Advancing Health Equity: The Impacts of SDoH on Mental Health and Wellbeing
Law directly impacts the health and well-being of citizens, whether positively or negatively. While the law strives towards health equity, certain social determinants of health (SDoH) put individuals at a disadvantage and undermine their wellbeing [1]. The health issues vulnerable social groups face can be attributed to the cultural, socio-economic, and environmental conditions they experience [1]. In the Canadian context, the law profoundly influences equitable treatment in relation to the mental health crisis and its impact on vulnerable groups. This is portrayed through the role and application of laws, SDoH, COVID-19 pandemic, current governmental response, and potential solutions.
Original illustration by Raven Lee.
The law plays a significant role in determining the well-being of the population, whether these be laws associated directly with healthcare or those indirectly related, such as on housing, poverty, and the criminal justice system [1]. For instance, the Canada Health Act is a law that funds universal healthcare in Canada with the objective “to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers" [2]. Such laws establish rules and standards that aim to improve the wellbeing of Canadians, however, the law fails in some instances to benefit individuals from marginalised social groups [1]. While the law itself does not undermine individuals’ access to equitable treatment, it is the systematic conditions of attitudes that creates stigmas towards marginalised social groups [3]. The Mental Health Commission of Canada brings forward that the stigma associated with mental health issues, lack of privacy, and mental health care professional shortage are impacting the access and quality of mental health services in the criminal justice system [3]. In other instances, stereotypes become associated with individuals due to low socioeconomic status, race, age, and gender, which can affect individuals' access to appropriate healthcare [1]. Thus, while the aim of Canadian law is to promote wellbeing, this is not evident when it comes to healthcare and access/handling of healthcare. The disproportionate impact faced by certain social groups is not just specific to healthcare, rather this is evident when it comes to housing, criminalization, and homelessness [3]. Taken together, the treatment of marginalised social groups exhibits that laws promoting equitable treatment do not always result in such in practice, rather, systemic inequities become clearer.
“while the aim of Canadian law is to promote wellbeing, this is not evident when it comes to healthcare and access/handling of healthcare”
Certain groups in the population experience inequalities as a result of the role that their social and economic circumstances play in determining their wellbeing, which can be referred to as SDoH [1]. The SDoH specifically affecting Canadians include, Indigenous status, gender, disability, housing, race, employment, and education [1]. These factors have a notable impact on health outcomes. For instance, many individuals that suffer from homelessness or poverty are those that also suffer from mental health problems [3].This demonstrates how a social determinant of health, such as housing, has direct implications on the health and wellbeing of individuals. As such, resolving issues pertaining to the SDoH, such as housing, may generate relief in other sectors, such as healthcare. Actions in relation to the SDoH are likely to be long term goals, however it may play a significant role in assisting the healthcare sector to better respond to health crises, such as the ongoing mental health crisis in Canada [3].
The COVID-19 pandemic resulted in mandates such as social distancing, quarantining and limiting social gatherings [5]. Despite these restrictions being to limit the spread of COVID-19 amongst individuals, at the same time, this has profound implications for the wellbeing of individuals [5]. The mental health crisis has been amplified due to the pandemic not only due to self-isolation but due to financial circumstances such as unemployment [5]. Additionally, increased alcohol consumption is a growing health issue alongside Canadians dealing with mental health issues [5].
“resolving issues pertaining to the SDoH, such as housing, may generate relief in other sectors, such as healthcare“
The CAMH study identifies that certain groups are more vulnerable to the impacts of the mental health crisis, notably including marginalised groups identified by the MHCC report [3]. As such, racialized people, Indigenous peoples, people with disabilities, immigrants, and low wage-earning workers are at a higher risk of experiencing the impacts of the mental health crisis [4]. This is even more detrimental for those that were experiencing illness prior to the pandemic since physical distancing measures limit their access to supports and services, and virtual assistance may be insufficient [4]. Evidently, COVID-19 has brought forward the gaps in mental health care in Canada and necessitates greater variety of resources and supports, including improvement and expansion of virtual services, and emphasising workplace mental health [4]. While precautionary measures during pandemic lockdowns are meant to limit the spread of COVID-19, these measures simultaneously take a huge toll on the mental health of Canadians as it results in isolation, stress, and anxiety [4]. Taken together, the impacts of the COVID-19 pandemic on the mental health crisis demonstrate that legal and federal input resulted in inequitable support for communities and unintended consequences on population health.
A comprehensive approach to the issue of equitable treatment in healthcare for all is dependent on laws that govern Canadian society holistically. The health of individuals cannot be considered as a separate entity from job availability or homelessness because the SDoH are interconnected in their impact on individuals [3]. For example, an unemployed individual unable to afford housing or facing food insecurity may have poor physical health, which over time leads to mental health problems. Inevitability, this scenario is worse for vulnerable populations [6]. COVID-19 sheds light on this interconnectedness of the issues Canadian society faces and emphasises the reality of vulnerable social groups. It is clear given the ability of laws to dictate our health outcomes, public policy needs to emphasise the SDoH in constructing plans for responding to the mental health crisis alongside COVID-19. In order to effectively respond to mental health problems, the root of action is centred on issues that contribute to these problems, such as housing or employment [3].
It is worth noting that the government is aware of some instances in which the SDoH can be targeted to improve conditions for specific social groups and it is prompting action that is suitable in improving conditions of specific social groups. For instance, in the National Housing Strategy, the Government of Canada has committed to supporting vulnerable populations through its Gender-Based Analysis Plus approach which ensures that individuals will not be impacted negatively by assessing the potential impacts of policies on a diverse range of individuals [4]. In response to the COVID-19 pandemic, the government provided assistance programs such as CERB, CESB, EI which provided financial support to individuals to relieve financial stress [4]. In addition, in describing the plan of priority access concerning the distribution of the COVID-19 vaccine, the federal government made it clear that they recognize Indigenous peoples as a vulnerable group which necessitates putting their health as a priority in the pandemic [6]. Evidently, the incorporation of cultural safety is evident when it comes to responding to the needs of certain marginalised groups [6]. Overall, the pandemic has highlighted the need for action when it comes to mental health services and affordable housing, which may convince the government to take an immediate response despite its long-term objectives.
“The health of individuals cannot be considered as a separate entity from job availability or homelessness because the SDoH are interconnected in their impact on individuals“
Even though Canada vastly differs from the United States, the issue of the mental health crisis is similar to a certain extent, so it is useful to consider the application of medical-legal partnerships (MLPs) [1]. MLPs are a form of collaboration between health care professionals and lawyers that contribute to public health in numerous ways [1]. They are important in not only improving individuals’ health but also serve a broader purpose of health equity within a community [1]. They provide a comprehensive approach given that their experience in the health care setting allows them to better understand the SDoH in relation to the law and this enables them to take immediate solutions and preventative ones as well [1]. This could be a useful approach in dealing with the mental health issues that are arising amidst the COVID-19 pandemic as well as in improving the mental health services in the criminal justice system. In relation to the COVID-19 pandemic, given the historical success of MLPs in unpreceded times in the United States such as the HIV/AIDS crisis, such an approach could improve the situation through resources and supports that become embedded into the system [1]. Additionally, this approach could be beneficial in response to the barriers that exist for mental health services in corrections; for instance, MLPs could combat stigma associated with mental health issues by taking a frontline approach to an effective response [1, 3]. Given the role of the MHCC to share best practices, this should be one of the practices they should look into as it could apply to Canadian communities [6]. Clearly, in order for the law to provide equitable treatment in its application, effort may be required by professionals in healthcare and legislation through such partnerships to better overcome these interconnected issues. Accordingly, MLPs are a potential solution that may be suitable in responding to the mental health crisis concerning both the COVID-19 pandemic and the criminal justice system in Canada.
To conclude, while laws are intended to have a positive impact on the health and wellbeing of Canadians, their application can result in inequities to be experienced by vulnerable social groups. This is demonstrated in the lack of acknowledgment for the SDoH when targeting health crises – notably the mental health crisis in Canada, which was exacerbated during the COVID-19 pandemic. Overall, for the law to have equitable consequences the government should carefully consider the role of the SDoH, as well as consider new solutions like MLPs.
Harleen Kundan is a fourth year undergraduate student at the University of Toronto pursuing a combined specialist in History and Political Science as well as minoring in Sociology. She is interested in public health policy and how addressing the social determinants of health can help achieve health equity in society.
References
[1] Teitelbaum, Joel B., Joanna Theiss, and Colleen Healy Boufides. "Striving for Health Equity through Medical, Public Health, and Legal Collaboration." The Journal of Law, Medicine & Ethics, 47 no.2 (2019): 104-107.
[2] Government of Canada. “Canada Health Act.” 2020. https://www.canada.ca/en/health- canada/services/health-care-system/canada-health-care-system-medicare/canada-health- act.html
[3] Mental Health Commission of Canada. “Mental Health in the Criminal Justice System: What we heard.” 2020. https://www.mentalhealthcommission.ca/sites/default/files/2020- 08/mental_health_and_the_law_evidence_summary_report_eng.pdf
[4] Centre for Addiction and Mental Health. “Mental Health in Canada: Covid-19 and Beyond CAMH Policy Advice.” July 2020.http://www.camh.ca/-/media/files/pdfs---public-policy -submissions/covid-and-mh-policy-paper-pdf.pdf
[5] Government of Canada. “Canada’s National Housing Strategy.” 2018. https://assets.cmhc-schl.gc.ca/sf/project/placetocallhome/pdfs/canada-national-housing- strategy.pdf?rev=97491935-2a97-405f-bd38-decf72266ee9
[6] MacCharles, Tonda. “Vast majority of Canadians could have access to a COVID-19
vaccine by late 2021, says public health deputy chief.” thestar.com. November 17, 2020. https://www.thestar.com/politics/federal/2020/11/17/vast-majority-of-canadians-could-have-access-to-a-covid-19-vaccine-by-late-2021-says-public-health-deputy-chief.html