Structural Stigma: The invisible barrier to equitable health care
Most Canadians are familiar with the heartbreaking final moments of Joyce Echaquan. While seeking help for severe stomach pain at a hospital in Quebec, she was incorrectly diagnosed as suffering from opioid withdrawal. In hospital, Ms. Echaquan was restrained, given medications contraindicated due to her pre-existing health conditions, and endured insulting and mocking comments from an attending nurse and orderly.
An investigation into the incident revealed a pattern of mutual mistrust between the staff and indigenous patients at the hospital. Joyce Echaquan had hesitated to go the hospital due to prior mistreatment and ultimately her concerns were validated.
Ms. Echaquan’s tragic death is now widely seen as a flashpoint showing the need for action to address systemic racism and structural stigma in Canada’s healthcare system.
UNDERSTANDING STRUCTURAL STIGMA
HealthCareCAN collaborates with the Mental Health Commission of Canada (MHCC) on addressing structural stigma, recovery-oriented practice, and improving access to quality mental health care across Canada.
Together the two organizations co-lead the Quality Mental Health Care Network (QMHCN), a pan-Canadian network of health sector leaders dedicated to promoting recovery-oriented practice and enabling psychological health and safety in healthcare workplaces. HealthCareCAN is also an advisory committee member of the MHCC’s Structural Stigma Planning Committee for the development of a structural stigma training module.
The implicit and explicit biases of healthcare providers and laws, policies, or practices at an organizational level, can result in discrimination against people with lived and living experiences. People with mental health and substance use issues are particularly vulnerable to structural stigma.
Since 2019, the Mental Health Commission of Canada (MHCC) has worked to increase understanding of the problems caused by structural stigma in healthcare among people with lived and living experiences. MHCC conducted a comprehensive literature review, that identifies two key impacts of structural stigma – reduced access through inequitable distribution of resources or inadequate services, and a lower quality of care. The MHCC has attempted to address these gaps through identifying priority areas for structural change through a variety of tools, such as their Framework for Action as well as measures to identify and assess the current situation in healthcare organizations.
MHCC is developing training modules to further address the gaps in understanding, recognizing, and combating structural stigma. As part of the Structural Stigma Planning Committee, HealthCareCAN advises on:
Identifying priority issues and engagement strategies related to addressing mental illness and substance use related structural stigma in health care environments;
Development of the training modules content, length, target audience, learning objectives, and accreditation requirements, and;
Strategic counsel on implementation and knowledge exchange efforts useful for the release and uptake of the training modules.
The training modules are aimed at health leaders, providers, and people with lived and living experiences, and cover four areas:
Description of structural stigma and the impact it has on Mental Health Substance Use (MHSU) clients;
How and where MHSU-related structural stigma exists in healthcare contexts;
Reframing what the concept of MHSU-related structural stigma means to you;
Recognizing opportunities to dismantle structural stigma.
Each module consists of training content, interactive components, case studies, videos featuring people with lived and living experiences, health providers and subject matter experts, and resources.
OTHER RESOURCES ADDRESSING STRUCTURAL STIGMA
HealthCareCAN led the development of the Quality Mental Health Care Framework, which is a key deliverable of the QMHCN and identifies and defines quality mental health care and the 10 essential quality dimensions that encompass its provision.
Structural stigma is addressed in the Stigma-Free and Inclusive quality dimension, which was informed by health professionals across Canada and people with lived and living experiences. Quality mental health care must address “drivers of mental health stigma and prevents stigma practices in mental health care.” The dimension also stresses that multiple layers of stigma (individual, interpersonal, intersectoral, and structural) must be addressed to “better support individuals who have experienced stigma and discrimination.” People seeking care must always feel “respected and valued.”
The implementation and next steps of translating the Framework into practice is moving forward with the MHCC and network members.
A journal article on the development of the Framework produced by HealthCareCAN was also recently published in the Healthcare Management Forum, a peer-reviewed journal.