Using Community-Based Participatory Research to Explore Social Determinants ofWomen's Mental Health and Barriers to Help-Seeking in Three Urban, EthnicallyDiverse, Impoverished, and Underserved Communities

Mary Molewyk Doornbos a,, Gail Landheer Zandee a, Joleen DeGroot b, Megan De Maagd-Rodriguez aa Department of Nursing, Calvin College, Grand Rapids, MIb Department of Nursing, Spectrum Health, Grand Rapids, MI

a b s t r a c t

Depression and anxiety are signicant mental health issues that affect urban, ethnically diverse, impoverishedwomen disproportionately. This study sought to identify social determinants of mental health and barriers tohelp-seeking for this population. Using community based participatory research and focus groups, sixty-oneBlack, Hispanic, and White women identied economic, family, cultural, and neighborhood issues asperceived determinants of their depression/anxiety. They identied practical, psychosocial, and culturalbarriers to their help-seeking behavior. These results can promote women's health by fostering anunderstanding of social factors as perceived determinants of depression/anxiety and shaping practice andpolicy initiatives that foster positive aggregate outcomes.

2013 Elsevier Inc. All rights reserved.

In 2012, the World Federation for Mental Health estimated that350million people worldwide struggle with depression, accompaniedby anxiety, and designated this as a global crisis (World HealthOrganization, 2012). Depression rates vary with lifetime prevalencerates ranging from 3% in Japan to 16.9% in the United Stateswithmost countries between 8 and 12% (WHO, 2012). Persons living inpoverty have greater rates of depression and anxiety symptoms(WHO, 2012). Globally, women experience depression at a rate two tothree times greater than men (WHO, 2012). Further, the burden ofdepression is 50% higher for females than males and is the leadingcause of disease burden for women in high, middle, and low-incomecountries (World Health Organization, 2008).

The US mirrors the dire global circumstances. Women are 70%more likely to experience depression and 60% more likely toexperience an anxiety disorder during their lifetime than men(National Institute of Mental Health (NIMH), 2012). In 20052010,the prevalence of depression among adults was ve times higher forthose below the poverty level compared with those above the povertylevel (Centers for Disease Control (CDC), 2011). African-Americansare 20% more likely to report psychological distress than do non-Hispanic Whites (Ofce of Minority Health (OMH), 2012a).

In addition, barriers to care for depression/anxiety are prevalent.Despite the known effectiveness of treatment for depression, many inneed do not receive care. WHO (2012) estimates that in the majorityof global regions only 30% of persons receive needed mental healthcare. In the US, ethnic minority persons with low incomes remaineduntreated or received inadequate treatment for mental health issues(Wang et al., 2005). In 2008, US Hispanics received mental healthtreatment nearly three times less often than non-Hispanic Whites(Ofce of Minority Health (OMH), 2012b) did. Similarly, non-Hispanics Blacks were more than two times less likely to receiveantidepressants than non-Hispanic Whites (OMH, 2012a) were. Theoverlap of gender, poverty, and ethnicity appears to create signicantvulnerability to depression/anxiety and barriers to care.

DEFINITIONS OF SOCIAL DETERMINANTS OF HEALTH

The Centers for Disease Control and Prevention assert thatbiological, socioeconomic, psychosocial, behavioral, and social in-uences determine the health of a population (Centers for DiseaseControl and Prevention (CDC), 2012). Of those, the social determi-nants of health have been least explored. Social determinants ofhealth:

are the conditions in which people are born, grow, live, work,and age, including the health system. These circumstances areshaped by the distribution of money, power, and resources atglobal, national, and local levels. The social determinants of healthare mostly responsible for health inequities - the unfair and

Archives of Psychiatric Nursing 27 (2013) 278284

Corresponding Author: Mary Molewyk Doornbos, PhD, RN, Calvin College Depart-ment of Nursing 1734 Knollcrest Circle SE Grand Rapids, MI 495464403.

E-mail addresses: door@calvin.edu (M.M. Doornbos), gzandee@calvin.edu(G.L. Zandee), joleen.degroot@gmail.com (J. DeGroot), mad24@students.cavin.edu(M. De Maagd-Rodriguez).

0883-9417/1801-0005$34.00/0 see front matter 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.apnu.2013.09.001

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avoidable differences in health status seen within and betweencountries (World Health Organization, 2011).

Social determinants incorporate: (a) the social environmentincluding discrimination, income, and gender; (b) the physicalenvironment including where persons live; (c) health servicesincluding access to quality care and health insurance; and (d)structural and societal factors (Centers for Disease Controland Prevention (CDC), 2012). Healthy People 2020 addedsocial determinants of health as one of four goals for the decadesuggesting that:

Understanding the relationship between how population groupsexperience place and the impact of place on health isfundamental to the social determinants of healthincluding bothsocial and physical determinants (United States Department ofHealth and Human Services (USDHHS), 2010).

Social Determinants of Mental Health

The literature links discrimination and mental health. In qualita-tive interviews, discrimination contributed to symptoms of depres-sion and anxiety in Mexican immigrant mothers (Ornelas, Perreira,Beeber, & Maxwell, 2009). Among African-American women living inhigh-poverty areas, a signicant association existed between percep-tions of daily discrimination and potentially dire psychologicalconsequences (Ajrouch, Reisine, Lim, Sohn, & Ismail, 2010). Discrim-ination was also associated with major depression among Asian-Americans (Chae, Lee, Lincoln, & Ihara, 2012). Further, the risk forantenatal depression increased ve-fold among low-income African-American women over the age of 30 compared to teen mothers. Theresearchers suggested a weathering effect that resulted from yearsof cumulative stress due to discrimination and socioeconomicmarginalization (Luke et al., 2009). A similar investigation of low-income African-American women found that discrimination was aconsiderable source of stress predicting antepartum depressivesymptoms (Dailey & Humphreys, 2010). Additionally, high levels ofself-reported discrimination and low levels of self-reported languageprociency were signicant predictors of depressive symptoms inKorean immigrants in New York City (Bernstein, Park, Shin, Cho, &Park, 2011).

Across ethnic groups, studies have also linked mental health toeconomic factors. Economics contributed to symptoms of depressionand anxiety in Mexican immigrant mothers and Finnish individuals(Ornelas et al., 2009; Pulkii-Raback et al., 2012). A study of Britishwomen corroborated the role of nancial hardship as a strongpredictor in the development of depression (Dunn et al., 2008).Goyal, Gay, and Lee (2010) found that rst-time mothers with fourSES risk factors (low monthly income, non-college graduate, unmar-ried, and unemployed) were 11 times more likely to have clinicallyelevated depression scores at 3 months post-partum than womenwith no SES risk factors. Additionally, cumulative exposure to familypoverty across early developmental stages was associated with aconsistent impact on adolescent/young adult anxiety and depressionin an Australian sample (Najiman et al., 2010). Watson, Roberts, andSaunders (2012) reported a contrary nding wherein neitherneighborhood poverty nor race was a predictor for anxiety ordepression such that African-American women, facing neighborhoodpoverty, low income, and discrimination, had lower depression andanxiety scores than their White counterparts.

Social stressors such as family separation and social isolationcontributed to symptoms of depression and anxiety in Mexicanimmigrant mothers (Ornelas et al., 2009). Similarly, a study of low-income African-American women found that social conict was aconsiderable source of stress predicting antepartum depressive

symptoms (Dailey & Humphreys, 2010). Among Asian-Americans,negative interactions with relatives were associated with majordepression (Chae et al., 2012).

Barriers to Utilization of Mental Health Resources

The World Health Organization (2012) suggested that barriers toeffective mental health care include lack of resources, lack of trainedproviders, and the social stigma associated with mental disorders. Astudy of perceived barriers to depression treatment during theperinatal period found that both White and African-Americanwomen were most concerned with structural barriers to treatment,including lack of insurance coverage, inability to pay, inadequatechildcare, transportation, and distance to clinic, rather than attitudinalor knowledge barriers (OMahen & Flynn, 2008). A Canadian researchproject studied a homeless or impoverished population and deter-mined that even in the absence of economic barriers to health care,impoverished persons experienced signicant barriers to the use ofmental health services. Specically, limited social networks predictedrestricted utilization of mental health resources (Bonin, Fournier, &Blais, 2007). A subsequent Canadian study found that the odds of notseeking treatment for depression were highest for single motherswith adult children, women with low social support, and those withlittle formal education (Gadalla, 2008).

Social determinants of mental illness have received increasingattention and may constitute a critical factor surrounding thevulnerability of urban, ethnically diverse, impoverished women todepression/anxiety. Given the discrepancy between numbers ofwomen struggling with depression/anxiety and those receivingintervention, it is also vital that our understanding of barriers totreatment expand. Further, it is essential to hear the voices of urbanwomen since unless target populations perceive that social de-terminants and barriers are relevant, corresponding practice andpolicy changes are ill advised. The purpose of this studywas to explorecontributing factors to depression/anxiety and barriers to help-seeking for this population.

METHODS

Design

The ideological perspective of community based participatoryresearch (CBPR) was used to explore the following researchquestions: (1) What contributes to the experience of depressionand anxiety of urban, ethnically diverse, impoverished women? and(2) What barriers prevent urban, ethnically diverse, impoverishedwomen from using existing mental health resources? The designationof urban, ethnically diverse, and impoverished women included citydwelling women who are Black, Hispanic, or White and perceivethemselves to have insufcient nancial resources to meet personaland family needs. CBPR was utilized to develop partnerships betweenthree midwest urban neighborhoods, that were predominately Black,Hispanic, and White, respectively, and a department of nursing. Thepartnerships were intended to identify resident health concerns,create student learning experiences, engage in resident-drivenresearch, and promote the health of these communities (Feenstra,Gordon, Hansen, & Zandee, 2006; Heffner, Zandee, & Schwander,2003; Zandee, Bossenbroek, Friesen, Blech, & Engers, 2010; Zandee,Bossenbroek, Slager, & Gordon, 2013).

The researchers used a qualitative design within the ideologicalperspective of CBPR. Data collection occurred via focus groupsstratied by neighborhood/ethnicity. Blending focus groupswith CBPR is useful in understanding health disparities and exploringways to provide culturally competent care to marginalized popula-tions (Cristancho, Garces, Peters, & Mueller, 2008; Lutz, Kneipp, &Means, 2009).

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Community health workers (CHW) from each neighborhood wereinstrumental in ensuring that this study remained true to the goals ofCBPR (Zandee et al., 2010; Zandee et al., 2013). The CHWs participatedin a pilot focus group aimed at the development of the semi-structured interview guide, recruited participants, and translated/transcribed recordings of the Spanish group. The CHWs andneighborhood residents reviewed thematic results and participatedin determining next steps.

Sample

This study employed a non-probability sampling strategy. Eligibleparticipants were female residents of one of the neighborhoods, atleast 18 years old, and concerned about women's mental health issuesin their neighborhood. A sample of sixty-one women participated inthe studyconsistent with the goal of including approximately 10women in each of the six focus groups. Table 1 provides thedemographic characteristics of the participants.

Procedure

The authors conducted two homogeneous focus groups relative torace in each neighborhood. A strategy of segmentation wasemployed whereby homogeneity was created in each focus groupwhile allowing for diversity across focus groups (Krueger, 1994;Morgan, 1988). Homogeneous groups tend to quickly move partici-pants to a discussion of issues and engender greater levels ofcondent expression (Morgan, 1988; Sim, 1998). The researchersconducted six focus groups of 912 participants each. In the Hispanicneighborhood, one focus group was conducted in English and one inSpanish. The primary and secondary investigators facilitated ve ofthe focus groups while a trained native speaking Hispanic CHWfacilitated the sixth group. The researchers used a semi-structuredapproach and the primary questions, developed in conjunction withthe CHWs, are presented in Table 2.

The team offered transportation to and childcare during the focusgroups. The focus groups lasted 75 minutes, and upon completion,participants received a $20 gift card. Participation in the study wasvoluntary, and the investigators obtained informed consent prior to

commencement. The authors' institutional review board approved thestudy, participants gave informed consent, and respondent anonymitywas preserved.

Data Analysis

The focus groups were audio taped and transcribed verbatim. Anative Spanish speaker and an undergraduate research assistant, withmajors in nursing and Spanish, attended the Spanish focus group andassisted with transcription. NVivo 9 was used for analysis. The teamanalyzed the transcripts line-by-line and coded into nodes based onthe global categories of contributing factors and barriers. Thisapproach closely approximates the template analysis style - theresearcher begins with a rudimentary coding guide prior to datacollection and continuously revises it as data are collected (Crabtree &Miller, 1999). Subsequently, the team created focused nodes andclusters of related nodes. To conrm the accuracy, relevance,meaning,and authenticity of the data, the researchers employed an ethnicallydiverse sample and returned to each partner community to presentthe preliminary results and seek feedback on them (Guba & Lincoln,1994; Lincoln & Guba, 1985).

RESULTS

These results are part of a larger study on women's mental health.Themes, derived from six focus groups, and subthemes, from at leastfour of the six groups, are presented in Table 3. Quotations support theresults and include the designation P to indicate the contributionsof participants.

Contributing Factors

Economic IssuesThe rst theme identied was economic issues. The participants

painted a picture in which nancial matters overwhelmed them innearly every area of their daily life. Predictably, the women cited theeconomic subtheme of unemployment as having a direct link to theirmental health issues.

P: I am going to give you a reason why I think a lot of people aregoing through this. Number one, they are used to having a job.After 25 years, out of the blue, they have no job. So that is majornumber one depression right now.

Correspondingly, respondents also identied the economic sub-theme of bills/expenses as a major stressor.

P: The phone is ringing because its the bill collectors. Theyrecalling 24/7 which is very stressful.P: At the same time that I picked up the phone to make paymentarrangements a guy is showing up at my door to shut my gas off.

Table 1Participant Characteristics.

Overall (N = 61)

Age Range: 1869 yearsMean: 38.93 years

Race/Ethnicity Black: 36%Hispanic: 31%White: 33%

Family income $10,00014,999: 48%$15,00024,999: 23%$25,00034,999: 16%$35,00049,999: 11%$50,00074,999: 2%

Education No high school: 3%Some high school: 20%High school graduate: 34%Some college: 38%College graduate: 5%

Marital status Single: 34%Married: 43%Divorced: 13%Signicant other: 10%

Ever used mental health services Yes: 46%No: 54%

According to the US Census Bureau (2010), each of the three partner neighbor-hoods is ethnically distinctthe rst is 65% African-American, the second is 74%Hispanic/Latino, and the third 64% White.

According to the US Census Bureau (2010), the percentage of residents below thepoverty level in the three partner neighborhoods ranged from 25 to 43%.

Table 2Focus Group Semi-Structured Interview Guide.

Contributing factors a. What kinds of things contribute to depressionand anxiety experienced in your community,neighborhood, family, or personal life?b. What sort of life circumstances might triggerdepression and anxiety?

Barriers a. How do you perceive the adequacy of yourcommunity's resources for persons struggling withanxiety and depression?b. Which of the existing resources are particularlyhelpful? How so?c. Which of the existing resources are less thanhelpful? How so?d. What barriers might exist that would preventresidents from accessing mental health resources?

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P: When you have kids, you get to a low because wheres the nextmeal coming from? They need shoes because everybody else gotshoes.P: Foreclosures and depression is a big one.

Cultural IssuesThe participants were articulate about cultural issues that played a

role in the etiology of anxiety and depression. The theme of culturalissues touched women across ethnic groups in multifaceted ways.Discrimination was a notable cultural subtheme.

P: My son is very well aware of all this. He sees it on the TVwhere they dont like Hispanics and he asks me why and thisaffects him a lot. And now anything that happens is because wereHispanic. It makes me feel bad.P1: They dont respect us as customers and I dont like that. Theyfeel like since they are from a different ethnic P2: They cantreat you any way! P1: I went into a store in the neighborhoodone time and he [proprietor] took this mans money that wasbehind me and I was here rst. He disrespected me.

The respondents identied separation from family as anothersalient cultural subtheme.

P1: We are far away from our families and our culture. We feelalone and unprotected without knowing where to go or what todo. P2: Alone.P: Im from New Orleans and its different here in the North. I missmy people. Back at home we can with no shoes on we can justparty and wed be happy. But were all scattered now. And thereaint nothing for us. I think about home all the time and there aintno home for me to go to. So thats what depressed is to me.

Neighborhood IssuesThe third theme was neighborhood issues. The participants

outlined the impact of one's geographic surroundings on mental

health. The rst subtheme identied was general decline of theneighborhood.

P: I was born and raised right down here. So I know this area andI have seen this area all my life. What a change! You could say thatpeople must be depressed because the neighborhood is not keptup like it was when I grew up.

A second neighborhood subtheme was safety issues, crime, andgang activity.

P: The neighborhood isnt safe anymore like when I grew up andwe all knew each other. Everybody watched everybody elses kids.Youd better not misbehave or your Mama would hear about itfrom the neighbors. Now the kids are hanging out on the streets.They are depressed, acting out, and doing whatever they do whichis usually not goodP1: Yeah, deaths and gang activities in our community youngmen and these gang activities. P2: Very depressing.

Family IssuesAll groups identied family issues as a contributor to their anxiety

and depression. They spoke about the conict and stress in their co-occurring roles as spouses, parents, and daughters and how thisaffected their mental health. Marital issues and private violenceconstituted a family issues subtheme.

P: I am divorced and experienced a lot of domestic violence. Thisaffected me greatly.

Single parenting was a second subtheme.

P: Another problem is being a single mom. I have a lot of friendsthat are also single moms that deal with a lot of stress and thatturns into depression.

A third subtheme emerged around behavioral problems withchildren.

P: I had four boys and two girls and one son just did everythinghe thought he was big enough and bad enough to do. OK, so thatwas depressing for me.

The participants saw themselves as caregivers for multiplepersons, and the resulting caregiving stress constituted asubtheme.

P: We had to take some of our siblings kids or our childrens kidsbecause somebody is on drugs. This is a big issue.P: I feel like I have to serve two families. I know I need to spendtime with my husband and kids but I also feel responsible for myparents and my siblings.

Finally, the death of familymemberswas a family issues subtheme.

P: We had a cousin die two of them got killed at the same time.And two years ago my other nephew passed away unexpectedly.And so its like it all builds up.

Barriers

Practical BarriersThe women identied practical barriers to help-seeking. Practical

barriers enveloped the absence of things essential to accessing mentalhealth services. First, the women believed that there were insufcientclinics for low-income persons.

Table 3Global Categories, Themes, and Subthemes.

Global categories Themes Sub-themes

Contributing factors Economic issues UnemploymentBills/Expenses

Cultural issues DiscriminationSeparation from family

Neighborhood issues General decline ofneighborhoodSafety issues/crime/gang activity

Family issues Marital issues andprivate violenceSingle parentingBehavioral problemswith childrenCaregiving stressDeath

Barriers Practical Lack of clinics for lowincome personsLack of transportationLack of awareness ofexisting resourcesLack of insuranceLack of nancial resources

Psychosocial StigmaLack of trust ofexisting services

Cultural Discrimination Themes occurred in six of six focus groups. Sub-subthemes occurred in at least four of six focus groups.

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P: It takes forever [to get in]. I mean they tell you that you cancall at the beginning of the month and you call at 8:05 a.m. andthey say, Oh, we already took our ve patients for the month.P: And by the time you nally get help you almost want tocommit suicide.

The respondents identied a lack of transportation as a secondsignicant practical barrier.

Facilitator: What barriers might exist? P: Transportation!

The third practical barrier to help-seeking was a lack of awarenessof existing resources.

P1: People dont know where they can go. P2: Yeah, lack ofawareness of different resources.

A salient subtheme also evolved around the lack of insurance.

P: You know the kids if they dont have insurance they haveMedicaid, but it is harder for an adult to get Medicaid. There has tobe an alternative to that!

Predictably, a lack of nancial resources constituted a nalsubtheme under practical barriers. Participants lacked money formental health services and health promotion activities.

P: You know, if its between do you get your kid a winter coat ordo you pay for the counseling appointment you know what youneed to go do.P: I dont have the money for shoes to go jogging or walking orwhatever it is. So there are a lot of barriers that come up.

Psychosocial barriersThe theme of psychosocial barriers encompassed attitudes and

feelings that created an obstruction to accessing mental healthservices. The rst psychosocial barrier subtheme was stigma.

P: If we talk about depression and anxiety they think we are crazy!P: Thats where the word ashamed comes in. They dont wantpeople to make fun of them.

The second psychosocial barrier subtheme was a lack of trust inexisting services. There were concerns about the condentiality ofinformation and a specic fear of Child Protective Services.

P: They have programs out here for women depressionprograms and whatever. I would not suggest them only becauseonce you get into those programs, you are in the system andeverybody is in your business. They say it is condential but itsnot condential to the housing department! Its not condentialto the case worker! Its not condential to CPS!P: [CPS] use[s] it against you in court.

Further, the women had a lack of condence in professionals andconcerns about a lack of professional follow through.

P: They dont know the neighborhood!P: For people to understand it, they have to actually go through[depression]. You have to literally experience it.P: People come into this community all the time, but when themoney runs out so do they. This happens over and over.

Cultural BarriersWhile the women identied cultural issues as a contributing

factor to mental health issues, the theme also surfaced as a barrier to

existing services. The women experienced discrimination in healthcare settings.

P: Being Latina, there is a lot of discrimination unfortunately.There are a lot of Americans that I respect that treat us well. Andthere are others that dont. We are human beings!P: If youre poor and you miss an appointment theyre far lesslikely to let you come back.

DISCUSSION

The economic, cultural, neighborhood and family contributingfactors as well as the practical, psychosocial, and cultural barriers tohelp-seeking identied by the study participants clearly constitutesocial determinants of health. The themes encompass the socialenvironment, the physical environment, and health services (Centersfor Disease Control and Prevention (CDC), 2012) as well as comprisingthe conditions in which people are born, grow, live, work, and age,including the health system (World Health Organization, 2011). Thestudy participants veried the utility of the concept of socialdeterminants as it relates to mental health.

The economic, cultural, and family themes emerging from this studysupport the existing body of literature in linking social factors todepression/anxiety. Additionally, these results elucidate a holisticperspective of the interrelated role of economic, cultural, and familyissues. For example, the participants described scenarios includingsingle parenthood, unemployment connected to lesser educationallevels and lack of childcare, bill/expenses around necessities such asfood and utilities, behavioral problems with children, geographicseparation from family at times of crisis, and racial discrimination.Gjeseld, Greeno, Kim, and Anderson (2010)moved toward document-ing this interrelatedness by determining that the specic mechanismwhereby poverty is associated with depression in low-income,ethnically diverse American women is via reducing social support.Further, these results gave voice to the women. This is especiallyimportant when considering quantitative ndings suggesting that self-reported economic difculties are more strongly associated with poormental health outcomes than the more conventional indicator of low-income level (Ahnquist & Wamala, 2011). These results also assisted inexplicating the full nature of these factors and putting them in context.For example, the inability to cover expenses particularly concerned thewomen as they feared being unable to feed their children. Correspond-ingly, an earlier study found that the percentage of mothers with eithermajor depression or generalized anxiety disorder increased as foodinsecurity worsened (Ivers & Cullen, 2011). Thus, this study adds to thebody of literature by exploring and providing context to themultifaceted social processes by which the phenomena of mentalhealth outcomes evolve.

The results of this study also add to the literature by outlining thesignicance of place as a perceived determinant of anxiety anddepression. The women described neighborhood issues such as crimeand decline as social determinants. To date, there has been limitedempirical support for the role of neighborhood issues in depression/anxiety symptoms. One study of African-American women found thatperceived neighborhood deterioration was associated with signi-cantly higher depressive symptoms at the end of a 24-week walkingintervention (Wilbur, Zenk, Wang, et al., 2009). Further work hasfocused on linking housing disarray and housing instability todepression and anxiety outcomes among young US mothers (Suglia,Cuarte, & Sandel, 2011).

One potential solution to depression and anxiety issues lies in theuse of existing resources. While limited research exists aroundbarriers to mental health help-seeking, it is apparent that thisresearch supports previous work in documenting practical barriersincluding lack of insurance, nancial resources, transportation, and

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the psychosocial barrier of stigma (OMahen & Flynn, 2008; WHO,2012). Additionally, the participants were articulate about the lack ofawareness of existing resources, which may constitute a fruitful areaof intervention.

Several sub-themes manifested. The discrimination subtheme,cited as both a contributing factor and a barrier to help-seeking, wasrelevant in ve of the six focus groupsexcept one group of Whitewomen. The women of color described discrimination related toethnicity while the White women identied discrimination related tosocioeconomic status. Perhaps the women reported the most obvioustype of discrimination they experienced while having limitedawareness of the multiple subtle forms of discrimination that theyregularly encountered. Previous research suggests a causal linkbetween everyday encounters with racial discrimination and depres-sion (Schulz et al., 2006) as well as a positive association betweengender discrimination and depression and economic discriminationand depression (Canady, Bullen, Holzman, Broman, & Tian, 2008).Canady et al. (2008) argue for a comprehensive assessment of ethnic,socioeconomic, and gender discrimination as it relates to depressivesymptoms in women.

The practical barrier subtheme entitled lack of trust of existingservices pertained to the Black and Hispanic groups of women. LikelytheWhite womenwere more comfortable with predominately-Whitehealth care providers. This is consistent with previous ndings wheredepressed African-American women had a deep mistrust of thehealth care system as a White system (Nicolaidis et al., 2010, 1470).Practitioner failure to acknowledge the larger historical perspectivesfrom which they and their patients of color draw conclusions andmake decisions contributes to mistrust of the mental healthcommunities and to perpetuation of health care disparities (Suite,La Bril, Primm, & Harrison-Ross, 2007).

Next Steps

This qualitative study was intended to facilitate in-depth discus-sion and capture the perceptions of urban, impoverished, ethnicallydiverse women relative to the contributing factors to depression/anxiety and barriers to help-seeking. This study explored these topicsand connected the ndings to previous research. Moving forward,quantitative studies aimed at prediction and control are warranted.For example: Does neighborhood crime/gang activity predict depres-sion/anxiety? Can barriers to help-seeking be reduced if providerdiscrimination issues are addressed? Can barriers to help-seeking bereduced if neighborhood level anti-stigma campaigns are initiated? Inthe interim, various interventions may warrant consideration.

Potential Policy Implications

In spite of the fact that this is a small-scale qualitative study, policyimplications might at least be considered. Addressing the perceivedcauses of depression/anxiety and barriers to help-seeking requirescoordinated effort. Meaningful progress in narrowing health dispar-ities is unlikely if perceived determinants are not addressed (Woolf &Braveman, 2011). Healthy People 2020 suggests:

The Social Determinants of Health topic areais designed toidentify ways to create social and physical environments thatpromote good health for allto ensure that all Americans have thatopportunity, advances are needed not only in health care but also inelds such as education, childcare, housing, business, law, media,community planning, transportation, and agriculture. Making theseadvances would involve working together to explore howprograms, practices, and policies in these areas affect the healthof individuals, families, and communities (USDHHS, 2010).

A health in all policies approach may be fruitfully contemplatedsuch that every policy decision considers its impact on health

outcomes (Robert & Booske, 2011). Unfortunately, the difcultiesinherent in this are signicant. The US public views personal healthbehaviors and access to affordable health care as strong determinantsof health while far fewer recognize social and economic determinantsof health (Robert & Booske, 2011). Many do not view social policy andhealth policy as intimately linked. Consequently, political willconstitutes a key barrier to translating knowledge into action, andsignicant effort will be necessary to move social policy onto thepolicy agenda as a health improvementmethod (Braveman, Egerter, &Williams, 2011; Robert & Booske, 2011).

Potential Practice Implications at the Local Community Level

Successful mental health change will require a multi-levelapproach, in which local nurses assume a broad view of health andcollaborate with new partners (Braveman et al., 2011). Given theseresults, it may be prudent to include questions on individual, family,and aggregate health assessments related to economic, family,cultural, and neighborhood issues. Further, it may be visionary todirect resources and programming toward these social determinants.Such programming may include collaborative partnerships acrossdisciplines and among local agencies such as neighborhood associa-tions, parks departments, police departments, community centers,churches, housing authorities, nancial and legal services, foodpantries, schools, libraries, and transportation authorities (Hunter,Neiger, &West, 2011). Previous research documented the potential ofcomprehensive city/community coalitions to strengthen the organi-zational infrastructure of communities to promote health (Kegler,Norton, & Aronson, 2008). Nurses can lead in forging broad alliancesat the local level that may successfully address the perceiveddeterminants of depression and anxiety in urban women.

Limitations

There are two limitations to this study. First, the three partnerneighborhoods are located in a single midwest city such that theresults may not be applicable to urban, impoverished Black, Hispanic,andWhite women in other areas. However, the intent of focus groupsis for in-depth discussion rather than the development of generaliz-able information. Therefore, these themes may serve as the basis forfuture studies and may evoke innovative ideas on the part of policy-makers. Additionally, although the CHWs signicantly facilitated ourrecruitment process, this approach to subject recruitment couldintroduce bias into the sample via the pursuit of participants who hadpre-existing relationships with the CHW, wished to please the CHW,or were known to be likely to participate.

Summary

This study documented perceived social determinants of anxietyand depression as well as barriers to help-seeking across three urban,impoverished, underserved, and ethnically diverse neighborhoods inthe midwest region of the US. The identied social determinantsincluded economic, family, cultural, and neighborhood issues whilethe perceived barriers to help-seeking were practical, psychological,and cultural in nature. The results add momentum to the growingrecognition that mental health and mental health care must beapproached from a multifaceted and multidisciplinary vantage point.

Acknowledgment

The authors gratefully acknowledge the support of the CalvinCollege Sabbatical Leave Program, the Marian Petersen NursingResearch Fund, and the Perrigo Company Charitable Foundation forproviding nancial support for the research activities of the primary

283M.M. Doornbos et al. / Archives of Psychiatric Nursing 27 (2013) 278284

investigator, stipends for the participants, and wages for theresearch assistants.

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Using Community-Based Participatory Research to Explore Social Determinants of Women's Mental Health and Barriers to Help-S...Definitions of Social Determinants of HealthSocial Determinants of Mental HealthBarriers to Utilization of Mental Health Resources

MethodsDesignSampleProcedureData Analysis

ResultsContributing FactorsEconomic IssuesCultural IssuesNeighborhood IssuesFamily Issues

BarriersPractical BarriersPsychosocial barriersCultural Barriers

DiscussionNext StepsPotential Policy ImplicationsPotential Practice Implications at the Local Community LevelLimitationsSummary

AcknowledgmentReferences