Barriers to help-seeking in Israeli Arab minority adolescents with mental health problems: results from the Galilee study

The prevalence of mental disorders among adolescents, according to a worldwide pooled estimate, is 13.4% [1]. The Israeli Survey of Mental Health among Adolescents (ISMEHA), which included a nation-wide representative sample of 14–17 year old Israeli adolescents, reported a prevalence rate of 8.1% for internalizing disorders and of 4.8% for externalizing disorders [2]. The Galilee Study, focusing on Muslim and Druze Arab minority adolescents in Israel reported prevalence rates of internalizing and externalizing disorders of 15.8 and 4.2%, respectively, among Muslim adolescents and rates of internalizing and externalizing disorders of 5.9 and 5.5%, respectively, among Druze adolescents [3]. Many studies show that only half of those children and adolescents with a mental disorder receive any care and that less than one-fourth are cared for by a mental health specialist [4‐11]. The percentage of untreated adolescents is known to be larger among minorities [5, 9, 12‐19], and among socio-economically disadvantaged adolescents [20‐22].

The ISMEHA showed that parents belonging to the Arab minority in Israel were much less likely to seek help when concerned for their children’s mental health than parents from the majority population [9], although rates of mental disorders of Jewish and Arab adolescents did not differ significantly [2]. A possible reason for the disparity in help-seeking could be lack of public mental health services. A mapping of public mental health clinics for children and adolescents in Israel showed that in the Northern and the Southern District, where over 80% of the Israeli Arab population lives [23], only 16.8 and 4.3% of Israeli Arab children in need of care, respectively, were cared for by the mental health clinics [24].

Several factors may explain what prevents different population groups from accessing mental health care for themselves and their children. According to Cauce and colleagues, help-seeking, whether from formal or informal sources, is influenced by structural, organizational, cultural and social contexts [25]. Structural contexts shape conditions of access—the number, type, affordability and quality of psychosocial supports available in a community and those resources necessary to access those further away [26‐30]. Different organizational settings serve different populations: community-based mental health centers are usually accessible to parents, whereas teachers and school staff are an important and available source for consultation by both parents and the children themselves [5, 9, 25, 31‐35]. Cultural factors influence perceptions of need for services, which rely upon one’s explanatory framework for psychosocial problems—beliefs about their origin, how they can best be resolved, and what constitutes a problem that is serious enough to necessitate assistance from a professional helper [14]. In addition, negative consequences and perceptions, including stigma [36, 37], or negative effects of treatment or mental health services [38], have been associated with reduced help seeking behaviors. The Child and Adolescent Service Assessment (CASA) [39], in its assessment of obstacles to help-seeking, includes additional factors such as fear, dislike, or distrust of professionals; prior negative experiences with professionals; shame or anticipation of negative reactions; anticipation that the child may be removed from the home or anticipation of loss of parental rights; and lack of accessibility (information about services, bureaucratic hindrances, language compatibility). Reardon and colleagues [11] in their systematic review of 144 quantitative and qualitative studies concerning barriers to care, found that the main barriers were systemic-structural barriers such as accessibility, cost of services, waiting periods and getting a referral. Following in order of importance were barriers related to views and attitudes towards services, in particular feeling not listened to or dismissed/ blamed by professionals. These were followed by barriers related to loss of trust in professionals and fears concerning the negative consequences of treatment, fear associated with treatment itself, the detrimental impact of perceived negative attitudes of others on help seeking, as well as personal discomfort about mental health [11].

A number of concerns led us to further examine these obstacles. First, the low percentage of Israeli Arab mothers of children with mental disorders who consulted a professional source – 9% according to the ISMEHA [9]. Second, the need to inform the health authorities responsible for supervising and managing the Israeli Mental Health Reform approved as law in 2015, regarding ways to improve service provision to minority Arab Palestinian citizens of Israel (Arabs in Israel) in need of mental health care through the HMOs. The Arabs in Israel are an indigenous population, constituting about 21% of all Israeli citizens and 25.5% of those below 19 years of age. Over 80% of Arabs in Israel are Muslims, and the rest are mainly Druze and Christian [23], and they are over-represented in all the indicators of poverty, distress and underdevelopment, with high unemployment rates and school drop-out rates [40]. The Druze comprise a traditional and conservative Arabic-speaking cultural group [41] who participate in the Israeli military service. Druze males’ main employment is with the security forces. This improves their economic status and increases their adoption of norms of the Jewish majority [42]. The Muslim Israeli citizens, on the other hand, are a non-assimilated minority, mainly due to the continuing state of conflict between Israel and the Arab world, which has placed them in the status of a hostile minority outside the national consensus [43].

Considering the urgent need for mental health care for adolescents, the aim of the present study was to identify the barriers to mental health care among Muslim and Druze minority adolescents and their mothers. We posed several questions that needed clarification. They were: Which barriers to help-seeking are considered to be most important by mothers? Do these perceptions differ by ethnicity or type of disorder suffered by the adolescent? In what ways are mothers’ perceived barriers to help-seeking different according to whether they consulted or not? The goal of this study is to better understand obstacles to help-seeking for mental health concerns, in particular structural obstacles related to accessibility to services and cultural factors associated with stigma.

One of the main findings of the Galilee Study was that 37.3% of Muslim and 47.9% of Druze mothers of children with any mental disorder consulted a professional or school source, in comparison with 9% of Arab Israeli mothers in the ISMEHA study carried out in 2004–2005. The treatment gap was between 63% and 52% for any mental disorder, which is somewhat higher than the average in many parts of the world [5‐8, 55], but is lower than the treatment gap found in the ISMEHA among Arab Israeli mothers [9]. There may be a number of possible explanations for this. One is the secular trend – the time elapsing between the studies, which may point to an increase in help-seeking among minority populations with increasing engagement with Israeli norms [56]. Another possible explanation is that the Galilee Study included a different population than that of the ISMEHA, as only Muslim and Druze living in the Northern and Haifa Districts were included, while the ISMEHA included also Bedouin populations in the Southern District, who have the lowest socio-economic and educational status of all Israeli citizens [57]. A third possible explanation for the increase in help-seeking among minority groups between 2004 and 2005 and 2012–2014 is that rates of mental disorders may be actually increasing among minority adolescents in Israel: while the ISMEHA found a prevalence of internalizing and externalizing disorders of 9.1 and 1.9%, respectively for Arabs in Israel [2] the Galilee study found a prevalence of internalizing and externalizing disorders of 15.8 and 4.2%, respectively, among Muslim adolescents who comprise nearly 80% of the Arabs in Israel [3].

A multivariable analysis indicated, as expected, that over and above the effect of other variables, mothers of children with an internalizing or externalizing disorder were 2 times and 5.7 times more likely, respectively, to seek help. Similar findings have been reported by others [5, 10, 33, 58]. Mothers in families in welfare care were 2.2 times more likely to seek help and mothers with a high GHQ score themselves were 1.5 times more likely to seek help. These findings may be related to the fact that both groups are familiar with or have had previous exposure to positive experiences with similar services. Our findings support studies that have found that the main variable promoting help-seeking is the existence of a mental disorder or mental distress in the adolescent [10, 31, 59‐61], as well as those who have found that mental distress of the mother [60, 62, 63] and other problems in the household which require the intervention of the welfare agencies make help-seeking more likely. There is very likely an interplay between child and maternal health, their reciprocal relationships and cumulative disadvantage [64], which makes sense of the higher rates of mental problems among adolescents who experience poor parental emotional well-being and family adversity [65].

In our assessment of attitudes towards help-seeking we found that 87% of mothers stated that they would seek help if their child had a mental disorder. However, among them, less than half (43.4%) of mothers of children with a mental disorder, actually consulted. In the analysis of attitudes of mothers towards possible potential structural and cultural barriers to help-seeking, one of our most important findings was that, contrary to the common prejudice that minorities do not seek treatment due to fear of stigma [66, 67], the main obstacles for mothers in our study were those related to access to mental health care, that is, structural factors that may be remedied by the authorities responsible. This finding is in agreement with what was found by Reardon and colleagues [11] in their systematic review, that in the first place, systemic-structural barriers such as accessibility, cost of services, waiting times and getting a referral were the most dominant cultural attitudes related to obstacles to help-seeking. We found that the beliefs that treatment might be detrimental and that there might be reprisal by the authorities if they find out about help-seeking, were ranked in second and third place. In the fourth place mothers mentioned stigma as an obstacle to help-seeking and lastly they mentioned their distrust in professionals.

Our exploratory factor analysis suggests that the factors underlying the CoBaQ are distinct constructs, although in our study population three items in the original scales are cross-loaded to other scales. Of particular interest are our findings that two items which originally were part of the “Accessibility” scale were cross-loaded: ‘lack of information’ was cross-loaded to “Fear of reprisal by authorities” and ‘professionals do not speak Arabic’ was cross-loaded to the “Treatment damages” subscale. This would imply that ‘lack of information’, is perceived by our minority populations as being the fault of the help-seeker rather than that of the service provider. This is an important distinction, with implications for the role of service providers to engage the community and provide information through schools, maternal and child health clinics and HMOs regarding how to access mental health services when needed. The cross-loading of the second item – ‘professionals do not speak Arabic’, which originally belonged to the “Accessibility” scale to the “Treatment damages” scale would indicate that the fact that professionals speak Hebrew and interview the adolescents and their parents in a language that is not their own may be deleterious in terms of miss-diagnosis and/or inappropriate treatment. Language here is perceived as more than a tool for access; it may have powerful potential for damage. Mental health diagnosis and treatment are based on communication between patient and caregiver, and therefore, without the aid of language-free and objective tools, language is of utmost importance.

A third item – ‘public knowledge of treatment may damage future chances’, originally belonging to the “Stigma” scale, was cross-loaded by our minority population to the “Treatment damages” scale. In this case, it is not just a matter of stigma for the subject seeking help but rather concrete future damage that makes mothers prefer to do without.

Our finding concerning the perception that “treatment damages” is in agreement with findings among black ethnic minorities in the USA [68, 69], that report that black and ethnic minority populations are cautious about their contact with mental health care; “… black people are disadvantaged in society, and there is a perception that mental health services reinforce some of these disadvantages, as they believe that mainstream mental health services cannot offer positive help” [68].

When studying the meaning of the different constructs in different cultural contexts and languages, it is also necessary to address questions related to translation. Questionnaires that are translated and used in cultures that are very different from those for which they are originally created, may partly explain the disagreement between our EFA and the original “Perception of Barriers to Service” of the CASA version 5.0 [39]. For one, there might be inherent problems in the scale which measures more heterogeneous content than intended [9]. It is also possible that the translation suffers from lack of semantic equivalence [70] as could be the case if one of the items had a slightly different meaning in Arabic and among these subjects than in English. A third possibility, favored by us, is that different cultural norms, social desirability and experience as a discriminated minority produce different results.

Although of less importance than “Accessibility” for both population groups, a finding that called our attention was that more Druze than Muslim mothers believed “Reprisal by authorities” to be an obstacle to help-seeking. This is a very interesting finding, given that the Druze are much more integrated into Israeli society; their male citizens participate in the military and security forces and they are recognized as partners to the Jewish population. The Muslim population, on the other hand, are perceived as “on-trial citizens”. Thus, despite their somewhat elevated status, Druze mothers believed that an obstacle to help-seeking would be the reprisal by authorities. One possible explanation for this is that Druze youth are enrolled in the Israeli Defense Forces (IDF), and this is the main venue for them to enter the Israeli mainstream and improve their socio-economic status. Since they aim for high ranking positions in the IDF and for future employment in the security forces, they may be wary to jeopardize their future chances by having been diagnosed or labelled with, or treated for a psychiatric problem [71, 72], especially when considering employment-related discrimination [73].

Mothers of adolescents with an externalizing disorder were more likely to perceive obstacles related to accessibility as being very important. When analyzing perceived obstacles to help-seeking according to actual practices of mothers we found that mothers who did consult gave more importance to obstacles related to accessibility and distrust of professionals, and less importance to obstacles related to stigma than mothers who did not consult. It is possible that mothers who did consult actually had a realistic perspective of barriers to help seeking as they experienced difficulties related to accessibility and faced problems related to their trust in the professionals caring for their kin.

Lack of access to mental health services, rather than cultural obstacles such as stigma, was considered the main obstacle to help-seeking in this Arab minority population. This findings stands in opposition to a common belief among many health professionals and policy makers who believe that even if services were available, the Arabs in Israel would not use them due to stigma. That stigma is not the main obstacle to help seeking is significant because a change in cultural norms requires long-term process involving the population, whereas lack of accessibility to professional services, which is the responsibility of the regulator (the Ministry of Health) and of those providing the care (the HMOs), could be remedied more promptly by a change in policy. It is important to emphasize that this study deals with help-seeking and not with obtaining treatment but we might deduce that the rates of youth in need that do not get treated are even higher. Consequently, a major recommendation is to increase the number of public mental health clinics in the minority localities; to provide appropriate transportation and to make services available in a reasonable period of time. Since lack of knowledge about the existence of treatment was perceived in our study as the fault of the population itself, a further recommendation is the development of information campaigns by the authorities in order to acquaint the minority populations with the different services available. Psychoeducation for parents, who are the gatekeepers and responsible for their children’s mental health service use [38, 75, 76], as well as interventions to address anxiety related to detrimental treatment and stigma may be very helpful in advancing mental health service use among adolescents and their families. As well, psychoeducation for the schools’ educational staff, who could be made aware of the need for referral to more professional mental health services for some students would be beneficial and this would require strengthening the ties between the school staff and the child and adolescent mental health clinics in the vicinity.

In this population, mothers and adolescents seek help mainly from school sources, which have the advantage of being free and available at all times without the need for transportation, and are characterized by a language and cultural fit between students and school staff. There is, therefore, an urgent need to coordinate the government agencies involved in mental health service provision for children and adolescents, so that school mental health services are integrated into the rest of the services and provide quality professional mental health care to adolescents and their families. It is important that policy makers create a plan with clear goals and schedules that must be met in order to reduce the treatment gap, giving preference to population groups where the gap is highest.