A joint blog by Crystal Truman and Alex Jocic
How a multilevel approach is needed to both understand and solve the opioid crisis in Canada’s Aboriginal communities.
Multilevel Approaches to Mental Health & Addictions
A multilevel approach to health considers the various factors and exposures that interact to produce health outcomes. This approach considers numerous determinants of health at different levels, including, “social, biological, geographic, political, and temporal” (Galea, 2010). Given that mental health affects about 20% of Canadians (CMHA, n.d.) and can be devastating for the individual, their social circles, and for society at large, it is imperative to approach determinants of mental health with a multilevel approach that accounts for not just individual and biological factors, but broader societal and environmental determinants as well.
In April 2016, the BC government declared a public health emergency (“Federal Action on Opioids”, 2017). This emergency is not the sort one might expect—of infectious disease running rampant and overcrowding emergency rooms. Rather, this is a quiet and insidious crisis that affects people of all socio-economic backgrounds, ages, and genders.
The opioid crisis has remained one of Canada’s most enduring mental health crises. In 2017, the federal government proposed an action plan, but given the level of autonomy provinces have to decide their own healthcare systems, it is questionable whether such a plan could be actualized. Nonetheless, mental health issues, including those related to addictions and substance abuse, are a multilayered issue that must be addressed with a multilevel approach.
It would be overly simplistic to assume that addiction is a challenge faced by only one demographic. With opioid abuse causing approximately 10 deaths per day nation-wide (Canada, 2017), it would be impossible to examine this health crisis without the use of a multilevel model. The Canadian Mental Health Association has echoed this sentiment, writing that, “policies and programs must address individuals, their connections within the community and the broader environment in which they live”. Keleher & Armstrong (2006) have proposed that the three leading determinants of mental health are social inclusion, freedom from discrimination and violence, and access to economic resources (Keleher & Armstrong, 2006). Put another way, risk factors for mental health challenges operate on multiple levels; social connectedness, physical and psychological safety, and socio-economic status interact to determine the likelihood of mental illness.
The use of supervised injection sites opened by the Vancouver Coastal Health Authority have done well to consider these different levels of health determinants. By reducing stigmatization and providing a safe space for substance users, these sites have improved social inclusion, reduced the likelihood of physical and psychological harm, and are providing users with resources for seeking help (Vancouver Coastal Health). Also importantly, BC has taken a leading roll in tackling the opioids crisis by designating their own Minister of Mental Health Addictions—a position that is not seen in any other province. The minister’s main role is to prioritize the opioid overdose crisis and to expand treatment and recovery options for those struggling with addiction (BC Pharmacy Association, 2018).
Conversely, Ontario is in the midst of changing policies with the new government, which has a radically different approach to the mental health and addictions crisis. While the previous premiere, Kathleen Wynne, dedicated a four year-investment of $2.1 billion to mental health care, the new Progressive Conservative government has cancelled the program and replaced it with a meager $1.9 billion over ten years, cutting $330 million annually (Benzie, 2018). Furthermore, despite being the most populous province, Ontario has no dedicated minister for mental health and addictions. As a result, the system is difficult to navigate, with access remaining both limited and convoluted for many.
Understanding Aboriginal Health Through Multilevel Models
However, are these differences between the two provinces significant enough to address the disparity in health outcomes for vulnerable populations? The specific issue of Aboriginal health, for example, is challenging to address because of the multitude of factors serving to impose disadvantage on Native peoples in Canadian society. Although there are important differences in the lives of Native peoples depending on their province of residence, Ontario and BC may be more alike than different.
We have already established that health promotion should act on multiple levels. Kelly et al. (1993) argues for health promotion at four levels: social, organizational, environmental, and individuals. Furthermore, Kelly et al. (1993) argues for an integrated approach that accounts for the relationships between these four levels, and the ways they interact to produce particular outcomes (Kelly et al., 1993). It would make sense then to apply such an approach to Aboriginal health, especially in populous provinces like Ontario and BC.
However, how does one apply such a layered approach to diverse populations? There are over 600 Native bands in Canada and over 60 different languages—a fact that dismantles the common misconception of Natives being a homogeneous group (Aboriginal Peoples in Canada, n.d.). Furthermore, self-governing agreements, as well as other expansions to Native peoples’ “involvement in the provision of locally needed services and programs” has made it more difficult to address Aboriginal health (National Collaborating Centre for Aboriginal Health, 2011). It has remained an ambiguous affair, with jurisdiction caught between provincial and federal authority due to the remnants of the 1867 British North America Act (National Collaborating Centre for Aboriginal Health, 2011). The feasibility of applying a multilevel approach to Aboriginal health is thus undermined by multilevel problems: the bureaucratic confusion over provincial/federal jurisdictions, provincial differences in health care approaches, the immense diversity among Native peoples, and the challenges in accommodating self-government agreements.
For example, Aboriginal health in both BC and Ontario is affected by federal policy (Government of Canada, 2013), yet this is complicated by the fact that healthcare is provincially governed. Furthermore, not all Natives live on reserves; in Ontario, 37% of Native peoples live on reserves (the second lowest among all provinces), yet Ontario has the largest population of Natives, at 301, 425 (approximately 21% of all Natives in Canada) (Statistics Canada, 2011). Because of this split between Natives on reserves and Natives in mainstream society, different health outcomes can be expected not only because of jurisdictional differences, but also due to the interaction of social inclusion, safety, and the availability of economic resources. Recalling Keleher & Armstrong (2006) and the determinants of mental health, we can surmise that people living on reserves have less access to economic resources, are more subject to discrimination and harm, and experience isolation from mainstream society, where most support systems and health services are available. As a result, it can be expected that Native peoples living on reserves in Ontario and BC will experiences worse mental health outcomes.
The complexities surrounding Native people’s specific historical, social, economic, and cultural challenges illustrates well the need for a multilevel approach to mental health determinants in this population. Furthermore, a multilevel approach to health promotion is very much needed, but remains hindered by bureaucratic inefficiencies.
References
Aboriginal Peoples in Canada: First Nations People, Métis and Inuit. (n.d.). Retrieved February 23, 2019, from https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-011-x/99-011-x2011001-eng.cfm
BC Pharmacy Association (2018, November 27). Meet B.C.’s Minister of Mental Health and Addictions Judy Darcy. Retrieved February 16, 2019, from https://www.bcpharmacy.ca/news/meet-bcs-minister-mental-health-and-addictions-judy-darcy
BCCDC (2018). By the Numbers: The Opioid Overdose Emergency in BC. Retrieved from http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/Infographic_Opioid_Emergency_in_BC.pdf
Benzie, R. (2018, July 26). Tories blasted for $335M cut in planned spending on mental health. Retrieved online from https://www.thestar.com/news/queenspark/2018/07/26/tories-blasted-for-335m-cut-in-planned-spending-on-mental-health.html
Canada, H., & Canada, H. (2017, August 23). Federal Action on Opioids [transparency – other]. Retrieved February 16, 2019, from https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/federal-actions.html
Canadian Centre on Substance Use and Addiction & Health Canada (2017). Joint Statement of Action to Address the Opioid Crisis: A Collective Response (Annual Report 2016–2017). Retrieved online from http://www.ccsa.ca/Resource%20Library/CCSA-Joint-Statement-of-Action-Opioid-Crisis-Annual-Report-2017-en.pdf
CMHA Ontario. (n.d.). Mental Health Promotion in Ontario: A Call to Action. Retrieved February 16, 2019, from http://ontario.cmha.ca/documents/mental-health-promotion-in-ontario-a-call-to-action/
House of Commons of Canada. (2017, April 11). GOVERNMENT RESPONSE TO THE REPORT OF THE STANDING COMMITTEE ON HEALTH ENTITLEDReport and Recommendations on the Opioid Crisis in Canada. Retrieved February 17, 2019, from https://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-6/response-8512-421-134
Keleher H. & Armstrong R. (2006). Evidence based mental health promotion resource. Retrieved online from https://www2.health.vic.gov.au/about/publications/policiesandguidelines/Evidence-based-mental-health-promotion-resource—entire-resource
Kelly, M. P., Charlton, B. G., & Hanlon, P. (1993). The four levels of health promotion: an integrated approach. Public Health, 107(5), 319–326. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8248466
Lim, K.-L., Jacobs, P., Ohinmaa, A., Schopflocher, D., & Dewa, C. S. (2008). A new population-based measure of the economic burden of mental illness in Canada. Chronic Diseases in Canada, 28(3), 92–98. Retrieved online from https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/hpcdp-pspmc/28-3/pdf/cdic28-3-2eng.pdf
National Collaborating Centre for Aboriginal Health, (2011). THE ABORIGINAL HEALTH LEGISLATION AND POLICY FRAMEWORK IN CANADA. Retrieved February 22, 2019 from http://www.arnbccommunitiesofpractice.ca/ahnn/wp-content/uploads/2015/03/Health-Legislation-Policy-eng.pdf
Ontario Making Historic Investment in Mental Health Care. (2018, March 21). Retrieved online from https://news.ontario.ca/opo/en/2018/03/ontario-making-historic-investment-in-mental-health-care.html
Table 2 Number and distribution of the population reporting an Aboriginal identity and percentage of Aboriginal people in the population, Canada, provinces and territories, 2011. (n.d.). Retrieved February 23, 2019, from https://www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-011-x/2011001/tbl/tbl02-eng.cfm
Vancouver Coastal Health (n.d.) Insite – Supervised Consumption Site. Retrieved February 17, 2019, from http://www.vch.ca/locations-services/result?res_id=964
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