Archives of Psychiatric Nursing 27 (2013) 278284

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Using Community-Based Participatory Research to Explore Social Determinants of

Women's Mental Health and Barriers to Help-Seeking in Three Urban, Ethnically
Diverse, Impoverished, and Underserved Communities
Mary Molewyk Doornbos a,, Gail Landheer Zandee a, Joleen DeGroot b, Megan De Maagd-Rodriguez a
a
b

Department of Nursing, Calvin College, Grand Rapids, MI

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, impoverished
women disproportionately. This study sought to identify social determinants of mental health and barriers to
help-seeking for this population. Using community based participatory research and focus groups, sixty-one
Black, Hispanic, and White women identied economic, family, cultural, and neighborhood issues as
perceived determinants of their depression/anxiety. They identied practical, psychosocial, and cultural
barriers to their help-seeking behavior. These results can promote women's health by fostering an
understanding of social factors as perceived determinants of depression/anxiety and shaping practice and
policy initiatives that foster positive aggregate outcomes.
2013 Elsevier Inc. All rights reserved.

In 2012, the World Federation for Mental Health estimated that

350 million people worldwide struggle with depression, accompanied
by anxiety, and designated this as a global crisis (World Health
Organization, 2012). Depression rates vary with lifetime prevalence
rates ranging from 3% in Japan to 16.9% in the United Stateswith
most countries between 8 and 12% (WHO, 2012). Persons living in
poverty have greater rates of depression and anxiety symptoms
(WHO, 2012). Globally, women experience depression at a rate two to
three times greater than men (WHO, 2012). Further, the burden of
depression is 50% higher for females than males and is the leading
cause of disease burden for women in high, middle, and low-income
countries (World Health Organization, 2008).
The US mirrors the dire global circumstances. Women are 70%
more likely to experience depression and 60% more likely to
experience 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 for
those below the poverty level compared with those above the poverty
level (Centers for Disease Control (CDC), 2011). African-Americans
are 20% more likely to report psychological distress than do nonHispanic Whites (Ofce of Minority Health (OMH), 2012a).

Corresponding Author: Mary Molewyk Doornbos, PhD, RN, Calvin College Department 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

In addition, barriers to care for depression/anxiety are prevalent.

Despite the known effectiveness of treatment for depression, many in
need do not receive care. WHO (2012) estimates that in the majority
of global regions only 30% of persons receive needed mental health
care. In the US, ethnic minority persons with low incomes remained
untreated or received inadequate treatment for mental health issues
(Wang et al., 2005). In 2008, US Hispanics received mental health
treatment nearly three times less often than non-Hispanic Whites
(Ofce of Minority Health (OMH), 2012b) did. Similarly, nonHispanics Blacks were more than two times less likely to receive
antidepressants than non-Hispanic Whites (OMH, 2012a) were. The
overlap of gender, poverty, and ethnicity appears to create signicant
vulnerability to depression/anxiety and barriers to care.
DEFINITIONS OF SOCIAL DETERMINANTS OF HEALTH
The Centers for Disease Control and Prevention assert that
biological, socioeconomic, psychosocial, behavioral, and social inuences determine the health of a population (Centers for Disease
Control and Prevention (CDC), 2012). Of those, the social determinants of health have been least explored. Social determinants of
health:
are the conditions in which people are born, grow, live, work,
and age, including the health system. These circumstances are
shaped by the distribution of money, power, and resources at
global, national, and local levels. The social determinants of health
are mostly responsible for health inequities - the unfair and

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

avoidable differences in health status seen within and between

countries (World Health Organization, 2011).
Social determinants incorporate: (a) the social environment
including discrimination, income, and gender; (b) the physical
environment including where persons live; (c) health services
including access to quality care and health insurance; and (d)
structural and societal factors (Centers for Disease Control
and Prevention (CDC), 2012). Healthy People 2020 added
social determinants of health as one of four goals for the decade
suggesting that:
Understanding the relationship between how population groups
experience place and the impact of place on health is
fundamental to the social determinants of healthincluding both
social and physical determinants (United States Department of
Health and Human Services (USDHHS), 2010).

Social Determinants of Mental Health

The literature links discrimination and mental health. In qualitative interviews, discrimination contributed to symptoms of depression and anxiety in Mexican immigrant mothers (Ornelas, Perreira,
Beeber, & Maxwell, 2009). Among African-American women living in
high-poverty areas, a signicant association existed between perceptions of daily discrimination and potentially dire psychological
consequences (Ajrouch, Reisine, Lim, Sohn, & Ismail, 2010). Discrimination was also associated with major depression among AsianAmericans (Chae, Lee, Lincoln, & Ihara, 2012). Further, the risk for
antenatal depression increased ve-fold among low-income AfricanAmerican women over the age of 30 compared to teen mothers. The
researchers suggested a weathering effect that resulted from years
of cumulative stress due to discrimination and socioeconomic
marginalization (Luke et al., 2009). A similar investigation of lowincome African-American women found that discrimination was a
considerable source of stress predicting antepartum depressive
symptoms (Dailey & Humphreys, 2010). Additionally, high levels of
self-reported discrimination and low levels of self-reported language
prociency were signicant predictors of depressive symptoms in
Korean immigrants in New York City (Bernstein, Park, Shin, Cho, &
Park, 2011).
Across ethnic groups, studies have also linked mental health to
economic factors. Economics contributed to symptoms of depression
and anxiety in Mexican immigrant mothers and Finnish individuals
(Ornelas et al., 2009; Pulkii-Raback et al., 2012). A study of British
women corroborated the role of nancial hardship as a strong
predictor in the development of depression (Dunn et al., 2008).
Goyal, Gay, and Lee (2010) found that rst-time mothers with four
SES risk factors (low monthly income, non-college graduate, unmarried, and unemployed) were 11 times more likely to have clinically
elevated depression scores at 3 months post-partum than women
with no SES risk factors. Additionally, cumulative exposure to family
poverty across early developmental stages was associated with a
consistent impact on adolescent/young adult anxiety and depression
in an Australian sample (Najiman et al., 2010). Watson, Roberts, and
Saunders (2012) reported a contrary nding wherein neither
neighborhood poverty nor race was a predictor for anxiety or
depression such that African-American women, facing neighborhood
poverty, low income, and discrimination, had lower depression and
anxiety scores than their White counterparts.
Social stressors such as family separation and social isolation
contributed to symptoms of depression and anxiety in Mexican
immigrant mothers (Ornelas et al., 2009). Similarly, a study of lowincome African-American women found that social conict was a
considerable source of stress predicting antepartum depressive

279

symptoms (Dailey & Humphreys, 2010). Among Asian-Americans,

negative interactions with relatives were associated with major
depression (Chae et al., 2012).
Barriers to Utilization of Mental Health Resources
The World Health Organization (2012) suggested that barriers to
effective mental health care include lack of resources, lack of trained
providers, and the social stigma associated with mental disorders. A
study of perceived barriers to depression treatment during the
perinatal period found that both White and African-American
women were most concerned with structural barriers to treatment,
including lack of insurance coverage, inability to pay, inadequate
childcare, transportation, and distance to clinic, rather than attitudinal
or knowledge barriers (OMahen & Flynn, 2008). A Canadian research
project studied a homeless or impoverished population and determined that even in the absence of economic barriers to health care,
impoverished persons experienced signicant barriers to the use of
mental health services. Specically, limited social networks predicted
restricted utilization of mental health resources (Bonin, Fournier, &
Blais, 2007). A subsequent Canadian study found that the odds of not
seeking treatment for depression were highest for single mothers
with adult children, women with low social support, and those with
little formal education (Gadalla, 2008).
Social determinants of mental illness have received increasing
attention and may constitute a critical factor surrounding the
vulnerability of urban, ethnically diverse, impoverished women to
depression/anxiety. Given the discrepancy between numbers of
women struggling with depression/anxiety and those receiving
intervention, it is also vital that our understanding of barriers to
treatment expand. Further, it is essential to hear the voices of urban
women since unless target populations perceive that social determinants and barriers are relevant, corresponding practice and
policy changes are ill advised. The purpose of this study was to explore
contributing factors to depression/anxiety and barriers to helpseeking for this population.
METHODS
Design
The ideological perspective of community based participatory
research (CBPR) was used to explore the following research
questions: (1) What contributes to the experience of depression
and anxiety of urban, ethnically diverse, impoverished women? and
(2) What barriers prevent urban, ethnically diverse, impoverished
women from using existing mental health resources? The designation
of urban, ethnically diverse, and impoverished women included city
dwelling women who are Black, Hispanic, or White and perceive
themselves to have insufcient nancial resources to meet personal
and family needs. CBPR was utilized to develop partnerships between
three midwest urban neighborhoods, that were predominately Black,
Hispanic, and White, respectively, and a department of nursing. The
partnerships were intended to identify resident health concerns,
create student learning experiences, engage in resident-driven
research, 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 ideological
perspective of CBPR. Data collection occurred via focus groups
stratied by neighborhood/ethnicity. Blending focus groups
with CBPR is useful in understanding health disparities and exploring
ways to provide culturally competent care to marginalized populations (Cristancho, Garces, Peters, & Mueller, 2008; Lutz, Kneipp, &
Means, 2009).

280

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

Community health workers (CHW) from each neighborhood were

instrumental in ensuring that this study remained true to the goals of
CBPR (Zandee et al., 2010; Zandee et al., 2013). The CHWs participated
in a pilot focus group aimed at the development of the semistructured interview guide, recruited participants, and translated/
transcribed recordings of the Spanish group. The CHWs and
neighborhood residents reviewed thematic results and participated
in determining next steps.

Table 2
Focus Group Semi-Structured Interview Guide.
Contributing factors

Barriers

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

Table 1
Participant Characteristics.
Overall (N = 61)

Race/Ethnicity

Family income

Education

Marital status

Ever used mental health services

Range: 1869 years

Mean: 38.93 years
Black: 36%
Hispanic: 31%
White: 33%
$10,00014,999: 48%
$15,00024,999: 23%
$25,00034,999: 16%
$35,00049,999: 11%
$50,00074,999: 2%
No high school: 3%
Some high school: 20%
High school graduate: 34%
Some college: 38%
College graduate: 5%
Single: 34%
Married: 43%
Divorced: 13%
Signicant other: 10%
Yes: 46%
No: 54%

According to the US Census Bureau (2010), each of the three partner neighborhoods 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 the
poverty level in the three partner neighborhoods ranged from 25 to 43%.

commencement. The authors' institutional review board approved the

study, participants gave informed consent, and respondent anonymity
was preserved.
Data Analysis

The authors conducted two homogeneous focus groups relative to

race in each neighborhood. A strategy of segmentation was
employed whereby homogeneity was created in each focus group
while allowing for diversity across focus groups (Krueger, 1994;
Morgan, 1988). Homogeneous groups tend to quickly move participants to a discussion of issues and engender greater levels of
condent expression (Morgan, 1988; Sim, 1998). The researchers
conducted six focus groups of 912 participants each. In the Hispanic
neighborhood, one focus group was conducted in English and one in
Spanish. The primary and secondary investigators facilitated ve of
the focus groups while a trained native speaking Hispanic CHW
facilitated the sixth group. The researchers used a semi-structured
approach and the primary questions, developed in conjunction with
the CHWs, are presented in Table 2.
The team offered transportation to and childcare during the focus
groups. The focus groups lasted 75 minutes, and upon completion,
participants received a $20 gift card. Participation in the study was
voluntary, and the investigators obtained informed consent prior to

Age

a. What kinds of things contribute to depression

and anxiety experienced in your community,
neighborhood, family, or personal life?
b. What sort of life circumstances might trigger
depression and anxiety?
a. How do you perceive the adequacy of your
community's resources for persons struggling with
anxiety and depression?
b. Which of the existing resources are particularly
helpful? How so?
c. Which of the existing resources are less than
helpful? How so?
d. What barriers might exist that would prevent
residents from accessing mental health resources?

The focus groups were audio taped and transcribed verbatim. A

native Spanish speaker and an undergraduate research assistant, with
majors in nursing and Spanish, attended the Spanish focus group and
assisted with transcription. NVivo 9 was used for analysis. The team
analyzed the transcripts line-by-line and coded into nodes based on
the global categories of contributing factors and barriers. This
approach closely approximates the template analysis style - the
researcher begins with a rudimentary coding guide prior to data
collection and continuously revises it as data are collected (Crabtree &
Miller, 1999). Subsequently, the team created focused nodes and
clusters of related nodes. To conrm the accuracy, relevance, meaning,
and authenticity of the data, the researchers employed an ethnically
diverse sample and returned to each partner community to present
the 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 least
four of the six groups, are presented in Table 3. Quotations support the
results and include the designation P to indicate the contributions
of participants.
Contributing Factors
Economic Issues
The rst theme identied was economic issues. The participants
painted a picture in which nancial matters overwhelmed them in
nearly every area of their daily life. Predictably, the women cited the
economic subtheme of unemployment as having a direct link to their
mental health issues.
P: I am going to give you a reason why I think a lot of people are
going 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 major
number one depression right now.
Correspondingly, respondents also identied the economic subtheme of bills/expenses as a major stressor.
P: The phone is ringing because its the bill collectors. Theyre
calling 24/7 which is very stressful.
P: At the same time that I picked up the phone to make payment
arrangements a guy is showing up at my door to shut my gas off.

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

health. The rst subtheme identied was general decline of the

neighborhood.

Table 3
Global Categories, Themes, and Subthemes.
Global categories

Contributing factors

Economic issues

Themes

Cultural issues
Neighborhood issues

Family issues

Barriers

Practical

Psychosocial

Cultural

281

Sub-themes

Unemployment
Bills/Expenses
Discrimination
Separation from family
General decline of
neighborhood
Safety issues/crime/
gang activity
Marital issues and
private violence
Single parenting
Behavioral problems
with children
Caregiving stress
Death
Lack of clinics for low
income persons
Lack of transportation
Lack of awareness of
existing resources
Lack of insurance
Lack of nancial resources
Stigma
Lack of trust of
existing services
Discrimination

Themes occurred in six of six focus groups.

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

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

Cultural Issues
The participants were articulate about cultural issues that played a
role in the etiology of anxiety and depression. The theme of cultural
issues 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 TV
where they dont like Hispanics and he asks me why and this
affects him a lot. And now anything that happens is because were
Hispanic. It makes me feel bad.
P1: They dont respect us as customers and I dont like that. They
feel like since they are from a different ethnic P2: They can
treat you any way! P1: I went into a store in the neighborhood
one time and he [proprietor] took this mans money that was
behind me and I was here rst. He disrespected me.
The respondents identied separation from family as another
salient cultural subtheme.
P1: We are far away from our families and our culture. We feel
alone and unprotected without knowing where to go or what to
do. P2: Alone.
P: Im from New Orleans and its different here in the North. I miss
my people. Back at home we can with no shoes on we can just
party and wed be happy. But were all scattered now. And there
aint nothing for us. I think about home all the time and there aint
no home for me to go to. So thats what depressed is to me.

Neighborhood Issues
The third theme was neighborhood issues. The participants
outlined the impact of one's geographic surroundings on mental

P: I was born and raised right down here. So I know this area and
I have seen this area all my life. What a change! You could say that
people must be depressed because the neighborhood is not kept
up like it was when I grew up.
A second neighborhood subtheme was safety issues, crime, and
gang activity.
P: The neighborhood isnt safe anymore like when I grew up and
we all knew each other. Everybody watched everybody elses kids.
Youd better not misbehave or your Mama would hear about it
from the neighbors. Now the kids are hanging out on the streets.
They are depressed, acting out, and doing whatever they do which
is usually not good
P1: Yeah, deaths and gang activities in our community young
men and these gang activities. P2: Very depressing.

Family Issues
All groups identied family issues as a contributor to their anxiety
and depression. They spoke about the conict and stress in their cooccurring roles as spouses, parents, and daughters and how this
affected their mental health. Marital issues and private violence
constituted a family issues subtheme.
P: I am divorced and experienced a lot of domestic violence. This
affected me greatly.
Single parenting was a second subtheme.
P: Another problem is being a single mom. I have a lot of friends
that are also single moms that deal with a lot of stress and that
turns into depression.
A third subtheme emerged around behavioral problems with
children.
P: I had four boys and two girls and one son just did everything
he thought he was big enough and bad enough to do. OK, so that
was depressing for me.
The participants saw themselves as caregivers for multiple
persons, and the resulting caregiving stress constituted a
subtheme.
P: We had to take some of our siblings kids or our childrens kids
because somebody is on drugs. This is a big issue.
P: I feel like I have to serve two families. I know I need to spend
time with my husband and kids but I also feel responsible for my
parents and my siblings.
Finally, the death of family members was 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 Barriers
The women identied practical barriers to help-seeking. Practical
barriers enveloped the absence of things essential to accessing mental
health services. First, the women believed that there were insufcient
clinics for low-income persons.

282

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

P: It takes forever [to get in]. I mean they tell you that you can
call at the beginning of the month and you call at 8:05 a.m. and
they say, Oh, we already took our ve patients for the month.
P: And by the time you nally get help you almost want to
commit suicide.
The respondents identied a lack of transportation as a second
signicant practical barrier.

existing services. The women experienced discrimination in health

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

Facilitator: What barriers might exist? P: Transportation!

The third practical barrier to help-seeking was a lack of awareness
of existing resources.
P1: People dont know where they can go. P2: Yeah, lack of
awareness of different resources.
A salient subtheme also evolved around the lack of insurance.
P: You know the kids if they dont have insurance they have
Medicaid, but it is harder for an adult to get Medicaid. There has to
be an alternative to that!
Predictably, a lack of nancial resources constituted a nal
subtheme under practical barriers. Participants lacked money for
mental health services and health promotion activities.
P: You know, if its between do you get your kid a winter coat or
do you pay for the counseling appointment you know what you
need to go do.
P: I dont have the money for shoes to go jogging or walking or
whatever it is. So there are a lot of barriers that come up.

Psychosocial barriers
The theme of psychosocial barriers encompassed attitudes and
feelings that created an obstruction to accessing mental health
services. 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 want
people to make fun of them.
The second psychosocial barrier subtheme was a lack of trust in
existing services. There were concerns about the condentiality of
information and a specic fear of Child Protective Services.
P: They have programs out here for women depression
programs and whatever. I would not suggest them only because
once you get into those programs, you are in the system and
everybody is in your business. They say it is condential but its
not condential to the housing department! Its not condential
to 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 and
concerns 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 the
money runs out so do they. This happens over and over.

Cultural Barriers
While the women identied cultural issues as a contributing
factor to mental health issues, the theme also surfaced as a barrier to

DISCUSSION
The economic, cultural, neighborhood and family contributing
factors as well as the practical, psychosocial, and cultural barriers to
help-seeking identied by the study participants clearly constitute
social determinants of health. The themes encompass the social
environment, the physical environment, and health services (Centers
for Disease Control and Prevention (CDC), 2012) as well as comprising
the conditions in which people are born, grow, live, work, and age,
including the health system (World Health Organization, 2011). The
study participants veried the utility of the concept of social
determinants as it relates to mental health.
The economic, cultural, and family themes emerging from this study
support the existing body of literature in linking social factors to
depression/anxiety. Additionally, these results elucidate a holistic
perspective of the interrelated role of economic, cultural, and family
issues. For example, the participants described scenarios including
single parenthood, unemployment connected to lesser educational
levels and lack of childcare, bill/expenses around necessities such as
food and utilities, behavioral problems with children, geographic
separation from family at times of crisis, and racial discrimination.
Gjeseld, Greeno, Kim, and Anderson (2010) moved toward documenting this interrelatedness by determining that the specic mechanism
whereby 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 especially
important when considering quantitative ndings suggesting that selfreported economic difculties are more strongly associated with poor
mental health outcomes than the more conventional indicator of lowincome level (Ahnquist & Wamala, 2011). These results also assisted in
explicating the full nature of these factors and putting them in context.
For example, the inability to cover expenses particularly concerned the
women as they feared being unable to feed their children. Correspondingly, an earlier study found that the percentage of mothers with either
major depression or generalized anxiety disorder increased as food
insecurity worsened (Ivers & Cullen, 2011). Thus, this study adds to the
body of literature by exploring and providing context to the
multifaceted social processes by which the phenomena of mental
health outcomes evolve.
The results of this study also add to the literature by outlining the
signicance of place as a perceived determinant of anxiety and
depression. The women described neighborhood issues such as crime
and decline as social determinants. To date, there has been limited
empirical support for the role of neighborhood issues in depression/
anxiety symptoms. One study of African-American women found that
perceived neighborhood deterioration was associated with signicantly higher depressive symptoms at the end of a 24-week walking
intervention (Wilbur, Zenk, Wang, et al., 2009). Further work has
focused on linking housing disarray and housing instability to
depression and anxiety outcomes among young US mothers (Suglia,
Cuarte, & Sandel, 2011).
One potential solution to depression and anxiety issues lies in the
use of existing resources. While limited research exists around
barriers to mental health help-seeking, it is apparent that this
research supports previous work in documenting practical barriers
including lack of insurance, nancial resources, transportation, and

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

the psychosocial barrier of stigma (OMahen & Flynn, 2008; WHO,

2012). Additionally, the participants were articulate about the lack of
awareness of existing resources, which may constitute a fruitful area
of intervention.
Several sub-themes manifested. The discrimination subtheme,
cited as both a contributing factor and a barrier to help-seeking, was
relevant in ve of the six focus groupsexcept one group of White
women. The women of color described discrimination related to
ethnicity while the White women identied discrimination related to
socioeconomic status. Perhaps the women reported the most obvious
type of discrimination they experienced while having limited
awareness of the multiple subtle forms of discrimination that they
regularly encountered. Previous research suggests a causal link
between everyday encounters with racial discrimination and depression (Schulz et al., 2006) as well as a positive association between
gender discrimination and depression and economic discrimination
and 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 depressive
symptoms in women.
The practical barrier subtheme entitled lack of trust of existing
services pertained to the Black and Hispanic groups of women. Likely
the White women were more comfortable with predominately-White
health care providers. This is consistent with previous ndings where
depressed African-American women had a deep mistrust of the
health care system as a White system (Nicolaidis et al., 2010, 1470).
Practitioner failure to acknowledge the larger historical perspectives
from which they and their patients of color draw conclusions and
make decisions contributes to mistrust of the mental health
communities 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 discussion and capture the perceptions of urban, impoverished, ethnically
diverse women relative to the contributing factors to depression/
anxiety and barriers to help-seeking. This study explored these topics
and 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 depression/anxiety? Can barriers to help-seeking be reduced if provider
discrimination issues are addressed? Can barriers to help-seeking be
reduced if neighborhood level anti-stigma campaigns are initiated? In
the interim, various interventions may warrant consideration.
Potential Policy Implications
In spite of the fact that this is a small-scale qualitative study, policy
implications might at least be considered. Addressing the perceived
causes of depression/anxiety and barriers to help-seeking requires
coordinated effort. Meaningful progress in narrowing health disparities is unlikely if perceived determinants are not addressed (Woolf &
Braveman, 2011). Healthy People 2020 suggests:
The Social Determinants of Health topic areais designed to
identify ways to create social and physical environments that
promote good health for allto ensure that all Americans have that
opportunity, advances are needed not only in health care but also in
elds such as education, childcare, housing, business, law, media,
community planning, transportation, and agriculture. Making these
advances would involve working together to explore how
programs, practices, and policies in these areas affect the health
of individuals, families, and communities (USDHHS, 2010).
A health in all policies approach may be fruitfully contemplated
such that every policy decision considers its impact on health

283

outcomes (Robert & Booske, 2011). Unfortunately, the difculties

inherent in this are signicant. The US public views personal health
behaviors and access to affordable health care as strong determinants
of health while far fewer recognize social and economic determinants
of health (Robert & Booske, 2011). Many do not view social policy and
health policy as intimately linked. Consequently, political will
constitutes a key barrier to translating knowledge into action, and
signicant effort will be necessary to move social policy onto the
policy agenda as a health improvement method (Braveman, Egerter, &
Williams, 2011; Robert & Booske, 2011).
Potential Practice Implications at the Local Community Level
Successful mental health change will require a multi-level
approach, in which local nurses assume a broad view of health and
collaborate with new partners (Braveman et al., 2011). Given these
results, 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 to
direct resources and programming toward these social determinants.
Such programming may include collaborative partnerships across
disciplines and among local agencies such as neighborhood associations, parks departments, police departments, community centers,
churches, housing authorities, nancial and legal services, food
pantries, schools, libraries, and transportation authorities (Hunter,
Neiger, & West, 2011). Previous research documented the potential of
comprehensive city/community coalitions to strengthen the organizational infrastructure of communities to promote health (Kegler,
Norton, & Aronson, 2008). Nurses can lead in forging broad alliances
at the local level that may successfully address the perceived
determinants of depression and anxiety in urban women.
Limitations
There are two limitations to this study. First, the three partner
neighborhoods are located in a single midwest city such that the
results may not be applicable to urban, impoverished Black, Hispanic,
and White women in other areas. However, the intent of focus groups
is for in-depth discussion rather than the development of generalizable information. Therefore, these themes may serve as the basis for
future studies and may evoke innovative ideas on the part of policymakers. Additionally, although the CHWs signicantly facilitated our
recruitment process, this approach to subject recruitment could
introduce bias into the sample via the pursuit of participants who had
pre-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 anxiety
and depression as well as barriers to help-seeking across three urban,
impoverished, underserved, and ethnically diverse neighborhoods in
the midwest region of the US. The identied social determinants
included economic, family, cultural, and neighborhood issues while
the perceived barriers to help-seeking were practical, psychological,
and cultural in nature. The results add momentum to the growing
recognition that mental health and mental health care must be
approached from a multifaceted and multidisciplinary vantage point.
Acknowledgment
The authors gratefully acknowledge the support of the Calvin
College Sabbatical Leave Program, the Marian Petersen Nursing
Research Fund, and the Perrigo Company Charitable Foundation for
providing nancial support for the research activities of the primary

284

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

investigator, stipends for the participants, and wages for the

research assistants.
References
Ajrouch, K. J., Reisine, S., Lim, S., Sohn, W., & Ismail, A. (2010). Perceived everyday
discrimination and psychological distress: Does social support matter? Ethnicity &
Health, 15, 417434.
Ahnquist, J., & Wamala, S. P. (2011). Economic hardships in adulthood and mental
health in Sweden: The Swedish National Public Health Survey. BMC Public Health,
11, 788.
Bernstein, K. S., Park, S. Y., Shin, J., Cho, S., & Park, Y. (2011). Acculturation,
discrimination, and depressive symptoms among Korean immigrants in New
York City. Community Mental Health Journal, 47, 2434.
Bonin, J. -P., Fournier, L., & Blais, R. (2007). Predictors of mental health service
utilization by people using resources for homeless people in Canada. Psychiatric
Services, 58, 936941.
Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health:
Coming of age. Annual Review of Public Health, 32, 381398.
Canady, R. B., Bullen, B. L., Holzman, C., Broman, C., & Tian, Y. (2008). Discrimination and
symptoms of depression in pregnancy among African-American and White
women. Womens Health Issues, 18, 292300.
Centers for Disease Control (CDC). (2011). Health, United States, 2011. http://www.cdc.
gov/nchs/data/hus/hus11.pdf#highlights.
Centers for Disease Control and Prevention (CDC). (2012). Social determinants of
health Denitions. http://www.cdc.gov/socialdeterminants/Denitions.html.
Chae, D. H., Lee, S., Lincoln, K. D., & Ihara, E. S. (2012). Discrimination, family
relationships, and major depression among Asian Americans. Journal of Immigrant
Minority Health, 14, 361370.
Crabtree, B. F., & Miller, W. L. (1999). Doing qualitative research (2nd ed.). Newbury
Park, CA: Sage.
Cristancho, S., Garces, D. M., Peters, K. E., & Mueller, B. C. (2008). Listening to rural
Hispanic immigrants in the midwest: A community-based participatory assessment of major barriers to health care access and use. Qualitative Health Research, 18,
633646.
Dailey, D. E., & Humphreys, J. C. (2010). Social stressors associated with antepartum
depressive symptoms in low-income African-American women. Public Health
Nursing, 28, 203212.
Dunn, N., Inskip, H., Kendrick, T., Oestmann, A., Barnett, J., Godfrey, K., et al. (2008).
Does perceived nancial strain predict depression among young women?
Longitudinal ndings from the Southampton womens survey. Mental Health in
Family Medicine, 5, 1521.
Feenstra, C., Gordon, B., Hansen, D., & Zandee, G. (2006). Managing community and
neighborhood partnerships in a community-based nursing curriculum. Journal of
Professional Nursing, 22, 236241.
Gadalla, T. M. (2008). Comparison of users and non-users of mental health services
among depressed women: A national study. Womens Health, 47, 119.
Gjeseld, C. D., Greeno, C. G., Kim, K. H., & Anderson, C. M. (2010). Economic stress,
social support, and maternal depression: Is social support deterioration occurring?
Social Work Research, 34, 135143.
Goyal, D., Gay, C., & Lee, K. (2010). How much does low socioeconomic status increase
the risk of prenatal and postpartum depressive symptoms in rst-time mothers?
Womens Mental Health Issues, 20, 96104.
Guba, E. G., & Lincoln, Y. S. (1994). Competing paradigms in qualitative research. In N. K.
Denzin, & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 3347).
Thousand Oaks, CA: Sage.
Heffner, G., Zandee, G., & Schwander, L. (2003). Listening to community voices:
Community- based research, a rst step in partnership and outreach. Journal of
Higher Education Outreach and Engagement, 8, 127139.
Hunter, B. D., Neiger, B., & West, J. (2011). The importance of addressing social
determinants of health at the local level: The case for social capital. Health and
Social Care in the Community, 19, 522530.
Ivers, L. C., & Cullen, K. A. (2011). Food insecurity: Special considerations for women.
American Journal of Clinical Nutrition, 94, 17401744.
Kegler, M. C., Norton, B. L., & Aronson, R. (2008). Achieving organizational change:
Findings from case studies of 20 California healthy cities and communities
coalitions. Health Promotion International, 23, 109118.
Krueger, R. A. (1994). Focus groups: A practical guide for applied research. Thousand
Oaks, CA: Sage.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.

Luke, S., Salihu, H. M., Alio, A. P., Mbah, A. K., Jeffers, D., Berry, E. L., et al. (2009). Risk
factors for major antenatal depression among low-income African-American
women. Journal of Womens Health, 18, 18411846.
Lutz, B. J., Kneipp, S., & Means, D. (2009). Developing a health screening questionnaire
for women in welfare transition programs in the United States. Qualitative Health
Research, 19, 105115.
Morgan, D. L. (1988). Planning focus groups. Thousand Oaks, CA: Sage.
Najiman, J. M., Hayatbakhsh, M. R., Clavarino, A., Bor, W., OCallaghan, M. J., & Williams,
G. M. (2010). Family poverty over the early life course and recurrent adolescent and
young adult anxiety and depression: A longitudinal study. American Journal of
Public Health, 100, 17191723.
National Institute of Mental Health (NIMH). (2012). Statistics. http://www.nimh.nih.
gov/statistics/index.shtml.
Nicolaidis, C., Timmons, V., Thomas, M. J., Waters, A. S., Wahab, S., Mejia, A., et al. (2010).
You dont go tell White people nothing: African-American womens perspectives
on the inuence of violence and race on depression and depression care. American
Journal of Public Health, 100, 14701476.
Ofce of Minority Health (OMH). (2012a). Mental health and African-Americans. http://
minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=9&ID=6474.
Ofce of Minority Health (OMH). (2012b). Mental health and Hispanics. http://
minorityhealth.hhs.gov/templates/content.aspx?lvl=3&lvlID=9&ID=6477.
OMahen, H. A., & Flynn, H. A. (2008). Preferences and perceived barriers to treatment
for depression during the perinatal period. Journal of Womens Health, 17,
13011309.
Ornelas, I. J., Perreira, K. M., Beeber, L., & Maxwell, L. (2009). Challenges and strategies
to maintaining emotional health: Qualitative perspectives on Mexican immigrant
mothers. Journal of Family Issues, 30, 15561575.
Pulkii-Raback, L., Ahola, K., Elovainio, M., Hintsanen, M., Isometsa, E., Lonnqvist, J., et al.
(2012). Socio-economic position and mental disorders in a working-age Finnish
population: The health 2000 study. European Journal of Public Health, 22, 327332.
Robert, S. A., & Booske, B. C. (2011). US opinions on heath determinants and social
policy as health policy. American Journal of Public Health, 101, 16551663.
Schulz, A. J., Gravlee, C. C., Williams, D. R., Israel, B. A., Menta, G., & Rowe, Z. (2006).
Discrimination, symptoms of depression, and self-rated health among AfricanAmerican women in Detroit: Results from a longitudinal analysis. American Journal
of Public Health, 96, 12651270.
Sim, J. (1998). Collecting and analyzing qualitative data: Issues raised by focus groups.
Journal of Advanced Nursing, 28, 345353.
Suglia, S. F., Cuarte, C. S., & Sandel, M. T. (2011). Housing quality, housing instability, and
maternal mental health. Journal of Urban Health, 88, 11051116.
Suite, D. H., La Bril, R., Primm, A., & Harrison-Ross, P. (2007). Beyond misdiagnosis,
misunderstanding and mistrust: Relevance of the historical perspective in the
medical and mental health treatment of people of color. Journal of the National
Medical Association, 99, 879885.
United States Census Bureau. (2010). American FactFinder. http://factnder.census.gov.
United States Department of Health and Human Services (USDHHS). (2010). Healthy
People. http://www.healthypeople.gov.
Wang, P. S., Lane, M., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005).
Twelve- month use of mental health services in the United States: Results from the
National Comorbidity Survey Replication. Archives of General Psychiatry, 62,
629640.
Watson, K. T., Roberts, N. M., & Saunders, M. R. (2012). Factors associated with anxiety
and depression among African-American and White women. ISRN Psychiatry, 18.
Wilbur, J. E., Zenk, S., Wang, E., et al. (2009). Neighborhood characteristics, adherence to
walking, and depressive symptoms in midlife African-American women. Journal of
Womens Health, 18, 12011210.
Woolf, S. H., & Braveman, P. (2011). Where health disparities begin: The role of social
and economic determinants And why current policies may make matters worse.
Health Affairs, 30, 18521859.
World Health Organization. (2011). Social determinants of health. http://www.who.
int/social_determinants/en/.
World Health Organization. (2008). The Global Burden of Disease 2004 update. http://
www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.
pdf.
World Health Organization. (2012). Depression: A global crisis. http://www.who.int/
mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf.
Zandee, G. L., Bossenbroek, D., Friesen, M., Blech, K., & Engers, R. (2010). Effectiveness of
community health worker/nursing student teams as a strategy for public health
nursing education. Public Health Nursing, 27, 277284.
Zandee, G. L., Bossenbroek, D., Slager, D., & Gordon, B. (2013). Teams of community
health workers and nursing students effect health promotion of underserved urban
neighborhoods. Public Health Nursing, 30(5), 439447.