Older Immigrant African Women Depression in Metro West Massachusetts

Running head: DEPRESSION AMONG OLDER IMMIGRANTS

DEPRESSION AMONG OLDER IMMIGRANTS 2

Depression among Older Immigrant African Women in Metro West Massachusetts

Table of Contents

Abstract 3

Section 1: Foundation of the Study and Literature Review 4

Problem Statement 7

Purpose of the Study 8

Research Questions 9

Definition of Key Terms 10

Significance of the Study 12

Theoretical Framework 12

Review of Professional and Academic Literature 13

Cultural Competence 14

Mental Health of Immigrants 15

Depression Among Older African Immigrant Women 16

Stressors faced by Older African Immigrant Women 18

Summary 20

Section 2: Research Design and Data Collection 22

Research Design 22

Methodology 23

Data Analysis 25

Ethical Procedures 27

Limitations, Challenges, and/or Barriers 29

Summary 30

References 31

Abstract

This study titled ‘Depression among Older Immigrant African Women in Metro West Massachusetts’ set out to understand the causes and prevalence of depression among older women coming from Africa to live in the United States of America. The study situated older women to be women above the age of 55 and focused on exploring the views of social workers in relation to issues of depression among these women. The present study is guided by the following questions: a) from the social work perspective, what factors influence older immigrant African women’s adaptive capacity in Metro West Massachusetts? (b) from a social work perspective, what mental health service do social works offer to older women from Africa living in the USA? (c) How do social workers assess the need for mental health services for their clients and (d) what service modifications can social workers introduce to enhance mental health service delivery for older women coming from Africa? These questions led to the investigations in this study that was guided by the structural-functional theory. Data was collected using the quota sampling. Interviews and questionnaires were most appropriately used to collect date and the SPSS software was used to analyze data. The study respected ethical issues strictly.

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 indicated African American heterogeneity prevents 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 underscored 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.

Overview of the Problem, Its History and Significance Related To The Study

In recent years, there has been a growing need of social work for the immigrants, particularly the old immigrants aging from 65 years and above (Social Work Today, n.a.). They are the ones who experience the relocation in an entirely new geographical region where people are strangers to them. The society’s acceptability is low towards them that create negative impacts on their physical and cognitive health. The impacts could be observed in the form of social isolation, loss of independence, cognitive declines and health problem in old age.

Old age is the critical time of life when the elderly people need special care and attention. Their socialization patterns are changed, especially when they have to migrate. The negative effects may emerge in terms of economic, social, psychological, political and cultural terms (Lotfi, 2020). Immigration has adverse effects on ageing people as they are mentally weakened to take the pressures enforced on them by a variety of changes. Their family and social relations are affected, resulting in more complex problems like physical, psychological and sociological difficulties.

Social work interventions are innovative strategies to uplift the emotional and physical wellbeing of elderly migrating people. Social workers help the elderly individuals towards the adaptation process so that social exclusion should be mitigated and social justice could be served (Haidar, n.a.). Since they work with ‘mixed status’ families, they have to take care of their individual rights, especially targeting towards their ethnic backgrounds.

An increase in African American older migrants is expected to increase by the year 2050 with racial ethnic needs arising along with those who have low educational levels (Gilmore, 2013). Their social and emotional needs have to be addressed by culturally competent social workers so that medical and therapeutic healthcare services should be appropriately provided to the needy ones. However, it has been observed that there are healthcare access barriers to the racial and ethnically diverse older immigrants (Koehn, 2009). There is a vast disparity of the healthcare provision to the native populations and those aging migrants who are transferred to other regions, adversely affecting the morbidity and mortality rates of these populations (Kristiansen et al., 2016).

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, & Schade, 2016). As such, this negative health predisposition created 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. It is due to an inference that Metro West Massachusetts has a cluster of cities and towns where one of the fastest growing communities in African Americans, having a rate of 95% growth since 2000 (Impact Metro West, n.a.). However, disparities in educational and social gains are still seen for the people of ‘color’, as are evident in other parts of the United States (Rosenberg, 2020). 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

This study would focus on answering the following research questions:

1. From the perspective and benefits of social workers, 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 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 (Health Policy Institute, n.a.). 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 65 years of age (Noubicier & Charpentier, 2013), 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.a.-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. Comment by Juanita White: There are specific entities recognized as references for definitions

1. African women - African women refers to a native or inhabitant woman of Africa or a woman who has African ancestry (Ythera, 2017). 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." (Dictionary, n.a.) 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 (Dictionary, n.a.). 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.a.-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 workers are trained to understand that the society is like a system where all the parts will work together to create a whole. 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). A comprehensive search from peer-reviewed publications was conducted for this study 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 depression in older women, depression in older immigrant women, older African American women, older immigrant African women, depression in immigrant African women, depression, and older immigrant women. To specifically target the research towards ‘African American women’, this keyword is included for keeping the literature concise.

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 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. Most researchers have pointed out the impact of immigration and how African immigrants begin developing depression and other mental health issues. The synthesis of these studies indicates that social workers should target the older women in immigrant population and must rethink their strategies for addressing the relocation challenges of this segment. The articles were selected for the purpose of enforcing this notion that older immigrant women are under serious threat of depression and the social work organizations must direct their energies to specifically work for this stratum of population.

Section 2: Research Design and Data Collection

Research Design

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. 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 three or more years, are graduate level social workers or higher, 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. All participants will need to complete consent forms prior to participating in the study. In the contemporary times of Civid-19, the new recruits for social works must be vaccinated as their vaccination firms would be checked. They would be required face masks at all times. Also, they must possess a hand sanitizer either in the pockets of their white robes or attached with hanging chains along with their name tags around their necks.

The interviews will be audio recorded and the researcher will be taking notes as the interview progresses after taking consent from the participants in written form. The audio recordings would be used as the available transcriptions of the interview, deeming it to be the first step of data analysis. These transcriptions would be used by the researcher to develop codes before entering the data into the system. For this study, the researcher will make use of SPSS Statistics software to analyze the data. The reason for the selection of this software for the analysis purpose is to determine the factors, or more specifically, the barriers to health services that older immigrant women face. The researcher would analyze the data himself as he would be closer to the obtained data and would know the dimensions upon which the responses could be verified. The data could be verified by inviting the participants to review those recording and ascertain that those were the actual words in their voice uttered by them. Any manipulations should be negated by the participants so that data is considered valid. Ethical consideration must also be taken into account by taking the permission from the participants for repeated future use of those recording for research purposes.

Methodology

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, suggested by the social workers. Experienced social workers have the ability to understand their clients and they can educate us on the impact culture has on women's depression (University of Southern California, 2020). To conduct the research, samples will be selected from social workers who are currently serving the MetroWest MA region, which is a prior place of employment for the researcher. 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 research questions endeavor to help determine the role social workers play in insuring the availability of mental health services as well as modifications that can help improve service delivery. For example, what role do you play in ensuring 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 administered to probe for relevant information from 10-12 social workers working with elderly immigrants participating in various institutions throughout West Massachusetts. Some of them were excluded due to no consent, leaving the study early or no conduction of interview due to time constraints, which limit the number of respondents to 10-12 social workers. An acceptable sample size is considered as 10% of the total population (Tools for Dev, n.a.).. 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 on their agreed upon space and time where all information obtained could be kept confidential, off work hours will also be an option.

Participants

Social workers operate by 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. They will offer vital insights related to depression, particularly associated with this community. 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 presents with depressive symptoms. 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 have discussions with them about how they are feeling. By making these visits, it is expected that the social worker can discover undiagnosed cases of depression.

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. According to the above-mentioned criteria of accurately representing sample size, which is 10% of the total population, 12 participants is the right choice. 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.

Instrumentation

This study will make use of quota sampling, due to the inclusionary criteria which identifies the characteristics for participants to be included in this study. Quota sampling is similar to purposive sampling (Family Health International, n.a.); the only difference is that 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 (Glen, n.a.). 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 (Iliyasu & Etikan, 2021). 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 reason researcher chose quota sampling is that the researcher has a specific criterion of the participants he would like to have for the study.

Data Analysis

All the interviews will be audio recorded and transcribed verbatim. This will protect against bias and will provide a permanent record of the data collected from the interviewer. The researcher will make field notes during the interview indicating the observations noted, thoughts, and opinion about the interview. During face to face interviews, observations like body language and general composure of the interviewee is vital as it gives a picture of how the interview process will be conducted; however this information could be limited when using internet-based technology. To whatever extent it is available, it will be helpful in the data analysis process. The data analysis will come after all the interviews have been conducted. There is also a need to do a proper analysis to ensure there is validity of the results. The researcher might have preconceived assumptions of what they expect to uncover from the interviewees. With a thorough and objective analysis, these biases will be eliminated in order to conduct a systematic analysis (Pannucci & Wilkins, 2011). Data analysis gives others a way of understanding exactly how the researcher reached various conclusions and makes the results much more trustworthy. Since the researcher will be conducting semi-structured interviews, I 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 (Nowell et al., 2017). 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 (Mortensen, 2020).

As discussed in previous chapters, it is vital to ensure that the study is reliable and valid. Towards this end, the researcher will make sure during the data analysis process that the analysis is done with 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 (Bengtsson, 2016). 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 (Austin & Sutton, 2014). 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 (Taherdoost, 2016). In the final report the researcher will provide information on how the analysis was carried out, which will allow future researchers to replicate the study and confirm its validity.

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 one of the underlying reasons 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 (Barrett, 2019). Comment by Juanita White: Review for accuracy

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 be available 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 (Univeristy of California San Francisco, 2021). Use walden IRB policy The process for verbal consent has three steps (UCI Office of Research, n.a.). 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 questions to ensure that they have understood what the study entails. The second step is where the potential subject is given a study information sheet. 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. Comment by Juanita White: This is not a universal procedure. Please review the informed consent approval process as stated by Walden University’s IRB and refer to it in your explanation. Comment by Juanita White: Make sure you describe what Walden’s IRB considers and accepts as verbal agreement

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 and ask any questions before they are allowed to sign the consent form ( UCI Office of Research, n.a.). 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 either physically hand it back, mail the form, or send it via email to the researcher. Comment by Juanita White: This is required regardless of whether it is verbal or written. Again, refer to Walden’s IRB requirements and use them as your Comment by Juanita White: Please see prior comment