Dissertation Nigeria Africa's most depressed country

Chapter 1

Introduction

Nigeria is Africa’s most depressed country with 31.6% of the population, or seven million people, having reported depressive symptoms in 2015, compared to that of 4.48 million people from Ethiopia and 2.87 million people from the Dominican Republic (World Health Organization, 2017). Perceptions of depression demonstrate stark differences between Nigerian males and females. Nigerian men tend to believe that depression does not exist, whereas the women perceive depression as an experience of a spiritual attack, or the result of sociomoral concerns over gender roles (Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). 

Many Nigerian immigrants to the United States (U.S.) experience acculturation issues, including socio-cultural adaptation, issues with parent-child interactions, and limited community support for child-rearing, often leading to depressive symptoms (Onwujuba, Marks, & Nesteruk, 2015). Depression is amongst the most serious mental health condition experienced by immigrants, with approximately 40,000 Nigerians immigrating to the United States between

2016 and 2017 (United States Census Bureau, 2018). majority of Nigerian immigrants in the U.S. typically reside in the states of New York, Texas, and California; with 4.5 million Nigerian immigrants residing in New York, 4.8 million residing in Texas, and 10.6 million residing in California (United States Census Bureau, 2018). 

Some Nigerian women living in the United States continue to perceive depression in the same ways as when they were living in their country of birth, as experiences of craziness, madness, or curse and possession of evil spirit (Ezeobele, Malecha, Landrum, & Symes, 2010). Many Nigerian women living in the U.S. do not seek mental health help for depression. Derr (2015) reported that African immigrants tended to access mental health treatment at lower rates than non-immigrants. 

This dissertation will follow a tradition five-chapter format; Chapter 1 will introduce the topic and highlight the problem statement, the purpose of the study, and the research questions. Additionally, Chapter 1 will also provide a brief overview of the methodology, will discuss the significance of the study and highlight definition of terms. Chapter 2 will include a robust review of the literature, discussing research that focuses on both the historical and recent aspects of depression on Nigerian immigrants for both males and females. Chapter 3 will provide an overview of the methodology, highlighting the population in which will be studied, the data collection and study procedures, data analysis plan, and ethical assurances. Chapter 4 will discuss the results of the data analysis and Chapter 5 will conclude the study with a strong discussion on the findings in relation to the literature, study recommendations, recommendations for future research, and any limitations that were experienced.

Background of the Problem

As mental health continues to expand, and is becoming more accessible to the general population, many Nigerian women living in the United States are not utilizing the mental health services (Ezeobele, et. al., 2010; Derr, 2015). Despite Nigeria being the most depressed country in Africa with 31.6% of the population experiencing depressive symptoms, and Nigerian immigrants the fastest growing population immigrating to the United States, very few studies focus on married Nigerian women living in the United States (Pew Research Center, 2015; World Health Organization, 2017). Nigerian women living in United States experience higher rates of depressive symptoms through the experience of acculturation issues that include sociocultural adaptation, parent-child interactions, and limited community support for child-rearing (Onwujuba, Marks, & Nesteruk, 2015).

Ezeobele, Ekwemalor, and Ogunbor (2019) study on 18 Nigerian men living in Texas, that Nigerian men deny that depression existed within the Nigerian culture. The authors posited that Nigerian males living in the United States perceived depression differently from those of the dominant culture, and as well as their female compatriots, who viewed depression as an experience of a spiritual attack, or the result of sociomoral concerns over gender roles (Ezeobele, et. al., 2019; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017). Nigerian immigrants experience higher rates of depression than their dominant culture counterparts (Onwujuba, Marks, & Nesteruk, 2015). 

Less than 17% of the population of Nigerian who have been diagnosed with depression are treated (Adewuya, Adewumi, Ola, Abosede, Oyeneyin, Fasawe, & Idris, 2017). Primary health care workers within the country agreed that the low treatment levels have to do with the country’s perceptions and experiences of depression, and the Nigerian health care industry system. Adewuya et. al., (2017) found that only 56.2% of health workers correctly diagnosed depression, in part due to 77% being assumed as spiritual illness by nature. The authors discovered that 42% of health workers in Nigeria have poor outlook and attitude toward depressed patients (Adewuya et. al., 2017). 

Understanding how Nigerians treat depression in Nigeria, should serve to delineate how

Nigerian immigrants in the U.S. view and seek treatment for depression (Onwujuba, Marks, & Nesteruk, 2015; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Adewuya et al, 2017). The barriers to treatment experienced in Nigeria will also allow a broader understanding as to how married Nigerian women experience depression while residing in the United States. Many Nigerian mothers’ experience post-partum depression (Danasabe & Elias, 2016; Tungchama, Piwuna, Armiya'u, Maigari…& Uwakwe, 2017). Approximately 45% of Nigerian mothers’ experience post-partum depression, with many refusing treatments (Odinka et el, 2018). Problem Statement

Married Nigerian women living in the U.S. are experiencing depression at a high rate due to acculturation issues such as socio-cultural adaptation, parent-child interactions, and limited community support for child-rearing (Onwujuba, Marks, & Nesteruk, 2015). Derr (2015) found that African immigrants access mental health treatment at lower rates than non-immigrants, as Nigerian women perceive depression as instances of craziness, madness, a curse and evil spirit possession, or the result of socio-moral concerns over gender roles (Ezeobele, Malecha,

Landrum, & Symes, 2010; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele,

Ekwemalor, & Ogunbor, 2019). Nigerians experience high prevalence rate of depression, with

31.6% of the population, or seven million people, having reported depressive symptoms in 2015 (World Health Organization, 2017); and, Nigerian women immigrating to the United States are prone to depressive symptoms (Onwujuba, Marks, & Nesteruk, 2015).

The problem is that married Nigerian women living in Los Angeles, California suffering from depression are not seeking mental health treatment (Onwujuba, Marks, & Nesteruk, 2015; Derr, 2015; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). The qualitative descriptive study will describe the experiences and perceptions of 15 married Nigerian women living in the Los Angeles area. The study seeks to understand the barriers that prevent depressed married Nigerian women from accessing mental health treatment.

Purpose of the Assignment

The purpose of this qualitative descriptive study is to describe the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment. The study will interview 15 Nigerian women in the Los Angeles, California on the experiences and perceptions with accessing mental heath treatment.

The study will seek to understand the barriers the participant faced to seeking mental health care. 

The participants in this study will include middle-aged, married Nigerian women who are currently residing in Los Angeles and are currently experiencing depression. Participants will be recruited via a convenience sampling method, a non-probability form of selecting participants, where the researcher will gather participants that is close to her locale (Etikan, Musa & Alkassim, 2016). The researcher intends to interview between approximately 15 participants; however, the final sample size will depend on data saturation. Data saturation occurs when the researcher gleans no new information that would be helpful in answering the research questions and will hence complete the data collection process (Fusch & Ness, 2015).

Population and Sample

Fiftteen participants will be selected using a convenience sampling method from Aniocha Women Association and other Nigerian women organizations in Los Angeles, whom are married and are between the ages of 30 - 60 years. A convenience sampling method is employed where the researcher will select participants based upon the closeness of her geographical locale

(Etikan, Musa & Alkassim, 2016), as in this study. The researcher resides in the city of Los

Angeles, California, and the participants in this study will be required to reside in the city of Los Angeles. Convenience sampling is a non-probability form of gathering participants (Etikan, Musa & Alkassim, 2016). The following criteria will be used to determine the eligibility of interested individuals:

1. Each participant must be female.
2. Each participant must be married.
3. Each participant must have been born in Nigeria and having immigrated to the United States.
4. Each participant must be a member of one of the following: Anioma Association Los Angeles, and Closed Married friends from the age of 30 - 60 years.
5. Married Nigerian women who are depressed
6. Immigrated from Nigeria to United States
7. Have experienced depression

Meeting the above named criteria are vital to effective collection of quality data. 

An Institutional Review Board (IRB) approval will be sort and obtained from the University of Phoenix IRB office (see Appendix A) and other applicable permissions letters from participant organizations (see Appendice section), a permission to recruit letter will be obtained from the Nigerian association in Los Angeles. A flyer (see Appendix C) will contain information about the study, for example, the problem being studied, the purpose, and the criteria needed to be considered will be disseminated. The informed concent letter will be given to the potential participants who respond to the flyers. The concent form will outline the details of the study and participant confidentiality. Once each participant has agreed to participate in the study by signing and returning the completed consent and confidentiality forms, she will then set up a time where she can complete a private interview. 

The private interview will take place at a location that is conducive to confidentiality and convenient to both the researcher and the participant. Before beginning each of the semistructured interviews, the researcher will ask each participant whether they agree to participate in the study. Once they agree to participate, she will then ask each participate the same 10 openended questions. Utilizing semi-structured interviews as the data collection tool, the researcher will be able to minimally guide each participant when describing their experiences of the phenomenon being explored (McIntosh & Morse, 2015).

Significance of the Assignment

Between 2000 and 2013 the immigration of African to the U.S. increased by 41%, and this population is experiencing the fastest growth rate from other major immigration groups (Pew Research Center, 2015). The current study investigates the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment is significant as it allows for a better understanding to barriers of mental health treatment, particularly that of depression, in which this population experiences a high prevalence rate (World Health Organization, 2017). The findings of this study may be significant to allow for a better understanding of how married Nigerian women, residing in Los Angeles, experiences depression and will provide an insight as to any barriers that they may face when seeking mental health treatment. Some Nigerians immigrants to the United States experience acculturation issues including socio-cultural adaptation, parent-child interactions, and limited community support for child-rearing, all leading to increased rates of depressive symptoms (Onwujuba, Marks, & Nesteruk, 2015). The results of the current study may provide effective ways to deal with these issues. 

Because this study aims to highlight how married Nigerian women perceive depression, as research indicated that Nigerian women tend to perceive depression as an experience of a spiritual attack, the result of sociomoral concerns over gender roles, and instances of craziness and madness or a curse and evil spirit possession (Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). The results of this research study may signal a paradigm shift from the aforementioned beliefs. The findings may allow mental health professionals to better understand married Nigerian women and their perceived barriers to treatment, and offer treatments that are in alignment with cultural. 

Importance of the Assignment to the Field of Psychology

The purpose of this qualitative descriptive study is to describe the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment. Because the Nigerian culture perceive depression and its effects differently than Western cultures, there may be barriers that married Nigerian women experience when attempting to access mental health treatment while living in Los Angeles. This study is important to the field of psychology because it may allow for the identification of treatment barriers, and the ways in which treatment providers can offer services the patients, while being mindful of culture differences. Derr (2017) postulated that African immigrants access mental health treatment at lower rates than their mainstream counterparts. Nigerian men have the tendencies to deny that depression exists within the culture, while women associate that experiences of depression are likened to that of a spiritual attack, or the result of sociomoral concerns over gender roles (Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). Because there is a dearth of research that focuses on how treatment providers in the United States take the cultural differences into consideration when offering treatment regimens to married Nigerian women, the results of the study change the perceptions about any identified barriers to treatment.

Nature of the Assignment

The nature of this study will utilize a qualitative methodology that follows a descriptive study design. The goal of a qualitative descriptive study is to obtain a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). The purpose of this qualitative descriptive study is to investigate the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment. Participants will be recruited from Facebook, Anioma Association Los Angeles, and Nigerian Women Nurses Association where they will then be able to describe their experiences of depression and barriers to treatment when residing in the Los Angeles area (Lewis, 2015). A quantitative methodology is not selected for this study as the goal of quantitative studies is to focus on a statistical analysis using numbers through survey instrumentation. Quantitative methodology is not selected because the goal of this proposed study is to describe the experiences of married Nigerian women living in Los Angeles that experience depression and the barriers they face when seeking treatment, which cannot be completed through a statistical analysis (McCusker & Gunaydin, 2015). Utilizing a qualitative methodology will allow the participants to convey their thoughts using words and non-verbal cues in order to answer the open-ended questions during their semi-structured interviews (Creswell & Creswell, 2017).

Research Method Appropriateness

A qualitative descriptive research method was appropriate for this study as it allows for a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). Other qualitative research methods were considered, such as that as Ethnography and grounded theory but ultimately rejected. Ethnographic studies are observational by nature, thereby, making this research design difficult as the goal of this study is to describe the experiences of married Nigerian women with depression and any barriers that they experience when accessing mental health treatment (Hammersley, 2018). Additionally, grounded theory was excluded as a research method for this study, as grounded theories generate new theories that are grounded by the data (Glaser & Strauss, 2017).

Research Questions 

Qualitative research questions narrow the focus of the study and present inquiries in a question format. The inquiries are open-ended and provide responses to the researcher’s queries within the research process. Creswell and Creswell (2017) suggested the researcher should consider proposing three to seven questions to allow participants to exchange information. The division of the qualitative research questions includes three different categories: The central question, the sub-questions, and the procedural questions. Creswell and Creswell recommended the researcher use leading terms such as “what” and “how” to begin the research question. The study includes two questions which narrows the purpose of the research project, as well as outline the phenomenon under study. Nigerian women living in Los Angeles from accessing mental health treatment. The following questions will guide this qualitative research study:

RQ1: How do married Nigerian women residing in Los Angeles describe their experiences and perceptions of depression?

RQ2: What barriers do married Nigerian women residing in Los Angeles face when experiencing depression?

Theoretical Framework

Three theoretical frameworks will guide this study, because the study will be constructed and analyzed through a social determinants of health lens (Castañeda, Holmes, Madrigal, Young, Beyeler, & Quesada). The three frameworks include the Health Belief Model from a behavioral perspective, Culture Theory from a cultural perspective, and structural functionalism from a structural perspective. Combined, the three frameworks will allow the researcher to understand behavioral, cultural, and structural issues of married Nigerian women who are experiencing depression. Castañeda et al (2015) found that for immigrants behavioral choices are limited, thereby impacting other life areas, including social positioning, race, ethnicity, gender, and socioeconomic status. This in turn can limit choices of all kinds of healthy treatment, including that of mental health.

Health Belief Model is used to predict individual changes in health behaviors. It aims to identify key factors that influence any health-related behaviors including an individual’s perceived susceptibility to illness, perceived severity to illness, perceived barriers to action, and confidence in the ability to succeed (Skinner, Tiro, & Champion, 2015). This model would be beneficial as the participants in this study are asked to describe their experiences of depression and any barrier that they experience when seeking treatment.

The second theoretical model that will be utilized in this study is Culture Theory. Culture

Theory purposes to conceptualize and understand the dynamics of culture (Storey, 2018). Culture Theory understands that an individuals’ culture includes distinctive ideas, beliefs, values, and knowledge, which are fundamental in this study. Nigerian immigrants perceived depression and mental health conditions from cultural beliefs (Serrat, 2017). 

The third theoretical model that will be utilized in this study is structural functionalism. Structural functionalism is a framework that allows the researcher to view society as a complex system, working together to promote solidarity and stability (Kingsbury & Scanzoni, 2009).

From a structural functionalism standpoint, this construct’s may help highlight how Nigerian immigrants experience a limited access to health care than their native-born counterparts. Structural functionalism can also take into account one’s immigration status and other social, economic, and political factors (Garner, 2019).

Definition of Terms

It is important for each concept, variable, or phenomena to be defined when completing a research study, in order to facilitate readers with a clear meaning. The following terms will be used throughout this research study:

Acculturation. Acculturation is defined as assimilation to a different culture. According to Commodore-Mensah, Ukonu, Cooper, Agyemang, and Himmelfarb (2018), stress based upon acculturation issues can be detrimental to one’s health in many different aspects. This is due to having to experience a new dominant culture within the country with which one moves to. 

Barriers. Barriers are defined as obstacles that an individual can experience when accessing or attending mental health treatment. Barriers can also be known as interpersonal (perceptions), which can limit whether an individual can seek treatment (Clement, Schauman, Graham, Maggioni…. & Thornicroft, 2015).

Depression. The World Health Organization (2017) defined depression as “depression is a mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things” (P.34).

Scope

The scope of a study refers to the parameters under which the study will be conducted (Simon & Goes, 2013). When discussing the scope, it is important to highlight the data collection methods, the sample size, and the method for analyzing the data. Limitations and delimitations will also be discussed, with limitations being defined as items outside the area of control of the researcher, and delimitations are defined as items within the researcher’s control, but they are items that she does not choose to control (Whittemore, Chase, & Mandle, 2001). The scope of this study is inclusive to the experiences of married Nigerian women who have depression and are residing in Los Angeles. Participants of this study will include married Nigerian women who currently live in Los Angeles, California and will contribute their experiences of depression by describing any barriers that they experience when accessing mental health treatment. The sample will include approximately 15 depressed, married Nigerian women, where data analysis will occur through the participants open-ended semi-structured interviews.

Assumptions

The assumption in this qualitative research study is that the participants are a strong representative of married, Nigerian women living in Los Angeles and experiencing depression. Assumptions in research are defined as assertations that are not verifiable, but nonetheless, they are assertations toward the research (Creswell & Poth, 2017). The current research study assumptions are concerned with the reliability of the data and the participants themselves. The first assumption includes that of the participants and that they have the knowledge, experience, and insight when answering the semi-structured interview questions. In this instance, it is assumed that the participants will also be honest, candid, and forthright regarding their experiences of depression and any barriers that they have experienced. A second assumption allows for the discovery of experiences of the participants, which in turn can promote reliable data being collected.

Limitations 

Limitations are discussed in qualitative research, with the concerns for areas of weakness found throughout the study. The first limitation of this study is the geographical location of this study. Because this study is focusing on married, Nigerian women who are currently residing in Los Angeles, California, the results of this study cannot be generalized to outside of this geographical location. Additionally, because this study is focusing on experiences of depression, the results of this study cannot be generalized to other mental health conditions. 

The second limitation can include the researcher herself. Because qualitative studies experience higher rates of bias, the researcher may influence the results of the study. For example, this can occur in the manner in which she conducts the semi-structured interviews, and also includes any perceptions or personal experiences that she may have had, while living in Los Angeles and being close to the community in which she is conducting the study. 

In order to limit instances of researcher bias, the researcher will construct an interview protocol, where she will layout the manner in which she will conduct the data collection and consequence analysis. When constructing the interview protocol, the researcher will provide a copy of the problem statement, the purpose of the study, the research questions, the interview questions, the data analysis plan, and the methodology to three individuals who have similar educational and professional experiences as herself and request feedback to ensure that the study is in alignment (Turner, 2010). After receiving feedback from these three individuals, the researcher will then make any changes necessary in conjunction with consulting with her university’s Chair.

Delimitations

The objective of this study is to describe the experiences of married Nigerian women with depression who live in Los Angeles, California and to identify any barriers that they experience when accessing mental health treatment. This study is delimited to the geographical area of Los Angeles, California and will only apply to married Nigerian women who are experiencing depression and have immigrated from Nigeria to the U.S. Only participants who meet these eligibility requirements will be able to participate in this study.

Chapter Summary

The purpose of this qualitative descriptive study is to investigate the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment. The problem is that married Nigerian women living in Los Angeles, California suffering from depression are not seeking mental health treatment

(Onwujuba, Marks, & Nesteruk, 2015; Derr, 2015; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). The next chapter is the literature review that will provide a robust review of the literature, discussing research that focuses on both the historical and recent aspects of depression on Nigerian immigrants for both males and females.

Chapter 2 

Literature Review

This chapter will provide an overview of the literature that addresses the topic under study. The review will highlight the search strategy that was utilized to collect both geminal and recent articles on the Nigerian immigrants in the U.S., in addition to the discussion of the theoretical framework that guides this study. Additionally, this review will also include discussions of the treatment of depression and any associated barriers that are found within the United States and will then provide an overview of depression within the Nigerian culture and any barriers that have been identified within the culture with regard to treatment engagement. Chapter 2 will end with a conclusion on the current discussion of the literature reviewed and the chapter summary. 

Title Searches and Documentation

The title searches for the literature review included peer-reviewed articles and studies that focused on the treatment of depression in the United States, treatment barriers experienced by individuals who seek treatment within the United States, and an overview of the perceptions of depression as a mental health illness within the Nigerian culture. The articles and studies sort focused on depression and barriers that have been identified within the Nigerian culture in regard to treatment engagement. A review of the literature was conducted in order to obtain a broader understanding of all relevant topics related to barriers of treatment engagement for depression within both the United States and Nigerian cultures. Additional references, such as published reports and online sources, were searched. Search terms used included the following; depression treatment, depression in the United States, depression in Nigeria, perceptions of depression in Nigeria, perceptions of depression in the United States, barriers to mental health treatment, barriers to depression treatment, barriers to depression treatment in Nigeria, barriers to depression treatment AND Nigerians, African immigration to the United States

 Historical Context - Nigerian Women & Depression

African immigration to the U.S. has increased by 41% between 2000 and 2013, with this population experiencing the fastest growth rate from other major immigration groups (Pew Research Center, 2015). The countries that experience the largest immigrant population within the United States include Nigeria, Egypt, Ethiopia, Ghana, South Africa, Somalia, and Kenya.

Because the state of California is considered home to 10.6 million immigrant Nigerians (United

States Census Bureau, 2018), this study of why married Nigerian women living in Los Angeles,

California suffering from depression are not seeking mental health treatment (Onwujuba, Marks,

& Nesteruk, 2015; Derr, 2015; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019) is centered here.

According to the United States Census Bureau (2010) the main cities within the United

States that African immigrants moved to included that of Washington D.C. (171,000),

Minneapolis-St. Paul, Minnesota (70,100), Atlanta, Georgia (70,100), and Boston, Massachusetts (61,600). Additionally, 55% of African immigrants are male, whereas the remaining 45% are female. Typically, when moving to the United States, African immigrants tend to move toward busy city centers; however, over time, move to a more suburban environment (Capps, McCabe, & Fix, 2012).

Depression is one of the most widely experienced psychological conditions that affect the global population and there are high chances of it going undiagnosed. It is a major cause of concern as it causes dysfunction of the general populous and it leads them to pursue a wide variety of treatment methods. As stated in the above sections, Nigeria experiences the highest margins of persons affected by depression in the African continent. Even though depression is recognized as a major cause for concern to the Nigerian population, the Nigerian cultural and social views on depression are very condescending. Both men and women have very different perspectives on depression within the Nigerian culture. While men are in denial of the prospect of depression as a medical condition, the women of the community believe that depression is manifested as a spiritual possession of their minds. The cultural background of this ethnic group is one of the forces that carved out such varying views among the community (Aderinto, David & Alabi 2018). Many studies conducted on this subject have confirmed this root cause. Depression needs to be considered as harmful and derogatory to the health of a person irrespective of the community’s cultural, religious or socioeconomic backgrounds (Abdullahi, & Suleiman 2015).

The lack of belief among the Nigerian women in attaining medical help to cure depression is the main reason for the number of suicides sky-rocketing in the nation. Nigeria ranks among the global top 30 in terms of the number of suicides being committed each year. A major chunk of this demising population can be traced to psychological issues and delicate mental health conditions. Depression is a leading cause of these suicide nationwide. It needs to be addressed with adequate care. Nigerian women are strongly held in their beliefs regarding depression and its implications. Nigerian women tend to believe that the streaks of spiritual possessions are attributed to angered ancestors and spirits. These kinds of beliefs are difficult to change and it may take a long period of time to tame such beliefs. Since the community is so stuck up on their beliefs and refuses to consider alternative perspectives, they are fostering a community of individuals who are driven by a cultural stigma. Such stigmas are difficult to break and many fall victim to such negative thought processes. It may even lead to extremely severe situations where the individual is pushed towards taking one’s own life. The near and dear ones of such victims will be heavily demoralized. Women of the Nigerian community are often faced with so many difficulties with having to deal with a lot of stress in their lives. Adding on to the existing psychological imbalance, the cultural views of the community infuses more weight on the mental health of the patient. In a study conducted by Adejoke et al. (2018), it was found that one of the causes of depression among Nigerian women is violence inflicted by their intimate partners. Their study concluded that intimate partner violence can directly affect the possibility of the individual being diagnosed with postpartum depression. Such circumstances act as psychosocial stressors and prove to be deadly when combined with depression. Both depression and intimate partner violence occurring simultaneously in an individual’s life can lead to increased chances of suicides and homicides. Nigerian women are exposed to many resources that would educate them on the reality of depression and its existence. The socioeconomic and family settings of these women play major roles in dictating the way the Nigerian women perceive depression. When the society that they live in itself is caught in a staunch stigma, it is a difficult task to educate the women and change their perspectives on depression. The medical condition needs to be explained to the women of the Nigerian community with clarity and they should be encouraged to avail professional help to mitigate it. The mood moderation differences between the men and the women of the community stiffly affect the chances of the individual being depressed. Women are found to have more intense variations in their mood and it is very common among college students as found in a study conducted by Okwaraji, Onyebueke, Nduanya, and Nwokpoku (2016). The unique religious beliefs that exist in Nigeria encourages Nigerian women to seek help from religious prayer meetings and traditional medicines as found by a study conducted by Nwankwo (2018). 

Nigeria is the most depressed country in Africa with 31.6% of the population experiencing depressive symptoms, Additionally, depression is amongst the most serious mental health condition experienced by immigrants (United States Census Bureau, 2018). Many Nigerians immigrating to the United States experience depression due to acculturation issues, including, socio-cultural adaptation, issues of parent-child interactions, and limited community support for child-rearing, all leading to increased rates of depressive symptoms (Onwujuba, Marks, & Nesteruk, 2015). Nigerian genders viewed depression differently. The males tend to deny that depression exists within the Nigerian culture, whereas women tend to perceive depression as an experience of a spiritual attack, or the result of sociomoral concerns over gender roles

(Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019). Many studies have shown that Nigerian culture influence how Nigerians respond to depression (Okwaraji, Aguwa, & Shiweobi-Eze, 2016; Adeponle, Groleau, Kola, Kirmayer,

Gureje, 2017; Afolabi, Bunce, Lusher, & Banbury, 2017). Because the study of depression on Nigerian patients are conducted amongst many different genres, for examples adolescents, females, and pregnant mothers, reviewing current researches studies in full may help to understand how the Nigerian cultural experiences responds to depression. Adeponle et al (2017) revealed that perinatal depression is common, yet oftentimes untreated in Nigeria, as culture shapes both the social determinants of depression and how it is experienced. The authors study on 14 Nigerian women diagnosed with perinatal depression found that the participants perceived depression to be tied to sociocultural concerns over gender roles and the women’s’ position within the household. 

An example over gender roles and the position within the household included that the participants felt that they experienced a conflict between being assertive in order to address interpersonal problems, yet from a cultural standpoint needed to be seen as non-aggressive (Adeponle et al., 2017). Oyewunmi, Oyewunmi, Iyiola, and Ojo (2015) found that the Nigerian cultures attribute mental health issues to angered ancestors and possessions by the spirits. The authors revealed that mental illness, particularly depression is aggravated by a culture of indifference, denial, and evasion. 

Okwaraji, Onyebueke, Nduanya, and Nwokpoku (2016) study at the University of Nigeria on gender differences, loneliness, self-esteem, and depression amongst university students concluded that there was a significant association between gender and depression. The study found the mood disorders to be more common in females than that of their male counterparts. Okwaraji et al (2016) maintained that the levels of loneliness, self-esteem, and depression amongst university students are high and they encouraged the government to identify the students so that regular psychological services can aid in mitigating these experiences. Alloh, Tait, and Taylor (2018) studied depression on Nigerian students living abroad and the experiences they encountered when studying in the United Kingdom. , Alloh et al., found that the experiences of studying overseas and outside of their culture caused transitional changes and financial concerns that contributed to depression. The authors stated that culture shock added to the symptoms of depression. In general the authors reported that Nigerians studying overseas tend to experience social exclusion and a rapid change in environment, leading to lifestyle changes, insufficient medical control, and genetic factors. 

Nwankwo (2018) studied the theoretical causes and effects of mental illness within the Nigerian society. While there are many preconceived notions regarding depression and its causes within Nigerian contex, the Nwankwo found that the typical treatments depressive Nigerians employ when experiencing mental illnesses, including depression, were psychotherapy, family therapy, medication, life adjustments, and traditional and faith-based treatment options. Several factors are considered when Nigerians are selecting a form of treatment, and according to Nwankwo, such factors include the belief that mental illness is caused by a demonic attack, voodoo and possession of the evil spirit. The author concluded that orthodox treatments were not often sort, as many individuals would rather obtain assistance from an approach that utilizes traditional medicine. 

Prayer houses are another form of treatment approach within the Nigerian culture, as when individuals believe that their depressions or mentals illness are caused by a demonic attack, the patients and their family will opt for this form of treatment (Nwankwo, 2018). Uwakwe (2007) cross-sectional descriptive study on the views of Nigerians when it came to the treatment of mental disorders, resulted in approximately 29% of participants stating that they believed that evil spirits caused mental disorders, 88% of participants posited that they would recommend a prayer house as a treatment option for mental health issues. Uwakwe revealed that even some medical doctors within Nigerian society believed that evil spirits caused mental illnesses, based on religious beliefs, while disregardng the scientific knowledge.

A study conducted by Sulyman et al. (2016) targeting the Nigerian women of the Northeastern region of Nigeria, discovered that the postnatal depression was the most common type of depression in women who are undergoing pregnancy. They also found that in such situations the women will be more prone to being overwhelmed by the stress and it often led to interferences in the way the new mothers provided care to their babies. Postpartum depression or postnatal depression is found in women who underwent childbirth. A lot of observations can be made in women who are experiencing postnatal depression, such as sleep problems, degraded appetite feeling of sadness, easy fatigability, loss of interest, and the inability to cope with daily activities. WOmen in their postnatal stages who are experiencing postpartum depression tend to treat their babies with less heed and in extreme cases, they may even pose a threat to their babies. These dangerous situations have to be avoided by the women and it is very crucial for the women to seek professional help. As found by Adewuya et al.(2006) in a study conducted among college students in Western Nigeria, it was found that one of the leading causes of depression among college students was because they were from the female gender. They conducted a Mini-International Neuropsychiatric Interview (MINI), collecting responses from a survey sample population of n=1206. Hence, it is evident that Nigerian women are more prone to depression than men. It should be adequately addressed by the community as well as a national-level recognition of this issue is required to protect the mental health of the Nigerian women who are suffering from depression.

Nigerian Immigration to the United States. 

Approximately 40,000 Nigerians immigrated to the United States between 2016 and 2017 (United States Census Bureau, 2018). Within the United States, the majority of Nigerian immigrants typically reside in the states of New York, Texas, and California; with 4.5 million Nigerian immigrants residing in New York, 4.8 million residing in Texas, and 10.6 million residing in California (United States Census Bureau, 2018). Reynolds (2006) stated that some Nigerian professional women have decided to move to the United States in order to fulfil and meet the cultural expectations, of raising a family. 

Nigeria is an African country with the largest population counts and is also ranked very high on the global indexes of having the highest number of individuals facing depression. The passage of Nigerians to the U.S. began in the 17th century, where the colonialists were enslaving Nigerians and shipping them to the U.S. During those twothree centuries a large number of Nigerians were enslaved and shipped. There is incomplete or inconsistent data available regarding the number of slaves that were shipped away from their homes. In the modern-day, the immigration of Nigerians to the U.S. is attributed to the political instability of the nation and the growing number of

Nigerians who were seeking quality higher education. In the aftermath of the Biafra War in 1960-1970, the Nigerian government starts funding scholarship programs for students of the Nigerian ethnicity to go abroad and attain higher education (Fafunwa 2018). Nigeria experienced a decline in the intellectual resources owing to the number of educated persons migrating to the U.S. and other countries abroad. After the instating of the multi-party democracy in Nigeria, the state head, Olusegun Obasanjo sought after recalling the Nigerians who migrated out of the country in appeal to help in the rebuilding of the nation. Education is a leading factor that drives individuals of Nigerian descent to migrate to the U.S. In 2016 it was discovered by a report called Open Doors, that the Universities in the U.S. with the highest number of Nigerian student population were University of North Texas, Texas Southern University, the University of Texas at Arlington, University of Houston, and Houston Community College. 11,710 individuals of the Nigerian descent availed education in the U.S. in the years 2016-2017 as found by a report. The American Community Survey report tells us that the states with the highest number of Nigerian born American residents were living in Texas (60,173), Maryland (31,263), New York (29,619), California (23,302), and Georgia (19,182). In recent years, the Trump administration has sought to cut down on the number of B1/B2 visas lent out to the nationals of Nigeria. Such regulations are being proposed as a result of immigrants from Nigeria practicing overstaying in the country after their short visa periods are completed. It was also reported that 25% of the visas issued to Africans were awarded to Nigerians. As a result of these new regulations and the clampdown on privileges, there has been observed a rise in the number of visa denials to Nigerian immigrants. A major issue in the eyes of the Nigerian administration is that they are losing the educated citizens to the Western countries, especially the U.S. This phenomenon can be explained as a result owing to the better education standards as well as living standards in the U.S when compared to their home nation, Nigeria (Fafunwa 2018). The accommodation of Nigerian immigrants in the U.S. has been extensively studied by many researchers. In a study conducted by Ndika (2013), it was found that the average salary of the sample population was 60,000$, with 76% being university graduates, 74% being employed, and 76% being married. 

Crisis in the new environment

Between 2000-2013, the inflow of African immigrants to the U.S. increased drastically by a stunning 41%. According to the United States Census Bureau (2010) the main cities within the United States that African immigrants moved to included that of Washington D.C. (171,000), Minneapolis-St. Paul, Minnesota (70,100), Atlanta, Georgia (70,100), and Boston, Massachusetts (61,600). Additionally, 55% of African immigrants are male, whereas the remaining 45% are female. Typically, when moving to the United States, African immigrants tend to move toward busy city centers; however, over time, move to a more suburban environment (Capps, McCabe, & Fix, 2012).

Nigerians account for the largest population of immigrants from the African continent in the U.S. Nigeria is the second-largest partner in terms of trade among all the other nations of Africa. It is also one of the top countries that export oil into the U.S. In a report presented by Black Alliance for Just Immigration (BAJI) and NYU School of Law researchers states that the applicants for Deferred Action for Childhood Arrivals (DACA) who hail from countries with predominantly black ethnicity are found to be denied (Azuh, Fayomi, Ajayi 2015). Many reports also cite that an individual coming from a black ethnic background is more likely to be deported on account of criminal activities, than any other group of immigrants from other countries. Nigerian immigrants to the U.S. face a dire case of racism and are often left out from policies and laws (Azuh, Fayomi, Ajayi 2015). The negative effects of such unfair practices against the Nigerian community in the U.S. can be the cause of the degradation of the community’s mental health and can lead to depression. Moreover, the Nigerian immigrants to the U.S. have faced an acute financial crisis owing to the unfair distribution of wealth among the population. Lower incomes and financial conditions prevail among Nigerian immigrants to the U.S. and it is barring them from moving up in the society. Lower wealth is synonymous with fewer opportunities for these individuals to thrive in society. Discrimination at the workplace and unfair tax laws are also the leading cause of lower wealth among the Nigerian immigrants to the U.S. Such dire conditions can be directly linked to the cause of depression among the Nigerian community. They are engaged in a constant struggle to keep their family out of bankruptcy and in some extreme conditions, they are fighting for a day’s meal for their family. Such negative conditions are pushing the Nigerian community to the verge of depression and other mental illnesses. The stress that is experienced by the Nigerian women in the U.S. can be attributed to all the diverse factors mentioned in the above sections. The lack of having access to a stable income, a steady job, and retirement benefits are pushing the Nigerian community backward in the U.S. The Nigerian community in the U.S. is constantly caught in a vicious cycle of discrimination at the workplace, in tax regulations, housing loans, and income levels. It is crucial for them to come out of this stagnant state and push for prosperity. Without that strife, it will be difficult for the Nigerian community to mitigate depression from its face. Nigerian women in the U.S. are facing depression at a more frequent rate than their non-immigrant counterparts and this is attributed to the problems they face while attempting to adapt to the the socioeconomic setting of the new country. As most of the Nigerian women are burdened by the intensely competitive and discriminatory work culture in the U.S., they are increasingly finding it difficult to find time for their children or look after the affairs at home. Child-rearing is rendered very difficult for the women of Nigerian origin who are working in the U.S. due a lot of pressure from the office as well as other socioeconomic factors (Azuh, Fayomi, Ajayi 2015). This is a major cause of the prolonged backward socioeconomic status of the majority of the women coming from the Nigerian community. As a result of such situations, depression comes as a common outcome which is a frequently appearing phenomenon among the women of the Nigerian community. 

Cultural beliefs

The cultural background of Nigeria is very complex and it has a very diverse history dating back at least 12,000 years. There are 250 identified ethnic groups or tribes within the country. The major part of the population comprises of three primary tribes, namely, the Hausa, Yoruba, and Igbo. Each tribe had a unique identity and culture before the European colonial conquest of the region. Nigeria was created by the imperial rulers aggregating the many tribes and the areas they lived in (Ellis 2016). Yet the European colonial forces failed to realize that the tribes could never consider each other alike. These differences among the ethnic groups did not farewell for the nation that was created later, even after independence from the colonial forces. To date there are conflicts and regular bloody confrontations between the various tribes (Aderinto, David & Alabi 2018).

Nigeria has a diverse geographical environment with three major divisions: the tropical forests, coastal wetlands, and the savanna. Each geographical region has multifariously affected the communities that resides there. For instance, herding and farming cereal crops in the grasslands of savanna is the means of living for the Hausa and the lesser known tribe, Fulani (Suleiman 2018). Fruits and vegetables are the primary crops farmed in the southern region of Nigeria where the wet tropical forests are found and this region is inhabited by the Yarubo, the Igbo, and the other smaller ethnic tribes present (Suleiman 2018). In the eastern wetlands, smaller tribes like the Ijaw and Kalabari earn a living by fishing and the salt trade. These tribes face the lack of dry lands, hence they are cornered into living between creeks and marshy lands (Suleiman 2018). The different lines of occupation practiced by the numerous ethnic groups created a rift in the way their cultures were shaped. The trade deals with the Arab world brought these ethnic groups to be converted to Islam. The entire region was converted to Islam by the end of 1807 and a Sokoto Caliphate was formed by the Fulani tribe (Sklar 2015). The British with its arrival, brought an end to the Islamic rule in the region.The colonial rule in the region encouraged the trade of slaves for goods. This caused a streak of violence among the tribes, as they very in search of slaves to sell to the colonial forces. Later in 1861, the British captured the city of Lagos in a move to flag off its first official colony and established a state where slavery was abolished. New trade culture and a brand new class of Nigerian merchants rose to new economic heights (Sklar 2015). The merchants wanted economic freedom and did not want to be held by the shackles of the tribal leaders anymore. Westernization took over most of Nigeria and many were converted to Christianity by the Christian missionaries (Ellis 2016). All theses serve as factors that contribute to the cultural differences that exist between the various ethnic tribes that reside in Nigeria.

Cultural Stigmas

As of 2018, Nigeria ranks at the 15th place globally in terms of the number of individuals suffering from depression. The National Depression Report of Nigeria cites that a third of the population (60 million individuals) have observed symptoms that instigate depression. Being the economic powerhouse of the continent of Africa, Nigeria is falling behind in terms of the mental health of the average citizen reported. The country never did put much effort into gathering any substantial data about depression. There are no laws regarding the control of depression followed by the nation and it has only a Lunacy Act which was the primitive rules implemented by the colonial rulers back in 1958 (Armiyau 2015). This law dictates that any person suffering from mental illness may be detained and isolated without any legal procedures. Such restrictive and unfair laws do not accommodate depression or recognize the existence of such medical conditions. The cultural background of the people affects their ability and readiness to come out, and talk about their mental conditions (Aderinto, David & Alabi 2018). The society is so caught up with the cultural stigmas that the individuals in the society are rendered unable to participate in open talks. Having an open conversation and maintaining a transparent environment is crucial to facilitate the people suffering from depression to easily seek outside help. The majority of the Nigerian population is stopped from engaging in open talks when they need it, owing to the cultural stigmas that exist within the community. Since there are no strict laws that would guide the community to the right methods of curing this mental ailment, people are forced to resort to spiritual help based on their faith (Armiyau 2015). Such traditional means of dealing with depression is common among the Nigerian community owing to their cultural and religious backgrounds (Abdullahi, & Suleiman 2015). Dr. Bem Tivka, who is working with the Neem Foundation as a psychologist says that the people of the Nigerian community do not recognize depression as a medical condition (Sunday 2018). He also cites that many a time individuals are marred by the beliefs that perceive depression as an attack using witchcraft. These bizarre ideas are facilitated by the cultural beliefs of the Nigerian community. Several research studies conducted also confirms with this notion (Okwaraji, Aguwa, & Shiweobi-Eze, 2016; Adeponle, Groleau, Kola, Kirmayer, Gureje, 2017; Afolabi, Bunce, Lusher, & Banbury, 2017). According to Dr. Tivka’s observations, the individuals who are affected by depression often turn to cheap chemical drugs available on the streets, the likes of codeine, in order to numb their pain. In the absence of any effort put forth by the government or the community to help the patients suffering depression, it is highly unlikely that the general population of the nation can ever break out of the cultural stigmas associated with depression (Aderinto, David & Alabi 2018). New laws have to be brought to the place and the education systems have to be improved in order to cope with this major issue (Fafunwa 2018). In the past, Nigerians have resorted to severe practices like burning, abandoning, hanging, mutilating and restraining the persons suffering from mental illnesses with chains (Sunday 2018). This was meant to cleanse the souls of the victims of demonic possessions and save the family from any repercussions. The Nigerian community setting encourages the formation of stereotypes pertaining to how the community should treat the mentally ill persons. Quite often the mentally ill individuals were deemed as being dangerous, unreliable, suspicious, irresponsible, unstable, suicidal and homicidal. In a community that refuses to accept the medically proven nature of depression and remains staunch on their cultural beliefs are difficult to deal with. This is the major cause of leading individuals to stigmatize the idea of depression. A study conducted by Okpalauwaekwe, Mela, and Oji confirmed the stereotypes and discrimination that exists among the Nigerian community is a cause for their unieuqe beliefs about depression. These issues must be addressed at the community as well as the institutional level in order to make strife towards removing the stigmas revolving around depression. Adequate knowledge has to be passed onto the Nigerian community for educating them on the reality of depression. If this issue is ignored and left unnoticed, a lot of other issues can arise as a result of it. The cultural integrity of the Nigerian community has to be given enough recognition while addressing the issue at hand. A strategy that does not tarnish the cultural etiquette of the Nigerian community has to be adopted. A lot of health workers hailing from the Nigerian community also fails to accept the medical implications of depression and are ignorant of the treatment methods followed by medical professionals. The healthcare workers need to be well educated on the severity of depression and be well prepared to deal with the cultural stigma that the general population is caught in. In another study conducted by Lavender, Khondoker, and Jones on the Yoruba tribe of Nigeria, it was found that evil spirits, curses, black magic and the devil were mentioned frequently amongst the Yoruba people (Lavender, Khondoker & Jones 2006). The people of the Yoruba community felt ashamed if they were diagnosed with depression. Such individuals were afraid of jeopardizing their marriage proposals in lieu of being diagnosed with depression. Such cultural implications of various communities within Nigeria cause the individuals to believe in and adhere to the cultural stigmas that are manifested as a result of such beliefs.

Issue at focus

The norms that exist within Nigeria relating to the gender differences among the various ethnic tribes are very diverse. Women and men perceive the concept of depression very differently. Women are largely affected by depression whereas the men are less likely to be diagnosed with clinical depression. Nigerian women who are married face a lot of issues related to depression and mental illness. This may be owing to the diverse cultural backgrounds that these women come from. Also, immigration to the U.S. and the problems they have faced to get accustomed to the contrasting cultures of Western civilization are contributing factors to this issue. The challenges that these women are faced with on a daily basis overwhelmed them and it costs them their mental peace. The stigmatized cultural beliefs among the Nigeran women lead to such dire situations. The society that they live in has to be more supportive of the situation that these individuals are caught in and aid them in gaining professional help. Adequate educational and training sessions have to be conducted for the individuals hailing from the Nigerian community in order to mitigate the issue of depression. Owing to the diverse cultural backgrounds of the Nigerian community that resides in the U.S. and their staunch belief regarding mental health, it is a very difficult task to provide an efficient method of treatment to the general population. Within each ethnic group that exists within the Nigerian community, different beliefs and backgrounds dictate the way of life. Many of the immigrants from Nigeria to the U.S. have been exposed to mild levels of modernization, owing to which they are slightly more at an advantage when compared to the individuals from the community who sticks to their cultural beliefs. In the U.S. About 15 million women experience the repercussions of depression on a yearly basis (Vermeiden et al. 2019). Education plays an important role in the way Nigerian perceive the medical condition of depression, just like any other community around the world. The reality the medical implications of depression needs to be instilled within the communities of Nigeria that resides in the U.S. But the financial and societal stance of the community at present does not facilitate the smooth transition of beliefs among within this sect of society (Vermeiden et al. 2019). The political dilemmas within the nation of America also do not support this notion. Constraints that arise from the cultural, societal and religious factors that exist between the Nigerian community that resides in the U.S. to the present day affect their efforts put in hope of a better future for their community. A holistic view and an approach that is indifferent to the various ethnic backgrounds of the Nigerian community has to be adopted by the administration in order to successfully mitigate the mental ailment. Different cultures within the Nigerian community believes in different perspectives pertaining to the reality of depression. The cultural differences in the cultural backgrounds of the people dictate how social perceptions are formed. Depression is found to be the leading cause that is found to be the major cause of a burden on the society of the Nigerian community (Vermeiden et al. 2019). The individuals in the community should understand that there are methods of treatment that can be applied by professionals who can easily cure such mental issues. Illnesses that are related to the mental health of a person can be addressed by professionals who are trained in the medical field. The successful diagnosis of a symptom of depression can help in addressing the general population of the Nigerian community (Fried & Nesse 2015). 

Case-study on Depression

In a research study conducted by Aluh et al. (2018), the knowledge possessed by the adolescents of the Nigerian community was assessed. The study was conducted among a sample population of 285 participants who students at the Federal Government College in the south-eastern region of Nigeria. The chosen students were of the age ranging from 12 to 18. The high-school students who gave their consent to participate in the study were presented with two case-studies. The case-studies presented a type of questionnaire that was designed similar to the ‘friend-in-need’ model of interview, wherein the students were asked to identify the disorder and provide their view on the method to seek help (Aluh et al. 2018). The first instance presented before the students was a clinical case of depression, while the second one revolved around the normal life crisis that a girl goes through in her lifetime. 

After the survey was conducted, a total of 277 legitimate responses were gathered that was complete in nature. That accounts for a 97.2% response rate that was recorded. The results of the study concluded that a 4.8% (n=13) of the respondents were successful in identifying the case which presented the example of clinical depression. Only a mere 1.5% (n=4) respondents suggested that seeking professional help was an ideal approach to address the issue. 17.1% of the students identified insomnia as the issue presented in the case of clinical depression, while female students displayed higher knowledge of the medical condition of depression. The female students were observed to be more empathetic to the issue presented before them and they were also found to be of the thinking that depression would take a longer period of time to rectify than normal teenage problems faced by students. Among the observed results, the majority of students felt that the best remedial measure that can be applied for the affected individual to approach and seek help from friends and family.

The conclusion of this study is that the adolescent population of Nigeria are unaware of the truth behind depression and its several extreme implications. There is a need for the students to be educated at a young age itself in order to prevent the chances of this issue going unnoticed by them. Proper and adequate treatment has to be sought by the individuals suffering from depression. These realities have to be instilled in the minds of the future generations of Nigeria in order to mitigate the proliferation of depression among the nation’s population. The mood disorders that are generally observed among adolescents needs to be recognized and diagnosed in its onset stages. Adolescents who are affected by depression are more likely to perform at sub-par levels in academics. The general attitude of ignoring the medical facts pertaining to the condition of depression needs to be changed among the Nigerian communities. The case-study presented conforms with this notion and reinforces the fact that educating the members of the community at a young age is extremely beneficial.

Symptoms of Depression

Symptoms of depression can vary depending on the gender of the patient. According to a report released by the National Institute of Mental health in the U.S., it was found that about 17.3 million adults in the U.S. went through depression in the year 2017, which accounts for 17.3% of the total adult population in the U.S. It is also a relevant observation to our study that women are more likely to experience a severe episode of depression in their lifetime when compared to men. The following observations on the differences between grief, sadness, and depression, and the symptoms of depression are defined by the American Psychiatric Association. Sadness or grief may be felt by an individual in case of the loss of a loved one, the loss of a job, the abrupt ending of a relationship, and due to many other reasons. But this cannot be termed as depression as it is classified as a medical condition wherein an individual will have to seek adequate medical help from a professional. The grievous situations may seem similar to the condition of depression, but there are several things to be kept in mind before accepting that an individual is affected by depression (Fried & Nesse 2015). Greif is normally felt in waves or pangs of pain, but it does not normally last for longer than a week or two. These feelings may be overcome by attending some counseling sessions or by just having a conversation with close friends or kin. On the other hand, depression is a medical condition where the patient does not feel any excitement or feeling of pleasure for a period of at least two weeks (Fried & Nesse 2015). If the period of feeling uninterested lasts for two weeks in the individual, then he/she should seek professional medical help. When a person is feeling grief, the person’s self-esteem is not necessarily lowered. But in the case of depression, the person may develop the feeling of worthlessness or even loathe oneself in the process. It becomes difficult for them to accept or acknowledge their value and wears a mask of gloom for a prolonged period of time. In some circumstances, grief and depression may overlap with each other. It is crucial to accurately differentiate between the two in order to avail suitable help and methods of treatment for the detected root cause. 

Some symptoms that can be observed among depressed people are as follows (Fried & Nesse 2015):

• Rejected feeling or the loss of interest in activities that they otherwise enjoyed.
• A fluctuation in the individual’s appetite leading to weight loss or gain irrespective of the dietary plans followed.
• Increased levels of fatigue and extended streaks of tiredness felt by the
• Some individuals may exhibit an increase in the amount of unproductive physical exertion (ex: pacing, hand-wringing, etc.) or slow down of the normal pattern of speech and/or movements.
• Feeling of guilt and/or deeming oneself as being worthless.
• Facing difficulty in thought processes which may lead to an inability in the decision-making process.
• Depression in its extreme conditions can lead the individual to ponder about death more frequently and even have suicidal thoughts.
• Major variations in the sleeping patterns observed in the individual.

There are also a bunch of other factors that can cause depression, it may not definitively be caused by mental constraints. In biochemical terms, if there is an imbalance in the chemicals that reside within the brain, then the individual may be prone to depression (Fried et al. 2015). Depression as an ailment can also be hereditary and run in the family. If one among the twins are suffering from depression, then the other sibling is most likely to experience depression in their life. The play of genetics can also dictate the presence of depression in an individual (Fried et al. 2015). Also, the personality traits of an individual can facilitate the occurrence of depression among those who are more prone to be worked up easily by normal stressful situations in life, or one who predominantly has a low self-esteem owing to a range of factors, or even individuals who are pessimistic in nature. When such obvious symptoms are observed in an individual for longer than two weeks, the person in question must seek some professional help. It could most probably be the beginning of depression. Depression needs to be treated a medical condition rather than any other possible explanation that may be believed to be the case. Especially those views that are marred by the cultural stigmas and societal preachings needs to be kept at bay. In the case of married Nigerian women, this is exactly the problem, that they do not consider depression an ailment that can be treated using medical science. Instead they are adamant in their belief that depression is caused due to some sort of spiritual or demonic possession and that it needs to be cured by employing self-help or participating in prayer sessions.

The Treatment of Depression

The National Alliance on Mental Illness (2017) defined depression as a “common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working (n.d.)”. Mental health experts reported that individuals who have depression can experience symptoms of feelings of hopelessness, a persistent sadness, anxious, or empty mood, decrease energy or fatigue, and a loss of interest or pleasure in hobbies or activities (Tandoc, Ferrucci, & Duffy, 2015; Stringaris, 2017; Beardslee, 2019). When experiencing depression, patients have a variety of ways in which to treat their symptoms, including the following, psychotherapy, psychoeducation and support groups, medications, and brain stimulation therapies (Tandoc, et al., 2015; Stringaris, 2017; Beardslee, 2019). 

Psychotherapy. Psychotherapy is a way to treat depression. Barth, et al., (2016) compared the efficacy of seven different psychotherapeutic interventions using a network metaanalysis of adults that were experiencing depression. The authors focused on seven different psychotherapeutic techniques and found that the most effective psychotherapeutic approach in treating depression amongst adults included that of interpersonal therapy. Interpersonal therapy is a psychotherapeutic technique that is used to treat a patients’ interpersonal relationships and social functioning, which in turn lowers distress levels (Lemmens, DeRubeis, Arntz, Peeters, & Huibers, 2016).

Lemmens et al (2016) compared the differences between interpersonal therapy and cognitive therapy for adults that were experiencing depression and the amount of sudden gains that they experienced. The authors found that individuals who were participating in cognitive therapy experienced more sudden gains versus individuals who participated in interpersonal therapy (42.2% versus 24.5%). Cognitive therapy is a type of psychotherapy where patients’ negative thoughts are challenged in order to alter any unwanted negative behavior patterns (Dobson & Dozois, 2019).

Other studies completed on psychotherapy and the effectiveness of the treatment of depression, content that how psychotherapy impacts a patients’ quality of life remains largely unknown (Kolovos, Kleiboer, & Cuijpers, 2016; Lemmens, Muller, Arntz, & Huibers, 2016). Kolovos, et al., (2016) meta-analysis study attempted to address a patients’ level of quality of life when participating in psychotherapy and found that if participating in psychotherapy on a consistent basis, quality of life levels will improve. Kolovos, et al., measured quality of life levels on a global scale, from a mental health component, and a physical health component. All three areas found that psychotherapy provided effective treatment for depressive patients. 

Karyotaki, et al., (2016) explored the long-term effects of the acute phase of psychotherapy. The acute phase of psychotherapy is typically a six to eight-week module with adults who experience mild to moderate symptoms of depression. Although positive effects of acute psychotherapy have been noted within the six to eight weeks sessions, little was known regarding the long-term effects of this form of treatment. Karyotaki et al (2016) found that individuals who participated in an acute-psychotherapeutic program experienced better treatment effects on depression and quality of life levels in the long-term.

Remedial strategies

In this section, we will go over the remedial strategies that can be adopted. Depression can be treated in an assortment of methods. We will go over each and scrutinize its effectiveness in the scenario of our case-study. As we have gone over the symptoms of depression in the previous sections, we should be aware that depression may be caused due to a range of reasons. For each of these causes, there can different implications for the approach of treatment that needs to be administered. First and foremost, we have to make an effort to understand the underlying cause of depression. Depression may arise from a rejected feeling or the loss of interest in activities that they otherwise enjoyed, a fluctuation in the individual’s appetite leading to weight loss or gain irrespective of the dietary plans followed, increased levels of fatigue and extended streaks of tiredness felt by the individual (Schuch et al. 2016), some individuals may exhibit an increase in the amount of unproductive physical exertion (ex: pacing, handwringing, etc.) or slow down of the normal pattern of speech and/or movements (Schuch et al. 2016), feeling of guilt and/or deeming oneself as being worthless, facing difficulty in thought processes which may lead to an inability in the decision-making process, depression in its extreme conditions can lead the individual to ponder about death more frequently and even have suicidal thoughts, major variations in the sleeping patterns observed in the individual. There are also an array of other reasons that may cause depression, like biochemical imbalances, predominant personality traits, genealogical factors, or some medical conditions that leads the individual towards symptoms of depression (Fried & Nesse 2015).

If the cause of depression in an individual is due to some latent medical condition, then that needs to be addressed first. The root cause has to be eliminated in order to deal with this case of depression. Each approach to the treatment of depression can take some considerable amount of time to actually begin to work as not every approach is a sureshot success. It is ill-advised to rely only on medications for a person suffering from depression (Schuch et al. 2016). Engaging in open talks with friends and family, and maintaining good social connections can help in keeping depression at bay. Bringing about some changes in the lifestyle of the individual can drastically change the symptoms of depression. Focusing on attaining an adequate nutritional diet can improve the mental health of the patient suffering from depression. Indulging in regular exercise regimes can positively impact the condition of depression as well.

Medication is one approach to fight depression, but recognizing and prescribing the proper treatment through medication is a very difficult task. A person suffering from varying medical conditions can have different side-effects when the antidepressants are prescribed to them. For instance, individuals who are having serious heart-related issues, kidney diseases or medical problems with the liver may not be ideal contestants to receive prescribed medication for depression as it can have negative impacts on the person’s health. It is observed that only a mere 30% of the patients who are depressed goes into full remission on the intake of their first set of antidepressants. In some cases, the patients will require more than one medication type to successfully fend off depression. The placebo for suicidal tendencies are common among the patients aged between 18-24 who are actively taking antidepressants to cure depression. The doctor who is attending to the depressed patient should actively monitor the condition of the patient regularly and administer changes in the medication depending on the observations. Normally, professionals in this realm suggests the applications of antidepressant medications in combination with the psychotherapeutic treatments. This approach is most common treatment method followed to address a patient who is diagnosed with depression at first. Variations on the dosage of the medication and the time period of administration of the medication has to be regularly monitored in order to soothe the mental health of the patient.

In a research study conducted by Aluh et al. (2018), the knowledge possessed by the adolescents of the Nigerian community was assessed. Among the observed results, the majority of students felt that the best remedial measure that can be applied for the affected individual to approach and seek help from friends and family. The conclusion of this study was that the adolescent population of Nigeria are unaware of the truth behind depression and its several extreme implications. There is a need for the students to be educated at a young age itself in order to prevent the chances of this issue going unnoticed by them. Proper and adequate treatment has to be sought by the individuals suffering from depression. Hence, it is important to address the symptoms of depression at a young age and it is a necessary requirement for all individuals to be educated with the facts about the implications of depression. Teaching the children in school about the symptoms of depression, preparing them to actively identify these symptoms, and enlightening them on the different ways in which depression can be eliminated is extremely quintessential in every community around the globe. Reasoning with the children and engaging in healthy debates can be ideal approaches to successfully educate them on the reality of depression.

A study conducted by Sulyman et al. (2016) targeting the Nigerian women of the Northeastern region of Nigeria, discovered that the postnatal depression was the most common type of depression in women who are undergoing pregnancy (O’Connor et al. 2016). They also found that in such situations the women will be more prone to being overwhelmed by the stress and it often led to interferences in the way the new mothers provided care to their babies. Postpartum depression or postnatal depression is found in women who underwent childbirth (Gangwisch et al. 2015). A significant step that may be taken by the national authorities is to ensure that the mental health of the pregnant women of the nation is secured. This requires the constant monitoring of the woman who is pregnant and ensuring that they are not experiencing any traumatic situations. The healthcare professionals who are being consulted by the pregnant women have to be prepared to ask the relevant questions and pin-point the cause for metal stress in them, if any (Gangwisch et al. 2015). The government should implement policies wherein pregnant women are supposed to mandatorily attend some workshops pertaining to the mental and physical health during the period of pregnancy (O’Connor et al. 2016). Awareness has to be spread among the population of the nation in order to successfully mitigate the issue of depression.

Nigerians account for the largest population of immigrants from the African continent in the U.S. As found by Adewuya et al.(2006) in a study conducted among college students in Western Nigeria, it was found that one of the leading causes of depression among college students was because they were from the female gender. Dr. Bem Tivka, who is working with the Neem Foundation as a psychologist says that the people of the Nigerian community do not recognize depression as a medical condition (Sunday 2018). These studies highlights the need to educate the women of the Nigerian community on the facts of depression and the various remedial measures associated with the mental ailment. In the following sections we will cover some of the treatment methods employed to cure depression.

 

Psychoeducation and support groups

Psychoeducation can be an effective tool when treating individuals with depression as it allows them to become familiar with their illness and the effects that depression can have both from an internal and external perspective (Conradi, Bos, Kamphuis, & de Jonge, 2017; Jones, et al., 2018). The benefits of completing psychoeducation are that it allows patients to better understand depression, while being able to actively identify symptoms of their illness. Alternatively, the participation of support groups aids patients in being able to share their experiences of depression while learning new coping skills that other members of the support group report. This can allow the patients to build a support system that can help them in the recovery and remission of their symptoms either through a face-to-face or online format (Frison & Eggermont, 2015; Behler, Daniels, Scott, & Mehl-Madrona, 2017).

Behler et al (2017) study focused on the perceptions of members of a depression and bipolar support group. The authors explored the perceptions of support group members regarding the effectiveness of the support groups and the differences experienced from that of other mental health services. Behler et al (2017) investigated the perceptions of 43 adults from four different support groups, all of whom experienced depression or bipolar disorder and found that the members perceived support groups as a thriving community where they could practice their recovery skills and give practical advice. Consequently, the members of the support groups found that they felt a strong form of acceptance, as all other support group members were able to easily accept and understand their diagnosis. 

In terms of psychoeducation, Jones et al (2018) believed that these forms of interventions can be very effective in terms of depression treatment, as long as they deliver accurate information about health issues and self-management. The authors conducted a study on psychoeducational interventions within adolescents who were experiencing depression and found that this form of intervention can play a major role in preventing and managing adolescent depression as a first-line or adjunctive approach. Within the groups, the adolescent participants were able to include family members, which additionally aided in treating depression, as the family was able to better understand depression and its effects as a whole, how to identify symptoms, communicate with family members, and the different mental health outcomes. 

Psychological Treatments for Depression

Talking therapies or psychological treatment methods are very common among the approaches to address depression. Talking one’s mind out to someone else can aid in changing the way an individual perceives the idea of depression (Compas et al. 2015).

It will help them to better cope with the conflict of interests and other stresses that arise from everyday life. Unwanted thoughts and behavior can be prevented by talking to some professional on mental health issues. Many kinds of treatments are present in the psychological approach to treat depression and there are also a range of delivery options that can be considered. Cognitive Behavior Therapy (CBT) is one of the psychological approaches to treat depression clinically (Brent et al. 2015). This approach dictates that the way a person thinks (cognitive) and acts (behavior) are major contributing factors to the way we feel (Compas et al. 2015). CBT is observed to be effective for the vast majority of the population, be it adults, older individuals or even for children and adolescents. Main focus of this approach is to find the underlying thought processes and behavioral traits in a patient that is inhibiting them to think in a rationale way (Brent et al. 2015). A professional will sit with the patient and attempt to identify these problems in order to rectify them. Helping the patient to overcome the difficulties that they are facing with coping with stress and aiding them in shaping a positive thought process instead of the negative way of thinking that is hindering them are the means by which a professional can treat depression. In recent years, the administration of these therapies can even take place over the internet, often called e-therapy. Another approach in the psychological realm to treat depression is Interpersonal Therapy (IPT). IPT recognizes the issues related to problems faced by individuals in their relationships that may be the cause of depressive symptoms among patients. The professional in this case will sit with the patient, conversing with them to identify the problems that the patient is facing in the relationships and will try to help them to understand methods to cope with such indifference. The vulnerabilities and insecurities of a person needs to successfully identified in order to carry out IPT (Compas et al. 2015). Behavior therapy is another form of psychological treatment for depression. It is a component of CBT itself, but it differs in its methodology, in a way that this approach does not try to change the attitudes of a person intentionally. In behavioral therapy the professional will try to encourage and inculcate activities that are rewarding, pleasant or satisfying to the patient in order to make them feel better about themselves (Topper et al. 2017). This approach is adopted in the wake of patterns of inactivity, withdrawal, and avoidance that is observed in the patient. Mindfulness-based Cognitive Therapy (MBCT) is yet another approach in the psychological realm that aims to address depression through engaging the patient in meditation (Thompson et al. 2015). The treatment starts out with focusing on breathing patterns and later on, the focus is on the feelings and experiences of the patient. This method tries to teach the patient to be more conscious of the present and to live in the moment by feeling whatever emotion they are experiencing in its purest form. Meditation is the prime method in this approach and it is normally conducted in groups. MBCT is identified as an approach that is effective in cancelling the chances of reappearance of depression in the individual’s life as it taches the individual to think in positive ways (Thompson et al. 2015).

 

Medication Types for Depression

Medication therapy are a strong form of treatment when it comes to depression as they can aid in the reduction or control of symptoms (Antonuccio, Danton, & DeNelsky, 1995; DeRubeis,

Siegle, & Hollon, 2008). Although medication are effective form of treatment for depression, there may be other modalities that could be just as, or more effective. For example, Antonuccio, Danton, and DeNelsky (1995) study on psychotherapy versus medication treatment for depression. The authors found that cognitive behavioral psychotherapy was just as effective as medication when it came to the treatment of depression. A study Davey and Chanen (2016) on both medication and psychotherapy together, concluded that a combined treatment provides greater effects on patients. The authors urged that when medications are prescribed, they should be prescribed in a manner that is in combination with psychotherapy and other lifestyle modifications. Davey and Chanen (2016) posited that medications are only effective if they are prescribed in a way that maximizes their effectiveness, this means, that they should be taken in conjunction with lifestyle modifications, improved diets, and increased exercise. The goal of taking medications to treat symptoms of depression is take control or minimize symptoms. Antidepressants typically take two to four weeks to have an effect on an individual, the most common medications used to treat depression include that of Prozac, Zoloft, Paxil, Celexa, and Lexapro (Jacobsen, et al., 2019). Different medications can have different effects on patients, therefore, it is essential for patients to work closely with their psychiatrists in order to better understand the most effective drug for them when used in combination of other therapies.

Selective serotonin reuptake inhibitors (SSRIs) are the most common form of drugs used as medication to treat depression today (Topper et al. 2017). It was invented in the mid 1980s. There are a range of drugs that comes under this type, namely, citalopram (Celexa), fluoxetine (Prozac, Sarafem), paroxetine (Paxil, Pexeva), sertraline (Zoloft), and escitalopram (Lexapro). Two medicines, classified as "serotonin modulators and stimulators" or SMS's (meaning they have some similar properties as SSRIs but also affect other brain receptors) are vilazodone (Viibryd) and vortioxetine (Trintellix). There are some side-effects that are found to affect some patients who are under this medication. For instance, sickness, stomach irritated, sexual issues, weariness, dazedness, sleep deprivation, weight change, and cerebral pains. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a more recent kind of stimulant. This class of drugs incorporates venlafaxine (Effexor), desvenlafaxine (Pristiq and Khedezla), duloxetine (Cymbalta), and levomilnacipran (Fetzima). Reactions induce resentful stomach, sometimes a sleeping disorder, sexual issues, nervousness, wooziness, and weakness. 

Tricyclic antidepressants (TCAs) were a portion of the main drugs used to treat gloom. Models are amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), doxepin (Adapin, Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil). Reactions incorporate stomach upset, tipsiness, dry mouth, changes in circulatory strain, changes in glucose levels, and sickness. 

Monoamine oxidase inhibitors (MAOIs) were among the most punctual medications for discouragement. The MAOIs hinder a catalyst, monoamine oxidase, that at that point causes an expansion in cerebrum synthetic compounds identified with state of mind, for example, serotonin, norepinephrine and dopamine. Models are phenelzine (Nardil), tranylcypromine (Parnate) , isocarboxazid (Marplan), and transdermal selegiline (the EMSAM skin fix). In spite of the fact that MAOIs function admirably, they're not endorsed all the time due to the danger of genuine collaborations with some different meds and certain nourishments. Sustenances that can contrarily respond with the MAOIs incorporate matured cheddar and matured meats. Bupropion (Aplenzin, Wellbutrin) is a one of a kind stimulant that is thought to influence the cerebrum synthetic concoctions norepinephrine and dopamine. Reactions are normally mellow, including irritated stomach, cerebral pain, a sleeping disorder, and nervousness. Bupropion might be less inclined to cause sexual symptoms than different antidepressants. Esketamine (Spravato) is a one of a kind drug initially created as a soporific and suspected to treat discouragement however its impacts on a cerebrum synthetic called glutamate. It is controlled as a nasal splash and is for use in the individuals who have not reacted to treatment by different antidepressants. Its most basic symptoms incorporate sedation, separation (having odd discernments about existence, or feeling as though things around you are not genuine), issues with intuition, and hypertension. In the event that any of these reactions happen they are generally mellow and transitory. Mirtazapine (Remeron) is likewise an extraordinary upper that is thought to influence for the most part serotonin and norepinephrine through various mind receptors than different prescriptions. It is typically taken at sleep time since it frequently causes sleepiness. Reactions are normally mellow and incorporate tiredness, weight increase, raised triglycerides, and discombobulation. Trazodone (Desyrel) is normally taken with sustenance to lessen risk for stomach upset. Opposite reactions incorporate laziness, wooziness, stoppage, dry mouth, and foggy vision.

Brain Stimulation Therapies. As a more severe and desperate effort to control or relieve symptoms of depression, brain stimulation therapies can assist people that are experiencing severe depression, where other treatment modalities have not worked (Chau, Fogelman,

Nordanskog, Drevets, & Hamilton, 2017). Electroconvulsive shock therapy (ECT), Repetitive Transcranial Magnetic Stimulation, and Vagus Nerve Stimulation are just some of the brain stimulation therapies that can be used when other treatment modalities have failed (Kiebs, Hurlemann, & Mutz, 2019). Akhtar, Bukhari, Nazir, Anwar, and Shahzad (2016) said that individuals with severe depression can experience relapse even while taking anti-depressant medication. Approximately 20% of patients experience relapse, and using brain stimulation therapies have shown promising results in treating such patients. 

Electroconvulsive Therapy is an option for severely depressed patients where short electrical impulses are transmitted into the brain (Akhtar, et al., 2019). The short electrical impulses create a seizure, which in turn relieves depression. Although it is not clear how the seizure relieves depression, research suggests that up to 80% of patients receiving ECT will see improvements with their depression symptoms (Duxbury, et al., 2018).

Repetitive Transcranial Magnetic Stimulation (rTMS) is a brain stimulation technique that uses magnetic fields to stimulate nerve cells in the brain, which in turn relieves symptoms of depression (Duxbury, et al., 2018). The difference between ECT and rTMS is that rTMS does not produce a seizure in patients and anesthesia is not required. During a session, a magnetic coil is placed around the patient’s head and then switched on and off which produces magnetic impulses. Depressive symptom relief can occur in as little as a few weeks after treatment, with patients being able to return to normal daily activities after each session (Fertonani & Miniussi, 2017).

Barriers for the Treatment of Depression

In the United States depressive patiens experience many barriers when searching for treatment for their depression. Chekroud, et al., (2018) reported that although there are many safe and effective treatments for depression in the U.S., many individuals with depression do not seek treatment due to perceived barriers that they experience. The authors completed a cross-sectional study with 20,785 adults who were diagnosed with depression and found that 30.6% of the participants did not seek treatment. Chekroud, et al., concluded that many individuals did not complete any other sessions after their initial one, meaning that the patients did not seek treatment that was recommended by their primary health provider. Consistent with Chekroud, et al., Mohr, et al., (2010) reported that the top barriers experienced by patients with depression included stigma, lack of motivation, emotional concerns, negative evaluations of therapies, misfit of therapy to needs, time constraints, participation restriction, availability of services, and cost of services. 

Stigma appears to be the biggest barrier within the United States when it comes to obtaining treatment for depression. Campbell, et al., (2016) study on the stigma of depression treatment amongst veterans within the United States found that stigma predicts not only whether an individual decides to attend treatment, but also predicts treatment preferences and care engagement. The results of the study indicated that high stigma patients were less likely to obtain treatment from mental health professionals and were less likely to take medications for mood disturbances, and other appropriate self-care exercises in order to relieve symptoms. Cruwys and Gunaseelan (2016) study to understand stigma in relation to depression found that stigma went beyond the stigmatized thoughts regarding the treatment of depression, it was also indicated regarding the illness itself. The authors revealed that experiencing stigma within depression is associated with poorer levels of well-being, and that individuals who experienced the stigma of depression were more likely to identify as a depressed person. Cruwys and Gunaseelan concluded that social identification magnified the relationship between stigma and the reduction of well-being. The authors concluded that for individuals who experience depression, relating and interacting with other depressed individuals may actually increase the experience of harmful social influence processes. 

Gearing et al., (2015) study on stigma and mental health treatment of adolescents living with depression, identified that stigma is one of the major barriers in seeking and engaging in mental health treatment. The authors found that gender and mental health treatment influenced stigma, concluding that females were more affected by personal stigmas, while males were more affected by public stigmas of depression. Gearing et al., reported that adolescents are more likely to seek and receive treatment for their depression if a family member had previously sought treatment.

Brenes, Danhauer, Lyles, Hogan, and Miller (2015) study on the major barrier to treatment of depression and personal stigma found that the most common barrier to treatment was the personal belief of “I should not need help”, followed by other barriers that consisted of cost, mistrust of mental health providers, not believing that treatment would work, and not wanting to talk to strangers about private issues. Martinez-Tyson, Arriola, and Corvin (2016) examined the perceptions of depression and access to mental health services amongst the Latino community in the U.S. Compared to their Caucasian counterparts, Latinos typically experience lower rates of depression, however, Latinos are less likely to seek and receive treatment. Martinez-Tyson et al (2016) found that personal stigmas to depression made it difficult to obtain data in their study. 

Black Americans experience barriers when it comes to mental health treatment for depression in the U.S. Gaston, Earl, Nisanci, and Glomb (2016) cross-sectional study found that there was not enough research that highlights the barriers for the Black American community as a whole. Although, the authors noted that stigma, discrimination, and racism mired the perceptions of the African American community when investigating mental health services. The authors concluded that it is important to identify and understand the stark differences between the different ethnic groups within the Black American population so that barriers to treatment can continue to be explored and investigated. 

Depression Treatment in the Nigerian Culture

Ezeobele, Malecha, Landrum, and Symes (2010) study on Nigerian women who live in the United States with experience of depression. While this study did not concentrate on barriers to treatment, it provided an insight into how depression is perceived by Nigerian women residing in the United States. The authors found six themes that highlighted how depression was perceived within this population. The six themes of how depression was perceived included craziness and madness, curse and evil spirit possession, denial and secrecy, isolation and rejection, spirituality and religion, and the need for education. 

At the essence of the study, the authors highlighted that Nigerian-born women residing in the United States perceived depression as being unacceptable and labeled the illness as a form of craziness and being associated with evil spirits or a curse. The types of treatment that the participants would consider included, the use of spirituality or religion (Ezeobele, et al., 2010). The findings are consistent with previous studies on depression within the Nigerian culture 

Andrade, et al., (2014) discussed barriers to mental health treatment set forth by the World Health Organization (WHO). WHO collected data from many families from over 24 different countries and found that barriers to mental health treatment included, low perceived need for treatment, the desire to handle the mental health ailment from an individual perspective, perceived ineffectiveness of treatments, and negative experiences from a treatment provider.

Abdulmalik (2015) stated that stigma and misconceptions are the main barriers to mental health treatment within the Nigerian culture, and that barriers to treatment are not only from the patients themselves, but also from that of providers. Many barriers to treatment exist within the Nigerian health care system.

Healthcare clinics and primary care physicians in Nigeria experience similar stigmas and misconceptions to that of their patients, which can hinder the type of treatment and the level of effectiveness when treating conditions such as depression (Abdulmalik, 2015). Because mental health professionals experience similar stigma as their patients, other barriers abound within the Nigerian medical systems, including inadequate training of primary care staff and nonavailability of medication for the treatment of depression (Abdulmalik). Abdulmalik concluded that the Nigerian health care system itself possess as a barrier to treatment. 

Issa, Yussuf, Abiodun, and Olanrrewaju (2015) approached psychological problems differently within their study. The authors conducted a study with Nigerian doctors at the University of Ilorin Teaching Hospital to understand their perceptions about mental health treatment. Ninety percent of the doctors that were surveyed reported that they would welcome increased times where they could talk to their patient and agreed that psychological and social factors should be routinely assessed to ensure that mental health conditions such as depression are minimized. The doctors said that they would more than likely refer a patient that was experiencing anxiety for treatment at higher levels than they would a depressed patient. This continued to highlight barriers toward treatment recommendations and barriers within the Nigerian culture. 

Adeosun (2016) found that many adolescents believed that barriers to the treatment of depression included the non-availability of community-based mental health services and professionals and unfriendly mental health professionals. Other barriers appeared to concentrate on the stigma and identification of depression from both individuals and physicians, as depression was predominantly misidentified as a physical illness, the effects of stress and overthinking, emotional problems, or a reaction to maltreatment or abuse. Adeosun discovered that only 6.5 percent of participants would recommend going to a mental health professional if experiencing depression, 43.9% of participants recommended going to a general practitioner if experiencing depressive symptoms.

Theoretical Framework Literature

Three theoretical frameworks will guide this study, the frameworks will be discussed from a social determinants of health lens (Castañeda, Holmes, Madrigal, Young, Beyeler, &

Quesada). The three frameworks include the Health Belief Model from a behavioral perspective, Culture Theory from a cultural perspective, and Structural Functionalism from a structural perspective. Combined, the three models will allow the researcher to understand behavioral, cultural, and structural issues of married Nigerian women who are experiencing depression. The first theoretical framework discussed in this study is the Health Belief Model. Used to predict individual changes in health behaviors, the theory is aimed to identify key factors that influence any health-related behaviors including that of an individual’s perceived susceptibility to illness, perceived severity to illness, perceived barriers to action, and confidence in the ability to succeed, as depicted in Figure 1 (Skinner, Tiro, & Champion, 2015). 

Figure 1. The Health Belief Model

This model would be beneficial as the participants in this study are asked to describe their experiences of depression and any barrier that they experience when seeking treatment. The

Health Belief Model has been used in a variety of studies that have focused on immigrants. Lee, Stange, and Ahluwalia, (2015) in a study that focused on the utilization of clinical breast examinations in the face of breast cancer screenings with Korean immigrant women living in the United States, found that the immigrants who perceive themselves to be susceptible to breast cancer were more likely to complete a mammogram; the authors the Health Belief Model and highlighted the importance of utilizing the constructs of susceptibility, barriers, and confidence when working with immigrants.

Similarly, Blanas, et al., (2015) study on West African immigrant population that aided the linkage of Hepatitis B screening to the residents of New York City, using the Health Belief Model, found different challenges were highlighted when it came to Hepatitis B screening. The authors postulated that cost and health insurance were the biggest challenges as the majority of the West African immigrant population were ineligible for health insurance. This study utilized a qualitative methodology where four focus groups were completed on 39 participants.

The second theoretical model proposed for this study is Culture Theory. Culture Theory conceptualizes and understands the dynamics of culture (Storey, 2018). Cultural Theory pertains to an individuals’ culture to distinctive ideas, beliefs, values, and knowledge, which is crucial in this study, as the majority of research has highlighted the differing perceptions that Nigerian immigrants may have on depression and mental health conditions (Serrat, 2017). Byron, et al., (2015) study examined the mental health staff and the importance of mindfulness training when it came to working with adolescents. Using Culture Theory, the authors found that environmental factors aided in shaping attitudes and the acculturation of the implementation of wellness programs, thereby, highlighting the importance that understanding different cultures impact the treating adolescents. Additionally, the authors revealed different barriers that got in the way of mental health clinicians, when it came to understanding different cultures and the importance of acculturation, limited staff time, lack of training, and insufficient training coverage. 

The third theoretical model employed for this study is the structural functionalism. Structural functionalism is a framework that allows the researcher to view society as a complex system, working together to promote solidarity and stability as depicted in Figure 2 (Kingsbury & Scanzoni, 2009). 

Figure 2. Structural-Functional Model of Society

From a structural functionalism standpoint, this study will benefit from this theoretical framework as it discusses how immigrants experience an increased limited access to health care than their native-born counterparts. Structural functionalism also takes into account one’s immigration status and other social, economic, and political factors (Garner, 2019). 

To understand how Structural Functionalism operates within a larger milieu, Jing (2016) in a study of the construction of network governance structures of urban communities found that it is important that governing systems take into account community interests, while dealing with community members effectively, sharing public rights, and cooperating. Viewing his study through the lens of Structural Functionalism allowed for a stronger delineation of how to view a complex system and work effectively with each member; in this case, the author was able to construct a strong network governance platform, integrate the relationships between the different substructures, and build the mechanism of network governance. With the three theoretical construct combined, the researcher will be able to describe how structural aspects of one’s life (e.g. immigration status and social, economic, and political factors), are effected by social and economic policies, in conjunction with an individual’s belief in health, providing an increased robust and strong understanding.

Preventive measures

Depression is not something that is generally treated as an ailment that can be prevented intentionally. There are many differing opinions on the topic from a range of professionals. A large portion of the things that make you bound to get depression are things that aren’t in your control, including your qualities, synthetic substances in your cerebrum, and your state of mind. For some individuals, depression begins after a noteworthy event that caused life change or an injury. It can likewise occur on the off chance that you have another medical issue, for example, malignant growth, diabetes, or Parkinson's infection (Topper et al. 2017). You will be unable to thoroughly shield yourself from these things. Yet, you can change how you handle the pressure they can cause. Mental readiness is an essential factor that will help an individual to stay away from depression. It can only be cultivated in oneself if they take some time out to introspect and put it in an effort to change their negative perceptions. It requires some amount of effort to be put in by the individual itself and there is very little that a second person can do in order to help them.

Monitoring methods

Indeed, even with numerous treatment choices accessible for significant depression issue, numerous patients neglect to accomplish reduction and come back to their presymptomatic degrees of working at the office, in relaxation exercises, and when seeing someone (Pfeiffer et al. 2017). All through the treatment methods, clinicians should execute estimation based consideration by methodically observing patients' reaction utilizing self-evaluated scales, for example, the PHQ-9, QIDS-SR, or BDI (Canzian & Musolesi 2015). By following burdensome manifestations, just as suicidality, treatment adherence, and symptoms, clinicians can alter treatment to enable patients to accomplish the best results. Estimation based consideration empowers clinicians to settle on educated choices at basic focuses all through the treatment procedure and to include patients in settling on those choices (Canzian & Musolesi 2015). In the case of Nigerian women who are living in the U.S., they have access to all sorts of healthcare facilities. It is upto them to utilize these facilities and make the best use of them. They are responsible to be aware of the implications of depression and also the related remedies. The healthcare professionals should be able to successfully monitor the patient only with the cooperation of the patient. Up to 80% of antidepressants are recommended by essential consideration specialists - and given the high pace of clinical depression. Truth be told, numerous protection plans require a primary care doctors to be the initial phase in treatment. "Pediatricians, healthcare specialists, and family specialists have consistently given a colossal measure of emotional wellness care. Essential case providers can by and large analyze clinical gloom in grown-ups. Sadness, trouble concentrating, issues related to inadequate rest, absence of vitality, and misery are great side effects. Examine them with your PCP, and discussion pretty much all the treatment alternatives. As it is the case in the present scenario, with youngsters and youths, depression isn't so natural to analyze, says David Fassler, MD, private practitioner and pre-adult therapist and teacher of psychiatry at the University of Vermont. A therapist's assessment is frequently important to decide exactly what is new with a kid. As often as possible, a child specialist does the underlying assessment and recommends prescription. At that point the youngster is alluded back to the pediatrician for observing and development, ideally related to treatment of mental or emotional issues. Utilization of approved scales in screening, determination, and estimating reaction to treatment in depression is a basic piece of giving proper consideration. Professionals who become acquainted with their utilization can improve indicative precision, spare time, give progressively predictable patient consideration, and screen a patient's unpredictable passionate and social reactions to treatment. The decision, utilizes, and clinical pertinence of some regularly utilized apparatuses, and makes suggestions for their normal fuse into family practice. In spite of the fact that we routinely depend on clinical information, most clarifications of how to translate indicative information are restricted to research center and X-beam reports (Canzian & Musolesi 2015). However indications and signs for the most part produce unmistakably more dominant help of symptomatic speculations than we can ever get from the research center. Rating scales are not planned to give a substitute to great clinical judgment. We need psychometrically stable, easy to use instruments that give us clinically helpful data, and that are solid, substantial, and steady for an assortment of patients and settings when regulated by various clinicians (Canzian & Musolesi 2015). 

To pick the right instruments we have to decide the objectives of our appraisal. Screening devices, which give us a brisk sign of whether further evaluation is justified, need high affectability (Pfeiffer et al. 2017). Analytic devices need great substance legitimacy, test-retest unwavering quality, great between rater dependability, and high explicitness.

In most clinical settings we are probably going to have different objectives of appraisal and at least time, so cautious selection of apparatuses is pivotal. Any evaluation must be individualized to recognize language/social contrasts, scholarly or subjective hindrances, age-explicit issues (kids, youngsters, the old), co-sullen mental or different disease (nervousness, bipolar confusion), or simultaneous substance misuse (e.g., the CAGE survey is valuable). Danger of suicide should consistently be assessed. 

The total assessment procedure is unreasonable for an individual doctor to apply to each test the person in question uses, so it is imperative to outline the absolute and most helpful approved apparatuses used in depression. As a bustling specialist you can pick and get comfortable with these few tools, in this way improving the nature of your patient evaluations. The greater part of the every now and again utilized instruments show powerful connections among themselves, in spite of the fact that oneself rating scales show preferred relationship among themselves over with the clinician-appraised scales. Enticing however it might be to utilize a cut-off score on a self-report stock as a solitary method for determining an outcome. Numerous clinicians want to utilize a patient self-appraised scale, for example, the Beck Depression Inventory (BDI, secured by copyright and requiring consent and installment of a charge for repeated use). The BDI-II is a 21item self-report proportion of the seriousness of depression indications. It has high affectability and particularity and is substantial and dependable in evaluating the seriousness of burdensome side effects. Among its weaknesses are its high thing trouble (requires the patient to have the option to peruse and comprehend the inquiries) and poor discriminant legitimacy against tension.

Methodology Literature

This study will utilize a qualitative methodology that follows a descriptive study design. The goal of a qualitative descriptive study is to obtain a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). In this study, the phenomenon being explored is that of barriers to treatment that married Nigerian women experience when experiencing depression. A descriptive study will allow participants to describe their experiences in relation to depression, while also highlighting any barriers that may limit their ability to seek mental health treatment. In this study, participants will be recruited from Anioma Association of Los Angeles, where they will then be able to describe their experiences of depression and barriers to treatment when residing in the Los Angeles area (Lewis, 2015). 

A quantitative methodology was not selected for this study as the goal of quantitative studies is to focus on a statistical analysis using numbers through survey instrumentation. Therefore, this type of methodology was not selected as the goal of this proposed study is to describe the experiences of married Nigerian women living in Los Angeles that experience depression and the barriers they face when seeking treatment, which cannot be completed through a statistical analysis (McCusker & Gunaydin, 2015). Utilizing a qualitative methodology will allow the participants to convey their thoughts using words and non-verbal cues in order to answer the open-ended questions during their semi-structured interviews.

A qualitative descriptive research method was appropriate for this study as it allows for a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). Other qualitative research methods were considered, but ultimately rejected such as that as Ethnography and grounded theory. Ethnographic studies are observational by nature, thereby, making this research design difficult as the goal of this study is to describe the experiences of married Nigerian women with depression and any barriers that they experience when accessing mental health treatment (Hammersley, 2018). Additionally, grounded theory was rejected as a research method for this study, as grounded theory generates a theory that is grounded by the data (Glaser & Strauss, 2017). In this study, three theoretical frameworks were selected to both construct the study and view the results of the study, which included the Health Belief Model, Culture Theory, and Structural Functionalism, resulting in a stronger understanding of the results via a lens of social determinants of health. 

A convenience sampling method will be utilized in this study, where the researcher will select participants based upon the closeness of her geographical locale (Etikan, Musa &

Alkassim, 2016). This is important in this study, as the researcher resides in the city of Los

Angeles, California, and the participants in this study will be required to reside in the city of Los Angeles. Convenience sampling is a non-probability form of gathering participants (Etikan, Musa & Alkassim, 2016).

Research Design Literature

The nature of this study will utilize a qualitative methodology that follows a descriptive study design. The goal of a qualitative descriptive study is to obtain a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). In this study, the phenomenon being explored is that of barriers to treatment that married Nigerian women experience when experiencing depression. A descriptive study will allow participants to describe their experiences in relation to depression, while also highlighting any barriers that may limit their ability to seek mental health treatment. In this study, participants will be recruited from Facebook, Anioma Association Los Angeles, and Nigerian Women Nurses Association where they will then be able to describe their experiences of depression and barriers to treatment when residing in the Los Angeles area (Lewis, 2015). 

A quantitative methodology was not selected for this study as the goal of quantitative studies is to focus on a statistical analysis using numbers through survey instrumentation. Therefore, this type of methodology was not selected as the goal of this proposed study is to describe the experiences of married Nigerian women living in Los Angeles that experience depression and the barriers they face when seeking treatment, which cannot be completed through a statistical analysis (McCusker & Gunaydin, 2015). Utilizing a qualitative methodology will allow the participants to convey their thoughts using words and non-verbal cues in order to answer the open-ended questions during their semi-structured interviews.

This study will utilize a qualitative methodology that follows a descriptive study design. The goal of a qualitative descriptive study is to obtain a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). In this study, the phenomenon being explored is that of barriers to treatment that married Nigerian women experience when experiencing depression. A descriptive study will allow participants to describe their experiences in relation to depression, while also highlighting any barriers that may limit their ability to seek mental health treatment. In this study, participants will be recruited from Facebook, Anioma Association of Los Angeles, and Nigerian Women Nurses Association, where they will then be able to describe their experiences of depression and barriers to treatment when residing in the Los Angeles area (Lewis, 2015). 

A quantitative methodology was not selected for this study as the goal of quantitative studies is to focus on a statistical analysis using numbers through survey instrumentation. Therefore, this type of methodology was not selected as the goal of this proposed study is to describe the experiences of married Nigerian women living in Los Angeles that experience depression and the barriers they face when seeking treatment, which cannot be completed through a statistical analysis (McCusker & Gunaydin, 2015). Utilizing a qualitative methodology will allow the participants to convey their thoughts using words and non-verbal cues in order to answer the open-ended questions during their semi-structured interviews.

Chapter Summary

 The purpose of this qualitative descriptive study is to describe the experiences of married Nigerian women when experiencing depression while living in Los Angeles, with a secondary purpose of this study being to identify barriers that married Nigerian women face when seeking treatment of depression, in conjunction with their perceptions about this mental health disorder. This chapter provided the discussion on the treatment of depression and any associated barriers that are found within the United States and then provided an overview of depression within the Nigerian culture context, and the barriers that have been identified within the culture in regard to treatment engagement. The purpose of this literature review was to highlight the gap that ensured the need for this study. Chapter 3 will follow this literature review and will provide a discussion of this study’s methodology, highlighting the research design, the study’s sample, the data collection process, the data analysis process, and limitations of the study.

 

Chapter 3

Research Methodology 

The purpose of this qualitative descriptive study is to describe the experiences, perceptions and the barriers keeping depressed married Nigerian women living in Los Angeles from accessing mental health treatment. This study will utilize a qualitative methodology that follows a descriptive study design. A qualitative descriptive research method was appropriate for this study as it allows for a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). A qualitative descriptive research method was appropriate for this study as it allows for a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016).

The goal of a qualitative descriptive study is to obtain a comprehensive summarization of the phenomenon being explored (Colorafi & Evans, 2016). In this study, the phenomenon being explored is that of barriers to treatment that married Nigerian women experience when experiencing depression. A descriptive study will allow participants to describe their experiences in relation to depression, while also highlighting any barriers that may limit their ability to seek mental health treatment.

Chapter 3 will discuss the research methods that will be used to conduct this research study. The chapter will outline the study design, method, data collection, data analysis, ethical concerns, informed consent, instrumentation, sample, sample method and population of the study. 

Research Method and Design Appropriateness

A qualitative research method is appropriate for this study as it allows for a summarization of the phenomenon being explored (Colorafi & Evans, 2016). Other qualitative research methodologies for example, ethnography and grounded theory were considered, but ultimately rejected. Ethnographic studies are observational by nature, thereby, making the design difficult as the goal of this study is to describe the experiences of married Nigerian women with depression and any barriers that they experience when accessing mental health treatment (Hammersley, 2018). Additionally, grounded theory was rejected as a research method for this study, because grounded theories are used to generate theories that are grounded by the data (Glaser & Strauss, 2017), which is not the goal of this research study. 

A quantitative methodology was not selected for this study as the goal of quantitative studies focus on statistical analyses using numbers through survey instrumentation. Quantitative methodology was not selected as the goal of this proposed study is to describe the experiences of married Nigerian women living in Los Angeles that experience depression and the barriers they face when seeking treatment, which cannot be completed through a statistical analysis

(McCusker & Gunaydin, 2015). Utilizing a qualitative methodology will allow the participants to convey their thoughts using words and non-verbal cues in order to answer the open-ended questions during their semi-structured interviews (Creswell & Creswell, 2017).

Research Questions

Research questions in qualitative studies are typically open-ended in nature, and the participants in this study will be asked to describe their experiences in relation to depression, and any barriers that may have limited their ability to seek mental health treatment throughout the data collection process. The concentration of the current research is to describe the experiences of married Nigerian women with depression who live in Los Angeles and to identify any barriers they are experiencing when accessing mental health treatment. The following research questions will guide this study: 

RQ1: How do married Nigerian women residing in Los Angeles describe their experiences and perceptions of depression?

RQ2: What barriers do married Nigerian women residing in Los Angeles face when experiencing depression?

Population and Sample

Fiftteen participants will be selected using a convenience sampling method from Aniocha Women Association and other Nigerian women organizations in Los Angeles, whom are married and are between the ages of 30 - 60 years. A convenience sampling method is employed where the researcher will select participants based upon the closeness of her geographical locale

(Etikan, Musa & Alkassim, 2016), as in this study. The researcher resides in the city of Los

Angeles, California, and the participants in this study will be required to reside in the city of Los Angeles. Convenience sampling is a non-probability form of gathering participants (Etikan, Musa & Alkassim, 2016). The following criteria will be used to determine the eligibility of interested individuals:

1. Each participant must be female.
2. Each participant must be married.
3. Each participant must have been born in Nigeria and having immigrated to the United States.
4. Each participant must be a member of one of the following: Anioma Association Los Angeles, and Closed Married friends from the age of 30 - 60 years.
5. Married Nigerian women who are depressed
6. Immigrated from Nigeria to United States
7. Have experienced depression

Meeting the above named criteria are vital to effective collection of quality data.

An Institutional Review Board (IRB) approval will be sort and obtained from the University of Phoenix IRB office (see Appendix A) and other applicable permissions from participants (see Appendice section), a letter via email to recruit partiscipants will be sent women in the Anioma association in Los Angeles (see Appendix B) with information about the study, for example, the problem being studied, the purpose, and the criteria needed to be considered will be disseminated. The informed consent letter will be given to the potential participants who respond to the email. The consent form will outline the details of the study and participant confidentiality. Once each participant has agreed to participate in the study by signing and returning the completed consent and confidentiality forms, she will then set up a time where she can complete a private interview. 

The private interview will take place at a location that is conducive to confidentiality and convenient to both the researcher and the participant. Before beginning each of the semistructured interviews, the researcher will ask each participant whether they agree to participate in the study. Once they agree to participate, she will then ask each participate the same 10 openended questions. Utilizing semi-structured interviews as the data collection tool, the researcher will be able to minimally guide each participant when describing their experiences of the phenomenon being explored (McIntosh & Morse, 2015).

Informed Consent and Confidentiality 

IRB permission will be obtained from the University of Phoenix’s Institutional Review Board (IRB) prior to data collection. Participants will be assured that there is minimal in participating in this study as they are describing their experiences of experiencing depression when living in Los Angeles, California and identifying any barriers that they experience when accessing mental health treatment. Because the researcher is working with individuals who have experienced symptoms of depression, she will provide them with a list of community mental health treatment providers they can contact if they feel they need any treatment. Participants will also be informed that they can end the study at any time without repercussions and will be provided with the researcher’s contact number if they have any questions or concerns. The researcher will also address confidentiality by ensuring that any identifying information will not be released regarding the participants. During the study, each participant will be referred to in a numerical order (e.g. Participant 1, Participant 2, etc.) and each organization that the participant is a member of will be referred to in an alphabetical order [e.g.

Organization 1, Organization 2, etc.] (Denzin & Giardina, 2016).

The researcher will further ensure that all documents (consent forms, electronic recordings of the interviews, physical transcriptions of the interviews) will follow confidentiality and will store electronic files in a password-protected, encrypted file on an external hard drive. The researcher will also store the external hard drive and paper copies of documents in a locked filing cabinet that is located inside the researcher’s personal residence. The data will be deleted after a period of three years which is the recommended timeframe of the institutional review board.

Instrumentation

A semi-structured interview will be used to collect data for this study. McIntosh and Morse (2015) said that semi-structured open-ended questions allow for an in-depth understanding of a phenomenon, as participants are able to be in control of the information that they provide. Each participant will be asked the same 10 open-ended questions, and each interview will be electronically recorded and transcribed in preparation for data analysis. After the transcription process has occurred, each electronic file and hard-copy will be stored in a password-protected file and in a locked filing cabinet. 

Before conducting the interviews with each participant, an interview protocol will be created in order to ensure that the research questions are in alignment with the study’s problem statement, the purpose, the research questions, and the methodological design (Castillo-Montoya, 2016). By developing an interview protocol, the researcher will account for researcher bias, which can be a limitation in some qualitative studies (Creswell & Creswell, 2017). To create the interview protocol, the researcher will contact three potential individuals who have met the same criteria as the study’s participants. The researcher will then provide them with a copy of the study’s problem statement, the purpose of the research, the research questions, an overview of the methodology, and the list of open-ended questions that she will ask each participant. Each of the three individuals who are participating in the creation of the interview protocol will review the interview questions and provide their perceptions on the alignment of the research questions in conjunction with the study. Recommendations for changes will be reviewed and adjustments to the interview questions made as needed.

In qualitative research, the researcher gathers information by communicating directly with the participants of the study (Patten, 2016). Patten, explained phenomenological researchers obtain information or data by talking directly to the people who have experienced the phenomena. The primary instrument in this study will be the interviewer, who will use an interview guide consisting of open-ended questions developed by the researcher. Prior to conducting the official interviews for the research, the questions will be field tested in the field. The researcher will then schedule interviews with the participants in a mutually agreed upon location after IRB approval. During the interview the researcher will ask the participants the open-ended questions, record the interviews with participant permission, take notes, and collect data (Patten, 2016). Pilot studies are often used as trial runs in research studies to help prepare the researcher for the actual study (Patten, 2016). Patten (2016) expressed the advantages of process is to allow the researcher to see advance warnings about possible errors in methods, instruments, and question wording and order.

Field Test

In order to ensure that each question is appropriate for and in alignment with the study, a field test of the interview questions will be conducted to increase reliability. Field testing occurs when the researcher sends a list of the interview questions to individuals who meet the criteria to participate in the study but will not serve as active participants (Dikko, 2016). Because the researcher is following a convenience sampling method, a field test be conducted using the first three individuals who contacted the researcher as interested candidates for the study. Each participant will review the interview questions being used in this study and will provide the researcher with feedback regarding their level of understanding of the interview questions. The researcher will use the feedback provided that aids in ensuring that the interview questions are easy to understand, convey a strong meaning for what is being asked, and are in alignment with the purpose of the study and the problem being explored (Dikko, 2016). Yin (2009) indicated that field testing is an important phase of research and can assists in developing relevant questions and provide conceptual clarifications of the study’s researched design.

The field participants will be giving a written explanation of the study and the 10 interview questions to review and analyze prior to discussion for familiarity prior to responding. Prior to beginning the interview process, the researcher will greet the research participants. The researcher will discuss the interview process and inform the interviewee that the interview session will take approximately 30-40 minutes and would be audio-recorded. The researcher will answer any questions or concerns of the interviewees before beginning the interviews. The field participants will be giving a written explanation of the study and the 10 interview questions to review and analyze prior to discussion for familiarity prior to responding. Credibility and Transferability

Qualitative methodologies require multiple sources of data to converge evidence from varied sources (Yin, 2014). In this qualitative descriptive study, the researcher will collect data from semi structured personal interviews. Four aspects are considered to establish trustworthiness or credibility; credibility, transferability, dependability, and confirmability in qualitative studies (Chapman, 2014). Lincoln and Guba (1985) said the aforementioned four criteria help to reduce the bias of the data.

Credibility is essential for establishing trustworthiness and expertise such as the responses obtained from the participants in the research study. Trustworthiness helps to increase the audience confidence in the rigor of the research findings (Lewis-Beck, Bryman, & Liao,

2004). Providing sufficient information of the participants experiences and providing accurate description or interpretation of the phenomenon help to ensure the quality and trustworthiness of the study (Cope, 2014). Cope (2014) and Krefting (1991) believed that credibility and trustworthiness is strengthened in the study when the description of the participants’ experiences are recognized by others who share the same experience. Trustworthiness is the most important criterion for ensuring the intergrity of the findings in a qualitative study (Connelly, 2016; Krefting, 1991). Seale (2002) posited that the most crucial way to establish credibility is through member checks. Lincoln and Guba (1985) posited providing participants with a copy of the interview transcripts or dialogues to review so they can indicate their agreement or disagreement with the way in which they are represented.

In qualitative research, testing and increasing trustworthiness, quality, and rigor are important (Golafshani, 2003). The participants for the study will of why Married Nigerian women living in Los Angeles, California suffering from depression are not seeking mental health treatment (Onwujuba, Marks, & Nesteruk, 2015; Derr, 2015; Adeponle, Groleau, Kola, Kirmayer, & Gureje, 2017; Ezeobele, Ekwemalor, & Ogunbor, 2019) will be selected for experiences, using convenience sampling model. The credibility of the qualitative research is presented with truthfulness, authenticity, and professionalism. 

Credibility. Credibility will be maintained with the use of 10 semi-structured openended interview questions for each participant (see Appendix C). Anney (2014) stated that credibility in a qualitative study is ensured through confirmation and reflection of the factors addressed in the study. Conducting a field test will ensure proper credibility of the research interview questions and the study.

Credibility is often displayed when the researcher uses strategies like observations, prolonged engagement, triangulation, and member checks (Leung, 2015). It is believed that as long as the researcher describes the data clearly to ensure comparison credibility would be achieved. Credibility will be ensured following the aforementioned, including conducting a field text.

To increase credibility, the researcher will field test the interview questions (Appendix C) with professionals who met the same criteria as the potential participants for the study. The field tested participants will not be included in the actual study interviews. This will allow the researcher to determine if the questions are clear, appropriate, and worded correctly to answer the research questions. During the interview process the researcher will ask open-ended questions allowing the participants to share their personal experiences. If a comment or statement is unclear the researcher would then ask a follow-up question to clarify. To ensure credibility the researcher will also record the field test interviews. Once the recordings are transcribed the researcher will share the transcriptions with the participants by email allowing the participant to make edits and corrections to the transcripts before proceeding the study. This will help to ensure accuracy or credibility of the data.

Transferability. Trochim (2006) explained that transferability involves generalizing about a larger population of the sampled participants. Detailing a complete account of the context and the assumptions that are central to the research could promote transferability (Jensen, 2008; Trochim, 2006). Transferability is the point at which the results may be transferred or generalized to other contexts or settings (Jensen, 2008). Leedy and Ormrod (2010) postulated that research should be conducted in a real-life setting to enhance external credibility to produce results that have broader applicability to similar real-world contexts. 

Transferability refers to the ability of the researcher to transfer the findings to another population or reproduce the results (Leung, 2015). The researcher will keep organized, detailed notes. Labeling each participant with a pseudonym and creating a folder on the computer where all correspondence, notes, and copies of the transcribed interview were kept until participants approve the transcribed interview. Then the transcribed interviews will be archived. Although the research process can be replicated, the research does have some limitations when considering transferability. Limitations include the sample size as well as the specific population restrictions. The researcher will only interview Nigerian married women living in Los Angeles with depression; therefore, it could not be expected that the findings would transfer to another population.

Dependability. Establishing dependability in a qualitative study is important. Long and Johnson (2000) stated that in qualitative research, identical questions should be asked to participants at different times to promote consistent answers, which also safeguards for stability and dependability. In the current study, consistency will be maintained by selecting participants who will help provide in-depth answers about their experiences with depression and barriers in seeking help with it (Jangu, 2012; Long & Johnson, 2000). Maintaining consistency of the data will be achieved through verification and examination of the raw data (Bashir, Afzal, & Azeem, 2008; Campbell, 1996). Conducting a field test for this study will ensure credibility and dependability in this research study.

Dependability refers to the consistency of the findings, this is considered attainable through credibility (Elo, Kääriäinen, Kanste, Pölkki, Utriainen & Kyngäs, 2014). Elo et al. (2014) explained that when dealing with phenomenological interviews, the researcher would need to use methods allowing for follow-up questions and if needed asking for clarification to ensure the participant understands what is being asked. Accuracy requires the researcher to listen carefully to the interviewee, obtaining, recording, and reporting exactly what he or she has heard (El et al, 2017). To prevent inaccuracies, the researcher must be extra careful not put words into the mouth of the interviewee (Elo et al, 2017). To increase dependability, the researcher will record the interviews, transcribed them, and then allowed the interviewees to read and edit them for accuracy. The researcher will also use qualitative data analysis software to allow for analyzing the qualitative data using pattern-based auto coding and increasing dependability.

Confirmability. Confirmability is considered a combination of credibility and transferability. Cope (2014) claimed using triangulation strategies and ensuring an audit trail would increase confirmability. According to Cope (2014), experimenter bias exists when a researcher unconsciously influences or changes the behavior of participants in a way that favors the outcome of the results. This includes a researcher who has experienced the phenomenon or has certain beliefs about the nature of the research (Cope (2014). Cope stated confirmability signifies the extent to which the research findings can be confirmed or substantiated by other researchers. Several strategies can help to increase the effectiveness of confirmability (Cope, 2014). In this investigation, the researcher will conduct a data audit to confirm the truth and negate bias potential in the study (Cope, 2014). Maintenance of the authenticity of the research process will be protected by the researcher through examining and re-examining the data throughout the entire process (Cope, 2014).

Data Collection

After approval has been obtained from the University of Phoenix’s IRB office, the researcher will contact member organizations to select participants, and subsequently collect data. The researcher will contact members directly through member Facebook pages, and in addition to contacting the Anioma Association Los Angeles and the Nigerian Women Nurses Association to obtain permission to place an advertisement in their electronic newsletter to recruit participants to the study. When interested individuals contact the researcher, she will then send them an electronic mail (email) describing the study’s purpose and aim, along with a consent form and confidentiality agreement. The consent form (see Appendix D) will highlight the study’s problem statement, purpose statement, confidentiality, and any risks associated with participating in the study. There are no forceable risks for participants of this study, greater than the everyday minimal risks experience by all. After the participant has signed the consent form and has agreed to participate in the study, the researcher will then schedule a time for them to complete a private interview. 

Each interview will take place at a confidential location and the researcher will use the interview protocol and ask each participant the same 10 open-ended questions. The researcher will minimally guide the participants when they answer each question by asking follow-up questions or requesting clarification in order to increase the reliability of the data. Each interview will be electronically recorded and will be transcribed in preparation for data collection. A copy of each transcribed interview will be sent to every participant so that they can review the interview to ensure the reliability of the information obtained. The researcher will be able to adjust any of the participants’ answers if they feel that the content was not appropriately transcribed (Birt, Scott, Cavers, Campbell, & Walter, 2016).

After approval has been obtained from the University of Phoenix’s IRB office, the researcher will contact member organizations to select participants, and subsequently collect data. The researcher will contact members directly through member Facebook pages, and in addition to contacting the Anioma Association Los Angeles and the Nigerian Women Nurses Association to obtain permission to place an advertisement in their electronic newsletter to recruit participants to the study. When interested individuals contact the researcher, she will then send them an electronic mail (email) describing the study’s purpose and aim, along with a consent form and confidentiality agreement. The consent form (see Appendix D) will highlight the study’s problem statement, purpose statement, confidentiality, and any risks associated with participating in the study. There are no foreseeable risks for participants of this study, greater than the everyday minimal risks experience by all. After the participant has signed the consent form and has agreed to participate in the study, the researcher will then schedule a time for them to complete a private interview. 

Each interview will take place at a confidential location and the researcher will use the interview protocol and ask each participant the same 10 open-ended questions. The researcher will minimally guide the participants when they answer each question by asking follow-up questions or requesting clarification in order to increase the reliability of the data. Each interview will be electronically recorded and will be transcribed in preparation for data collection. A copy of each transcribed interview will be sent to every participant so that they can review the interview to ensure the reliability of the information obtained. The researcher will be able to adjust any of the participants’ answers if they feel that the content was not appropriately transcribed (Birt, Scott, Cavers, Campbell, & Walter, 2016).

Prior to beginning the interview process, the researcher will greet the research participants. The researcher will discuss the interview process and inform the interviewee that the interview session will take approximately 30-40 minutes and would be audio-recorded. The researcher will answer any questions or concerns the interviewees may have, before beginning the interviews. Each perspective interviewee will be presented with the informed consent document. The researcher will discuss the purpose and importance of the informed consent document. Perspective interviewees will have an opportunity to ask questions about the informed consent. Participants will be reminded that, although they signed the informed consent document, they could, if necessary, withdraw from the research study at any time without penalty or consequence.

 

Data Analysis

Data analysis for this study will be completed using both NVivo 12.0 and a qualitative codebook. NVivo is a qualitative software program that is utilized by the majority of research universities that aid in coding and the development of themes (Corbin, Strauss & Strauss, 2014). Additionally, a qualitative codebook aids the researcher in completing a content and thematic analysis, where each of the interview transcripts, highlighting keywords to code the data and identifying emerging themes are reviewed. A qualitative codebook will highlight the participants’ responses to each question allowing the researcher to become familiar with the content found in the data.

Interview will be audio-taped verbatim. By taping the interview verbatim, the research will be better able to create text to enrich themes and concepts to be analyzed. The researcher will provide an identification code using pseudonym for all intending participants. This will ensure participant information from being tampered with or loss. 

Taping the interviews will help the researcher in transcribing audio-taped interviews. It will allow the researcher to conduct a more detailed interview. The researcher will analyze interviews several times using this system. The processes will allow for the organization of themes and concepts most important for data analysis accuracy. Participants lived experiences will be assessed in small portions to show the rich description of their experiences. 

Themes will be created from the meanings to create clusters and later categories of themes. A color-code system will be used to highlight particular themes from the analysis. Data from various sources will be triangulated to create a logical explanation supporting themes. Data sources will be classified and background data will be collected.

To aid data triangulation, interview data will be interpreted; a note of trends across datasets will be made and data relating to themes will be connected. The researcher will check, corroborate and or refute the data and if necessary, identify additional data. The findings will be evaluated, conclusions drawn, the results and recommendations will be communicated. The researcher will conduct a careful review of all participant interview responses and transfer the information to the data collection form. As discussed previously, the researcher will record and code the raw data obtained from the interviews to decrease the complicated process as well as prevent human error in transposing the numeral responses incorrectly (Creswell & Creswell, 2017). The researcher will make every effort to conduct outreach to participants who miss an interview session (Creswell & Creswell, 2017).

Summary

Chapter 3 discussed the fundamentals of qualitative research method. Included in the chapter were the research methodology, research method and design appropriateness, research questions, population and sample, informed consent and confidentiality, instrumentation, and field test. The the process of data collection, data analysis and ethical concerns were discussed. The process of ensuring credibility and transferability of qualitative data through triangulation, coding, and transcription were delineated.

Chapter 4 will include a review of the purpose statement and the limitations of the study. 

The participant demographic summary will be presented. Also included in Chapter 4 will be the results of data analysis in response to the research questions and dominant themes worthy of further research and reflection. This study will utilize a qualitative descriptive design, recruiting 15 participants following a convenience sampling method. 

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