key: cord-0258536-x1vjmam1 authors: Bamgbose Pederson, A. O.; Waldron, E.; Burnett-Zeigler, I.; Clark, C. T.; Lartey, L.; Wisner, K. title: Perspectives on mental illness stigma among African immigrant pregnant and post-partum women in an urban setting: a brief report date: 2021-11-11 journal: nan DOI: 10.1101/2021.11.06.21266011 sha: 6d16b850740547f29e05bf1d2d67dc0b182e143b doc_id: 258536 cord_uid: x1vjmam1 Purpose: This study assessed the perspectives of pregnant and post-partum African immigrant women on mental illness. Methods: We conducted a focus group session (N=14) among pregnant and postpartum African immigrant women in June 2020. We used an inductive driven thematic analysis to identify themes related to mental health stigma. Results: Five core themes emerged: conceptualization of mental health, community stigmatizing attitudes, biopsychosocial stressors, management of mental health and methods to reduce stigma. Conclusion: Understanding the perspectives of pregnant African immigrant women at the intersection of their race, ethnicity, gender and migration is necessary to improve engagement with mental health services. In the US, 13-19% of women who give birth experience postpartum depression (3, 5) . Despite the similarity in prevalence of postpartum depression among White, Black and Latina people, utilization of mental health services is lower among African immigrants (6, 7) . Rates of depression treatment are particularly low among Black compared to White pregnant women (8) . Moreover, migrant status affects health outcomes; for example, Canadian-born women experienced significantly different risk factors for postpartum depression compared to immigrant women (9) . Data on mental health and associated stigma among pregnant and post-partum immigrant women in the US has focused more on Latina rather than Black immigrant women (10) . To address mental illness stigma and improve engagement in mental health services (11) (12) (13) (14) , dedicated studies are necessary in the peripartum and postpartum period for African immigrant women. We assessed the perspectives of pregnant and postpartum African immigrants on the conceptualization of their emotional health, views on mental health stigma and the underlying religious and cultural beliefs influencing mental health service use. The institutional review board at Northwestern University approved this study. Written and informed consent was completed. Setting. The study was completed in partnership with the United African Organization (UAO). UAO provided social services to African immigrants. The Northwestern University team included a psychiatrist and a research coordinator. Participants. The focus group and survey participants (N=14) inclusion criteria were:1) identifying as an African immigrant, 2) pregnant or postpartum within the past 12 months, 3) English speaking, and 4) 18 years of age or older. Participants were recruited using All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted November 11, 2021 notes were taken to aid reliability and validity. Probes and member checking were used to expand ideas and verify meaning expressed by participants (15). All participant' information was de-identified to ensure confidentiality. The focus group questions are presented in Table 1 . We used a grounded theory thematic approach (16, 17). NVivo software, a qualitative analysis tool, was used. The focus group was audio recorded and transcribed using Rev, an authenticated platform for transcription. We employed five iterative steps (16): initial review, line coding, organization of meaning units, discussion and final review of consistency between coders. Intercoder reliability (K > 0.80) was reached. Coders applied the codebook to the full transcript. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted November 11, 2021. ; https://doi.org/10.1101/2021.11.06.21266011 doi: medRxiv preprint reported people with depression are unpredictable. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Respondents offered several ways to manage mental health in the context of pregnancy including self-motivation, religious resources and talking to others (both in the community and professionally). While 50.0% of respondents reported that they would call 911 or seek immediate help if someone was having suicidal thoughts, five (35.7%) said they would never or rarely seek immediate help. Theme 5. Methods to reduce stigma. One respondent described mental health as invisible and difficult to "normalize." Respondents suggested public health campaigns and awareness groups in the community, similar to the focus group forum. In particular, one respondent described the need to support pregnant women due to the added psychosocial stressors that come with pregnancy. Insert Table 3 . Core themes and representative quotes All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted November 11, 2021. ; https://doi.org/10.1101/2021.11.06.21266011 doi: medRxiv preprint Our main finding was that stigma towards mental health was associated with the label of being "crazy" or being judged. In addition, medication was not viewed as acceptable, but there was openness to activities such as support from the community and psychotherapy. There was acceptance of the biopsychosocial aspects of pregnancy (including hormonal changes); despite this acknowledgement, most respondents had stigmatizing views of medications. Majority of respondents (64.3%) reported they would rarely or never take prescription medications. And some respondents endorsed beliefs that sadness or depression is a moral failure, a sin or caused by evil spirits. Past studies show that stigmatizing beliefs similar to these led to low utilization of mental health services and worse mental health outcomes related to higher morbidity and mortality (20, 21). Previous studies have also shown that pregnant African immigrant women had better self-rated physical and mental health compared to US-born and Caribbean-born pregnant Black women (10), likely due to the healthy migrant effect (6, 22) . The healthy migrant effect refers to the concept that migrants tend to have better health status than people of similar backgrounds in the host country (23); however, over time, likely due to the effect of racism, gender and migration, this apparent advantage is diminished (23, 24). In our sample, the willingness to seek professional mental health services, especially pharmacotherapy was particularly low. There are higher somatization rates among African immigrants, compared to US born Black people; African immigrants tend to focus on physical health symptoms and prefer primary care health professionals (6, 7) . In our study, respondents endorsed anxiety and low mood symptoms, such as difficulty sleeping, elevated heart rate, tearfulness, irritability and generally feeling overwhelmed. Due to somatization, pregnant African immigrant women are at elevated risk of health care professionals not recognizing their symptoms. Therefore, they may experience further delay in initiation and engagement in mental health services in pregnancy, where early intervention is critical (4, 25). All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted November 11, 2021. ; https://doi.org/10.1101/2021.11.06.21266011 doi: medRxiv preprint Our finding should be considered in the context of the study design; though the sample size was small, there were several areas of consensus around conceptualization of mental illness and associated stigma. This study shows conceptualization of mental illness, stigmatizing views and specific negative attitudes towards medication use among peripartum and postpartum African immigrant women. Understanding the perspectives of pregnant African immigrant women at the intersection of their race, ethnicity, gender and migrant status is necessary to address mental illness stigma that leads to low utilization of mental health services within our health systems (6, 7). 2) What is your understanding of changes in emotional wellness including stress or distress that can happen while pregnant or after pregnancy? 3) What are your perceptions of your community's understanding of stigma of emotional wellness while pregnant or after pregnancy? Do you believe emotional wellness of mothers is looked down upon in our society/community? In what ways? 4) What is the definition of mental health stigma? 5) Tell us about personal stigma of emotional wellness while pregnant or after pregnancy: All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Table 3 . Core themes and representative quotes Core themes Key participant quotes Conceptualization of mental health in the community "Emotional wellness is when an individual is able to handle stressful situations and they're able to adapt to certain changes and when times are difficult, they're able to deal with it." "I think it's really accepting how I'm feeling, that, "This is real. This is how I really feel or what I'm really experiencing as part of myself and who I am." "In our culture … when you use the word mental health, you are crazy, you are not normal, whatever normal is, functional person in society, you are literally a mad person who's not... or nobody should really associate with you because you are not normal. And for that reason, it hinders people from seeking the support they need. So it's, it's, it's very difficult for anybody" "Depression is in different stages, you know. If somebody is depressed, do that mean that they can't get a job? It depend on what, uh, the stage of their depression or why they're depressed, you know." "Talking about mental health, and the stigma that is associated to it. For instance, I personally, I went through that and it was something that …I've never had any experience of that, so it was something very strange to me…. I couldn't sleep, I was just going up and down, I couldn't do anything, I felt like my throat is closing up, I felt like my heart rate is beating so fast" "For example, you're pregnant, you don't wanna tell somebody, "Oh, All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. I have this problem and I have that problem," because they will just jump into a conclusion of, "Uh-oh, this person is, you know, having these issues, maybe, you know..." Using that word "mental health," or emotionally unstable, all of these things are negative connotation in our, in our community," Community stigmatizing attitudes towards mental health challenges during pregnancy "Some look down on pregnant women, you're just supposed to stay home, rest and such, but it's like they forget the fact that even though you're pregnant, you still need some type of financial support; if you don't have anyone supporting you, you still have to support yourself somehow." "That's the first thing they will just say, "You crazy." And that's what frustrated me even more throughout the pregnancy and this postpartum, that word crazy. I'm not crazy because I'm having some emotional issues, because I'm having some mental issues, I'm not crazy." "I just feel like there's no need for me to even open my mouth and tell you my problem because the first thing you just say is I'm crazy" "you know, a lot of people will not open up, they'll prefer to get the help from outsiders, because sometimes you can have mental issue and the only thing you just want is to talk to someone that can understand you, have someone hear you out and give you different perspective, different answers on how you can help yourself. But when you're dealing with your own emotional health and mental health, and the other person is just saying, "You're crazy." "And by this being my first pregnancy, I get really frustrated because when the baby cries, she doesn't stop crying, I'm just holding her in my hand, like, it irritates me, I get frustrated even more and then, like, many people don't understand that. Instead of giving me different ideas and solutions how I can make it better, you're just standing there telling me I'm crazy, I'm freaking out, like, and that word me, the word crazy." "Check that family, maybe they have mental health history, 'this person comes from the mentally retarded people.' And I'm just, you know, sometimes looking at people like… 'you are diagnosing somebody's entire family based on a challenge'" "But when, because they cannot see your emotional pain, they are quick to judge and call it crazy…. Start opening a door for that conversation, we will get a chance to make it a normal way of knowing, "Oh, mental health is not craziness, it's just another form of physical health that is not seen." "Yes, I've called my doctor and he said if I keep having that feeling then I should come for... then they will have to put me on medication." So when I told my friend, as a nurse, I thought she All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted November 11, 2021. ; https://doi.org/10.1101/2021.11.06.21266011 doi: medRxiv preprint would be a, a pillar of support but it was something that she was even panicking more than me, and she made me... she gave me more anxiety because she was like, "You can't take any medication. You have to talk to somebody." She [said] "You, you're going to end up in the psych home if you start this medication," so it made the anxiety worse than how it was." Biopsychosocial stressors and hormonal changes during the peripartum and post-partum period "One minute your hormones can be like, they're like very unstable, out of control, very high, and you're just very frustrated, every little thing frustrates and irritates you…. And then sometimes the other person does not understand that, and you're not even understanding how you reacting to the person." "I was actually enjoying being pregnant. You know, it could be because the people I surrounded myself with, from work to home, and everything, It was like a support system, it was like an understanding. But the hormones have their own time, but I just find a way to balance it." "You know, there were challenges... challenging time in the middle of it but I just paced myself accordingly. So it was about me thinking, "Okay, there is somebody in me, she's a priority, not even myself, not even my feeling." But as time goes by, until about eight months when my feet were swelling…. And I have to get away and r-remind myself that nobody understands" "And after having the baby…. How am I gonna sleep when I have all this 20 things to do? And whether I sleep or not, I still have to get those things done. And then your body is telling you, " Listen, I'm still hurting, I'm still healing, you can't do all this stuff." "And after the pregnancy, it was anything can make me cry. Anything happen, I was like just crying, crying. Sometime when you look at back what happened, you, you feel like, "This one, I shouldn't cry regarding this," but when I was feeling it, everything I was just crying, crying." "After having the baby, three months after that, I was still tired. The best thing that ever happened, Corona might be negative, but somehow it saved me because I didn't have to get up and drive. Because I just realized that I could not wake up at 3:AM and be with her for about two hours and then get up and start driving to get to work at 9:00 AM." Management of mental health during the perinatal and postpartum period, views on "For me, the pregnancy was so easy but adjusting to the schedule of the baby and waking up and doing this every day; when I wake up at midnight, when I wake up at 3:00 AM, when I wake up at 4:00 AM just to feed and put her back to bed, there are times where I'm tired but I have to look at the positive feedback to gain my strength and All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. "I didn't tell her but I didn't even know who to talk again, because if I can tell someone who is in the medical field and she put more fear in me than I was going through. So I, I just decided to call the doctor, I saw the doctor and I started taking the medication." All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. "Just go pick up the Quran," and they say you'll get better. No, I want to talk. Everything is not spiritual to everyone, and that's just my thing. because every individual is different. And to you, oh, once you just get up and pray everything will go away, no. And that's like a lot of conflict during pregnancy and after pregnancy." "You know, when you just go like, "Oh, something is wrong." "Oh, you're crazy. Just pick up the Quran and you start reading, and then you will feel better." I'm like, "No. Like, I need someone to actually hear me out. I need to talk to this person. I need to talk to somebody who can, you know, give me different ideas and different perspectives and how I can manage things." Methods to reduce stigma "First of all we need to normalize mental health just like where you have the physical health. Physical health is because you cannot hide it, mental health is because you cannot see it. But how can normalize and make people comfortable to know that, "It's okay to be feeling the way I feel. I talk to somebody and no judge." "How can we get to that place where mental health is not a stigma, men-mental health is not craziness? Mental health is just like you having a headache, [00:38:00] and maybe you need to rest or need someone to talk to, or need to address that problem that's causing your stress. Or at least help the community understand that mental health is this and that, and not craziness. Mental health is you having a challenge in your life that's not changing for a long period of time and it starts to affect you emotionally" "We need the campaign, we need the awareness, we need the training, we need the group and the community. We need it all to, you know," "Well, if there's any campaign, any awareness, any group, like we're doing now, to be able to educate each other, to be able to speak freely, and understand what those things means … if you need to go for counseling, if you need to chat with your friend, then you can do that. You can even... There's Zoom now, you can have friends on Zoom, like, evening time, with your wine, chat, whatever, hence you are not recording it, you can chat" "And I also feel like the community should be more involved with helping pregnant women have even some type of part-time job because some people are different …. My experience, my stress was financial stress, my stress was emotional stress and someone else's pregnancy may not be financial stress or that kind of emotional stress, it can be just something else Facts on U.S. Immigrants 2017, Statistical portrait of the foreign born population in the United States Pew Research Center Hispanic Trends Key facts about black immigrants in the U.S. Pew Research Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and metaanalysis Treatment of Peripartum Bipolar Disorder Postpartum depression: current status and future directions African Immigrant Health Mental Health Concerns Among African Immigrants Stigma and Depression During Pregnancy: Does Race Matter? The healthy migrant effect and predictors of perinatal depression Variations in health and health behaviors by nativity among pregnant Black women in Philadelphia Evidence for effective interventions to reduce mental-health-related stigma and discrimination