Data sources.

To ensure methodological transparency and obtain high-quality results and synthesized evidence, we developed and implemented a comprehensive research strategy, using the PRISMA-ScR checklist (S1 File) as a guide [38]. The scoping review was conducted following the guidelines for scoping reviews outlined by The Joanna Briggs Institute (JBI), based on the earlier work of Arksey and O’Malley [39] and improved by O’Brien, Colquhoun, Levac and colleagues [40].

An information specialist (K.F.) conducted a literature search in multiple databases, including MEDLINE(R) ALL (OvidSP), Embase (OvidSP), CINAHL (EBSCOHost), Education Source (EBSCOHost), and Web of Science, from the inception of the databases to January 27th, 2022. We used a combination of subject headings and keywords related to the concepts of "international or immigrant students," "mental health," and "access or use of health or mental health services." From these keywords, we developed MeSH terms for database searches. We searched for articles in these databases from their creation. An example of the final search strategy for MEDLINE is presented in S2 File. Search Terms.

We used the bibliographic software Zotero to store, organize, and manage all references [41] and Covidence (Veritas Health Information, Melbourne, Australia) to manage the title/abstract and full-text screening phases [42].

Inclusion criteria.

• Articles addressing access to and use of mental health care
• Articles about immigrant/international students
• Participants in the study are adolescents or older
• Original language is English
• High-income countries

Exclusion criteria.

• Do not address access to and use of mental health care
• Not about immigrant’s/international’s students
• Studies involving on children (younger than adolescents)
• Language other than English
• Any commentaries, editorials, or opinion pieces
• Low-income countries

Sample size.

The studies had varying numbers of participants, ranging from 2 to 10,730. The 36 quantitative studies had larger participant numbers, with a range of 45 to 10,730 individuals. In contrast, the qualitative studies had fewer participants, ranging from 2 to 33. The mixed studies had 11, 177, and 197 participants, respectively [48–50]. A significant number of participants in several studies were immigrant/international students. However, in at least 10 studies [47, 51–59], the representation of immigrant students in the total sample was small due to factors such as the study’s aim, setting, or ability to recruit immigrant students.

Age of participants.

Data on the age of participants varied widely. Several studies gave an age range in years from 14 to 59 years, while others gave the average age of participants (16.6 years—28.9 years). However, three studies did not specify either the mean age or age range of participants [47, 60, 61]. But, since the sample of participants targeted was university students, it is very likely that they were adolescents or younger adults.

Gender of participants.

Of the total studies (n = 45), most had both male and female participants, with females being predominant. However, Jones (2013) and Galligan (2017) studies had only female or male participants, respectively. Moreover, four articles referred to transgender and other gender identities to define gender among the participants [47, 57, 59, 62], in addition to men and women.

Origins of participants.

Most studies included only immigrant student participants (n = 31) while others studied international students in comparison to domestic students (n = 17).

The majority of student participants in the studies were from Asia. Forty-six studies explicitly stated that at least one Asian country, such as China, Korea, Thailand, India, Vietnam, or Saudi Arabia, was the country of origin for the participating immigrant students. Only one study did not clearly specify the origin of its participants [63]. Among these studies, eight focused solely on Chinese immigrant students [24, 61, 64–68], two were exclusively on Korean students [69, 70], one on Saudi Arabian students [50], and one on Thai students [71].

Additionally, six studies mentioned African-origin student participants [22, 52, 62, 72, 73], and three studies included African Americans [51, 53, 62]. On the other hand, some studies referred to "other" backgrounds without specifying which ones precisely [51, 53, 60], and a study by Zhou, Zhou & Sun [2022] mentioned a range of nationalities from St. Vincent and the Grenadines to China. Only Meyer’s study in 2010 included Oceania as a student origin [52].

Barriers to mental health service utilization.

The majority of the studies included in this review (n = 45) reported one or more barriers to accessing mental health services. These barriers were classified according to Wang et al.’s categorization from their 2019 study on Asian immigrant parents’ perception of barriers to school-based mental health services for adolescents. Wang et al.’s study relied on previous research on barriers to mental health services among Asians and Asian Americans and aimed to categorize the barriers to adolescents’ utilization of school-based mental health services. The authors suggested that these barriers are present among other culturally and linguistically diverse groups, such as Latinos and African Americans [85]. Therefore, we organized the barriers into five major categories: attitudinal, cultural, knowledge, structural/practical/logistical, and relational as shown in Table 1.

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Table 1. An overview of key barriers and facilitators to mental health service use among immigrant students in high-incSome countries.

https://doi.org/10.1371/journal.pone.0287162.t001

Attitudinal barriers.

These barriers pertain to the attitudes of immigrant students towards mental illness and mental health services in their host countries. These attitudes may also be influenced by their immediate environment, such as family and peers, or non-immediate environment, such as their cultural community or fellow citizens, which can affect their utilization of mental health services. Attitudinal barriers are characterized by prominent themes including stigma, stereotypes, discrimination, doubt, and fear (n = 31). These barriers are often associated with culture. For example, Lee’s 2014 study on the barriers faced by Asian international students when joining counseling groups highlights that they may be concerned about how others perceive them, particularly when seeking mental health assistance is stigmatized in their home culture [34].

Additionally, in quantitative studies conducted in United States, students were uncomfortable self-disclosing in the presence of a student from the same country of origin as they are, especially if their issues cannot be accepted by their ethnic community (e.g., sexual orientation). They would be more comfortable sharing their information with students from other countries than their own for fear of being stigmatized [34]. Also, according to Nguyen et al. in 2019, even for informal help, there would be a stigma, shame, and fear of sharing with others among international students. This is because they may not want to worry their family and loved ones, as they are often seen as the pride of their parents, or even their entire family. This makes it more difficult to exchange and share such problems with those back home [81]. Furthermore, certain parents of Asian immigrant students may experience shame with regards to their child’s use of mental health services due to the strong cultural pressure and collectivism that is often experienced by Asian nationals, even outside of their home country [79].

In several studies, it was found that masculinity or being male could be a barrier to mental health service utilization for many immigrant students, especially Asian students (n = 10). According to Galligan in 2017, norms of masculinity would be influenced by cultural norms and would advocate for the desire to manage oneself such as the desire to be seen as tough or strong, the feeling of not being able to cry and not having to express one’s emotions, and the desire not to be seen as weak [86]. Thus, the strong adherence to masculinity among men in Asian communities often leads to their reluctance in seeking mental health services when faced with mental health issues [49, 50, 52, 56, 63, 68, 74, 81, 86]. For instance, Alajlan’s study revealed that men were more likely to feel stigmatized by counseling and had lower tolerance scores compared to women [50]. Furthermore, being a man from an Asian community with a strong adherence to Asian culture could act as an additional barrier to accessing mental health services [50, 56, 81, 86].

Also, lack of trust in mental health services and professionals in the host country could be another barrier to using such services [54, 64, 71, 73, 76, 80, 86, 87]. These studies show that international students are skeptical and have some reservations about using mental health care. Tang et al.’s 2012 study reported that some students were not open to their new host society or were even culturally suspicious [75]. According to the authors, these students would not believe in the effectiveness of the services, the legitimacy of the professionals, and their ability to understand them to help them effectively. In addition, Wong’s 2014 American study shows that Asian international students who strongly adhered to emotional self-control and humility tended to have negative attitudes toward seeking professional psychological help [35]. According to the author, those who strongly adhere to the cultural value of humility may be uncomfortable asserting their needs and thus may have more negative attitudes due to the perception that psychotherapy encourages a focus on the self, which would be contrary to their value [35].

Cultural barriers.

These are all barriers related to the original culture of the immigrant students and its interaction with the culture of the host country. The mismatch between the cultural aspects of the two countries (home and host) [71] can create a culture shock for these students who must somehow adapt to it in order to succeed. While most of the cultural barriers identified in this review are specific to the students themselves, some also relate to the mental health professionals they encounter.

Several studies have reported that being a non-Western student, and particularly Asian, can be a barrier to seeking mental health care (n = 8). Dadfar and Friedlander’s 1982 study reported that being a non-western student (African and Asian) could be a barrier to mental health service use [72]. Authors have indicated that strong ethnic identity, adherence to traditional values or cultural pressure on immigrant students, particularly Asians, may inhibit their openness and willingness to use mental health services (n = 8). For example, Santiago’s 2006 study indicated that the Asian identity of international students, particularly those from the Far East (e.g., China, Japan, both Koreas), who strongly adhere to traditional Asian values, would be a barrier [88]. Xie’s 2008 study of Chinese international students in the U.S. shows that many participants had an ambivalent attitude toward counseling; on an intellectual level, they thought that counseling could be helpful, but on a more personal level, they doubted the effectiveness because their cultural background would not be understood during such counseling [64]. However, Li et al.’s 2013 study noted that Asian international students tended to have more favourable attitudes towards mental health services than towards traditional forms of help specific to their culture [49].

Several studies indicate that the lack of culturally appropriate mental health services can also hinder immigrant students’ use of such services in their host countries [50, 52, 58, 60, 84]. These studies reveal that mental health care professionals’ lack of cultural competence which can result in immigrant students feeling misunderstood in terms of their culture. For instance, a qualitative investigation by Rogers-Sirin et al. (2015) on immigrant perceptions of therapist cultural competence found that therapists’ cultural competence significantly impacts their impressions of therapy, which can lead them to avoid further consultation [73]. However, Meyer’s (2009) research on international students from various backgrounds in the Boston School of Architecture in the US revealed that strong acculturation was unexpectedly a barrier [52]. The author suggests that this may be because developing English proficiency increases exposure to stigma within the host culture while reducing psychological distress as the individual becomes more culturally competent, which could reduce help-seeking attitudes and use of psychological services.

Barriers related to knowledge.

This refers to lack of knowledge/low level of information about mental health services (or the host country system itself) and the identification of mental health symptoms/illnesses. Thus, lack of perception or doubt about the usefulness of mental health services and non-familiarity with the system are factors that may deter immigrant students from using mental health services in their host country.

About ten studies cite low knowledge and lack of information as a barrier to service utilization by immigrant students [22, 47, 51, 60, 63, 64, 78, 79, 86, 89]. The 2019 study by Clough et al. that examined mental health knowledge and help-seeking attitudes between domestic and international students in Australia showed that low levels of mental health knowledge were related to less favorable help-seeking attitudes. It found that mental health literacy was also lower among males, students who had recently arrived in Australia, and students who had never had contact with mental health services [63].

Some authors have suggested that students who lack knowledge about mental health often do not perceive the need for mental health services [57, 59, 64, 78, 86]. Zhou, Zhou & Sun find in their study in 2021 that there’s a significant disparity between students (especially among international students) in need of services and those who receive services, which indicates that not all those who screened positive were aware of their need for services. So, there was low perceived need of services. This can be associated with doubts about the actual usefulness of mental health services and thus may be a barrier to utilization of these services [54, 63, 76, 78, 79, 86]. Xie’s 2008 research revealed that although most participants in the study were aware of the existence of mental health services and demonstrated some level of understanding of psychological counselling concepts, many reported being unfamiliar with the counselling process and procedures [64]. In addition, Rhee’s research work showed that language difficulties such as lack of fluency in English are barriers to utilizing mental health services. The author found that some Thai students in the U.S. preferred to see a Thai counsellor as they believed the Thai counsellor would have a better understanding of their situation, especially since certain Thai words cannot be translated into English [71].

Structural, practical/logistical barriers.

Structural, practical, and logistical barriers are often not dependent on the students themselves, but rather on host country factors. For the most part, these are factors that impede access to mental health care.

Time or time-related factors have been mentioned in several studies (n = 8) [24, 50, 63–65, 78, 86, 89]. The long-time due to long waiting lists could demotivate immigrant students to use mental health services. The 2020 study by Lian et al. noted, for example, that full-time employed students, very often older and graduate students, were less likely to use mental health services often due to lack of time [24].

Cost can be a barrier to access and use of mental health services [50, 64, 71, 86, 87, 89, 90]. Rhee’s 2018 study reveals, for example, that the Thai international students in the study seemed to prefer using social support over services with professionals because of the associated expenses. Since they typically do not have access to student loans like American students and use personal savings to pay for their education, they are very often on a tight budget and therefore cannot afford additional expenses while in school [71].

The lack of prior experience with mental health services [54, 63, 72] and concerns about the confidentiality of counseling sessions [64, 78, 86] are additional barriers to immigrant students accessing care in their host countries. Clough et al. [2019] found that international students who had never used mental health services had less knowledge about mental health, making it difficult for them to seek services for the first time [63]. In another study by Cha et al. [2019], students without legal documentation expressed greater concerns about the confidentiality of counseling sessions, which may discourage them from seeking services [78].

Social/relational barriers.

These barriers are due to the relationships that immigrant students have in their host country or in their country of origin. These relationships can be with members of their respective communities or people within their institution such as their advisors. Studies have demonstrated that Asian students, who had strong cultural adherence and thus collectivism remained strong even outside their home country [34, 49, 55, 66, 67, 70, 84, 91] preferred not to use services especially when there were other fellow citizens in the sessions. For example, Lee’s 2014 study that examined Asian international students’ barriers to participating in counseling groups showed that they were uncomfortable and did not like participating in counseling groups with other Asian students [34]. They preferred to be in groups with other domestic or international students so that they would not be stigmatized and lose face in front of their community [34].

Also, Hyun’s 2007 study found that international students who had a good functional relationship with their advisors (academic/academic advisor, supervisor, professional career advisor, or any other type of advisor) were less likely to have had a stress-related problem or an emotional problem. They were then less likely to use mental health services [51]. The study of Lee & al. in 2017 also found that international Asian students in New-Zealand who have a good relationship with their parents were less likely to use the services [87].

Facilitators to mental health service utilization.

Facilitators are factors that makes it easier or more likely that students will seek mental health care. Thus, any positive experience that immigrant or international students have would be considered a facilitator. In contrast to barriers, we identified fewer facilitators and some studies reported none [35, 55, 56, 58, 59, 68, 70, 76, 78, 89, 92]. As with barriers, we also drew on the categorization by Wang et al. to group facilitators (attitudinal, cultural, knowledge-related, structural or practical/logistical and relational) to mental health service use [85]. Similarly, for each of these categories, similar data were grouped into themes developed from the terminology used in the literature reviewed.

Attitudinal facilitators.

Attitudinal facilitators are factors related to the attitudes or behaviours of immigrant students that are thought to have a positive impact on mental health care utilization. Several studies have reported that women are more likely to seek help [49, 50, 52, 54, 60, 74, 77, 81]. Although these authors offer little explanation for this, it is believed that unlike men who have a high degree of masculinity (considered a barrier), women are more tolerant and willing to use mental health services [50]. For example, international female students used counseling services more often than males in most of these studies [54, 60, 74, 77].

Having confidence in mental health professionals and the system may also facilitate the use of mental health services by immigrant students [75, 79, 80, 84]. Indeed, students who have confidence in professionals, especially after an initial contact [64], would be more likely to return for further consultation when necessary. In terms of the system, it is those who are confident of safety and privacy who would be more confident in using mental health services [79].

Openness and high tolerance, which is highly dependent on the home culture, but also on the host culture, could facilitate students’ use of mental health care [50, 64, 80]. Openness depends largely on the students’ own state of mind and this is often induced by the level of acculturation or time spent in the host country [80] or perhaps related to several other factors [64]. Indeed, Li et al.’s 2013 study explains that many Asian countries such as China are characterized by the collectivist culture, which is characterized by a group-oriented social identity (the family and kinship groups). Thus, the success or failure of an individual is not only a personal matter but concerns the whole family and the community. This group pressure may cause individuals to hide embarrassing events in their lives to protect their family honour and to do their best to resolve them themselves. Hence, they use emotional self-control and resilience, which are considered virtues, especially during difficult life events [49]. These cultural norms and values explain why Asian international students often view counseling as the last resort for solving life problems, but, those who are more open and tolerant are more likely to consider and utilize services [50, 64, 80].

Several studies revealed that undergraduates had more mental health consultations than graduate students [24, 49]. Thus, being an undergraduate could play a facilitating role in mental health service utilization. In Lian et al.’s 2020 study, Chinese graduate students had lower levels of help-seeking intentions compared to undergraduate students [24]. However, the author noted that the undergraduate student population was a small proportion. Thus, interpretation should be made with care [24]. In addition, Hyun’s 2007 study found that Asian graduate students who were experiencing financial difficulties or difficulties completing their course or semester were more likely to seek counseling [51]. Thus, international graduate students tend to seek counseling for problems that are less psychological or emotional. Also, according to Nguyen et al. in 2019, age may be a significant predictor of help-seeking behaviors among students and older international students who are typically graduated, less likely to cope with their emotional problems that would cause them to seek help [81]. In contrast, the authors stated that the correlation between age and willingness to self-help among international students may be difficult to explain due to the dynamics of cultural difference among the students in the study [81].

Cultural facilitators.

Cultural facilitators are factors related to the culture of immigrant students that play a positive role in their use of mental health services in their host country. Strong acculturation, which is the process of breaking away from one’s original culture and adopting the culture of one’s host country for easy integration [83], seems to be a facilitator of mental health service utilization. Studies have found that the stronger the acculturation of immigrant students, the less adherent they were to their native culture, the more open they were to mental health care and the easier it was for them to use mental health services [34, 51, 66, 67, 71, 80, 81, 84]. A cross-sectional study conducted by Li, Marbley, Bradley & Lan in United-States in 2016 demonstrated that acculturation, ethnic identity, and English proficiency were statistically significant predictors for Attitudes Toward Seeking Professional Counseling Services among Chinese International students. Similarly, the quantitative study by Zhang and Dixon in 2003 showed that there was a significant positive relationship between Asian international students’ level of acculturation, tolerance, and confidence in mental health practitioners. Thus, students who were more acculturated were also more tolerant of mental illness and had greater confidence in mental health professionals and thus, more willingness to consult them [80]. Furthermore, Nguyen et al. found that acculturation stress was a significant predictor of help-seeking and willingness to seek formal help for international students [81]. Thus, integrated acculturation strategies tend to be associated with the most positive attitude toward mental health services as in Chauv’s cross-sectional study in the United States in 2020 that predicted the use of mental health professionals [81].

The backgrounds and origins of individuals may act as a catalyst in certain instances. Studies have suggested that immigrant students from Western countries tend to be more inclined to utilize services compared to those from non-Western backgrounds [72, 74]. Santiago’s research has also indicated that South Asian students are more prone to using mental health services compared to their peers from other Asian countries, such as those in the Far East [88]. It seems that individuals who do not strongly adhere to traditional Asian values are more open to integrating with the Western culture and utilizing mental health services [84].

Knowledge-related facilitators.

These are factors related to students’ level of knowledge that would have an impact on immigrant students’ use of mental health services. Having good knowledge about mental health [51, 63, 64] and being aware of existing services [51] has the potential to facilitate students’ use of mental health services. Australian studies by Clough et al. in 2019 and 2020 on mental health literacy show that immigrant students with good mental health literacy are more likely to use services [22, 63]. The good mental health literacy of international and domestic students could enable them to identify early signs and symptoms of mental disorders and thus seek help when needed [63]. In addition, immigrant students who had experience with mental health and psycho-emotional challenges were more likely to use services [64]. The severity of the disorder could also play a positive role in their use of mental health services [24, 81, 86]. Moreover, research indicates that immigrant students who have had experienced with mental health and psycho-emotional difficulties are more inclined to seek mental health services [64]. Furthermore, the severity of the mental health problem may have a beneficial effect on their utilization of mental health services [24, 81, 86].

Furthermore, possessing a strong command of the English language and being fluent in it can aid in the utilization of mental health services by immigrant students [61, 66, 81, 84]. Being proficient in English enhances communication and boosts the confidence of immigrant students, enabling them to seek assistance and utilize services with greater ease. Additionally, immigrant students’ proficiency in English is linked to their level of acculturation, which also acts as a facilitator [84]. Mesidor and Sly [2014] also suggested that having a sense of control over one’s behavior could motivate immigrant students to seek mental health care [53].

Structural or practical/logistical facilitators.

These are facilitators related to the accessibility of mental health services. Studies have reported that previous contact with services play a facilitating role in the use of mental health services [49, 64, 72, 91]. In these studies, students who have used mental health services in the past are more likely to use them again, especially if their first experience was positive [64]. In addition, Arora and Algios’ study showed that immigrant students are more willing to use mental health services when they feel confident that their privacy is well protected [79].

Social/relational facilitators.

The social and relational factors that may prompt immigrant students to use mental health services are numerous. Certain studies indicate that conflicts or relationship issues with their counselors or professors could facilitate the utilization of mental health services among immigrant students [64, 86]. Since these students frequently have a restricted social network in their host country, their professors or counselors hold significant importance to them. As a result, conflicts with such figures could have a more profound psychological impact and motivate them to seek help. Lian et al. reported that American professors were among the preferred sources of aid for Chinese international students, albeit not the primary one [24]. Additionally, a strained relationship with an advisor might be linked to greater mental health symptoms [24, 51] that could result in seeking assistance. BongJoo et al.’s research in 2014 revealed that international students are more likely to seek referrals from authority figures rather than seeking help independently [60].

Furthermore, possessing a strong social support system is considered a crucial factor in promoting the utilization of mental health services [24, 81, 84]. Having a robust support network means having individuals with whom one can share their difficulties and seek assistance [24, 87]. For instance, in Lian et al.’s study in 2020, some immigrant students reported using mental health services after receiving advice or information from a friend, relative, or partner [24]. Interestingly, some studies have identified unexpected and counterintuitive facilitators, such as stress arising from racism [88], feelings of isolation [86], or being in the same group as other international students [34].