Depression among older African immigrant women in metro west Massachusetts

Depression Among Older Immigrant African Women in Metro West Massachusetts Abstract
In West Massachusetts, United States, the most common health disorders are anxiety and depression and is prevalent in elderly immigrant women aged between 50 and 79 years. This is according to a research done by Agbemenu, (2016). Despite a variety of efficacious interventions for depression and anxiety, elderly immigrant women experience mental health care disparities in their access to mental health services and the quality of treatment they receive. Research indicates that 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 the depression. A total of 50 self-identified social workers were interviewed about their patient’s mental health problem symptoms and treatment experience, what they thought was their cause of their anxiety, stressors facing their life in West Massachusetts, their access to mental health services, and how they 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. Problem Statement This study aims to explore the views of social workers in relation to depression among older immigrant African women currently living in west Massachusetts. 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. An article published in the Journal of Psychiatric Service by Derr (2017) points out that immigrants typically face stressors relating to migration experience that may cause or intensify mental health problems (Derr, 2017). Moreover, the publication also reports that immigrants tend to access mental health services at a lower rate as compared to non-immigrants (Derr, 2017). Subsequently, this leaves immigrants at risk of untreated health conditions leading to increased disease burden as suggested by 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 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, the 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 prove challenging, and many immigrant women experience challenges that affect their mental health. For example, the changes in practices, values, social factors and cultural identification are considered as factors that contribute to the potential risk of developing mental health issues (Alegría, Álvarez, & DiMarzio, 2017). Similarly, S. Foo et al. (2018) asserts that 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 research links back to the occurrence of psychiatric disorders (S. Foo et al., 2018). Therefore, examining stressors surrounding the migrant experiences from the social work perspective should offer excellent insight into the issues faced by this vulnerable population (especially for women aged 50 years and above).
Based on the highlighted problem, it emerges as imperative to determine the views of social workers from West Massachusetts state who work with older immigrant African women in Metro West Massachusetts affected by depression (Priebe et al., 2011). 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 (Priebe et al., 2011). As suggested by research, immigration can create worry, which may increase the risks of experiencing depression, and this can be exacerbated by cultural factors, such as language barriers that may cause difficulty in diagnosing and treating this disorder among immigrant populations (Landa, Skritskaya, Nicasio, Humensky, & Lewis-Fernández, 2015). Failure to appropriately determine the views of social workers on depression within a certain community translates to neglecting the social health and welfare. In response, this study will seek 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. The Purpose of the Study The study will bring the views of social workers regarding depression in older immigrant African women in Metro West Massachusetts. It will also offer insights into ways that professionals within the healthcare sector can assist to meet the emerging needs of the population. The study will reveal any service modification that is needed to meet the needs of the immigrant African women located in Metro West Massachusetts (Takeuchi, 2016). This will enhance access to quality mental health services and ensure that women can understand the implication of not seeking mental health services. Having examined the stressors that are faced by the migrant women, insights will be gained into the issues that the women face within the population and solutions can be developed that will be directly targeted to the population (Agbemenu, 2016). Social workers will also benefit in that they will use the findings of the study to determine methods that they can use to reach out to the population under study.

Research Questions This study will focus on the following questions:

From the social work perspective, what are the stressors facing older immigrant African women in Metro West Massachusetts? From the social work perspective, what are the health service access disparities faced by older immigrant African women in Metro West Massachusetts? What role do social workers play in bridging mental health service access disparities facing older immigrant African women in Metro West Massachusetts? What service modifications can social workers introduce in practice to enhance mental health service delivery for older immigrant African women in Metro West Massachusetts?

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 living in Metro West Massachusetts. Our findings will offer insights into ways that social workers can meet the emerging needs of this population. The stressors that older immigrant African women face will be uncovered in the study. The results of this study will help to address any health service access disparities that are faced by older African immigrant women and the strategies that can be employed to seal the loopholes or address the disparities. More specifically, this study will focus on older immigrant African women in Metro West Massachusetts who are suffering from depression. Findings in the study will equip social workers with the knowledge to develop strategies that they can use to treat depression and bring awareness to the unique needs of this target population. With a better understanding of cultural competence, the social workers will approach the subject with caution and with consideration of the impact of depression to the women and to their culture. Strategies for dealing with depression will be culturally appropriate to ensure that the women will accept the interventions.

Theoretical Framework One of the theoretical frameworks that can be used to frame this project is the theoretical framework of anxiety and social support. Some theorists such as Cassel and Cobb expressed that social support serve as a resistance factor, and play 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 that there are various social demands associated with being a migrant. Further, Kinser and Lyon (2014) pointed out 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 uncovered that will be vital in determining the methods that can be used to treat this population. o become culturally competent when dealing with this population, the social worker would need to be familiar with the structural-functional theory. This theory explains why society functions the way it does, and it emphasizes on the relationships between the different social institutions that make up society. Some of these social institutions are education, law, government, religion, and culture. The social worker should understand that society is like a system where all the parts will work together to create a whole society. Therefore, 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 a manner that will be acceptable.

Literature Review Background
From the review conducted, there is a lack of literature that is primarily focused on older African immigrant women. This shortage is due to numerous factors that mostly deals with the perception that African immigrants have regarding depression. Most times, depressed individuals are stigmatized and people believe depression is caused by bad spirits. With this notion it becomes hard for the women to seek professional health services as they would be labelled and judged by other community members harshly. searched for peer-reviewed publications focusing on mental health among older African immigrant women, from the following sources, MEDLINE, PsycINFO, CINAHL, Health star, and EMBASE, where examined for the purpose of this study. Forty-six articles were found meeting the inclusion criteria and from these fifteen were selected and included in this literature review. These are all summarized and placed under different headings. The headings used are prevalence of depression, causes of depression, older African women with depression, access to mental health services, coping with depression for older African migrants, and stressors facing older immigrant African women Therefore, depression rates among older African migrants have not been sufficiently reported in the literature, which makes it difficult to gauge the prevalence rates. The review has highlighted the need to educate the women and give them the knowledge they need to better understand depression and how different it is from madness. Culturally appropriate services should also be included for the women. This will benefit the women as they will have a professional who understands their culture and one who is able to articulate the illness using terms that are culturally acceptable by the women. Prevalence of Depression There are over 120 million people worldwide who are affected by depression. In the United States, depression is considered to be a debilitating mental health issue. This is according to a search conducted on the online databases PubMed and ScienceDirect whole using the terms “depression”, “depressive disorder”, “immigration”, “immigrant”, “migration”, and “migrant”. 25 samples of data were analyzed and from the results, 15.6 percent of the participants recorded an aggregate prevalence of depression. It affects individuals from across races, cultures, nationalities, and genders (Baldwin-Clark, Ofahengaue Vakalahi, & Anderson, 2016). Depression is one of the most common mental health issues that affect the older adult population. It is estimated that within the older adult population, about 15% to 25% of them have a mental illness (Baldwin-Clark et al., 2016). Across the world, depression has been identified to be a leading cause of disability and illness. It has an aggregate point of 12.9%, one year 7.2%, and a lifetime prevalence of 10.8% (S. Q. Foo et al., 2018). Depression has been shown to cause suicide in its most severe form. It is estimated that 800,000 people die from suicide annually and these suicides are due to depression. According to the American Psychiatric Association, depression may occur as major depressive disorder (MDD), which is the most severe form, or minor depression (Baldwin-Clark et al., 2016). Depression is currently the world’s fourth most common disorder among women. By the end of this year, it is estimated that depression will be the second-highest cause of disability. The first one being heart disease. Some studies have shown that depression differences in rates between men and women decrease with age, while other studies have pointed out that depression is more common in women regardless of age (Baldwin-Clark et al., 2016). Depression estimates among African American women have not been reported sufficiently and this makes it difficult to gauge the prevalence rate amongst African American women. Baldwin-Clark et al. (2016) posits that the rates might be higher than we think considering that depression is commonly misdiagnosed due to its undetected symptoms.
As noted earlier most African migrants will not discuss depression or mental health issues nor will they report they are suffering from any of these conditions. Depression is considered to be taboo and this discourages the women from seeking health services for such conditions (Thomson, Chaze, George, & Guruge, 2015). While it would be easier to manage the symptoms and uncover the underlying causes, a failure to accept the condition means that one will suffer in silence. This aggravates the condition since the individual does not have the proper mechanism for dealing with the condition. Older immigrant women are most likely to not seek health services for mental health issues, bringing up such a subject will be met with resistance since it is equivalent to calling them mad. Depression is a mental health issue that is considered a disease that affects those who are mad and they will see it as though one is suggesting they are mad or should be kept in a mental health institution (Thomson et al., 2015). It is for this reason that it becomes hard to determine the prevalence of the disease among African migrants.
According to Lazar-Neto, Louzada, de Moura, Calixto, and Castro (2018) women are more sensitive to adverse life events, cultural norms, and social roles and this could explain the reason why there is a large prevalence of depression among women. Concerning immigrants in the United States depression could be caused by cultural conflicts, social isolation, language proficiency, and poor social integration. Other possible correlates of depression could be employer exploitation, unauthorized immigration status, disrupted marital status, discrimination, unemployment, lack of health insurance, and pre-migration factors (Alegría et al., 2017). It is estimated that there are over 42 million foreign-born people in the United States and this accounts for 13% of the total U.S. population (Lazar-Neto et al., 2018). African immigrants account for 38%. Massachusetts is the state that has the highest number of African immigrants and immigrants from other countries. Ethnic minorities are most likely to experience disparities in access to quality mental health services. Immigrants have been shown to suffer from depression and it is assumed that this is due to their relocation to a different country (S. Q. Foo et al., 2018). However, there is no definite cause-and-effect relationship that has been established between migration, acculturative stress. Therefore, subsequent development of depression might seem arbitrary as best. Numerous studies have found a link between depression and migration inconsistent. This should not be ignored and further research should be conducted to determine the relationship (S. Q. Foo et al., 2018).
A majority of the literature has discussed depression in the elderly and has mostly focused on White older adults. Without information regarding the prevalence of depression among African Americans, it is not possible to determine the linkages (S. Foo et al., 2018). There should also be a differentiation between African Americans who immigrated when they were old and those who were born in the U.S. This will give the requisite information that is vital for determining the impact of migration on the elderly African women migrants (Babatunde-Sowole, Jackson, Davidson, & Power, 2016). It has been noted that the diagnosis of depression is more prevalent among Whites than it is for African Americans and Africans as well. The reason for this is not clear. With this kind of discrepancy, it becomes hard to determine how prevalent depression is among African migrants. It is well known that African migrants face racism and sexism especially women (Landa et al., 2015). Examining their lived experiences will give us a view of the impact of these circumstances and how they cope with them. Causes of Depression The causes of depression will vary based on the individual's gender, age, marital status, and origin. In our case, we will focus on the causes of depression that are related to older immigrant women. More women tend to suffer from depression as compared to men. This is irrespective of age and immigrant status. For many African immigrants discussing mental health problems is taboo. This makes it difficult to determine their mental health status. Moreover, relocating to a different country with one's family has its challenges. The immigration process can also be dehumanizing and this can have adverse effects on the health of women in general (Delara, 2016). African migrants are likely to feel socially isolated and depressed. These feelings can be aggravated by discrimination and racism that most of them are likely to face. Within the relatively dominant white culture society, it is easy to differentiate an African migrant from Black Americans (Babatunde-Sowole et al., 2016). There are visible linguistic and cultural differences that can be seen and this makes the African migrant vulnerable. While learning and embracing a new culture can be a rewarding feeling, it not so easy for African migrant women. The women end up losing their close social bonds, cultural values, and family roles. The loss of these leads to a secluded and antisocial lifestyle that is forced upon the women. By the mere fact that the woman is in a new country and location, they will not have any friends or have formed any connections. Also, one should not forget the relatively antisocial culture of the United States that is in contrast to the African culture of socialization (Delara, 2016). In an attempt to adjust to the fast pace and culture of the U.S. most women find that they are struggling and this negatively affects their mental health.
According to Ezeobele, Malecha, Landrum, and Symes (2010) immigrants are forced to adapt to a new way of life and a new home. Here the migrant has to embrace different morals, standards, and values (Baldwin-Clark et al., 2016). This can be conflicting, especially for older women. Having grown and knowing the morals, values, and standards of your community and having to uproot all this and embrace new ones is a big challenge. While for younger migrants it can be easy, it is a challenge for the older migrants and this confliction results in an imbalance mental state. Baldwin-Clark et al. (2016) posits that the African women's traditional patterns of behavior and cultural values are different from those of black women born in the U.S. Being unfamiliar with the western culture and experience creates difficulty when it comes to adjusting. A majority of the older women have grown up taking care of the family and it was the role of the husband to provide food and look for jobs. However, when they come to the U.S., they are forced to take up jobs in addition to performing their traditional roles of taking care of the children and the house. This additional responsibility comes as a shocker for most women and they struggle to embrace it, which results in them finding it hard to cope with all that is required leading to depression (Ezeobele et al., 2010).
Difficulty in communication is another cause of depression among African immigrant women. While most of them are well educated with college degrees a significant number of them struggle to communicate with potential employers. This forces the women to take up jobs that have low pay and completely unrelated to their training and education (Ezeobele et al., 2010). This will result in women facing individual stressors and questioning themselves regarding their migration decision. Other social determinants that have an impact on the mental health of women immigrants are poor work conditions, poverty, and social exclusion (Guruge, Thomson, George, & Chaze, 2015). There is a preference by some migrant African women especially Nigerian to seek healthcare services back home since they do not trust the western healthcare system. The costs for seeking treatment in the U.S. can be prohibitive and some migrants might prefer to keep away since they do not have the funds. Nigerian women migrants will use spiritual beliefs, stigma, and lack of health insurance as their justification for not seeking health services in the U.S. (Okudo & Ross, 2016). While these are genuine concerns, they have adverse effects on the women's health since they might not get the health assistance they need on time and this can lead to deterioration of their health.
First-generation immigrants will have a health advantage over their U.S. born counterparts. However, this advantage will erode over time as they continue to live and work in the U.S. As a migrant continues to live in the U.S., they become assimilated into the U.S. cultural and social norms and their health will begin to resemble that of the individuals born in the U.S. (Alegría et al., 2017). When it comes to depression this might still hold water but there is a major difference. For the majority of the African migrants, they might be excited to relocate to a new country and they will not be depressed when they get to the U.S. As time passes and they adapt to the new home and life reality does check-in. When leaving their home country most African migrants do not have jobs and they leave in pursuit of greener pastures (Dow, 2011). With the hope and dreams that life in the U.S. will be much better than that of their home country. However, once they get to the U.S. and settle down, they are faced with the difficult reality where they find it hard to get jobs, face facial discrimination, and struggle to adjust to the new environment. This reality will have a positive and negative effect on the individual and for some, it might be too much. For older African immigrants, when they are faced with the reality of the situation, they find it hard to cope and they start developing depressive symptoms (Delara, 2016). Older African American women's health deteriorates significantly late in life and this is due to their disadvantaged statuses that are linked to gender, race, and age.
Acclimatizing to the new environment can have its fair share of challenges for older women. Acclimatization is necessary for one to become socially integrated (Babatunde-Sowole et al., 2016). Learning about cultural and social principles is one of the ways that one gets acclimatized in a society. It is very important for one to social adjust to his or her new environment. This holds true especially for migrants because if they fail to integrate properly, they might be faced with numerous negative outcomes of depression being one of them. Migrant women when compared to the migrant men, are faced with numerous challenges including loneliness and segregation in their new country (Babatunde-Sowole et al., 2016). There are cases where the woman was not prepared to migrate and she was forced to follow her husband to the new country. The woman will be bound to the home and will only have her household chores to keep her busy. Focusing on these chores reduces the chances of the woman socializing since she is always at home and she gets no chance of meeting and interacting with other women. Considering that the woman is in a new country and she is yet to make friends, she finds herself stuck in the house most of the time. Her only interaction is with her family and this will lead to her developing resentment toward the new country. The woman is likely to remember the good old days in her home country and yearn for this socialization. This will lead to negative outcomes for her as she will be in a constant state of denial (Delara, 2016). Men being the breadwinners have to leave the house and interact with others from the minute they migrate. Women do not have this opportunity. Instead, they have to stay indoors and only tend to the household and their children. The only interaction they get is when their husbands return home in the evening. This creates a gap that cannot be filled and as time passes the woman falls deep into depression and she cannot be able to seek help due to her cultural beliefs. Older African Women with Depression There is a possibility that older women struggle to assimilate and integrate into their new culture when they migrate from Africa. Assimilation refers to the process of a migrant adopting the culture of their host country and forgetting their own culture. With assimilation, one replaces their background culture with a new one (Ezeobele et al., 2010). This could be an issue for older African women since they have lived most of their lives knowing and understanding a particular culture. With them being required to start learning a new one and forget their old culture could have negative adverse issues in their lives. The women are likely to struggle with the conflict that comes with learning the new culture and they will also struggle to forget their old culture (S. Q. Foo et al., 2018). This conflict will affect their mental health state and they are likely to start developing depressive symptoms. Assimilation results in the loss of cultural, religious, and ethnic identity and this cause conflict with most migrants who would prefer to maintain their culture. When migrants are assimilated into society, they have to forego their culture and this creates resistance since they are battling inside to embrace a new norm. This resistance is what will lead to them becoming depressed. We already know from the literature that African migrants do not readily embrace a diagnosis of mental illness and it is taboo for them to see the services of a psychologist (Guruge et al., 2015). This means that the women will continue to battle the mixed feelings they harbor inside, which will impact them negatively as time passes.
Integration, on the other hand, refers to the addition of a new culture to the existing culture. With integration one does not have to forget their own culture, they have to figure out how to live with both cultures (Guruge et al., 2015). While this is the best notion in psychological terms it is easier said than done when it comes to older African migrants. Having lived the majority of one's life in a different culture and relocating to a new country where one is forced to learn a new culture can be challenging. In most cases, integration requires one to maintain his or her culture as he or she embraces the new culture. The individual is required to follow the two cultures concurrently and this can cause conflict (Lazar-Neto et al., 2018). Considering how reserved some African cultures are when compared to the American culture, it is clear how difficult women will find it to observe both cultures. For example, in most African cultures, women are not allowed to show off their body skin and the wearing of tight clothes is frowned upon. Picture a woman who migrates to American with such a notion and comes to find that American women can dress as they like and no one questions or judges them. This person is likely to have conflict in her mind, which can cause depression or anxiety every time they have to leave the house. Learning how to embrace both cultures can be a challenge and for most women, they prefer to hold on to their old culture and not learn the new culture (Lazar-Neto et al., 2018). This would mean they do not integrate and instead they would prefer to be assimilated into the society while holding on to their culture. Without forming roots in their new culture and location, the migrants will begin missing home and this, in turn, will make them resentful of their new home, which will be a great contributor to them developing depression.
For many African women, fulfillment in their lives will be attributed to the community they live in. Being able to exist in a community that they can identify with and has cultural values that they can relate with is vital for African women (Okudo & Ross, 2016). The community offers the women the social interaction they need to interact and share their experiences with each other. However, on migration, this is no longer available and the women are forced to seek out new connections that are not easy to make. The void they feel for socialization cannot be filled by their husbands or children and this contributes to their loneliness. Social support is vital for African American women communities (Okudo & Ross, 2016). It is a coping resource that assists women to prevent functional decline and depression. For most African women migrants, the best form of social support they can get is through religion and spirituality when they are in the U.S. While this will offer them the support they need as they adjust to the new environment, it is not easily forthcoming. Before one can identify the church, they can be going and find one where they would be comfortable it might take months and during this time the woman might be suffering internally. Religion and spirituality have been shown by Baldwin-Clark et al. (2016) to be effective in offering the older women the social support they need. It is the perfect connection for women to relieve and alleviate depression. Coming from a background linked to religion and spirituality, many African women migrants will continue to rely upon their faith in a Higher Power to get healing and breakthrough in life (Baldwin-Clark et al., 2016).
Chaze, Thomson, George, and Guruge (2015) recognizes this phenomenon of African migrants seeking alternative solutions for mental health issues. In other cases, some of the migrants might not be familiar with mental health and mental illness as depicted in the Western world (Chaze et al., 2015; Thomson et al., 2015). This creates a vacuum since the migrant cannot conceptualize what the health practitioner is talking about. For example, some African migrants view mental health as being at peace with oneself and mental illness as a bad spirit. Bad spirits are frowned upon in African culture and most of the women will not talk or discuss anything that has to do with bad spirits. This could be taboo in other cultures, which discourages the women from discussing the topic. These kinds of hindrances make it hard for women to seek health services that are related to mental illness. Older African migrants are likely to make use of family and friends when it comes to dealing with mental health issues instead of formal hospital services (Rashid & Gregory, 2014). One should not be surprised to learn that in most African countries people do not visit or go to see a psychiatrist. This is because the notion of mental illness is not encouraged and only people who have lost their minds would seek those services. Depression is also not focused upon in most countries and people have no proper understanding of what depression is. The challenges that one goes through that are related to mental health are linked to other issues and justification is given for those issues provided there is no correlation being made to mental health illness.
In the study conducted by Ezeobele et al. (2010), 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 (Ezeobele et al., 2010). Well, Nigeria is not the only country that uses this reference but there are other African countries that have the same view. It is also believed that depression is a disease that is passed from a person to their children. The idea that depression develops due to life challenges and struggles is not possible in the African culture. Therefore, one cannot be able to openly admit to having depression as that might tarnish his or her family name. Older African women migrants have grown up with this idea and teaching and even if they have stayed in the U.S. for years it is not surprising to find out that they still hold on to the same cultural beliefs that are held by her people back home (S. Q. Foo et al., 2018). Having been integrated into the new culture does not mean that she forgot her own culture.
Depression in older African migrant women is contributed by pluralism in society. While ethnic and racial differences are allowed to thrive, they should not threaten the dominant values and norms of the host country (Lazar-Neto et al., 2018). What this does to the women is that they feel they are independent to maintain their ethnicity but at the same time they are not allowed to overshadow the ethnicity of the host nation. This is what causes some people to be discriminated against as the host nation residents will be exerting their dominance over the migrant women. Nowadays, discrimination is subtle and not so outspoken as it was in the past. Silent discrimination is far worse than any other form of discrimination since it is only the migrant who feels it and they cannot share it with anyone else (Ezeobele et al., 2010). Older migrant women have lived in peace in their country of origin and migrating to a new country was thought to be simple and will not cause them emotional torture. However, when the reality strikes, the women suffer the most since they were not prepared psychologically, and all this comes as a shocker to them. Adjusting and adapting becomes hard since they are struggling to understand the reason behind the struggles they are facing (S. Q. Foo et al., 2018). Undergoing such torment can have adverse effects and there are women who toy with the idea of suicide. While most of them will not actualize it, having suicidal thoughts could be a sign of depression. In the U.S. diversity is tolerated rather than been accepted and appreciated. This creates an issue since most people are only allowed to continue holding on to their culture, but deep down the hosts are not happy. When the hosts get an opportunity to demonstrate how they feel, they can be harsh towards the migrants making them feel unwelcome in the country or state. Access to Mental Health Services Older African women migrants face numerous stressors that are related to their migration and settling down. While some of them might have stayed in the U.S. for over five years, they still struggle to adjust and accept the reality of the country. Depression could also be caused by their children or husbands. Access to mental health services could also be a challenge and stressor in their lives (Lazar-Neto et al., 2018). Without appropriate mental health services, women cannot seek the assistance of a professional. While some might be willing to seek the services of a professional, they would like to ensure that it remains secret, which is not possible in some of the communities where they stay. The stigma that is associated with mental health issues can be overwhelming to an older woman and they will opt to not seek the services if this is not readily available within their community. According to Chaze et al. (2015), mental health services are underutilized by a majority of African migrants and the reason could be multifaceted. The first reason could be related to a lack of knowledge about the availability of the services offered. The second one is that most migrants view the services negatively and this drives them off the services. The availability of the services within their community is the last reason. Without proper knowledge of the services being offered, most migrants will work with the idea they have of mental health services, which to them means it is only the mad people who seek those services (Lazar-Neto et al., 2018). The lack of understanding as to the different levels of mental health causes them to keep their problems to themselves and not seek any assistance from a professional.
Mental health services are viewed as unnecessary and are normally avoided by most African migrants. This view is perpetuated even in old age when one needs the services the most. For most older women they still do not see the need for the services, and they opt to stay away since there is no justification for them accessing the services. The services are viewed negatively and to most of the older women they have grown up knowing too well that anyone who seeks mental health services is mad (Chaze et al., 2015). These services are reserved for the people who talk to themselves and have no coordination with their minds. This is the perception that most African women migrants hold. The stigma associated with this is hard to remove and most would rather suffer in silence than seek any assistance (Babatunde-Sowole et al., 2016). As one gets older, they might lose their sense of community because other community members are busy at work and they do not have much time to interact with the elderly community members. Older African women migrants will feel this loss and they will struggle to adjust to the new reality of them being at home and no longer being able to work as they normally had. With this change, the individual is likely to begin experiencing signs of depression (Okudo & Ross, 2016). Instead of them seeking mental health services they are likely to ignore the signs. This is based on their upbringing where they believe that feeling lonely is okay and all they need to do is seek interaction, which is not readily available.
In some communities, there is a dearth of mental health services (Sánchez et al., 2014). This shortage means that most people who would like to receive the services have no access. A shortage of mental health services is a contributor to the reduced rates of access to mental health services. This could also be a contributor to the increasing rates of depression among African migrants and especially older women. Lack of insurance and or a lack of funds for paying for the services is another hindrance that most African migrants face when it comes to access to mental health services. Without medical insurance the costs for accessing these services are prohibitive and most people will prioritize other things instead (Sánchez et al., 2014). Understanding that most migrants are not working in their dream jobs and the pay they get it meager will indicate the reasoning that most of them hold. Most of the migrants have to choose between seeking professional services and feeding their families. It is a no brainer that a sane person will opt to feed their family first and mental health services will be sort when funds are available, which never happens. Having learned to deal with the situation alone, it becomes harder for them to seek for assistance even when they age. One will have learned some coping strategies and these strategies might have worked in the past (Sánchez et al., 2014). However, as they age, they discover that the strategies are no longer working and they find themselves falling into depression.
Cultural competency also contributes towards reduced access to mental health services (Sánchez et al., 2014). The number of professionals who are culturally competent to handle African migrants is few. Therefore, the possibility that an African migrant will be served by a professional who does not understand their culture is high. This makes it hard for the migrant to express him/herself appropriately. Without a person who understands the implication of the patient's culture, it is hard for the professional to understand why the patient will not accept a diagnosis of depression or any other mental health issues. With a culturally competent professional, the older women will get someone who will guide them on how to battle depression in a way that it does not seem they are considered mad. The cultural impact of this is that one will get professional help and they will not feel like they are being stigmatized in their community (Sánchez et al., 2014). Stigma plays a vital role in mental health service access. The negativity that is associated with depression can cause a person to avoid seeking the services of a professional. Stigma has made any person who seeks mental health services to be perceived as dangerous. This prevents the open-access of services by African migrants. Having a culturally competent professional who understands the stigma that is associated with mental health access will ensure that the migrants are treated using methods and terms that do not reinforce their stigma or fear. Understanding the culture of a person allows one to give professional assistance while avoiding the use of terms that would not be acceptable to the patient. This will allow the patient to get the service he or she needs without them feeling stigmatized in any way. The culturally competent manner for dealing with depression would be to call it feeling down or feeling low (Atkins, 2016). This way the African migrant will relate to the terms used and they are more likely to open up to the professional. Calling it depression or mental health issues will be met with resistance and the patient is likely not to take the prescribed drugs or even come back for a follow-up visit.
Access to mental health services can be affected by language barriers. Migrants could have problems discussing their symptoms or expressing what they are undergoing, which would lead to misdiagnosis (Sánchez et al., 2014; Thomson et al., 2015). For most migrants, the description they might have for depression or mental health illness will be different from the standard description of the same. This makes it hard to properly determine what the patient is ailing from and in most cases, the patient will be treated for another illness. There have been instances where the patient has been properly diagnosed and treatment recommended but the patient fails to understand the treatment regimen (Dow, 2011; Thomson et al., 2015). This will cause the patient to fail to follow the recommended treatment regimen and their treatment will not be effective. Noncompliance with therapy will result in patient suffering and the patient is likely to seek the services of another professional believing that the doctor who saw them was incompetent.
Migrating to a new country has its fair share of challenges. The first one being learning and understanding the culture of the new country or state (Baldwin-Clark et al., 2016). While for the younger generation it is easy for them to adapt to the new culture, the older generation tends to struggle. This struggle psychologically causes issues that most elderly African migrants will not want to acknowledge as they perceive it as being a sense of weakness or showing weakness. African women like to show they are strong and not vulnerable and with this view, they will not admit to having any struggles adjusting to the new culture and location. With time the migrant will start missing home and missing his or her friends, which will cause her to yearn for the companion she had back home (Atkins, 2016; Takeuchi, 2016). Being an elderly person, she might find it hard to make new friends and there will always be a void that is not filled all the time. She will find herself keeping more to herself and this will be done unknowingly. Withdrawing from society is one sign of depression and before long she will have completely withdrawn only doing the bare minimum for the household. The woman must establish close bonds as soon as she can and embrace the new culture even though it might be an uphill task. No matter the challenges that are presented one can overcome them even if they would prefer not to seek the services of mental health professionals. As Rashid and Gregory (2014) have posited African migrant women are resilient and they can overcome many obstacles that are related to migrating, However, there are still challenges that most of them will face that can cause depression and without a strong support system many of them suffer a lot in silence.
White people have access to mental health services, which makes it easy for them to get the assistance they need when they have depression or anxiety (Delara, 2016). This is not the case for the African migrants. Most of the areas where the migrants stay are poor communities and there are only limited services that are offered in those areas. For the majority of them, they do not have the luxury of having a community center or health center that is close to them offering mental health services (Alegría et al., 2017). This shortage denies the migrants the vital services they need, which forces them to adapt to new methodologies for handling their mental issues. The strategies employed are individual and while most of them choose to avoid or escape the issue, it is still unclear what strategy works best for the migrants. Limited access means that the number of people who suffer from depression or any other mental health issue is not properly documented amongst African migrant women. Therefore, determining the actual number of people who suffer from depression becomes hard and providing access to the services is hindered due to this fact (Alegría et al., 2017). When authorities understand the prevalence of depression in a community, they can plan better to ensure that there are enough service providers to comfortably offer services to the people who need the services. Therefore, there is a need to determine the actual number or establish the prevalence of depression amongst African migrant women with the aim of making services accessible to them. Coping with Depression for Older African Migrants Coping with depression is defined as the ability of a person to constantly change their cognitive and behavioral efforts in order to manage certain external and internal demands that are considered to be exceeding the individual's resources. Life demands are stressful encounters that cause emotional fluctuations and acute stressors that precipitate the onset of depressive emotions in women (Thomson et al., 2015). How one copes to alter the impact of their stressors will affect their psychological well-being and this has the potential to impact their levels of depressive symptoms. There are problem-focused and emotion-focused behavioral and cognitive strategies that people employ to manage external and internal demands when they are faced with stressful encounters. Emotion-focused strategies are escape avoidance, self-control, accepting responsibility, distancing, and positive reappraisal (Atkins, 2016). Escape-Avoidance involves running away from the problem and this might entail changing behavior and adapting dangerous behaviors that will have adverse effects on the person's health. Some of the escape-avoidance strategies are increased eating, smoking, sleeping, using drugs, or shopping. The goal here is that the individual is avoiding the problem instead of facing it head-on. Self-control is a strategy of controlling or regulating one's feelings. This is quite hard and requires one to have enough practice. Accepting responsibility is acknowledging the role that one plays in the problem. Acceptance is said to be the first step towards healing. Without accepting the role that one plays there is no way that one can begin to heal. Distancing refers to withdrawing from people and trying to forget the whole thing (Atkins, 2016). Keeping distance can be effective in assisting one to stay focused and not be reminded of the stressful situation. However, the downside to it is that most people tend to distance themselves even from those who are close to them and this aggravates the whole situation. Positive reappraisals are efforts aimed at creating positive meaning by focusing on personal growth. This can be therapeutic in that one seeks positive things that assist them to grow. For most African migrants that choose to pray and rediscover their faith as a way to cope with stress or depression (S. Foo et al., 2018).
Problem-focused strategies are planful problem solving and confrontative coping. Planful problem solving involves creating a plan that one can use to overcome their depression. These are problem-focused efforts that assist one to deal with the issue they are faced with. One has to create and follow through with the plan that they have created. Confrontative coping is an aggressive effort for altering the situation. In most cases, the aggressive action is something that no one would have thought that it would work and it ended up working. Sometimes all that one needs is to make some sort of effort to deal with the situation.
These coping strategies can be chosen based on the problem that one is faced with. When it comes to African migrant women, emotion-focused strategies are sanctioned methods for coping with depressive symptoms (Atkins, 2016). Considering that these women have left their homes and are now living in a new place, they become culturally mandated to work hard and face life obstacles. They also need to show strength when faced with challenges or when they are under distress. With these views, most African migrant women will be fighting the depressive symptoms and they will find it hard to ask for help. It is the expectation of the society that these women are strong and they should not show any signs of weakness. Therefore, they are required to work through their physical and mental distress. They should also hide or deny their depressed feelings (Chaze et al., 2015). The expectations placed on African migrant women are internalized and the women are forced to deny any weak feeling that they might harbor. With these cultural expectations, women are forced to rely upon their faith and increase their social support. The church is paramount for most African migrants since this is where they get to listen to the word and strengthen their faith (Rashid & Gregory, 2014). It also offers them the social support they need to overcome the most distressful situations. Clinging on to their faith allows them to overcome most of the depressive symptoms as they rely upon the supernatural powers and focus on their faith to increase their strength. Religion is a buffer for African women migrants, in particular, the elderly ones. Going to church and have faith is associated with positive reappraisal.
Older African migrant women tend to focus on emotion-focused strategies and the reason for this is not quite clear. Most researchers have made assumptions as to why they choose these strategies. For most of the women, it is assumed that the emotion-focused strategies work best for them as compared to the problem-focused strategies. Religion plays a big part in determining the strategy a woman chooses (Chaze et al., 2015; Rashid & Gregory, 2014). The older women tend to rely upon their religion more to overcome the challenges they face. This strategy has worked for most of them. However, there are situations where they have to seek professional assistance. Religion gives one the courage they need to overcome the challenges and to fight off the depressive symptoms. The only issue is that there are instances when they might suffer deep inside and religion can only offer them simple healing. Depression might be deeply ingrained and only professional help can offer them the relief they need. Therefore, there should be strategies or programs that encourage women to seek assistance from outside. These could be done in conjunction with the church leaders (Guruge et al., 2015). Coping with depression is no easy thing and there is a need to ensure that the women get the help they most need. Coming from the church it might be reasonably accepted by most of the women as they will link it with their religion. This will reduce the stigma that is associated with mental health issues. With a linkage to religion, the women will feel the assistance being offered is culturally acceptable and does not go against their beliefs. There is also the possibility that there are other women who would be going through the same and sharing amongst themselves will give the women the group support they need. Sharing can also be open as the women trust each other and are familiar with one another (Alegría et al., 2017).
Many older African migrant women have reported that they use self-control to overcome depression. Their self-control strategy mostly involves not admitting they are suffering from depression and keeping their feeling inside (Dow, 2011). These strategies do work and for some women, they are able to fight off depression using these strategies. The problem comes when the pressures are too much and not recognizing or admitting to having depression is not viable. In such a situation the woman is required to openly speak about it to let it off her chest, but this does not happen and they end up suppressing these negative feelings (Baldwin-Clark et al., 2016). With time the pressures will pile up and the woman will be required to let it all out. Hopefully, it will not be too late. However, in most cases, by the time she is sharing all this it might be too late and overcoming her depression becomes harder. Accepting that life will have its stressors and that it is normal to be faced with emotional and physical challenges is acceptable for all human beings. There are situations and cases where there is a need to seek or use problem-focused strategies to confront the problems that cause depression. Older African migrants have reported that they do not see a need for this as they already know that life is hard and the problem facing them is a part of life. This also indicates that they will not seek the professional help of a counselor. The option of seeking professional help is never part of what most women state and it is clear that they do not consider getting this kind of help or prioritizing it. Stressors Facing Older Immigrant African Women Migration has been noted by Dow (2011) to be a stressful event even whether it is voluntary or involuntary. There are African migrant women who voluntarily left their native countries in pursuit of better living conditions, and with a desire to achieve their life goals. While this might have been exciting for them when they were leaving their native country, reality hits them hard when they arrive at their new country. There are numerous authors who have noted that moving to a new place or getting a new job has its fair share of stressors that could lead to physical illness. This is similar to what migrant’s face and have to deal with when they move to a new country. The hopes of a new life are fast changed with the struggles of living in the new country (Dow, 2011). Finding out that things are not as easy as one had imagined can have a devastating effect on the individual's psychology. Adjusting to a new culture and the culture shock that most African migrants face when they move to the U.S. might be too much for older African migrants. Migration leads to extreme adjustment problems since one no longer has the comfort they had been used to initially, which forces one to readjust their expectation with each passing day. This creates stressors that one is not even aware of and while they are struggling to adjust, they are also being battered from inside since there is an emotional and psychological struggle within themselves. The chaos that migration creates is only seen on the outside by many people. The toll of it on the individuals could take years for it to be discovered since it was well masked with the hustle and bustle of everyday life and pushing to ensure that one settles down (Takeuchi, 2016). Older African migrants experience the effects later on in life and they are unable to understand what could be causing it all.
There are profound losses and changes that many migrants suffer. Many of the changes have to do with financial and status changes that migrants have to contend with in their new country. This can be quite traumatic and a source of huge disappointment for a majority of them. There are migrants who relocate in search of greener pastures and they had a good life in their native country. These are the migrants who will suffer more losses. When it dawns on them that their socioeconomic status is different and they cannot get similar jobs as they had before they really feel it. It is shown that the migrants who had a lower class do not suffer as much though they still struggle to adjust and to get new jobs. Finances have been shown by various researchers to be a huge issue and cause of grief for many migrants. Struggling to settle down and not having enough finances takes a huge toll on the migrants (Atkins, 2016). Older African women suffer the most since they are not used to the new lifestyle and they find it hard to adjust to the hardships that they are facing in their new country. With time they might adjust though they still will not attain the level of socioeconomic status they had when they were in their native country. Discrimination for the elderly African women is there and this can be a huge stressor for the women. When combined with financial issues and continued discrimination one finds it hard to cope since they seem to be beaten from all sides in life (Priebe et al., 2011).
Discrimination hits most migrants the hardest. Coming from a racially homogenous native country and relocating to a country where racial and ethnic minorities are marginalized comes as a shocker for many African migrants. Discrimination has been associated with the worsening health of many African migrants. Many African migrants arrive in the U.S. being relatively healthy but with time this advantage becomes eroded. The cases of mental health outcomes for migrants have been noted to increase over time to end up matching those of the other population (Atkins, 2016; Dow, 2011). Discrimination has adverse effects on the migrant’s health in that they have to contend with this for the rest of their lives and the toll it takes on one's life is having constant anxiety, panic disorder, and depression. There are many triggers that can cause this to reoccur in a person's life and many a time even facing a person with a history of discriminating against others can be a trigger (Priebe et al., 2011). Avoidance will become the norm and sometimes African migrants have to meet up with other white people if they are to get employment. The stigma caused by discrimination can last forever if one does not get the professional help needed to learn how to deal with discrimination.
Elderly migrants have to rely heavily on the support of their children to interpret for them due to language barriers. Being assisted by your children in order to perform your daily living activities creates a lot of stress for the elderly migrants (Dow, 2011). Learning a new language can be easy for the younger generation and within a year one can have managed to understand the language and speak proficiently. This is never the case for the older African migrants who struggle a lot to learn the new language and due to age, they find it hard to understand (Ezeobele et al., 2010). This means that they have to be assisted by their children or other relatives every now and then. This denies them the independence they had when they were in their native country and forces them to only wait for their children to help them out. Reaching social fluency is hard for the older African migrant and it is shown that many of them never reach this level no matter how many years they live in the new country (S. Q. Foo et al., 2018). The older African migrant has to heavily rely on her children to navigate the new living situation and country. This scenario will create conflicts between the parents and children since the child has to care for the parent and the parent has to rely on the child. Depression develops in both parent and child since they are both conflicted and they cannot seek external assistance due to financial constraints (Lazar-Neto et al., 2018).
Another stressor is between couples who migrate together. Migration causes inevitable stressors between spouses. The struggle of living and caring for each other can take a huge toll on the couple and this puts a strain on their marriage (Dow, 2011). Having no other person, they have to rely on each other for almost everything, which can be tiring and could lead to conflicts. The most common disorder reported is that of depression in one partner or both partners. One of the issues the couple face is one parent could be willing while the other was unwilling to relocate. This mostly happens to women who find that they are forced to relocate with their husbands who were willing to relocate (Dow, 2011). The wife will then become resentful of the husband for he took her out of her comfort zone. This resentment makes the wife unwilling to adapt to the new life and country and she will constantly be nagging the husband instead of supporting him. As they continue to age, one finds that the woman is still unhappy although she has lived in a new country for years. Having learned to keep her struggles and problems inside she will move to old age in depression as she still is fighting internally. People learn and adapt differently. When one parent is able to acculturate rapidly and the other is struggling there is bound to be conflict in the family since they both do not understand why the other is the way they are (Dow, 2011). A new culture brings with it a fair share of problems and without proper understanding, they will find they are continuously arguing with each other. Changes are bound to occur and if the changes are not monitored then the parents might find they are growing apart instead of growing together. This will lead to the loss of their basis for their original relationship.
Depression burden is multi-fold. Depression affects an individual's overall mortality, increases the risk of suicide, increases mortality from cardio and cerebrovascular disease (Lazar-Neto et al., 2018). There is the probability that depression may lead to individual impairment, family disruption, and problems with social interaction. Immigrants are affected by the healthy immigrant effect where they arrive in the country healthy and without any mental health illness. Over time the immigrant becomes unhealthy as the host nation's citizens and begins to have mental health issues. The main difference in regard to the immigrant mental health illness is that it is somewhat predictable. The first phase is the euphoria or excitement stage Delara (2016) since the immigrant is finally relocating and they will get to actualize their lifelong dream. Immigrants have the belief that relocating to the U.S. will offer them the much-needed opportunities that they did not have in their native country. This is mostly further from the truth as most of them come to discover. The relative ease they might have had in getting the required relocation papers is how they assume life will be when they arrive in the country. During the euphoria phase, the mental state of the immigrant is better than that of the host population.
The second phase is where the nostalgia and disillusionment occur (Delara, 2016). In this phase, the immigrant is faced with the reality of the situation and he or she is forced to start missing home and longing for his or her home. While it is acceptable to miss a familiar place, it is also not good for the mental health of the immigrant to focus on the past. This is because the feelings that are evoked could be too strong and considering that the immigrant is now realizing that life is not as rosy as they had thought holding on to these thoughts could cause a lot of pain. In the second phase, the immigrant’s mental health begins to deteriorate (Baldwin-Clark et al., 2016). The final phase is the adaptation phase. At this phase, the immigrant begins to adapt and they now have to seek for ways to make a living. Having established that life is harder than initially thought, the immigrant will not accept any job offers or even low pay just to make a few coins and feed his or her family.
Overall, there is a decline in the mental and physical health of the immigrant as time passes by. There are many factors that contribute towards this decline including financial, socioeconomic status, and employment constraints (Thomson et al., 2015). For the older African immigrant woman, these challenges can be too harsh and they might striker at the worst of times. Without finances, the women are fully dependent on their husbands or other relatives for survival and they might begin to question their relocation decision (Rashid & Gregory, 2014). Getting a stable job will be difficult for her as her past credentials and qualifications might not be recognized by the host nation. The truth is that many immigrants must contend with having to take up jobs that are way below their qualifications and this can be discouraging for people with families. A lack of finances has been linked to depression and also been linked to difficulty in accessing mental health services (Okudo & Ross, 2016). Without finances, one struggles with their illness and they still cannot access professional services forcing the individual to use cultural methods for dealing with the stressors. Employment constraints mostly have to do with the lack of jobs that are in line with what the immigrant has studied or was doing in their native country (Sánchez et al., 2014). Getting a suitable job becomes harder with each passing day and the immigrant has to accept the available jobs even if they are below her qualifications. This results in reduced salary and loss of finances.
Highly educated people in the native country will struggle so much to adapt to the new reality that their qualifications are not recognized in the host country. Coming to terms with this reality of losing one’s socioeconomic status can be heartbreaking. This could be compounded by the fact that one is not able to get the job they desire, and they cannot reclaim back their socioeconomic status. Conclusion The literature review has provided a good example of the level of prevalence on depression among elderly immigrants in West Massachusetts. It has shed light on the mental health care disparities faced by vulnerable community’s especially black/ African American immigrants. It was evident from various sources that an individual's gender, age, marital status, and origin were the main causes of depression. Also, assimilation resulting from the loss of cultural, religious, and ethnic identity that caused conflict with most migrants leading them to prefer to maintain their culture was as well a determining factor in depression among the elderly immigrants. Besides, emotion-focused strategies which include escape avoidance, self-control, accepting responsibility, distancing, and positive reappraisal were rated as the best methods for coping up with depression. The integration of national-level theory of information to particular communities should assure that mental health care disparities among the vulnerable groups are accurately identified and, thus, can inform the adaptation of mental health interventions to those specific needs.