Levels of Depression in West Massachusetts

Running head: DEPRESSION AMONG OLDER IMMIGRANTS

DEPRESSION AMONG OLDER IMMIGRANTS 32

Depression among Older Immigrant African Women in Metro West Massachusetts

Section 1: Foundation of the Study and Literature Review

In West Massachusetts United States, the most common health disorders are anxiety and depression, which are prevalent in elderly immigrant women aged between 50 and 79 years (Agbemenu, 2016). Despite a variety of efficacious interventions for depression and anxiety, it is clear elderly immigrant women experience mental health care disparities in their access to mental health services and the quality of treatment they receive. Research indicates African American heterogeneity impacts access to depression and anxiety treatment. In addition, African Americans are becoming an increasingly visible minority within the United States especially in West Massachusetts and are often depicted as Blacks. The current study sought to understand the causes and prevalence of depression among older immigrant African American women in Metro West Massachusetts as well as how the older immigrants cope with depression. A total of 12 self-identified social workers were interviewed about their patient’s mental health problem symptoms and treatment experience, what they thought was the cause of their patient’s anxiety, stressors facing their patient’s life in West Massachusetts, their patient access to mental health services, and how patients coped with depression. Results indicated considerable variability across the two groups, with African American elderly immigrant women endorsing higher rates of depression and anxiety, as well as higher rates of treatment seeking, than the whites. Individual's gender, age, marital status, and origin played a major role in the endorsement of anxiety and depression for the immigrants. Finally, although the two groups differed in the extent to which they experienced stigma about mental health issues, stigma did not predict symptom endorsement or treatment-seeking behavior for any of the two groups. These findings underscore the importance of attending to both between-groups and within-group differences in the mental health and mental health treatment experiences of different ethnic groups.

The data collection methodology that will be used for the research study will be discussed in this section. The methodology will be semi-structured interviews, which will give the researcher an opportunity to explore the participant’s responses further in order to provide clarification of an answer given. Semi-structured interviews make use of open-ended questions that require an explanation and not just a yes or no answer. Data collection will be done using interviews and the study participants will comprise of social workers working in Metro West Massachusetts. All the interviews will be conducted using internet services like GoToMeeting, skype, Zoom, or any other web-based service due to the current pandemic of Covid-19. Only 10 questions will be asked. The reason for using social workers is for the researcher to get information that is credible and to also be able to get varied insights as the social workers will be dealing with numerous clients. The study participants will be social workers who have been working in the area for a minimum of three years. The idea for this criterion is to ensure that the researcher only interviews social workers who have enough knowledge, and they have been attending to clients in the area for some time. The researcher anticipates to have at least 10-12 social workers taking part in the study. It is assumed that this number will be representative of the population and it is an easy number to work with. Having a large number of participants would result in a lot time spent conducting the interviews and data analysis, which may not offer any considerable difference in the results.

The data analysis process will begin with transcription of the audio tapes. The researcher aims at uncovering patterns and making codes for use in the themes that they will discover. The researcher will try to assign each code to a particular theme if possible. However, the researcher is aware there are some codes they will not be using. The data analysis process will comprise of familiarization with the data, assigning preliminary codes for describing the content, searching for patterns in the codes, reviewing themes, defining and naming themes, and producing the report. These steps will be followed systematically to ensure the study does not miss out on anything vital.

This researcher has analyzed the ethical procedures that will be used to ensure they safeguard the interview participants, and the research study is ethical. The researcher will seek approval of the IRB since they are using human subjects in this study. This is a requirement for all studies that will be involving human subjects. Once they get the approval, the researcher will need to get written consent from the potential participants before they can begin data collection. During the consent seeking process, the researcher will discuss with the participants the role they will play, the purpose of the study, the benefits, risks, and alternatives to participation. It is the duty of the researcher to ensure the potential subjects understand the information given and the participants can ask questions to clarify anything they did not understand. While the researcher might be time pressed, they will give the potential subjects adequate time to review all the information presented before they sign the consent forms. Only after they have signed can they be included in the study. The study participants will have a right to withdraw from the study at any time and they will be provided with all the data collected up until the point of their withdrawal. The study participants shall be provided with information on their right to withdraw as part of the consent seeking process. All the data collected in the study will be securely stored to protect it from prying eyes and the researcher plans to store the data for at least one year after the results are published. Access to the data will be restricted to only authorized personnel. All the data will be destroyed after the specified period has lapsed.

Problem Statement

The intent in this study is to explore the views of social workers in relation to depression among older immigrant African women currently living in west Massachusetts. Older immigrant African women refers to women who are over 55 years of age and they relocated from any African country after acquiring permanent residency in the United States. Depression among elderly immigrant women stands out as an important phenomenon for study in the context of social work taking into consideration the extent to which the condition affects vulnerable populations. Derr (2017), pointed out immigrants typically face stressors relating to migration experience which may cause or intensify mental health problems. Moreover, Derr (2017) also discussed that immigrants tend to access mental health services at a lower rate as compared to non-immigrants. Subsequently, this situation leaves immigrants at risk of untreated health conditions leading to increased disease burden (Lynch, Berg, Manna, and Schade (2016). As such, this negative health predisposition creates greater need for mental health services among immigrants who seem more susceptible to develop depression. This situation makes it imperative to establish the views of social workers addressing the mental health needs, especially depression, among older immigrant African women in Metro West Massachusetts. In turn, insights gained should play a critical role in the development of comprehensive mental health programs aimed at improving the immigrants’ health outcomes.

As noted, migration can be challenging, and many immigrant women experience challenges that affect their mental health (Foo et al., 2018). For example, the changes in practices, values, social factors and cultural identification are considered as factors contributing to the potential risk of developing mental health issues (Alegría, Álvarez, & DiMarzio, 2017). Similarly, Foo et al. (2018) asserted migration into a new country leads to drastic changes in essential aspects of normal day life. Here, the process of assimilating to new environments and cultures causes considerable levels of acculturative stress, which researchers have linked to the occurrence of psychiatric disorders (Foo et al., 2018). Therefore, examining stressors surrounding the migrant experiences from the social work perspective should offer insights into the issues faced by this vulnerable population, especially for women aged 50 years and above.

Based on the highlighted problem, it is imperative to determine the views of social workers from West Massachusetts who work with older immigrant African women in Metro West Massachusetts affected by depression (O’Donnell et al., 2016). Such an undertaking may reveal service modifications such as giving patients with language barriers more time needed to enhance access to quality mental health services (O’Donnell et al., 2016). As suggested by researchers, immigration can create worry, which may increase the risks of experiencing depression, and this can be exacerbated by cultural factors, such as language barriers which may cause difficulty in diagnosing and treating this disorder among immigrant populations (Landa, Skritskaya, Nicasio, Humensky, & Lewis-Fernández, 2015). Failure to determine appropriately the views of social workers on depression within a certain community translates to neglecting social health and welfare (Baldwin-Clark, Ofahengaue Vakalahi, & Anderson, 2016). In response, the intent of this study is to obtain the perspective of social workers regarding depression within the selected migrant population as well as insights into the ways in which professionals in the healthcare sector can help meet emerging needs.

Purpose of the Study

In this study, the views of social workers regarding depression in older immigrant African women in Metro West Massachusetts will be obtained. Through analyzing these perspectives, insights can be provided into ways the social workers sector can assist to meet the emerging needs of the population. Expected in the results of this study will be any service modification needed to meet the needs of the immigrant African women located in Metro West Massachusetts (Takeuchi, 2016). These findings can enhance access to quality mental health services and ensure the women understand the implications of not seeking mental health services. Having examined the stressors faced by the migrant women, insights will be gained into the issues the women face within the population and solutions directly targeted to the population can be developed (Agbemenu, 2016). Social workers will also benefit as they will use the findings of this study to determine methods they can use to reach out to the population under study.

Research Questions

Focused upon in this study will be the following research questions:

1. From the social work perspective, what factors influence older immigrant African women’s adaptive capacity in Metro West Massachusetts?

2. From the social work perspective, what mental health services do social workers offer to older immigrant African women in Metro West Massachusetts?

3. How do social workers assess the need for mental health services for their clientele, particularly to older immigrant African women in Metro West Massachusetts?

4. What service modifications can social workers introduce in practice to enhance mental health service delivery for older immigrant African women in Metro West Massachusetts?

Definition of Key Terms

1. Culturally informed - Culturally informed is defined as the offering of care by healthcare professionals that respects, acknowledges, and integrates the patient's cultural values, practices, and beliefs. In our study, culture extends beyond identifying the patient and family by race and ethnicity to include variables like faith, country of origin, education level, socioeconomic status, and level of acculturation. In this study culturally informed refers to the ability of the social workers to offer services that recognize, affirm, and value the worth of the clients, their families, communities, and preserves and protects their dignity.

1. Older immigrant African women - Older immigrant African women refers to women who are over 55 years of age and they relocated from any African country to the United States. The women could have come to the US legally or illegally. The phrase also refers to women who came to the US as refugees and they have remained there till their advanced age. For this study, the focus will be on older immigrant African women who live in West Massachusetts and suffer from depression.

1. Immigrant - According to the Oxford University Press (n.d.-b), an immigrant is defined as a person who comes to permanently live in a foreign country. There are four types of immigration status namely citizens, residents, undocumented, and non-immigrants. In this paper the focus will not be on the status of the immigrant, but we expect the status of the immigrant to contribute to how the immigrant access mental health services. Therefore, the study will consider all immigrants provided they immigrated from Africa and they have been living in the selected community.

1. African women - African women refers to a native or inhabitant woman of Africa or a woman who has African ancestry. In this study, African women refers to the older immigrant African women who were born outside of US in Africa and they had to migrate to the US either legally or illegally and they currently reside in West Massachusetts. The women will have lived almost half their life in Africa before they immigrated to the US.

1. Coping mechanisms - Coping mechanism is defined as "an adaptation to the environmental stress based on the conscious and unconscious choice and that enhances control over behavior." In the study, coping mechanism refers to the different cultural strategies used by the women and to deal with the stressful situations they encounter. The methods the women will use to adjust to the stress they face and assist them to maintain their emotional well-being.

1. Migration - Migration is the movement of people or animals from one place to another. In the study, migration refers to the movement of people from any African country to the United States. The focus will only be on the women who have migrated from Africa to the US either alone, with their family, or with a relative and they are currently living in West Massachusetts. The process of the women migrating will not be a major focus, but it can be relied upon to determine if it contributes to the women failing to access mental health services.

1. Host country - According to the Oxford University Press (n.d.-a), a host country is a country that holds a cultural event or sporting event to which others are invited. In this study, host country refers to the country that is accommodating the African immigrants or where the immigrants are living, which is the US.

Significance of the Study

The findings of this study will contribute new knowledge to address the gap in research regarding depression in older immigrant African women residing in Metro West Massachusetts. Findings will offer insights into ways social workers can meet the emerging needs of this population. The study results will assist the community social workers to better address the emerging needs and challenges older immigrant African women face when accessing mental health services. More specifically, the study will focus on how the target population is affected by depression when there are barriers to them receiving support. Findings in the study will equip social workers with the knowledge to develop strategies they can use to treat depression and bring awareness to the unique needs of the older immigrant African women.

Theoretical Framework

The theoretical framework that can be used to frame this project is the Structural-Functional Theory. Some theorists such as Cassel (1995) and Cobb (1976) expressed social support serves as a resistance factor, and plays an important role in reducing adverse impact of exposure to negative life events (Thoits, 1985). This theory should play a key role in understanding the onset of depression among older immigrant African women, given the various social demands associated with being a migrant. Further, Kinser and Lyon (2014) emphasized that depressing experiences may increase a person’s possibility to suffer from stressful episodes. Stress and vulnerability add up to the possibility of developing depression, where changes in the environment, lack of coping mechanisms and lack of support have an adverse impact on the mental health outcome of this group (Alegría et al., 2017). Cultural influences can be revealed that will be vital in determining the methods that can be used to treat this population. To become culturally competent when dealing with this population, social workers would need to be familiar with the Structural-Functional Theory. Explained in this theory is why society functions the way it does, and it emphasizes on the relationships between the different social institutions that make up society (Emadpoor, Lavasani, & Shahcheraghi, 2016). Some of these social institutions are education, law, government, religion, and culture. The social worker should understand society is like a system where all the parts will work together to create a whole society. Emadpoor et al. (2016) posit societies will need culture for them to function. Therefore, being culturally informed is beneficial to the social worker and it will allow them to reach out to the community members and approach them in an acceptable manner (Sabbioni et al., 2018).

Review of Professional and Academic Literature

From the review conducted, a lack of literature exists in which the primary focus was placed on older African immigrant women (Okudo & Ross, 2016). This shortage is due to numerous factors that mostly involve with the perception that African immigrants have regarding depression (Thomson, Chaze, George, & Guruge, 2015). Most times, depressed individuals are stigmatized, and most African communities believe depression is caused by bad spirits. With this notion it becomes difficult for the women to seek professional health services as they would be labelled and judged by other community members harshly (Sánchez et al., 2014). For this study, search was conducted for peer-reviewed publications focusing on mental health among older African immigrant women, from the following sources, MEDLINE, PsycINFO, CINAHL, EBSCO, Research Gate, ProQuest, SAGE Journals, and EMBASE. The keyword(s) used to search for the appropriate literature for this study was older African American women, older immigrant African women, depression in immigrant African women, depression, and older immigrant women.

Cultural Competence

Okudo and Ross (2016) offered information on the various health challenges that African Immigrants from different parts of Africa face when they relocate to the US over time and the exploration of the healthy immigrant effect (HIE) When African immigrants relocate to the US, they are healthier than their American counterparts due to HIE. However, as the immigrants acclimatize into the US system, they will adopt the unhealthy lifestyles and behaviors of the US, which leads to them developing lifestyle diseases they would not have developed had they not relocated to the US. This article is significant as it supports our study by offering insights into the change immigrants undergo regarding their health and how this population is neglected by physicians. Without understanding the peculiarities pertaining to the African immigrant population, physicians cannot offer culturally useful care to the immigrants. The significance of this article is that we can use the information to determine if social workers make use of culturally acceptable practices when treating older immigrant African women.

Sánchez et al. (2014) identified the most commonly occurring mental health disorders are depression and anxiety. The authors also note there is disparity in the quality of care given and in their access to mental health services. The role of culture and stigmatization was explored in the study. This article indicates there are mental health care disparities experienced by immigrants due to insufficient mental health services in their communities, lack of cultural competency, and mental health stigmatization. With this information is becomes clear as to why many African immigrants do not receive or seek mental health services. Understanding how to overcome some of these barriers will assist in reducing the cases of depression among older African immigrant women in the community.

As noted by Delara (2016) the mental health of African immigrant women is affected by social, cultural, and the health care system and there is a need to embrace different methodologies for promoting mental health among the women. According to Delara (2016) the mere fact a woman is a migrant makes her more vulnerable to negative and positive mental effects of migration. The effects felt by the woman will be dependent on their legal status, stage of migration cycle, and mode of travel. The authors note the immigration process could be traumatizing for most women especially if the women had to seek clandestine means to arrive in the US. Asking these women repetitive questions regarding their immigrant victimization could bring about mental disorders like depression. The women could also avoid seeking mental health services as they fear being asked questions about their immigration experience. Older immigrant African women have been found to experience problems of isolation, language, abuse, culture, and mobility. These problems hinder their access to mental health services. The relevance of this article is that is shows the problems older immigrant women face and the reasons why they fail to seek professional mental health services.

Mental Health of Immigrants

Rashid and Gregory (2014) focused on the experiences of African Immigrant women with a focus on their life before and after their relocation. Rashid and Gregory (2014) have demonstrated African immigrant women face numerous challenges when they relocate to the US. However, there are women who have managed to overcome the challenges and withstand the adversity they faced. It is vital to know why some older immigrant African women will suffer from depression while others will not. This article offers vital information on how some of the women managed their relocation and avoided developing depression, which could be used by other African immigrant women when they relocate to the US.

Thomson et al. (2015) the relocation process can impact the mental health of immigrants and without information on mental health and helpful services many immigrants are denied access to mental health services. The authors noted immigrants are underrepresented in the mental healthcare system and they underutilize mental health services. Barriers to service utilization play a key role in older immigrant African women. This article notes economic hardships faced by the immigrants affect their mental health and access to mental health services. For this study, this article is relevant as it allows us to understand why most immigrants do not access mental health services and why they suffer from depression. The three major barriers noted by the authors are barriers in the uptake of health information and services, inadequacy of linguistically and culturally appropriate services, and barriers related to the settlement experience. The researcher wants to determine if these are the same barriers faced by the older immigrant African women in West Massachusetts.

Depression Among Older African Immigrant Women

Baldwin-Clark et al. (2016) noted depression is a major problem among older African immigrant women and since they are understudied, their depression is rarely discussed or researched. The lack of relevant research focusing on older immigrant African women is an indication the prevalence rates of depression might be higher than what is thought. The focus of most depression studies has been White older adults. It is rare to find African immigrants making use of healthcare, social services, and long-term care and the reason is they lack awareness of the resources, limited financial resources, differences in the interpretation of mental health issues, and mistrust of the systems. This study is beneficial to our current study as it focuses on older immigrant African women. The authors have demonstrated the reason why mental health services are not accessed by the women and strategies to use to encourage the women to access the services. Understanding why they fail to access the services is beneficial to our study as it will assist the researcher to formulate questions to the social workers aimed at establishing if these are the same issues faced by the population under study.

Lazar-Neto, Louzada, de Moura, Calixto, and Castro (2018) assessed the frequency of depression among immigrants living in Massachusetts to determine correlates of depression. The authors demonstrate that most immigrants do suffer from depression. By analyzing Brazilian immigrants who have relocated to Massachusetts, the authors indicate the migrants encounter the same barriers as those faced by older immigrant African women. Therefore, the problem of access to mental health services could be due to systemic issues and not the migrants themselves. Understanding what hinders migrants from accessing or seeking mental health services will be beneficial to the communities as those problems can be eliminated. This article enables the researcher to determine the access of mental health services by different migrants within the same state.

While it might be easy to state the failure to access is due to a lack of knowledge by the migrants, there are other issues like cultural preferences and lack of services. Immigrants from Africa and Brazil face the same language barriers where they are not competent in English, which results in them failing to understand what physicians or mental health professionals are recommending or advising. Culture plays a key role in the treatment of migrants. Therefore, cultural competency should be analyzed to establish if the social workers are culturally aware or if they understand the role of culture when it comes to treating or dealing with immigrants. The significance of this article is that immigrants seem to share the same experiences when it comes to depression once they relocate to the US. Therefore, there is a need to investigate the issues surrounding mental health services in the communities and establish the reasons behind the discriminatory access to the services.

Stressors faced by Older African Immigrant Women

Stressors faced by African immigrants and refugees when they relocate to the United States were analyzed by Li, Liddell, and Nickerson (2016). The authors link the stressors to the development of depression. Many immigrants face social and interpersonal challenges when they migrate to a new country. Some of the social and interpersonal difficulties include separation from family, social isolation, and discrimination in the host country. Another difficulty posited by Li et al. (2016) is loss of social identity tied with their former cultural and community groups. These difficulties will lead to depression symptoms in the older immigrant African women. The article by Li et al. (2016) increases the knowledge on the development of depression among immigrant women and the underlying causes of the symptoms. The authors have gone further to demonstrate the strategies employed by most of the immigrants to reduce the symptoms of depression, which would be significant for our study as we can question if the same strategies could be applied to the population under study. The post-migration factors affecting mental health in migrants should be closely analyzed. Adding to the current information we have regarding the stressors and issues faced by immigrants, the authors have demonstrated there is need to not only consider the pre-migration factors, but the post-migration factors as well. Post-migration factors have been found to be high contributors to the immigrants developing depressive symptoms and failing to seek mental health services.

Foo et al. (2018) was analyzing the extent of depression among immigrants and explored the variations on prevalence based on demographic and educational factors. When older immigrant African women have to assimilate to new cultural practices and surroundings, they develop acculturative stress, which leads to the development of depression. The authors wanted to examine the link between migration and development of depression. The article has noted that the early post-migration phase is highly attributed with increased levels of acculturative stress, which tend to reduce as the immigrant settles down in the host country. The increased levels of acculturative stress could lead to increase mental distress and if not properly treated could result in depression later on in life. However, the authors have noted there is no relation between migration and development of depression since once the immigrant is well acclimatized with the new environment they will adapt and settle down to the new culture. The adjustment period involves adjustment of cultural values and social networks, which leads to confusion and development of depression. The lack of social support is shown as a huge contributor towards the development of depression later on in life as the older immigrant will be lonely, and she will not have the social support she would have in her home country.

Ekwemalor and Ezeobele (2020) explored the portrayal of depression among Nigerian-born immigrant women who were living in the United States. When moving from a patriarchal culture to a more democratic one can be challenging for immigrants. With limited knowledge of what services are available to the immigrants and the culture of being secretive denies most migrants the opportunity to receive assistance with mental health problems. Disruption of the traditional family structure is one of the effects of migrating to the US. Family structure as it is known back in African is not the same and this causes distress to the women who are used to socialization between the extended family members. When Nigerian migrants are faced with stressful situations they can be guarded in their interactions and they will not divulge information. Therefore, there is need for cultural competence on the part of the social workers. Without cultural competence, the social workers will not get through to the immigrants and they will continue suffering in silence. Cultural expectations play a key role when it comes to mental health problems like depression. The beliefs they had back home will be harbored in the host country and the women will not want to hear they have been diagnosed with depression. In the study conducted by Ekwemalor and Ezeobele (2020), the researchers established that most Nigerian Women who have immigrated to the U.S. label depression as craziness or madness. One participant stated that ‘You people in the U.S. call it depression; we call it madness in Nigeria.’ This shows the level of stigma that one would have if they were to be diagnosed with depression and they happen to come from Nigeria. The authors have proposed the use of conversational style of interview to assist in relaxing the Nigerian immigrants when they are undergoing their health assessment. Using conversational style interviews will break the cultural shield an allow the women to disclose their health conditions.

Summary

The professional and academic literature indicate older immigrant African women do not receive adequate mental health services. There are systemic and cultural barriers promoting the lack of access to mental health services, which should be investigated further. Identifying the missing links only is not enough and there should be investigation on how to overcome the barriers and make it easier for the women to access mental health services. The studies under review have all confirmed there is a discrepancy when it comes to access and usage of mental health services among the elderly women. Most immigrants will come to the USA healthy and they will only begin developing these lifestyle diseases due to the challenges they face after relocation. Social workers interact closely with the immigrants and they can offer vital insights to how the immigrants make use of the available mental health services. The lack of services can also be confirmed by the social workers as they are charged with offering the available services to the population. The key point to the review of the literature is the genuine lack of focus on the social workers. Most researchers have pointed out the impact of immigration and how African immigrants begin developing depression and other mental health issues. However, the lack of information on access to mental health services is a gap the researcher would like to fill by conducting the present study.

Section 2: Research Design and Data Collection

Research Design

Nature of the Study

This will be an exploratory study with the aim of uncovering the views of social workers who work with immigrant African women located in Metro West Massachusetts. The focus of the study is to gain insights into the barriers older immigrant African women face in accessing mental health resources, which will also include an analysis of the availability of those resources. Due to their understanding of and interaction with this population, the views of the social workers will be examined to ensure the information being presented is reliable. Social workers are responsible for addressing the health challenges that this community faces. With this in mind, vital insights can be revealed by interviewing and gaining their perspective regarding the current situation. The views expressed by the social workers should be analyzed to determine the effect of depression among older immigrant African women. The source of information for this study will come from the responses obtained from the individual interviews with each social worker. Secondary data will come from documents and archival data. The epistemology of this study will focus on exploring the experiences of social workers working with older African immigrant women living in Metro West Massachusetts. Social workers working in the community for 3 or more years, are graduate level social workers or higher, female, and are over 30 years of age will be used for this study. Exclusions will include social workers who meet the above criteria but have not worked with older African immigrants. This inclusion process will ensure experienced social workers are providing information relevant to the study.

The interviews will be audio recorded and the interviewer will be taking notes as the interview progresses. Transcription will be the first step of data analysis where all audio recorded interviews will be written down and typed into a word document. This researcher will use transcription to develop codes to use before the data is entered into the system. For this study, the researcher will make use of SPSS Statistics software to analyze the data. Data analysis will be conducted by independent analysts who will not be privy to the participant information (Scheider, Ostermann, & Adams, 2017). The analysis will be used to verify the data collected from social workers by identifying differences and similarities from the views expressed by the social workers.

Methodology

Data Types and Sources of Information

The data types of the study will be qualitative as the researchers will rely on interviews with the social workers using internet services like GoToMeeting, skype, Zoom, or any other web-based service. Experienced social workers have the ability to understand their clients and they can educate us on the impact of culture on the women's depression. To conduct the research, samples will be selected from social workers who are currently serving the MetroWest MA region, a prior place of employment. This researcher will post flyers around mental health offices, retirement homes, and hospitals inviting social workers to participate in the study. Additional method will be handing out flyers to social workers attending conventions, trainings, and programs within the area. The social workers will also be requested to answer certain questions about the role they play in ensuring the availability of mental health services to the population as well as service modifications that can help improve health delivery. For example, how do you ensure elderly African immigrant women are able to access mental health services? The data collection process will rely on internet services like GoToMeeting, skype, Zoom, or any other web-based service to conduct the interviews, where 10 questions are developed to probe for relevant information from 10-12 social workers working with elderly immigrants in West Massachusetts. As is the case in other studies we foresee there might be some social workers who will leave the study early or might not be interviewed due to time constraints. The GoToMeeting, skype, or Zoom interview will last approximately 45 minutes to one hour. To ensure the interviewees will be comfortable during the interview process, this researcher will propose conducting the interviews in the social worker's office during their lunch break or another agreed upon space where all information obtained could be kept confidential.

This study will make use of quota sampling, because we have identified the characteristics of participants to be included in the study. Quota sampling is similar to purposive sampling with the only difference being that in quota sampling the researcher decides on the number of participants and the characteristics they are looking for in the participants. In purposive sampling, the participants are grouped to a preselected criterion. The sample sizes are not fixed on purposive sampling as they are in quota sampling. The characteristics used in quota sampling are age, gender, class, residence, profession, experience, or marital status. By using the quota sampling strategy, this researcher will focus on the social workers who would be most likely to have experience working with older African immigrants, know about depression in the community, and have vital insights into the research topic. The researcher chose quota sampling as the researcher has a specific criterion of the participants he would like to have for the study.

Social workers operate on a daily basis interacting with different people in the community. They handle numerous cases, and they are at the forefront of the community initiatives regarding healthcare. This makes them the best candidates for our study as they deal with different clients and they handle cases of depression. Interviewing the social workers will offer the researcher information on the prevalence of depression and understand why it is not highly reported. By understanding the impact of culture, the social workers can treat the women without them realizing they are being treated for depression. Social workers will also offer vital insights and give depth to our study as they will be willing to discuss depression in the community as compared to the women themselves. Social workers are in a strategic position to interact even with people who had not come to their facility for depression. Being able to spot an issue gives them the edge to initiate conversation with a woman who looks depressed. Social workers are charged with visiting the members of the community in their households, which gives them an advantage as they can check up on the older women and discuss with them about how they are feeling. Making these visits, the social worker can discover cases of depression that remain undiagnosed.

The projected number of study participants is 10-12 social workers who have been working in the Metro West Massachusetts area for a minimum of three years. The researcher has determined that working with this number of social workers would be representative of the population under study as there are around 120 social workers in the area. With a large sample size, the researcher will spend too much time conducting the interviews and performing data analysis (Okudo & Ross, 2016). It would be unethical to select a large sample size because the researcher might end up being unable to interview all the participants. Also, there is a possibility that this researcher will be pressed for time and opt to shorten the interview timeline. This will result in unclear answers and the research study would be affected.

Data Analysis

All the interviews will be audio recorded and transcribed verbatim. This will protect against bias and will provide a permanent record of what the interviewer said. The interviewee will make field notes during the interview indicating the observations they have noted, thoughts, and opinion about the interview. Observations like body language and general composure of the interviewee is vital as it gives a picture of how the interview process was conducted. All this information can be helpful in the data analysis process. Data analysis comes after all the interviews have been completed. It is possible that the interviewer might feel they have a fairly good idea about what people have told them and one might be eager to begin implementing the insights they have gained. However, there is need to do a proper analysis to ensure there is validity of the results. The interviewer might have preconceived assumptions of what they expect to uncover from the interviewees. With a proper analysis, these biases are eliminated and there is a systematic and thorough analysis conducted. Data analysis gives others a way of understanding exactly how the researcher reached their various conclusions and makes the results much more trustworthy. Since the researcher will be conducting semi-structured interviews, he will make use of thematic analysis of the data. Thematic analysis is flexible and can be used for explorative studies where there are no clear patterns being searched for. The steps for a thematic analysis are familiarization with the data, assigning preliminary codes for describing the content, searching for patterns in the codes, reviewing themes, defining, and naming themes, and producing the report.

At this point, transcription is done of the audio recordings that will allow for the researcher to work with the data. The researcher will then go through all the data from the entire interview process and begin taking notes. It is at this point that the researcher will begin making preliminary ideas for codes they can describe from the content. The amount of data that is transcribed will depend on what the researcher is looking for. The second step will be generating the initial codes from the data collected. A code is a brief description of what the interviewee said during the interview. So, every time something interesting is noted, the researcher will write down a code. A code is a description not an interpretation. It will be the researcher’s way of organizing the data into meaningful groups. This study will be exploratory, which means the codes will depend on the data. Initially, the researcher will have to code for as many interesting themes as he possibly can, to ensure that he does not lose too much of the context.

In the third phase the researcher will begin to sort the codes into themes. Themes will involve active interpretation of the data and codes. The researcher will begin by looking at the list of codes and the associated extracts. Then he will collate the codes into broader themes that will say something interesting regarding the data. The process of searching for themes is an iterative process where the researcher will be moving back and forth to try and form different themes. There are some codes that will seem redundant, which can be placed in a temporary mixed theme. Codes that do not fit anywhere should not be thrown away at this point, they might be of interest later. Phase 4 will involve the reviewing of themes. The themes the researcher identified in phase 3 will be reviewed. This will be done through the reading of all the extracts that are related to the codes to explore if they support the theme. The researcher will also aim at determining if there are any contradictions and theme overlap. If a theme is too broad, it will be split into separate themes. The researcher might also have to move some of the codes into existing themes where they are better suited. This process will be done until the researcher feels he has a set of themes that are distinctive and coherent. The researcher will have to do the same process for the entire data set. This is done to ensure the study has themes that adequately represent the interesting themes from the interviews. At this phase, the researcher might discover new themes that had been missed before. Since this is an iterative process, the researcher will keep going back and forth between themes perfecting the themes endlessly. When the researcher can no longer add anything significant to the analysis, they can now finish reviewing the themes.

Phase five involves defining and naming of the themes we identified in the previous steps. The name of the themes should be descriptive and it if possible engaging. When the researcher will be giving the theme description, he will not only describe what the theme is about, but he will also describe what is interesting about the theme. The story that each theme tells will be uncovered and how the story relates to the other themes and to the overall research question. When the researcher gets to this point, he should be able to tell a coherent story about a theme. If the researcher finds that a theme is too complex to tell a coherent story, he might have to revisit phase 4 to rework the theme. The final phase is report production. When writing the final report, the researcher will strive to ensure there is enough information regarding the study and process for the reader to evaluate the quality of the research. To achieve this, the researcher will have to write up a clear account of what was done when they were carrying out the research and the analysis. The researcher will aim to use quotes of what some of the participants said to demonstrate the findings. The job will be to make the participants feel real to the people reading the findings, while at the same time respecting the participants right to privacy.

As discussed in previous chapters, it is vital to ensure that the study is reliable and valid. Towards this, the researcher will make sure during the data analysis process, they will conduct the analysis by following all the required steps of analysis and to maintain a high level of objectivity. the researcher might have his/her preconceived assumptions regarding the study and these have a way of creeping up on them as they perform the data analysis. By adhering to the steps laid down for thematic analysis, the researcher will eliminate the preconceived assumptions they might be harboring, which will give the study the validity it needs. Also, by documenting the processes that the researcher has undertaken for data analysis and collection they can manage to demonstrate to the reader that they remained objective in the data collection and analysis. Giving a step-by-step representation of what will be done ensures the reader can follow the researcher through the journey and they will feel confident the researcher has conducted the study with the utmost credibility. The researcher intends to offer all the information regarding the study including the number of social workers, the selection criteria, and questions asked during the interview. This information will give the study the reliability and validity needed. In the final report the researcher will provide information on how the analysis was carried out, which will allow a person to replicate the study and confirm its validity.

The researcher is certain with the information they will offer it is possible for the same results to be achieved if a researcher was to make use of the same methods under the same conditions. The researcher will have an outside researcher to conduct an inquiry audit for our study. The independent researcher will have a look at the process of data collection, data analysis, and results of our study to determine the accuracy of our findings. By using an external audit, the researcher will give this study the dependability that it needs. It will also confirm the findings of the study are consistent and repeatable. The researcher would be involving an external auditor to ensure that if other researchers were to look over the data they would arrive at the same conclusions. The external researcher will also point out something the researcher might have missed in the study. The external researcher will challenge, explore, and examine how data analysis and interpretation took place.

Trustworthiness of a study is determined by credibility, transferability, confirmability, and dependability. Credibility refers to how confident the researcher is in the truth of the study findings. The researcher will use triangulation to demonstrate the study findings are credible. Transferability determines how the researcher demonstrates the findings of the study to be applicable to other contexts. The researcher will use thick description to demonstrate the study findings can be applied to other contexts, situations, and circumstances. Confirmability is the degree neutrality in the study findings. This indicates the study findings are based on the responses from the participants and not from any potential bias of the researcher. To establish confirmability, the researcher will provide an audit trail that will highlight every step of data analysis that they made to provide a rationale for the decisions made. Dependability is the extent to which the study can be repeated by others and they will find the same results. The researcher will give out enough information from the study for other researchers who are interested in replicating the study to be able to do so. To ensure dependability the researcher will make use of inquiry audit.

Ethical Procedures

Any research that involves human subjects, has interaction or intervention that involves human subjects, or involves the access to identifiable private information should undergo an Institutional Review Board (IRB) review and approval (Wolf, Clayton, & Lawrenz, 2018). For this study, the researcher plans on interviewing social workers, which indicates that the researcher will be involving human subjects in the study. Therefore, the researcher is required to undertake an IRB review and cannot begin the study before receiving the IRB approval number. The IRB Approval is a federal requirement put in place to safeguard human subjects who are involved in any research study. The Tuskegee Syphilis study was the underlying reason why there was requirement that before human subjects are involved in any research study, the researchers must seek approval from the board to ensure that they have put in place measures for safeguarding the interests of the participants. The Tuskegee Syphilis study had numerous ethical violations that necessitated for the involvement of an independent board to oversee research studies that involve human subjects.

Any research study that involves human subjects must seek informed consent from the study participants before the study begins (Wolf et al., 2018). There should be both a written and verbal consent for participation in the research. As researchers, we are charged with educating and informing the potential study participants about the research study and the role they will play in the study. We understand that the information we will share with the participants might be complex or distressful and the participants might need some time to absorb all the information (Biros, 2018). Towards this the researcher will give the participants at least 48 hours to review the information provided before they can sign off on participation. The researcher will avail himself to the potential research participants to answer any questions they might have. Ensuring the study participants receive all the assistance and support they need before they append their signatures on the consent form. Verbal consent can only be allowed with the approval of the IRB (Biros, 2018). In this case the researcher will not be required to have signed consent forms from the study participants. The process for verbal consent has three steps. The first step involves the researcher explaining to the potential study subjects verbally information pertaining to study purpose, procedures, benefits, risks, and alternatives to participation. The researcher is required to give the potential subjects ample time to process the information and ask question. The potential subjects should be encouraged to ask question to ensure that they have understood what the study pertains. The second step is where the potential subject is given a study information sheet. The potential study subjects are given ample time to consider if they are willing to participate or not. The timeline can range from minutes to hours. The time given depends on how much one considers to be reasonable time for the potential subjects to evaluate the procedures, benefits, risks, and alternatives. The final step is where the researcher will answer any further questions that the potential subjects might have and once, they are satisfied they can offer their verbal agreement to participate in the study.

Written consent is not just about receiving a signature from the participant. The process is similar to the one for verbal consent. However, for written consent, the researcher must provide the consent document to the potential subjects before they begin the discussion. The consent document will be a guide for the researcher to explain to the potential subjects all information pertaining to the research study. The informed consent process involves giving the subject adequate time to review the information given and the potential subject is given adequate time to consider all options. The researcher is required to answer all the questions posed by the potential subject to clarify anything that is not clear. It is vital that the researcher ensures the potential subject comprehends all the information. There should be ample time given for the researcher and the subject to exchange information and ask questions. Once the potential subject is certain about the information they might be given further time to review the information before they are allowed to sign the consent form (Liu, Zeng, Deng, & Zhou, 2018). Written consent involves three steps as the ones for verbal consent. The only difference is that for the written consent the potential subject is given a written consent form. Once the subject is certain they are willing to participate they will sign the form and hand it back to the researcher.

Summary

The data collection will be done using online interviews through internet services like GoToMeeting, skype, Zoom, or any other web-based service, and the study participants will comprise of 10-12 social workers working in Metro West Massachusetts. The idea is to only interview social workers as they will offer vital insights into the information, we seek like services available, cultural competence of the social workers, and access to the services by the women. All the interviews will be recorded to aid in transcription during the data analysis process. The researcher aims to uncover patterns and make codes for use in the themes to be discovered. During the data analysis process, the researcher will familiarize himself with the data, assign preliminary codes for describing the content, search for patterns in the codes, review the themes, define and name themes, and produce the report. These steps will flow systemically ensuring the researcher does not miss anything vital. Once the data analysis process is completed, the researcher will move to the presentation of his findings. In this stage the researcher will describe the findings uncovered and report on the interesting things they discovered from the data.

Limitations, Challenges, and/or Barriers

Recruiting of the social workers will be a huge challenge for this research mainly due to having no prior relationship with prospective participants. Getting them to trust the researcher will be an uphill task as the nature of their work is sensitive and their discomfort sharing patient information. Another challenge is time limitation, as the social workers might be unavailable for the interviews. Another challenge that might occur is some social workers might have an emergency and, as a result, might have to cancel their interview. This will result in attrition and reduce the number of study participants. This researcher estimates he will have an attrition of less than 5%, which will not have a huge impact on the study results. However, if the researcher notices the attrition is higher than 6% then there is a possibility of attrition bias. To reduce or eliminate attrition bias, the researcher proposes to follow-up with the study participants who cancelled their interviews and encourage them to reschedule the interview. Face-to-face interviews may not be feasible due to COVID 19. To overcome this challenge the researcher proposes to make use of internet services like GoToMeeting, skype, Zoom, or any other web-based service. Some social workers may not be familiar with these technologies.

Summary

According to Saeidimehr, Geravandi, Izadmehr, and Mohammadi (2016), reducing the causes of depression is beneficial to society due to a reduced number of people who need mental health services or are living with mental conditions. Results from this investigation can benefit the social workers as they will get insights into strategies, they can use to assist older immigrant African women who are suffering with depression to get mental health services. This study aims to uncover the cultural influences faced by social workers when working with this population. By understanding the impact culture has on the community, social workers can develop strategies they will use to become culturally competent.

Section 3: Presentation of the Findings

The study aims to get the views of social workers regarding depression in older immigrant African women in Metro West Massachusetts. The perspectives of the social workers will offer insights into ways the older immigrant women can be assisted. The study results can offer service modification suggestions and enhance access to quality mental health services. The research questions focus on the factors that influence older immigrant African women adaptive capacity, the mental health services offered by the social workers to the older immigrant women, how social workers assess the mental health services needs for the older immigrant women, and service modifications social workers can introduce to their practice to enhance service delivery. Data for this study will be collected using interviews with the social workers. All interviews will be conducted using internet services like GoToMeeting, Skype, Zoom, or any other web-based service due to the current Covid-19 pandemic. The social workers were asked ten questions probing them for relevant information, and the study population comprised 11 social workers working with elderly immigrants in West Massachusetts. The researcher will start by describing the data analysis techniques used in the study and then present the study's findings.

Data Analysis Techniques

The social workers' schedules differed, and this researcher has to work around the social worker's schedules. Therefore, the time frame for data collection was initially set to two weeks. However, there was a possibility of extending this time frame to accommodate those participants who might have missed their initial time slots. The social workers' recruitment was conducted using fliers posted around mental health offices, hospitals, and retirement homes, inviting social workers to participate in the study. Another method used to recruit participants was handing out flyers to social workers attending training, conventions, and programs around Metro West Massachusetts. It is estimated there might be a high number of interested study participants, and this researcher will have to review all the study participants to determine those who are qualified or meet the criteria of the study. Only social workers who have experience working with older African immigrants, know about depression in the community, and have vital insights into the research topic will be considered for participation in the study.

Quota sampling will be used as the researcher has a specific criterion of the participants he would like to have for the study (Etikan & Bala, 2017). Social workers who show interest in the study will be requested to provide information regarding the number of years worked in the area, the clientele they work with the most, and the vital insights they might bring to the study. The researcher will have to reduce the number of study participants to ensure he will have adequate time to interview the proposed number and get adequate social workers' information. Since quota sampling will be used, the researcher will select the participants based on the characteristics he is looking for from the social workers. Sample sizes are fixed in quota sampling, and there is no room for increasing the number of participants.

The projected number of study participants is between 10-12 social workers. The researcher has determined this is a representative number as about 120 social workers are working in the area. Due to time restrictions, it is not possible to have more than 12 social workers. The time taken to code and perform data analysis would prolong the study duration and result in unclear answers. Interviewing the participants will take the bulk of time, and scheduling interviews with more than 12 participants can result in the researcher failing to interview them.

All the interviews will be conducted using internet services like GoToMeeting, Skype, Zoom, or any other web-based service and recorded. After each interview, the researcher will transcribe the interview verbatim, which will protect against bias and provide a permanent record of what the interviewee said. The interviewer will be making field notes as the interview progresses, noting the interviewee's body language, thoughts, and opinions regarding the interview. Body language is vital as it offers a picture of how the interview process was conducted and the interviewee's feelings, which is vital in data analysis (Farooq & De Villiers, 2017). The study will use semi-structured interviews, and the researcher can use thematic analysis of the data. There are no clear patterns expected or identified before the study commenced. Therefore, using thematic analysis, the researcher can uncover themes they can use for their study (Castleberry & Nolen, 2018). To begin the analysis, the researcher will familiarize themself with the data. Familiarization involves transcribing the audio, reading the text and taking notes, and generally looking through the data. Without familiarization, the researcher will find it hard to understand the data and struggle to perform the analysis. The second step is coding, where the researcher highlights sections of the text they find interesting or jumps out from the interview. The researcher will create shorthand labels (codes) describing the highlighted phrases or sentences (Castleberry & Nolen, 2018). The researcher has to go through each interview transcript and highlight all those phrases or sentences that seem interesting or relevant to the study. The researcher can keep on adding new codes as they go through the text. All the data will be collated into groups based on the identified codes.

The third step is generating themes. During this phase, the researcher will go over the identified codes, identify patterns, and begin generating themes. Themes will comprise several codes. Some of the identified codes can be discarded if they are deemed vague or not relevant enough. Some codes might be converted into themes. The themes identified will offer more information about the data for the research. Next, we review themes to ensure they accurately represent the data. The researcher will return to the data set and compare the identified themes against the data set. The objective is to ensure nothing is missing and all the vital information has been captured. The researcher has to ensure the themes represent the data. Themes can be modified, discarded, or combined, ensuring they are valuable and accurate.

The identified themes will then be defined. Defining involves formulating what each theme means and determining how it assists the researcher in understanding the data. After the definition is done for the themes, each theme will be given a succinct name and can be easily understood. Finally, the researcher will write up their report on the analysis of data.

The researcher will make use of peer de-briefers or peer debriefing to establish the validity of the study (Cheng et al., 2017). Using peer debriefing, this researcher will ensure they collected valid information. The researcher will work with one of his colleagues who is not involved in the study and holds impartial views regarding the study. The peer will examine the study transcripts, general methodology, and final report. They will then offer feedback to the researcher, enhancing validity and credibility (Cheng et al., 2017). The peer can detect overemphasized points, underemphasized points, vague descriptions, biases made by the researcher, and general data errors. The peer de-briefer can assist the researcher in becoming aware of his views on the data. The researcher will determine the debriefing schedule, and the best schedule will involve sharing of information regularly after vital tasks have been achieved.

Due to the Covid-19 pandemic, the researcher was forced to use internet services to conduct the interviews. With internet services like GoToMeeting, Skype, or Zoom, technical challenges could occur like loss of internet connection or computer problems. The researcher has to persevere through them, and in the worst cases, the interviews could be rescheduled to a later date or time. It is not easy to gauge body language when conducting an interview online. The main area the interviewer will see is the face, and this might not offer much information as would have been possible if the interview was conducted face-to-face (Farooq & De Villiers, 2017). Another challenge was the lack of personal touch available when conducting an interview face-to-face. There was a general disconnect between the interviewer and the interviewee, which could affect the study results. The social workers could find it hard to concentrate on the online interviews since they are not used to them, and the nature of their work requires them to have a physical presence when dealing with a client.

Findings

The researcher will look out for patterns and characteristics in the datasets. The researcher will make investigations on the data to discover anomalies and check for assumptions with the help of graphical representations. They are looking out for common patterns within the social workers' responses to achieve the research objectives and aims. All collected data will be keyed into a computer program, and for this study, the researcher will use SPSS software to analyze the data. Since the researcher shall be using online interviews, all the interview answers will be converted into codes before entering into the system. Data analysis will then be conducted by independent analysts who will not be privy to the participant information. The researcher aims to uncover the differences and similarities in the data collected from the interviews conducted. The study results will be presented in tables and figures for ease of reading and presentation. The results will answer the research questions proposed, and vital insights will be gained from the data.

Section 4: Application to Professional Practice and Implications for Social Change

The study was conducted to uncover social workers' views regarding depression in older immigrant African women in Metro West Massachusetts. Social workers offered insights on how they deliver mental health services and the responses they get from the women. The results of the study will assist in service modifications and enhancing access to quality mental health services. The study was carried out since there are disparities in mental health access by older immigrant African women. There are mental health disparities among the women, and most struggle to receive assistance and accept a mental health diagnosis. Social workers have had issues when it comes to discussing mental health problems like depression and anxiety with women, mainly due to culture. The social workers have to be culturally aware and approach the women based on their culture. Therefore, cultural awareness plays a crucial role in the treatment of women. Social work practice has been modified in this location as social workers have to learn different cultures and understand how each culture approaches the issue of mental healthcare. Reducing the causes of depression is beneficial to society as there will be fewer people who need mental health services or are living with mental conditions. The study will benefit the community by reducing cases of depression amongst the older immigrant African women caused by their migration experience.

This study's results can be used by other social workers who are dealing with a similar population. Based on this study's results, other social workers will benefit from finding out the strategies they can employ to reach out to such a population and the strategies they should avoid. Cultural influences have been uncovered that will be vital in determining the methods that can be used to treat this population. Being culturally informed is beneficial to the social worker, and it will allow them to reach out to the community members and approach them in a manner that will be acceptable. Social work will benefit the most since the results will suggest strategies social workers can use when dealing with older immigrant African women. Considering the women will have different cultures based on their country of origin, it will be vital that a social worker first understands the culture before he or she can begin offering treatment or counseling to the individual.

Application for Professional Ethics in Social Work Practice

The social work problem highlighted in this study relates closely to these two principles of the National Association of Social Workers (NASW) Code of Ethics, cultural awareness, and social diversity and competence of the social worker (National Association of Social Workers, 1996). A social worker should understand the culture of the population they are serving and the role culture plays in human behavior and society. Without understanding culture, a social worker will struggle to interact with the clients, and this will create a rift between the clients and the social worker resulting in the client not receiving adequate service. The services offered by a social worker should be sensitive to the client's culture. Cultural sensitivity allows the social worker to understand the client's culture and offer services that are in line with the client's culture. Being culturally sensitive ensures the social worker can offer services that will be acceptable to the client. A social worker must understand the nature of social diversity and oppression as they relate to race, national origin, ethnicity, sex, sexual orientation, color, age, marital status, religion, immigration, and mental health (National Association of Social Workers, 1996). The study confirms the importance of being culturally sensitive as there is evidence to support this principle. Social workers who are not culturally sensitive have had a hard time treating older immigrant African women, which has mainly been due to failure to understand their culture.