Barriers to diagnosis and treatment of depression: voices from a rural African-American faith community.

NIH Public Access Author Manuscript J Natl Black Nurses Assoc. Author manuscript; available in PMC 2014 April 11.

NIH-PA Author Manuscript

Published in final edited form as: J Natl Black Nurses Assoc. 2013 July ; 24(1): 31–38.

Barriers to Diagnosis and Treatment of Depression: Voices from a Rural African-American Faith Community Keneshia Bryant, PhD, RN, FNP-BC [Assistant Professor], Translational Research Institute KL2 Scholar, College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR Nancy Greer-Williams, PhD, MPH, PCPH [Assistant Professor], Assistant Director for Community Based Research, AHEC Research Practice and Improvement, University of Arkansas for Medical Sciences, Little Rock, AR Nathaniel Willis, MPH, MPA [Research Assistant], and College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR


Mary Hartwig, PhD, APN [Director of Nursing Education] Area Health Education Center-Northeast, University of Arkansas for Medical Sciences, Jonesboro, AR

Abstract


Mental health disparities exist for rural African-Americans regarding the early detection of depression and its effective treatment. Disparities that are evident in rural communities include limited mental health resources and the stigma of depression. The faith community has a longstanding history of being the initial source of help to those who experience depression. The purpose of this qualitative study was to examine how rural African-American faith communities view the barriers to diagnosis and treatment of depression. A convenience sample of 24 persons (N = 24) participated in focus groups and interviews. Four internal barriers were identified: personal business, “mind-set,” “denial,” and “put on a front.” Additionally, four external barriers were identified: “spiritual beliefs,” “lack of medical resources,” “lack of education about depression,” and “stigma.” The identified barriers supported the results from previous studies, but they also highlighted other less acknowledged barriers. In conclusion, interventions are needed to overcome these barriers in order to eliminate the depression disparities experienced by this population.

Keywords African-Americans; barriers; depression; faith; rural communities

Introduction Barriers to seeking and receiving adequate mental healthcare for major depressive disorders (MDD) are a longstanding problem for rural African-Americans (National Healthcare Disparities Report, 2011). In recent years, there have been increased efforts to understand the roles that culture, gender, and social differences play in the diagnosis and treatment of MDD. Cultural barriers and reliance on the support of the religious community have been identified as potential reasons for under recognition of MDD and inadequate treatment for Address Requests for Reprints and Correspondence to: Keneshia Bryant, PhD, RN, FNP-BC, College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot #529, Little Rock, AR 72205. [email protected].

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African-Americans with major depressive disorders (National Mental Health Association, 2003; Das, Olfson, McCurtis, & Weissman, 2006).


Background and Significance Only a few studies have explored the African-American clergys’ perspectives on MDD (Stansbury, Brown-Hughes, & Harley, 2009; Stansbury & Schumacher, 2008; Kramer, Blevins, Miller, Phillips, Davis, & Burris, 2007). Even fewer studies have included the voices of the African-American faith community (Wittink, Joo, Lewis, & Barg, 2009). Only one study has looked at how the characteristics of a community affect mental health, with an emphasis on rural African-American communities (Taylor, Repetti, & Seeman, 1997). However, that study did not incorporate the voices of the rural African-American faith community. Although it has been demonstrated that the built environment can shape how people perceive circumstances in their community and how they form relationships, barriers to the diagnosis and treatment of MDD in African-Americans is rarely addressed in the literature from their perspective (Gehlert, Sohmer, Sacks, Mininger, McClintock, & Olopade, 2008).


Rural areas often lack sufficient numbers of mental health professionals or they lack the infrastructure to provide the population with mental health services (Gamm, Hutchison, Dabney, & Dorsey, 2003). Understanding the rural African-American faith community’s perceptions of depression and their built environment might reveal why barriers to mental healthcare exist for this population. This understanding can further suggest interventions to address those barriers. Given the perceived central role of the faith community in dealing with African-American mental health issues, it would be instructive to view mental health access from that perspective. Therefore, this qualitative study examined how AfricanAmerican faith leaders and members in a rural community viewed the barriers to the diagnosis and treatment of MDD. Institutional Review Board Approval Institutional Review Board approval was sought and obtained from the University prior to the recruitment of participants and any data collection.

Methodology Design, Setting and Sample


This was a qualitative study that followed the principles of community-based participatory research (CBPR) (Minkler & Wallerstein, 2008). These principles provided a starting point for building partnerships in the rural African-American faith community. Setting The county that was targeted for the study is located in northeastern Arkansas, near the borders of Missouri and Tennessee, in the Mississippi River Delta region. The AfricanAmerican population of this county is higher than in other Arkansas counties (U.S. Census, 2010). Of the total population, African-Americans comprise 33.7% (49.46% male). The primary industry in the county is agriculture, but there are other industries such as metals, plastics, and food processing. In 2010, the median household income was $32,940 and the percentage of families below the poverty level was 21.5%, compared to 9.9% for the United States (U.S. Census, 2010). Many of the health statistics and resources of this county mirror those of the state of Arkansas. There is a high percentage of people with chronic diseases: 12.2% have diabetes,

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35.8% have hypertension, and 38% have hyperlipidemia (USDHHS, Arkansas Behavioral Risk Factor Surveillance Survey, 2009). The number of primary care physicians per 10,000 people is similar to that of other counties in Arkansas at 7.8 (U.S. Department of Health and Human Services, 2010). Sample The target population in the community for the study was the “Black Church,” defined as the African-American Christian community in the county. Participants were identified and recruited by a community leader who had completed training in protection of human subjects.


The 24 participants (N = 24) included three groups: pastors, church parishioners interested in health, and men who had experienced symptoms of stress and/or depression. The inclusion criteria for pastors (n = 9) was their ability to speak English and having held a position as the primary pastor of a predominantly African-American Christian church in the county for a minimum of one year. Pastors were given an option to send a representative from their congregation. The second group (n = 11) consisted of men and women who spoke English, were 18 years of age and older, attended a predominantly African-American Christian church in the county, and were interested in improving the health of their community. The third group (n = 4) were English-speaking men, 18 years of age and older, and who had experienced either stress or depressive symptoms at some time in their lives.

Data Collection


The primary data came from focus groups. This method provided an “insider” point of view (Willgerodt, 2003). The focus groups were conducted at locations convenient to the participants: a meeting room in a local restaurant, a local church, and a conference room at a community organization. Prior to beginning each session, participants were informed of their rights, including the right to withdraw from the study at any time. Participants were also asked to complete a demographic questionnaire. The focus groups were led by the first author and were digitally recorded. The first three focus groups were designed to collect data about the community and the beliefs of its residents. Therefore, a grand tour question was asked: “What does mental health mean to you?” This question was followed by probe questions, which varied slightly depending on the audience. For example, pastors were asked to describe their experiences with depressed parishioners and the way in which they identified those parishioners who were depressed. Parishioners were asked to describe their expectations of the church and pastor for those persons experiencing depression. After the first three focus groups, subsequent focus groups included preliminary results, and the participants were asked to comment on those preliminary results. At the conclusion of each focus group, participants were thanked for their time and participation and given a $25.00 (USD) gift card as a token of appreciation. Immediately following the focus groups, the first author summarized the session discussions, including interpersonal interactions, and then wrote field notes. The digital recordings were transcribed and reviewed for accuracy prior to analyses. The transcribed data excluded any identifying information, ensuring confidentiality.

Data Analysis Morse, Barrett, Mayan, Olson, and Spiers (2002) noted that rigor in qualitative research includes investigator responsiveness, methodological consistency, sampling adequacy, an active analytic stance, and saturation. In this study, analysis was done concurrently with data collection, allowing increasing refinement of interview foci as data were cross-checked with


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developing patterns. Rigor was enhanced by providing consistency in style and technique and by having one investigator conduct all of the focus groups.


Qualitative data collection, coding, analysis, and interpretation were integrated to ensure that interpretations were grounded in the data. The verbatim transcripts of focus groups and field notes were entered into a qualitative data analysis and management software package (Ethnograph 6.0). This process enabled the researchers to mark blocks of text with codes, explore the relationships among codes, and compare the participants and groups. The transcripts were reviewed by two team members, as were the field notes, and an initial set of inductively derived codes with definitions was developed. The code words and definitions were then verified. The transcripts were also reviewed by an additional experienced qualitative researcher, who provided verification of concepts and categories. Focus group transcripts were jointly coded to ensure that the definitions captured the meanings of the text and were mutually exclusive. This process enhanced consistency in coding. Definitions were revised as necessary. After the initial coding, codes were collapsed into more general and related constructs and were aggregated into broad themes.

Results


As previously stated, the first three focus groups were designed to collect data on the community and the beliefs of its residents. For the initial focus groups, the participants included two pastors, three persons interested in health, and four African-American men. There were additional focus groups with pastors (7 participants), persons interested in health (12 participants), and two individual interviews (one with a pastor and one with an AfricanAmerican male). The total convenience sample included 24 individuals (N = 24) (8 females and 16 males) from the community (See Table 1).


The participants included 9 pastors (all African-American males), 11 parishioners, and 4 African-American men with a history of stress or depressive symptoms. All of the participants were self-identified as African-American/Black; the average age was 42.6 years (24–70 years old). The majority (62.5%) of the participants were married; most (91.7%) had some college education or a degree and were employed full-time (62.5%). Some participants’ household incomes (33%) were less than $20,000/year; other participants’ household incomes (25%) were between $20,000 and $50,000; but the largest income category (37.5%) was $50,000/year. The denominations represented included Baptist (33.3%); Non-denominational (25.0%); Pentecostal (20.8%); and Church of God in Christ (COGIC) (12.5%). The average number of years at the current church, for all participants, was 10.7 years (range 1 to 40 years). The average number of years in the ministry for pastors was 20.9 (range 5 to 40 years); and they had been at their current church for an average of 14.7 years. The participants identified a number of barriers to recognition, diagnosis, and treatment of MDD. The barriers were in two distinct categories: internal or individual, and external (environment and the community) (See Table 2). The internal or personal barriers were addressed first. There were four internal themes: “personal business,” “mind-set,” “denial,” and “put on a front.” The first theme that emerged as a barrier to diagnosis, and threaded throughout all the focus groups, was “personal business.” This was the result of living in a small community and the potential for private information to spread throughout the community. Participants felt that they did not want to divulge personal information about themselves because of the likelihood of gossip, what others might think of them, and because they wanted to avoid having people make


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assumptions about them. Therefore, the participants suggested a private, non-disclosure approach as the best format for discussion:


“That’s one of the barriers that you run into dealing with a small knit community. It’s the phobia that I don’t need everything being known about me ‘cuz these are people I see on a day-to-day basis. I don’t wanna’ have no more people than I already have, judging me about what’s going on with me.” (Parishioner) “I don’t want everybody knowing. Whereas in a metropolitan city, if I go here and I let this [depression] be known, I may not see this person for another three or four months. Here, I’m gonna’ see this person tonight walking in the Wal-Mart.” (Parishioner) “A Black person ain’t going to tell you they problems.” (African-American male) The main reason for not sharing one’s “personal business,” or experiences with stressors and depressive symptoms, was the belief that nothing would be held in confidence. Since the community was small, they thought that everyone would eventually know that that person was experiencing some problems: “Nine times out of ten, it’s gonna’ get back to you. It’s gonna’ get back to you. Some folks can tell you how many times you peed today.” (Parishioner)


Not wanting to share one’s personal business, or having a lack of trust, can directly affect interventions available to people in rural communities. This was apparent when a “depression hotline” was mentioned: “The hotline is good in the sense that, the anonymous aspect, but theoretically, how many people gonna’ pick up the phone and say ‘Man, you know what? Let me talk to somebody.’” (Parishioner) “No 1–800-number. You can call and I done it many a time and before you know it, you know what they want? Your bankcard number.” (Parishioner) One pastor recommended that a layperson from each church should be trained as a depression care specialist to provide support to people in the congregation. This idea was shared with the other groups, but surprisingly, they were not very supportive. One parishioner said: “Train somebody in my church. I don’t care. No ma’am, no ma’am.” (Parishioner) Others were even skeptical about medical providers and mental health providers. They said: “Be careful even with your doctor.” (Parishioner)


“I don’t wanna’ tell anybody my business. I don’t want anybody to know. I don’t care who it is. I don’t care if I don’t know them. We just don’t believe in it.” (Parishioner) They did not want to share their personal business, and they also did not want to pry into anyone else’s personal business. One participant described how he went to visit a friend and when he arrived, he discovered that his friend had taken pills with the intent to commit suicide. He had not realized that his friend was depressed, did not see the signs, and certainly was not expecting him to attempt to take his own life: “And I’m looking at ‘John’ like, “‘John’, what happened?” ‘Cuz you know, I don’t get in people business, their personal business.” (African-American male) Others said they did not openly seek out the personal business of others, but would offer them an open invitation to come and talk to them:


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“I’m the kind of person that don’t really expect for people to tell me they problems. It ain’t my business, you know, what kind of problems they having at home. I tell them that if they need somebody to talk to, just come to me.” (African-American male) Others believed that no one really wanted to hear about another person’s personal business. One African-American male participant said: “Everybody don’t wanna’ hear about another’s business, really.” (AfricanAmerican male) The second internal barrier was “mind-set.” These participants believed that depression was a part of life, and was something that everyone had to deal with, but that it was something that did not necessarily require professional intervention. This point of view was described as being long-term or chronic: “There’s got to be some kind of a change in the mind-set of the people to want it [help].” (Pastor) “The people around here don’t wanna’ be helped.” (Parishioner)


“When you have certain families that have lived in a depressed environment, it’s been depressed, they get accustomed to it, and so to a certain extent, some of them don’t know that they are. That it’s just a trend of life for them, but then they don’t rebound well from it, because they believe that it’s just a trend of life.” (Pastor) Many of the participants thought that people did not recognize depression or depressive symptoms as being something abnormal or unusual. In their opinions, depression was just a part of life. Therefore, the idea that one should seek help was viewed as irrational. They also believed that other people might think that what they were experiencing was something different from depression. They thought that if a person was diagnosed with MDD, and he or she was depressed, it might not be accepted: “You get used to toting the weight around until you get used to it. I mean it will be a norm for you to let it be norm and then people try to talk about it, it’s like, ‘well this is the norm for me.’ It isn’t what they say it is because it’s just been this way.” (Pastor) Participants also thought that some people wanted to remain in a state of depression because they were comfortable in it or they were seeking attention. As one pastor explained:


“There are people that just naturally want to be depressed and stay depressed because they’ve grown accustomed to it being in their life. Those are the hardest ones to pull out. They don’t have a shout…they don’t have an Amen…they don’t have a thank you, Jesus.” (Pastor) “Denial” of depression was also identified as a barrier to seeking help. This was largely a result of the belief that depression was a sign of weakness, and the idea that one can handle the symptoms or that they will go away in time: “I’m not going to do that. I’m going to suppress it. I’m going to find a way to get it fixed. That’s admitting I’m weak, and I can’t control it. As Black men, we don’t do it.” (Pastor) “When we’re in denial about a problem, one thing we do is we try to fight through it, fight through it, fight through it.” (Parishioner) “They won’t admit it. I think they try to work it out on they own.” (AfricanAmerican male)


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In addition to denying their depression or depressive symptoms, participants said that people would “put on a front,” either consciously or unconsciously; i.e., to pretend that everything was okay, either to keep others from asking or getting into their personal business, or as a form of defense. Mostly the descriptions were of people smiling to cover up their sadness. But a mask of anger and frustration was also described: “They act behind a mask, so they’re pretending to be something that they’re really not.” (Pastor) “They have been that way so long until it’s the norm, because they’re good performers.” (Pastor) “Everybody just try to put on this facade that everything is okay when they don’t wanna’ admit that they dealing with this thing [depression].” (Parishioner) “You might be going through and display a certain kind of anger or feeling to disguise how you really feel.” (African-American male)


From a spiritual viewpoint, “putting on a front” was not considered denial. One participant provided the example that a person might be asked, “how are you doing?” The response would be, “blessed and highly favored” [a common utterance among members of the Black Church]. Although the person may be experiencing depression, they did not want to “act the part,” because doing so would be claiming the spirit of depression. Since they knew that God was going to pull them through, however, there was no need to “act the part.” The second category of barriers to recognition and treatment of MDD was external barriers (the environment and the community). Four external themes were identified: “spiritual beliefs,” “lack of resources,” “education,” and “stigma.” The first theme, “spiritual beliefs,” was exemplified by the following responses: “Convince them [people] that it [depression knowledge] is important, especially the minister, it won’t go forth because a lot of times we demonize stuff. Depression is a demon. Ain’t nobody going to get demonized.” (Pastor) “We are behind the ballgame on it [depression] because it’s already there. I’ve even heard it before, ‘you’re depressed, that demon, you ain’t got no business being filled with the Holy Ghost.’” (Pastor)


In addition to the belief that depression was a demonic spirit that could inhabit someone, there was also a discussion of generational curses, particularly among pastors. The “generational curse” had a tone similar to the “mind-set” barrier. It was believed that the “curse” of depression could be passed on from one generation to the next. Researchers might view depression in families as a genetic risk factor, but religious leaders thought that it might be due to spiritual causes: “It [depression] stays undercover and it goes to the next generation, because every generation’s been taught, ‘Shhh, don’t say nothing about that.’” (Pastor) “Momma was depressed, so nothing new for me to be depressed…Daddy was depressed so that’s the way we live this life.” (Pastor) However, participants also believed that the generational curse could be broken: “I teach and believe generational curses can be broken.” (Pastor) “With generational curses…until somebody just wake up and say, ‘we got a problem in the family, and everybody, soon, they gonna’ find out. We might as well get this stuff out here now.’” (Pastor)


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The second external barrier that emerged was a “Jack of medical resources” in tine community. Several pastors described their attempts to help their parishioners:


“I think it could be a money issue as well. They go on qualifications, and a benefit that’s not provided. There’s been a time a few years ago, I was trying to get help… they took a pysch evaluation on them, and because they were not suicidal, and they did not have any insurance, they couldn’t accept them.” (Pastor) One pastor recognized a parishioner who needed mental health services, but she was denied access as a result of a lack of medical insurance, until her status deteriorated. The pastor said: “Yeah, they got her some help then, but see, for three years, I tried to get some help before she got to that point.” (Pastor) Barriers to mental health services in the community included limited services, unaffordable co-pays, specialization in child/adolescent mental health issues, and severe mental illness. But even when resources were available, they were often inadequate, or did not fit the needs of the community:


“They’re [primary care doctor] losing time sitting and talking to you. They’ll write you a prescription and say you going to be fine, go home and get some rest. But they’re going to be quick to get back to the ones that have the physical issues.” (Pastor) “They want to do a quick fix. You know what I’m saying?” (Parishioner) One participant believed that medications for mental health issues were evil, and strongly believed that primary care doctors promote this evilness. “All they [primary care doctor] resource [endorse] is evil. They just want to give you a prescription." (Parishioner) One pastor was concerned about potential liability if he referred a parishioner to mental health services, not about a lack of resources. He also expressed concern about counseling parishioners: “Insurance companies now are telling us that we can’t talk to people one-on-one behind a closed solid door. The door can be closed, but it’s got to have a glass [window] in it.” (Pastor)


The pastors also thought that not only were they faced with limited resources, they also lacked knowledge and understanding of depression. They were well aware of their boundaries as clergy, but they wanted to know how to distinguish “clinical depression” from stress or other psychological disorders. “Lack of education” about depression, the third external barrier, was identified in each of the groups. Participants agreed that the ignorance about the etiology and presentation of depression affected the community’s beliefs and attitudes about depression. One pastor said that it was important for clergy to know and understand depression in order to minister effectively to their congregation: “If you ain’t trained, then you can’t train others.” (Pastor) “They’ve got to want to be educated. They’ve got to recognize that many things are greater than what they can provide themselves.” (Pastor) The final external category, “stigma,” was related to the lack of understanding of MDD, labeling those with it as “crazy” or inhabited by the spirit of depression. Some participants


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thought that because of the stigma, people might not seek help or would not desire to share their “personal business” with others, especially in the church:


“That’ll [depression] follow you forever in your work history record.” (Parishioner) “You can’t even get help, so you keep sinking and sinking, because once you reach out for the help, you end up getting your hand cut off, so you just kinda’ keep it quiet.” (Pastor) It was suggested that any program or intervention that was developed should not include the word “depression,” because it would turn people away. The word “stress” seemed less intrusive and more accepted within the community: “The word depression will spook people, because, number one…the ignorance of the word makes us put a shield up…now stress, anybody can tell you ‘Lord, I know I stay stressed about something’ and that’s [stress] a softer word.” (Pastor) “Some are afraid to admit to depression because it makes them out like they’re crazy or they losing their mind and not very many of them want to admit that. There’s a word that makes them feel like that they’re on the borderline of going crazy.” (Pastor)


Not only was stigma associated with the word ‘depression,’ but also with mental health providers, such as psychologists and psychiatrists: “When you talk to a psychiatrist, you crazy. Why? You talk to a shrink?” (Pastor) “She’s going to a psychiatrist. She crazy…so I think as Black people we grew up thinking you know, we just saying ‘crazy.’” (Parishioner) Many participants thought that the stigma of depression persisted as the result of a lack of education and understanding. They said they had a greater tolerance of MDD after they were exposed to psychology classes, personal experiences, mental health training, or other resources.

Discussion


Understanding the rural African-American faith community’s views of depression is vital to addressing barriers to depression recognition, and help seeking. Previous studies have found that African-Americans face a variety of barriers to the detection and treatment of depression. These include the stigma about a depression diagnosis, comorbid medical conditions, problems with provider-patient relationships, and the presentation of MDD with somatization symptoms such as headache, body aches, and gastrointestinal problems (Das et al., 2006). In addition, persons from rural communities face environmental barriers including: (1) limited access to specialty mental health providers; (2) insufficient mental health training and education; and, (3) limited awareness of mental disorders (Gamm, Hutchinson, Dabney, & Dorsey, 2003). Many of the current study findings confirm earlier work on the internal barriers of “personal business,” “mind-set,” “put on a front,” and “denial,” and have been recognized previously. The idea of masking one’s depression consciously or unconsciously has also been acknowledged, particularly among men (BryantBedell & Waite, 2010; Hart, 2001; Lynch & Kilmartin, 1999). In general, “the church” is thought to be a place in which people should feel comfortable expressing their feelings and emotions. However, in the rural faith community, that might not always be the case because of the concerns of confidentiality and privacy. The external barriers identified here, including “spiritual beliefs,” “lack of resources,” “education,” and “stigma” are also consistent with the findings of other studies. The belief


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that depression can be caused by a spiritual source, as demonstrated by belief in demonic spirits and generational curses, is similar to the findings of Payne (2009) and Schnittker, Freese, and Powell (2000). This belief is also similar to the “Faith-Based Explanatory Model of Depression” which suggests that a “Loss of Faith” can lead to depression (Wittink, Joo, Lewis, & Barg, 2009). It is believed by many that if the etiology of the depression is spiritual, then the treatment should be spiritual. The use of the term “stress” or other terminology as a substitute for depression has been found in several studies among AfricanAmericans (Bryant-Bedell & Waite, 2010; Kendrick, Anderson, & Moore, 2007). However, it is not clear whether the term is used because of the stigma of depression or whether that is how the community views depression. Interestingly, these participants believed that education about depression would decrease stigma. Previous studies, however, have shown that education alone does not decrease stigma. This raises the question of whether other variables might influence anti-stigma campaigns, such as who delivers the educational program and how. Web-based programs developed to decrease depression stigma have been shown to have some success (Finklestein & Lapshin, 2007).

Limitations of the Study


One limitation of the study was that the community partner recruited participants in the county; therefore, the participants might represent one social network within the faith community. Additionally, the impact of the participants’ built environment on their perceptions of depression, and barriers to seeking and receiving adequate mental health care for MDD, was not measured here. Although many of the concerns shared by these participants mirrored those found in other studies, this study included only a small community. Nevertheless, the study provided some insight into issues that rural AfricanAmericans face in obtaining appropriate care for depression.

Conclusions Future studies should address the concerns and barriers described by this rural AfricanAmerican faith community, in particular, the recognition of depression and help seeking. Church and faith-based health promotion and prevention programs have been successful in addressing other chronic health problems and racial disparities, but evidence-based programs for depression and other mental health programs are limited (Hankerson & Weissman, 2012). Evidence-based community outreach programs that are specific to the needs of African-American men should include the faith community and other support networks (Ward & Collins, 2010).


Acknowledgments Funding for this study was received from the University of Arkansas for Medical Sciences, AHEC Pilot Grant. Support was received from the University of Arkansas for Medical Sciences Translational Research Institute (UL1RR029884) and the KL2 Scholar Program (KL2RR029883). And a special thank you to Promiseland Church, Dr. Jean McSweeney, and Dr. Cornelia Beck for their support.

References Bryant-Bedell K, Waite R. Understanding major depressive disorder among middle-aged African American men. Journal of Advanced Nursing. 2010; 66(9):2050–2060. [PubMed: 20626494] Das AK, Olfson M, McCurtis HL, Weissman MM. Depression in African Americans: breaking barriers to detection and treatment. The Journal of Family Practice. 2006; 55(1):30–39. [PubMed: 16388764] Ethnograph 6.0. Qualitative Data Analysis Software. 2012 Retrieved from: http:// www.qualisresearch.com.


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Table 1

Participant Demographics


Variable

N = 24

Gender Male

16

Female

8

Age 18–25

3

26–45

13

46–65

7

66-older

1

Marital Status Never married

6

Married

15

Divorced

3

Education


High school diploma

2

Some college / trade school

13

Associate degree

4

Bachelor’s degree (BS, BA, etc.)

3

Graduate degree

2

Employment Employed full-time

15

Employed part-time

3

Unemployed

1

Retired / Veteran

1

Disabled

4

Household Income


Less than $20,000 / year

8

$20,000–50,000 / year

6

$50,001–100,000 / year

8

Greater than $100,000 / year

1

Did not answer

1

Religion Baptist

8

Pentecostal

5

Church of God in Christ (COGIC)

3

Non-denominational

6

Other / Did not answer

2


Bryant et al.

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Table 2

Barrier Themes


Internal Barriers

External Barriers

“Personal Business”

Information about oneself that should be kept confidential

“Mind-Set”

The way an individual thinks and their beliefs

“Denial”

For a person not to recognize and accept a depression diagnosis

“Putting on a Front”

Pretending nothing is wrong to others / covering up or wearing a mask

“Spiritual Beliefs”

Beliefs about depression and how it relates to religious beliefs and faith

“Lack of Resources”

Limited local healthcare providers and available mental healthcare

“Education”

Need for depression education for the community

“Stigma”

How a community views depression or a depressed person in a negative manner

NIH-PA Author Manuscript NIH-PA Author Manuscript J Natl Black Nurses Assoc. Author manuscript; available in PMC 2014 April 11.

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