Perspective of Mental Health Services Needs and Use in Immigrant Families: An Online Survey

doi:10.21203/rs.3.rs-4998822/v1

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Perspective of Mental Health Services Needs and Use in Immigrant Families: An Online Survey

https://doi.org/10.21203/rs.3.rs-4998822/v1

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An online survey of 682 people, 41.3% of whom were immigrants, compared child mental health service needs and use between immigrants and Canadian-born parents. The survey also assessed the expressed need for child mental health support, parental utilization of services, methods of accessing information, and the presence of other support systems. We found a significant underuse of child mental health services among immigrant participants (1.5 times less use) despite a higher reported child need. This disparity was most pronounced in the use of child psychologists, family physicians and other allied health professionals. Results also showed that immigrant and non-immigrant parents used informational platforms at comparable frequencies. An examination of personal support systems showed immigrant parents struggling with their child's mental health and behaviour were less likely to seek support from other Canadians. They also reported less support from their significant other and friends. These findings highlight the importance of considering cultural background in clinical approaches to child mental health and the need for targeted interventions to improve accessibility and utilization of mental health services to ensure health equity.

Psychology

Immigrants

parents

child mental health

service use

social support

Mental health challenges among children are a growing concern in Canada, with the increased recognition of conditions such as Attention-Deficit/Hyperactivity Disorder (ADHD), anxiety and mood disorders, and autism spectrum disorder (ASD). The rate of Canadian Youth diagnosed with ADHD, mood, and anxiety disorders has increased significantly [1], [2], [3]. Despite this growth in prevalence and awareness, significant gaps remain in the understanding of whether these rates represent all Canadian youth. A survey of British Columbian Youth reported a 50% lower diagnosis rate of ADHD, mood disorders, and conduct disorders in youth whose parents were born in another country and permanently resettled in Canada [4]. Given that immigrants make up 23% of the Canadian population, with a projected increase to 34% by 2041 [5], the underutilization of needed mental health services by their children presents a potential health equity issue.

Understanding reported gaps in immigrant youth diagnoses requires a concurrent assessment of child need for such services. Existing research on this comparative need has shown confounding results. Certain studies support the "healthy immigrant effect," a phenomenon of newcomers reporting superior mental health compared to the native population [6], [7], while other findings highlight greater mental health needs in this population due to unique stressors such as acculturation, language barriers, and socioeconomic challenges [8], [9]. Canadian research on this topic has been limited to mostly provincial-scale studies that separate the underutilization of mental health services from child-need for services [6], [7].

In the Canadian healthcare system, mental health resources for children include physicians, psychologists, community support groups, and social workers. Many physicians provide initial assessments and referrals to specialists [10]. While services provided by general physicians can usually be covered by public health insurance in Canada, most other mental health services are not[10]. Socioeconomic status, long wait times, and cultural and linguistic barriers act as deterrents to seeking services. Among parents who have used services, many did not find them beneficial due to language barriers and insensitivity to their cultural needs. These experiences of discrimination, paired with difficulty communicating, poses harm to both to immigrant parents as well as their children by reducing their overall willingness seek services [11]. Furthermore, Mental Health Literacy (MHL), defined as the ability to recognize mental health symptoms, attitudes that promote support-seeking, and knowledge of available resources, are strong predictors of accessing services [12].

This study seeks to address these gaps by comparing a nationwide sample of parent reports between immigrant and non-immigrant participants. We also examine the prevalence of child mental health struggles, the use of mental health services and other support systems, school-based barriers, as well as how these relate to other sociodemographic factors. These factors will be used to better characterize and understand disparities in mental health service utilization. Together, these research questions contribute to a comprehensive understanding of the referral and support ecosystem for immigrant families and their children, informing both clinical practice and policy development aimed at enhancing the well-being of all Canadian families.

Study Design and Participants

This study was approved by McGill University’s Research Ethics Board 2 (REB protocol # 23-09-053-01). An online survey was administered to the eligible participants via Qualtrics. The survey completed February-March 2024, included primarily multiple-choice answer options and few short open-ended questions. This survey was distributed to eligible Canadian parents with a profile on AskingCanadians ( https://portal.askingcanadiansprojects.com/ ), a Canadian crowdsourcing data collection company. Upon completion of the survey, participants received a $5.00 compensation which is delivered through their desired loyalty.

Inclusion Criteria

Individuals who were at least 18 years old, residing in Canada, and were caregivers to a child between the ages of 5 to 17 years old were eligible to participate in this study. Participants must also be able to comfortably read, write and understand English, as well as have an electronic device with internet access. Additionally, specifiers were added to hit the target or equal number of immigrant and Canadian-born parents through AskingCanadians, to achieve national representativeness of the data.

Measures

This paper focuses on questionnaires related to mental health services, child mental health, and family demographic information. Parents provided sociodemographic data, including age, sex, ethnicity, education level, English skills, number of children, years in Canada, total household income, and province of residence. To assess the child's need for support, parents reported on their child's interest in using mental health services and their history of using such services. Participants also indicated where they accessed information about support services and looked for support when their child was struggling. The Multidimensional Scale of Perceived Social Support (MSPSS) measured perceived social support from family, friends, and significant others, assessing parents' perceptions of having someone close for comfort ([13]. Additionally, parents identified school-related barriers their children faced, such as language issues, limited access to special education resources, or a lack of cultural understanding (See Appendix I for more details).

Procedure

Eligible participants with profiles on the AskingCanadians platform were emailed and provided with information about the study. Interested individuals were directed to a consent form administered through the University's approved Qualtrics platform. If participants consented to the survey, they were redirected to a brief 1–2-minute eligibility screener. If eligible, they were redirected to complete the full anonymous survey. The questionnaires and eligibility screener were administered using Qualtrics, an online software platform. The survey took participants 30–40 minutes to complete. After completing the survey, participants were compensated in $5.00 worth loyalty program points of their choice.

Statistical Analyses

Survey data was first inspected to check for accuracy, outliers and normality assumptions. Descriptive statistics were computed for variables of interest, and assumptions of homogeneity of variance were tested using Levene’s test. For continuous variables (i.e., child need, age, income, number of children, language skills), Mann-Whitney U Tests and one-way analyses of variance (ANOVA) were used to examine group differences. Between-group comparisons for multiple categorical variables (i.e., use of mental health services, accessing the information on support services, other support services, sex, education level, and province) were conducted through Chi-square analysis. Continuous variables were compared using linear models for normally distributed data and generalized linear models for non-normally distributed data. Bonferroni corrections were used to control for multiple comparisons. All analyses were performed in SPSS version 29.1.

Sample Characteristics

A total of 682 participating parents completed the survey, 53.9% of which were men, with a mean age of 32 old (SD = 7.4) with 2 children per household on average. The mean age of the child being reported on was 12 years old (SD = 4). The sample included respondents from Ontario (49.0%), followed by Alberta (17.6%), British Columbia (15.7%), and Quebec (8.4%). A total of 41.3% of respondents self-reported themselves as immigrants, and their average years in Canada were 19.6 (SD = 12.2). Most immigrants were primarily from Asia (e.g. South Asia, Southeast Asia and the Middle East). Notably, immigrant participants reported significantly higher levels of education, lower English language proficiency, lower household income, and similar financial well-being and number of children compared to non-immigrants. Refer to Table 1 for more information.

Child Need and Access to Mental Health Services

Results from the Mann-Whitney U Test showed that immigrant parents reported that their children expressed a greater need for mental health services (i.e., mental health professional, school counsellor, online service, community-based support group than children of non-immigrant parents, U = 31073.00, z = 3.36, p < .001, Fig. 1). Non-immigrant parents, however, reported accessing mental health services for their children at 1.5 times greater frequency than immigrant parents (Chi-square test, χ² = 11.43, p < 0.001, Fig. 2). Of the specific services used, the immigrant parent group showed a difference in the use of child psychologists (χ² = 9.47, p = 0.002), family physicians (χ² = 8.25, p = 0.004), school counsellors (χ² = 5.11, p = 0.02) and other allied health professionals (χ² = 7.20, p = 0.007, See Fig. 3).

Demographic predictors of child expressed need for mental health support were investigated through linear regressions, generalized linear regressions, and ANOVA. Linear regression analysis found that a child's request for access to services was significantly associated with participant age, F (1, 551) = 6.03, p = 0.037) and their parents' English language proficiency, F (1, 548) = 10.70, p = .005). Child's request for access to services was not significantly associated with child age (p > 0.05) and length of time in Canada (p > 0.05). ANOVA revealed that participant sex (p > 0.05), education (p > 0.05), province of residence (p > 0.05) and household income (p > .05) were not associated with a child's request for access to services.

ANOVA and Chi-square tests were also conducted to examine the demographic differences between participants who utilized mental health services for their children and those who did not. The analysis revealed significant group differences in English language proficiency, F (1, 555) = 8.05, p = .005, η² = .01, and total numbers of school-barriers faced, F (1, 558) = 26.97, p < .001, η² = .05, between participants who utilized mental health services for their child and those who did not. No significant group differences were observed between the groups related to age of the child (p > 0.05), age of the parent (p > 0.05) and parents’ length of stay in Canada (p > .05). The Chi-square test found no significant group difference based on the sex of the parent (p > 0.05), province of residence (p > 0.05), level of education (p > 0.05), and household income (p > 0.05).

Accessing Information on Support Services

A Chi-square analysis showed that immigrant and non-immigrant parents did not access information about support services differently χ² = 10.68, p > 0.05. The most common methods for accessing support related information for both groups included browsing online (35% for non-immigrant parents, 35% for immigrant parents), utilizing social networks (33.3% for non-immigrant parents, 30% for immigrant parents), and contacting the child's school (24% for non-immigrant parents, 26% for immigrant participants). Similar patterns of information-seeking behaviour were observed across both the immigrant and non-immigrant participant groups.

Other Support

A Chi-square test showed that non-immigrant parents used significantly more family members in Canada for support compared to immigrant parents (51% vs. 26.7%, χ² = 14.29, p < 0.001). Conversely, immigrant parents were more likely to rely on family support from their country of origin than non-immigrant parents (13.2% vs. 3.6%, χ² = 10.68, p < 0.001). Additionally, immigrant parents were significantly more inclined to seek support from a friend from their country of origin compared to the non-immigrant parent group (6% vs. 1.9%, χ² = 5.67, p = 0.005).

Multidimensional Scale of Perceived Social Support

The results from the MANOVA reported an overall significant main effect, with Canadian-born parents reporting significantly greater perceived social support compared to immigrant parents, F (3,532) = 4.67, p < .01. Univariately, Canadian born parents reported receiving more support from significant others, F (1, 534) = 5.95, p < .01, as well as from friends, F (1, 534) = 6.85, p < .01, than immigrant participants. No significant difference was observed for the family subscale, F (1, 534) = .44, p > .05.

Barriers

Parents were asked to identify school-related barriers affecting their child's academic success. The total number of barriers were summed across the participants. There was no significant difference in the total barriers reported by immigrant families compared to non-immigrant families (U = 55830.00, z = .27, p > .05). However, immigrant families identified significantly more culturally related barriers than the non-immigrant group (χ² = 14.19, p < 0.001).

The present study aimed to identify the mental health challenges reported by immigrant parents for their children as well as the types of resources, services, and social support they seek through an online survey. We also investigated the relationship between sociodemographic factors (i.e., age, sex, language barriers, and household income) to better understand the impact of these variables on mental health assessments and access to resources. Overall, our results show that immigrant parents report a greater need for availability of mental health services for their children than non-immigrant parents, while non-immigrant parents reported accessing mental health services for their children at a higher rate than immigrant parents. In terms of accessing mental health related information, both groups reported primarily browsing online for information. Immigrant families report preferring support from either family members or friends from their country of origin. Finally, the level of perceived social support was lower for immigrant parents compared to Canadian born parents.

Child needs and parental access to services

The main finding from this study is the significant difference in the identification of child mental health service needs and rates of access of these services between immigrant and non-immigrant families in Canada. The present study found that children of immigrant families report wanting more access to mental health services. This contrasts previous studies which show lower levels of mental health problems being reported in first generation immigrants [4]. It is possible that children may express the perceived need for mental health support, but their challenges are inadequately addressed by their families, considering that immigrant families utilize support 1.5 times less than their non-immigrant counterparts. These differences in utilization were also further confounded by English language proficiency barriers of immigrant parents and increased school-related barriers. The results of the present study are consistent with existing literature, which reports that differences in cultural beliefs and values, language barriers, and lack of linguistically appropriate services are some of the most common barriers to accessing services [14]. More targeted culturally sensitive services are required to increase mental health support uptake by immigrant families.

Accessing Information on Support Services

Our present study also surveyed sources families use when accessing information related to their child’s mental health needs and their perceived levels of support. Results showed no significant group difference in the sources used for information with the most common methods for accessing support related information for both groups including browsing online (35% for non-immigrant parents, 35% for immigrant parents), utilizing social networks (33.3% for non-immigrant parents, 30% for immigrant parents), and contacting the child's school. In addition, Canadian-born parents reported significantly greater perceived total support from significant others and friends than immigrant participants. However, there were no differences in the perceived social support from family members. These results highlight the importance of offering community-based resources and supports for immigrant families as they prefer obtaining information from members of their community. Furthermore, to ensure that appropriate evidence-based knowledge is being shared, researchers and mental health workers need to offer more online virtual-based resources to families, given that both Canadian-born and immigrant families prefer accessing online information. With the increased availability of online resources, there is an increased risk of misinformation being available [15]. Furthermore, it is also important to engage with special education teams and community centres to ensure that programs and workshops are offered to improve mental health literacy.

In comparison to Canadian census data, our survey yielded a sample of immigrant parents that proportionally reflected the ethnic diversity of the population, with the exception of capturing only half as many white European immigrants [16]. This sample contained people with a higher sociodemographic status than the general population, with individuals being 1.8 times more likely to hold a bachelor’s degree and having a greater median household income [17]. Our sample was mostly consistent with census data across provinces, with the exception of Ontario and Quebec, which were over and underrepresented, respectively, by factors of 1.3 and 2 [18]. Given that the survey was only administered in English, this may explain the lack of representation from Quebec. Administering the survey in both English and French is important for future research.

Although our survey was biased towards a more educated group of immigrants and a lower percentage of people from White-European ancestry compared to census data, this difference likely would enhance our significant results in comparison to census data, given that higher education, income, and a lower proportion of visible minority status have been associated with increased use of and decreased need for mental health services among immigrants [19], [20]. Additionally, since provincial residence did not show any association with these variables, the overrepresentation of immigrants from Ontario in our sample is unlikely to impact the generalizability of these findings.

Limitations, Strengths, and Future Research

The findings of this study should be considered in the context of several limitations, such as potential sampling bias due to recruitment methods (e.g. online survey), reliance on self-report measures from parents may be susceptible to biases, not accounting for other potential confounding factors such as acculturation effects etc. These limitations warrant caution in interpreting and applying the findings to a broader population. Future research should address these issues by recruiting participants through more targeted community agencies to enhance the study's validity. Given that immigrant families are diverse and have different experiences, future research with more qualitative interviews is required to identify barriers and positive factors (e.g., life experience, family traditions, conceptualization of well-being) in immigrant families. Nevertheless, the findings from the present study provide valuable and novel information regarding the mental health supports and challenges of immigrant families compared to non-immigrant families.

This study highlights significant disparities in the use of child mental health services between immigrant and Canadian-born parents despite a higher reported need among immigrant children. Our findings show that immigrant parents reported lower utilization rates of mental health services. These results underscore the necessity for culturally sensitive mental health interventions and improved accessibility to services for immigrant families. Future research should delve deeper into the cultural, linguistic, and systemic factors contributing to these disparities to inform policy and practice changes aimed at promoting health equity.

Author Note

Conflict of Interest: The authors report no conflicts of interest to disclose.

Ethical approval: This research has been approved by the McGill University Research Ethics Board 2 (23-09-053-01)

Acknowledgements: We would like to thank Sebastiano Icono and Marie Claire McPolin for their involvement with the project setup. We would also like to thank all the participants for their time.

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Table I Demographic and social characteristics of the survey sample

		All Participants	Immigrants	Non-immigrants	p value^a
		n = 682	n = 282	n = 400
Child age		13.2 (4.1)	13.0 (4.1)	13.4 (4.0)	0.27
Participant age		31.8 (7.4)	31.6 (7.4)	31.9 (7.3)	0.8
Parent Sex (% females)		46.1	40.8	49.6	0.03
Number of Children		2.0 (1.0)	1.9 (0.98)	2.0 (1.0)	0.4
Financial Wellbeing^b		2.97 (0.94)	2.94 (0.9)	2.99 (0.96)	0.4
English skills^d		18.45 (2.68)	17.80 (2.87)	18.89 (2.44)	<.001^*
Household Income^e	$0-$19,000	2.0	2.3	1.8	.04
	$20,000-$ 39 999	4.1	4.5	3.9
	$40,000 -$69 999	12.2	14.3	10.8
	$70,000-$99,999	18.3	23.7	14.7
	$100,000- $124,999	15.9	16.5	15.5
	$125,000-$149,999	12.7	9.8	14.7
	$150,000-$174,999	6.6	6.4	6.7
	$175,000-$199,999	7.0	5.3	8.2
	$200,000 +	15.0	11.7	17.3
Educational Attainement^e					< 0. 001*
	Partial/full high school	23.2	12.4	30.7
	College/Bachelors Degree	52.3	55.6	50.0
	Graduate Degree	23.9	30.8	19.1

Province of Residence^e
	Alberta	17.6	15.9	18.8
	Ontario	49.0	55.1	44.8
	British Columbia	15.7	14.5	16.5
	Manitoba	2.5	1.8	3
	Saskatchewan	2.1	2.2	2
	Quebec	8.4	9.1	8
	New Brunswick	1.3	0.7	1.8
	Newfoundland and Labrador	1.0	0.4	1.5
	Nova Scotia	2.2	0.4	3.5
	Prince Edward Island	0.1	0	0.3
Years in Canada^e	0-5 years		9.5
	6-10 years		16.4
	11-15 years		17.8
	16-20 years		14.5
	21-25 years		14.2
	26+ years		27.6
Ethnicity^e
	Indigenous	1.6	0.5	2.2
	Latin American	2.8	6.3	1.4
	East Asian	18.0	23.8	15.7
	Indo-Caribbean	0.1	0.5	0.0
	Black Caribbean	1.7	2.1	1.6
	South Asian	9.7	28.0	2.8
	Middle Eastern	3.8	2.1	4.4
	Southeast Asian	4.4	2.1	5.2
	White Canadian/ American	39.8	7.4	51.7
	White European	13.7	15.9	13.3
	Black Canadian/African American	0.4	0.5	0.4
	Black African	2.3	7.9	0.2
	Other	1.6	2.6	1.2

^aP-values represent the results of a One -way ANOVA (age, household income) or Chi-square analysis (education) between immigrant and non-immigrant groups.

^bFinancial wellbeing represents Likert scale data from 1-5, with 1 being very well off, and 5 being not well off.

^c Education level is rated on a 9-point scale, where categories were combined into three main groups.

^d English skills are calculated as a mean total score of four Likert-scale questions (conversation, writing, reading and media literacy), verified through reliability analysis.

^eData are shown as n (%) of participants from each category

^*Significance after Bonferroni correction (α=0.008)

Appendix 1 is not available with this version

The authors declare no competing interests.

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Perspective of Mental Health Services Needs and Use in Immigrant Families: An Online Survey

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Abstract

Figures

Introduction

Methods

Study Design and Participants

Inclusion Criteria

Measures

Procedure

Statistical Analyses

Results

Sample Characteristics

Child Need and Access to Mental Health Services

Accessing Information on Support Services

Other Support

Multidimensional Scale of Perceived Social Support

Barriers

Discussion

Child needs and parental access to services

Accessing Information on Support Services

Limitations, Strengths, and Future Research

Conclusion

Declarations

References

Table

Appendix

Additional Declarations

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