Does Stigma Keep Poor Young Immigrant and U.S.-Born Black and Latina Women From Seeking Mental Health Care?

Using a large, ethnically diverse sample of low-income immigrant and U.S.-born women from racial and ethnic minority groups, we found that stigma may indeed play an important role in understanding mental health service use by these women. Ethnic differences in stigma were most pronounced among women with depression, with black women, particularly immigrant black women, reporting the most stigma concerns. Among women with depression, compared with U.S.-born white women, immigrant African woman had over three times higher odds and immigrant Caribbean women had over six times higher odds of reporting stigma concerns. Ethnic differences were also evident among women without depression, suggesting broader community-based differences in stigma-related concerns between immigrant black and Latina women and U.S.-born white, Latina, and black women. In the group without depression, compared with U.S.-born white women, the odds of reporting stigma concerns were 26% higher among immigrant Latinas, 39% higher among immigrant African women, and 45% higher among immigrant Caribbean women.

Settings providing care for immigrant women should be alert to the substantial concerns that these women might have about entering mental health care. Client education about mental health treatment, efforts to ensure privacy, and effective stigma-reducing educational campaigns might be helpful for immigrant populations. Further research is needed to explore what accounts for the higher levels of stigma-related concerns in these groups. These differences may reflect general attitudinal differences between the United States and the immigrant women's countries of origin in regard to mental health. For example, evidence from the United Kingdom suggests that black Caribbean women believe that it is inappropriate to discuss personal matters outside the home and that disclosure of mental health problems is considered a sign of moral weakness ( 40 ).

Interestingly, among women who are depressed and in need of care, stigma is related to being in treatment for white Americans but not for women from ethnic minority groups. Even among whites, however, the relationship did not reach significance and thus was not robust after considerations of multiple comparisons. Nonetheless, the pattern is suggestive that other barriers to care likely inhibit utilization among low-income women from ethnic minority groups to such an extent that stigma does not have an impact on the already extremely low rates. Our models controlled for insurance and perceived logistical barriers to care. However, other practical barriers may account for the low treatment rates among women from ethnic minority groups and may have prevented detection of more subtle stigma-related effects. In the event that practical barriers to care were no longer impeding persons from ethnic minority groups from getting care, stigma would be more likely to play a role. This interpretation is consistent with research showing greater mental health service use disparities among blacks and whites who were privately insured than among blacks and whites who were uninsured ( 41 ).

On the other hand, stigma is more clearly linked to desire for care, an important part of the treatment-seeking process. Among the subsample with depression, stigma concerns were associated with lower rates of wanting care. This association was most pronounced among immigrant women from ethnic minority groups. These patterns could be attributed to the fact that women with depression are faced with the reality of making decisions about whether to seek care, with immigrants having the greatest concerns about stigma. Efforts to eliminate stigma associated with mental health care are likely to result in more women wanting care. It is also possible that characteristics of depression itself may lead women to have more negative views about others and the helpfulness of treatment.

There are also a number of noteworthy racial and ethnic differences in regard to wanting care. Among the subsample with depression, we found that compared with U.S.-born white women, immigrant black women, U.S.-born black women, and U.S.-born Latinas were all less likely to want care. For black women, in particular, this may be because they do not trust the mental health system to treat them fairly ( 26, 42, 43 ). Interestingly, immigrant Latinas were more likely than U.S.-born white women to want mental health care. This is in sharp contrast to commonly held assumptions that more "traditional" Latinas are reluctant to seek care, and it is intriguing in light of our finding that immigrant Latinas were among those most likely to report stigma concerns. One possible hypothesis is that they may have felt that our interviewers, who interviewed them in county health settings, were offering them something that they should agree to want. Our clinical experience in providing depression care to this population is that immigrant Latinas may feel that they are being respectful by accepting an offer for help from an interviewer, but they may later experience stigma or other barriers to care and not actually attend the offered treatment.

U.S.-born white women were far more likely to be in treatment than the women from ethnic minority groups. This is not surprising given the extensive literature showing ethnic disparities in mental health care ( 2 ). Because women from ethnic minority groups are much more likely to be poor than white women, minority status is often confounded with income inequalities. In this study, most all of the women were poor, and the women from ethnic minority groups were still underserved.

There are limitations to the study presented here. First, the study was correlational, limiting conclusions about the direction of observed effects. Second, the study relied on self-report. Women were asked to think about whether they thought that any of the barriers or concerns would get in the way of their seeking mental health care, which may not reveal all of the subtlety in the treatment-seeking process. Similarly, the study measured perceived stigma in interacting with others and not self-stigma or other aspects of stigma that may have a unique impact on treatment seeking. Third, our study did not specify relations between variables based on countries of origin. Clearly, not all Latino cultures, or all African or Caribbean cultures, are the same. However, research conducted with various Latino cultural groups, for example, reveals similarities in key values, such as reliance on family ( 44 ), that influence help-seeking processes. Additionally, our study used immigrant status as the primary method to distinguish between those who had greater or less exposure to mainstream U.S. culture and services systems. However, acculturation and immigration are multifaceted processes, and additional considerations, such as language barriers and acculturative stress, should be considered in future research. Nonetheless, the study presented here is the first of its kind to include a sample as rich in ethnic diversity and to explore differences among immigrant and nonimmigrant women of Latina, African, and Caribbean backgrounds.

Overall, our results indicate that stigma is meaningful in understanding treatment-seeking processes among immigrant and U.S.-born black and Latina women and U.S.-born white women, despite the fact that it was endorsed with lower frequency than logistical barriers to care. Immigrant women were most likely to report stigma-related concerns about care, and depressed immigrant women with stigma concerns were least likely to state that they wanted care. Stigma appears to dampen women's desire to get needed mental health care.

This research was funded by grants MH-R01-070260 and MH-56864 from the National Institute of Mental Health. Writing of this article was funded through three centers. The Center for Health Improvement of Minority Elderly of the Resource Centers for Minority Aging Research is funded by grant 3P0-3AG-021684 from the National Institute on Aging of the National Institutes of Health. Drew Project EXPORT of the University of California, Los Angeles, is funded by grant 1P20-MD-00148-01 from the National Center for Minority Health and Health Disparities of the National Institutes of Health. The UCLA-RAND Center for Research on Quality in Managed Care is funded by grant MH-068639-01 from the National Institute of Mental Health and by funding from the John D. and Catherine T. MacArthur Foundation.

The authors report no competing interests.

Dr. Nadeem, Ms. Lange, and Dr. Miranda are affiliated with the Health Services Research Center and the Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 10920 Wilshire Blvd., Suite 300, Los Angeles, CA 90024 (e-mail: [email protected]). Dr. Edge is with the Faculty of Medical and Human Sciences, University of Manchester, United Kingdom. Dr. Fongwa is with the School of Nursing, and Dr. Belin is with the Department of Biostatistics, School of Public Health, University of California, Los Angeles.