-severe issues.^55
-57 However, males showed a higher likelihood of consulting speech/audiology/occupational therapists, likely linked to their higher labor participation⁵⁸ and occupational risks compared to females.^59,60 Immigrants demonstrated lower overall healthcare utilization but increased physiotherapy consultations, suggesting diverse healthcare needs, affordability, cultural factors, and system accessibility.^27,61
-68

Regional variations in healthcare utilization reflected diverse preferences and access challenges, necessitating tailored healthcare policies. Quebec and the territories exhibited lower medical doctor utilization but higher likelihood of consultation with nurses and speech/audiology/occupational therapists, potentially due to more severe physician shortages⁶⁹ and integrated role of alternative providers. Alberta and Quebec exhibited higher psychologist consultation rates, reflecting regional mental health disparities and service availability.^70
-72 Quebec, Newfoundland and Labrador, Prince Edward Island, and Nova Scotia, showed lower likelihood of consulting chiropractors and social workers/counselors despite their high prevalence of chronic back problem and disability.^73,74 Barriers may include variations in healthcare infrastructure, referral practices, insurance coverage, awareness, and regional cultural factors.⁷⁵ For example, while Ontario and western provinces (British Columbia, Alberta, Saskatchewan, and Manitoba) provided varying levels of public insurance coverage for physiotherapy and chiropractic care, most eastern provinces and 3 territories lacked coverage for chiropractic care, and physiotherapy was often only covered when administered in hospital settings.^76,77

We found disparities in healthcare utilization related to smoking status and alcohol consumption, like in other studies.^78
-81 Compared to occasional consumers and abstainers, daily smokers were more likely to consult social workers/counselors and psychologists, possibly related to mental health implications.^82,83 Conversely, regular drinkers were more likely to consult medical doctors, physiotherapists, and chiropractors. Previous studies showed mixed results, likely influenced by variations in study populations and alcohol intake classifications.^80,81,84

Implications

Our findings have important implications for healthcare policy and practice. First, the population with participation and activity limitations is diverse and includes individuals with multifaceted healthcare needs.^85
-87 Second, the increasing trend of consulting non-medical providers, conflated with significant challenges with access to rehabilitation services, highlights the need for inclusion of rehabilitation in our universal health system.⁸⁵ Policymakers should consider integrating rehabilitation services within primary care to enhance equitable accessibility.^5,34,88 The recent WHO resolution on strengthening health systems supports this approach.⁸⁹ Finally, the disparities in healthcare utilization experienced by disadvantaged groups suggest targeted interventions need to be developed to remove access barriers rooted in sociodemographic inequities.^49,50 Policy reforms could also focus on improving health literacy, increasing affordability of services, and ensuring equitable access across different regions. Tailored strategies for different jurisdictional regions, reflecting local healthcare needs and resource availability, could help address regional variations in service utilization.

Strengths and Limitations

Our study’s strength lies in its use of large, comprehensive, and representative population-based data from 5 cycles of the CCHS, focusing on Canadians with participation and activity limitations. This provides a crucial historical overview of their healthcare utilization, essential for future planning and research. Additionally, employing both univariable and multivariable modified Poisson regression enhances methodological rigor by thoroughly exploring associations between personal characteristics and healthcare use. Limitations include potential biases with self-reported data, the study’s timeframe not fully capturing current healthcare needs, and the cross-sectional nature of the survey not allowing for causal inference.

Conclusion

Approximately 8.1 million (30%) Canadians aged 12 years and older experience participation and activity limitations annually between 2001 and 2010. About 30% of this population did not attribute their restrictions and limitations to injury, disease, or aging related conditions. Although the most common health reasons for participation and activity limitations are musculoskeletal disorders, we found that consultations with rehabilitation providers (eg, physiotherapists and chiropractors) were low. Our historical overview of healthcare utilization provides crucial insights for addressing diverse healthcare needs in this population and informing evidence-based strategies for implementing integrated and equitable healthcare. Improving access to rehabilitation services and integrating them into universal healthcare coverage should be a priority. Future research could benefit from adopting a cohort study design and using more reliable measures of healthcare utilization, such as electronic health records, to provide more accurate and current insights.

Supplemental Material

sj-pdf-1-jpc-10.1177_21501319241284971 – Supplemental material for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study

Supplemental material, sj-pdf-1-jpc-10.1177_21501319241284971 for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study by Dan Wang, Jessica J. Wong, Sheilah Hogg-Johnson, Silvano A. Mior and Pierre Côté in Journal of Primary Care & Community Health

Supplemental Material

sj-pdf-2-jpc-10.1177_21501319241284971 – Supplemental material for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study

Supplemental material, sj-pdf-2-jpc-10.1177_21501319241284971 for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study by Dan Wang, Jessica J. Wong, Sheilah Hogg-Johnson, Silvano A. Mior and Pierre Côté in Journal of Primary Care & Community Health

Supplemental Material

sj-pdf-3-jpc-10.1177_21501319241284971 – Supplemental material for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study

Supplemental material, sj-pdf-3-jpc-10.1177_21501319241284971 for Characteristics and Healthcare Utilization of Canadians Living With Participation and Activity Limitations (2001-2010): A Population-Based Cross-Sectional Study by Dan Wang, Jessica J. Wong, Sheilah Hogg-Johnson, Silvano A. Mior and Pierre Côté in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

We extend our gratitude to the participants of the Canadian Community Health Survey (CCHS) cycles from 2001 to 2010, as well as to Statistics Canada, the Canadian Institute for Health Information, and Health Canada for their contributions to the development and implementation of the CCHS survey. We are grateful for members of the advisory committee (ie, Canadian Chiropractic Association, Ontario Chiropractic Association, Chiropractors’ Association of Saskatchewan, Chiropractic Association of Alberta, and British Columbia Chiropractic Association). Their expertise and guidance were instrumental in shaping the methodology, interpreting the results, and ensuring the rigor of our study. We would like to clarify that the advisory committee provided advice and insights without intervention in the research process, and there were no conflicts of interest.

Author’s Note

Jessica J. Wong is also affiliated to Canadian Memorial Chiropractic College, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada and Western University, London, ON, Canada.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a research grant from the Canadian Chiropractic Research Foundation (CCRF) and by the following organizations (Canadian Chiropractic Association, Ontario Chiropractic Association, Chiropractors’ Association of Saskatchewan, Chiropractic Association of Alberta, and British Columbia Chiropractic Association). The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dan Wang’s contribution to this project was supported by a postdoctoral fellowship at Ontario Tech University (funded by Ontario Tech University and Canadian Memorial Chiropractic College). Pierre Côté’s contribution to the project was supported, in part, by the Canadian Institutes of Health Research—Canada Research Chair Program.

Ethical Approval and Informed Consent Statements

The study protocol was reviewed and approved by the Research Ethics Board at Ontario Tech University (Reference# 15791-130103). Informed consent was obtained from all CCHS respondents by Statistics Canada. “Statistics Canada is prohibited by law from releasing any information it collects that could identify any person, business, or organization, unless consent has been given by the respondent or as permitted by the Statistics Act. Various confidentiality rules are applied to all data that are released or published to prevent the publication or disclosure of any information deemed confidential. If necessary, data are suppressed to prevent direct or residual disclosure of identifiable data.” [From: https://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=3226].

ORCID iD

Dan Wang

Data Availability Statement

Statistics Canada makes available the CCHS public use microdata file (PUMF), which is designed to improve statistical analytic capabilities using publicly accessible Canadian data resources while ensuring respondent confidentiality.

Supplemental Material

Supplemental material for this article is available online.

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