Depression Among Older Immigrant African Women in Metro West Massachusetts

Introduction and Overview

This paper presents a literature review and research design for a study examining depression among older immigrant African women in Metro West Massachusetts. The data collection methodology used for the research study will be semi-structured interviews, which give the researcher an opportunity to explore participants' responses further in order to clarify the answers given. Semi-structured interviews make use of open-ended questions that require explanation rather than a simple yes or no answer. Data collection will be conducted through interviews, and study participants will comprise social workers working in Metro West Massachusetts. All interviews will be conducted using internet services such as GoToMeeting, Skype, Zoom, or any other web-based platform due to the ongoing COVID-19 pandemic. Only 10 questions will be asked per interview.

The reason for focusing on social workers is to obtain credible information and to gather varied insights, as social workers interact with numerous clients. Study participants will be social workers who have been working in the area for a minimum of three years. This criterion ensures that only social workers with sufficient knowledge and experience attending to clients in the area are interviewed. The researcher anticipates having at least 10–12 social workers participate in the study. It is assumed this number will be representative of the population and manageable in terms of workload. Having a large number of participants would result in considerable time spent conducting interviews and performing data analysis, without offering a proportionate difference in results.

The data analysis process will begin with transcription of the audio recordings. The researcher aims to uncover patterns and develop codes for use in identifying themes. Each code will be assigned to a particular theme where possible, though the researcher acknowledges that some codes may not fit neatly into a theme. The data analysis process will comprise familiarization with the data, assignment of preliminary codes to describe content, searching for patterns in codes, reviewing themes, defining and naming themes, and producing the final report. These steps will be followed systematically to ensure nothing vital is missed.

In Metro West Massachusetts, the most common mental health disorders are anxiety and depression, which are prevalent among elderly immigrant women aged between 50 and 79 years (Agbemenu, 2016). Despite the availability of efficacious interventions, elderly immigrant women experience significant mental health care disparities in access to services and quality of treatment. Research indicates that African American heterogeneity impacts access to depression and anxiety treatment. African Americans are an increasingly visible minority within the United States, particularly in West Massachusetts. 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 older immigrants cope with depression. A total of 12 self-identified social workers were interviewed about their patients' mental health symptoms and treatment experiences, the perceived causes of their patients' anxiety, stressors their patients face in West Massachusetts, patients' access to mental health services, and how patients cope with depression.

Results indicated considerable variability across groups, with African American elderly immigrant women endorsing higher rates of depression and anxiety, as well as higher rates of treatment-seeking, than white counterparts. Gender, age, marital status, and country of origin played a major role 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 mental health and treatment experiences across ethnic groups.

Problem Statement

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 who are over 55 years of age and who 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, given the extent to which the condition affects vulnerable populations. Derr (2017) pointed out that immigrants typically face stressors related to migration experiences that may cause or intensify mental health problems. Moreover, Derr (2017) also noted that immigrants tend to access mental health services at a lower rate compared to non-immigrants. This situation leaves immigrants at risk of untreated health conditions, leading to 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. It is therefore imperative to establish the views of social workers addressing the mental health needs — particularly depression — of older immigrant African women in Metro West Massachusetts, so that insights gained can inform the development of comprehensive mental health programs aimed at improving health outcomes for this population.

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 risk factors for developing mental health issues (Alegría, Álvarez, & DiMarzio, 2017). Foo et al. (2018) similarly 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. Examining stressors surrounding the migrant experience from the social work perspective should therefore offer valuable insights into the issues faced by this vulnerable population, especially for women aged 50 and above.

Based on the highlighted problem, it is imperative to determine the views of social workers in West Massachusetts who work with older immigrant African women affected by depression (O'Donnell et al., 2016). Such an undertaking may reveal necessary service modifications — such as allowing patients with language barriers additional time — that could enhance access to quality mental health services (O'Donnell et al., 2016). As researchers have suggested, immigration can create worry and increase the risks of depression, a process that may be exacerbated by cultural factors such as language barriers, which can make diagnosing and treating this disorder among immigrant populations more difficult (Landa, Skritskaya, Nicasio, Humensky, & Lewis-Fernández, 2015). Failing 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 perspective of social workers regarding depression within the selected migrant population and to gain insights into how professionals in the healthcare sector can help meet emerging needs.

Purpose of the Study and Research Questions

This study aims to obtain the views of social workers regarding depression in older immigrant African women in Metro West Massachusetts. By analyzing these perspectives, insights can be provided into ways the social work sector can assist in meeting the emerging needs of the population. Expected findings include any service modifications needed to meet the needs of immigrant African women in the Metro West Massachusetts region (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, the study will gain insights into the challenges these women face and support the development of solutions directly targeted to this population (Agbemenu, 2016). Social workers will also benefit, as they will be able to use the findings of this study to determine methods they can employ to reach out to the population under study.

This study is focused upon the following research questions:

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

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

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

Theoretical Framework and Significance

The theoretical framework used to frame this project is the 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 exposure to negative life events (Thoits, 1985). This theory plays a key role in understanding the onset of depression among older immigrant African women, given the various social demands associated with being a migrant. Kinser and Lyon (2014) further emphasized that depressing experiences may increase a person's vulnerability to stressful episodes. Stress and vulnerability compound the likelihood of developing depression, where environmental changes, lack of coping mechanisms, and lack of social support have an adverse impact on mental health outcomes (Alegría et al., 2017).

Cultural influences revealed through this framework will be vital in determining the methods that can be used to treat this population. To become culturally competent when working with this population, social workers need to be familiar with the Structural-Functional Theory. This theory explains why society functions as it does and emphasizes the relationships among different social institutions — including education, law, government, religion, and culture (Emadpoor, Lavasani, & Shahcheraghi, 2016). Social workers should understand society as a system in which all parts work together. Emadpoor et al. (2016) posit that societies require culture in order to function. Being culturally informed is therefore beneficial to the social worker and will allow them to reach out to community members in an acceptable and effective manner (Sabbioni et al., 2018).

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. The results will assist community social workers to better address the emerging needs and challenges this population faces when accessing mental health services. More specifically, the study will focus on how the target population is affected by depression when barriers to support exist. Findings will equip social workers with the knowledge needed to develop strategies for treating depression and raising awareness of the unique needs of older immigrant African women.

Literature Review

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, many of which involve the perception that African immigrants hold regarding depression (Thomson, Chaze, George, & Guruge, 2015). Depressed individuals are often stigmatized, and many African communities believe depression is caused by malevolent spiritual forces. With this belief system in place, it becomes difficult for women to seek professional mental health services, as they risk being harshly labeled and judged by other community members (Sánchez et al., 2014). For this study, peer-reviewed publications focusing on mental health among older African immigrant women were searched from the following databases: MEDLINE, PsycINFO, CINAHL, EBSCO, Research Gate, ProQuest, SAGE Journals, and EMBASE. Keywords used included: older African American women, older immigrant African women, depression in immigrant African women, depression, and older immigrant women.

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, including an exploration of the healthy immigrant effect (HIE). When African immigrants first relocate to the US, they are generally healthier than their American counterparts due to the HIE. However, as immigrants acclimate to the American system, they tend to adopt unhealthy lifestyle behaviors that lead to the development of lifestyle diseases they would not have encountered had they remained in Africa. This article is significant because it supports the current study by offering insights into the health changes immigrants undergo and how this population is often neglected by physicians. Without understanding the particularities of the African immigrant population, physicians cannot offer culturally useful care. The article will help determine whether social workers make use of culturally acceptable practices when treating older immigrant African women.

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 given and in access to mental health services. The role of culture and stigmatization was explored in their study. Their findings indicate that mental health care disparities among immigrants result from insufficient mental health services in their communities, a lack of cultural competency, and mental health stigmatization. This information helps clarify why many African immigrants do not receive or seek mental health services. Understanding how to overcome these barriers will assist in reducing cases of depression among older African immigrant women.

Rashid and Gregory (2014) focused on the experiences of African immigrant women, with attention to their lives both before and after relocation. Their work demonstrated that African immigrant women face numerous challenges when they move to the US; however, some women have managed to overcome adversity and withstand these challenges. It is vital to understand why some older immigrant African women suffer from depression while others do not. This article offers important information on how some women successfully managed their relocation and avoided depression, providing insights that could be applied to other African immigrant women in similar circumstances.

Thomson et al. (2015) found that the relocation process can negatively impact immigrants' mental health, and that without information on available mental health services, many immigrants are effectively denied access to care. The authors noted that immigrants are underrepresented in the mental healthcare system and underutilize mental health services. Barriers to service utilization play a key role for older immigrant African women. The three major barriers identified were: barriers in the uptake of health information and services, the inadequacy of linguistically and culturally appropriate services, and barriers related to the settlement experience. The researcher aims to determine whether these same barriers exist for 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 group is understudied, their depression is rarely discussed or researched. The lack of relevant research on older immigrant African women suggests that prevalence rates of depression may be higher than currently estimated. Most depression studies have focused on White older adults. African immigrants are rare users of healthcare, social services, and long-term care, largely because of limited awareness of available resources, insufficient financial resources, differences in interpreting mental health issues, and mistrust of systems. This study informs the current research by explaining why older immigrant African women often fail to access mental health services and offers strategies for encouraging utilization of those services.

Delara (2016) found that the mental health of African immigrant women is shaped by social, cultural, and healthcare system factors, and argued for the adoption of diverse methodologies for promoting mental health among these women. The mere fact of being a migrant increases a woman's vulnerability to both negative and positive mental effects of migration. The effects experienced depend on 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 their immigration experiences may trigger mental disorders like depression; the women may also avoid seeking services out of fear of being questioned about their history. Older immigrant African women have been found to experience problems of isolation, language barriers, abuse, cultural displacement, and reduced mobility — all of which hinder access to mental health services.

Lazar-Neto, Louzada, de Moura, Calixto, and Castro (2018) assessed the frequency of depression among immigrants living in Massachusetts and examined its correlates. By analyzing Brazilian immigrants who relocated to Massachusetts, the authors indicated that these migrants encounter barriers similar to those faced by older immigrant African women. Therefore, barriers to mental health service access may reflect systemic issues rather than individual failings. Immigrants from Africa and Brazil face comparable language barriers, where limited English proficiency results in difficulty understanding the recommendations of physicians or mental health professionals. Culture plays a key role in the treatment of migrants, and this article highlights the need to investigate the systemic reasons behind unequal access to mental health services across immigrant communities.

Li, Liddell, and Nickerson (2016) analyzed the stressors faced by African immigrants and refugees when they relocate to the United States and linked those stressors to the development of depression. Many immigrants face social and interpersonal challenges upon migrating, including separation from family, social isolation, and discrimination in the host country. Li et al. (2016) also identified loss of social identity tied to former cultural and community groups as a significant difficulty. These challenges contribute to depressive symptoms in older immigrant African women. The article's discussion of strategies employed by immigrants to reduce depressive symptoms is particularly valuable, as the current study will explore whether similar strategies might apply to the population under study. Post-migration factors have been found to be major contributors to the development of depressive symptoms and to avoidance of 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 must assimilate to new cultural practices and environments, they develop acculturative stress, which contributes to the onset of depression. The early post-migration phase is highly associated with elevated levels of acculturative stress, which tend to diminish as the immigrant settles into the host country. The authors also noted that the adjustment period — involving realignment of cultural values and social networks — leads to confusion and potential depression. The lack of social support during this period is identified as a significant contributor to depression later in life, as the older immigrant may experience loneliness without the social networks available in her home country.

Ekwemalor and Ezeobele (2020) explored the portrayal of depression among Nigerian-born immigrant women living in the United States. Moving from a patriarchal culture to a more democratic one can be challenging. Limited knowledge of available services, combined with a cultural norm of secrecy, denies many migrants the opportunity to receive mental health assistance. Disruption of the traditional family structure is one of the effects of migrating to the US; the extended family socialization familiar to African women is often absent, causing significant distress. When Nigerian migrants face stressful situations, they may be guarded in their interactions and reluctant to share personal information, which underscores the need for cultural competence on the part of social workers. The authors propose the use of a conversational interview style to help relax Nigerian immigrants during health assessments, as this approach may help lower the cultural barriers that prevent women from disclosing their mental health conditions.

Conclusion

According to Saeidimehr, Geravandi, Izadmehr, and Mohammadi (2016), reducing the causes of depression is beneficial to society by decreasing the number of people who require mental health services or who are living with untreated mental health conditions. The results of this investigation can benefit social workers by providing insights into strategies they can use to assist older immigrant African women suffering from depression in accessing mental health services. This study aims to uncover the cultural influences encountered by social workers when working with this population. By understanding the impact of culture on the community, social workers can develop strategies to become more culturally competent, thereby improving the reach and effectiveness of mental health services for this underserved group.

References

Agbemenu, K. (2016). Acculturation and health behaviors of African immigrants living in the United States: An integrative review. ABNF Journal, 27(3).

Alegría, M., Álvarez, K., & DiMarzio, K. (2017). Immigration and mental health. Current Epidemiology Reports, 4(2), 145–155.

Baldwin-Clark, T., Ofahengaue Vakalahi, H. F., & Anderson, B. (2016). What about African American older women and depressive symptoms? Educational Gerontology, 42(5), 310–320.

Biros, M. (2018). Capacity, vulnerability, and informed consent for research. The Journal of Law, Medicine & Ethics, 46(1), 72–78.

Cassel, J. (1995). The contribution of the social environment to host resistance: The fourth Wade Hampton Frost lecture. American Journal of Epidemiology, 141(9), 798–814.

Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic Medicine.

Delara, M. (2016). Social determinants of immigrant women's mental health. Advances in Public Health, 2016.

Derr, A. S. (2017). Mental health service use among immigrants in the United States: A systematic review. Psychiatric Services, 67(3), 265–274.

Ekwemalor, C. C., & Ezeobele, I. E. (2020). Psychosocial impacts of immigration on Nigerian immigrants in the United States: A phenomenological study. Journal of Transcultural Nursing, 31(3), 276–283.

Emadpoor, L., Lavasani, M. G., & Shahcheraghi, S. M. (2016). Relationship between perceived social support and psychological well-being among students based on mediating role of academic motivation. International Journal of Mental Health and Addiction, 14(3), 284–290.

Foo, S., Tam, W., Ho, C., Tran, B., Nguyen, L., McIntyre, R., & Ho, R. (2018). Prevalence of depression among migrants: A systematic review and meta-analysis. International Journal of Environmental Research and Public Health, 15(9), 1986.

Kinser, P. A., & Lyon, D. E. (2014). A conceptual framework of stress vulnerability, depression, and health outcomes in women: Potential uses in research on complementary therapies for depression. Brain and Behavior, 4(5), 665–674.

Landa, A., Skritskaya, N., Nicasio, A., Humensky, J., & Lewis-Fernández, R. (2015). Unmet need for treatment of depression among immigrants from the former USSR in the US: A primary care study. The International Journal of Psychiatry in Medicine, 50(3), 271–289.

Lazar-Neto, F., Louzada, A. C. S., de Moura, R. F., Calixto, F. M., & Castro, M. C. (2018). Depression and its correlates among Brazilian immigrants in Massachusetts, USA. Journal of Immigrant and Minority Health, 20(4), 832–840.

Li, S. S., Liddell, B. J., & Nickerson, A. (2016). The relationship between post-migration stress and psychological disorders in refugees and asylum seekers. Current Psychiatry Reports, 18(9), 82.

Liu, D., Zeng, S., Deng, F., & Zhou, J. (2018). Existing problems and solutions of informed consent in clinical research. Chinese Medical Ethics, 31(6), 732–735.

Lynch, J. R., Berg, S. T., Manna, J., & Schade, C. P. (2016). Making a dent in undiagnosed and untreated depression among older West Virginians. West Virginia Medical Journal, 112(3), 60–66.

O'Donnell, C. A., Burns, N., Mair, F. S., Dowrick, C., Clissmann, C., van den Muijsenbergh, M., . . . Saridaki, A. (2016). Reducing the health care burden for marginalised migrants: The potential role for primary care in Europe. Health Policy, 120(5), 495–508.

Okudo, J. C., & Ross, M. W. (2016). Common health concerns in African immigrants in the US — implications for the family physician. International Journal of Medical and Health Sciences Research, 3(4), 44–49.

Oxford University Press. (n.d.-a). Host country. Retrieved from https://www.oxfordlearnersdictionaries.com/definition/english/host_1

Oxford University Press. (n.d.-b). Immigrant. Retrieved from https://www.oxfordlearnersdictionaries.com/definition/english/immigrant?q=immigrant

Rashid, R., & Gregory, D. (2014). 'Not giving up on life': A holistic exploration of resilience among a sample of immigrant Canadian women. Canadian Ethnic Studies, 46(1), 197–214.

Sabbioni, D., Feehan, S., Nicholls, C., Soong, W., Rigoli, D., Follett, D., . . . Curtis, K. (2018). Providing culturally informed mental health services to Aboriginal youth: The YouthLink model in Western Australia. Early Intervention in Psychiatry, 12(5), 987–994.

Saeidimehr, S., Geravandi, S., Izadmehr, A., & Mohammadi, M. J. (2016). Relationship between the "quality of life" and symptoms of depression among older adults. Iranian Journal of Ageing, 11(1), 90–99.

Sánchez, M., Cardemil, E., Adams, S. T., Calista, J. L., Connell, J., DePalo, A., . . . Kaminow, P. (2014). Brave new world: Mental health experiences of Puerto Ricans, immigrant Latinos, and Brazilians in Massachusetts. Cultural Diversity and Ethnic Minority Psychology, 20(1), 16.

Scheider, S., Ostermann, F. O., & Adams, B. (2017). Why good data analysts need to be critical synthesists: Determining the role of semantics in data analysis. Future Generation Computer Systems, 72, 11–22.

Takeuchi, D. T. (2016). Vintage wine in new bottles: Infusing select ideas into the study of immigration, immigrants, and mental health. Journal of Health and Social Behavior, 57(4), 423–435.

Thoits, P. A. (1985). Social support and psychological well-being: Theoretical possibilities. In Social support: Theory, research and applications (pp. 51–72). Springer.

Thomson, M. S., Chaze, F., George, U., & Guruge, S. (2015). Improving immigrant populations' access to mental health services in Canada: A review of barriers and recommendations. Journal of Immigrant and Minority Health, 17(6), 1895–1905.

Wolf, S. M., Clayton, E. W., & Lawrenz, F. (2018). The past, present, and future of informed consent in research and translational medicine. SAGE Publications.