Voices from Minority Youth on Help-Seeking and Barriers to Mental Health Services: Partnering with School-Based Health Centers

Abstract

Objective

Schools and school-based health centers (SBHCs) play an important role in reducing disparities in access to mental health treatment. However, there is a need to increase student engagement in school mental health services. This study sought to understand the perceptions of low-income minority youth on help-seeking and barriers to mental health services at SBHC sites.

Setting

A network of SBHCs, called Wellness Centers, developed as part of a strategic plan to serve students and community members in under-resourced areas of a large urban school district.

Participants and Procedures

We conducted focus groups with 76 middle and high school students at nine SBHC sites through a community-academic partnered approach from January to May 2014. The focus groups were audio-recorded, transcribed, and major themes coded with Atlas.ti.5.1.

Results

Students identified teachers as a primary source of support for mental health issues, followed by peers and mental health counselors. Students felt that trust and connection were vital for help-seeking. Barriers to using SBHCs included: embarrassment; fear of judgment; concerns about confidentiality; a sense that they should keep things inside; and lack of awareness.

Conclusions

Despite the resources available at SBHCs, students face barriers to help-seeking. SBHCs can help teachers and school staff gain awareness of mental health issues and services available to students. The students’ recommendations—making SBHCs more comfortable, raising mental health awareness, and bolstering connections with school and SBHC staff—may improve engagement in mental health services at schools with SBHCs.

Introduction

Mental health disorders are common among youth. While approximately 22% of US youth aged 13 to 18 years are affected by mental health disorders with severe impairment, less than half receive mental health services.1,2 Disparities persist in access to mental health care and treatment among low-income ethnic and racial minority youth,3-5 who are at increased risk for mental health problems due to higher exposure to poverty, violence, and trauma.6-8 For example, suicide rates among African American children increased significantly from 1993 to 2012, while they decreased among White children.9

School-based health centers (SBHCs) can help address unmet mental health needs for all children, but especially low-income minority youth, as most students in schools with SBHCs are minorities.10 SBHCs are comprehensive health clinics located on school sites and most provide health and mental health services. SBHCs can provide services to uninsured youth and families, and eliminate transportation barriers.11,12 Students unable to pay for care are 64% more likely than privately insured students to seek mental health services from a SBHC.11

Although SBHCs increase access to mental health services,13-15 there is a need to increase student engagement in services. One study found that only 23% of students with mental health problems had visited their SBHC.16 Another demonstrated that difficulty getting a teacher’s permission to leave class and needing parent consent for clinic enrollment were barriers to using SBHCs.17 A systematic review from the Community Guide Branch of the Centers for Disease Control and Prevention highlighted the discrepancy between those in need of services at SBHCs and those actually receiving services, and called for strategies to enhance SBHC use.18

Despite the potential for addressing mental health inequities through schools, there is a dearth of literature describing barriers among low-income minority youth to using school mental health services. One qualitative study of African American and Latino youth at SBHCs that explored why students sought care was limited to students already receiving mental health services.19 There is however, a strong body of research describing barriers to help-seeking among minorities in the community.20,21

We conducted a community partnered research project with a non-profit organization that works with a large urban school district to support the health and readiness to learn of 647,000 K-12 students. One significant effort of the non-profit was establishing a strategic plan that resulted in 14 innovative SBHCs called Wellness Centers. These Wellness Centers provide a range of wellness programs, primary care, and mental health services for students, their families, and community members living in the most under-resourced areas of the district. The Wellness Centers emphasize student and family engagement. Efforts with students include: social media outreach, developing Youth Advisory boards at Wellness Center sites, and bringing students together for a bi-annual Youth to Youth (Y2Y) summit focusing on student leadership skills and health dialogue.

Building on these efforts, the non-profit identified the need for student feedback about seeking mental health services on campuses with Wellness Centers, and the barriers to seeking these services. We sought to capture the voices of students in under- resourced areas with SBHC sites to inform care and student engagement strategies.

Methods

Participants

We conducted focus groups with 76 students from January to May 2014 at nine SBHCs in a large urban school district serving predominantly low-income, ethnic minority students. Staff at each site invited students to participate and obtained parental consent and student assent. Participants did not receive monetary compensation for participating. Seventy-six students volunteered to participate and were all ethnic or racial minorities and from higher grades (Table 1).

Table 1. Student characteristics.

	Total, n=76
Sex
Male	34.2%
Female	65.8%
Grade
6-8 grade	11.8%
9-10 grade	21.0%
11-12 grade	67.2%
Race
African American	3.9%
Asian	13.2%
Latino	77.6%
Multiracial	3.9%
Family or friend with mental health problem	20%

Procedures

We used a community partnered research approach for this study. The community partner (the non-profit organization) identified that, although the Wellness Centers offer mental health services, students often do not access care. To help understand this issue, a semi-structured interview guide was developed by the team that inquired about: 1) student help-seeking for mental health problems; 2) barriers and facilitators to mental health care; and 3) recommendations for improving information at school about mental health. The Behavioral Model for Vulnerable Populations served as a conceptual model for the interview guide.22 Facilitators—child psychiatrists, a research associate with a master’s degree in clinical psychology, and a medical student—were trained on conducting focus group interviews. Students were administered a brief demographic survey before each group. Each group lasted approximately 45 minutes and average attendance was 8.4 students. The University of California, Los Angeles’ Institutional Review Board and the District’s Research Review Committee approved all study procedures.

Data Analysis

All focus groups were audio-recorded, transcribed, and analyzed using content analysis to explore topics that arose during the focus groups.23 Coders were health services researchers trained in qualitative analysis. Three members of the study team (RM, SK, KN) reviewed the transcripts to preliminarily code for major domains of inquiry derived from the interview guide topics. Two members of the team conducted independent coding and met to review initial codes and agree on consensus codes (RM and KN). The research team refined the coding scheme by expanding, collapsing, and eliminating codes through iterative discussion until there was a mutually agreeable list, and codes were developed into consensus themes. Analyst triangulation (using multiple analysts to analyze data) was used to check against interpreter bias.24 Codes were managed using the qualitative data analysis software Atlas.ti 5.1.25

Following the focus groups, the findings were shared at a Wellness Center Learning Collaborative meeting, which included non-profit members, Wellness Center staff, school social workers, and students. Feedback on the findings was obtained.

Results

Students’ Help-Seeking

Students identified teachers as a primary source of help with mental health problems, followed by peers and mental health counselors. They were least likely to report obtaining help from family members.

Teachers

In eight of the nine groups, students described seeking help from teachers. Many students reported that they would first reach out to a teacher due to trust or a personal connection. One student said, “If I would tell her what was going on…she would tell me the right things to do.” Others discussed how teachers could help with

life stressors: “The teacher could act like one way during the class, but after the class…He could be your mentor, your counselor…” Another student described the impact of a teacher who discussed his personal struggles. The teacher’s lesson of resilience resonated with the student, “you’ll always have times you’ll go down. . .the point is you can go up.”

Some students were more likely to seek out teachers than counselors. “There are a few teachers who I’ve formed pretty strong bonds with… sometimes they are better than counselors … they’ll talk to you about life in general…” Participants also discussed an expectation that teachers would maintain confidentiality, “some teachers are like a friend, and they’re very confidential.”

In two focus groups, located at schools with a high percentage of immigrant families, participants described teachers as understanding their life experiences. Students described a connection to teachers who had attended their school, because they empathized with their experiences: “There are some who have been through a lot…Growing up in these types of areas …and knowing what you have to face.”

Peers

In eight out of the nine groups, students said that they would approach peers for help—yet voiced positive and negative opinions about peers. On the one hand, students felt that peers would understand certain problems better than teachers, particularly relationship issues. Several groups discussed first going to a friend, then to a teacher. “First I would visit my friend…consult with them…after that I would just tell a teacher if I needed someone more mature…” However, in five of the groups, students articulated concerns about trusting peers. Some had trepidations that friends might gossip, turn against them, and spread intimate information: “You tell something personal to a friend and then in an argument they use it against you.” Students also worried that friends might “sugarcoat” a situation instead of giving an honest assessment.

Some of the school sites had formal peer-counseling programs, but overall, students had concerns about confidentiality and inappropriate advice-giving from peers. At one site where peer counseling was available, participants described that students did not use the program because “they are afraid of people talking.” Some participants were peer-counselors and described this experience favorably. Others were apprehensive that peer counselors could be blamed for giving the “wrong advice.”

Students recommended using the role of a friend to build trust and help peers: “because they’re not just going to feel comfortable with a random stranger coming up to them.” Students also discussed how to approach a peer who could be lonely; “go talk to a random person…there’s many people…that are alone…and those are the ones that need to talk to someone…” Finally, students felt they could help peers by accompanying them to the SBHC or encouraging them to seek care.

School-Based Mental Health Clinicians

In seven of the groups, students reported they would see a counselor or mental health clinician for help. Yet, generally, reaching out to counselors was less common than peers and teachers. Many students were receptive to the idea of academic counselors checking on their psychological well-being: “Maybe if we had a counselor once in a while to keep up with us, like how you’ve been.”

However, some voiced concerns about reaching out to school mental health clinicians. Students described unfamiliarity with the mental health clinicians on campus, a lack of understanding about the role of the clinician, and worries about their ability to maintain confidentiality. Additionally, students felt that counselors may not understand the student’s background or situation. One student articulated, “if she’s just telling me ‘oh well you need to do this,’ well I’d be like ‘have you walked in my shoes? Have you been like this?’”

Family Members

Seven groups voiced that they would go to family members for help, although students generally conveyed mixed feelings about this. Some students described that they would go to specific family members who could understand their experience, such as an older sibling. However, at two sites, students reported strong hesitation reaching out to family members because parents were too strict, or, as one student clarified, “they don’t understand and are judgmental.”

Student-Perceived Help-Seeking Barriers

Students articulated five overarching themes across the groups regarding barriers to seeking help, as described below.

Embarrassment

At six of the sites, students discussed feeling embarrassed to access services at the SBHCs. Several students brought up worries about being seen by others going to the SBHC: “They’ll probably be embarrassed if someone saw them go to that office… People see and they just talk.” Students also highlighted the stigma of seeking help for mental health problems at the SBHC, rather than physical issues, “A person wouldn’t be embarrassed for…a physical, but they would be embarrassed to come talk about their depression…”

A Fear of Being Judged

The fear of being judged by others for seeking help was voiced as a powerful deterrent across six of the sites. As one student articulated, “They keep stuff inside because they are scared of how other people will react.” Students explained a fear of being viewed as “insane,” as “having problems,” or judged for not “handling” problems on their own, “People think you’re a wimp that you need someone to help you like you can’t handle your own problems.”

Confidentiality

A concern about confidentiality arose at six of the sites as a barrier to seeking help. As one middle school student described, “Trust is a really big issue, especially at our age.” Some students brought up concerns that peers would learn of their problems, or that the police would become involved. Many expressed fear that parents would be alerted, “Some people want to ask for help but they don’t want to risk their parents knowing…” Students felt that their peers didn’t access school mental health services because they didn’t understand what information would be kept confidential, “They don’t know that there are only certain things that will be told to your parents . . . that’s why they’re scared.”

Keeping Things Inside

Across five of the sites, students described a theme of keeping things inside as a significant obstacle to seeking help. One belief was that problems would get better if students didn’t speak about them. Several groups voiced concern about adding to others’ distress, “They just don’t want to feel like they’re bothering people.” Students also described a reliance on self, which came from a sense of pride or toughness, “A lot of time it’s pride. I don’t need help, or I’m not crazy. I can pull through it. It happens to everyone.” Several participants felt that peers could turn to substances to cope as a consequence of keeping problems inside: “their family…or friends don’t even help them, so their solution is to use drugs.”

Lack of Awareness

Students described not knowing who their providers were or where they were located. Many suggested increased visibility of school mental health providers to encourage students to seek services, “I never really personally met [the school mental health provider] so I think she should…hold an assembly…because a lot of people didn’t know.” Students also conveyed that peers might not understand the role of mental health providers or know that mental health services were available at the SBHC.

Students also described a lack of awareness about one’s own mental health problems as a barrier to seeking help. In several groups, students explained that peers may not self-identify symptoms of anxiety or depression, but instead think that they were “just going through a phase.” One student described, “Say someone has anxiety issues, but they had it their whole life…they wouldn’t know they had mental problems.”

Student Recommendations for Increasing Help-Seeking

The SBHC as a Second Home

One robust theme that emerged was to make SBHCs feel more comfortable. One student explained, “They have to make it feel like it’s a second home. Like make you feel welcome.” Students recommended making the clinics seem more fun by offering snacks, games, movies, and computer access. Students also suggested efforts to destigmatize the SBHCs, especially as some students viewed the clinics as primarily reproductive clinics. One student advised, “Try to not label the [school clinic] as just a center for sex stuff.”

Bolstering Connections

Students emphasized that it was important for them to feel connected to an individual in order to reach out for help. For example, one student explained how counselors could foster connection among students by simply offering support: “[Counselors] could create bonds with people…Just to say that you can come here, and I will be there if you need me.”

Raising Awareness

Students voiced a need for disseminating mental health information through classroom presentations, announcements, hall posters, or videos. One recommendation was to not only talk about mental health issues, but to talk about issues relevant to students: “I think a really strong topic would be stress because we all get stressed about homework and stuff.”

Finally, students articulated that providing information about mental health could be transformational for those who were struggling. Many discussed the powerful effect of students sharing positive experiences of seeking help, and the important role teachers could play by raising awareness of the SBHC and services and encouraging students to seek help. As one student explained, “If we talk about it in front of a whole class…they might like laugh…but like about 3 or 4 students inside that class might think in their head…‘I might really need this but I’m too embarrassed to say it in front of the whole class.’”

Discussion

Despite the benefit of SBHCs in expanding access, our findings show factors that may prevent students from seeking care and highlight a critical need to improve engagement and communication with youth about services. By addressing these voiced barriers, schools can further increase the use of SBHCs. Students revealed important perceptions about help-seeking and issues to consider when raising mental health awareness, that is typically delivered through three major approaches in schools: 1) teacher-led, 2) peer-led, and 3) school-wide approaches.

Teacher-Led Approaches

It was striking that students in our study described feelings of connection with their teachers, more than with peers and family members, when seeking help. This contrasts with previous findings that youth tend to reach out to family members first for help with mental health concerns,26 and differs from reports from youth of concerns about betrayal and legal sequelae when seeking help from teachers.20

Our finding that teachers play an important role in students’ lives represents a promising point of intervention.27-29 Mental health advocacy through teachers can increase access to care among youth, especially low-income minority youth, who are less likely than White youth to be referred for mental health services from schools.30 One study showed significantly increased positive attitudes about mental health among students who received a teacher-delivered mental health literacy curriculum.27 Yet, despite these encouraging results, a Canadian study found that the majority of high school teachers were not prepared to respond to mental health needs and students did not know where to go for help.31 Schools and SBHC staff can help teachers gain awareness about mental health and the school services available.

Peer-Led Approaches

Students revealed that peers were also an important source of support, which is consistent with prior findings.26,32 One unique aspect to our study was that many students were involved in peer-to-peer programs. Peer programs are increasingly utilized for suicide prevention.33 Sources of Strength is a program found to increase student help-seeking by training peer leaders to encourage others to seek care and to refer friends for care.33 However, it was notable that students in our study strongly emphasized the importance of confidentiality, particularly among peers. It is important for schools to recognize these real concerns about confidentiality, especially when implementing mental health peer programs. Students in our focus groups recommended alternative methods of peer support to address this issue, including peers sharing their own stories to encourage help-seeking, and accompanying students to SBHCs.

School-Wide Approaches

A prominent finding from our study was that students revealed misconceptions about seeking treatment and concerns that peers did not know how to detect symptoms in themselves or others. This is consistent with findings that adolescents often have poor mental health literacy that can impede care, and further illustrates the need for helping youth learn more about mental health.34 There are several approaches that can improve mental health literacy and awareness through a school-wide approach. One example is Teen Mental Health First Aid, a program that teaches mental health literacy through a classroom curriculum and showed significant improvements in youth mental health literacy and helping behaviors.35 This program has been launched in schools through broad training of school staff including coaches and school health aides. The Australian MindMatters Program is another approach that utilizes a school-wide integrated response, including youth forums and mental health days, to enhance understanding of mental health; it was found to improve teachers’ comfort with mental health issues.36 This approach aligns with the students’ recommendations that schools raise awareness of mental health beyond the classrooms.

Finally, we found that students expressed confusion about confidentiality when reaching out for help. Although this was a voiced barrier to care, staff must comply with mandatory state reporting laws. Providing education to students about confidentiality and

reporting requirements should be disseminated throughout the schools and may be a role that SBHC staff and peer advocates could lead.

Role of SBHCs and Student Engagement

SBHCs have the potential to not only improve access to needed mental health services, but also raise awareness and improve education about the impact of mental health on educational and social outcomes. Soliciting perspectives from students on school campuses where SBHCs are located can identify where barriers and issues still exist. The focus group discussions demonstrated the importance of partnering with students in SBHC quality improvement efforts, including expanding engagement and access to services.

Students in our focus groups led the call for increasing mental health knowledge within schools and voiced innovative recommendations for enhancing SBHC services. We recommend that SBHCs utilize ongoing student-centered discussions, develop student advisory boards, cultivate student leadership, focus on student partnership to lower mental health stigma, and use the SBHC platform to enhance mental health understanding on school campuses.

Limitations

Our study had several limitations. Findings may not be generalizable; while we conducted the focus groups at multiple sites, these findings represent experiences of predominantly low-income racial/ethnic minority students in under-resourced areas of a large city. Selection bias is possible as students volunteered to participate. Nevertheless, there were diverse views on mental health among participants. Finally, this study was conducted in a district that had Wellness Centers with mental health services on campus, resources that may not be available in other districts. Our study also had notable strengths, including that the focus groups were conducted as part of a long-standing community- academic partnership with the District.

Conclusion

Despite health care reform, critical disparities persist in access to mental health services among low-income ethnic and racial minority youth in under-resourced communities. School-based mental health services, and particularly SBHCs, can promote health equity, reduce racial and ethnic disparities in access to care, and enhance engagement in mental health services among youth who face significant barriers to care. By understanding the barriers to help-seeking, implementing student recommendations to enhance mental health awareness in schools, increasing engagement in SBHCs, and harnessing the power of teachers and peers to reach youth in need, schools can positively impact the emotional trajectory of our most vulnerable youth.