Depression Among Older Immigrant African Women in Metro West MA

Introduction and Problem Statement

In Metro West Massachusetts, the most common health disorders affecting elderly immigrant women aged between 50 and 79 years are anxiety and depression (Agbemenu, 2016). Despite a variety of efficacious interventions for these conditions, elderly immigrant women continue to experience mental health care disparities in both their access to services and the quality of treatment they receive. Research indicates that African American heterogeneity impacts access to depression and anxiety treatment. African Americans are also an increasingly visible minority within the United States, particularly in West Massachusetts, and are often identified as Black. The present study sought to understand the causes and prevalence of depression among older immigrant African American women in Metro West Massachusetts, as well as how these older immigrants cope with depression.

A total of 12 self-identified social workers were interviewed about their patients' mental health symptoms and treatment experiences, perceived causes of their patients' anxiety, stressors facing their patients in West Massachusetts, their patients' 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 their white counterparts. Individual gender, age, marital status, and country of origin played major roles in the endorsement of anxiety and depression. 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 either group. These findings underscore the importance of attending to both between-group and within-group differences in the mental health experiences of different ethnic communities.

The intent of 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 over 55 years of age who relocated from any African country after acquiring permanent residency in the United States. Depression among elderly immigrant women is an important phenomenon for study within social work, given the extent to which the condition affects vulnerable populations. Derr (2017) pointed out that immigrants typically face stressors related to the migration experience that may cause or intensify mental health problems. Moreover, immigrants tend to access mental health services at a lower rate than non-immigrants (Derr, 2017). This situation leaves immigrants at risk of untreated health conditions, leading to an increased disease burden (Lynch, Berg, Manna, & Schade, 2016). This negative health predisposition creates a greater need for mental health services among immigrants, who appear more susceptible to developing depression.

Migration can be challenging, and many immigrant women experience difficulties that affect their mental health (Foo et al., 2018). Changes in practices, values, social factors, and cultural identification are considered contributing risk factors for developing mental health issues (Alegría, Álvarez, & DiMarzio, 2017). Similarly, Foo et al. (2018) asserted that migration into a new country leads to drastic changes in essential aspects of daily life. 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). Examining the stressors surrounding the migrant experience from a social work perspective should offer insights into the issues faced by this vulnerable population, especially for women aged 50 years and above.

Determining the views of social workers from West Massachusetts who work with older immigrant African women affected by depression may reveal service modifications — such as giving patients with language barriers additional time — needed to enhance access to quality mental health services (O'Donnell et al., 2016). Immigration can create worry that increases the risks of depression, and this can be exacerbated by cultural factors such as language barriers, which may complicate diagnosis and treatment among immigrant populations (Landa, Skritskaya, Nicasio, Humensky, & Lewis-Fernández, 2015). Failure to determine the views of social workers on depression within a community translates to neglecting social health and welfare (Baldwin-Clark, Ofahengaue Vakalahi, & Anderson, 2016). The intent of this study is therefore to obtain the perspectives of social workers regarding depression within the selected migrant population, as well as insights into ways healthcare professionals can help meet emerging needs.

In this study, the views of social workers regarding depression in older immigrant African women in Metro West Massachusetts are examined. Through analyzing these perspectives, insights can be provided into how the social work sector can assist in meeting the emerging needs of the population. Expected among the results are service modifications needed to address the needs of the immigrant African women in Metro West Massachusetts (Takeuchi, 2016). These findings can enhance access to quality mental health services and ensure that women understand the implications of not seeking mental health care. By examining the stressors faced by migrant women, insights can be gained into the issues women face and targeted solutions can be developed (Agbemenu, 2016). Social workers will also benefit, as they can use the findings to determine methods for reaching out to the study population.

This study is focused on the following research questions:

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

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

Purpose, Research Questions, and Key Terms

3. How do social workers assess the need for mental health services for their clientele, particularly 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?

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

Older immigrant African women — This term refers to women who are over 55 years of age and who relocated from any African country to the United States, whether legally or illegally, including those who came as refugees and have remained into their advanced years. For this study, the focus is on older immigrant African women living in West Massachusetts who suffer from depression.

Immigrant — According to the Oxford University Press (n.d.-b), an immigrant is a person who comes to permanently live in a foreign country. There are four types of immigration status: citizens, residents, undocumented, and non-immigrants. This study does not focus on the status of the immigrant; however, immigration status is expected to influence how individuals access mental health services. The study will consider all immigrants who emigrated from Africa and currently reside in the selected community.

African women — African women refers to a native or female inhabitant of Africa, or a woman of African ancestry. In this study, the term refers to older immigrant African women who were born in Africa and migrated to the United States — either legally or illegally — and who currently reside in West Massachusetts, having lived a significant portion of their lives in Africa before immigrating.

Coping mechanisms — A coping mechanism is defined as an adaptation to environmental stress based on conscious and unconscious choice that enhances control over behavior. In this study, coping mechanism refers to the various cultural strategies the women use to deal with stressful situations they encounter, and the methods they employ to adjust to stress and maintain their emotional well-being.

Migration — Migration is the movement of people or animals from one place to another. In this study, migration refers to the movement of people from any African country to the United States. The focus is on women who have migrated from Africa to the US — either alone, with their families, or with relatives — and who currently live in West Massachusetts. The migration process itself is not a primary focus but may be relevant for understanding barriers to mental health service access.

Host country — According to the Oxford University Press (n.d.-a), a host country is a country that holds a cultural or sporting event to which others are invited. In this study, host country refers to the country accommodating the African immigrants — in this case, the United States.

Theoretical Framework and Literature Review

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 community social workers in better addressing the 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 barriers prevent them from receiving support. The findings will equip social workers with the knowledge to develop strategies for treating depression and bring awareness to the unique needs of this population.

The theoretical framework used to frame this project is Structural-Functional Theory. Theorists such as Cassel (1995) and Cobb (1976) expressed that social support serves as a resistance factor and plays an important role in reducing the adverse impact of negative life events (Thoits, 1985). This theory is central to understanding the onset of depression among older immigrant African women, given the various social demands associated with being a migrant. Kinser and Lyon (2014) emphasized that depressing experiences may increase a person's vulnerability to stressful episodes. Stress and vulnerability compound the possibility of developing depression, where environmental changes, lack of coping mechanisms, and lack of support adversely affect the mental health of this group (Alegría et al., 2017).

Cultural influences revealed through this framework will be vital in determining appropriate methods for treating this population. To become culturally competent when working with this population, social workers need familiarity with Structural-Functional Theory, which explains why society functions as it does and emphasizes the relationships among social institutions — including education, law, government, religion, and culture (Emadpoor, Lavasani, & Shahcheraghi, 2016). Society operates as a system in which all parts work together to create a coherent whole. Emadpoor et al. (2016) posit that societies require culture to function effectively. Being culturally informed is therefore beneficial to social workers, enabling them to reach out to community members and approach them in an acceptable manner (Sabbioni et al., 2018).

A review of the literature revealed a lack of studies with a primary focus on older African immigrant women (Okudo & Ross, 2016). This shortage stems from numerous factors, most involving the perception African immigrant communities hold regarding depression (Thomson, Chaze, George, & Guruge, 2015). Depressed individuals are frequently stigmatized, and many African communities believe depression is caused by evil spirits. With this belief, it becomes difficult for women to seek professional health services for fear of harsh judgment by community members (Sánchez et al., 2014). For this study, searches were conducted in MEDLINE, PsycINFO, CINAHL, EBSCO, Research Gate, ProQuest, SAGE Journals, and EMBASE using keywords including "older African American women," "older immigrant African women," "depression in immigrant African women," "depression," and "older immigrant women."

Okudo and Ross (2016) provided information on the various health challenges that African immigrants from different parts of Africa face when they relocate to the United States, as well as an exploration of the healthy immigrant effect (HIE). When African immigrants arrive in the US, they tend to be healthier than their American counterparts due to the HIE. However, as immigrants acclimate to the American system, they adopt unhealthy lifestyles and behaviors, which leads to the development of lifestyle diseases they would not have developed had they remained in their home countries. This article is significant because it offers insights into the health changes immigrants undergo and the degree to which this population is neglected by physicians. Without understanding the peculiarities of the African immigrant population, physicians cannot offer culturally appropriate care.

Sánchez et al. (2014) identified depression and anxiety as the most commonly occurring mental health disorders and noted disparities in both the quality of care provided and access to mental health services. The role of culture and stigmatization were explored in the study. Mental health care disparities experienced by immigrants were attributed to insufficient community services, lack of cultural competency, and mental health stigmatization. Understanding how to overcome these barriers will assist in reducing cases of depression among older African immigrant women.

Delara (2016) noted that the mental health of African immigrant women is affected by social, cultural, and health care system factors, and argued for embracing different methodologies for promoting mental health among these women. The mere fact that a woman is a migrant makes her more vulnerable to both negative and positive mental effects of migration. These effects are dependent on the woman's legal status, stage of the migration cycle, and mode of travel. The immigration process can be traumatizing, particularly if women had to use clandestine means to arrive in the US. Asking these women repetitive questions about immigration victimization could trigger mental disorders like depression, and the women may also avoid mental health services out of fear of such questioning. Older immigrant African women have been found to experience problems related to isolation, language, abuse, culture, and mobility — all of which hinder access to mental health services.

Rashid and Gregory (2014) focused on the experiences of African immigrant women, exploring their lives before and after relocation. Their work demonstrated that while African immigrant women face numerous challenges upon relocating to the US, some have managed to overcome adversity and avoid developing depression. Understanding why some older immigrant African women suffer from depression while others do not is vital. This article offers important information on how some women managed their relocation and successfully avoided depression — insights that could be valuable for other African immigrant women.

Thomson et al. (2015) noted that the relocation process can affect the mental health of immigrants, and without information on mental health services, many immigrants are denied access to care. Immigrants are underrepresented in the mental healthcare system and underutilize mental health services. Economic hardships further affect both their mental health and their access to services. Three major barriers identified were: barriers in the uptake of health information and services; inadequacy of linguistically and culturally appropriate services; and barriers related to the settlement experience. The present study seeks to determine whether these same barriers affect older immigrant African women in West Massachusetts.

Baldwin-Clark et al. (2016) noted that depression is a major problem among older African immigrant women, and because this population is understudied, their depression is rarely discussed or researched. The lack of relevant research suggests prevalence rates of depression may be higher than currently assumed. Most depression studies have focused on white older adults. African immigrants rarely make use of healthcare, social services, and long-term care; reasons include lack of awareness of available resources, limited financial resources, differing interpretations of mental health issues, and mistrust of the healthcare system. Understanding why women fail to access services will assist this researcher in formulating questions for social workers aimed at establishing whether 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 its correlates. By analyzing Brazilian immigrants who had relocated to Massachusetts, the authors demonstrated that migrants encounter barriers similar to those faced by older immigrant African women. Therefore, barriers to accessing mental health services may be systemic rather than inherent to the migrants themselves. Understanding what hinders migrants from accessing mental health services will be beneficial to communities as those problems can then be addressed.

While failure to access services is sometimes attributed to a lack of knowledge among migrants, other factors include cultural preferences and a lack of appropriate services. Immigrants from Africa and Brazil face similar language barriers, resulting in difficulty understanding physicians' recommendations. Culture plays a key role in treatment, and cultural competency should therefore be analyzed to determine whether social workers are culturally aware. The significance of this body of literature is that immigrants appear to share similar experiences regarding depression after relocation to the US, underscoring the need to investigate systemic issues surrounding mental health services in immigrant communities.

Li, Liddell, and Nickerson (2016) analyzed stressors faced by African immigrants and refugees when they relocate to the United States and linked these stressors to the development of depression. Many immigrants face social and interpersonal challenges upon migrating, including separation from family, social isolation, discrimination, and loss of social identity tied to their former cultural and community groups. These difficulties contribute to depressive symptoms in older immigrant African women. Post-migration factors affecting mental health should be closely analyzed, as they have been found to be significant contributors to both depressive symptoms and the failure to seek mental health services.

Foo et al. (2018) examined the extent of depression among immigrants and explored variations in prevalence based on demographic and educational factors. When older immigrant African women assimilate to new cultural practices and surroundings, they develop acculturative stress, which can lead to depression. The early post-migration phase is particularly associated with elevated acculturative stress, which tends to diminish as the immigrant settles into the host country. Although the authors found no direct causal relationship between migration and depression — as immigrants eventually adapt — the adjustment period involving changes in cultural values and social networks can generate confusion and depressive symptoms. The lack of social support is identified as a significant contributor to the development of depression in later life, as older immigrant women may be isolated and lack the social networks they would have had in their home country.

Ekwemalor and Ezeobele (2020) explored the portrayal of depression among Nigerian-born immigrant women in the United States. Moving from a patriarchal culture to a more democratic one can be challenging, and limited knowledge of available services — combined with cultural tendencies toward secrecy — denies many migrants the opportunity to receive assistance for mental health problems. Disruption of the traditional family structure is one significant effect of migrating to the US. When Nigerian migrants face stressful situations, they may be guarded and unwilling to divulge information; therefore, cultural competence on the part of social workers is essential. The researchers established that most Nigerian women who have immigrated to the US label depression as "craziness" or "madness." One participant stated: "You people in the US call it depression; we call it madness in Nigeria." This illustrates the level of stigma attached to a depression diagnosis for women from this cultural background. The authors proposed the use of a conversational interview style to help relax Nigerian immigrants during health assessments, thereby breaking cultural barriers and encouraging disclosure of health conditions.

The professional and academic literature indicates that older immigrant African women do not receive adequate mental health services. Systemic and cultural barriers promote the lack of access to care and require further investigation. Merely identifying these barriers is insufficient; there must also be investigation into how to overcome them and make it easier for the women to access mental health services. All studies reviewed confirmed a discrepancy in the access and usage of mental health services among elderly immigrant women. Most immigrants arrive in the US in good health and begin developing mental health issues due to the challenges they face after relocation. Social workers interact closely with immigrants and can offer vital insights into how this population utilizes available mental health services. A key finding from the literature review is the genuine lack of focus on the social workers' perspective. While researchers have documented the impact of immigration on African immigrants and the development of depression, the gap in information about access to mental health services from the social work perspective is what the present study aims to address.