College students' perceptions of telemental health to address their

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Journal of American College Health

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College students’ perceptions of telemental health

to address their mental health needs

Natalia Gatdula, Christine B. Costa, Mayra S. Rascón, Cathleen M. Deckers &

Mara Bird

To cite this article: Natalia Gatdula, Christine B. Costa, Mayra S. Rascón, Cathleen M. Deckers &

Mara Bird (2022): College students’ perceptions of telemental health to address their mental health

needs, Journal of American College Health, DOI: 10.1080/07448481.2022.2047697

To link to this article: https://doi.org/10.1080/07448481.2022.2047697

Published online: 10 Mar 2022.

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MAJOR ARTICLE

JOURNAL OF AMERICAN COLLEGE HEALTH

College students’ perceptions of telemental health to address their mental

health needs

Natalia Gatdula, MPH

, Christine B. Costa, DNP, APRN, PMHNP-BC, CNE

, Mayra S. Rascón, MPH

Cathleen M. Deckers, EdD, RN, MSN, CNE, CHSE

and Mara Bird, PhD

Center for Latino Community Health, Evaluation, and Leadership Training, California State University Long Beach, Long Beach, California,

USA;

School of Nursing, California State University Long Beach, Long Beach, California, USA

ABSTRACT

Objective: To understand the feasibility of using telehealth for mental health services among

college students. Participants: College students (N = 16) attending a university in Southern California,

18 years or older, and living in the residential halls. Methods: Two face-to-face semi-structured

focus groups were conducted using a semi-structured moderator guide. Written consent and a

demographic survey were completed. Descriptive thematic analysis was conducted independently

by members of the research team. Results: Participants reported mixed feelings about their level

of comfort using technology to access mental health services. Some participants acknowledged

the value of using technology, while many voiced issues of distrust and privacy, in addition to

the loss of empathy and personal connection with the mental health practitioner. Conclusion:

Offering a menu of telehealth options including a hybrid approach (in-person/telehealth) may be

necessary to address the issues of comfort, privacy, and trust to effectively reach college students

with technology-based mental health services.

Introduction

Young adults (ages 18–25) have the highest prevalence of

mental illness compared to other adult age groups.

In 2018,

8.9 million young adults reported having a mental illness.

The proportion of students entering college with preexisting

mental health conditions has also increased since 2007.

The

2019 Association for University and College Counseling

Center Directors (AUCCCD) Annual Survey reported anx-

iety as the most frequent concern among college students,

followed by depression, stress, family concerns, relationship

problems, academic performance difficulties, and other items

including sleep disturbance, social isolation, trauma, adjust-

ing to a new environment, self-image concerns, and suicidal

thoughts.

Further, college students have experienced increas-

ing rates of depression and suicidality.

Utilization of mental health services by college students

also has increased steadily over recent years. Lipson et al.

documented an increase of 15.1% in mental health service

utilization between 2007 and 2017 in a sample of 155,026

college students across 196 campuses.

Colleges have increas-

ingly used telemental health services to keep up with the

increased demand for mental health services. During the

2018-2019 academic year, 47.8% of colleges who completed

the AUCCCD Annual Survey reported having at least one

service available via telehealth.

However, the primary tele-

health service available to college students consisted of men-

tal health screening (27.5%) followed by a small percentage

of educational modules via Therapist Assisted Online (9.9%),

telephone (7.6%) or video (3.4%) counseling sessions, online

tools like WellTrack and SilverCloud (5.7%), and other

online programs and after-hours services (12.4%). There

was a 6811% increase in use of video sessions to provide

mental health services on college campuses between March

and June 2020 due to the pandemic.

Technology-based mental health care (telemental health)

is the use of a technological device to access mental health

support services from a remote location rather than

in-person/in-office. Digital platforms used for telemental

health include mobile text messaging, smartphone applica-

tions, websites, computer software, and virtual reality.

Telemental health allows patients to receive timely medical

advice, diagnosis, monitoring and encouragement, and it

provides the equivalent of in-person care for a variety of

mental health conditions.

Research has demonstrated effec-

tive prevention and treatment of psychological issues among

young adults using telemental health including depression

and anxiety among college students.

6,8,9

In one study, college

students described telemental health as convenient, accessi-

ble, easy to use, and helpful.

However, other studies have

concluded that college students prefer in-person/face-to-face

services for mental health concerns versus online.

11–13

Issues

of privacy, discomfort, and lack of personalized care are

cited barriers to using online platforms for mental

health care.

CONTACT Natalia Gatdula Natalia.Gatdula@csulb.edu 1250 Bellower Boulevard, SSPA-024, Long Beach, CA 90840, USA.

https://doi.org/10.1080/07448481.2022.2047697

ARTICLE HISTORY

Received 23 April 2021

Revised 30 December 2021

Accepted 23 February 2022

KEYWORDS

College students; mental health;

technology acceptance;

telehealth; university; young

adults

2 N. GATDULA ETAL.

There is a dearth of qualitative data on college students’

perceptions of utilizing telemental health. The increased

demand for mental health services among college students

and the push to utilize telemental health among this pop-

ulation, even prior to the COVID-19 pandemic when ser-

vices quickly shifted to telehealth, warrants consideration

and exploration of telehealth as a sustainable method among

this population. This article presents findings on the per-

ceptions of college students living in dormitories and their

use of a technological device to access mental health services

prior to COVID-19.

Materials and method

Study design

The aim of this qualitative study was to understand and

describe the issues surrounding the use of technology to

address college students’ mental health needs. This study is

part of a larger qualitative study conducted to explore the

mental health needs of youth and young adults in Los

Angeles and Orange County, California.

Findings from the

larger study were used to inform the development of a pilot

mental health training program using telemental health for

psychiatric mental health nurse practitioner students. The

current study includes analysis of two out of a total of six

focus groups, which were conducted at a large 4-year uni-

versity in Southern California with a diverse student pop-

ulation. The remaining four focus groups were conducted

among non-college enrolled youth and young adults and

therefore were excluded. The California State University,

Long Beach (CSULB) Institutional Review Board (IRB) for

the Protection of Human Subjects (IRB) approved all study

procedures prior to implementation.

Sampling and participants

Purposive sampling methods were used to recruit students

in collaboration with the university’s campus housing office.

Over 2,500 eligible students received an email from the

Office of Housing and Residential Life with information on

the study and a link to register if interested using Qualtrics

Provo, UT, USA. https://www.qualtrics.com). A total of 90

students registered, providing their name, contact informa-

tion, age, class standing, and name of their residential village

in order to verify eligibility. Program staff verified potential

participants’ eligibility using the following criteria: (1)

18 years or older; (2) student actively enrolled at the large

urban university; and (3) living in the residential halls. Two

groups of 15 students were selected using the date and time

stamp in the order they submitted their registration. A fol-

low up email with focus group details was sent to eligible

selected students by program staff prior to the scheduled

date. Fifteen students per group were contacted to partici-

pate anticipating 50%–60% participation, which would allow

for approximately 7 − 10 students per focus group. Those

who registered and were not selected were thanked for their

interest via email by program staff. One group of six and

one group of ten students participated for a total of 16

college students (mean age = 20 years, 68.8% female).

Data collection

Written informed consent was obtained upon arrival to the

scheduled focus group. The two focus groups took place

concurrently April 2019 in two separate private conference

rooms in the residential halls for ease of access and famil-

iarity. Aliases and unique identification numbers were

assigned to ensure confidentiality. Participants completed a

brief demographic survey using Qualtrics software on

project-owned and password-protected iPads. Two items

were developed to measure participants’ confidence in the

use of a technological device for telehealth: (1) “How com-

fortable are you with live video-streaming?”; and (2) “How

confident are you that you could use a phone or computer

for two-way health services?” Response options ranged from

1 = Not at all comfortable to 10 = Extremely comfortable.

A semi structured focus group guide was designed as part

of the larger qualitative study to understand the mental health

needs of Hispanic/Latinx and other underserved youth and

young adults. To gain college students’ perception of using a

technological device for mental health services, participants

responded to the following: (1) “How would you feel about

going to a professional for help?”; and (2) “How would you

feel about using your phone or a computer to talk to some-

one?” Each focus group was conducted by trained research

staff which included a moderator, two notetakers, and a board

certified Psychiatric Mental Health Nurse Practitioner (PMHNP)

to provide supplemental referrals and address any immediate

mental health needs raised after the discussions were com-

pleted. Focus group discussions were digitally recorded and

notetakers took handwritten notes to document nonverbal

responses. The moderator, notetakers, and PMHNP debriefed

privately at the end of each respective session and completed

a debrief form to summarize the session and note key take-

aways. Participants received a $20 gift card for their time.

Analysis

Descriptive statistics were analyzed using IBM SPSS (Version

26.0 IBM Corp. Released 2019, Armonk, NY) to report

participant characteristics and confidence in the use of a

technological device for telehealth. Qualitative data were

analyzed using descriptive thematic coding to allow for a

flexible approach to explore patterns across the data.

Focus

group digital recordings were transcribed verbatim, coded

and analyzed using Dedoose (Version 8.1.9, 2018, Los

Angeles, CA: SocioCultural Research Consultants, LLC,

www.dedoose.com) by three trained members of the research

team. After each member independently read the transcripts,

the team met to develop an initial coding scheme using the

session debrief notes as base documents. The transcripts

were then independently coded by each team member.

Emerging themes within the data were identified. Team

members met regularly to discuss and cross-validate codes

JOURNAL OF AMERICAN COLLEGE HEALTH 3

and prominent themes in an iterative process for consensus.

Quotes which best illustrate prominent themes were selected.

Results

Participants reported an average of two devices for telehealth

use. All reported having a smartphone, while 50% reported

having a desktop/laptop as an additional device. It is unclear

whether other students did not indicate a desktop/laptop

because they did not own one, did not have a built-in

camera, was not located in a location that provided privacy

or whether they did not view it as a device that could be

used for telehealth. Participants on average reported being

comfortable with accessing live video-streaming and using

a phone or computer for two-way health services. See

Table 1 for participants’ demographic characteristics.

Emerging themes from the qualitative analysis were cat-

egorized into three major topics: perceived comfort, per-

ceived usefulness, and perceived barriers.

Perceived comfort

Participants expressed mixed feelings about their level of

comfort using technology for mental health services. Some

participants were not comfortable at all talking about per-

sonal or mental health problems using a technological device

and preferred in-person conversations with a mental health

professional. For example:

I wouldn’t personally feel very comfortable talking about my

personal problems over phone because face to face conversation

just has an aura to it that mobile or texting doesn’t because

their soothing voice…the voice of the other person talking

might…the way they talk, the way they move could possibly

put you at calm.

For those who were comfortable using a technological

device, comfort varied by the type of engagement (e.g.,

online chat, texting, videoconferencing, phone call with no

video). Some participants expressed comfort with seeking

help via an online chat to maintain anonymity, but not

through a phone or video call, as described by a

participant.

No, just the chat because for me, it’s more like, okay, if they

see my face, if they hear my voice that kind of takes away from

my anonymity. Yeah, I’m not that anonymous anymore. So,

just having the opportunity to be a 100% anonymous, kind of

drives me toward it. And then once you’re comfortable doing

that, then I might be open to a phone call or a Skype, and

then eventually doing it in person.

Others preferred a phone call without video over an

online chat because it allows them to adequately talk about

their issues while keeping their anonymity. One participant

described their preference:

But personally, I would prefer a phone call because if I was

going to call a friend or a family member, I would go to a phone

call rst for a problem because especially when I’m talking about

my mental health, there’s a lot that I want to say and I get tired

and lazy typing it all out so I like phone call the best.

Perceived usefulness

Some participants acknowledged the value of having the

option to use technology to talk to someone about mental

health issues; primarily for its ease of use and accessibility.

Participants noted that it could help those who need imme-

diate assistance when an in-person meeting is not feasible.

I think just having that even an option to be available or acces-

sible to certain people is actually really great. I think it’s actually

a really great idea. Because 9 times out of 10 you’re not going

to always be in someone’s face or things can come at dierent

points of time in a day. So, if it was 10 o’clock at night, you’re

having a hard time, of course, I’m not able to see somebody.

So, I think that’s a great alternative to not being able to talk

to someone in person face to face.

I feel like using a computer or when the other thing you said,

would be a lot easier for a lot of students especially because like

since it, when we always don’t have time to go to [counseling

center] and like sit down for an hour and talk. But like if we’re

in our room studying, we feel like we’re having a stressful day,

we just need to talk to someone right away and we’re able to

like call them up. I think it’d be so benecial for people.

Participants also noted the benefit of having the option

to choose telehealth or face-to-face based on preference and

comfort. This would be particularly useful for college stu-

dents who need flexibility given their busy schedules.

“[…] And so, whether you’re more comfortable doing it face-to-

face or online, they have both options available. So, you don’t

really have to choose one or the other anymore. Like you can

kind of do both or choose whatever works.”

Additionally, participants expressed that the option to

use technology to ask for help would be useful in combating

self-stigma. Participants who internalize feelings of shame

for needing mental health services would greatly benefit

from an online option, as described by a participant:

Table 1. Sample characteristics (N = 16).

Demographic characteristics n % SD Range

Sex

Male 5 31.3

Female 11 68.8

Age in Years* 20 ±1.2 18 − 22

Hispanic or Latino 4 25.0

Race/Ethnicity

White 9 56.3

Black 2 12.5

American Indian/Alaska Native 1 6.3

Asian/Pacic Islander 3 18.8

Other 1 6.3

Technology Access n % Range

# of Devices for Telehealth Use* 2 ±1.2 2 − 5

Devices for Telehealth Use**

Smart Phone 16 100

Tablet 5 31.3

Computer (desktop or laptop) 8 50.0

Smart Watch 1 6.3

Comfort with Live

Video-Streaming*

6.9 ±3.2 1 − 10

Condence Utilizing Device for

Telehealth*

7.8 ±2.2 4 − 10

Mean and standard deviation.

Not mutually exclusive.

4 N. GATDULA ETAL.

And for me, I’ve always had a big self-image problem. So,

going to [counseling center] or putting yourself in that situation

where, you have to admit to yourself you have a problem. When

you want to be such a perfect person is really a big thing. I

remember someone giving me knowledge about someone’s not

going to want to go get help, they’re going to cover themselves

up and wear a hoodie. And I don’t wear hoodies, and I don’t

want to do that. I think that would help a lot of people who

are denitely just afraid of like seeking help.

Perceived barriers

Stigma was described a barrier to seeking professional men-

tal health services. Participants described seeking profes-

sional help as a last resort for serious mental health issues

due to the judgment received from friends, family, and

strangers as described by a participant:

I denitely agree with [name] that there’s most denitely a

stigma behind it. […] there’s a whole notion of if you go to a

professional, there’s something seriously wrong with you.

Participants agreed that having an online option would

be beneficial if a person is hesitant to seek professional

help. It could serve as a stepping stone for people to

become comfortable expressing their feelings and getting

their questions answered by a mental health professional.

“Yeah, I agree with what [name] said. I kind of feel like online,

it’s like, if you’re kind of hesitant about seeking help, it’s a good

gateway to get there.”

Additionally, several barriers to using telemental health

were described by participants. Lack of private space where

young adults can have conversations using technology with-

out others overhearing was an issue. This is especially prob-

lematic among college students who live on-campus in

shared and confined spaces as described by a participant:

[…] But then you have the issue of somebody overhearing

you. Most devices that we could Skype, FaceTime, text, email,

whatever it is, they’re mobile. And so, we don’t have necessarily

private place to do it. I live at [name] dorms. And I know I can

hear every conversation that people across the hall are having.

Participants shared concerns regarding data privacy and

security when using technological devices in general, but

particularly when utilizing them to discuss personal prob-

lems with a mental health professional. For example:

I don’t like the whole communication over media because I am

paranoid that somebody could follow it and see where I am, see

what I’m saying. Even if it’s typing, phone calls, whatever, every-

thing’s recorded. So, in therapy sessions, when you’re sitting in

the room, it’s all private, because you turn o the phones, you’re

the…the person is writing. So no, I would not be okay with

it. I would not be able to do it. I would just wait if I had to.

In addition, participants noted the need to educate the

public on trusted online mental health tools (hotlines, chat,

texting) to increase the use of existing resources. This high-

lights the need to move beyond just accessibility; and

increase awareness of resources and how to use them as

one participant described:

But yeah, having a trusted source I think is a really key point

because like I don’t like to seek advice from, you know, some

random nobodies, who aren’t aware or aren’t you know trained

to handle certain issues.

Additionally, some participants expressed concern with

not knowing with certainty who they are communicating

with when using a device whether it be chat, phone or

video call. Although most participants saw this as a barrier

to using a device for mental health services, some saw it

as a potential benefit on days when help is needed, but a

person does not feel like talking to someone. For example,

participants said:

So then, you know, if you get a hold of their oce or something

then you can know for sure who you’re talking to as opposed

to the text option, which would, I think, a lot of people would

think “that was really easy”, but maybe not trusted.

And if you’re just talking to a screen, it’s like, am I talking

to a robot? Or who am I actually talking to, but then I also

sometimes I just don’t want to talk to anybody. Talking to that

screen, could be very benecial. So, it’s kind of a mixed.

Despite participants acknowledging the benefits of tech-

nological devices and how they connect strangers, authen-

ticity in a client/therapist relationship was highly regarded.

Participants acknowledged the benefit of in-person conver-

sations when seeking mental health services and having the

ability to interface with a mental health professional, seeing

their body language as they respond, and picking up on

cues that a person would not be able to pick up on via

telehealth. Participants perceived using a technological device

would lead to a loss of empathy and connection between

the client and professional. For example, participants said:

“[…] I think there’s something special about having an in-person

conversation where people are fully present, as opposed to like

the online split between multiple things.”

I’ve started using [counseling center] this semester and I’m

really grateful for it. And the person that I’m speaking to, she

really does a really good job of…feeling that empathy the way

that I need her to…the emotion that I feel, she feels it. So,

it really feels like okay, you actually feel me…I’d even argue

that…when people do consider therapy as an option of like,

on the road to healing and everything, that it’s not so much

the person that they want, but to actually have someone that

feels what they’re going through. So, I think that’s a big part

that you can easily lose when it’s behind the screen or just

over the telephone. I think like the technology part are great

buers, but if you don’t have a follow up or an in-person. I

don’t really know how long it’ll last or how real and genuine

it’d feel. I think the convenience, that aspect is there, but in

terms of like, the technology aspect, I don’t really like and then

I also think just in terms of like who else is listening?… I just

get paranoid about that stu, too. So yeah.

Still, some participants acknowledged that although using

a device to communicate with a mental health professional

can feel impersonal, it could be benefit those who need

immediate assistance. Ultimately, a telehealth option is better

than not being able to seek professional help at all.

I do think over phone or other ways other than in person can be

a bit impersonal, which can be a big problem. But I think overall,

if someone’s really down and out, they’re going to call or whatever

other means of way, which it is. I think you can have obstacles,

but at the end of the day, if they need it, they are going to go.

JOURNAL OF AMERICAN COLLEGE HEALTH 5

Access

Some participants mentioned access as a potential barrier,

acknowledging that not all students have access to a personal

device and rely on computer labs on campus. For example,

one participant described:

Not everybody has access to these devices. Some people’s only

access to an electronic device is the computer lab. So, if maybe

there was designated rooms, if you could go in and sound-

proofed I mean, relatively soundproofed and be able to talk or

type with somebody, that would also be a benet.

Discussion

This study highlights the perceived comfort, usefulness, and

barriers of using a technological device to seek mental health

services among college students living in dormitories. The

qualitative approach provides insight to the variability in

college students’ preference of telemental health options.

College students varied in their level of comfort to seek men-

tal health services on an online platform and using a tech-

nological device. Their comfort may have been influenced by

whether or not they had sought mental health services pre-

viously or their previous experience with a mental health

practitioner. The variability in students’ preferences (e.g., chat,

phone call, or videoconferencing) suggests universities should

consider offering a menu of options to allow students to

choose the most appropriate modality based on their need

and comfort. This would increase access to mental health

services and cater to an increasingly diverse group of adults

on college campuses. The latest data demonstrates the major-

ity of undergraduate students (43% of full-time, 83% of

part-time) are employed

; and 22% of college students (about

one in five) are parents,

highlighting the various responsi-

bilities outside of college coursework and thereby indicating

that college students have a diverse set of needs.

Consistent with previous studies, participants expressed

preference for in-person mental health services and will

need time to increase comfort using telemental health.

12,13,18

For college students who prefer face-to-face mental health

services and are not ready to utilize a telehealth option, a

hybrid approach could provide a solution to introduce the

modality, and increase comfort and trust between the mental

health practitioner and this population. The hybrid approach

could consist one to two initial in-person sessions followed

by ongoing videoconferencing sessions with the flexibility

to incorporate additional in-person sessions. A hybrid

approach could also help address the issues regarding data

privacy and security that are consistent with previous stud-

ies

19,20

by using an initial in-person session to inform stu-

dents about the videoconferencing software or system that

would be used and the measures that would be taken to

keep their information private and secure once they tran-

sition to telemental health. In addition, a hybrid approach

would help mitigate the loss of connection noted by par-

ticipants with the use of technology. More than one

in-person session may be considered before transitioning to

telemental health to allow students to build a connection

with their mental health professional and further develop

the patient/practitioner relationship.

For some students, telemental health could mitigate issues

related to internal feelings of shame when seeking mental

health services and feeling prejudice from others for seeking

professional help. Additionally, some participants in this

study noted that they were feeling uncomfortable with the

lack of anonymity. This supports a need for patients and

providers to trust telehealth systems to keep personal infor-

mation private and secure in order to utilize this platform

to access health services.

Universities can provide a live

chat or phone call option for those who would prefer to

receive help using a chat feature or a phone call to remain

anonymous. Still, valid concerns exist over privacy and data

security.

There is a need to advocate for federal policy to

address security safeguards and cover data collection, use,

and disclosure, for both the intended purpose of the tech-

nology and any secondary data uses, such as for analytics

as to the use, since telehealth continues to be utilized more

frequently given the increasing need for mental health ser-

vices.

21,22

Considerations for increasing access to private

spaces on campus, especially in dormitories and on-campus

housing, for students to participate in telemental health

services are also needed.

Future research is needed to determine whether students’

comfort with telemental health services has increased since

2019. The COVID-19 pandemic not only brought many

activities online, including college classes and meetings with

other university staff, it also accelerated the expansion and

use of telehealth for mental health services.

It is possible

this experience with online communication will increase

their comfort with telemental health services. Conversely,

students’ craving for in-person interactions after COVID-19

could cause them to prefer in-person mental health care.

From a policy perspective, as noted by Huilgol etal., ensur-

ing provider compliance with ongoing changing government

regulations and policies, and expanding licensure to increase

accessibility will be key to the success and sustainability of

telemental health. Finally, there is a need for modification

of payment and reimbursement policies with government

and private insurances for telemental health to remain at

parity with in-person visits and fiscally sustainable.

Limitations

These findings represent a small sample size of college stu-

dents consisting primarily of female students and those

living on-campus. The majority (96%) of undergraduates

enrolled at the university where the study took place are

commuter students. Moreover, freshmen and sophomores

make up the majority of students who live in the residential

dormitories, thereby leaving out junior and senior level

students who may differ in opinion. Future studies should

include commuters and students from various class stand-

ings. Additionally, there are inherent biases with the use of

focus group methodology. Participants may have altered

their responses to conform to others’ opinions as a means

to fit in, avoid conflict, or to achieve a unified response.

Moreover, the authors developed the focus group guide with

the intent to develop a telehealth mental health service for

college students, therefore seeking practical feedback from

6 N. GATDULA ETAL.

students. Nonetheless, findings from these focus groups pro-

vide useful insights to inform the development and/or

expansion of telemental health services for college students.

Conclusion

College students are vulnerable to stress and need accessible

mental health services, but they often experience barriers

to accessing services. It is expected that the need for addi-

tional mental health services will continue to grow given

increased stress, anxiety, and depression among college stu-

dents during the COVID-19 pandemic.

21,22

As society tran-

sitions back to in-person activities, it is imperative to

consider how telemental health can be utilized as a perma-

nent platform to provide mental health services to college

students. This research provides baseline information to

consider when exploring the expansion of telemental health

services within a college setting. It suggests that telemental

health can be effective with some students, but other stu-

dents have concerns about quality of care, data security, and

the need for a personal connection with the mental health

professional. Further research is recommended to understand

college students’ lived experiences using telemental health

to guide the tailoring of treatment to individuals’ needs.

Acknowledgments

We would like to acknowledge Lea Ann Gomez and Alex Garbanati

for their assistance with data collection and transcription. We also

acknowledge University Housing and Residential Life at California

State University Long Beach for working closely with the research

team to recruit participants. Finally, we thank the college students

who shared their perspective and experiences with us.

Conict of Interest Disclosure

e authors have no conicts of interest to report. e authors conrm

that the research presented in this article met the ethical guidelines,

including adherence to the legal requirements, of the United States of

America and received approval from the Institutional Review Board

of California State University, Long Beach.

Funding

Funding was provided by the State of California, Oce of Statewide

Health Planning and Development Award #18-90714.

ORCID

Natalia Gatdula, http://orcid.org/0000-0002-2942-5374

Christine B. Costa,

http://orcid.org/0000-0003-0992-3023

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