Introduction

A growing body of literature has focused on unhealthy alcohol use and treatment needs of immigrant men who identify as Latino. Latino immigrant men are at increased risk for unhealthy alcohol use, including the spectrum ranging from risky use (average use exceeding 14 drinks per week or heavy episodic drinking) to meeting diagnostic criteria for alcohol use disorders [1,2,3]. Latino immigrants face many economic and social stressors related to immigration, and Latino immigrant men may cope with these stressors through unhealthy alcohol use [2, 4,5,6]. Heavy episodic drinking, often defined as exceeding 5 drinks per day, is common but often unrecognized by Latino immigrant men as harmful [2]. Among low-income Latino immigrant men with high levels of alcohol use, there is also a high risk for alcohol use disorder [7]. Unhealthy alcohol use also increases with time in the USA for Latino immigrants [4].

Several evidence-based treatment options for unhealthy alcohol use exist. For those at low to moderate risk, brief interventions in primary care settings can effectively reduce unhealthy alcohol use [8,9,10]. For those with more severe alcohol use, behavioral interventions, generally delivered in specialty addictions treatment settings, and medication are both effective and recommended [11]. Self-help options (such as Alcoholics Anonymous) are also available and appear to improve outcomes among those who engage [12, 13].

Despite these options, rates of help-seeking and treatment receipt among men, Latino men, and Latino immigrant men remain low [14]. Findings from the National Epidemiological Survey of Alcohol and Related Consequences (NESARC) suggest that Latino immigrants with unhealthy alcohol use or alcohol use disorder report low treatment rates [15]. According to one study, only 16% of Latino immigrants with an alcohol use disorder received treatment compared to 14% of whites [16, 17]. Some studies suggest that Latinos are more likely to seek help through peer-support or detox programs than other racial/ethnic groups [18, 19]. Also, Latino immigrant men are less likely to seek behavioral treatments offered in specialty addiction settings, such as rehabilitation or in/outpatient programs), than Whites or Blacks in part because they perceive them to be less effective [19].

One of the most significant barriers to care for Latino immigrants is lack of access [20, 21]. Due to low socioeconomic status and immigration status, Latinos are much less likely to have health insurance. Latino immigrants frequently report barriers to seeking treatment such as cost, not having time, inability to identify services, and childcare issues, than other racial/ethnic groups [21,22,23,24,25].

More recent qualitative studies have identified additional barriers to treatment such as cultural barriers (e.g., services not available in the preferred language, providers unfamiliar with Latino culture), low perceived treatment efficacy, stigma about seeking services, and lack of social support [19, 26]. For some Latino immigrant men, their immigration status also serves as a barrier to treatment [19, 26]. Undocumented immigrants are unable to access health insurance or fear deportation if they seek services [20]. Very few studies have explored help-seeking patterns and barriers to care among Latino immigrant men. Our study sought to build on existing literature in this area by describing patterns of help-seeking and barriers to care in a sample of Latino immigrant men with unhealthy alcohol use. Because the need for treatment varies by severity of alcohol use, we also sought to describe help-seeking and barriers to care across levels of severity.

Methods

Study Population

The present study represents a secondary analysis of data collected for the Vida PURA study a pilot randomized control trial testing the efficacy and feasibility of a culturally adapted brief intervention for Latino immigrant men with unhealthy alcohol use [7]. The Vida PURA study included Latino immigrant men recruited from a community organization providing employment and education opportunities to Latino immigrants in King County, Washington State. To participate in the study, men had to identify as Latino, speak Spanish, be born outside of the USA, have a score of six or higher from the Alcohol Use Disorders Identification Test (AUDIT), and consent to participate. This study used baseline data collected prior to randomization from all participants recruited for the Vida PURA present study.

Data Collection

Baseline data collection occurred between July 2015 and October 2016. Surveys were administered in-person by a trained community health worker in Spanish in a community organization’s private location. The survey included questions on demographics, discrimination, social support, acculturation stress, alcohol use, help-seeking, barriers to care, and alcohol-related consequences. Previous studies have also described participants’ mental health and social support [27]. Surveys took an average of 40 min to complete, and participants received $30 for their time. The University of Washington’s Institutional Review Board approved all study activities.

Measures

Demographic Characteristics

Participant demographic measures included age, country of origin, length of time in the USA (in years), education (primary or less, high school diploma or GED, secondary school), weekly income (in USD 100 increments ranging from 200 to 400 or more), living situation (house/apartment, homeless/temporary housing, and staying with a friend/family), and marital status (single, married or living with a partner, and divorced or widowed).

Severity of Unhealthy Alcohol Use, Help-Seeking Patterns, and Perceived Barriers to Care

Severity of Unhealthy Alcohol Use

The severity of unhealthy alcohol use was measured using the Alcohol Use Disorder Identification Test (AUDIT), a validated, self-report 10-item measure with total scores ranging from 0 to 40. For this study, participants were screened and enrolled in the study only if they had an AUDIT score of 6 or more to include a broader range of unhealthy alcohol use [28]. While this cutoff is slightly lower than levels recommended for treatment, we wanted to include all men that might benefit from screening or treatment. Higher AUDIT scores indicate an increased risk for unhealthy alcohol use [29, 30]. We categorized participants into two groups: those with scores of 6-19 indicating less severe risk and scores of 20-40 indicating more severe risk [30].

Help-Seeking Patterns

To understand help-seeking patterns, we adapted a measure used in previous national epidemiological studies to assess help-seeking for health services among American Indian and Alaskan Native populations [31,32,33]. The instrument includes 12 items assessing three domains: (1) help-seeking, (2) preferred sources of help, and (3) types of treatment sought. We assessed help-seeking using a single yes/no question, “Have you ever sought help for your drinking?” Of those who endorsed ever seeking help, we also asked whether they had sought help in the past 12 months. This measure consisted of a single yes/no question “If yes [to Help-Seeking History], was it in the last year?” We assessed preferred sources of help with a single item—“Where would you go if you felt you needed help with your alcohol use?”—with response options: family, doctor, church/pastor, friend, agency, and no one. We assessed types of treatment sought among those reporting any help-seeking by offering a list of types of treatment and response options, including health provider/counselor, other community agency, and Alcoholics Anonymous (A.A.) [32, 34]. Participants could select all responses that applied, and responses were grouped into three (3) categories: health provider/counselor, alcoholics anonymous, or other.

Perceived Barriers to Care

To understand perceived barriers to care, we adapted the barriers to care measure of the American Indian Services Utilization, Psychiatric Epidemiology, Risk, and Protective Factors Projects (AI-SUPERPFP) health services survey [31,32,33]. This measure includes 20 items; participants could select all for the first six items and check yes to as many as were relevant for the last 14 items. We categorized responses into two domains: (1) barriers to care and (2) problems when seeking services. We assessed barriers to care with the question, “What reasons would keep you from seeking help for alcohol abuse?” followed by five response options: do not know whom to call; do not think the problem is bad enough; cost; do not believe treatment works; and, other. Perceived problems when seeking services were assessed by asking participants to “indicate if you (or someone you know) have had the following problems when seeking services for alcohol abuse or other physical, mental, or behavioral health concerns in the past 12 months.” We grouped the 14-item responses into categories relating to the healthcare system (“Quality of Care”), stigma (“Wanted to solve the problem on your own, thinking the problem was not serious enough, and being concerned about what others might think”), access/availability (“Interfered with home, work, or school”), and perceived efficacy (“Previous treatment did not help”). Perceived efficacy of treatment was asked of all participants regardless of whether they had previously sought treatment, because the question asks about “you (or someone you know).”

Analysis

We calculated descriptive statistics on all study measures in the overall sample. We then described demographic characteristics, help-seeking patterns, perceived barriers to care across alcohol severity levels, and perceived barriers to care across help-seeking patterns. We conducted all analyses in Stata S.E. Edition v14 [35].

Results

Table 1 presents the participants’ demographic characteristics (N=121), both overall and by the severity of unhealthy alcohol use. The sample’s average age was 48 years, and the average length of time in the USA was 20 years. Income and education levels were low overall, and many were in unstable housing. The mean AUDIT score was 20 (SD = 10), with just over half having AUDIT scores indicating less severe unhealthy alcohol use (51%; n= 61), and just under half (49%; n=60) indicating more severe unhealthy alcohol use. Among men with more severe unhealthy alcohol use, many were single, had low levels of education and income, and were homeless or living in temporary housing use (Table 1).

Table 1 Characteristics of recruited Latino immigrant men with unhealthy alcohol use by severity level (N=121)
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Table 2 shows patterns of help-seeking and preferred sources of help. Overall, 30% (n=36) of participants reported ever seeking help for drinking, and 19% (n=23) reported seeking help within the past year. Among those reporting help-seeking, Alcoholics Anonymous (59%) was the most common type of help sought. With regard to preferred sources of help, 32% of men (N=121) preferred an agency, 27% preferred family, and 25% preferred their church or pastor. Men with more severe unhealthy alcohol use most often sought help from Alcoholics Anonymous (63%), followed by health providers or counselors (44%). Men with more severe unhealthy alcohol use preferred seeking help from an agency (37%) or a doctor (30%). In contrast, men with less severe unhealthy alcohol use preferred help from family (31%) or an agency (28%).

Table 2 Help-seeking and preferred sources of help by alcohol use severity level (N = 121)
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Table 3 shows the barriers to care and problems when seeking services for all participants stratified by prior help-seeking. The most commonly reported problem when seeking services for all men (N=121) was that they wanted to solve the problem on their own (65%), followed by feeling the problem was not serious enough to warrant help (55%). Among those who had sought help for drinking (n=36), 51% thought treatment would not help, compared to 17% among those that had not sought help for their drinking (n=85).

Table 3 Barriers to care and problems seeking services by help-seeking patterns of recruited Latino immigrant men with unhealthy alcohol use (N=121)
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Table 4 describes barriers to care and problems when seeking services by the severity of alcohol use. Men with more severe alcohol use reported more barriers to care than men with less severe unhealthy alcohol use. Men with more severe alcohol use (n=60) reported problems when seeking services, such as cost (55%), quality of care (50%), and interference with home, work, or school (52%), compared to men with less severe alcohol use. In addition, men with more severe unhealthy alcohol use reported that treatment would not help.

Table 4 Barriers to care and problems seeking services of recruited Latino immigrant men with unhealthy alcohol use by severity level (N=121)
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Discussion

Our study describes the help-seeking patterns and perceived barriers to care among Latino immigrant men with unhealthy alcohol use and compares these patterns across unhealthy alcohol use severity levels. Over half the participants in our sample reported drinking at very severe unhealthy levels, yet few sought treatment for their alcohol use. Most cited multiple barriers to care indicative of stigma related to treatment seeking, including low perceived need for treatment and low perceived efficacy of treatment.

Levels of unhealthy alcohol use identified in our sample indicated that most participants would benefit from some kind of alcohol treatment or intervention. However, rates of treatment-seeking were low even among men with the most severe alcohol use. Alcoholics Anonymous (A.A.) was the most common source of treatment received. A.A. can be effective for those who attend, especially among those with less severe unhealthy alcohol use [30]. A.A. meetings are often available in Spanish, held on evenings and weekends, and free or low cost (and thus may be more accessible to Latino immigrant men). Treatment options with stronger evidence of efficacy, such as behavioral treatment or FDA-approved medications, were less commonly sought. Preferred sources of help for future treatment-seeking included more formal sources (agency, doctor) and informal sources (family, church), which may also reflect barriers such as access and stigma. Overall, our findings suggest that this population could benefit from better linkages to effective, evidence-based alcohol treatment.

Regardless of prior help-seeking, the most common perceived problems when seeking services were stigma-related. For example, despite high levels of severe alcohol use, many men felt a low perceived need for treatment. Many reported that they preferred to solve their drinking problems independently, did not think their problem was serious enough, or had concerns about what others would think if they sought treatment. Consistent with multiple studies in other populations [15, 36], these findings suggest that Latino immigrant men may have stigma about seeking help for their drinking. Other studies among Latino immigrant men have found that it can be difficult for them to accept that they need help and that not being able to handle their drinking is a sign of weakness [37]. A recent qualitative study of barriers to treatment among Latinos found a low perceived need for treatment, especially among those with family and work obligations [19]. In addition, many in the study were embarrassed to seek treatment or saw it as a sign of failure.

In our study, another barrier was the low perceived efficacy of treatment. Previous studies among Latinos with alcohol use disorder have identified similar barriers to treatment, including the fact that providers are unfamiliar with Latino culture and may not relate to their unique experiences [19, 21, 25]. Several men (including those with severe unhealthy alcohol use) reported that their previous attempts at treatment had not worked. These attitudes may reflect that men sought help from informal sources, such as A.A., family, and church. Latino immigrant men may benefit from knowing more about different types of evidence-based alcohol treatment services to enhance their treatment options’ perceived efficacy. While sources such as family and church may provide needed social support, they may not be enough to sustain long-term changes in alcohol use.

Other commonly cited barriers reflect a lack of access to effective treatment. For example, participants noted cost, lack of transportation, and treatment availability as common barriers, particularly among those who had previously sought help for their drinking. Many also noted concerns about communication with staff or experiencing racial discrimination when seeking services. Previous studies have shown that Latino immigrant men are receptive to community-based programs to reduce alcohol use, especially when offered in Spanish with trusted providers [7, 38, 39]. Interventions in community organizations that serve Latino immigrants may be particularly useful in addressing the structural barriers that prevent Latino immigrant men from receiving treatment in healthcare settings [20, 26]. Also, community-based programs can work to destigmatize unhealthy alcohol use and treatment-seeking in this population. Research also suggests that culturally adapting evidence-based interventions for men with more severe unhealthy alcohol use can help address stigma and structural barriers to care [40].

Further research in larger populations is needed to inform intervention development to increase access to needed treatments among Latino immigrant men who report multiple barriers. Our results are consistent with previous research indicating unmet needs for treatment and treatment barriers among Latino immigrants [6, 41]. However, given that we identified both internal and external barriers to care, there may be a need for multilevel interventions that address both individual barriers (such as stigma and perceived efficacy) and more system level barriers (such as cost and provider competency). Our findings suggest that interventions may need to vary by severity level, including providing greater access to evidenced-based treatment among those with more severe unhealthy alcohol use.

Limitations

There are some limitations to our study. First, this is a small sample of men recruited from a community-based organization that serves Latino immigrants, who may have had more access to services than Latino immigrant men not already connected to community resources. Our measures were all self-reported and therefore subject to recall bias or under-reporting of unhealthy alcohol use severity due to social desirability. Nevertheless, because these samples can often be hard to recruit into research studies, our paper makes a significant contribution. The majority of the men recruited in our sample were from Mexico; therefore, we were unable to assess differences in severity or treatment seeking by country of origin. Future studies should include larger samples of Latino immigrant men with unhealthy alcohol use in different social contexts to examine differences in help-seeking patterns and barriers to care, by country of origin and history of alcohol use.

Implications

Our findings examined the help-seeking patterns and barriers to care for Latino immigrant men with unhealthy alcohol use. We found high rates of unhealthy alcohol use and low rates of help-seeking patterns in this recruited sample. The majority of men in our sample reported barriers consistent with stigma and other structural barriers (e.g., treatment conflicting with prior work family commitments), which may be limiting their help-seeking for unhealthy alcohol use. Further research is needed to understand the societal and individual factors associated with help-seeking patterns and perceived barriers to care for Latino immigrant men with unhealthy alcohol use and to address barriers via culturally appropriate interventions.