Effectiveness of Mental Health Literacy and Stigma Interventions for Latino/a Adults in the United States: A Systematic Review

Abstract

Latinos/as in the United States (U.S.), face persistent mental health care disparities, even after adjusting for education, health insurance, and socioeconomic factors. While there has been increased attention on mental health stigma and mental health literacy, no systematic literature review currently exists of interventions developed to reduce mental health stigma and improve mental health literacy in the Latino/a community. This review aimed to (1) examine the methodological rigor of these intervention studies, (2) describe the mental health literacy and stigma interventions developed for Latinos/as in the U.S., and (3) summarize the outcomes of these studies focusing on mental health literacy and stigma outcomes. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to inform our systematic literature review. The methodological rigor of each study was assessed using an adapted version of the Methodological Quality Rating Scale. Seven articles met the inclusion criteria for this review. The majority of studies were small pilot studies with small samples and short follow-up periods of less than a month. These interventions showed promising results for improving knowledge of mental disorders and mixed results for reducing stigma towards people with mental illness and mental health treatments. As the Latino/a population continues to grow, future research should continue investigating and developing more intensive and prolonged mental health stigma interventions that use multiple media platforms (e.g., radio, television, website, print, and social media) to help reduce mental health care disparities in this population.

Introduction

Latinos/as in the United States (U.S.) represent 18.3% of the population and are projected to increase to 28% by 2060 (Kahar & Negroni, 2020). Despite the remarkable growth of this diverse population, their mental health care needs are still not being met. Compared to non-Latino/a whites, Latino/as face persistent mental health care disparities in the access, utilization, and outcomes of care, even after adjusting for education, health insurance, and socioeconomic factors (Cabassa, 2016). Foreign-born and less acculturated Latinos/as are also more susceptible to mental health care disparities than their U.S. born and more acculturated counterparts (Cabassa, 2016). Furthermore, Latinos/as who access and use services are more likely to receive poor-quality mental health care and prematurely discontinue mental health treatment than non-Latino/a whites (López et al., 2012). While the Latinos/as face numerous structural barriers (e.g., lack of health insurance, lack of availability of culturally appropriate services) to mental health care, mental health stigma and low mental health literacy limits help-seeking, service use, treatment engagement, and quality of care (Ahmedani, 2011; Mascayano et al., 2015; Vega et al., 2010).

Corrigan and Watson (2002) posit that there are two types of stigma: public and self-stigma. Public stigma refers to the general population endorsing negative attitudes and beliefs of individuals with a mental illness that leads to stereotyping, prejudice, and discrimination (Corrigan & Fong, 2014). Self-stigma refers to the internalization of these negative attitudes and beliefs in people with mental illness. Both types of mental health stigma influence help-seeking behaviors for mental disorders as individuals resist or delay seeking help to avoid the labels, embarrassment, and the desire to escape the negative social consequences linked to mental illness and receiving mental health treatments (Corrigan & Fong, 2014). Jorm and colleagues (1997) define mental health literacy as the public knowledge and beliefs of mental disorders that allow for recognition, management, or prevention. Mental health literacy is different from stigma as it focuses on people’s knowledge and understanding of mental disorders and treatments rather than attitudes, beliefs, and stereotypes. Stigma and mental health literacy are two significant barriers to mental health care that can be targets for intervention.

Low mental health literacy and public stigma in the Latino/a population prevent many individuals from seeking, engaging, and remaining in mental health care (Cabassa, 2016). Studies have shown that Latinos/as reported higher rates of shame and embarrassment about having a mental illness than non-Latino/a whites, thus limiting their help-seeking for mental health problems (Jimenez et al., 2013). Lopez et al. (2018), using baseline data from 319 female Latinas, found that participants with at least some college education reported significantly higher knowledge of depression and statistically significant lower mental health stigma towards depression and medication than Latinas with lower education levels, indicating that levels of education may influence mental health literacy and public stigma in the Latino/a population. Moreover, other studies have shown that Latinos/as adults with limited English proficiency reported low mental health literacy (Bauer et al., 2010; Cabassa, 2016). Therefore, improving mental health literacy and reducing mental health stigma are two critical modifiable targets for decreasing mental health care disparities in the Latino/a population.

Several interventions have been developed throughout the U.S. to reduce public stigma and increase mental health literacy in the general population and among Latinos/as (Corrigan & Rao, 2012; National Academies of Sciences, Engineering, and Medicine, 2016). However, mental health stigma persists, and people with mental disorders continue to face prejudice and discrimination in their daily life. Despite the increased attention to mental health stigma and mental health literacy, to our knowledge, no systematic literature review currently exists of interventions developed to reduce public mental health stigma and increase mental health literacy in the Latino/a population. To address this gap, we conducted a systematic literature review to (1) examine the methodological rigor of these intervention studies, (2) describe the mental health literacy and stigma interventions developed for Latinos/as in the U.S, and (3) summarize the outcomes of these studies focusing on mental health literacy and public mental health stigma outcomes.

Methods

Search Methods.

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to inform our systematic literature review (Moher et al., 2009). We searched the APA PsycINFO, Applied Science & Technology Full Text, CINAHL Plus, Education Full Text, Family & Society Studies Worldwide, Gender Studies, Global Health, Medline SocINDEX with Full Text, Scopus, and Web of Science databases to identify peer-reviewed journals articles written in English or Spanish between December 2000 to February 2020 reporting the result of mental health literacy and stigma interventions for among Latino/a adults in the U.S. We used the year 2000 as our starting date since that was the year the seminal report Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General was published, identifying stigma as one of the critical barriers that drive racial and ethnic disparities in mental health care (Office of the Surgeon General (U.S.), 2011). We used multiple keyword combinations in our search strategy, including terms for mental disorders (e.g., PTSD, bipolar disorder, depression), interventions (e.g., psychoeducation, educational material), the population of interest (e.g., Latino, Latina, Hispanic), mental health literacy and anti-stigma. We also conducted manual searches to identify overlooked articles.

Study selection.

Articles included in our review had to meet the following criteria: (1) published in English or Spanish in a peer-reviewed journal between 2000 and February 2020 and conducted in the U.S., (2) described a mental health literacy and/ or stigma intervention delivered to Latinos/a adults 18 years of age or older, and (3) evaluated the impact of the intervention on mental health literacy and stigma outcomes for Latino/a adults. The two authors reviewed and evaluated the identified articles’ titles, abstracts, and full texts. Figure 1 presents the study flow chart. The initial database search resulted in 477 results, and a manual search identified one additional record. After removing duplicates, we screened the abstracts of 445 articles for eligibility and excluded 423. We then conducted a full-text review of 19 articles that met our inclusionary criteria. Twelve articles were excluded as six did not include mental health literacy or stigma outcomes, four were not relevant, and two did not focus on the population of interest. In total, seven articles reporting findings from six unique intervention studies were included in our review.

Figure 1.

PRISMA Flow Diagram

Analytical strategy.

A data abstraction form was used to systematically code: study characteristics, including study aims, sites, design, intervention characteristics (e.g., type of staff delivering the intervention), total sample size, outcome measures, and studies’ main findings. One author abstracted this information from each identified article. We used an adapted version of the Methodological Quality Rating Scale (MQRS: Cabassa & Hansen, 2007; Vaughn & Howard, 2004) to rate each article’s methodological quality. This instrument measures the methodological quality of intervention studies across 13 dimensions (e.g., study design, replicability, follow-up length, follow-up rate, cultural and linguistic adaptation). Two authors independently rated each article using the MQRS. The total MQRS scores for each study were derived by adding the 13 items. In our sample, the MQRS scores ranged from 5 to 10, with higher scores representing higher methodological quality. When MQRS rating discrepancies arose, a consensus approach between the two raters was used to resolve the discrepancy.

Results

Study characteristics.

The characteristics of the seven articles included in our review are displayed in Table 1. The articles’ samples ranged from 41 to 4122 participants, with a median sample size of 142 participants. The studies were conducted in a variety of settings, such as primary care clinics (Sanchez et al., 2019), community-based clinics (Hernandez & Organista, 2013; López et al., 2009; Tran et al., 2014; Wong et al., 2017) and adult community schools (Cabassa et al., 2015b; Unger et al., 2013a).

Table 1.

Study Characteristics

Main Author	Sample size	Country of origin	Setting/Location	Design	MQRS score	Mental Health Literacy Outcomes and Results	Mental Health Stigma Outcomes and Results
Cabassa et al., 2015	n=132	Self-identified as Latino, most of Mexican descent	Three community adult schools in the Los Angeles Unified School District (LAUSD)	RCT	10	• Knowledge of depression symptoms • Knowledge of depression treatments • Compared to a depression brochure, the depression fotonovela significantly improved knowledge of depression treatments, not symptoms, at both the posttest and the one-month follow-up.	• Social distance • Perceptions of dangerousness • No statistically significant differences between the depression fotonovela and the depression brochure at both the posttest and the one-month follow-up on both stigma outcomes.
Hernandez & Organista, 2013	n= 142	Mexico (n=112; 78.8%) Other (n=30; 21.1%)	Community-based setting	RCT	8	• Depression knowledge • Compared to the group discussion condition, the depression fotonovela significantly improved in depression knowledge at posttest,	• Stigma concerns about mental health care • Antidepressant stigma • No statistically significant differences between the group discussion and the depression fotonovela on stigma concers about mental health care. There was a pre to post statistically significant decrease found for antidepressant stigma scores among the depression fotonovela compared to the groups’ discussion comparison condition.
López et al., 2009	n=96	Foreign-born (86%) U.S. born (14%)	Community-based setting	Single group	7	• Health knowledge/ symptom identification • Community residents and caregivers increased their knowledge of psychosis symptoms after receiving La CLAVE intervention at three weeks follow-up. However, community residents had a statistically significantly lower mean of knowledge of psychosis symptoms compared to caregivers.	• Not reported
Sanchez et al., 2019	n= 350	Entirely Hispanic and their country-of-origin unknown, though 88% of Hispanics in Texas are of Mexican descent	Primary Care clinic	Single group	8	• Depression knowledge • The depression fotonovela significantly increased depression knowledge from baseline to one-month follow-up.	• Stigma concerns about mental health care • Antidepressant stigma • Social distance • Stigma concerns about mental health care and the desire for social distance from an individual with a mental illness significantly decreased over time (i.e., from baseline to follow-up). However, antidepressant stigma significantly increased from baseline to follow-up,
Tran et al., 2014	n=58	United States (n=1; 2 %) Mexico (n= 38; 65%) South America (n=12;(21%) Caribbean/Central American (n=7;12%)	Local community-based organization; In person/ phone	Single group	7	• Not reported	• Attitudes toward depression and treatment • The compañeras program significantly increase attitudes toward depression treatment from pretest to post-test
Unger et al., 2013	n=157	Mexico n=85 (61.2%); Guatemala n=11 (7.9%); El Salvador n=12 (8.6%); US n= 22 (15.8%); Other n=9 (6.5%)	Three community adult schools in the Los Angeles Unified School District (LAUSD)	RCT	10	• Depression knowledge • Compared to a depression brochure, the depression fotonovela significantly increase depression knowledge from baseline to post-test, but these differences were no longer significant at the one one-month follow-up.	• Stigma concerns about mental health care • Antidepressant stigma • Compared to a depression brochure, the depression fotonovela significantly decrease stigma concerns towards mental health treatments at post-test and the 1-month follow-up. At the posttest, antidepressant stigma statistically decreased for participants who received the fotonovela but remained consistent for the brochure group. At the one-month follow-up, there were no differences in antidepressant stigma between the two groups
Wong et al., 2017	n= 4122	Hispanic/Latino (n=1039;25%)	Community-based setting	Single group	5	• Not reported	• Belief about people with mental illness • Perceived public stigma • Attitudes toward mental illnesses • Social distance  Latino/as reported significantly greater improvements in several stigma domains, including fewer beliefs about dangerousness and social distance than their white counterparts from pretest to post-test.

Note: RCT: Randomized Controlled Trial; MQRS: Methodological Quality Rating Scale. Possible scores range from 1 to 17, with higher scores indicating higher study quality

Methodological quality ratings.

The total MQRS scores for the identified articles ranged from 5 to 10, with a median of 8. Three articles reporting two different intervention studies used a randomized control group design (Cabassa et al., 2015; Hernandez & Organista, 2013; Unger et al., 2013a), and four studies utilized single group pre/post designs (López et al., 2009; Sanchez et al., 2019; Tran et al., 2014; Wong et al., 2017). All articles provided sufficient detail to replicate the intervention reported detailed baseline participant characteristics (e.g., gender, ethnicity, race), and had short follow-up periods of less than six months. Four articles had less than 70% completion rate (Hernandez & Organista, 2013; López et al., 2009; Tran et al., 2014; Wong et al., 2017), two articles had 70%-84.9% completion rate (Cabassa et al., 2015b; Unger et al., 2013a), and one had a completion rate of 85%-100% (Sanchez et al., 2019). No articles utilized collateral verification of participant self-report (e.g., medical records, interviewing family members) or blinded assessors. All articles enumerated drop-out rates and used appropriate statistical analyses to evaluate intervention outcomes. Two articles reported findings from a single-site study (Hernandez & Organista, 2013; Sanchez et al., 2019), and five articles reported findings from multisite studies (Cabassa et al., 2015; López et al., 2009; Tran et al., 2014; Unger et al., 2013; Wong et al., 2017). All but one article (Wong et al., 2017) reported and discussed their interventions’ cultural and linguistic elements.

Intervention characteristics.

Intervention characteristics are presented in Table 2. Cabassa et al. (2015) and Unger et al. (2013) are two articles reporting findings from the same intervention and are evaluated as one intervention. Wong et al. (2017) included multiple interventions within their study. Interventions ranged in duration from 20 minutes (Hernandez & Organista, 2013) to six hours (Wong et al., 2017). They used multiple formats such as individual sessions (Sanchez et al., 2019), distributing printed materials (e.g., fotonovelas, brochures) to classrooms (Cabassa et al., 2015; Unger et al., 2013), and group sessions (Hernandez & Organista, 2013; López et al., 2009; Tran et al., 2014; Wong et al., 2017). Interventions were delivered by bilingual research team members (Cabassa et al., 2015, López et al., 2009, Unger et al., 2013), promotoras (Hernandez & Organista, 2013; Tran et al., 2014), community members (Wong et al., 2017), and bilingual/ bicultural licenses clinical social workers (Sanchez et al., 2019). Four interventions focused on depression (Cabassa et al., 2015; Hernandez & Organista, 2013; Sanchez et al., 2019; Tran et al., 2014; Unger et al., 2013) and one on psychosis (López et al., 2009). Wong et al. (2017) included multiple interventions focusing on general mental health.

Table 2.

Intervention Characteristics

Author(s)	Intervention length	Format	Type of staff delivering the intervention	Brief Intervention Description	Language Options
Cabassa et al., 2015 and Unger et al., 2012	Thirty minutes to read the brochure or fotonovela.	Individual	Bilingual data collectors	The fotonovela, Secret Feelings (Sentimientos Secretos), uses a soap opera narrative with photographs and text bubbles to tell the story of a Latina wife and mother who experiences depression and eventually decides to obtain counseling and medication. Through an engaging and entertaining story, the fotonovela presents factual information about the symptoms of depression and the use of antidepressants. Moreover, it addresses other salient issues, including depression in the family and stigma about seeking help. The story is presented in both English and Spanish at a 4th-grade reading level. The fotonovela booklet also includes a question-and-answer page and coupons to a local pharmacy. Comparison Condition: The NIMH depression brochure (National Institutes of Health publication 08 3561) is publicly available in English and Spanish and provides basic information about depression symptoms and treatments. NIMH’s text pamphlet is approximately the same length as the fotonovela (26 pages of text in the pamphlet compared with 30 pages of text and pictures in the fotonovela), which is intended for low-literacy audiences.	English and Spanish
Hernandez & Organista, (2013)	The fotonovela was read in 20–30 min.	Group	First author and Lay health advisors (known as promotoras)	This article evaluates the fotonovela’s effectiveness with immigrant Latinas at high risk for depression and low literacy in a community-based setting in which promotoras, trained by a local community-based clinic, conduct health education activities. This article explored the fotonovela’s compatibility with the promotora model of health education, given that immigrant Latinas are likely to use promotoras as a link between informal and formal health and mental health services. Comparison Condition: Participants were exposed to a discussion of family communication and intergenerational relationships lasting 45 min to an hour developed by the study site’s clinicians. The discussion identifies maladaptive communication patterns between immigrant parents and their US-born children and offers techniques for its improvement	Spanish
López et al., (2009)	35-min	Group	Bilingual research team members and PI	La CLAve (The clue or key) is a psychoeducational Spanish language program organized as a 42-powerpoint slides with five audio clips, three videos, and four paintings/ drawings. La CLAve holds multiple meanings to recognize the critical symptoms of psychosis in others: the “C” represents creencias falsas (false beliefs or delusions), “L” stands for lenguaje desorganizado (disordered speech or thought disorder), “A” signifies alucinaciones (hallucinations), and “v” and “e” represent the type of hallucination: ver cosas que no existen (see things that do not exist) and escuchar cosas que no existen (hear things that do not exist). For example, illustrate delusions, the program included a 2-min segment of the song “El Muelle de San Blas.” The song is about a young woman who holds on to the false belief that her lover will return and who lives waiting at a pier for him to return. Eventually, psychiatric personnel come to retrievela loca del muelle (the crazy woman from the pier). As the song is playing, we also present the lyrics so that participants can more closely follow the content of the given recording. To add a visual component to the music-based illustrations, the program included paintings.	Spanish
Sanchez et al., 2019	Not reported	Individual	Bilingual Clinical Social Worker (LCSW)	The Options to Reduce Barriers to Treatment (DESEO) implemented the fotonovela, Secret Feelings developed by Cabassa et al. (2015) within a sample of Latino/a primary care patients diagnosed with depression. The fotonovela was presented in both English and Spanish at a 4th-grade reading level and used an entertainment-education approach to portray the story of a Latina woman experiencing depression. She describes her symptoms, presents common fears and misconceptions (addiction, sexual dysfunction), and displays informal and formal help-seeking behavior (a friend and a trusted pharmacist). She discusses her mental health concerns with her family and engages in formal depression treatment.	English and Spanish
Tran et al., (2014)	At least six 2- to 3-hour training sessions on mental health	Group	Lay health advisors (known as promotoras)	ALMA (Amigas Latinas Motivando el Alma/Latina Friends Motivating the Soul) intervention used promotoras to identify up to three women (compañeras) in the community with whom to share their mental health promotion resources and information on a regular basis with the goal of preventing and reducing negative mental health outcomes. Promotoras were directed to conduct at least three contacts with the selected compañeras and to report on the resources discussed with and types of support (e.g., emotional, tangible, informational, companionship) provided to these individuals).	Spanish
Wong et al., 2017	Single versus multiple sessions, range of one to six hours	Group	Community members and research team members	Five different English contact-based educational programs were included in the article. For example, In Our Own Voice (IOOV): targets the community at large; Training Parents and Teachers as Allies (PTasA): targets teachers and educational staff; Provider Education Program (PEP): targets service providers, such as mental health professionals, health care providers, and criminal justice personnel, and Ending the Silence (ETS): targets high-school students. IOOV is a 60- to 90-minute educational presentation aimed at changing attitudes, stereotypes, and behaviors toward people living with mental illness. IOOV is conducted by two presenters who have experienced mental health challenges. All IOOV presenters undergo a two-day training conducted by trainers who are certified by the national NAMI office. The programs varied targeted audience (e.g., general community, human resources, school staff), delivery methods (e.g., in-person group presentations, online webinars, documentary viewing events), and intervention length (e.g., single versus multiple sessions, range of one to six hours). Program topic areas included equipping school personnel to recognize and assist students with mental health needs, increasing knowledge and advocacy of anti-discriminatory laws, policies, and practices, targeting personal wellness and stigma in the workplace and improving knowledge and attitudes toward mental illnesses in the general public.	English

Mental health literacy outcomes.

Six articles examined the impact of interventions on mental health literacy outcomes, including knowledge of depression symptoms and treatments and knowledge of psychosis symptoms (See Table 2). For example, Unger et al. (2013) evaluated the effectiveness of a depression fotonovela. They found that compared to a depression brochure, participants randomized to receive the depression fotonovela achieved statistically significantly larger gains on depression knowledge at the post-test. Still, these gains were no longer statistically significant between the two groups at the one-month follow-up. In a subsequent analysis of these data, Cabassa et al. (2015) evaluated the impact of a depression fotonovela among Latinos/as, uncovered that compared to a depression brochure, the fotonovela improved knowledge of depression treatments, not symptoms, at both the posttest and the one-month follow-up.

Moreover, Hernandez and Organista (2013) compared the impact of the depression fotonovela versus receiving a discussion of family communication and intergenerational relationships in a sample of Latina immigrants at-risk for depression receiving services at a community-based clinic. They found statistically significant posttest improvements in depression knowledge, including depression symptoms and depression treatments in the fotonovela group. Similarly, Sanchez et al. (2019) utilized a one-group pretest-posttest design to assess Latino/a primary care patients diagnosed with depression. They found the depression fotonovela to report a statistically significant increase in the knowledge of depression symptoms and treatments at the second session and one-month follow-up.

López et al. (2009) conducted a 35-min psychoeducational program, La CLAve (The Clue), on psychosis knowledge and efficacy beliefs among Spanish speaking Latino/a community residents and caregivers of individuals with mental illness. They found that both groups increased their knowledge of psychosis symptoms after receiving La CLAVE intervention at three weeks follow-up. However, community residents had a statistically significantly lower mean of knowledge of psychosis symptoms compared to caregivers.

Mental health stigma outcomes.

Six articles examined mental health stigma outcomes, including perceiving people with depression as dangerous, social distance, stigma towards mental health treatments, stigma towards antidepressant medications, beliefs about people with mental illness (PWMI), and perceived public stigma (See Table 2). Unger et al. (2013) found that compared to a depression brochure, participants randomized to receive the depression fotonovela achieved a statistically significant decrease in stigma towards mental health treatments at post-test. At the 1-month follow-up, stigma towards mental health treatments had been reduced even further in the fotonovela group, but the brochure group regressed to their baseline value. At the posttest, antidepressant stigma had statistically decreased for participants who received the fotonovela but remained consistent for the brochure group. At the one-month follow-up, antidepressant stigma had regressed toward its baseline value for both the fotonovela group and the brochure group resulting in no statistically significant differences between these two groups. In a subsequent analysis of these data, Cabassa et al. (2015) examined two stigma outcomes, social distances and perceptions of dangerousness. They found no statistically significant differences between the depression fotonovela and the depression brochure at both the posttest and the one-month follow-up on these stigma outcomes.

Hernandez and Organista (2013) assessed stigma towards mental health care and antidepressants. From pretest to posttest, there were no differences for stigma concern about mental health in the fotonovela group and the comparison group (exposure to a discussion of family communication and intergenerational relationship). At posttest, stigma concerns about mental health care slightly increased for the depression fotonovela and comparison groups. However, there was a pre to post statistically significant decrease found for antidepressant stigma scores among the depression fotonovela compared to the comparison group.

Sanchez et al. (2019) examined the impact of the depression fotonovela on antidepressant stigma, social distance, and stigma towards mental health care. They found that stigma concerns about mental health care significantly decreased over time (i.e., from baseline to follow-up). Similarly, social distance scores also significantly increased over time, indicating less desire for social distance from individuals with mental disorders. However, they found that the Latino/a scale for antidepressant stigma significantly increased from baseline to follow-up, indicating greater concerns about others’ negative perceptions of psychiatric medication use.

Lastly, Tran et al. (2014) trained community-based lay health advisors (known as promotoras) to conduct outreach to Latina women in their social network (compañeras). They examined attitudes toward depression and depression treatment from pretest to post-test using a pre–post-test design and found a significant increase for the compañeras. Finally, Wong et al. (2017) examined the effects of contact-based educational programs (e.g., program delivered by a person with lived experiences with mental illness) on various stigma domains among Asians, Whites, Latinos/as who received five different contact-based educational programs. Latino/as reported significantly greater improvements in several stigma domains, including fewer beliefs about dangerousness and social distance than their white counterparts from pretest to post-test.

Discussion

To our knowledge, this is the first systematic literature review of mental health literacy and stigma interventions for Latino/a adults in the U.S. Although stigma and low mental health literacy are significant barriers to mental health care for Latinos/as, our findings indicate that few interventions have been developed and tested to address these determinants of mental health care disparities. The few studies in this emerging literature seem to be small pilot studies with short follow-up periods. The interventions tended to focus on depression and psychosis and incorporated a series of cultural and linguistic elements to make these interventions relevant, salient, and culturally appropriate to Latino/a population. These elements included, using fotonovelas and soap opera narratives, incorporating Latino/a music and art, and delivering these interventions in English and Spanish in trusted community locations (community centers and schools). Our review of these intervention studies indicated that the existing interventions showed promise in improving mental health literacy, particularly knowledge of mental disorders (i.e., depression and psychosis) and treatments, and showed mixed results for reducing stigma.

Findings from our methodological quality ratings identified essential areas for improving these intervention studies’ rigor and advancing the development of empirically supported anti-stigma and mental health literacy interventions in the U.S. for the Latino/a population. Only 2 of the 6 intervention studies included in this review used a randomized control group design comparing different interventions, and none of the studies used blind assessors to collect data. All articles were short termed with follow-up periods of less than six months, and most studies used small sample sizes with the exception of Sanchez et al. (2019) and Wong et al. (2017). Furthermore, more studies are also needed to test the effectiveness and impact of these interventions and examine how, for whom, and under which conditions these interventions work. For example, studies included in this review were conducted in California, Texas, and North Carolina, and most of these samples were Latinas of Mexican descent. Given the growth and diversity of the Latino/a population in the U.S., more studies are needed in different U.S. locations, among subgroups of Latinos/as (e.g., Salvadorans, Guatemalans, Dominicans), gendered identities, and languages (e.g., Quechua, Nahuatl, Q’anjob’al). More multisite randomized control trials with larger sample sizes and longer follow-up periods are needed to improve the methodological rigor of anti-stigma and mental health literacy interventions for Latinos/as.

We found that the effects of the intervention included in our review showed promising results for improving mental health literacy outcomes, particularly knowledge of depression and psychosis and knowledge of depression treatments. Latinos/as are at higher risk for low mental health literacy, specifically Spanish-speaking individuals, less acculturated to the U.S. culture, and those that have low reading levels (Hernandez & Organista, 2013; Valle et al., 2006). Improving knowledge of mental disorders and treatments is a critical step for helping people seek help in times of need and initiating and hopefully engaging in mental health care. The studies included in this review suggest that interventions that communicated knowledge about mental disorders and treatments to Latino/a adults in a culturally and linguistically appropriate manner, particularly using narrative approaches (e.g., soap operas) and used Latino/a music and art to deliver an educational message, seemed to be critical for increasing the mental health literacy of this historically marginalized populations. Future work is needed to expand the dissemination and use of these interventions to a broader Latino/a audience and those segments of the Latino/a population (e.g., foreign-born, less acculturated Latinos/as) who would benefit most from these interventions. Examining how to increase the reach of these interventions via multiple media approaches like radio, television, the web, and social media platforms can be an important next step for improving mental health literacy in the Latino/a population.

Moreover, we found mixed results related to mental health stigma outcomes examined in the studies reviewed. Some studies found improvements in some stigma indicators (e.g., stigma towards mental health treatments, social distance), while other studies reported no improvements in other stigma indicators (e.g., antidepressant stigma). Many of the interventions included in this review were one session. Reducing stigma may require longer approaches and multiple attempts to create and sustain changes in stigma. The existing literature indicates that compared to knowledge-based interventions, contact-based anti-stigma interventions work better for reducing public stigma in adults (Corrigan & Fong, 2014). Contact-based interventions move beyond providing general information about mental disorders and treatments; they humanize mental illness by enabling individuals to interact either in-person or via media with a person living with mental illness. Contact challenges stigma by framing mental illness as treatable and humanizing the experience of living and recovering from a mental disorder. Longer interventions, like a community anti-stigma campaign that last several weeks or months and increase contact with people living and coping with mental illness, may be needed to create lasting changes in reducing this critical barrier to mental health care in the Latino/a population.

The interventions included in this systematic literature review placed culture at the center, emphasizing its importance to reduce stigma and improve mental health literacy. Our findings suggest that interventions that aim to improve mental health literacy and reduce stigma in the Latino/a population must go beyond matching intervention materials and messages to the superficial cultural characteristic of the population of interest, like delivering the intervention in Spanish and using Latino/a characters. They should use more sophisticated approaches that embed cultural elements into the fabric of the intervention to create messages and content that engage Latino/a audiences, promote attitudinal and behavioral change, and resonate with their lived experiences. For example, the depression fotonovela used in three studies included in our review, was informed by an entertainment-education approach. The approach embedded specific educational messages derived from previous studies examining Latino/as views of depression and depression treatments, thus, focusing on specific stigma and mental health literacy targets unique to Latino/as (Cabassa, 2016). These unique targets were then embedded within a soap opera narrative designed to entertain and educate the audience to increase their knowledge of depression and its treatments, create favorable attitudes toward seeking professional help for depression and motivate people to seek help in times of need (Cabassa, 2016).

Another great example is La CLAve (The Clue), a psychoeducational program informed by the concept of illness attributions and social cognitive theory. The program incorporated everyday language, familiar music, art, videos, and a mnemonic device for Spanish-speaking Latinos/as community residents and caregivers to obtain timely mental health care by increasing their mental health literacy of psychosis (López et al., 2009). For example, La CLAve utilizes a 2-min segment of a well-known Spanish Latin Rock song, “El Muelle de San Blas,” lyrics and a visual art component to illustrate the symptoms and experience of delusions to the Latino/a community. The song was inspired by a young woman, Rebeca Méndez Jiménez, who holds on to the false belief that her fiancé will return from a fishing trip. Eventually, psychiatric personnel come to retrieve her from the pier. The goals of La CLAve are to increase knowledge of psychosis, efficacy beliefs that a person can identify psychosis in others, shift illness attributions to a real mental illness that requires professional attention, and encourages people to seek professional help for psychosis (López et al. 2009).

Limitations

Several limitations need to be considered. The small number of studies included in our review prevented us from conducting a more formal meta-analysis and identifying which specific intervention elements were most effective for specific outcomes and groups. This limited number of published intervention studies is a function of the lack of research investment by funders (e.g., NIH, private foundations) in this important area of research. More studies are needed to continue to build the evidence-based for improving mental health literacy and reducing stigma in Latino/a communities. No systematic literature review is free of biases (e.g., missing published studies, publication biases). To minimize these biases, we followed the PRISMA guidelines, searched multiple sources (e.g., databases, manual searchers), used an array of keywords, and used independent raters and an established measure to rate the methodological quality of eligible studies.

Conclusion

Our findings highlight a significant deficit of mental health literacy and stigma interventions for the Latino/a population. As the Latino/a population continues to grow, future research should continue investigating and developing more evidence-based anti-stigma and mental health literacy interventions. In addition, as the field continues to move from understanding racial and ethnic mental health care disparities to reducing them, interventions that focus on improving mental health literacy and reducing stigma that are also culturally-grounded, theoretically-sound, and empirically-supported, are needed to achieve mental health equity for all Latino/as.