Abstract
Background:
Adolescence is a critical period for mental health and social exclusion, a key social determinant of mental health. Early intervention approaches are key to mitigating the impact of mental ill-health during adolescence, however social exclusion can create additional barriers to accessing care.
Aim:
We aimed to better understand help-seeking experiences of adolescents facing co-occurring social exclusion and mental ill-health, including sources of support, barriers and preferences for service provision.
Method:
Cross-sectional data were analysed, from the 2022 Mission Australia Youth Survey (N = 18,800). Adolescents aged 15 to 19 years were recruited from around Australia, through schools, community organisations and digital platforms. Indices of four domains of social exclusion (housing, finances, relational and education/employment) were created using existing Youth Survey variables, and supplemented with demographic characteristics, psychological distress and help-seeking behaviours (perceived need, mental health supports, barriers to access and preferences). Relationships between social exclusion domains, mental health concerns and help-seeking behaviours were explored using logistic regression models.
Results:
A total of 9,743 young people reported having needed mental health support, yet only 58.1% reportedly sought support (n = 5,565). Social exclusion domains were associated with different help-seeking behaviours: housing challenges with higher help-seeking (OR = 1.28; 95% CI [1.15, 1.42]); relational difficulties and edu-employment issues with lower (OR = 0.75; 95% CI [0.68, 0.83] and OR = 0.82; 95% CI [0.75, 0.89]). Stigma, confidentiality concerns, cost and not knowing where to seek help were common barriers to help-seeking; those experiencing social exclusion more likely to report these. Participants reported a strong preference for face-to-face support.
Conclusions:
This study highlights the additional needs and challenges faced by adolescents dealing with both social exclusion and mental ill-health. With greater barriers to help-seeking, concerted efforts are needed to reduce stigma, improve mental health literacy and increase access to trusted information sources. Further initiatives should focus on structural factors that socially exclude young people and exacerbate inequitable access to mental healthcare.
Adolescence is a critical period for mental health; almost 50% of all mental health disorders have their onset by age 18 years, and 62.5% by 25 years (Solmi et al., 2022). Social inclusion is a key social determinant of mental health (World Health Organization and Calouste Gulbenkian Foundation, 2014), representing the available opportunities people have to participate fully in society and access services, including those that help maintain health and wellbeing (Levitas et al., 2007). Social inclusion is operationalised as consisting of multiple interrelated domains including social participation and connectedness, housing and neighbourhood, finances and engagement in meaningful work or study (Filia et al., 2018, 2019). Social exclusion (on the other end of the spectrum) is disproportionately experienced by people with mental ill-health (World Health Organization and Calouste Gulbenkian Foundation, 2014). It acts as both a determinant and outcome of mental health (Rickwood et al., 2023), existing in a circular relationship that is difficult to break. For adolescents, the interaction between social exclusion and mental ill-health during this important developmental period can result in lifelong disadvantage and poor mental health (Patton et al., 2016).
Early intervention and prevention approaches are key to mitigating longer-term mental ill-health, poor functioning and quality of life (McGorry et al., 2022). However, adolescents who experience social exclusion and mental ill-health typically also experience a multitude of social issues that negatively impact treatment engagement and service accessibility (Brown et al., 2016; Filia, Menssink, et al., 2022; Gao et al., 2023; Seidler et al., 2020). While access to care provides opportunities to improve both mental health and social exclusion, these inequities create additional barriers and can exacerbate the cyclical relationship, leading to poorer outcomes and further disadvantage (Krist et al., 2017).
The issues that contribute to inequities in accessing mental healthcare are complex. Recent systematic reviews have identified common barriers to help-seeking for adolescents such as stigma and concerns regarding confidentiality, as well as structural barriers including cost, logistics (transport) and service availability (e.g. time spent on waitlists; Aguirre Velasco et al., 2020; Radez et al., 2021). Adolescents and caregivers have reported issues such as loss of status among peers, risk of upsetting family members and interference with other activities (Radez et al., 2021). Rural and immigrant populations report different types of barriers than urban and non-immigrant groups (Aguirre Velasco et al., 2020), demonstrating the need to understand the unique help-seeking experiences of different groups. While the impact of social determinants was not accounted for in these studies, it could be hypothesised that these barriers are likely exacerbated for people experiencing social exclusion.
Using an existing dataset from the 2022 wave of the largest annual youth survey in Australia, the Mission Australia Youth Survey, the overall aim of this study was to better understand help-seeking experiences of adolescents (aged 15–19 years) experiencing co-occurring social exclusion and mental ill-health. Specific aims were to: (i) delineate help-seeking practices for adolescents needing support for their mental health; (ii) identify barriers to accessing mental health supports for adolescents; (iii) detail preferences for mental health supports and (iv) for each of these, examine relationships with experiences of social exclusion.
Methods
Sample and setting
The Mission Australia Youth Survey is conducted annually with information collected from adolescents aged 15 to 19 years in each state and territory of Australia. In 2022, 18,800 adolescents completed the Youth Survey between 6th April and 31st August. Participants were recruited through schools, community organisations, Mission Australia services, local government services, the Mission Australia website and social media.
Procedures
The Youth Survey was completed online or on paper following presentation of an informed consent script. All procedures were approved by the University of Melbourne Human Research and Ethics Committee (#2022-22721-32663), State and Territory Education Departments and Catholic Education offices. Participants did not receive any reimbursement.
Measures
The Youth Survey dataset
The 2022 Youth Survey consisted of 45 question sets (for a detailed description see Leung et al. (2022)). The 2022 Youth Survey included questions related to adolescents’ experiences of education and employment, their social and family support, level of community engagement, mental health and general wellbeing. The Youth Survey consists of single- and multi-item questions, and validated measures such as the Kessler 6-item (K6) measure of psychological distress (Kessler et al., 2002) and the Personal Wellbeing Index (PWI-SC; Cummins & Lau, 2005; Tomyn & Cummins, 2011). Each year, amendments are made to the survey to reflect current issues or explore a particular area of concern. In 2022, questions were added to better understand experiences of mental health help-seeking for adolescents. These questions were utilised here along with those relating to social exclusion. Indices of the four domains of social exclusion (relational difficulties, financial hardships, housing challenges and edu-employment issue (Filia et al., 2018; Filia et al., 2019) were formed by selecting variables most closely related to each; for a full description of variables used, see Table 1. Demographic information including age, gender, Indigenous status and whether a person spoke a language other than English at home were included. Remoteness and socioeconomic statistics of participants’ residential area (using Index of Relative Socio-economic Advantage and Disadvantage; IRSAD (Australian Bureau of Statistics [ABS], 2018), were based on self-reported residential postcode. Psychological distress, perceived wellbeing and whether a person reported a mental health condition were also used.
Variables, classifications and items from the 2022 Youth Survey.
Statistical methods
Data cleaning and processing
This analysis includes a subsample of adolescents (n = 9,743) from the Youth Survey who reported ever having a need for mental health support. Missing data were imputed using multiple imputation (predictive mean matching with ‘mice’ package) with 20 imputed datasets (Buuren & Groothuis-Oudshoorn, 2011) for all logistic regression models and results pooled using Rubin’s rule (Rubin, 1996; details of missing cases in Table 2).
Characteristics of the participants in the total sample and subgroups experienced different domains of social exclusion.
Note. Missing data: 488 instances for gender, 345 for IRSAD and remoteness, 227 for speaking a language other than English at home and for psychological distress (K6), 186 for the housing challenges domain, 117 for edu-employment, 106 for Indigenous status and 5 for age.
Statistical analysis
Simple descriptive analyses were used to demonstrate demographic and health and wellbeing characteristics of those included in the analysis versus those not. Participants’ help-seeking behaviours, including whether they had ever sought mental health support, source of support, barriers to seeking support and preferences, were compared between those who did or did not experience each domain of social exclusion. For each help-seeking variable, two logistic regression models were used to evaluate the role of social exclusion domains, the first including single domains of social exclusion controlling for confounding factors (partially adjusted model), and the second including all social exclusion domains controlling for confounding factors (fully adjusted model). Potential confounding factors included age, gender identity, Indigenous status, remoteness, IRSAD of residential area, speaking a language other than English at home and psychological distress (K6). Subjective wellbeing and self-reported mental health conditions were not included due to high overlaps with psychological distress. All analyses were performed in R version 4.3.1 (2023-06-16).
Youth consultation
Youth consultation was conducted to obtain the input of young people with lived experience of social exclusion and/or mental ill-health into findings. Four young people reviewed findings and proposed recommendations, providing feedback and suggestions to enhance and ensure appropriateness, feasibility and acceptability based on their experiences of accessing mental health supports during adolescence.
Results
A total of 18,243 adolescents provided a valid response to whether they had ever felt the need for mental health support, with 53.4% (n = 9,743) reporting having needed support. Characteristics of these young people are detailed in Table 2. Most identified as female, were aged 15 to 17 years, were non-indigenous and lived in major cities.
Comparisons between those who did and did not report a need for mental health support are provided in Supplemental Table 1. Participants who reported needing mental health support were more likely to report social exclusion, and included higher proportions of adolescents who identified as gender diverse, reported speaking only English at home, lived in lower socioeconomic areas, reported a mental health condition, high psychological distress or low wellbeing. Nearly a third reported having a mental health condition.
Social exclusion
Of the 9,743, 34.6% reported social exclusion in one domain, 34.5% in multiple and 30.9% did not report any. Approximately, 22.3% reported housing challenges, 26.5% relational difficulties, 28% financial hardships and 42% education or employment issues. Characteristics differed slightly between subgroups of participants who experienced different domains of social exclusion, with marginalised or minority groups (e.g. gender diverse, indigenous, low socioeconomic status, living in regional or remote areas and experiencing mental health conditions) over-represented in most of these subgroups (Table 2).
Help-seeking experiences
Table 3 summarises the help-seeking experiences, barriers and preferences of the 9,743 adolescents. Of those who reported ever needing support for their mental health, only 58.1% had sought it. Most participants had sought support from health professionals (68.1%), family (55.4%) and friends (46%). Most commonly reported barriers to seeking mental health support were stigma/shame (36%), confidentiality concerns (34.3%), cost (24.2%) and not knowing where to go (‘service knowledge gap’, 23.9%). Most participants indicated a preference for face-to-face mental health services. Around a quarter reported no preference, and online and over the phone were preferred in smaller proportions.
Support seeking characteristics, overall and by social exclusion domain.
Relationships between help-seeking and social exclusion
Help-seeking
Participants who experienced relational difficulties and those with edu-employment issues were less likely to seek support (51.6%, 53.6% respectively). Results from logistic regression models exploring associations between social exclusion domains and help-seeking are provided in Table S2. In partially adjusted models, housing challenges were associated with higher help-seeking (OR = 1.28; 95% CI [1.15, 1.42]), whereas relational difficulties and edu-employment issues were associated with lower help-seeking (OR = 0.75; 95% CI [0.68, 0.83] and OR = 0.82; 95% CI [0.75, 0.89]). Associations were similar in fully adjusted models, suggesting that higher odds of help-seeking were related to being female or gender diverse, older in age, of higher socioeconomic status, speaking only English at home and reporting lower psychological distress.
Where adolescents accessed mental health supports differed between those who did and did not experience social exclusion. The largest variations were observed in the housing and relational domains (Table 3 and Supplemental Figure1). Those who experienced housing challenges reported higher proportions of mental health support from health professionals compared to those who did not (71.8% vs. 67.1%), and those who experienced relational difficulties reported higher proportions of mental health support from health professionals (76.9%) compared with those who did not (65.4%). Similarly, higher proportions of participants who had experienced housing challenges and financial hardships reported higher rates of accessing support from organisations (housing: 33.1% vs. 17.9%; financial: 30.3% vs. 17.8%); however, this was reversed for young people who experienced relational difficulties (70.2% vs. 81.3%). Across all domains of social exclusion, adolescents were less likely to have received familial mental health support compared to those who did not experience any social exclusion. This was not seen with respect to support from friends; only those who reported relational difficulties reported lower prevalence of help-seeking from friends (41.7% vs. 48.2%). Participants who reported housing challenges and relational difficulties were also more likely to report accessing mental health support at school, and using apps or online sources, as did those who reported financial hardships (15.9% vs. 10.7%).
Confounding factor-adjusted logistic regression model results are shown in Figure 1, demonstrating that adolescents experiencing exclusion in different domains had received different sources of support. After accounting for confounding factors, only relational difficulties were associated with higher help-seeking from professionals (OR = 1.37; 95% CI [1.17, 1.60] partially adjusted, see Table S3). Housing challenges, financial hardships and relational difficulties were all associated with increased odds of help-seeking from organisations, but not edu-employment issues. Social exclusion domains were associated with a 45% to 18% reduction in odds of help-seeking from family members, whereas only relational difficulties were associated with reduced help-seeking from friends (OR = 0.68; 95% CI [0.59, 0.78]). Edu-employment issues were negatively associated with help-seeking from schools (OR = 0.84; 95% CI [0.75, 0.95]). Although there was an overall low proportion of mental health support sought from apps and online resources (12.2%), the experience of housing challenges and financial hardships were associated with 34% to 47% increased odds of seeking help from digital sources (OR = 1.34; 95% CI [1.11, 1.62] and OR = 1.47; 95% CI [1.23, 1.76]). Interestingly, results from fully adjusted models were almost identical to partially adjusted models suggesting that experiencing social exclusion across multiple domains had little overlap in impacting from where and who adolescents sought support.
Relationship between social exclusion domains and sources of support among participants who sought support (n = 5,565). Partially and fully adjusted odds ratio (OR) and 95% CI describing the relationship between the social exclusion domains and the sources of support among participants who sought support (n = 5,565).
Barriers to mental health supports
Those who experienced social exclusion in any domain were significantly more likely to report each of the listed barriers to help-seeking (Table 3 and Supplemental Figure 2), except for those with edu-employment issues, for whom all but operating hours differed significantly.
These associations largely remained after adjusting for confounding factors. Barriers of ‘cost’, ‘distance/location’ and ‘operating hours’ were most likely to affect those with housing challenges and financial hardships, while barriers of ‘confidentiality’, ‘stigma’ and ‘service knowledge gaps’ were most likely to affect those reporting relational difficulties (Figure 2a and Supplemental Table 4). When the impact of confounding factors was taken into consideration, only experiences of relational difficulties showed a large effect on barriers of ‘stigma’ and ‘service knowledge gaps’. When all social exclusion domains were included in the fully adjusted model, point estimates were found to be slightly smaller. However, all social exclusion domains remained independently associated with various barriers.
Relationships between social exclusion domains and (a) barriers to mental health supports and (b) preferred mode of support. Partially and fully adjusted Odds Ratios (ORs) and 95% CI describing the relationship between social exclusion domains and (a) barriers to seeking mental health support and (b) preferred mode of support.
Preferences for mental health support
Small variations in preferences were observed across social exclusion domains. Those who reported relational difficulties were slightly more likely to prefer online support (18.5% vs. 12.0% overall, OR = 1.26; 95% CI [1.03, 1.53], Figure 2b), while those with housing challenges preferred phone support (9.9% vs. 7.5% overall, OR = 1.32; 95% CI [1.03, 1.68], Figure 2b).
Discussion
Seeking mental health support can be difficult and challenging for adolescents. For those also experiencing social exclusion, these challenges are exacerbated. In this study, the first to investigate relationships between social exclusion and help-seeking behaviours for adolescents, we have highlighted the increased challenges faced by those who experience both social exclusion and mental ill-health.
Over half of the 2022 Youth Survey sample reported needing mental health support at some time in their lives, and almost three quarters reported some form of social exclusion. Adolescents who reported social exclusion in any domain were more inclined to report needing mental health support. Despite this, 42.4%, or 4-in-10 adolescents who reported a need for mental health support also reported not having received any. These rates are consistent with similar research in Australia and more broadly (Johnson et al., 2016; Lifestyles Team & NHS Digital, 2021) and are concerning. These rates are concerning given the increasing prevalence of mental ill-health in adolescent populations, highlighting the need to address this gap and ensure effective and early intervention care for young people (Radez et al., 2021).
Social exclusion was associated with differences in help-seeking. Participants with relational and/or edu-employment issues were less inclined to have sought support, whereas those experiencing housing challenges were more likely to have. Higher rates of help-seeking among those with housing challenges may be attributed to factors such as higher clinical complexity or severity of mental ill-health, and/or a greater likelihood of accessing mental health supports through engagement with other social services. Interestingly, adolescents who experienced higher psychological distress were less inclined to have sought support. With only cross-sectional data, this finding is difficult to interpret and would benefit from further exploration in future research.
Participants experiencing housing challenges and financial hardships were more likely to access support from organisations, and those with relational difficulties less likely to seek help from family/friends. As adolescents typically turn to family members and friends for mental health support in the first instance (Radez et al., 2021), help-seeking delays can occur for those without access to such supports. During our youth consultations, a strong emphasis was placed on the need for personal support when first accessing mental health services. Roles such as youth and/or peer workers within mental health settings may provide this type of broader person-focused support.
We also noted that adolescents who reported edu-employment issues were less likely to seek support from school. This implies that being ‘dissatisfied’ with studies likely represents more than dissatisfaction with the academic component. Given that schools serve as a primary point of contact for most adolescents, and school connectedness is an important protective factor (Bond et al., 2007), we need a better understanding of how dissatisfaction with school impacts opportunities for school-based supports.
Common barriers affecting help-seeking included stigma/shame, concerns about confidentiality, cost and a lack of knowledge about where to access supports. Concerns about confidentiality are complex (Aguirre Velasco et al., 2020; Radez et al., 2021). Adolescents are strongly peer-oriented and can be especially concerned about mental health service use becoming known (Pretorius et al., 2019). Our youth consultation group also highlighted concerns that parents or caregivers may be privy to sensitive information as legal guardians, or when paying for services. Many adolescents may be unaware of their right to privacy, especially if not accessing youth-specific services. Increased messaging detailing confidentiality in health settings should be promoted widely to adolescents, to help break down this barrier to accessing mental health services. As per confidentiality, stigma and shame have been long recognised as barriers to mental health support for young people (Aguirre Velasco et al., 2020; Radez et al., 2021; Rickwood et al., 2005; Rowe et al., 2014). With stigma most strongly affecting young people reporting relational difficulties, there is an impetus to mitigate mental health-related stigma in families and communities.
These attitudinal or information-based barriers were common amongst participants. Practical barriers, such as cost and distance/location, were reported more frequently by those with financial/housing hardships. While young people reporting any social exclusion reported more barriers overall, those with relational difficulties in particular reported higher proportions of almost all barriers. This highlights the importance of social networks to draw on to overcome practical barriers of accessing care, and the need for targeted outreach efforts to connect with young people with poor social support.
Adolescents in this sample overwhelmingly indicated a preference for receiving mental health support face-to-face. Young people in our consultations also had concerns about how to identify trustworthy and reputable mental health information online. However, they also acknowledged the increased accessibility and flexibility of online supports and a willingness to consider hybrid approaches, combining online or phone sessions following initial in-person interactions during which rapport and trust can be established. Hybrid models may cater to a broader spectrum of preferences, particularly for those who lack immediate support networks and seek more accessible options.
Implications and future directions
These findings hold significance in the context of shaping and expanding youth mental healthcare. They highlight the need for services to adapt to the unique challenges faced by the adolescent mental health community and respond by increasing accessibility and tailoring interventions to provide more personalised care. Further, approaches to build community awareness of available options by facilitating broad access to information related to available resources and where to access low- to no-cost interventions are critical to empower young people to navigate the help-seeking process independently.
Previous research indicates that good community engagement, and trusted relationships with adults facilitate help-seeking among adolescents (Aguirre Velasco et al., 2020). School-based interventions that address stigma (e.g. via psychoeducation), and provide peer support with other adolescents with a lived experience of mental ill-health, also contribute to increased help-seeking (Aguirre Velasco et al., 2020). To promote open discussions about mental health and foster autonomous help-seeking behaviour, existing public health initiatives and school-based programs designed to reduce stigma and enhance mental health literacy should be widely disseminated. These interventions should equip adolescents to initiate help-seeking, armed with relevant information about where and how to access mental health supports, enable them to engage in conversations about mental health with peers, and improve their understanding of mental health issues (Radez et al., 2021). This is of particular importance for adolescents without strong family support.
Viable alternatives to providing mental health services in clinical settings include positioning mental health services within environments where young people naturally congregate, such as schools and local community settings (e.g. sports) and providing assertive outreach programs. These approaches can alleviate systemic barriers, minimising effort, cost and lengthy wait times to access youth mental health services (Radez et al., 2021). They can also mitigate logistical obstacles such as time constraints, transportation issues, reduce the barrier of ‘not knowing where to go’ and offer a less stigmatising alternative than clinical settings. Additionally, increasing the youth work and peer workforce in mental health services, educational settings and other services (e.g. housing) could address some of the barriers identified. Youth and peer workers provide an informal approach outside the young person’s own social network, can promote the acceptability of help-seeking and provide valuable support to young people when local support networks are lacking (Aguirre Velasco et al., 2020).
Finally, it is important to note that research often lacks the perspective of people with diverse lived experiences. In this study, adolescents who reported social exclusion were more likely to be gender diverse, have an Indigenous background, reside in economically disadvantaged areas, live in regional or remote locations, speak languages other than English at home, report higher psychological distress, lower well-being and mental health conditions. Inclusivity is crucial, and adolescents from a variety of backgrounds should be involved in co-designing and evaluating mental health supports, including informing how best to promote information related to accessibility. Additionally, identifying and addressing barriers from the perspective of all involved in accessing and supporting access to care (e.g. adolescents, caregivers and families) is crucial to ensuring that adolescents receive the support they need.
Study limitations
Findings must be interpreted within study limitations. First, the sample was primarily comprised of school-attending adolescents. For those who disengage from school early, barriers are likely to be more pronounced given an increased vulnerability to socioeconomic deprivation (Aguirre Velasco et al., 2020). The study was also limited by use of an existing dataset drawn from a survey designed to reflect a range of issues for young people, albeit from a very large sample. While informed by prior work regarding key domains of social exclusion (Filia, Gao, et al., 2022; Filia et al., 2018, 2019), our measurement of social inclusion was limited, and future studies should consider using validated tools such as the Filia Social Inclusion Measure (F-SIM16), which offers a more comprehensive and consistent measure of social inclusion (Filia, Gao, et al., 2022).
Conclusions
In this work we highlighted the role of social exclusion as a determinant of mental health, and one that influences health equity. Key to reducing health inequities, and promoting equality of outcomes for all adolescents, is understanding relationships between domains of social exclusion, mental health and help-seeking experiences. Facilitating timely and effective treatment to prevent the long-term implications of mental ill-health in adolescence requires careful consideration of the nature and impacts of different types of social exclusion.
Supplemental Material
sj-docx-1-isp-10.1177_00207640241262703 – Supplemental material for Inequitable access to mental healthcare for socially excluded adolescents
Supplemental material, sj-docx-1-isp-10.1177_00207640241262703 for Inequitable access to mental healthcare for socially excluded adolescents by Kate Filia, Shu Mei Teo, Naheen Brennan, Tamara Freeburn, David Baker, Vivienne Browne, Myriam Ziou, Jana Menssink, Amity Watson, Ellie Brown, Alesha Prasad, Eóin Killackey, Patrick D McGorry, Debra Rickwood, Sue M Cotton and Caroline X Gao in International Journal of Social Psychiatry
Footnotes
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Orygen are funded by the Australian Government Department of Health to provide technical advice and policy direction on a number of youth mental health topics, including social determinants (this is relevant for DB and VB). Orygen funded the academic paper, which involved data analysis, data interpretation, and writing of this paper. Mission Australia funds and manages the Youth Survey and owns the data.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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