Dealing with distress from the COVID-19 pandemic: Mental health stressors and coping strategies in vulnerable latinx communities.

Distress secondary to the COVID-19 pandemic has been substantial, especially in vulnerable Latinx communities who are carrying an undue share of the pandemic-related social, health and economic burden in the United States. In collaboration with 43 community health workers (CHWs) and Promotor/as serving the needs of underserved Latinx communities in South Texas and guided by principles of community-based participatory research (CBPR), the purpose of this study was to identify relevant mental health stressors and related consequences, and to identify strategies for coping with distress among underserved Latinx communities during the COVID-19 pandemic. Data were collected on July 2020 using mixed methods to obtain more in-depth information. Surveys were administered, and three focus groups were conducted. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed systematically by starting with a priori questions and themes followed by data categorisation, reduction, display and conclusion drawing. Results showed six themes related to mental health stressors including economics (e.g., job insecurity), immigration (e.g., undocumented status), misinformation, family stress (e.g., changes in family dynamics and the home environment), health (e.g., limited healthcare access) and social isolation. Coping skills of the community were categorised into four themes with multiple codes including behavioural strategies (e.g., identifying reliable information), cognitive strategies (e.g., collectivistic thinking), social support and spirituality. Findings indicate that underserved Latinx communities are dealing with substantial distress and mental health concerns secondary to the COVID-19 pandemic; yet these are resilient communities. Implications of these findings can inform development of resources, interventions, best practices and training avenues to address the mental health needs of underserved Latinx communities, while considering relevant cultural and contextual factors that may influence their effectiveness.

What is known about this topic

The COVID‐19 pandemic has increased distress in the general population, yet underserved communities are at increased risk.

Latinxs face significant barriers limiting their access to mental health services.

Culturally sensitive interventions are needed to effectively address the mental health needs of underserved Latinxs.

What this paper adds

Compounded stressors faced by underserved Latinxs pertain to economics, immigration, misinformation, family, health and social isolation.

Immigration related distress is increasing mistrust and fear among Latinxs, which interferes with prevention efforts.

Primary strategies used by Latinxs to cope with distress from the COVID‐19 pandemic include behavioural and cognitive strategies, social support and spirituality.

INTRODUCTION

The United States has faced a longstanding mental health crisis prior to the Coronavirus 2019 (COVID‐19) pandemic. According to the National Institute of Mental Health (NIMH), 19% of US adults were living with a mental illness in 2017, and 4.5% of adults were living with a severe mental illness (National Alliance on Mental Illness, n.d.). Although Latinx adults are reported to have a lower prevalence of mental illness than non‐Latinx White adults (17% versus. 20%, respectively), the prevalence varies across Latinx sugroups (National Alliance on Mental Illness, n.d.). For instance, prevalence of mental illnesses increases with greater acculturation or as people reside longer in the United States, thus removing any health advantages of the healthy immigrant paradox (Ruiz et al., 2016). Moreover, high mental health stigma, variations in socio‐demograhic and cultural factors, differences in immigration legal status, and limited access to health services may confound prevalence estimates for mental health among Latinxs (Alegría et al., 2002; Cabassa et al., 2006; Rastogi et al., 2012).

The mental health crisis in the United States has been exacerbated by the COVID‐19 pandemic, which has disproportionately affected Blacks and Latinxs (Centers for Disease Control & Prevention, 2020; Johns Hopkins University, 2020; Yancy, 2020). Latinxs have COVID‐19 infection rates that are higher than population proportions across several states (Stokes et al., 2020). Notably, Latinxs are dying at higher rates per population—Latinxs represent 18% of total US population, but 26% of adult COVID‐19 deaths (Calo et al., 2020). These disparities may be due to Latinxs' increased exposure through employment in frontline jobs that do not allow for working remotely; working and living in crowded spaces that do not allow for social distancing; lack of health insurance and access to health services; and cultural‐linguistic barriers to care (Calo et al., 2020).

The COVID‐19 pandemic has contributed to a worsening of mental health in the United States overall, with rates of adverse mental health conditions increasing by three to four times since spring 2019 (Czeisler et al., 2020). A recent survey of US adults found that 10.7% of respondents reported seriously considering suicide in the 30 days before the survey, which was highest among ethnic/racial minorities including Latinxs (18.6%), unpaid caregivers (30.7%) and essential workers (21.7%) (Czeisler et al., 2020). It is likely that worsening mental health among Latinxs is due to inequities in COVID‐19 morbidity and mortality and has been exacerbated by increased feelings of financial instability, uncertainty, social isolation and decreased healthcare access (Calo et al., 2020; Czeisler et al., 2020; Khan et al., 2020).

Latinxs across United States has been disproportionately affected by the COVID‐19 pandemic. However, less information has been reported from regions along the US–Mexico border where communities are predominantly Latinx. South Texas, which encompasses a 37,800 square mile area from San Antonio to Del Rio and Brownsville at the Texas‐Mexico border, is a unique part of the United States that faces a number of health disparities, socio‐economic vulnerabilities, and a high disease burden (Ramirez et al., 2013). Most counties in South Texas are rural, majority Latinx and home to a large number of undocumented immigrants (Ura & McCullough, 2015). In addition, while Texas has the highest rate of uninsured (17.7% uninsured), Texas' Lower Rio Grande Valley (LRGV) has the highest proportion of uninsured people in the state (25%) (Fernandez, 2019). Lack of insurance combined with poor healthcare access has resulted in a high and growing burden of infectious (e.g., HIV/AIDS and tuberculosis) and chronic diseases (e.g., diabetes, hypertension), which in turn has contributed to the fast increase in COVID‐19 cases and mortality in this region (Fernandez et al., 2020). In addition to the aforementioned stressors, other salient and chronic stressors among underserved Latinx communities include poverty, marginalisation, restricted access to resources and social support, limited opportunities, acculturative stress (e.g., limited English proficiency, changes in cultural values, traditions and social networks), exploitation and discrimination (Bekteshi & Kang, 2020; Garcini et al., 2016). Migration‐related loss and trauma‐related distress are also prevalent, including loss and trauma that occurred pre and post‐migration (Garcini et al., 2017, 2019). Occupational stress and hazardous living conditions are additional stressors that often increase distress among Latinos (Hargreaves et al., 2019). In the face of the current pandemic, all of the aforementioned vulnerabilities can further increase mental health risk in underserved Latinx communities.

Identifying coping strategies that may help vulnerable Latinx communities to overcome adversity is essential to inform culturally and contextually sensitive interventions aimed at reducing health risk. Among Latinxs, building strong family connections and robust social support networks have been identified as useful strategies to cope with distress (Garcini et al., 2020; Yakushko, 2010). Likewise, engagement in religious or spiritual practices and building trusting networks in the community have been shown to increase perceptions of hope and trust among Latinos (Garcini et al., 2020). A study among 20 leaders working with Latino immigrant and refugees highlighted that cognitive reframing focusing on individual values, such as hopefulness, not giving up, having a focus, accepting suffering as part of life, and having a vision of the future, are constructive strategies used by Latino immigrants to cope with adversity (Benuto et al., 2018; Yakushko, 2010). Likewise, attributes such as be giving towards others have been found to be helpful strategies for managing distress among Latinos (Yakushko, 2010). In the face of the current pandemic, additional research is needed to fully identify and contextualise specific effective coping strategies that may be use day‐to‐day to ameliorate distress.

Purpose

In collaboration with community health workers (CHWs) and Promotor/as serving the needs of underserved Latinx communities in South Texas, and guided by principles of community‐based participatory research (CBPR), this study (1) treats the Latinx population as the unit of identity while recognising this population is not monolithic, (2) promotes co‐learning and different ways of knowing, (3) aims to build upon community's strengths and resources, and (4) strives to balance research and action (Wallerstein et al., 2017). Promotor/as are trained Latinx community members that provide health education and resources to Latinx communities. The overall goal of this project was to identify relevant mental health stressors and related consequences, while identifying strategies for coping with distress among Latinx communities during the COVID‐19 pandemic. This information is essential to inform the development of resources, interventions, best practices and training avenues to address the mental health needs of underserved Latinxs.

METHODS

To facilitate obtaining diverse data, purposeful sampling was used to recruit study participants (Palinkas et al., 2015). The study sample was comprised of 43 CHWs and Promotor/as that were recruited using networks‐based referrals from academia, community partners and collaborators who facilitate outreach, research, and the provision of health services for underserved Latinx communities in South Texas. Specific active strategies used in recruitment included emails, social networks, and recruitment from online meetings for local CHWs' associations. To be eligible, CHWs and Promotor/as had to be fluent in English and/or Spanish, and reside and work with underserved Latinx communities in South Texas. The University of Texas Health Science Center at San Antonio (UTHSCSA) IRB reviewed and approved this study [IRB # HCS20200306N].

Data were collected using mixed methods to obtain more in‐depth information about a novel situation with a diverse community (Palinkas et al., 2011). Quantitative data were collected using a brief online socio‐demographic survey developed by our team via Qualtrics, whereas qualitative data were collected via virtual focus groups to comply with social distancing recommendations for protection against COVID‐19. All participants completed the brief survey prior to participating in one of three focus groups. Quantitative data in the survey included questions about CHW or Promotor/a demographic information (e.g., age, sex, education and employment status), working history as CHW or Promotor/a (e.g., length of time working as CHW/P, licensing, health topics or areas and populations of expertise), and an assessment of psycho‐social stressors in underserved Latinx immigrant communities that was based on prior work (Garcini et al., 2016). To denote the prevalence of psycho‐social stressors in their communities, participants used a checklist to indicate prevalent stressors, which was followed by an open‐ended answer to indicate any additional stressors prevalent in their communities that were not included in the checklist. Questions for the focus groups were semi‐structured and were aimed at fostering discussion pertaining to (a) the experience of distress from the current COVID‐19 pandemic and relevant mental health concerns among underserved communities in South Texas and (b) the identification of protective factors or mental health coping strategies. A bilingual, native Spanish speaker facilitator and two research assistants conducted the focus groups. Based on participants' preferences, one of the three focus groups was conducted in English, while the other two were facilitated in Spanish. The virtual focus groups lasted an hour, whereas the online survey took on average 30 min to complete. The survey was completed prior to attending the focus groups in order to introduce the topic and motivate discussion. No compensation was provided for participation. Participants consented to the audiotaping of the focus groups prior to participation, and all audiotapes were transcribed to facilitate data analysis.

Analyses

Quantitative data were analysed using descriptive statistics (i.e., frequencies and measures of central tendency) to develop a demographic profile of participating CHWs and Promotor/as and the communities they serve. Qualitative data were analysed systematically, as outlined by (Miles and Huberman 1994), by starting with a priori questions and themes, before proceeding through steps of data categorisation, reduction, display and conclusion drawing. To confirm data categorisations and ensure validity, we engaged in data triangulation by comparing survey data with data, notes and observations from the focus groups.

FINDINGS

Participants' characteristics

The majority of participants were women of Latinx origin, with an average age of 45 years (SD = 11.1). Most participants had graduated from high school and were working full or part‐time. On average, participants had been working as CHWs or Promotor/as for 7 years (SD = 6.8), and most were certified. Also, most participants reported working with low‐income Latinx communities facing significant barriers accessing healthcare, in both rural and urban locations. Most participants do their work across various community settings including people's homes, schools, community centres, non‐profit offices or facilities, churches or faith based centres, and primary care clinics. Approximately half reported working with immigrant communities, including undocumented immigrants. Most CHWs or Promotor/as reported working with families and adults, specifically young adults, middle age adults, and older adults. Regarding the health needs that these CHWs or Promotor/as address, the majority reported that they work to address mental health and wellness needs of members in their community (n = 31; 72%) (see Table 1).

TABLE 1

CHW and Promotor/as characteristics

Characteristics	Participants (N = 43)
Age (M, SD)	45 (11.1)
Sex (n, %)
Women	40 (93%)
Ethnicity (n, %)
Latinx	39 (91%)
Education (n, %)	38 (88%)
>High school
Employment (n, %)
Full or part time	35 (81%)
Length as CHW or Promotor/a (M, SD)	7 (6.8)
Certified CHW or Promotor/a (n, %)	39 (91%)

Primary stressors, causes and consequences

Different stressors, along with their causes and consequences, were identified as concerns in underserved Latinx communities in South Texas during the COVID‐19 pandemic. Quantitative data showed that most participants identified economic and financial stress as primary stressors (n = 36; 84%), followed by problems with transportation (n = 29; 67%), limited sources of social support (n = 25; 58%), immigration‐related stress (n = 22; 51%), discrimination (n = 20; 47%) and work‐related stress (n = 19; 44%). Additionally, 29 participants (67%) identified difficulties accessing health services as a primary stressor in their communities, followed by problems obtaining or purchasing medications (n = 24; 56%), and limited access to reliable sources of information (n = 14; 33%). Participants also reported domestic violence (n = 21; 49%), trauma (n = 16; 37%) and substance use (n = 15; 35%) as relevant concerns.

Results from qualitative data provided further information on causes of the aforementioned stressors and how they contribute to mental distress and symptoms among underserved Latinxs (see Table 2). For instance, economic stress from job and income loss was associated with increased food and housing insecurity, inability to access needed health services and resources (i.e., technology and purchasing of protective equipment), and for those of immigrant backgrounds, an inability to provide remittances to their families in their home countries. All of these factors contributed to despair, reduced sleep and symptoms of anxiety and depression. Economic stress was reported by most of the participants as severe. Indeed, a CHW commented, “they are getting sick… they don't eat, they want to commit suicide.” Similarly, family‐related stress from changes in the family dynamics and home environment are exerting a tremendous amount of pressure among family members to perform multiple roles and share limited resources and space (e.g., one computer for all members of the family; multiple family members sharing a room), while also increasing intergenerational conflict among family members (e.g., disagreements over values and roles). As a result, several of the participants reported that their communities have had an increase in despair, tension, hostility, sense of losing control, diminished view of self, irritability, trauma and interpersonal violence within families. A CHW commented, “[parents] are stressing about not being able to help [their children] because of language barriers, because they don't know how to use the computer.” Another CHW reflected on how a mother in their community described parenting after attempting suicide due to family distress, “I don't know what to do. I got to a point where I let him destroy my entire room while I concentrated with the older two… I am not a good mom. I do not have patience. I feel like hitting [my child].” Some of the CHWs commented that family stressors are magnified in households with a prior history of domestic violence, single parent households, and families with shared custody as divorced or separated parents try to co‐parent with imposed social restrictions and limited resources.

TABLE 2

Environmental and social stressors and mental health symptoms among underserved Latinx communities in South Texas

Type of stressor	Cause	Effects of stressor
		Environmental consequences	Symptoms of distress
Economic	Job and income loss	Food and housing insecurity; inability to access health services and needed resources (e.g., technology, PPE); inability to provide financial assistant for family outside the United States.	Despair; anxiety; depression; suicidality; reduced sleep.
Immigration related	Undocumented, temporary or non‐citizen immigration legal status; variations in acculturation and values (i.e., language barrier).	Discrimination; stigmatization; difficulties communicating with or helping others (e.g., family); avoidance to engage in help seeking behaviors (e.g., healthcare) testing); mistrust to release information; deportation and family separation.	Anxiety; suspiciousness; fear; diminished sense of self‐efficacy; somatization.
Misinformation	Inconsistent, unclear, and unreliable information	Mistrust and misunderstanding that impairs action or leads to undesirable or inadequate actions (e.g., engaging in unsafe protective practices).	Confusion; fear; uncertainty; panic; anxiety; agoraphobia; obsessions; compulsions; somatization.
Family	Changes in family environment and dynamics; loss and separation from family	Need to perform multiple roles; sharing of limited resources; limited household space; intergenerational conflict.	Despair; tension; hostility; sense of losing control; diminished view of self and self‐care; irritability; trauma; interpersonal violence.
Health related	Susceptibility to become ill; previous existing health conditions	Not having access to needed health services if ill; unable to receive continuity of care; effect of ill health on ability to work under current conditions.	Anxiety; obsessions; compulsions; somatization; reduced sleep
Social isolation	Loss of or changes in social networks and support systems	Limited assistance in case of need or if ill; difficulties being or staying connected with social networks.	Depression; loneliness; despair.

Three additional stressors identified pertain to misinformation about COVID‐19, immigration‐related stressors, and social isolation. For instance, several participants pointed out that information about resources (e.g., where to seek help) or practices to keep safe is inconsistent, unclear and unreliable. This in turn leads to mistrust and misunderstanding that increases confusion, fear, uncertainty and anxiety. In this regard, a CHW commented, “[people] grab unverified information… this alters people's nerves… it alters their mental health,” while another commented, “there is a lot of confusion… [people] don't know what to believe, they don't know who to believe, or what is a good source of information. In the news, everybody is saying something different.” The fear associated with confusing information is becoming so severe that in some cases it has led to panic attacks, symptoms of agoraphobia (e.g., fear and avoidance of leaving home), obsessions (e.g., having severe hygiene concerns), compulsions (e.g., using sanitizers obsessively and on unsafe areas of the body like the face), and unexplained somatic symptoms. Regarding immigration‐related stress, distress from not having US citizenship or a permanent immigration legal status, along with low levels of acculturation, are increasing risk for experiencing discrimination, stigmatisation, difficulties in communication, and—most concerning—difficulty obtaining information and health care if sick. As a result, there is widespread anxiety, suspiciousness, diminished sense of self‐efficacy and fear of deportation and/or family separation among those of immigrant backgrounds. A participant reflected, “it is a stress for [the undocumented]… it is costing too much stress the simple fact of going [out].” As people become increasingly isolated, distress from misinformation and immigration‐related stress has been worsening. Many of the participants identified older adults, those with limited English proficiency, and those with difficulties accessing technology as being at elevated risk for social isolation. A CHW commented, “I was struggling hearing the despair in the seniors’ voices when I would check in on them and them telling me that they don't talk to anybody for a week until I speak to them… they think that they're going mad or they're just talking to the wall.” Likewise, another participant mentioned, “[people] are just desperate for someone to talk to because no one calls them… not [going] out at all is affecting [people].” The loss of, or changes in social networks, has made it difficult for people to get help when needed, particularly if sick; thus, symptoms of despair and depression, particularly loneliness, are increased (Table 2).

Furthermore, findings from qualitative data emphasised the compounded effect of all of the aforementioned stressors on mental and physical health. Indeed, reflecting on compounded stress, a CHW commented, “there is a lot more stressors on top of being alone, on top of not being able to see your family members, on top of not having a job, on top of not being able to pay your bills, on top of not knowing where your next meal is going to come from. It's a very, very hard situation.” The effects of compounded stress are not only worsening symptoms of mental health distress but also affecting people's health behaviours (e.g., sleep patterns) while also increasing somatic symptoms; this is especially notable for those with pre‐existing conditions. A CHW reflected, “I have a case of a boy about 14 years old… he is so anxious that he cannot sleep… I have another case of an older adult who started with high blood pressure when the coronavirus started… I have a woman who complains a lot about pain in the brain and pain in the chest… they did not have these conditions before.” Another participant described compounded stress as, “the body is reacting to what the mind cannot longer [process],” while another stated, “It is like a snowball that grows, unfortunately.”

Strategies for coping with distress from COVID‐19

Four primary themes emerged that represented different types of strategies for coping with COVID‐19 related stress (see Table 3). The participants reflected on how they and their community members are coping using behavioural strategies, cognitive strategies, social support and faith. Several codes within these themes emerged to denote more specific coping strategies and related outcomes. For instance, within behavioural strategies, five codes emerged that represented ways people seek to reduce stress. These included: (a) behavioural activation; that is, engaging in pleasurable or distracting activities including gardening, cooking, painting, sewing, reading and pet therapy that can elicit feelings of empowerment, renewal, and distraction; (b) use of relaxation techniques, specifically engaging in mind/body exercises such as deep breathing or yoga which lead to greater sense of control, calmness, reduced overthinking, and connection of the mind with the body; (c) mindfulness, which involves focusing one's full attention and awareness in the present moment or in a setting, such as looking at nature, as a way to build resilience and strength; (d) stimulus control, that is, engaging in attempts to try to re‐establish life prior to the pandemic, such as restoring routines or keeping a schedule in order to regain control and a sense of normality; and (e) education, which entails gathering information from reliable sources about how to be safe during this pandemic, which in turn helps people feel empowered. To describe the positive effects of using behavioural strategies such as behavioural activation, a CHW reflected, “I put my mind out of work for an hour or two and I focus on [my] animals and plants… this has worked for me a lot. I feel very renewed,” while another participant reflected on the positive effects of mindfulness by saying: “in going outside into nature and just letting it go… just like you let go of your monkey mind when it's overthinking… that's one big thing that I will take away from this experience.”

TABLE 3

Undertaken coping strategies for COVID‐19 among Latinx communities in South Texas

Coping strategy		Definition	Examples	Outcome
Theme	Code
Behavioral strategies	Behavioral activation	Engaging in pleasurable or distracting activities to reduce stress	Gardening; cooking; painting; sewing; reading; pet therapy.	Feeling empowered; feeling renewed; being distracted from stressful thoughts; increases motivation
	Relaxation	Engaging in mind/body exercises that help release tension.	Breathing exercises; yoga.	Greater sense of control; feeling calm; frees from overthinking; helps the mind body connection.
	Mindfulness	Ability to engage in full awareness of the present moment or setting to induce peace and release stress	Spending time appreciating nature.	Sense of relief; slowing down; builds resilience; increases sense of strength.
	Stimulus control	Re‐establishing behaviors by exposure to environments in which such behaviors were learned or established.	Restoring a routine; keeping a schedule.	Greater sense of control; sense of normality.
	Education/information	Gathering information from reliable sources about how to be safe.	Know your rights; know where to go and what to do if you have symptoms.	Feeling empowered.
Cognitive strategies	Normalizing	Making sense of distress as normal and understandable	Understanding distress based on context.	Acceptance.
	Validation	Recognizing or affirming emotions, experiences, or opinions as valid and worthwhile	Sharing experiences or testimony with someone who will listen.	Feeling connected; feeling supported.
	Perspective taking/reframing	Shifting one's mindset or attitude in order to see things in a new, more positive light.	Silver lining; comparing oneself to people facing greater adversity.	Feeling comforted; feeling thankful; feeling reassured; benefit finding.
	Collectivistic thinking	Thinking of how one's behaviors or actions impact those of others	Repeating collective statements to one self (e.g., “I'm fine, you're fine, we're fine.”)	Builds resilience; increases sense of strength.
	Self‐compassion	Having patience and kindness towards oneself	Making statements of self‐care.	Releases tension; increases patience towards self; feeling rested.
	Gratefulness	Positive thoughts and feelings that come from appreciation	Making grateful statement about one's life; counting blessings.	Benefit finding.
Social Support	Building/maintaining social networks	Finding comfort from distress in people that are loved and/or trusted	Finding ways to stay connected with loved ones and supportive networks	Feeling connected; feeling supported.
Spirituality	Faith	Having trust and confidence in God.	Placing worries in God's hands.	Feeling supported.
	Religiosity	Engagement in religious practices or rituals; engaging with religious groups.	Attending religious services or groups; praying.	Feeling connected; feeling supported.

Regarding cognitive strategies, these involved using different ways of thinking about problems in a way that reduces distress. Six codes emerged: (a) normalising or making sense of distress as normal and understandable to reduce anxiety; (b) validation, which helps people share experiences or testimonies with someone who will listen while feeling valued, understood, supported, and connected; (c) perspective taking or reframing, that is, having the ability to shift one's mindset or attitude in order to see things in a new, more positive light, which leads to feelings of reassurance and facilitates benefit finding in the face of adversity; (d) collectivistic thinking, which involves focusing on how one's behaviours or actions impact others, which helps to build resilience and fosters feelings of strength; (e) self‐compassion, which pertains to being patient and kind towards oneself, which releases tension and facilitates rest; and (f) gratitude, which involves developing positive thoughts and feelings that come from appreciation, in learning to count blessings people discovered the silver linings of gloomy situations. To describe the use of cognitive strategies such as perspective taking or reframing, a CHW reflected, “we look at [the pandemic] as an opportunity to spend time together… we try to look at the silver lining I guess so we can kind of lower the stress,” while another participant mentioned, “sometimes we think that we are drowning in a glass of water and then you hear another person who has a much bigger problem and that makes you think again and know that we have to thank God because our problems are serious, but there are many people who have bigger problems.” Moreover, participants’ phrases such as, "I'm fine, you're fine, we're fine” or “If we are strong, our family and our community are strong,” provide good examples to illustrate the power of collectivistic thinking in fostering feeling of strength and resilience during this pandemic.

Two additional coping strategies that emerged were spirituality and social support. Pertaining to spirituality, two codes were identified. One was faith, which refers to having trust and/or confidence in God or a Higher Power. In putting their worries in God's hands, people are able to feel supported. In this regard, a CHW recommended, “[try] to focus on faith… it does not have to be [of a specific denomination.]” The other code pertaining to spirituality was religiosity, specifically engagement in religious practices or rituals, as well as engaging with or keeping in contact with religious groups. This was identified as a way to feel more connected and supported, which highlights the relevance of religiosity in facilitating the development of social support. Social support pertains to building and maintaining social networks while complying with social distancing recommendations in order to find comfort and help from loved ones and/or trusted people. To emphasise the importance of social support during difficult times, a participant commented, “trying to stay in contact: calling cousins, calling ‘tias,’ calling uncles… reaching out as much as possible so we can keep our sanity.” (Table 3).

DISCUSSION

In this paper, we identified mental health stressors and coping strategies in vulnerable Latinx communities during the COVID‐19 pandemic. Our participants, CHWs and Promotor/as based in largely Latinx communities, were uniquely situated to provide insights into the context and concerns of the underserved communities where they work and live. Findings identified substantial mental health stressors during the current pandemic, but they also reflect robust and collective coping skills to foster resilience during these challenging times.

Primary mental health stressors were related to economic difficulties, immigration, misinformation, family strain, health problems and social isolation. Our findings are consistent with current research on the effects of the COVID‐19 pandemic on the mental health of Latinx communities (Lund, 2020) and highlight the compounded effect that the aforementioned stressors have on wellbeing outcomes that are often overlooked, but are key determinants of mental health (e.g., diminished self‐image and sense of self‐efficacy). Also, consistent with existing research (Bekteshi & Kang, 2020; Garcini et al., 2016, 2017, 2019), our findings also emphasise the effect of immigration‐related stressors (e.g., undocumented immigration legal status, migration‐related loss and acculturative stress), poverty, marginalisation, discrimination and trauma as important determinants of mental health among Latinxs that leads to increased fear and feelings of mistrust. All of the aforementioned stressors have been prevalent in many Latinx communities for a long time, yet the current pandemic is magnifying their effects on mental health given that these stressors are now compounded with a severe economic and public health crisis in the face of limited access to needed healthcare, resources and social support.

Coping skills identified included numerous behavioural and cognitive strategies. Research indicates that adaptive behavioural and coping strategies are powerful skills in mitigating the effects of stress, and reflect the resilience of Latinxs (Consoli et al., 2011). For instance, behavioural activation or engagement in pleasurable or distracting activities is often recommended in psychological treatment due to its effectiveness in reducing depression (Benson‐Flórez et al., 2017; Dimidjian et al., 2006; Santiago‐Rivera et al., 2008). Behavioural activation also effectively treats symptoms of anxiety in different age and ethnic populations (Boswell et al., 2017; Taheri et al., 2016; Turner & Leach, 2010). Indeed our findings emphasise that taking time for daily and easy‐to‐implement activities are powerful ways to ameliorate distress during the pandemic. Likewise, our findings show that engaging in the use of culturally relevant cognitive strategies, such as embracing collectivistic thinking or putting the common good above self‐interest, is helpful to build resilience. This is consistent with prior research that emphasises collectivism as a culturally relevant construct among Latinxs, which is important to incorporate in the development of interventions (Chang et al., 2016; Gonzalez & Padilla, 2016).

Social support and spirituality were identified as other important coping strategies during the pandemic, and they are well‐established protective factors against many types of mental health problems (Kessler & McLeod, 1985). Notably, social support and spirituality are two particularly salient coping methods among Latinxs (Sanchez et al., 2019). For undocumented Latinx immigrants, engagement with religion has been associated with more social support, which in turn protected against immigration‐related stress (Sanchez et al., 2019). Similarly, social support from friends, family and faith institutions helps mitigate the stress of acculturation among Latinxs in the United States (Finch & Vega, 2003). Family may be a key source of support, as one study found that even when controlling for language, education and socio‐economic status, family support was strongly associated with better perceived mental health (Mulvaney‐Day et al., 2007). Familismo is a Latino cultural value that emphasises the need to put one's family above oneself, including protecting family bonds and making contributions to the wellbeing of family members (Campos et al., 2014). Our findings that family and faith were important sources of strength against the stressors of COVID‐19 echoes findings of other studies about how Latinx communities cope with stress (Consoli et al., 2011; Winkelman et al., 2013).

The strategies our participants identified can be easily reinforced by CHWs or Promotor/as, using principles of CBPR and popular education, thus increasing evidence‐informed practices across underserved Latinx communities. CHWs and Promotor/as are uniquely situated to promote the health and wellbeing of their communities, and research supports the promise of CHW and Promotor/a‐supported mental health interventions for underserved populations (Weaver & Lapidos, 2018). A recent review found that mental health interventions delivered by CHWs and Promotor/as led to improved mental health (Barnett et al., 2018). Indeed, CHWs and Promotor/as are critical to pandemic preparedness (Bhaumik et al., 2020; Boyce & Katz, 2019) and have played pivotal roles in supporting the treatment of physical and mental health problems during the pandemic (Ballard et al., 2020; Falicov et al., 2020). Further, CBPR and popular education strategies have been described as effective approaches for working with underserved populations (Mosavel et al., 2005; Scarinci et al., 2007). There is growing evidence that when CHWs utilise peer group strategies, social support can be reinforced, while additional culturally appropriate strategies can be collectively developed and disseminated (Chung et al., 2006; Doornbos et al., 2013; Stacciarini et al., 2010; Wallerstein et al., 2017). The Community Health Club (CHC) model is one strategy recently adapted in the United States where trained CHWs form voluntary peer groups who meet weekly to co‐create knowledge, build consensus and take action to address social and structural determinants of health (Waterkeyn & Cairncross, 2005; Meza et al., 2020). To date, a CHC programme in South Texas has contributed to participants' increased preventive health knowledge, adoption of healthy lifestyle behaviours and social support and belonging, ultimately improving their physical, mental and social well‐being (Rosenfeld et al., 2020).

Our study has several strengths. Notably, it is the first paper to date that examines the perspectives of CHWs and Promotor/as on COVID‐19‐related distress and coping in their communities. We gathered data from both English and Spanish‐speaking CHWs and Promotor/as to allow a more diverse perspective, greater participation and more accurate data. Also, we utilised social‐distance strategies to gather these data, including virtual and tele‐focus groups which allowed for more participation across a large and diverse region. Our participants were from urban settings, rural areas, and US–Mexico border communities; they represented communities with different levels of acculturation, immigration status, environmental resources and access to services. Additionally, we gathered both qualitative and quantitative data, which allowed all voices to be heard—participants less comfortable sharing in a group format could contribute via anonymous questionnaire responses. Limitations of our findings include that the generalizability of findings should be done with caution; we focused on perspectives of a specific population (CHWs and Promotor/as) from a particular region, which may not be representative of other regions in the United States.

There are several implications of our findings. First, it is important to acknowledge the tremendous distress and impact on mental health functioning that the COVID‐19 pandemic has had on Latinx communities. Resources and changes that directly address sources of distress, such as clearer messaging to reduce misinformation and provision of straightforward avenues for healthcare, are critical. Second, the cultural and contextual factors of regional communities must be considered when developing resources or interventions to improve mental health outcomes. For example, technology‐driven interventions will have limited uptake because many in these communities do not have reliable (or any) internet access. CBPR should continue to be utilised to further identify needs and to facilitate the development of culturally and contextually appropriate solutions. Third, immigration legal status is a sizeable stressor because a large segment of the population are marginalised and cannot or are unwilling to access preventive interventions or health services. This increases distress, fear and risk for discrimination; structural inequities worsen stigmatisation in a population that has already been targeted within the current sociopolitical context. Advocacy and policy efforts aimed at reducing risk, preventing harm and increasing access to health and social services for this vulnerable population must be prioritised. Fourth, interventions to address distress and mental health concerns in largely Latinx communities must consider the role of cultural values that focus on collectivistic approaches. The importance of intergenerational differences, the collective good and familismo need to be considered in the development of interventions. Fifth, despite significant stressors, Latinx communities are resilient. The numerous coping strategies identified in our study highlight the resilience of Latinxs in the face of the current pandemic. It is important to reinforce and further develop these strengths, and for CHWs and Promotor/as in the community to reinforce and continue utilising such skills with their members. Lastly, our findings have highlighted the value of CHWs and Promotor/as, who uniquely know, understand and support their communities. Our participants reported many of the same stressors of their community members and are at high risk for compassion fatigue and burnout due to their helping role in crises like the COVID‐19 pandemic. CHWs and Promotor/as need additional training, resources and support to bolster their own well‐being and the health of their communities. It is our hope that our findings may inform the development of resources, interventions, best practices and training avenues to address the mental health needs of underserved Latinx communities while considering relevant cultural and contextual factors that may influence their effectiveness.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

AUTHOR CONTRIBUTIONS

All authors contributed to the study conception and design, material preparation, data collection and analysis. The first draft of the manuscript was written by Luz Garcini, Jason Rosenfeld, and Kathryn Kanzler. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.