{'fraction_non_alphanumeric': 0.03347240659965864, 'fraction_numerical': 0.01953347240659966, 'mean_word_length': 5.26678550207962, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Predicting Women’s Utilization of Primary Care Mental Health Services in Mexico City

Objective: To analyze factors associated with and predicting Mexican women seeking primary care mental health services (PCMHS) and provide suggestions to increase PCMHS utilization. Method: We administered a questionnaire to (N = 456) female patients in Mexico City primary care clinics. We conducted chi-square analyses of seeking PCMHS and sociodemographic variables, perceptions of and experiences with PCMHS. Our results and literature review guided our logistic regression model. Results: Women referred to a mental health provider (MHP; odds ratio [OR] = 10.81, 95% CI = 3.59-32.51), whose coping mechanisms included talking to a MHP (OR = 5.53, 95% CI = 2.10-14.53), whose primary worry is loneliness (OR = 8.15, 95% CI = 1.20-55.10), and those who follow doctor’s orders; were more likely to seek PCMHS (OR = 0.28, 95% CI = 0.09-0.92). Conclusions: Primary care providers play a fundamental role in women’s decisions to seek PCMHS. Proper referrals to PCMHS should be encouraged.

seeking predictive factors of service utilization. We expected older age, higher income, and education, marriage/coliving, and finances, family, and loneliness worries to predict seeking mental health care 5,[18][19][20][21][22][23][24][25] We also hypothesized receiving mental health information, being referred by a PCP to a MHP, following doctor's orders, and coping by talking with MHPs would predict seeking care.

The Current Investigation
The current investigation analyzed demographics and experiences among Mexico City women's mental health treatment seeking through 3 objectives: (1) analyzing associations of seeking mental health services, (2) developing a predictive model of women likely to seek these services, and (3) providing suggestions that may increase mental health treatment.

Methods
Data was extracted from a 2-part multimethods study assessing primary care patients' mental health beliefs and behaviors through (1) observations and 35 semistructured interviews in 19 primary care clinics and (2) questionnaires administered to convenience sample of 566 workers and 529 general health care users in 82 primary health care clinics. 23,26 Participants The current study focused on female participants, N = 456. The inclusion criteria included (1) being older than 14 years, (2) currently utilizing primary care, (3) being willing and able to share primary care experiences through the questionnaire, and (4) willingly providing informed consent. Interviewed women utilized primary care for various reasons not limited to mental health.

Procedures and Measures
Measures. Questionnaire measures from the larger study were validated for accuracy and precision through a pilot study. 24 Our mental health service usage literature led us to focus on the following measures: Demographic variables. Age, gender, household income, number of dependents, occupation, education, and marital status data were collected.
Use of health care resources and services. Participants answered polar questions about attempts to alleviate physical and psychological ailments to operationalize health care use. Participants specified the physical or psychological ailment and the last time the resource (eg, vitamins) was used as treatment.
Experiences during the doctor's appointment. Participants shared about the time PCPs spent with them, actions PCPs took during the consultation, and whether they followed the PCPs' orders.

Knowledge of mental health information.
Participants answered polar questions about whether they received mental health information at health centers and its content.
Attention to mental health. Participants ranked worries on a scale from 1 (primary worry) to 7 (least important worry). Only primary worries were considered for chi-square analyses. Participants answered polar questions of actions taken when worried (eg, hold it in, seek a priest, seek medical care) to operationalize personal attention on mental health.

Data Analyses
Two trained members of the research team created the coding handbook and coded the questionnaires. Two trained psychologists analyzed the data using statistical software SPSS and STATA. Missing data were removed and preliminary analyses confirmed normality. Frequencies, bivariate correlations and chi-squares analyzed scale and categorical responses. A sequential logistic regression analyzed predictors of seeking mental health services.

Ethical Considerations
The Instituto Nacional de Psiquiatría "Ramón de la Fuente Muñiz" granted the overarching study IRB approval. Ethical considerations included participants giving informed consent prior to answering the questionnaire, permission from each primary care clinic to conduct studies on their patients, and the current study being made anonymous.

Descriptives
Women's ages ranged from 17 to 79 years; 59.4% of women were younger than 40 (M = 37.56 years, SD = 15.49,). Nearly half (49.4%) of women had a household salary of minimum wage or less (minimum wage = MXP2018.70 or US$108 per month), and only 30% completed high school. Most women (68.9%) self-identified as homemakers and had M = 3.25 dependents (SD = 1.36). Most women (70.8%) were married or coliving with a significant other (see Table 1).

Attention to Mental Health
Only 25% of women knew their closest medical center offered mental health services and 48.5% were unsure.

Predictors of Seeking Primary Level Mental Health Care
We excluded women without mental health service access and those unsure if they had it, leaving n = 169 participants. Our chi-square results and literature review guided the following factor regressions with seeking care: age, income, education level, marital status, being referred to a MHP, following doctor's orders, receiving mental health information, worrying about loneliness, financial, or family problems, and the coping mechanisms talking to a priest or MHP.

Discussion
To our knowledge, this is the first study reporting that the strongest predictive factor of primary care mental health treatment initiation by Mexican women is being referred to a MHP by a PCP. Initiating mental health treatment involves: access to appropriate treatment resources, mental health screening, referral, referral acceptance, and treatment initiation. 27 Failure at any of these steps may cause treatment initiation failure. 27 Women being 10 times more likely to initiate mental health treatment if they receive a referral from their PCP suggests that patients with primary care mental health resources that are screened for mental health maladies and referred to MHPs accept referrals and initiate treatment. We posit that the underutilization of mental health services may be a consequence of lack of primary care mental health resources, lack of mental illness recognition, and lack of MHP referrals among PCPs.
Previous research shows that patients only seek mental health services when they receive a referral if the services are integrated into their primary care facility. 27 Additionally, PCPs' ability to identify and treat mental health problems depends on the availability of treatment resources. [28][29][30] Thus, PCPs' abilities to recognize mental illness and make appropriate referrals depend on the availability of primary care mental health services.
Considering only 31.8% of our participants' PCPs inquired about emotional or personal problems and less than 10% of our participants were referred to a MHP by a PCP, we suggest future interventions should prioritize: (1) mental health service integration throughout Mexican primary care facilities and (2) training PCPs on mental illness screening and proper follow-up measures (eg, patient referrals to MHP).
Interventions involving primary care mental health service integration and PCP mental health training have been successfully implemented in Argentina, Chile, Australia, and Brazil. 31 In these countries, PCPs are trained to assess patients' physical and mental health, treating when capable and referring to a MHP when not. 31 As a result, most PCPs in these countries are able to detect and often even treat mild cases of mental disorders. 31 Our study also showed that women who perceive loneliness to be their primary worry were more likely to seek MHPs. Additionally, loneliness for the women revealed to not refer to the absence of relationships, but to their quality because more than 90% of participants lived with a partner and each woman had 3 dependents on average. 32,33 Research shows individuals with frequent feelings of loneliness tend to suffer high rates of depression. 34 Loneliness is not only a precursor to depression, but Mexican women dealing with isolation and loss of family support are also at higher risks of additional mental disorders. [35][36][37] In Mexico, loneliness is perceived as a responsibility of the individual, being especially burdensome because of cultural expectations of family meeting one's need for companionship. [37][38][39] These perceptions foster the idea that one should "pick oneself up by the bootstraps" to overcome depression when lonely. 40 This may explain why women are more likely to seek mental health services when worried about loneliness. Culturally, loneliness may be perceived as out of the ordinary while other worriesfinances, education, or family problems-may be perceived as quotidian and unavoidable to current Mexican society.
Future studies should also consider obtaining a larger, randomized, more representative sample size. We used a small convenience sample rather than random sample. Our study was not only limited in size, but also in gender and location, as well as in the skip logic of certain questions in our survey. Because the questionnaire was not designed specifically for this study, only participants who answered that their primary care facility included mental health services were asked whether they had ever sought such services. Future investigations should also consider patients who sought but did not find services.
Despite its limitations, this study suggests that PCPs play a fundamental role in women's decisions to utilize primary care mental health services. This leads us to suggest that simple and specific changes (eg, ensuring an adequate amount of MHPs and training PCPs to screen for mental illness) may be implemented to improve early detection of mental illness and referrals to MHPs, as long as mental health services are integrated into the primary care facility.