Disparities in health and well-being have existed since the outset of modern medicine, likely well before this time. Fortunately, within our own country, Saskatchewan lead the way in creating a provincial health care system based on universality. This was eventually modified and then adopted by the Canadian government enacting the Canada Health Act (CHA). While I won’t go into great detail about the pros and cons of modernizing the CHA, Flood and Thomas (2016) describe Canada’s failure to provide sufficient oversight related to transfer fund payments created “health inequities” across provincial institutions for services rendered.
Much effort has been placed with primary health care (PHC) practitioners to address familiar chronic diseases such as heart disease, hypertension and diabetes. Incentivising PHC to spend more time with patients, i.e., “billable time” does not necessarily address the growing concerns related to health disparities. Individuals must take the first step in arranging this interplay and then disclose personal health information to a potentially unfamiliar practitioner. Radl-Karimi et al. (2020) attempt to provide guidance for practitioners interacting with new immigrants and or refugees by providing six recommendations including “reciprocity of trust” whereby practitioners refrain from dictating behaviours based on their values, “engaging in self-reflection” and using translators during patient encounters.
Unfortunately, many barriers exist preventing access to PHC services including known shortages of medical practitioners, location of PHC services, preferred spoken language, individuals may need to take time off work i.e., paid vs unpaid, etc. Since the early 2000’s a handful of Manitoba and other interprovincial family physicians implemented a 1 complaint policy per visit, furthering the disparity of services available to its residents. While not supported by Manitoba’s College of Physicians and Surgeons nor the Canadian Medial Protective Association, they’ve been unable to curb this trend. Fullerton (2008) tries to address this issue suggesting a team-based approach and or fee restructuring to provide sufficient time to deal with multiple concerns. In my previous blog post “Multi-level Model: Addressing Health Inequity,” Horowitz and Lawlor (2008) suggest a multi-disciplinary team to “make clinical care more responsive to vulnerable populations and to make clinical interventions more effective in improving their health.”
In this blog post, I will discuss mental illness focusing primarily on children and youth. Over the last 2 decades mental health has garnered much attention, more so than other health conditions. As mentioned earlier, the Canadian health care system has historically dealt with chronic diseases such as heart disease, and hypertension, but a shift has occurred as federal and provincial governments tailor care to those experiencing mental health issues. The World Health Organization (2018) defines mental health as a “state of well-being in which an individual realizes his or her own abilities, can cope with normal stresses of life, can work productively and is able to make a contribution to his or her community.” Youth Mental Health Canada (n.d.), estimates 1.2 million children and youth are affected by mental illness. Waddell et al. (2005) reports similar numbers suggesting these individuals are experiencing “significant distress and impairment at home, at school, and in the community.”
The Government of Canada (2019) identifies negative circumstances such as “poverty, family conflict or violence, neglect in early childhood, having a parent with substance abuse problem, and living in inadequate or unsafe housing,” increases one’s risk for developing mental illness. Therefore, mental health is directly impacted by social determinants of health (SDH). The WHO (2014) has taken a similar stance stating, “common mental disorders (depression and anxiety) are distributed according to a gradient of economic disadvantage across society and that poor and disadvantaged suffer disproportionately from common mental health disorders and their adverse consequences.”
Fig 1. Retrieved from: https://www150.statcan.gc.ca/n1/pub/89-653-x/89-653-x2015007-eng.htm
Research has shown mental health problems in low-income families occur at a higher percentage during childhood and or adolescence (WHO, 2014). Waddell et al. (2005) suggest 75-80% of children and youth are experiencing a mental health issue and are unable to access specialized mental health services. They discuss various methods to improve treatment for Canadian children. The first is to offer universal programs in order to reach a larger portion of children, this method reduces stigma associated with mental health. The second is targeted programs for children at risk. Lastly clinical programs would offer treatment for established disorders.
Navaneelan (2012) reports grave statistics related to suicide for Canadian children and youth citing suicide as the second leading cause of death for people aged 15-34, eclipsed only be accidents. Suicide rates for First Nations and Inuit youth have already surpassed a breaking point averaging 3-11 times the national average compared to non-aboriginals (GoC, 2019). Given the aforementioned information, I purport children and youth experiencing mental health issues represent the most vulnerable group in Canada, with potentially catastrophic outcomes for First Nations and Inuit youth. These individuals are dependent on parents, families, community’s and government services to improve health outcomes. When a multitude of health inequities arise, they do not possess the necessary knowledge or coping strategies to improve their own health and well-being.
Unfortunately, First Nations and Inuit Peoples are disadvantaged from birth regardless of location of residence. Countless individuals and or groups have experienced or been exposed to racism, colonization and or discrimination leading to generational trauma secondary to residential schools and or the 1970’s “scoop” (GoC, 2020). Disadvantages seem to abound for those living in rural areas when one considers access to services such as clean water, housing, food security, education, dental and general healthcare, let alone employment opportunities. What we know with certainty is that globally, mental health disorders “continue to grow with significant impacts on health and major social, human rights and economic consequences in all countries of the world” (WHO, 2019). Females carry with them greater overall risk for “internalizing mental health” as they take on new roles and responsibilities whilst maintaining traditional norms (Campbell, Bann, Patalay, 2021); Males are more likely to use lethal force. The Centre for Suicide Prevention confirms rates for male children and youth range from 1-3.5 times higher than females depending on age group (10-24 years).
All is not lost as government and non-government organizations continue to shed light on issues surrounding mental health and work to improve health for vulnerable groups; For example, Bell Canada’s “Let’s Talk” campaign. Even though stigma exists for many conditions including mental health, exposure for all children at an early age though standardized and informal education, as well as targeted resources for those at risk will hopefully curtail future loss of life. Tonelli, Tang and Forest (2020) suggest necessary change must cross all levels of government as many of the factors which determine health and well-being are beyond the health sector’s reach. As mentioned in my previous blog post, Tonelli et al. contend that an Indigenous-led national strategy following the truth and reconciliation commission’s recommendations would produce “substantial health gains for Indigenous Peoples.”
In 2004, a national aboriginal youth suicide prevention strategy (NAYSPS) was created with assistance from Aboriginal leaders, the Prime minister and First Ministers to address health disparities to address First Nations Peoples living on reserve and Inuit Peoples living in Inuit communities (GoC, 2019). The 2-phase approach spread over 10 years (2005-2015) may take many years to fully realize its impact. A First Nations specific guide was developed by the Assembly of First Nations (AFN) and their First Nations youth council in collaboration with Health Canada Regions. Inuit specific activities were designed by Inuit Tapiriit Kanatami’s (ITK) and ITK’s National Inuit Youth Council in collaboration with Health Canada Regional offices. Implementation will be carried out by communities or Tribal councils, while governance be a joint effort by AFN, ITK, First Nations and Inuit Health Branch (GoC, 2019).
Despite numerous reports addressing health inequities such as the Romanov Report, Kelowna Accord and Truth and Reconciliation Commissions Report, First Nations and Inuit Peoples have yet to see substantial improvements to their individual health or community’s health. One exception exists, British Columbia’s First Nation Health Authority (FHNA) seeks to address service delivery by reforming services that were previously governed by the federal government. With a greater role in self-governing services, self-management of chronic disease and attempts to address health inequities, I’m optimistic other provinces and or health regions will undertake a similar approach to FHNA for the betterment of First Nations Peoples, Inuit Peoples and society as a whole.
References
Anderson, T. (2015). The social determinants of higher mental distress among Inuit. Ottawa: Statistics Canada. Retrieved April 1, 2021 from: https://www150.statcan.gc.ca/n1/pub/89-653-x/89-653-x2015007-eng.htm
Campbell, O., Bann, D., & Patalay, P. (2021). The gender gap in adolescent mental health: A cross-national investigation of 566,829 adolescents across 73 countries. SSM - population health, 13, 100742. https://doi.org/10.1016/j.ssmph.2021.100742
Canadian Medical Protective Association, 2019. Limiting discussion to one medical issue per visit: Know the risks. Retrieved March 30, 2021 from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2011/limiting-discussion-to-one-medical-issue-per-visit-know-the-risks
Centre for Addiction and Mental Health, n.d. The Crisis is Real. Retrieved March 29, 2021 from: https://www.camh.ca/en/driving-change/the-crisis-is-real
Centre for Suicide Prevention (n.d.). Suicide stats for Canada, provinces and territories. Retrieved March 31, 2021 from: https://www.suicideinfo.ca/resource/suicide-stats-canada-provinces/
Flood, C. M., & Thomas, B. (2016). Modernizing the Canada Health Act. Dalhousie LJ, 39, 397. Retrieved March 31, 2021 from: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2907029
Fullerton, M. (2008, September 23). Understanding and improving on 1 problem per visit. CMAJ: Canadian Medical Association Journal, 179(7), 623. Retrieved March 30, 2021 from: https://www.cmaj.ca/content/179/7/623.short
Government of Canada (2019). National Aboriginal Youth Suicide Prevention Strategy (NAYSPS) Program Framwork. Retrieved March 31, 2021 from: https://www.sac-isc.gc.ca/eng/1576092066815/1576092115467
Government of Canada. (2020). From risk to resilience: An equity approach to COVID-19. Retrieved March 30, 2021 from: https://www.canada.ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/from-risk-resilience-equity-approach-covid-19.html#a2.1
Horowitz, C., & Lawlor, E. F. (2008). Community approaches to addressing health disparities. Report for the Institute of Medicine. Retrieved March 30, 2021from: https://www.ncbi.nlm.nih.gov/books/NBK215366/
Kling, J. R. (2008). A Summary Overview of Moving to Opportunity: A Random Assignment Housing Mobility Study in Five US Cities. Retrieved March 30, 2021from: http://www2.nber.org/mtopublic/MTO%20Overview%20Summary.pdf
Navaneelan, T. (2012). Suicide rates: An overview. Retrieved Mar 31, 2021 from: https://www150.statcan.gc.ca/n1/pub/82-624-x/2012001/article/11696-eng.pdf
Pearson, C., Janz, T., & Ali, J. (2013). Mental and substance use disorders in Canada. Retrieved March 31, 2021 from: https://www150.statcan.gc.ca/n1/en/pub/82-624-x/2013001/article/11855-eng.pdf?st=uDpeltj9
Radl-Karimi, C., Nicolaisen, A., Sodemann, M., Batalden, P., & von Plessen, C. (2020). Under what circumstances can immigrant patients and healthcare professionals co-produce health? An interpretive scoping review. International Journal of Qualitative Studies on Health and Well-being, 15(1), 1838052. Retrieved March 31, 2021 from: https://www.tandfonline.com/doi/full/10.1080/17482631.2020.1838052
Romanow, R. J. (2002). Building on values: the future of health care in Canada. Retrieved April 2, 2021 from: http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf
Tonelli, M., Tang, K. C., & Forest, P. G. (2020). Canada needs a “Health in All Policies” action plan now. Canadian Medical Association Journal, 192(3), E61-E67. DOI: https://doi.org/10.1503/cmaj.190517
Truth and Reconciliation Commission of Canada. (2015). Truth and reconciliation commission of Canada: Calls to action. Truth and Reconciliation Commission of Canada. Retrieved April 4, 2021 from: http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf
Waddell, C., McEwan, K., Shepherd, C. A., Offord, D. R., & Hua, J. M. (2005). A Public Health Strategy to Improve the Mental Health of Canadian Children. The Canadian Journal of Psychiatry, 50(4), 226–233. https://doi.org/10.1177/070674370505000406
World Health Orgranization. (2018). Mental health: Strengthening our response. Retrieved March 30, 2021 from:
World health Organization. (2019). Mental disorders: Key facts. Retrieved April 5, 2021 from: https://www.who.int/news-room/fact-sheets/detail/mental-disorders
Youth Mental Health Canada (n.d.). Youth Mental Health Reality: The Difference We Can Make. Retrieved March 31, 2021 from: https://ymhc.ngo/resources/ymh-stats/
Comments