Exploring attitudes towards seeking help for mental health problems among university students from racially minoritised backgrounds: A systematic review and thematic synthesis

Exploring attitudes towards seeking help for mental health problems among university students from racially minoritised backgrounds: A systematic review and thematic synthesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Exploring attitudes towards seeking help for mental health problems among university students from racially minoritised backgrounds: A systematic review and thematic synthesis Rosa Hardy, Helen West, Peter Fisher This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5638764/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: University students from racially minoritised backgrounds are at an increased risk of experiencing mental health difficulties but are less likely to seek support compared to students from racial and ethnic majority backgrounds. To increase the accessibility and appropriateness of mental health support for university students, it is important to understand the attitudes towards seeking help for mental health of underserved student groups. This is the first systematic review to synthesise the available qualitative data which explores attitudes toward seeking help for mental health problems among students from racially minoritised backgrounds. Methods: This systematic review includes qualitative studies exploring attitudes towards seeking help for mental health difficulties among racially minoritised university students. A literature search was carried out using PsycINFO, CINAHL, Medline and Web of Science in March 2024. Participants were racially minoritised university students. Data were synthesised using a thematic synthesis. Results: Of 493 papers identified, 15 were included in the final thematic synthesis following methodological appraisal of their quality using the Critical Appraisal Skills Programme. There were a total of 314 participants across all included papers. Four analytical themes were identified: “cultural dynamics" outlined how culturally specific experiences of stigma, lack of conversations about mental health, faith, and gender influenced attitudes; “the influence of relationships” explored the impact of family and peer relationships on attitudes; “internal barriers” described how preference for self-reliance and feared consequences of disclosure were culturally-informed barriers to help-seeking; and “systemic barriers” encompassed the structural barriers, discriminatory practices and perceived cultural incompetence of services that negatively impacted on attitudes towards help-seeking for mental health difficulties. Conclusion: Culture, identity and social inequality inform attitudes towards help-seeking among racially minoritised students. Exploration of how these factors interact with university systems may improve the provision of mental health support. Systemic change is needed within universities and mental health services to tackle inequality and improve support for racially minoritised students. Psychology university students racially minoritised mental health attitudes help-seeking Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction There are an estimated 254 million students enrolled at universities globally (1). Universities worldwide have undergone rapid and diverse changes, such as greater accessibility of higher education for a more diverse student group. Currently, 25% of domicile UK university students are from racially minoritised backgrounds (2). This does not include the approximately 600,000 international students currently studying in the UK, many of whom will also be racially minoritised (2). In the US, the percentage of students from Latinx, Black and Asian backgrounds has increased from 15.36% in 1976 to 45.23% in 2022 (3)(4). This has required higher education institutes globally to quickly adapt to the needs of their students. A key aspect of adapting to the changing student population has been developing mental health support services. In 2022, 57% of UK university students reported experiencing a mental health difficulty (5). In the US, a longitudinal study across 196 universities found that suicidal ideation increased by approximately 90%, from 5.8% in 2007 to 10.8%, in 2016-2017 (6). University students from racially minoritised backgrounds are at an increased risk of mental health issues (7) (8) (9) (10). In the US, students of colour are more likely to experience symptoms of clinical depression than students from other racial/ethnic groups (3) (11). Furthermore, multiracial students in US are more likely to experience suicidal ideation and to have attempted suicide than white students (12). Universities must understand the mental health needs and attitudes towards seeking help of students. Identifying underserved student populations and exploring why they are reticent to seek support is essential to creating a more inclusive and supportive environment. The Psychological Impact of Discrimination and Racism on Mental Health The minority stress model proposes that discrimination and stigma experienced by minoritised individuals contributes to adverse health outcomes (13). Furthermore, minority status leads to exposure to distal and proximal stressors (13). Distal stressors include experiences of discrimination and rejection, while proximal stressors are internal processes caused by distal stressors; for example, anxiety, rumination, feeling the need to hide one’s own identity, and holding negative feelings towards one’s own minority group (14) (15) (16). There is increased minority stress and poor mental health outcomes among sexual and gender minority individuals (14) (15). The intersection of other minoritised aspects of identity, such as race and ethnicity, also increases the risk of poor mental health (17) (18). By understanding the role of minority stressors in racially minoritised students’ psychological wellbeing, universities and mental health services can implement targeted interventions, and address inequalities and discrimination in HEIs and services. Racially minoritised students face specific challenges, structural inequalities and Eurocentric curriculums. HEIs are often built on historical colonial ideologies and practices, with racial hierarchies and inequalities embedded within. The presence of statues of and buildings named after colonial figures, such as Cecil Rhodes, have sparked controversy and protests within universities (19). Lack of diversity among university staff led to the grassroots campaign “ why isn’t my professor black?” , which sought to highlight the underrepresentation of racially minoritised academics in HEIs, the systemic barriers racially minoritised scholars face, and institutional racism (20) (21). Similarly, the “ decolonise the curriculum ” global movement sought to challenge the colonial legacies shaping educational frameworks (22). These movements demonstrated the ongoing need for HEIs to enhance representation among staff, students, and in the curriculum. Racially minoritised students may experience covert forms of racism (such as microaggressions) and overt racism both within universities and in wider society. Microaggressions are subtle comments or actions that can marginalise and demean racially minoritised groups or individuals and can lead to isolation and low self-esteem (23). Carter (24) proposed that such experiences can be sudden, uncontrollable, threatening, and memorable, and can lead to traumatic stress reactions. Smith et al. (25) explored the experiences of black men in US universities and found that microaggressions can lead to ‘racial battle fatigue’, defined as experiences of hypersensitivity, hypervigilance, fear, and anxiety when entering the predominantly White American academic settings. Understanding the psychological impact of racism is crucial for mental health services which support university students to inform therapeutic interventions and formulations, and challenge systemic discrimination and abuse. In the UK, the Equality and Human Rights Commission (26) found that 24% of students surveyed had experienced racial harassment and one in 20 university students had left their studies due to racial harassment. Moreover, two thirds of students who had experienced racial harassment did not report it to their university. Evidently, universities need to be doing more to tackle racism in all forms and support students to report racial harassment to ensure that students feel safe, their wellbeing is supported, and they can complete their studies. Specific Challenges Faced by International Students Addressing these issues is particularly pertinent in the US and UK, which have the highest proportion of international students in the world, many of whom may face discrimination and require support for their mental wellbeing (27). In the UK, approximately 24% of students are international students (28). International students have become crucial to the financial growth of universities, contributing a fifth of the total income of universities through tuition fees. (29). The presence of international students enriches the academic environment, allowing for cultural exchanges of knowledge and fostering global connections (30). However, international students face specific challenges when studying abroad; for example, adapting to a new culture and social norms, potential language barriers, loss of social support (such as family and friends back home) and homesickness (12). International students may experience ‘culture shock’ (such as anxiety and confusion over cultural norms and practices) (30). Many international students also report feeling isolated from their fellow students (31) (32). Not only will many international students experience the unique stressors of living and studying abroad, but they may also experience being racially minoritised in their country of study (33). There was a drastic increase in anti-Asian discrimination following the outbreak of Covid-19, with many Asian international students reporting experiences of racism and abuse (34) (35). Therefore, there are shared experiences between both home and international students who would identify as from a racially minoritised background within their country of study. Help-Seeking for Mental Health Among Minoritised Students In the UK, disclosure of mental health rates by undergraduate university students increased from 6% on 2016/17 to 16% in 2022/23 (36). However, demographics of students who access services are not representative of the student community (37) (38) (39). Racially minoritised students, including both home and international students, are less likely to seek help for mental health problems than students from a racial and ethnic majority background (6).There is clear evidence that racially minoritised students (both domicile and international) experience systemic and personal stressors while at university, and racially minoritised students and international students are at an increased risk of experiencing mental health problems while studying (3) (40). Consequently, understanding the attitudes that racially minoritised students hold towards seeking support for mental health is critical to ensuring the psychological wellbeing of this student group. Rationale Previous systematic reviews have explored barriers and facilitators to seeking help for mental health difficulties among young adults and university students; for example, stigma, self-reliance and accessibility of support (41) (42). Systematic reviews have been conducted exploring factors associated with help-seeking among people of racially minoritised backgrounds (43) (44). However, no review to date has explored attitudes toward seeking help for mental health difficulties among students who are of racially minoritised within the university system.To support the mental health of racially minoritised students, it is important that universities and mental health services understand how these students feel about seeking support for their mental health. No existing review to date has synthesised the perspectives of racially minoritised students on seeking help for mental health problems. Aim The primary aim was to explore the perspectives of racially minoritised students on help-seeking for mental health problems by asking the question “what are the attitudes towards seeking help for mental health problems among racially minoritised students?”. A secondary aim of the review was to explore how universities and mental health services can support help-seeking for mental health among racially minoritised students. Method Based on Cochrane guidance, a thematic synthesis approach, as described by Thomas & Harden (45), was used (46). Attitudes and experiences of mental health difficulties are highly subjective and culture-bound; a thematic synthesis approach allows for integration of diverse perspectives and, by using an inductive approach, it allows researchers to uncover culturally specific phenomenon (47). Moreover, it enables new insights and interpretations that may not be seen in the primary studies (48) (49). The review was registered to the PROSPERO database (https://www.crd.york.ac.uk/prospero/; ID number: CRD42023485699). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting of systematic reviews were followed (50) (51). Eligibility Criteria Studies were included if they used direct interviews (such as focus groups and 1:1 interviews), recruited current university students who identified as a racial or ethnic minority within their country of study, included discussion of attitudes toward seeking help for mental health problems, were primary research, applied a qualitative or mixed design, and were available in English. Exclusion criteria were scoping papers or systematic reviews, commentary regarding the subject area, or from books, conference presentations or unpublished dissertations. Search Strategy Papers were identified through comprehensive searches. Search terms were linked to the review question, which was devised using the SPIDER tool (Table 1) (52). Search syntax terms were based on key words prevalent in the relevant literature identified through scoping searches; this was discussed with a University Librarian and reviewed with the supervisory team (see Table 2). In December 2023, literature searches were conducted via the following databases: APA PsycINFO, CINAHL, Web of Science and MEDLINE. These databases were chosen as they focused on healthcare disciplines. After titles and abstracts were screened, studies that met the inclusion criteria were retrieved. Full text and hand-searching of references of key studies was completed. Studies were stored on EBSCO, processed using Microsoft Excel and codes synthesised on NVivo. (Version 14). Searches were updated in March 2024; 493 possible publications were identified. 15 papers were identified which met the inclusion criteria for the review. Reflexive Statement Reflexivity is important to ensure rigour in qualitative research (53). When completing this review, the primary author considered how their own identity as a White British person could affect the data-analysis; for example, by not having lived experience of being from a racially-minoritised background, the primary author could overlook or minimise important experiences or interpretations. It was therefore important to use a reflexive diary to help the primary author to critically appraise their own interpretations and thoughts and discuss these reflections within the supervisory team. Collaborative reflexivity acknowledges that, to uncover one’s own blind spots, it is necessary to discuss assumptions and decisions with others from a diversity of backgrounds (54). The research team comprised members of different genders, professional roles, and training backgrounds, allowing for a broad range of perspectives and insights. However, as no member of the team identified as racially minoritised, consultation was sought from an expert by experience who had been an international university student, had experience of seeking help for their mental health problems and was of a racially minoritised background. The primary author’s own experience of being a university student may have influenced the process of creating initial codes and generating analytic themes. As a Trainee Clinical Psychologist, the primary author recognised from professional experience that mental health services are often not accessible or do not appropriately meet the needs of people from racially minoritised backgrounds. Results Screening and Selection This reviewed followed the methods and results reporting of PRISMA guidelines (50) (51) (Figure 1). In total, 493 articles were returned in the search (PsycINFO n = 189, CINAHL n = 54, Web of Science n = 147 , MEDLINE n = 103). Search results were transferred to Endnote (Version 21). 212 duplicates were removed and 84 papers which were not peer-reviewed were removed. One further paper was identified from handsearching. Articles were then transferred to Rayyan (www.rayyan.ai); this AI assisted systematic review tool facilitates the collaboration of the screening process. The title and abstract of these papers were reviewed by the primary author (RH) and 109 were removed through application of the inclusion/exclusion criteria; an independent reviewer (JM) completed the same process on a random sample of 50% of the papers. RH reviewed the full text of 88 articles, and JM completed the same process on a random sample of 10% of the papers. One discrepancy was discussed by the research team, and consensus achieved. Fifteen papers were identified for the final thematic synthesis. Quality Assessment The Critical Appraisal Skills Programme (CASP) (55) appraisal tool for qualitative research was used to appraise the papers. This tool uses 10 questions which were scored as follows: yes = 1, can’t tell 0.5, and no = 0. Overall scores of seven and above indicate moderate quality and scores of nine or above indicate high quality (56). All CASP assessments conducted by RH were independently checked by JM. All discrepancies were discussed between RH and JM to achieve consensus. The quality of the papers was moderate with overall scores for each paper ranging from 7.5-10 (Table 3). Most studies clearly outlined their aims, methodology, design, recruitment, and data collection (57) (58) (59) (60) (61) (62) (63) (64) (65) (66). All studies appropriately outlined their findings and the valuable contribution to clinical practice and research. However, most studies failed to explore researcher positionality and reflexivity. Data Extraction and Study Characteristics Key information from the studies is in Table 4 (and see additional files). The total number of participants across all studies was 314, with a range of six to 48 participants in each study. Seven studies were conducted in the UK (57) (61) (64) (65) (66) (67) (68), seven in the US (58) (59) (60) (62) (63) (69) (70) and one in Israel (71). Three studies specifically recruited participants who were international students (61) (63) (70). Data Synthesis Data from the ‘results’ or ‘findings’ section of each paper were extracted to NVivo (Version 14) and analysed using a thematic synthesis approach to explore the attitudes toward seeking help for mental health problems among university students from racial or ethnic minority backgrounds (45); this included both direct quotes from participants and the interpretations made by the authors of the papers. Free line-by-line coding of each paper was completed, and subsequent ‘descriptive’ themes were identified. This led to the development of ‘analytical’ themes. Themes Four themes and 12 subthemes are outlined in Table 5 and with exemplar quotes in Figures 2, 3, 4 and 5. Theme one – “they taught us about mental health, it’s just for the crazy people” (62): Cultural dynamics Cultural dynamics were reported universally as adversely influencing attitudes toward seeking help for mental health problems. Stigmatising attitudes towards mental health and help-seeking within cultural communities negatively impacted on individuals’ views on seeking help for their mental health were common across studies. Cultural dynamics subtheme – “It’s seen as a characteristic of a problematic family” (60): shame and stigma. Fear of being stigmatised by cultural communities was reported in all studies. Individuals feared that their experiences of mental health difficulties would bring shame on their family (57) (60) (61) (62) (64) (66) (67) (70), that it would limit their future opportunities within their cultural community (57) (60) and reported that therapy had negative connotations (68) (70) (71). “We Arabs do not look favorably upon mental therapy, think that mental therapy is not helpful, [and] identify those who seek mental therapy as a weak and crazy person [. . .]. It’s [therefore] difficult to seek treatment and most who do so hide the fact that they’re in therapy” (71) Cultural dynamics subtheme – “Mental health is obviously still not talked about enough ” (62): Lack of conversations about mental health and support. Silence within cultures around mental and culturally-specific understandings of mental health were reported as barriers to seeking help by participants in several studies (59) (62) (63) (66) (67) (68) (69) (70). Some participants reported their cultural communities only associated ‘mental health’ with severe presentations; for example, someone who is ‘crazy’ or ‘suicidal’ (62) (70) (71). Because ‘mental health’ was only conceptualised in terms of severe presentations, milder presentations were often unrecognised; this led participants to not acknowledge that their difficulties were mental health related and not seek support. “Growing up […] people weren’t taught about mental health, and it inevitably forced my whole household to never discuss mental health ” (59) Cultural dynamics subtheme – “ Everything always links back to God ” (68): How faith informs understandings of mental health and help-seeking. Participants reported that faith informed how they conceptualised mental health (57) (64) (65) (66) (67) (68) (71). For some participants, mental health problems were seen within their culture as punishment from God; they stated that if they disclosed mental health difficulties to friends or family, they would be told to pray rather than seek formal help (57) (66) (67) (68) (71). This dissuaded some from seeking any help for their mental health difficulties, as they felt they would be judged negatively within their religious community for having a mental health problem or for seeking formal help instead of engaging in religious practices. For others, they reported that they would seek out help for mental health problems from faith leaders and found prayer helpful (61) (64) (65) (68) (71). “I think some of those religions and some of the doctrines in the past have given the Black community the impression that mental health is an indication that something is evil or something to be stayed away from.” (67) “If I’m overwhelmed or stressed; they’ll be like it’s because I’m not praying enough, or you’ve lost your way on the right path” (68) Cultural dynamics subtheme – “ If the black male has mental issues you just think he’s aggressive ” (66): Gender as a barrier to help-seeking. Male students faced additional barriers to help-seeking due to cultural beliefs that men should not show their emotions (57) (62) (66) (68) (70). Moreover, there was a fear that male students from ethnic minority backgrounds, particularly Black students, who sought help for mental health problems would be discriminated against and stereotyped (57) (66). “Until they reach a crisis point or rock bottom and, as a black male, you are already stigmatized and you are aware that you will be further [stigmatized] upon being diagnosed with this illness, which will consequently affect your university studies”. (57) Theme two – "mak[e] sure that the people you associate with don’t look down on mental health” (60): the influence of relationships This theme highlighted the impact of family and peer relationships on attitudes toward seeking help for mental health problems. If families had negative attitudes toward seeking help for mental health problems, this increased fear of disclosure and reticence toward seeking help amongst participants. The influence of relationships subtheme – “It was easier to get help when my parents weren’t there” (69): family dynamics. Many participants reported that their families did not discuss mental health and would hold negative views regarding seeking help for mental health problems (57) (59) (60) (62) (66) (67) (69) (70). Some participants reported that their families were supportive of their mental health and help-seeking (59) (60) (66); however, some stated that, while their families held positive views of help-seeking in general, they would still disapprove if their own family members sought help for mental health problems (60). Participants stated that having mental health difficulties and seeking help would bring shame on their family; mental health difficulties were associated with dysfunctional families and poor parenting. “My parents were aware that I sought counseling at first, but they discouraged it […] They were under the impression that if I just tell myself that I won’t have it, then I won’t have it.” (59) The influence of relationships subtheme – “ I know [it] starts with us first […] people of color ” (59): Support from racially minoritised peers. Participants spoke about how they often felt more able to talk about mental health and seek help if this was modelled by racially minoritised peers (59) (60) (63) (64) (66) (67) (69) (70). Some international students stated that they did not feel able to speak about mental health or seek help because their fellow international students perpetuated stigmatising beliefs from their home country (61) (70). “I feel like people are slowly trying to let people know that it’s okay to not be okay and go seek help.” (59) Theme three – “brush it under the rug and carry on” (67): internal barriers to help-seeking. internal barriers, such as a desire to be self-reliant and fear of the consequences of seeking help, were barriers to help-seeking for racially minoritised students. Internal barriers to help-seeking subtheme – “If we don’t show our emotions, then we’re strong ” (66): self-reliance. Participants felt the need to keep struggles to themselves and associated help-seeking for mental health with personal weakness (59) (61) (62) (66) (67) (69) (70) (71). Some participants spoke about how their families and cultures had struggled for generations with racism, slavery, and civil war; they expressed that they should therefore be able to cope with the struggles of studying at university as these were comparatively less difficult (57) (59) (67). “Within African families, there is an expectation to continuously be resilient as you are reminded of the sacrifices made for you to attend university”. (57) Internal barriers to help-seeking subtheme – “Being black and mad isn’t a good look out here” (68) : feared consequences of disclosure. Participants feared that disclosing mental health difficulties could negatively impact on their studies and future employment opportunities (57) (61) (66) (68). International students worried about lack of confidentiality when disclosing mental health problems and that seeking help would result in them being deported (61) (66). Students also worried that they would be sectioned, given treatments against their will, and discriminated against because of their racial background (57) (66) (68). “My fear is receiving an inappropriate investigation into my psychological state, which could affect my studies and potential treatments. As a result, between university and my GP. . . I prefer not to say anything”. (57) Theme four – “we receive inadequate treatment because of our skin color” (57) : s ystemic barriers to help-seeking Systemic barriers appeared as difficulties faced when seeking help for their mental health problems; for example, experiences of discrimination, lack of diversity on campus and in mental health services, and lack of cultural competence in services. The therapeutic relationship emerged as crucial for addressing these barriers by fostering trust, safety, collaboration, and the feeling of being respected and understood. It was noted that participants felt that this was often lacking in university support and external mental health services. Systemic barriers to help-seeking subtheme – “I don’t even know where to start” (61) : Structural barriers. Participants reported that technicalities of health insurance, costs of accessing mental health services, and distance from services prevented them from seeking help (60) (71). Confusion and uncertainty around how to access support and navigate services was also a key barrier (62) (63) (68). This was particularly difficult for international students who were unfamiliar with the health systems of their countries of study (61) (62) (63) (70). “I think for international students, everything is a lot harder because we don’t know how anything works. I think that them saying, “yeah here we have resources,” that’s not helpful. We don’t know how to access the resources, even though we know they’re there” (62) Systemic barriers to help-seeking subtheme – “There aren’t enough minority ethnic people within the mental health system” (67): lack of diversity. Participants noted a lack of racial and ethnic diversity on campus and within mental health services (57) (58) (64) (65) (66) (68) (70). They perceived that university staff and mental health professionals (MHPs) would not understand their experience, which prevented them from seeking help. “ You feel weird being a Muslim in a place where you do not see any Muslim staff, you don’t know who to approach and how to do it and if you’re going through anxiety and stress, this can seem like a bigger mountain to climb.” (64) Systemic barriers to help-seeking subtheme – “We’ll be treated lesser than our white counterpart” (66): discrimination and microaggressions. Microaggressions and perpetuation of stereotypes by university staff and by MHPs had a negative impact on students’ mental health and attitudes toward seeking help (57) (58) (68) (70); for example, Asian students reported that staff perpetuated the “model minority” stereotype, which led them to not want to ask for help. “When I told [my therapist] I am from South Korea, ... she said “Oh, your English is really good”; I don’t know what she meant. I felt negative. Maybe she does not really have much experience with Asians.” (70) Systemic barriers to help-seeking subtheme – “If you can’t understand us as people, then you’re not going to understand our mind” (59): cultural (in)competence and the therapeutic relationship. A lack of diversity within universities and mental health services coupled with discrimination and microaggressions led participants to feeling that institutions were not culturally competent (57) (58) (60) (62) (64) (65) (66) (67) (68) (70). Students felt that professors and MHPs did not understand their cultural background, minimised experiences of racism, isolation, and culture shock, and were not willing to discuss race and religion (57) (59) (62) (64) (65) (66). This negatively impacted on the therapeutic relationship and made students feel unwilling to seek help for their mental health problems. Some participants reported that they felt these barriers could be overcome if MHPs were open to learning about a culture, respectful and empathetic (65) (68) (70). “I would prefer to have a psychological doctor who can speak some Chinese and was raised in Chinese culture……[but] barriers of gender, race, and language can be overcome. It will be fine if the doctor can understand me.” (70) Discussion The review identified that cultural dynamics encompassing stigma, understandings of mental health, faith and gender norms significantly influence attitudes toward help-seeking. Family attitudes towards seeking help for mental health problems can also exacerbate or alleviate students’ mental health. Supportive peer relationships and modelling facilitate positive attitudes towards help-seeking. Participants expressed internal barriers to seeking help, including the need to be self-reliant and fearing the consequences of disclosing mental health difficulties. Additionally, systemic barriers, such as structural barriers, a lack of diversity on campus and in mental health services, experiences of discrimination and microaggressions, and perceived cultural incompetence of mental health professionals, pose critical challenges for racially minoritised students’ mental health help-seeking. Multifaceted and nuanced influences on mental health help-seeking for racially minoritised students were apparent and highlighted the urgency for strategies which address the barriers and foster an inclusive and supportive environment for racially minoritised students. Culture permeates and affects all aspects of mental health experiences (72). Kleinman et al. (73) used the explanatory model of illness to propose that how individuals understand and experience illness is embedded within a social context. Thus, cultural norms and beliefs impact on how psychological distress is conceptualised, experienced, expressed and responded to (73). Negative and stigmatising views on mental health and help-seeking among individuals’ cultural communities were key barriers to seeking help. Faith can be both a powerful coping resource and perpetuator of stigma (74). In this review, some participants reported their faith as central to their identity and how they coped with distress. For other participants, beliefs about mental health difficulties as indicative of moral failings or lack of prayer were highly stigmatising, shaming and silencing. Male students are less likely than female students to seek help for their mental health problems (75) (76) (77). In the UK racially minoritised men are less likely to access mental health support in primary care and are more likely to access mental health services through the criminal justice system than white people (78). Male students faced additional barriers to help-seeking; this was due to cultural beliefs that men should hide their emotions, and fear of structural discrimination, such as being sectioned or treated inappropriately based on racial biases. Various policies in the UK have highlighted the pervasive mental health inequalities experienced by racially minoritised groups, in particular black men (79) (80). The Patient and Carer Race Equality Framework (PCREF) seeks to embed anti-racist practice and policies in NHS mental health services to advance mental health equalities (81). Underpinning this is the NHS Constitution, which details that it is every professional’s duty to ensure the human rights of patients are upheld and equality is promoted (82). Uptake of the PCREF in student services could facilitate more co-production with racially minoritised experts by experience of policies, guidance, and services, and tackle structural discrimination and inequality. Greater integration of research on racial discrimination and gender-related biases should be incorporated into training of MHPs, such as Clinical Psychologists, and university staff who support students. Students (particularly international students) often feared that disclosure of mental health difficulties could result in them being forced to leave the university. This demonstrates a lack of awareness of confidentiality and its limits which underpin mental health services. Students also felt confused about how to navigate mental health systems and which services were available to them. Greater promotion to racially minoritised and international students of mental health services, how to access them, and services’ responsibilities to ensure confidentiality is necessary to build awareness and trust. Racially minoritised students often feel reluctant to seek help due to the belief that self-reliance is indicative of personal strength, while help-seeking is associated with weakness (41) (83). Reluctance to seek help appeared due to beliefs that they should be able to cope independently, particularly given the challenges their families and communities had faced historically. Wellbeing resources provided to students could challenge notions of self-reliance to reduce this barrier to help-seeking. MHPs working with racially minoritised students should be mindful of how self-reliance may impact on psychological wellbeing; for example, how seeking help may negatively impact on self-esteem if an individual believes that they should be self-reliant and that seeking help is a weakness. Psychotherapeutic approaches which target unhelpful core beliefs while also recognising and respecting individual strengths and cultural contexts, such as culturally adapted cognitive behavioural therapy, could be utilised to modify these cognitive patterns (84). Social support is associated with good mental and physical health (85) (86). However, many racially minoritised students felt unable to discuss mental health or help-seeking with their family due to fear of their response; students described feeling pressured by their families to excel academically and feared that seeking help for their mental health problems would be perceived as failure and would bring shame to their family. Public stigma is often experienced by families of those with mental health difficulties and has been shown to be associated with greater psychological distress and less perceived closeness between family members (87) (88) (89). Therefore, interventions targeting stigma and mental health literacy at the levels of communities and families could reduce public stigma, increase levels of social support, and reduce barriers to help-seeking for mental health problems. Peer support can facilitate help-seeking for mental health difficulties, particularly within the student population, where loneliness and isolation are prevalent (90) (91) (92). Social learning theory states that people learn through observing the actions of others (93). This review found that racially minoritised students felt that talking to fellow racially minoritised peers about mental health was more helpful than accessing other sources of support. They were also more likely to seek help if this had been modelled by peers. Mental health first aid training for students has been shown to be effective in improving self-awareness of mental health and when to seek help, as well as increasing students’ confidence in their abilities to help peers who are experiencing a mental health difficulty (94) (95). Developing culturally-sensitive mental health first aid training and promoting this within diverse student populations could enhance peer support systems and promote professional help-seeking (96). The minority stress model can be applied to the experiences of racially minoritised students to demonstrate how stressors (such as microaggressions, discrimination and self-stigma) contribute towards poor mental health (13). Indeed, the university environment can have a significant detrimental effect on mental health and help-seeking attitudes for racially minoritised students (97) (23) (68). This review corroborated previous findings that overt and covert experiences of racism (such as microaggressions) impacted negatively on the mental health of racially minoritised students (23) (24) (25). Moreover, experiences of microaggressions prevented students from seeking help for their mental health difficulties. This presents a concerning picture that racially minoritised students are both at increased risk of mental health problems because of these experiences and feel unable to seek appropriate support for their mental health because of microaggressions and discrimination. A lack of MHPs from racially minoritised backgrounds is also a barrier to help-seeking. The review found that many participants would favour an ethnic-matched MHP to work with, and that all participants felt that MHPs and universities needed to develop cultural competence. Increased training and recruitment of racially minoritised MHPs and additional training to develop cultural competence among MHPs is essential to culturally representative and sensitive workforces. This review found that language was a key barrier to accessing support. Culturally-sensitive services must therefore be able to meet the linguistic needs of students by ensuring that staff are representative of the communities they serve and that translator services are available. Strengths and Limitations A notable strength of this review was that the robust search strategy, which included searches from multiple databases and handsearching, produced a homogenous sample of studies whose aims related to the review question. Moreover, it focused on a particular phenomenon; while attitudes toward seeking help for mental health problems have been researched and reviewed for students in general, reviews have not explored experiences and attitudes of racially minoritised students. The research evidence discussed above shows that racially minoritised students are unlikely to disclose and seek help for their mental health problems (11) (41) (78) (83); the current review contributes to understandings of why this may be the case. Despite no limit on year of study publication, all studies included were conducted within the past six years, with six studies being published in the last year; this implies that this is an emergent area of research. Furthermore, as universities are seeking to be more inclusive and diverse, this synthesis of the current evidence is particularly timely and relevant. A key limitation of this review was that racially minoritised is an umbrella term for multiple identities, within which there is heterogeneity of experiences. Therefore, there is a risk of overgeneralising and overlooking important, culturally-specific differences. Furthermore, studies around the world were included; while there were shared experiences and themes identified, there will be key differences in healthcare and university systems in different countries. Further research could explore differences and similarities in specific countries and racially minoritised groups. A potential limitation was that the primary author was not of a racially minoritised background and therefore risked bias and oversight. This risk was somewhat reduced by discussion with the research team, engagement in reflective practice and consultation with an expert by experience who was of a racially minoritised background. Finally, 10 out of the 15 papers included did not include adequate reflexivity and researcher positionality. It is important that researchers engage in critical reflection on how their personal characteristics, experiences and beliefs can shape the research and its outcomes. Implications and Future Research Understanding the barriers faced by racially minoritised students is crucial for universities and mental health services to provide support. This review has shown the impact on individuals’ mental health and attitudes toward help-seeking of cultural understandings and stigma of mental health problems, gender norms and pressures to be self-reliant. MHPs could engage in community outreach and provide tailored resources for universities which focus on psychoeducation, decrease stigma and challenge gender norms and notions of self-reliance. Better integration of faith-based mental health support may increase accessibility and acceptability of services for racially minoritised students but could also reinforce unhelpful cultural norms (such as linking mental health difficulties with punishment from God). MHPs working in student services should facilitate collaboration between mental health services, faith-based organisations and racially minoritised students and could help to develop culturally-sensitive resources and support. This review has also demonstrated how social support can impact on attitudes toward seeking support for mental health problems among racially minoritised students. While some students experienced their families as supportive, many found their families’ attitudes to be a barrier to help-seeking. Universities and MHPs should be aware of the additional stressors facing racially minoritised students and potential lack of familial support putting them at increased risk of distress. Peer support was demonstrated to be a key facilitator to help-seeking. Universities could improve psychological wellbeing and attitudes toward seeking help for mental health problems among racially minoritised students through peer-to-peer networks and support groups, providing training to these groups, such as culturally sensitive mental health first aid. Many students reported feeling unsure what services were available to them, how to navigate the systems and felt concerned about the consequences of seeking help. Greater information on the services available and on confidentiality and its limits should be communicated to students to alleviate anxiety. Systemic change within universities and mental health services is necessary to increase the accessibility of mental health support for racially minoritised students. MHPs can utilise their positions within services and their research skills to advocate for policy change and initiatives within universities and mental health services that will promote equality, diversity and inclusion. It is important that universities and mental health services increase staff diversity and are representative of the populations that they serve, engage in anti-racism training (including increasing awareness of unconscious biases and the unfair treatment of people of racially minoritised backgrounds), provide culturally-sensitive and appropriate support, and provide greater availability and promotion of translator services. This is critical to improve care for racially minoritised students and facilitate more positive attitudes toward seeking help for mental health difficulties. The therapeutic alliance is central to building culturally sensitive and appropriate services. The therapeutic alliance refers to the collaborative relationship between a professional and client. Bordin (98) argued that the therapeutic alliance consisted of three elements: shared treatment goals, agreement on tasks, and the development of a strong therapeutic relationship. The therapeutic alliance has been consistently linked to positive treatment outcomes (99) (100) (101). This review found that participants felt cultural barriers could be overcome if MHPs were open, respectful, and able to talk about differences and experiences of racism; this could strengthen the therapeutic relationship. Enactment of racial microaggressions and discrimination by MHPs will have a detrimental effect on the therapeutic relationship, further exacerbated by the power differentials between MHPs and clients (102). MHPs working therapeutically with racially minoritised students should be open to discussing differences in identity and how this could affect the therapeutic relationship, as well as the psychological impact of experiences of discrimination and racism. Doing so will facilitate a respectful, trusting, and collaborative therapeutic alliance. Future research should build upon the limitations of this study and seek to explore experiences of and attitudes toward help-seeking among specific racially minoritised student populations. Future research should consider intersectionality; while this review has focused on race and ethnicity, it has demonstrated that there is overlap with faith, language, gender, and nationality. Moreover, exploration of the impact of racial and ethnic differences between MHPs and clients on the therapeutic alliance is integral to improving care and therapeutic outcomes. For universities and mental health services to meet the needs of underserved and at-risk groups, there needs to be more understanding of the complex and multifaceted aspects of identity that affect mental health and attitudes toward and experiences of seeking help. Abbreviations Higher Education Institutes (HEIs) Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Critical Appraisal Skills Programme (CASP) Patient and Carer Race Equality Framework (PCREF) British Psychological Society (BPS) Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Competing interests The authors declare no competing interests Data availability The datasets used/or analysed during the current study are available from the corresponding author on request. Funding Not applicable Author information Authors and affiliations Rosa Hardy: Doctorate in Clinical Psychology, Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom. Helen West: Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom. Peter Fisher: Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom. Contributions RH conceived and designed the study, and screened, extracted and interpreted the data from the studies. RH wrote the manuscript. PF and HW contributed significantly to the conception, design and drafting of the manuscript. All authors read and approved the final version of the manuscript. Acknowledgements We thank the expert by experience who provided consultation for this study and JM, a Trainee Clinical Psychologist, who was the second screener and quality assessor for the study. References UNESCO. What you need to know about higher education. Unesco.org. 2024. [Accessed 15 May 2024]. Available from: https://www.unesco.org/en/higher-education/need-know#:~:text=Some%20254%20million%20students%20are,and%20is%20set%20to%20expand Higher Education Statistics Agency. Higher Education Student Statistics: UK, 2019/20 . 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14:17:34","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5638764/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5638764/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":72204692,"identity":"be0c6279-f11d-4fb8-bd61-d7bb20e68910","added_by":"auto","created_at":"2024-12-23 16:26:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45538,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA diagram.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/d294b910ba13f4f7e178245c.png"},{"id":72204693,"identity":"dd862cef-a085-4922-b632-7f1942e654a3","added_by":"auto","created_at":"2024-12-23 16:26:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":81159,"visible":true,"origin":"","legend":"\u003cp\u003eTheme one: “they taught us about mental health, it’s just for the crazy people” (62): cultural dynamics.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/d19f3a94c3b60fe93ee0f5c1.png"},{"id":72204695,"identity":"2876ae5d-020d-46fc-9cbd-c90c6a025cbc","added_by":"auto","created_at":"2024-12-23 16:26:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":60868,"visible":true,"origin":"","legend":"\u003cp\u003eTheme two:\u003cstrong\u003e \u003c/strong\u003e“Mak[e] sure that the people you associate with don’t look down on mental health” (60): the influence of relationships.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/2029acd3768f6912c6c09b9e.png"},{"id":72204701,"identity":"54e9465e-2944-49b6-aa23-662281fe8487","added_by":"auto","created_at":"2024-12-23 16:26:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":56267,"visible":true,"origin":"","legend":"\u003cp\u003eTheme three: “Brush it under the rug and carry on” (67): internal barriers to help-seeking.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/4136974d28e0fd389f7d7c98.png"},{"id":72204696,"identity":"747c62cd-0567-43d6-8f69-ed32f8b56da0","added_by":"auto","created_at":"2024-12-23 16:26:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":67799,"visible":true,"origin":"","legend":"\u003cp\u003eTheme four: “We receive inadequate treatment because of our skin color” (57):\u003cstrong\u003e \u003c/strong\u003esystemic barriers to help-seeking.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/9d156aec03ade973f5456cb4.png"},{"id":72207126,"identity":"03f6256d-b77a-43e4-9245-8c5e1f16f374","added_by":"auto","created_at":"2024-12-23 16:50:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1227874,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/3bf18bf9-db14-48c7-bdd5-5dc310491aca.pdf"},{"id":72205321,"identity":"7df7f162-fdb8-4cdf-b425-e59217a00612","added_by":"auto","created_at":"2024-12-23 16:34:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":3311140,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5638764/v1/2aeaeabd5143c3f280bffc70.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eExploring attitudes towards seeking help for mental health problems among university students from racially minoritised backgrounds: A systematic review and thematic synthesis\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are an estimated 254 million students enrolled at universities globally (1). Universities worldwide have undergone rapid and diverse changes, such as greater accessibility of higher education for a more diverse student group. Currently, 25% of domicile UK university students are from racially minoritised backgrounds (2). This does not include the approximately 600,000 international students currently studying in the UK, many of whom will also be racially minoritised (2). In the US, the percentage of students from Latinx, Black and Asian backgrounds has increased from 15.36% in 1976 to 45.23% in 2022 (3)(4). This has required higher education institutes globally to quickly adapt to the needs of their students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA key aspect of adapting to the changing student population has been developing mental health support services. In 2022, 57% of UK university students reported experiencing a mental health difficulty (5). In the US, a longitudinal study across 196 universities found that suicidal ideation increased by approximately 90%, from 5.8% in 2007 to 10.8%, in 2016-2017 (6). University students from racially minoritised backgrounds are at an increased risk of mental health issues (7) (8) (9) (10). In the US, students of colour are more likely to experience symptoms of clinical depression than students from other racial/ethnic groups (3) (11). Furthermore, multiracial students in US are more likely to experience suicidal ideation and to have attempted suicide than white students (12). Universities must understand the mental health needs and attitudes towards seeking help of students. Identifying underserved student populations and exploring why they are reticent to seek support is essential to creating a more inclusive and supportive environment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Psychological Impact of Discrimination and Racism on Mental Health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe minority stress model proposes that discrimination and stigma experienced by minoritised individuals contributes to adverse health outcomes (13). \u0026nbsp;Furthermore, minority status leads to exposure to distal and proximal stressors (13). Distal stressors include experiences of discrimination and rejection, while proximal stressors are internal processes caused by distal stressors; for example, anxiety, rumination, feeling the need to hide one’s own identity, and holding negative feelings towards one’s own minority group (14) (15) (16). There is increased minority stress and poor mental health outcomes among sexual and gender minority individuals (14) (15). The intersection of other minoritised aspects of identity, such as race and ethnicity, also increases the risk of poor mental health (17) (18). By understanding the role of minority stressors in racially minoritised students’ psychological wellbeing, universities and mental health services can implement targeted interventions, and address inequalities and discrimination in HEIs and services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRacially minoritised students face specific challenges, structural inequalities and Eurocentric curriculums. HEIs are often built on historical colonial ideologies and practices, with racial hierarchies and inequalities embedded within. The presence of statues of and buildings named after colonial figures, such as Cecil Rhodes, have sparked controversy and protests within universities (19). Lack of diversity among university staff led to the grassroots campaign “\u003cem\u003ewhy isn’t my professor black?”\u003c/em\u003e, which sought to highlight the underrepresentation of racially minoritised academics in HEIs, the systemic barriers racially minoritised scholars face, and institutional racism (20) (21). Similarly, the “\u003cem\u003edecolonise the curriculum\u003c/em\u003e” global movement sought to challenge the colonial legacies shaping educational frameworks (22). These movements demonstrated the ongoing need for HEIs to enhance representation among staff, students, and in the curriculum.\u003c/p\u003e\n\u003cp\u003eRacially minoritised students may experience covert forms of racism (such as microaggressions) and overt racism both within universities and in wider society. Microaggressions are subtle comments or actions that can marginalise and demean racially minoritised groups or individuals and can lead to isolation and low self-esteem (23). Carter (24) proposed that such experiences can be sudden, uncontrollable, threatening, and memorable, and can lead to traumatic stress reactions. Smith et al. (25) explored the experiences of black men in US universities and found that microaggressions can lead to ‘racial battle fatigue’, defined as experiences of hypersensitivity, hypervigilance, fear, and anxiety when entering the predominantly White American academic settings. Understanding the psychological impact of racism is crucial for mental health services which support university students to inform therapeutic interventions and formulations, and challenge systemic discrimination and abuse.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the UK, the Equality and Human Rights Commission (26) found that 24% of students surveyed had experienced racial harassment and one in 20 university students had left their studies due to racial harassment. Moreover, two thirds of students who had experienced racial harassment did not report it to their university. Evidently, universities need to be doing more to tackle racism in all forms and support students to report racial harassment to ensure that students feel safe, their wellbeing is supported, and they can complete their studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific Challenges Faced by International Students\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing these issues is particularly pertinent in the US and UK, which have the highest proportion of international students in the world, many of whom may face discrimination and require support for their mental wellbeing (27). In the UK, approximately 24% of students are international students (28). International students have become crucial to the financial growth of universities, contributing a fifth of the total income of universities through tuition fees. (29). The presence of international students enriches the academic environment, allowing for cultural exchanges of knowledge and fostering global connections (30).\u003c/p\u003e\n\u003cp\u003eHowever, international students face specific challenges when studying abroad; for example, adapting to a new culture and social norms, potential language barriers, loss of social support (such as family and friends back home) and homesickness (12). International students may experience ‘culture shock’ (such as anxiety and confusion over cultural norms and practices) (30). Many international students also report feeling isolated from their fellow students (31) (32). Not only will many international students experience the unique stressors of living and studying abroad, but they may also experience being racially minoritised in their country of study (33). There was a drastic increase in anti-Asian discrimination following the outbreak of Covid-19, with many Asian international students reporting experiences of racism and abuse (34) (35). Therefore, there are shared experiences between both home and international students who would identify as from a racially minoritised background within their country of study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHelp-Seeking for Mental Health Among Minoritised Students\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the UK, disclosure of mental health rates by undergraduate university students increased from 6% on 2016/17 to 16% in 2022/23 (36). However, demographics of students who access services are not representative of the student community (37) (38) (39). Racially minoritised students, including both home and international students, are less likely to seek help for mental health problems than students from a racial and ethnic majority background (6).There is clear evidence that racially minoritised students (both domicile and international) experience systemic and personal stressors while at university, and racially minoritised students and international students are at an increased risk of experiencing mental health problems while studying (3) (40). Consequently, understanding the attitudes that racially minoritised students hold towards seeking support for mental health is critical to ensuring the psychological wellbeing of this student group. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRationale\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrevious systematic reviews have explored barriers and facilitators to seeking help for mental health difficulties among young adults and university students; for example, stigma, self-reliance and accessibility of support (41) (42). Systematic reviews have been conducted exploring factors associated with help-seeking among people of racially minoritised backgrounds (43) (44). However, no review to date has explored attitudes toward seeking help for mental health difficulties among students who are of racially minoritised within the university system.To support the mental health of racially minoritised students, it is important that universities and mental health services understand how these students feel about seeking support for their mental health. No existing review to date has synthesised the perspectives of racially minoritised students on seeking help for mental health problems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary aim was to explore the perspectives of racially minoritised students on help-seeking for mental health problems by asking the question “what are the attitudes towards seeking help for mental health problems among racially minoritised students?”. A secondary aim of the review was to explore how universities and mental health services can support help-seeking for mental health among racially minoritised students.\u0026nbsp;\u003c/p\u003e"},{"header":"Method","content":"\u003cp\u003eBased on Cochrane guidance, a thematic synthesis approach, as described by Thomas \u0026amp; Harden (45), was used (46). Attitudes and experiences of mental health difficulties are highly subjective and culture-bound; a thematic synthesis approach allows for integration of diverse perspectives and, by using an inductive approach, it allows researchers to uncover culturally specific phenomenon (47). Moreover, it enables new insights and interpretations that may not be seen in the primary studies (48) (49). The review was registered to the PROSPERO database (https://www.crd.york.ac.uk/prospero/; ID number: CRD42023485699). Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting of systematic reviews were followed (50) (51).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudies were included if they used direct interviews (such as focus groups and 1:1 interviews), recruited current university students who identified as a racial or ethnic minority within their country of study, included discussion of attitudes toward seeking help for mental health problems, were primary research, applied a qualitative or mixed design, and were available in English.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExclusion criteria were scoping papers or systematic reviews, commentary regarding the subject area, or from books, conference presentations or unpublished dissertations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSearch Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePapers were identified through comprehensive searches. Search terms were linked to the review question, which was devised using the SPIDER tool (Table 1) (52).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSearch syntax terms were based on key words prevalent in the relevant literature identified through scoping searches; this was discussed with a University Librarian and reviewed with the supervisory team (see Table 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn December 2023, literature searches were conducted via the following databases: APA PsycINFO, CINAHL, Web of Science and MEDLINE. These databases were chosen as they focused on healthcare disciplines. After titles and abstracts were screened, studies that met the inclusion criteria were retrieved. Full text and hand-searching of references of key studies was completed. Studies were stored on EBSCO, processed using Microsoft Excel and codes synthesised on NVivo. (Version 14). Searches were updated in March 2024; 493 possible publications were identified. 15 papers were identified which met the inclusion criteria for the review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexive Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eReflexivity is important to ensure rigour in qualitative research (53). When completing this review, the primary author considered how their own identity as a White British person could affect the data-analysis; for example, by not having lived experience of being from a racially-minoritised background, the primary author could overlook or minimise important experiences or interpretations. It was therefore important to use a reflexive diary to help the primary author to critically appraise their own interpretations and thoughts and discuss these reflections within the supervisory team. Collaborative reflexivity acknowledges that, to uncover one\u0026rsquo;s own blind spots, it is necessary to discuss assumptions and decisions with others from a diversity of backgrounds (54). The research team comprised members of different genders, professional roles, and training backgrounds, allowing for a broad range of perspectives and insights. However, as no member of the team identified as racially minoritised, consultation was sought from an expert by experience who had been an international university student, had experience of seeking help for their mental health problems and was of a racially minoritised background. The primary author\u0026rsquo;s own experience of being a university student may have influenced the process of creating initial codes and generating analytic themes. As a Trainee Clinical Psychologist, the primary author recognised from professional experience that mental health services are often not accessible or do not appropriately meet the needs of people from racially minoritised backgrounds.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eScreening and Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis reviewed followed the methods and results reporting of PRISMA guidelines (50) (51) (Figure 1). In total, 493 articles were returned in the search (PsycINFO \u003cem\u003en\u003c/em\u003e = 189, CINAHL \u003cem\u003en\u003c/em\u003e = 54, Web of Science \u003cem\u003en\u003c/em\u003e = 147\u003cem\u003e,\u003c/em\u003e MEDLINE\u003cem\u003e\u0026nbsp;n\u003c/em\u003e = 103). Search results were transferred to Endnote (Version 21). 212 duplicates were removed and 84 papers which were not peer-reviewed were removed. One further paper was identified from handsearching. Articles were then transferred to Rayyan (www.rayyan.ai); this AI assisted systematic review tool facilitates the collaboration of the screening process. The title and abstract of these papers were reviewed by the primary author (RH) and 109 were removed through application of the inclusion/exclusion criteria; an independent reviewer (JM) completed the same process on a random sample of 50% of the papers. RH reviewed the full text of 88 articles, and JM completed the same process on a random sample of 10% of the papers. One discrepancy was discussed by the research team, and consensus achieved. Fifteen papers were identified for the final thematic synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Critical Appraisal Skills Programme (CASP) (55) appraisal tool for qualitative research was used to appraise the papers. This tool uses 10 questions which were scored as follows: yes = 1, can\u0026rsquo;t tell \u0026nbsp; 0.5, and no = 0. Overall scores of seven and above indicate moderate quality and scores of nine or above indicate high quality (56). All CASP assessments conducted by RH were independently checked by JM. All discrepancies were discussed between RH and JM to achieve consensus.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe quality of the papers was moderate with overall scores for each paper ranging from 7.5-10 (Table 3). Most studies clearly outlined their aims, methodology, design, recruitment, and data collection (57) (58) (59) (60) (61) (62) (63) (64) (65) (66). All studies appropriately outlined their findings and the valuable contribution to clinical practice and research. However, most studies failed to explore researcher positionality and reflexivity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Extraction and Study Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey information from the studies is in Table 4 (and see additional files). The total number of participants across all studies was 314, with a range of six to 48 participants in each study. Seven studies were conducted in the UK (57) (61) (64) (65) (66) (67) (68), seven in the US (58) (59) (60) (62) (63) (69) (70) and one in Israel (71). Three studies specifically recruited participants who were international students (61) (63) (70).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from the \u0026lsquo;results\u0026rsquo; or \u0026lsquo;findings\u0026rsquo; section of each paper were extracted to NVivo (Version 14) and analysed using a thematic synthesis approach to explore the attitudes toward seeking help for mental health problems among university students from racial or ethnic minority backgrounds (45); this included both direct quotes from participants and the interpretations made by the authors of the papers. Free line-by-line coding of each paper was completed, and subsequent \u0026lsquo;descriptive\u0026rsquo; themes were identified. This led to the development of \u0026lsquo;analytical\u0026rsquo; themes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour themes and 12 subthemes are outlined in Table 5 and with exemplar quotes in Figures 2, 3, 4 and 5.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme one \u0026ndash;\u003c/em\u003e \u003cem\u003e\u0026ldquo;they taught us about mental health, it\u0026rsquo;s just for the crazy people\u0026rdquo; (62): Cultural dynamics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCultural dynamics were reported universally as adversely influencing attitudes toward seeking help for mental health problems. Stigmatising attitudes towards mental health and help-seeking within cultural communities negatively impacted on individuals\u0026rsquo; views on seeking help for their mental health were common across studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCultural dynamics subtheme \u0026ndash; \u0026ldquo;It\u0026rsquo;s seen as a characteristic of a problematic family\u0026rdquo;\u003c/em\u003e (60): shame and stigma.\u0026nbsp;\u003c/strong\u003eFear of being stigmatised by cultural communities was reported in all studies. Individuals feared that their experiences of mental health difficulties would bring shame on their family (57) (60) (61) (62) (64) (66) (67) (70), that it would limit their future opportunities within their cultural community (57) (60) and reported that therapy had negative connotations (68) (70) (71).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We Arabs do not look favorably upon mental therapy, think that mental therapy is not helpful, [and] identify those who seek mental therapy as a weak and crazy person [. . .]. It\u0026rsquo;s [therefore] difficult to seek treatment and most who do so hide the fact that they\u0026rsquo;re in therapy\u0026rdquo;\u0026nbsp;\u003c/em\u003e(71)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCultural dynamics subtheme \u0026ndash; \u0026ldquo;Mental health is obviously still not talked about enough\u003c/em\u003e\u0026rdquo; (62): Lack of conversations about mental health and support.\u0026nbsp;\u003c/strong\u003eSilence\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewithin cultures around mental and culturally-specific understandings of mental health were reported as barriers to seeking help by participants in several studies (59) (62) (63) (66) (67) (68) (69) (70). Some participants reported their cultural communities only associated \u0026lsquo;mental health\u0026rsquo; with severe presentations; for example, someone who is \u0026lsquo;crazy\u0026rsquo; or \u0026lsquo;suicidal\u0026rsquo; (62) (70) (71). Because \u0026lsquo;mental health\u0026rsquo; was only conceptualised in terms of severe presentations, milder presentations were often unrecognised; this led participants to not acknowledge that their difficulties were mental health related and not seek support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Growing up [\u0026hellip;] people weren\u0026rsquo;t taught about mental health, and it inevitably forced my whole household to never discuss mental health\u003c/em\u003e\u0026rdquo; (59)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCultural dynamics subtheme \u0026ndash;\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003e\u0026ldquo;\u003cem\u003eEverything always links back to God\u003c/em\u003e\u0026rdquo; (68): How faith informs understandings of mental health and help-seeking.\u003c/strong\u003e Participants reported that faith informed how they conceptualised mental health (57) (64) (65) (66) (67) (68) (71). For some participants, mental health problems were seen within their culture as punishment from God; they stated that if they disclosed mental health difficulties to friends or family, they would be told to pray rather than seek formal help (57) (66) (67) (68) (71). This dissuaded some from seeking any help for their mental health difficulties, as they felt they would be judged negatively within their religious community for having a mental health problem or for seeking formal help instead of engaging in religious practices. For others, they reported that they would seek out help for mental health problems from faith leaders and found prayer helpful (61) (64) (65) (68) (71).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think some of those religions and some of the doctrines in the past have given the Black community the impression that mental health is an indication that something is evil or something to be stayed away from.\u0026rdquo;\u003c/em\u003e (67)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If I\u0026rsquo;m overwhelmed or stressed; they\u0026rsquo;ll be like it\u0026rsquo;s because I\u0026rsquo;m not praying enough, or you\u0026rsquo;ve lost your way on the right path\u0026rdquo;\u003c/em\u003e (68)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCultural dynamics subtheme \u0026ndash;\u0026nbsp;\u003c/em\u003e\u0026ldquo;\u003cem\u003eIf the black male has mental issues you just think he\u0026rsquo;s aggressive\u003c/em\u003e\u0026rdquo; (66): Gender as a barrier to help-seeking.\u0026nbsp;\u003c/strong\u003eMale students faced additional barriers to help-seeking due to cultural beliefs that men should not show their emotions (57) (62) (66) (68) (70). Moreover, there was a fear that male students from ethnic minority backgrounds, particularly Black students, who sought help for mental health problems would be discriminated against and stereotyped (57) (66).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Until they reach a crisis point or rock bottom and, as a black male, you are already stigmatized and you are aware that you will be further [stigmatized] upon being diagnosed with this illness, which will consequently affect your university studies\u0026rdquo;.\u003c/em\u003e (57)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme two\u003cem\u003e\u0026nbsp;\u0026ndash; \u0026quot;mak[e] sure that the people you associate with don\u0026rsquo;t look down on mental health\u0026rdquo;\u0026nbsp;\u003c/em\u003e(60):\u003c/strong\u003e \u003cstrong\u003ethe influence of relationships\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis theme highlighted the impact of family and peer relationships on attitudes toward seeking help for mental health problems. If families had negative attitudes toward seeking help for mental health problems, this increased fear of disclosure and reticence toward seeking help amongst participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe influence of relationships subtheme \u0026ndash; \u0026ldquo;It was easier to get help when my parents weren\u0026rsquo;t there\u0026rdquo;\u0026nbsp;\u003c/em\u003e(69): family dynamics.\u0026nbsp;\u003c/strong\u003eMany participants reported that their families did not discuss mental health and would hold negative views regarding seeking help for mental health problems (57) (59) (60) (62) (66) (67) (69) (70). Some participants reported that their families were supportive of their mental health and help-seeking (59) (60) (66); however, some stated that, while their families held positive views of help-seeking in general, they would still disapprove if their own family members sought help for mental health problems (60). Participants stated that having mental health difficulties and seeking help would bring shame on their family; mental health difficulties were associated with dysfunctional families and poor parenting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My parents were aware that I sought counseling at first, but they discouraged it [\u0026hellip;] They were under the impression that if I just tell myself that I won\u0026rsquo;t have it, then I won\u0026rsquo;t have it.\u0026rdquo;\u003c/em\u003e (59)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe influence of relationships subtheme \u0026ndash;\u0026nbsp;\u003c/em\u003e\u0026ldquo;\u003cem\u003eI know [it] starts with us first [\u0026hellip;] people of color\u003c/em\u003e\u0026rdquo; (59): Support from racially minoritised peers.\u0026nbsp;\u003c/strong\u003eParticipants spoke about how they often felt more able to talk about mental health and seek help if this was modelled by racially minoritised peers (59) (60) (63) (64) (66) (67) (69) (70). Some international students stated that they did not feel able to speak about mental health or seek help because their fellow international students perpetuated stigmatising beliefs from their home country (61) (70).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel like people are slowly trying to let people know that it\u0026rsquo;s okay to not be okay and go seek help.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(59)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheme three\u003cem\u003e\u0026nbsp;\u0026ndash; \u0026ldquo;brush it under the rug and carry on\u0026rdquo;\u0026nbsp;\u003c/em\u003e(67): internal barriers to help-seeking.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003einternal barriers, such as a desire to be self-reliant and fear of the consequences of seeking help, were barriers to help-seeking for racially minoritised students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInternal barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;If we don\u0026rsquo;t show our emotions, then we\u0026rsquo;re strong\u003c/em\u003e\u0026rdquo; (66): self-reliance.\u0026nbsp;\u003c/strong\u003eParticipants felt the need to keep struggles to themselves and associated help-seeking for mental health with personal weakness (59) (61) (62) (66) (67) (69) (70) (71). Some participants spoke about how their families and cultures had struggled for generations with racism, slavery, and civil war; they expressed that they should therefore be able to cope with the struggles of studying at university as these were comparatively less difficult (57) (59) (67).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Within African families, there is an expectation to continuously be resilient as you are reminded of the sacrifices made for you to attend university\u0026rdquo;.\u003c/em\u003e (57)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInternal barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;Being black and mad isn\u0026rsquo;t a good look out here\u0026rdquo;\u0026nbsp;\u003c/em\u003e(68)\u003c/strong\u003e: \u003cstrong\u003efeared consequences of disclosure.\u0026nbsp;\u003c/strong\u003eParticipants feared that disclosing mental health difficulties could negatively impact on their studies and future employment opportunities (57) (61) (66) (68). International students worried about lack of confidentiality when disclosing mental health problems and that seeking help would result in them being deported (61) (66). Students also worried that they would be sectioned, given treatments against their will, and discriminated against because of their racial background (57) (66) (68).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;My fear is receiving an inappropriate investigation into my psychological state, which could affect my studies and potential treatments. As a result, between university and my GP. . . I prefer not to say anything\u0026rdquo;.\u003c/em\u003e (57)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme four \u0026ndash; \u0026ldquo;we receive inadequate treatment because of our skin color\u0026rdquo;\u0026nbsp;\u003c/em\u003e(57)\u003cem\u003e: s\u003c/em\u003eystemic barriers to help-seeking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Systemic barriers appeared as difficulties faced when seeking help for their mental health problems; for example, experiences of discrimination, lack of diversity on campus and in mental health services, and lack of cultural competence in services. The therapeutic relationship emerged as crucial for addressing these barriers by fostering trust, safety, collaboration, and the feeling of being respected and understood. It was noted that participants felt that this was often lacking in university support and external mental health services. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystemic barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;I don\u0026rsquo;t even know where to start\u0026rdquo;\u0026nbsp;\u003c/em\u003e(61)\u003cem\u003e:\u0026nbsp;\u003c/em\u003eStructural barriers.\u0026nbsp;\u003c/strong\u003eParticipants reported that technicalities of health insurance, costs of accessing mental health services, and distance from services prevented them from seeking help (60) (71). Confusion and uncertainty around how to access support and navigate services was also a key barrier (62) (63) (68). This was particularly difficult for international students who were unfamiliar with the health systems of their countries of study (61) (62) (63) (70).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think for international students, everything is a lot harder because we don\u0026rsquo;t know how anything works. I think that them saying, \u0026ldquo;yeah here we have resources,\u0026rdquo; that\u0026rsquo;s not helpful. We don\u0026rsquo;t know how to access the resources, even though we know they\u0026rsquo;re there\u0026rdquo;\u003c/em\u003e (62)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystemic barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;There aren\u0026rsquo;t enough minority ethnic people within the mental health system\u0026rdquo;\u0026nbsp;\u003c/em\u003e(67):\u003c/strong\u003e \u003cstrong\u003elack of diversity.\u003c/strong\u003e Participants noted a lack of racial and ethnic diversity on campus and within mental health services (57) (58) (64) (65) (66) (68) (70). They perceived that university staff and mental health professionals (MHPs) would not understand their experience, which prevented them from seeking help.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eYou feel weird being a Muslim in a place where you do not see any Muslim staff, you don\u0026rsquo;t know who to approach and how to do it and if you\u0026rsquo;re going through anxiety and stress, this can seem like a bigger mountain to climb.\u0026rdquo;\u003c/em\u003e (64)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystemic barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;We\u0026rsquo;ll be treated lesser than our white counterpart\u0026rdquo;\u0026nbsp;\u003c/em\u003e(66):\u003cem\u003e\u0026nbsp;\u003c/em\u003ediscrimination and microaggressions.\u0026nbsp;\u003c/strong\u003eMicroaggressions and perpetuation of stereotypes by university staff and by MHPs had a negative impact on students\u0026rsquo; mental health and attitudes toward seeking help (57) (58) (68) (70); for example, Asian students reported that staff perpetuated the \u0026ldquo;model minority\u0026rdquo; stereotype, which led them to not want to ask for help.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I told [my therapist] I am from South Korea, ... she said \u0026ldquo;Oh, your English is really good\u0026rdquo;; I don\u0026rsquo;t know what she meant. I felt negative. Maybe she does not really have much experience with Asians.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(70)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSystemic barriers to help-seeking subtheme \u0026ndash; \u0026ldquo;If you can\u0026rsquo;t understand us as people, then you\u0026rsquo;re not going to understand our mind\u0026rdquo;\u0026nbsp;\u003c/em\u003e(59):\u003c/strong\u003e \u003cstrong\u003ecultural (in)competence and the therapeutic relationship.\u0026nbsp;\u003c/strong\u003eA lack of diversity within universities and mental health services coupled with discrimination and microaggressions led participants to feeling that institutions were not culturally competent (57) (58) (60) (62) (64) (65) (66) (67) (68) (70). Students felt that professors and MHPs did not understand their cultural background, minimised experiences of racism, isolation, and culture shock, and were not willing to discuss race and religion (57) (59) (62) (64) (65) (66). This negatively impacted on the therapeutic relationship and made students feel unwilling to seek help for their mental health problems. Some participants reported that they felt these barriers could be overcome if MHPs were open to learning about a culture, respectful and empathetic (65) (68) (70).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I would prefer to have a psychological doctor who can speak some Chinese and was raised in Chinese culture\u0026hellip;\u0026hellip;[but] barriers of gender, race, and language can be overcome. It will be fine if the doctor can understand me.\u0026rdquo;\u003c/em\u003e (70)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe review identified that cultural dynamics encompassing stigma, understandings of mental health, faith and gender norms significantly influence attitudes toward help-seeking. Family attitudes towards seeking help for mental health problems can also exacerbate or alleviate students’ mental health. Supportive peer relationships and modelling facilitate positive attitudes towards help-seeking. Participants expressed internal barriers to seeking help, including the need to be self-reliant and fearing the consequences of disclosing mental health difficulties. Additionally, systemic barriers, such as structural barriers, a lack of diversity on campus and in mental health services, experiences of discrimination and microaggressions, and perceived cultural incompetence of mental health professionals, pose critical challenges for racially minoritised students’ mental health help-seeking. Multifaceted and nuanced influences on mental health help-seeking for racially minoritised students were apparent and highlighted the urgency for strategies which address the barriers and foster an inclusive and supportive environment for racially minoritised students.\u003c/p\u003e\n\u003cp\u003eCulture permeates and affects all aspects of mental health experiences (72). Kleinman et al. (73) used the explanatory model of illness to propose that how individuals understand and experience illness is embedded within a social context. Thus, cultural norms and beliefs impact on how psychological distress is conceptualised, experienced, expressed and responded to (73). Negative and stigmatising views on mental health and help-seeking among individuals’ cultural communities were key barriers to seeking help.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFaith can be both a powerful coping resource and perpetuator of stigma (74). In this review, some participants reported their faith as central to their identity and how they coped with distress. For other participants, beliefs about mental health difficulties as indicative of moral failings or lack of prayer were highly stigmatising, shaming and silencing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMale students are less likely than female students to seek help for their mental health problems (75) (76) (77). In the UK racially minoritised men are less likely to access mental health support in primary care and are more likely to access mental health services through the criminal justice system than white people (78). \u0026nbsp;Male students faced additional barriers to help-seeking; this was due to cultural beliefs that men should hide their emotions, and fear of structural discrimination, such as being sectioned or treated inappropriately based on racial biases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVarious policies in the UK have highlighted the pervasive mental health inequalities experienced by racially minoritised groups, in particular black men (79) (80). The Patient and Carer Race Equality Framework (PCREF) seeks to embed anti-racist practice and policies in NHS mental health services to advance mental health equalities (81). Underpinning this is the NHS Constitution, which details that it is every professional’s duty to ensure the human rights of patients are upheld and equality is promoted (82). Uptake of the PCREF in student services could facilitate more co-production with racially minoritised experts by experience of policies, guidance, and services, and tackle structural discrimination and inequality. Greater integration of research on racial discrimination and gender-related biases should be incorporated into training of MHPs, such as Clinical Psychologists, and university staff who support students.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudents (particularly international students) often feared that disclosure of mental health difficulties could result in them being forced to leave the university. This demonstrates a lack of awareness of confidentiality and its limits which underpin mental health services. Students also felt confused about how to navigate mental health systems and which services were available to them. Greater promotion to racially minoritised and international students of mental health services, how to access them, and services’ responsibilities to ensure confidentiality is necessary to build awareness and trust.\u003c/p\u003e\n\u003cp\u003eRacially minoritised students often feel reluctant to seek help due to the belief that self-reliance is indicative of personal strength, while help-seeking is associated with weakness (41) (83). Reluctance to seek help appeared due to beliefs that they should be able to cope independently, particularly given the challenges their families and communities had faced historically. Wellbeing resources provided to students could challenge notions of self-reliance to reduce this barrier to help-seeking. MHPs working with racially minoritised students should be mindful of how self-reliance may impact on psychological wellbeing; for example, how seeking help may negatively impact on self-esteem if an individual believes that they should be self-reliant and that seeking help is a weakness. Psychotherapeutic approaches which target unhelpful core beliefs while also recognising and respecting individual strengths and cultural contexts, such as culturally adapted cognitive behavioural therapy, could be utilised to modify these cognitive patterns (84).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocial support is associated with good mental and physical health (85) (86). However, many racially minoritised students felt unable to discuss mental health or help-seeking with their family due to fear of their response; students described feeling pressured by their families to excel academically and feared that seeking help for their mental health problems would be perceived as failure and would bring shame to their family. \u0026nbsp; Public stigma is often experienced by families of those with mental health difficulties and has been shown to be associated with greater psychological distress and less perceived closeness between family members (87) (88) (89). Therefore, interventions targeting stigma and mental health literacy at the levels of communities and families could reduce public stigma, increase levels of social support, and reduce barriers to help-seeking for mental health problems.\u003c/p\u003e\n\u003cp\u003ePeer support can facilitate help-seeking for mental health difficulties, particularly within the student population, where loneliness and isolation are prevalent (90) (91) (92). Social learning theory states that people learn through observing the actions of others (93). This review found that racially minoritised students felt that talking to fellow racially minoritised peers about mental health was more helpful than accessing other sources of support. They were also more likely to seek help if this had been modelled by peers. Mental health first aid training for students has been shown to be effective in improving self-awareness of mental health and when to seek help, as well as increasing students’ confidence in their abilities to help peers who are experiencing a mental health difficulty (94) (95). Developing culturally-sensitive mental health first aid training and promoting this within diverse student populations could enhance peer support systems and promote professional help-seeking (96).\u003c/p\u003e\n\u003cp\u003eThe minority stress model can be applied to the experiences of racially minoritised students to demonstrate how stressors (such as microaggressions, discrimination and self-stigma) contribute towards poor mental health (13). Indeed, the university environment can have a significant detrimental effect on mental health and help-seeking attitudes for racially minoritised students (97) (23) (68). This review corroborated previous findings that overt and covert experiences of racism (such as microaggressions) impacted negatively on the mental health of racially minoritised students (23) (24) (25). Moreover, experiences of microaggressions prevented students from seeking help for their mental health difficulties. This presents a concerning picture that racially minoritised students are both at increased risk of mental health problems because of these experiences and feel unable to seek appropriate support for their mental health because of microaggressions and discrimination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA lack of MHPs from racially minoritised backgrounds is also a barrier to help-seeking. The review found that many participants would favour an ethnic-matched MHP to work with, and that all participants felt that MHPs and universities needed to develop cultural competence. Increased training and recruitment of racially minoritised MHPs and additional training to develop cultural competence among MHPs is essential to culturally representative and sensitive workforces. This review found that language was a key barrier to accessing support. Culturally-sensitive services must therefore be able to meet the linguistic needs of students by ensuring that staff are representative of the communities they serve and that translator services are available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths and Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA notable strength of this review was that the robust search strategy, which included searches from multiple databases and handsearching, produced a homogenous sample of studies whose aims related to the review question. Moreover, it focused on a particular phenomenon; while attitudes toward seeking help for mental health problems have been researched and reviewed for students in general, reviews have not explored experiences and attitudes of racially minoritised students. The research evidence discussed above shows that racially minoritised students are unlikely to disclose and seek help for their mental health problems (11) (41) (78) (83); the current review contributes to understandings of why this may be the case.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite no limit on year of study publication, all studies included were conducted within the past six years, with six studies being published in the last year; this implies that this is an emergent area of research. Furthermore, as universities are seeking to be more inclusive and diverse, this synthesis of the current evidence is particularly timely and relevant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA key limitation of this review was that racially minoritised is an umbrella term for multiple identities, within which there is heterogeneity of experiences. Therefore, there is a risk of overgeneralising and overlooking important, culturally-specific differences. Furthermore, studies around the world were included; while there were shared experiences and themes identified, there will be key differences in healthcare and university systems in different countries. Further research could explore differences and similarities in specific countries and racially minoritised groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA potential limitation was that the primary author was not of a racially minoritised background and therefore risked bias and oversight. This risk was somewhat reduced by discussion with the research team, engagement in reflective practice and consultation with an expert by experience who was of a racially minoritised background.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, 10 out of the 15 papers included did not include adequate reflexivity and researcher positionality. It is important that researchers engage in critical reflection on how their personal characteristics, experiences and beliefs can shape the research and its outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications and Future Research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding the barriers faced by racially minoritised students is crucial for universities and mental health services to provide support. This review has shown the impact on individuals’ mental health and attitudes toward help-seeking of cultural understandings and stigma of mental health problems, gender norms and pressures to be self-reliant. MHPs could engage in community outreach and provide tailored resources for universities which focus on psychoeducation, decrease stigma and challenge gender norms and notions of self-reliance. Better integration of faith-based mental health support may increase accessibility and acceptability of services for racially minoritised students but could also reinforce unhelpful cultural norms (such as linking mental health difficulties with punishment from God). MHPs working in student services should facilitate collaboration between mental health services, faith-based organisations and racially minoritised students and could help to develop culturally-sensitive resources and support.\u003c/p\u003e\n\u003cp\u003eThis review has also demonstrated how social support can impact on attitudes toward seeking support for mental health problems among racially minoritised students. While some students experienced their families as supportive, many found their families’ attitudes to be a barrier to help-seeking. Universities and MHPs should be aware of the additional stressors facing racially minoritised students and potential lack of familial support putting them at increased risk of distress. Peer support was demonstrated to be a key facilitator to help-seeking. Universities could improve psychological wellbeing and attitudes toward seeking help for mental health problems among racially minoritised students through peer-to-peer networks and support groups, providing training to these groups, such as culturally sensitive mental health first aid.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany students reported feeling unsure what services were available to them, how to navigate the systems and felt concerned about the consequences of seeking help. Greater information on the services available and on confidentiality and its limits should be communicated to students to alleviate anxiety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSystemic change within universities and mental health services is necessary to increase the accessibility of mental health support for racially minoritised students. MHPs can utilise their positions within services and their research skills to advocate for policy change and initiatives within universities and mental health services that will promote equality, diversity and inclusion. It is important that universities and mental health services increase staff diversity and are representative of the populations that they serve, engage in anti-racism training (including increasing awareness of unconscious biases and the unfair treatment of people of racially minoritised backgrounds), provide culturally-sensitive and appropriate support, and provide greater availability and promotion of translator services. This is critical to improve care for racially minoritised students and facilitate more positive attitudes toward seeking help for mental health difficulties.\u003c/p\u003e\n\u003cp\u003eThe therapeutic alliance is central to building culturally sensitive and appropriate services. The therapeutic alliance refers to the collaborative relationship between a professional and client. Bordin (98) argued that the therapeutic alliance consisted of three elements: shared treatment goals, agreement on tasks, and the development of a strong therapeutic relationship. The therapeutic alliance has been consistently linked to positive treatment outcomes (99) (100) (101). This review found that participants felt cultural barriers could be overcome if MHPs were open, respectful, and able to talk about differences and experiences of racism; this could strengthen the therapeutic relationship. Enactment of racial microaggressions and discrimination by MHPs will have a detrimental effect on the therapeutic relationship, further exacerbated by the power differentials between MHPs and clients (102). MHPs working therapeutically with racially minoritised students should be open to discussing differences in identity and how this could affect the therapeutic relationship, as well as the psychological impact of experiences of discrimination and racism. Doing so will facilitate a respectful, trusting, and collaborative therapeutic alliance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFuture research should build upon the limitations of this study and seek to explore experiences of and attitudes toward help-seeking among specific racially minoritised student populations. Future research should consider intersectionality; while this review has focused on race and ethnicity, it has demonstrated that there is overlap with faith, language, gender, and nationality. Moreover, exploration of the impact of racial and ethnic differences between MHPs and clients on the therapeutic alliance is integral to improving care and therapeutic outcomes. For universities and mental health services to meet the needs of underserved and at-risk groups, there needs to be more understanding of the complex and multifaceted aspects of identity that affect mental health and attitudes toward and experiences of seeking help.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHigher Education Institutes (HEIs)\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Critical Appraisal Skills Programme (CASP)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patient and Carer Race Equality Framework (PCREF)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;British Psychological Society (BPS)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u0026nbsp;\u003cbr\u003e\u003c/em\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u0026nbsp;\u003cbr\u003e\u003c/em\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003cbr\u003e\u003c/em\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData availability\u003cbr\u003e\u003c/em\u003eThe datasets used/or analysed during the current study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003cbr\u003e\u003c/em\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003cbr\u003e\u003c/strong\u003e\u003cem\u003eAuthors and affiliations\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003eRosa Hardy: Doctorate in Clinical Psychology, Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.\u003c/p\u003e\n\u003cp\u003eHelen West: Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.\u003c/p\u003e\n\u003cp\u003ePeter Fisher: Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003cem\u003eContributions\u003cbr\u003e\u0026nbsp;\u003c/em\u003eRH conceived and designed the study, and screened, extracted and interpreted the data from the studies. RH wrote the manuscript. PF and HW contributed significantly to the conception, design and drafting of the manuscript. All authors read and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eWe thank the expert by experience who provided consultation for this study and JM, a Trainee Clinical Psychologist, who was the second screener and quality assessor for the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNESCO. What you need to know about higher education. Unesco.org. 2024. [Accessed 15 May 2024]. Available from: https://www.unesco.org/en/higher-education/need-know#:~:text=Some%20254%20million%20students%20are,and%20is%20set%20to%20expand \u003c/li\u003e\n\u003cli\u003eHigher Education Statistics Agency. Higher Education Student Statistics: UK, 2019/20\u003cem\u003e. \u003c/em\u003eHigher Education Statistics Agency. 2021. 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Therapeutic alliance in enhanced cognitive behavioural therapy for bulimia nervosa: probably necessary but definitely insufficient. Behaviour research and therapy. 2014 Jun 1;57:65-71.\u003c/li\u003e\n\u003cli\u003eWeck F, Grikscheit F, Jakob M, H\u0026ouml;fling V, Stangier U. Treatment failure in cognitive‐behavioural therapy: Therapeutic alliance as a precondition for an adherent and competent implementation of techniques. British Journal of Clinical Psychology. 2015 Mar;54(1):91-108.\u003c/li\u003e\n\u003cli\u003eVasquez MJ. Cultural difference and the therapeutic alliance: an evidence-based analysis. American Psychologist. 2007 Nov;62(8):878.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Liverpool","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"university students, racially minoritised, mental health, attitudes, help-seeking","lastPublishedDoi":"10.21203/rs.3.rs-5638764/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5638764/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eUniversity students from racially minoritised backgrounds are at an increased risk of experiencing mental health difficulties but are less likely to seek support compared to students from racial and ethnic majority backgrounds. To increase the accessibility and appropriateness of mental health support for university students, it is important to understand the attitudes towards seeking help for mental health of underserved student groups. This is the first systematic review to synthesise the available qualitative data which explores attitudes toward seeking help for mental health problems among students from racially minoritised backgrounds.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis systematic review includes qualitative studies exploring attitudes towards seeking help for mental health difficulties among racially minoritised university students. A literature search was carried out using PsycINFO, CINAHL, Medline and Web of Science in March 2024. Participants were racially minoritised university students. Data were synthesised using a thematic synthesis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eOf 493 papers identified, 15 were included in the final thematic synthesis following methodological appraisal of their quality using the Critical Appraisal Skills Programme. There were a total of 314 participants across all included papers. Four analytical themes were identified: “cultural dynamics\" outlined how culturally specific experiences of stigma, lack of conversations about mental health, faith, and gender influenced attitudes; “the influence of relationships” explored the impact of family and peer relationships on attitudes; “internal barriers” described how preference for self-reliance and feared consequences of disclosure were culturally-informed barriers to help-seeking; and “systemic barriers” encompassed the structural barriers, discriminatory practices and perceived cultural incompetence of services that negatively impacted on attitudes towards help-seeking for mental health difficulties.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eCulture, identity and social inequality inform attitudes towards help-seeking among racially minoritised students. Exploration of how these factors interact with university systems may improve the provision of mental health support. Systemic change is needed within universities and mental health services to tackle inequality and improve support for racially minoritised students.\u003c/p\u003e","manuscriptTitle":"Exploring attitudes towards seeking help for mental health problems among university students from racially minoritised backgrounds: A systematic review and thematic synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-23 16:26:47","doi":"10.21203/rs.3.rs-5638764/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21b752df-39cd-4a95-afc2-c6e6e011a320","owner":[],"postedDate":"December 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":41572652,"name":"Psychology"}],"tags":[],"updatedAt":"2024-12-23T16:26:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-12-23 16:26:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5638764","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5638764","identity":"rs-5638764","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}