Strategies to Improve Engagement of Latino Adolescents in Mental Health Research

Abstract

Introduction:

While Latino adolescents of all genders in the US experience inequities in depressive symptoms, suicide attempts, and access to mental health services in comparison to non-Latino White peers, they are underrepresented in adolescent mental health research. Additionally, little has been written on how to best engage Latino adolescents in mental health research. Given that this population has unique developmental and cultural needs, our purpose is to outline strategies for increasing engagement of Latino teens in mental health-focused studies based on lessons learned from three investigators’ programs of research.

Methods:

This manuscript describes the research programs of three bilingual investigators who have dedicated their research careers to addressing mental health inequities of Latino adolescents. We synthesize lessons learned across all aspects of study design, focusing on recommendations to facilitate the engagement of Latino adolescents in mental health research.

Results:

Based on the successes and challenges in our programs of research, we provide four key recommendations to increase engagement of Latino adolescents in mental health research: 1) Become knowledgeable about the values, culture, and language of the local Latino community; 2) Consider recruitment strategies that are inclusive of both clinical and community Latino teen samples; 3) Balance the autonomy of the Latino teen with family values throughout the research process; and 4) Offer flexible data collection options knowing that teens and parents may have various levels of comfort with sharing information about themselves and their mental health.

Conclusion:

Researchers can build upon the lessons from our combined almost 40 years of research experience with Latino adolescents, emerging adults, and parents. Through consideration of these recommendations, the recruitment of diverse groups of Latino teens into mental health research can be bolstered with the goal of generating translatable knowledge to help address mental health inequities faced by this population.

Introduction

Latino¹ adolescents (ages 12–17) in the United States (US) experience inequities in mental health problems and access to mental health services relative to their non-Latino White peers. In 2021, both Latino male teens (30%) and Latina female teens (62%) reported a higher prevalence of depressive symptoms than their non-Latino White male (28%) and female counterparts (55%; Centers for Disease Control and Prevention [CDC], 2022a). Similar patterns are also present for suicidality among Latina female teens, with a higher prevalence of suicide attempts among Latina teens (14%) than non-Latina White peers (12%; CDC, 2022b). Inequities in access to mental health services among Latino teens compound these mental health disparities. In 2023, only 44% of Latino teens experiencing major depression received treatment in comparison to 54% of non-Latino White peers (Substance Abuse and Mental Health Services Administration, 2023). Nationally representative data also demonstrates that Latino teens are more likely to end antidepressant and psychotherapy depression treatments prematurely as compared to their non-Latino peers (Cummings et al., 2019). If left unaddressed, these mental health inequities will likely result in the perpetuation of further health inequities throughout the lifespan for Latino adolescents.

There is a plethora of research highlighting factors that are associated with depressive symptoms among Latino adolescents (McCord et al., 2019). Interpersonal factors include discrimination (Schwartz et al., 2014) and acculturation gap conflict with parents (McCord et al., 2019), particularly around gender roles (Céspedes et al., 2008). Community-level stressors associated with depressive symptoms include context of reception, or how one feels received and treated in their local community (Schwartz et al., 2014). Macro- and system-level stressors included immigration stress, such as the fear of deportation, and acculturative/bicultural stress, or the stress associated with adapting to life in a new country and having to navigate between multiple cultures (McCord et al., 2019; Piña-Watson et al., 2015).

Multi-level factors that play a role in mental health service use disparities include individual and family-level factors, such as knowledge and attitudes toward mental health and treatment-seeking (Lu et al., 2021; Stafford et al., 2020) and lack of health insurance (Lu et al., 2021; Stafford et al., 2020). Healthcare system-level barriers to mental health services include a shortage of bilingual and bicultural mental health providers, as well as isolation from services in more rural areas of the US (Held et al., 2022; Place et al., 2021). Additionally, policy-level barriers related to the passage of exclusionary immigration policies have likely impacted mental health service use among Latino teens. Recent studies have found higher rates of visit cancellations among uninsured Latino children in NC following 2017 US executive actions on immigration enforcement (Cholera et al., 2021), as well as documented fear of applying for public benefits among Latino families after the 2016 US presidential election (Held et al., 2022).

While researchers have documented inequities in mental health concerns among Latino adolescents and explored factors leading to these inequities, the Latino population has been underrepresented in studies of mental health treatments. A review of participant demographics enrolled in clinical trials of depression treatments revealed that Latino individuals only composed 6.8% of participants in adult depression trials, while Latino teens represented 20.9% of participants (Polo et al., 2019). Additionally, only 7.8% of child depression trials included non-English speaking participants, and 2% of trials reported treatment effects according to racial/ethnic group (Polo et al., 2019). Latino youth are also severely underrepresented in suicide-related research. As of writing this manuscript, the literature includes no randomized controlled trials focusing on suicide prevention among Latino youth (Villarreal-Otálora et al., 2019). This underrepresentation of Latino adolescents in trials of mental health treatments has led to a lack of understanding about what types of treatments are efficacious among Latino adolescents specifically. Furthermore, we have a poor understanding of when cultural adaptations to treatment are necessary and would enhance the efficacy of these interventions (Pina et al., 2019). Due to inequities in various mental health concerns among Latino adolescents and their underrepresentation in mental health intervention research, our purpose is to describe various strategies for engaging Latino adolescents in mental health research based on the programs of research of three investigators focused on addressing inequities in depression and suicide among Latino adolescents.

Engaging Latino Populations in Research

There is consensus among researchers working with Latino populations that community engagement is key to successful recruitment of research participants (Brandt et al., 2020; Díaz et al., 2017; Mansfield et al., 2022; Sage et al., 2018; Lopez-Owens et al., 2018; Waheed et al., 2015). Community engagement strategies include community member review of study materials (Díaz et al., 2017; Lopez-Owens et al., 2018; Waheed et al., 2015), partnership with community organizations (Lopez-Owens et al., 2018; Quandt et al., 2016), and employing community partners on the research team (Mansfield et al., 2022). During the recruitment and data collection process, the use of face-to-face recruitment strategies (Mansfield et al., 2022; Quandt et al., 2016; Lopez-Owens et al., 2018; Sage et al., 2018), bilingual and bicultural recruiters and data collectors (Mansfield et al., 2022; Quandt et al., 2016; Díaz et al., 2017; Waheed et al., 2015), and flexible data collection methods and timing (Díaz et al., 2017; Sage et al., 2017; Waheed et al., 2015) have facilitated the successful recruitment and retention of Latino families in research studies. Attending to cultural and contextual factors during the research process is also important. For example, one recent study addressed the hostile sociopolitical climate towards immigrants in the US by partnering with trusted community partners in the recruitment process as well as providing training to add data collectors on how to respond to an Immigration and Customs Enforcement raid if it were to happen in the participant’s home during data collection (Mansfield et al., 2022). Others have written about attending to important cultural values for Latino families such as simpatía (respectful interaction), familismo (emphasis on helping the family unit), confianza (support and trust), and poderismo (power of choice); Díaz et al., 2017; George et al., 2014; Sage et al., 2018; Waheed et al., 2015). While most researchers have documented successful recruitment strategies among Latino adults, parents, and young children, little has been written on how to successfully engage Latino adolescents in studies concerning mental health.

Latino adolescents experiencing mental health symptoms represent a unique research population as they are often at developmental and cultural crossroads. Adolescents undergo cognitive and social changes to become more independent decision-makers while maintaining close ties to family, especially in Latino cultures, which typically value family closeness and interdependence (Fuller & García Coll, 2010). Many Latino adolescents must also navigate differences between mainstream U.S. culture and their family’s Latino culture (Fuller & García Coll, 2010). Pertinent to mental health research are differences in cultural beliefs about mental health conditions between Latino teens and older generations in their family. While mental health issues are talked about more freely amongst young people in the United States, these topics are often still viewed as “taboo” among older generations (Pescosolido et al., 2021) and some Latino immigrant cultures (Malonee et al., 2023). Many Latino family members follow “cultural scripts of silence” regarding mental health and culturally-based stressors (Gulbas & Zayas, 2017, p. 59). This places Latino teens in a unique position in which they may be willing to engage in research related to their mental health, but due to their status as a minor, they are often reliant on obtaining their parent’s permission to take part in a study. This would require teens to make their parents aware of their mental health symptoms, which they may not yet have disclosed due to concerns about judgement or overburdening parents (Stafford et al., 2019). They would also need to get their parent’s support for participation in the research project, which may be difficult for a variety of reasons, such as the stigmatization of mental health within Latino communities, Latino’ mistrust and fear towards government-affiliated systems and researchers related to anti-immigrant climates, competing social and financial demands, and language barriers (Martinez et al., 2016; Shedlin et al., 2011).

For these reasons, developing rapport and trust with both teens and parents is paramount due to the involvement of minors in the research, as well as the sensitive nature of mental health concerns (Zayas et al., 2009). Parents play a significant role in youths’ lives and often are the determining factor as to whether youth participate in research. This is particularly salient for Latinos who often carry collectivist-based beliefs from their families’ countries of origin, where decisions regarding one’s activities are often made within and in consideration of the family unit (Arevalo et al., 2015). Even when parental consent is bypassed, retention of Latino youth in research is largely influenced by parental support and involvement (Villarruel et al., 2006). Thus, Latino parents’ involvement and partnership in Latino youth research need to be accounted for during the study design. Zayas and colleagues (2009) have studied suicidality among Latina adolescents for several decades and have noted several strategies that facilitate recruitment of Latina adolescents in studies of suicide, such as strategic partnerships with established clinics and organizations and building research infrastructure into these settings. Beyond this guidance, few researchers have shared recommendations to increase the involvement of Latino teens and their parents in mental health research (e.g., Villarreal-Otálora et al., 2022).

Methods

Due to the mental health inequities faced by Latino teens in the U.S., there is an important need to involve them in research studies to better understand the inequities they face and to develop interventions to promote mental health equity among this population. To promote equitable inclusion of Latino teens in mental health research, we discuss lessons learned throughout the research process based on three different programs of research focused on promoting mental health equity among Latino adolescents. While we have utilized different methodologies and work with varying populations, our programs of research all have a central focus on promoting mental health equity among Latino young people through engagement of youth and their families in the research process. We also provide several recommendations for researchers seeking to engage this population in studies of mental health.

Programs of Research

Dr. Stafford’s program of research is focused on addressing inequities in depression and depression treatment use among Latino youth in the United States. Across several qualitative studies, she has investigated the process by which Latina teens experience and self-manage depressive symptoms (N = 25), facilitators and barriers to depression treatment use among Latino teens (N = 15 parent-teen dyads and N = 27 healthcare providers), and preferred implementation strategies to mitigate barriers to depression treatment use among Latino teens (N = 11 youth; N = 8 parents; N = 8 healthcare providers; Stafford et al., 2019; Stafford & Draucker 2020; Stafford et al., 2024). She has primarily engaged Latina female adolescents aged 13–17 and their parents in this research but has also recruited healthcare providers, Latino male teens, Latine/x non-binary teens, and Latino young adults for her research. She has recruited in local communities in the US Midwest and Southeast, as well as nationally, and utilized a variety of recruitment strategies in community, primary care, and online settings to engage participants in her research.

Dr. Pulgar’s research agenda aims to expand our knowledge on suicide and suicide prevention in Latino youth (10–18) and emerging adults (18–24), using a culturally based model to explore protective, risk and strengths factors needed to be included interventions to reduce suicide rates in this population. Her dissertation is the steppingstone for this work (Pulgar, 2021) where she found that over 70% of her sample (N = 150) reported having thoughts of suicide in the past year. For this study, she used web-based recruitment, fliers, social media, and her professional and personal networks. Her past work has also focused on depression rates for farmworkers mothers (Pulgar et al., 2016; N = 248 child-mother dyads) and diet quality among Latino farmworker children (Quandt, et al., 2016; N = 237).

Dr. Villarreal-Otálora’s research centers around the sensitive topic of suicide among Latino adolescents, aged 10 to 18, in the United States, primarily focusing on their caregiver’s suicide-related prevention communication (SPC). Her research directly involves Latino caregivers and inquires into their understanding, comfortability, and use of potentially life-saving skills (e.g., asking their adolescents about their mood, directly asking about suicide, securing lethal means access). She has substantive experience recruiting and retaining Latino research participants and health professionals working with this population in exclusionary anti-immigrant policy climates through online-platforms (Held et al., 2022; Villarreal-Otálora et al., 2022a,b). The most recent study situated in an exclusionary immigrant-policy climate in which she recruited Latino immigrant caregivers was a two-phased mixed method sequential nested design project conducted during the COVID-19 pandemic (see Villarreal-Otálora et al., 2022a,b,c). That project relied heavily on online-based recruitment (e.g., social media, WhatsApp) and used quantitative and qualitative data collection methods. Phase 1 of the project consisted of a Qualtrics-based survey for which she employed a multi-strategy three-part recruitment approach: (1) community gatekeeper recruitment, (2) responsive-driven advertisement, and (3) flyer distribution at Latino public-serving sites. The data recruitment efforts for Phase 1 yielded a sample size of 133 survey responses. Phase 2 of the project consisted of in-depth interviews via Zoom, for which she used a purposive sampling approach to recruit a sub-sample of Phase 1 participants. Recruitment efforts for Phase 2 yielded a sample size of 22.

Results

Based on our collective experience conducting research with Latino teens for studies of mental health, we share various lessons learned across the stages of the research process, including project planning, recruitment, study enrollment, safety and distress protocols, and data collection, highlighting the various successes and challenges encountered in each phase. Across our studies, we have enrolled various sample sizes due to differing methodologies (e.g., cross-sectional quantitative, grounded theory, qualitative description), but we describe our successes and challenges in relation to our ability to meet enrollment targets over time.

Project Planning

Recognizing the importance of confianza (trust) and personalismo (personal connection), all of our projects begin with engagement of community organizations and incorporating a personal touch throughout the research process (García et al., 2020). Strategies that have fostered building such relationships include providing direct services to the community, volunteering at local programs, and drawing upon established connections to find community partners with shared interests. For example, Dr. Pulgar has fostered relationships with local pastors, leaders, teachers, therapists, and volunteers who are able to help spread the word about her studies over the past twenty years, and before starting her research career, Dr. Villarreal-Otálora spent five years providing direct social work services to the Latino community, building a lengthy Latino network consisting of various community stakeholders. Dr. Villarreal-Otálora has also continued to provide direct social work services to the Latino community, allowing for the continuation of trust and collaboration. When beginning her research career, Dr. Stafford began by volunteering at events, such as a local summer camp for Latino teens, to learn about the community and begin building trusting relationships with community members who became consultants on her dissertation research. When moving to a new state for a faculty position, Dr. Stafford then drew upon established Latino health research partnerships between her institution and the community to identify two community organizations with common goals to address mental health inequities among Latino youth, a community mental health clinic and a Federally Qualified Health Center (FQHC).

Throughout each of our programs of research, the process of community collaboration has required humility, patience, and flexibility to shift directions when the research is not going as planned due to slow enrollment or competing community demands, such as the COVID-19 pandemic. For example, when Dr. Stafford and a clinical partner wanted to apply for funding for a joint project, several grant deadlines passed over a period of several months while accommodating the collaborative grant writing and clinic approval process. Eventually, they submitted a grant and received funding for their project when an opportunity arose at the right time.

Recruitment Materials

Over time, we have iteratively developed recruitment materials that are linguistically and culturally aligned with the Latino teens and parents we serve. At the level of language, our teams ensure that all study materials have undergone a rigorous process of translation by native Spanish speakers and are available in both Spanish and English. To add a sense of personalismo, our teams have also incorporated videos into our online recruitment materials that allow the researcher to introduce herself and extend an invitation to participate.

Based on feedback received from Latino families, Dr. Stafford has also adapted her study materials to be more culturally aligned with their views of mental health. For example, she has shifted the language around “depression” on her recruitment materials to be less stigmatizing. Instead of recruiting teens with diagnoses of “depression,” she includes a range of mental health symptoms on her recruitment materials (e.g., Infelicidad/unhappiness, tristeza/sadness, desesperanza/hopelessness, sentirse abrumado/feeling overwhelmed, estrés emocional/emotional stress) and then screens for depressive symptoms with the Patient Health Questionnaire-9 to verify eligibility. This adjustment addressed both the stigmatizing label of “depression” as well as the fact that some Latino teens may not be presenting to primary care to receive diagnoses of depression. Additionally, instead of including photos of teenagers appearing sad on her recruitment flyers and advertisements, Dr. Stafford began using photos of families supporting teenagers, after receiving feedback from Latino parents. These changes contributed to an increase in enrollment a qualitative descriptive study, from only three Latino teens in a years-time to eight additional youth in less than three months.

Recruitment Strategies

Throughout our studies of Latino adolescent mental health, we have utilized a variety of face-to-face and virtual recruitment strategies across several settings, and have experienced varying degrees of success. We discuss these strategies below and summarize their general benefits, challenges, and cost further in Table 1.

Table 1.

Recruitment Strategies and Relevant Considerations

Strategy	Benefits	Challenges	Time Investment	Associated Costs	Success Rate
Face-to-Face Methods
Outpatient Clinic Recruitment	- Can reach teens who meet criteria for a mental health condition. - Provider endorsement can add credibility to the research project.	- Teens may “no-show” to scheduled visits. - Not all teens may be interested in the study. - Clinics have little space for research staff to wait. - Providers may forget to introduce study due to competing demands. - May need both a clinic and University IRB, which can cause delays.	- High time investment including weekly check-ins with providers, travel to and from clinic, and waiting at the clinic for the family.	- Best practice is to compensate clinic/staff for their time. - Wages for research staff to travel to and wait at clinic.	- Moderate success recruiting Latina teens with depressive symptoms in partnership with a FQHC.
Community Event Recruitment	- Can reach teens who may not be presenting to primary care setting. - Good opportunity to network with other local organizations.	- May be difficult to find teens who meet inclusion criteria. - Recruitment is less private which may deter interested families due to the sensitive nature of the research. - Could present ethical dilemmas if teens present with severe mental health symptoms and are not already connected to care.	- Moderate time investment requiring some planning and physical presence of research staff at the event.	- Registration costs for events which can range from free to several hundred USD. - Wages for staff to recruit at the event.	- Good success with recruiting Latino parent-teen dyads for qualitative research at a Latino mental health-focused event.
Community Word-of-Mouth Dissemination	- Community members can add credibility to the research project. - Easy accessibility of research materials to community.	- May be difficult to track the reach of materials. - The more people involved in recruitment, the more chances for potential participants to fall through the cracks.	- Relationships with community members take time to build (months-years), but info could also be distributed quickly.	- If community member is embedded in research team, then part-time wages.	- Good success with recruiting Latina teens for quantitative and qualitative research.
Flyer Distribution	- Provision of information about the research in areas that are easily accessible to the community. - Offers opportunity to network with community organizations.	- Cannot easily track the reach of materials. - Does not allow for chance to make personal connection.	- Moderate time investment including printing materials and travel through the community to place materials	- Cost of printing materials - Wages of staff to distribute.	- Moderate success in recruitment Latina young adults with depression for qualitative research.
Virtual Methods
Electronic Health Record (EHR) Messaging	- Can reach teens who meet inclusion criteria and may not be coming to in-person clinic visits. - Can track the reach of messages.	- Teens may not check the online EHR system to open the message.	- Requires several hours of planning to identify appropriate inclusion criteria. - Messages can reach many patients in a short time.	- Cost to hire an analyst to query EHR for potential participants and send messages.	- No success for recruiting Latino teens with depression for qualitative research.
Research Recruitment Platforms	- Can reach a large number of potentially eligible participants who have a committed interest in research participation.	- Only adults enrolled on platforms. - Some users appear to be bots. - Sample may differ from general population in awareness of research.	- Requires a few hours of planning with the potential for reaching hundreds of potentially eligible participants in a short time frame.	- Research Match – Free - Prolific - Prices varies depending on sample size needs.	- Some success recruiting Latino parent-teen dyads for qualitative research. - Good success for Latino emerging adults for survey research.
Community WhatsApp and Facebook Groups	- Can reach many potentially eligible participants. - WhatsApp groups are Latino parents’ most common form of communication regardless of acculturation levels. - Does not require access to a data plan.	- Difficult to track how participants are learning about a study. - Can lead to issues with bots in survey research.	- Requires several hours of planning to identify appropriate groups and create posts that can be tracked.	- Free	- High success in recruiting Latino parents of teens in quantitative on suicide prevention.
Facebook and Instagram Ads	- Large reach to potentially eligible families. - Facebook is commonly used by Latino parents, while Instagram is more popular among teens.	- Facebook recruitment strategies can reach a large audience but are not specific to mental health concerns. - IRB may require parental consent before communicating with teens, precluding teens from indicating interest in the study.	- Requires several hours of planning to identify appropriate inclusion criteria. - Ads can reach many in a short time. - Requires learning the platform if not using a social media consultant.	- Cost of ads is flexible event with smaller budgets (e.g., under $500 USD). - May need to hire social media consultant.	- Low success in recruiting Latino parent-teens dyads for qualitative research on depression.

Face-to-Face Strategies.

Our teams have engaged in face-to-face recruitment in both community and clinical settings. Community settings represent important recruitment venues since not all Latino teens may present to clinical settings and receive diagnoses of mental health conditions. Clinical outpatient settings, particularly federally qualified health centers (FQHCs), can also be good partners in face-to-face recruitment since they are important safety net systems for immigrant health in the United States (Lee et al., 2024). We discuss a variety of recruitment methods employed across these settings including community events, word-of-mouth referrals, flyer distribution, and clinic recruitment.

Community Events and Word-of-Mouth Referrals.

Drs. Stafford and Villarreal-Otálora have experienced success recruiting from community settings for their qualitative and quantitative research studies, especially when community organizations are embedded in the research team. For example, Dr. Villarreal-Otálora was able to enlist Latino stakeholders at various Latino servicing organizations in the area (e.g., Spanish-speaking social service agencies, Latino-plazas, Latino neighborhood associations, and Latino non-profit local agencies) to refer possible participants. She was able to immerse the stakeholders in the project by involving them in the development of the study questionnaires and providing them with preliminary findings in the form of infographics. Dr. Stafford has employed and collaborated with community consultants on her research team who worked for local Latino health non-profits. These individuals would provide feedback on study recruitment procedures, directly refer teens and parents who were being served by community programs to the study, and recruit families from local Latino community events (e.g., health fairs, cultural celebrations). Around a third of Dr. Stafford’s dissertation sample (8/25 Latina youth participants), and most of the teens in her latest ongoing qualitative study (8/11 Latino youth participants) were recruited using this community-based face-to-face approach.

Flyer Distribution.

Our teams have generally experienced little recruitment success with the passive strategy of posting flyers in community settings. For example, Dr. Stafford posted dozens of flyers for her dissertation research directing individuals to contact her about participation in the study at Latino-serving community organizations, churches, and public libraries. However, only flyers placed on college campuses resulted in participant enrollment, perhaps due to the established familiarity with research in university settings.

Outpatient Clinic Recruitment.

Dr. Stafford has been able to successfully recruit Latina female teens with depression from clinical settings when partnering directly with a pediatric or behavioral health champion in Federally Qualified Health Centers (FQHCs) and being present on the day of the participant’s visit to the clinic. Dr. Stafford would check in with champions on a weekly basis and come to the clinic for face-to-face recruitment on the day of the potential participant’s appointment, both as a reminder of the study to the provider and to establish trust with the potential participant and their family. While some families were absent on the day of the appointment, Dr. Stafford was still able to recruit one-third of her dissertation research participants using this method (8/25 participants).

We have also experienced many challenges recruiting in clinical settings. Community health centers, such as FQHCs, represent important points of healthcare for immigrant populations, but often lack infrastructure and resources to partner in research efforts (Brandt et al., 2015; Lee et al., 2024). For example, Dr. Villarreal-Otálora had difficulties recruiting in privately and publicly funded behavioral health clinics due to issues with IRB reciprocity between the clinic’s IRB and the university’s IRB. Even after IRBs were duplicated, clinic staff provided very few referrals. Her success in this setting was mostly found in privately funded not-for-profit clinics, such as family violence centers and child advocacy centers. Dr. Stafford also attempted to recruit Latino teens diagnosed with depression virtually at an FQHC with little success during the COVID-19 pandemic. When Dr. Stafford was no longer able to physically come to clinic appointments to recruit potential patients for a qualitative descriptive study, her enrollment slowed by half, from one participant per month to one every two months.

Online settings.

We have also used various types of online engagement to recruit Latino teens and their parents for our research including electronic health record messaging, social media and WhatsApp groups, social media advertisements, and online research recruitment platforms.

Electronic Health Record (EHR) Messaging.

In a qualitative descriptive study of Latino teens’ experiences of depression treatment, Dr. Stafford attempted to recruit using EHR messaging in an academic medical center. She worked with information technology to identify teens who might be eligible for the study from data in the EHR. Of the 62 teens who were potentially eligible and sent messages in their portal about the study, only six teens opened the message, and none completed the enrollment survey.

Facebook and WhatsApp Groups.

Dr. Villarreal-Otálora has successfully used existing social media and WhatsApp groups to recruit parents of Latino youth for quantitative research with good success. Most of the WhatsApp groups that Dr. Villarreal-Otálora was granted access to were moderated by individuals who learned about the project through community organizations. For example, one individual reached out to her after learning about the project through a non-profit community organization that works to empower the Latino immigrant community in a specific catchment area (Bufford, GA) “by bringing resources directly to families in apartment complexes in the community, tenant’s rights, and creating future leaders throughout the vibrant corridor” (Los Vecinos, 2024). This individual had started a WhatsApp group for Latino parents that were part of the organizations catchment area and granted Dr. Villarreal-Otálora access to the group. Dr. Villarreal-Otálora was able to recruit 50% of a Latino parent sample to participate in suicide-related research through online groups such as these, and this strategy resulted in 77 complete survey responses over a month. In her research, Dr. Villarreal-Otálora also observed higher enrollment for Latino parents of teens that learned about the study through a community organization’s (non-profit grassroots neighborhood serving agencies) local WhatsApp group than those that learned about the study through clinical staff. Additionally, participants who were recruited to the study by a friend or family member were more likely to complete survey data collection than those recruited by mental health providers (64% v. 5%).

While Dr. Villarreal-Otálora was able to successfully use WhatsApp to enroll Latino parents in her study, similar strategies with Facebook groups were less successful for Dr. Stafford. In recruiting Latino teen-parent dyads for a qualitative descriptive study, Dr. Stafford reached out directly to facilitators of Latino parent groups and individuals running Latino mental health-focused pages on Facebook. While many of the group moderators agreed to share her recruitment flyer with their members and connected her with other relevant groups, ultimately no participants were enrolled using this approach.

Social Media Advertising.

Dr. Stafford has used social media advertisements for her research with little success. While her Facebook and Instagram advertisements garnered hundreds of clicks per week, she was only able to enroll two parent-teen dyads from social media recruitment across two months of advertising. Additionally, while many teens completed the initial interest survey using the link in the ad, she was only successful in enrolling dyads from social media ads when the parent filled out the enrollment form, underscoring the importance of engaging parents in the recruitment process.

Online Research Platforms.

We have also had mixed success recruiting Latino teens and parents from online recruitment platforms such as Research Match and Prolific. Dr. Villarreal-Otálora recruited most of her dissertation sample of Latino emerging adults via Prolific (Palan & Schitter, 2018), an online subject recruitment platform. It combines rigorous recruitment standards with reasonable cost and explicitly informs participants that they are recruited for participation in research. While Dr. Stafford was able to successfully enroll four out of seven Latino parent-teen dyads for a qualitative study using the Research Match platform in 2021, she encountered issues with internet bots attempting to complete the screening survey in a second study conducted in 2023 and was only able to enroll one participant.

Enrollment and Consent

We have modified several aspects of the consent and enrollment process to meet the cultural and language needs of Latino families, as well as to consider the developmental needs of teens.

Language and Cultural Considerations.

Across our studies, all individuals involved in the research process are bilingual in Spanish and English, and thus, can communicate with families without the need for an interpreter. Additionally, Dr. Villarreal-Otálora has incorporated a video option during the enrollment process instead only providing a written study information sheet. She found that 77% of the parents choose the video option as opposed to the written option. Across our teams, we also apply for waivers of written consent to minimize the content that needs to be read and the need to sign a legal document, which may be a concern for participants who are undocumented.

Adolescent Developmental Considerations.

Dr. Stafford also has employed several measures to provide teens with autonomy throughout the research process. During recruitment, Dr. Stafford requests to speak with the teen first about the study, and if the teen is interested, then asks for their permission to speak with the parent. During the consent process, she is also very clear about any instances in which she would have to break the teen’s confidentiality (e.g., suicidality and child abuse concerns) and what would happen in these instances. In online recruitment, Dr. Stafford also developed separate advertisements allowing both teens and parents to make the first contact. However, Dr. Stafford was only able to successfully enroll teens from online platforms in the study when the parents, not teens, made the first contact.

Safety and Distress Protocols

Due to the nature of mental health research, we have all developed safety and distress protocols if any concerns become apparent during the research process. Over time, the protocols have been adapted to better address stigma towards mental health concerns and provide additional mental health supports beyond what may be needed in studies of adolescent depression in general populations.

Dr. Stafford uses a modified version of an adolescent distress protocol (Draucker et al., 2009), which includes: 1) pausing the interview/data collection if thoughts of self-harm or suicidality are being exhibited; 2) conducting an assessment to determine if there are imminent safety concerns (e.g., suicidality or self-harm); and 3) follow up actions such as providing resources, offering a follow up call to check in the next day, informing the parent of the concern, and immediate transport to ED for imminent suicidality (by family member if possible). This protocol has been modified to better anticipate stigma towards suicidality and provide resources for families knowing that many Latino teens may not have access to mental health services. First, teens and parents are informed during the consent process of the safety and distress protocol that will be followed if the teen shares any information that may put them at a safety risk. When a safety concern is discovered, Dr. Stafford has a private discussion with the teen about the situation, including how they think their parents might respond to learning about the safety concern. Dr. Stafford then facilitates a discussion between the parent and teen, encouraging the teen to share as much as they are comfortable with about their thoughts and experiences with their participating parent to help them understand their perspective.

Knowing that many Latino teens may not be connected to a mental health provider, Dr. Stafford has modified this protocol to provide additional resources to families. She shares a mental health promotion handout in English and Spanish developed by the Pan American Health Organization and a list of local mental health resources with any teens experiencing safety concerns. The resource list includes local mental health providers who are bilingual and can provide therapy with a sliding scale fee, as well as the crisis hotline number and information about the local non-violent behavioral health crisis response team. Additionally, Dr. Stafford, who is not a trained mental health provider, has a psychologist on her team who is available for consultation if there is an imminent safety concern.

Data Collection

Our teams have prioritized methods that allow for flexibility and comfort given that Latino families often have many competing demands and may be skeptical of researchers. Dr. Villarreal-Otálora surveyed mothers (N = 22) in one of her studies and found that many preferred a two-step data collection process which allowed for soft introductions of mental health research. Per the mothers, given their view of the subject as being taboo and sensitive, they preferred to first fill out a topic-focused questionnaire without the presence of the investigator, and then be spoken to directly by the investigator via phone, in person, or via zoom.

We also have learned that families have different preferences regarding the format of data collection. For example, most of the mothers in Dr. Villarreal-Otálora’s study liked the Zoom format because it was practical and convenient. However, some mentioned negative feelings about using zoom as an interview method due to issues with connectivity. To increase flexibility of data collection methods, Dr. Stafford has started offering multiple options for qualitative data collection with Latino parent-teen dyads including: 1) In-person interviews at public libraries or community centers with availability on evenings and weekends; 2) Zoom interviews with available options on nights and weekends; and 3) qualitative open ended surveys with video explanations by the researcher for those participants who are not comfortable with live data collection. We also ensure participants’ confidentiality as much as possible by getting waivers of Social Security Numbers for participant compensation, collecting only as much identifiable information as needed, and not requiring signatures on consent or other documents. Additionally, we ensure that participants are compensated for their time, an average of $30–50 an hour, in the form of a digital gift card.

Discussion

Given the mental health inequities faced by Latino youth and their underrepresentation in studies of adolescent mental health, we have discussed our successes and challenges in recruitment of Latino teens and their parents to inform researchers who seek to engage this population in mental health research. Others have written about how to engage Latino families in research, but we add to this body of literature by describing how the unique needs of Latino families, such as mental health stigma, resource access, and language, intersect with adolescent development, to necessitate unique approaches to recruiting Latino teens and their parents in mental health research.

Our recruitment strategies were most successful when we drew upon existing networks and trusted resources in our local communities. We engaged trusted individuals, such as healthcare providers or community advocates, who were able to spread news of the study via word-of-mouth or help us recruit at local events. We also engaged trusted local networks, such as existing WhatsApp groups, that could disseminate study information. Recruitment activities were less successful when they were built from the ground up and dissociated from any sort of trusted individual or community network, such as EHR messaging and social media advertisements.

The success of our recruitment strategies also differed by the study population and type of methodology used. For example, Dr. Villarreal-Otálora was able to successfully recruit 77 parents of Latino teens in a month’s time for a quantitative study concerning suicidality using an established WhatsApp group. However, Dr. Stafford was unable to recruit Latino teens and their parents for qualitative interviews about teen depression via existing Facebook groups associated with Latino families and mental health. This may be partially due to the nature of the research studies and the involvement of dyads vs. individuals in the research process. Qualitative interviews are often more time-intensive and require more intimate data collection than quantitative surveys, which may deter individuals from participating in a project on a sensitive mental health topic. Additionally, to recruit dyads for a study, both parent and teen must agree to participate. In Dr. Stafford’s research, this was often a barrier to participation, in which one person in the dyad (either parent or teen) wanted to participate, but the other did not. In replicating any strategies used in our studies, researchers should consider the methods as well as the population they would like to recruit.

We enhanced the success of recruitment through being mindful of language about mental health throughout the research process. When possible, we use culturally appropriate terms to describe distress (e.g., “stress”, “overwhelm”, “sadness”) instead of labeling adolescents with a more stigmatized term (e.g., “depressed”). We also try to mirror the language that the family uses to describe the problem instead of placing our label on the issue. When confidentiality must be broken with adolescent participants, such as in the case of suicidal ideation, we aim for collaboration between the data collector, teen, and parent to ensure the best outcome for the teen.

Recommendations

Due to the mental health inequities experienced by Latino youth in the areas of depression, suicide, and mental health treatment utilization, strategies are urgently needed to bolster recruitment of this population into research studies that aim to address these inequities. We offer four key recommendations based on the challenges and successes of our own research (See Table 2).

Table 2.

Recommendations for Conducting Research with Latino Teens on Mental Health

1.	Become knowledgeable about the values, culture, and language of the local Latino community.  - Get involved in community events and volunteer opportunities.  - Hire community members onto the research team.  - Personalize recruitment and data collection processes based on knowledge of values and culture.
2.	Consider recruitment strategies that are inclusive of both clinical and community samples of Latino teens.  - Partner with local clinics who see a high proportion of Latino families.  - Form relationships with key community organizations that serve the local Latino community.
3.	Balance the autonomy of the teen with family values throughout the research process.  - Take care not to “out” teen’s mental health struggles to family members in the recruitment process.  - When handling safety or suicide concerns, allow teen to control the flow of information as much as possible.  - Recognize that data collection may be more successful when parents can also be involved in the process.
4.	Offer flexible data collection options knowing that teens may have various levels of comfort with sharing information about themselves and their mental health.  - Consider the topic of the study and depth of data collection.  - Allow teens and parents to have options for data collection that prioritize their comfort while maintaining rigor in the research process.

First, researchers need to ensure that they are knowledgeable about the values, history, culture, and language of the specific Latino population with which they are working. This should begin before a research project starts. Researchers can begin this process through attending local events, volunteering with Latino community organizations, and networking with local Latino leaders. Because it is not possible for an outsider to be completely in tune with the needs of the local community, researchers should also partner with community members who can advise them throughout the research process. For example, they can help inform research priorities, ensure that important cultural values are integrated throughout the research process, and inform how the study findings can be used to enhance work in the community.

Our second recommendation is to consider recruitment strategies that are inclusive of both clinical and community samples of teens. Since Latino teens may not be presenting to primary care and/or disclosing their mental health concerns in these settings, it is important for researchers to recruit from both community and clinical settings to ensure that diverse groups of Latino youth are represented in their research on mental health. In the clinical setting, FQHCs and community clinics that see a large proportion of Latino families may be good partners. Local organizations that serve the Latino community and have a focus on mental health education or services are also important sources of collaboration. As with all community-engaged projects, researchers should thoughtfully nurture these relationships over time and consider how they can offer valuable resources and information back to the partnering organizations.

We also recommend considering ways that researchers can balance the autonomy of Latino teens with family involvement in the research. Due to the stigma towards mental health issues, researchers should think carefully about how they will determine which teens are eligible for the study and how they will present the nature of the research as to not “out” a teen who may be experiencing mental health concerns of which their family is unaware. Another way to promote the teen’s autonomy is to allow them to control the flow of information with the parent if any suicide or distress concerns arise during the research. Because the role of the family is so crucial in the Latino culture, researchers also need to consider how parents will be involved throughout the research process, including being invited to participate themselves.

Finally, we recognize that Latino families often have competing demands and may be wary of taking part in mental health research studies. For this reason, we recommend that researchers offer a variety of options for how data collection can proceed. It might be helpful to offer a “soft introduction” to the topic of the study that is done virtually before doing any live data collection. While focus groups might be appropriate for some populations, others may not be comfortable sharing in a group setting. Individual interviews or open-ended surveys may be better options, especially for teens who may be wary of sharing personal information with a stranger or group about their mental health. Through this process, researchers need to be flexible in response to the flow of data collection and feedback from participants.

Conclusion

Latino adolescents experience mental health inequities, particularly in the areas of depressive symptoms, suicide attempt, and mental health service use. Underrepresentation of Latino adolescents in mental health research has not helped to improve these inequities, and in some cases, may have contributed to worsening them. Researchers can build upon the lessons learned from our combined experience conducting research with Latino adolescents and parents. Through consideration of our recommendations, the recruitment of diverse groups of Latino teens into mental health research can be bolstered with the goal of generating translatable knowledge about both the etiology of mental health inequities and solutions to address them that will ultimately promote mental health equity among this population.

Data Availability Statement:

The data that support the findings of this study are available from the corresponding author upon reasonable request.