First-Generation Disparities In Mental Health Service Utilization: A Moderated Mediation Model of Insurance Adequacy and Perceived Need

Background/Purpose: First-generation (FG) college students are much less likely than continuing-generation students to get mental health care, even though they face unique stresses like financial instability and "culture shock" that make them more likely to become mentally ill. People often talk about structural barriers, but the psychosocial factors that contribute to this gap in use have not been studied enough. This study employs Andersen’s Behavioral Model of Health Services Use to examine if "perceived need" mediates the association between FG status and therapy utilization. It further examines whether race and insurance adequacy moderate this pathway, providing an intersectional view of the barriers to care. Furthermore, it examines how this pathway is moderated by race and insurance adequacy to identify cumulative obstacles to care.

Methods: The data comes from the Healthy Minds Study (HMS) 2024-2025, which included a sample of 20,522 undergraduate students. The FG status was the independent variable. The perceived necessity served as the mediator, whereas the moderators encompassed Black student status and insurance adequacy. The dependent variable was the therapy or counseling received in the preceding 12-month period. We employed Hayes' PROCESS macro (Models 4 and 14) to conduct mediation and moderated mediation analyses, while accounting for demographic variables, clinical markers such as depression and anxiety, and structural factors.

Results: FG students exhibited a 31% reduced likelihood of therapy utilization (OR = 0.69) in comparison to continuing-generation counterparts. The analyses indicated that FG students felt they needed services far less (b = .21, p < .001), even though their symptoms were just as bad, and this lack of acknowledgment was a big reason for the discrepancy in service use. Race did not influence the indirect pathway; however, Black students experienced an additional disadvantage, exhibiting 23% lower usage independently (OR = 0.77, p < 0.05). Insurance adequacy was the most important factor in getting care (OR = 3.66), but it also made the gaps bigger because it mostly helped people who already knew they needed care, putting FG students with needs they didn't know they had even further behind.

Conclusions and Implications: The findings suggest that FG students face a "Matthew effect" where structural facilitators like insurance primarily benefit those with high mental health literacy. To achieve equity, institutions must go beyond just giving out resources and put in place "upstream" measures like universal mental health screening and literacy programs that are built into FG-specific support mechanisms. Students of color also experience extra challenges, thus delivery approaches that are culturally responsive are needed. For example, clinical staff should be more diverse and counselors should be placed in cultural centers on campus.