The Impact of COVID-19 on Rural and Remote Mental Health and Substance Use

Impact of the Pandemic on Rural/Remote Mental Health and
Substance Use. Overview of developing issues and unique challenges.

Our new policy brief examines the pandemic’s distinct impact on mental health and substance use in rural and remote communities, which is brought to life through a case study from the community of Princeton, British Columbia.

COVID-19’s continuing impact on mental health and substance use has shed new light on the growing need and decreasing access to adequate services and supports for people in rural and remote communities. Health equity issues, the unique context, and influence of the social determinants of health are making these individuals even more vulnerable to the pandemic’s effects.

Although governments have quickly pivoted to provide innovative virtual services, challenges across the mental health system remain, and rural and remote communities still lack access to timely and appropriate services.

Given the pandemic’s expected long-lasting effects on mental health and substance use, the post-pandemic period will be critical.

The policy brief — The Impact of COVID-19 on Rural and Remote Mental Health and Substance Use — contributes to the ongoing collaborative efforts to transform the system and address the unique impacts of COVID-19 for mental health and substance use of people living in rural and remote communities. In making new policy recommendations, it draws on a case study as well as some of the practical approaches and best practices developed domestically and internationally.



This policy brief provides an overview of the developing issues and unique mental health and substance use challenges that COVID-19 poses for rural and remote communities. It builds on a preliminary scan the Mental Health Commission of Canada (MHCC) completed at the outset of the pandemic and on an evidence brief on best and promising practices written just before it began. The current brief includes an updated literature review, a section on diverse populations and social determinants of health, domestic and international policy responses, and policy recommendations. Also included is a case study that highlights the British Columbia (B.C.) community of Princeton, in collaboration with the Princeton Community Health Table. Its primary audience comprises policy makers and organizations across the mental health and substance use sectors that serve rural and remote communities.

Key messages

  • The COVID-19 pandemic continues to have a substantial impact on the mental health and substance use needs in rural and remote communities and on a growing lack of access to adequate and timely services and supports.
  • The unique context, the influence of the social determinants of health, and health equity considerations play major roles in how COVID-19 affects these communities in terms of mental health and substance use.
  • Provinces and territories pivoted quickly to provide innovative virtual mental health and substance use services. However, the lack of access to broadband internet coverage and information and communication technology (ICT) make it harder for people living in rural and remote communities to access services and supports.
  • The pandemic has been a challenge on the resources, capacity, and solidarity of rural and remote communities but has reinforced the importance of resilience.
  • Given the pandemic’s expected long-lasting effects on mental health and substance use, the post-pandemic period will be critical. It will also be an opportunity to transform the system and address unique impacts for people living in rural and remote communities.

Click here to: DOWNLOAD THE PDF



The Mental Health Commission of Canada (MHCC) operates primarily on the unceded traditional territory of the Anishinabe Algonquin Nation, whose presence here reaches back to time immemorial. The Algonquin people have lived on this land as keepers and defenders of the Ottawa River watershed and its tributaries. We are privileged to benefit from their long history of welcoming many nations to this beautiful territory. We also recognize the traditional lands across what is known as Canada, on which our staff and stakeholders reside.

Our policy research work uses an intersectional sex- and gender-based plus lens to identify, articulate, and address health and social inequities through policy action. In this respect, it is guided by engagement with diverse lived experiences (and other forms of expertise) that shape our knowledge syntheses and policy recommendations. We are committed to continuous learning, and we welcome feedback.

The MHCC would like to thank the Princeton Community Health Table and our other partners, external reviewers, and staff for their important and valued contributions to this work.


Nelly D. Oelke, PhD, RN, Associate Professor, University of British Columbia school of nursing, Okanagan Lauren Airth, MSN, RN, University of British Columbia school of nursing, Okanagan

Expert reviewers

Carolyn Szostak, PhD, Associate Professor, University of British Columbia department of psychology, Okanagan

Rebecca Jesseman, MA, Policy Director, Canadian Centre on Substance Use and Addiction

Matthew Young, PhD, Senior Research and Policy Analyst, Canadian Centre on Substance Use and Addiction

Denika Ward, Community Suicide Prevention Coordinator, Roots of Hope Project — Eastern Health

Tanya Wilson, Senior Health Consultant, New Brunswick Department of Health, on behalf of the Roots of Hope New Brunswick team: Dr. Jalila Jbilou, coordinator Celine Fortin, Serge Robichaud, and Dominic Bourgoin.

MHCC staff

Katerina Kalenteridis, Francine Knoops, Dr. Mary Bartram

Case Study: Princeton Community Health Table

Description of the community

Princeton is a beautiful town, situated in the Similkameen Valley and surrounded by mountains, as seen in the pictures below. Among the 4,780 people who live there, the majority are 50 and older. Over 10 per cent of the population identifies as Indigenous. While the mean income is $57,000, eight in 10 residents fall below the poverty line. Mental health and substance use have both been identified as significant concerns. The rates of anxiety, mood disorders, and depression are eight times as high as those in the rest of the province, and like many rural communities in B.C., the community suffers disproportionately from the toxic drug crisis and consistently has one of the highest drug-related death rates per capita.53 Over the past year, these high rates of mental health and substance use have been further exacerbated by the COVID-19 pandemic.

Like other rural communities, Princeton has more limited resources for addressing mental health and substance use concerns than urban settings. Currently, it has one mental health and substance use counsellor, one mental health adult psychiatric nurse, one youth mental health worker, and one outreach worker (shared with another town about 45 minutes away). These limits make it difficult for the community to provide services and supports that are adequate for the population’s needs. Another concern is the ability to retain staff, which is common in rural settings.

Despite these challenges Princeton has many strengths, which include the high level of resilience common to rural communities and the many people and organizations who work together to address the needs of community members. One such initiative is the Princeton Community Health Table (PCHT).

Development of the PCHT

The PCHT was formed in June 2020 as part of the BC Rural and First Nations Health and Wellness Summit, sponsored by the Rural Coordination Centre of BC and the First Nations Health Authority. At the summit, partners came together to discuss and plan for health services delivery in Princeton and surrounding areas. The PCHT identified mental health and substance use as priorities for the health and wellness of the community. The group began with eight members representing various partner groups, including community members, providers, policy makers, and academic partners. It decided to continue to meet after the summit to plan, develop, and implement various community- based activities to promote mental health and well-being. The final makeup of the group provided a strong representation of community members who could lead this grassroots initiative to improve services and supports for the community at large.

Today, PCHT membership includes 14 people representing several organizations:

  • Support Our Health Care
  • Princeton and District Community Services Society
  • Princeton Family Services Society
  • Vermillion Forks Métis Association
  • Okanagan Regional Library
  • School District 58
  • Princeton Secondary School
  • Vermillion Forks and John Allison Elementary schools
  • Town of Princeton
  • Princeton Regional Hospital
  • Princeton RCMP Victim Services
  • Princeton Community Support
  • Upper Similkameen Indian Band
  • University of British Columbia, Okanagan The PCHT meets every four to six weeks.

    Goals of the PCHT
  1. Develop a community-driven package of mental health/substance use improvements.
  2. Study the implementation of specific enhancements to mental health/substance use service accessibility.
  3. Evaluate the outcomes attributed to the implementation of mental health/substance use service advancements.
  4. Sustain progress via new partnerships and existing community partnerships.
  5. Develop a transferable and adaptable model for implementing improved mental health/substance use services in rural and remote B.C. communities.

Current PCHT activities

1. Increasing awareness of mental health and substance use and the available services and supports:

  • two brochures (adults and youth) that include information about local and provincial resources
  • education sessions for students in the Princeton Secondary Highs Schoo
  • Princeton Secondary School forum with speaker
  • virtual public forum on Breaking the Stigma

2. Providing services and supports:

• Working in partnership with the South Okanagan Women in Need Society, a Penticton- based agency that comes to Princeton one day each week to provide drug-testing resources and harm reduction information. Also offered is a pop-up table for health information (inclulding COVID) and basic wound care, along with other harm reduction materials.

Successes and challenges

As the PCHT continues to work toward its goals, one significant success is the enthusiasm and commitment provided by its individual and organizational representatives and the new partnerships being developed. A second success has been a practicum with two fourth-year nursing students in Princeton, supported by the school of nursing at the University of British Columbia, Okanagan. These students worked half their hours with the PCHT in the community and the other half in the local hospital, contributing to various PCHT activities (e.g., the two brochures, education materials for secondary school students). Also, by connecting what was happening in acute care with what was occurring in the community, the students were able to see the importance of prevention and early intervention as a way to better serve those who live with mental health and substance use needs. A third PCHT success has been the strong partnership with the secondary school in Princeton, which enabled it to deliver education and awareness for the students. Having a student PCHT member has been key to facilitating this connection.

Alongside these successes, two main challenges remain. One is developing a strong connection, both with organizations that deliver harm reduction services and the individuals who use or may need them. The PCHT continues to build partnerships with additional organizations to explore further services and supports for this population. Funding is also a major challenge. While the PCHT has applied for numerous community-based and research funding opportunities, apart from some funding for the printing of brochures, it has had minimal success to date.


The PCHT has brought together a grassroots group of individuals and community organizations that have prioritized the mental health and substance used needs in their community. It includes a broad representation of partners who are working together to address these areas, which is particularly important in the pandemic context. Following some early successes, the PCHT continues to work on various activities and approaches to address the needs of community members. Despite some current challenges, the PCHT’s commitment to improving the mental health and well-being of the Princeton community continues to be at the forefront of its work.

Peer Support Worker Training for Rural Residents

We would like to share with you a new upcoming peer support program hosted by a partner organization of ours called the Stigma-Free Society. The Society is a registered Canadian Charity located in Vancouver, B.C. since 2010 and aims to reduce stigma of all kinds with a focus on mental health.  

This November 2021, the Stigma-Free Society is holding their second online Peer Support Worker Training Session for rural residents with a generous grant from Pacific Blue Cross – BC.

Peer Support Worker Training Information:  

  • 2-day course: Nov. 1st & 8th (8 am-4 pm PDT) and (10 am-6 pm CDT) and (11 am-7 pm EDT) (with breaks) 
  • Training is free of cost with a $50 deposit required to secure your spot. The deposit will be refunded once you attend the session unless you choose to donate the $50 to the Stigma-Free Society. Donations are always welcome. If you do not attend, there is no refund of the deposit. (Peer Support Training is originally valued at $375) 
  • Participants will gain an understanding of peer support fundamentals and how to apply them effectively when supporting peers and gain valuable knowledge to effectively communicate and share personal experiences to enhance interactions as peer supporters and group facilitators.

For more information and to register, please go HERE or email 

Thank you so much in advance and please register today as spots fill up quickly.


Interested in becoming a Nav-CARE hub?

With a contribution from Health Canada, we are inviting hospice palliative care organizations to apply for 2-year funding ($30,000 per year) to implement Nav-CARE in their site and to support implementation in additional hospice palliative care sites.  

Hub Responsibilities 

The Nav-CARE project team will provide: 

  • Access to the entire Nav-CARE toolkit, including the online volunteer training platform 
  • Monthly ‘Hub Huddles’ to discuss emergent issues 
  • Monthly volunteer training reports specific to your Hub over the 2-year period 
  • Profiling your Hub in our knowledge products 

Visit our home page for background on the Nav-CARE program

How to apply?

Please download and complete the following application and submit to Dr. Gloria Puurveen ApplicationDownloadChecklist Download

Application Timeline

  • Request for proposal: October 1, 2021 
  • Deadline for proposal submission: March 1, 2022 
  • Notice of decision: March 31, 2022
  • Implementation start date: June 1, 2022  

Are you eligible?

To determine whether your organization would be eligible to become a Nav-CARE Hub, please refer to the following materials: 

1. Implementation manual: this manual walks you through 5 key questions to consider prior to implementing the Nav-CARE program; Nav-CARE Implementation ManualDownload

2. Implementation video: this 2-minute video gives you an overview of the implementation manual;

3) The RFP video: this 7-minute video introduces the Nav-CARE program and the RFP process;

4) Frequently asked questions: FAQ.PdfDownload

For more information, please contact Dr. Gloria Puurveen  

Leaving No One Behind in Long-Term Care: Enhancing Socio-Demographic Data Collection in Long-Term Care Settings

Socio-demographic data is an important tool for measuring and reducing health disparities
among people across different population groups and from different backgrounds.
Evidence from Canadian literature clearly demonstrates that health outcomes differ based on social and demographic factors such as sexual orientation, gender identity, language, race, immigration status, and ethnicity, as well as access to affordable housing, adequate income, social inclusion and other factors. While limited, current research findings shed light on some of the existing inequities in Canadian long-term care settings, highlighting the importance of
collecting and analyzing socio-demographic data, as well as the need for better data collection on diverse population groups living in long-term care settings. This report makes clear that without taking steps to enhance the collection of socio-demographic data in long-term care settings, the needs of  Canadians living in long-term care settings will continue to be misunderstood and preventable inequities in care and outcomes will persist. 

Canada continues to lag behind other countries (e.g., United Kingdom, Australia, United States) in collecting population-based socio-demographic data—such as ethnicity, race, gender identity, and sexual orientation. There are, however, several sources of data which provide insight into Canada’s older adult population, as well as the portion of the Canadian population currently residing in long-term care settings. These include: Canadian Institute for Health Information’s CIHI) Continuing Care Reporting System (CCRS) and Statistics Canada’s Census of the Population, Canadian Community Health Survey, and Nursing and Residential Care Facility Survey. However, CIHI acknowledges that the CCRS, along with other CIHI and Statistics Canada health data repositories, fail to capture the information that can be effectively used to identify health inequities among people living and working in Canadian long-term care homes. By addressing this lack of socio-demographic data, we will begin to build a better understanding of the diverse populations living in long-term care settings, which will enable us to develop more targeted interventions to effectively address any existing health disparities. This report highlights that reliably collecting in-depth socio-demographic data across Canada would enable better policy and planning processes to address known gaps in care options for Canadians of all backgrounds.

How can rural community-engaged health services planning achieve sustainable healthcare system changes?

Campbell Stuart Johnston,  Erika Belanger, Krystal Wong, David Snadden
Correspondence to Dr David Snadden

Published: October 14, 2021

Excerpts from the Abstract

Objectives The objectives of the Rural Site Visit Project (SV Project) were to develop a successful model for engaging all 201 communities in rural British Columbia, Canada, build relationships and gather data about community healthcare issues to help modify existing rural healthcare programs and inform government rural healthcare policy.

Setting  The 107 communities visited thus far have healthcare services that range from hospitals with surgical programs to remote communities with no medical services at all. The majority have access to local primary care.

Primary and secondary outcome measures A successful process was developed to engage rural communities in identifying their healthcare priorities, while simultaneously building and strengthening relationships. The qualitative data were analysed from 185 meetings in 80 communities and shared with policy makers at governmental and community levels.

Results 36 themes have been identified and three overarching themes that interconnect all the interviews, namely Relationships, Autonomy and Change Over Time, are discussed.

Conclusion The SV Project appears to be unique in that it is physician led, prioritises relationships, engages all of the healthcare partners singly and jointly in each community, is ongoing, provides feedback to both the policy makers and all interviewees on a 6-monthly basis and, by virtue of its large scope, has the ability to produce interim reports that have helped inform system change.

Excerpts from the Introduction – without footnotes.

British Columba (BC), Canada, has a population of approximately 5 million. About 14% (631 776) are rural citizens distributed unevenly over an area of 944 738 km2. BC is geographically diverse with a broken 27 000 km coastline and extensive mountain ranges that make for long and often dangerous travel, complicated at times by wildfires, floods, avalanches and harsh winter conditions. Access to healthcare services for rural citizens is often limited by the expansive geography, provider availability and transportation issues.

Support programmes for rural physicians in BC are overseen by the Joint Standing Committee on Rural Issues (JSC), a committee comprised of equal numbers of provincial Ministry of Health representatives and rural physicians. The JSC manages approximately C$150M (2020) of funding annually for programmes and projects that improve healthcare delivery in rural BC (JSC Programme Booklet). Some of this work is delivered by the Rural Coordination Centre of BC (RCCbc), which is funded by the JSC to coordinate and improve rural healthcare throughout the province. The RCCbc is a networked organisation that includes many rural physicians and a small number of rural health professionals in its network.

The Rural Site Visits Project (SV Project) was initiated in 2017 by rural physicians with a proposal to the JSC who tasked the RCCbc with visiting 201 rural and Indigenous BC communities identified as eligible for rural benefits under the Rural Practice Subsidiary Agreement (RSA). The RSA is an agreement between the Government of BC and the Doctors of BC (a professional organisation that represents 14 000 physicians, medical residents and medical students in BC).

The purpose of the SV Project was to build relationships between rural physicians, healthcare providers, health administrators, municipal leadership, First Nations leadership, first responders, academia and policy makers through listening and gathering data systematically about local successes, innovations and challenges relating to rural healthcare delivery. These data are guiding the development of JSC programmes and informing government Rural Health Care policy.

In 1978, the declaration of the Alma-Ata International Conference on Primary Health Care stated that: ‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’.  Current trends in rural health services, however, aim to reduce infrastructure and support to achieve greater efficiencies through centralization of services.  Small rural communities have had to be proactive in securing local health services to resist this development,requiring improved relationships and communication between the policy makers and communities.

Community participation has been seen as a more complete approach to health development leading to culturally and contextually appropriate decisions being made about rural health services. Relationship building between stakeholders is also seen as more effective than attempting to provide a myriad of healthcare services, especially as each rural community is unique and ‘one size fits all’ approaches are largely ineffective. While there have been efforts by health service policy makers to align their actions with rural communities’ expressed priorities,the processes used for community engagement have received less attention and descriptions seldom include adequate documentation of the processes involved.

The community engagement literature does not show examples of rural health projects initiated and led by physicians, even though physicians have been key partners in other research on rural community-engaged health services planning.Much of the research on community engagement in rural health service planning has had a specific focus, for example, in improving immunisation programmes in Nigeria or chronic disease care in the Torres Strait Islands. There are some examples of research focused on community participation for broader primary care reform, for example, in the Northern Health Authority region of BC and the Remote Service Futures (RSF) Project in Scotland. The former has resulted in some sustained changes to date, for example the establishment of Primary Care Nurses, improved antenatal care and regional palliative care services. 

When the RSF outcomes were reviewed in 2014: ‘Only one direct sustained service change was found’. These raise the question of how best to achieve sustainable beneficial rural health system changes using community engagement processes. The project described here attempts to address this issue. Due to the complex nature of this initiative, it is presented in this article as two components. First, the process of engagement in terms of how communities were engaged and how information was shared with them after the visits. Second, as the data gathering and engagement process are entwined, information on the research methods and broad early results are included to provide a context for future more detailed publications arising from the data.

To access the full report, click on: How can rural community-engaged health services planning achieve sustainable healthcare system changes?


Continuity in Primary Care is Linked to Mortality

Dawn O’Shea, August 12, 2020

A systematic review published in the British Journal of General Practice (BJGP) provides evidence of the links between reduced mortality rates and continuity of primary care.

In the primary-care focused study, authors from the University of Leicester, Imperial College London and McGill University in Montreal, examined 13 quantitative studies that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality.

A statistically significant protective effect of greater care continuity was found in nine, absent in two and in one, effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality.

Improved clinical responsibility, physician knowledge and patient trust were suggested as causative mechanisms, although these were not investigated.

In a second study published in the same issue of the BJGP, a thematic analysis was carried out based on secondary analysis of interviews with 25 patients with long-term conditions.

Patients said they believed that relational continuity facilitates a GP knowing their history, giving consistent advice, taking responsibility and action and trusting and respecting them.

Patients acknowledged practical difficulties and safety issues in achieving the first three of these without relational continuity.

However, they felt that GPs should trust and respect them even when continuity was not possible.

The studies provide further evidence of the benefit of continuity of care in the primary care setting.

Murphy M, Salisbury C. Relational continuity and patients’ perception of GP trust and respect: a qualitative study. Br J Gen Pract. 2020 Aug 11 [Epub ahead of print]. doi: 10.3399/bjgp20X712349.

Baker R, Freeman JK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract. 2020 Aug 11 [Epub ahead of print]. doi: 10.3399/bjgp20X712289.  Abstract.

This article originally appeared on Univadis, part of the Medscape Professional Network.


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Health Standards Organization (HSO)

Engage with Us

Find out how you can keep engaged and contribute to HSO’s National Long-Term Care Services Standard.

Throughout the development of HSO’s National Long-Term Care Services Standard we are committed to hearing the voices of all – through our successful inaugural National Survey that garnered more than 16,000 responses, our Consultation Workbooks, and Town Halls.

We are on a mission to capture the diverse perspectives of residents, families, health service providers, clinicians and policymakers from across Canada on the needs and gaps in long-term care services — including the voices of First Nations, Inuit and Métis peoples and vulnerable populations.


We are pleased to have received more than 16,000 responses to our Developing National LTC Services Standards: Your Opinion Matters! Survey. The survey insights are helping the LTC Services Technical Committee understand the themes that are important to Canadians when it comes to defining the type of care and services Canadians want to see provided in their long-term care homes. Read our What We Heard Report #1: Findings from HSO’s Inaugural National Survey on Long-Term Care to learn more.

We Want to Hear From You

Complete a Consultation Workbook or Host a Roundtable with a Group 

Our Consultation Workbooks have been developed to ensure Canadians have a clear voice in the development of HSO’s new National Long-Term Care Services Standard.

Our Consultation Workbooks can be completed by anyone who is interested in providing their input on improving the delivery of long-term care in Canada, whether you are a long-term care resident, family member, health care provider, researcher or anyone else.