An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations
Abstract
Objective:
Indigenous populations, compared with majority populations, have a reduced likelihood of receiving professional help for mental health, contributing to health disparities. To increase use of and access to mental health services for Indigenous people, specific factors that affect service use need to be examined. An integrative review was undertaken of the barriers to and facilitators of help seeking and service use for Indigenous populations in Canada, the United States, Australia, and the Pacific Islands.
Methods:
Five databases—PsycINFO, PubMed, Web of Science, Social Services Abstracts, and Bibliography of Native North Americans—and gray literature were searched to identify original studies with data specific to Indigenous people. A qualitative analysis of common themes among the studies was conducted, along with a quality appraisal of included articles. Of the 1,010 records identified, the final synthesis included 41 articles.
Results:
Six main themes emerged: informal supports, which were often used as a first choice for help seeking compared with formal services; structural obstacles and supports; stigma and shame; self-reliance and uncertainty about services; cultural factors and mistrust of mainstream services; and the need for outreach and information regarding mental illness and services.
Conclusions:
Policy implications include needed structural changes to decrease mistrust of mainstream systems and services and increased funding and resource availability. Along with technology-facilitated treatment, programs for Indigenous people, families, and communities that enhance education and foster positive relationships can serve as a first step toward Indigenous people becoming comfortable with the idea of talking about mental health and with seeking treatment.
HIGHLIGHTS
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Mental health service barriers and facilitators for Indigenous populations are distinct from those for majority populations.
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Indigenous people in this review generally preferred informal mental health supports and expressed mistrust of mainstream services.
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Health systems must address structural and community barriers to seeking and receiving care, minimize stigma, and include cultural components in programs to increase help seeking among Indigenous people.
Indigenous populations are groups of people who have inhabited lands for thousands of years. Compared with prevalence of mental disorders in non-Indigenous populations, prevalence among Indigenous populations varies (1), yet the overall health status is lower (2), and suicide rates are consistently two to five times higher (3). Despite the disproportionate need, Indigenous populations of Canada, the United States, Australia, and the Pacific Islands are less likely than other groups to receive professional help for mental health difficulties (4).
Cultural differences in help seeking may account for some of these disparities (5, 6), along with a set of broader factors that affect the health behaviors of Indigenous people, including proximal determinants such as income and physical environments, intermediate determinants of community infrastructure and resources, and distal determinants of historical and ongoing colonialism and racism (7). Multiple forms of inequality and discrimination sometimes compound themselves (8); people with mental health difficulties from racial-ethnic minority groups can be subject to stereotypes and often report experiencing discrimination related to their cultures and mental illnesses (9). Health care policy makers need to be informed about social determinants of health among nonmajority cultural groups to better understand the health attitudes and behaviors of those groups (9, 10).
Several help-seeking models have been proposed to describe decision making and planned behaviors that individuals engage in when contemplating whether to seek care (11–13). Common assumptions of these models are that individuals must first accept the idea that they have a problem, decide whether they are willing to seek help, and then select and use the type of service needed (14). However, culture and context influence every aspect of help seeking, from how the problem is defined to how individuals and their families participate in treatment (15). Help-seeking models must therefore account for culture and context to provide meaningful insight into differences in service access and utilization. For example, the cultural influences on mental health model explicates how cultural perceptions of health may influence the recognition of mental health problems and how culture-related and economic barriers lead to service underutilization (10). Cauce and colleagues (15) have presented a model of adolescent help seeking influenced by culture and context, which they describe as both guiding adolescents toward and pushing them away from services. This model begins with problem definition; moves to a decision to seek help; and ends with the selection of a service provider, treatment, or both, which may include informal supports (family, clergy), collateral services (school counselors, juvenile justice), and formal mental health services (15). Similarly, Eiraldi and colleagues (14) propose four stages of help seeking by parents from ethnic minority groups who have children with attention-deficit hyperactivity disorder, which include variables specific to ethnic minority populations in relation to problem recognition, the decision to seek help, service selection, and service use. Thus, service-engagement factors (i.e., systems-level issues and barriers) can influence help seeking insofar as they are of concern for people considering whether to seek care. For example, historical and ongoing racism and discrimination, past government interventions that disrupted families, lack of trust in mainstream services, language, and stigma have been reported as help-seeking barriers among Australian Indigenous people (16). Systemic deficits and cultural barriers to hiring, training, and retaining mental health professionals from ethnic minority groups may be responsible for the shortages of these needed workers, despite client requests to receive help from professionals from these groups (10). Rurality can also affect worries about confidentiality and overall distrust of mental health services (17).
The behavioral model of health service use (18) is commonly utilized to study access to care and help seeking. In a qualitative study including youths, adults, and elders from eight First Nations communities, Isaak and colleagues (19) demonstrated that some conceptualizations of mental health help seeking mapped onto this model, such as social structures, health beliefs, and enabling and impeding access to resources. Perceived need for care, spirituality, and personal health and lifestyle practices only moderately mapped onto the model, whereas use of health services and strategies of avoidance had low or no degree of fit (19). Roh and colleagues (20) reported that this model has little predictive utility for help-seeking attitudes among American Indian adults ages 50 and older. There is, therefore, a need to determine the cultural pathways of help seeking among Indigenous people.
The present study is an integrative review of international literature that examined barriers to and facilitators of mental health help seeking among Indigenous populations. Previous reviews have explored similar themes among young people (21, 22) and rural populations (17), but this study is the first, to our knowledge, to investigate these themes specifically among Indigenous people. Because help seeking also entails selecting informal supports, such as family, friends, or religious or cultural healers (15), this review also included information related to informal help seeking when it was discussed alongside formal (professional) help seeking. We looked at help seeking along with treatment access, with a focus on reporting service system factors that affect those who decide to seek care. We then considered the implications of the barriers and how the public, mental health services, and policy makers can enhance needed help seeking and service access among Indigenous populations.
Methods
Search Strategy
The review followed the PRISMA guidelines (23), the gold standard for synthesizing the literature with a systematic analytic method. Five databases were searched: PsycINFO, PubMed, Web of Science, Social Services Abstracts, and Bibliography of Native North Americans. Additional searches were conducted in the gray literature, including the Native Health Database, Indigenous Studies Portal, Mental Health Commission of Canada website, Australian Indigenous HealthInfoNet, and EBSCO Open Dissertations. Databases were chosen on the basis of similar reviews (24, 25).
Search terms were designed to target four primary concepts for Indigenous populations: “help seeking,” “barriers,” “facilitators,” and “mental health” focus. Keywords were derived from previous reviews, including terms for Indigenous people in Canada, the United States, Australia, and the Pacific Islands (25); help seeking and barriers and facilitators (24); barriers to or facilitators of access or navigation (26); and mental health problems (27, 28). An iterative process was used to develop the final search terms. Preliminary searches were compared with subsequent searches to ensure the inclusion of relevant articles. Subject and Medical Subject Headings terms included those used in the review mentioned earlier (24), along with additional ones found within the selected databases that were deemed relevant. See the online supplement to this review for the search strings used for each database and study-selection details.
Eligibility Criteria
Studies were limited to those published in English in any year. Inclusion criteria included reporting original data about barriers to or facilitators of mental health help seeking, with data specific to Indigenous people.
Indigenous populations.
To be included, a study had to report data specific to Indigenous people in Canada, the United States, Australia, or the Pacific Islands. These locations are commonly examined in published North American literature on health topics related to Indigenous populations (25). Indigenous Canadian populations include Métis, First Nations, and Inuit peoples. Indigenous U.S. populations include Native Americans (American Indians), Alaska Natives, and Hawaiian Natives. Indigenous Australian populations include Aboriginal people and Torres Strait Islanders. Indigenous populations of the Pacific Islands include the Māori people of New Zealand and natives of Polynesia, Micronesia, and Melanesia. Articles that did not report Indigenous population data separately from data of other populations were excluded.
Help seeking.
The inclusion criteria for help seeking included professional help-seeking behaviors and help-seeking attitudes. Examples included terms that addressed seeking, using, or accessing treatment, care, or services. Articles were excluded if they addressed treatment engagement without mentioning treatment initiation or access.
Barriers to and facilitators of help seeking.
The review included only articles that addressed help seeking if they reported on barriers, facilitators, or other relevant factors that affect help-seeking success or access. This criterion included steps of deciding to seek treatment or contact a service (13, 14) and barriers and facilitators at a personal, community, treatment, or institutional level that affected the availability or accessibility of services (26); it did not include basic demographic factors, degree of mental health impairment, or prevalence rates of help seeking.
Mental health.
The review included articles on help seeking specifically for mental health concerns. Examples are mental illnesses and mental health problems, including psychological distress, mood disorders, psychotic disorders, trauma, anxiety disorders, obsessive-compulsive disorder, eating disorders, conduct disorder, personality disorders, and suicide. Addictions and substance use disorders were excluded from this review, because a preliminary review of the literature revealed a plethora of articles specific to help seeking among Indigenous people for addictions separate from general mental health.
Data Extraction and Synthesis
All included articles were downloaded as full text. Information from each of the included articles was summarized by one author (C.G.) in an Excel sheet in the categories of author(s), study design, country, Indigenous population, participant information, mental health concern, barriers to help seeking, facilitators of help seeking, and other relevant factors for help seeking.
The data were qualitatively synthesized. See the online supplement for a table of the included studies. A quality assessment was also conducted, with mixed-methods studies being assessed with two appraisals. All studies were included regardless of quality. Because this project involved reviewing published research findings, no institutional review board approval was required.
Results
Study Selection
The PRISMA flow diagram (see the online supplement) delineates the study-selection process conducted by one author (C.G.). From the 1,010 records identified, 41 studies were included in the final selection.
Study Characteristics
Publication dates ranged from 1983 to 2020, but 85% of the studies were published in or after 2000 (N=35 of 41). Study methods included 20 quantitative studies, 18 qualitative studies, and three mixed-methods studies (having both quantitative and qualitative components). A majority of the studies were conducted in the United States (N=26, including some Pacific Island populations), followed by Australia (N=10), Canada (N=3), and New Zealand (N=2). U.S. populations included Native Americans (American Indians), Polynesians, Alaska Natives, Apache people, and Pacific Islanders; Australian populations included Aboriginal people and Torres Strait Islanders; Canadian populations included First Nations people; and New Zealand populations included Māori people and Pacific Islanders. Some studies compared Indigenous populations with other populations (e.g., African American, Asian, Caucasian).
Of the studies, six were related to mental health services (e.g., needs, preferences). Another five studies focused on attitudes or beliefs about help seeking for mental health concerns. More than one-third (N=15) of the studies focused on psychological distress or on emotional or personal problems. Other studies focused on suicide (N=8), depression (N=4), and psychiatric rehabilitation (N=2). The ages of the participants ranged across the lifespan. Two studies focused on only female participants, and two studies focused primarily on male participants.
A majority of studies examined the perspectives of Indigenous clients (e.g., college students, incarcerated individuals, rural-living people, health care system patients, veterans). Eight studies included the perspectives of service providers who treat Indigenous clients. One study in Canada interviewed urban Indigenous elders, community members, and stakeholders.
Quality Assessment
The quantitative studies were evaluated for quality with the Cincinnati Children’s Hospital Medical Center LEGEND (let evidence guide every new decision) checklists (29, 30). The average quality of the 22 cross-sectional prevalence studies (29) was 9.73 out of 12 (range 6–12). All 22 studies had a fairly homogeneous composition of participants, appropriate statistical analyses (if relevant), and a helpful description of results. Most studies described appropriate methods (95%, N=21), clinical significance (95%, N=21), statistical significance (if relevant; 91%, N=20), and applicability to the population of interest (91%, N=20). Items that were less well fulfilled or not described included noting reliable and valid variables (64%, N=14), freedom from conflict of interest (32%, N=7), and sufficiency of power size (14%, N=3). In addition, there was one implementation study with quantitative components that met only nine items on the 15-item intervention checklist (30).
The 21 qualitative studies were evaluated by using the Critical Appraisal Skills Programme Checklist, for which the authors suggest not using a scoring system (31). All 21 studies had a clear research aim, clear data analyses, and reasonably valuable research findings. A majority of these studies addressed the justification for the research design (95%, N=20), data collection (95%, N=20), maintenance of ethical standards (95%, N=20), and the appropriateness of the recruitment strategy (86%, N=18). Less than half of the studies described whether the relationship between researcher and participants had been adequately considered (43%, N=9).
Themes
Across all 41 studies, six themes were identified that were related to barriers, facilitators, or other relevant factors for help seeking.
Theme 1: informal supports, often used as a first choice for help seeking rather than formal services.
Participants reported being more comfortable talking to family and friends than to a psychologist or counselor (32–40). Sometimes, the availability of family and friends was the reason for not seeking formal support (33, 36). Other times, family and friends were the gateways to seek professional help later (41, 42). For suicidal ideation, friends were likely to be the first people participants reached out to, because they were trustworthy and less likely to report the participant’s potential self-harm to his or her parents (34). Other preferred informal supports included traditional spiritual or folk healers (39, 40).
Two quantitative studies reported the percentage of participants willing to seek help from various sources (32, 35). In a study of 74 American Indian service consumers, about one-quarter of male participants were willing to talk to family about problems, whereas less than 10% were willing to talk to doctors, North American Indian Alliance (NAIA) providers, or their Alcoholics Anonymous sponsor. More than one-third of female participants were willing to talk to family, about 10% were willing to talk to a minister or priest, and less than 10% were willing to talk to an NAIA counselor, doctors, or other counselors (32). Similarly, in a study that included 23 Aboriginal people and Torres Strait Islanders, participants reported feeling more comfortable talking to family (74%, N=17) or friends (57%, N=13) than to a psychologist or counselor (35%, N=8) or to a general practitioner (35%, N=8) (35).
Although participants preferred family and friends’ support, many still had positive attitudes about people getting professional help if they need it (33). Other participants would consider professional help if things were perceived as more serious (37) and if they had exhausted other sources of support (38). Professional services were necessary if family and social support were not available (33) or if participants did not want to burden their loved ones, whom they perceived as having problems of their own (19). In an Australian study on suicide, not being in a relationship at the time of death was a predictor of recent mental health service utilization (43).
Theme 2: structural obstacles and supports.
Many participants spoke of the unavailability of needed mental health services and resources for Indigenous clients (34, 36, 42, 44–46). Not having access to Indigenous service providers (32, 47), language (41), and long waitlists (42, 44, 46) were reported to be barriers. For telehealth treatment, lack of access to computers was a barrier (48). High turnover rates and inexperienced staff also affected Indigenous clients (49, 50). Lack of collaboration of mental health services with other services (e.g., general medical health, family issues, housing) also made it difficult for Indigenous people to seek mental health care when needed (46). One participant referred to the lack of collaboration as a “run-around referral” (46).
Several studies reported cost or financial barriers to accessing mental health services (32, 35, 36, 38, 41, 42, 49, 50). Rural Pacific Islander veterans, in particular, had cost difficulties if they had no or a low disability status and high copayments (42). Some American Indian people also perceived a lack of local government support for Indigenous mental health services (34), rendering it a structural and personal barrier. A study on participants with eating disorder symptoms found that Native Americans were less likely to be referred for further services than were Caucasians (51). Geography was also significant: Indigenous communities (e.g., reservations) experienced isolation or inaccessibility to services (43, 47, 52). In addition, reliable transportation to services was desired but often unavailable (34, 49, 50, 53).
Facilitators of help seeking and service use were greater service availability, referrer support, and transportation provision for clients (49). Indigenous veterans, in particular, could benefit from free services offered by veteran organizations (42). Living in urban areas was associated with three times greater odds of receiving mental health services compared with living in regional or remote places (43). Having access to a counselor of the same ethnicity (46, 54) and overall mental health clinician availability (49, 55) were also associated with greater access to mental health services. Moreover, some mental health workers suggested bringing mental health services into the community (55, 56). At times, the flexibility to see Aboriginal clients at first presentation promoted access to services, rather than requiring the client to make an appointment for a later time (57). Also, Indigenous Australian adolescents saw telephone counseling as quick, accessible, and readily available (38).
Theme 3: stigma and shame.
Stigma against mental illness and stigma against help seeking for mental health conditions were commonly experienced by Indigenous participants (20, 33, 35–37, 41, 45, 58–64). Perceptions of stigma against mental illness held by Indigenous people included believing that mental illness is not accepted by society (35), endorsing the avoidance of people who have mental illness (35), and fear of being judged (35). Greater familiarity or contact with persons with severe mental illness predicted greater odds of avoiding or delaying services; this avoidance was assumed to derive from greater awareness of the potential for stigmatization and discrimination (65).
Likewise, self-stigma (internalized stigma) against seeking help for mental health concerns (i.e., being perceived as weak for asking for help) was associated with personal shame and embarrassment and with a decreased likelihood of wanting to use psychological services (35–38, 45, 47, 48, 58, 60, 61). Participants worried about being called “crazy” or “psycho” (33, 42, 63) and feeling inferior for seeking help (58). Beyond personal shame, participants worried about disgracing the family if others were to find out that they were seeking psychological help (38, 47). Fears regarding privacy and confidentiality were also reported (33, 35, 38, 60, 64), for example, in small, tight-knit communities where everyone knows one another and “people blab things” (33). On the other hand, anonymity encouraged help seeking (37, 38, 48). For example, depressed youths reported being more likely to engage in treatment if their peers did not know they were depressed (48).
Compared with European and other non-Indigenous populations, Māori people had significantly more negative attitudes toward help seeking and less intention to seek help for suicidal thoughts (59). In contrast, a study of older adults found no significant differences between the American Indian culture and majority culture in the stigma of seeking help and attitudes toward mental health services (5). Another study identified similar attitudes and stigma toward help seeking, with some differences between Indigenous and non-Indigenous participants (35). Percentages of beliefs about mental health literacy and stigma among Indigenous participants (N=22) were compared with overall beliefs of both Indigenous and non-Indigenous participants (N=282): whereas both groups were similar in their willingness to seek help and their knowledge of where to go to receive it, Indigenous participants more often believed that only people who are weak or overly sensitive let illness affect them (35%, compared with 11%) and noted that their peers make jokes about mental illness (48%, compared with 28%) (35).
Perceived or experienced discrimination also affected help seeking. Some participants avoided treatment because they believed that their community and health care staff would discriminate against them (42). Also, experiences of discrimination due to one’s culture and discrimination in seeking a job, acquiring housing, applying for social services, and dealing with the police were associated with reduced mental health service use (66).
One method with the potential to reduce the stigma of help seeking is to integrate mental health services into general medical health care (45). For instance, avoiding overt terms such as “mental health” can promote mental wellness programs by reducing stigma and fear (56). Also, Māori and Pacific Islander teenagers suggested that embarrassment about help seeking could be reduced if communities could deliver mental health programs to an entire class or if programs were more subtle about their mental health focus (48).
Theme 4: self-reliance and uncertainty about services.
Many participants reported uncertainty about whether services would be helpful (33, 36, 60, 67). Sometimes, a feeling of helplessness (36, 39) or a lack of faith in the mental health care system (42) accounted for the belief that such services would not help. Moreover, compared with White participants, Native American participants were less likely to believe that therapy can help individuals learn new coping skills and that therapy is not a waste of money (67). Some participants believed that their problem was not a big deal or was insufficient to receive help (36, 60); conversely, having a perceived need for services facilitated more service use (52).
Self-reliance regarding mental health comprised the desire to figure out problems alone without treatment (36, 60). Self-reliance beliefs were more common in discussing treatment for mental illness, compared with beliefs concerning substance use treatment (60). It was common for participants to have difficulty talking about problems and not to tell anyone they had mental health struggles (32, 34, 44, 48, 60). Some participants did not want to share struggles and be a burden to others (36).
The availability of electronic forms to enroll in mental health treatment helped increase confidence in the idea of seeking assistance from others, because individuals could initiate treatment on their own before talking to a therapist in person (37, 42, 48). In one study, electronic mental health applications (apps) helped young people take the first step in opening up before speaking to someone in person, as expressed in a quotation from an Indigenous youth: “I think sitting down with someone would be kind of daunting, so . . . at the beginning you could do it on your own and it gets sent away to a counselor . . . and then they can review it and send it back” (37).
Theme 5: cultural factors and mistrust of mainstream services.
A history of damaging institutional experiences of Indigenous people was associated with a reluctance to use formal services (34). Some participants reported contending with the urban American Indian population’s invisibility and stereotypes that American Indian people no longer exist (34). Similarly, participants with high enculturation levels (e.g., traditional identifications) were more likely to prefer informal mental health services (40) and have less favorable attitudes toward formal services (68), whereas participants with a strong identification with Caucasian culture were more likely to have positive attitudes toward services (61). The use of technical language within mainstream services was also a setback for Aboriginal people whose families did not use mental health jargon (64).
Indigenous people emphasized culture in their preferences for mental health workers and treatment. Some participants did not trust non-Indigenous providers (32, 53). Canadian Indigenous community members identified White privilege as a barrier to the relationship between service providers and Indigenous clients (53). One participant spoke about liking to go “where my people are” and needing “cultural safety” (53). There was an expectation that Indigenous people and communities support one another (34), and there was distrust that non-Indigenous counselors would have cultural competence (38). One participant reported, “How can they help? They don’t know anything about me or my culture” (38). Other participants scorned evidence-based treatment that did not include cultural considerations (42). American Indians in one study preferred traditional informal services, followed by on-reservation formal services, with the lowest preference being for off-reservation formal services (40).
Fearfulness of mainstream services was common. There was a fear of being hospitalized (34) or locked up (36). Some younger people expressed outright anger about being referred to treatment, with forced involvement making them want to run away and avoid being in a “mental health institute” (48). There was also fear of government intervention and having youths removed from the home (38, 46, 64). Conversely, feeling understood and being made comfortable during treatment (34), as well as perceiving professionals as well trained and qualified (19, 38, 49), were important factors in continuing to seek help.
Facilitators of help seeking included efforts to combat mistrust and fear, such as services with cultural awareness training and skill development (49). Coordination with existing Aboriginal services facilitated improvements in mental health services (49, 57). Allowing families access to traditional modes of health care, based on Indigenous values, paved the way for Aboriginal patients who had never accessed mental health services to receive those services (57). In addition, having access to a counselor of the same ethnicity ensured cultural appropriateness (46, 54).
Theme 6: need for outreach and information regarding mental illness and services.
Indigenous people not being aware of and not recognizing mental health concerns were significant barriers to help seeking (5, 19, 34, 42, 47, 64). A community of American Indian youths did not openly discuss suicide because of the fear that talking about it could lead to more suicide (34). Some Indigenous participants reported that mental illness was not discussed by their family, friends, or community (35). Studies noted the need in some Indigenous communities for public education about mental illness (42, 50). For example, some remote First Nations community members viewed mental illness as an intellectual disability (50). In another community, people referred to mental illness as “craziness of the mind” (19). On the other hand, greater knowledge of mental illness, such as depression, correlated with more positive attitudes toward mental health services (69).
Lack of mental health problem recognition was also common (36, 64). Some men reported mistaking mental illness symptoms for general medical symptoms (e.g., high blood pressure) (64). One participant said, “[T]hey don’t know they are sick . . . and they don’t realize that there is help for them” (64). Cultural norms, such as having a tough-it-out attitude toward distress unless general medical symptoms are present, contributed to not recognizing problems (41). Even when participants were aware of their need for services, some reported not knowing whom to talk to or having difficulty navigating the mental health care system (42, 44, 47). In one study, Aboriginal people and Torres Strait Islanders were also less likely than non-Indigenous people to encourage family and friends to seek help (35). However, other studies found that tight-knit and supportive communities embraced opportunities to educate each other about mental health and the available mental health services (41, 42).
Discussion
This review identified barriers and facilitators experienced by Indigenous people seeking treatment for mental health concerns. Forty-one studies were reviewed and included in a qualitative synthesis, resulting in six themes: informal supports that are often used as a first choice for help seeking rather than formal services, structural obstacles and supports, stigma and shame, self-reliance and uncertainty about services, cultural factors and mistrust of mainstream services, and the need for outreach and information regarding mental illness and services. Here, we discuss these barriers and facilitators in the context of the help-seeking models discussed earlier, which are broadly focused on problem recognition; the decision to seek help; and the selection of treatment, service providers, or both. Using our review’s findings, we highlight how cultural and contextual factors may affect pathways to care and care utilization among Indigenous people.
Problem Recognition
A significant theme across studies was the need for outreach and information regarding mental illness and services (theme 6). Sometimes, participants did not know how to recognize mental illness symptoms, because they may have been taught only to seek help if they have severe general medical symptoms (41). Mental illness was sometimes not viewed in terms of health or medicine but rather as something that is unknown or “crazy.” Participants also lacked knowledge of how to access and navigate mental health care systems.
Decision to Seek Help
Many factors related to the decisions of Indigenous clients to seek help emerged from this review. Indigenous people perceived a stigma against mental illness and mental disorders while also perceiving a stigma against seeking help for mental health concerns (theme 3). Stigma was internalized and led to a great sense of personal shame; stigma was also associated with worries about disgracing the family. The theme of stigma among Indigenous people seeking help is significant: Indigenous people with mental health conditions not only experience psychiatric symptoms and distress, but also are subject to racial prejudice and discrimination (70). Greater stigma is consistently associated with lower perceived need for help and is a direct barrier to help seeking (71).
The review also identified that many Indigenous people did not seek help because of cultural values related to the importance of self-reliance, or believed that treatment would not be effective and, therefore, was not worth it (theme 4). Self-reliance and uncertainty about mainstream services are likely predicted by cultural factors and history (theme 5), as well as by internalized stigma (theme 3). These attitudes were generally barriers for people, causing them to isolate and stay “tough,” even when they needed help. However, a self-reliant attitude can be helpful when it is constructive and adaptive, such as through self-help or self-care strategies that improve mental illness symptoms (39).
Treatment and Service Provider Selection
A preference for informal supports was a strong theme (theme 1) directly related to the choice of treatment and service provider (the final step in many help-seeking models). Intuitively, people in distress want to talk to someone they know and trust at first, which sometimes leads to formal help seeking and is associated with positive attitudes about help seeking in general. These results imply that informal or unconventional services can be valuable pathways to conventional services (33, 42). Even if one form of help does not lead to another, informal supports can be viewed as a beneficial alternative to formal services, because the individual in distress is still being listened to and supported (36). However, if peers are perceived as supportive yet advise their friends against seeking professional help when needed, then they could cause harm and add to the stigma of seeking help (36). Furthermore, stigma endorsed by one’s social circle predicts both self-stigma and self-reliance, negatively affecting help-seeking attitudes (72).
Cultural factors were also significant barriers to and facilitators of help seeking (theme 5). Uncertainty about mainstream White culture was a block to engaging with formal services, which often featured a Western perspective. Participants emphasized the importance of cultural sensitivity between providers and Indigenous clients (33). Many Indigenous people would prefer to work with an Indigenous clinician, because that would allow them to feel more understood and comfortable. Themes related to past damaging institutional experiences appeared in some studies, indicating how Indigenous people are still hurting from the societal injustices that have targeted and continue to target Indigenous populations. Indigenous people may be not only uncertain about help seeking but also fearful of government intervention.
The presence of structural and external barriers encountered by Indigenous people was substantial and included the lack of Indigenous service providers, language barriers, lack of integrated care, and financial and transportation barriers. It is possible that many of these structural and external barriers can be attributed to rurality rather than to Indigenous populations. However, these barriers correlate with the significant disparities that Indigenous people experience in seeking mental health treatment, compared with other populations (4), and they point to a need for a significant change in the response of government systems that affect funding, public awareness, and coordination among services offered to Indigenous people. Clinicians have a responsibility to be aware of the many obstacles that Indigenous clients face in seeking treatment and to show flexibility when possible. In addition, clinical biases in referrals were present (51), indicating that clinicians may need more cultural training, supervision, and collaboration when working with Indigenous clients to reduce errors that affect the availability of services. Beyond treatment access, additional service system barriers are examined in the literature on treatment engagement (73). Service system barriers and facilitators are important when considering help seeking insofar as they affect the decision of Indigenous clients to seek services.
It is evident that distinct factors that affect Indigenous people do not neatly fit into the assumptions of help-seeking frameworks that do not explicitly acknowledge culture and context. The first step, problem recognition, is affected by cultural differences in labeling stress and disorder. The step of choosing to seek treatment can be influenced by stigma, shame, and fear or, conversely, by stigma resistance and positive attitudes. Last, the step of contacting a mental health system assumes service availability and access, which is not always the case for Indigenous populations. Preference for informal supports, self-reliance and uncertainty about services, and cultural factors are also salient factors for Indigenous people. We add that contacting a mainstream mental health service requires trust in the system, congruence with a Western worldview, and favoring the values of Western service paradigms over other ways of knowing and healing. Future research should explore a more tailored and comprehensive framework for help seeking for Indigenous people.
Limitations
This review’s search strategies were limited to the English language, which may have ruled out relevant studies in other languages. Additionally, other synonyms of and relevant phrases related to “barriers” and “facilitators” might have been unintentionally excluded. Another term that could be added to searches on help seeking in the future is “stigma,” because of the large presence of this construct in the help-seeking literature. It is also important to note that the terminology regarding mental health could be limited by a Western conceptualization. Also, reducing study selection to those reporting data about Indigenous populations in certain regions did not allow for inclusion of studies on Indigenous populations in other countries. Studies from the United States were most plentiful, and it is likely that Indigenous populations from the three other locations were underrepresented. Moreover, the studies were screened and coded by one researcher, which may have limited the validity and reliability of the review. It should also be noted that we chose not to exclude studies on the basis of quality appraisal. The quality appraisal items that were rated as poor (or missing entirely) were related to reliability and validity of measured variables, sufficiency of sample size, freedom from conflict of interest, and description of the researcher’s relationship to participants or positionality; these are common methodological challenges in this area of research.
Implications
This integrative review presents many barriers and facilitators that clinicians, researchers, and policy makers can target on behalf of Indigenous people seeking mental health services. Because the family can be a powerful first point of contact, Isaak et al. (19) have recommended that family empowerment programs be implemented in Indigenous communities. Programs that target informal supports, such as family, friends, and local elders and healers, could be significant in helping Indigenous people to seek formal support when needed. Important in this approach is appropriate compensation (aligned with cultural and community values) for the work of those in the community who are called on to help.
There is a need for policy changes that reduce the health disparities between Indigenous and non-Indigenous people to address structural barriers. Increased funding, increased availability of culturally sensitive services, and incentives for Indigenous people to be educated and trained in mental health services delivery would enhance help seeking among Indigenous people. Moreover, the continued mistrust and fear of mainstream services and local governments indicate that Indigenous people are significantly and negatively affected by past and ongoing injustices. Doubt and trepidation should be acknowledged and validated. Local and federal policies should continue to make reparations. Beyond those steps, organizations that serve Indigenous people should implement practical changes to create new trust and dispel fear among Indigenous people. Culturally responsive care would enhance self-determination of and collaboration with Indigenous people and communities (74).
There have been calls for health systems to become more involved in destigmatizing help seeking by focusing on overall wellness (45). Participants gave suggestions to help decrease stigma and increase help seeking, which included combining mental health check-ups with general medical health appointments and delivering a program on mental health to an entire school class, so no one feels singled out. It is crucial to explore feasible ways of destigmatizing help seeking and facilitating positive attitudes and willingness to help people who need mental health services. Also, there is a clear need for mental health literacy promotion among Indigenous communities, but a collaboration between providers of these programs and Indigenous stakeholders is necessary (64).
Finally, help seeking would be facilitated by clinicians, health care systems, and governments listening to Indigenous people regarding what is working for them and their communities. Outreach programs can educate people about mental illness and increase awareness of how to seek support while increasing mental health literacy and reducing stigma. Electronic forms of treatment (e.g., computer-based therapy, mental health apps) may be a valuable alternative to in-person care or a first point of contact for seeking mental health services, to teach a person that it is okay to seek help and talk to someone. Given the importance of connectivity in help seeking, it would be imperative to focus on help-seeking facilitators for those living in more rural locations, such as telehealth interventions (75). Researchers should explore different methods of seeking needed help as society grows technologically in this digital age.
Conclusions
This study revealed barriers and facilitators for Indigenous people in seeking treatment for mental health problems. Help-seeking behaviors were influenced by a preference for informal supports, significant structural barriers, stigma, cultural factors, and awareness of services. A new framework incorporating help-seeking and service-use determinants specific to Indigenous populations is needed. Clinicians and local health workers have obligations to meet the needs of Indigenous clients and reduce barriers to care. On a larger scale, policy makers have a responsibility to address the systemic barriers that inordinately affect access to proper mental health support for Indigenous populations.
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References
1.
Kisely S, Alichniewicz KK, Black EB, et al: The prevalence of depression and anxiety disorders in Indigenous people of the Americas: a systematic review and meta-analysis. J Psychiatr Res 2017; 84:137–152
2.
Valeggia CR, Snodgrass JJ: Health of Indigenous peoples. Annu Rev Anthropol 2015; 44:117–135
3.
Hunter E, Harvey D: Indigenous suicide in Australia, New Zealand, Canada and the United States. Emerg Med 2002; 14:14–23
4.
McIntyre C, Harris MG, Baxter AJ, et al: Assessing service use for mental health by Indigenous populations in Australia, Canada, New Zealand and the United States of America: a rapid review of population surveys. Health Res Policy Syst 2017; 15:67
5.
Moon H, Lee Y-S, Roh S, et al: Factors associated with American Indian mental health service use in comparison with White older adults. J Racial Ethn Health Disparities 2018; 5:847–859
6.
Manson SM: Mental health services for American Indians and Alaska Natives: need, use, and barriers to effective care. Can J Psychiatry 2000; 45:617–626
7.
Reading CL, Wien F (eds): Health Inequalities and Social Determinants of Aboriginal Peoples’ Health. Prince George, Canada, National Collaborating Centre for Aboriginal Health, 2009. https://www.ccnsa-nccah.ca/docs/determinants/RPT-HealthInequalities-Reading-Wien-EN.pdf
8.
Crenshaw K: Mapping the margins: intersectionality, identity politics, and violence against women of color. Stanford Law Rev 1991; 43:1241–1299
9.
Gary FA: Stigma: barrier to mental health care among ethnic minorities. Issues Ment Health Nurs 2005; 26:979–999
10.
Hwang WC, Myers HF, Abe-Kim J, et al: A conceptual paradigm for understanding culture’s impact on mental health: the cultural influences on mental health (CIMH) model. Clin Psychol Rev 2008; 28:211–227
11.
Andersen R: A Behavioral Model of Families’ Use of Health Services. Chicago, Center for Health Administration Studies, University of Chicago, 1968
12.
Rosenstock IM: Why people use health services. Milbank Mem Fund Q 1966; 44:94–127
13.
Saunders SM: Applicants’ experience of the process of seeking therapy. Psychother Theory Res Pract Train 1993; 30:554–564
14.
Eiraldi RB, Mazzuca LB, Clarke AT, et al: Service utilization among ethnic minority children with ADHD: a model of help-seeking behavior. Adm Policy Ment Health 2006; 33:607–622
15.
Cauce AM, Domenech-Rodríguez M, Paradise M, et al: Cultural and contextual influences in mental health help seeking: a focus on ethnic minority youth. J Consult Clin Psychol 2002; 70:44–55
16.
Isaacs AN, Pyett P, Oakley-Browne MA, et al: Barriers and facilitators to the utilization of adult mental health services by Australia’s Indigenous people: seeking a way forward. Int J Ment Health Nurs 2010; 19:75–82
17.
Cheesmond NE, Davies K, Inder KJ: Exploring the role of rurality and rural identity in mental health help-seeking behavior: a systematic qualitative review. J Rural Ment Health 2019; 43:45–59
18.
Andersen RM: Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav 1995; 36:1–10
19.
Isaak CA, Mota N, Medved M, et al: Conceptualizations of help-seeking for mental health concerns in First Nations communities in Canada: a comparison of fit with the Andersen Behavioral Model. Transcult Psychiatry 2020; 57:346–362
20.
Roh S, Burnette CE, Lee KH, et al: Predicting help-seeking attitudes toward mental health services among American Indian older adults: is Andersen’s behavioral model a good fit? J Appl Gerontol 2017; 36:94–115
21.
Gulliver A, Griffiths KM, Christensen H: Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry 2010; 10:113
22.
Brown A, Rice SM, Rickwood DJ, et al: Systematic review of barriers and facilitators to accessing and engaging with mental health care among at-risk young people. Asia Pac Psychiatry 2016; 8:3–22
23.
Moher D, Shamseer L, Clarke M, et al: Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; 4:1
24.
Gulliver A, Griffiths KM, Christensen H, et al: A systematic review of help-seeking interventions for depression, anxiety and general psychological distress. BMC Psychiatry 2012; 12:81
25.
Pomerville A, Burrage RL, Gone JP: Empirical findings from psychotherapy research with Indigenous populations: a systematic review. J Consult Clin Psychol 2016; 84:1023–1038
26.
Robards F, Kang M, Usherwood T, et al: How marginalized young people access, engage with, and navigate health-care systems in the digital age: systematic review. J Adolesc Health 2018; 62:365–381
27.
Gone JP, Alcántara C: Identifying effective mental health interventions for American Indians and Alaska Natives: a review of the literature. Cultur Divers Ethnic Minor Psychol 2007; 13:356–363
28.
Storrie K, Ahern K, Tuckett A: A systematic review: students with mental health problems—a growing problem. Int J Nurs Pract 2010; 16:1–6
29.
LEGEND: Evidence Appraisal of a Single Study: Etiology, Risk Factors, Prevalence: Cross-sectional Study. Cincinnati, Cincinnati Children’s Hospital Medical Center, 2012. https://www.cincinnatichildrens.org/-/media/cincinnati%20childrens/home/service/j/anderson-center/evidence-based-care/legend/evidenceappraisalform-etiologyprev-crosssection.pdf?la=en
30.
LEGEND: Evidence Appraisal of a Single Study: Intervention: Cross-sectional Study. Cincinnati, Cincinnati Children’s Hospital Medical Center, 2012. https://www.cincinnatichildrens.org/-/media/cincinnati%20childrens/home/service/j/anderson-center/evidence-based-care/legend/evidenceappraisalform-intervention-crosssection.pdf?la=en
31.
CASP Qualitative Checklist. Oxford, Critical Appraisal Skills Programme, 2018. https://casp-uk.b-cdn.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_form.pdf
32.
Barron L, Oge LL, Markovich J: North American Indian Alliance mental health needs assessment report. Am Indian Alsk Native Ment Health Res 1999; 8:13–24
33.
Burnette CE, Liddell J, Roh S, et al: American Indian women cancer survivors’ perceptions and experiences with conventional and non-conventional mental health care for depressive symptoms. Ethn Health 2021; 26:186–205
34.
Burrage RL, Gone JP, Momper SL: Urban American Indian community perspectives on resources and challenges for youth suicide prevention. Am J Community Psychol 2016; 58:136–149
35.
Coates D, Saleeba C, Howe D: Mental health attitudes and beliefs in a community sample on the Central Coast in Australia: barriers to help seeking. Community Ment Health J 2019; 55:476–486
36.
Freedenthal S, Stiffman AR: “They might think I was crazy”: young American Indians’ reasons for not seeking help when suicidal. J Adolesc Res 2007; 22:58–77
37.
Povey J, Sweet M, Nagel T, et al: Drafting the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app: results of a formative mixed methods study. Internet Interv 2020; 21:100318
38.
Price M, Dalgleish J: Help-seeking among Indigenous Australian adolescents. Youth Stud Aust 2013; 32:10–18
39.
Ta Park VM, Kaholokula JK, Chao PJ, et al: Depression and help-seeking among native Hawaiian women. J Behav Health Serv Res 2018; 45:454–468
40.
Walls ML, Johnson KD, Whitbeck LB, et al: Mental health and substance abuse services preferences among American Indian people of the northern Midwest. Community Ment Health J 2006; 42:521–535
41.
Kwan PP, Soniega-Sherwood J, Esmundo S, et al: Access and utilization of mental health services among Pacific Islanders. Asian Am J Psychol 2020; 11:69–78
42.
Whealin JM, Nelson D, Kawasaki MM, et al: Factors impacting rural Pacific Island veterans’ access to care: a qualitative examination. Psychol Serv 2017; 14:279–288
43.
Sveticic J, Milner A, De Leo D: Contacts with mental health services before suicide: a comparison of Indigenous with non-Indigenous Australians. Gen Hosp Psychiatry 2012; 34:185–191
44.
Isaacs AN, Sutton K, Hearn S, et al: Health workers’ views of help seeking and suicide among Aboriginal people in rural Victoria. Aust J Rural Health 2017; 25:169–174
45.
Shaw JL, Beans JA, Comtois KA, et al: Lived experiences of suicide risk and resilience among Alaska Native and American Indian people. Int J Environ Res Public Health 2019; 16:3953
46.
Williamson AB, Raphael B, Redman S, et al: Emerging themes in Aboriginal child and adolescent mental health: findings from a qualitative study in Sydney, New South Wales. Med J Aust 2010; 192:603–605
47.
Takeuchi DT, Leaf PJ, Kuo HS: Ethnic differences in the perception of barriers to help-seeking. Soc Psychiatry Psychiatr Epidemiol 1988; 23:273–280
48.
Fleming TM, Dixon RS, Merry SN: ‘It’s mean!’ The views of young people alienated from mainstream education on depression, help seeking and computerised therapy. Adv Ment Health 2012; 10:195–203
49.
Reifels L, Nicholas A, Fletcher J, et al: Enhanced primary mental healthcare for Indigenous Australians: service implementation strategies and perspectives of providers. Glob Health Res Policy 2018; 3:16
50.
Schmidt G: Barriers to recovery in a First Nations community. Can J Commun Ment Health 2000; 19:75–87
51.
Becker AE, Franko DL, Speck A, et al: Ethnicity and differential access to care for eating disorder symptoms. Int J Eat Disord 2003; 33:205–212
52.
Barney DD: Use of mental and health services by American Indian and Alaska Native elders. Am Indian Alsk Native Ment Health Res 1994; 5:1–14
53.
Schill K, Terbasket E, Thurston WE, et al: Everything is related and it all leads up to my mental well-being: a qualitative study of the determinants of mental wellness amongst urban Indigenous elders. Br J Soc Work 2019; 49:860–879
54.
Haviland MG, Horswill RK, O’Connell JJ, et al: Native American college students’ preference for counselor race and sex and the likelihood of their use of a counseling center. J Couns Psychol 1983; 30:267–270
55.
Snowden L, Masland M, Ma Y, et al: Strategies to improve minority access to public mental health services in California: description and preliminary evaluation. J Community Psychol 2006; 34:225–235
56.
Sayers JM, Cleary M, Hunt GE, et al: Service and infrastructure needs to support recovery programmes for Indigenous community mental health consumers. Int J Ment Health Nurs 2017; 26:142–150
57.
Laugharne J, Glennen M, Austin J: The “Maga Barndi” mental health service for Aboriginal people in Western Australia. Australas Psychiatry 2002; 10:13–17
58.
Allen GEK, Kim BSK, Smith TB, et al: Counseling attitudes and stigma among Polynesian Americans. Couns Psychol 2016; 44:6–27
59.
Deane FP, Skogstad P, Williams MW: Impact of attitudes, ethnicity and quality of prior therapy on New Zealand male prisoners’ intentions to seek professional psychological help. Int J Adv Couns 1999; 21:55–67
60.
Duran B, Oetzel J, Lucero J, et al: Obstacles for rural American Indians seeking alcohol, drug, or mental health treatment. J Consult Clin Psychol 2005; 73:819–829
61.
Freitas-Murrell B, Swift JK: Predicting attitudes toward seeking professional psychological help among Alaska Natives. Am Indian Alsk Native Ment Health Res 2015; 22:21–35
62.
Roh S, Brown-Rice KA, Lee KH, et al: Attitudes toward mental health services among American Indians by two age groups. Community Ment Health J 2015; 51:970–977
63.
Tingey L, Cwik MF, Goklish N, et al: Risk pathways for suicide among Native American adolescents. Qual Health Res 2014; 24:1518–1526
64.
Isaacs AN, Maybery D, Gruis H: Help seeking by Aboriginal men who are mentally unwell: a pilot study. Early Interv Psychiatry 2013; 7:407–413
65.
Subica AM, Aitaoto N, Link BG, et al: Mental health status, need, and unmet need for mental health services among US Pacific Islanders. Psychiatr Serv 2019; 70:578–585
66.
Burgess DJ, Ding Y, Hargreaves M, et al: The association between perceived discrimination and underutilization of needed medical and mental health care in a multi-ethnic community sample. J Health Care Poor Underserved 2008; 19:894–911
67.
Hunt J, Sullivan G, Chavira DA, et al: Race and beliefs about mental health treatment among anxious primary care patients. J Nerv Ment Dis 2013; 201:188–195
68.
Price BK, McNeill BW: Cultural commitment and attitudes toward seeking counseling services in American Indian college students. Prof Psychol Res Pract 1992; 23:376–381
69.
Roh S, Brown-Rice K, Pope ND, et al: Depression literacy among American Indian older adults. J Evid Inf Soc Work 2015; 12:614–627
70.
Corrigan P: How stigma interferes with mental health care. Am Psychol 2004; 59:614–625
71.
Corrigan PW, Druss BG, Perlick DA: The impact of mental illness stigma on seeking and participating in mental health care. Psychol Sci Public Interest 2014; 15:37–70
72.
Jennings KS, Cheung JH, Britt TW, et al: How are perceived stigma, self-stigma, and self-reliance related to treatment-seeking? A three-path model. Psychiatr Rehabil J 2015; 38:109–116
73.
Interian A, Lewis-Fernández R, Dixon LB: Improving treatment engagement of underserved US racial-ethnic groups: a review of recent interventions. Psychiatr Serv 2013; 64:212–222
74.
O’Keefe VM, Cwik MF, Haroz EE, et al: Increasing culturally responsive care and mental health equity with Indigenous community mental health workers. Psychol Serv 2021; 18:84–92
75.
Butzner M, Cuffee Y: Telehealth interventions and outcomes across rural communities in the United States: narrative review. J Med Internet Res 2021; 23:e29575
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History
Received: 18 August 2021
Revision received: 31 January 2022
Revision received: 30 April 2022
Accepted: 27 May 2022
Published online: 6 September 2022
Published in print: March 01, 2023
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
This work was partially supported by the Canada Research Chairs Program and the Canada Foundation for Innovation.
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