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. Author manuscript; available in PMC: 2014 Oct 11.
Published in final edited form as: Am J Orthopsychiatry. 2014 Jul;84(4):353–363. doi: 10.1037/h0099844

Family Culture in Mental Health Help-Seeking and Utilization in a Nationally Representative Sample of Latinos in the United States: The NLAAS

Alice P Villatoro 1, Eduardo S Morales 2, Vickie M Mays 3
PMCID: PMC4194077  NIHMSID: NIHMS629989  PMID: 24999521

Abstract

Considering the central role of familismo in Latino culture, it is important to assess the extent to which familismo affects mental health help-seeking. This study examined the role of behavioral familismo, the level of perceived family support, in the use of mental health services of Latinos in the United States. Data come from the National Latino and Asian American Study (NLAAS), a representative household survey examining the prevalence of mental disorders and services utilization among Latinos and Asian Americans. Analyses were limited to Latino adults with a clinical need for mental health services, indexed by meeting DSM–IV diagnostic criteria for any mood, anxiety, or substance use disorder during the past 12 months (N = 527). One-third of Latinos with a clinical need used any type of service in the past year, including specialty mental health, general medical, and informal or religious services. High behavioral familismo was significantly associated with increased odds of using informal or religious services, but not specialty or medical services. Self-perceived need and social perceptions of need for care within close networks (i.e., told by family/friends to seek professional help) also were significant predictors of service use. These results carry important implications toward expansions of the mental health workforce in the informal and religious services settings.

Keywords: Latinos, Familismo, Mental Health Services, Disparities, Perceived Need

Latinos represent the fastest growing racial/ethnic minority group in the United States. In the past decade alone, the population of Latinos has increased by 43%, and they currently make up 16% of the total U.S. population (Humes, Jones, & Ramirez, 2011; U.S. Census Bureau, 2011). Projections suggest that Latinos will make up approximately 25% of the nation’s total population by 2050, with certain states expecting Latinos to represent the majority of its residents much sooner: New Mexico by 2015, Texas by 2027, and California by 2042. In light of this projected population growth and the activation of the Patient Protection and Affordable Care Act (ACA), there is an emerging necessity to be better prepared to address the mental health needs of Latinos, particularly in the use of mental health services given the passage of parity for mental health and substance abuse services (Mechanic, 2011). The Surgeon General’s report on mental health estimates that fewer than one in 11 Latinos with mental disorders have contact with mental health specialists, and fewer than one in five contact general health care providers for a mental health-related problem (DHHS, 2001). It is expected that as a function of the ACA greater attention will be paid to the screening and treatment of mental health concerns within the primary care setting. Therefore, research that examines the barriers, especially culture-specific barriers, in service utilization among Latinos is imperative to ensuring equity in mental health care treatment and services.

Epidemiological studies such as the National Latino and Asian American Study (NLAAS; Alegría, Takeuchi, et al., 2004) have shown that approximately 60% of Latinos meet diagnostic criteria for any lifetime mood, anxiety, or substance use disorder, including 30% who meet criteria for any past-year psychiatric disorder (Alegría, Mulvaney-Day, Torres, et al., 2007), which are comparable with patterns observed among non-Latino Whites (Breslau, Aguilar-Gaxiola, Kendler et al., 2006; Grant, Stinson, Hasin et al., 2004). Although in the aggregate Latinos demonstrate lower risk of most psychiatric disorders than non-Latino Whites, they exhibit higher prevalence of affective disorders and active mental health comorbidities (Kessler et al., 1994) and have higher prevalence of persistent mood disorders compared to non-Latino Whites (Breslau, Kendler, Su, Gaxiola-Aguilar, & Kessler, 2005). Findings from the NLAAS also highlight differences in the prevalence of mental disorders within the Latino population. For example, although Latinos of Mexican descent represent the largest subgroup of U.S. Latinos, Puerto Ricans have significantly higher prevalence of any lifetime and past-year psychiatric disorder compared with other Latino subpopulations (Alegría, Mulvaney-Day, Torres, et al., 2007). Empirical evidence also points to the healthy immigrant effect within mental health, as U.S.-born Latinos are more at risk of having a past-year psychiatric disorder than foreign-born Latinos (Alegría, Canino, et al., 2008; Alegría, Mulvaney-Day, Torres, et al., 2007).

Despite the mental health needs of Latinos, their participation in mental health services lags behind that of the general population (Alegría et al., 2002; Alegría, Chatterji, et al., 2008). Among individuals meeting diagnostic criteria for a past-year depressive disorder, 64% of Latinos versus 40% of non-Latino Whites do not use any form of mental health service (Alegría, Chatterji, et al., 2008). Similarly, Latinos are more likely to have less mental health care than needed as well as delayed and less active care than non-Latino Whites (Wells, Klap, Koike, & Sherbourne, 2001). Even when Latinos have similar observed characteristics as non-Latino Whites, Latinos continue to be less likely to access and receive adequate depression treatment (Alegría, Chatterji, et al., 2008).

Although studies have identified costs of care (Alegría et al., 2002; Cabassa, 2007), organizational barriers like workforce shortages (Vega & Lopez, 2001) and the supply of mental health facilities (Cabassa, Zayas, & Hansen, 2006), beliefs and attitudes about mental health services (Cabassa & Zayas, 2007), and cultural barriers such as language of services (Alegría, Mulvaney-Day, Woo et al., 2007; Sentell, Shumway, & Snowden, 2007) as critical factors in service utilization by Latinos, little focus has been placed specifically on the role of family in the mental health help-seeking process. Prior work has examined the importance of including Latino families in mental health interventions and treatment (Bernal, 2006; Bernal & Flores-Ortiz, 1982; Bernal & Sáez-Santiago, 2006), but not necessarily in the context of help-seeking. The current study examines the role of the Latino family value of familismo (i.e., the importance of family) in the context of perceived family support on the use of mental health services among Latinos with a demonstrated need for mental health care.

Understanding Underutilization of Mental Health Services

There are two theoretical frameworks relevant for understanding the issues that undergird the underutilization of mental health services by Latinos in need of care: barrier theory and alternative resource theory (Rogler & Hollingshead, 1985; Rogler, Malgady, & Rodriguez, 1989). Barrier theory suggests that institutional barriers relating to characteristics of the mental health system (Kouyoumdjian, Zamboanga, & Hansen, 2003; Woodward, Dwinell, & Arons, 1992) and cultural barriers concerning cultural values and norms deter Latinos from using formal mental health services (Cabassa, Lester, & Zayas, 2007; Ramos-Sánchez & Atkinson, 2009). For example, insufficiencies in language of services within mental health facilities (e.g., lack of interpreters or lack of available information in the language of preference) are of concern for Latinos with limited English language proficiency trying to access mental health services (Alegría, Mulvaney-Day, Woo et al., 2007; Barrio et al., 2008; Sentell et al., 2007). Other barriers to mental health care include lack of insurance coverage, immigrant status, and poor economic resources (Alegría, Mulvaney-Day, Woo et al., 2007; Vega, Kolody, Aguilar-Gaxiola, & Catalano, 1999).

Alternative resource theory, on the other hand, suggests that prominent social organizations enmeshing Latinos—the family, friends, and so forth—act as alternative resources to formal mental health services for coping with emotional distress and other mental health-related problems (Rogler & Hollingshead, 1985; Rogler et al., 1989). For example, there is a perception in the Latino community that mental health services are only for persons who are severely disturbed and not meant for persons who are functioning but facing various stressors (Alvidrez, 1999; Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007). In this context, seeking mental health services can be seen as a stigma rather than a resource. Consequently, Latinos in need of mental health care may be more receptive to seeking help from family and friends whom they can trust and confide in (Alvidrez, 1999; Keefe, Padilla, & Carlos, 1979), as well as seek help from more culturally accepted resources such as folk healers or religious-oriented services (Kane & Williams, 2000; Loera, Muñoz, Nott, & Sandefur, 2009). Thus, the underutilization of mental health services as observed by Latinos would not solely be because of barriers to care, but also may result from the resourcefulness of supportive familial and social networks that help with the coping of emotional distress.

Latino Familismo and Mental Health Service Utilization

A core value in Latino culture relevant to the pathway of seeking mental health services is familismo (Rogler et al., 1989). Familismo places a strong emphasis on an individual’s identification and attachment to nuclear and extended family members, which includes attributes of loyalty, reciprocity, and solidarity (Sabogal, Marín, Otero-Sabogal, Marín, & Perez-Stable, 1987; Triandis, Marín, Betancourt, Lisansky, & Chang, 1982). Three key tenants of familismo are: (a) familial obligations— commitment to provide material and emotional support to family members; (b) perceived support from family—perception of family members as reliable providers of help and support to solve problems; and (c) family as referents—family members serving as role models (Sabogal et al., 1987). In essence, the family acts as a natural support system for Latinos as family members are important sources of emotional support and advice-giving during times of emotional distress (Keefe et al., 1979; Sabogal et al., 1987; Snowden, 2007). However, this support system is not solely limited to immediate family members, but also crisscrosses blood relationships and includes extended relatives and fictive kin (Rogler et al., 1989). As a consequence, discussing emotional problems with individuals outside the family support system would not be consistent with the cultural values of familismo as it may bring shame on the family (Alvidrez, 1999; Cabassa, 2007; Ramos-Sánchez & Atkinson, 2009; Sabogal et al., 1987). For this study, we examined the effect of Latino familismo on service utilization in the context of perceived support from family.

The specific role of family support on the use of mental health services among Latinos is not well understood. Few empirical studies in this area exist, resulting in unclear findings as most of these studies have been couched under the larger framework of social networks—which include family, friends, coworkers, and so forth. Empirical evidence suggests that Latinos with highly supportive social networks are less likely to use formal mental health services than those with less supportive social networks (Golding & Wells, 1990; Hansen & Aranda, 2012; Miville & Constantine, 2006; Pescosolido, Wright, Alegría, & Vera, 1998; Snowden, 2007). In such cases, the help-seeking behaviors of Latinos may be delayed because of their preference to trust and confide in reliable and supportive family and friends before considering a mental health professional that carries the stigma of mental disorders (Cabassa, 2007; Cabassa & Zayas, 2007). Additionally, nonuse of services may be a reflection of the supportive network’s negative attitudes toward mental health providers and treatment modalities (e.g., psychotropic medications) as well as distrust of the services themselves (Cabassa, Hansen, Palinkas, & Ell, 2008). Alternatively, other studies suggest the absence of a supportive family or social network may lead to increased use of services as a way of searching for and enhancing human support (Abe-Kim, Takeuchi, & Hwang, 2002; Sherbourne, 1988).

Studies also point to the influential nature of social networks in utilizing mental health services (García, Chang, Young, López, & Jenkins, 2006; Vera et al., 1998; Vogel, Wade, Wester, Larson, & Hackler, 2007). A study of Puerto Ricans on the island found that among individuals who self-recognized a mental health problem, discussing emotional problems with family and friends was strongly associated with use of formal mental health services (Vera et al., 1998). Similarly, it was also common for Puerto Ricans with highly supportive social networks to seek help from mental health specialists in combination with family and friends and other health professionals (Pescosolido et al., 1998). In addition, family support has been linked to improvements in medication adherence among Mexican Americans with schizophrenia (García et al., 2006). This persuasion to use mental health services and adhere to treatment modalities may be a product of information or advice from supportive family members and friends (Vogel et al., 2007).

Other studies suggest that perhaps these social networks may not always represent the most optimal sources of information about mental health care as there is a concern about the misconceptions and lack of knowledge of formal mental health services in the Latino population (Vega et al., 1999). As an alternative to formal mental health services, family and friends may prefer to recommend folk healers or religious-oriented services for mental health-related problems (Kane & Williams, 2000; Loera et al., 2009). Given religion’s prominent role and acceptability in the Latino culture and community (Campesino & Schwartz, 2006; McField & Belliard, 2009; Taylor, Lopez, Martínez, & Velasco, 2012), these services may be less stigmatizing to Latinos in need of care as compared to formal mental health services.

Lastly, the family or social network of Latinos can also help the individual identify a need for mental health care, particularly when the burden of mental illness is perceived to create undue stress and disruption to the group (Alegría, Chatterji, et al., 2008; Cauce et al., 2002). Although perceiving a personal need for care is a strong indicator of utilization (Mojtabai, Olfson, & Mechanic, 2002), few studies have examined the influence of perceptions of need by family members. Although alternative resource theory posits supportive Latino families serve as substitutes for formal mental health care, it is not known whether perceptions of mental distress by the family will influence mental health utilization.

Study Aims

Most studies examining the relationship between family and mental health help-seeking among Latinos are framed in the context of these families as a part of a larger social network, not specifically within families as defined by a cultural framework of familismo. Considering the central role of familismo in Latino culture, it is important to assess the extent to which this family dynamic affects help-seeking for mental distress. In examining the role of familismo on Latino mental health service utilization, there are two dimensions of Latino familismo that need to be addressed. First, although a person without a family may not have actual tangible emotional support from family available, the values and attitudes of familismo (i.e., attitudinal familismo) may still be in effect and influence utilization (Sabogal et al., 1987). For example, an individual with deceased parents raised within the cultural principles of familism may remain reluctant to seek professional mental health services for a mental health concern to avoid bringing shame to the memory of his or her family. Second, there is the behavioral component of familismo (i.e., behavioral familismo) that relates to the actions and behaviors that are associated with attitudes about families (Sabogal et al., 1987). For example, Latinos may choose to seek out help and support from close family members instead of mental health professionals because of the strong trust and confianza (confidence) they have in these individuals. In this study, we focus on the behavioral component of familismo by examining the degree of perceived family support.

The current study examines the effect of perceived family support, our proxy for behavioral familismo, on mental health service utilization in a nationally representative sample of Latino adults who demonstrate a clinical need for mental health care. Using alternative resource theory as the foundation of our theoretical framework, we hypothesized that Latinos with highly supportive families would be less likely to utilize formal mental health services but more likely to use informal services. However, the robustness of this effect would depend on perceptions of need for mental health care from family, friends, and other significant individuals.

Method

Sample

The sample was drawn from the National Latino and Asian American Study (NLAAS), a nationally representative community household survey examining the prevalence of mental disorders and rates of mental health service use among subpopulations of Latinos and Asian Americans residing in the United States (Alegría, Takeuchi, et al., 2004). Data collection took place between May 2002 and November 2003. Only the Latino sample was used in this study.

Latino participants in the NLAAS were 18 years of age or older, living in the noninstitutionalized population of the United States or Hawaii, and were of Latino or Spanish decent. Four Latino subgroups were determined by the respondent’s self-reported ethnicity including Puerto Rican, Cuban, Mexican, and other Latino origins. The NLAAS sampling design included a four-stage national area stratified probability sampling of U.S. Latinos with supplemental samples of Cubans and Puerto Ricans, capturing a nationally representative sample of Latino subpopulations. Details on the sampling design have been published elsewhere (Heeringa et al., 2004). In total, 2,554 Latino respondents were interviewed with an overall response rate of 75.5% (Heeringa et al., 2004). Our analysis was limited to the subsample of Latino adults meeting diagnostic criteria for any past 12-month psychiatric disorder, referred to as the clinical need sample. The family variables used for this study were drawn from an earlier study by Mulvaney-Day and colleagues in which they examined the relationships between social support, social cohesion, and health in Latinos (Mulvaney-Day, Alegría, & Sribney, 2007). Interviews were administered face-to-face by trained bilingual, lay interviewers in the respondent’s language of choice, English or Spanish. Data collection took place between May 2002 and November 2003.

Clinical need for mental health services was defined as meeting diagnostic criteria for any past-year mood disorder that included major depression and dysthymia, anxiety disorder that included generalized anxiety, agoraphobia, social phobia, panic attack, and panic disorder, or substance use disorder that included alcohol or drug abuse/dependence. Bipolar disorder was not assessed in the NLAAS. Psychiatric disorders were evaluated using the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (CIDI), and diagnoses were based upon criteria from the Diagnostic Manual of Mental Health Disorders, 4th edition (DSM–IV; American Psychiatric Association, 2000). There were 538 respondents eligible for the analyses. However, cases with missing data on the variables needed for this study (approximately 2%) were excluded, bringing the final analytical sample size to 527.

Measures

Mental Health Service Utilization

The study’s dependent variables were constructed as described in an earlier study that used the NLAAS to examine patterns of mental health service utilization among Latinos (Alegría, Mulvaney-Day, Woo et al., 2007). Past-year mental health service utilization was defined as making at least one visit with a service provider from a list of 10 health care professionals for “problems with emotions, mental health, or use of alcohol or drugs” within the 12 months preceding the interview. For each type of provider specified, respondents were then asked a series of follow-up questions about the recency (i.e., the last time saw a specific type of provider) and frequency of use (i.e., number of visits to a specific type of provider in the past year), satisfaction with care, and overall helpfulness of the services received. To differentiate service utilization by types of service providers, four mental health service dichotomous dependent variables were developed using information on the recency and frequency these services were used. Specialty mental health services were defined as seeing a psychiatrist, therapist, social worker or counselor in a mental health setting, other mental health professional, or using a mental health-related hotline. General medical services were defined as seeing a physician, nurse practitioner, or other health professional. Informal or religious services included seeing a religious leader, healer, self-help group, or online support groups. A composite variable of any mental health service combined use of specialty mental health, general medical, and informal or religious-based services.

Family Support as Behavioral Familismo

As a behavioral component of Latino familismo, the primary construct of interest was family support, measured as the level of emotional support the respondent perceived to receive from family or relatives outside the home. Three family support items used in this study examined (a) the frequency of communication and interactions with family or relatives (responses range from 1 = “less than once a month” to 5 = “most every day”); (b) the dependability on family or relatives for help with serious problems (responses range from 1 = “not at all” to = “a lot”); and (c) the ability to open up to family or relatives about worries (with similar response ranges as the previous item). Because response types differed across items, exploratory factor analyses using principal axis factoring and promax rotation were conducted and yielded one common factor. Together the items yielded respectable internal consistency (α = .68). Factor scores were calculated and used for the analyses.

Covariates

Objective and subjective measures of need for mental health care were included in the analyses. Objective need was assessed as the total number of concurrent past-year DSM–IV psychiatric diagnoses (a proxy for mental health severity). Respondents were grouped as having one (referent category), two, or three or more disorders. Subjective need was assessed by two measures of perceived need for mental health services. Personal perceived need was measured by a single item, “During the past 12 months, did you think that you should talk to a medical doctor or other health professional about problems with your emotions, nerves, mental health, or use of alcohol or drugs?” Yes was coded 1 and no was coded 0. Social perception of need also was assessed with a similar item that inquired whether “any other person such as a family member, friend or coworker” encouraged the respondent to speak to a mental health professional in the past year.

The analysis also controlled for aspects of the Latino immigrant experience that may influence mental health service use, such as: nativity (i.e., U.S.-born vs. foreign-born); nationality (i.e., respondent’s nation of origin or ancestry categorized as Cuban, Puerto Rican, Mexican—referent category, and other Latino—includes Central or South American ancestry); and English language proficiency (i.e., measured as a self-rating of how well the individual spoke, wrote, and read English, with proficient speakers coded 1 and nonproficient speakers coded 0). Demographic and socioeconomic characteristics were also controlled for, including age (categorical); gender (females were the referent category); years of education (categorical); and a poverty index (i.e., measured as an income-to-needs ratio based on the 2001 US Census). Other variables included marital status and insurance status (i.e., whether or not the individual had any form of health insurance— e.g., employer sponsored or private insurance, Medicaid, Medicare, etc.—at the time of interview).

Analyses

For comparisons, weighted descriptive statistics were calculated for the full sample of Latinos, as well as for subsamples with and without clinical need for mental health services (see Table 1). Wald tests were conducted to compare Latinos with and without clinical need for mental health services on several socioeconomic, demographic, and cultural characteristics as well as perceptions of need. Logistic regression models were performed to examine the relationship between behavioral familismo (i.e., perceived family support) and past-year mental health service utilization in each service sector (i.e., specialty mental health services, general medical services, informal or religious services, and any mental health service). All analyses controlled for the sociodemographic, cultural, and need characteristics described earlier. Sample design variables and sampling weights developed by Heeringa et al. (2004) were applied to correct for clustering, unequal probabilities in selection, and nonresponse patterns of underrepresented populations. All analyses were conducted using Stata Statistical Software, Version 11 (StataCorp., 2009).

Table 1.

Weighted Descriptive Statistics of Latino Sample by Clinical Need for Mental Health Servicesa in the Past Year: NLAASb, 2002–2003

Total samplec
(N = 2,521)
Mean (SD) or percent		 Without clinical needc
(N = 1,994)
Mean (SD) or percent		 With clinical needc
(N = 527)
Mean (SD) or percent
Age distribution
    18–29 years old 35.2 35.1 35.4
    30–44 years old 36.1 35.7 37.9
    45–64 years old 21.3 21.4 20.6
    65+ years old 7.4 7.7 6.1
Male 51.5 53.1 44.8*d
Latino subgroups
    Cuban 4.6 4.7 4.3
    Puerto Rican 10.0 8.9 14.2**
    Mexican 56.5 57.2 53.7
    Other Latino 28.9 29.2 27.8
Marital status
    Married/cohabiting 64.4 66.5 55.8**
    Previously marriede 14.5 13.7 17.8*
    Never married 21.0 19.7 26.4*
Foreign-born 58.3 60.4 49.6***
English language proficient 50.4 47.8 61.1**
Years of education
    Less than 12 years 44.1 44.5 42.7
    12 years 24.7 24.3 26.3
    13–15 years 21.0 21.2 20.0
    16+ years 10.2 10.0 11.0
Poverty index (1 to 17) 3.19 (3.45) 3.21 (3.39) 3.12 (3.58)
Uninsured 34.8 35.7 31.4*
Family support − .07 (1.00) − .05 (1.00) − .17 (1.01)**
No. of current diagnoses
    None 80.4 — —
    One disorder 7.5 — 38.5
    Two disorders 5.5 — 28.0
    Three or more disorders 6.6 — 33.5
Personal perceived need 9.1 3.6 31.5***
Social perceived need 6.9 2.6 249***
Mental health service utilization
    Any mental health service 11.3 5.9 33.5***
    Specialty mental health services 5.5 2.3 18.8***
    General medical services 5.6 2.5 18.5***
    Informal or religious services 4.8 2.5 14.6***
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a

Clinical need for mental health services was defined as meeting DSM-IV diagnostic criteria for one or more mood, anxiety, or substance use disorder in the past 12 months.

b

NLAAS = National Latino and Asian American Study.

c

Limited to respondents with complete data on all measures of interest.

d

Wald tests for clinical need differences.

e

Previously married category includes divorced, separated, and widowed respondents.

*

p < .05.

**

p < .01.

***

p < .001.

Results

Over half of Latinos in the NLAAS are of Mexican descent (57%) and foreign-born nativity (58%). In addition, over 40% have a less than high school education (see Table 1). About 20% of Latinos display a current clinical need for mental health services (i.e., respondent meets DSM–IV diagnostic criteria for any past-year psychiatric disorder), including 12% who concurrently meet criteria for more than one disorder. Less than 12% of the full sample utilized any type of mental health service in the past 12 months.

When compared with Latinos without a past-year diagnosis (i.e., without clinical need), those with clinical need for mental health services were more likely to be female, of Puerto Rican descent, single (i.e., divorced/separated or never married), and U.S. born. Approximately a third—or one in three—Latinos with clinical need used any type of mental health service in the past year and were also more likely to use specialty mental health, general medical, and informal or religious services than those without clinical need. Another important distinction between these two groups is that the clinical need subsample, on average, reported significantly lower levels of family support compared to those without need.

With respect to mental health severity, over one-third (39%) of the clinical need subsample met criteria for one DSM–IV diagnosis in the last 12 months, while the remaining two-thirds (62%) met criteria for more than one concurrent disorder. A third of respondents with clinical need also reported perceiving a need for mental health services in the past year, as well as approximately 25% reported having a social perceived need in which someone encouraged them to seek professional mental health care for a mental health-related problem.

Behavioral Familismo and Service Utilization

We tested the hypothesis that among Latinos with a clinical need for mental health services, those with high levels of behavioral familismo, measured as the degree of family support, would be less likely to use formal mental health services in the past year but more likely to use informal services. With respect to informal or religious services, family support significantly predicted use of these services for a mental health or substance use-related problem (see Table 2). Particularly, Latinos with elevated levels in the family support factor score, as opposed to those with lower levels, had increased odds of using informal or religious services after controlling for sociodemographic and need characteristics in the model. In other words, Latinos with a clinical need for services were more likely to use informal or religious services for mental health-related concerns when levels of family support were high. Although the pattern of results was in the hypothesized direction for both the specialty and general medical service models, the results were not statistically significant.

Table 2.

Logistic Regressions of Past-Year Mental Health Service Utilization on Family Support and Other Covariates Among Latinos With a Clinical Need for Mental Health Services (N = 527): NLAAS, 2002–2003

Any mental health
service
 Specialty mental health
Services
 General medical
services
 Informal or religious
services
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Family support 1.05 [0.84, 1.31] 0.91 [0.72, 1.14] 0.99 [0.70, 1.39] 1.48* [1.05, 2.08]
Marital status
    Married/cohabiting 1.00 1.00 1.00 1.00
    Previously married 1.13 [0.50, 2.58] 2.22 [0.96, 5.16] 1.47 [0.69, 3.10] 2.26* [1.07, 4.75]
    Never married 0.51* [0.30, 0.86] 1.32 [0.72, 2.44] 0.49 [0.23, 1.05] 0.96 [0.44, 2.08]
No. of current diagnoses
    One disorder 1.00 1.00 1.00 1.00
    Two disorders 2.06* [1.03, 4.12] 1.29 [0.59, 2.82] 2.16* [1.02, 4.63] 2.17 [0.99, 4.74]
    Three or more disorders 2.24** [1.29, 3.91] 2.74** [1.55, 4.86] 2.02 [0.92, 4.39] 1.47 [0.81, 2.65]
Personal perceived need 3.06*** [1.74, 5.36] 4.70*** [2.14, 10.31] 3.78** [1.58, 9.01] 3.16*** [1.83, 5.44]
Social perceived need 2.21** [1.34, 3.64] 2.19* [1.03, 4.65] 1.59 [0.69, 3.66] 2.47* [1.22, 4.98]
Poverty index (1 to 17) 0.96 [0.89, 1.03] 1.00 [0.93, 1.06] 0.98 [0.89, 1.07] 0.91 [0.80, 1.03]
Years of education
    Less than 12 years 1.00 1.00 1.00 1.00
    12 years 0.76 [0.41, 1.40] 0.41* [0.19, 0.89] 1.15 [0.53, 2.51] 0.69 [0.29, 1.66]
    13–15 years 0.83 [0.38, 1.81] 0.78 [0.29, 2.12] 0.91 [0.43, 1.91] 1.52 [0.75, 3.10]
    16+ years 1.50 [0.41, 5.38] 1.38 [0.48, 3.97] 2.54* [1.11, 5.85] 1.00 [0.26, 3.81]
Uninsured 0.24** [0.09, 0.62] 0.27** [0.13, 0.55] 0.31* [0.09, 0.99] 0.35** [0.18, 0.67]
Age
    18–29 years old 1.00 1.00 1.00 1.00
    30–44 years old 1.07 [0.55, 2.12] 1.38 [0.79, 2.41] 1.40 [0.65, 3.02] 0.62 [0.29, 1.33]
    45–64 years old 1.96 [0.90, 4.27] 3.27* [1.34, 7.97] 1.65 [0.82, 3.32] 1.35 [0.64, 2.85]
    65+ years old 0.78 [0.11, 5.31] 0.86 [0.16, 4.66] 1.46 [0.29, 7.03] 0.20 [0.03, 1.50]
Male 0.78 [0.39, 1.54] 1.06 [0.58, 1.93] 0.41* [0.23, 0.75] 2.27 [0.79, 6.55]
Latino subgroups
    Mexican 1.00 1.00 1.00 1.00
    Cuban 0.96 [0.51, 1.82] 1.45 [0.40, 5.34] 0.97 [0.44, 2.17] 0.35 [0.09, 1.34]
    Puerto Rican 1.30 [0.67, 2.52] 1.52 [0.44, 5.23] 0.87 [0.32, 2.36] 0.72 [0.24, 2.20]
    Other Latino 0.94 [0.61, 1.46] 1.41 [0.62, 3.22] 0.67 [0.32, 1.40] 1.52 [0.61, 3.76]
Foreign-born 1.57 [0.69, 3.58] 1.80 [0.94, 3.44] 0.98 [0.32, 2.96] 1.30 [0.52, 3.28]
English language proficient 1.99 [0.86, 4.66] 2.70 [0.86, 8.50] 1.16 [0.45, 3.02] 1.58 [0.77, 3.26]
Open in a new tab
*

p< .05.

**

p < .01.

***

p < .001.

Other noticeable findings with respect to family include marital status. Specifically, the odds of using any type of service in the past year were about half as great among Latinos who have never married when compared to their married counterparts. In contrast, previously married Latinos were about twice as likely than married Latinos to use informal or religious services for a mental health or substance use-related problem.

Perceptions of Need and Service Utilization

Consistent and significant predictors of past-year service utilization were perceptions of need for mental health services. Respondents perceiving a personal need for mental health care were significantly more likely to use mental health services in all service sectors, even after controlling for other covariates including mental health severity (as indexed by the number of concurrent disorders). Unlike other studies in this area, we also included a measure of social perceptions of need for mental health services. In most of our models, except the general medical service use model, social perceived need was significantly associated with increased odds of service utilization. In general, the marginal effect of personal perceived need for mental health services (i.e., the mean difference in predicted probabilities of using mental health services between individuals with and without a perceived need) was consistently larger when compared with the marginal effect of social perceived need (not shown). However, the statistically significant findings of social perceived need demonstrated that social influences pertaining to perceptions of need also play a significant role in the use of specialty, informal or religious, and any mental health services.

Other important findings included the relationships of mental health severity and being uninsured with mental health service utilization. Lack of insurance was significantly related to lower odds of using mental health services in all service models. Latinos who met diagnostic criteria for three or more past-year psychiatric disorders compared to respondents with only one past-year diagnosis were more likely to use any mental health service and specialty care services. In contrast, for the any service and general medical services models, Latinos meeting criteria for two disorders were significantly more likely to use these services when compared with those who only met criteria for one disorder. Number of concurrent diagnoses was not significant in the informal or religious services model. Other common predictors of service utilization like nationality, nativity, and English language proficiency were not statistically significant in any of the models.

Moderating Effects of Perceived Need

The interaction between family support and social perceived need was also examined. We hypothesized that the impact of family support would differ by whether or not respondents were encouraged by someone in their network of family, friends, and coworkers to seek professional help for mental health-related concerns. Adding the interaction term in all the models, we noticed a marginally significant interaction between family support and social perceived need in the any service, F(1, 47) = 3.31, p = .08, and general medical service use models, F(1, 47) = 3.77, p = .06 (not shown). The marginally significant result is most likely because of insufficient power. Further analyses with larger sample sizes would be necessary to better investigate these effects. The interaction in all other models was nonsignificant.

Discussion

The underutilization of formal mental health services by Latinos in the face of their growing mental health services needs continues to be a problem of serious concern for those charged with eliminating mental health disparities in racial/ethnic minority populations (Aguilar-Gaxiola et al., 2012; Aguilar-Gaxiola et al., 2002; Alegría et al., 2012; Barrio et al., 2008). Although many studies have concluded that a cultural inclusion framework in our approach to mental health services would be an asset in reducing mental health disparities, research identifying cultural domains is still fairly nascent. Our study examined behavioral familismo, the level of perceived family support, as a factor in mental health service utilization among Latino adults meeting criteria for a clinical need for mental health services. Our findings demonstrate that culture and family influences are important in efforts designed to understand and improve help-seeking and actual utilization of formal mental health services by Latinos.

Family support was found to positively influence the use of informal or religious services. In particular, Latinos with high family support were significantly more likely to use informal or religious services as a form of mental health care than those with low family support. With the smallest observed rate of utilization among the study’s sample (15%), informal or religious services represents a mixture of alternative services—including folk healers, self-help groups, online support groups, and religious leaders. Although these types of services are typically considered to be sources of informal care, they may not be perceived as informal or less than formal sources of care within the Latino community. The use of these services may be more culturally aligned with the core values of Latino familismo (Kane & Williams, 2000; Loera et al., 2009) as well as be more culturally accepted and encouraged by members of the Latino community (Kane & Williams, 2000). Furthermore, these types of services may be perceived within the Latino community to be less stigmatizing than formal mental health services because of their perceived cultural alignment.

The significant effect found between family support and informal or religious services is likely driven by the use of religious services. Over half of Latinos in our study who utilized informal or religious services (61%) sought the help of a religious advisor or leader for a mental health concern. Traditionally, Latinos emphasize the importance of religion and spirituality in their culture and everyday life (Campesino & Schwartz, 2006; Taylor et al., 2012). In particular, religion and faith are believed to play important roles in maintaining mental health and coping with mental illness (McField & Belliard, 2009). For example, as part of the Catholic faith, Latinos often times consider confesión (confession) as a form of therapy where they can share their concerns and receive advice from trusted religious leaders (McField & Belliard, 2009). In the current study, we also observed a significant overlap in the use of both formal and religious services: Among Latinos who sought religious leaders for mental health concerns, 44% of them also used specialty mental health services and an additional 43% also used medical services. However, we were unable to decipher whether the use of religious services directly led these individuals to also seek out formal mental health services or vice versa.

Akin to alternative resource theory, we expected family support to negatively influence service use; however, no statistically significant effect emerged with respect to formal mental health services. This nonfinding may be partly because of family support influencing utilization of formal mental health services indirectly through need for services (Sherbourne, 1988). Positive familial characteristics like high family support, cohesion, and warmth have been shown to have protective effects against poor mental health outcomes (Ayón, Marsiglia, & Bermudez-Parsai, 2010; Rivera et al., 2008; Snowden, 2007), thus minimizing a need for care. In our bivariate analysis, we found that Latinos with clinical need for services had significantly lower levels of family support than Latinos without need. In contrast, negative familial characteristics like high family conflict have been shown to be a detriment to an individual’s own mental health (Rivera et al., 2008; Umberson & Williams, 1999), hence creating a need for care. This mediating role of mental health need in service utilization has been previously observed, such that persons with many social contacts and resources had the lowest probabilities of using mental health services but only as a function of their mental health status (Sherbourne, 1988). In other words, the effect of family support on utilization of formal mental health services may only emerge indirectly through mental health need. Thus, the influential nature of family in formal mental health service utilization may not persist once a need for mental health care has already been established.

With the exception of mental illness severity, perceptions of need were strong predictors of service use in all service categories. Several studies have demonstrated the strong influence of personal or self-perceptions of need on mental health service utilization (Bauer, Chen, & Alegría, 2012; Mojtabai et al., 2002; Rabinowitz, Gross, & Feldman, 1999; Sareen et al., 2007). However, findings from this study also point to the importance of social perceptions of need. When family members and friends believe an individual to need mental health services, Latinos were more likely to use any type of mental health service with the exception of general medical services. Family can help identify mental distress and advise individuals to seek appropriate care when perceived to be necessary (Cauce et al., 2002). Nevertheless, whether or not a need for care is perceived by family members will depend on their beliefs and classification of what constitutes mental distress as well as on how mental distress is thought to manifest (Cauce et al., 2002).

Policy Implications

Findings from this study point to the importance of familismo in the help-seeking behaviors of Latinos. Although shortages in the supply of formal mental health providers require attention (Latino Mental Health Concilio, 2012; Vega & Lopez, 2001), our result concerning family support and use of informal or religious services illustrates the need to expand the mental health workforce in these settings as a way to facilitate access to mental health services for Latinos. Although most Latinos in need of mental health services are likely to prefer care from mental health specialists, a significant proportion report a preference in seeking care from clergy or faith leaders (Moreno & Cardemil, 2013; Nadeem, Lange, & Miranda, 2008). If Latino families are comfortable in recommending religious-oriented services for mental health care, it would be important to expand mental health care training among these providers to assure they are knowledgeable about mental illness, understand the limits of their training in handling mental health problems, and know where to refer individuals who present themselves with complex mental health problems (Latino Mental Health Concilio, 2012). Surveys of religious leaders reveal that many are insufficiently trained to recognize the presence and severity of mental illnesses, yet the majority feel a strong tendency and obligation to offer counseling services to individuals in need (Dossett, Fuentes, Klap, & Wells, 2005; Kane, 2003). Similarly, there is a significant problem with referring and transitioning individuals with serious mental health needs from religious care to the formal mental health sector given insufficiencies in establishing partnerships with formal mental health providers (Latino Mental Health Concilio, 2012). Developing liaisons between faith communities and local mental health clinics and service providers can be beneficial to facilitating access and care management for Latinos with mental health needs.

Our study also found that social influences, particularly social perceptions of need, are important indicators of mental health utilization. Increasing funding for the expansion and training of promotores de salud that target individuals, families, as well as faith leaders could also facilitate promotion of mental health services among Latinos. As trusted members of the Latino community, promotores can address common misconceptions, concerns, and barriers about mental illness and care at the patient, family, and community levels (Reinschmidt & Chong, 2007). These programs can focus on personal identification and treatment of mental health problems, as well as focus on educating family members about mental illness and mental health care. This paradigm has been successfully implemented in interventions focusing on depression, diabetes, and heart disease and has been positively received by Latinos (Medina, Balcázar, Hollen, Nkhoma, & Mas, 2007; Reinschmidt & Chong, 2007; Waitzkin et al., 2011).

Although not the primary focus of this analysis, it was interesting to note that in the bivariate analysis (see Table 1) Latinos with clinical need for mental health services, on average, reported lower levels of family support than those without need. Developing prevention programs that emphasize strong familial bonds and emotional support may prove to be a successful strategy toward preventing poor mental health outcomes among Latinos. Programs such as Familia Adelante (Cervantes, Goldbach, & Santos, 2011) and Familias Unidas (Prado & Pantin, 2011) that target adolescents and their parents and engage in approaches to enhance familial relationships and communication have demonstrated effectiveness in reducing anxiety and risky health behaviors like alcohol and drug use. Although most of these preventive efforts are in the context of adolescents, this model may be adaptable for programs targeting Latino adults.

Limitations

Our results should be considered in the context of some limitations. First, the cross-sectional nature of the data limits our ability to make causal inferences. Second, the measures used to assess clinical need for mental health care and mental health services use were self-reported. Recall bias and social desirability may underestimate the true effect of family support on mental health service utilization within this sample. Third, the dependent variables capture a mix of individuals who may be in the initial (e.g., first-time users) or later stages (e.g., engagers of services) of the help-seeking process. We were unable to effectively distinguish between individuals in the initial stages of the help-seeking process and individuals who are fully engaging in the receipt of services because of overlap in use across categories. For example, close to half of Latinos who used specialty mental health services also used medical services for a mental health concern in the past year. This overlap was significantly more pronounced when patterns of service use prior to the past year were considered. Moreover, the data did not provide information on the total length of time respondents have been in care, the frequency and intensity of care received prior to the 12 months preceding the interview, and whether respondents who engaged in help-seeking received services from the same provider during the 12 months preceding the interview.

In spite of these limitations, data from this national sample of Latinos provide new evidence and insights into the help-seeking patterns of Latinos. Few studies in the past have been able to examine characteristics of Latino familismo, most especially behavioral familismo, and mental health service utilization in the context of the greater U.S. Latino population. Additionally, we were able to look beyond formal sources of care and examine utilization of alternative sources for the seeking of mental health care. As we continue to implement the Patient Protection and Affordable Care Act, ensuring that the preferences and behavioral health patterns such as the unique help-seeking paths of Latinos are known and accounted for in establishing effective mental health services is critical.

Conclusions

As the U.S. Latino population continues to grow, it becomes increasingly important to provide equity in the development and use of effective mental health care services. One path to do this is with greater emphasis on care drawn from mental health research that includes cultural dimensions as part of evidence-based approaches in mental health services (Bernal, Bonilla, & Bellido, 1995; Bernal & Domenech-Rodríguez, 2012; Bernal & Scharrón-del-Rio, 2001). Traditions and values pertaining to Latino familismo may prove instrumental in the development of interventions and policies aimed at getting Latinos with mental health problems to seek mental health services. Future studies should investigate how other aspects of Latino familismo like attitudinal familismo affect service utilization for Latinos. Additionally, future studies should further examine the potential synergistic effect of family support and social perceptions of need in Latino mental health services utilization. Families may be more than alternative sources of mental health care to Latinos; they may also be a gateway into mental health treatment.

Acknowledgments

This work was supported by the Agency for Health Care Quality Research (AHRQ) grant (T32 HS000046) to the University of California, the National Insitutes of Health (NIH) National Institute of Minority and Minority Health Disparities (MD000508 and MD006923), and the NIH/ National Center for Advancing Translational Science (NCATS) UCLA CTSI grant (TL1 TR000121). The content is solely the responsibility of the authors and does not necessarily represent the official views of AHRQ or NIH.

Contributor Information

Alice P. Villatoro, Department of Health Policy and Management, University of California, Los Angeles

Eduardo S. Morales, Department of Clinical Psychology, Alliant International University, San Francisco

Vickie M. Mays, Departments of Psychology and Health Policy and Management, University of California, Los Angeles, and UCLA Center for Bridging Research Innovation, Training and Education for Minority Health Disparities Solutions

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