Substance use has always been a significant health care problem that exists on many multifaceted levels of our system and contributes to billions per year in costs. However, research indicates that since the start of the pandemic of COVID-19, there has been an exponential increase in use. The pandemic has presented many endured hardships, including the challenges many and magnifies as public health measures have intensified to limit transmission throughout our vulnerable populations. The potential increased use of substances, alcohol specifically, has individual impacts and ones reaching entire populations. The Canadian Center on Substance Use and Addiction (CCSA, 2020) summary report estimate that over 20% of Canadians over 18 years of age say they have increased the amount of alcohol they drink while spending more time at home during the COVID-19 pandemic. The concern is the trajectory from an individual who uses substances casually with progression to problematic substance use, leading to dependence (Canadian Mental Health Association [CMHA], 2021). Problematic use is when a person uses a substance in a harmful way and negatively impacts their health and life (Government of Canada, 2019) and is often associated with physical, psychological, economic or social problems. Problematic use could lead to chronic addiction when patterns of substance use or behaviors interfere with a person's life and can lead to physical and psychological dependence, which can disrupt the person's ability to maintain a healthy life (CMHA, 2021).
Figure 1
Spectrum of Substance Use
People may choose to consume alcohol as a coping response to life's circumstances. Although this may bring temporary relief, they are generally known to have unhealthy long-term effects that could lead to other chronic mental and physical health problems (Center for Disease Control and Prevention [CDC], 2016). The World Health Organization (WHO, 2021) suggests avoiding or limiting the use of alcohol and drugs to deal with fear, anxiety, boredom, and social isolation to protect our mental health throughout the COVID-19 pandemic.
Infographic 1
The Alcohol Harm Paradox
Understanding the circumstances and the reasons that can lead to substance use is crucial in strategizing supportive and effective interventions to minimize risk and harm when problematic use occurs to prevent dependence. When faced with developing or initiating a public health or health promotion program, a theory or model can explain more effective ways to influence change through understanding the circumstances or behavioral context associated with the problem (Glanz & Bishop, 2010).
SEM (Socio-ecological Model)
The introduction of this first multilevel health approach occurred in the 1970s by Bronfenbrenner (Kilanowski, 2017). Illustration of the initial approach included nesting circles that placed the individual in the center surrounded by various other systems and showed embeddedness of how "health is affected by the interaction between the characteristics of the individual, the community, and the environment that included the physical, social and political components" (Kilanowski, 2017., p. 295).
The CDC (2021) has adapted Bronfenbrenner's Socio-Ecological Model (SEM) for various health promotion endeavors, including the four-level model below developed for violence and prevention, which considers the complex interplay between the layers (CDC, 2021). The SEM adds to the concept that health is not influenced by one's personal health choices but by the more extensive societal system and experiences within that system (Golden & Earp, 2012).
Figure 2
The Socio-Ecological Model: A Framework for Prevention
I have chosen to use this model to explain problematic alcohol use and dependence as a public health concern. As the pandemic prevails, it is essential to guide successful development programs to understand the various factors contributing to alcohol consumption. Sudhinaraset et al., (2016) article reveals some of the cultural and societal influences on alcohol use with the contexts and environments where people live and interact. The use of alcohol can be linked to a complex array of factors ranging from an individual level, from within their home, work, and school environment to ultimately within their larger community at a population level (Berkman et al., 2000; Krieger, 2001; Link & Phelan, 1995., as cited in Sudhinaraset et al., 2016).
Individual
This first level identifies biological and personal history factors that increase the likelihood of someone using alcohol. Some of these factors may include age, education, income, history of substance use (WHO, 2010) and are usually strong indicators of health behaviors and outcomes (Sudhinaraset et al., 2016). A knowledge synthesis report for the Canadian Institute of Health Research informs that people with a higher level of anxiety and loneliness, along with feelings of depression, were most likely to increase their alcohol use (Shield et al., 2020). Changes in alcohol use were also substantially associated with age, household income, living situation, and employment status changes (Shield et al., 2021), and studies have shown an increase with being at home, lack of routine, and negative coping styles (Gonçalves et al., 2020). The Centre for Addictions and Mental Health (CAMH, 2020) reports concerns of individual stress levels almost double since the start of the COVID-19 pandemic.
Understanding why the individual continues to use and prevent substantial harm promotes more effective and healthier coping behaviors and provides a strong knowledge base on the magnitude and determinants of alcohol-related harm and effective interventions to reduce usage (WHO, 2010). Support for this can be through access to health checkups that support behavior stages of change, holistic approaches to treatment and withdrawal management or diagnostics for short and long-term implications with appropriate referrals to community programs (CCSA, 2017). Also, providing education and awareness to the individual regarding harm reduction and minimizing health risks such as low-risk alcohol drinking guidelines is important (CCSA, 2018) or a mobile application for those who want to quit drinking alcohol which can track and habits (CAMH Education, 2014). Specific approaches may include employee assistance programs, life skills training, social-emotional learning, healthy behaviors, and coping skill programs. It is important to consider that undertaking initial behavior changes and, even more so, maintaining behavior change require different strategies (Glanz & Bishop, 2010).
Brochure
Canada's Low-Risk Alcohol Drinking Guidelines
Video 1
Saying When: How to Quit Drinking or Cutting Down
Relationship
The second level examines close relationships that may increase the risk of alcohol use. A person's closest friends, partners, and family members influence their behavior and contribute to their life experience. Sudhinaraset et al. (2016) suggest that some of the strongest influences on drinking behavior come from peers and family support and bonding associated with lower alcohol use. Some substantial harm related to alcohol use may include neglect of children or household responsibilities and intrapersonal problems such as arguing with family members or losing meaningful friendships (American Addiction Centers, n.d.-b.). Relationships may have had difficulties pre-pandemic and now possibly more because of implementing guidelines to reduce spread, such as working and schooling from home. Strategies may include family-focused prevention and strengthening programs such as partner therapy and individual counselling for family members.
Community
The third level examines the settings such as schools, workplaces, and neighborhoods. Social settings occur and seek to identify the characteristics of those settings associated with the behavior (CDC, 2021). The literature on alcohol and community influences describes an increase in use, often depending on neighborhood characteristics and opportunity for purchasing and consumption. In a poorly built neighborhood, 150% are more likely to report heavier drinking than those living in a better-built environment (Bernstein et al., 2007., as cited in Sudhinaraset et al., 2016). Rapheal et al., (2020) reports people who experience high levels of stress often attempt to relieve these pressures by adopting unhealthy coping behaviors such as excessive use of alcohol. When a community lacks focus on problems, it may make behavior change more difficult. Even when individuals are highly motivated, their environment and their perception of their environment may constrain their positive behavior changes (Glanz and Bishop, 2010). The American Addictions Center strongly suggests community ownership of addiction and quotes a familiar saying, "every addict impacts six other people in their addiction" (n.d.-a., para. 2) and believes that recovery is possible through community connections.
Strategies at the community level focus on providing education and creating awareness through various health promotion strategies to reduce the stigma about alcohol use and addictions. Often the individual is resistant to seek support due to stigma and places sole responsibility on the individual (American Addiction Centers, n.d.-a.). Other strategies may include improving the physical and social environment and addressing other social determinants of health such as neighborhood poverty, unemployment rates, and job loss due to the pandemic and examining if there is a high density of alcohol venues within a community. It is also essential to re-evaluate substance use disorder and harm reduction services availability or other disrupted community programs. Specific strategies may include peer mentoring and support groups, family support groups, school guidance counsellors, spiritual or cultural leaders (CCSA, 2017).
Societal
The fourth level is the most outer ring of this model or, as I like to refer to as the upstream approach that consists of broad societal factors that help shape all other downstream layers. In regards to alcohol use, this layer could help create an environment in which alcohol use is encouraged or inhibited. I believe that interventions at the societal level that address people's social determinants change their context to help make healthier choices. The WHO (2010) emphasizes the importance of strengthening partnerships and better coordination amongst stakeholders, and increased mobilization of resources required for appropriate action to prevent alcohol use.
Advocacy for prevention strategies at a local and national level should include decision-making regarding implementing alcohol policies with health ministries such as alcohol marketing, pricing and availability (Public Health Ontario [PHO], 2016; WHO, 2010; CDC, 2016). Hobin & Smith (2020) emphasize the delicate decision regarding liquor retailers remaining open during the pandemic. Although considered an essential service, this may pose new risks and unintentionally send the message that alcohol is essential and encourage consumption (Hobin & Smith, 2020). Furthermore, the CDC (2016) suggests strong evidence that increasing alcohol price effectively reduces excessive consumption and related harms such as motor vehicle accidents, hospitalization, and chronic illnesses. Other strategies but not limited to include impaired driving policies and countermeasures, regulation of alcohol strength and the number of on-premise and off-premise outlets, and availability of shelters for intoxicated people (WHO, 2010). Broader strategies could focus on other social determinants of health known to create stress and unhealthy means of coping, such as substance abuse such as income, housing, employment, early childhood development, and education (Raphael et al., 2020).
Table 1
Date created: March 2021
Conclusion
The impact of substance and alcohol use involves many intricate layers that intertwine from an individual problem to those much larger at a societal level. Through my research and application of the SEM, it is evident that alcohol use has also been a problem historically with other mass events and is not a new public health concern. However, dependence has increased as many people cope with the hardships endured due to our current pandemic. There will likely be long-term health impacts for many years to follow as people learn to manage their lives in this unprecedented time. It is essential to understand that changing one's behavior is not merely as easy as informing them of their risks. It takes a deeper understanding of the relational, communal, and upstream societal context that helps shape individual lives to develop comprehensive and supportive strategies. It is not too late to acknowledge the problems that are exacerbated by the pandemic and address the urgent need to implement strategies to minimize the harm associated with increased alcohol use and dependence.
References
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