Perceptions of Depression and Access to Mental Health Care Among Latino Immigrants: Looking Beyond One Size Fits All.

588499

research-article2015

QHRXXX10.1177/1049732315588499Qualitative Health ResearchMartinez Tyson et al.

Article

Perceptions of Depression and Access to Mental Health Care Among Latino Immigrants: Looking Beyond One Size Fits All

Qualitative Health Research 1–14 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315588499 qhr.sagepub.com

Dinorah Martinez Tyson1, Nora B. Arriola1, and Jaime Corvin1

Abstract Compared with non-Latino Whites, Latino immigrants have a lower prevalence of depression. However, they are also less likely to seek professional mental health services. Our objective was to compare and contrast perceptions of depression and access to mental health care among four of the largest Latino immigrant subgroups in Florida (Puerto Rican, Cuban, Mexican, and Colombian). We conducted a total of 120 interviews (30 men and women from each subgroup). Thematic analysis of qualitative data revealed that participants across the four groups were aware of the signs and symptoms of depression and had similar perceptions of depression. However, notable differences by subgroup emerged with regard to perceptions of access to mental health care. We suggest that the variation stems from differences in life experiences and the immigration context. Understanding the variances and nuances of Latino immigrants’ cultural construction of depression and immigration experience will enable practitioners to better serve this community. Keywords culture; depression; ethnicity; health behavior; illness and disease, immigrants / migrants; interviews, semistructured; Noth America; Latino / Hispanic people; mental health and illness; research, qualitative Depression is a major public health concern, presenting a significant challenge to both those who suffer from it and to their families (Borges et al., 2008; Snowden, 2007). Current research, including both the Surgeon General’s (U.S. Department of Health and Human Services, 2001) report “Culture, Race, and Ethnicity: A Supplement to Mental Health” and the National Council of La Raza’s (2005) report “Critical Disparities in Latino Mental Health: Transforming Research into Action,” suggests the need to explore depression and issues associated with access to mental health care among Latinos. These reports also point to the need for specific mental health research that explores the cultural variation and heterogeneity of the Latino population (Rios-Ellis et al., 2005; U.S. Department of Health and Human Services, 2001). Furthermore, a review of the recent literature on culture and depression suggests the need to consider ethnic and cultural issues in developing an evidence base for mental health care and minorities (Bernal, 2006; Bernal & Scharron-del-Rio, 2001; Kohn-Wood & Hooper, 2014; Leong & Kalibatseva, 2011; Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005; Miranda, Nakamura, & Bernal, 2003). Guided by these recommendations, in

this study, we explore intracultural variation to better understand depression and perceptions of access to mental health care among Latinos. Latino immigrants as a whole have a lower prevalence of depression and other mental illnesses compared with their non-Latino White counterparts (Alegria et al., 2008). However, data suggest that rates of depression vary among Latino subgroups, revealing the importance for reporting these subgroups, who differ in culture, historical context, and health needs (Gonzalez, Tarraf, Whitfield, & Vega, 2010). For example, National Institute of Mental Health Collaborative Psychiatric Epidemiology Surveys (CPES) data suggest differences in the estimated lifetime prevalence of major depression among Mexican (14.5%), Cuban (17.4%), and Puerto Rican (22.2%) populations (Gonzalez et al., 2010). While these rates vary 1

University of South Florida, Tampa, Florida, USA

Corresponding Author: Dinorah Martinez Tyson, College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd, MDC56, Tampa, FL 33612-3805, USA Email: [email protected]

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Qualitative Health Research

slightly in the literature, epidemiologic studies consistently report Puerto Ricans as having the highest prevalence of depression among Latino subgroups (Alegria et al., 2008; Alegria et al., 2007; Gonzalez et al., 2010; Wassertheil-Smoller et al., 2014). Additional data show that although U.S.-born individuals are more likely to experience major depression than foreign-born individuals, island-born Cuban and Puerto Ricans are an exception to this pattern (Gonzalez et al., 2010). Similarly, findings suggest that while foreign-born Latinos have an overall lower lifetime prevalence of major depression, foreign-born Latinos above the age of 65 have higher prevalence than their U.S.-born counterparts (Gonzalez et al., 2010). In other words, as Latino immigrants age in the United States, they are at greater risk of developing depression than non-Latino Whites. It is also important to note that, while immigrant Latinos might experience lower rates of depression than nonLatino White Americans, they are also less likely to seek professional mental health services when depressed (Aguilera & López, 2008; Cabassa & Zayas, 2007; Karasz, 2005; U.S. Department of Health and Human Services, 2001; Vega, Canino, Cao, & Alegria, 2009; Vega et al., 2007; Vega & Lopez, 2001). This underutilization of mental health services by minorities has been long recognized (Leong & Kalibatseva, 2011). A recent epidemiological study on the distribution of health care utilization by Latino subgroups based on country of origin shows noteworthy disparities between mental health care utilization, and depression-related morbidity between Mexicans, Cubans, Puerto Ricans, and other Latino subgroups (Gonzalez et al., 2010). Studies also report variation in anti-depressive medication use among Latino subgroups. For example, while 8.3% of Puerto Ricans and 7.2% of Cubans use anti-depressive medication, only 3.3% of Mexicans and 2.3% of South Americans use anti-depressive medication (Wassertheil-Smoller et al., 2014). Psychotherapy is utilized more frequently than pharmatherapy for Mexicans, Cubans, and Puerto Ricans compared with non-Latino Whites (Gonzalez et al., 2010). Shame, fear of stigmatization, and beliefs that mental illness exposes weakness of character are commonly cited as barriers to seeking professional help for mental illness among Latino populations (Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007; Leong, Wagner, & Tata, 1995; Vega, Rodriguez, & Ang, 2010). Social stigma associated with having emotional problems or seeking mental health services (Interian et al., 2010; Rojas-Vilches, Negy, & Reig Ferrer, 2011; Vega et al., 2010), or shame for needing to seek help (Gonzalez et al., 2010; Vega et al., 2010) might also influence the experience of depression and thus can moderate the effectiveness of depression prevention and treatment interventions (Pérez & Muñoz, 2008). Therefore, given the large

number of Latino immigrants in the United States, the relevancy of immigration status (nativity) to service provision needs, and the importance of understanding perceptions of mental disorders like depression, a focus on Latino immigrants by country of origin is both timely and important (Alegria, Canino, Stinson, & Grant, 2006; Gonzalez et al., 2010; O’Mahony & Donnelly, 2007; Rios-Ellis et al., 2005).

Latinos in West Central Florida The population of Latino immigrants in West Central Florida is heterogeneous with regard to socioeconomic status, nationality, and immigration experience. Between the years 2000 and 2010, there was a 57% increase in the number of Latino immigrants living in the area (U.S. Census Bureau, 2010). The four largest Latino subgroups in the study area are Puerto Ricans (31%), Cubans (23%), Mexicans (19%), and Colombians (5%; U.S. Census Bureau, 2014). Puerto Ricans, comprising the largest group, are U.S. citizens, which enables them to travel between Puerto Rico and the mainland United States with ease, providing the opportunity to maintain social ties and familial relationships on the island. This status also facilitates Puerto Ricans’ eligibility for services (e.g., health insurance). However, the other subpopulations lack these same opportunities, and each faces a unique set of challenges. The Mexican population in West Central Florida, for example, is much younger both in terms of historical immigration waves and median age than the other subpopulations. In addition, most live in rural parts of the county, work in agricultural and related industries, and encounter barriers accessing services because of their immigration status. Owing to increased border security and immigration regulations, many encounter isolation and long-term separation from family in Mexico. Similarly, the Cuban population does not have easy access to their homeland, as U.S. travel restrictions and the U.S. embargo prevent travel. This might affect enduring social ties with family and friends who were left behind. Yet the Cuban population in this area has strong historical roots dating back to the late 1880s when Cuban immigrants first came to the area to work in cigar manufacturing. In recent years, the area has seen an influx of Colombian immigrants, many of whom are seeking political asylum. Most retain strong social ties and communicate frequently with family and friends in their homeland. However, although many have higher education and were professionals in Colombia, it is often difficult for them to find work in their profession, and they are often relegated to work in the service industry (Martinez Tyson, Castaneda, Porter, Quiroz, & Carrion, 2011). Given the diverse Latino population in Hillsborough County, this area provided an ideal location for the


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Martinez Tyson et al. further exploration of Latino immigrants’ perceptions of depression and perceptions of the factors that influence access to mental health care services. This project was guided by the social-ecologic framework (Coreil, 2009) and the underpinnings of the anthropological cognitive theory of culture (D’Andrade, 1995; Strauss & Quinn, 1997), which proposes that a culture is shared between participants of the same group and that sets of guidelines or models for a particular domain (in this case, depression) are shared between the members of that culture (Romney, Weller, & Batchelder, 1986; Weller, Baer, Garcia de Alba Garcia, & Salcedo Rocha, 2008). Thus, in this article, we attempt to fill a gap in the current literature and explore intracultural variation by comparing perceptions of factors that influence access to mental health care services in the United States and depression among foreign-born Mexican, foreign-born Cuban, island-born Puerto Rican, and foreign-born Colombian immigrants.

Florida area were used to aid in the recruitment of participants.

Data Collection

We conducted 120 ethnographic interviews with foreignborn Mexican, foreign-born Cuban, island-born Puerto Rican, and foreign-born Colombian Latinos residing in West Central Florida. Ethnographic interviews consisted of both (a) structured (e.g., free lists) and (b) semistructured (e.g., open-ended items) qualitative data collection techniques (Bernard, 2011). Institutional Review Board approval was obtained from the University of South Florida. This article focuses specifically on results obtained from the semistructured portion of the interviews. Results from the structured portion of this study are reported elsewhere (see Martinez Tyson et al., 2011).

Face-to-face ethnographic interviews took an average of 45 minutes to complete. Interviews were conducted by one of the members of the three-person research team. The research team included two research assistants and Martinez Tyson, all bilingual native Spanish speakers. All interviews were digitally recorded after obtaining participant consent. A semistructured interview guide with open-ended questions was used to elicit Latino immigrants’ cultural beliefs and perceptions of the factors that influence access to mental health care in the United States. All participants were asked the same questions, which provides a structure for counting thematic code applications across the four groups in the analysis (Guest, MacQueen, & Namey, 2012), which enabled the comparison across the groups. Questions were guided by (a) the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev; DSM-IV-TR; American Psychiatric Association [APA], 2000) Outline for Cultural Formulation (CF; Lewis-Fernandez, 1996; LewisFernández & Díaz, 2002), (b) questions from Kleinman’s explanatory models (Bhui & Bhugra, 2002; Kleinman, Eisenberg, & Good, 1978), and (c) a vignette adapted from Cabassa, Lester, and Zayas (2007). The interview guide was pilot tested with an individual from each Latino subgroup. Minor modifications were made to improve the flow and wording of the questions. Participants received a US$10 cash incentive after completion of the interview.

Sample and Recruitment

Data Analysis

The community-based sample population for this study consisted of foreign-born Cuban, Mexican, Colombian, and island-born Puerto Rican men and women. Purposive, snowball and quota sampling techniques (Bernard, 2011) were used to recruit 120 Latino immigrants, which included 30 men and women from each of the selected Latino subgroups. Based on previous difficulties in recruiting Latino men and noted difficulties in the literature (Ojeda, Flores, Rosales Meza, & Morales, 2011), quota sampling was used to ensure that at least one third (10/30) of the participants from each country of origin were men. Inclusionary criteria for the community sample included Latinos who (a) self-identify as foreign-born Mexican, Cuban, Colombian, or island-born Puerto Rican; (b) were 18 years of age and older; (c) had moved to the United States after the age of 16; and (d) were Spanish-speaking. Established relationships with community organizations that serve Latinos in West Central

Qualitative data were transcribed verbatim. The transcripts were coded by two bilingual native Spanishspeaking members of the research team using ATLAS.ti 6.2, a qualitative data software program. Using thematic analysis (Guest et al., 2012), codes were based on a priori interview themes as well as themes that emerged from the data. The principal investigator, Martinez Tyson, trained the two coders. The preliminary set of codes was developed after reading over several transcripts. Using the preliminary codebook, the two coders independently coded 6 interview transcripts. After the initial 6 transcripts were coded, the research team met, discussed discrepancies until consensus was reached, and revised the codebook accordingly. Then, they coded the remaining 114 interview transcripts independently. The team met weekly to debrief and discuss any inconsistencies during the coding process. Ten interview transcripts were randomly selected and coded by both coders to assess intercoder reliability

Method


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(Bernard & Ryan, 2010). The average consistency rate of coding between the two coders in this study was above kappa .78. After the 120 transcripts had been coded, descriptive summaries and data display matrices were developed and discussed by the members of the research team. Then, codes were grouped into broader thematic categories. Participant quotes were then selected to illustrate emergent themes. We also report relative thematic frequencies based on the number of individual participants who mentioned a particular theme, thematic categories from the same interview transcript were only counted once (Guest et al., 2012). This allowed us to compare themes across the four groups (Namey, Guest, Thairu, & Johnson, 2007). In this article, we report the themes that were mentioned by at least five participants in one of the four Latino ethnic groups and those related to the aims of the present study.

Results

Vignette For the last 2 weeks, Laura/Juan has been feeling down. She/He wakes up in the morning with a flat, heavy feeling that sticks with her/him all day long. She/He isn’t enjoying things the way she/he normally would. In fact, nothing seems to give her/him pleasure. Even when good things happen, they don’t seem to make Laura/Juan happy. She/He pushes on through her/his days, but it is really hard. The smallest tasks are difficult to accomplish. She/He finds it hard to concentrate on anything. She/He feels out of energy and out of steam. She/He is feeling pain in her/ his stomach and muscles. And even though Laura/ Juan feels tired, when night comes she/he can’t get to sleep. Laura/Juan feels pretty worthless, and very discouraged. Laura’s/Juan’s family has noticed that she/he hasn’t been herself/himself for about the last month and that she/he has pulled away from them. Laura/Juan does not feel like talking.

Study Sample Demographics Thirty participants from each Latino subgroup— Colombia (CL), Cuban (CB), Mexico (MX), and Puerto Rico (PR)—were interviewed. A high proportion of participants were married (CL 57%, CB 54%, MX 70%, and PR 53%). Many more Puerto Ricans (60%) described themselves as having “very good” English proficiency than participants from the other subgroups (CL 3%, CB 10%, MX 3%). The majority of the Colombian (63%), Puerto Rican (60%), and some Cuban (47%) participants had attended at least some college compared with only 3% of Mexican participants. Mexicans were the youngest of the subgroups with a median age of 36 years. Length of time in the United States varied across subgroups, with Puerto Ricans having lived in the country the longest. Compared with the other subgroups, a much higher percentage of Puerto Ricans (73%) had health insurance. Participants were asked if they had ever been diagnosed with depression, and responses varied across the subgroups with Puerto Ricans (33%) and Cubans (30%) having higher percentages than Colombians (13%) and Mexicans (10%). Compared with other subgroups, a much higher percentage of Puerto Ricans reported a family member being diagnosed with depression. For details of the sample description, see Table 1.

Perceptions of Depression Participants were presented with a vignette adapted from Cabassa et al. (2007) depicting an individual with major depression. The participants were then asked to describe what was happening to the individual, named either Laura or Juan, with the character matching the participant’s sex.

An overwhelming majority of participants across the four groups said that the person in the vignette was depressed as illustrated in Table 2 and in the following dialogue between a Colombian man and the interviewer: Man (M): Juan has a problem, an internal problem. Call it health, call it economic, call it a romantic relationship, but something that leads a person to not eat, to not sleep. It is exactly that; having anxiety is precisely—the worry that he has about something, yes. But besides that, when they speak about his family, he doesn’t speak with his family. He doesn’t want to speak with his family. It is more than anything to not involve the family in the problem that he has out of fear also of not causing them—not making the family suffer. And so usually the person that has depression closes up. Yes. He is not one of the people that let’s go. Now, there are people that want to have a friend to tell their problems too. At that moment is when they need someone, a psychologist, because a friend cannot advise him as a psychologist or psychiatrist is going to advise him. For that he needs to go to a professional, a run of the mill person is going to tell him “man, look, do this, do that.” All of a sudden it results in him committing suicide. Yes, so he has a problem. Interviewer: So what would your say is wrong with Juan? M: Juan is depressed, completely.

Depression was described as a result of situations and problems of everyday life that the person thinks they cannot get out of and/or did not have the resources to do so. Along these lines, a large number of Colombians and some of the Puerto Ricans specifically said that the person in the vignette was stressed because of economic


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Martinez Tyson et al. Table 1. Demographic Characteristics of Participants.

Characteristics

Colombian (%)

Cuban (%)

Mexican (%)

Puerto Rican (%)

n = 30

n = 30

n = 30

n = 30

67 33

67 33

67 33

3 54 30 13

13 70 17 0

20 53 23 4

10 53 37

3 47 50

60 30 10

13 3 33 47 4

30 30 37 3 0

10 7 23 60 0

57 (23–86)

36 (18–62)

52 (26–77)

43 33 7 17

27 37 30 6

20 23 20 37

57 43

70 30

67 33

57

10

73

30

10

33

37

13

67

Gender Women 67 Men 33 Marital status Single 30 Married 57 Divorced 13 Widow 0 English proficiency Very good 3 More or less 73 Not at all 24 Education level Elementary or less 7 Some high school 17 High school 13 Some college or more 63 Vocational/Technical 0 Age M 54 Range (24–77) Time living in the United States 5 years of less 17 6 to 15 years 60 16 to 25 years 10 26 or more years 13 With whom immigrated to the United States Family or friends 43 Alone 57 Health insurance Yes 23 Ever diagnosed with depression Yes 13 Family member ever diagnosed with depression Yes 40

problems and/or loss of their job. For example, one Puerto Rican man describes, [Juan] is going through a difficult time in his life, maybe economic. He is stressed. He doesn’t get up and he doesn’t know how he is going to provide for his family. Sometimes we drown ourselves in the problem instead of looking for a solution. We shouldn’t do that [eso no]. I think he should share his problem so that he can get the help he needs because if he keeps it to himself it will get worse. . . . [He needs] maybe a job, but besides that emotional help, the support of his family and friends.

A smaller number of Mexicans and Cubans said the person was suffering from a physical illness such as diabetes or cancer. For example, one participant explained,

First, I think that it may be a health problem, because [Laura] is in pain . . . she is having pains [physical pain]. Yes, it may be a health problem that she has and she can go to the doctor and get treated because it may be a serious health problem. (Mexican woman)

Participants were then asked what type of help they felt the person in the vignette needed. Many participants across the four groups mentioned the person in the vignette needed to see a counselor or psychologist and needed to share or be able to talk to someone about what was going on. Representative of participants’ comments, a Colombian woman explained, I think that first [Laura] needs to open up. She needs to share what is going on with her. I also believe that the first option


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Qualitative Health Research is to share what is going on . . . If after that she sees that things continue as they are, in other words that things continue on the same path, then just talking is not needed. It is necessary to look for help with a person that can help her deal with things, a psychologist.

Participants across the four groups mentioned that depression could be overcome by working through problems and having the self-motivation to “get out of it,” as illustrated by this quote: [Depression] requires . . . you do your part. You have to do your part to get out of it, motivate yourself, because instead of improving you will get worse, and all the people who surround you should be positive, so that you can get out of it. That’s what I understand. (Cuban woman)

Participants also discussed how the person in the vignette needed to take his or her mind off of things/distraerse and to talk/desahogarse with his or her friends/family. Although participants discussed the need to talk to friends or family, they also recognized and acknowledged the person might not want to talk or open up to their family because they do not want to burden them. Compared with Mexican and Puerto Rican participants, a higher number of Cuban and Colombian participants mentioned that they needed to go to a doctor (primary care). With the exception of Puerto Ricans, very few participants mentioned that the person in the vignette needed medication. For example, one Puerto Rican participant indicated, “I think that [Laura] should first go to a doctor to see if there is some chemical or hormonal imbalance. If she is physically ok, then she will need therapy or some type of treatment, like medications” (Puerto Rican woman). Participants were asked if they thought depression could be prevented (see Table 2). In all, 15 Mexican, 13 Colombian, 11 Cuban, and 11 Puerto Rican participants felt that it could not be prevented. Many participants felt that the inability to prevent depression was because it depended on the person’s circumstances (situational) or life context. As delineated by a Colombian woman, I don’t think [it can be prevented]. No one can prevent it. Depression happens because of problems. At least right now as things are, people get depressed because they don’t have a job. People look for work and there are no jobs, so people get depressed. The bills and everything piling up.

Perceptions of Factors that Influence Access to Mental Health Care in the United States Study participants were also asked about their perceptions of the factors that influence access to mental health care in the United States. Thematic results are presented

by levels of influence of the socio-ecological model (see Table 3). Societal-level factors include cost and inability to pay, lack of health insurance, language, and immigration status. Community-level factors include negative reactions from the community (e.g., indifference), community perceptions of those seeking mental health care (e.g., seeing them as crazy), and providing support and linkages to services. Interpersonal-level factors include negative reaction from family and friends (e.g., lack of support), support from friends and family (e.g., understanding), and family/friends helping find mental health services. Intrapersonal-level factors include not knowing where to go, fear, lack of acceptance, and stigma/shame. Societal-level factors. Mexicans and Colombians tended to discuss barriers to mental health treatment related to economic challenges more than Cubans and Puerto Ricans, although a large number of participants from all subgroups mentioned such economic barriers. As stated by a Mexican woman, “Many people don’t use those programs for mental help, maybe because they feel that are not going to have money to pay for psychological treatment.” Puerto Ricans and Cubans also mentioned economic barriers to mental health treatment; however, a larger number of participants from these subgroups specifically identified lack of insurance as a barrier to mental health treatment. Another common barrier identified by members of all Latino subgroups was the inability to communicate with mental health providers in their native language. There was an emphasis on the need for mental health services to be available to Spanish speakers. As a Puerto Rican woman stated, “Lots of people don’t speak English and how are you going to express yourself and say what is bothering your [te aqueja] if they don’t understand you?” Immigration status was identified as another problem to accessing mental health care in the United States by all subgroups, although it was most frequently mentioned by Mexicans. Immigration status was seen as a barrier particularly for those who were undocumented and did not access services for fear of deportation. As stated by one participant, “At least immigrant people, people without their documents, that makes them afraid, afraid of [getting help]” (Colombian woman). Lack of transportation was also discussed as a barrier to accessing mental health care in the United States. Compared with the other groups, Puerto Ricans most often mentioned lack of transportation to mental health care facility as a barrier to accessing care in the United States. For instance, when discussing transportation as a barrier, a Cuban woman explained, “Not being able to move on your own . . . [here] whoever does not have a car or transportation goes through a lot, in that case, I am like that, sometimes without mobility things cannot be resolved.”


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Martinez Tyson et al. Table 2. Perceptions of Depression. Theme Frequency

CL (n = 30)

CB (n = 30)

MX (n = 30)

PR (n = 30)

22 14 —

27 — 5

24 — 6

28 5 1

11 9 9 7 5 —

12 10 11 10 9 2

9 1 6 4 3 1

13 5 5 5 2 6

17 23

11 17

15 21

11 24

What is happening to Laura/Juan? Person is depressed Person is stressed because of economic problems/loss of job Person is suffering from an illness like diabetes or cancer What type of help does someone with depression need? See a counselor or a psychologist Go to the doctor (primary care) To talk with their friend/family/desahogarse To have self-motivation and work through problems To take their mind of things, stay active/distraerse To take medication Can depression be prevented? Depression cannot be prevented Depression will not go away on its own Note. CL = Colombia; MX = Mexico; PR = Puerto Rico; CB = Cuban.

Table 3. Perceptions of Factors That Influence Access to Mental Health Care. Theme Frequency Societal factors Immigration status (undocumented) Lack of health insurance Language (lack of services in Spanish) Economic (cannot pay) Lack of transportation Community factors Community acts negatively/ignores Community sees them as crazy Community does not help Community organizations provide support Community members guide/provide links to services Interpersonal factors Negative reaction from friends/family Support (help and understanding) from friends/family Family/friends look for professional help Intrapersonal level Lack of information/Do not know where to go Fear Person does not accept or think they need help Stigma/shame

CL (n = 30)

CB (n = 30)

MX (n = 30)

PR (n = 30)

3 6 7 18 1

1 10 4 3 2

9 5 7 24 3

5 17 15 11 6

2 7 9 12 5

6 6 7 11 7

8 8 6 — 1

12 11 10 7 6

6 11 6

6 11 4

2 18 7

6 21 6

7 3 15 9

9 3 18 1

5 7 12 9

12 15 17 15

Note. CL = Colombia; MX = Mexico; PR = Puerto Rico; CB = Cuban.

Community factors. Participants were asked to discuss how their community in the United States reacts to someone who seeks mental health care and how that might affect access to mental health care. Participants provided both negative and positive reactions. Compared with participants from the other groups, a higher number of Puerto

Rican participants shared that in general their community does little to help, acts negatively toward the individual (e.g., ignores or makes fun of), and/or sees them as crazy. The community’s negative reactions were expressed across the four groups as illustrated by the following quote from a Cuban woman:


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Qualitative Health Research In my Latino community there is a lack of understanding. So they make fun of them [people seeking mental health care]. Then the person isolates themselves, so they get worse because people will react that way. It is not easy to look for help.

With the exception of Mexican participants, participants from the other three groups also discussed the support provided by community organizations such as Hispanic social clubs, mutual aid societies, and Hispanicoriented non-profit organizations that are willing to help provide assistance that includes linking them to services and helping them navigate the health care system in the United States. As illustrated by the following quote from a Colombian woman, There are a lot of people that don’t have medical insurance, and money is very important because they are not going to be able to look for a private psychologist. So we come to these centers that give us the necessary help. . . . We are able to get them to help us by offering more economic options, to be able to get someone that helps us.

Interpersonal factors. Participants discussed how support from family and friends was vital and would help motivate a person to get care as illustrated by the following quote: When a person is very depressed and is so isolated that they don’t have any desire to do anything. . . . they need to have a relative to be there helping them, imposing themselves and saying, “come on,” and takes the person [to get care], and takes them out of that hole. (Cuban woman)

Participants also mentioned that friends and family can help find professional help, especially for those who were recent immigrants, were less familiar with the system, and/or did not speak English. Some participants discussed how negative reactions (e.g., indifference) from family/friends might deter someone from getting care; a few also mentioned that family/friends would have difficulty helping because of life stress (e.g., working two jobs) and the demands of living in the United States. Intrapersonal factors. A majority of study participants across the four groups discussed that one of the biggest issues that keeps someone from accessing mental health care is that the person does not accept, recognize, or think he or she needed help. As explained by a Cuban man, “Not recognizing the symptoms of the disease, not accepting it, that is the case when it is more dangerous, but that is when it is more difficult.” Fear and stigma/ shame associated with accessing care were also discussed by participants from all subgroups. However, this theme

emerged much more frequently in discussions with Puerto Ricans. As delineated by this participant, I feel that they are afraid of the stigma, and so when they look at the balance of the consequences of the stigma and the possibilities of getting better, sometimes they think that it is not worth being stigmatized even though they feel that they are going to be better. They prefer, like me, to get out of it on their own before going to a clinic and being monitored. So, if you look for help you are admitting you are weak. (Puerto Rican man)

Being unaware of where to go for mental health services and lack of information about services emerged as another issue. For example, one Puerto Rican man mentioned, “Here in the United States there are [services], but I believe that the Hispanic [individual] is not wellinformed, sometimes because of the language.” Although lack of information was also mentioned by Mexican and Colombian participants, fewer Mexicans and Colombians mentioned lack of information as a factor that would negatively affect access to mental health care.

Discussion To better understand depression etiology among Latino immigrants and properly address the specific mental health needs of Latino populations living in the United States, a closer look at the differing perceptions of depression and preferences for treatment by country of origin should be considered (Alegria et al., 2008). Qualitative research on understandings of depression as well as perceived barriers to accessing mental-health-related services and utilizing treatments can provide insight into the disparities found in epidemiological studies (Ennis, RiosVargas, & Albert, 2011; Gonzalez et al., 2010). Below, we discuss the overall findings followed by a discussion of similarities and differences across the groups.

Perceptions of Depression When presented with a vignette adapted from Cabassa et al. (2007), participants clearly recognized depression and were familiar with its signs and symptoms. Although less than a quarter of study participants had ever been diagnosed with depression and less than half had a family member who had been diagnosed with depression, the vast majority of participants across all four groups identified that the person in the vignette was depressed. This suggests that study participants were familiar with the signs and symptoms of depression even if they, themselves, had not experienced depression. Such findings are similar to those reported by Martinez Pincay and Guarnaccia (2007) who found that Latinos across all


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Martinez Tyson et al. groups and ethnicities widely recognized depression as a mental health problem and recognized the affective, behavioral, and interpersonal aspects of depression. Findings might also allude to the success of recent public health campaigns focused on depression (Caplan et al., 2010). In recent years, there have also been a dramatic increase in the number of pharmaceutical advertisements for depression medications; enhanced awareness of depression might also be a direct result from these advertisement efforts (Alegria et al., 2007; Caplan et al., 2010). When discussing perceptions of depression, our findings support much of the reported literature through which depression is discussed in the context of daily life and the stressors associated with economic hardships, acculturative stress, job loss, and social distress (Cabassa et al., 2007; Caplan et al., 2013; Lackey, 2008; Martinez Pincay & Guarnaccia, 2007; Vega et al., 2007). As depression is often viewed as situational and problem-based, the lines between depression and stress can be blurred. This might be most widely apparent among Latino immigrants, whose perceptions of depression might reflect their life circumstance (Cabassa et al., 2007; Caplan et al., 2013). There was an interesting dichotomy that emerged when discussing the vignette. Many participants shared that desahogarse, the concept of getting things off your chest/venting or unburdening oneself, was the ideal course of action for the person in the vignette. However, participants also noted that doing so might place further stress and burden on one’s family. This suggests the duality of helping oneself and the fear of burdening others with one’s problems. Findings reveal the need to consider refocusing depression programs, which often focus on the individual and one-on-one counseling, to include family, as such services might be beneficial to both the patient and their family in better understanding the condition and balancing the need to desahogarse with the fear of burdening others. While several participants reported that depression could not be prevented because of the situational and problem-based nature of depression, generally participants reported a perception of controllability over depression. Perception that the person with depression needed to take an active role in working through it emerged. This finding is contradictory to previous literature that reports on Latino’s “fatalistic” views or beliefs that reflect God’s will or destiny (Anez, Paris, Bedregal, Davidson, & Grilo, 2005; Chavez, Hubbell, Mishra, & Valdez, 1997). In fact, the need to overcome emerged and was repeatedly echoed in participants’ responses. One had to do his or her part to overcome. These findings do not conform to the concept of fatalism (Caplan et al., 2013) and caution against making inferences based on broad cultural generalizations. Along this same vein, while the literature reports the

importance of religion and prayer among Latinos, interestingly, very few (only 8 participants from the 120 who were interviewed) mentioned prayer or the church as a way of coping with depression. This finding might be indicative of a study sample comprising immigrants, who by the very nature of immigrating are affirming their belief in their own self-efficacy (Caplan et al., 2010). Perceptions of depression: Differences by subgroup. While participants shared similar perceptions of depression, subtle, nuanced differences by Latino immigrant subgroup did emerge. For example, more Cubans placed emphasis on self-motivation and working through one’s own problems. This might be reflective of the overall Cuban immigration experience, many of whom have been here longer and have established roots in the United States. Also, having refugee status supports the incorporation of Cuban immigrants into American society through English language classes, vocational and professional training, and other services afforded to refugees, which place emphasis on self-sufficiency and social integration (Florida Department of Children and Families, 2014; Horton, 2004). In addition, a higher percentage of Cubans immigrated to the United States alone compared with Mexicans and Puerto Ricans in our sample, indicating that their immigration experience might have required more self-reliance. It is important to note that Cuban participants tended to be older in age, in comparison with other, younger Latino immigrant subgroups, and the cultural value of self-reliance in solving mental health problems is strong among the Latino elderly (Starrett, Rogers, & Decker, 1992). Perhaps the greatest area of difference between subgroups emerged in discussing the need for medical care and depression medication. Cuban and Colombian participants were most likely to report that the individual needed to see a doctor. A higher number of Puerto Rican participants mentioned the use of medications to treat depression compared with the other ethnic groups. A possible explanation is that a large percentage of Puerto Ricans had higher English proficiency (very good, 60%), lived in the United States for a longer period of time (16 plus years, 57%), had ever been diagnosed with depression (33%) or had a family member who had been diagnosed with depression (67%), and had health insurance (73%). These factors might have exposed Puerto Ricans to a more biomedical understanding of the treatment of depression and possibly resulted in greater familiarity with the U.S. health care system and depression medication. However, overall, very few participants mentioned the need for prescribed medications for the person in the vignette, supporting the prevalent ideology that Latino immigrants might be less likely to view depression as a biomedical problem or chemical imbalance requiring


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medical treatment (Jacob, Bhugra, Lloyd, & Mann, 1998; Karasz & Watkins, 2006; Vega et al., 2007) and confirming studies that report Latinos’ preferences for counseling and psychotherapy more than medication (Cabassa, 2007; Cabassa et al., 2007; Fernandez y Garcia, Franks, Jerant, Bell, & Kravitz, 2011; Lackey, 2008).

Factors That Influence Access to Mental Health Care An important aim of this study was to assess perceptions relating to accessing mental health services. While our study population appeared to have greater awareness of depression than others reported in the literature (Cabassa et al., 2007), stigma remains one of the most important barriers to accessing care (Interian et al., 2010; RojasVilches et al., 2011; Vega et al., 2009). In general, Latinos in this study recognized the role of stigma as a barrier to accessing mental health. However, it is important to note that a much higher number of Puerto Ricans mentioned it. In addition, research shows that Latinos might believe that they do not need professional mental health services because strong social support such as family and religious leaders can help ameliorate emotional distress (Rojas-Vilches et al., 2011). Although social support has been found to successfully reduce the symptoms of depression and need for professional treatments (Briones et al., 1990; Ibarra-Rovillard & Kuiper, 2011; Leong et al., 1995), this does not dismiss the need to consider barriers to accessing professional care among minorities. Our findings also illustrate the important role family and friends play in encouraging access to mental health care. And, while stated less often, participants also discussed how negative reactions from family would discourage someone from accessing mental health care. Accessing services: Differences by subgroup. Important differences in subgroups were noted with regard to perceptions of access to mental health care. These variations might stem from differences in life and immigration experiences. For example, compared with participants from the other subgroups in the study, a higher number of Puerto Rican participants identified negative factors that affect mental health care access in the United States. One reason for this might be that 70% of the Puerto Ricans in our sample had been in the United States for 16 or more years and thus might have encountered and/or are more familiar with the issues accessing mental health care in the United States. Mexicans and Colombians more frequently discussed economic barriers such as not being able to pay for mental health, while Puerto Rican and Cuban participants tended to emphasize lack of insurance. These subtle but notable differences might be a

reflection of differences in poverty status or legal/immigration status. For example, Mexican participants were the most likely to mention immigration status as a barrier. This perception is likely effected by the higher rates of undocumented immigrants in this population when compared with other subgroups. Interestingly, while Puerto Rican participants were U.S. citizens and had a greater familiarity with the system, they were the second most likely subgroup to discuss immigration status as a barrier to care. This suggests that they might have an increased awareness about the difficulties in accessing mental health services as a result of legal status. While the need for services available in Spanish is especially important for monolingual Spanish speakers seeking mental health care, studies have also found that many Latinos, regardless of their English proficiency, still prefer to discuss health matters and receive healthrelated information in their native language (Centers for Disease Control and Prevention, 2012; Escarce & Kapur, 2006), which is likely why half of the Puerto Ricans, who were also the most fluent in English, also listed language as a barrier. In addition, because of their unique status and familiarity with the United States, Puerto Ricans might also have expectations that the health services in the Unites States be provided in Spanish. Thus, they might be able to identify with the plight of those who do not speak English and are aware of the many barriers facing nonEnglish-speaking individuals in accessing care. Compared with Mexican participants, a higher number of Colombian, Cuban, and Puerto Rican participants mentioned community organizations providing support and/or linkages to mental health programs and/or services. This might be in part because of a higher concentration of community-based services and Hispanic organizations in the metro and suburban area of the county where these groups are concentrated. There are several Colombian and Cuban cultural and social clubs in the area that serve to keep traditions alive and provide trusted social networks for recent immigrants who also enable members to establish strong social ties and support here in the United States. Previous research also points to high levels of social capital and civic engagement among Colombian and Cuban immigrants (Balcazar, Garcia-Iriarte, & Suarez-Balcazar, 2009; DeSipio, 2002; Escobar, 2004; Liang, 1994). In contrast, it is important to note that Mexicans did not mention community organizations providing support. This might be in part because of their location, as the majority of the Mexican population in this area resides in rural parts of the county where less organization exists, and might also point to a general feeling of marginalization among this community. Interestingly, nearly twice as many Puerto Ricans as Colombians or Cubans discussed that support from family members and friends was vital. This could be related


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Martinez Tyson et al. to the fact that Puerto Ricans have family and friends in the mainland United States because of the ebb and flow between the United States and Puerto Rico, while Cubans and Colombians might not have immediate family here. These groups might instead rely more heavily on the previously mentioned social organizations and clubs as social support/networks, which are important sources of social support and social capital locally.

Limitations This study has several limitations. First, we used a nonrandom, purposive sample that limits the generalizability of results to Latino immigrants outside of West Central Florida or to U.S.-born Latinos. The second limitation of this study is that it does not account for other social and demographic factors such as gender, education, and income that might affect perceptions of depression and access to care. In addition, other than data on health insurance status, which is an incomplete indicator on access (affordability) of mental health care, this study did not collect objective data on participants’ actual access to mental health care. These will be addressed in a future study.

Implications for Practice Findings regarding perceptions of depression allude to the importance of treatments such as problem-solving therapy (Cabassa et al. 2007; Nezu, Nezu, & D’Zurilla, 2012), which provides participants with the skills needed to cope with life’s stressors. Given the life situations of participants in this study and the perceived barriers to mental health care that emerged, such treatments might be well received by and beneficial to Latino immigrants. Findings also suggest that Latino immigrants view depression as a result of hardships and social distress. Therefore, interventions that build up social relationships, potentially filling a void in social capital and social support networks for Latino immigrants, might also be beneficial (Martinez Pincay & Guarnaccia, 2007). Research has repeatedly shown that perceptions of mental illness vary culturally, and one of the greatest barriers to seeking professional help is stigmatization (Interian et al., 2010; Rojas-Vilches et al., 2011; Vega et al., 2009). While our findings suggest the need to focus public health efforts on addressing issues related to stigma/negative perceptions of seeking care for depression (Interian et al., 2010; Rojas-Vilches et al., 2011; Vega et al., 2009), especially among Puerto Ricans in our community, they also suggest that we need to consider societal-level factors, such as affordability of mental health care, especially for Mexicans who identified inability to pay as a factor for accessing care. We need to take into consideration the heterogeneity of Latino immigrants’ perceptions and experiences when developing

campaigns and advertising access to mental health care. For a Puerto Rican urban/suburban community, more emphasis might be placed on addressing intrapersonallevel issues (e.g., stigma), and for a Mexican rural community more emphasis might be placed on affordability. Efforts at the interpersonal and/or community level, such as partnering with Hispanic organizations and social/cultural groups, might be a better way to promote/provide access to mental health care for Colombians and Cubans, as immediate family might not be in the United States. In summary, while there does appear to be a shared model of depression among Latino immigrants (Martinez Tyson et al., 2011), there seems to be differences within the Latino subgroups in their perceptions of the factors that influence access to mental health care that are in part informed by their immigration experiences. Understanding the variances and nuances in the Latino immigrant cultural construction of depression and immigration experience will enable practitioners to better serve Latino immigrant communities (Cabassa & Zayas, 2007; Caplan et al., 2013; Guarnaccia, Martinez, & Acosta, 2005). Latino immigrant’s views of depression might differ from clinician’s biomedical views of depression. Thus, when working with Latino immigrants, clinicians should ask patients about their understanding of the causes, perceived controllability of the illness and consequences, immigration experience, stressors, and support systems, and use this information to develop a care plan that is congruent with their perceptions of depression and life context (Cabassa et al., 2007; Caplan et al., 2013). In addition, public health policy aimed at increasing the prevention and utilization of depression services must consider how each subgroup’s needs can be addressed and how culturally competent care can be provided (Alegria et al., 2006; Rojas-Vilches et al., 2011) to look beyond the one size fits all. Acknowledgments We are grateful to the participants who took part in the study and to the community leaders who facilitated recruitment and provided feedback. We thank Larry Schonfeld and Junius Gonzales for their support. We also thank Marisol Quiroz and Milagro Porter for their assistance with the data collection and analysis, and Coralia Vázquez-Otero for her editorial suggestions.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by an internal grant from the College of Behavioral and Community Sciences at the University of South Florida.


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Author Biographies Dinorah Martinez Tyson, PhD, MPH, is an assistant professor in the Department of Community and Family Health in the College of Public Health at the University of South Florida in Tampa, Florida, the United States. Nora B. Arriola, MA, MPH, CPH, is a research assistant in the Department of Community and Family Health in the College of Public Health at the University of South Florida in Tampa, Florida, the United States. Jaime Corvin, PhD, MSPH, CPH, is an assistant professor in the Department of Global Health and is joint faculty in the Department Community and Family Health in the College of Public Health at the University of South Florida in Tampa, Florida, the United States.


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Prediction of Response in Melanoma Therapy by Systemic Inflammatory Response - One Size Fits Not All.

Looking Beyond Income and Education: Socioeconomic Status Gradients Among Future High-Cost Users of Health Care.

Re: Accreditation of Graduate Medical Education Programmes: One size fits all-or does it?

Pre- to postimmigration alcohol use trajectories among recent Latino immigrants.

One size fits all? Direct evidence for the heterogeneity of genetic drift throughout the genome.

One size (never) fits all: segment differences observed following a school-based alcohol social marketing program.