Valerie Borum
Professor, School of Social Work, Toronto Metropolitan University, Canada.
Corresponding Author Details: Valerie Borum, Professor, School of Social Work, Toronto Metropolitan University, Canada.
Received date: 11th March, 2024
Accepted date: 16th April, 2024
Published date: 18th April, 2024
Citation: Borum, V., (2024). Attitudes and Beliefs of African American Women Regarding Mental Health Services: A Womanist Exploration. J Soci Work Welf Policy, 2(1): 110.
Copyright: ©2024, This is an open-access article distributed under the terms of the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Although studies indicate the influence of cultural beliefs on attitudes toward mental health and depression care services, there is a need to focus on the process of how culture plays a role in perceptions of mental health and depression care [1]. The purpose of this study is to explore, utilizing qualitative methods (e.g., focus groups), how cultural beliefs influence 40 African American women in their perceptions, attitudes, and beliefs about mental health services and mental health assistance-seeking behaviors, specifically regarding depression care. Participants’ narratives reveal a clear preference for service provider-client race concordance. Participants’ narratives also reveal cultural and communal stigma and gender socialization to be a “Strong Black Woman” as deterrents to mental health assistance seeking behaviors. Recommendations for incorporating the role that ethnocultural beliefs and values of different culturally-gendered groups regarding mental health and assistance-seeking behaviors be included in social work and allied health professions [2].
Keywords: Depression, African American Women, Help-seeking Behavior, Womanism, Mental Health, Stigma, Strong Black Woman, Qualitative Methods, Provider-Client Race Concordance, Ethnoculture
Several studies [3-7] have highlighted the significant influence of culture on the attitudes, beliefs, and usage of mental health services, such as depression care. However, there has been less attention given to the impact of ethnocultural factors on the help-seeking behaviors of ethnically-gendered women when it comes to accessing viable mental health support, which may include support networks such as churches, clergy members, and family members. This underscores the urgent need to explore how ethnocultural beliefs influence African American women's perceptions, attitudes and beliefs about mental health services and assistance-seeking behaviors and to incorporate these beliefs into the provision of mental health services.
Studies conducted by Ayalon & Young [8], Molock et al. [9], Cauce et al. [5], Settles [6], and Williams et al. [7] have highlighted that culture plays a crucial role in shaping the contextual landscape of factors that lead to depression and help-seeking behaviors. However, there is a dearth of information regarding how culture, particularly ethnoculture, affects African-American women's attitudes and beliefs toward mental health services and assistance-seeking behaviors concerning depression care. This study aims to use qualitative methods, such as focus groups, to explore how the ethnocultural beliefs of 40 African-American women influence their perceptions, attitudes, and beliefs about mental health services and assistance seeking behaviors for depression care.
Depression is a common mood disorder that affects an estimated 17.3 million adults aged 18 or older and accounts for approximately 7.1% of all adults in the United States [4, 10, 11][4,10,11]. Common feelings associated with depression can include sadness, anger, grief, and frustration with daily life and can last weeks, months, or longer [12]. Results from both survey and clinical research studies have indicated that women are at a higher risk of experiencing depression in comparison to men [11-15]. Each year, the prevalence rate of depression among women is higher than that of men (i.e., 8.7 to 5.3 percent). Depression is a significant public health concern and can lead to increased vulnerabilities in other areas of life (e.g., high stress, substance abuse, suicide, etc.) in this population [11].
Studies have shown that the prevalence of depression among American women varies. Some studies suggest that African American women are at a higher risk compared to European American women. However, other studies have found equivalent rates of depression between the two groups, and some have even reported lower rates of depression among African American women. More research is needed to better understand the differences in risk factors based on gender, race, and other factors. There is no congruence or agreement among the research studies focusing on rates of depression among USA women, in particular, African American women and European women.
Research outcomes indicate that higher rates of depression are linked to the emergence of young adulthood [16,17,18]. Emerging adulthood (18-25 years of age) is associated with a developmental phase encompassing critical social and identity developmental challenges such as independence and academic and professional explorations [16]. Young adults experiencing depression and other mood disorders have been studied in college and university settings where diverse populations can be explored [14,18,19].
It has been observed that depression is a significant risk factor for academic performance among college-aged students in various settings. The consistency of this finding highlights the importance of addressing mental health concerns among students to promote academic success [14 ,17, 20][14,17,20]. Further, being female, along with these elements, predictably correlated with depression. Additional studies have shown other factors, such as perceived racial discrimination and stress [21-23]. However, few studies exist looking specifically at the intersection of being female and Black as related to depression.
González et al. [24] proposed that African Americans’ sense of spirituality and strength through adversity has been linked with a lower rate of depression in African American female samples. Studies have shown that African Americans tend to have fewer mental health sessions and terminate services earlier than their European American counterparts [6,7,14]. Although this could be representative of the resilience African Americans display during adversity, it could also be indicative that African Americans must rely on their resiliency rather than seek treatment from mental health services that are unable to provide culturally appropriate assistance. In other words, a difference in ethnic coping responses may also occur because of a paucity of culturally sensitive mental health care services and programs. Without appropriate depression care and treatment, depression experienced by African American women can be exacerbated by the additional psychological distress created by incidents of racism and racial-gendered discrimination [6,25].
Further investigation into the experiences of African American women in the context of depression and depression care is warranted [14,26]. For example, more research is required in terms of addressing the differential experiences with depression and depression care among African American women in the context of their cultural and communal lived experiences [4].
Womanism encourages a critical examination of the limitations of feminist theory by promoting the different realities and experiences of African American women from a distinguishing standpoint [14,27,28]. Rather than trying to prove whether African American women share a singular or fixed “voice” as women, womanism is primarily concerned with how African American women’s voices dynamically foster a common foundation, a reclaiming, and preservation of their unique and self-defined perspectives [27,28]. “The use of a cultural analysis enables one to trace the social and ideological construction of race, gender, and class structures…” [29].
A womanist worldview involves comprehending the cosmological aspects of reality from a perspective of interdependence. This worldview is based on the understanding that all elements are universally interconnected. Unlike a dualistic (either/or) worldview, womanism flows from a diunital (both/and) worldview. This means that seemingly opposite ways of being (for example, being Black and female) can exist harmoniously and in balance [27,28,30,31]. Black and female identities are not mutually exclusive for African American women, as they are both Black and female. The intersectional confluence of what appears to be separate identities, Black and female, creates unique experiences for African American women. Womanism views the universe as a spiritual entity, with all its elements created from a spiritual source and possessing a universal nature. In obtaining knowledge, womanism stresses the importance of interpersonal relationships and the affective way of knowing [14,27,28,30,31].
Collins [27] explains four dimensions of a womanist epistemology that can be used in research with African American women. These dimensions are experience as a criterion of meaning, the use of dialogue to assess knowledge claims, an ethic of caring, and an ethic of personal responsibility. Knowledge obtained through a womanist epistemological methodology and qualitative interpretive approach can also inform theoretical relationships and develop culturally specific measures based on the participant's understanding of the concepts studied [14,27]. For example, “Central to misconception is the notion that grounded theory is an entirely inductive process, that it does not verify findings, and that it somehow molds the data to the theory rather than the reverse” [32].
Using grounded theory in an inductive and deductive approach to develop culturally specific measures provides a flexible understanding of the importance of culturally specific research. For example, previous studies have highlighted the significance of cultural expressions of mental illness and how symptoms are presented based on race, ethnicity, and gender. It is worth noting that mental illness and subsequent help-seeking behavior can be influenced by cultural factors [14]. According to Cauce et al. [5], African American women tend to exhibit non-traditional depressive symptoms, including delaying seeking care [33]. It is essential to examine how the culture of a particular ethnic group can affect the use of mental health services among African American women. This investigation aims to study the ethnocultural beliefs and attitudes that influence African American women's views on depression care and mental health services, using a womanist theoretical perspective based on their complex history and cultural values [28,34,35].
Integrating a theoretical framework, such as womanism, requires that it be based on and expressed in the context of African American women's sociocultural experiences. Utilizing qualitative interpretive analysis, a womanist framework could create a preliminary healthcare model catering to African American women's unique needs. This is evident from the research conducted by Settles et al. [6] and Williams et al. [7]. Womanism offers an interpretive framework that incorporates a structural analysis of the lived experiences of African American women, considering their unique history, culture, and sense of community. A comprehensive understanding of the circumstances surrounding the lives of African American women is necessary to inform the theory of depression among this population.
A qualitative, exploratory research study consisting of focus groups with 40 African American women was reviewed and approved by the Institutional Review Board at the site of the study. An exploratory, qualitative research design was chosen to investigate in-depth research questions on how ethnoculture influences perceptions, attitudes, and beliefs about mental health services and depression care among African American women [14,36]. Qualitative research focuses on understanding the experiences of research participants and identifying their needs, which are central to developing and validating knowledge [34,37]. According to Rubin and Babbie [38], a qualitative exploratory approach is an appropriate study method when there is a lack of information about a research area. There is a lack of research and theoretical perspectives that explain how African American women perceive mental health services and depression care. Therefore, a qualitative, interpretative research design is the most suitable approach for this study [14,39,40].
After obtaining institutional review board approval, a purposive sampling method was used to recruit participants for the study. This method aims to ensure that participants possess specific attributes that match the study criteria, as Berg [32] noted. In order to account for the role of ethnoculture, only African American women who self- identified as such were eligible for participation in this study. The study's focus did not include "race" as a pan-ethnic concept; therefore, women of African descent who belong to different ethnic groups, such as Nigerian American, Jamaican American, and Afro-Latina, were not included. By specifically recruiting African American students 18 and older, the investigator could more readily establish unique ethnocultural and historical experiences among a "relatively homogenous" ethnic sample consisting of inherent diversity related to attitudes and beliefs about mental health services and depression care. In this instance, African Americans refer to the direct descendants of the transatlantic enslavement of African peoples in the United States.
Existing literature suggests that the non-random sampling method is acceptable until a database can be developed to assess a population more adequately [14,37,41,42]. A sample was recruited from a predominantly white university in an urban, diverse northeastern U.S. state. Flyers were posted on campus for research recruitment.
In this study, the main focus was to understand the attitudes and beliefs of African American women toward mental health services and depression care. The researcher did not use any standardized questionnaires or depression screening tools, nor did they confirm if the participants had a depression diagnosis. Participants were given information about mental health services available on campus, Chaplain services, African American mental health services in the area, and depression/suicide prevention and intervention after the focus group discussions. This was to increase their awareness of the available support and demonstrate ethical social work research. The researcher's goal was to understand how African American women collectively construct, affirm, and preserve their meaning regarding mental health services and depression care [14].
This study's primary data collection strategy was focus groups, which are informal and structured discussions. The researcher explores general topics in these discussions to uncover the participants' perspectives. The researcher records the participants' responses and notes how they frame and structure their answers. Thomas and Sillen [43] state that the African American community is rebelling against excessive questionnaires and investigators because the results of these studies do not enhance needed resources, elements of self-determination, as well as their lives or life chances. In culturally sensitive research, focus groups allow all parties involved to contribute to collecting and analyzing information. In assessing knowledge claims, the epistemology of dialogue assumes connectedness, immersion, and reciprocity as essential components of the knowledge-validation process. Dialogue has deep roots in African-based oral traditions and African American culture, as asserted by Asante [30], Borum [14], Collins [35], and Schiele [44].
After obtaining written consent, the participants were informed that their participation in the study was voluntary and that they could withdraw at any time during the research process. The study involved conducting seven 60-90-minute focus groups, with focus questions established ahead of time to guide the process. These questions included but were not limited to the following: What comes to mind when you think about mental health services? How do you deal with depression? What are some of the reasons someone might seek out mental health services? What are some of the obstacles that might prevent someone from seeking mental health services? What other information should we know in order to better understand your beliefs about mental health services and depression?
All the discussions in focus groups were recorded for transcription purposes. To ensure the validity of the research findings, the researcher/facilitator used reflexive journaling. At the end of each focus group session, a member-checking strategy was employed by the researcher/facilitator to summarize the focus group discussions and receive feedback from the participants on the accuracy of the discussion summaries, thereby enhancing the validity of the findings.
Finally, as mentioned earlier, the participants were provided with brochures and information concerning campus mental health, Chaplain, African American mental health, and suicide prevention services.
This study involved a grounded theory approach and a thematic analysis of focus group discussions [45]. Grounded theory is a method utilized in expanding theory (e.g., womanism) grounded in qualitative data gathered and analyzed systematically [14,46]. The focus group discussions were transcribed verbatim by a professional transcription agency and reviewed for accuracy. Following transcription, focus group discussions were analyzed by this researcher by identifying topical coding schema (i.e., meaning units) in the form of themes and codes based on the transcript data. Analyzing the transcript data required generating a list of critical ideas, words, quotations, and phrases that reflected the participants’ views of mental health services and depression care [14,46]. Categories were then developed based on this list and clustered alongside topics to identify themes and meaning units [45].
The coding schemes were created based on the theoretical framework of the study regarding participants' attitudes and beliefs about using formal mental health and depression care services. Inductive codes were grouped into meaningful categories within this interpretive framework. At the same time, womanism was integrated as an organizing framework to categorize inductive and emerging themes into a preliminary explanatory model. As mentioned earlier, grounded theory is not solely an inductive process; it can also involve verifying findings and shaping empirical qualitative data into theory, such as womanism [14,[32,46]. Each theme is supported by at least two to three independent and representative statements from focus group discussions.
Focus group participants varied in age, from 18-29 years old, with a mean age of 29. All 40 focus group participants self-identified as African American women. The majority (32/40, i.e., 80 percent) of participants were undergraduate students, less than a quarter (8/40, i.e., 20 percent) were graduate students. Three overarching and intersecting themes with interlocking needs and concerns emerged from the focus groups. The first theme includes a strong preference for provider-client race concordance. In other words, there was a strong preference for the provider of mental health services to also be of African descent, and more specifically, African American [1]. The second theme consists of ethnocultural stigma in seeking treatment for depression stemming from the African American community. The third theme includes the gender socialization of African American women to be “Strong Black Women” as a barrier to seeking mental health services.
During seven focus group discussions centered around mental health services and depression care, a recurring theme emerged. Participants expressed their reluctance to seek professional help due to a belief that most mental health professionals are from the dominant culture, i.e., White Americans. This hesitancy and even refusal to seek help stems from a lack of trust in mental health professionals who do not share their cultural background. Perceptions of racism, mistrust, cultural incompetence, and neglect overseen by White- and European American professionals led participants to describe the overall mental health system as an invalid option for depression care and mental health support. Participants stated that they would only seek and utilize formal mental health services when they knew that the mental health professional was also African American. One participant exclaimed, “If I cannot find a Black psychologist, I don’t want to go!” Participants also admitted that the lived experiences of persons of African American descent were valued more than the professional’s credentials. Mental health services were viewed as culturally incongruent with the participants’ self-identified needs and concerns (e.g., culturally relevant mental health services, understanding of African American lived experiences, etc.). The following statements further illustrate how participants perceived overall mental health care and service, with attention to depression:
We don’t like medication, don’t like doctors, and a lot of counselors and psychiatrists, psychologists, and psychotherapists are White, and they don’t understand the cultural issues. I am not going if I have to be with someone who has no idea. I don’t care if you went to school for that, and you took a Black studies class…You don’t know this (me)!–you cannot––there’s no way you can meet me and see what I’m talking about.
Even something that could be totally unrelated to just being Black, everything we do is related to being Black, so we are not going to mesh. ..a lot of people––as you said––are like that.
Right, I agree with that because so many students have come into the centre where I work and just ask to be placed with a Black counselor. And if we do not have a Black counselor? I think about that often, which is why I want to go into this field–to help and work with Black people.
As indicated by the participants, a lack of African American mental health professionals has deterred them from utilizing mental health and depression care services despite the availability of such services. The participants perceived a professional disparity in the mental health industry, which made them hesitant to seek help. The participants’ perceptions are congruent with the data. In 2015, African Americans made up only 2% of psychiatrists, 4% of psychologists, and 4% of social workers in the United States [47].
Ethnocultural stigma presents another obstacle in seeking assistance and utilizing mental health services that may be of support to African American women. Like African American men, African American women face the ethnocultural stigma that stems primarily from their families, communities, and churches [5,14,48,49]. Some African Americans still believe that expressing depressive feelings is a sign of personal weakness and a privilege reserved for White women [50,51]. The African American community tends to view depression related suicidal behaviour as a “White thing” [51]. Thus, depression has been racialized and defined as a “White” mental health issue.
I would wonder the same thing because, like, three of my roommates were Caucasian––it was just completely different culturally…like the three White girls had their Prozac. They were clinically depressed and had been diagnosed clinically depressed. All of them had their own medication and all kinds of crazy stuff; you know things that don’t happen in my–– you know, that is just not acceptable.
I think one thing may be to help counselling centers and churches well, not just churches, but the churches and the families that need the help. If it weren’t for the fact that the whole stigma was attached, then people would probably feel more comfortable.
In response to a participant pleading that African Americans “need to reach out” despite stigma in their community, another participant remarked, “I think that is easier said than done.” Given the impact of ethnocultural stigma regarding mental illness, one participant explained:
“You know, I think depression is viewed as a weakness amongst African Americans.” Another participant added, “…that you’re weak, so you want people to judge you like in ways that are okay… We are all in the [same] situation, so what are you whining about?”
Similar to personal weakness, when discussing mental health support services, participants described the expectation to be a “Strong Black Woman” as a barrier to seeking treatment. Many participants talked about the cultural and communal expectations of strength and resilience as a barrier to recognizing depression and other mental health issues amongst themselves [52,53]. Participants described their ethnocultural and gendered socialization process as demanding a sense of Black femininity grounded in African heritage and community. Additionally, participants described how the requirement to be strong in the face of depression hindered their perceived needs for professional mental health care and treatment services, as well as the ethnocultural stigma attached to seeking and using these supports. A participant stated, “We’re supposed to be able to withstand; we’re supposed to be resilient!” The ethnocultural, gendered expectation is unique to African American women as members of an ethnic group of African descent [28,35,54,55].
A problem when a Black man cries is that we tell him to “man up,” he shouldn’t cry [other participants express agreement]. The same thing goes for Black women. We are supposed to be that strong Black woman, but we shouldn’t be able to––we’re not supposed to crack.
Because we’re like that mother aspect [another participant adds, “Strong.”] ––strong Black women [a participant says, “Independent.”] ––independent thing [participants express agreement]
One participant continued in agreement:
It’s kind of like the gift is a curse.
…depression, like what is depression? Yeah, depression––what––you can’t be sad. There’s no such thing as clinical depression; make yourself happy then [participant laughs].
It’s a “Catch 22” …I’m supposed to get a job, be this strong Black woman for the community, and do well, but there are days when I just want to stay in bed and cry all day [participants show acknowledgment]–you know, but I would never tell anybody that because I don’t want them to think of me any less.
The literature [2,52,53] confirms that the cosmological aspects of womanism involve viewing reality from the perspective of interdependency, which flows from a diunital (both/and) worldview rather than a dualistic/binary (either/or) worldview. Seemingly opposite ways of being (Black female: strength) can and do coexist in a womanist reality [2,14,28,35,53]. The participants discussed how both African American men and African American women are expected to be strong and resilient in the context of the African American community. However, the Strong Black Woman schema [3,4] impacts African American women’s assistance-help-seeking behaviors [3,4,56].
Nearly all participants (95 percent) stated that members outside African American ethnic and racial groups cannot thoroughly understand depression in the African American context. One participant asserted, “We need African Americans––people who look like us to diagnose our problems, or people with experience with African Americans [other members expressed agreement].” Although there may be mental health services available in the diverse urban area in which this study was conducted, there is a disparity related to the number of available African American mental health professionals compared to their White cohorts [47]. Another participant added, “…then it’s the thing that we have the resources, but we don’t have the resources. There are professionals, but we want a certain type of professional, and they’re hard to find.”
To understand African American women’s responses in focus groups, it is essential to frame them within their distinct history and socio-cultural experiences as members of an ethnic group. The distrust expressed by participants was based on their ethnic experiences, history, encounters, and perceptions of medical professionals and the White population in the U.S., as well as the systemic inequities revealed through social relationships [50]. It is not surprising that African Americans who have a high level of distrust towards White and European Americans are less likely to seek mental health services from the campus counseling center, according to a study by Jordan [57]and Nickerson et al. [58]. The research found that African American participants in the study had an ethnocultural perception based on historical and current experiences of discrimination and receiving inadequate support [14,46,57]. This perception has led to less successful treatment outcomes and barriers to mental health services. A womanist theoretical perspective can help to explain the historical tensions between African American women, a minoritized and unique ethnic group, and the White population.
Regarding depression care, ethnocultural stigma is one of the most discouraging obstacles to seeking treatment for depression within an African American cultural context. Ethnic culture, as opposed to concepts of “race,” focuses on shared values, experiences, and history or ancestral heritage. Although there is diversity within ethnic groups (e.g., gender, socioeconomic, sexuality, generation, etc.), many ethnic members share common cultural values that are deeply entrenched, even if they may not be conscious of their shared value system. Perceptions of mental health services and depression care vary across cultures [59]. Race and ethnicity are not considered demographic indicators in understanding the differences in mental illness stigma; however, these demographic indicators have been determined to act as proxies for cultural and contextual factors [57], typically unmeasured, that could be considered proximal causes of racial and ethnic differences [48,57].
To understand the mental health of African American women, the historical and cultural context must be considered [14,46]. Similar gender socialization among African Americans consists of men and women as models of strength and power, differing from other ethnic groups. One participant spoke about the expectation of Black women to be strong. They said, “Yeah, strength is like very big; we’re supposed to be these strong Black men and strong Black women.” Womanism provides an intersectional framework for understanding African American women's lived experiences and perceptions within a sociocultural context distinct to their ethnoculture, history, and phenomenological being where gender roles are fluid (both/and).
The push for self-reliance and strength must also be contextualized and understood within a framework that analyzes African American women's community, ethnoculture, and history. Womanism provides such intricacies. For example, African American families, communities, and Black churches perceive occurrences of depression and mental illness not only as a sign of weakness but also as a denial of African Americans’ historical legacy of struggle and protest [35]. In other words, acknowledging mental illness (e.g., depression) within a culturally contextualized setting is viewed as a denial of one’s African heritage and history of struggle and resilience. Thus, the lack of perceived support from the overall African American community for African American women experiencing depression causes these women to secretly shoulder their feelings of depression in fear of being perceived as weak and a disgrace to their strong African lineage.
One of the most compelling and complicated subject matters involving African American womanhood is the cultural concept of a “Strong Black Woman” [53,60-64]. This concept has set unfair expectations of African American women, demanding they demonstrate strength when facing adversity and depression. The construct and the assumed identity of being a “Strong Black Woman” can conceal the torment of mental illness [3,4,65,66]. Exploring the gender socialization of African American women requires an understanding of their historical legacy, one that is embedded in struggle, enslavement, Jim Crow, racism, racialized sexism, resilience, spirituality, and collectivism [14,[27].
Womanism represents an overarching social identity that constitutively intersects African American women’s history, community, and ethnoculture rather than separating them from their common connections and experiences [27,28]. Womanism entails a dedication “to the wholeness of an entire people” [28]. African American women are group members, and in African American culture, the identity of each person is closely linked to that of the collective group [28,67]. The self is closely linked to that of the collective group [28,67]. In African American culture, the self is defined collectively, including one's people [14,46,67].
Womanism is a theory that emphasizes the importance of collective identity and development. According to Settles [68], African American women are more likely to experience depression and low self-esteem when their African American identity is interfered with rather than their gender identity. This is due to the complex worldview of African Americans, where both men and women must show strength [52]. Therefore, it is essential to have a thorough understanding of African American collectivism when working with African American women and providing culturally sensitive services [14,46]. Participants noted cultural dissonance in response to the Westernized push for individualism compared to the African/ African American tradition of collectiveness. They explained, “So it’s self, self, self when the family’s still like family, family, family, church, church, church, community, community, community. So, it’s very fragmented; it is not matching up, and that’s going to be a huge problem.” mental health professionals must consider and respect the unique cultural experiences and expectations of African American women. They should also understand the significance of "strength" and the social and cultural context in which it is promoted. Several studies, including Borum [14,46] and Haynes et al. [2], have emphasized the importance of this approach. For example, “Integrating a Womanist theoretical perspective into counseling approaches for Black women and recognizing strength as an asset, along with its hidden liabilities, has the potential to increase the number of Black women who receive needed mental health support” [3].
Mental health is a concept that is influenced by culture. For example, depression is defined and understood differently within different ethnic groups. The cultural context also shapes the parameters of mental health based on the psychological and behavioral patterns of a specific ethnic group. Researchers have used the womanist framework to understand better the perceptions and beliefs about mental health services and depression care among African American women [14,46,52]. This framework considers their unique ethnocultural background, history, heritage, and life experiences [69]. In understanding depression among African Americans, from a womanist perspective, the realm moves beyond individual contexts to a communal, sociocultural context, which is necessary to appreciate the cultural values (e.g., the extended self) undergirding depression and depression care. By understanding how ethnocultural beliefs impact mental health service and depression care utilization, healthcare providers can better serve African American women with their mental health needs.
Clinicians should be aware that the "strong Black woman" stereotype can cause African American women to underreport or refrain from discussing their stressors openly. As a result, clinicians must investigate the origin and impacts of this stigmatizing concept [4,55]. Ward and Brown [70] established that a culturally adapted intervention for depression amongst African American women proved significant results in a reduction in depressive symptoms. However, their study did not find a change in help-seeking attitudes toward mental health services [70].
This study used a womanist theoretical framework to guide and organize its research. The study included 40 African American women enrolled in a predominantly White university in a racially diverse city in the northeastern United States. The participants were divided into seven focus groups to discuss their perceptions, attitudes, and beliefs about mental health services and depression care. From these discussions, three sociocultural themes emerged.: (1) a clear preference for provider-client race concordance; (2) ethnocultural stigma regarding mental health help-seeking behaviour; and (3) ethnocultural gender socialization to be a “strong Black woman.”
During focus group discussions about mental health support services, participants expressed hesitancy and reluctance to seek professional help from White European Americans. Due to perceptions of racism, cultural incongruence, and cultural unawareness exhibited by White mental health professionals, participants described the mental health system and subsequent support services as unrealistic and an even discouraging option for depression and mental health care overall. Unless African American professionals were available, participants saw mental health services as inaccessible. In other words, participants stated that their willingness to seek and receive mental health services regarding depression care was dependent on the availability of African American professionals.
Participants in this study faced an additional hurdle in seeking help for depression and mental health issues due to the ethnocultural stigma within the African American community. Depression was perceived as a symbol of personal inadequacy and a luxury only afforded to White people, specifically White women. Stigma can only be understood within the framework of community, culture, and history. For example, the church confronts occurrences of mental illness within the purview of spirituality and prayer [51]. The lack of perceived support from the community and the church due to the ethnocultural stigma attached to mental illness and depression care resulted in African American women being less likely to pursue mental health practitioner support. This reluctance to seek services may cause African American women experiencing depression or other mental health issues to secretly dismiss their need for mental health support and depression care. The fear of being seen as weak or a disgrace to their African heritage and community acts as a deterrent to finding and accepting mental health assistance.
Many Black women, as did most participants in this study, feel pressure to be a "strong Black woman," which can discourage them from seeking treatment for depression [10,71]. According to the participants, this expectation is both a gift and a curse. On one hand, it reflects cultural and communal expectations of strength and resilience. However, on the other hand, it can make it difficult for women to seek help for mental health issues like depression. The stigma attached to seeking treatment can discourage them from accessing the care they need [71]. The cultural, gendered expectations to demonstrate strength are distinct to African American women, contrasting the conceptualization of femininity or womanhood in other ethnic and cultural groups [3,4,35,55,68]. It is essential to acknowledge that certain historical realities, such as the Transatlantic Slave Trade, were intentionally designed to facilitate the enslavement of people of African descent. These circumstances were explicit and directly aimed at subjugating and exploiting African populations [69,72], and their sociocultural existence continues to be a challenge in a society of high social instability and unacceptance, such as racialized sexism or misogynoir [73,74].
The authors declare that they have no competing interests.
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