Abstract
Current Latinx college students seek mental health treatment at much lower rates compared to the general student population. This is particularly concerning, as these rates have remained stubbornly low, even as the COVID-19 pandemic exacerbated existing sources of anxiety. Thus, university officials and mental health practitioners across the country have emphasized the need for interventions encouraging these students to utilize campus mental health resources. However, additional research is needed to form a foundation of knowledge for help seeking interventions. This investigation applies the theory of planned behavior to understand Latinx students’ help-seeking perspectives. Findings revealed that Latinx students viewed campus mental health resources as lacking value for them. Additionally, cultural norms established by family members represented a barrier to help seeking. Finally, Latinx students faced steep challenges navigating US health care systems and felt that mental health resources were not designed to serve minorities. This key insight can guide mental health help-seeking interventions.
Keywords
Mental health disorders have been shown to generate cascading effects—ripples of negative outcomes impacting various areas of life. In 2020, the unemployment rate among American adults with a mental illness was higher than those who did not (6.4% and 5.1%, respectively; Substance Abuse and Mental Health Services Administration [SAMHSA], 2022). Also in 2020, 32.1% of American adults suffering from mental illness simultaneously experienced a substance use disorder (SAMHSA, 2021). In addition, individuals with serious mental illnesses, compared to the general population, are almost twice as likely to develop metabolic and cardiovascular diseases (Firth et al., 2019). These issues also impact the economy; serious mental illness in the United States causes nearly $200 billion in lost earnings each year (Kessler et al., 2008). Against this backdrop, scholars, community leaders, and citizens across the United States have called for interventions to improve mental health (Abrams, 2022; Harris et al., 2022; World Health Organization, 2022).
The Role of College Campuses
To that end, experts have emphasized that, for multiple reasons, college campuses represent strategic settings for interventions in mental health. First, approximately 75% of all lifetime mental health disorders begin by age 24 (National Alliance on Mental Illness, 2021). Additionally, college campuses often offer a variety of mental health resources for students. In particular, nearly half of US campuses have adopted the stepped care model, in which the counseling center provides a menu of resource options (Gorman et al., 2021). In an article published by the National Institutes of Health, Harris et al. (2022) cited the suite of stepped care services at the State University of New York (SUNY) campus system as a model for diversified on-campus mental health offerings. The authors noted that services were expanded during the COVID-19 pandemic.
SUNY (1) partnered with Thriving Campus, a mobile-friendly app, to connect students to a network of over 6000 licensed mental health providers to break down help-seeking barriers; (2) added an additional tele-counseling hub; (3) expanded the University at Albany’s Middle Earth peer-to-peer assistance hotline to all students across the 64-campus system; (4) launched a public awareness campaign to reduce stigma, increase knowledge of available services, and promote help-seeking; (5) partnered with the New York State College Health Association and the Suicide Prevention Center of New York to host a virtual suicide prevention symposium “Mental Health in the Changing Higher Education Landscape,” free of charge to all students, faculty, and staff, which attracted over 520 participants; (6) made Question, Persuade, Refer (QPR) suicide prevention training free-of-charge; and (7) is promoting and tracking the use of Crisis Text Line.
Of course, the breadth of services varies by campus (AUCCCD, 2021). However, nationwide trends indicate that colleges are addressing this issue with a renewed focus (Buizza et al., 2022). This is significant given that nearly half of Americans between the ages of 18 and 24 enroll in a postsecondary institution (National Center for Education Statistics, 2022).
Accordingly, a broad range of research has focused on college students and their mental health help-seeking behavior, with resultant data pointing to the same, core challenge: the low rates at which Gen Z students seek treatment for mental health. More recent investigations have begun to focus on the current generation of college students (Gen Z, born 1996–2012; Twenge, 2017), a cohort that has exhibited distinct behavioral and attitudinal differences from their millennial counterparts (Rue, 2018), but nonetheless also has demonstrated concerningly low rates of help seeking, both before and during the COVID-19 pandemic. In the 2019 National College Health Assessment, implemented annually by the American College Health Association, 65.7% of postsecondary students disclosed that they experienced “overwhelming anxiety” (p. 14) in the past year; only 24.3% indicated that they were treated for anxiety. During the beginning months of the pandemic, more than 60% of students at a university with free mental health resources never utilized them (Lee et al., 2021); this occurred at a time when students’ rates of anxiety tripled (Santabárbara et al., 2021). Even as pandemic restrictions have loosened, scholars and university officials continue to emphasize that the mental health implications remain, as does the imperative to increase help-seeking rates among students (Abrams, 2022; Harris et al., 2022).
More specifically, research indicates that different populations of students continue to face distinct challenges associated with mental health; different student populations also face distinct barriers to help seeking. More to the point, existing mental health disparities deepened among ethnic and racial minorities during the pandemic (Thomeer et al., 2023). These data underscore a need for focused research efforts that illuminate the specific experiences and perspectives of various demographic populations.
Mental health trends among Latinx adults over the past several years are particularly concerning; a 2021 CDC report (McKnight-Eily et al., 2021) noted, “the prevalence of current depression, suicidal thoughts/ideation, and increased or newly initiated substance use was also higher for some racial and ethnic minority groups, especially Hispanic respondents” (para. 6). These findings underscore a need for a focus on help seeking among underserved populations generally, and Latinx individuals specifically. This investigation aims to answer this call.
Mental Health and Latinx Populations
Latinx individuals accounted for 18.7% of the United States population in 2020 (U.S. Census Bureau, 2021); by 2060, it is estimated that approximately 28% of the American population will be Latinx (U.S. Census Bureau, 2017). Amid these growing numbers, this population continues to face discrimination, prejudice, and racism (Noe-Bustamante et al., 2021). In fact, 54% of Latinx adults report having experienced at least one instance of discrimination within a 1-year period, including being treated as if they were not smart, being told to leave the U.S., and being stopped by police for no reason (Lopez et al., 2021). As Chávez (2017) argued, “individuals living in a society that provides them limited social, professional, or political acceptance are more likely to become isolated from and disenchanted within the broader society” (p. 18). These experiences create a concerning landscape of mental health.
These challenges also are compounded by low rates of mental health service utilization among Latinx individuals generally. On average, 46.2% of adults with mental health conditions in the United States seek professional treatment (SAMHSA, 2022). In contrast, only 35.1% of Latinx adults with mental health conditions in the United States seek professional treatment (SAMHSA, 2022). Previous research suggests that a variety of cultural barriers contribute to this disparity in addition to the barriers that exist for adults in general (Christensen et al., 2021; Conde et al., 2020; Crowe et al., 2022; Gearing et al., 2023; Kuo et al., 2015; Wang et al., 2020).
Cultural barriers for Latinx individuals include the emphasis on family promoted in Latinx culture (Kuo et al., 2015). For some individuals, this barrier manifests as a belief that their families provide the only mental health support they need (Kuo et al., 2015; Wang et al., 2020; Zhou et al., 2022). Latinx people also are concerned their families will be ashamed if members of the family’s social network learn they have sought professional help (Christensen et al., 2021). Additionally, some individuals believe help seeking may contribute to existing discrimination (Gearing et al., 2023). Zhou et al. (2022) found that, the more Latinx individuals prioritized retaining public respect for their families, the less likely they were to seek professional help.
Other help-seeking barriers reported by Latinx individuals include the belief that the problem was not worth addressing (Conde et al., 2020), along with a lack of knowledge regarding existing resources and treatment options; negative perceptions of mental health resources; and the belief that the resources will not be helpful or that the mental health professionals are not equipped to help them (Wang et al., 2020). Additionally, Latinx individuals have reported that they were taught mental illness is “not real” (Crowe et al., 2022, p. 460).
Current Latinx college students seek mental health treatment at a much lower rate (35.9%) compared to white college students (55.8%) and as compared to college students overall (50.2%; Lipson et al., 2022). Lipson et al. (2022) suggested these data indicated “a lack of attention and resources devoted to serving these populations and their unique needs” (p. 145). This assessment is particularly poignant, when one considers that this population faces a disproportionate burden of stressors. For example, when analyzed by race, data indicate that Latinx students experience higher levels of anxiety related to debt than their white counterparts (Deckard et al., 2022). Additionally, 41% of Latinx college students report experiencing some sort of trauma (Menendez et al., 2020). Further, research suggests that Latinx students were disproportionately impacted by the COVID-19 pandemic (Kakol et al., 2021).
Despite these factors, Latinx college students often only seek mental health services when experiencing “acute psychological pain” (Menendez et al., 2020, p. 310) as opposed to using these services as an intervention for general mental health. While cultural barriers, as previously mentioned, may also negatively impact Latinx students’ help-seeking, an additional barrier affecting these students is that fewer Latinx students tend to know what mental health resources their colleges provide (59.8%) compared to white students (70.2%) and college students overall (67.6%; Lipson et al., 2018). For these reasons, Menendez et al. (2020) recommend additional research on barriers specific to Latinx students.
As these data illustrate, and as scholars, mental health experts, and university administrators have implored, help-seeking interventions—that recognize and address the distinct experience of Latinx students—must be developed to meet this public health imperative. Persuasion scholarship, which focuses on the content, structure, and style of persuasive messages, provides an avenue for developing these strategies (Miller, 2002). More specifically, theories of persuasion provide frameworks for gathering crucial formative insight that creates a foundation for message design efforts. The current investigation utilized the theory of planned behavior (TPB) to explore Latinx college students’ perspectives on mental health help seeking. This evidence could be used to design persuasive messages with the goal of increasing help-seeking behavior; in other words, this insight could inform help-seeking interventions.
The Theory of Planned Behavior
The TPB is one of the most extensively cited frameworks designed to explain and predict human behavior (Stiff & Mongeau, 2016). The model consists of three mechanisms, theorized as antecedents to behavioral intention: attitude toward the behavior, subjective norms, and perceived behavioral control. The attitude toward the behavior is conceptualized as the degree to which a person considers the target behavior to be favorable or unfavorable (Ajzen, 1985). Subjective norms represent pressures or social standards associated with the target behavior (Ajzen, 1991). Perceived behavioral control is defined as the grade of difficulty an individual ascribes to the target behavior (Ajzen, 1985, 1991). The theory holds that these three factors together form the basis of behavioral intention, which is inextricably tied to actual behavior.
Meta-analytic findings have demonstrated the TPB’s utility to explain and predict health behaviors (e.g., Hagger et al., 2022; McDermott et al., 2015; McEachan et al., 2011). More specifically, the theory has been widely used in the health context as a framework for qualitative inquiry. Investigations focused on health care providers have utilized the TPB to explore attitudes and behaviors related to pharmacists’ engagement with patients regarding prescription drug misuse (Fleming et al., 2019); nursing students’ compliance with standard precautions (Kim & Oh, 2015); and health professionals’ use of evidence-based practices (Klaic et al., 2019). Studies also have analyzed the general populations’ health-related attitudes and behaviors, using the theory to examine topics such as organ donation (DuBay et al., 2014), alcohol use (Zoellner et al., 2012), and tobacco-free policies (Record et al., 2018). While the theory has been primarily used in quantitative studies, scholars have underscored its use in identifying and organizing key factors and experiences relevant to individuals’ attitudes, perception of norms, and perceptions of behavioral control (Silva et al., 2014).
With respect to mental health specifically, several studies conducted among international populations have found the TPB effective in explaining and predicting individuals’ willingness to seek mental health treatment (Bohon et al., 2016; Chandrasekara, 2016; Shi & Kim, 2020). More recently, two studies used the TPB as a guide for formative, qualitative inquiry focused on American college students generally (Geegan et al., 2022a, 2022b). Again, these studies utilized the theory as a framework for organizing the insight related to attitudes, norms, and perceived behavioral control. Geegan et al. focused on the overall Gen Z college student population through the lens of the TPB, uncovering nuanced information regarding barriers to help seeking; these included a general discomfort with the experience of being vulnerable (attitude), the idea that other students needed mental health resources more (norm), the perception that influential older generations did not value mental health (norm), and the expectation that mental health resources would be prohibitively expensive (perceived behavioral control). Importantly, however, neither study explored the distinct experiences or cultures of underrepresented groups. Rather, the investigations collected the perspectives of a primarily Caucasian population and did not capture factors rooted in minority experiences. The current investigation mirrors and extends these studies theoretically and methodologically, with a narrow focus on the experiences and cultural perspectives of Latinx students. As such, the following research questions are proposed:
RQ1: What attitudes exist related to mental health and mental health help seeking among Latinx Gen Z college students?
RQ2: What subjective norms exist related to mental health and mental health help seeking among Latinx Gen Z college students?
RQ3: To what extent do Latinx Gen Z college students perceive they have the ability to seek mental health resources?
Methods
Focus groups were used to understand perspectives of Latinx students toward mental health and help seeking. This data collection method provided a key advantage over traditional self-report measures or one-on-one, in-depth interviews, because focus group discussions reveal insights from dynamic group interactions and engagement (Morgan, 2019).
Participants
Undergraduate Latinx Gen Z students, (N = 28) enrolled at a large, public Southeastern university were recruited through snowball convenience sampling via IRB approved materials shared through Latinx campus organizations. More specifically, the research team communicated via email to share IRB-approved recruitment content with leaders of Latinx student organizations on the campus that served as the study site. Additionally, research team members encouraged members of the Latinx student organizations to engage in word-of-mouth information sharing among their social networks. Individuals were provided with contact information of research team members and were instructed to sign up for the study if they were interested and met eligibility criteria. These criteria included self-identification as a member of a Latinx population. Notably, the institution where the study was conducted utilizes the same system (self-identification) to collect student demographic data. All individuals who identified as Latinx, were enrolled at the institution, and who were 18 years or older were eligible to participate. The university serving as the site for the study reported that, at the time of data collection, 73% of all enrolled students (graduate and undergraduate) were White; 5% of the same student population were Latinx. The university at the time of the study offered a range of mental health resources, including in-person counseling, telehealth counseling, and group counseling, along with a suite of other mental health resources.
Participants ranged in age from 18 to 23 (M = 20.3) and were randomly placed in focus groups. Focus groups (N = 4) included 6 to 7 participants each, and the discussions ranged from 70 to 77 min (M = 73). Of these 28 participants, 15 were female, and 13 were male. Some individuals were international students; others were American citizens of Latinx heritage. Accordingly, individuals represented eight countries across the Americas, (N = 8) including: Brazil (4), Colombia (6), Costa Rica (2), Guatemala (3), Honduras (4), Mexico (5), Nicaragua (1), Puerto Rico (3). Of these participants, five individuals were born in the United States and traced their family heritage to one of the above listed countries; the other 23 were born outside the United States. In the results section of this paper, individuals born in the United States are designated with the country of their family’s heritage and the United States (e.g., Participant 24, Guatemala and United States, age 21, male, English and Spanish). All participants are identified in this format throughout the results section; each reference includes the individual’s country of origin/heritage, age, gender, and languages spoken.
The research was approved by the IRB at the first author’s institution. Participation was voluntary, and the students did not receive class credit or financial incentives. Recruitment took place on a rolling basis during March-April 2022 until the researchers reached a saturation point (Morgan, 2019).
Procedures
After receiving written informed consent, the moderator presented ground rules for the discussions and conducted the focus groups. The fourth author, a trained, culturally matched facilitator, moderated all the focus groups utilizing both Spanish and English when needed during all of the focus groups. The moderator was trained by the second author, a moderator with over 20 years of experience moderating focus groups. The moderator utilized a semi-structured series of open-ended questions tied to attitudes, subjective norms, and perceived behavioral control, consistent with the investigation’s theoretical foundation. These prompts were intended to elicit conversation, elaboration, and engagement throughout the discussion. Examples of these questions included the following: What do you know about the counseling center, utilizing prompts, such as location, virtual offerings, and how to schedule an appointment. How do you think the Counseling Center could better reach Latino/a students or cultivate positive interactions with Latino/a students? From your perspective, are there any cultural factors that shape how Latino/a students navigate these types of issues? Are you comfortable talking to your friends about mental health? Do you feel like Latinos/Latinas are more vulnerable to any of these feelings/experiences you have shared?
Because of health and safety regulations in place at the time of the study, the focus groups took place virtually, over the video conferencing platform, Zoom. Videos of the conversations were recorded with participant consent and transcribed verbatim; when necessary, the fourth author translated the transcripts from Spanish to English. Afterward, the team developed a codebook which reflected initial emergent themes from the data. The team discussed the codes and refined the codebook for clarity and consistency (MacQueen et al., 1998). Any discrepancies were resolved through discussion and gaining consensus by the coding team. Quirkos 2.4.2 (2021), a manual data coding software, was used to organize the data. Quirkos software gives users the ability to visually classify data, apply more than one code, and cluster emergent themes. Two trained and previously experienced research assistants coded one transcript independently, utilizing a recursive process to identify and code prominent themes, patterns, and commonalities (Braun & Clarke, 2006) and achieving 84% inter-coder agreement. The remainder of the transcripts were coded separately by the two research assistants, utilizing Braun and Clarke’s (2006) six-step process for inductive thematic analysis.
Results
The focus groups participants shared their experiences and perspectives through the framework of the TPB. As a result, four themes emerged. Participants, representing both international students new to the United States, as well as the children of immigrants, overwhelmingly characterized their attitudes toward seeking help on their campus as negative; they believed that campus resources were worthless for Latinx students (RQ1). Participants also discussed subjective norms in Latinx culture, noting specifically that their community shuns discussions of mental health and help seeking (RQ2). With respect to perceived behavioral control, participants discussed (1) their discomfort and lack of familiarity with United States health care systems and (2) the idea that being a minority in United States culture heightens these challenges (RQ3). In the following sections, individuals are identified by their country of origin/heritage, age, gender, and languages spoken (primary language is listed first). For the five individuals who were born in the United States, both the United States and the country that represents the participant’s family heritage are listed.
Attitude: “They’re Not Really Listening”
Participants expressed negative attitudes toward campus resources, rooted in expectations that services were not structured to benefit Latinx students (RQ1). In other words, although they recognized that mental health resources were available on their campus, they viewed those services as worthless or of minimal value to their community, due to the perceived lack of culturally appropriate systems, Latinx counselors, and services tailored toward the Latinx population. Participants’ attitudes toward the mental health resources were colored by previous experiences navigating an American college campus. Specifically, participants noted times throughout their student experiences when they struggled with language barriers or when they felt invalidated because of cultural differences. These instances fueled their expectation that, even if they did pursue mental health services on their college campus, they would not find them beneficial. For example, Participant 3 (Brazil, age 20, male, English and Portuguese) articulated skepticism that the American counselors would truly listen to a Latinx student’s concerns, noting, “I feel a lot of times when you talk with Americans, they’re not really listening to you. They’re just waiting for their turn to speak.” This concern that non-Latinx counselors would truly listen to them permeated the discussions.
Similarly, participants questioned counselors’ capacity to understand their experiences and, thus, doubted they would extract any value from their services. This expectation was punctuated by Participant 6 (Nicaragua, age 19, female, English and Spanish) who described previous experiences with English-speaking Americans in general: Some moments you feel like they don’t believe you and understand what you had in the past and endured in your country, in your culture. . . the experience you have and how you act in that way. So maybe that affects our mental health. Because, for example, I came from a country where we had a war four years ago. So, they don’t believe I was in the war. I lived that. I speak Spanish. I have some experience. The way I am, that’s not normal for them. So, that puts you in that lower position. And sometimes they don’t believe you and understand what you had happen in your life.
As they gauged the value that campus resources offered the Latinx community, they considered these negative experiences. As a result, they evaluated them negatively.
More specifically, participants shared concerns about the lack of culturally appropriate counseling services, including Spanish-speaking therapists. Participant 24 (Guatemala and United States, age 21, male, English and Spanish) emphasized the importance of these resources, noting, “Finding a therapist who can understand, culturally, some barriers. . . is way more important to getting better and improving your mental health.” Participant 23’s (Puerto Rico, age 19, male, English and Spanish) comment further encapsulated the need for services unencumbered by language barriers, expressing that “resources in Spanish and people that come from the same culture, or at least understand or are very well versed makes the students feel more comfortable.” To that point, the lack of Spanish-speaking counselors significantly influenced how participants evaluated the services’ utility for their community. For instance, Participant 27 (Brazil, age 19, female, English and Portuguese) emphasized that that complex thoughts and experiences inherent to mental health are simply easier to convey in one’s native language: It’s way more difficult to translate your thoughts and what you’re going through. Regardless of the context, it’s more difficult to translate your thoughts that you’re thinking in your native language as opposed to projecting that in English. It’s definitely a lot more difficult.
Participant 25 (Honduras, age 19, male, English and Spanish) affirmed this idea, reiterating that shared cultural connection would be crucial in times of crisis. In these circumstances, he explained, Latinx students would likely need to explain their struggles in Spanish: Crisis is harder to speak about in English and to explain everything that we are feeling in English, so sometimes I am feeling not super good, or I don’t know exactly what to do, because I can’t imagine myself explaining what I’m feeling in English, so I feel that this can be a burden, like a language burden.
Participant 7 (Honduras, age 20, male, English and Spanish) articulated the need for both types of connection: linguistic and cultural. He viewed the experiences and hardships he had faced—and that students like him had faced—as fundamental to his identity. Thus, he viewed that type of shared understanding as necessary in the context of discussing mental health. Moreover, despite being fluent in English, he felt a much deeper sense of comfort communicating such topics in Spanish: The struggles your cultures go through, I think just like shaped you into who you are. So, we all have similar experiences. The language barrier definitely exists. I speak English since I was a little kid, because I was lucky enough to go to a bilingual school. So, I’ve been listening to English classes since I was in nursery. And even though that’s the case, I still think I struggle sometimes in trying to communicate how I feel.
As these examples illustrate, the students perceived a profound gap between the types of services they needed to improve their mental health and the resources actually available to them. This gap shaped their belief that campus resources were not valuable to them. Unfortunately, these expectations were validated by the few participants who had actually engaged with campus mental health care providers, as demonstrated by Participant 11’s (Colombia, age 20, female, English and Spanish) poignant anecdote: I remember talking about how it was my first semester here. I was like, I feel lonely. I don’t have a lot of friends. It’s a completely different culture, and the therapist. . . she looked at me and was like, ‘yeah I get it.’ But, they don’t really get it.
This participant desired a conversation with a provider who had experienced similar challenges—those tied to navigating a new culture and cultivating relationships in a new place. When the campus resources failed to provide that perspective, the student saw no value in the interaction.
In summary, the participants did not consider the campus resources as helpful or valuable resources for them in times of crisis. Because the students doubted that their campus provided culturally appropriate care, they viewed the services negatively—as resources that provided no value to them. They did not view campus resources as valuable or beneficial for their community.
Subjective Norm: “Suck It Up; Move On”
The second theme represented a subjective norm, as participants emphasized that Latinx people do not talk about mental health (RQ2). Specifically, they stated that the Latinx community does not discuss this topic with family, around men, or with professionals. These observations culminated in a belief that family members expected them to manage their mental health independently. For example, Participant 18 (Brazil, age 19, female, Portuguese and English) shared, “I agree. . .about being raised to deal with everything by yourself. That’s also how I was raised. I try to share more, but I usually just do it myself because that’s what I was trying to do my entire life.” Individuals expressed deep discomfort, and even fear, associated with the idea of violating this norm; they anticipated negative consequences from voicing mental health struggles, as Participant 22 (Guatemala and United States, age 21, male, English and Spanish) shared: “If I was to tell my parents, I’m having a bad day, or I’ve been struggling, their answer would be to just work more.” Moreover, they maintained this conversational distance, because of the importance of norms, despite recognizing how it adversely impacted them; for example, Participant 4 (Puerto Rico, age 19, female, English and Spanish) expressed that “being raised like that has made me feel like my feelings and my problems are a burden.”
Participants attributed the origin of these norms to an assumption that family members had spent their lives navigating mental health challenges without help. For example, Participant 15 (Colombia, age 18, female, English and Spanish) articulated that: It’s usually something you don’t talk about because, well, everybody’s aware that they may have problems. . . Everybody’s expected to be like, ‘oh, you let it out.’ So after that, suck it up; move on. We’re all going through this, so, you gotta move on as well.
They also attributed these norms to core beliefs about the nature of mental health challenges, as conceptualized in the Latinx community. For example, Participant 17 (Mexico, age 19, female, English and Spanish) shared, “I feel that the word ‘therapy’ in the Latin culture has a negative connotation. It’s not something that you want to talk about within the family. It’s just something that’s avoided.” They emphasized that their family members had used words such as “crazy” and “shameful” to characterize mental health, as Participant 19 (Colombia, age 20, female, English and Spanish) articulated, “When my family found out that one of my cousins was going to therapy, it was a shameful thing, so it’s always a shameful thing you don’t want your family to know.” Participant 5 (Guatemala, age 19, female, English and Spanish): expressed similar normative experiences, encapsulated in the following comment: I think that in general, the Latino culture is very toxic in that area because, well, they taught us about mental health, it’s just for the crazy people. And if you are okay, you don’t need that. You don’t need to go to the psychologist or anything like that or therapies. That’s just for crazy people.
Participant 18 (Brazil, age 19, female, English and Portuguese) further echoed this experience, sharing that a family member also labeled therapy as a resource for crazy people: I had the same experience when I first started therapy like two years ago. I remember talking to my parents about it, and my parents, really, what do you need therapy for if you’re not crazy? I was like that’s not really how that works, so I think it’s usually like either you think therapy is for crazy people or it’s just you’re fine just if you’re not actively suicidal you’re totally fine like there’s nothing wrong with you.
These subjective norms appeared to be accentuated for men, as male participants expressed that they, even more so than females, could not share their emotional needs, nor would they consider seeking help. This hesitancy was tied to culture. For example, Participant 21 (Mexico and United States, age 20, male, English and Spanish) stated: Being a Latino man it’s like that, but 10 times because they tell you to suck it up and just put it in the back of your mind because you’re a man, and guys are not allowed to, you know, show emotions and crap. . . therapy and stuff like that. . .so that’s kind of something that I’ve seen throughout my whole life.
Participant 2 (Colombia, age 19, male, English and Spanish) expressed a similar sentiment, noting, I think we’ve also been raised in a culture of manhood and trying to man up in every situation. So, it’s difficult to talk about what you feel. Although the resources are available. It’s difficult to find the courage inside of you to say, ‘Okay, I need help’.
Overall, male participants shared that conversations about mental health would not be productive because they represented a violation of established behavior. Thus, such interactions would not lead to mental health help seeking.
These comments painted a picture of normative influences in Latinx culture. Participant 19 (Colombia, age 20, female, English and Spanish) demonstrated the impact of these norms over time, sharing, Well, coming from a third world country where mental health is obviously still not talked about enough, I feel like coming here and seeing all of these resources. You don’t really feel like you need them; you don’t really feel like there’s something wrong with you because you’ve been pushing it back for so long.
Taken together, this insight demonstrated the cultural underpinnings of help-seeking hesitancy among Latinx students. Avoidance of mental health discussions represented a significant barrier to help-seeking for Latinx students.
Perceived Behavioral Control: “Everything is a Lot Harder”
Additional barriers arose with respect to perceived behavioral control, materializing in two distinct themes. First, participants described a general sense that, subjective norms in their culture notwithstanding, help seeking for mental health represented a difficult task. Participants referenced a lack of self-efficacy in help seeking due to their outsider status, cultural shock, and unfamiliarity with the United States healthcare system (RQ3). These statements mirrored challenges the international students faced in being new to the United States. Specifically, the students frequently referenced their belief that United States systems were confusing and daunting for students like them, as Participant 18 (Brazil, age 19, female, English and Portuguese) articulated: I think for international students, everything is a lot harder because we don’t know how anything works. I think that them saying, “yeah here we have resources,” that’s not helpful. We don’t know how to access the resources, even though we know they’re there.
Various participants emphasized that they lacked key knowledge in how to access resources. As expressed in the previous quote, they knew that resources existed, but they felt wholly unequipped to navigate the systems surrounding those services. Participant 19 (Colombia, age 20, female, English and Spanish) faced similar challenges: I feel like there’s very little orientation towards how to get there, if you are a minority, and you don’t really have any experience with the American healthcare system. Because what I’ve heard from people here is my “parents make my appointments” or “my parents take care of that.” I feel like there needs to be more outreach towards people like us that don’t have those resources here and teach minorities or students like us how to actually reach this resource.
Participants frequently referenced this lack of knowledge beyond general recognition that services existed; they knew, generally, that their campus offered mental health support, but they perceived the system as too complicated to detangle. Participant 21 (Mexico and United States, age 20, male, Spanish and English) expressed this feeling perhaps most succinctly, stating, “I don’t necessarily know how to access them [the services]. You know, it was never really made clear.” More specifically, Participant 4 (Puerto Rico, age 19, female, English and Spanish), told a story of wanting to arrange an appointment with a mental health care provider. The individual lacked knowledge regarding how to do so, sharing, “I didn’t make an appointment because I didn’t know where to make an appointment.” Participant 19 (Colombia, age 20, female, Spanish and English) became quickly overwhelmed when researching campus mental health resources, noting, “the platform is just difficult and inaccessible.” As these examples demonstrate, various stages in the route to help seeking posed insurmountable barriers to Latinx students.
Along similar lines, participants perceived the process of accessing counseling services as a procedure with multiple steps. This in and of itself was intimidating. Moreover, the thought of identifying specific services to fit their distinct needs, as Latinx students, constituted yet another step that inhibited their efficacy, as Participant 18 (Brazil, age 19, female, English and Portuguese) expressed: You have to reach out to them [Counseling Center] and be like, hey, I want the resources; that’s already a step. That’s already you having to reach out for help, you know. Instead of [the Counseling Center] being like you can go here, here. . . like these are the things that they can do, this is what you can do. These are all those steps and then they’re like giving us more things to do, and then that’s already more stuff. It’s complicated to access that resource. They tell us that it exists, but they never tell us how to get there.
Participant 21 (Mexico and United States, age 20, male, English and Spanish) echoed this frustration—and exasperation—regarding the number of tasks involved in the help-seeking process, specifically connecting this additional barrier to the experience of being Latinx. He said, “And especially being Latino when just reaching out and trying to get help already is a step. . .” This same participant further positioned his exhaustion with the system as a whole, noting So I think they should really focus on the actual function and how the whole system works rather than promoting it. It’s actually making it work for students because right now, I feel like it’s complicated for no reason when it shouldn’t be.
In sum, the students described navigating United States systems as challenging and overwhelming; this created an environment in which they felt unequipped to access campus mental health resources.
Perceived Behavioral Control: “Okay. Actually Make It Work”
A second recurring theme related to perceived behavioral control was the participants’ shared experience of being minorities. Negative experiences tied to this status shaped the students’ beliefs that mental health resources were not meant for them (RQ3). Participants emphasized that their identity as outsiders shaped their perspectives toward seeking certain opportunities or resources. Participant 16 (Costa Rica, age 21, male, English and Spanish) explained: “I’d say, in general, in college, something that I’ve noticed a lot is that minorities don’t have the same opportunities, and this is something that stems from just society and how society works.” Participant 21 (Mexico and United States, age 20, male, English and Spanish) shared this sentiment, noting “A non-white American, you know with us. . . they’re not going to be as urgent with us.” In line with this comment, they communicated a general sense that they, as minorities, were not considered or prioritized as the institution designed and delivered mental health services. As a result, the students felt a strong lack of efficacy in addressing mental health concerns via campus resources.
To be sure, this sense was strongly linked to their attitudes, which positioned the resources as not valuable for them. However, in describing their attitudes, they elaborated on the specific, deficient components of the services (i.e., language barriers and shared cultural experiences). In describing their perceived behavioral control, they articulated an overall salient perception—which they carried throughout their student experiences—that certain opportunities or services were simply not for them: that they were left out. This feeling was intertwined throughout their daily lives and impacted their trust that the campus could offer helpful resources for them specifically. Participant 11 (Colombia, age 20, female, English and Spanish) characterized this perception, as such, “I think, not only Latinos, but also any other culture, I feel like. . . It’s just maybe a lot more vulnerable to those experiences of feeling like left out.” Participant 21 (Mexico and United States, age 20, male, English and Spanish) shared a perception that university administrators simply expected minority students to adapt to the resources designed for other populations, noting “They often say ‘hey, here’s what we have.’” To this notion, the individual responded, “But ok, actually make it work.”
At times, individuals discussed these feelings in terms of discrimination, as Participant 13 (Costa Rica, age 19, female, English and Spanish) described; however, irrespective of others’ perceived intent, they simply felt that they, as minorities, lacked equal opportunity: Since our culture, and how we grew up, and sometimes how we look is pretty different to how most of the people look, you will probably feel discrimination in certain ways. Maybe how the system works. Maybe how certain rules are implemented. People from the US have much more liberty on what they can do or certain opportunities they can have.
This shaped their perception of their ability to receive help through campus resources. Participant 20 (Mexico and United States, age 20, female, English and Spanish) echoed this sentiment: “In a room with a bunch of white Americans. . . society has told me that I’m not as high up as these people in that room.” As this statement reflects, they didn’t feel that campus resources would help them, on the basis of their identity.
In discussing these concerns, the students emphasized the juxtaposition between the heightened vulnerability they regularly experienced as outsiders and the lack of resources designed for them, referencing the belief that their university did not prioritize the needs of international communities. They juxtaposed the fact that their community faced significant mental health struggles with the feeling that the institution allocated minimal resources to culturally appropriate care. Participant 12 (Honduras, age 20, female, English and Spanish) expressed this feeling, stating: The whole culture shock and the whole starting new in a completely different country and culture is a very big deal that affects almost all international students. Then, maybe because the majority of the school population isn’t international, they don’t necessarily give it as much importance as they should.
In discussing this disparity, they expressed frustration. These comments spanned the groups of international students and Latinx American citizens. An international student, Participant 14 (Brazil, age 18, male, English and Portuguese) shared, “International students are a little bit more, well. . . They are vulnerable compared with everyone else.” Other students enrolled via education abroad expressed frustration that they, perhaps, needed these services more, but did not feel they could access them. Participant 16 (Costa Rica, age 21, male, English and Spanish): “I believe that culture shock is a whole different thing, but it messes with your mental health in a different way compared to others. . . it can obviously lead to anxiety and depression.” Against this backdrop, Participant 11 (Colombia, age 20, female, English and Spanish) expressed a desire for the institution to improve its services and outreach, noting “they could do a better job.”
Again, this frustration spanned the perspectives of both international and domestic Latinx students. Participant 4 (Puerto Rico, age 19, female, English and Spanish) articulated the distinct pressures and stressors associated with being the child of immigrants in the United States, another illustration of heightened vulnerability among this student population: “They came to the US looking for a better life and better jobs.” Sometimes they can’t even go to the store or go somewhere without having fear of facing racial discrimination, or even deportation. Participant 24 (Guatemala and United States, age 21, male, English and Spanish) expressed similar experiences, sharing: “I think growing up, and my parents were immigrants. . . It made me mature faster than anyone else.” Along similar lines, Participant 21 (Mexico and United States, age 20, male, English and Spanish), who self-described as a “non-White American” expressed frustration. The individual described having friends who were members of other minority groups; those peers also felt that, due to their status, the resources were not meant for them: “I know people who have [tried to seek help] who are not Latino and have been trying to get ahold of these resources. And they. . . they’re not as effective.” As these comments illustrated, individuals experienced heightened vulnerability paired with serious doubt that campus resources would render a positive experience for them. Together, these feelings hindered their perception that they could receive real help.
Discussion
As Gearing et al. (2023) noted, even in parts of the United States with high concentrations of Latinx individuals, low levels of mental health help-seeking persist. As such, the insight reflecting help-seeking hesitancy was not particularly surprising on a campus in a more rural part of the country. However, taken together, these findings provide a framework for addressing help-seeking attitudes and behaviors specific to the Latinx Gen Z college student population. The results parallel evidence indicating that health-related attitudes held by different demographic groups are culturally situated, signaling a need for targeted, rather than one-size-fits-all, interventions (Kreuter & McClure, 2004). Importantly, persuasion studies have found greater success with messages rooted in audience-centric insight regarding message features like relevant content, platforms, and message sources (Andreasen, 2002). Messaging strategies should leverage formative insight, such as the evidence stemming from this study and utilize communication or message design theories to optimize their persuasive power.
Moreover, these results further highlight the utility of employing the TPB as a framework for qualitative inquiry, as demonstrated in extant literature (e.g., DuBay et al., 2014; Fleming et al., 2019; Kim & Oh, 2015; Klaic et al., 2019). The qualitative data reflect nuanced insight into—and illuminated distinctions between—the factors that shaped the participants’ attitudes, perceptions of norms, and perceptions of behavioral control. The two different, yet substantial, barriers related to perceived behavioral control illustrate this important point, as the confusion related to the American health care system and the difficulties experienced as a minority represent two separate issues, but both contribute to a diminished sense of behavioral control. The recurring themes, and the nuance associated with them, offer direction for both university administrators and communication practitioners as they develop and promote mental health services on university campuses. The translational value of these data suggests that this qualitative application of the TPB may be useful in other contexts as well.
With respect to this context, individuals designing interventions rooted in this data should bear in mind that the dominant attitude—the belief that services were not valuable or useful for Latinx students—represented a strong barrier to help-seeking. This belief is consistent with existing research outside of the college student domain (Cabassa, 2007) and underscores the importance of culturally situated interventions. Students assumed that their experiences with mental health resources would mirror their experiences engaging other campus resources on a predominantly White campus; they expected to face language barriers, and they doubted that the organizations employed Latinx care providers. Importantly, very few of the participants had actually interacted with or researched campus mental health services. Rather, they assumed, in line with other experiences, that the services would be inherently insufficient for them. Officials engaging in help-seeking promotion should recognize that these students come to the table, so to speak, with these assumptions. Interventions, therefore, should address, and aim to correct, these underlying assumptions.
A variety of communication platforms should be explored to address these messaging goals. These include social media platforms, campus emails, campus signage, physical presence at campus events, and syllabus language, to name a few. These platforms should be leveraged to express a welcoming environment to Latinx students and, if applicable, emphasize the presence of staff members of various cultures. Crucially, as this study demonstrates, Latinx students themselves are sources of invaluable insight. Campus resource centers may create internships to minority students to provide ongoing feedback as they roll out communications efforts. Again, optimal interventions would leverage communication and persuasion theories to frame the messages.
The students’ comments regarding the necessity for Spanish-speaking and minority care providers represent invaluable insight to university administrators who oversee these services. To utilize the marketing vernacular in reference to “the four Ps” (product, price, place, promotion; McCarthy, 1964), this represents a product issue, where the product is the campus mental health resource. The best communication strategy in the world could not convince students that the services are valuable if they do not, in fact, employ Latinx providers. Against that backdrop, campuses that do provide these crucial cultural perspectives should design interventions, utilizing the platforms listed above, that strongly emphasize the availability of Latinx counselors. Campuses that do not should strongly consider increasing the diversity of their counseling staff to better serve a more diverse student body.
The findings related to subjective norms provided insight more poised for communication interventions. Research among Gen Z college students, overall, suggests that this population hesitates to discuss mental health (Geegan et al., 2022a; Horwitz et al., 2020; Lee et al., 2021). Interestingly, however, Latinx college students, unlike the general population, specifically cited their heritage as the foundation for this hesitancy. They began their explanations with phrases like “as a Latino man,” and “in my Latino community,” highlighting that these feelings were inextricably tied to their Latinx identities.
As such, messages should be built upon these salient perspectives. In response to younger generations’ preferences for digital platforms, universities should rely heavily on social media messages in an effort to shift student’s perspectives of help-seeking norms. For instance, social media strategies may find success in leveraging the voices of fellow Latinx students who have utilized mental health resources. For instance, peer experiences or testimonials in social media posts could be designed to shift students’ perspectives of norms among members of their generation, even if expectations from their family members remain constant. Moreover, intervention developers hoping to influence students’ perceptions of help-seeking norms should consider designing messages in Spanish. Additionally, messaging strategies may include acknowledgments of cultural barriers related to help seeking. Demonstrating a difference in norms among peers versus family members may be key to this endeavor.
The first theme related to perceived behavioral control demonstrated a resounding need for assistance navigating the American health-care system. The students were intimidated and overwhelmed before they even began attempting to utilize mental health resources. As a result, university administrators would benefit from evaluating existing programs, orientations, and ongoing outreach to provide more detailed information and tailored support. Further, officials should refrain from assuming students have an existing foundation of knowledge with respect to engaging with such systems. They need clear instructions and support in terms of where to go, who to call, how the services work, etc. Communication strategies should mirror this approach, providing these simple instructions in ways that do not presuppose this population has engaged in similar efforts previously. Given the students’ emphasis on cultural connections, messaging may be more successful if delivered by individuals or campus units who support minority students, such as an international center; a diversity, equity, and inclusion office; or a student success office with minority staff members.
In expressing the second theme tied to perceived behavioral control, students communicated heart-wrenching feelings about feeling undervalued, underprioritized, and underserved. These perspectives were coupled with heightened anxiety and a reluctance to express these feelings to members of their community. In contrast to their discussion of attitudes, which was evaluative in nature and took into consideration the various dimensions of campus resources that would render them useless (language barriers, cultural connections with providers, etc.), students expressed their perception that services are not “for them,” as an extension of their minority experience. As such, this barrier is deeply rooted in disparities, prejudice, and other systemic social concerns. Individuals evaluating service delivery and designing interventions should be cognizant of this background as they conduct their work. At the same time, this insight illuminates the value of infusing expressions of community and belonging throughout messages encouraging help seeking. Students need to believe that the services are for them too. To that end, messaging strategies should emphasize, through all message components (e.g., language, text, imagery, sources, partnerships, etc.), that campus mental health services are created to support all students—not simply members of the majority. Emphasizing the availability of minority care providers also may address this barrier.
These results paint a concerning picture of mental health help seeking among this population of college students. On a more optimistic note, however, the evidence indicates a number of opportunities to influence attitudes and encourage behavioral change. This formative work represents an initial step toward meeting these objectives. Designing theoretically driven messages, rooted in these data, represents the next step.
Limitations and Future Studies
This study faced a few limitations. Consistent with any study utilizing focus group discussions, results are limited in their generalizability (Lindlof & Taylor, 2002). In particular, these conversations occurred among a small group of Latinx students studying at a Southeastern university, in a more rural part of the country. Further, the study was conducted at a single university, and the findings may not be representative of Latinx students at other universities or in other geographic locations. Thus, although these data revealed nuanced and rich insight, the findings are inherently narrow in their applicability.
Additionally, as detailed in the findings, the participants in this investigation hailed from a variety of countries. As such, it should be noted that, although they shared many similarities, the findings may have failed to illuminate insight more specific to individual countries of origin. Also notable is the inclusion of Brazilian students in the sample. Self-identification as a Latinx student was an eligibility criterion for this study; at the same time, it is important to note that Brazilians do not universally consider themselves Latinx. Moreover, Portuguese served as the native language for many of these students. This information should be considered as the results are examined or applied.
Future studies should replicate these methods on campuses that are markedly different from the current site in terms of student demographics, geography, etc. In addition, future studies should consider survey or experimental designs that examine the efficacy of messages or interventions designed for this audience and which have the potential to generate findings beyond a single study.
Future studies also should leverage this model to explore similar questions among other underserved student populations. This should include other racial minority groups, as well as populations that have been shown to report higher levels of anxiety and depression compared to the general population, such as first generation students (House et al., 2020) or LGBTQ students (Gonzales et al., 2016), among others. As demonstrated through the current investigation, studies focused on these distinct student populations could reveal specific barriers, perspectives, and experiences that impact help-seeking attitudes and behaviors.
Finally, future studies may further explore particular themes identified in the current investigation. The qualitative use of the TPB generated nuanced insight related to attitudes, norms, and perceptions of behavioral control held by Latinx students. These rich, complex experiences could be further illuminated with an even deeper dive into the individual themes.
Conclusion
As such, the current investigation achieved two key goals. It produced rich, nuanced data focused on the Latinx population, which gave voice to their unique experiences. Secondly, it generated a foundation of theoretically driven evidence, which can inform future help-seeking interventions.
The findings can be utilized by practitioners and scholars, for both the development of services and the communication of those resources. For example, university officials and counseling center directors may consider these key themes as they build their suite of campus mental health services. Crucially, these individuals also should consider these findings as they promote and communicate those services to this student population. Additionally, scholars should utilize these findings to develop, evaluate, and refine help-seeking messaging and interventions.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
