There is limited empirical evidence documenting the magnitude and correlates of area-level variability in unmet need for children’s mental health services. Research is needed that identifies area-level characteristics that can inform strategies for reducing unmet need in the population. The study purpose is to: (1) estimate area-level variation in children’s unmet need for mental health services (using Service Areas as defined by the Ontario Ministry of Children and Youth Services), and (2) identify area-level service arrangements, and geographic and population characteristics associated with unmet need. Using individual-level general population data, area-level government administrative data and Census data from Ontario, Canada, we use multilevel regression models to analyze unmet need for mental health services among children (level 1) nested within Service Areas (level 2). The study finds that 1.64% of the reliable variance in unmet need for mental health services is attributable to between-area differences. Across areas, we find that Service Areas with more agencies had a lower likelihood of unmet need for mental health services. Compared to other Service Areas, Toronto had much lower likelihood of unmet need compared to the rest of Ontario. Rural areas, areas with unsatisfactory public transport, and areas with higher levels of socio-economic disadvantage had a higher likelihood of unmet need for mental health services. These findings identify challenges in service provision that researchers, policymakers and administrators in children’s mental health services need to better understand. Policy implications and potential Service Area strategies that could address equitable access to mental health services are discussed.
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Achenbach, T. M. (2001). Manual for the child behavior checklist/6-18 and 2001 profile. Burlington, VT: University of Vermont.
Allin, S., & Masseria, C. (2009). Unmet need as an indicator of health care access. Eurohealth,15(3), 7–9.
Andersen, R. M., Yu, H., Wyn, R., Davidson, P. L., Brown, E. R., & Teleki, S. (2002). Access to medical care for low-income persons: How do communities make a difference? Medical Care Research and Review,59(4), 384–411. https://doi.org/10.1177/107755802237808.
Arcury, T. A., Gesler, W. M., Preisser, J. S., Sherman, J., Spencer, J., & Perin, J. (2005). The effects of geography and spatial behavior on health care utilization among the residents of a rural region. Health Services Research,40(1), 135–156. https://doi.org/10.1111/j.1475-6773.2005.00346.x.
Benjamini, Y., & Hochberg, Y. (1995). Controlling the false discovery rate: A practical and powerful approach to multiple testing. Journal of the Royal Statistical Society: Series B (Methodological),57(1), 289–300. https://doi.org/10.1111/j.2517-6161.1995.tb02031.x.
Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care. JAMA,307(14), 1513–1516. https://doi.org/10.1001/jama.2012.362.
Bhattacharya, D., & Bhatt, J. (2017). Seven foundational principles of population health policy. Population Health Management,20(5), 383–388. https://doi.org/10.1089/pop.2016.0148.
Boydell, K. M., Bullock, H., Goering, P.N. (2009). Getting our acts together: Interagency collaborations in child and youth mental health. Retrieved from https://www.excellenceforchildandyouth.ca/sites/default/files/position_integration.pdf.
Boydell, K. M., Pong, R., Volpe, T., Tilleczek, K., Wilson, E., & Lemieux, S. (2006). Family perspectives on pathways to mental health care for children and youth in rural communities. The Journal of Rural Health,22(2), 182–188. https://doi.org/10.1111/j.1748-0361.2006.00029.x.
Boyle, M. H., Duncan, L., Georgiades, K., Wang, L., Comeau, J., Ferro, M. A., … Kata, A. (2018). The 2014 Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) part II: Psychometric adequacy for categorical measurement of selected DSM-5 disorders. The Canadian Journal of Psychiatry,64(6), 434–442. https://doi.org/10.1177/0706743718808251.
Boyle, M. H., Georgiades, K., Duncan, L., Comeau, J., Wang, L., & 2014 Ontario Child Health Study Team. (2019). The 2014 Ontario Child Health Study—Methodology. The Canadian Journal of Psychiatry,64(4), 237–245. https://doi.org/10.1177/0706743719833675.
Bradshaw, J. (1972). Taxonomy of social need. In G. McLachlan (Ed.), Problems and progress in medical care: Essays on current research, 7th Series (pp. 71–82). London, UK: Oxford University Press.
Bradshaw, J. (2005). The conceptualization and measurement of need: A social policy perspective. In J. Popay & G. Williams (Eds.), Researching the people’s health (pp. 57–70). London, UK: Routledge.
Canadian Mental Health Association. (2009). Rural and northern community issues in mental health. CMHA Public Policy: Backgrounders, ed. Rural and Northern Advisory Committee. Toronto: Canadian Mental Health Association, 1–11. Retrieved from https://ontario.cmha.ca/documents/rural-and-northern-community-issues-in-mental-health/
Cornia, G. A. & Stewart, F. (1995). Two errors of targeting. In D. van de Walle & K. Nead (Eds.), Public spending and the poor: Theory and evidence. Baltimore, MD: The Johns Hopkins University Press.
DesMeules, M., Pong, R., Lagacé, C., Heng, D., Manuel, D., Pitblado, R., … Koren, I. (2006). How healthy are rural Canadians? An assessment of their health status and health determinants. Ottawa, ON: Canadian Institute for Health Information.
Duncan, C., & Jones, K. (2000). Using multilevel models to model heterogeneity: Potential and pitfalls. Geographical Analysis,32(4), 279–305. https://doi.org/10.1111/j.1538-4632.2000.tb00429.x.
Duncan, G. J., & Raudenbush, S. W. (1999). Assesing the effects of context in studies of child and youth development. Educational Psychologist,34(1), 29–41. https://doi.org/10.1207/s15326985ep3401_3.
Duncan, L., Boyle, M. H., Abelson, J., & Waddell, C. (2018a). Measuring children’s mental health in Ontario: Policy issues and prospects for change. Journal of the Canadian Academy of Child and Adolescent Psychiatry,27(2), 88–98.
Duncan, L., Georgiades, K., Birch, S., Comeau, J., Wang, L., Boyle, M. H., & 2014 Ontario Child Health Study Team. (2019). Children’s mental health need and expenditures in Ontario: Findings from the 2014 Ontario Child Health Study. The Canadian Journal of Psychiatry,64(4), 275–284. https://doi.org/10.1177/0706743719830036.
Duncan, L., Georgiades, K., Wang, L., Comeau, J., Ferro, M. A., Van Lieshout, R. J., … Boyle, M. H. (2018b). The 2014 Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) Part I: A checklist for dimensional measurement of Selected DSM-5 disorders. The Canadian Journal of Psychiatry,64(6), 423–433. https://doi.org/10.1177/0706743718808250.
Duncan, L., Georgiades, K., Wang, L., Van Lieshout, R. J., MacMillan, H. L., Ferro, M. A., … Boyle, M. H. (2018c). Psychometric evaluation of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). Psychological Assessment,30(7), 916–928. https://doi.org/10.1037/pas0000541.
Erskine, H. E., Moffitt, T. E., Copeland, W. E., Costello, E. J., Ferrari, A. J., Patton, G., … Scott, J. G. (2015). A heavy burden on young minds: The global burden of mental and substance use disorders in children and youth. Psychological Medicine,45(7), 1551–1563. https://doi.org/10.1017/s0033291714002888.
Flisher, A. J., Kramer, R. A., Grosser, R. C., Alegria, M., Bird, H. R., Bourdon, K. H., … Narrow, W. E. (1997). Correlates of unmet need for mental health services by children and adolescents. Psychological Medicine,27(5), 1145–1154. https://doi.org/10.1017/s0033291797005412.
Fulda, K. G., Johnson, K. L., Hahn, K., & Lykens, K. (2013). Do unmet needs differ geographically for children with special health care needs? Maternal and Child Health Journal,17(3), 505–511. https://doi.org/10.1007/s10995-012-1029-4.
Georgiades, K., Duncan, L., Wang, L., Comeau, J., Boyle, M. H., & 2014 Ontario Child Health Study Team. (2019). Six-month prevalence of mental disorders and service contacts among children and youth in Ontario: Evidence from the 2014 Ontario Child Health Study. The Canadian Journal of Psychiatry,64(4), 246–255. https://doi.org/10.1177/0706743719830024.
Glisson, C. (2002). The organizational context of children's mental health services. Clinical Child and Family Psychology Review,5(4), 233–253.
Government of Ontario. (2015a) Child and family services act. Revised statutes of Ontario (1990. c. C.11). Retrieved from https://www.ontario.ca/laws/statute/90c11.
Government of Ontario. (2015b). Community-based child and youth mental health—Program guidelines and requirements #01: Core services and key processes. Retrieved from https://www.children.gov.on.ca/htdocs/English/documents/specialneeds/mentalhealth/pgr1.pdf.
Hart, J. T. (1971). The inverse care law. The Lancet,297(7696), 405–412.
Holley, H. L. (1998). Geography and mental health: A review. Social Psychiatry and Psychiatric Epidemiology,33(11), 535–542.
Howell, E., & McFeeters, J. (2008). Children's mental health care: Differences by race/ethnicity in urban/rural areas. Journal of Health Care for the Poor and Underserved,19(1), 237–247. https://doi.org/10.1353/hpu.2008.0008.
Inkelas, M., Raghavan, R., Larson, K., Kuo, A. A., & Ortega, A. N. (2007). Unmet mental health need and access to services for children with special health care needs and their families. Ambulatory Pediatrics,7(6), 431–438. https://doi.org/10.1016/j.ambp.2007.08.001.
Jensen, P. S., Goldman, E., Offord, D., Costello, E. J., Friedman, R., Huff, B., … Conger, R. (2011). Overlooked and underserved:“Action signs” for identifying children with unmet mental health needs. Pediatrics,128(5), 970–979. https://doi.org/10.1542/peds.2009-0367.
Kataoka, S. H., Zhang, L., & Wells, K. B. (2002). Unmet need for mental health care among US children: Variation by ethnicity and insurance status. American Journal of Psychiatry,159(9), 1548–1555. https://doi.org/10.1176/appi.ajp.159.9.1548.
Kelleher, K. J., & Gardner, W. (2017). Out of sight, out of mind—behavioral and developmental care for rural children. New England Journal of Medicine,376(14), 1301–1303. https://doi.org/10.1056/nejmp1700713.
Khan, A. A., & Bhardwaj, S. M. (1994). Access to health care: A conceptual framework and its relevance to health care planning. Evaluation & the Health Professions,17(1), 60–76. https://doi.org/10.1177/016327879401700104.
Kreft, I. G. G. (1996). Are multilevel techniques necessary? An overview, including simulation studies. Unpublished manuscript, California State University, Los Angeles.
Law, J., & Perlman, C. (2018). Exploring geographic variation of mental health risk and service utilization of doctors and hospitals in Toronto: A shared component spatial modeling approach. International Journal of Environmental Research and Public Health,15(4), 593. https://doi.org/10.3390/ijerph15040593.
Maas, C. J., & Hox, J. J. (2005). Sufficient sample sizes for multilevel modeling. Methodology,1(3), 86–92. https://doi.org/10.1027/1614-2241.1.3.85.
Marshall, M., Crowther, R., Sledge, W. H., Rathbone, J., & Soares‐Weiser, K. (2011). Day hospital versus admission for acute psychiatric disorders: Cochrane database of systematic reviews, (12), Art. No.: CD004026. https://doi.org/10.1002/14651858.CD004026.pub2
McIntyre, D. I., Thiede, M., & Birch, S. (2009). Access as a policy-relevant concept in low-and middle-income countries. Health Economics, Policy and Law,4(2), 179–193. https://doi.org/10.1017/s1744133109004836.
McNeish, D. M., & Stapleton, L. M. (2016). The effect of small sample size on two-level model estimates: A review and illustration. Educational Psychology Review,28(2), 295–314. https://doi.org/10.1007/s10648-014-9287-x.
Mental Health Commission of Canada. (2017). Strengthening the case for investing in Canada’s mental health system: Economic considerations. National Library of Canada. Retrieved from https://www.mentalhealthcommission.ca/English/resources/mhcc-reports/case-for-investing
Mitura, V., & Bollman, R. (2004). Health status and behaviours of Canada’s youth: A rural-urban comparison. Statistics Canada, Agriculture Division. Retrieved from https://publications.gc.ca/site/eng/257736/publication.html
Nagarajan, K. V. (2004). Rural and remote community health care in Canada: Beyond the Kirby Panel Report, the Romanow Report and the federal budget of 2003. Canadian Journal of Rural Medicine,9(4), 245–251.
Philo, C. (2005). The geography of mental health: An established field? Current Opinion in Psychiatry,18(5), 585–591. https://doi.org/10.1097/01.yco.0000179502.76676.c8.
Pickett, K. E., & Pearl, M. (2001). Multilevel analyses of neighbourhood socioeconomic context and health outcomes: A critical review. Journal of Epidemiology & Community Health,55(2), 111–122. https://doi.org/10.1136/jech.55.2.111.
Pong, R. W., DesMeules, M., & Lagacé, C. (2009). Rural-urban disparities in health: How does Canada fare and how does Canada compare with Australia? Australian Journal of Rural Health,17(1), 58–64. https://doi.org/10.1111/j.1440-1584.2008.01039.x.
Racine, A. D. (2016). Child poverty and the health care system. Academic Pediatrics,16(3), S83–S89. https://doi.org/10.1016/j.acap.2015.12.002
Rasbash, J., Steele, F., Browne, W., & Prosser, B. (2004). A user’s guide to MLwiN Version 2. London, UK: Institute of Education.
Reid, G. J., Tobon, J. I., & Shanley, D. C. (2008). What is a mental health clinic? How to ask parents about help-seeking contacts within the mental health system. Administration and Policy in Mental Health and Mental Health Services Research,35(4), 241–249. https://doi.org/10.1007/s10488-008-0165-z.
Roberts, M., Hsiao, W., Berman, P., & Reich, M. (2003). Getting health reform right: A guide to improving performance and equity. Oxford, UK: Oxford University Press.
Ryvicker, M. (2018). A conceptual framework for examining healthcare access and navigation: A behavioral-ecological perspective. Social Theory & Health,16(3), 224–240. https://doi.org/10.1057/s41285-017-0053-2.
Sheehan, D. V., Sheehan, K. H., Shytle, R. D., Janavs, J., Bannon, Y., Rogers, J. E., … Wilkinson, B. (2010). Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The Journal of Clinical Psychiatry,71(3), 313–326. https://doi.org/10.4088/jcp.09m05305whi.
Stanley, J., & Lucas, K. (2008). Social exclusion: What can public transport offer? Research in Transportation Economics,22(1), 36–40. https://doi.org/10.1016/j.retrec.2008.05.009.
Statistics Canada. (2015). Census division (Census Dictionary). Ottawa (ON) Catalogue no. 98–301-X2011001. Retrieved from https://www12.statcan.gc.ca/census-recensement/2011/ref/dict/geo008-eng.cfm
Statistics Canada. (2017a). 2014 Ontario Child Health Study (Master File) (p. 3824). Survey No: Statistics Canada.
Statistics Canada. (2017b). Microdata User Guide 2014 Ontario Child Health Study. Ottawa (ON): Special Surveys Division.
Statistics Canada. (2018). Census profile, 2016 census. Statistics Canada. Catalogue no. 98–316-X2016001
Sturm, R., Ringel, J. S., & Andreyeva, T. (2003). Geographic disparities in children’s mental health care. Pediatrics,112(4), e308–e308. https://doi.org/10.1542/peds.112.4.e308.
Waddell, C., Schwartz, C., & Andres, C. (2017). Making children’s mental health a public policy priority: For the one and the many. Public Health Ethics,11(2), 191–200. https://doi.org/10.1093/phe/phx018.
Waddell, C., Shepherd, C., Schwartz, C., & Barican, J. (2014). Child and youth mental disorders: Prevalence and evidence-based interventions. Vancouver, BC: Children’s Health Policy Centre, Simon Fraser University.
Watt, G. (2002). The inverse care law today. The Lancet,360(9328), 252–254. https://doi.org/10.1016/s0140-6736(02)09466-7.
Weich, S., Twigg, L., Holt, G., Lewis, G., & Jones, K. (2003). Contextual risk factors for the common mental disorders in Britain: A multilevel investigation of the effects of place. Journal of Epidemiology & Community Health,57(8), 616–621. https://doi.org/10.1136/jech.57.8.616.
Wichstrøm, L., Belsky, J., & Jozefiak, T. (2014). Predicting service use for mental health problems among young children. Pediatrics,133(6), 2013–3184. https://doi.org/10.1542/peds.2013-3184d.
Wikipedia Contributors. (2019). Northern Ontario. In Wikipedia, The Free Encyclopedia. Retrieved from https://en.wikipedia.org/w/index.php?title=Northern_Ontario&oldid=919663896
Wilson, W. J. (2012). The truly disadvantaged: The inner city, the underclass, and public policy. Chicago, IL: University of Chicago Press.
World Health Organization. (2000). The world health report 2000: Health systems: Improving performance. Public Health Reports,116(3), 268–269. https://doi.org/10.1016/s0033-3549(04)50043-2.
The authors would like to thank the Ontario Ministry of Children, Community and Social Services (formerly the Ministry of Children and Youth Services) for providing administrative data used in the analysis.
The 2014 Ontario Child Health Study was funded by research operating grant 125941 from the Canadian Institutes of Health Research (CIHR), Health Services Research Grant 8-42298 from the Ontario Ministry of Health and Long-Term Care (MOHLTC) and from funding from MOHLTC, the Ontario Ministry of Children and Youth Services and the Ontario Ministry of Education. Dr. Boyle was supported by CIHR Canada Research Chair in the Social Determinants of Child Health, Dr. Georgiades by the David R. (Dan) Offord Chair in Child Studies and Dr. Reid by the Children’s Health Foundation.
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee (Hamilton Integrated Research Ethics Board 13-140), Statistics Canada’s Statistics Act and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study.
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Duncan, L., Georgiades, K., Reid, G.J. et al. Area-Level Variation in Children’s Unmet Need for Community-Based Mental Health Services: Findings from the 2014 Ontario Child Health Study. Adm Policy Ment Health 47, 665–679 (2020). https://doi.org/10.1007/s10488-020-01016-3
- Mental health
- Children and youth
- Unmet need
- Multilevel modelling
- Area-level variation