An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations

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.

Facilitators and Barriers to Seeking Mental Health Care Among Primary Care Veterans With Posttraumatic Stress Disorder

Although posttraumatic stress disorder (PTSD) is common in primary care patients, many do not seek mental health treatment. Existing research on barriers and facilitators to receiving PTSD treatment are not specific to primary care patients. In this study, we sought to understand the psychosocial concerns, treatment barriers, and treatment facilitators among non-treatment-seeking primary care veterans with PTSD who reside in both rural and urban settings. Using a concurrent triangulation design, we collected qualitative focus group and quantitative self-report data concurrently, analyzed them separately, and merged the results for interpretation. In total, 27 veteran primary care patients with PTSD participated in 1 of 4 focus groups. A modified conventional content analysis approach was used. Team-based coding began with three broad primary codes (psychosocial concerns, barriers, and facilitators) and subcodes were allowed to emerge from the data. Self-report measures were used to collect clinical characteristics and barriers to care. The results expanded upon existing models of PTSD treatment initiation by (a) specifying treatment preferences, such as patient-centered care, peer support services, and open access scheduling, and (b) presenting concerns, such as anger and core symptoms of PTSD. Results also indicated that a commonly used quantitative barriers measure may offer an incomplete picture of why veterans do not seek treatment as it does not assess how past negative treatment experiences may affect utilization. Strategies to help veterans overcome barriers to care may benefit from a focus on negative treatment-seeking beliefs and tailoring based on a veteran's rural or urban status.

Culture as a Double-Edged Sword: The Posttraumatic Experience of Indigenous Ethnic Minority Veterans

The applicability of Western concepts regarding the treatment of trauma in soldiers from indigenous ethnic minority backgrounds has scarcely been researched. This study explored the subjective meaning of living with chronic posttraumatic stress disorder (PTSD) among indigenous Bedouin veterans of the Israel Defense Forces (IDF), who are of Arab ethnicity and Muslim faith. In-depth, semistructured qualitative interviews were conducted with 10 Bedouin veterans suffering from PTSD and three Bedouin mental health clinicians working with this population. Two themes emerged: "I wanted to be like everyone else," referring to participants' experiences during their military service, and "Fluctuating between belonging and abandonment," referring to veterans' experiences of living with mental health problems in a traditional minority community. These findings highlight the importance of conducting a comprehensive inquiry into the complex cultural and social backgrounds of indigenous minority veterans suffering from PTSD, and the interplay between the conflicted identities and multiple "realities" they experience.