Intra-Provincial Variation in Publicly Funded Mental Health and Addictions “Services” Use Among Canadian Armed Forces Families Posted Across Ontario

Abstract

Being a member of a Canadian Armed Forces (CAF) family includes frequent geographic relocations, which may affect the use of mental health and addictions (MHA) services. This was a retrospective cohort study to examine intra-provincial variation in MHA services among CAF children, youth, and spouses posted across the province of Ontario using administrative datasets. Our sample included 5478 CAF children and youth, and 3358 female spouses who were relocated to Ontario between 2008 and 2012. CAF family members were assigned to one of five regions of the province based on their postal code. Publicly funded, physician-based MHA services included related visits to family physicians, paediatricians, and psychiatrists and emergency department (ED) visits and hospitalizations. Adjusted comparisons, including age, sex, and income, were made using linear, logistic, and modified Poisson regression. We found that the majority of our sample did not use MHA services following relocation. Among those who did so, we documented a small amount of intra-provincial variation. Children and youth living in the South East and “other” regions were less likely to see a family physician than in the Champlain region. Children and youth living in the North Simcoe region were more likely to have an MHA specialist visit and less likely to have an MHA ED visit than in the Champlain region. Female spouses living in the North Simcoe and “other” regions were more likely to have an MHA family physician visit than in the Champlain region. Our findings suggest that additional MHA support may be required to meet the needs of military families, in particular when relocated to MHA resource-poor areas of the country.

Full text

Intra-Provincial Variation in Publicly Funded Mental
Health and Addictions “Services”Use Among
Canadian Armed Forces Families Posted
Across Ontario
I. Garces Davila
1
&H. Cramm
2
&S. Chen
3
&A. B. Aiken
4
&B. Ouellette
5
&
L. Manser
5
&P. Kurdyak
3,6
&Alyson L. Mahar
1,3
Received: 3 October 2019 /Accepted: 26 February 2020 /Published online: 18 March 2020
#Springer Nature Switzerland AG 2020
Abstract
Being a member of a Canadian Armed Forces (CAF) family includes frequent geo-
graphic relocations, which may affect the use of mental health and addictions (MHA)
services. This was a retrospective cohort study to examine intra-provincial variation in
MHA services among CAF children, youth, and spouses posted across the province of
Ontario using administrative datasets. Our sample included 5478 CAF children and
youth, and 3358 female spouses who were relocated to Ontario between 2008 and
2012. CAF family members were assigned to one of five regions of the province based
on their postal code. Publicly funded, physician-based MHA services included related
visits to family physicians, paediatricians, and psychiatrists and emergency department
(ED) visits and hospitalizations. Adjusted comparisons, including age, sex, and income,
were made using linear, logistic, and modified Poisson regression. We found that the
majority of our sample did not use MHA services following relocation. Among those
who did so, we documented a small amount of intra-provincial variation. Children and
youth living in the South East and “other”regions were less likely to see a family
physician than in the Champlain region. Children and youth living in the North Simcoe
region were more likely to have an MHA specialist visit and less likely to have an
MHA ED visit than in the Champlain region. Female spouses living in the North
Simcoe and “other”regions were more likely to have an MHA family physician visit
than in the Champlain region. Our findings suggest that additional MHA support may
be required to meet the needs of military families, in particular when relocated to MHA
resource-poor areas of the country.
Canadian Studies in Population (2020) 47:27–39
https://doi.org/10.1007/s42650-020-00027-7
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s42650-020-
00027-7) contains supplementary material, which is available to authorized users.
*Alyson L. Mahar
alyson.mahar@umanitoba.ca
Extended author information available on the last page of the article

Résumé
Être membre d'une famille des Forces armées canadiennes (FAC) implique des
réinstallations géographiques fréquentes, ce qui peut avoir une incidence sur
l'utilisation des services de santé mentale et de lutte contre les dépendances. Nous
avons effectué une étude rétrospective visant à examiner la variation intraprovinciale
dans l’utilisation de ces services parmi les enfants, les jeunes et les conjoints des FAC
affichés dans la province de l'Ontario à l'aide de données administratives. Notre
échantillon comprenait 5478 enfants et jeunes des FAC et 3358 conjoints de sexe
féminin qui ont été réinstallés en Ontario entre 2008 et 2012. Les membres des familles
des FAC ont été affectés à l'une des cinq régions de la province en fonction de leurcode
postal. Les services de santé mentale et de lutte contre les dépendances offerts par des
médecins et financés par l'État comprenaient des visites connexes chez les médecins de
famille, les pédiatres et les psychiatres, ainsi que des visites et des hospitalisations aux
urgences. Des comparaisons ajustées, y compris l'âge, le sexe et le revenu, ont été faites
en utilisant une régression de Poisson linéaire, logistique et modifiée. Nous avons
constaté que la majorité de notre échantillon n'a pas utilisé les services de santé
mentale et de lutte contre les dépendances après la réinstallation. Nous avons
également documenté une petite quantité de variation intra-provinciale. Les
enfants et les jeunes du Sud-Est et des «autres» régions étaient moins suscep-
tibles de consulter un médecin de famille que dans la région de Champlain. Les
enfants et les jeunes vivant dans la région de Simcoe Nord étaient plus
susceptibles de recevoir une visite chez un spécialiste de la santé mentale et
moins susceptibles d'avoir une visite à l'urgence pour un problème de santé ou
de dépendance que dans la région de Champlain. Les conjointes vivant dans la
région de Simcoe Nord et dans les «autres» régions étaient plus susceptibles de
consulter un médecin de famille pour un problème de santé ou de dépendance
que dans la région de Champlain. Nos résultats suggèrent que des soutiens
supplémentaires pourraient être nécessaires pour répondre aux besoins des
familles des militaires, en particulier, lorsqu'ils sont réinstallés dans des régions
du pays pauvres en ressources pour les services de santé mentale et de lutte
contre les dépendances.
Keywords Military families .Mental health services .Child .Adolescent .Spouses
1 Introduction
In 2017, there were 57,000 families of serving Canadian Armed Forces (CAF)
members (Manser 2018b). Being a member of a CAF family implies participat-
inginthe‘military lifestyle’, which requires frequent relocations within and
across provinces and territories to meet military operational demands. As a
result, CAF families move three to four times as often as civilian families do
(Daigle 2013;Kiburietal.2018). This residential mobility can have many
benefits for the family, like making children and youth resilient and adaptable
to changing environments (Neil 2019). However, it also has the potential to
disrupt provincial and territorial services such as education and healthcare
(Manser 2018a,b). Civilian family members of CAF families access healthcare
28 Canadian Studies in Population (2020) 47:27–39

within their province or territory of residence and must re-engage with health
services with each move, while CAF members’health services are organized and
provided federally through the military.
Continuity of healthcare and access to health services, including mental health and
mental healthcare providers, are a key concern following new postings for CAF
families (Daigle 2013;Manser2018a;Rowan-Legg2017). Relocation requires the
military family to adjust to a new place, develop new routines, and establish new
community relations, transitions that are associated with the socio-emotional well-being
of children and spouses (Manser 2018a). A comparison of medical health service use
between female spouses and the children of CAF members and civilians concluded that
military family members have longer intervals to their first healthcare service visits and
a lower likelihood of receiving care from medical specialists than civilians do (Mahar
et al. 2018).
Understanding geographic variation in the Canadian context is critical for CAF
families, since there are established differences in mental health resources and funding
within and across Canadian provinces (Butler et al. 2017). Within Ontario specifically,
geography of residence is associated with different availability of and access to mental
healthcare providers, as well as variation in key mental health service quality indicators
(Brien et al. 2015; Amartey et al. 2017). Yet no research has explored geographic
variation in the use of mental health services within the military family community in
the province (Davis et al. 2016;DavisandFinke2015;Milleganetal.2014; Alfano
et al. 2016; Brownlow et al. 2018).
Understanding geographic variation in MHA services use is one step toward
ensuring CAF families have equal opportunity to achieve good mental health, regard-
less of where they live in the country. Therefore, the purpose of this study was to
examine intra-provincial differences in mental health and addictions (MHA) services
use among children, youth, and spouses of CAF members posted across the province of
Ontario.
2 Methods
Data Sources This study was conducted at ICES, formerly the Institute for Clinical
Evaluative Sciences. Six datasets were linked using unique encoded identifiers and
analysed at ICES. The Registered Persons Database provided demographic infor-
mation (age, sex, community-level socioeconomic status, rurality of residence, and
region of residence). The OHIP database contained information on physician
services and diagnostic information. Physician speciality was measured using the
Physician Database. The National Ambulatory Care Reporting System (NACRS)
provided diagnostic and service informationonemergencydepartment(ED)visits.
The Canadian Institute for Health Information Discharge Abstract Database (CIHI-
DAD) and the Ontario Mental Health Reporting System (OMHRS) database
provided information on hospital admissions. Queen’s University granted ethical
clearance for the study (REH-598-14).
Study Design This was a retrospective cohort study designed to describe and
compare geographic differences in publicly funded physician-based MHA services
Canadian Studies in Population (2020) 47:27–39 29

use for CAF family members following relocation to Ontario. Ontario is home to
eight of the thirty-eight Canadian federal military bases. On average, more than
one-third of the 18,000 military personnel who relocate each year moved to one of
three bases in Ontario (Borden, Ottawa, and Kingston) (Manser 2018b). Each
year, approximately 40% of CAF families reside in the province (Manser 2018b).
In 2007, Ontario waived the 3-month waiting period for provincial health cover-
age to families of active CAF personnel under the Fairness for Military Families
Act. This act grants immediate access to and payment of provincial health services
for the spouses and dependants of CAF members returning or new to the province
following an out-of-province or out-of-country posting and to the families of
reservists who were activated out of province.
Study Population The study population included CAF children, youth, and spouses
who were relocated to Ontario from out-of-province or out-of-country between
January 1, 2008, and December 31, 2012, and who self-identified to the Ontario
Ministry of Health and Long-Term Care as being a member of a CAF family
during their application for Ontario Health Insurance Plan (OHIP) coverage. A
dependent was defined by OHIP as a child or adolescent under the age of 22 years
or older than 22 with mental or physical disability. A spouse was identified as a
person to whom one is married, or with whom one has been living in a relation-
ship provided the two have (a) cohabitated for at least 1 year, or (b) are together
parents of a child or (c) have a cohabitation agreement under the Family Law Act
(Government of Ontario Ministry of Health and Long-Term Care 2018). For this
study, the spouse study population was restricted to women due to the small
number of men spouses in the sample, which would result in statistically unreli-
able information and unreportable data due to privacy and re-identification con-
cerns (Mahar et al. 2015). While this study included CAF families with children
and youth, not all CAF families include children.
Geographic Information Ontario was divided into fourteen geographically bounded
locations responsible for regional administration of public healthcare services called
Local Health Integration Networks (LHINs) until 2019. Based on previous work, we
knew that the majority of CAF families were concentrated within three areas (Mahar
et al. 2015). There is also evidence of variation in MHA services availability at this
level of geography in the province (Brien et al. 2015; Amartey et al. 2017). CAF
families were thus classified as living in one of five areas of the province using their
postal code: South East (CFB Kingston, CFB Trenton), Champlain (CFB Ottawa, CFB
Petawawa), North Simcoe Muskoka (CFB Borden), North East (CFB North Bay), or
other (CFB Meaford, CFB Toronto). A categorical CAF family geography variable was
created to reflect the five areas considered.
Outcomes In this study, we had three outcomes of interest for physician-based publicly
funded MHA services: outpatient physician visits, emergency department (ED) visits,
and hospitalizations.
Physician visits were measured using OHIP data and sub-classified as being with a
family physician, paediatrician, or psychiatrist. Paediatric consultations were only
measured in individuals who were aged 19 years and younger at the time of the study
30 Canadian Studies in Population (2020) 47:27–39

start date. MHA physician visits were identified using the diagnosis field of the billing
record. Reasons for visits were coded using a modified version of the International
Classification of Disease (ICD) - 9th Edition.
ED visits were measured using the NACRS database, and hospitalisations were
measured using the CIHI-DAD database. MHA ED visits and hospitalizations were
identified from the diagnosis fields of the ED and hospitalization records. Diagnoses
were coded using the ICD-10 classification system.
Each outcome was operationalized both as a dichotomous yes/no variable, as an
average number of visits (excluding hospitalizations), and as a rate per 1000 person
years (Amartey et al. 2017). Time to first paediatrician or psychiatrist visit after
relocation was also measured. The interval was from the start date of OHIP registration
to the date of the first specialist visit and was reported in days.
Covariates Age, sex, and median community income quintile (lowest, 2nd, 3rd, 4th,
highest) were included as baseline variables. Age at relocation was measured from the
RPDB. Age categories were determined by a combination of data distribution and
comparability to existing general population reports: for children and youth, we chose
0–6, 7–9, 10–14, and 15–19 years; for spouses, 20–29, 30–34, 35–39, 40–44, and 45+
years. Community-level income measured using census data is an established proxy
measure of individual income available in the administrative data. Community income
quintiles were determined by postal code at relocation linked to Census 2010 data. A
community was considered rural if it had less than 10,000 inhabitants.
Statistical Analysis Baseline sample characteristics were presented as frequencies and
proportions, and they were compared using chi-square tests for independence among
geographic regions of Ontario.
Unadjusted comparisons of MHA services use were made using chi-square and
Kruskal-Wallis tests. Comparisons of family physician visits were made using multi-
variate modified Poisson regression with robust error variance. Comparisons of paedi-
atrician visits, psychiatrist visits, and ED visits were made using multivariate logistic
regression. Comparisons of the number of days to first MHA specialist visit were
conducted using multivariate linear regression, in those who had at least one visit. All
multivariate comparisons were adjusted for age, sex, and income.
The Champlain region was used as the comparison group due to its large sample
size, allowing for appropriate comparisons among regions. Relative risks and 95%
confidence limits were presented for dichotomous outcomes. Intercepts and beta
coefficients were presented for time to first visit. Pvalues < 0.05 were considered
statistically significant. All analyses were performed separately for children and youth,
and spouses, using SAS 9.4 Copyright 2008 (Cary, NC, USA). Cell sizes under 6 were
not reported in accordance with ICES privacy and confidentiality regulations.
3Results
This study included 5478 children and youth and 3358 female spouses in CAF
families posted to Ontario from another province or returning from out of country
postings during the period 2008–2012. Table 1presents descriptive statistics about
Canadian Studies in Population (2020) 47:27–39 31

Table 1 Baseline characteristics of children, youth and female spouses in CAF families living in five
geographic regions of Ontario
Children and youth
n(%)
Female spouses
n(%)
Number 3358 5478
Average age (SD) 7.5 (5.3) 36.2 (8.8)
Boys 2813 (51.4%) –
Median community income quintile
Lowest 457 (8.3%) 318 (9.5%)
Q2 878 (16.0%) 613 (18.3%)
Q3 1277 (23.3%) 817 (24.3%)
Q4 1513 (27.6%) 865 (25.8%)
Highest 1341 (24.5%) 735 (21.9%)
Geographic region
South East 1379 (25.2%) 867 (25.8%)
Champlain 2527 (46.1%) 1567 (46.7%)
North Simcoe Muskoka 1096 (20.0%) 664 (19.8%)
North East 177 (3.2%) 87 (2.6%)
Other 299 (5.5%) 173 (5.1%)
Rural residence 1147 (20.9%) 731 (21.8%)
n, number; SD, standard deviation; Other, all other regions of Ontario; Q, quintiles
0
1
2
3
4
5
6
Children and Youth Female spouses
snoitciddadnahtlaehlatnemforebmunnaeM
st
isivnaic
i
syh
pd
e
ta
le
r
Region of the Province
South East Champlain North Simcoe North East Other
Fig. 1 Mean number of mental health and addictions outpatient physician visits for children and youth and
female spouses in Canadian Armed Forces families inthosewho had atleastone visit, stratified by their region
of residence in the province
32 Canadian Studies in Population (2020) 47:27–39

their age, sex, community income, and rural residence. Almost half of the sample
lived in the Champlain region (46%), 25% lived in the South East region, 20%
lived in the North Simcoe Muskoka region, about 3% lived in the North East
region, and about 5% were spread out across the remainder of the province. The
age distribution, median community income, and rurality of residence varied
across regions of the province, while the ratio of boys to girls was similar
(Online Resource 1). On average, children living in the North Simcoe region were
younger (mean age 6.6 years) and children living in the North East area were older
(mean age 8.4 years) than in other areas of the province (p< 0.001). The average
age of women in the North Simcoe region (mean 33 years) was also significantly
younger than other areas by 3 to 4 years (p< 0.001). A significantly larger
percentage of families living in the North Simcoe region (82%) were considered
rural compared to other regions (p< 0.001). Similarly, a significantly smaller
Table 2 Adjusted comparison of mental health service use among children and youth in CAF families
stratified by geographic region in the province of Ontario
Geographic region Outcome
n(%)
Crude RR
(95% CI)
aRR1*(95% CI) aRR2** (95% CI)
Physician visits (any)+
Champlain 564 (22.3%) Reference Reference Reference
South East 271 (19.7%) 0.87 (0.77–0.99) 0.90 (0.79–1.02) 0.91 (0.80–1.04)
North Simcoe 215 (19.6%) 0.94 (0.81–1.08) 1.00 (0.86–1.15) 1.00 (0.86–1.15)
North East 41 (23.2%) 1.04 (0.79–1.37) 1.02 (0.77–1.34) 1.02 (0.77–1.34)
Other 51 (17.1%) 0.84 (0.65–1.09) 0.86 (0.67–1.11) 0.85 (0.66–1.1)
Family physician visits+
Champlain 471 (18.6%) Reference Reference Reference
South East 215 (15.6%) 0.83 (0.72–0.96) 0.86 (0.74–0.99) 0.87 (0.75–1.01)
North Simcoe 175 (16.0%) 0.91 (0.78–1.07) 0.99 (0.85–1.16) 1.00 (0.85–1.18)
North East 38 (21.5%) 1.15 (0.86–1.55) 1.12 (0.83–1.50) 1.12 (0.84–1.51)
Other 36 (12.0%) 0.71 (0.52–0.97) 0.74 (0.54–1.01) 0.72 (0.53–0.99)
Paediatrician and psychiatrist visits++
Champlain 225 (8.9%) Reference Reference Reference
South East 132 (9.6%) 1.08 (0.86–1.35) 1.10 (0.87–1.38) 1.12 (0.89–1.41)
North Simcoe 115 (10.5%) 1.28 (1.01–1.63) 1.33 (1.05–1.69) 1.31 (1.02–1.68)
North East 16 (9.0%) 1.02 (0.60–1.73) 1.01 (0.59–1.73) 1.01 (0.59–1.74)
Other 26 (8.7%) 1.08 (0.70–1.65) 1.09 (0.71–1.67) 1.11 (0.73–1.70)
ED visits++
Champlain 63 (2.5%) Reference Reference Reference
South East 30 (2.2%) 0.86 (0.55–1.34) 0.90 (0.58–1.42) 0.98 (0.63–1.55)
North Simcoe 12 (1.1%) 0.46 (0.24–0.86) 0.54 (0.29–1.01) 0.51 (0.27–0.97)
North East - 1.14 (0.45–2.88) 1.05 (0.40–2.72) 1.12 (0.42–2.93)
Other 6 (2.0%) 0.88 (0.37–2.05) 1.02 (0.43–2.40) 1.02 (0.42–2.46)
Not reported if cell size < 6. *Adjusted for age and sex. **Adjusted for age, sex, and income quintile.
+Modified Poisson regression, with offset. ++ Logistic regression
Canadian Studies in Population (2020) 47:27–39 33

percentage of children, youth, and spouses in the North Simcoe region (≤5%)
lived in communities with the highest median income compared to other regions
of the province (p< 0.001).
MHA hospitalizations were rare in all regions of the province, occurring in 0.6% of
children and youth (intra-provincial range 0.3–1.1%), and 0.8% of female spouses
(intra-provincial range 0 to 2.3%). MHA ED visits were also uncommon, occurring in
2.1% of children and youth (intra-provincial range 1.1 to 2.8%) and 2.6% of spouses
(intra-provincial range 0.6 to 3.1%).
Twenty-one percent of children and youth (intra-provincial range 17.1 to
23.2%) and 31% of spouses (intra-provincial range 23.0 to 36.4%) had at least
one MHA outpatient physician visit. Having at least one MHA visit with a family
physician was more common (intra-provincial range: children and youth 12.0–
21.5%; female spouses 23.0–35.3%) than a visit to a psychiatrist or paediatrician
(intra-provincial range: children and youth 8.7–10.5%; female spouses 2.9–5.3%).
In those who had at least one MHA outpatient physician visit, the average number
of visits ranged from 3.8 to 4.5 visits per child/youth and from 3.4 to 5.0 visits per
female spouse. There was no difference in the overall average number of MHA-
Table 3 Adjusted comparisons of mental health services use among spouses in CAF families stratified by
geographic region in the province of Ontario (reference = Champlain LHIN)
Geographic region Outcome
n(%)
Crude RR
(95% CI)
aRR1*(95% CI) aRR2** (95% CI)
Physician visits (any)+
Champlain
South East
North Simcoe
North East
Other
470 (30.0%)
265 (30.6%)
214 (32.2%)
20 (23.0%)
63 (36.4%)
Reference
1.01 (0.89–1.14)
1.18 (1.03–1.35)
0.79 (0.53–1.17)
1.29 (1.04–1.59)
Reference
1.01 (0.89–1.14)
1.17 (1.02–1.34)
0.79 (0.53–1.17)
1.29 (1.04–1.59)
Reference
0.99 (0.87–1.13)
1.14 (0.99–1.31)
0.79 (0.54–1.18)
1.29 (1.04–1.60)
Family physician visits+
Champlain
South East
North Simcoe
North East
Other
465 (29.7%)
253 (29.2%)
211 (31.8%)
20 (23.0%)
61 (35.3%)
Reference
0.97 (0.86–1.11)
1.17 (1.03–1.34)
0.80 (0.54–1.18)
1.26 (1.01–1.57)
Reference
0.97 (0.85–1.11)
1.17 (1.02–1.34)
0.80 (0.54–1.18)
1.26 (1.01–1.57)
Reference
0.96 (0.84–1.09)
1.13 (0.99–1.30)
0.80 (0.54–1.19)
1.26 (1.01–1.57)
Psychiatrist Visits++
Champlain
South East
North Simcoe
North East
Other
66 (4.2%)
46 (5.3%)
19 (2.9%)
-
6(3.5%)
Reference
1.26 (0.86–1.86)
0.74 (0.44–1.24)
1.13 (0.40–3.19)
0.87 (0.37–2.04)
Reference
1.26 (0.85–1.86)
0.73 (0.43–1.24)
1.13 (0.40–3.19)
0.87 (0.37–2.04)
Reference
1.25 (0.84–1.85)
0.75 (0.43–1.30)
1.14 (0.40–3.24)
0.85 (0.36–2.00)
ED visits++
Champlain
South East
North Simcoe
North East
Other
49 (3.1%)
23 (2.7%)
16 (2.4%)
-
-
Reference
0.84 (0.51–1.38)
0.84 (0.47–1.49)
1.14 (0.35–3.75)
0.19 (0.03–1.40)
Reference
0.83 (0.49–1.38)
0.81 (0.45–1.45)
1.14 (0.35–3.76)
0.19 (0.03–1.39)
Reference
0.76 (0.46–1.28)
0.77 (0.42–1.41)
1.10 (0.33–3.70)
0.19 (0.03–1.38)
Cell size < 6. *Adjusted for age. **Adjusted for age and income quintile. +Modified Poisson regression, with
offset. ++Logistic regression
34 Canadian Studies in Population (2020) 47:27–39

related outpatient physician visits across the province, in those who had at least
one visit (not shown) (Fig. 1).
After adjusting for age, sex, and community income, children and youth living
across the province had a similar likelihood of seeing a family physician for MHA
reasons with the exception of children and youth living in the “other”regions (Table 2).
Children and youth in the “other”region were less likely to see a family physician for
mental health reasons than those living in the Champlain region. Children and youth
living in the North Simcoe region were significantly more likely to see a paediatrician
or psychiatrist and significantly less likely to have an MHA ED visit than children and
youth living in the Champlain region.
After adjusting for differences in age, sex, and community income, there was no
variation in the likelihood of MHA ED visits or specialist visits for female CAF
spouses living across the province (Table 3). Women living in North Simcoe and the
“other”regions of Ontario were more likely to see a family physician for MHA reasons
than women living in the Champlain region.
We compared the time to first MHA specialist visit in those children, youth, and
spouses who had at least one visit to a paediatrician or psychiatrist during the study
time period (Fig. 2). There was no evidence for statistically significant intra-provincial
variation for children and youth, nor for spouses (Online Resource 2).
4Discussion
There are no other studies comparing the use of MHA services by CAF families across
geographic regions to understand if different postings are associated with different
0
100
200
300
400
500
600
700
800
900
Children and Youth Female spouses
tis
ivtsilaic
e
pshtlaehlatnemtsrifotlavretninaideM
(days)
Region of the Province
South East Champlain North Simcoe North East Other
Fig. 2 Median time to first mental health and addictions specialist visit for children and youth (n=514) and
female spouses (n= 141) in Canadian Armed Forces families in those who had at least one visit, stratified by
their region of residence in the province
Canadian Studies in Population (2020) 47:27–39 35

access, use, or need for services. Our study adds to the international literature about
military families’use of outpatient and inpatient MHA services following relocation.
Research conducted in the USA has found that military children and spouses may be at
risk for high levels of stress and difficulty using services after relocation (Liming and
Grube 2018; Finkelhor et al. 2013; Davis et al. 2016;DavisandFinke2015). Millegan
and colleagues (Millegan et al. 2014)reportedthatchildrenaged12–17 years with a
geographic move were more likely to have MHA outpatient visits, psychiatric hospi-
talizations, and emergency psychiatric visits than military children without a geograph-
ic move.
The trends in intra-provincial variation in MHA outpatient physician services for
children and youth in CAF families mirror those documented overall in the province
(Amartey et al. 2017). In our study, children and youth living in the North East region
had the lowest rate of psychiatrist visits and some of the highest rates of MHA ED visits
in the province. The North East region of the province has the lowest per capita supply
of full-time psychiatrists (8.3 per 100,000 residents) compared to other areas of the
province (e.g., 24.3 per 100,000 in the Champlain region; 62.7 per 100,000 in Toronto
Central) and the longest wait times to psychiatry (Brien et al. 2015). In addition,
research has found that death rates by suicide among children and youth are six times
higher than the national average in the North East region (Amartey et al. 2017). This
suggests access to MHA services may be driven by factors other than need and that
these mismatches between need and receipt of care may have significant consequences.
Areas where unmeet need exists could benefit from additional MHA resources and
supports both from the province as well as from the CAF.
The complexity of MHA services delivery, including services provided across
differenthealthcaresettingsaswellasoutsidetheformalboundariesofhealthcare
(e.g., community housing, private addictions residential treatment, most psychological
services) (Butler et al. 2017), requires accurate measurements to capture the experi-
ences of populations facing transitional challenges (e.g., CAF families relocation and
absences). Ideally, MHA services measurement needs to reflect care delivered across
public and private settings and sectors (Butler et al. 2017). Regardless of measurement,
if a CAF relocation requires a family move to an area with fewer publicly funded MHA
services or longer wait times for those services, it is critical to better understand the
potential clinical impact of this disruption or re-shuffling of services.
Studies conducted with civilian populations have found that household income, as
well as differences in income among regions, can lead to a higher number of emergency
department visits (Health Quality Ontario 2016) and consults for speciality services not
covered by provincial insurance (Starkes et al. 2005;Slaunwhite2015). For example, a
report from Health Quality Ontario (2016) indicates that people living in
neighbourhoods with the lowest median income are more likely to have mental
health-related emergency department visits compared to people living in
neighbourhoods with the highest median income (104,494 visits versus 54,457 visits
from 2010 to 2013). In this study, we observed a similar pattern. Children, youth, and
spouses living in Champlain (the region with lowest median community income) had a
higher number of emergency department visits and outpatient visits compared to
families living in regions with higher median community income (e.g., North Simcoe).
Given that CAF members and families have access to resources outside the provin-
cial health system (e.g., private services, government-subsidized social workers at
36 Canadian Studies in Population (2020) 47:27–39

Military Family Resource Centres), it may be that geographic differences in the
availability of publicly funded resources are not problematic, if needs are easily
supplemented by private resources. CAF families may have better access to MHA
services than civilians when needed. However, if private MHA service availability and
programs at different Military Family Resource Centres vary across regions of the
province, as well as between provinces and territories, attention to inter-provincial
variation is needed.
The results of this study should be interpreted considering the following
limitations. We were not able to link individuals within a family unit to study
how MHA services use varied across families and across geographic locations.
Therefore, if multiple individuals within a family used MHA services in an area, it
could inflate intra-provincial variation. We were also unable to capture spouses or
children of CAF members who were separated due to divorce, families who do not
relocate with their CAF partner, CAF partners who do not meet Ontario’sdefini-
tion of a spouse, parents of CAF members who travel with their family, or older
adolescents and young adults who may not relocate with their family. However,
the CAF dependents included in this study represent the majority of CAF family
members implicated in relocation (Manser 2018b). In addition, if the intra-
provincial variation we observed in this study is the result of issues accessing
care, our findings are likely generalizable to relocating family members not
represented in our study. We also did not have access to CAF member character-
istics (e.g., rank, deployments), which have been associated with mental health
diagnoses and health services use in family members (Kritikos et al. 2018;Fear
et al. 2018; White et al. 2011). Importantly, we did not have informatio on the
underlying need and unmet need for MHA services (Sareen et al. 2007)which
may differ across families and across geographic postings within the province.
Understanding unmet need variation would be important for providing supports
alongside specific CAF relocation destinations. Other variables that have been
found to be related to MHA services use which may vary across regions, such as
ethnic background (Breland et al. 2014; Yeh et al. 2002) or parental education
level (Merikangas et al. 2011), were not available in this study.
5 Conclusion
The purpose of this study was to examine intra-provincial differences in mental health
and addictions services use among children, youth, and spouses of CAF members
posted across the province of Ontario. We found that the majority of CAF families
relocated to Ontario did not use public mental health services across the province,
regardless of posting location. Among those who did so, we identified intra-provincial
difference in the use of mental health services, specifically for outpatient mental health
physician visits. Children and youth living in the South East and other regions were less
likely to see a family physician than in the Champlain region. Children and youth living
in the North Simcoe region were more likely to have an MHA specialist visit and less
likely to have an MHA ED visit than in the Champlain region. Female spouses living in
the North Simcoe and other regions were more likely to have an MHA family physician
visit than in the Champlain region.
Canadian Studies in Population (2020) 47:27–39 37

Our findings suggest that additional MHA support and services may be required to
meet the needs of military families posted across the province. Future studies should
evaluate the impact of relocation on the mental health and mental health services use of
Canadian military families by looking at pre- and post-relocation time periods. Engag-
ing with family members to better understand a family’s strengths and needs following
relocation could better deliver mental health services across postings and maintain
resiliency among CAF families.
References
Alfano, C.A., Lau, S., Balderas, J., Bunnell, B. E., & Beidel, D. C. (2016). The impact of military deployment
on children: placing developmental risk in context. Clinical Psychology Review, 43,17–29. https://doi.
org/10.1016/j.cpr.2015.11.003.
Amartey, A., Chiu, M., Gatov, E., Guttman, A., Lebenbaum, M., Kurdyak, P., et al. (2017). The mental health
of children and youth in Ontario: 2017 scorecard. Toronto:ON.
Breland, D. J., McCarty, C. A., Zhou, C., McCauley, E., Rockhill, C.,Katon, W., et al. (2014). Determinants of
mental health service use among depressed adolescents. General Hospital Psychiatry, 36(3), 296–301.
https://doi.org/10.1016/j.genhosppsych.2013.12.003.
Brien, S., Grenier, L., Kapral, M., Kurdyak, P., & Vigod, S. (2015). Taking stock: a report on the quality of
mental health and addictions Services in Ontario. Toronto.
Brownlow, J. A., Zitnik, G. A., McLean, C. P., & Gehrman, P. R. (2018). The influence of deployment stress
and life stress on post-traumatic stress disorder (PTSD) diagnosis among military personnel. Journal of
Psychiatric Research, 103,26–32. https://doi.org/10.1016/j.jpsychires.2018.05.005.
Butler, A., Adair, C., Jones, W., Kurdyak, P., Vigod, S., Smith, M., et al. (2017). Toward quality mental health
services in Canada: a comparison of performance indicators across 5 provinces. Vancouver, BC:.
Daigle, P. (2013). On the homefront: assessing the well-being of Canada’s military families in the new
millennium. Ottawa, Ontario.
Davis, J. M., & Finke, E. H. (2015). The experience of military families with children with autism spectrum
disorders during relocation and separation. Journal of Autism and Developmental Disorders, 45(7), 2019–
2034. https://doi.org/10.1007/s10803-015-2364-2.
Davis, J. M., Finke, E., & Hickerson, B. (2016). Service delivery experiences and intervention needs of
military families with children with ASD. Journal of Autism and Developmental Disorders, 46(5), 1748–
1761. https://doi.org/10.1007/s10803-016-2706-8.
Fear, N. T., Reed, R. V., Rowe, S., Burdett, H., Pernet, D., Mahar, A., et al. (2018). Impact of paternal
deployment to the conflicts in Iraq and Afghanistan and paternal post-traumatic stress disorder on the
children of military fathers. British Journal of Psychiatry, 212(6), 347–355. https://doi.org/10.1192
/bjp.2017.16.
Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a
national sample of children and youth: an update. JAMA Pediatrics, 167(7), 614–621. https://doi.
org/10.1001/jamapediatrics.2013.42.
Government of Ontario Ministry of Health and Long-Term Care (2018). Military family members - Ontario
health insurance (OHIP) - public information. http://health.gov.on.
ca/en/public/publications/ohip/military_family.aspx. Accessed March 12, 2018 2018.
Health Quality Ontario (2016). Income and health: Opportunities to achieve equity in health. Toronto, Ontario.
Kiburi, S. K., Molebatsi, K., Obondo, A., & Kuria, M. W. (2018). Adverse childhood experiences among
patients with substance use disorders at a referral psychiatric hospital in Kenya. BMC Psychiatry, 18(1),
197. https://doi.org/10.1186/s12888-018-1780-1.
Kritikos, T. K., Comer, J. S., He, M., Curren, L. C., & Tompson, M. C. (2018). Combat experience and
posttraumatic stress symptoms among military-serving parents: a meta-analytic examination of associated
offspring and family outcomes. Journal of Abnormal Child Psychology, 47, 131–148. https://doi.
org/10.1007/s10802-018-0427-5.
38 Canadian Studies in Population (2020) 47:27–39

Liming, K. W., & Grube, W. A. (2018). Wellbeing outcomes for children exposed to multiple adverse
experiences in early childhood: a systematic review. Child and Adolescent Social Work Journal, 35(4),
317–335. https://doi.org/10.1007/s10560-018-0532-x.
Mahar, A., Aiken, A., Cramm, H., Groome, P., & Kurdyak, P. (2015). A new resource to study the health of
military families in Ontario. Journal of Military, Veteran and Family Health, 1(2), 3–4. https://doi.
org/10.3138/jmvfh.1.2.002.
Mahar, A., Aiken, A. B., Cramm, H., Whitehead, M., Groome, P., & Kurdyak, P. (2018). Access tohealth care
and medical health services use for Canadian military families posted to Ontario: a retrospective cohort
study. Journal of Military, Veteran and Family Health, 4(2). https://doi.org/10.3138/jmvfh.2018-0014.
Manser, L. (2018a). Relocation experiences the experiences of military families with relocations due to
postings –survey results. Ottawa, Ontario.
Manser, L. (2018b). State of military families in Canada: issues facing regular force members and their
families. Ottawa, Ontario.
Merikangas, K. R., He, J.-P., Burstein, M., Swendsen, J., Avenevoli, S., Case, B., et al. (2011). Service
utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey–
Adolescent Supplement (NCS-A). Journal of the American Academy of Child and Adolescent Psychiatry,
50(1), 32–45.
Millegan, J., McLay, R., & Engel, C. (2014). The effect of geographic moves on mental healthcare utilization
in children. Journal of Adolescent Health, 55(2), 276–280. https://doi.org/10.1016/j.
jadohealth.2014.01.009.
Neil, K. C. (2019). Families on the move, families in Canada 2019. St John's, Newfoundland and Labrador.
Rowan-Legg, A. (2017). Caring for children and youth from Canadian military families: special consider-
ations. Paediatrics & Child Health, 22(2), e1–e6. https://doi.org/10.1093/pch/pxx021.
Sareen, J., Cox, B. J., Afifi, T. O., Stein, M. B., Belik, S.-L., Meadows, G., & Asmundson, G. J. (2007).
Combat andpeacekeeping operations in relation to prevalence of mental disorders and perceived need for
mental health care. Archives of General Psychiatry, 64(7), 843–852.
Slaunwhite, A. K. (2015). The role of gender and income in predicting barriers to mental health care in
Canada. Community Mental Health Journal, 51(5), 621–627. https://doi.org/10.1007/s10597-014-9814-8.
Starkes, J. M., Poulin, C. C., & Kisely, S. R. (2005). Unmet need for the treatment of depression in Atlantic
Canada. Canadian Journal of Psychiatry, 50(10), 580–590.
White, C. J., de Burgh, H. T., Fear, N. T., & Iversen, A. C. (2011). The impact of deployment to Iraq or
Afghanistan on military children: a review of the literature. International Review of Psychiatry, 23(2),
210–217. https://doi.org/10.3109/09540261.2011.560143.
Yeh, M., McCabe, K., Hurlburt, M., Hough, R., Hazen, A., Culver, S., et al. (2002). Referral sources,
diagnoses, and service types of youth in public outpatient mental health care: a focus on ethnic minorities.
The Journal of Behavioral Health Services & Research, 29(1), 45–60.
Affiliations
I. Garces Davila
1
&H. Cramm
2
&S. Chen
3
&A. B. Aiken
4
&B. Ouellette
5
&L.
Manser
5
&P. Kurdyak
3,6
&Alyson L. Mahar
1,3
1
Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba,
443 Brodie Centre, 727 McDermot Ave, Winnipeg, Manitoba R3E 3P5, Canada
2
School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
3
ICES, Toronto, Ontario, Canada
4
Dalhousie University, Halifax, Nova Scotia, Canada
5
Canadian Forces Morale and Welfare Services (CFMWS), Ottawa, Ontario, Canada
6
Department of Psychiatry and Institute for Health Policy, Management, and Evaluation, University of
Toronto, Toronto, Ontario, Canada
Canadian Studies in Population (2020) 47:27–39 39