Building Equitable Mental Health Care for Latino Children: Perspectives from Providers and Communities

Abstract

Background

The current pediatric mental health crisis has disproportionately impacted Latino youth in the United States (US), as demonstrated by their elevated risks of depression, substance use disorder, and anxiety. Despite this, research suggests Latino youth receive inequitable mental health services.

Objective

To understand best practices, challenges, and priorities in providing accessible and equitable mental health care for Latino youth from the perspectives of front-line mental health providers and Latino community members.

Methods

A bicultural, bilingual researcher conducted semi-structured interviews with 20 participants with expertise in Latino mental health. Topics included barriers and facilitators to mental health care access and cultural tailoring of treatment for Latino youth. Rapid qualitative analysis was used to identify themes.

Results

Four themes were identified: (1) Navigating immigration concerns and acculturation, practitioners should consider immigration-related concerns and be trained to address acculturation-related stressors respectfully; (2) Adapting to the cultural needs and strengths of the communities, cultural humility education can allow providers to engage with both the strengths and needs of Latino families; (3) Engaging Latino caregivers as partners, it is critical to engage with Latino caregivers’ cultural perspectives on parenting and mental health collaboratively; and (4) Addressing systemic barriers to promote access, providers must recognize and attempt to alleviate the systemic barriers that limit families from seeking care.

Conclusions

Participants identified several practical strategies to improve the provision of mental health services for Latino children. Future directions, policy and practice implications, and limitations are discussed.

Introduction

In 2021, health organizations in the United States (US) declared a state of emergency for child and adolescent mental health [1]. Poor mental well-being during childhood is associated with negative outcomes [2], including increased risks of incarceration, dependence on social services, and suicide [3]. Youth identifying as Hispanic, Latino, or Latine (herein Latino) are among the most at-risk for mental health concerns. Nearly one in four Latino youth have depressive symptoms, one of the highest rates in the country [4]. Latino youth also have higher rates of suicidal ideation, post-traumatic stress disorder, substance use disorder, and risk for anxiety compared to their non-Hispanic white peers [4].

Despite increased need, Latino youth attend about half as many outpatient mental health visits and have lower hospitalization rates for mental illness than non-Hispanic white youth [5]. Several factors contribute to this disparity, including systemic barriers like inadequate mental health supports in geographic areas where new Latino immigrant families are settling [6] and limited access to technology that restricts telehealth services [7]. Sociocultural factors like stigma [8–11] and distrust of healthcare systems [12] also contribute to the Latino youth mental health disparity. Understanding how community members and practitioners perceive and address barriers experienced by Latino youth seeking mental health services can inform strategies to improve access to and quality of care.

North Carolina (NC) ranks 42nd in the country in youth mental health care [13], with 72.2% of children with mental health conditions in NC not receiving needed care [14]. During the period of Oct 2017–Sept 2018, a total of 28 counties in NC had no more than one child psychiatrist per 10,000 Medicaid-enrolled youth [15]. Twenty-two of these counties are rural counties [16]. Simultaneously, the Latino population is the fastest-growing demographic in the state, comprising 11% of the total population and 18% of youth [17]. As of 2021, 50% of the NC Latino population identifies as Mexican followed by 18% Central American and 12% Puerto Rican [17]. Although recent immigrant arrivals mostly settle in urban areas, a significant proportion also pursue agricultural work in rural counties [18]. It is in these same rural counties that the Latino communities of NC make up greater proportions of the population due to faster rates of growth [19] thereby exposing them to a scarcity of mental healthcare. This is reflected in Duplin and Sampson counties where Hispanics comprise 22% and 21% of the populations, respectively, [19] and where there are only 4 and 1 child psychiatrists per 10,000 Medicaid-enrolled youth [15]. While NC is working towards addressing the youth mental health crisis via school-based services and strengthened mental health resources, it is unclear how strategies should be tailored for Latino youth and families.

In this study, we explored systemic and sociocultural barriers to equitable mental health care for Latino youth in NC from the perspectives of mental health practitioners and experts. Mental health diagnoses vary significantly between developmental stages in their presentation and treatment. However, our focus was on general youth including early childhood to young adulthood with the aim of providing a review of existing strategies for addressing barriers and actionable implementation strategies for mental health providers and policymakers.

Methods

Research Framework

We utilized the Consolidated Framework for Implementation Research (CFIR) to frame our study questions [20]. The CFIR has been frequently used in healthcare settings to guide systematic assessment of barriers and facilitators to tailor implementation strategies or interventions. We also developed a LOGIC model based on a literature review to facilitate understanding of existing barriers, facilitators, and strategies to address disparities in Latino youth mental health (Appendix B). A semi-structured interview guide (Appendix A) was designed to understand views on barriers, best steps forward, and significant cultural components of Latino culture for mental health specialists. Guided by existing literature and our LOGIC model, we also probed specifically for strengths and limitations of promotoras (i.e., community health workers) and telehealth, two widely used strategies to promote equity in mental health treatment.

Data Collection and Participants

A bicultural, bilingual researcher conducted 20 semi-structured individual interviews with participants. Participants included mental health practitioners (n = 12), policy experts (n = 5), community service workers (n = 2), and a pediatrician (n = 1) based in NC (n = 15) and in other US states (n = 5). The team purposively recruited initial participants via email based on characteristics including expertise, roles, and geographic spread. The team then used snowball sampling to expand the sample. Interviews were conducted virtually, recorded, and transcribed verbatim. This study was determined exempt from obtaining informed consent by the Duke University Health System Institutional Review Board.

Data Analysis

The team used rapid qualitative analysis, a team-based approach that emphasizes actionable results and a shorter timeline compared to traditional qualitative analysis [21, 22]. After each interview, summaries were developed according to domains identified a priori. Summaries were integrated into a centralized matrix. The first author used NVivo to code summary templates based on the a priori domains to identify initial themes. Rigor was ensured by having two researchers independently code 18 of the 20 interview summaries and through study team discussions to reach consensus on themes. Saturation was achieved as no new themes were identified [23].

The study team consisted of diverse individuals. Two team members (FB, AT) are bilingual Latinos with lived experience in Latino communities. Two other team members (RC, MF) work closely with Latino populations in clinical pediatric and psychiatric practice. Five team members are members of immigrant communities in the US. As noted above, the primary interviewer shared a cultural and linguistic background with most participants and connected with participants through this shared background with the intent of encouraging further insight and depth of engagement. Two interviews were conducted in Spanish and most English-language interviews featured brief code switching to Spanish. The study team implemented debriefing, reflexivity, and positionality work to minimize potential biases, especially acknowledging and critically assessing the teams’ own experiences with the study topic.

Results

Four themes emerged across interviews (Table 1): (1) Navigating immigration concerns and acculturation, (2) Adapting to the cultural needs and strengths of the communities, (3) Engaging Latino caregivers as partners, and (4) Addressing systemic barriers to promote access.

Table 1.

Themes, categories, and supporting quotes

Themes	Categories	Supporting quotes
Theme 1: Navigating immigration concerns and acculturation	Immigration concerns	“As a new immigrant destination our population is growing fairly rapidly compared to other places that have perhaps larger populations, but they’re more established so they possibly have more established systems in place to support that community. Whereas here we’ve been growing so quickly that perhaps we haven’t had time to catch up to the systems needed to support the community.”— Participant 5	“[Latinos are] more likely to be concerned about the effect on their documentation status…getting mental health services means [they’re] ‘crazy’ and that that somehow will work against them when they’re applying for documentation or citizenship status.”—Participant 15
	Acculturation	“[Parenting practices are] a really big place of difference between cultures, like all cultures have different parenting practices and beliefs. So, we’ve had to do education with some immigrant families about what is allowed in the United States, or what is considered neglect or abuse…So, I think that’s a place where policymakers could consider how those policies affect families from other cultures.”—Participant 12	“Clinicians really need to understand [acculturative stress] and really understand all the different facets…There can also be intergenerational gaps. Maybe the caregivers want the children to be more traditional and the children want to be more Americanized. And there can be a lot of conflict related to that.”—Participant 20
Theme 2: Adapting to the cultural needs and strengths of the communities	Adapting to the communities’ cultural needs	“Number one, I think the way the clinic is designed and decorated I think is important, even though it’s often overlooked. But if you want to make people feel comfortable you want to offer them a comfortable space.”—Participant 4	“We just need to be inclusive and diversify the different ways in which we are extending access to mental health services. So, if people have the most trust in their religious communities and that’s really where they’re going to go as their first line, I think we need to meet them where they’re at, and we need to equip those professionals, those religious parties, to know how to best support someone with mental health issues.”—Participant 20
	Leveraging the communities’ strengths in favor of mental health	“There’s a lot of research that has already been done around how some of these social, cultural values protect the first generation of immigrants. Like family meals, it’s a protective factor. If we all knew more about it and knew how to promote it, I think it would be helpful.”—Participant 3	“[Latino communities are] a very like family-oriented, community-oriented kind of group of people—which is a beautiful thing. And I think tapping into that would be a really wonderful thing to do. Instead of always one on one therapies maybe more group therapy so that they can share openly with each other and create a community within themselves.”—Participant 5
Theme 3: Engaging Latino caregivers as partners		“The therapist needs to arrive one day before: ‘Okay, I’m going to be your therapist, I’m going to explain how occupational therapy works…these are the goals we have for your child, this is how we are going to try to reach them. Do you have any questions?’ No one does this!…How do they expect the system to work when no one considers the family?”—Participant 10	“There exists a pride, the pride of the father, the pride that, ‘My children are perfect, so how are my children going to be unwell, how is it that my child could have a mental problem?’… And so we’ve seen caregivers decline services.”—Participant 19
Theme 4: Addressing systemic barriers to promote access		“A lot of what I’ve seen as well is the fact that a lot of [Latinos] are, you know, living paycheck to paycheck so work is a priority, and making time to go to an appointment sometimes is very challenging.”—Participant 1	“As I mentioned earlier, there’s very rural communities [in NC] that have primary care providers, but there are counties that don’t even have a single psychiatrist within their county. Or maybe they don’t have one therapist available to offer CBT in their entire county, and that’s still like a 40-min drive away from them…”—Participant 5

Theme 1: Navigating Immigration Concerns and Acculturation

Participants recognized North Carolina as a relatively new, booming destination for immigrants. They discussed how immigration-related fears, such as fear of deportation and family separation, can burden Latino families. Such fears exacerbate distrust of healthcare systems by discouraging families from disclosing their circumstances. Latino immigrants may also be fleeing dangerous situations which fuel immigrant-related trauma. Mental health practitioners should respect the fears of Latino families reluctant to discuss documentation status. Families with undocumented members may feel that their only support systems are schools and churches, which can increase stress and alienation by contributing to a perceived or actual lack of support from safety net resources (Table 2). Participants cited several model campaigns, often community-based and communityled, that attempt to buttress Latino family support systems (Table 3). Mental health providers can consider referring families to these and other similar resources.

Table 2.

Recommendations by participants to improve mental health equity among Latinos

Topic	Recommendations
Leveraging language	Avoid using stigmatized or confusing medical terminology with caregivers. Use terms like “behavioral health” or “emotional health” over “mental health” since these carry less stigma. Be aware of subtle Spanish language connotations like the “Spanish No,” a gentle negative hidden behind the affirmative “esta bien.”
Parent collaboration	Keep caregivers in the loop about their child’s treatment. Along with culturally responsive care [41], caregivers would appreciate a one-on-one meeting with the practitioner dedicated to helping them understand their child’s diagnosis and prognosis, what their treatment will look like, major goals in the treatment plan and how they will be reached, etc. in a manner that avoids implicitly placing any blame on the parent and in Latin American languages if possible
Guided navigation	Use promotoras or dedicated professional positions as liaisons guiding caregivers through the complicated and confusing mental health and federal benefits systems to keep families from falling through the cracks
Faith-based alternatives	Given the Latino communities’ strong faith and spirituality, they are likely to turn to faith-based alternatives before or while simultaneously seeking out professional mental health care. Connect with local faith-based community centers [42] to facilitate collaboration. Be prepared to give families time to pray or engage in other rituals during therapy sessions
Group therapy	Latino communities highly value collectivism and the family unit. Consider group therapy as one of several avenues for leveraging the communities’ cultural strengths in favor of mental health. Community support networks [43] can also leverage the collectivism of the communities
Financial and structural barriers	Due to the strong work ethic of the Latino communities, consider offering material resources like food and childcare stipends to help caregivers offset taking their time off work to attend appointments. Expand services past the 9–5 workday and offer childcare in the clinic to make managing appointments simpler for caregivers. Implement remote care, in-home visits, and payment policies that ease the payment burden on the family for these modalities
Medical hierarchy	Members of the Latino communities might expect a strict practitioner-family hierarchy due to cultural expectations. Regularly open the floor to caregivers’ potentially withheld concerns or questions and empower the caregivers by giving them choices during treatment

Table 3.

Model campaigns and services

Campaign	Description	Location
El Futuro	Mental health and cultural community center	Durham, NC
MOM’s Partnership at Yale	Community resources, courses, therapeutic and general support program	New Haven, CT
Metropolitan Family Services	Non-profit that offers holistic educational, economic, psychological, and general support	Several locations, headquartered in Illinois
El Centro Hispano	Community service organization that provides health, civic, economic, educational, and general support and resources	Durham, NC
El Pueblo	Non-profit providing youth programs, domestic violence and sexual assault support, leadership development, and community support	Raleigh, NC
El Vinculo Hispano/The Hispanic Liaison	Provides community support programs and advocacy, serving as bridge between community and government agencies	Siler City, NC
Catholic Charities of the Diocese of Raleigh	Catholic organization that provides wide range of community services and resources aimed at addressing poverty and immigration issues, and strengthening vulnerable families	Durham, NC

A fourth of Latino kids have an unauthorized parent. And these families are going to be very fearful and skeptical of systems that they don’t already know. So, working within systems that they already know is really key… reinforcing confidentiality over and over again is really critical.

(Participant 17)

Immigrants can also experience significant acculturative stress from adapting to US conventions, systems, and culture. This stress may be experienced differently between generations and cause further distress within a family. Intergenerational differences among first-generation immigrants and their US-raised children can result in opposing perspectives on topics like gender roles and adherence to tradition. This can potentially lead to familial conflict and distress. Practitioners should be aware of these stressors and receive training to address them when providing mental health services.

So, the [Latino] child is being raised in a place where most of their [friends] are talking back and arguing a little bit with their caregivers about rules, and [Latino] caregivers who come from a more traditional, old school…are then cracking down with punishment and the child feels like, ‘Wait, why am I being punished? What’s wrong with me? When my friend does that they don’t get punished’. And so, there’s that acculturative gap and acculturation that can cause mental health problems.

(Participant 15)

Theme 2: Adapting to the Cultural Needs and Strengths of the Communities

Improved awareness and incorporation of cultural humility into mental health practice was the most cited need by our participants. This refers to the understanding and inclusion of Latino cultural considerations relevant to treatment, and practitioner reflection on and adaptation to these considerations. Participants noted that certain cultural components could become risk factors or protective factors. For example, familismo (Fig. 1) may present greater vulnerabilities to distress. Simultaneously, many participants encouraged collaboration with community members to leverage the communities’ strengths. For instance, participants proposed including family members in group therapy to harness the intrinsic collective support in Latino culture via familismo and collectivismo (Table 2; Fig. 1). Participants recognized that many Latino families will turn to spiritual or faith-based options when seeking treatment for mental health. Diversifying outreach to Latino communities through collaborations with churches and spiritual groups is imperative to addressing mental health needs (Table 2).

Fig. 1.

Latino cultural terms and definitions; adapted from UnidosUS [4]

Our indigenous communities probably have a better handle on the herbal teas and the rituals that maybe some of the indigenous communities do whether its incensing, cleaning the house, cleaning the air, the energy levels and see that as a good thing. But then we stigmatize that when they come to this country because, you know, we have professionals. Well, yeah, we have professionals but some of that stuff is good too!

(Participant 16)

Participants highlighted overgeneralization and stereotyping as barriers to cultural humility. Although often treated as a single group, diverse, distinct cultures comprise Latino communities. Moreover, patients should not be reduced to their ethnicity alone. Participants underscored an intersectional framing of Latino patients as individuals with different identities. Cultural humility also encompasses efforts to build awareness among providers of linguistic ambiguities crucial to building trust with Latino families. For example, being aware of language nuances like the “Spanish no” which refers to the use of “esta bien” as a gentle negative despite being phrased as an affirmative (Table 2). Such ideas are tied to efforts to diversify the medical workforce and train providers who better understand Latino families. One non-Hispanic white and Spanish-speaking participant shared that their institution had hired a Latino social worker with whom caregivers were sharing information about their parenting practices:

In all my time working with Spanish-speaking families, no one has ever disclosed anything like that to me…I just was not trusted with that information which I totally understand.

(Participant 12)

Participants praised promotoras de salud (promotoras) or community health worker (CHW) initiatives, in which members of the communities are trained to provide health education and refer to clinics when needed. By employing members of Latino communities, such initiatives can help overcome distrust, language barriers, and cultural disconnects while providing an opportunity to share psychoeducational resources and amplify community voices. Participants also highlighted limitations to promotora initiatives, including risk for burnout, and the need for more comprehensive, standardized trainings.

Theme 3: Engaging Latino Caregivers as Partners

Collaborating with caregivers in healthcare is crucial as they are the best advocates for their child’s care and provide insights into cultural beliefs and practices. Though this is true of all caregivers, our participants suggested that this is particularly important for Latino caregivers because they may not always recognize mental health issues in their child given diverse cultural perceptions of mental health. Even when families receive mental health treatment, Latino caregivers may not always understand their children’s diagnosis, or available resources and services. Misunderstandings can arise due to a lack of Spanish language materials, poor communication among caregivers and providers, challenges interpreting clinical visits, and cultural perspectives on mental well-being.

[Policymakers and mental health providers] don’t consider culture. Before arriving in this country, I had never heard of mental health illnesses. Never… It was here that I first heard about autism, ADHD, schizophrenia, bipolar. If I’ve never heard of these illnesses, how am I going to go seek treatment… There need to be ways to share information, to help communities understand why it’s important and what the symptoms are.

(Participant 10)

Participants also noted different cultural views on parenting, including disciplinary practices (e.g., corporal punishment). Mental health providers should communicate with caregivers regarding cultural differences in parenting and mental health, taking a collaborative role with the parent, listening to concerns and needs that might impede their child’s treatment. One participant acknowledged that Latino caregivers often believe that doctors always know best. Practitioners should work to ensure caregivers are comfortable enough to share questions and concerns while supporting them to make choices in their child’s care (Table 2).

Culturally in Latin America there is a hierarchy with physicians and people in power, that are traditionally seen as in power. I think that’s always a tricky dance for me because how do you manage this expectation…there is like this deference to whatever you choose…so they’re like ‘Whatever you think, doctor, is best.’

(Participant 4)

Theme 4: Addressing Systemic Barriers to Promote Access

Systemic barriers to Latino youth mental health care were repeatedly mentioned. Participants emphasized employment-related barriers. For instance, since many Latino families live paycheck to paycheck, caregivers may feel that they are missing valuable time off work when taking their children to appointments. Offering practical support services and offering appointments outside of work hours were endorsed by our participants to ease the burden on caregivers (Table 2). Among the most mentioned obstacles for Latino families was language barriers. Participants mentioned the difficulties Latino caregivers might experience navigating health-care and benefits systems, given the scarcity of Spanish-language resources, services, and guidance. One participant shared their experience in being the only Spanish-speaking employee at a NC agency with 130 Spanish-speaking clients. Several participants pointed out the demand for liaison roles to guide caregivers through these systems and ensure families do not fall through the cracks.

…Or they’ll send [the caregivers] bills for things that Medicaid is supposed to cover. When the caregivers don’t know better, they’ll go and pay and then afterwards Medicaid covers it. So, then they lost their money because they don’t know how to ask for their money back…It’s difficult to understand the system—even for Americans themselves.

(Participant 10)

Participants also spoke extensively about high uninsurance rates in Latino communities. One participant emphasized the need to expand Medicaid in NC to improve access to care. Another participant posited that the boom in Latino immigration in recent years had made it difficult for services in NC to catch up to the rapidly growing demand. Participants recommended efforts to connect families to safety net resources for food, insurance, reduced-cost treatment, and housing needs. Participants also encouraged greater reimbursement for in-home and school-based mental health services since doing so would make them more available to Latino youth.

Rurality is a crucial factor to consider when serving Latino communities, particularly in NC. Participants acknowledged that Spanish-language services are often concentrated in urban areas of the state, exacerbating the scarcity of services in rural counties where the Latino populations have been growing most rapidly, often to seek employment as farmworkers. Specialty care such as mental health services are especially scarce in rural areas of the state. Participants endorsed embedding mental health services in community centers like schools and churches. Such interventions help address both structural barriers, like transportation, and sociocultural barriers, like distrust. Telehealth was mentioned as a response to overcome practical issues like transportation and increasing access to Spanish-language services. However, participants mentioned limitations including that younger children can experience difficulties with engagement and distraction. Additionally, for Latino communities, the digital divide, or limited access to technology and broadband internet connection, can make engaging with telehealth impossible. Several participants also acknowledged that Latino families see a greater prevalence of multi-family households making it difficult to find a location where patients can discuss private matters via telehealth.

When you live in a house where there are ten different people, you’re not going to have privacy easily. And that’s often times how our Hispanic families live, right? Intergenerational families or families who cannot afford high rent, they’re going to have many people living in the same household. And so, privacy is really hard.

(Participant 3)

Discussion

This study provides invaluable insight into barriers Latino youth and families experience in accessing mental health care from the perspectives of community members and mental health providers. We identified four themes related to providing quality mental health care for a community that has not been fully served yet, with key implications regarding both protective and risk factors to consider in both practice and policy decisions, and strategies to promote improved collaboration with the Latino community.

Participants recognized the profound influence of immigration-related stressors on the mental well-being of Latino children and families [24–26]. Migration trauma can significantly affect mental health [27, 28], sometimes resulting in transgenerational trauma or the transferring of trauma or traumatic symptoms to subsequent generations [6]. Post-migration trauma, including discrimination, can moderate immigrants’ abilities to recover from pre-migration trauma [29] and is associated with depressive symptoms [30]. Latino youth in rural communities experience higher levels of healthcare discrimination [31], a particularly alarming concern as Hispanics are projected to become the largest rural minority nationwide by as early as 2025 [32] and are already making up a significant, growing proportion of rural counties in NC as established above. This increased discrimination, in conjunction with lower access to mental health resources in rural areas noted by our participants, highlights the heightened vulnerability of Latino families in rural areas. Policymakers can take action to increase mental health-care resources in rural areas by establishing rural clinical centers and offering incentives to work in these areas, such as scholarships or loan forgiveness [33]. Additionally, telehealth services, stipends to cover internet connection, and technology borrowing programs can help address the digital divide while leveraging telehealth’s major strength of alleviating transportation issues.

Many interview conversations centered on tailoring care to consider cultural components. Future research should aim to develop interventions that amplify cultural strengths and create models for including community voices in developing these interventions. Practitioners need to be educated about and responsive to Latino cultural components to provide effective care. Developing cultural humility curricula and training sites in diverse areas might allow practitioners to build cultural humility early in their careers. Meanwhile, advancing culturally adapted psychotherapeutic techniques and expanding use of promotoras can help foster a more comprehensive model for addressing the unique mental health needs of Latino families.

Participants emphasized the importance of engaging Latino caregivers in mental health treatment for children and addressing power dynamics between providers and caregivers. While family engagement is crucial in a child’s mental health care, families from minority groups are less likely to engage in their child’s mental health treatment [34]. For Latinos specifically, decreased family engagement has been attributed to factors related to the communities’ mental health systems, and cultures [35]. Several obstacles raised by our participants are related to family engagement. Community participants highlighted how treatment by practitioners who did not look like them, did not relate to them, or did not try to help them understand their child’s diagnosis and treatment could push Latino caregivers toward disengaging.

Participants recommended promoting parent engagement through bolstering workforce diversity [36, 37], improving cultural trainings [36], and utilizing promotoras [9, 10, 38, 39]. Carolina Conexiones, a navigation program staffed by bilingual volunteers at University of North Carolina (UNC) Health, was suggested as one example program that boosts Latino families’ access to high-quality care. Educational campaigns in community centers like schools and churches may help families better understand mental health diagnoses while also helping to destigmatize conversations around these topics. Interventions to encourage Latino parent engagement by boosting caregivers’ psychoeducation and, thus, sense of self-efficacy and competence have recently found promising success [40].

This study has limitations. First, our focus on youth was inclusive of multiple developmental stages, from early childhood to young adulthood. This approach limited nuanced consideration of developmental differences and challenges, which should be considered further in future studies. Second, our sample was primarily from NC and most of our interviews centered on this state, limiting the generalizability of findings. Third, although we have confidence in reaching saturation with our sample size of 20 participants, their experiences are not necessarily comprehensive. Through an intersectionality lens, it is worth noting that little was shared about treatment of LGBTQIA + , Afro-Latino, people with disabilities, and other sub-groups within the Latino communities. Thus, the ideas shared by our participants here should not be considered representative of the entire Latino experience. Special attention should be given to these groups in future research. Finally, though our participants included members of Latino communities, we did not interview families. Our study also has strengths. Participants came from a breadth of disciplines, all had experience working directly with the Latino communities, and most were members of Latino communities themselves. Interviews were also conducted by a bicultural and bilingual interviewer allowing for greater mutual understanding with participants.

New Contribution to the Literature

Though child mental health and general Latino mental health have received abundant attention from researchers, this study sheds light on the intersection of the two, Latino child mental health. Our study also provides timely insight into immigrant mental well-being considering recent surges in arrivals at the southern border. The study helps advance mental health providers’ understanding of the complexities of Latino cultural values and their positive and negative impacts on families’ mental well-being. Finally, all our interviews took place well after the onset of the COVID-19 pandemic, allowing participants to reflect on how their views may have changed. As such, this study can inform interventions like promotoras and telehealth in the wake of the pandemic.

Conclusion

As the ongoing Latino child mental health crisis continues, policymakers, public health professionals, and healthcare practitioners must hone in on Latino family experiences, identifying barriers and interventions that aim to improve access to and quality of care from the perspectives of community members and practitioners. Further research is required on approaches to leverage cultural strengths, developing sub-group understandings, and methods to provide more comprehensive support and material resources. Finally, healthcare professionals and policymakers must work to amplify community voices, enabling sustainable collaboration and supporting Latino communities’ agency in their own well-being.

Appendix

A. Interview Guide

Verbal Consent:

My name is Francisco and I am a research assistant at Duke University. Thank you once again for agreeing to participate in our study.

The aim of our project is to understand barriers and facilitators to accessing behavioral health or mental health services among Latino children and families. We are conducting exploratory interviews with participants like you who have connections to mental health in the Latino communities in order to gain a better understanding of ongoing programs, strategies, and experiences. We will be audio-recording this interview to ensure accuracy as our team reflects on what you share with us and will discard recordings after the study is complete. To protect your privacy, we will not report your name, organization name, or any other identifying information. This data will be handled carefully and safely. It will only be seen by members of our team before being permanently deleted at the end of our research.

Your participation in this study is completely voluntary. If you would like to take a break, decline to answer a question, or end the interview at any time let me know.

Before we proceed do I have your permission to record and transcribe this interview? We can still proceed with the interview if you prefer it not be recorded.

Do you have any questions for me before we get started? Interview Questions:

1. I’d like to start off by confirming the information I was able to find about your work/organization. [Explain your understanding of their work]. Is this all accurate? Is there anything you would add?

2. A major goal of health policy is that of pushing for equitable healthcare. We can define this as the fair and just distribution of healthcare services and resources to communities according to their need—especially to support disadvantaged groups. In your opinion, what are the biggest obstacles hindering the equitable mental health care treatment of the Latino population?

   1. Probing questions:

      1. If not mentioned by the participant: What sort of direct experiences with this/these obstacles, if any, either from your background or from your work, can you share?
      2. If not mentioned by the participant: Our major interest is with Latino children specifically. How do these obstacles you mention, or any other that come to mind, apply to children?
      3. What steps should be taken and what policies implemented to address these obstacles?
      4. Do any major campaigns in the country that push for these efforts come to your mind?
3. Next, I want to get your thoughts on obstacles and responses. Through our research, I found an emphasis on practical issues for the Latino population such as language barriers, financial limitations, transportation, and even just difficulties in finding the time of day or someone to watch children while receiving treatment. From your perspective, what steps could policymakers and/or practitioners take to address the systematic nature of such problems?

   1. Probing questions:

      1. If not mentioned by participant: What are your thoughts on telehealth as a tool meant to address these problems?
      2. Are there any limitations to telehealth that you see?
      3. How can we address these limitations?
4. Other commonly mentioned obstacles in the literature can be described as socio-cultural. These include stigma against mental health treatment, distrust of healthcare systems, and insufficient cultural humility. From your perspective, what initiatives and/or policies can we take to address and overcome such barriers?

   1. Probing questions:

      1. If not mentioned by participant: What are your thoughts on promotora, or community health worker, initiatives as a response to these obstacles?
      2. If not mentioned by participant: I know other similar initiatives have attempted to reach out to community centers like schools and particularly churches. What are your thoughts on these programs as a response to these obstacles?
      3. What limitations or pending questions, if any, do you see with such initiatives?
5. Now I’m hoping to hear from you what ideally tailoring mental health care for children in the Latino communities looks like. What specific components of Latino cultures, traditions, values, and perspectives should mental health specialists be especially adaptive to?

   1. Probing questions:

      1. In some ways, addressing the obstacles impeding the equitable behavioral health treatment of the Latino communities can sometimes imply changes to components of its culture. As a quick example… [Give stigma/faith example] Some see this process as problematic while others feel it’s for the best. Do you have any thoughts on this?
      2. If participant expresses concerns about acculturation process: How do you think medical professionals and policymakers can go about implementing change into these communities in a respectful way?

6. As a final question, do you recommend any other programs/individuals we should reach out to help us with this project? Is there anything else you’d like to share with us that you think might be helpful for our research?

Spanish Version

Mi nombre es Francisco y yo soy un asistente de investigación en Duke University. Gracias de nuevo por platicar con nosotros para nuestro estudio.

El objetivo de nuestro proyecto es entender las barreras y ayudas para el acceso de servicios por la salud del comportamiento y de la salud mental. Estamos conduciendo entrevistas exploratorias con individuos y organizaciones como usted que tienen conexiones a la salud mental en la comunidad Latina para obtener una mejor comprensión de los programas en curso, estrategias, y experiencias. Estaremos grabando esta entrevista en el interés de evitar errores cuando nuestro equipo empieza a reflexionar sobre todo lo que usted comparta con nosotros antes de borrar las grabaciones cuando el estudio este completo. Para proteger su privacidad, nosotros no vamos a reportar su nombre, nombre de su organización, o alguna otra información que se pueda usar para identificar lo/la. Los datos de nuestra conversación serán tratados con cuidado y seguridad. Solo serán vistos por miembros de nuestro equipo antes de ser permanentemente borrados al fin de nuestra investigación.

Su participación en este estudio es completamente voluntaria. Si le gustaría tomar un descanso, brincar cualquier pregunta, o terminar la entrevista a cualquier momento por favor solo avíseme.

¿Antes de empezar, tengo su permiso para grabar y transcribir esta entrevista? Aun podemos continuar con la entrevista si prefiere que no se grabe.

¿Tiene alguna pregunta para mi antes de que empecemos? [Can we share interview data with participant?].

Preguntas de Entrevista:

1. Me gustaría comenzar confirmado la información que pude encontrar sobre su trabajo/organización. [Explica tu comprensión de su trabajo]. ¿Me podría confirmar que todo lo que dije es correcto? ¿Hay algo que usted agregaría?

2. Una de las principales metas de la política pública de salud es la equidad en el servicio de salud. Podemos definir este concepto como la distribución justa de los servicios y recursos de salud según las necesidades de las comunidades—especialmente para apoyar a los grupos desfavorecidos. En su opinión, ¿Cuáles son los obstáculos que impiden el tratamiento equitativo de la salud mental para los niños en la población Latina?

   1. Preguntas suplementarias:

      1. Si no es mencionado por el entrevistado: ¿Si es que tiene experiencias directas con estos obstáculos que ha mencionado, ya sea por parte de su pasado personal o por su trabajo, que nos puede compartir sobre esas experiencias?
      2. En su opinión, ¿Qué pasos se deben tomar y que pólizas se deben implementar para abordar estos obstáculos?
      3. ¿Hay algunas campañas importantes en el país que le vengan a la mente las cuales estén apoyando estas iniciativas que menciona?
3. Ahora me gustaría conocer su opinión sobre los obstáculos y respuestas a ellos. A través de nuestra investigación, encontré un énfasis en cuestiones prácticas para la comunidad, como las barreras de idioma, limitaciones financieras, el transporte e incluso las dificultades para encontrar tiempo en el día o alguien para cuidar a los niños durante el tratamiento. En su opinión, ¿Qué pasos podrían tomar líderes de política pública y profesionales médicos para abordar la naturaleza sistemática de tales problemas?

   1. Preguntas suplementarias:

      1. Si no es mencionado por el entrevistado: ¿Qué piensa sobre la telesalud, o específicamente en nuestro caso la terapia virtual, como una herramienta que pueda abordar estos problemas?
      2. ¿Hay alguna limitación para la telesalud que usted vea?
      3. ¿Qué pasos debemos tomar para abordar estas limitaciones?
4. Otros obstáculos comúnmente mencionados en la literatura se podrían categorizar como socioculturales. Estos incluyen el estigma contra el tratamiento de salud mental, la desconfianza en los sistemas de atención médica, y la falta de humildad cultural. En su opinión, ¿Qué iniciativas y pólizas podemos tomar para abordar y superar tales barreras?

   1. Preguntas suplementarias:

      1. Si no lo menciona el entrevistado: ¿Qué piensa sobre las iniciativas de promotoras, o por otro nombre, las trabajadores comunitarias de salud, como respuesta a estos obstáculos?
      2. Si el entrevistado no lo menciona: ¿Qué le parece las medidas adoptadas para llegar a locales comunitarios como escuelas y especialmente las iglesias como una respuesta a estos obstáculos?
      3. ¿Qué limitaciones o cuestiones pendientes ve con este tipo de iniciativas?
5. Ahora me gustaría aprender sobre cómo sería la atención de salud mental creada especialmente para niños de la comunidad Latina. ¿A cuáles componentes específicos de las culturas, tradiciones, valores y perspectivas Latinas deberían adaptarse los especialistas en salud mental?

   1. Preguntas suplementarias:

      1. De ciertas maneras, abordar los obstáculos que impiden el tratamiento equitativo de la salud mental para la comunidad Latina a veces puede implicar cambios en los componentes tradicionales de su cultura. Por ejemplo, es muy común que los Latinos busquen la ayuda de la Iglesia o figuras religiosas antes de la ayuda de profesionales de salud mental. Para algunos, este proceso es problemático, pero para otros es preferible. ¿Usted tiene algunos pensamientos sobre esto?
      2. Si el entrevistado menciona dudas sobre el proceso de aculturación: ¿De qué manera podrán los profesionales médicos y líderes de política pública implementar tales cambios de maneras respetosas?

6. Como pregunta final, ¿recomienda algún otro programa o persona a la que debamos contactar para que nos ayude con este proyecto? ¿Hay algo más que le gustaría compartir con nosotros que podría ser útil para nuestra investigación?

B. LOGIC Model