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African Immigrants’ U.S. Experience of Mental Health, Mental African Immigrants’ U.S. Experience of Mental Health, Mental

Illness, and Help-Seeking Illness, and Help-Seeking

Bartholomew Edem-Enang
Walden University

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Walden University

College of Social and Behavioral Sciences

This is to certify that the doctoral dissertation by

Bartholomew A. Edem-Enang

has been found to be complete and satisfactory in all respects,
and that any and all revisions required by
the review committee have been made.

Review Committee

Dr. Susan Marcus, Committee Chairperson, Psychology Faculty

Dr. Chet Lesniak, Committee Member, Psychology Faculty
Dr. Georita Frierson, University Reviewer, Psychology Faculty

Chief Academic Officer and Provost
Sue Subocz, Ph.D.

Walden University
February 2021

Abstract

African Immigrants’ U.S. Experience of Mental Health, Mental Illness, and

Help-Seeking

By

Bartholomew A. Edem-Enang

MS, Walden University, 2012

BS, Walden University, 2010

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Clinical Psychology

Walden University

December 2020

Abstract

The purpose of this study was to qualitatively examine and explore African immigrants’

U.S. experience of mental health, mental illness, and help-seeking. Mental health, mental

illness, and help-seeking are misunderstood public health issues. Indigenous cultural

stigma concerning mental illness and help-seeking and mistrust of Western medicine

inhibit African immigrants from reporting mental illness and seeking treatment. The

segmented assimilation theory (SAT) and cultural risk theory (CRT) and interpretive

phenomenological analysis (IPA) were used to guide data collection and analysis. Data

were collected from a sample of 9 African immigrants who migrated from countries

within the Five Main Regions of Africa to the U.S. using a semi-structured interview

guide. The six-step data analysis method was used in this study as a guide to the thematic

analysis. The themes associated with each research question were as follows:

assumptions and expectations and experience of mental health, cultural experience of

mental illness and participant occupation, meanings of help-seeking and subject of story,

and importance of cultural understanding and dissatisfaction. The results of this study

show how different traditional cultural beliefs are experienced in a foreign country and

how culturally distinct immigrants struggled with risks and problems. The results of this

research point to rigorous and meaningful recommendations for policy and practice,

leading to positive social change including recruitment and training of psychologists who

understand African immigrants and come from the same cultural background.

African Immigrants’ U.S. Experience of Mental Health, Mental Illness, and Help-Seeking

By

Bartholomew A. Edem-Enang

MS, Walden University, 2012

BS, Walden University, 2010

Dissertation Submitted in Partial Fulfillment

of the Requirements for the Degree of

Doctor of Philosophy

Clinical Psychology

Walden University

December 2020

Dedication

I dedicate this study to my late father, Chief (Pastor) Joseph Offiong Edem, who

was my best friend, counselor, and teacher who taught me the significance of education

for continued development and progress. I dedicated this study to my late mother,

Deaconess Affiong Edem, who never got a chance to be formally educated yet instilled

the value of education in all her seven children. I dedicate this study to my late aunt,

Deaconess Aggie Sampson, who like my mother never got a chance to be formally

educated but instilled the value of higher in education in me. I dedicate this study to my

late senior brother, Mr. Ime Joseph Offiong Edem and late sister, Miss Grace Joseph

0ffiong Edem who believed before I did, that I should be given a chance for higher

education beyond Primary School and above. I dedicate this study to my eldest brother,

His Elate Excellency, Ambassador Samuel Joseph Offiong Edem, the first university

graduate in the Edem Family who encouraged and believed before I did, that I could

complete this Ph.D. Finally, I dedicate this study to all the members of the Edem Family

for them to know that age is not a barrier to education, negativity has no room in success,

positive thinking enhances hope and that the sky is the only limit to academic and

professional accomplishments.

Acknowledgments

First and always, I am grateful to God that this is even a reality. A Ph.D. was

nowhere in my plans or my wildest dreams, but the Almighty God, the maker of heaven

and earth, had more real and better plans for me. With great respect and high regards, I

wish to acknowledge and express my gratitude and appreciation to several individual

groups who have tremendously supported me throughout the study. A special thank-you

goes to “Walden Academic Community Friends and Fellow Class Members” who were

formerly strangers but progressed to become “Accomplished Members of the Walden

University Family Network”, who with unlimited encouragement willingly shared their

academic knowledge and professional experiences with me during Academic Year

Residencies (AYRs). I am privileged to have such friends and well-wishers around who

helped and strengthened me to focus on the attainment of my designated objective.

Primarily, I would like to acknowledge with heartfelt gratitude the great

contributory efforts of each of the men and women who participated in this study and

trusted me with some of their most trying academic and professional experiences, which

without this study would not have been possible. I want to thank the Chairperson of my

Dissertation Committee, and my able Supervisor, Dr. Susan H. Marcus, who from the

first day never failed to assure me of completing my dissertation successfully. Her

thoughtfulness, inclusive support, patience, supervision, and encouragement enhanced

my capabilities to prevail throughout all challenges and demanding circumstances

embedded with this academic venture, officially defined as Dissertation Research. I also

want to acknowledge my former Second Committee Member, Dr. Yoly Zentella, for her

interest in my study and cultural understanding, which permitted and enabled me to

integrate some related concepts in the study, and that, enhanced my abilities to move

forward. I thank you for your support, contribution, willingness to work with me during

Dr. Marcus’s absence, constructive and insightful feedback you offered to me and your

presence all the time in my dissertation process. I am grateful to my current Second

Committee Member, Dr. Chet F. Lesniak for his kindness and support, and consideration

to serve in my Dissertation Committee and contribute to the final part my study. Know

that I am incredibly grateful for your kindness, compassion, and support you have shown

me through the years at Walden University. I am also grateful to the former URR, Dr.

Thomas Edman, and the current URR, Dr. Georita M. Frierson for their commitments to

overseeing and supporting this challenging academic project. I also want to thank Dr.

Susana Verdinelli, the Program Director for her kindness and support. I am forever

grateful to Dr. Marilyn J. Powell, former Dean of School of Psychology, Vice Provost,

Riley College of Education and Leadership; College of Management and Technology;

Academic Residencies for her kindness, consideration and unwavering support during the

most challenging times of this journey, and being available for me throughout the time. I

would also like to I thank the Walden University IRB members for their kindness and

support to offer approval to my study.

I thank the immediate and supportive Bartholomew Abasi J.O. Edem-Enang

Family Members, Enobong B. Edem-Enang, RN, MSN, Iferke Abasi Offiong Edem-

Enang, Inemesit Bartholomew Edem, and Destiny Abasi Offiong Edem-Enang for their

encouragement, challenges to do better, success in my endeavors, and expectations for

improvement, all of which I simply accepted as mobilized implements for completion of

this study. I thank the members of Metropolitan Baptist Church of Altadena, CA, and all

my friends and colleagues for their constant support and kindness. Most especially, Dr.

Dean Cooper and Linder Cooper for their kindness and support that will always be

remember. I want to thank everyone that I do not mention by name here from the bottom

of my heart. I offer all the praise and magnificence to the Almighty God for blessing my

life, my native country Nigeria and my new country United States of America, which

offered improved educational opportunities that enabled me to attain this tremendous

academic accomplishment.

i

Table of Contents

List of Tables ……………………………………………………………………………………………………… vii

List of Figures ……………………………………………………………………………………………………. viii

Chapter 1: Introduction to the Study ……………………………………………………………………….. 1

Background …………………………………………………………………………………………………….. 2

Problem Statement …………………………………………………………………………………………… 5

Purpose of the Study ………………………………………………………………………………………… 6

Research Questions …………………………………………………………………………………………. 6

Theoretical Frameworks …………………………………………………………………………………… 6

SAT ………………………………………………………………………………………………………….. 6

CRT …………………………………………………………………………………………………………. 7

Theories’ Relation to the Study Approach and Research Questions ………………….. 7

Nature of the Study ………………………………………………………………………………………….. 8

Brief Summary of the Methodology ……………………………………………………………… 9

Definitions ……………………………………………………………………………………………………… 9

Assumptions …………………………………………………………………………………………………. 11

Scope and Delimitations …………………………………………………………………………………. 11

Limitations ……………………………………………………………………………………………………. 13

Significance ………………………………………………………………………………………………….. 14

Summary ………………………………………………………………………………………………………. 15

Chapter 2: Literature Review ……………………………………………………………………………….. 16

Literature Search Strategy ………………………………………………………………………………. 16

ii

Theoretical Framework ………………………………………………………………………………….. 17

SAT ………………………………………………………………………………………………………… 17

CRT ……………………………………………………………………………………………………….. 19

Relationship of Frameworks to the Proposed Study ……………………………………… 20

Literature Review Related to the Key Concepts ………………………………………………… 21

African Migration to the U.S. …………………………………………………………………….. 21

Acculturation of Immigrants to Life in the U.S. …………………………………………… 22

Challenges to African Immigrants’ Acculturation ………………………………………… 23

Culturally Relevant Mental Health Care for African Immigrants ……………………. 24

Mental Health ………………………………………………………………………………………….. 24

Mental Illness ………………………………………………………………………………………….. 28

Help-Seeking …………………………………………………………………………………………… 30

Role of Stigma in the Mental Health Help-Seeking ………………………………………. 32

Research on the Experience of Stigma ………………………………………………………… 32

Summary and Conclusions ……………………………………………………………………………… 36

Chapter 3: Research Method ………………………………………………………………………………… 39

Research Design and Rationale ……………………………………………………………………….. 39

Research Questions ………………………………………………………………………………….. 39

Central Concepts/Phenomenon of the Study ………………………………………………… 39

Rationale for IPA Design ………………………………………………………………………….. 39

Role of the Researcher ……………………………………………………………………………………. 40

Methodology …………………………………………………………………………………………………. 43

iii

Participant Selection Logic ………………………………………………………………………… 43

Instrumentation ……………………………………………………………………………………………… 47

Basis for Instrument Development ……………………………………………………………… 47

Procedures for Recruitment, Participation, and Data Collection …………………………… 49

Data Analysis Plan …………………………………………………………………………………… 51

Issues of Trustworthiness ……………………………………………………………………………….. 53

Credibility ……………………………………………………………………………………………….. 54

Transferability …………………………………………………………………………………………. 55

Dependability ………………………………………………………………………………………….. 55

Confirmability …………………………………………………………………………………………. 55

Ethical Procedures …………………………………………………………………………………………. 57

Summary ………………………………………………………………………………………………………. 59

Chapter 4: Results ……………………………………………………………………………………………….. 60

Setting ………………………………………………………………………………………………………….. 60

Demographics ……………………………………………………………………………………………….. 61

Summary of Participants’ Experiences ……………………………………………………….. 62

Data Collection ……………………………………………………………………………………………… 69

Data Analysis ………………………………………………………………………………………………… 70

Procedures ………………………………………………………………………………………………. 70

First Cycle ………………………………………………………………………………………………. 71

Second Cycle …………………………………………………………………………………………… 72

Evidence of Trustworthiness …………………………………………………………………………… 73

iv

Credibility ……………………………………………………………………………………………….. 73

Transferability …………………………………………………………………………………………. 74

Dependability ………………………………………………………………………………………….. 74

Confirmability …………………………………………………………………………………………. 75

Results: First Cycle ………………………………………………………………………………………… 75

Experience of Mental Health ……………………………………………………………………… 77

Experience of Mental Illness ……………………………………………………………………… 78

Meaning of Help-Seeking Experience …………………………………………………………. 82

The Experience of Prejudice and Discrimination in Mental Health …………………. 86

Occurrence of Indigenous Cultural Stigma in Mental Illness …………………………. 88

Occurrence of Indigenous Cultural Stigma in Help-Seeking Experience …………. 92

The Experience of the Participant ………………………………………………………………. 95

Utilization of U.S. Services ……………………………………………………………………….. 99

Results: Second Cycle ………………………………………………………………………………….. 102

Category 1: Assumptions and Expectations ……………………………………………….. 104

Category 2: Importance of Cultural Understanding …………………………………….. 108

Category 3: Experience of Mental Health ………………………………………………….. 111

Category 4: Cultural Experience of Mental Illness ……………………………………… 113

Category 5: Meanings of Help-Seeking …………………………………………………….. 116

Category 6: Dissatisfaction ………………………………………………………………………. 119

Racial Prejudice and Discrimination …………………………………………………………. 120

Accessibility of Mental Health Services ……………………………………………………. 121

v

Assessment and Diagnosis ………………………………………………………………………. 122

Category 7: Subject of Story ……………………………………………………………………. 123

Category 8: Participant Occupation …………………………………………………………… 125

Summary …………………………………………………………………………………………………….. 127

RQ1 ………………………………………………………………………………………………………. 128

RQ2 ………………………………………………………………………………………………………. 129

RQ3 ………………………………………………………………………………………………………. 132

RQ4 ………………………………………………………………………………………………………. 132

Chapter 5: Discussion ………………………………………………………………………………………… 134

Interpretation of Findings ……………………………………………………………………………… 135

Assumptions and Expectations …………………………………………………………………. 135

Importance of Cultural Understanding ………………………………………………………. 136

Experience of Mental Health ……………………………………………………………………. 136

Cultural Experience of Mental Illness ……………………………………………………….. 137

Meanings of Help-Seeking ………………………………………………………………………. 137

Dissatisfaction ……………………………………………………………………………………….. 139

Subject of Story ……………………………………………………………………………………… 140

Participant Occupation ……………………………………………………………………………. 141

Interpreting Findings in the Context of the Theoretical Frameworks …………….. 143

Limitations of the Study ……………………………………………………………………………….. 144

Recommendations ……………………………………………………………………………………….. 146

Implications ………………………………………………………………………………………………… 147

vi

Conclusions ………………………………………………………………………………………………… 149

References ……………………………………………………………………………………………………….. 153

Appendix A: Invitation to Participate in Research …………………………………………………. 188

Appendix B: Consent Form ………………………………………………………………………………… 190

Appendix C: Interview Guide …………………………………………………………………………….. 194

Appendix D: Mental Health Resources ………………………………………………………………… 196

Appendix E: Transcriptionist Confidentiality Agreement ………………………………………. 198

Appendix F: NVivo Code Book of Research Data ………………………………………………… 200

Appendix G: Recognized Main Five Regions in Africa …………………………………………. 204

Appendix H: United Nations Map of Five Main Regions in Africa …………………………. 208

vii

List of Tables

Table 1. Sources for Developing Interview Questions for Content Validity ……………….. 48

Table 2. Summary of Participants’ Characteristics ………………………………………………….. 61

Table 3. First Cycle …………………………………………………………………………………………….. 75

Table 4. Results of Second Cycle ………………………………………………………………………… 103

viii

List of Figures

Figure 1. Arrangement of key content areas …………………………………………………………… 72

Figure 2. Arrangement of merged categories ………………………………………………………….. 73

1

Chapter 1: Introduction to the Study

This qualitative study explored African immigrants’ experiences in the United

States (U.S.) involving mental health, mental illness, and help-seeking. The rationale for

this study was to explore the unique experiences of this immigrant group, as their

numbers in the U.S. constitute a substantive minority who need mental health services

that could address mental health issues as well as challenges regarding cultural

assimilation and loss of home and identity. Furthermore, different and culturally-based

social stigma involving mental health conditions and help-seeking problems inhibit

minority immigrants from reporting mental illnesses and seeking treatment (Schock-

Giordano, 2013). African immigrants are vulnerable to social discrimination and

assumptions of criminality, which impacts their willingness to explore and use mental

healthcare services (Dale & Daniel, 2013).

Social implications for understanding the cultural beliefs of this ethnically diverse

population involve how to better understand their mental health help-seeking, assessment,

and treatment needs. This chapter includes background and research on mental health

help-seeking and treatment for minority immigrant populations. This is followed by the

problem statement, purpose of the study, research questions, theoretical frameworks, and

critical definitions, as well as a discussion of assumptions, scope and delimitations, and

design limitations. The chapter concludes with a statement of potential social change

significance, summary, and transition to Chapter 2.

2

Background

The majority of African immigrants came to the Unites States as foreign students

during the early 1920s. This changed drastically during the early 1990s, that most African

immigrants were coming to the U.S. as refugees to seek better conditions of living and

religious freedom. The United States Census Bureau (USCB, 2010) said the number of

African immigrants living in the U.S. increased from 881,300 in 2002 to 1.9 million in

2011. About 75% were Black, 19% were Arabs (mostly White) from the northern region

of Africa (Immigration Policy Center (IPC), 2012; McCabe, 2011; Ross-Sheriff & Moss-

Knight, 2013).

Most Africans brought with them their cultural beliefs influenced views of mental

health, mental illness, and help-seeking which are distinctly different from normative

U.S. perspectives, resources, and interventions (Amri & Bemak, 2013; Amuyunzu-

Nyamongo, 2013; Hirschman, 2015). African cultures consider spiritual phenomena as

fundamental to success and wellbeing in life. Religious beliefs include the notion that

individuals who pass away transform into ascended masters and unseen ancestral spirits

who involve themselves in daily affairs, including protection from evil forces, good

fortune, success during day-to-day undertakings, marital relationships, and prevention of

mental illness (Aina & Morakinyo, 2011; Akomolafe, 2012). Mental illness is viewed as

spiritual possession or beliefs that animals, aliens, demons, extraterrestrials, gods, idols,

or spirits can take control of a human body. Individuals experiencing mental illness may

be dangers to themselves, others and law enforcement officers. Perceived sorcery is often

3

assigned responsibility for loss of personal resources, family, and friends (Aina, 2004;

Aina & Morakinyo, 2011).

American mental healthcare systems (AMHCSs) do not recognize the unique

challenges of African immigrants (Monteiro, Ndiaye, Blanas, & Ba, 2014). Individuals

who belong to ethnically diverse minority population groups including African

immigrants receive less treatment than their White counterparts, even though the demand

for mental healthcare services is comparable (Amuyunzu-Nyamongo, 2013; Bauldry &

Szaflarski, 2017; Hirschman, 2015). Language dissimilarities and communication

impediments, distrust of American Mental Health Care System (AMHCS), higher rates of

health coverage, and financial hardship are main explanations offered by ethnic and racial

minorities for not seeking treatment (Wasem, 2014).

Many Africans do not recognize the U.S. mental health system’s

conceptualization of mental illness as contextually and biologically based. Conditions

like posttraumatic stress disorder (PTSD), depression, major depression, attention deficit

hyperactivity disorder (ADHD), and youth suicide are thought to be treated by African

traditional medicine practitioners (ATMPs) and African indigenous spiritual healers

(AISH). Such treatment includes purification rituals, exorcism reliefs, propitiation,

supernatural counterattack, use of herbal remedies, spiritual healing, and magical

practices (Aina, 2004; Aina & Morakinyo, 2011; Akomolafe, 2012; Ventevogel, Jordans,

Eris, & Jong, 2013).

Country-of-origin beliefs can become obstacles to appropriate help-seeking in

terms of mental health concerns (Amuyunzu-Nyamongo, 2013; Lindingeran-Sternart,

4

2015; Myers & Speight, 2010). Africans may be unwilling to talk about mental health,

mental illness, and help-seeking because of their mistrust of Western health approaches,

which they believe do not work because approaches lack consideration of cultural beliefs

(Campbell & Long, 2014; Oluwatoyosi, Kimbrough, Obafemi, & Strack, 2014;

Perciasepe & Cabassa, 2013). However, this has not been studied from a qualitative

experiential perspective.

A further complication is cultural ignominy and stigmatization of mental illness

(Aina & Morakinyo, 2011; Akomolafe, 2012; Amuyunzu-Nyamongo, 2013). Africans

with mental illness are assumed to be crazy, suffering from a condition that has no cure.

In most African countries, families with mentally ill relatives keep them at home, fearing

embarrassment and humiliation (Sam & Moreira, 2012; St. Louis & Roberts, 2013;

Ventevogel et al., 2013). Stigma, discrimination, prejudice, and shame can lead to

disgrace and involve risks for such individuals, making it impossible for them to report

mental illness symptoms and seek treatment in African cultures (Amuyunzu-Nyamongo,

2013; Padayachee & Laher, 2014).

Individuals with mental illness are not permitted in public gatherings and have

limited access to education, affordable housing, and employment. Their ability to interact

socially is limited, as they are marginalized because they are claimed to be crazy and

dangerous. Family members and advocates may also be stigmatized and discriminated

against without consideration (Akomolafe, 2012; Amuyunzu-Nyamongo, 2013;

Padayachee & Laher, 2014). As the influx of African immigrants continues to rise

(Chung, Bemak, & Grabosky, 2011; Kabuiku, 2017; Thomas, 2011), so does resistance to

5

seeking treatment because of perceived stigma. However, most literature documenting

these phenomena is journalistic, anecdotal, or policy based. Formal studies of the

meaning of mental health, mental illness, and help-seeking are needed to scientifically

document the experiences of this immigrant group. In sum, there is considerable research

on mental health help-seeking in immigrant populations, as well as relationships between

perceived stigma and mental health-seeking. However, unique challenges and constraints

experienced by African immigrants regarding the meaning of mental health, mental

illness, and help-seeking have not been intensively investigated from a qualitative

perspective.

Problem Statement

While there have been numerous policy studies and conceptual papers describing

how cultural beliefs influence conceptualization of mental health and help-seeking among

African immigrants, there is little research that has systematically examined experiences

involving mental health, mental illness, and help-seeking among African immigrants in

the U.S. The rate of refusal is higher and the rate of seeking treatment is lower compared

with other minority immigrant population groups in the U.S. (Giacco, Matanov, &

Priebe, 2014; Hacker, Anies, & Zallman, 2015; Leong & Kalibatseva, 2011; Perciasepe

& Cabassa, 2013; Renner & Salem, 2014; Suphanchaimat, Kantamturapoj, Putthasri, &

Prakongsai, 2015). However, what is missing is an understanding of beliefs, experiences,

and perceptions that underlie how mental health and mental illness is constructed, and

how help-seeking experiences occur in their new homeland. Therefore, the proposed

6

research will contribute to understanding African immigrants’ lived experience of mental

health and mental illness and the role of stigma during the help-seeking process.

Purpose of the Study

The purpose of the proposed qualitative research was to explore the lived

experience of mental health, mental illness, and help-seeking among African immigrants

in the U.S. The phenomena of interest were mental health, mental illness, and mental

health help-seeking.

Research Questions

RQ1: What is the lived experience of mental health for African immigrants in the U.S.?

RQ2: How does indigenous cultural stigma occur in the meaning of mental illness?

RQ3: How do African immigrants in the U.S. describe their help-seeking experiences?

RQ4: How does indigenous cultural stigma occur in help-seeking?

Theoretical Frameworks

Two theories were proposed as theoretical frameworks to guide the development

of the design interview questions and analysis. These were the segmented assimilation

theory (SAT) and the cultural risk theory (CRT).

SAT

The SAT is widely used in psychological research studies to examine immigrant

population groups. Specifically, the theory involves identifying appropriate structural,

cultural, and social contributing factors that differentiate patterns of successful and

unsuccessful assimilation that immigrant population groups go through in different host

countries, including the U.S. (Fleischmann & Verkuyten, 2015). Some immigrants may

7

have higher mobility in terms of being accepted by the mainstream culture of their host

countries, and this may be rewarded with better social and economic benefits (Amri &

Bemak, 2013; Hacker et al., 2015). Other immigrants may not have such opportunities

because of racial, ethnic, or religious discrimination, which leads to higher risks for

poverty and suffering (Amri & Bemak, 2013). These differences in terms of assimilation

success can occur within a single immigrant group and are affected by factors such as

kinship, family ties, and social support (Zhou, 2014). Developing interview questions to

explore unique experiences and issues involving families and the SAT will guide this

study.

CRT

The CRT begins with the assumption that reality is socially constructed, and

culture is the shared vision of that social reality that makes it work. The concept of

cultural risk suggests that adverse events can happen because of moral or cultural

transgressions and cures or changes are culturally determined (Bagasra & Mackinem,

2014; Ciftci, 2013; Shiraev & Levy, 2010; Tansey & Rayner, 2008). This theory has been

used to test hypotheses and examine mental illness and barriers to seeking mental illness

treatment, especially among ethnically diverse minority and vulnerable immigrant

population groups.

Theories’ Relation to the Study Approach and Research Questions

It is essential to recognize and explore how persons experience and struggle with

quality of life and livelihood issues. Specifically, the SAT concepts that were applied in

the proposed study included questions about acculturation and socioeconomic mobility to

8

understand experiences involving mental health and help-seeking. Cultural cognition,

which involves how people frame their beliefs concerning the public, personal dangers

that strengthen their responsibilities to each other, and collective understanding of that

risk and impact on behavioral choices (Douglas & Wildavsky, 1982; Knudtzon, 2013;

Shiraev & Levy, 2010). It may be that African immigrants who have had relatives

diagnosed with mental health conditions in their home country and have experienced

exclusion, prejudice, and ostracism from their community may be resistant to seeking

help for fear that seeking help in their new home country will lead to further isolation.

Participants were asked to explore prior and current help-seeking experiences and

describe how their beliefs about help-seeking influenced their attitudes, feelings, and

actions.

Nature of the Study

Interpretative Phenomenological Analysis (IPA) is proposed as the approach for

the proposed research because it examines the meaning that individuals make out of their

lived experiences (Smith, Flowers, & Larkin, 2009). IPA is derived from

phenomenology, hermeneutics, and idiographic philosophical concepts and emphasizes

that researchers should focus on the whole experience while searching for and listening to

lived experience of the phenomenon from the participants’ descriptions (Chan et al.,

2013; Smith et al., 2009; Yuksel & Yildirm, 2015). The other unique aspect of IPA is the

emphasis of the research process as dynamic and involves both participant and

researcher. Referred to this as a “double hermeneutic”; i.e., observing how the participant

is making sense of his/her world, and how the researcher is trying to make sense of the

9

participant’s efforts (e.g., “What is the participant trying to achieve?”). This stance was

particularly crucial in the effort to explore how participants make sense of their mental

health and help-seeking experiences.

Purposeful homogeneous snowball sampling was used to recruit eight to 12

African immigrants in the U.S. who have experienced mental health issues, mental

illness, and help-seeking in terms of indigenous cultural barriers. A sample size of eight

to 12 was recommended for IPA studies. Semi-structured first-person-interviews with

participants were conducted using an interview guide that was developed using

fundamental concepts from the literature (see Appendix C). These included the SAT and

CRT.

Brief Summary of the Methodology

IPA involves use of semi-structured and one-to-one interview procedures to attain

narratives, reflections, thoughts, and reactions from research participants (Smith et al.,

2009). These interviews require facilitating a natural flow of conversation and including

vital questions and probing follow ups that include questions about sensory perceptions,

memories, and personal interpretations (Pietkiewiez & Smith, 2014). NVivo was used for

the management and organization of data and facilitated the organization of transcribed

data into categories and themes that were interpreted and shared with participants.

Definitions

Acculturation: The process of assuming cultural qualities or social manners of a

different ethnic group or culture (Rogers-Sirin, Melendez, Refano, & Zegarra, 2015).

10

Acculturative stress: Stress caused by the acculturation process as immigrants

attempt to learn and adapt to the social manners of their host country (Rogers-Sirin et al.,

2014). Despite challenging and complex social and psychological demands of

acculturation, most immigrants find it to be meaningful and advantageous (Rogers-Sirin

et al., 2014).

African Americans: Individuals who are citizens and residents of the U.S. with

African ancestry or shared origins within one of the Black population groups of Africa

(Myers & Speight, 2010).

African immigrants: Individuals who migrated willingly from their native African

countries to live permanently in the U.S. African immigrants come to the U.S. with

distinctive cultural perceptions. Additionally, they share similar African ancestry with

most African Americans (Bhugra & Becker, 2005; Myers & Speight, 2010).

African native doctors: Traditional medicine practitioners in African cultures with

no formal education or Western medical training. They use culturally-based treatments

that are useful for individuals with mental illness (Akomolafe, 2012; Leighton & Hughes,

2005).

African spiritual or faith healers: Individuals who use prayer and spiritual

cleansing as a culturally-based treatment for mental illness (Akomolafe, 2012; Leighton

& Hughes, 2005).

Culture: An expression of an individual’s way of life, illustrated by behaviors,

traditions, ideology, customs, and attitudes (Leong & Kalibatseva, 2011; Shiraev & Levy,

2010).

11

Ethnicity: A group of individuals connected by specific cultural beliefs and shared

heritage (Leong & Kalibatseva, 2011; Shiraev & Levy, 2010).

Assumptions

As a qualitative researcher, the investigator was the primary research tool for

collecting, transcribing, and analyzing data. It was assumed that participants in the

research had ample opportunity to truthfully share their experiences to generate rich,

thick descriptions about their relevant experiences. Another assumption was that

interviews with selected samples of African immigrants would be adequate to attain

saturation and results would be specifically generalizable to all African immigrants.

Investigator put aside personal biases, preconceived concepts, and culturally-influenced

notions concerning mental health to be fully present and aware of stories and meanings of

participants. I tried to address and attempted to reduce the influence of bias by

implementing appropriate steps to ensure the trustworthiness of data and focus on

credibility, transferability, dependability, and confirmability.

Scope and Delimitations

Participants in the research were limited to individuals who had experienced

mental health disorders, mental illness, and help-seeking and were currently living in a

large West Coast urban area that supports a vital and prominent African immigrant

community. Other areas of the U.S. were not sampled. Participation in the proposed

research was limited to African immigrants 21 years and older from the five main regions

of Africa. African immigrant participants who are younger may exhibit challenging

developmental complications that may exceed the scope of the proposed research.

12

Individuals from other ethnically diverse minority immigrant population groups in the

U.S. did not fall within the purview of this proposed research. Participants had lived in

the U.S. for at least one year and were willing to talk about their lived experiences. All

participants were fully informed of the nature of their participation and signed informed

consent forms (see Appendix B).

There has been considerable discussion across many disciplines regarding the

nature of assimilation, acculturation, and integration of racial, ethnic, and religious

groups in the U.S. While political and policy discussions tend to focus on questions of

acceptance, tolerance, and diversity, social scientists have focused on how unique

country-of-origin characteristics can facilitate or detract from quality of life and

socioeconomic wellbeing (Schneider & Crul, 2010). Assimilation across and within

immigrant populations was relatively consistent and monotonic (Gordon, 1964).

Investigator chose the SAT and CRT as theoretical frameworks. Other theories that

proposed linear and monotonic approaches were not chosen.

The target group for the proposed research was African immigrants who have

mental health, mental illness, and help-seeking lived experiences in the U.S. Most

African immigrants in the U.S. prefer to live in large metropolitan settings, and most

have settled in Washington, DC, New York, Georgia, Texas, Maryland, Virginia,

Massachusetts, Pennsylvania, and California (Immigration Policy Center [IPC], 2012). In

IPA research, individuals selected to participate in the research represent the phenomenon

of interest rather than the population under study (Smith, 2011; Smith et al., 2009).

Therefore, individuals selected to be interviewed were able to provide descriptions of

13

lived experiences in terms of the phenomenon under study. Furthermore, all participants

were required to be fluent in the English language as stipulated by participant inclusion

and exclusion criteria.

Limitations

The quality of the research was dependent upon access to enough individuals who

met the criteria for inclusion and could provide rich, thick descriptions of their

experiences with mental health, mental illness, and help-seeking experiences. A

purposeful and homogeneous sample was used through the combination of referral and

snowball sampling of African immigrants who have experienced mental illness and help-

seeking. It was hoped that this process would enable saturation, although a bigger sample

size may have been able to generate additional differing data.

To enhance transferability, I provided explanations of procedures for data

gathering, analysis, and interpretation. I described settings, research design,

methodology, and participants with complete information in order to be transferable to

other groups and contexts. I enhanced transferability using rich descriptions for

establishing credibility in qualitative research.

To enhance dependability, I consulted with methodology and content experts to

evaluate the interview and research questions. Additionally, I asked participants to review

a summary of their transcripts as part of the member-checking process and recorded

comments and reflections during all parts of data collection and analysis as part of an

audit trail process.

14

Significance

The study will contribute to scholarly literature regarding African immigrants by

providing more contextual and detailed information concerning their experience with

mental health, mental illness, and help-seeking. It will lead to comprehensive information

regarding African immigrants’ experiences with mental health, mental illness, meaning of

help-seeking experiences, occurrence of indigenous stigma in mental health, occurrence

of indigenous stigma in mental illness, the occurrence of indigenous stigma during help-

seeking experiences, and other experiences of participants. The study was conducted in a

conducive and advantageous setting in order for participants to reflect on their lived

experiences while reviewing their deepest feelings. It is a goal of this study to explain

how different cultural beliefs are experienced in a foreign country, particularly regarding

interacting with established and culturally different processes involving managing risks

and problems. The results of this research may provide rigorous and meaningful

recommendations for policy and practice. Many African immigrants believe that

mainstream Western and American mental healthcare services cannot efficiently respond

to their problems (Amuyunzu-Nyamongo, 2013; Ciftci, 2013; Corrigan et al., 2014).

Therefore, understanding of these phenomena could lead to the development of more

sensitive intake and treatment systems for culturally unique persons. The findings of this

study suggest that African immigrants’ mental health, mental illness, and help-seeking

needs are fundamental in terms of maintaining good health and wellbeing. The following

are recommendations for comprehensive improvement:

15

● Providing appropriate information to mental health clinicians and researchers

concerning possible impediments for African immigrants and instructing them to

obtain necessary information from African immigrants regarding trust in terms of

help-seeking for mental health problems and illnesses.

● Encouraging recruitment and training of psychologists who understand African

immigrants and come from the same cultural background.

● Establishing community mental health programs (CMHPs) within community

health centers (CHCs) that offer culturally-appropriate information to African

immigrants concerning mental health, mental illness, help-seeking, recovery,

wellness, rehabilitation, and available modalities of treatment.

● Amalgamating primary healthcare services and mental healthcare services

through community public health partnerships for African immigrants.

Summary

This chapter included an overview of research. Background information discussed

in this chapter was given to provide specifics regarding the gap in knowledge. The

problem statement illustrated that the challenges of African immigrants’ cultural beliefs

regarding mental health, mental illness and help-seeking which have not been examined

by researchers. The purpose of the research and theoretical framework that guided the

study was documented in this chapter. Primary terminologies that were used in the

research were also reviewed. Significance of the research was also established in this

chapter. A literature review is presented in Chapter 2.

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Chapter 2: Literature Review

The purpose of this study was to explore African immigrants’ the lived experience

of mental health, mental illness, and help-seeking in the U.S. This chapter explains the

literature search strategy, literature regarding the theoretical framework, and available

empirical studies. This includes studies that describe how African immigrants in the U.S.

share a cultural ideology that attributes mental illness problems to supernatural causative

factors which then must be cured through culture-specific interventions and how this

contrasts with Western methods of assessment, diagnosis, and intervention. Lack of

culture-sensitive processes plus cultural stigmatization associated with mental illness

reduces opportunities for African immigrants with mental health problems to get

appropriate care (Chukwuemeka, 2009; Mori et al., 2007). This chapter contains an

introduction, literature search strategies, information about the theoretical framework,

and a literature review related to fundamental concepts, as well as a summary and

conclusion.

Literature Search Strategy

Psychology databases such as PsychARTICLES, PsychINFO, PsychEXTRA,

SocINDEX with Full Text, Academic Search Complete, Primary Search, PsycBooks, and

PsychCRITIQUES were accessed using the following search terms: assimilation,

acculturation stress, Africans, African Americans, African immigrants, American Muslim

immigrants, African native doctors, and African spiritual or faith healers.

17

Theoretical Framework

Two theories were proposed as theoretical frameworks to guide the development

of the design interview questions and analysis. These were the SAT and CRT. There has

been a considerable discussion across many disciplines regarding the nature of

assimilation, acculturation, and integration of racial, ethnic and religious groups to the

U.S. (Kivisto, 2015). While political and policy discussions tend to focus on questions of

acceptance, tolerance, and diversity, social science theories have focused on how unique

country-of-origin characteristics can facilitate or detract from the quality of life and

socio-economic well-being (Schneider & Crul, 2010). Most current are the frameworks

that do not presume a “monotonic, upward social mobility trajectory” across and within

the immigrant population typical of classic immigration theory (Gordon, 1964). Instead,

modern theories incorporate culture-of-origin and assimilation factors that put some

individuals and groups at higher risk (Akresh et al., 2016). The proposed research

employed segmented assimilation theory and cultural theory of risk (Amri & Bemak,

2013; Viruell-Fuentes et al., 2012). Both theories propose constructs and hypotheses that

frame how immigrant individuals take divergent pathways towards health and mental

health, as well as socio-economic integration (Fleischmann & Verkuyten, 2015; Yuksel

& Yildirm, 2015). A discussion of segmented assimilation theory and cultural theory

follows below.

SAT

Segmented assimilation theory, as formulated by Portes and Zhou (1993), was

developed as an alternative to other models of assimilation theories because of their

18

inability to further researchers’ understanding of the relevant issues pertaining to modern

assimilation patterns, socioeconomic barriers, acculturation stress, racial discrimination,

and mental health problems (Viruell-Fuentes et al., 2012; (Portes & Zhou, 1993). The

segmented assimilation theory focuses on the circumstances (e.g., cultural bias,

socioeconomic barriers, acculturation stress, and assimilation issues) that could lead to

deterioration or improvement in health and wellbeing. Socioeconomic context modifies

the relationship between assimilation and physical health. Fox, Thayer, and Wadhwa

(2017) said factors like social support and community cultural orientation could moderate

the extent to which immigrants maintain their mental and physical health status.

Stressful familial arrangements that challenge immigrant families include single

parents raising children, children with no fathers, increasing rates of female-headed

households in addition to increasing occurrence of domestic violence and emotional

abuse, alcohol and drug abuse, and social and economic problems (Akresh et al., 2016;

Fox et al., 2017; Shishehgar et al., 2015). The There are two different assimilation paths

for second generation African immigrants . The first assimilation path is an upward

mobility process that makes it possible for second generations of African migrants to

attain higher social and economic status, employment opportunities, affordable housing,

suitable marital partner, and families, resembling majority White American lifestyles

(Okonofua, 2013; Fleischmann & Verkuyten, 2015). The second assimilation path is a

descending process that leads to continuous suffering and reduced quality of life, low

social and economic status, language barriers, academic and professional deficiencies,

unemployment, affordable housing problems, dysfunctional family structures, and

19

marginalization caused by racism and cultural discrimination, all of which are

contributing factors to acculturation stress and mental illness problems.

CRT

The CRT is the second theory that guided the proposed research. The CRT

originated from the work of Douglas and Wildavsky; it has since become a dominant

theoretical framework that is used in psychological research studies to examine

culturally-related concepts of mental illness and barriers that prevent individuals from

seeking mental illness treatment (Schock-Giordano, 2013; Shiraev & Levy, 2010). The

CRT is a theoretical framework for understanding sociocultural factors that shape

traditional beliefs of African immigrants.

The theory proposes that social consciousness and culture determine the concept

of risk, or what is acceptable and not acceptable. According to Douglas and Wildavsky

(1982), “The different social principles that guide behavior affect the judgment of what

dangers should be most feared, what risks are worth taking and who should be allowed to

take them” (p. 6). There are three common factors that shape understanding of how

cultural concepts influence perceptions of mental illnesses and mental illness treatments:

cultural concepts that influence how mental illness symptoms are expressed among group

members, cultural concepts that influence contributory factors of mental illness, and

cultural implications that negatively impact willingness to seek mental illness treatment

(Leong & Kalibatseva, 2011; Schock-Giordano, 2013). This theoretical framework has

been used to determine the influence of culturally-related factors on mental illness and

mental illness treatment. Sam and Moreira (2012) said cultural factors play a significant

20

role in shaping the ethnically diverse minority immigrant population groups’ attitudes

and perceptions concerning mental illness and treatment and should be carefully

considered by mental health clinicians and researchers in developing and providing

culturally sensitive and acceptable mental illness interventions to ethnically diverse

minority population groups in the U.S.

Relationship of Frameworks to the Proposed Study

The proposed research involved the SAT and CRT. Both theories propose

constructs and hypotheses that frame how immigrant individuals take divergent pathways

towards health and mental health, as well as socio-economic integration (Fleischmann &

Verkuyten, 2015; Yuksel & Yildirm, 2015). The segmented assimilation theory

recognizes that assimilation and living in a new culture can take many different paths and

that it is essential to recognize and explore how persons experience and struggle with the

quality of life and livelihood issues. Specifically, the segmented assimilation theory

concepts that were applied in the proposed study included questions about acculturation

and socioeconomic mobility to understand the experience of mental health and help-

seeking (Akresh et al., 2016; Portes & Zhou, 1993). The fundamental concept of the

cultural theory of risk is cultural cognition (Douglas & Wildavsky, 1982; Knudtzon,

2013; Shiraev & Levy, 2010). This concept describes how people frame their beliefs

concerning the public and personal dangers that strengthen their responsibilities to each

other, and the collective understanding of that risk and impact on their behavioral choices

(Douglas & Wildavsky, 1982). For example, it may be that African immigrants who have

had relatives diagnosed with mental health conditions in their home country (and have

21

experienced exclusion, prejudice, and ostracism from their community) may be resistant

to seeking help for fear that seeking help in their new home country will lead to further

isolation. This concept will be utilized in the development of the interview guide and

analysis plan to answer the research questions.

Literature Review Related to the Key Concepts

African Migration to the U.S.

The current developments in the African migration to the U.S. differ from the

trans-Atlantic calamitous slave-trade when Africans were forcefully brought against their

wishes to the U.S. as migrants in the early 16th to 19th centuries to work in the plantations

with no human rights (IPC, 2012; McCabe, 2011; Solomon, 2017). Voluntary

immigration to the U.S. commenced in the late 1980s and progressed through 2009 to the

present, with a significant influx of African immigrants from different countries in the

Five Main Regions of Africa (IPC, 2012; McCabe, 2011). The population of African

immigrants living in the U.S. increased from below 200,000 in 2002 to approximately 1.9

million in 2016. Currently, the total population of African immigrants to the U.S. has

increased to 1.9 million, and by ratio is, “(3.9 %) by the mounting share of the U.S. 38.5

million immigrants from different worldwide countries” (McCabe, 2011, p. 1). During

early 2010, the number of immigrants from other countries including African immigrants

living in the U.S. was estimated to be 40 million. This number will continue to grow as

more African immigrants arrive in the U.S., as will immigrants’ problems that include

mental health, mental illness, and help-seeking (Hirschman, 2015; IPC, 2012; McCabe,

2011; Solomon, 2017).

22

Ross-Sheriff and Moss-Knight (2013) studied two groups of African immigrants –

refugees and legal immigrants. The distinguishing characteristics of the recent African

immigrants to the U.S. are that they attain higher academic degrees, higher English

proficiency level and have lower unemployment rates than immigrant population groups

from other countries. According to Ross-Sheriff and Moss-Knight (2013):

New York, California, Texas, Maryland, New Jersey, Virginia, Georgia, and

Massachusetts are the eight states that are selected destination locations by black

African immigrants and gravitate more to states with a significant number of other

black residents where they settle in large numbers and establish ethnic enclaves.

(p. 5)

Based on their cultural beliefs, collectivist tendencies, and traditional commitment

to family orientation, African immigrants who are established in the U.S. help new

immigrants from their native countries, family units, tribal, ethnic, religious groups, and

social network to find affordable housing and employment and tend to localize to these

geographic regions (Ross-Sheriff & Moss-Knight, 2013).

Acculturation of Immigrants to Life in the U.S.

Acculturation in context of immigration refers to the process of, “cultural contact

and exchange through which a person or group come to adopt certain values and practices

of a culture that is not originally their own, to a greater or lesser extent” (Cole, 2018, p.

1). Recently, two articles, (Fox et al., 2017, 2017a, 2017b) extensively reviewed the

literature and proposed a model that established the importance of acculturation

(successful and unsuccessful) in understanding overall health, mental health, and health

23

disparities among minority populations. How immigrants adopt characteristics of the host

cultural beliefs, values, and attitudes, either consciously or unconsciously can lead to

successful acculturation or the adoption of harmful behaviors.

These sources found many characteristics appropriate to acculturation together

with neighborhood ethnocultural composition, discrimination, discrepancy between

origin and host environments, inconsistency involving heritage and host cultures, origin

group, host group, individual attitudes towards assimilation, variation in targets of

assimilation within host community, public policy, resources, and migration selection

prejudice. Established that, the most challenging system of acculturation process was

assimilation, characterized by the acquirement of host cultural beliefs together with the

hammering of inheritance cultural beliefs. Ndika (2013) established that immigrants

living in pluralistic cultures might have to create an assortment of acculturation strategies

through which they deal with and muddle through with the multi-cultural conditions of

the individuals with whom they interact.

Challenges to African Immigrants’ Acculturation

Migration and challenges of acculturation experience of African immigrants to the

U.S. broaden the scope of the proposed investigation (Kasturi, Iyengar, & Haile, 2014).

The following studies, Conner et al. (2010), Leong and Kalibatseva (2011), and Renner

and Salem (2014) found that, “the challenges of migration to the U.S. and complicated

acculturation experience of African immigrants would aggravate mental health, mental

illness, and help-seeking problems (Conner et al., 2010; Leong & Kalibatseva, 2011;

Lindinger-Sternart, 2015; Renner & Salem, 2014). Kasturi et al. (2014) confirmed that

24

this is somewhat surprising given that African immigrants are a significant part of the

emergent ethnically diverse minority population group with continuous future emigration

to the U.S. However, a closer look at cultural beliefs specific to mental health, mental

illness and help-seeking illuminate why the risk to mental health can increase.

Culturally Relevant Mental Health Care for African Immigrants

According to Ross-Sheriff and Moss-Knight (2013), the availability of culturally

relevant and useful mental health care services for African immigrants is inconsistent and

potentially inadequate. The primary obstacle to availability is the lack of culturally

acceptable mental health practices. Several studies have found that social inequality,

racial discrimination, and prejudice are ongoing problems that affect African immigrants

in the U.S. mental health system (Mori et al., 2007). Previous qualitative research has

demonstrated through interviews and observations of ethnic minorities that individuals

seeking treatment often experienced barriers to accessing treatment and turned towards

more culturally and emotional supportive methods of care (Conner et al., 2010;

Lindinger-Sternart, 2015; Padayachee & Laher, 2014; Renner & Salem, 2014); and the

lack of culturally appropriate resources make it difficult for mental health clinicians and

to develop and offer adequate mental health services (Kabir, Illiyasu, Abubakar, & Aliyu,

2004; Leong & Kalibatseva, 2011; Ngo, 2008).

Mental Health

Ethnically diverse minority population groups like African immigrant’s

experience and interpret mental health, mental illness, and interventions differently

(Amuyunzu-Nyamongo, 2013; Bagasra & Mackinem, 2014; Ciftci, 2013). Many

25

international organizations have studied and provided physical and mental health

resources and services to African countries in efforts to improve lives. Within American

medical system, the terminology characterized as mental health is collectively utilized in

allusion to mental illness. Mental health and mental illness remain as connected

phenomena individually but demonstrate different psychological conditions among

individuals (Glide & Frank, 2016; Gureje & Stein, 2012). Mental health is defined as the

“state of well-being in which the individual realizes his or her abilities, can cope with the

normal stresses of life, can work productively and fruitfully, and be able to make

contributions to his or her community” (Center for Disease Control and Prevention

[CDC], 2013, p. 1). There is a general approximation that no more than, “17% of U. S.

adults are considered to be in a state of optimal mental health” (CDC, 2013, p. 1).

More broadly defined, mental health is regarding the ability to perform mental

and cognitive functions successfully, complete productive daily activities, maintain

rewarding relationships with other individuals, and gain adaptive capacity to change and

deal with adversities (CDC, 2013; Glide & Frank, 2016; Gureje & Stein, 2012).

Amuyunzu-Nyamongo (2013) described mental health as a socially defined construct,

and that it is a taboo subject that attracts stigma. Mental health is also profoundly affected

by war, poverty, and other significant disasters: Amuyunzu-Nyamongo (2013) said,

“there is a correlation between the level of mental health in a community and general

level of social well-being” (p. 59). To further complicate the lack of access and resources,

African cultures consider spiritual phenomenon as fundamental to success and well-being

in life, believing that individuals who passed away transform into ascended-masters,

26

unseen ancestral spirits who involve themselves in the daily affairs, including self-

protection from evil forces, good fortune, success in day to day undertakings, marital

relationships, and prevention of mental illness (Aina & Morakinyo, 2011; Akomolafe,

2012; Perciasepe & Cabassa, 2013). For example, a study described “a variety of cultures

in West Africa but with prominent similarities in customs, and beliefs, dress, food, music,

religion, etc. hence one may talk of a West African culture that is different from other

parts of the world” (Aina & Morakinyo, 2011, p. 2).

These researchers conducted a wide-ranging search for literature with connected

relevance to culture-bound syndromes in West Africa, initiated personal contacts, and

conducted individual interviews with medical and mental health clinicians in the West

Africa sub-region to collect the required data. They emphasized that four mental health

disorders, including “The Brain Fag Syndrome (TBFS), Koro and Koro-like (Magical

penis loss), Ode On and Ogun Oru, and the so-called culture-bound concepts (CBCs)

such as Abiku or ogbanje and pobough Lang” (p. 3), deemed to meet the criteria for

culture-bound syndrome (CBS) were documented to have been identified in West Africa.

Akomolafe (2012) asserted that psychological assessments, established diagnoses,

and treatments are mental health constructs shaped by Western hegemonic perceptions

which are drastically in contrast with the traditional beliefs and practices of ethnically

diverse groups, thereby causing a crisis condition for the groups not represented by

Western assertions. The author found that indigenous understanding platforms in mental

health healing and wellbeing are well-informed by the notion that offering indigenous

individuals mental health treatment from a non-indigenous perspective is an understated

27

form of colonialism and oppression as it does not recognize their worldviews or treat

cosmologies as legitimate in their rights with the existence of different ethnic groups

within the society formulation and distribution for a mental health care system that will

not benefit one model more than other models.

Perciasepe and Cabassa (2013) literature review summarized negative attitudes on

mental illness from 34 public-based studies that explored the public stigma of mental

illness. The authors found out that, mental illness stigma involve undervaluing,

humiliating and disrespecting individuals with mental illness by the general population.

There are preconceived negative attitudes concerning the dangerousness of individuals

with mental health and mental illness problems that expand with rapidity over time.

These negative attitudes include embarrassment, humiliation, blameworthiness,

incompetency, chastisement, punishment, and established criminality of individuals

diagnosed with mental disorders. Additionally, that stigmatization attitudes,

stigmatization actions, and stigmatization beliefs differ significantly among the categories

of mental illness diagnoses, mental health problems, socio-economic conditions, and

demographic characteristics (Perciasepe & Cabassa, 2013). Precisely, the sensitivities and

perceptions of dangerousness among individuals with mental illness and contributory

factors are known to be generally appropriate and vary based on the social environment

(Parcesepe & Cabassa, 2013). Therefore, mental health is seen because of being in good

stead with the invisible forces that support the ability to be productive in work and

relationships and function to solve the problems of daily life (Parcesepe & Cabassa,

2013).

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Mental Illness

In the U.S., the definition and assessment of mental health problems evolved

through the paradigm of scientific method and had been codified and described in

regularly peer-reviewed compendiums like the Diagnostic and Statistical Manual of

Mental Disorders (American Psychiatric Association [APA], 2013; Glied & Frank, 2016;

Gureje & Stein, 2012). The concept of mental disorder is like the other conceptions in

medical science, in that clarification and acceptance of diagnostic categories require an

ongoing operational clarification that covers all conditions (APA, 2013). American

mental health and medical system perspectives emphasized that mental illness is a

physical condition within the category that comprises. Glied and Frank (2016) found the

following:

A vast number of conditions (schizophrenia, bipolar disorder, depression, anxiety

disorder, dissociative disorders, posttraumatic stress disorder (PTSD), obsessive-

compulsive disorder, borderline personality (BPD), and schizoaffective disorder

among others) have a wide range of effects on individuals experiencing those

conditions, such as social withdrawal, limits on functioning, work, parenting,

cognitive impairments, troubling behavior, and in some cases violent behavior. (p.

545).

While some mental illness does not have a final biological assessment, these

classifications of mental illnesses are conditions which are overwhelmingly disabling, and

which significantly impede in daily living functioning abilities.

29

Some mental illnesses occur intermittently, some are unremitting (example, many

individuals diagnosed with depression stand a chance of 50% recurrence), and some are

single event experiences (Glied & Frank, 2016). In contrast, the African immigrant

perspective sees the onset of mental illness as sourced in spiritual “possession” (i.e., they

believe that animals, aliens, demons, extraterrestrials, gods, idols, or spirits can take

control of a human body). Individuals experiencing a spirit possession may progress to

danger to self, others, contact with the law and confrontation with law enforcement

officers. The perceived sorcery is assigned responsibility for loss of personal resources,

family, and friends (Aina, 2004; Aina & Morakinyo, 2011; Parcesepe & Cabassa, 2013).

Africans may be unwilling to talk about mental health, mental illness, and help-

seeking because of their mistrust of Western physical and mental health approaches

which they believe will not work because they lack consideration of their cultural beliefs

(Campbell & Long, 2014; Oluwatoyosi, Kimbrough, Obafemi, & Strack, 2014; Parcesepe

& Cabassa, 2013). For example, Campbell and Long (2014) said that, while the help-

seeking behaviors and mental health service use among African Americans are affected

by various factors, the significance of culture and culturally informed beliefs and notions

of mental health, mental illness, and help-seeking must be recognized in their behaviors

to seek treatment.

Oluwatoyosi, Kimbrough, Obafemi, and Strack (2014) said challenges in dietary

acculturation (availability of healthy foods, limited access to occupations consistent with

their country of origin, and challenges to cultural competence in navigating the health

care system). In addition to dealing with the effects of illness, individuals are often

30

shunned or made an outcast in their communities. Amuyunzu-Nyamongo (2013) said

girls from homes known to have mental illness are disadvantaged in marriage, which

limits their opportunities for security qualitative of life.

Help-Seeking

The U.S. medical and mental health systems have evolved to make access to

professional help more accessible and less intimidating (CDC , 2012; Glied & Frank,

2016; Hacker et al., 2015; Hwang, Myers, Abe-Kim, & Ting, 2008; Singh, Rodriguez-

Lainz, & Kogan, 2013). Nevertheless, the decision and actions to seek help are still

known to pose multiple barriers. The thought of seeking help may create personal distress

more significant than the perception of the actual problem, thereby, reducing the chance

of the person seeking help. Minority and immigrant population groups’ attitudes towards

mental health and mental illness help-seeking have been widely studied in the U.S. The

negative thoughts “are associated with demographics and cultural characteristics that

influence how much persons with psychological problems will avoid seeking help”

(Vogel et al., 2007, p. 410). According to Amri and Bemak (2013), collectively with

mistrust of U.S. mental health system and accessible mental health care treatments,

African immigrants’ help-seeking is impacted by the following: “Mental health service

needs, cultural mistrust of mental health clinicians, social stigma of mental health

problems and help-seeking, social stigma and cultural mistrust, trauma treatment, alcohol

and poly-substance use and abuse, and family centered services” (p.47-51).

Despite access to Western (European and American) developed mental illness

treatments, African immigrants may prefer to ask for assistance from immediate family

31

members, traditional medicine practitioners, faith and spiritual healers, and fortune-tellers

to cure the manifesting mental illness symptoms (Lindinger-Sternart 2015; Renner &

Salem, 2014). Attitudes of African immigrants concerning mental illness and European

and American treatment may be influenced by these practices from their native countries

(Lindinger-Sternart, 2015). Such treatment includes purification rituals; exorcism

relieves, propitiation, supernatural counterattack, utilization of herbal remedies, spiritual

healing, and magical practices (Aina, 2004; Aina & Morakinyo, 2011; Akomolafe, 2012;

Ventevogel et al., 2013).

Derr (2017) said that non-immigrants have access to mental health services at a

higher rate while immigrants have access to services at a lower rate. Also, there are

significant uncertain mental health care demands and explanations associated with the

use of services by immigrants.

Villatoro et al. (2014) said that family and culture influences are significant in

exertions intended to know and enhance help-seeking behaviors and appropriate

utilization of acceptable mental health care services by Latinos in the U.S. Venters and

Gary (2009) said that the occurrence of mental health problems of African immigrants

differs widely among published information. The healthcare necessities and practices of

African immigrants continue to remain inadequately characterized. The significant

impediment to understanding the health conditions and practices of African immigrants

in the U.S. is the non-existence of accurate recording of national origin and language

dissimilarities in medical care settings. Additionally, the utilization of different research-

identifications for African immigrants, like African-born-black, foreign-born-black,

32

African-ancestral, and non-Caribbean-black influences data interpretation and assesses

data from different studies entirely complicated.

Role of Stigma in the Mental Health Help-Seeking

While the understanding and acceptance of mental health and mental illness have

evolved considerably over the past 50 years, there still exists, mainly in ethnic minority

populations residing in the U.S., a social problem regarding the way individual families

experience and cope with mentally unhealthy members (Mak, Chong, & Wong, 2014;

Schock-Giordano, 2013). This problem is conceptualized as a stigma defined as,

“devaluing, disgracing, and disfavoring by the general public of individuals with mental

illnesses” (Abdullah & Brown, 2011, p. 2). The stigma of mental illness and treatment

makes it difficult for people to seek mental illness treatment. Dale and Daniel (2013) said

that ethnically diverse minority individuals, including African immigrants, are vulnerable

to social discrimination, which might prohibit access to receiving quality mental health

service.

Research on the Experience of Stigma

The stigma of mental illness is marked by stereotyping, shaming, dishonoring,

disrespecting, and humiliating the ill person and his/her family, and is an ongoing

problem (Quinn et al., 2015). The experience of stigma is magnified due to the mistrust

of mental health clinicians and researchers from other cultures, mental health clinicians’

lack of awareness concerning immigrants’ sociocultural concepts of mental illness

symptoms, language dissimilarities, and mistrust of treating mental illness with

psychotherapy and pharmacotherapy (Quinn et al., 2015). African immigrants experience

33

poor outcomes against the number of primary social and mental health indicators; they

are more likely to be given established diagnoses and are over-represented in inpatient

mental health care services, confronted with racial prejudice and discriminated against by

mental health clinicians.

Abdulla and Brown (2011) examined ethnocultural beliefs and stigma of mental

illness. For example, although a few Native American Indian population groups abstain

from the stigmatization of mental illness, the researchers found that most groups

stigmatize just a few mental illnesses, and others conform to the practices that stigmatize

all mental health problems and mental illnesses suffered by their tribal members. Among

Asian cultures that emphasize traditional values with conformity to cultural norms,

family acknowledgment through accomplishment and emotional self-control,

stigmatization of mental illnesses is universally practiced because mental illnesses are

assumed as sources of embarrassment. Carpenter-Song et al. (2010) explored help-

seeking varied along ethnic-racial lines, with 25 African Americans, Latinos, and Euro-

Americans diagnosed with a severe mental illness. Carpenter-Song et al. (2010) said:

Euro-American participants were most similar in beliefs to the professional

disease-oriented perspectives on severe mental illness and found it less stressful to

seek mental health professionals. African American and Latino participants

emphasized non-biomedical interpretations of behavioral, emotional, and

cognitive problems and were critical of mental health services. (p. 1)

Clement et al. (2014) found that stigma was the fourth highest ranked barrier to help-

seeking, with disclosure concerns the most reported stigma barrier, among ethnic

34

minority population groups. Link, Wells, Phelan, and Yang (2015) established the

significance for understanding the emblematic communication stigma and the extent to

which the beliefs concerning other individualistic reactions contribute to the complexity

of stigma of mental illness. In another example, Mantovani, Pizzolati, and Edge (2017)

found factors that influenced help-seeking behavior among African-descended

individuals including beliefs about the causes of mental illness, silencing of mental

illness resulting from heightened levels of ideological stigma, and stigma (re) production

and maintenance at the community level. These sources established that these factors

were likely to cause a triple danger in expressions of stigma in individuals struggling with

mental health.

Quinn et al. (2015) explored the stigma of mental illness, by utilizing an

ethnically diverse minority population group sample of participants with an established

range of mental illness problems and experiences. While the authors used only the

ethnically diverse sample, the participants were specially selected from low-income

socio-economic backgrounds, and with less than a high school education. The authors

found out that there was an emergent affirmation that equally internalized and anticipated

stigmas influence the entire mental health care services, in addition to treatment

utilization that encompasses acquiescence, interpersonal associations, and understanding

of care, treatment commitment, treatment effectiveness, and cultural sensitivity.

Wong, Kong, Tu, and Frasso (2018) analyzed data from scales and narratives

obtained from eight Chinese family-dyads and found that individuals identified with

schizophrenia disorder and their caregivers equally internalized negative valuation from

35

their social networks and reduced commitment in the community. In sum, the causes of

the stigma of mental illness are consistent across cultures and worldwide countries,

however, Monteiro (2015) said, “while every country’s social and cultural realities are

different, there are a number of underlying themes and evidence-based methods for using

these actualities to contextualize appropriate guidelines for mental health care service” (p.

87).

Mantovani et al. (2016) did a qualitative study that investigated stigma connected

with a mental illness involving, “faith-based African-descended communities in South

London, locating the narratives of 26 interviewees within an interpretative framework

constructed by the reading of the interdisciplinary literature on stigma” (p. 375). Results

revealed that, “three key themes that emerged from the data, which were illustrated by

direct quotes related to the following: beliefs about mental illness and production of

stigma, the social consequences of stigma of mental illness, the impact of avoidance

behavior on help-seeking, and the reproduction of stigma in faith communities”

(Mantovani et al., 2016, p. 373).

St. Louis and Roberts (2013) revealed that mental illness is one of the most

misconstrued conditions in African cultures, and the individuals who have mental illness

are stigmatized and discriminated against. For example, in most African countries,

families with mentally ill relatives keep them at home, fearing embarrassment and

humiliation from the community (St. Louis & Roberts, 2013). These sources explored the

public behaviors concerning mental illness in two extensively diverse cultures, Canada

and Cameroon with 120 participants with mental illness. The results revealed that within

36

Canada and the U.S., behaviors were generally more encouraging and less commonly

stigmatizing concerning mental illness in Cameroon. These fears serve as barriers that

prevent individuals from African cultures from seeking professional treatment for mental

illness (Bagasra & Mackinem, 2014). The stigma of mental illness is pervasive in African

culture and is marked by the stereotyping, shaming, dishonoring disrespecting, and

humiliation of individuals who have a mental illness (Quinn et al., 2015).

Summary and Conclusions

African immigrants undiagnosed and untreated mental illness problems in the

U.S. are not usually recognized and addressed by mental health clinicians and researchers

because despite access to the Western (European and American) modalities of mental

illness treatments, African immigrants may instead seek assistance from close family

members, traditional medicine practitioners, faith and spiritual healers, and fortune-tellers

to cure the manifesting symptomatic complications of mental illness (Conner et al., 2010;

Leong & Kalibatseva, 2011; Lindinger-Sternart, 2015; Renner & Salem, 2014). African

immigrants have experienced challenging problems of racial discrimination, racial

profiling, barriers to financial success, language differences, and adaptation of ways of

life (Kasturi et al., 2014). These problems increase the potential for African immigrants

to develop mental illnesses (Kasturi et al., 2014). There is a significant and confirmed

rate of undiagnosed and untreated mental illness problems among African immigrants to

the U.S. The recognized mental illnesses that are well-known among African immigrants

include depression, anxiety, schizophrenia, bipolar disorder, depression, somatic

37

disorders, PTSD, suicidal ideation, and alcohol and chemical substance abuse and

dependence (Kasturi et al., 2014).

The challenges of acculturation among African immigrants with undiagnosed and

untreated mental illness remain unresolved. Socially and culturally related factors alone

should not be utilized to explain these problems faced by migrants. Carefully considering

discrimination and inequalities embedded within the mental illness treatments process

should also be considered. Failing to resolve immigrants’ mental illness problems and

remove the barriers that prevent individuals from seeking mental illness treatment pose

serious dangers to the whole nation and limits immigrants’ access to effective mental

healthcare services (Rogers-Sirin et al., 2015). Undiagnosed and untreated mental illness

is a challenge for African immigrants. Migrating from one’s country of birth to another

country can become a traumatic and distressing experience (Rogers-Sirin et al., 2015).

Specifically, transitioning to a new way of life in another culture involves a range of

challenging issues including acculturation, barriers to financial success, and prejudices

(Rogers-Sirin et al., 2015).

Migration has complicated issues that require careful consideration of the

circumstances proceeding and following migration, such as family problems (Rogers-

Sirin et al., 2015). When mental health clinicians and researchers fail to consider these

relevant cultural factors, they are not able to develop and offer compelling and acceptable

mental illness treatments for immigrants, including African immigrants to the U.S. Their

inability, in turn, may adversely affect psychological assessment and lead to establishing

incorrect diagnoses, stereotyping, and ineffective mental illness treatment outcomes

38

(Kasturi et al., 2014). A limited number of research studies have been conducted to

examine migration and challenges of acculturation as contributing factors to mental

illness problems of African immigrants. Even though the U.S. is a country that welcomes

immigrants from different continents, no specific preparations have been made to

facilitate mental health care services for immigrant populations, including African

immigrants (Rogers-Sirin et al., 2015; Viruell-Fuentes et al., 2012). Immigrants must

understand these immigration policies, must have financial resources to support

themselves, must not become a public charge, and must fulfill the requirements to live in

the U.S. as law-abiding immigrants (Viruell-Fuentes et al., 2012).

The SAT and CRT were discussed as the frameworks for illuminating the

interview development and analysis process. Many African immigrants believe that the

mainstream Western and American mental healthcare services cannot be efficiently

responding to their problems (Ciftci, 2013; Corrigan et al., 2014). Therefore,

understanding of these phenomena could lead to the development of more sensitive

intake and treatment systems for culturally unique persons. It is hoped that the results of

this study will contribute to a better understanding of African immigrants’ experiences

involving mental health, mental illness, and help-seeking in the U.S. Chapter 3 includes

the rationale for selecting IPA as the research design and will also describe the study’s

methodology in greater detail.

39

Chapter 3: Research Method

The purpose of this qualitative research was to explore the lived experience of

mental health, mental illness, and help-seeking experiences among African immigrants in

the U.S. Chapter 3 contains the introduction, research design and rationale, role of the

researcher, methodology, issues of trustworthiness, and a summary.

Research Design and Rationale

Research Questions

RQ1. What is the lived experience of mental health for African immigrants in the

U.S.?

RQ2. How does indigenous cultural stigma occur in the meaning of mental illness?

RQ3. How do African immigrants to the U.S. describe their help-seeking experience?

R41. How does indigenous cultural stigma occur in help-seeking?

Central Concepts/Phenomenon of the Study

The primary phenomena of interest were mental health, mental illness, and help-

seeking. All phenomena were explored within the context of cultural backgrounds and

present immigrant experiences of participants. Experience and meanings involved in

mental health, mental illness, and stigma are strongly related to traditional cultural beliefs

and practices, and therefore EW different from Western and American cultural beliefs.

Rationale for IPA Design

The phenomenological approach selected for the proposed research was IPA. IPA

involves exploring methodically the meaning individuals attach to their lived

experiences, which helped me make sense of their private and social world IPA s

40

premised on three significant philosophical concentrations: phenomenology,

hermeneutics, and ideography (Finlay, 2009; Smith et al., 2009; Smith et al., 2013).

Another unique feature of IPA is the “double hermeneutic” perspective on the

experience of the participants. Smith et al. (2009) said, “The participant is trying to make

sense of their personal and social world; the researcher is trying to make sense of the

participant trying to make sense of their personal and social world” (p. 40). According to

Smith et al. (2009), it is challenging “to critically and reflectively evaluate how these pre-

understandings influence the research” (p. 40). Other phenomenological approaches were

reviewed but not selected because IPA most suited to this task.

Role of the Researcher

The role of the researcher as observer, participant, or observer-participant in IPA

is to fully understand participants’ thorough descriptions of their lived experiences

regarding the phenomenon and present the findings using common themes (Patton, 2015;

Smith, 2011). I aimed to understand participants’ perspectives and meanings they made

of their experiences, while asking questions and encouraging participants to examine and

reflect over their experiences.). I developed the data collection tools and collected,

analyzed, and interpreted data. As such, I recognized that potential biases were present

throughout the research process. In IPA studies, the researcher is an active participant

during data gathering as well as the analysis and interpretation processes (Patton, 2015,

Smith et al., 2011). I implemented double hermeneutic or two-stage interpretation

processes that involved participants in the study attempting to make sense of their lived

41

experiences. I helped participants examine their experiences in ways that guided them

toward clarification and understanding.

I share cultural beliefs with participants in terms of their experiences with mental

health, help-seeking, and mental illness treatment. I was born and raised in Akwa Ibom

State in the South-South Region of Nigeria and West Africa and have traveled widely in

Africa, Asia, Europe, the U.S., and Canada. I understood with clarity African

immigrants’ attitudes regarding American cultural beliefs, language dissimilarities,

spirituality, and migration. I came to the U.S. as an international student to study and then

became a legalized resident and African immigrant before becoming a U.S. naturalized

citizen. Because of life experiences, I understood the challenges regarding acculturating

to Western society and difficulties in terms of reconciling fundamental cultural beliefs

regarding experience and meaning of mental health, mental illness, and help-seeking. I

worked as a behavioral health analyst, mental health counselor, and mental health

therapist with different accredited behavioral and mental health organizations, all of

which offered mental health services to ethnically diverse minority population groups,

including African immigrants. Based on these experiences and expertise, I decided to

pursue a Ph.D. in Clinical Psychology and explore African immigrants’ experiences

regarding mental health, mental illness, and help-seeking in the U.S. To minimize ethical

dilemmas, I ensured that there were no existing professional or business relationships

between or among prospective participants and myself. I recognized that there was a risk

of bias which could arise from shared African ancestry, traditional cultural beliefs,

42

historical backgrounds, socioeconomic backgrounds, religious convictions, language

similarities, and values.

I focused on participants’ interpretations of their lived experiences regarding the

phenomenon under study. African immigrants have different experiences in terms of

mental health, mental illness, and help-seeking trends and patterns. Investigator alleged

that understanding African immigrants’ experiences concerning mental health, mental

illness, and help-seeking conditions, as a distinct ethnically diverse minority immigrant

population group in the U.S. would enhance understanding of their problems and how to

address them properly as the phenomenon under investigation. Descriptions of lived

experiences of African immigrants concerning mental health, mental illness and help-

seeking conditions, the phenomenon under study, and information obtained from the

literature review would be beneficial to the discipline of psychology science, psychology

research community and mental health professionals and researchers, and the mental

health policy makers.

The researcher, who was the only investigator in the proposed research, selected

the prospective participants for an interview, organized and managed interview sessions,

and collected and analyzed data. Through careful effort, the researcher collected unbiased

data and made sure that the prospective participants in the research were not friends or

known or familiar individuals. The participants were offered ample opportunity to review

the summary of their interview transcription to validate that they depicted what they

discussed in the interview to establish trustworthiness and accuracy. The researcher

explained the purpose of the research, the risks that may be involved, and the

43

participation benefits to the participants. Additionally, the researcher informed the

participants of their right to withdraw from the research at any time, during the data

collection and analysis. The researcher also clarified how the participant’s confidentiality

was protected during and after the research and obtained informed consent from every

participant.

Methodology

Participant Selection Logic

Population. The target group for the proposed research was African immigrants

who have mental health, mental illness, and help-seeking experience in the U.S. Most

African immigrants to the U.S. prefer to live in large metropolitan settings, and most

have settled in Washington, DC, New York, Georgia, Texas, Maryland, Virginia,

Massachusetts, Pennsylvania, and California (Immigration Policy Center [IPC], 2012).

The participants for the study were recruited in Los Angeles, CA, a large metropolitan

area with a large African immigrant population that participates in African social,

cultural, and religious organizations.

Sampling strategy. A purposeful, homogeneous sample was developed through a

combination of referral and snowball sampling of African immigrants with mental health,

mental illness, and help-seeking experience (Patton, 2015). Referrals included associates

and colleagues of the researcher who had access to individuals meeting the inclusion

criteria. An invitation letter was sent by email or distributed in person by asking these

referral sources to pass along the invitation (see Appendix A).

44

Snowball sampling was utilized for the identification and selection of

information-rich cases connected to the phenomenon of under study (Patton, 2015). This

was a compelling recruitment procedure in which the research participants were

requested to help the researcher to identify other prospective respondents who could

participate in the research (Patton, 2015). It was an excellent technique for conducting

qualitative research with a specific and reasonably small group that could be difficult to

find or identify. When the researcher identified two or three African immigrant

participants in the research, they were almost certain to know other African immigrants

who could participate in the research (Patton, 2015). This technique worked for ethnically

diverse minority population where individuals with mental health, mental illness, and

help-seeking problems preferred to conceal their problems because of cultural stigma

(Patton, 2015). This procedure revealed developments that utilized and established social

networking, with the ability to enhance trustworthiness and dependability because the

referral sources were able to affirm eligibility of prospective respondents and make

possible the eagerness of the respondents to participate in the study with conformity. The

process continued until the researcher obtained all the interviews needed or until the

contacts had been exhausted (Patton, 2015).

Criteria for selection. IPA researchers chose individual participants on

conditions of whether they could be able to provide substantial information concerning

the phenomenon under consideration (Smith et al., 2009; Smith, 2011). Researchers

affirmed that, in IPA research, the individuals selected to participate in the research

represented the phenomenon of interest rather than the population under study (Smith et

45

al., 2009; Smith, 2011). Therefore, the individuals selected to be interviewed must be

able to provide descriptions of lived experiences with the phenomenon under study.

Furthermore, all participants were required to be fluent in the English language as

stipulated by the inclusion and exclusion criteria of participants in the research.

Participants:

● Have migrated from one of the countries in the Five Main Regions of Africa.

● Have migrated to the U.S. as an adult, i.e., at age 21 or older

● Already lived in the U.S. for at least one year and was willing to talk about their

lived experiences.

● We’re willing to discuss mental illness and barriers that prevent individuals from

seeking mental illness treatment.

● We’re willing to discuss social and cultural factors, including traditional beliefs,

relevant to mental illness and its significance.

● Read and agreed to the guidelines of the study as described in the Statement of

Informed Consent (Appendix B).

Participant recruitment. The study was approved by the Walden University

Institutional Review Board (IRB). Approval number for this study was 01-04-19-

0170177 and expires on December 17, 2020. African immigrant participants were

contacted through referrals from different wardens who because of their professional

positions, cultural identities, and social connections had comparatively straightforward

contact with individuals who conformed to the recruitment criteria of the research. The

researcher exploited opportunities for referrals through personal contacts in addition to

46

snowballing developments that materialized when the distinguished participants

convinced other respondents that they deemed met the research recruitment criterion. The

research recruitment flyer explained the purpose of the research and encouraged

interested parties to directly contact the researcher (see Appendix A).

Respondents who were interested in participating contacted the researcher by

email or telephone and were given more information about the research study and a

Consent Form (see Appendix B). The interviews took place at a central location, which

could be reached easily through public and other means of transportation. The total

number of cases preferred, and the trend of the referral and patterns of the referral

revelation were guided by the distinguishing of the proposed sample and the recurrence

of information (Smith et al., 2009). The researcher scrutinized the need for the experience

and meaning of mental health, mental illness, and help-seeking experience and the

saturation of data, accelerating or stopping the rapidity as desirable (Smith et al., 2009).

Sample size. The IPA researchers consider a high quality; comprehensive

analysis of a small number of cases an appropriate strategy for this type of research

(Smith et al., 2009). The qualitative phenomenological researchers contemplate on a

small sample size that will reach the expected saturation point, which means that it has

provided enough adequate and quality data to support the outcome of the research

(Yuksel & Yildirm, 2015). Researchers established that the saturation point is contingent

on whether the researcher is looking for large depiction meta-themes or more

comprehensive dissimilarity and controlled themes. Furthermore, researchers established

that saturation could be reached by completing the first scheduled 12 interviews and even

47

fewer if the researcher were investigating simpler or meta-themes (Finlay, 2009; Padilla-

Diaz, 2015). Based on these concepts, the target sample size for the proposed research is

eight to 10 participants. The researcher carefully monitored the richness and depth of the

data, during the analysis process to assess the potential for data and thematic saturation of

the critical phenomena. One indicator of saturation to be used is to observe when the

codes become monotonous before or after the determined number of interviews with the

sample, and the demand for multiple-valued viewpoints and saturation of data;

accelerating, measured and will be at rapidity as required (Gentles et al., 2015; Suri,

2011).

Instrumentation

Basis for Instrument Development

The semi-structured one-on-one in-depth interview guide was developed by the

researcher (see Appendix C). It was grounded in the investigative principle of

phenomenology. The IPA customarily involves the use of semi-structured one-to-one

interview procedures to attain narratives, reflections, thoughts, and reactions from the

research participants (Smith et al., 2009). This method was used in the proposed research

to obtain African immigrants’ lived experiences with mental health, mental illness and

help-seeking trends and patterns; the meaning of mental health, mental illness, and help-

seeking experience with the phenomenon under study (Smith et al., 2009). African

immigrants were the investigational experts who provided descriptions of their lived

experience with mental health, mental illness, and the help-seeking trends and patterns in

the proposed research. Therefore, the interview questions were designed to be open-

48

ended (Smith et al., 2009). The analytical guide was flexible, and the participants were

able to communicate their concerns and insights that may be predictable and

unpredictable. The methodology and content experts on the researcher’s committee

assessed research questions, sub-questions, and interview questions for feedback on the

language, tone, and wording. The interview guide was also reviewed by methodological

experts to improve the credibility of the proposed instrument.

The proposed interview questions were formulated from published literature

reviewed in Chapter 2 that identified the following key content areas as relevant to

answering the research question. These key concepts were used to formulate each of the

questions. While content validity cannot be formally established, the researcher made

substantive efforts to justify the choice and focus of questions based on the literature and

theoretical frameworks described in Chapter 2. In Chapter 5, the results based on these

questions will be interpreted in the light of these published studies in order to enhance

credibility and content validity (Shenton, 2004).

Table 1

Sources for Developing Interview Questions for Content Validity

Key Content Area Article Source

Experience in mental
health

(Bagsgasra & Mackinem, 2014; Ciftci, 2013;
Fleischmann & Verkuyten, 2015; Gureje &
Stein, 2012).

Experience of mental
illness

(Akresh, et al., 2016; Glied & Frank, 2016;
Parcesepe & Cabassa, 2013).

49

Meaning of help-seeking
experience

(Amri & Bemak, 2013; Derr; 2017).

The occurrence of
indigenous stigma in
mental health

(Clement et al., 2014; Douglas & Wildavsky,
1982; Lindinger-Sternart, 2015; Renner &
Salem, 2014).

The occurrence of
indigenous stigma in
mental illness

(Abdullah & Brown, 2011; Dale & Daniel, 2013;
Schock-Giordano, 2013).

The occurrence of
indigenous stigma in the
help-seeking experience

(Aina & Morakinyo, 2011; Akomolafe, 2013;
Leong & Kalibatseva, 2011; Schock-Giordano,
2013).

Procedures for Recruitment, Participation, and Data Collection

The researcher started preliminary inquiries through the relaxed verbal

presentation to describe the purpose of the research and recruitment process. A flyer

about the study was distributed (see Appendix A). Certain individuals distributed the

flyer, and those responding to the flyer by email was sent and asked to return a fully

signed consent form (see Appendix B). Once the consent form was received, the first

interview was scheduled. The plan was to complete eight to 10 interviews. However, if

the recruitment process fell shortly after the initial effort, then the researcher was to re-

contact colleagues and other referral sources and re-distribute the invitation letter by

email or distributed in person to another group of individuals (see Appendix A).

All participants in the proposed research were interviewed in English, using the

semi-structured interview guide (see Appendix C). The researcher reserved a private,

50

quiet room in the community center. The researcher created a calm and comfortable

environment for every interviewee. The setting had appropriate furnishings, including

arrangement of chairs to enhance face-to-face interviewing techniques, as well as ensure

that the audio-recording system was working correctly. Water was provided for the

interviewees. The researcher reviewed the objective and the nature of the proposed

research, reminded the participants concerning their agreement to participate, addressed

the participants’ concerns and answered all the questions that arose concerning the

proposed research. Furthermore, the researcher explained the compositions of the

interviews, the procedures of the interviews, and the probing questions determined by the

participants’ information concerning the phenomenon under study.

The researcher reminded the participants of their right to decline to participate and

right to withdraw and leave the study at any time once the interview began. The

researcher also informed the participants of ethical protection and confidentiality before

the beginning of every interview. All the interviews were individually conducted to

collect data for this proposed research study, and the approximate length of time for each

interview was 45 minutes to 1 hour. After the interview, each participant was debriefed,

which included a brief reiteration of confidentiality and a description of future contact for

the member checking process.

The audio-recorded interviews were given to a recognized and approved data

transcription agency for transcription. The researcher released no personal information

concerning the participants to the transcription agency. The transcription agency signed

the mandatory Transcriptionist Confidentiality Agreement in (see Appendix F). After

51

transcription, the agency presented three categories of interview audio-recording,

including (1) the original interview audio-recording, (2) an electronically transcribed

interview audio-recording, and (3) the hard-copy of the interview audio-recording.

The researcher summarized each interview transcript by question and sent the summary

to each participant for member checking and feedback. The procedure offered the

participants ample opportunities to review their experiences and add, change, or delete

content. This technique improved the trustworthiness of qualitative analysis (Carlson,

2010; Koelsch, 2013; Smith & Noble, 2014).

Data Analysis Plan

The following research questions guided the study:

RQ1: What are lived experiences involving mental health for African immigrants

in the U.S.?

RQ2: How does indigenous cultural stigma occur in terms of mental illness?

RQ3: How do African immigrants in the U.S. describe their help-seeking

experiences?

RQ4: How does indigenous cultural stigma occur in help-seeking?

Interview guide question #4 inquired individually about the lived experience of

mental health (RQ1). Interview guide questions #2 and #3 inquired into the experience of

stigma in identifying and seeking help for mental illness in the U.S. and the country of

origin (RQ2). Interview guide questions #1 and #5 inquired concerning experiences with

American Mental Health System (RQ3). Interview guide question #4 inquired about the

description of what mental health means in the U.S. (RQ4).

52

The IPA approach necessitates that the transcripts of all audio-recorded interviews

must explain all the expressions communicated by the interviewees and comments

explaining non-verbal declarations like mirth, a significant break in proceedings, and

indecisions (Smith et al., 2009). The researcher assigned a code to each transcript to

protect the participant’s privacy.

The audio recording was reviewed, and the verbatim transcripts carefully read

through for sometimes as appropriate to have clarity for easy understanding and

interpretation of the interview data. The researcher took notes in the areas of expounding,

conceptual interpretation, and exact synonyms. The expounding notes focused on

interview content. Conceptual explanation notes focused on interpretative and integrated

searching of data for more substantial ideas and use of exact synonyms specifically

considered the communicative abilities of the participants (Smith et al., 2009). The

developing themes among individuals were first determined among individual

participant’s case before the classified patterns (category with a system of classification)

and themes that join the developing themes (Smith et al., 2009). The rate of recurrence

that the developing theme appears in the transcripts was noted as a sign of its relative

significance to the participant (Smith et al., 2009). The perspective and meaning of the

developing themes were considered in following educational and explanation

components (Smith et al., 2009). The researcher thoroughly investigated the action of

combating connections. The perception was that knowing the meaning of mental health,

mental illness, and self-seeking experience among African immigrants may offer a better

understanding of the problem (Smith et al., 2009).

53

After the analysis of individual cases, the focus was changed to evaluating the

group relationship and recurring themes which may be relevant to a more significant part

of participants. The group themes were determined and confirmed by identifying their

rapidity of recurrence among the cases and were shown through paradigms taken from

individuals (Smith et al., 2009). The researcher explored the discrepant cases and

responses to determine for their particular significance, which may enhance the

understanding of the meaning of mental health, mental illness, help-seeking with

indigenous cultural stigma in the meaning of mental illness and help-seeking among

African immigrants to the U.S. The researcher used NVivo, a qualitative data analysis

(QDA) software program for management and storage of data (Hamed et al., 2013). The

QDA enhanced data management by organizing several clustered data categorizers,

organizing impressions generated in the study, and reporting the clinical findings based

on the transcript information (Halim et al., 2013).

Issues of Trustworthiness

Trustworthiness involves the degree of confidence that the qualitative research

maintains, which may be compared to the quantitative terminologies of reliability,

objectivity, and validity (Denzin & Lincoln, 2012; Marshall & Rossman, 2015).

Universally, the qualitative and quantitative researchers utilize comprehensive empirical

techniques designed to confirm the trustworthiness of their clinical findings (Patton,

2015). The trustworthiness in qualitative research is measured according to the four

established criteria of credibility, transferability, dependability, and confirmability

(Patton, 2015; Smith et al., 2009).

54

Credibility

Credibility is a trustworthiness criterion that is comparable to internal validity in

qualitative research (Denzin & Lincoln, 2012; Marshall & Rossman, 2015). Credibility

requires establishing that the findings of qualitative research are trustworthy from the

perspective of the research participants. Credibility was determined through prolonged

engagement with the participants during data collection. The researcher immersed

himself in the participants’ world to gain insight into the context of the research. The

researcher decreased distorting information which may have transpired during interviews.

The researcher’s prolonged time with the participants to conduct multiple interviews

enhanced confidence. Spending enough time with the participants enabled the researcher

to understand the main issues that may influence data quality and enhance trust with the

study participants.

The researcher also employed member checking of interview transcript

summaries to verify that the researcher’s interpretation of the interview key points aligns

with the participants’ intents (Denzin& Lincoln, 2012; Marshall & Rossman, 2015). Peer

debriefing technique in the proposed research involved getting feedback from

methodology expert and content expert who were the researcher’s reviewers to assess

research findings. Peers may address issues of bias, mistakes of actuality, challenging

explanations, and/or increasing differences involving data and the phenomenon and

materialization of themes; all of which comprise of a prolonged but essential technique

for establishing credibility (Denzein & Lincoln, 2012; Marshall & Rossman, 2015). The

researcher requested support from other professionals who were willing to offer scholarly

55

guidance. The researcher sought peer-review subject matter experts and methodologists

on the review of research questions and the interview guide (Denzin & Lincoln, 2012;

Marshall & Rossman, 2015).

Transferability

Transferability refers to the extent to which the reader may transfer the research

findings to meaningful contexts and individuals (Shenton, 2006). The researcher

provided a thoroughly defined explanation of the procedures through the data gathering

process and analysis process (Denzin & Lincoln, 2012; Marshall & Rossman, 2015). The

researcher described the settings, research design, and methodology and provided the

participants with a complete explanation for the information to be transferable to other

groups and contexts. The researcher accomplished transferability, using rich description

and another technique for establishing credibility in qualitative research.

Dependability

Dependability ensures that the research findings are dependable and may be

repeated (Denzin & Lincoln, 2012; Marshall & Rossman, 2015). Dependability is

considered the standards under which the research is executed, analyzed, and presented.

This process also facilitates the researcher’s ability to understand the methodologies and

their usefulness.

Confirmability

Confirmability in qualitative research is comparable to objectivity in quantitative

research and relates to the degree that the clinical findings transpire from the participants’

perspectives and lived-experiences, not the researcher’s preferences and characteristics,

56

and is supported by the data collected and analyzed by the researcher (Denzin & Lincoln,

2012; Marshall & Rossman, 2015; Patton, 2015). The qualitative researcher can establish

confirmability by presenting a clear audit trail that encompasses raw data, documentation

of course of actions, accurate analysis, and routine reflexive individual annotations

(Marshall & Rossman, 2015; Patton, 2015). Data was organized consecutively to make it

possible for others to understand the research course of action. The researcher’s audit trail

was comprised of preliminary annotations on research questions, suggestions, sampling

selection process, interview schedules, audio recordings, word for word transcriptions,

memorandums, theme-tables, paradigms, draft- reports, and the concluding report.

Fundamentally, researchers must understand the epoch process, understanding their

inclinations, prejudices, perspectives, and assumptions (Marshall & Rossman, 2015;

Patton, 2015; Shenton, 2004). The epoch process is an enduring problem-solving

procedure that allows the researcher to be exposed to innovative insights and mutual

comprehensions (Marshall & Rossman, 2015; Patton, 2015).

The researcher was involved in the epoch process and worked to manage personal

biases, prejudices, presumptions, and presumed meanings so that research data was

collected, analyzed, and interpreted on its possible terms. Conformability was established

by making available the supportive research information that enabled others to

authenticate the research interpretations and arguments (Marshall & Rossman, 2015;

Patton, 2015). The researcher utilized a significant quantity of word-for-word quotations

from every participant and not only a few that were offered to authenticate the research

57

interpretations and clinical conclusions. The interpretations and conclusions are relevant

to the literature review analysis. Expressly, the IPA authorizes the possibility of utilizing

a measure of justifiable descriptions so that the problem can be addressed by generating a

logical and apparent description of the research data (Smith et al., 2009; Smith, 2011).

The intra- and intercoder reliability (where applicable) were not used in this research.

Ethical Procedures

The researcher sought and obtained approval, before collecting any of the data

from the Walden University Institutional Review Board (IRB). Approval Number for this

study was 01-04-19-0110147 and expires on December 17, 2020. Approval guaranteed

that the research met the required guidelines for an institution-supported research project,

including ethical guidelines. The participants in the research participated voluntarily,

without compensation, and were recruited separately from the researcher’s employment,

professional and social circles. The study had no known dangerous conditions that may

affect their safety and security. However, the subject matter was construed as personally

sensitive. Therefore, to respect potential ethical challenges in the conduct of this study,

the researcher made every effort to address the participants’ concerns, offered

participants debriefing information before registering of interest in the study, and

thoroughly communicated the expectations of the study to all participants. Also, the

researcher reminded participants at several stages of the interview that if interview

questions provoked distress, they may discontinue at any point without penalty, and they

would be supplied with mental health resources on which to call (see Appendix D).

58

The proposed research was conducted in conformity with the information storage

and safety procedures (5 years in locked and password protected files), as established in

the Walden University Institutional Review Board application. Every participant in the

proposed research was presented with a Consent and Security Form in to read and

complete, after establishing individual eligibility for participation (see Appendix B). The

researcher also maintained a chronological research journal with participants’ contact

information, notes for specific purposes, summarized concerns, follow-up issues, and

other relevant information.

This journal, along with all the study files, organized computer data, audio tapes,

and transcripts relevant to the proposed research, was stored in a locked security safe

cabinet located at the researcher’s home office. Only the researcher had access to the

data. A secure password protected all electronic files related to the proposed research

study. Additionally, the researcher will maintain the raw data files for five consecutive

years before removing them permanently from the computer system and shredding the

paper documentation. Each participant was assigned a pseudonym for the study, to ensure

his/her safety and confidentiality. The researcher eliminated identifying information from

the transcripts after information verification.

Before the research began, the participants were given detailed information

concerning the dangers and threats, time constraints, benefits, and potential follow-ups

involved in the proposed research. They were also given information on available local

community mental health care services and treatment centers, in case participating in the

study caused them stress. The participants were informed that the published research will

59

not include any of their individual recognizable information, that any information they

supply will remain confidential, and that it will not be communicated to any person

except the members of the researcher’s dissertation committee and the Walden University

IRB. Finally, the participants were guaranteed that no danger or exposure to harm would

occur because of their participation in the proposed research.

Summary

This chapter introduced an IPA study that explored African immigrants’

experience of mental health; mental illness and help-seeking in the U.S. Segmented

assimilation theory and the cultural theory of risk were utilized as a theoretical

framework for the study. A purposeful, homogeneous sample was developed through a

combination of referral and snowball sampling of African immigrants with mental health,

mental illness and help-seeking experience. Data was analyzed for the consistent

experience of mental health, mental illness and help-seeking themes and patterns that

contributed to an improved understanding of the procedure. Additionally, it presented and

defended the chosen theoretical framework and explained how the study would be

conducted. Specific topics included participant selection, interview techniques, data

collection techniques, and methods for organizing and analyzing the data. The data

resulting from this study was used to determine African immigrants’ experience of mental

health, mental illness and help-seeking in the U.S. Chapter 4 will describe the results of

the research in detail as well as demographics, data collection and data analysis, and

trustworthiness evidence.

60

Chapter 4: Results

In this phenomenological study, I explored the experiences of nine African

immigrants who migrated to the U.S. from countries within the five main regions of

Africa regarding mental health, mental illness, and help-seeking. There were four

research questions:

RQ1: What is the lived experience of mental health for African immigrants in the

U.S.?

RQ2: How does indigenous cultural stigma occur in the meaning of mental

illness?

RQ3: How do African immigrants in the U.S. describe their help-seeking

experiences?

RQ4: How does indigenous cultural stigma occur in help-seeking?

I used IPA as the approach to define the sample, develop interview guide questions, and

analyze data. This chapter includes descriptions of the research setting, demographics,

data collection, data analysis, and evidence of trustworthiness, results, and a summary.

Setting

I conducted interviews from February 17, 2019 through April 18, 2019.

Interviews were conducted at times and places selected by and convenient to the

participants. Two interviews were conducted in participants’ homes with their approval;

seven interviews were conducted through the telephone as requested and approved by

participants. No significant deviations from planned primary procedures were

encountered or experienced.

61

Demographics

Seven participants were male and two were female. Participants’ ages ranged

from 41 to 68. All but two of the participants completed higher professional education in

their respective areas of learning. All participants migrated from African countries to the

U.S. and were living in the U.S. at the time of the interview. All participants were fluent

in English, and interviews were conducted in English. Table 2 includes a summary of

participant demographics and characteristics. In one case, the participant referred to two

individuals, male and female. Only one participant referred to him or herself in terms of

relating the experience of the phenomena: the rest referenced family, friends, and work-

related relationships. Also, persons who used patients as examples referred to only those

individuals who they observed but had no direct patient care interactions or

responsibilities.

Table 2

Summary of Participants’ Characteristics

Code Gender of

Participant

Age Occupation Gender

of the

Person

Seeking

MH

Services

Relationship

to the

Person Who

Was

Interviewed

Help-

Seeking

Condition

P1 Male 57 Caregiver Male Patient Mental
Health

P2 Male 60 Community
Development
Consultant

Female Family
Friend

Mental
Illness

62

P3 Female 57 Medical
Practitioner

Female Patient Mental
Illness

P4 Female 60 Medical
Social Worker

Male Family
Friend

Mental
Health

P5 Male 60 Health Care Male Family
Friend

Mental
Illness

P6 Male 68 Health/Human
Services
Consultant

Female Family
Member

Mental
Illness

P7 Male 41 Professional
Counselor

Male Self
(reported on
experience)

Mental
Health

P8 Male 62 Mental Health
Clinician

Male Family
Friend

Mental
Illness

P9 Male 41 Professional Male Roommate Mental
Illness

Summary of Participants’ Experiences

P1. The first interviewee was a 57-years old man identified as an African

immigrant. He migrated from his native African country to the U.S. more than 10 years

ago. He works at a local community health facility as a Care Manager. He described his

experiences with two individuals, a man and a woman diagnosed with mental health

disorders and mental illnesses. The male individual was diagnosed with Alzheimer’s

disorder, and the female individual was diagnosed with postpartum depression, and both

were patients at the local community health facility. However, he had no direct

involvement with their care. P1 emphasized that his academic preparation and

professional experience enabled him to understand with clarity the entrenched challenges

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and complications involved with these two medical conditions. He described his

understanding of the perceived contributory factors of mental health disorders and mental

illness, and there was a significant need for help-seeking. He described the notion of

mental health in his native African country as distinctly different from the construct of

mental health in the U.S., including modalities of treatment based on traditional cultural

beliefs and family involvement during the treatment process and recovery. Furthermore,

in the U.S., there was no family support and this creates difficulties and challenges.

P2. The second interviewee was a 60-year-old man who migrated from his native

African country to the U.S. more than 10 years ago. He is a professional community

development consultant who described mental health as a neglected medical condition

among African immigrants that is directly linked to other physical conditions. He

emphasized that mental health was the foundation for emotions, communications,

thinking, resilience, attentiveness, self-esteem, better relationships, individual wellbeing,

and career advancement. P2 asserted that through mental health, African immigrants

could be exposed to other medical conditions that require medication treatment, but

mental illness was complicated due to his cultural beliefs. He worked with individuals

who were coming out of transition and reentry social programs. P2 described being called

one day by a family friend who told him that her daughter was throwing things carelessly

all over the place and becoming dangerous to herself and other family members. P2

witnessed that the girl was transported to a community medical center, and from there,

she was referred to a psychiatric hospital where she was diagnosed and treated for mental

illness.

64

P3. The third interviewee was a 57-year-old woman who migrated from her

native African country to the U.S. more than 10 years ago. She said that she was a

medical practitioner and worked at a community health center that provides primary care

and mental health services to the general public, including African immigrants. P3

emphasized that her academic preparation and professional experience enabled her to

understand embedded challenges of mental health, mental illness, and help-seeking

among ethnically diverse minority immigrant population groups. Furthermore, she

described how depressed individuals come to the community health center for physical

and psychological assessment before established diagnosis and treatment for mental

illness. She mentioned that some patients are considered for referral and others are

handled through in-patient care and out-patient care services. P3 described her

understanding of the U.S. mental health system, mental health services offered, and

disparity issues in terms of services offered to ethnically diverse minority immigrant

population groups. P3 described her personal understanding of challenges caused by

African immigrants’ traditional cultural beliefs that hindered their ability to submit

themselves to be assisted or being helped by medical professionals. Significant

challenges for medical care professionals and mental health treatment teams were not

talking about mental health issues, not being willing to take medication or believing in

prayer to get well.

P4. The fourth interviewee was a 60-year-old woman identified as an African

immigrant. She migrated from her native African country to the U.S. more than 10 years

ago. She said she is a medical social worker and works for a local school district. P4

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emphasized that her academic training and professional experience enabled her to

understand the challenges of mental health among African immigrants, with social and

economic challenges they face in the U.S. P4 described her experience with a family

friend who was not able to do anything to help himself but claimed to be depressed all the

time, and understanding that depression is linked with mental health issues, decided to

help the person to seek help for his problems. P4 reported that the person was taken to the

community mental health clinic, where he was diagnosed and treated for mental health

disorders, but medical insurance and cultural beliefs were significant challenges to the

mental health clinicians.

P5. The fifth interviewee was a 60-year-old man identified as African immigrant.

He migrated from his native African country to the U.S. more than 10 years ago. He said

he works as a health care management consultant for a local medical group. P4

emphasized that being an African enabled him to understand that African cultures

stigmatize individuals with mental health issues and their families, and African

immigrants to the U.S. should not be exempted. P5 stated that, because of stigma, mental

health-related issues are not openly discussed outside the family in African cultures. P5

emphasized that, mental health problems could extend to include emotional instabilities,

because as an African immigrant to this country sometimes economic challenges and

pressures that you face could cause you to develop certain medical conditions that you

never experienced, also, maybe your family members of your native African country

never experienced. P5 described that his understanding of the American mental health

system offered clarity for knowing available resources for individuals with mental health

66

problems, and also described his experience with a family friend who reported to me that

he was having severe problems and did not know what to do or how to seek help for his

problems. P5 asserted that, he told him to go to his primary doctor, and from there, he

was referred to a mental health treatment center for further psychological evaluation and

treatment. Finally, P5 confirmed that his friend was diagnosed with mental health

disorder and placed on psychotherapy and medication therapy, and the mental health

clinicians were able to help him despite cultural and language dissimilarities.

P6. The sixth interviewee is a 68-year-old man identified as African immigrant.

He migrated from his native African country to the U.S. more than 10 years ago. He is a

professional health and human services consultant in private practice with many years of

experience. P6 emphasized his academic preparation and professional experience enabled

him to understand that, mental health problem as the sickness of the mind, which

individuals could not comprehend what is happening to them, preferably in the way

healthy individuals do as they go about completing their daily functional responsibilities.

P6 described his experience of mental health issues with a family member who was

seeing things that others could not physically see, received and greeted imaginary guests

that were not there, became frightened when not threatened, exaggerated un-realistic

things, over thinking about conditions that were not threatening to other people. P6

reported that he recognized the condition as an imbalance of position of things but were

appropriate usually to other family members but seemed not the same together when

measured. P6 also described the experience with his niece who was taken to the hospital

to be seen by the primary doctor, after an evaluation, established that her problem was a

67

mental health problem; she was referred to a psychiatric hospital for further evaluation,

diagnosis, and treatment.

P7. The seventh interviewee is a 41-year-old man identified as African

immigrant. He migrated from his native African country to the U.S. more than 10 years

ago. He works as professional counselor for a local counseling services organization.

Described his experience of contacting the local department of justice, law enforcement

agency, and the American mental health system because of his mental health problem. P7

emphasized that, the contributory factor of my mental health problem was being that, at

the graduate school, he became friendly with a lady that he met, and who did not inform

me that she had a boyfriend. P7 reported that, later on, in the same year, she told him that

she had a boyfriend and was engaged to the boyfriend, and the problem he had was trying

to separate himself from the relationship he had with her because now she was engaged,

and he was no longer the boyfriend. P7 asserted that this was a mental health problem

from the standpoint that he had to detach from the relationship with somebody that was

very close to him and being forced to detach myself with no exceptions. P7 reported that,

there was a court order that he could no longer contact the lady because she was engaged

to be married to somebody else; and was more of a case for him having to find a way to

live without this lady in his life and to find a new friend. Finally, P7 asserted that, this

led to being evaluated and diagnosed with an established mental health disorder and

treated for this disorder with psychotherapy counseling sessions that were effective for

my problem.

68

P8. The eighth interviewee is a 62-year-old man identified as an African

immigrant. He migrated from his native African country to the U.S. more than 10 years

ago. He works as a mental health clinician at the community mental health treatment

center, with many years of experience working with ethnically diverse minority

immigrant population groups, including African immigrants. P8 emphasized that his

academic preparation and professional experience enabled him to understand that most

individuals who are diagnosed with mental illness do not want to talk about it, but mental

illness was nothing to be ashamed of; it is a medical condition just like heart disease or

diabetes. P8 stated that, mental health conditions are treatable and are unremittingly

expanding human understanding of how the human brain works, and treatments are

available to help people successfully manage their mental health conditions. P8 described

his experience with a family friend who was no longer able to go to work, and was no

longer able to function and take care of himself; he stayed at home and would not want to

go out but told the members of his family to close all the windows because he figured out

that people were using cameras to trace where he was so that they can arrest him and lock

him up without evidence of committing any crime. P8 reported that, his friend was

frightened with nothing to substantiate that people were following him and stopped going

to work because he assumed people were trying to arrest him. He lost appetite for food

and nutrient. He complained of hearing voices and seeing people pursued him with other

individuals experiencing what he complained about at present. P8 asserted that, he took

his friend to the community mental health treatment center, and he was evaluated and

69

diagnosed with mental illness and admitted for in-hospital treatment in a locked

psychiatric unit.

P9. The ninth interviewee is a 41-year-old man identified as an African

immigrant. He migrated from his native African country to the U.S. more than 10 years

ago. He works as a professional counselor for a counseling organization. P9 described his

experience of mental health, mental illness, and help-seeking with an understanding of

the American mental health system. P9 emphasized that his academic preparation and

professional experience enabled him to understand that American mental health system

leaned to the concept that, African immigrants do not understand American mental health

care systems because they are not familiar with how mental health treatment which

provided in the U.S. measured up to the mental health treatments provided in their native

African countries. P9 described experience with his college roommate that was diagnosed

with bipolar disorder and given treatment that was effective.

Data Collection

Snowball sampling was used to collect data from the nine participants in the

study. Referrals came from different community and professional sources that included

community leaders, community churches, family members, medical professionals, mental

health care providers’ professionals, and psychologists who worked in clinical settings

and policy-making organs with ethnically diverse minority immigrant population groups.

Data collection started on February 17, 2019, through May 17, 2019. Participants were

selected to participate in the study if they were African immigrants’ aged 21 years old

70

and older, who migrated to the U.S as adults and have lived continuously in the U.S for a

minimum of one year to the date of the study and could communicate in English.

The participants were interviewed either over the telephone or face to face. All

interviews lasted between 45 and 60 minutes, and the researcher took detailed notes

during the interview process. All interviews either by telephone or face to face were

audio-recorded by Sony digital stereo voice recorder. All the interviews were then

transcribed through Transcription Puppy transcription service. Transcriptions were edited

for accuracy while listening to the audio recording. Summaries were created based on the

content and these were sent to all participants for voluntary member checking for

accuracy, trustworthiness, and evaluation. Participants were advised to inform the

researcher of any misinterpretation and inaccuracies, as well as any additional

information they wanted to discuss. All the participants reviewed their interview

summaries and validated the summary’s data accuracy and trustworthiness. No

participant offered to correct discrepancies in descriptive data, and no participant offered

additional lived experience description of mental health, mental illness, and help-seeking.

Data Analysis

Procedures

The IPA approach includes six steps for data analysis including “reading and re-

reading, initial noting, developing emergent themes, searching for connections across

emergent themes, moving to the next case, and looking for patterns across cases” Smith

et al., 2012, p.81). These six-steps were utilized in this study as a guide to the thematic

analysis. The researcher began with a single transcript so that major thematic elements

71

could be identified. The researcher submerged himself in the original transcript to ensure

that the participant is the focus of the research.

This procedure slowed down the tendency of swift reduction and summation of

data, so the researcher was able to spend substantive and thoughtful time, note-taking and

reflecting during this initial stage. The researcher did this for the first three transcripts,

noting similar and unique thematic elements that could be organized into key content

areas. Then, as the researcher read and summarized each interview, he sought out where

similarities and dissimilarities occurred. By the time he had reached the 6th interview, no

new themes were emerging, and he continued to summarize the rest of the interviews.

The results of the process are described below.

First Cycle

After carrying out the above procedures, the researcher organized the results of the

analysis using the key content areas associated with the interview questions, and then

related the dimensions identified from the transcripts to each of the content areas. The

figure representing the key content areas is below, followed by the table of dimensions

associated with the content areas (see Figure 1). The key content areas were identified in

Table 1, Chapter 3, and were formed from the substantive areas identified in the research

reviewed in Chapter 1. I noted that while most of the transcript results fell within the

originally identified areas, further distinctions were made to reflect common experiences

that were distinct from or resulting from the original identified areas. The new key

content areas include the experience of prejudice and discrimination in mental health, the

experience of the patient, and the utilization of U.S. These are discussed in detail in the

72

results section, along with accompanying quotes from transcripts to illustrate the meaning

of each content area.

Figure 1. Arrangement of the key content areas.

Second Cycle

The second cycle approach involved going back to the details of the transcripts,

identifying unique codes within and across cases. A codebook was created to organize

and keep track of the codes. The code book contained the chronological descriptions of

the codes present in the analyzed interview data and supporting expressions. The

codebook enhanced the researcher’s abilities to remain focused on data analysis and gain

clarified insight for better understanding of the participants’ lived experience. By reading

and re-reading the detailed codes within each theme, the researcher was able to create

eight broad categories. The codes associated with each category are included in Appendix

G. This is shown in Figure 2, listing the eight categories that occurred in chronological

Key Content Area Summary

Experience of Mental
Health

The Experience of
Prejudice and

Discrimination in
Mental Health

The Occurrence of
Indigenous Stigma in

Mental Illness

Experience of Mental
Illness

The Occutrrence of
Indigenous Stigma in
the Help-Seeking
Experience

The Exprience of the
Participant

Utilization of U.S.
Services

Meanings of Help-
Seeking Experience

73

order. These are also discussed in detail in the results section, along with accompanying

quotes from transcripts to illustrate the meaning of each content area.

Figure 2. Arrangement of merged categories.

Evidence of Trustworthiness

The trustworthiness in qualitative research was measured according to the four

established criteria of credibility, transferability, dependability, and confirmability.

Credibility

The SAT and CRT were used to establish the credibility of the study to guide the

development of the interview and guide the interpretation of the results. IPA was used to

guide the analysis process, and this is a well-established qualitative methodology.

Member checking contributed to credibility because the participants were given ample

opportunity to review their interview transcription summaries of the key content areas.

Asssumptions
and

Expectations
Importance of

Cultural
Understanding

Experience of
Mental Health

Cultural
Experience of
Mental Illness

Meaning of
Help-Seeking
Experience

Dissatisfaction

Subject of
Story

Participant
Occupation

74

Peer feedback was obtained from reviews of the interview guide by methodology and

content experts.

Transferability

Transferability is the extent to which the reader could transfer the research

findings to meaningful contexts and individuals (Shenton, 2006). This study thoroughly

defined the procedures (data collection process, data analysis process), and the

participants sufficiently to be transferable to other groups and contexts. The study

ensured the lived experience descriptions of the participants were detailed enough to

support the development of the theoretical explanation and the study analyses of the data.

I strived to obtain rich, descriptions for transferability.

Dependability

Dependability is concerned with ensuring that the research findings are

dependable and can be repeated (Denzein & Lincoln, 2012; Marshall & Rossman, 2015).

All participants were asked the same questions via the Interview Guide, although not

necessarily in the same order (see Appendix C). Transcripts of the audio recordings of

participants’ interview responses were summarized and member checked. Research data,

together with interview transcriptions, summaries, researcher notes, and audio recordings,

were safely stored to enable replication of the study.

Gatekeepers who were familiar with the experience and history of the selected

participants referred the participants in this study. This process helped to enhance the

dependability of the study as referral sources were well-informed to verify the eligibility

of prospective participants and make possible their willingness to speak truthfully.

75

Confirmability

All interviews were recorded and transcribed verbatim. Audit trails were

employed throughout the data collection and analysis process. Follow up questioning was

utilized for clarity of participant’s answers and to explore for better understanding. For

the analyses, I employed a two-cycle coding method, and identified consistencies across

cases, and word for word quotations were utilized. I continually moved back to the

original recordings and transcripts to confirm that the meaning of the original data was

kept intact.

Results: First Cycle

Table 3 summarizes the results of the First Cycle, using the Key Content Areas

connected with the Interview Guide Questions, and the resulting dimensions. Each

content area is briefly defined, followed by a discussion of dimensions with quotes from

the transcripts.

Table 3

First Cycle

Key Content Area Thematic Analysis Dimensions

Experience of Mental
Health

• Unique Conception of Mental Health
• Family/Community Connection
• Utilization of Services
• Believes in Traditional Approaches of Healing

Experience of Mental
Illness

• Unique Conceptions of Mental Illness
• Challenging Life Issues
• Cultural Judgments
• Barriers to Seeking treatment

(Table continues)

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Key Content Area Thematic Analysis Dimensions

Meaning of Help-
Seeking Experience

• African Experience
• Traditional Methods of Treatment
• U.S. Experience
• Cultural Influences
• Utilization of Services
• Barriers and Implications

The Experience of
Prejudice and
Discrimination in
Mental Health

• Sensitivity and Discrimination
• Assessment and Diagnosis Issues

The Occurrence of
Indigenous Stigma in
Mental Illness

• Stigma and Culture
• Shame and Disgrace
• Attitudes Towards Treatment
• Social Cost of Stigma

The Occurrence of
Indigenous Stigma in
Help-Seeking
Experience

• Ordeals for Family Members
• Barriers to Help-Seeking
• Misunderstanding of Help-Seeking

The Experience of the
Participant

• Mental Health Problems and Treatment
• American Mental Health System
• Social and Economic Issues

Utilization of United
States Services

• Racial and Ethnic Differences
• Mental Health Professionals
• Cultural Exclusions and Inclusions
• Effectiveness and Acceptability Issues

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Experience of Mental Health

The data revealed that this theme had several dimensions. Each of these is

identified and described with support from the participants’ descriptions of experience

and responses. Overall, these dimensions reveal that participants have a unique

conceptualization of mental health that goes beyond the superficial differences between

the U.S. and the participants’ native country.

Unique conceptions of mental health. This dimension is best characterized by

seeing with evident African immigrants’ conception of mental health as embedded in the

physical wellbeing, social background, and understanding of the cultural belief systems

and cultural way of life. All participants described their experiences and offered the

following responses.

P1 stated:

The mental health issue in my native country is distinctively different from the construct

of mental health in the United States.

Most participants described mental health as more holistic.

P5 said:

Mental health is a state of physical, well-being through which as an individual, I

can recognize my own capabilities, can cope with my normal stressors of life, can

work effectively and successfully and be able to make meaningful contributions

to African immigrants’ community.

The family/community connection. The significances of family and community

support were noted to be vital to all individuals with mental health issues. P6 stated:

78

Africans and African immigrants’ cultural belief systems and values of collective

support give dignity to individuals regardless of their level in life. In many of the

different languages from the continent of Africa, there is no word for being alone.

Africans collective approach to human behavior emphasized collective

responsibility, shared concern, and commitment to a common cause, and family

that is a community center for better.

Beliefs in traditional approaches of healing. Most participants identified

traditional mental illness treatments as the mainstay and long-established curative

practices.

P1 said:

African cultures utilize the traditional and culturally accessible methods of

treatment provided by native African doctors and faith and spiritual healers.

Westernized conception of mental health problem is not accepted in native

African cultures; the general population commonly utilizes traditional

approaches of healing and culturally approved modalities of local treatment.

Experience of Mental Illness

Mental illness was also conceptualized in ways that were substantively different

than the U.S. system. Participants rooted their unique conceptualizations in their native

country as well as the immigration paths that lead them to the U.S.

Unique conceptions of mental illness. This dimension is best characterized by

seeing African cultures and African immigrants not believing in American

conceptualization that mental illnesses are medical problems or health conditions. Some

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participants distinguished between their cultural identity (coming voluntarily from

Nigeria in contemporary times) and the cultural identity African Americans (Black

Americans). P5 said:

While there are individuals of African ancestry in the U.S. whose families have

lived in African community settings in the U.S. for over one hundred years, there

is a significant need to understand that their ancestors did not willingly come to

the shores of this country.

Second, participants noted that mental illness is not readily discussed. P5 stated, “In my

native African culture, mental illness is prohibited from being addressed openly in all

circumstances.”

P9 said:

African cultures believe that mental illness and individual disaster are brought on

by the discord of wrongdoing such as lack of faith in their god; a person being

possessed by angry spirits and even accidents are believed to be under divine

control of occurrence.

Challenging life issues. Challenging life issues (demanding physical and

psychosomatic undertaking of a challenging category, resembling postpartum depression)

among African immigrants were recognized as connected to mental illness.

P1 described the complicated life problems like post-partum depression that

aggravate mental illness among African immigrants to the U.S.,

“Depressed and traumatic condition that occurred after child delivery among

African immigrants new mom without appropriate partner’s help, family support,

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money issues, problems with alcohol and drugs, and other massive sources of

stress, going through depression due to poor economic impediments and lack of

accessibility to needed relief resources.”

P7 addressed the culturally related challenging life issues relevant with mental illness,

stating:

African immigrants faced a difficult life in the United States, daily stressors wear

on their strength and their mentality. Anxiety and mood problems carried a

significant individual and collective encumber among African immigrants. The

chronological prevalence of mood and anxiety problems among African

immigrants could not be addressed appropriately when considered through the

conception of traditional cultural belief systems. Mental illness symptoms

affected emotions, thoughts, and behaviors among African immigrants; these

symptoms generated confused pattern of thinking, reduced abilities to

concentrate, withdrawal from families, friends, and society, and inability to cope

with daily stress and demands of individual daily life.

Cultural judgments. The identification and expression of mental illness was

clearly subject was to cultural influence on judgments in terms of negative behaviors,

which were nonconforming with the cultural values. Participants described their major

experience and offered responses. P4 stated that, “The contributing factors of mental

illness in native African culture are different from the Western conceptualized mental

illness; individuals with mental illness are labeled as socially undesirable.” P7 said, “The

mental health clinicians and researchers represent the White popular class orientation

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with their cultural beliefs, values, biases, misconceptions and stereotyping of African

immigrants and other ethnically diverse minority population groups.”

P5 brought up the issue of how mental health problems influence family and

marriage. P5 said, “Mental illness is viewed as a very serious problem in native African

cultures and among African immigrants; with vulnerabilities that influenced numerous

community and economic traditions, which one of them is marriage and matrimony. He

said:

Most importantly, mental illness is considered one of the major physical

conditions that contributed to a termination of marriage proposal. The individual

with mental illness is stigmatized and the family members suffer the

stigmatization also, with permanent description of vulnerabilities to mental

illnesses. Conversely, if the person were married before becoming sick with

mental illness, marriage would be automatically dissolved or allowed to

disintegrate based on culture. I deemed this to being informative to why the

general population, family members would not show much resemblance to

individuals who are taken in for mental illness treatments. The family members

would not want to relate to their family member who had crossed the most

advantageous cultural line of demarcation. Regrettably, indiscriminate

stigmatization of individuals with mental illnesses and their families most of the

time extended above the family to become a village, community, and a clan

calamity.

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Barriers to seeking treatment. Participants described their major experiences of

impediments that prevented individuals from seeking mental illness treatment and offered

their responses. P6 said:

Advocates are asking for culturally sensitive, linguistically, and culturally

competent effective mental health services to improve utilization and

effectiveness of treatment alternatives for ethnically diverse minority immigrant

population groups, including Africa immigrants. Without, culturally competent

services, the failure to serve racial and ethnically diverse minority immigrant

population groups including African immigrants effectively will become worst

based on the enormous demographic growth among these population groups

expected over the next number of years.

To confirm, the impediments to seeking treatment among African immigrants. P5

asserted:

African immigrants are under-represented in mental health professionals’

population who generally understand very little concerning their cultural beliefs,

values, and backgrounds of the individuals they are treating, with the traditions of

healing and real meaning of mental illness in their cultural perspectives.

Meaning of Help-Seeking Experience

The data revealed that meaning of help-seeking had several dimensions. Each of

these is identified and described with support content from the participants. Overall, these

dimensions reveal a very different way of conceptualization meaning of help-seeking

experience that goes beyond the superficial differences.

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African experience. In the African cultural belief systems, mental health

problems have no cure and are transmittable based on the revealed cultural belief factors:

and as a result, individuals with mental health problems are discriminated against and

separated from the general population. Consequently, help-seeking is misunderstood.

Participants described their major experiences and offered responses. P1 commented:

Mental health problems still bear great stigma in African cultures, therefore

individuals with mental health issues particularly will revert to spiritual and other

traditional healing methods, some based in primitive cultural practices, before

seeking mental health treatment from modern mental health systems.

Additionally, P2 offered the following response on the matter, adding:

Even though there are mental health facilities in his native African country where

individuals with mental health issues can go to seek-help from mental health

professionals and psychologists, people prefer to do various things based on their

cultural belief systems.

Traditional methods of treatment. There are the long-established curative

techniques in African cultures provided by traditional medicine practitioners, spiritual

and divine healers with strong beliefs that existence and activities of witches, ancestral

spirits, sorcerers, and diviners influence an individual’s wellbeing. Participants described

their major experiences and offered responses. P4 mentioned:

Mental health problems are stigmatized conditions among Africans and African

immigrants. Individuals with mental health problems and their families reverted

to spiritual and traditional healing systems, developed from primitive cultural

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practices with different conceptualizations of mental health problems to the

Western/American conceptualizations. Most significantly, the traditional healers

centered their therapeutic objectives based on their understanding of the problems

without contributing efforts of their beneficiaries.

P9 added:

Individuals within the spectrum of the mental health abnormality commonly

referred to by the general population to be suffering from craziness, madness, and

mental illness. However, as ignored as the mental health issues are in African

cultures, the significant dissimilarity when comparing United States. and African

countries is that individual wills seek-help or the family members will seek-help

from the traditional sources for that individual.

U. S. experience. Participants understood that the U.S. through American mental

health system offers services and treatments which are available for all, however, African

immigrants under-utilized these services. As a public health professional, P6 offered:

African immigrants believe that the American mental health care system is not

well equipped to meet the mental health needs of the ethnically diverse minority

immigrant population groups. Africans do not recognize indicators of mental

health and mental illness in the same way the three domains that they represent

including emotional well-being, psychosomatic well-being and social well-being.

Cultural influences. The help-seeking experience is also influenced by cultural

perceptions. Most participants described that the services modalities were mostly

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developed for the main-stream White population group. Further, the idea of seeking help

is not culturally relevant. P5 stated:

Mental health issues are not openly talked about in my culture; a person with

mental health problems will only be addressed as having personal issues; African

cultural beliefs and values of collective help give dignity to individuals regardless

of their level in life. In many of the different languages from the continent, there

is no word for being alone.

Utilization of services. The African immigrants’ experience of mental health

services utilization in the U.S. was described as “unwieldy,” perplexing and lacking

processes that bridge cultural differences. P1 asserted:

Mental health care services’ utilization rates vary by nativity and across racial

and ethnic groups including African immigrants. African immigrants have lower

rates of utilization of mental health care services for both mood and anxiety

disorders. My perception of mental health problems explains my help-seeking

behavior and unwieldiness to share my mental health problems with other people,

African cultures believe that mental health problem has no cure and it’s

contagious, based on the revealed cultural factors, individuals with mental health

issues are discriminated against, isolated, and separated from dealing with the

general population.

Barriers and implications. This dimension is best characterized for

understanding the inconsistencies in mental health care services linked with cultural

barriers to help-seeking that include stigma associated with mental illness, limited

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English ability, challenges to navigate the American mental health system for African

immigrants, alternatives mental health care and treatment that could be inconsistent for

African immigrants. All participants described their major experiences and offered their

responses. For example, P1 stated that “I am not persuaded with confirmed unwillingness

to seek mental health care in the U.S., because the process is different from my native

African country.” P8 offered the following response:

In my experience with American mental health system, African immigrants

believed that the American mental health care system is not well equipped to

meet the mental health needs of the ethnically diverse minority immigrant

population groups. African immigrants suffered from blocked accessibilities to

mental health care services and treatments, hence individuals with mental health

issues and their families are forced to be dependent on self-sufficiency with

psychosomatic well-being.

P5 stated:

Implications of lack of medical insurance, underinsurance, lack of culturally

competent mental health professionals, lack mental health professionals from

ethnically diverse minority immigrant population groups, distrust of American

mental health system, and stigma associated with mental illness barriers for help-

seeking for mental health problems among African immigrants.

The Experience of Prejudice and Discrimination in Mental Health

The data revealed that this content area had several dimensions

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Sensitivity and discrimination. This dimension is best characterized for

understanding racial discrimination and prejudice in mental health services. Different

issues of race and ethnicity were brought up on several occasions because of the lack of

cultural sensitivity. P7 declared, “African immigrants expect to be cared for by a medical

doctor or a psychologist and dislike the wide-spread utilization of other mental health

clinicians.” P9 stated that, “the American mental health system is not well equipped to

meet the mental health needs of the ethnically diverse minority immigrant population

groups.” Additionally, P7 thought that needs of African immigrants are, “…at odds with

the American mental health system; many African immigrants indicate that they prefer a

mental health professional who shares their cultural background.” P3 went on to say that,

“even if individual members of African immigrant population group succeed in accessing

mental health care services, their treatment may be inappropriate to meet their treatment

needs.” P9 emphasized that the, “cultural proscriptions caused complexities for African

immigrants to be using available mental health care services and treatments.” P6 said:

The lived experience descriptions of African immigrants with mental health issues

demonstrate a constellation of barriers that prevent African immigrants from

reporting mental health problems and seeking treatment due to systemic racism.

Because time for individuals of African ancestry is circular and not linear, the

mugging of slavery is still as significant as it was during that time. These

assertions may strongly influence African immigrants’ underlying problems of

acculturation, economic and social stigma, prejudice, and discrimination, which

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are contributing factors to mental health, mental illness, and help-seeking

problems.

Assessment and diagnosis issues. This dimension is best characterized by the

experiences of African immigrants getting inaccurate psychological assessments and

incorrect diagnoses. Participants described their major experiences and offered their

responses. For example, P6 stated that, “African immigrants are more likely to be

diagnosed with chronic and persistent, rather than episodic, mental health conditions.” P1

said:

African immigrants are more often diagnosed with schizophrenia and less often

diagnosed with mood disorders compared to the main-stream White people with

the similar symptomatic complications. Additionally, African immigrants are

offered psychopharmacology treatments and psychotherapies at the lower rates

than the broad-spectrum main-stream White population.

Occurrence of Indigenous Cultural Stigma in Mental Illness

This content area had several dimensions. Each of these is identified and

described with supporting content from the participants. Overall, these dimensions

revealed a very different way of understanding that the occurrence of indigenous stigma

in mental illness goes beyond the superficial differences.

Stigma and culture. African immigrants are influenced by their cultural

beliefs concerning stigma of mental illness and their attitudes about individuals with

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mental illness and their families. All participants described their major experiences and

offered responses. P4 stated:

Among African cultures, traditional cultural factors enhance stigmatization of

individuals with mental illness and their family members and claim them as crazy.

Mental illness tops the list of stigmatized public health conditions in African

cultures and among African immigrants to the U.S.

P5 added:

The impression of mental illness changed, among the ethnically diverse minority

immigrant population groups including African immigrants; emboldened by the

principles of protected family systems, individual thoughts, and traditional

cultural beliefs. Culturally integrated religious teachings influenced beliefs

concerning the contributing factors and nature of mental illness, and shaped

attitudes towards individuals with mental illness and their families. African

cultures exert stigma on mental illness and individuals with mental illness are

stigmatized with their families.

P8 also stated:

African cultures do not believe that mental illnesses are medical problems with

public health concern, and not a disgraceful condition. With aggravated

stigmatization, discrimination, and prejudices towards individuals who reported

mental illness symptoms and their families. Stigmatized individuals and their

families develop internalized feelings of disgrace and self-label of being socially

undesirable

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Shame and disgrace. African cultures placed a high value on social status

and reputation. Individuals with mental illness and are helped by family members until

they are not able to help anymore. African cultures support rejection of the individual

when help reaches the point of saturation. Participants described their major experiences

and offered their responses. P5 offered the following response:

Lower socioeconomic conditions, sequentially, are linked with mental health

problems. Some African immigrants who are impoverished, dispossessed,

imprisoned, or have alcohol and substance abuse problems are at higher risk for

having mental health problems, mental illness, and challenges for seeking help

and not getting the necessitated help. Family members reject some individuals

with mental illness that need help when their condition becomes worse than they

can handle. Some families dump their relatives with mental illness at the hospital

and never return to see how they were coping with their treatment.

P6 said:

In most instances, embarrassments supersede even the most distressing

symptomatic complications of mental illness; because mental illness is perceived

as an individual disaster brought by a discord of wrongdoing, like lack of faith in

one’s god and being possessed by angry spirits above human control.

Attitudes towards treatment. Participants agreed that African immigrants do

not trust the Western methods of treatment and do not consider mental illness to be a

medical issue; therefore, they prefer to treat mental illness with traditional approaches.

Participants described their major experiences and offered responses. P2 stated:

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In African cultures, mental illness is not only a problem for individuals and their

families, but a problem that threatens the unanimity and relationships within the

general public, while the focus on treatment is on the traditional healers, family

members are accustomed to taking individuals with mental illness to traditional

medicine healers and traditional native doctors before they think of going to

hospitals and mental health treatment facilities.

P7 saw that attitudes towards treatment came from what African immigrants preferred,

saying:

African immigrants seek out recognizable help from their family members and

used spiritual beliefs and culturally prescribed traditional practices as social

support and synchronization of meaning during times of emotional distress. This

affected their utilization of accessible mental health services and treatments.

Social cost of stigma. The significance of stigma of mental illness among

African immigrants was reported by most participants. For example, P4 stated that:

Stigma of mental illness tops the list of stigmatized mental health and physical

well-being conditions in African cultures and among African immigrants to the

United States; generating the categories of stereotypes, fear, and rejection that are

reminiscent of longstanding attitudes of assuming that individuals with mental

illness are crazy.

P7 said:

Stigma is a component of African cultures that generates different kinds of

stereotypes, fear, rejection, isolation, humiliation, and discrimination for

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individuals with mental illness and their family members, with barriers to seeking

treatment. African culture performed the most important function and influenced

Africans and African immigrants’ attitudes concerning mental illness, the

actuality is that no ethnic group could afford to disregard the significances,

economic impediments, and individual consequences of mental health disorder or

mental retardation.

P9 stated:

Stigmatization and discrimination of individuals with mental illness and their

families are uncontrolled in my native African country, due to lack of appropriate

information on mental health issues that is not linked with cultural stigma, the

treatment given to individuals with mental health disorders is not the same

treatment given to individuals with other medical conditions.

Occurrence of Indigenous Cultural Stigma in Help-Seeking Experience

In the previous section, the emphasis was on how mental illness stigma was

experienced within the culture. This experience gets more complicated as participants

reached out to their family members for help-seeking necessitates.

Ordeals for family members. This dimension is characterized by understanding

the ordeals generated by stigma for the family members. Two participants offered the

following responses. P7 discussed how help-seeking started from reaching out to the

family members, saying:

This affected their utilization of accessible mental health services and treatments.

African immigrants have culturally specific perceptions of stigma concerning

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their conception of mental illnesses that proscribed the help-seeking processes and

make different modalities of treatments culturally ineffective and unacceptable.

Due to these conditions, individuals depended solely on their family members for

their help-seeking necessitates.

P8 stated:

Amongst African cultures and African immigrants’ occurrence of indigenous

cultural stigma in help-seeking caused intolerance and discriminatory treatments

of individuals with help-seeking needs for mental illnesses, increased denial of

civil rights and unnecessary responsibilities from individuals. Stigmatization

caused major problems for individuals that encompassed denied access to

essential public resources, accessibility to equal opportunity employment, and

affordable housing privileges.

Barriers to seeking treatment. This dimension is best characterized by

understanding stigma of mental illness with evident among African immigrants.

Participants described their major experiences differently and offered responses. P4

offered the following response:

Stigma of mental illness denotes implications of ongoing discrimination,

prejudice, and humiliation that encompasses the stigmatized individuals with

mental illness and their families to undermines the help-seeking process and

ultimately obstruct recovery process.

P6 was very elaborate and detailed in his reply, which is rich with the identification of

psychological, social, and cultural barriers, stating:

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Despite the accessibility of mental health care services and treatments with

accommodating mental health professionals, African immigrants consistently

faced with multiple impediments to acceptable and effective mental health care

services and treatments which are not experienced by other cultures. My careful

itemization of these impediments encompassed the following: disgrace and

dishonor connected with mental health problems, differentiations in expression of

manifesting symptoms and ascriptions with differing concepts concerning the

causative factors of mental health issues and culturally supported coping skills,

lacking accessibility to relevant and culturally perceptive mental health care

services in indigenous African languages, accessibility to indigenous African

interpreters and language dissimilarities impact on the quality of interactions

between mental health professionals from other cultures, shortage of the

ethnically diverse minority immigrant mental health professionals of African

ancestry with multi-culturally and diverse competencies, complexities of

disclosing immigration status to mental health professionals and recurrent moves

to look for equal opportunity employment.

Misunderstanding of help-seeking. This dimension is best characterized for

understanding with evident misinterpretation of seeking treatment for mental illness

among African immigrants. All participants described their major experiences and

offered responses. P2 stated:

African immigrants’ help-seeking behaviors are affected by mistrust of the

American mental health system and often begin with seeking help from

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traditional healers and faith-based spiritual healing outreach sources. African

traditional healers’ roles of providing cure for mental illness is controversial and

their curative techniques differ from traditional Western/American approaches

based on psychological and psychiatric sciences their services are highly

appreciated and with unremitting utilization. These are long-established

assortments of curative techniques and support for mental illnesses provided by

African cultures’ traditional healers that include performing rituals with aim to

maintain the well-being of a whole community.

The Experience of the Participant

This content area focused on participants direct experiences, as patients or

observers of the struggles African immigrants have encountered.

Mental health problems and treatment. This dimension is best characterized

for understanding mental health issues with evident among African immigrants.

Participants described their experiences and offered responses. P7 shared:

My notion of mental health differed with the other cultures but embedded within

the significant sagacity of Africans and African immigrants’ traditional cultural

belief systems and ways of life that shaped the justification to dissimilar

understandings of pragmatism. African immigrants’ mental health problems

cannot be addressed by mental health professionals from other cultures without

taking into consideration the comprehensive cultural implication and meaning.

Within African countries, there is a significant ongoing argument concerning the

dependability of imposing Western/American conception of mental health

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treatments on African countries and inflamed confrontations from

Western/American mental health professionals to the appropriate help-seeking

trend for mental health issues and African traditional healer’s accountability.

P4 stated:

African immigrants faced a difficult life in the United States, daily stressors wear

on their strength and their mental health. Anxiety and mood problems carried a

significant individual and collective encumber among African immigrants. The

chronological prevalence of mood and anxiety problems among African

immigrants could not be addressed appropriately when considered through the

conception of traditional cultural belief systems. Mental illness symptoms could

affect emotions, thoughts, and behaviors among African immigrants; generate

confused pattern of thinking, reduced abilities to concentrate, withdrawal from

families, friends, and society, and inability to cope with daily stress and demands

of individual daily life.

American mental health system. This dimension is best characterized for

understanding with evident African immigrants’ perception of American mental health

system. Participants described their experiences and offered their responses. P3 offered

the following response:

African immigrants believed that the American mental health system was not well

equipped to meet the mental health needs of the ethnically diverse minority

immigrant population groups. The racially and ethnically diverse minority

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immigrant population groups were generally considered to be underserved by

American mental health system, because of disparities in delivery of services.

P5 added insight on the topic, saying:

African immigrants have negative attitudes towards mental health professionals in

American mental health system. They do not understand their long-established

cultural backgrounds, and cultural conceptualization of mental illness, which are

indispensable in the development of effectual and culturally sensitive mental

health care services and treatments for the ethnically diverse minority immigrant

population groups including African immigrants.

Social and economic issues. This dimension is best characterized for

understanding the social and economic issues that contribute to African immigrants’

mental health problems. Participant described their experiences and offered their

responses. P9 said:

Misunderstanding as an African immigrant is that, while poverty is not the only

contributing factor to mental health problems, economic impediment, lack of

money, lack of medical insurance, fear becoming a public charge, and being

reported to U.S. immigration to be processed for deportation are usually the most

important reasons offered by African immigrants for not seeking mental health

care service.

From a different viewpoint, P8 described how social and economic issues are

experienced within the African community, stating:

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Stigmatized individuals and experience social and economic discrimination,

seeking employment and living successfully with other individuals in a

community setting. Stigmatized individuals are prevented from seeking mental

illness treatment and compliance to the treatment regimens. While reason for

culturally embedded stigma in help-seeking for mental illness are consistent

across African cultures, known stigma of individuals with mental illness are

universally reported.

P3 also elaborated on the social and economic challenges, speaking on how

disenfranchised the immigrants are as a group, sharing:

Many Africans arrive in the US as individuals, leaving behind other family

members in their home countries. Most of them go through years of physical

separation from those family members that were left behind in their native

African countries. African immigrants engaged in long distance family

relationships and sending support to them, this created significant social and

economic challenges, and mental health complications. They faced challenges in

getting employment, affordable housing, marital and parent-child conflicts,

problems with child welfare and the criminal justice issues, social isolation,

systemic racism, and structural discrimination form the mainstream culture that

contributed to their range of mental health problems. African immigrants, like a

significant number of disenfranchised ethnically diverse minority immigrant

population groups in the United States, usually underutilized the available mental

health care services and treatments.

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P3 also described how these social and economic challenges create delays in reaching out

for and receiving services, so mental illness conditions worsen without treatment, saying:

African immigrants most of the time delayed help-seeking for mental health

problems at community mental health care centers, until the necessitate for

psychiatric emergency care and psychiatric hospitalizations became unavoidable.

Rather than help-seeking from mental health professionals, psychologists, and

psychiatrists, for mental health problems African immigrants would depend on

informal help from traditional healers, spiritual healers, family members, friends,

support groups, and seek medical-help care from general medical practitioners

Utilization of U.S. Services

The data revealed that “Utilization United States. Services” had several

dimensions. Each of these is identified and described with support content from the

participants. Overall, these dimensions reveal a different way of conceptualization and

utilization of U.S. services that goes above the superficial differences accessing the

offered services.

Racial and ethnic differences. This dimension is best characterized by seeing

racial and ethnic differences as evident in mental health care services offered to African

immigrants, without appropriate consideration of the procedures and outcome of the

culturally competent mental health care for all immigrants. Participants described their

experiences differently in affirmation to these assertions and offered their responses. P9

stated:

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Despite progress made over the years, systemic racism, racial discrimination, and

prejudice continued to have an impact on the mental health of African

immigrants. Negative stereotypes and attitudes of rejection are addressed, but

continued to occur with quantifiable, unfavorable consequences. Past and existing

occurrences of negative treatment have led to a mistrust of mental health

professionals from the main-stream culture, White majority who are not seen as

having the paramount interests of African immigrants in mind. There is

assumption of disparity, notion that African immigrants will not be given proper

treatment at community mental health clinics, this negative rumors, and bad news

are made known through the whole of African immigrant’s community.

Mental health professionals. This is dimension is best characterized by seeing

with evident African immigrants’ distrust and dislike of mental health-care professionals

from other cultural backgrounds with the services that they offer. Participants confirmed

these assertions and described their major experiences in different ways and offered their

responses. P3 offered the following response, saying:

African immigrants may find only White, mental health clinicians who represent a

White middle-class orientation, with its mainstream cultural values and traditional

beliefs, as well as its biases, misconceptions, stereotypes of other cultures, and

disadvantaged ethnically diverse immigrant population groups.

P7 said:

African immigrants feel that when mental clinicians do not effectively understand

their cultural background, their expectations, and their preferences, it creates

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mistrust and suspicious feelings among immigrants and their mental health

professional.

P7 went on to say that:

Throughout the ages, most African cultures and had sought after and received

mental health care services from African traditional healers, spiritual healers, and

their pastors. African immigrants are practitioners of these cultures and there are

good tendencies for their utilization of these services for their mental health

issues, while they also expect to be cared for by a medical doctor or a

psychologist and dislike the wide-spread utilization of other mental health

clinicians in the American mental health system.

Cultural exclusions and inclusions. This dimension characterized understanding

with evident embedded exclusions and inclusions for seeking mental health treatment in

African cultures and among African immigrants.

Participants described that in their native African countries, there was a cultural

provenance with stipulations that separated men and women into two main groups with

different rights and treatment benefits. Individuals with mental health problems were

treated by traditional and spiritual healers, medical doctors, and mental health

professionals according to their sexual characteristics. P7 asserted that:

Men were not allowed to be treated by female traditional healers, female medical

doctors, and female mental health professionals. Women were not allowed to be

treated by male traditional healers, male medical doctors, and male mental health

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professionals. African immigrants transported this cultural provenance to the U.S.

as embedded component in their cultural exclusions and inclusions for mental

health help-seeking this has influenced their willingness and unwillingness to

utilize accessible mental health care services and treatments in the United States.

P9 described the cultural proscriptions and complexities of using available services and

voiced other cultural concerns for African immigrants that include religious and gender

norms, which do not allow women to be treated by male mental health professionals.

Effectiveness and acceptability issues. Participants reported how practitioners

who were not trained to address specific cultural issues were rejected by immigrants

seeking help. P2 stated that, “African immigrants have negative attitudes about mental

health treatment because they believe that; mental health professionals from other

cultures are not methodically trained to address their individual mental health needs.” P3

felt that, “Mental health professionals have no understanding of the help-seeking trends

of African immigrants and the condition through which individual’s suffering becomes

open or internalized.”

Results: Second Cycle

The results of the second cycle analysis were produced by line by line analyses of

the transcripts; the coding process was described above. The results of this analysis were

very consistent with and confirmed the first cycle analysis experience. The table and

subsequent quotes arranged the concepts slightly different, but with considerable overlap

to the findings of the first cycle. There were eight categories, with dimensions under each

category, and these are represented by quotes and summaries in the discussion below.

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Table 4

Results of Second Cycle

Categories Dimensions

Assumptions and
Expectations

• Mental Health Professionals
• Cultural Exclusions and Inclusions
• Effectiveness and Acceptability Issues

Importance of Cultural
Understanding

• Stigma and Culture
• Significance of Social Status
• Attitudes Towards Treatment
• The Cost of Stigma

Experience of Mental
Health

• Unique Conception of Mental Health
• Family/Community Connection
• Believes in Traditional Approaches of Healing
• Utilization of Services

Cultural Experience of
Mental Illness

• Unique Conceptions of Mental Illness
• Challenging Life Issues
• Cultural Judgments
• Barriers to Seeking Treatment

Meanings of Help-
Seeking

• African Experience
• United States Experience
• Cultural Influences
• Barriers and Implications
• Traditional Methods of Treatment

Dissatisfaction

• Disparities in Mental Health Services
• Racial Prejudice and Discrimination
• Accessibility to Mental Health Services
• Assessment and Diagnosis Issues

(table continues)

Categories Dimensions

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Subject of Story
• Mental Health Issues
• Mental Illness and Treatment
• American Mental Health System
• Social and Economic Issues

Participant Occupation
• Stigma of Mental Illness
• Symptomatic Complications
• Cultural Perspectives on Mental Illness
• Misunderstanding of Help-Seeking

Category 1: Assumptions and Expectations

The data revealed that this category had several dimensions. Each of these are

identified and described below with support from the participants’ descriptions and

responses.

Mental health professionals. This category reflects African immigrants’ distrust

and dislike mental health-care professionals from other cultural backgrounds with the

mental health care services and treatments offered. Two participants responded as

follows, P2 said:

African immigrants perceived that, mental health professionals failed to

understand that, their culture prescribed the significances of every phenomenon of

wellbeing, and to greater extent influenced individuals’ impression concerning

mental health professionals from other cultures, values and norms that may

negatively prevail among them. There are also cultural proscriptions for un-

authentic and negative mores concerning mental health problems, mental illness,

and help-seeking trends.

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P6 asserted:

African immigrants are minorities in the U.S. and are less likely to seek mental

health treatment from mental health professionals from the main-stream White

culture, they would wait until the manifested symptoms were severe before

looking for help-seeking possibilities. There is existing and continuing complaint

that, the mental health professionals from other cultures do not understand the

role that culture plays in the experience and meaning of mental health care

services and treatments among African immigrants. African immigrants accused

mental health professionals from other cultures of failing to implement a careful

consideration of their values and norms with affirmation that African immigrant

families support their loved ones with mental health problems and encourage

them to seek culturally available help when it is most desired.

Cultural exclusions and inclusions. This dimension focused on African

immigrants’ conformity with traditional cultural beliefs ascription of specific exclusions

and inclusions to seeking mental health care services and treatments in the U.S. Three

participants offered the following responses. P3 said:

African immigrants have a different way of looking at mental health, mental

illness, and stigmatization of individuals with mental health disorder and their

families. Among most individuals there is a developing stigma around mental

health, and mental health challenges are considered a limitation and something to

conceal before the general population because of shame and disgrace. Stigma and

concealing of mental health problems make it harder for individuals struggling

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with the problem to talk openly concerning their mental health problems and

request for help.

P7 shared:

Understanding the manifesting symptomatic complications of mental illness is a

major problem among African immigrants. Culture influenced how individuals

described and feelings concerning their symptoms. Culture could affect whether

someone chooses to recognize and talk concerning only physical symptoms, only

emotional symptoms or both. Cultural factors determine how much support

someone gets from their family and community when it comes to mental health.

Because of prevailing stigmatization of individuals with mental health problems

and their families, individuals are sometimes left to find mental health treatment

and support services alone privately from the community traditional and spiritual

healers.

P8 stated:

What materialized expressively in African immigrants’ reflections concerning

mental health and traditional cultural beliefs are not always understood by other

cultures because of cultural discrimination and prejudice. Generally, between

African immigrants, these reflections remained centered on the thoughts of what

could be done to explain how their cultural beliefs inform their notion of mental

health experience to other cultures, alongside their different food and eating

traditions, exclusive different languages and lingua franca, unique clothing and

customs of colorful dressing. These are the best ways to explain myself with

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clarity for better understanding; among African immigrants, individual’s behavior

and concepts of emotional wellbeing are all impacted by culture, meanings of

mental health, mental illness and help-seeking impacted by culture, individuals’

willingness and unwillingness to seek treatment, accessibility of treatment,

effectiveness of treatment, and the community support available for the

individual with help-seeking needs are all influenced, informed, and impacted by

cultural background embedded with established collectivists principles and

values.”

Effectiveness and acceptability issues. African immigrants were concerned of

effectiveness and acceptability of the mental health care services and treatments offered

to them by mental health professionals from other cultures within American mental

health care system, and community mental health centers. P7 said that, “African

immigrants also have high demands for mental health professionals that are at odds with

the American mental health system; many African immigrants indicated that they

preferred a mental health professional who shares their cultural background.” P9 stated:

My perception is that long-established cultural beliefs, concept of wellness,

language differences, and spirituality must be recognized as entangled primary

contributing factors to mental health care services and treatments experiences of

African immigrants to the U.S. Additionally, deficiencies of available multi-

culturally-competent mental health professionals, mistrust, and involvedness, of

the American mental health system, inappropriate distribution of services, and

the exorbitant cost of obtaining effective and acceptable mental health care

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services and treatments must also be acknowledged as the most important

accessibility impediments to obtaining a culturally sensitive and effectual mental

health care services and treatments among African immigrants. There is also a

confirmed assumption among African immigrants, that, mental health

professionals from the main-stream White culture do not recognize and respect

their cultural identity at the time of mental health assessment, and the significant

deficiencies of reported information concerning their mental health care services

and treatments utilization experiences in the U.S.

Category 2: Importance of Cultural Understanding

The data revealed that this category had several dimensions. Each of these is

identified and described below with support from the participants’ described experiences

and responses.

Stigma and culture. Cultural stigma of mental illness conveyed the mark of

disgrace and shame borne by individuals with mental illness and their families in native

African cultures and among African immigrants. P5 said:

African immigrants believe that depression is the most common type of mental

illness conditions, but in their native African cultures, traditional cultural beliefs

do not support the perception, despite the fact that depression is one of the leading

causative factors of disability all through the worldwide countries and the U.S.

P6 said, “Mental illness is an individual disaster brought by a discord of wrongdoing such

as lack of faith in one’s god and being possessed by angry spirits above human control.”

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P9 said:

In African countries many individuals suffer silently from one of the most ignored

and misunderstood categories of public health pandemic which is mental health

problems, and only a selected few of those individuals affected are considered

good enough for help-seeking, the rest are deemed to be psychologically unfit for

help-seeking.

Significance of social status. The significance of social class in African cultures

and among African immigrants’ proscribed interactions with individuals with mental

illness and their families. P4 stated that, “Mental illness is perceived as a public

embarrassment condition that could damage peoples’ reputations; hence individuals

suffering from mental illness and their families are less expected to be given assistance

because of damaged social status.” P7 expressed thoughts on the matter by saying,

“African cultures do not believe that mental illnesses are medical problems, public health

conditions, and not a disgraceful circumstance.” P9 added:

There is a widespread belief linking mental illnesses to supernatural causes

including witchcraft, demonic possession, and ancestral gods, we believe that

mental health clinicians represent a White middle-class orientation with main-

stream cultural values and traditional beliefs as well as biases, misconceptions,

stereotypes of other cultures, and disadvantaged ethnically diverse immigrant

population groups.

Attitudes towards treatment. African immigrants’ attitudes towards treatment

differed from other individuals in distinctive ways. P4 stated, “There is established

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practice of racial discrimination included in mental health policies of private and

governmental mental health institutions that intentionally restrict the opportunities of

individuals with mental illness and their families from getting mental health care

services.” P5 said:

African immigrants disbelieve that the American mental health system, in the

mental health care and public health arena put more importance and resources

committed to psychological assessment, establishing diagnosis, and treatment of

mental illness than mental health. We felt that little has been done by American

mental health system to protect the mental health of African immigrants who are

free of mental illness, while ignoring the critical point which is the utilization of

mental health care services at the most needed time.

The cost of stigma. The cost of stigma was a significant barrier that prevented

African immigrants from seeking mental illness treatment. Participants described their

experiences in different ways and offered the following responses. P9 said, “There is lack

of appropriate information on mental health issues that is not linked with cultural stigma,

the treatment given to individuals with mental health disorders is not the same treatment

given to individuals with other medical conditions.” P8 affirmed community involvement

and mentioned:

Depending on every community, an individual with mental health issues is taken

in for oracle consultation; they use local medicine to treat the individual. Some

address the issue by taking this person to the herbalist, but this depends on the

cultural beliefs of the family.

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He went on further to say, “Sometimes, the family does not know what is going on; they

thought the person with mental health issues was just making intentional gestures

different from manifesting symptomatic complications of the infirmity initially and

believed that prayers were effective.”

Category 3: Experience of Mental Health

The data revealed that this category had several dimensions. Each of these is

identified and described below with support from the participants’ described experiences

and responses.

Unique conceptions of mental health. African immigrants have different

conceptions of mental illness embedded with physical, social and cultural ways of life. P1

said, “[The] Mental health issue in my native country is distinctively different from the

construct of mental health in the United States.” The American conceptualization of

mental health is described in terms of discrete emotional, cognitive, behavioral aspects of

daily life. Participants in this study described mental health as more holistic. P7 stated

that, “African cultures accept that mental health is linked to many other physical

conditions: therefore, mental health is the basis of all preventive medicines in terms of

physical illness.”

Family/community connection. African immigrants supported deep the

family/community connection with mental health. P6 postulated, “African cultural beliefs

and values of collective help give dignity to individuals regardless of their level in life. In

many of the different languages from the continent of Africa, there is no word for being

alone.” He further mentioned that, “Africans’ collective approach to human behavior

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emphasizes collective responsibility, shared concern, and commitment to a common

cause, a family that is a community center for better.” To further ascertain the concepts of

relationship with family and the public. P5 expressed:

While there are individuals of African ancestry in the U.S. whose families have in

African community settings in the U.S. for over hundred years, there is a

significant need to understand that their ancestors did not willingly come to the

shores of this country.

Beliefs in traditional approaches of healing. This dimension is characterized

evident for further authentication of the Results reported in the First Cycle, that beliefs in

traditional approaches of healing were long long-established curative practices in African

cultures and among African immigrants. P3 explained, “However, as ignored as mental

health issues are in African cultures, the significant dissimilarity when comparing U.S.

and Africa is that individual will seek help, or the family members will seek help from

the traditional sources for that individual.” P5 described mental health care in his native

African country by saying:

In my native African country, mental health and mental illness treatments are

handled by herbalists of native doctors, I mean not in the hospital setting because

I have never seen any hospital called mental health hospital, I have never seen

one.

Use of services. African immigrants’ utilization of services in the U.S. was

unachievable complicated and challenging processes bridged by cultural differences. P4

responded, “African cultures believe that mental health problem has no cure and it’s

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contagious. Based on the revealed cultural factors, individuals with mental health issues

are discriminated against, isolated, and separated from dealing with the general

population.” P6 added, “African immigrants disbelieve that the American mental health

system, in the mental health care and public health arena, put more importance and

resources committed to psychological assessment, establishing diagnosis, and treatment

of mental illness than mental health.”

Category 4: Cultural Experience of Mental Illness

The data revealed that this category had several dimensions. Each of these are

identified and described below with support from the participants’ descriptions and

responses.

Unique conceptions of mental illness. African cultures and African immigrants

disbelieved American conceptualization of mental illness as a diagnosed medical

condition, public health condition, and not a condition of humiliation and embarrassment.

P1 stated that, “In my native African culture, mental illness is prohibited from being

addressed openly in all circumstances.” Furthermore, depression and stress are not

considered to be mental illnesses in the same way that they are in the U.S. P8 said:

African cultures put the burden of taking care of individuals with mental illness

on the family members, and when they are not able to deal with care taking

problems any longer, individuals are always placed under the care of trained

mental health professionals.

Challenging life issues. Challenging life issues faced by African immigrants

were contributing factors of mental illness. African immigrants have possibilities of being

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deported because of criminal conviction than other minority immigrants. P5 described the

challenging experiences and offered the following response:

While mental health problems and mental illness do not discriminate, the

American mental health system does discriminate, African immigrants have less

access to mental health care service, although less likely to seek treatment due to

poor quality of treatment, higher levels of stigma, language barriers and

dissimilarities, lower rates of health insurance or no insurance, racism, prejudice,

and discrimination in treatment settings, and culturally homogeneous mental

health care system.

P7 added:
African immigrants faced innumerable challenging life predicaments

interconnected with the challenges of native-born African-Americans that

encompassed systemic racism, prejudice and racial discrimination, housing

discrimination, employment discrimination, disproportionate equal representation

in the mental health professionals, mental health care services and treatments, and

criminal justice systems. I deemed it better with affirmation that, I have paid my

price for living in the U.S. African immigrants expected none of these

challenges that they met until they were confronted with the challenging

predicaments in actualities. Additionally, the challenging life issues faced by

African immigrants are embedded with the following problems: Language barrier

problem, a significant challenging issue faced by African immigrants which had

being a problem and will continue to be a problem because African immigrants

are regarded as second English language speakers even though English is official

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language in their native country. Employment problem, African immigrants,

experienced and inexperienced equally faced challenges in getting employment in

the U.S., contrary to their beliefs and expectations, they quickly realized that it

was not easy for them to find employment. African immigrants’ academic

qualifications and professional experiences regrettably are not willingly accepted

for employment in the U.S. due to prejudice and racial discrimination. African

immigrants faced challenges in putting their children in school because of

immigration status conditions and English requirements for their children. African

immigrants faced lack of information and accessibility to essential services, and

mental illness resources and treatments.

Cultural judgments. Cultural judgments influenced and informed African

cultures and African immigrants on experience of mental illness. P5 offered the following

response:

That impinged upon the use of mental health care services among African

immigrants and concluded: there is prevalence of challenging acculturation,

social-economic and cultural problems that influence African immigrants’ mental

health, making them vulnerable to mental illness, whether we like it or not, we

must still recognize that in America, there is still issues of racism or prejudice and

something you never used to or wished to look to them as relevant with yourself.

P6 asserted:

African immigrants though incongruent from other immigrants faced multiple

cultural judgments in the U.S., itemized to include complexities in speaking

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American English, challenges in getting time off from work due to economic

necessitates, and restricted alternatives of transportation are existent time issues

aggravated by cultural judgments. Accessibility to mental health care services and

treatments are significant challenging conditions faced by African immigrants.

Most if the time, African immigrants had been exposed to violent behaviors of

physical abuse, human suffering, molestation, and sexual abuse which they did

not know how seek-help through contact with law enforcement agencies.

Barriers to seeking treatment. Barriers to seeking treatment among African

immigrants were aggravated by multiple factors including their traditional cultural

beliefs. P2 said, “The Western/American construct of mental health and managing mental

illness with non-culturally homogeneous developed methods of treatment keep African

immigrants away from reporting mental health problems and seeking help.” P6 added,

“Advocates are asking for culturally sensitive, linguistically, and culturally competent

effective mental health services to improve utilization and effectiveness of treatment

alternatives for ethnically diverse minority immigrant population groups, including

Africa immigrants.”

Category 5: Meanings of Help-Seeking

The data revealed that this category had several dimensions. Each of these is

identified and described below with support from the participants’ descriptions and

responses.

African experience. African immigrants had different meanings of help-seeking

in their native African countries before migration to the U.S. P1 stated:

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Mental health problems still bear great stigma in African cultures, therefore

individuals with mental health issues particularly will revert to spiritual and other

traditional healing methods, some based in primitive cultural practices, before

seeking mental health treatment from modern mental health systems, individuals

with mental health problems are discriminated separated from dealing with the

general population and misunderstanding of help-seeking.

P2 recalled that even though there are mental health facilities in his native African

country where individuals with mental health issues can go to seek-help from mental

health professionals and psychologists, people prefer to do various things based on their

cultural belief systems.

U. S. experience. African immigrants’ experience of help-seeking in the U.S.

differed from experience in their native African countries. American mental health

system offered mental health care services and treatments which were available for all

that could help assuage the social and economic outlays of mental illness problems, but

African immigrants under-utilized these services. P6 stated:

African immigrants believe that the American mental health care system is not

well equipped to meet the mental health needs of the ethnically diverse minority

immigrant population groups. Africans do not recognize indicators of mental

health and the three domains that they represent including emotional well-being,

psychological well-being and social well-being.

P9 African immigrants have high expectations concerning mental health professionals.

They are at odds with American mental health systems. Most African immigrants

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indicate that they prefer mental health professionals who share their cultural background

and understand their problems.

Cultural influences. Cultural influences impacted African immigrants’ concept

of mental health, mental illness, and help-seeking trends. P5 stated:

Individuals who desire help-seeking for mental illness will likely revert to prayers

and other traditional healing methods like traditional medicine practitioners and

faith and spiritual healers before going to Western-educated mental health

professionals for psychological assessment, established diagnosis, and treatment.

P8 said:

My concerns are that through personal understanding of our cultural beliefs, there

is no authentication that mental illness is real psychological predicament that

needs to be addressed appropriately by qualified mental health professionals, my

cultural concerns as an African immigrant include religious and gender norms,

which do not permit women to be treated by mental health professionals.

Barriers and implications. African immigrants faced barriers and implications

with help-seeking needs in the U.S. P3 responded:

African immigrants who do not have information about American mental health

systems and mental health resources do not always know where to go to seek

help, but most of them end up at the hospital as the last alternative when their

condition becomes worst.

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P4 stated:

I was denied treatment at the community mental health clinic because I was a

foreign-student with no green card, no medical insurance, and no money to pay; I

internalized the denial and linked it with prejudice and discrimination faced by

individuals suffering from mental illness, which leads to feelings of

embarrassment and label as socially undesirable in some cases because

embarrassment overrides even the most tormenting symptomatic complications of

mental illness.

Traditional methods of treatment. Traditional methods of treatment in African

cultures were carried by African immigrants to the U.S. P3 said that, “Traditional

therapists who provide traditional healing for mental illness have been in business

throughout the ages even before colonial times. Their healing techniques are not written

but vary among spiritual healers and native doctors.” P3 added:

Family members usually hide individuals with mental illness in the house because

mental illness is presumed to be a disgraceful infirmity; when the problem

becomes unbearable, the family members secretly rush the individual to a

traditional healer to be accepted with no conditions, no demands for insurance, no

personal information, no family history, and no money.

Category 6: Dissatisfaction

The data revealed that this category had several magnitudes. Each of these is

identified and described below with support from the participants’ described experiences

and responses.

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Disparities in mental health services. Disparities in mental health services

created impediments for African immigrants getting effective mental health care services

and treatments. P6 expressed that, “Without culturally competent services, the failure to

effectively serve racial and ethnically diverse minority immigrant population groups will

become worse based on the enormous demographic growth among these population

groups expected over the next number of years.” These impediments among African

immigrants were substantiated in the following way, according to P5, who shared:

African immigrants are under-represented in mental health professionals’

population who generally understand very little concerning their cultural beliefs,

values, and backgrounds of the individuals they are treating, with the traditions of

healing and real meaning of mental illness in their cultural perspectives.

Racial Prejudice and Discrimination

Prejudice and racial discrimination, systemic racism and bigotry faced by African

immigrants prevented them from seeking mental health care services and treatments in

the U.S. P5 said:

Whether we like it or not, we must still recognize that in America, there is still an

issue of racism or prejudice and something you never used to or wished to look to

them as relevant with yourself, you resented them, and through that you can

develop the sense of inferiority complex that can develop to other mental health

problems in one’s life.

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P5 also said:

African immigrants have less access to mental health care service, although they

are less likely to seek treatment due to poor quality of treatment, higher levels of

stigma, language barriers and dissimilarities, lower rates of health insurance or no

insurance, racism, prejudice, and discrimination in treatment settings, and

culturally homogeneous mental health care system.

Accessibility of Mental Health Services

Challenges of accessibility to mental health care services prevented African

immigrants from seeking mental health care services in the U.S. Three participants

described their experiences and noted some of the striking differences between American

culture and their descriptions of how mental health occurs in their cultures. P1 stated,

“African cultures believe that mental health problem has no cure and it’s contagious.

Based on the revealed cultural factors, individuals with mental health issues are

discriminated against, isolated, and separated from dealing with the general population.”

P2 stated:

Africans do not talk about mental health problems, but this is distinctly different,

where Americans are quite comfortable and expect mental health, distress, and

help-seeking to be a part of conversation; this could be exacerbated by the

circumstance of coming to a new culture and the complications that the

adjustment process creates.

P5 said, “While there is up-and-coming confirmation that positive mental health is

connected with improved health outcomes, this assertion may not apply to African

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immigrants who are known for unimproved health outcomes due to life complications

facing them in the U.S.”

Assessment and Diagnosis

There were confirmed actualities of African immigrants getting wrong

psychological assessments, misdiagnosis for mental illnesses, and wrong treatment

alternatives. P1 said:

African immigrants assumed that mental health professionals from other cultures

were not familiar with the progression of their cultural configuration of

implications; wrongly assessed them as psychopathology, with consistent

differentiation in their beliefs, behaviors and experiences which are challenges to

African immigrants’ cultural beliefs. African cultures and African immigrants

have differed in concept with the Western conceptualization of mental illness.

African cultures labeled Individuals with mental illness as socially undesirable.

P7 concurred that, “African immigrants do not trust the mental health professionals who

perform psychological assessment, establish diagnosis for mental illness, and make

treatment decisions that cannot communicate in languages other than English with

African immigrants whose first language is not English.” P8 stated:

The significant problems concerning mental health services, psychological

assessments, mental health diagnoses, and treatment alternatives common among

African immigrants are that, the quality of care is poor, they are not able to

participate in making treatment decisions due to language barriers and cultural

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differentiations, they have no understanding about the legitimacies of assessment,

diagnosis, and treatment.

Category 7: Subject of Story

The data revealed that this theme had several dimensions. Each of these is

identified and described below with support from the participants’ described experiences

and responses.

Mental health issues. Mental health issues prevailed among African immigrants.

This was indicated by P5 who said, “While there is up-and-coming confirmation that

positive mental health relates to improved health outcomes, this assertion may not apply

to African immigrants who are known for unimproved health outcomes due to life

complications facing them in the U.S.” According to P1:

African cultures accept that mental health is linked to many other physical

conditions; therefore, mental health is the basis of all prevention medicines in

terms of physical illness. Participants also noted some other striking differences

between American culture and their descriptions of how mental health occurs in

their culture.

P3 stated, “Mental health issues are highly stigmatized conditions among African

immigrants, and most individuals with mental health problems revert to traditional

healing methods based on their traditional cultural practices before seeking mental health

treatments from Western/American modern systems.”

Mental illness and treatment. African immigrants have dissimilar notions for

mental illness and treatment from other individuals. P6 shared that, “African cultures

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have many misconceptions concerning mental illness, some individuals’ associate mental

illness with traditional harmful practices, and others attribute it to evil spirits, wondering

and rebellious messengers of traditional deities, and blame individuals with mental

illness.” In addition, P9 said, “There is a widespread cultural belief linking mental illness

to numinous causes including witchcraft, demonic attack, possession by ancestral deities,

and wrongdoings of individuals against humanity.”

American mental health system. African immigrants failed to trust American

mental health system with the services provided by main-stream mental health

professionals. According to P5, “African immigrants believe that there is a significant

problem concerning the insufficiency of American mental health system diagnostic

implements which are not constructed on culturally broad-spectrum models which are not

to their advantage.” P9 followed up by stating, “African immigrants have high

expectations concerning mental health professionals; they are at odds with American

mental health systems.”

Social and economic issues. Social and economic issues faced by African

immigrants prevented them from seeking mental health care services and treatments. P3

stated:

Families that have individuals with mental illness suffer through public

embarrassment and disgrace; people do not want to have anything to do with any

family that has any person that has a mental illness because they are professed to

be suffering from mental retardation that has no cure and runs in the family.

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Category 8: Participant Occupation

The data revealed that this theme had several dimensions each of these is

identified and described below with support from the participants’ described experience

and responses.

Stigma of mental illness. Stigma of mental illness (the culture of negative and

demeaning views concerning individuals with mental illness and their families) in

African cultures and among African immigrants constituted impediments to seeking

treatment. P4 stated:

All African cultures and African immigrants know that stigma of mental health

leads to discrimination, and discrimination could be sufficiently noticeable and

direct, which negative remarks are made against individuals’ mental illness and

help-seeking trends; other people avoid individuals with mental health conditions

because of cultural beliefs assertions that they are crazy, instable, violent, vicious,

dangerous and dirty, based on these assertions, individuals are forced to

negatively judge themselves.

P5 said:

In all African countries and among African immigrants, stigma of mental illness

produces discrimination and prejudice in employment processes, impedes equal

housing opportunities, mental health care services, community involvement,

social relationships, and negatively impacts the quality of life for individuals with

mental illness, their family members, and friends.

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Symptomatic complications. Symptomatic complications of mental illness were

misunderstood by African immigrants. P1 stated:

Mental illness is a challenging physical condition that is not accepted by the

general population, and nobody wants to have anything to do with an individual who has

mental illness and their families……Postpartum depression is a severe mental illness and

seeking appropriate treatment for the symptoms is the only intervention for the problem;

while there are cultural differentiations concerning the meaning of mental illness and

manifesting symptoms, there must be understanding about effective treatment and

damaging effects of untreated mental illness conditions.

Cultural perspectives of mental illness. African immigrants’ faced implications

of their cultural perspectives of mental illness, differently from other cultures. In the

opinion of P1, “Mental illness is a challenging physical condition that is not acceptable

by the general population, and nobody wants to have anything to do with an individual

who has mental illness and the families.” P5 added:

Mental illness among African immigrants refers to collectively all diagnosable

mental disorders and mental health conditions that are characterized by alterations

in thinking, mood, or behavior associated with distress and impaired functioning;

mental illness is one of leading causes of mortality and morbidity in African

countries, and Africans with severe mental illness tend to die of preventable

conditions 25 years earlier that Africans without such diagnoses.

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P9 said:

African cultures believe that mental illness and individual disaster are brought by

the discord of wrongdoing such as lack of faith in their god, a person being

possessed by angry spirits, and even accidents are believed to be under divine

control of occurrence.

Misunderstanding of help-seeking. There is ongoing misunderstanding of help-

seeking needs among African immigrants to the U.S. P8 shared his experience with the

American mental health system stating, “African immigrants believe that the American

mental health care system is not well equipped to meet the mental health needs of the

ethnically diverse minority immigrant population groups.” P9 said:

Diversity has transformed the U.S. to a more motivating and open society blessed

in ideas, perspectives, and improvements, but nevertheless, the future of the U.S.

diverse, multi-cultural society cannot be realized until all Americans, including

ethnically diverse minority immigrant population groups and African immigrants

gain accessibility without disparity to effective culturally sensitive and acceptable

mental health care services that meet their mental health care necessitates.

Summary

The results of this study reveal a complex, multiple-dimensional experience of

mental health, mental illness, and help-seeking in African immigrants. In addition to the

struggles to understand and reconcile country-of-origin views with the US vision of

mental health, mental illness and treatment, participants painted a dismal view of how

they experienced mental illness through the lens of their cultural experience, and of the

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painful and non-responsive interactions with accessing and receiving care. The results are

summarized across the two analyses and organized to answer the four research questions.

RQ1

The results of both analysis cycles revealed that African immigrants face

negotiating the differences between their African country-of-origin culture and the U.S.

culture. In their country of origin, mental health is a state of well-being in which several

individuals realize their own abilities and manage with their stresses of life; work

productively; and make constructive contributions to their communities. Africans and

African immigrants perceived mental health problems as the consequence of an external

attack on the individual. The subject matter of mental health is proscribed in African

cultures and is considered generally unmentionable in all private and public discussions.

Africans and African immigrants come from a collectivist culture and believe that

the most important characteristics in their lives were having their full family support all

the time. African immigrants worried that one important component in their lives was

losing the community protection formerly provided by their protective family systems.

Back in their native African countries, African immigrants understood that the protective

family system that helped the members overcome the challenges of mental health

complications in their lives. Migration to the U.S. for better life conditions and advanced

economic broad-mindedness, created the leaning to culture of individualism and

abandonment of closed family systems. In addition, the social and economic problems,

housing and employment inequalities, and systemic racism, influenced African

immigrants’ mental health in negative ways. Africans and African immigrants’

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traditional cultural practices not only influenced their mental health but influenced all

components of life including social functioning abilities, family relationships, and

physical well-being. Africans and African immigrants’ connection with traditional values

and methodologies for health is unique.

One example of the influence and consequences of traditional African healing

practices is illuminated by the belief that disease, illness, and poor health condition were

due to bad luck. Individuals with mental health problems and their families in African

countries had only two options to choose from, African traditional medicine and spiritual

healing methods.

Africans and African immigrants’ traditional values are embedded with traditional

African healing practices, African traditional medicine, devination, herbalism, witchcraft,

voodoo, and spiritualism customarily amalgamated in African traditional methods

treatments, which are some of the most varied and oldest curative system in Africa and

the world. Africans and African immigrants embraced African traditional methods of

treatment because of the holistic approach to health in which mental health was assessed

side-by-side with physical health, and availability of culturally competent practitioners

and healers.

RQ2

Several interesting findings emerged in the data analysis process regarding mental

illness, culture and stigma. In particular, the dimensions of Cultural Experience of Mental

Illness and Participant Occupation were particularly illuminative. Of clear import

among participants was the understanding that mental illnesses were distinguished as

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spiritual problems instead of medical conditions. Individuals with mental illness were

hidden for long periods of time in the house by their families until they were healed, for

fear of shame and disgrace from their community and the general public. This process

became a cycle for families, and the manifested symptoms of mental illness were not

treated, and where healing took a long time or did no change, the individual would be

taken to the traditional medicine practitioners or spiritual healers for culturally acceptable

treatment. The participants reported the preference to utilize traditional methods of

treatment for mental illness. Traditional curative methods could not be compared with

approved Western/American developed mental illness treatments that utilized

psychotherapy and pharmacotherapy. Most African immigrants felt that, the traditional

methods of treatment would be the best curative method for mental illness because of the

causative factors of mental illness.

Many participants indicated that in rural areas in Africa, individuals with mental

illness were sent out by their families to protect the family legacy and name. This was

done because individuals with mental illness were assumed to be a curse for the whole

family. All members of the family could be ostracized if one of them is perceived to be

mad or crazy. In response to questions about indigenous stigma, participants indicated

that rural African cultures proscribed the marriage of girls and women from families

where a family member had mental illness into other families, because of the fear that

future family descendants would also be afflicted with mental illness. Most African and

African immigrants misunderstood manifesting symptoms of mental illness, and instead

characterized individuals with mental illness as victims of evil spirits, witchcraft, and

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metaphysical complication, that victims must be taken to the traditional medicine

practitioners and spiritual healers. The way things are done in the U. S. (visiting a mental

health care facility, getting diagnoses and treated) s also shaped their perceptions of

mental illness and help-seeking. In addition, African immigrants are not recognized as

being ethnically diverse, and reported the experience of cultural discrimination, racial

discrimination and hatred, ranging from racist comments to violent hate crimes.

Another interesting finding that illuminating the area of mental illness and

indigenous culture stigma was the differences between African country-of-origin culture

and the U.S. with respect to gender issues and language. African immigrants have gender

issues, and their culture proscribes mental health professionals from working with

opposite sex. African immigrants had problems with mental health professionals from

other cultures, feeling that because of language barriers they were not able to participate

in the treatment process. They reported that mental health professionals from the main-

stream White culture did not understand the cultural conceptions of mental illness.

The participants’ cultural meaning of mental illness characterized these disorders

because of suffering from the spirits of the dead, demons, witchcraft, and voodoo.

Participants pointed out that mental illness in the U.S. is a health condition involving

changes in emotion, thinking and behavior associated with distress and or problems with

social functioning and family activities and that this contrast is a source of confusion and

distress that adds to the distress of mental health problem. The participants also

identified that indigenous cultural stigma associated with mental illness has profound

effects on daily life. The experience of stigma was described as negative attitudes of

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discrimination with renunciation of needed social resources, no accessibility to affordable

housing, child-care, and employment, and the avoidance of help-seeking, and

unwillingness to seek treatment, and complete community withdrawal.

RQ3

To appropriately address this question, these two categories were selected to

answer the question: Meanings of Help-Seeking and Subject of Story. The participants

reported that immigration status and documentation created mistrust and resentment

towards American mental health system and were barriers to mental health help-seeking.

Participants reported delaying seeking treatment until the problems that could have been

treated or prevented became more challenging and difficult to treat. The participants also

noted that it would be more advantageous for individuals to work with mental health

professionals from their own cultural background who understand traditional treatments

and the stigma experienced by those seeking help. Social and economic challenges with

strained financial conditions, language barriers and dissimilarities with capabilities were

also identified as major impediments to help-seeking.

RQ4

The two categories were relevant and were selected to answer the question:

Importance of Cultural Understanding and Dissatisfaction. Participants responded both

broadly and specifically to this question. In other words, there was considerable mention

of the xenophobia, prejudice, racial discrimination and systemic racism in all aspects of

life in the U.S, particularly in parts of the country that were more conservative politically.

Chapter 5 will compare the results of the study with the literature review and interpret

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and analyze the clinical findings. The theoretical frameworks of segmented assimilation

theory and cultural theory of risk will be related to the findings of the study. Limitations

of the study will be addressed in addition to recommendations for further studies.

Implications for social change at individual, organizational, and national levels will be

offered with considerable recommendations for mental health professionals and the

psychological science community.

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Chapter 5: Discussion

The objective of this IPA was to explore African immigrants’ lived experience of mental

health, mental illness, and help-seeking. This study contributes to understanding how

traditional cultural beliefs held by African immigrants contrast and complicate the

meaning of mental health, mental illness, and help-seeking processes that are taken for

granted by the non-immigrant public. Nine participants from different countries within

the five main regions of Africa described their major mental health, mental illness, and

help-seeking experiences to explore the following questions:

RQ1: What is the lived experience of mental health for African immigrants in the

U.S.?

RQ2: How does indigenous cultural stigma occur in the meaning of mental

illness?

RQ3: How do African immigrants in the U.S. describe their help-seeking

experiences?

RQ4: How does indigenous cultural stigma occur in help-seeking?

Rich, thick data was analyzed in two ways. During the first cycle, key content

areas were identified from the literature to respond to the research questions. Each of the

eight content areas produced three to five dimensions (see Table 1). During the second

cycle, I went back to the transcripts, and using a line-by-line analysis of the transcripts,

generated eight themes. There were considerable overlaps between these two efforts, with

greater depth during the second cycle. In this chapter, I summarize key findings of the

study and discuss how they confirm, disconfirm, and broaden published literature.

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Limitations, recommendations, implications, and a summary are also included in this

chapter.

Interpretation of Findings

Assumptions and Expectations

Participants reported that they came to understand that former assumptions and

expectations before migration from their native African countries and on arrival in the

U.S. were unrealistic and idealistic. Most participants reported that challenges involving

migration and acculturation stress contributed to their mental health problems and need

for mental healthcare services and treatments. Renner and Salem (2014) said human

values and norms, economic needs, social behaviors, different symptoms of mental

illnesses, and approved cultural treatment approaches are embedded with indigenous

culture in African collectivist societies that cannot be compared to U.S. individualist

societies. Some participants reported that extreme unremitting struggles and frustrations

during their attempts to cope with assimilation challenges, systemic racism, cultural

discrimination, language dissimilarities, economic impediments, unemployment,

disparities in mental health services, and lack of accessibility in terms of effective and

acceptable mental healthcare services and treatments triggered their mental problems and

need for mental health services and treatments.

African immigrants’ traditional cultural belief systems strongly influenced their

conceptions of mental health and attitudes towards individuals with mental health

problems and their families. It was also found that African immigrants’ traditional

cultural belief systems influenced notions of mental illness and behaviors towards

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individuals with mental health issues and their families. One common response among

study participants was that African cultures and immigrants do not accept or trust

Western or American developed medical practices, and as an alternative preferred to use

traditional healing approaches to treat mental health symptoms.

Most participants did not consider mental health and mental illness as medical

problems but believed evil spirits to be contributing factors. These perceptions enhanced

the risk of continuing increases in terms of mental health problems. All participants

reported that their experiences with assessment and diagnosis processes and modalities of

treatments shaped by Western and American hegemonic understandings contrast with

their traditional cultural belief systems and practices. Attempts to use conventional

mental health systems were not suitable for African immigrants who retained their

traditional cultural beliefs.

Importance of Cultural Understanding

African immigrants’ cultural vulnerabilities to mental health problems were

misunderstood by other cultures. Cultural beliefs influence barriers to reporting mental

illness symptoms due to embarrassment linked with the illness. The findings of this study

confirmed that there was lack of understanding in terms of how powerful cultural stigmas

concerning mental health challenges had been studied among African immigrants.

Cultural stigma creates fears that serve as obstructions to professional help-seeking.

Experience of Mental Health

Participants believed in spiritual phenomena as essential to success and physical

wellbeing in life, and individuals who died transformed into ascended masters and unseen

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ancestral spirits who involved themselves in the affairs of daily living. They serve to

generate self-protection from evil forces, good fortune, and success in daily activities,

marital success, and protection from mental illnesses. Mental health was a consequence

of being in harmonized state with culturally recognized goddesses and spiritual forces

that control individuals’ abilities to be successful in terms of daily endeavors and

physical wellbeing.

Cultural Experience of Mental Illness

Participants reported that mental illness was one of the most misunderstood

mental health conditions in African cultures and among African immigrants, and that

among most of their native African countries individuals with mental illness are secluded

at home by their families for fear of humiliation and embarrassment. Individuals with

mental illnesses and their families were stigmatized and discriminated as harmful to the

general population. Participants reported that experience of indigenous stigma occurrence

in their meaning of mental illness was increased and emboldened by distrust of mental

health professionals from other cultures who did not understand their traditional cultural

beliefs, language dissimilarities, sociocultural notions of mental illness symptoms, and

distrust of psychotherapy and pharmacotherapy.

Meanings of Help-Seeking

The participants described their Help-Seeking Experience in five components of

African Experience; U.S. Experience; Cultural Influences; Barriers and Implications; and

Traditional Methods of Treatment. Participants soon came to understand that their

notions of help-seeking before migration and on arrival in the U.S. were totally

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unrealistic and idealistic based on the delivery system of mental health care services and

treatments in the U.S. Participants believed that mental health help-seeking created

individual distress that was more significant than their real current problem.

African immigrants migrated to the U.S. from a collectivist culture with

recognized value systems handed down from generation to generation; and carried

around the global communities beyond the borders of African continent by migrants.

Individuals from collectivist cultures always failed to conform with mental illness help-

seeking possibilities; and collectively circumvent every circumstance connected to

disclosing personal information and concerning reporting of experiencing mental illness

symptoms. Stigmatization of individuals with mental illness and their families, bring

never-ending humiliation to the secured family structures.

This study found that unremitting and unrelenting complications with help-

seeking, with willingness and unwillingness to seek treatment for mental health problems

were influenced by different negative traditional concepts. The different negative

traditional concepts were embedded with traditional cultural belief systems that informed

individuals on decision making to seek-help for mental illnesses and to avoid seeking-

help with no reasons.

The continuous problems with help-seeking were impacted by mistrust of

American mental health system, mental health care services and treatments offered, and

dealing the mental health professionals from other cultures. Some participants reported

that, the communal living established principles, secured family structures, and friends

played significant roles in their help-seeking inclinations. Other participants reported that,

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without consulting with conventional mental health professionals, they sought out

culturally approved and acceptable traditional treatments to recover from their mental

health problems. Several studies have also found that immigrants to the U.S. will still

seek culturally familiar sources of support and healing.

Dissatisfaction

The participants described their “Dissatisfaction” in four components of

Disparities in Mental Health Services; Racial Prejudice and Discrimination; Accessibility

to Mental Health Services; and Assessment and Diagnosis. Participants reported that they

came to understand that their notions of dissatisfaction before migration and on arrival in

the U.S. were totally unrealistic and idealistic based on the delivery of mental health care

services and treatments in the U.S. Stigma made it difficult for individuals to seek-help

for mental health problems and mental illnesses.

Participants reported that indigenous cultural stigma prevailed in help-seeking

despite their understanding of mental health and mental illness as acceptable medical

condition in the U.S. Some participants reported that, indigenous cultural stigma was a

major social-calamity that blocked family members understanding to conform with the

help-seeking needs of their loved ones diagnosed with mental illness. All participants

reported that indigenous cultural stigma was a conceptualized problem brought shame

and disgrace from the general population to individuals with mental illness and their

families. Some participants reported that, indigenous cultural stigma of mental health

help-seeking, vulnerability to systemic racism, and racial discrimination with limited

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access to effective mental health care services were obstructions to seeking mental illness

treatment.

Subject of Story

The participants described “Subject of Story” in four magnitudes of Mental

Health Issues; Mental Illness and Treatment; American Mental Health System; and

Social Economic Issues, all of which dispensed clarity to their descriptions of Subject of

Story as embedded with their help-seeking experience. Participants reported that they

came to understand that their subject of story before migration and on arrival in the U.S.

was totally unrealistic and idealistic based on the delivery of mental health care services

and treatments in the U.S. Negative attitudes concerning Western/American developed

treatments for mental health problems and mental illnesses were influenced by their

cultural beliefs systems.

Most participants reported that their help-seeking conditions for mental health

problems and mental illnesses were impacted by cultural mistrust of mental health

professionals from the main-stream White culture and stigmatization of individuals with

mental health problems and their families. Some participants reported that, despite

accessible modalities of mental illness treatments, they preferred to contact their family

members, traditional native doctors, herbalists, fortune-tellers, spiritualists and faith

healers for their help-seeking needs to treat the manifesting symptomatic complications

of mental illness.

Most participants reported that they preferred traditional cultural treatments for

mental illness to Western/American developed mental illness treatments based on their

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understanding of these methods of treatment in their native African countries.

Participants reported that the traditional cultural treatments were perceived to be effective

and acceptable among African cultures but differed in constituents from the

Western/American methods of treatments. Participants reported that accessibility

complications, limited accessibility, and no accessibility were major impediments to their

help-seeking necessitates. Some participants reported that, they had lower accessibility

rating to effective and acceptable mental health care services and treatments. Compared

to the main-stream White culture with higher accessibility rating to effective mental

health care services and treatments.

Participants reported major inconsistencies in assessments of their mental health

care needs and explanations related with utilization of services among. Occurrence of

mental health problems that needed treatment differed significantly from the currently

recorded information by mental health professionals and researchers. Participants

reported that their mental health care needs, and attitudes to seeking mental illness

treatment continued to be inappropriately characterized. The main complexity to

understanding mental health issues and help-seeking practices of African immigrants was

the shortage of correct recorded information of national origin, cultural identity, cultural

belief systems, and language differences in the medical care settings literature.

Participant Occupation

The participants described “Participant Occupation” in four magnitudes of Stigma

of Mental Illness; Symptomatic Complication; Cultural Perspectives of Mental Illness;

and Misunderstanding of Help-Seeking, all of which dispensed clearness to their

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descriptions of Participant Occupation, as relevant with occurrence of indigenous stigma

in their meaning of mental illness. Participants reported that they came to understand that

their notion of participant occupation before migration and on arrival in the U.S. were

totally unrealistic and idealistic. As more African immigrants arrived in the U.S. as would

their mental health, mental illness, and help-seeking problems increased, that would

exacerbate their mental health care services and treatment needs.

All participants reported that their cultural belief systems, collectivists’

tendencies, and protected family structures influenced their sensitivities of stigma of

mental illness, manifesting symptomatic complications, mental health help-seeking, and

the common meaning of mental illnesses. Most participants reported that, traditional

values and norms influenced their perceptions of mental illnesses, methods of mental

illness treatments, stigmatization of individuals with mental illnesses and their families.

Misunderstanding of mental illness symptoms among family members, causative factors

of mental illness, and cultural implications created barriers to seeking available mental

illness treatments among African immigrants to the U.S.

Participants reported that indigenous cultural stigma was a continuous culturally

justified condition embedded with the meaning mental illness that distinguished it from

the expectably culturally approved response to a conversant concern which is not

considered to be mental illness. Stigma of mental illness and stigmatization of individuals

with mental illness and their families created barriers for seeking mental illness

treatments despite the established vulnerabilities of individuals with mental illness.

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This study determined that Native American Indian population groups abstained

from stigmatization of individuals with mental illness, majority within the group,

stigmatized selected mental illnesses; others conformed with the established practices that

stigmatized all mental illnesses suffered by tribal indigenes. This study also found that by

contrast, Asian cultures emphasized on traditional values and compliance with cultural

norms, protected family structures, and understanding of expressive self-discipline.

Stigmatization of individuals with mental illnesses practiced collectively because mental

illnesses are presumed to being conditions of embarrassment and humiliation. Abdulla

and Brown (2011) found that irrespective of how other cultures conceptualized mental

illness and stigma, African individuals with mental illnesses and their families remained

stigmatized because of the deeply embedded cultural belief systems.

Interpreting Findings in the Context of the Theoretical Frameworks

The SAT and CRT were the theoretical frameworks for this study based on the

subject matter and population. As described in earlier chapters. segmented assimilation

theory recognizes that assimilation to a new culture can take different paths that affect

quality of life, support and livelihood (Portes & Zhou, 1993). The participants who were

involved with the mental health system were also struggling economically and

experienced a path of assimilation that was full of challenges and limited access to

resources. So, their mental health condition was made more complex and vulnerable to

stigma. These circumstances created more impediments that prevented individuals from

seeking mental health care services and treatments (Akresh et al., 2016; Portes & Zhou,

1993).

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The cultural theory of risk theory was used to explore the cultural cognitions that

influenced mental health, mental illness, and help-seeking attitudes among African

immigrants to the U.S. (Douglas & Wildavsky, 1982; Knudtzon, 2013; Shiraev & Levy,

2010). African immigrants whose family members suffered from mental health problems

in their native African countries experienced stigmatization of individuals and their

families, discrimination, prejudice, embarrassment, humiliation and banishment from

their local communities because of cultural presumption of being dangerous. They

became opposed to seeking mental health care services in the U.S. for fear that help-

seeking in the U.S., would lead to the same conditions that prevailed in their native

African countries. This was also apparent when participants described how mental health

professionals from other cultures did not understand their cultural beliefs about mental

health and illness and were not cognizant of other socialized interactions (e.g., gender

issues, use of traditional practices) (Douglas & Wildavsky, 1982). The participants

described experiences of utilizing help from family members, ritual practices, mystical

power, prayer from their pastors, and spiritual belief systems as social supports and

healing (Douglas & Wildavsky, 1982).

Limitations of the Study

This research study has the following limitations. First, it is recognized that

discrepant findings and cases were missing because the procedure of snowball sampling

kept the sample extremely homogenous. Other areas of the state or country were not

sampled. Participation in the research was limited to African immigrants 21 years and

older from the Five Main Regions in Africa who spoke English. African immigrant

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participants who were younger could have exhibited challenging developmental

complications that could have exceeded expectations and the scope of the research.

Individuals from other ethnically diverse minority immigrant population groups in the

U.S. did not fall within the purview of this research because they were not classified as

African immigrants to the U.S. IPA research focuses on selecting cases that represent the

phenomenon of interest rather than a heterogenous sample (Smith et al., 2009; (Smith,

2011; Smith et al., 2013), but the current study could suffer from too much homogeneity

in responses.

To enhance transferability, the researcher provided a thoroughly defined

explanation of the procedures for data gathering, analysis, and interpretation. The

researcher described the settings, research design, methodology and the participants with

a complete explanation for the information to be transferable to other groups and

contexts. The researcher enhanced transferability using rich, description, and another

technique for establishing credibility in qualitative research (Shenton, 2006). To enhance

dependability, the researcher consulted with methodology and content experts to evaluate

the interview and research questions. However, the researcher was the sole interviewer

and coder for the analyses. Having additional resources to interview, code and analyze

the data would have allowed for triangulation to enhance dependability further. The

researcher utilized verbatim transcripts and audio recordings and asked the participants to

review the summary of their interview transcriptions as part of the member-checking

process; and recorded comments and reflections on all parts of the data collection and

146

analysis as an audit trail process. These procedures support the credibility of the findings

(Shenton, 2006).

Recommendations

The results of the study were limited to a very homogeneous target group of

adults immigrating from the five main regions of Africa. Future research could, using the

same approach, explore the lived experience of young adult immigrants. These

individuals could have a very different world view of cultural assimilation and mental

health, and it would be worth understanding their point of view. Another direction could

also include immigrants from other parts of Africa or neighboring countries. Future

research could also employ research methods where greater triangulation of data sources

as well as interviewers could take place. I recommend future researchers to use

ethnographic approaches to get a broader assessment of stigma (both indigenous and

from the US mental health services), to interview multiple target groups, collect

observational data and documents Bengtsson, 2014).

One of most important findings out of this study was the extreme potency of both

indigenous stigma and stigma experienced during interactions with the US Mental Health

service. Future research is encouraged to study the interaction of these sources of stigma

on mental health and illness. Using the themes identified in this study regarding stigma,

survey research could be done to assess both and the use of resources and presenting

mental health status.

My research findings revealed the issue of economic challenges, but more is

needed on the effects of economic challenges African immigrants’ on mental health and

147

help-seeking conditions. Further research can also explore the influence of indigenous

cultural stigma of mental illness and treatment among African immigrants with mental

illness and their families. Research is also needed to examine the barriers that prevent

African immigrants from mental health help-seeking and care provided by mental health

professionals from the main-stream White culture.

The findings of this study established that the consequences of indigenous cultural

stigma are real, participants lost jobs and their spouses; nobody wants to marry from any

family that has a family member who suffers from mental illness. Mental health

professionals may not understand how these cultural stigmas influence African

immigrant’s decision and willingness to seek mental illness treatment. Future studies

should interview mental health professionals who work with African immigrant

communities, to better understand the obstacles and opportunities for providing better

accessibility to effective mental health care services and treatments.

Implications

The results of this study illuminated how different cultural beliefs are experienced

in a foreign country, particularly when interacting with established, culturally different

processes of managing mental illness and treatment Specifically, the following

recommendations are made:

1. Provide appropriate information to the mental health clinicians and

researchers concerning possible impediments for African immigrants and

instructing them to obtain necessary information from African immigrants

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regarding trust about help-seeking for mental health problems and mental

illnesses.

2. Encourage recruitment and training of psychologists who understand African

immigrants and who come from the same cultural background as African

immigrants.

3. Establish community mental health programs (CMHPs) within the community

health centers (CHCs) that will offer culturally appropriate information to

Africa immigrants concerning mental health, mental illness, help-seeking,

recovery, wellness, rehabilitation, and available modalities of treatment.

4. Amalgamate primary health care services and mental health care services,

through community public health partnerships for African immigrants.

5. Mental health professionals from other cultures who provide mental health

care services and treatments to African immigrants and other ethnically

diverse minority immigrant population groups should obtain appropriate

rudimentary education on multi-cultural sensitivity and cognizance of African

immigrants.

6. Mental health professionals and researchers can be educated in methodologies

of constructive communications, meaningful understanding, and attentiveness’

to effectively address African immigrants’ inimitable mental health, mental

illness, and help-seeking necessitates.

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Conclusions

In this study, African immigrants to the U.S. referred to immigrants who migrated

from the countries within the Main Five Regions of Africa to the U.S. I am the sole

researcher in this current study and also an individual of African ancestry and cultural

background; so I deeply understand and empathize with the challenges of culturally-

influenced conceptions and traditional cultural beliefs concerning experience of mental

health, mental illness, and help-seeking with African immigrants (Arzubiaga et al., 2008).

I was born and raised at Obot Ndiya, Ikot Ukap, Nsit Ubiom Local Government Area

(LGA) in Akwa Ibom State, South-South Region of Nigeria, West Africa, and migrated

to Los Angeles, CA, as a foreign student. I have a full understanding of migration and

acculturation challenges, language barriers and dissimilarities, prejudice and racial

discrimination, social and economic challenges, affordable housing and employment

challenges, family and marital problems, mental health, mental illness, and help-seeking

problems that African immigrants face in the U.S. My lived experience includes being a

foreign student, legalized resident, and naturalized U.S. citizen, and working as a mental

health professional with the ethnically diverse minority immigrant population groups that

includes African immigrants. This motivated my decision to pursue a Ph.D. in Clinical

Psychology and to explore this topic for my dissertation.

The subject matter of the study materialized through the desire to have better

understanding of African immigrants’ mental health problems, mental illness, and

barriers that prevent individuals from seeking accessible mental health care services

treatments as other ethnically diverse minority immigrant population groups in the U.S. I

150

used the double hermeneutic or two-staged interpretation process that involved

participants in the study, attempting to make sense of their world lived-experiences while

the researcher is trying to make sense of the participants’ attempting to make sense of

their lived-experiences. The findings from this study enhanced and emboldened the

researcher’s understanding of the significant challenges experienced by African

immigrants who associate mental illness with traditional harmful practices, and others

attribute it to evil spirits and blame individuals with mental illness. They come to the U.S.

with no change in opinion despite exposure to new sources of information. As an

individual of African ancestry and background, the investigator admits that he faced

comparable challenges in his earlier year’s acculturation and assimilation process in the

main-stream culture in the U.S. Understanding that African culture is a way of life for

Africans. Their behaviors, their traditional cultural beliefs, values, and symbols that they

accept are passed along by communication and simulation from one generation to another

generation. African culture is wide-ranging and different from the U.S. culture, expressed

in arts and crafts, traditions, religion, music, food, clothing, and languages. The study

established that, it is impossible for Africans and African immigrants to desert their

traditionally rich culture in totality but, tend to be retaining their culture once in the U.S.

Instead of deserting their numerous traditions, they find ways to re-establishing and re-

producing themselves through cultural connections cultivated through nationwide

association, shared ethnic values, and broad-spectrum objectives.

The findings of this study emphasized the need for better understanding of

African immigrants as they navigate through the American mental health system with

151

their mental health issues, mental illness, and help-seeking impediments comparable to

other ethnically diverse minority immigrant population groups in the U.S. African

immigrants who participated in this study reported their lived experience with mental

health, mental illness, and help-seeking, occurrence of indigenous cultural stigma in

mental health, the occurrence of indigenous cultural stigma in mental illness, and the

occurrence of indigenous cultural stigma in help-king experience. The researcher

anticipates that the findings of this IPA will offer information for better understanding of

African immigrants’ mental health, mental illness, and help-seeking necessities and

prompt the mental health clinicians and researchers to develop and offer effective

culturally sensitive and acceptable mental health care services for African immigrants.

The researcher hopes that the findings of this IPA will lead to the mental health policy

makers’ implementation of culturally sensitive mental health policies for African

immigrants and other ethnically diverse minority immigrant population groups, based on

their traditional cultural beliefs, value systems, norms, language dissimilarities, and

notions of mental health, mental illness, and help-seeking necessities.

This research revealed the need of making mental health care services accessible

and affordable for African immigrants through culturally appropriate community mental

health services. It also revealed the need to offer meaningful services to African

immigrants in their local communities which can help alleviate acculturation challenges,

social and economic problems, racial discrimination and prejudice, and language

dissimilarities which may come from the environment.

152

The chronological de-humanization, oppression, mistreatment, racial

discrimination, prejudice, racial injustice, judicial injustice, high-profile killings of

African immigrants, planned high-profile deportation of African immigrants to their

native African countries, and aggression against African immigrants has progressed into

present day systemic racism, structural barriers to essential mental health resources and

benefits, established practices of racism against individuals and families, and cultivated a

individually mistrustful and less affluent community experience, characterized by a

countless of disparities including insufficient accessibilities to and delivery of care in the

American mental health system, mental health care services and treatments. Processing

and dealing with layers of individual trauma on top of the current mass traumatic

conditions from COVID-19 (improbability, segregation, unhappiness from economic and

losses of human lives), police viciousness, multifarious news media complications, and

thoughtless opinionated public speaking adds compounding layers of complications for

African immigrants as a part of the ethnically diverse minority immigrant population

group to conscientiously manage while struggling to better their living conditions in the

U.S. needs to be carefully considered and addressed with effective solution for amicable

culmination.

153

References

Abbass, A. A., & Town, J. M. (2013). Key clinical processes in intensive short-term

dynamic psychotherapy. Psychotherapy, 50(3), 433-437. doi: 10.1037/a003

Abdullah, T., & Brown, T. L. (2011). Mental illness stigma and ethnocultural beliefs,

values, and norms: An integrative review. Clinical Psychology Review, 31(2),

934-948.

Adekeye, O., Kimbrough, J., & Obafemi, B. (2014). Health literacy from the perspective

of African immigrant youth and the elderly: A photovoice project. Journal of

Health Care for the Poor and Underserved, 25(2), 1730-1747.

Adetola, A. (1997). Theater on wheels: The Yoruba theatre, its origins, structure

organization (1st ed.). Toronto, Canada: Impact Communications, Inc.

American Immigration Council. (2012). African immigrants in America: A demographic

overview. Retrieved from, http://www.americanimmigrationcouncil.org

Agbayani-Siewert, P., Takeuchi, D. T., & Pangan, R. W. (1999). Handbook of the

sociology of mental health (1st. ed.). New York, NY: Kluwer Academy/Plenum

Publishers.

Agbemenu, K. (2016). Acculturation and health behaviors of African immigrants living

in the United States: An integrative review. The ABNF Journal, 27(3), 67-73.

Aggarwal, S. K., Carter, G. T., Zumbrunnen, C., Morrill, R., Sullivan, M., & Mayer, J. D.

(2012). Psychoactive substances and the political ecology of mental distress.

Harm Reduction Journal, 29(2), 1-15. doi.10.1186/1477-7517-94

154

Ahmed, K., & Bhugra, D. (2007). Depression across ethnic minority cultures: Diagnostic

issues. World Cultural Psychiatry Research Review, 2(213), 47-56.

Aina, O. F. (2004). Mental illness and cultural issues in West African films: Implications

for conventional psychiatric practice. Journal of Medical Ethics and Medical

Humanities, 30(2), 23-26. doi:10.1136/jmh.2003.000152

Aina, O. F., & Morakinyo, O. (2011). Culture-bound syndromes and the neglect of

cultural factors in psychopathologies among Africans. African Journal of

Psychiatry, 14(4), 278-285.

Akomolafe, A. C. (2012). Decolonizing the notion of mental illness and healing in

Nigeria, West Africa. Critical Psychology in Changing World, 2(2), 726-740.

Alarcon, R. D. (2009). Culture. Cultural factors and psychiatric diagnosis: Review and

projections. World Psychiatry, 8(2), 131-139.

Alase, A. (2017). The interpretative phenomenological analysis (IPA): A guide to a good

qualitative research approach. International Journal of Education &Literary

Studies, 5(2), 9-19. doi:10.7575/aiac.ijels.v5n.29.9

Albright, K. S. (2011). Psychodynamic perspectives on information behavior.

Information Research, 16(1), 1-14.

Alibeli, M. A., & Yaghi, A. (2012). Theories of prejudice and attitudes towards Muslims

in the United States. International Journal of Humanities and Social Science,

2(1), 21-19.

155

Ally, Y., & Laher, S. (2008). South African Muslim faith healers’ perceptions of mental

illness: Understanding, etiology, and treatment. J Relig Health, 47(2), 45-56.

doi.10.1007/s10943-007-9133-2

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders. (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychological Association. (2010). Ethical Principles of Psychologist and

Code of Conduct (http://www.apa.org/). Washington, DC: Government Printing

Office.

Amri, S., & Bemak, F. (2013). Mental health help-seeking behaviors of Muslim

immigrants in the United States: Overcoming social stigma and cultural mistrust.

Journal of Muslim Mental Health, 7(1), 43-63. doi.10.381607.0007.104

Amuyunzu-Nyamongo, M. (2013). The social and cultural aspects of mental health in

African societies. Commonwealth Health Partnerships, 59(2), 59-63.

Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Feilding, J. E., & Normand, J.

(2003). Culturally competent healthcare systems: A systematic review. American

Journal of Preventive Medicine, 24(3S), 68-79. doi.10.1016/S0749-3797

(02)00657-8

Angrmeyer, M. C., & Dietrich, S. (2006). Public beliefs about and attitudes toward

people with mental illness: a review of population studies. Acta Psychiatry

Scandinavica, 113(2), 163-179. https://doi.org/10.1111/j1600-0447-2005.00699.x

156

Arzubiaga, A., Artiles, A. J., King, K. A., & Harris-Muri, N. (2008). Beyond research ’on

cultural minorities: Challenges and implications of research as situated cultural

practice. Exceptional Children, 74(2), 309-327.

Astalin, P. K. (2013). Qualitative research designs: A conceptual framework.

International Journal of Social Science and Interdisciplinary Research, 2(1), 118-

124.

Babbie, E. (2015). The practice of social research (13th ed.). Belmont, CA: Thomson

Wadsworth Publishing.

Bagasra, A., & Mackinem, M. (2014). An exploratory study of American Muslim

conceptions of mental illness. Journal of Muslim Mental Health, 8(1), 57-76.

doi: 10.3998/jmmh.10381607.0008.104

Banerjee, A. (2012). The cross-cultural variance of schizophrenia in symptoms,

diagnosis, and treatment. GU Journal of Health Sciences, 6(2), 118-124.

Bauldry, S., & Szaflarski, M. (2017). Immigrant-based disparities in mental health

care utilization. Sociological Research for Dynamic World. 3(2), 1-14.

Bengtsson, T. T. (2014). What are data? Ethnographic experiences with young

offenders. Qualitative research, 14(6), 729-744.

Bhugra, D. (2006). Severe mental illness across cultures. Acta Psychiatry Scand,

113(Suppl.429), 17-23. 10.1111/j.1600-0447.2005.00712x

Bhugra, D., & Becker, M. A. (2005). Migration, cultural bereavement, and cultural

identity. World Psychiatry, 4(1), 18-24.

157

Blanch, A. (2007). Integrating religion and spirituality in mental health: The promise and

the challenge. Journal of Psychiatric Rehabilitation, 30(4), 251-260.

Cabassa, L. J., & Baumann, A. A. (2013). A two-way street: Bridging implementation

science and cultural adaptations of mental health treatments. Implementation

Science, 1-14. Retrieved from

http://www.implementationscience.com/contents/8/1/90

Cai, A., & Robst, J. (2015). The relationship between race/ethnicity and the perceived

experience of mental health care. American Journal of Orthopsychiatry, 1(2), 1-

11. 10.1037/ort000119

Callary, B., Rathwell, S., & Young, B. W. (2015). Insights on the process of using

interpretive phenomenological analysis in sports coaching research project. The

Qualitative Report, 20(2), 63-75.

Campbell, R. D., & Long, L. A. (2014). Culture as a social determinant of mental and

behavioral health: A look at culturally shaped beliefs and their impact on help-

seeking behaviors and service use patterns of Black Americans with depression.

Best Practices in Mental Health, 10(2), 50-62.

Carlson, J. A. (2010). Avoiding traps in member checking. The Qualitative Report, 15(2),

1102-1113. Retrieved from Retrieved from

http://nsuworks.nova.edu/tqr/vol15/iss5/a

Carpenter-Song, E., Chu, E., Drake, R. E., Ritsema, M., Smith, B., & Alverson, H.

(2010). Ethnocultural variations in the experience and meaning of mental illness

158

and treatment: Implications for access and utilization. Transcultural Psychiatry,

47(2), 224-251.

Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use

of triangulation in qualitative research. Oncology Nursing Forum, 41(5), 545-547.

http://dx.doi.org/10.1188/14.ONF545-547

Center for Disease Control and Prevention, Substance Abuse and Mental Health Services

Administration, National Association of County Behavioral Health &

Developmental Disability Directors, National Institute of Mental Health, The

Carter Center Mental Health Program. (2012). Attitudes toward mental illness:

results from the behavioral risk factor surveillance system. Retrieved from

www.cdc.gov

Chan, Z. C., Fung, Y., & Chien, W. (2013). Bracketing in phenomenology: Only

undertaken in the data collection and analysis process. The Qualitative Report,

18(59), 1-9. Retrieved from http://www.nova/ssss/QR/QR18/chan 59.pdf

Chenail, R. J. (2011). Interviewing the investigator: Strategies for addressing

instrumentation and researcher bias concerns in qualitative research. The

Qualitative Report, 16(1), 255-262. Retrieved from

http://www.nova.edu/ssss/QR16/interviewing.pdf

Choudhry, F. R., & Bokharey, I. Z. (2013). Perception of mental health in Pakistani

nomads: An interpretative phenomenological analysis. International Journal of

Qualitative Studies on Health and Well-Being, 8(22469), 1-6.

http://dx.doi.org/10.3402/qhw.v8i0.22469

159

Chukwuemeka, N. K. (2009). Traditional psychiatric healing in Igbo land in South

Eastern Nigeria. African Journal of History and Culture (AJHC), 1(2), 036-043.

Chung, R. C., Bemak, F., & Grabosky, T. K. (2011). Multicultural-social justice

leadership strategies: Counseling and advocacy with immigrants. Journal for

Social Action in Counseling and Psychology, 3(1), 86-102.

Ciftci, A. (2013). Mental health stigma in the Muslim community. Journal of Muslim

Mental Health, 7(1), 17-32. doi. 10381607.0007. 102.

Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., & Bezborodovs,

N. (2014). What is the impact of mental health-related stigma on help-seeking? A

systematic review of quantitative and qualitative studies. Psychological Medicine,

33(2), 1-17. https://doi.org/10.1017/S0033291714000129

Cole, N. L. (2018). What is the meaning of acculturation? Understanding acculturation

and how it differs from assimilation. Retrieved 6/20/2018, from

http://www.thoughtco.com/acculturation-definition-3026039?print

Conner, K. O., Copeland, V. C., Crote, N. K., Rosen, D., Albert, S., McMurray, M. L.,

Koeske, G. (2010). Barriers to treatment and culturally endorsed coping strategies

among depressed African American older adults — aging and Mental Health,

14(8), 971-983.

Constantine, M. G., Meyers, L. J., Kindaichi, M., & Moore III, J. L. (2004). Exploring

indigenous mental health practices: the roles of healers and helpers in promoting

well-being in people of color. Counseling and Values, 48(2), 110-125.

160

Cook, B. L., Zuvekas, S. H., Carson, N., Wayne, G. F., Vespa, A., & McGuire, T. G.

(2014). Assess racial/ethnic disparities in treatment across episodes of mental

health care. Health Services Research, 49(2), 206-229.

http://dx.doi.org/10.1111/1475–6773.12095

Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness

stigma on seeking and participating in mental health care. Psychological Science

in the Public Interest, 15(2), 37-70. doi.10.1177/1529100614531398

Creswell, J. W. (2009). Research design: Qualitative, quantitative, and mixed methods

approach. (3rd. ed.). Thousand Oaks, CA: Sage Publications, Inc.

Dako-Gyeke, M., & Asumang, E. S. (2015). Stigmatization and discrimination

experiences of persons with mental illness: Insights from a qualitative study in

Southern Ghana. Social Work and Society International Online Journal, 11(1), 1-

8. Retrieved from http://www.socialwork.net/sws/article/view/362/712

Dale, S. K., & Daniel, J. H. (2013). Talking about the Trayvon Martin case in psychology

and counseling training and psychotherapy. Journal for Social Action in

Counseling and Psychology, 5(1), 37-49.

Davidsen, A. S. (2013). Phenomenological approaches in psychology and health

sciences. Qualitative Research Psychology, 10(2), 318-339.

https://doi.org/10.1080/14780887.2011.608466

De Jesus, M., & Earl, T. R. (2014). Perspectives on quality mental health care from

Brazilian and Cape Verdean outpatients: Implications for effective patient-

centered policies and models of care. International Journal of Qualitative Studies

161

on Health and Well-Being, 9(22839), 1-10.

http://dx.doi.org/10.3402/qhw.v9.22839

De Jesus, M., & Earl, T. R. (2014). Perspectives on quality mental health care from

Brazilian and Cape Verdean outpatients: Implications for effective patient-

centered policies and models of care. International Journal of Qualitative Studies

on Health and Well-Being, 9(22839), 1-10.

http://dx.doi.org/10.3402/qhw.v9.22839

Delphin-Rittman, M. E., Andres-Hyman, R., Flanagan, E. H., Ortiz, J., Amer, M. M., &

Davidson, L. (2015). Racial-ethnic differences in access, diagnosis, and outcomes

in public-sector inpatient mental health treatment. Psychological Services, 12(2),

158-166. http://dx.doi.org/10.1037/a008858

Denzein, N. K., & Lincoln, Y. S. (2012). The SAGE handbook of qualitative inquiry (4th.

ed.). Thousand Oaks, CA: SAGE Publication, Inc.

Derr, A. S. (2017). Mental health service use among immigrants in the United States: a

systematic review. Psychiatry Services, 67(3), 265-274.

https://doi.org/10.1176/appi.ps.201500004.

doi.10.15640/jedd. v2n4a2

Douglas, M., & Wildavsky, A. (1983). Risk and culture: an essay on the selection of

technological and environmental dangers. Berkeley, CA: University of California

Press.Ed.). Boston, MA: Allyn & Bacon.

Essink-Bot, M., Lamkaddem, M., Jellema, P., Nielsen, S. S., & Stronks, K. (2012).

Interpreting ethnic inequalities in healthcare consumption: A conceptual for

162

research. The Journal of Public Health Advance Access, 1-5.

doi.10.1093/eurpub/cs170

Finlay, L. (2009). Debating phenomenological research methods: Phenomenology &

practice, 1(2), 6-25.

Flahaux, M., & Haas, H. D. (2016). African migration: trends, patterns, drivers.

Comparative Migration Studies, 4(1), 1-16. https://doi.org/10.1186/s40878-015-

0015-6

Fleischmann, F., & Verkuyten, M. (2015). Dual identity among immigrants: Comparing

different conceptualizations, their measurements, and implications. Cultural

Diversity and Ethnic Minority Psychology, 1(2), 1-15. doi.10.1037/cdp000058

Ford, C. L., & Harawa, N. T. (2010). A new conceptualization of ethnicity for social

epidemiologic and health equity research. Social Science and Medicine, XXX (2),

1-8. doi.10.1016/j costumed.2010.04.008

Fox, M., Thayer, Z. M., & Wadhwa, P. D. (2017). Acculturation and health: the

moderating role. American Anthropologist, 119(3), 405-421.

https://doi.org/10.1111/AMAN.12867

Fox, M., Thayer, Z., & Wadhwa, P. (2017). Assessment of acculturation in minority

health research. Social Science Medicine, 176(2), 123-132.

https://doi.org/10.1016/j.socscimed.2017.01.029

Fox, M., Thayer, Z., & Wadhwa, P. D. (2017). Acculturation and health: the moderating

role of socio-cultural context. American Anthropology, 119(3), 405-421.

https://doi.org/10.1111/aman.1867.12867

163

Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the

framework method for the analysis of qualitative data in multidisciplinary health

research. BMC Medical Research Methodology, 13(117), 1-8. Retrieved from

http://wwww.biomedcentral.com/1471-2288/13/117

Gentles, S. J., Charles, C., Ploeg, J., & McKibbon, K. (2015). Sampling in qualitative

research: Insights from an overview of the methods literature. The Quarterly

Report, 20(11), 1772-1789. Retrieved from

http://nsuworks.nova.edu/tqr/vol20/iss11/5

Ghafoori, B., Fisher, D. G., Koresteleva, O., & Hong, M. (2014). Factors associated with

mental health service use in urban, impoverished, trauma-exposed adults.

Psychological Services, 11(4), 451-459. dx.doi.10.1037/a0036954

Ghasfoori, B., Fisher, D. G., Koresteleva, O., & Hong, M. (2014). Factors associated with

mental health service use in urban impoverished, trauma-exposed adults.

Psychological Services Journal, 11(4), 451-459. doi.10.103/a00936954

Giacco, D., Matanov, A., & Priebe, S. (2014). Providing mental health care to

immigrants: Current challenges and new strategies. Current Opinion Psychiatry,

27(2), 1-7. doi: 10.1097/YCO.0000000000000085

Glied, S., & Frank, R. (2016). Economics and the transformation of the mental health

system. Journal of Health Politics, Policy, and Law, 41(4), 541-551.

https://doi.org/10.1215/03616878.3620809

Goodkind, J. R., Hess, J. M., Isakson, B., LaNoue, M., Roche, R., Githinji, A., Parker, D.

P. (2013). Reducing refugee mental health disparities: A community-based

164

intervention to address post migration stressors among African adults.

Psychological Services, 13(2), 1541-1559. http://dx.doi.org/10.1037/a0035081

Gordon, M. (1964). The nature of assimilation. In M. Gordon (Ed.), Assimilation in

American life (pp. 60-83). New York, NY: Oxford University Press.

Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An

experiment with data saturation and variability. Field Methods, 18(1), 59-82.

Retrieved from doi.10.1177/1525822X05279903

Gunawan, J. (2015). Ensuring trustworthiness in qualitative research. Belitung Nursing

Journal, 1(1), 10-11.

Gureje, O., & Stein, D. J. (2012). Classification of mental disorders: The importance of

inclusive decision-making. International Review of Psychiatry, 24(6), 606-612.

doi: 10.3109/09540261.2012.726214

Hacker, K., Anies, M., & Zallman, L. (2015). Barriers to health care for undocumented

immigrants: A literature review. Risk Management and Healthcare Policy, 8(2),

175-183.

Halim, M. L., Yoshikawa, H., & Amodio, D. M. (2013). Cross-generational effects of

discrimination among immigrant mothers: Perceived discrimination predicts a

child’s healthcare visits for illness. Health Psychology, 32(2), 201-211.

10.1037/a0027279

Hammed Hilal, A., & Alabri, S. S. (2013). Using Nvivo for data analysis in qualitative

research. International Interdisciplinary Journal of Education, 2(2), 1-6.

165

Hanlon, C., Wondimagegn, D., & Allem, A. (2010). Lessons learned in developing

community mental health care in Africa. World Psychiatry, 9(2), 185-189.

Harper, M., & Cole, P. (2012). Member checking: Can benefits be gained like group

therapy? The Qualitative Report, 17(T&L. Art. 2), 1-8. Retrieved from Retrieved

from http://www.nova.edu/ssss/QR/QR17/harper.pdf

Hays, K. (2015). Black churches capacity to respond to the mental health needs of

African Americans. Social Work and Christianity, 42(3), 296-312.

Hazzan, O., & Nutov, L. (2014). Teaching and qualitative learning research: Conducting

qualitative research. The Qualitative Report, 19(1), 1-29. Retrieved from

http://www.nova.edu/ssss/QR19/hazzan.pdf

Hirschman, C. (2015). Immigration to the United States: recent trends and prospects.

Malays Journal Economic Studies, 51(1), 69-85.

Holden, K. B., McGregor, B. S., Blanks, S. H., & Mahaffey, C. (2013). Psychosocial,

socio-cultural, and environmental influences on mental health help-seeking

among African American men. Journal of Men’s Health, 9(2), 63-69.

http://dx.doi.org/10.1016/j-jomh.2012.03.002

Holden, K., McGregor, B., Thandi, P., Fresh, E., Sheats, K., Belton, A., Satcher, D.

(2014). Toward culturally centered integrative care for addressing mental health

disparities among ethnic minorities. Psychological Services, 11(4), 357-368.

Retrieved from doi.10.1037/a0038122

Hwang, W., Myers, H. F., Abe-Kim, J., & Ting, J. Y. (2008). A conceptual paradigm for

understanding culture’s impact on manta; health: The cultural influences on

166

mental health (CIMH) model. Clinical Psychology Review, 28(2), 211-227.

doi: 10.1016/j.cpre.2007.05.001

Hwang, W., Myers, H. F., Abe-Kim, J., & Ting, J. Y. (2008). A conceptual paradigm for

understanding culture’s impact on mental; health: The cultural influences on

mental health (CIMH) model. Clinical Psychology Review, 28(2), 211-227.

doi.10.1016/j.cpre.2007.05.001.

Immigration Policy Center. (2012). African immigration in America: A demographic

overview. Retrieved from www.immigrationpolicy.org

Jacob, S. A., & Furgerson, S. P. (2012). Writing interview protocols and conducting

interviews: Tips for students new to the field of qualitative research. The

Qualitative Report, 17(T&L Art 6), 1-10. Retrieved from

http://www.nova.edu/ssss/QR/QR17jacob.pdf

Jesus, M. D., & Tara, T. R. (2014). Perspectives on quality mental health care from

Brazilian and Cape Verdean outpatient: Implications for effective patient-centered

policies and models of care. International Journal of Qualitative Studies in Health

and Well-Being, 9(22899), 1-10.

Jimenez, D. E., Bartels, S. J., Cardenas, V., & Alegria, M. (2013). Stigmatizing attitudes

toward mental illness among racial/ethnic older adults in primary care.

International Journal of Geriatric Psychiatry, 28(2), 1061-1068.

Kabir, M., Iliyasu, Z., Abubakar, I. S., & Aliyu, M. H. (2004). Perception and beliefs

about mental illness among adults in Karfi village, northern Nigeria. BMC

International Health and Human Rights, 4(3), 1-5. doi: 10.1186/1472-698X-4-3

167

Kabuiku, J. (2017). Immigrating to Northeast America: The Kenyan immigrants’

experience. Journal of Social, Behavioral, and Health Sciences, 11(2), 96-114.

https://doi.org/10.5590/JSBHS.2017.11.1.07

Kapungwe, A., Cooper, S., Mwanza, J., Mwape, L., Sikwese, A., Kakuma, R., Flisher, A.

J. (2010). Mental illness – stigma and discrimination in Zambia. African Journal

of Psychiatry, 13(2), 192-203.

Kelly, M. (2010). The role of theory in qualitative health research. Family Practice,

27(2), 285-290. http://dx.doi.org/10. 1093/fampra/cmp077

Kinyua-Gathetu, B. W. (2013). The challenges of “belonging”: Personal experience and

perception of counseling among African women immigrants in the United States

of America. Journal of Global Gender Studies, 1(2), 1-61.

Kinzie, J. D. (2006). Immigrants and refugees: The psychiatric perspectives.

Transconsuylt Psychiatry, 43(2), 557-586. doi: 10.1177/136348150607082

Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., … Pottie,

K. (2011). Common mental health problems in immigrants and refugees: a

general approach in primary care. CMAJ: Canadian Medical Association Journal,

183(12), E959-E967. https://doi.org/10.1503/cmaj.090292

Kirmayer, L. J., Narasiah, L., Munoz, M., Rousseau, M., Ryder, A. G., Guzder, J., Pattie,

K. (2011). Common mental health problems in immigrants and refugees: General

approach in primary care. Canadian Medical Association Journal, 183(12), 959-

972. doi.10.1503cmaj0909292

168

Kivisto, P. (2015). Incorporating diversity: Rethinking assimilation in a multicultural age.

In P. Kivisto (Ed.), Incorporating diversity: Rethinking assimilation in a

multicultural age. New York, NY: Routledge.

Knox, S., & Burkard, A. (2009). Qualitative research interviews. Psychotherapy

Research, 19(4-5), 1-22.

Knudtzon, K. (2013). Social and cultural theories. Retrieved from

https://www.cs.umd.edu/class/fall2202cms838s/tichi/social.html

Koelsch, L. E. (2013).

Reconceptualizing the member check interview — International Journal of Qualitative

Methods, 12(2), 168-179.

Kohn-Wood, L. P., & Hooper, L. M. (2014). Cultural competency, culturally tailored

care, and the primary care setting: Possible solutions to reduce racial/ethnic

disparities in mental health care. Journal of Mental Health Counseling, 36(2),

173-188.

Kouyoumkdjian, H., Zamboanga, B. L., & Hansen, D. J. (2003). Barriers to community

mental health services for Latinos: Treatment considerations. Clinical

psychology: Science and Practice, 10(4), 394-422.

Laher, S. (2014). An overview if illness conceptualizations in African, Hindu, and

Islamic traditions: Towards cultural competence. South African Journal of

Psychology, 44(2), 191-204.doi.10.1177/008124631428149

169

Latzer, Y. (2003). Traditional versus Western perceptions of mental illness: Women of

Moroccan origin treated in an Israeli mental health center. Journal of Social Work

Practice, 17(1), 77-94. doi.10.1080/0265053200071501

Leighton, A. H., & Hughes, J. M. (2005). Cultures as causative of mental disorder. The

Milbank Quarterly, 83(4), 1-22.

Leong, F. T., & Kalibatseva, Z. (2011). Cross-cultural barriers to mental health services

in the United States. Cerebrum, 1-13. Retrieved from

http://dana.org/news/cerebrum/detail.aspx.id=31364

Lindinger-Sternart, S. (2015). Help-seeking behaviors of men for mental health and the

impact of diverse cultural backgrounds. International Journal of Social Science

Studies, 3(1), 1-6. doi.10.11114/ijsss.vi.519

Link, B. G., Wells, J., Phelan, J. C., & Yang, L. (2015). Understanding the importance of

“symbolic interaction stigma:” how an expectation about the reactions of others

adds to the burden of mental illness stigma. Psychiatric Rehabilitation Journal,

38(2), 117-124. https://doi.org/10.1037prj0000142.

Loh, J. (2013). Inquiry into issues of trustworthiness and qualitative in historical studies:

A perspective. The Qualitative Report, 18(65), 1-15. Retrieved from

http://www.nova.edu/ssss/QR/QR18/loh65.pdf

Lu, Y., & Gatua, M. W. (2014). Methodological considerations for qualitative research

with immigrant populations: Lessons from two studies. The Qualitative Report,

19(2), 1-16.

170

Mak, W. W., Chong, E. S., & Wong, C. C. (2014). Beyond attributions: The

Understanding public stigma of mental illness with the commonsense model.

American Journal of Orthopsychiatry, 84(2), 173-181.doi.10.1037/6009373

Mantovani, N., Pizzolati, M., & Edge, D. (2016). Exploring the relationship between

stigma and help-seeking for mental illness in African-descended faith

communities in the UK. Health Expectations, 20(2), 373-384.

https://doi.org/10.1111/hex.12464

Marsella, A. J. (2010). Ethnocultural aspects of PTSD: An overview of concepts. Issues

and treatments. Traumatology, 16(4), 17-26. doi: 10.1177/1534765610388062

Marshall, C., & Rossman, G. B. (Eds.). (2015). Designing qualitative research (6th. ed.).

Thousand Oaks, CA: SAGE Publication, Inc.

Matthews, A. K., Corrigan, P. W., Smith, B. M., & Aranda, F. (2006). A qualitative

exploration of African Americans attitudes toward mental illness and mental

illness treatment seeking. Rehabilitation Education, 20(4), 253-268.

McCabe, K. (2011). African immigrants in the United States. Retrieved from https://.

migrationpolicy.org

McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic

disparities in mental health: Policy implications. Health Affairs, 27(2), 1-9.

doi.10.1377/hithaff.27.2.393

McLeod, S. (2008). Person-centered therapy. Simply Psychology. Retrieved from

http://www.simplypsychology.org/client-centered-therrapy.html.

171

Meffert, S. M., Musalo, K., McNiel, D. E., & Binder, R. L. (2010). The role of mental

health professionals in political asylum processing. Journal American Academy

Psychiatry Law, 38(2), 479-489.

Merriam, S. B. (2009). Qualitative research: Guide to design and implementation. San

Francisco, CA: Jossey-Bass.

Milstein, G., Guarnaccia, P., & Midlarsky, E. (1995). Ethnic differences in the

interpretation of mental illness: Perspectives of caregivers. Research in

Community and Mental Health, 8(2), 155-178.

Mlango, 1. D., Atashili, J., Gaynes, B. N., & Njim, T. (2018). Knowledge, attitudes and

practices regarding depression among primary health care providers in Fako

division, Cameroon. BMC Psychiatry, 18(66), 1-9.

https://doi.org/10.1186/s12888-018-1653-7

Monteiro, N. M. (2017). Addressing mental illness in Africa: global health challenges

and local opportunities. Community Psychology in Global Perspective, 1(2), 78-

95.

Monteiro, N. M., Ndiaye, Y., Blanas, D., & Ba, I. (2014). Policy perspectives and

attitudes towards mental health treatment in rural Senegal. International Journal

of Mental Health Systems, 8(9), 1-9. Retrieved from

http://www.ijmhs.com/contents/8/1/9

Mori, L., Panova, A., & Keo, Z. S. (2007). Perceptions of mental illness and

psychotherapy in a sample of Asian, Hispanic, and White college students.

Journal of Psychiatry, Psychology, and Mental Health, 1(2), 1-13.

172

Moustakas, C. (2014). Phenomenological Research Methods. Thousand Oaks, CA:

SAGE Publishing, Inc.

Mukolo, A., Heflinger, C. A., & Wallston, K. A. (2010). The stigma of childhood mental

disorders: A conceptual framework. Journal of American Child Adolescence

Psychiatry, 49(2), 92-198.

Myers, H. F., Wyatt, G. E., Ullman, J. B., Loeb, T. B., Chin, D., Prause, N., … Liu, H.

(2015). Cumulative burden of lifetime adversities: Trauma and mental health in

low-SES African Americans and Latino/as. Psychological Trauma: Theory,

Research, Practice, and Policy, 7(3), 243-251. http://dx.doi.org/10.

1037/a0039077

Myers, L. J., & Speight, S. L. (2010). Reframing mental health and psychological well-

being among persons of African descent: African/Black psychology meeting the

challenges of fractured social and cultural realities. The Journal of Pan African

Studies, 3(8), 66-82.

Myers, L. J., & Speight, S. L. (2010). Reframing mental health and psychological well-

being among persons of African descent: Africana/Black psychological meeting

the challenges of fractured social and cultural realities. The Journal of Pan

African Studies, 3(8), 66-82.

Nakamura, N., Tummala-Nara, P., & Za’rate, M. A. (2013). Expanding our borders:

Cultural diversity and ethnic minority psychology’s special issue on immigration.

Cultural Diversity and Ethnic Minority Psychology, 19(3), 233-235.

http://dx.doi.org/10: 10.1037/a0032959

173

Nazneen, U. A., & Mayadas, N. S. (2005). Assessment of issues facing immigrant and

refugee families. Child Welfare of League of America, 84(5), 563-583.

https://doi.org/0009-4021/2005/050563-21

Ndika, N. (2013). Acculturation: a pilot study on Nigerians in America and their coping

strategies. SAGE Open, 1-8. https://doi.org/10.1177/2158244013515687

Ngo, B. (2008). Beyond “culture clash” understandings of immigrant experiences. Theory

into Practice, 47(2), 4-11. doi: 10.1080/0040584070176456

Nguyen-Fen, V. N., Beydoun, H. A., McShane, M. K., & Blando, J. D. (2015).

Disparities in hospital services utilization among patients with mental health

issues: A statewide example examine insurance status and race factors from 1999-

2010. Journal of Health Disparities Research and Practice, 8(2), 88-101.

Retrieved from http://digitalscholarship.unlv.edu/jhdrp/

Nicolas, G., DeSilva, A. M., Grey, K. S., & Gonzalez-Eastep, D. (2006). Using a

multicultural lens to understand illness among Haitians living in America.

Professional Psychology; Research and Practice, 37(6), 702-707. doi:

10.1037/0735-7028-37.6.702

Nicolas, G., Desilva, A. M., Subrebost, K. L., Breland-Noble, A., Gonzalez-Eastep, D.,

Manning, N., Prater, K. (2007). Expression and treatment of depression among

Haitian immigrant woman in the United States: Clinical observations. American

Journal of Psychotherapy, 61(1), 83-98.

Njenga, F. (2007). The concept of mental disorder: An African perspective. World

Psychiatry, 6(3), 1666-167.

174

Number, S., & Stein, C. H. (2013). Consumer perspectives and mental health reform

movements in the United States: 30 years of first-person accounts. Psychiatric

Rehabilitation Journal, 36(3), 187-194. doi.10.1037/prj0000003

Nwoye, A. (2015). African psychology and the Afro-centric paradigm to clinical

diagnosis and treatment. South African Journal of Psychology, 45(3), 305-317.

https://doi.org/10.1177/0081246315570960

Nyang, S. S. (2011). African immigrant family in the United States of America:

challenges and opportunities. Retrieved August 20, 2017, from

www2.howard.edu

Ofori-Atta, A., Cooper, S., Akpalu, B., Osei, A., Doku, V., Lund, C., & Flisher, A.

(2010). Common understandings of women’s illness in Ghana: Results from a

qualitative study. Journal of Review Psychiatry, 22(6), 589-598. doi: 10.

3109/09540261.2010.536150

Okonofua, B. A. (2013). “I am blacker than you”: Theorizing conflict between African

immigrants and African Americans in the United States. SAGE Open, 1-14.

doi.10.1177/2158244013499162

Oluwatoyosi, A., Kimbrough, J., Obafemi, B., & Strack, R. W. (2014). Health literacy

from the perspective of African immigrant youth and elderly: A photovoice

project. Health Care for the Poor and Underserved, 25(4), 1730-1747.

doi:10.1353/hpu.2014.0183

175

Omonzejele, F. P. (2004). Mental health care in African traditional medicine and society:

A rational appraisal. Eubios Journal of Asian and International Bioethics, 14(2),

165-169.

Onwuegbuzie, A. J., Leech, N. L., & Collins, K. M. (2012). Qualitative analysis

techniques for the review of the literature. The Qualitative Report, 56(2), 1-28.

Retrieved from http://www.nova.edu/ssss/QR/QR17onwuegbuzie.pdf

Padayachee, P., & Laher, S. (2014). South African Hindu psychologists’ perception of

mental illness. J. Relig Health, 53(2), 424-437. doi: 10.1007/s10943-012-9646-1

Padilla-Diaz, M. (2015). Phenomenology in qualitative educational research: Philosophy

as science or philosophical science. International Journal of Educational

Excellence, 1(2), 101-110.

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K.

(2015). Purposeful sampling for qualitative data collection and analysis in mixed

method implementation research. Admin Policy Ment Health, 42(5), 533-544.

http://dx.doi.org/10.1007/s10488-013-0528-y

Pandey, S., & Kagotho, N. (2010). Health insurance disparities among immigrants’: Are

some legal immigrants more vulnerable than others? Health and Social Work,

35(4), 267-279.

Pannucci, C. J., & Wilkins, E. G. (2010). Identifying and avoiding bias in research. Plast

Reconstruct Surg, 126(2), 619-625. http://dx.doi.org/doi.

10.1097/PRS/0b013e3181de24bc

176

Parcesepe, A. M., & Cabassa, L. J. (2013). The public stigma of mental illness in the

United States: A systematic literature review. Administration Policy Mental

Health, 40(5), 1-21. doi.10.1007/s10488-012-0430-z

Park, S. M. (2012). The impact of methodological choices when using qualitative and

ethnographic approaches for conducting ethnic community-based research.

International Journal of Innovative Interdisciplinary Research, 3(2), 18-28.

Pasqual, J. C., Malagon, A., Corcoles, D., Gines, J. M., Soler, J., Garcia-Ribera, C., &

Perez, V. (2008). Immigrants and borderline personality disorder at a psychiatric

emergency service. The British Journal of Psychiatry, 193(2), 471-476.

doi.10.1192/bjp.bp.107.038208

Patton, M. Q. (2015). Qualitative research and evaluation methods (4th ed. ed.).

Thousand Oaks, CA: SAGE Publications, Inc.

Pautasso, M. (2013). Ten simple rules for writing a literature review. PLOS

Computational Biology, 9(7), 1-4. doi10.1371/journal.pcbi.1003149

Perkins, K., Wiley, S., & Deaux, K. (2014). Through which looking glass? Distinct

sources of public regard and self-esteem among first and second-generation

immigrants of color. Cultural Diversity and Ethnic Minority Psychology, 20(2),

213-219 doi: 10.1037/a0035435

Pietkiewicz, I., & Smith, J. A. (2014). A practical guide to using interpretative

phenomenological analysis in qualitative research psychology. Czosopismo

Psychologiczne Psychological Journal, 20(1), 7-14.

https://doi.org/10.14691/cpPPJ.20.1.7

177

Quinn, D. M., Williams, M. K., & Weisx, B. M. (2015). From discrimination to

internalized mental illness stigma: the mediating roles of anticipated

discrimination and anticipated stigma. Psychiatric Rehabilitation Journal, 38(2),

103-108. https://doi.org/10.1037/prj0000136

Quinn, D. M., Williams, M. K., & Weisz, B. M. (2015). From discrimination to

internalized mental illness stigma: the mediating roles of anticipated

discrimination and anticipated stigma. Psychiatric Rehabilitation Journal, 1(2), 1-

6. doi; 10:1037/prj0000136

Read, U. M., Adiibokah, E., & Nyame, S. (2009). Local suffering and the global

discourse of mental health and human rights: An ethnographic study of responses

to mental illness in rural Ghana. Globalization and Health, 5(13), 1-16. doi:

10.1186/1744-8603-5-13

Reid, S., & Mash, B. (2014). African primary care research: Qualitative interviewing in

primary care. African Journal of Primary Health Care Family Medicine, 6(1),

Article Number 632, 1-6. doi: 10.4102/pchfm. v6i1.632

Reinert, H., Russell-Mayhew, S., & Arthur, N. (2013). Recruiting ethnically diverse

participants into qualitative health research: Lessons learned. The Qualitative

Report, 18(2), 1-13. Retrieved from http://www.nova.edu/ssss/QR18/renert23.pdf

Renner, W., & Salem, I. (2014). Human values, health concepts, and treatment

approaches are culture-dependent: Why western [psychology does not suffice.

European Scientific Journal, Special Edition (2), 186-195.

178

Richardson, J., Morgenstern, H., Crider, R., & Gonzalez, O. (2013). The influence of

state mental health perceptions and spending on an individual’s use of mental

health services. Social Psychiatry Epidemiology, 48(2), 673-683. doi:

10.1007/a00127-012-0520-y

Rogers-Sirin, L., Melendez, F., Refano, C., & Zegarra, Y. (2015). Immigrant perceptions

of therapists’ cultural competence: A qualitative investigation. Professional

Psychology Research and Practice, 46(4), 258-269. doi: 10.1037/pro000033

Rogers-Sirin, L., Rayce, P., & Siren, S. R. (2014). Acculturation, acculturation stress, and

cultural mismatch and their influences on immigrant children and adolescents’

well-being. Global Perspectives on Well-Being in Immigrant Families, Advances

in Immigrant Family Research, XVII (2), 11-29. http://dx.doi.org/10.10007/978-1-

4614-9129-3_2

Ross-Sheriff, F., & Moss-Knight, T. (2013). African Americana: Immigrants of African

origin. Encyclopedia of Social Work, 1-9. doi:10.1093/9780199975839.013.507

Ruane, I. (2010). Obstacles to the utilization of psychological resources in South African

township community. South African Journal of Psychology, 40(2), 214-225.

Sam, D. L., & Moreira, V. (2012). Revisiting mutual embeddedness of culture and mental

illness. Online Readings in Psychology and Culture, 10(2), 1-18.

doi:10.9707/2307-0919.1078

Sarris, J., Hoenders, R., Duffy, J., & Lake, J. (2013). Integrative mental healthcare White

Paper: Establishing a new paradigm through research, education, and clinical

179

guidelines. Advances in Integrative Medicine, 33(2), 1-8. doi: 10.1016/j.aimed.

2012.x12.002

Scheid, T. L., & Brown, T. N. (Eds.). (2012). Mental health systems and policy. A

handbook for the study of mental health: social contexts, theories, and systems

(pp. 409-588). https://doi.org/10.1017/CBO978051198495.025

Scheppers, E., Van Dongen, E., Dekker, J., Geertzen, J., & Dekker, J. (2006). Potential

barriers to the use of health services among ethnic minorities: a review. Family

Practice Advance Access, 325-348. https://doi.org/10.1093/fampra/cmi113

Schock-Giordano, A. M. (2013). Ethnic families and mental health: Application of the

ABC-X model of family stress. Sage Open, 3(2), 1-7. doi:

10.1177/2158244013478015

Segal, U. A., & Mayadas, N. S. (2005). Assessment of issues facing immigrant and

refugee families. Child Welfare League of America, 85(5), 563-583.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research

projects. Education for Information, 22(2), 63-75.

Shiraev, E. B., & Levy, D. A. (2010). Cross-cultural psychology: Critical thinking and

contemporary applications (ed.). Boston, MA: Allyn & Bacon.

Shishehgar, S., Gholizadeh, L., DiGiacomo, M., & Davidson, P. M. (2015). The impact

of migration on the health status of Iranians: An integrative literature review.

BMC International Health & Human Rights, 15(20), 1-11.

http://dx.doi.org/10.1186/s12914-015-0058-07

180

Singer, R. R., & Tummala-Narra, P. (2013). White clinicians’ perspectives on working

with racial minority immigrant clients. Professional Psychology Research and

Practice, 44(5), 290-298. DOI: 10.1037/a0034299

Singh, G. K., Rodriguez-Lainz, A., & Kogan, M. D. (2013). Immigrant health

inequalities in the United States: Use of eight major national data systems. The

Scientific World Journal, 512313(2), 1-21. doi: 10.1155/2013/512313

Smedley, A., & Smedley, B. (2005). Race as biology is fiction; racism as a social

problem is real. American Psychologist, 60(1), 16-26.

http://dx.doi.org/10.1037/0003-066X.60.1.16

Smith, J. A. (2011). Evaluating the contribution of interpretative phenomenological

analysis: Theory, method, and research. Los Angeles, CA: SAGE Publishing, Inc.

Smith, J. A., Flowers, P., & Larkin, M. (2013). Interpretative phenomenological

analysis: Theory, method, and research. Los Angeles, CA: SAGE.

Smith, J. A., Flowers, P., & Larikin, M. (2009). Interpretative phenomeno9logical

analysis. Thousand Oaks, CA: Sage Publishing, Inc.

Smith, J., & Noble, N. (2014). Bias in research. Evidence-Based Nursing, 17(4), 1-6.

Retrieved from Retrieved from http;//prints.bhud.ac.uk/22163/

Solomon, S. (2017). African immigrant population on rises US. Retrieved, from

https//www.voanews.com/a/african-immigrant-population -on-the-rise-in-

us/3728715.html

Sorsdahl, K., Stein, D. J., & Flisher, A. J. (2013). Predicting referral practices of

traditional healers of their patients with mental illness: An application of the

181

Theory of Planned Behavior. African Journal of Psychiatry, 10(2), 35-40.

doi:10.4314/apsy. v16i1.6

Sorshahl, K. R., Flisher, A. J., Wilson, Z., & Stein, D. J. (2010). An explanatory model of

mental disorders and treatment practices among traditional healers in

Mpumulanga, South Africa. African Journal of Psychiatry, 13(4), 284-290.

St. Louis, K. O., & Roberts, P. M. (2013). Public attitude towards mental illness in Africa

and North America. African Journal of Psychiatry, 16(2), 123-133.

doi:10.14314/ajps162.16

Stangor, C. (2007). Research methods for the behavioral sciences (3rd. ed.). New York:

Houghton Mifflin Company, Inc.

Suphanchaimat, R., Kantamturapoj, K., Putthasri, W., & Prakongsai, P. (2015).

Challenges in the provision of healthcare services for migrants: A systematic

review through providers’ lens. BMC Health Services Research, 15(390), 1-14.

doi: 10.186/s12913-015-1065-z

Suri, H. (2011). Purposeful sampling in qualitative research synthesis. Qualitative

Research Journal, 11(2), 63-75. doi: 10.3316/QRJ1102063

Swanson, R. A. (2013). Theory building in applied disciplines (1st ed.). San Francisco,

CA: Berrett-Koehler Publishers’.

Tansey, J., & Rayner, S. (Eds.). (2008). Cultural theory and risk. Handbook of risk and

crisis communications (166). London, England: Routledge.

Tavallaei, M., & Abutalib, M. (2010). A general perspective on the role of theory in

qualitative research. Journal of International Social Research, 3(11), 570-577.

182

Teferra, S., & Shibre, T. (2012). Perceived causes of severe mental disturbance and

preferred interventions by the Borana semi-nomadic population in southern

Ethiopia: A qualitative study. BMC Psychiatry, 12(79), 1-9. doi: 10.1186/1471-

244X-12-79

Teklemariam, A. A. (2005). Understanding Abyssinian immigrants in the U.S.: Socio-

cultural background and contemporary experiences. The Western Journal of Black

Studies, 29(2), 571-579.

Thomas, K. J. (2011). What explains the increasing trend of African emigration to the

U.S.? International Migration Review, 45(1), 3-28

Thornicroft, G., Rose, D., & Kassam, A. (2007). Discrimination in health care against

people with mental illness. International Review of Psychiatry, 19(2), 113-122.

doi.10.1080/09540260701278937

Tibebe, A., & Tesfay, K. (2015). Public knowledge and beliefs about mental disorder in

developing countries: A review. Journal of Depression and Anxiety, S3 (2), 1-4.

https://doi.org/10.4172/2167-1044.S3-004

Truong, M., Paradies, Y., & Priest, N. (2014). Interventions to improve cultural

competency in healthcare: A systematic review of reviews. BMC Health Services

Research, 14(99), 1-17. Retrieved from http://www.biomedcentral .com/1472-

6963/14/99

Turner, III, D. W. (2010). Qualitative interview design: A practical guide for novice

investigators. The Qualitative Report, 15(3), 754-760. Retrieved from

http://www.nova.edu/ssss/QR/QR15-3/qid.pdf

183

Valentine, A., DeAngelo, D., Alegria, M., & Cook, B. L. (2014). Translating disparities

research to policy: A qualitative study of state mental health policymakers’

perceptions of mental health disparities report cards. Psychological Services,

11(4), 377-387. http://dx.doi.org/10.1037/a0037978

Vaughn, L. M., Jacquez, F., & Baker, R. C. (2009). Cultural health attributions, beliefs,

and practices: Effects of healthcare and medical education. The Open Medical

Education Journal, 2(2), 64-74.

Venters, H., Adekugbe, O., Massaquoi, J., Nadeau, C., Saul, J., & Gany, F. (2011).

Mental health concerns among African immigrants. Journal of Immigrants

Minority Health, 13(4), 795-797. http://dx.doi.org/10.1007/s10903-101-9357-1

Venters, H., & Gary, F. (2009). African immigrant help. Journal of Immigrant Minority

Health, I (2), 1-12. https://doi.org/10.10007/S10903-009-9243-X

Ventevogel, P., Jordans, M., Eris, R., & Jong, J. D. (2013). Madness or sadness? Local

concepts of mental illness in four conflict-affected African communities. Conflict

and Health, 7(3), 1-16.

Versola-Russo, J. M. (2006). Cultural and demographic factors of schizophrenia.

International Journal of Psychosocial Rehabilitation, 10(2), 89-103.

Villatoro, A. P., Morales, E. S., & Mays, V. M. (2014). Family culture in mental health

help-seeking and utilization in a nationally representative sample of Latinos in the

United States: the NLAAS. American Journal Orthopsychiatry, 84(4), 353-363.

https://doi.org/10.1037/H0099844

184

Viruell-Fuentes, E. A., Miranda, P. Y., & Abdularahim, S. (2012). More than culture:

Structural racism, intersectionality theory, and immigrant health. Social Science &

Medicine, 75(2), 2099-2106. doi: 10.1016/j.socscimed.2011.12.037

Vogel, D. L., Wester, S. R., & Larson, L. (2007). Avoidance of counseling:

Psychological factors that inhibit seeking help. Journal of Counseling and

Development, 85(2), 410-422.

Ward, E. C., Clark, L. O., & Heidrich, S. (2009). African American women’s beliefs,

coping behaviors, and barriers to seeking mental health services. Qual Health

Res., 19(11), 1589-1601. doi: 10.1177/1049732309350686

Ward, E., Wiltshire, J. C., Detry, M. A., & Brown, R. L. (2013). African American men

and women’s attitude toward mental illness, perceptions of stigma, and preferred

coping skills. Nurs Res, 62(3), 185-194. http://dx.doi.org/

Wasem, R. E. (2014). Immigration policies and issues on health-related grounds for

exclusion. Congressional Research Service, 7(5700), 1-13. Retrieved from

www.crs.gov

Waters, M. C., Tran, V. C., Kasinitz, P., & Mollenkopf, J. H. (2010). Segmented

assimilation revisited: types of acculturation and socioeconomic mobility in

young adulthood. Ethnic Racial Study, 33(7), 1168-1193.

https://doi.org/10.1080/0141987100364076

Watson, N. N., & Hunter, C. D. (2015). Anxiety and depression among African

American women: The costs of strength and negative attitudes toward

185

psychological help-seeking. Cultural Diversity and Ethnic Minority Psychology,

21(4), 604-612. doi: 10. 1037/cdp00000015

Wei, Y., McGrath, P. J., Hayden, J., & Kutcher, S. (2015). Mental health literacy

measures are evaluating knowledge, attitudes, and help-seeking: a scoping review.

BioMed Central Psychiatry, 15(291), 1-20. https://doi.org/10.1186/s12888-015-

0681-9

Whaley, A. L. (2001). Cultural mistrust: An important psychological construct for the

diagnosis and treatment of African Americans. Professional Psychology:

Research and Practice, 32(6), 555-562. doi:10.1037//0735-7028.32.6.555

Whaley, A. L. (2012). Psychiatric and demographic predictors of memory deficits in

African Americans with schizophrenia: The moderating role of cultural mistrust.

Psychiatric Q, 83(2), 113-126. doi: 10.1007/s11126-011.9188-9

Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based practice

in mental health services. American Psychologist, 62(6), 563-574. doi:

10.1037/0003-066X62.6.563

Wheeler, E. A., Brooks, L. J., & Brown, J. C. (2011). “Getting’ on my last nerve”:

Mental health, physiological and cognitive implications of racism for people of

African descent. The Journal of Pan African Studies, 4(5), 81-101.

Williams, D. R., & Williams-Morris, R. (2000). Racism and mental health: the African

American experience. Ethnicity and Health, 5(3/4), 243-268. doi:

10.1080/135578500009356

186

Wong, Y. I., Kong, D., Tu, L., & Frasso, R. (2018). “My bitterness is deeper than the

ocean”: understanding internalized stigma from the perspectives of persons with

schizophrenia and their family caregivers. International Journal of Mental Health

Systems, 12(14), 1-15. https://doi.org/10.1186/s13033-018-0192-4

WonPat-Borja, A. J., Yang, L. H., Link, B. G., & Phelan, J. C. (2012). Eugenics,

genetics, and mental illness stigma in Chinese Americans. Social Psychiatry

Epidemiology Journal, 47(1), 145-156.

Woodgate, R. L., Busolo, D. S., Crokett, M., Dean, R. A., Amaladas, M. R., & Plourde,

P. J. (2017). A qualitative study of African immigrant and refugee families’

experiences of accessing primary health care services in Manitoba, Canada: it’s

not easy! International Journal for Equity in Health, 16(5), 1-14.

https://doi.org/10.1186/s12939-016-0510-x

Xu, M. A., & Storr, G. B. (2012). Learning the concept of the researcher as an instrument

in qualitative research. The Qualitative Report, 17(42), 1-18. Retrieved from

http://www.nova.edu/ssss/QR/QR17/storr.pdf

Yang, L. H., Thornicroft, G., Alvarado, R., Vega, E., & Link, B. G. (2014). Recent

advances in cross-cultural measurement in psychiatric epidemiology: utilizing

’what matters most’ to identify culture-specific aspects of stigma. International

Journal of Epidemiology, 43(2), 495-510. http://dx.doi.org/10. 11093/ije/dyu039

Yinger, J. M. (1981). Toward a theory of assimilation and dissimilation. Ethnic and Rural

Studies, 4(3), 251-264.

187

Yuksel, P., & Yildirm, S. (2015). Theoretical frameworks, methods, and procedures for

conducting phenomenological studies in education settings. Turkish Online

Journal of Qualitative Inquiry, 6(1), 1-20.

188

Appendix A: Invitation to Participate in Research

Greetings,

This research is conducted by a doctoral researcher at Walden University, who is

conducting a dissertation research to explore the recent mental health, mental illness, and

help-seeking experiences of African immigrants to the U.S. Seeking out persons who are

fluent in English, have migrated as an adult from one of the countries in the five main

regions of Africa, and have personally sought help for mental health issues in the U. S.,

or have a friend or family member who sought help. The Walden University’s

Institutional Review Board (IRB) Approval Number for this study is 01-04-19-0170147

and expires on December 17th, 2020.

Interested individuals who meet these criteria are encouraged to participate in a

semi-structured, telephone or face- to- face interview lasting approximately for one hour,

through which they will share their mental health, mental illness, and help-seeking

experiences. All information received from the participants will be recorded and

maintained confidentially. The participants may withdraw from the scheduled interview

at any time if they so desired and will be offered an opportunity to review the interview

transcript summary and the interpretations for accuracy.

The researcher understands that time is essential for everyone and grateful for your

thoughtfulness to participate in the proposed research. Interested persons, and those who

may know individuals, who would like to be a participant in this study, are free to contact

the researcher at their earliest possible time to schedule a date and time for a meeting.

189

The researcher ’s contact telephone number (XXX-XXX-XXXX), and email,

[email protected] are enclosed here for convenience. Thanks for

kind consideration and support; looking forward to having a response at the earliest

possible time.

Respectfully,

Doctoral Researcher,

190

Appendix B: Consent Form

African Immigrants’ Experience of Mental Health, Mental Illness,

and Help-Seeking in the U.S.

Walden University, Minneapolis, MN

You are invited to participate in a dissertation research study about how African

immigrants with mental health issues – personal, family or friends – seek help in the U.

S. You are having been invited to participate because of your understanding and

experience connected to the subject matter of the research. The researcher in the proposed

research is inviting African immigrants aged 21 years old, who migrated to the U.S. as

adults and have lived continuously in the U. S. for a minimum of one year to the date of

the study. This form is a component of the process called informed consent. Please read

this form carefully and ask all the questions you may have to understand the study before

deciding to be or not to be in the study.

Researcher:

The study will be conducted by a doctoral researcher from School of Psychology,

Walden University.

Background Information:

The purpose of this study is to explore the meaning of mental health, mental

illness, and help-seeking experience among African immigrants to the U.S.

191

Procedures:

If you agree to be in this study, you will be:

● Requested to participate in one individual face-to-face interview to talk about the

meaning of mental health, mental illness, and help-seeking experiences.

● This will last from 45 to 60 minutes.

● . After the interview is completed and transcribed, requested to review the

summary of your interview to ensure the researcher has an accurate representation

of your view. This would take about 15 minutes.

Here are some sample questions:

● Tell me more about your help-seeking experience?

● How did you feel about this experience?

● How informed were the mental health clinicians about your culture?

● How informed were the mental health clinicians about your understanding of your

problem?

● How did they explain your problem? Your treatment?

● How much were they able to help?

Voluntary Nature of the Study:

This study is voluntary. Everyone will respect your decision of whether you choose to be

in the study. If you decide to join the study now, you can still change your mind later.

You may stop at any time.

192

Risks and Benefits of Being in the Study:

Being in this type of study involves some risk of minor discomforts that can be

encountered in daily life, such as exhaustion, nervous tension, becoming aggravated and

unpleasant memories. Being in the proposed study will not pose a risk to your safety or

wellbeing. A current list of Los Angeles City Mental and Behavioral Health and

Psychiatric Emergency Care is included in this form for you to contact should you

experience distress during or after the interview.

The research findings will contribute to a better understanding of help-seeking for mental

health issues for African immigrants and can be used to improve access to services. After

the study is completed, you will be sent a summary of the findings.

Payment:

Participation is voluntary. The $5.00 gift card will be provided prior to conducting the

interview to clarify that it is a token of appreciation

Privacy:

Any information you will provide will be kept confidential. The researcher will not use

your personal information for any purposes outside of this proposed research project.

Also, the researcher will not include your name or anything else that could identify you in

the research reports. As a mandated reporter of child abuse and abandonment, the

researcher will comply with the mandated reporter laws as stipulated by the State of

California during the study.

193

Data will be kept secure by password-protected computerized systems and locked

cabinets. Data will be kept for at least five years, as required by the Walden University.

Contacts and Questions:

You may ask any questions you have now. Alternatively, if you have questions later, you

may contact the researcher via my phone number (XXX) XXX-XXXX and email address

[email protected] If want to talk privately concerning your rights

as a participant; you can call the Walden University representative who can discuss this

with you and answer all of your questions. The phone number is (XXX) XXX-XXXX.

Walden University’s approval number for this study is 01-04-19-0170147, and it expires

on December 17
th

, 2020. Please print or save this Consent Form for your records.

Statement of Consent:

I have read the above information, and I feel I understand the proposed research well

enough to decide my involvement. I have asked questions and obtained appropriate

answers. By replying to this email with the words, “I consent,” I understand that I agree

to the terms described above.

194

Appendix C: Interview Guide

Date: —————————————————————————————————-

Location: ———————————————————————————————–

Name of Interviewer: ———————————————————————————

Name of Interviewee: ———————————————————————————

Interview Questions

1. Tell me about a time when you had to interact with the American Mental

Health system?

a. Who was it for? (self, family, friend)

b. Tell me what happened? (Was there an event, a problem……?)

c. How did you know this was a mental health issue?

i. Did you seek help?

ii. How did you find help?

d. What happened after that?

e. How did you handle this experience?

f. What did this experience mean to you? (How did you feel about

yourself as you were going through this?)

g. How did your family and friends respond to what happened?

2. Tell me more about your help-seeking experience?

a. How did you feel about this experience?

I. How informed were the mental health clinicians about your culture?

195

ii. How informed were the mental health clinicians about your

understanding of your problem?

iii. How did they explain your problem? Your treatment?

iv. How much were they able to help?

v. How did their approach meet your understanding of your

problem?

1. If you were in your native country, how would your

problem be described?

2. How would your problem be treated?

b. How did your family and friends feel about your help-seeking?

3. How would this have been if this had happened in your native country?

a. How was this experience different than what you would have experienced

in your native country? What would have been different?

b. How would your family and friends have reacted if this happened in your

native country?

4. How would you describe what mental health means in the U.S.?

a. How this is different than what mental health means in your native

country?

1. In closing, is there anything else you would like to describe that would help me

understand your experience?

196

Appendix D: Mental Health Resources

Los Angeles, CA, U.S.

1. Los County Mental Health Department (LACMHD)

Crisis Counseling

800-854-7771 /7 ACCESS)

800-854-7772

2. Exodus Recovery

Mental Health Urgent Care

323-276-6400

1920 Marengo Street, LA, CA 90023

3. Domestic Violence

Center for the Pacific Asian Family

800-339-3940

1102 Crenshaw Blvd.,

Los Angeles, CA 90019

4. Abuse Hotline – Child Protection Hotline

800-540-40000

1102 Crenshaw Blvd.,

Los Angeles, CA 90019

197

5. Dependent Adult Abuse Hotline

800-992-1660

6. Elder Abuse Hotline:

877-477-3646

7. California Suicide & Crisis Hotlines

Los Angeles County Department of Mental Health: Hotline

(24 Hours/7Days)

Tel: 1-800-854-7771

8. National Suicide Prevention Hotlines

Toll-Free / 24 Hours / Days a Week

1-800-SUICIDE / 1-800-784-2433

1-800-273-TALK / 1-800273-8255

TTY: 1-800-799-4TTY (4889).

198

Appendix E: Transcriptionist Confidentiality Agreement

Name of Signer:

During my action in transcribing data for the Proposed research: “African immigrants’

Perspectives on Mental Illness and Treatment in the United States,” I will have access to

information, which is confidential and should not be make known. I recognize that the

information must remain confidential and that improper disclosure of confidential

information in the proposed research will be damaging to the participants.

By signing this “Confidentiality Agreement,” I acknowledge and agree that:

1. I will not reveal or discuss any confidential information with others, together

with friends or family members.

2. I will not in any way make known, copy, release, sell, loan, change or destroy

any confidential information except as appropriately given permission.

3. I will not communicate confidential information where others may overhear

the discussion. I recognize that it is not tolerable to discuss confidential

information even if the participant’s name is not used.

4. I will not create any unauthorized transmissions, investigations, adjustment or

exclusion of confidential information.

5. I consent that my commitments under this conformity will extend after the

termination of the work that I will implement.

199

6. I recognize that any breach of this agreement will have serious legal

repercussions.

7. I will only entrance or utilize systems or devices which I am officially

permitted to access, and I will not reveal the operation of a function of

systems or devices to not permitted individuals.

Signing this Document, I recognize that I have the agreement and I agree to comply with

the circumstances and provisions confirmed above. I am fully aware that I may be held

lawfully responsible for any violation of this “Confidentiality Agreement,” and for any

harm sustained by the individual participants’ if I reveal identifiable information

contained in the audiotapes and files to which I will have access.

Transcriptionist’s Name (printed) ————————————————————–

Transcriptionist’s Signature ——————————————————————–

Date: _______________________________________________________________

200

Appendix F: NVivo Code Book of Research Data

Codes and Categories

Categories are designated in bold, followed by codes.

Assumptions and Expectations – African immigrants’ perception; immigrant population

groups; mental health; mental health care service utilization rates; mental health

clinicians; mental health clinics; mental health condition; mental health disorders; mental

health issues; mental health needs; mental health professionals; mental health services;

mental health system conception; mental health treatment centers; mental health

problems; and disorders.

Importance of Cultural Understanding – African cultures have many misconceptions

concerning mental illness; African cultures attitude concerning mental illness is negative;

public stigma is the reaction that the general population has to people with mental illness;

it is perceived that concerning causes of stigma a strikingly; my understanding of

stigmatization of individuals with mental illness; structural or established practice

discrimination includes the policies; after more fully assessing intentional and

unintentional forms of structure; African immigrants experience implications of ongoing

discrimination; among African immigrants to the U.S. there is no change in opinion of

discrimination; discrimination and prejudice faced by individuals who have mental

illness; stigma involves negative and demeaning views concerning individuals with

mental illness and their families; the most harmful effects of stigma of mental illness

among African immigrants; the culture of stigma and discrimination fueled by poor

awareness allocated to mental illness; African cultural beliefs and values of collective

201

help give dignity to individuals with mental illness; and there is a widespread believes

linking mental illness to supernatural philosophies.

Experience of Mental Health – Mental health is commonly utilized for mental illness;

mental health is a state of wellbeing in which individual realizes his or her full potentials;

understanding is that some African immigrants are estimated to be among; African

immigrants recognized that American mental health care system; African immigrants

believe that mental health problems and mental illness; African immigrants also have

high expectations concerning mental health system; African immigrants disbelieve that

American mental health system; African immigrants do not recognize indicators of

mental health; mental health is a neglected condition, there is need for organization;

although mental health refers to beliefs and notions of ethnically diverse minority

individuals; my lived experience and understanding of mental health; and there should be

a commitment by African cultures and African immigrants concerning mental health.

Cultural Experience of Mental Illness – African cultures have many misconceptions

concerning mental illness; most of the time you will hear Africans say that individuals

with mental illness are crazy; when individuals have mental illness their family keep

them in the house; their relatives reject some individuals with mental illness because of

the disgrace; mental illness among African immigrants refers to collectively all

diagnosable metal disorders; African cultures and African immigrants do not believe that

mental illnesses are medical conditions; mental illness is one of the leading causes of

mortality and morbidity in African cultures; mental illness in my native African country

made individuals miserable; mental illness symptoms can affect emotions, thoughts, and

202

behaviors; distressing symptoms exacerbated by inability to participate in work; and

mental illness refers to a wide range of mental health conditions.

Meanings of Help-Seeking – There are no community mental health treatment centers;

African immigrants have lower rates of utilization of mental health services; mental

health care treatment services and treatments are available for the ethnically diverse;

generally, mental health care services utilization rates vary by nativity; mood and anxiety

disorders carry a significant human and social burden; African immigrants expect to be

cared for by medical doctors or psychologists; African immigrants feel that when mental

health clinicians do not understand; if a family member exhibits symptoms that Western

medical professional; and my lived experience description that currently describes the

relation.

Dissatisfaction – Discrimination; cultural discrimination; ongoing discrimination;

practice of discrimination; racial discrimination; structural discrimination; stigmatized

health conditions; mental health needs; mental health condition; beliefs; cultural beliefs;

traditional beliefs; and widespread belief.

Subject of Story – Who the participant is referring to in the experience of mental health;

AMHS does not build relationships with immigrant groups; someone I know; there is

assumption of disparity; notion that African immigrants will not be given good treatment

at community mental health clinics; negative remorse and bad news which are made

known through the whole African immigrant’s community; Africans cultural beliefs

about mental; African immigrants believe that depression is their most common type of

mental illness; African immigrants disbelieve that American mental health system in the

203

mental health and the public health arena put more importance; and they feel that little

has been done by American mental health system.

Participant Occupation – Working in hospital legal department; immigrants; mental

illness after childbirth; economic conditions; services; health condition; involving health

conditions, anxiety disorder; bipolar disorder; eating disorders; medical disorders; mental

disorders; and mental health disorders.

204

Appendix G: Recognized Main Five Regions in Africa

1. North Africa: (Made up of Six Countries)

Egypt

Libya

Tunisia

Algeria

Morocco

Western Sahara

2. West Africa: (Made up of Eighteen Countries)

Benin

Burkina Faso

Cameroon

Cape Verde

Chad

Côte d’Ivoire

Gambia

Ghana

Guinea

Guinea-Bissau

205

Liberia

Mali

Mauritania

Niger

Nigeria

Senegal

Sierra Leone

Togo.

3. Central Africa: (Made up of Six Countries)

Central African Republic

Congo

Democratic Republic of Congo

Equatorial Guinea

Gabon

São Tomé and Príncipe

4. East Africa: (Made Up of Fourteen Countries in the Horn)

Eritrea

Ethiopia

206

Somalia

Djibouti

Sudan

Uganda

Kenya

Tanzania

Rwanda

Burundi

Comoros Island

Mauritius Island

Seychelles Island

Madagascar Island

5. Southern Africa: (Made up of Ten Countries)

Angola

Botswana

Lesotho

Malawi

Mozambique

207

Namibia

Southern Africa

Swaziland

Zambia

Zimbabwe

208

Appendix H: United Nations Map of Five Main Regions in Africa

RESEARCH ARTICLE Open Access

Understanding the healthcare experiences
and needs of African immigrants in the
United States: a scoping review
Ogbonnaya I. Omenka1* , Dennis P. Watson2 and Hugh C. Hendrie3

Abstract

Background: Africans immigrants in the United States are the least-studied immigrant group, despite the research
and policy efforts to address health disparities within immigrant communities. Although their healthcare experiences
and needs are unique, they are often included in the “black” category, along with other phenotypically-similar groups.
This process makes utilizing research data to make critical healthcare decisions specifically targeting African immigrants,
difficult. The purpose of this Scoping Review was to examine extant information about African immigrant health in the
U.S., in order to develop lines of inquiry using the identified knowledge-gaps.

Methods: Literature published in the English language between 1980 and 2016 were reviewed in five stages: (1)
identification of the question and (b) relevant studies, (c) screening, (d) data extraction and synthesis, and (e) results.
Databases used included EBSCO, ProQuest, PubMed, and Google Scholar (hand-search). The articles were reviewed
according to title and abstract, and studies deemed relevant were reviewed as full-text articles. Data was extracted
from the selected articles using the inductive approach, which was based on the comprehensive reading and
interpretive analysis of the organically emerging themes. Finally, the results from the selected articles were presented in
a narrative format.

Results: Culture, religion, and spirituality were identified as intertwined key contributors to the healthcare experiences
of African immigrants. In addition, lack of culturally-competent healthcare, distrust, and complexity, of the U.S. health
system, and the exorbitant cost of care, were identified as major healthcare access barriers.

Conclusion: Knowledge about African immigrant health in the U.S. is scarce, with available literature mainly focusing
on databases, which make it difficult to identify African immigrants. To our knowledge, this is the first Scoping Review
pertaining to the healthcare experiences and needs of African immigrants in the U.S.

Keywords: Immigrant health, African immigrant, Scoping review, Health experience, Health and culture, Healthcare
access, health disparities

Background
The health of African immigrants in the United States (U.S.)
is a vastly under-studied topic, despite the rapidly increasing
size of the population and its uniqueness. African immigrants
make up about 5% of the U.S. population, which represents a
41% increase from the year 2000 [1]. More than 36% of them
arrive from West Africa, followed by 29 and 17% from East-
ern and Northern Africa, respectively. Over 14% of African

immigrants in the U.S. come from Nigeria, followed by 10%
from Ethiopia [2]. Factors contributing to the migration of
Africans to the U.S. include family reunification, political dis-
turbances in their country of origin, and education. Other
reasons include the diversity lottery program, and brain drain
[3, 4]. For instance, many African physicians and nurses mi-
grate to the U.S. for higher-paying opportunities, leaving be-
hind dilapidated health systems in their home countries [5,
6]. The healthcare experiences and needs of African immi-
grants are not universal, and research has shown there is
considerable variation in healthcare experiences across popu-
lations [7, 8]. Prior to their arrival in the U.S., many African

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected]
1College of Pharmacy and Health Sciences, Butler University, 4600 Sunset
Avenue, PHSB 404E, Indianapolis, IN 46208, USA
Full list of author information is available at the end of the article

Omenka et al. BMC Public Health (2020) 20:27
https://doi.org/10.1186/s12889-019-8127-9

immigrants face severe health threats such as war, extreme
poverty and mental health challenges, in their countries of
origin [9]. Consequently, many African immigrants already
carry significant health vulnerabilities upon arrival in the
U.S., which can only worsen without proper healthcare ac-
cess [10].
The paucity of knowledge regarding the healthcare ex-

periences and needs of African immigrants in the U.S.
due to two main factors: the absence of research or
funding on immigrant health focused on this population
[11], and the view that all black populations in the U.S.
are the same [12]. The majority of research on immi-
grant healthcare in the U.S. has concentrated on popula-
tions from Latin and some Asian countries. However,
the healthcare needs and experiences of other immigrant
populations cannot be assumed to be identical to those
of African immigrants. Also, African immigrants, which
primarily comprises African Americans and Caribbean
immigrants are often included in the “black” category
[13–17]. This monolithic view of the black population in
the U.S. bears serious health and healthcare implications
for African immigrants, because while an Africa-born
black immigrant and a U.S.-born black citizen may be
phenotypically similar, their health beliefs and health
outcomes may differ [18, 19]. For instance, babies born
to Africa-born black mothers were found to have higher
birth weights than those born to U.S.-born black
mothers [20]. Also, African immigrants have shown
lower prevalence of cardiovascular risk factors, including
hypertension and diabetes, than African Americans [17].
Merging these groups obscures the distinctions that may
exist within them, including the unique cultural back-
grounds and healthcare experiences of African immi-
grant community [15–17, 21, 22].
Previously published studies have sought to gain

insight into African immigrant health in the U.S., with
focus ranging from barriers to healthcare—including
cancer and HIV screenings [9, 10, 13, 23–25]—to dietary
health and health status [11, 26–30]. However, the study
results did not provide insight into the underpinnings of
the healthcare experiences of African immigrants in the
U.S. In addition, there have been a few projects aimed at
understanding African immigrant health in other coun-
tries. Those studies revealed a number of barriers to Af-
rican immigrants’ healthcare access that were similar to
U.S. studies [31–33]. For instance, African immigrants in
other countries, like in the U.S., were found to be often
viewed as a part of a larger homogeneous population
[34–36]. However, unlike in the U.S., in some other
countries, African immigrants are grouped together in
the same immigrant population with Asian and Latin
Americans [37, 38]. While these studies have contrib-
uted to the African immigrant health knowledge-base,
healthcare experiences and needs of Africans in other

countries or continents cannot be assumed to match
with those of U.S. African immigrants. For instance, the
ways health insurances are operated in other countries
may not be obtainable in the U.S. [39, 40]. In addition,
policies that may affect health and healthcare access vary
across countries [41, 42]. The current scoping review as-
sesses existing data on the healthcare experiences and
access barriers specifically of African immigrants in the
U.S., with the aim of understanding the both impact of
those experiences, and the putative underlying causes.

Methods
A Scoping Review is ideal for the initial step in under-
standing African immigrant health due to its usefulness
for exploring an issue that has not been well studied [43,
44]. Following Arksey and O’Malley’s Scoping Review
framework, the review was carried out in five stages: (a)
research question identification, (b) identification of rele-
vant studies, (c) screening of studies, (d) data extraction
and synthesis, and (e) presentation of results [43]. This
study was approved by the Indiana University Institu-
tional Review Board (IRB) as a part of an overarching
study that examined the healthcare experiences of Afri-
can immigrants.

Identification of research questions
The specific questions this scoping review attempted to
answer are: [1] What do we currently know about the
healthcare experiences and needs of African immigrants
in the U.S.? [2] What are the knowledge-gaps to guide
the development of subsequent inquiries about African
immigrant health in the U.S.?

Identification of relevant studies
Table 1 contains a full list of the inclusion criteria. The
year 1980 was chosen as the starting point for included
articles because it coincided with the increased influx of
African immigrants due to favorable modifications to
the U.S. immigration laws [45]. The included articles
were peer-reviewed, written in the English language,
with research focus on the healthcare experiences of
African immigrants in the U.S.. We excluded articles de-
rived from secondary data, that is, data gathered by re-
searchers for other purposes [46] not primarily aimed at
African immigrant healthcare experiences. These data
lacked the necessary variables required to examine the
issue in question. Studies focused on African immigrant
refugees were equally excluded, due to the unique mi-
gratory experiences of those types of subjects. Contrary
to voluntary immigrants (i.e., those who decide to mi-
grate to other countries), many refugees often flee their
home countries in a hurry due to political unrest or nat-
ural disasters, with no time to prepare for their usually
unpredictable journeys, which expose them to different

Omenka et al. BMC Public Health (2020) 20:27 Page 2 of 13

health risks and experiences [47]. Also, many research
reports have not differentiated refugees from immi-
grants, thereby presenting their health experiences as
synonymous with voluntary immigrants [48].
Four databases were utilized in the search for relevant

studies, namely: Academic Search Premier (EBSCOhost)
Public Health (ProQuest), PubMed, and Google Scholar.
The database searches were run from April 2016 to Au-
gust 2016.1 In-line with scoping review recommenda-
tions [49], we first conducted a limited search of Google
Scholar and ProQuest Public Health, and identified the
following keywords: african immigrants, african immi-
gration, african emigrants, african emigration, healthcare
experiences, and immigrant healthcare. Following the
Cochrane Effective Practice and Organisation of Care
(EPOC) Database Syntax Guide [50], we used the key-
words to search the included databases. This involved
searching for two concepts (African immigrants AND
healthcare experiences) in the subject-headings field in
each study record to identify relevant studies. In
PubMed, we searched the “PubMed Advanced Search
Builder,” and in ProQuest Public Health Database, the
Advanced Search fields. In EBSCOhost Academic Prem-
ier and CINAHL databases, we searched the Advanced
Search fields in the Boolean/Phrase search modes. The
first author and a health science librarian performed the
article screening in duplicate through the titles first, then
abstracts approach [51], and using Microsoft Office
Excel spreadsheet [52]. Beyond the screening of the title
and abstract for inclusion evidence, the reviewers read
the full text to be certain of the article’s eligibility. The
articles were divided between the two reviewers and to
avoid bias, both parties were blind to each other’s deci-
sions until completion of assigned articles. Screening
discrepancies were resolved by the reviewers by meeting,
comparing and discussing perspectives, and arriving at a
consensus. In addition to searching the reference lists of
the selected studies, we searched the reference lists of
the articles identified in Google Scholar, and added the

selected articles to the ones identified from the other
four databases.

Data extraction and synthesis
The articles retrieved from the different databases were
stored in EndNote [53]. We followed an indicative coding
approach where themes were identified from the article
results [54, 55]. Using an open coding approach [56], the
first author and a health science librarian exhaustively
read the selected articles line-by-line, with attention to
cultural meanings, then met regularly to discuss, compare,
and contrast identified themes. Combining the two sets of
themes, axial codes were formed, which were transformed
into higher-level codes and refined with each the reading
of each article, until no new themes were emerging. This
process was also applicable to the selected articles which
were quantitative studies, because they included qualita-
tive data analyses with emerging themes as well. This ap-
proach to theme identification was necessary because it
allows themes to emerge organically, while also keeping in
check confirmation bias or assumptions [55, 57].

Data presentation
Findings from the selected studies were synthesized into
a narrative format. This form of result presentation al-
lows a deeper insight into people’s views of themselves,
especially when their experiences traverse different cul-
tural nuances such as language and ethnicity [58, 59].
The results were presented from the perspective of the
study participants regarding how the issues discussed
affected them.

Results
A PRISMA flowchart delineating the article screening
process is represented in Fig. 1. The entire screening
process yielded a total of 1446 articles, of which 206
were duplicates. Additional 644 were rejected for not
meeting the inclusion criteria, including those in differ-
ent languages from English, and studies not conducted
in the U.S.. Of the remaining articles 596 articles, 240
were excluded for not meeting additional criteria for in-
clusion, including articles based on secondary data. Arti-
cles derived from secondary databases were excluded
because those data were not primarily collected to exam-
ine African immigrant healthcare experiences. As such,
they lacked the necessary indicators for understanding
the problem. Also, studies deemed insufficiently empir-
ical, including those conducted with surveys, but lacking
qualitative data analyses, were excluded. Of the 356
remaining articles, 342 were rejected for ineligibility for
inclusion, including those that had refugees as partici-
pants, studies not focused on the healthcare experiences
or behavior of African immigrants, and articles we could
not access.

Table 1 Inclusion Criteria for Article Selection

Criterion Inclusion

Time period 1980–2016

Language English

Type of article Peer-reviewed

Population Non-refugee African immigrants in the United States

Study focus Healthcare experiences, needs, or health behaviors of
African immigrants in the United States

Data type Primary data collected directly from participants

1We ran new searches but did not identify any additional studies.
While new studies have been published since then, they did not
address questions guiding this review.

Omenka et al. BMC Public Health (2020) 20:27 Page 3 of 13

Description of identified studies
Figure 2 is a bar-chart depiction of the 14 articles that met
the inclusion criteria. The horizontal and vertical lines de-
note the years the articles were published, and how many
articles were included from each year, respectively. No art-
icle before 2005 met the inclusion criteria and no relevant
articles were identified from 2007 to 2009, and in 2011.
The highest number of relevant articles [4] were from 2015.

Characteristics of included studies
A summary of the characteristics of the 14 included arti-
cles is presented in Table 2. Seven articles focused spe-
cifically on female participants, while one article
concentrated on youth and the elderly. Of the other six
articles, one looked at individuals over 40 years old and

five focused on the general population of African
immigrants.
Table 3 contains the themes and sub-themes gener-

ated from the analysis of the included studies. The
theme of cultural influence comprises sub-themes in-
cluding traditional beliefs and stigma-based perceptions
of health, and the theme of the U.S. healthcare system
was made up of sub-themes including provider attitudes
and distrust of the system.

Identified themes
The two over-arching themes derived from the data ana-
lysis were the influence of culture on the provision of
health care and negative experiences of the African im-
migrants with the U.S. healthcare system. Each one,
along with the sub-themes, is discussed below.

Fig. 1 PRISMA [60] Flow Diagram of Data Search and Results

Omenka et al. BMC Public Health (2020) 20:27 Page 4 of 13

Cultural influence
Traditional beliefs
Cultural perspectives of diseases and illness determine
healthcare behaviors, which in turn shape healthcare ex-
periences. Eight articles discussed the impact of culture
on the healthcare experiences of African immigrants in
the U.S. [11, 61, 68, 69, 71–74]. In African immigrant
communities, for example, diseases such as HIV and
cancer are viewed as the result of spiritual issues? There-
fore, it is not uncommon for many African immigrants
to consult oracles and traditional healers in their home
countries, regarding those types of health problems [72,
73]. The study by Kaplan et al., showed it was common
for participants to delay office visits until the diseases or
illnesses were certifiably irreversible or severe enough to
halt daily activities [68]. Results from another study
showed HIV-positive African immigrant women sought
treatment when the condition was already in its late
stage [74]. In one study, participants believed that un-
necessary physician contact would lead to unwanted
diagnoses. In which case an unwarranted exam would be
tantamount to tempting fate. Thus, seeing a doctor was
reserved for cases requiring immediate medical treat-
ment [69]. Prior to their migration to the U.S., many
African immigrants utilized herbal remedies for different
health problems. In the U.S., the fear that such options
may not be explored by healthcare providers, resulted in
office visits and routine checks being viewed by some
participants as waste of time and resources, especially
given the high cost of healthcare [71]. Participants’ def-
erence to their culture also had dietary implications.
Turk and co. (2015) discovered some participants had
problems with their providers’ dietary recommendations.

These participants found it difficult to replace their long-
held cultural perspectives regarding food and health due
their contrasting outlook on body size. Whereas a big
body size was considered unhealthy in the U.S., it was
regarded as a sign of healthy eating in their cultures [11].
In addition, they described the fast-food culture in the
U.S. not only as inescapable but problematic, due to
its incongruence with their own cultural views of food
preparation and consumption [61, 68].

Religiosity and spirituality
The influence of African immigrants’ religious and spirit-
ual outlooks on health and well-being was presented in
eight articles [61, 65, 66, 69, 70, 72, 73, 75]. In Vaughn
and Holloway’s study, both the Muslim and Christian par-
ticipants ascribed health status and outcomes primarily to
God. They believed in spite of their efforts, their ultimate
health outcomes were beyond their, or anyone’s control.
Therefore, even if physicians were able to treat them suc-
cessfully, that could only happen through divine assist-
ance. Participants explained health imperfections such as
illnesses and diseases as the consequences of human inad-
equacies, from which no one was exempt [72]. One study
found that Muslim participants believed death by disease
was a result of the expiration of a person’s time on earth.
According to the participants, if it was God’s will that one
would die from cancer for example, then there was noth-
ing anyone could do about it. Conversely, if it was not des-
tined for one to die yet, then despite such a disease, one
would still live [66, 70, 73]. Findings from a study of key-
informant focus groups indicated the African immigrant
women participants were reluctant to go for cancer
screening, due to their belief that their health was

Fig. 2 Included Articles by Year (1980–2016)

Omenka et al. BMC Public Health (2020) 20:27 Page 5 of 13

determined by God, who would shield them from diseases
not meant for them [69]. Other participants felt Western
medical care was mainly dependent on human abilities to
rectify health problems, and almost negligent of the roles
of spirituality and God in shaping human health [75].
This connection between spirituality and health also

influenced how the participants viewed preventive
healthcare. Some participants refused to answer hypo-
thetical questions about what they would do, were they
to be diagnosed with diseases such as cancer. Their ra-
tionale was that words and thoughts could affect one’s
life outcomes, such as health experiences. Therefore,
speaking about adverse events hypothetically was equiva-
lent to invoking them into one’s life [65]. The Christian

participants in the study expressly rejected the question,
stating that it was not their lot to suffer from such dis-
eases [69]. In addition, Adekeye et al., found a connec-
tion between African immigrants’ religiosity and dealing
with mental health. Both the Christian and Muslim par-
ticipants described their church and mosque attendance
respectively, as necessary for coping with life’s chal-
lenges. In their views, religiosity was instrumental in
shaping healthy spiritual lives, which was crucial for
overall health and well-being [61].

Stigma in the African community
The significance of culturally-situated stigma in the
healthcare experiences of African immigrants in the U.S.,

Table 2 Characteristics of Included Articles

Author(s) Year Location Study Design Study Purpose Participants

Adekeye
et al. [61]

2014 Greensboro,
NC

Qualitative; Photovoice;
Community-based
participatory research (CBPR)

Comprehend African immigrants’ views
on their health and well-being, as well
as barriers to their healthcare access.

Youth: 5 females and 5 males; Elderly:
1 woman and 4 men; Average age: N/
A; Countries: N/A (West, North, East,
South Africa)

Asare &
Sharma [62]

2012 Cincinnati,
OH

Quantitative; Cross-sectional Understanding sexual communication
behaviors among African immigrants,
using health belief model (HBM) and
acculturation.

Males: 249; Females: 163; Average age:
36.9; Countries: Ghana, Nigeria,
Senegal, Cameroon, Kenya, Other

Blanas et al.
[63]

2015 New York,
NY

Qualitative; Focus Groups Assess factors that affect the access to
medical care of African immigrants
from French-speaking countries.

Females: 12; Males: 27; Average age:
39; Countries: Burkina Faso, Guinea,
Mali, Senegal

Chu &
Akinsulure-
Smith [64]

2016 New York,
NY

Qualitative; Focus Groups &
Questionnaires

Examine the health beliefs of African
immigrants regarding female genital
cutting (FGC), across different
demographics.

Females; Average age: 35.2; Countries:
Sierra Leone, Guinea, Mali, Gambia

Daramola &
Scisney-
Matlock [65]

2014 Detroit, MI Quantitative; Cross-sectional
(Correlational Surveys)

Examine the interaction between
migration and health behaviors of
African immigrant women.

Females; Average age: 56.5; Countries:
Nigeria

De Jesus
et al. [66]

2015 Washington,
DC

Qualitative; Semi-structured
Questionnaire

Explore health behaviors of East African
immigrant women regarding HIV
testing services.

Females; Average age: 31; Countries:
Ethiopia, Eritrea, Kenya, Tanzania,
Uganda

Foley [67] 2005 Philadelphia,
PA

Qualitative; Focus Groups Understand the cultural and structural
barriers that affect African immigrant
women’s access to HIV services.

Females; Average age: 32; Countries:
Liberia, Sierra Leone, Mali, Senegal,
Guinea, Ivory Coast, and Burkina Faso

Kaplan,
Ahmed, &
Musah [68]

2015 Kaplan,
Ahmed, &
Musah

Qualitative; Focus Groups Comprehend how Ghanaian
immigrants perceive their health
experiences.

Females: 16; Males: 37; Average age:
45; Countries: Ghana, Gambia, Nigeria,
Cameroon

Ndukwe,
Williams, &
Sheppard
[69]

2013 Washington,
DC

Qualitative; Focus Groups &
Questionnaires

Assess the health behavior of African
immigrants regarding breast and
cervical cancer prevention services.

Females; Average age: 46; Countries:
Ghana, Nigeria, Cameroon, Zambia,
Ivory Coast

Raymond et al.
[70]

2014 Minneapolis,
MN

Qualitative; Focus Groups Assess the health behavior and
attitudes of Somali immigrant women
regarding cancer prevention services.

Females; Average age: ~ 40+;
Countries: Somalia

Sellers, Ward, &
Pate [71]

2006 Madison, WI Qualitative; Focus Groups Understand the health and well-being
of black African immigrant women.

Females; Average age: 44; Countries:
Ghana, Cameroon, Nigeria

Turk,
Fapohunda, &
Zucha [11]

2015 Western
Pennsylvania,
PA

Qualitative; Photovoice Assess the influence of cultural beliefs
of Nigerian immigrants on healthy
eating and physical activity

Females; Average age: 34; Countries:
Nigeria

Vaughn &
Holloway [72]

2010 Cincinnati,
OH

Qualitative; Narrative
Interviews

Learn from West African immigrant
families in Cincinnati about their
perceptions, barriers

Females: 5; Males: 5; Average Age: N/A;
Countries: Mauritania, Senegal

Omenka et al. BMC Public Health (2020) 20:27 Page 6 of 13

was identified in eight studies [62, 63, 66–71]. Blanas
et al., found that one of the reasons why the African immi-
grant participants in their study did not make use of cer-
tain healthcare services in the U.S., was the resultant
negative reactions individuals within their communities.
They explained that even when the services were prevent-
ive and did not involve subjects commonly regarded as
taboo, such as sexual health, they still attracted stigma
from their communities [63]. This experience was applic-
able to participants in another study which focused on
utilization of human immunodeficiency virus (HIV) pre-
vention services. The participants emphatically preferred
not knowing their status to the potential stigma and social
consequences from utilizing such services, especially with
HIV-positive results. According to these participants,
merely going to get tested was sufficient to elicit stigma in
their communities; many would deem that a positive con-
firmation [66]. Healthcare-related stigma within African
immigrant communities is not restricted to sexually trans-
mitted diseases or infections. Participants in the study by
Ndukwe et al., explained that cancer was perceived as a
curse in their communities. Consequently, the notion that
the person with a cancer diagnosis has been cursed spir-
itually, translated to avoidance of, or cautious interaction
with, the affected person [69]. Another group of partici-
pants interviewed by Raymond et al., equated cancer with
HIV, in terms of perception. According to them, because
both diseases were viewed by community members as
death sentences and shameful, family and friends tended
to be distant from the sufferer [70].
Although not linked with death as are HIV and cancer,

depression is also stigmatized within African immigrant
communities. Results from Sellers et al., revealed that
even when participants were aware of depression, the
fear of the stigma attached to being identified as de-
pressed within their community often overrode the de-
sire to seek treatment. According to the participants,
depression was viewed as a conception and condition of

white people in their communities [71]. Also, because
depression was not a recognized mental health condition
in many African cultures, some participants could not
differentiate between health issues referred to in the U.S.
as mental health problems, such as bipolar disorder,
from those commonly known as “madness” in their
home countries, which described mentally ill individuals
roaming the streets [71]. Furthermore, the impact of
health-related culturally-situated stigma within African
immigrant communities, also extended beyond the af-
fected individuals. With a cultural emphasis on a good
reputation, many participants expressed fear of what
would happen to their families’ standings, were it to be
known that they suffered from dreaded health problems,
such as cancer and mental illness. Thus, they would ra-
ther not find out their health status [66]. Even when they
decided to utilize healthcare services, participants’ per-
ceptions of privacy were an obstacle. For instance, re-
sults from Foley’s study indicated participants saw
confidentiality, as managed by U.S. providers as inad-
equate, due to concerns about insufficient anonymity
[67]. In addition, some participants suspected certain
healthcare facilities were more interested in testing them
unnecessarily during office visits. They feared it was only
a matter of time before their private data were compro-
mised and their livelihoods jeopardized, especially in
cases of positive results for stigmatized diseases [68].

Linguistic discordance
Three studies discussed how the impact of language on
the healthcare experiences of African immigrants in the
U.S. [67, 68, 70]. Some participants experienced difficul-
ties with translating their health needs to terms and con-
cepts understood by U.S. providers, especially in dire
circumstances. Other participants believed the language
barriers they encountered were exacerbated by negative
provider attitudes towards them [67]. This challenge was

Table 3 Themes and subthemes generated from the analysis of included studies

Themes Sub-themes Examples

• Cultural
Influence

• U.S. Healthcare
System

• Traditional Beliefs
• Religiosity and Spirituality
• Stigma in the community
• Linguistic discordance
• Cultural competence
• Complex U.S. healthcare
system

• Cost of healthcare
• Biased/hostile provider
attitudes

• Lack of trust of the U.S.
health system

• “Why pay to find out that nothing is wrong? And why pay to find out that I have a costly problem
that I can’t feel, like diabetes and high blood pressure?”

• “God makes people differently and God creates people with imperfections. If you go to the doctor,
God gives the doctor power to help.”

• “In the eyes of a family with a person with hepatitis B, hepatitis B equals AIDS. If a family member is
sick, the family no longer has the same image in the community.”

• ‘If you don’t speak English, they just ignore you, or you can’t even understand your name when they
call it.”

• “If I’m seeing a doctor here, the doctor doesn’t understand what I’m eating in terms of the African
dishes …”

• “Whenever I have a hospital visit coming up, I always pray and fast for days to ensure it goes well.”
• “Hospital visits are expensive; unfortunately, there are very few ethno-medical centers. In America, I
don’t have access to local herbs…local herbs work!”

• “If you go to a hospital and you are wearing African clothing, they don’t even want to touch you.
They think we bring diseases from Africa.”

• “Cancer will kill you anyway … it is a cover-up meant to use African immigrants as guinea pigs.”

Omenka et al. BMC Public Health (2020) 20:27 Page 7 of 13

also pointed out by participants in the study by Kaplan
et al., who felt their communication with U.S. providers
would be greatly improved if the providers were more
patience and less dismissive. To the participants, the
poor attitudes resulted from those providers’ prejudiced
expectations of language barriers from their interactions
with their African immigrant patients [68].
According to some participants, productive interac-

tions with U.S. providers entailed more than linguistic
competency or availability of translators. Cultural know-
how, in their views, was an inseparable aspect of effect-
ive healthcare communication. These participants’ inter-
actions with providers were compounded by different
cultural names and descriptions which were difficult to
fully translate into the English language [70]. This was
true even for Somali immigrants, who, despite having
the highest number of translators in the public service
sphere, continue to find their interactions with U.S. chal-
lenging., Participants regarded this wearisome communi-
cation with providers as a deterrent to their healthcare
access, due to their fears their health needs would be un-
met, or they would receive wrong treatments [70].

Adverse experiences with the U.S. healthcare system
Lack of culturally-competent providers
The absence of healthcare sensitive to the backgrounds
of African immigrant patients, was a pervasive theme in
six articles [11, 61, 68, 70–72]. Participants in one study
were disinclined towards office visits, because they
feared they would result in complications, due to pro-
viders’ lack of understanding of their health needs. Not
only did the participants regard those unproductive of-
fice visits as a waste of scarce resources, they considered
them justifications of their lack of trust in the health sys-
tem [61]. Also, participants explained that their unique
cultural and healthcare backgrounds received little to no
attention from the providers. In their views, those en-
counters constituted missed opportunities for the pro-
viders to gain broader, deeper understanding of their
patients, which would have resulted in more informed
interactions, and effective treatment decisions. Accord-
ing to the participants, even when they initiated efforts
to bridge the providers’ knowledge-gap, the outcomes
were still the same, due to the providers’ unaccommo-
dating outlooks [61].
In another study, participants expressed their dissatis-

faction about not being asked about their cultural or re-
ligious beliefs, which could interfere with their care.
They described those omitted questions as crucial, with
the power to improve effectiveness of care, though they
might have seemed trivial to the providers [68]. Accord-
ing to other participants, the Christian or Muslim faith
came with certain considerations in healthcare, including
gender-roles in patient-provider interactions, and

treatment options, none of which was addressed in their
interactions with providers [70]. Some participants de-
scribed this experience as a double-edged barrier,
because their backgrounds and preferences were often
excluded from their healthcare, leaving them only with
the providers’ approaches, to which they had difficulties
comprehending and adhering [72]. For example, some
participants described how providers would often rec-
ommend difficult modifications to their diets, such as
substituting one of their culturally staple foods, but
without any guidance to help them achieve those goals
[11]. Results from the study by Sellers et al., showed par-
ticipants preferred physicians from comparable ethnici-
ties, or, with whom they could relate. They described
interactions with these types of providers as more emo-
tionally soothing, effective, and less resource-consuming,
due to quicker resolution of their health challenges [71].

Complex U.S. healthcare system
Difficulty navigating the U.S. healthcare system was dis-
cussed by four studies [61, 67, 71, 72]. However, this
barrier did not present itself similarly in every setting.
Results from the study by Adekeye et al., indicated par-
ticipants ascribed their challenges with navigating the
complicated U.S. healthcare system, mainly to linguistic
discordance. To them, this barrier was not only in refer-
ence to low English language proficiency, but also lack
of understanding of the culturally divergent aspects of
the U.S. healthcare system, including terms and policies.
Some participants highlighted inundation with excessive
information and paperwork, with little or no guidance
towards grasping their import, as a key challenge [61].
Other participants, although they had health insurance
coverage, described as difficult, utilizing healthcare ser-
vices, due to the challenges with deciphering which ser-
vices they were eligible for and which providers were
suitable [67]. Results from the study by Sellers et al.
showed participants viewed the U.S. healthcare system
as the most challenging aspect of their immigrant expe-
riences. They described their healthcare experiences as
replete with emotional and mental anguish, emanating
from caring for the sick individual while navigating the
myriad barriers to care, and knowing that the problems
might not be adequately addressed [71].

Cost of healthcare
Five articles described the relationship between the cost
of healthcare in the U.S. and the healthcare experiences
of African immigrants [61, 63, 67–69]. In the study by
Adekeye et al., participants identified high cost of care
and the lack of western treatment alternatives, as the key
barrier to their access to healthcare. Also in their views,
the western assessment of African treatments as quack,
inadvertently contributed to high cost of care, since it

Omenka et al. BMC Public Health (2020) 20:27 Page 8 of 13

left them without cheaper alternatives [61]. Due to the
exorbitant healthcare costs, some participants regarded
preventive care or cases not perceptibly serious, as
resource-wasting. Their rationale was that spending a lot
of time and money to determine the presence of a health
problem would be fiscally irresponsible, if it turned out
nothing was wrong [68].
According to findings by Foley, when participants did

go to the doctor, they felt it difficult to find out that the
services they received were not well-covered by their
health insurance. This did not only disincline the partici-
pants towards subsequent visits, it also further reduced
their already distrustful views of providers, who they felt
were not looking out for them as patients [67]. The prob-
lem of high healthcare cost was compounded for partici-
pants without health insurance. They could not afford the
payments because they held jobs that neither provided
health insurance nor paid high enough salary to allow the
participants to afford healthcare services [63]. Also, partic-
ipants cited the lack of transportation as one of the con-
tributors to the high cost of care. Due to family members
and friends always working, and unfamiliarity with, or ab-
sence of an easily accessible transit system, often the par-
ticipants could not take advantage of some healthcare
services, even including free screenings [69].

Biased/hostile provider attitudes
Five articles discussed the negative? role of discrimin-
ation in the healthcare experiences of African immi-
grants in the U.S. [61, 67, 68, 72, 73]. In one study, the
participants believed that their accents or dressing styles
often triggered unfavorable provider attitudes. They de-
scribed their poor experiences including hostile, condes-
cending staff approach, and provider dismissiveness and
reliance on African cultural stereotypes [61]. In another
study, participants described the perfunctory manners
providers interacted with them, both in-person and on
the telephone. The participants described that they and
their health needs, being considered as undesirable en-
cumbrances by providers, made then feel disrespects and
humiliated, rendering the prospect of interacting with
providers, difficult? [72].
Additionally, adverse provider behaviors towards Afri-

can immigrants were not restricted to one race or ethni-
city. According to Foley’s study results, participants’
accents, looks, names, amongst other background infor-
mation, elicited some type of hostile attitudes from both
white and black providers [67]. Other participants de-
scribed their experiences with providers whose ap-
proaches were mainly derived from uninformed or
stereotypical information about African immigrants,
which were manifested in the providers’ questions or
comments about their health issues. Still, other partici-
pants felt they were unreasonably subjected to certain

tests as a result of the providers’ suspicions, founded on
related stereotypes. For this reason, the participants felt
targeted and avoided those locations as well as growing
more distrustful of other providers [68]. Findings from
Opoku-Dapaah’s study revealed a similar pattern. Partic-
ipants avoided certain healthcare services, including can-
cer screenings, due to their suspicions that the services
provided to African immigrants were more harmful than
those received by their White counterparts [73].

Lack of trust of the U.S. health system
Three articles discussed African immigrants’ distrust of
the U.S. health system and its healthcare implications [70,
71, 73]. According to the study by Sellers et al., partici-
pants’ lack of trust in the U.S. healthcare system, was in-
spired by the unwelcome ways they felt African
immigrants and blacks in general were targeted in their
personal and public domains [71]. Other participants did
not believe U.S. providers had the best interests of African
patients at heart, and even if they did, they felt those pro-
viders were equipped with adequate information or tac-
tics. Also, some of the participants were convinced the
health of some of their community members deteriorated
after receiving western medical treatment. They expressed
their unwillingness to fully acquiesce to the views of US
providers, because they may not be aware of, or care
about, the adverse effects of western medical approaches
on African immigrants [71]. In addition, some partici-
pants’ distrust of the U.S. health system emanated from
their negative views of the possible role of the pharma-
ceutical industry. They believed that the operational phil-
osophy of the pharmaceutical industry primarily targeted
the general public’s susceptibilities. For instance, it was
their views that the expensive medical interventions were
inventions of the pharmaceutical industry, primarily aimed
at profiteering, while cancer screenings were smokesc-
reens used to identify unwitting Africans as possible par-
ticipants in pernicious Western health research [73].
Some participants in a study by Sellers et al. believed cer-
tain medications would result in previously absent health
complications, or the exacerbation of existing ones. They
were convinced they would be left to bear the brunt of the
cost should that happen, while the drug manufacturers’
agenda of profiting from people’s health challenges would
remain uninterrupted [71].

Discussion
This study’s findings have highlighted two themes that
underline some of the healthcare experiences of African
immigrants in the U.S.. Culture and spirituality inform
the ways African immigrants perceive their health and
healthcare experiences, as shown by both the explicit
and nuanced roles of traditional beliefs, stigma within
the community, and language variance. The importance

Omenka et al. BMC Public Health (2020) 20:27 Page 9 of 13

that African immigrants place on their culture with re-
gard to health, seem supported by evidence of its health
benefits. Studies of African immigrants in both the U.S.
and Australia found a link between African-style diets
and lower health risks, including obesity [76, 77]. Agye-
mang et al., found that well acculturated Ghanaian im-
migrants in the Netherlands had higher levels of
cardiovascular risks [78], while another study showed
higher colon cancer risk among African Americans in
the U.S. than Africans in their home countries [79]. Un-
derstanding African immigrants’ health beliefs is critical
due to potential discordance with U.S. providers’ views.
For instance, a common African health perception
equates higher weight with better nourishment, and
lower weight with malnourishment or illness, a notion
that is opposed to the predominant cultural view in the
U.S. [77, 80]. Also, the perception of diseases among Af-
rican immigrants has been found to emanate largely
from pre-migration notion of diseases which associates
most of them with spiritual origins, including cancer
[73, 81]. In addition, the U.S. healthcare system presents
some challenges to African immigrants, including the
lack of culturally sensitive care, cost of care, complexity,
and hostile provider attitudes that reinforce the lack of
trust in the system. While the complexity and high costs
associated with the U.S. healthcare system may not be
unique to African immigrants [82, 83], their poor treat-
ment by the U.S. medical institution is idiosyncratic [73,
84, 85]. This contributes to the pre-existing distrust of
the U.S. healthcare system, which makes it difficult to
engage them in intervention programs and research [86].
Contrary to the well-documented mistreatment of Afri-
can Americans by the U.S. health system, including the
Tuskegee Syphilis experiment [87], the underpinnings of
the cynicism among African immigrants towards the
U.S. healthcare system, have not yet been well identified
[75].
Despite the insight provided by this study and other

research examining the healthcare experiences of Afri-
can immigrants, some knowledge-gaps still need to be
addressed. We still need to understand the root-causes
of the identified barriers. The healthcare impact of the
consequences of the “black” grouping needs to be stud-
ied although it appears that being identified either as Af-
rican immigrants or African Americans attracts distinct
barriers, including provider biases and discrimination
[61]. However, some participants in the selected studies
were discouraged by the negative attitudes and biases
from both white and black providers. The interpretation
of barriers to African immigrants’ healthcare access in
the U.S. has been oversimplified, with language often be-
ing identified [25, 88]. However, language barrier should
not only include deficiency in English language profi-
ciency as witnessed by the fact that the availability of

translators for African immigrants does not guarantee
the absence of communication barriers in their health-
care experiences [25]. Accents, the complex U.S. health-
care system, and culture-derived healthcare expectations,
can still constitute barriers to African immigrants [18].
Even when providers communicated accurately the re-
quired dietary changes, the participants were at a loss re-
garding their implementation, because they were not
provided any guidelines. Not only did those health goals
go unmet, the opportunities for some critical patient
education were lost [11, 70]. African immigrants en-
counter barriers to good nutrition in the U.S. as regards
availability, affordability, and accessibility [61], so
provider-recommended nutrition changes are
insufficient.
Religion and culture also affect gender roles in African

immigrant communities, which then can influence their
healthcare experiences [89]. In order to meet this popu-
lation’s healthcare needs, it would be necessary to exam-
ine how gender roles affect both their perception of
healthcare, and the accurate understanding of provider
recommendations or treatments in their communities.
The antagonism between African immigrants and U.S.
providers cannot be addressed without the examination
of the views and attitudes of U.S. providers on African
immigrant health experiences and needs. This study’s re-
sults indicated many African immigrants felt U.S. pro-
viders were not adequately equipped to address their
health concerns. Finding the roots of this deep-lying dis-
trust with input from U.S. providers, would be funda-
mental in improving the African immigrant healthcare
experience.

Conclusion
Very little is known about African immigrant health in
the U.S.. Even as the number of African immigrants in
the U.S. continues to climb exponentially, healthcare
providers and policymakers have little information to
guide their decision-making concerning this population.
As far as we know, this is the first review of the health-
care experiences of African immigrants, which includes
the overall assessment of their barriers to care or specific
healthcare interventions. The findings from this review
clarify some critical issues with African immigrants’
healthcare in the U.S. In addition to the identified gaps,
they have also provided important cues for subsequent
lines of inquiries necessary for building an understand-
ing of the unique healthcare needs of African immi-
grants. However, the study still has some limitations.
The language of the selected articles was limited to Eng-
lish. Articles published in other languages may have
yielded additional findings. Also, the selected studies
were limited to peer-reviewed journal articles, which ex-
cluded potential findings in grey literature, and other

Omenka et al. BMC Public Health (2020) 20:27 Page 10 of 13

documents. Another limitation is the exclusion of
broader studies that may report on the experiences of
African immigrants within the context of other U.S. im-
migrants’ experiences. In addition, studies focused on
refugees were not included in this study, and the partici-
pants of the selected studies were mostly from Sub-
Saharan Africa. Therefore, the generalizability of the
findings is limited.

Abbreviation
U.S: United States

Acknowledgments
The authors thank Heather Coates, Ukamaka Oruche, Najja Modibo, and Josh
Vest for their important contributions.

Authors’ contributions
OIO carried out all the stages of the scoping review and developed the
manuscript. DPW and HCH critically reviewed the methods and results
sections. All authors reviewed and approved the manuscript.

Authors’ information
Corresponding Author
OIO is an Assistant Professor and the Diversity Initiatives Facilitator, at the
Butler University College of Pharmacy and Health Sciences. He earned his
doctorate in Public Health, with a Health Policy and Management concentration,
from the Richard M. Fairbanks School of Public Health at Indiana University. His
primary research interest is in immigrant health disparities, and his current research
focuses on African immigrant health because researchers, healthcare professionals,
and policymakers lack the necessary information for their decision-making regarding
the unique healthcare experiences and needs of African immigrants. As a Nigerian
immigrant to the U.S. alone at a young age, OIO understands the difficulties with be-
ing “invisible” in the healthcare system. This scoping review was the first phase of a
qualitative study of the African immigrant healthcare experience, using Nigerian im-
migrant participants in Indianapolis.

Funding
Not applicable.

Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated
or analyzed during the current study.

Ethics approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Author details
1College of Pharmacy and Health Sciences, Butler University, 4600 Sunset
Avenue, PHSB 404E, Indianapolis, IN 46208, USA. 2Center for Dissemination
and Implementation Science, Department of Medicine, College of Medicine,
University of Illinois at Chicago, Chicago, IL, USA. 3Department of Psychiatry,
Indiana University School of Medicine, Indianapolis, IN, USA.

Received: 29 July 2019 Accepted: 24 December 2019

References
1. Anderson M. African immigrant population in US steadily climbs. Pew Res

Cent. 2017;15(1).
2. Gambino CP, Trevelyan EN, Fitzwater JT. Foreign-born Population from

Africa, 2008–2012. American Community Survey Briefs. US Department of
Commerce, Economic and Statistics Administration, US Census …; 2014.

3. Arthur JA. Invisible sojourners: African immigrant diaspora in the United
States. Westport, CT: Praeger Publishers; 2000.

4. Nguyen L, Ropers S, Nderitu E, Zuyderduin A, Luboga S, Hagopian A. Intent
to migrate among nursing students in Uganda: measures of the brain drain
in the next generation of health professionals. Hum Resour Health. 2008;6:
1–11.

5. Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration
of physicians from sub-Saharan Africa to the United States of America:
measures of the African brain drain. Hum Resour Health. 2004;2:17–0.

6. Likupe G. The skills and brain drain what nurses say. J Clin Nurs John Wiley
Sons Inc. 2013;22(9–10):1372–81.

7. Jirovsky E, Hoffmann K, Maier M, Kutalek R. “Why should I have come here?”–A
qualitative investigation of migration reasons and experiences of health
workers from sub-Saharan Africa in Austria. BMC Health Serv Res. 2015;15:74.

8. Reed FA, Tishkoff SA. African human diversity, origins and migrations. Curr
Opin Genet Dev. 2006;16(6):597–605.

9. Venters H, Gany F. African immigrant health. J Immigr Minor Health. 2011;
13(2):333–44.

10. Chaumba J. Health status, use of health care resources, and treatment
strategies of Ethiopian and Nigerian immigrants in the United States. Soc
Work Health Care. 2011;50(6):466–81.

11. Turk MT, Fapohunda A, Zoucha R. Using photovoice to explore nigerian
immigrants’ eating and physical activity in the United States. J Nurs
Scholarsh Off Publ Sigma Theta Tau Int Honor Soc Nurs. 2015;47(1):16–24.

12. Blanas DA, Nichols K, Bekele M, Lugg A, Kerani RP, Horowitz CR. HIV/AIDS
among African-born residents in the United States. J Immigr Minor Health.
2013;15(4):718–24.

13. Adekeye OA, Adesuyi BF, Takon JG. Barriers to healthcare among African
immigrants in Georgia, USA. J Immigr Minor Health. 2018;20(1):188–93.

14. Barr DA. Health disparities in the United States: social class, race, ethnicity,
and health. 2nd ed. Baltimore: Johns Hopkins University Press; 2014.

15. Commodore-Mensah Y, Himmelfarb CD, Agyemang C, Sumner AE.
Cardiometabolic health in African immigrants to the United States: A call to re-
examine research on African-descent populations. Ethn Dis. 2015;25(3):373–80.

16. Read JG, Emerson MO, Tarlov A. Implications of black immigrant health for
U.S. racial disparities in health. J Immigr Health. 2005;7(3):205–12.

17. Sewali B, Harcourt N, Everson-Rose SA, Leduc RE, Osman S, Allen ML, et al.
Prevalence of cardiovascular risk factors across six African immigrant groups
in Minnesota. BMC Public Health. 2015;15:411.

18. Wafula EG, Snipes SA. Barriers to health care access faced by black
immigrants in the US: theoretical considerations and recommendations. J
Immigr Minor Health. 2014;16(4):689–98.

19. Williams DR, Jackson JS. Race/ethnicity and the 2000 census:
recommendations for African American and other black populations in the
United States. Am J Public Health. 2000;90(11):1728–30.

20. David RJ, Collins JW. Differing birth weight among infants of U.S.-born
blacks, African-born blacks, and U.S.-born whites. N Engl J Med. 1997;
337(17):1209–14.

21. Capps R, McCabe K, Fix M. New streams: black African migration into the
United States. Migr Policy Inst. 2012:45–74. https://www.migrationpolicy.org/
research/new-streams-black-african-migration-united-states.

22. Gwede CK, Jean-Francois E, Quinn GP, Wilson S, Tarver WL, Thomas KB, et al.
Perceptions of colorectal cancer among three ethnic subgroups of US
blacks: a qualitative study. J Natl Med Assoc. 2011;103(8):669–80.

23. Akpuaka SO, Clarke-Tasker VA, Nichols-English GJ, Daniel MG, Akpuaka AI.
Knowledge and perceptions of prostate cancer among Nigerian male
immigrants. ABNF J Off J Assoc Black Nurs Fac High Educ Inc. 2013;24(1):23–7.

24. Ojikutu BO, Nnaji C, Sithole-Berk J, Masongo D, Nichols K, Weeks N, et al.
African born women living with HIV in the United States: unmet needs and
opportunities for intervention. AIDS Care. 2018;30(12):1542–50.

25. KOA S, Hausman A, Wadenya RO, Lidicker J. Access impediments to health
care and social services between Anglophone and francophone African
immigrants living in Philadelphia with respect to HIV/AIDS. J Immigr Minor
Health. 2010;12(4):569–79.

26. Ngoubene-Atioky AJ, Williamson-Taylor C. Culturally based health
assumptions in sub-Saharan African immigrants: body mass index
predicting self-reported health status. J Health Psychol. 2019;24(6):750–60.

27. Kumar NB, Yu D, Akinremi TO, Odedina FT. Comparing dietary and other
lifestyle factors among immigrant Nigerian men living in the US and
indigenous men from Nigeria: potential implications for prostate Cancer risk
reduction. J Immigr Minor Health. 2009;11(5):391–9.

Omenka et al. BMC Public Health (2020) 20:27 Page 11 of 13

28. Kamya HA. African immigrants in the United States: the challenge for
research and Practice. Soc Work. 1997;42(2):154–65.

29. Carroll J, Epstein R, Fiscella K, Volpe E, Diaz K, Omar S. Knowledge and
beliefs about health promotion and preventive health care among
Somali women in the United States. Health Care Women Int. 2007;28(4):
360–80 21p.

30. Siegel JE, Horan SA, Teferra T. Health and health care status of African-
born residents of metropolitan Washington. DC J Immigr Health. 2001;
3(4):213–24.

31. Lin L, Brown KB, Yu F, Yang J, Wang J, Schrock JM, et al. Health care
experiences and perceived barriers to health care access: A qualitative study
among African migrants in Guangzhou, Guangdong Province, China. J
Immigr Minor Health. 2015;17(5):1509–17.

32. Lin L, Brown KB, Hall BJ, Yu F, Yang J, Wang J, et al. Overcoming barriers to
health-care access: A qualitative study among African migrants in
Guangzhou, China. Glob Public Health. 2015;23:1–13.

33. Anaman-Torgbor JA, King J, Correa-Velez I. Barriers and facilitators of
cervical cancer screening practices among African immigrant women
living in Brisbane, Australia. Eur J Oncol Nurs Off J Eur Oncol Nurs Soc.
2017;31:22–9.

34. Diaz E, Mbanya VN, Gele AA, Kumar B. Differences in primary health care
use among sub-Saharan African immigrants in Norway: a register-based
study. BMC Health Serv Res. 2017;17:1–8.

35. Wamwayi MO, Cope V, Murray M. Service gaps related to culturally
appropriate mental health care for African immigrants. Int J Ment Health
Nurs. 2019;28(5):1110–8.

36. Ndirangu EW, Evans C. Experiences of African immigrant women living with
HIV in the U.K.: implications for health professionals. J Immigr Minor Health.
2009;11(2):108–14.

37. Diaz E, Calderón-Larrañaga A, Prado-Torres A, Poblador-Plou B, Gimeno-Feliu
L-A. How do immigrants use primary health care services? A register-based
study in Norway. Eur J Pub Health. 2015;25(1):72–8.

38. Diaz E, Kumar BN. Differential utilization of primary health care services
among older immigrants and Norwegians: a register-based comparative
study in Norway. BMC Health Serv Res. 2014;14:623.

39. Rice T, Unruh LY, Rosenau P, Barnes AJ, Saltman RB, van Ginneken E.
Challenges facing the United States of America in implementing universal
coverage. Desafíos Los Que Se Enfrentan Los E U América En
Implementación Cober Univers. 2014;92(12):894–902.

40. Greer SL, Jarman H, Donnelly PD. Lessons for the United States from single-
payer systems. Am J Public Health. 2019;109(11):1493–6.

41. White J. Compared to other countries: how exceptional are the health and
income security arrangements of the United States? Generations. 2005;29(1):
7–12 Spring.

42. Klein SD, Torchetti L, Frei-Erb M, Wolf U. Usage of complementary medicine
in Switzerland: results of the Swiss health survey 2012 and development
since 2007. PLoS One. 2015;10(10):1–10.

43. Arksey H, O’Malley L. Scoping studies: towards a methodological framework.
Int J Soc Res Methodol. 2005;8(1):19–32.

44. Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the
methodology. Implement Sci. 2010;5:69–77.

45. Clark MK. Identity among first and second generation African immigrants in
the United States. Afr Identities. 2008;6(2):169–81.

46. Johnston MP. Secondary data analysis: A method of which the time has
come. Qual Quant Methods Libr. 2017;3(3):619–26.

47. Cunningham SA, Ruben JD, Narayan KMV. Health of foreign-born people in
the United States: a review. Health Place. 2008;14(4):623–35.

48. Shishehgar S, Gholizadeh L, Digiacomo M, Green A, Davidson PM. Health
and socio-cultural experiences of refugee women: an integrative review. J
Immigr Minor Health N Y. 2017;19(4):959–73.

49. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E.
Systematic review or scoping review? Guidance for authors when choosing
between a systematic or scoping review approach. BMC Med Res Methodol.
2018;18(1):143 N.PAG-N.PAG.

50. Practice CE, Care O of. EPOC Resources for review authors. Cochrane; 2017.
51. Mateen FJ, Oh J, Tergas AI, Bhayani NH, Kamdar BB. Titles versus titles and

abstracts for initial screening of articles for systematic reviews. Clin
Epidemiol. 2013;5:89–95.

52. Anderson DR, Sweeney DJ, Williams TA. Modern business statistics with
Microsoft Excel. 5th Edition. Boston: Cengage; 2014

53. Analytics C. Endnote X8 for windows. Philadelphia: Clarivate Analytics; 2017.

54. Strauss AL, Corbin JM. Grounded theory in practice. Thousand Oaks: Sage
Publications; 1997.

55. Thomas DR. A general inductive approach for analyzing qualitative
evaluation data. Am J Eval. 2006;27(2):237–46.

56. Hruschka DJ, Schwartz D, St. John DC, Picone-Decaro E, Jenkins RA, Carey
JW. Reliability in coding open-ended data: lessons learned from HIV
behavioral research. Field Methods. 2004;16(3):307–31.

57. Pugh AJ. What good are interviews for thinking about culture?
Demystifying interpretive analysis. Am J Cult Sociol. 2013;1(1):42–68.

58. Burck C. Comparing qualitative research methodologies for systemic
research: the use of grounded theory, discourse analysis and narrative
analysis. J Fam Ther. 2005;27(3):237–62.

59. Sanou D, O’Reilly E, Ngnie-Teta I, Batal M, Mondain N, Andrew C, et al.
Acculturation and nutritional health of immigrants in Canada: A scoping
review. J Immigr Minor Health. 2014;16(1):24–34.

60. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. Ann Intern
Med. 2009;151(4):264–9.

61. Adekeye O, Kimbrough J, Obafemi B, Strack RW. Health literacy from the
perspective of African immigrant youth and elderly: A photo voice project. J
Health Care Poor Underserved. 2014;25(4):1730–47.

62. Asare M, Sharma M. Role of health belief model on sexual communication
among African immigrants. Am J Health Stud. 2012;27(2):97–106.

63. Blanas DA, Nichols K, Bekele M, Shankar H, Bekele S, Jandorf L, et al.
Adapting the Andersen model to a francophone west African immigrant
population: hepatitis B screening and linkage to care in New York City. J
Community Health. 2015;40(1):175–84.

64. Chu T, Akinsulure-Smith AM. Health outcomes and attitudes toward female
genital cutting in a community-based sample of west African immigrant
women from high-prevalence countries in New York City. J Aggress
Maltreatment Trauma. 2016;25(1):63–83.

65. Daramola OI, Scisney-Matlock M. Migration and cognitive representations of
hypertension in african immigrant women. West J Nurs Res. 2014;36(2):209–27.

66. De Jesus M, Carrete C, Maine C, Nalls P. Attitudes, perceptions and behaviours
towards HIV testing among African-American and east African immigrant
women in Washington, DC: implications for targeted HIV testing promotion
and communication strategies. Sex Transm Infect. 2015;91(8):569–75.

67. Foley EE. HIV/AIDS and African immigrant women in Philadelphia: structural
and cultural barriers to care. AIDS Care. 2005;17(8):1030–43.

68. Kaplan SA, Ahmed R, Musah A. “When you walk in the rain, you get wet”: A
qualitative study of Ghanaian immigrants’ perspective on the
epidemiological paradox. J Immigr Minor Health. 2015;17(1):255–62.

69. Ndukwe EG, Williams KP, Sheppard V. Knowledge and perspectives of breast
and cervical cancer screening among female African immigrants in the
Washington D.C. metropolitan area. J Cancer Educ Off J Am Assoc Cancer
Educ. 2013;28(4):748–54.

70. Raymond NC, Osman W, O’Brien JM, Ali N, Kia F, Mohamed F, et al.
Culturally informed views on cancer screening: a qualitative research study
of the differences between older and younger Somali immigrant women.
BMC Public Health. 2014;14:1188.

71. Sellers SL, Ward EC, Pate D. Dimensions of depression: A qualitative study of
wellbeing among black African immigrant women. Qual Soc Work Res
Pract. 2006;5(1):45–66.

72. Vaughn LM, Holloway M. West African immigrant families from Mauritania
and Senegal in Cincinnati: a cultural primer on children’s health. J
Community Health. 2010;35(1):27–35.

73. Opoku-Dapaah E. Use of Cancer Screening by African Immigrants in NC. J
Best Pract Health Prof Divers Educ Res Policy. 2013;6(1).

74. Page LC, Goldbaum G, Kent JB, Buskin SE. Access to regular HIV care and
disease progression among black African immigrants. J Natl Med Assoc.
2009;101(12):1230–6.

75. Buseh A, Kelber S, Millon-Underwood S, Stevens P, Townsend L. Knowledge,
group-based medical mistrust, future expectations, and perceived
disadvantages of medical genetic testing: perspectives of black African
immigrants/refugees. Public Health Genomics. 2014;17(1):33–42.

76. Okafor M-TC, Carter-Pokras OD, Zhan M. Greater dietary acculturation
(dietary change) is associated with poorer current self-rated health among
African immigrant adults. J Nutr Educ Behav. 2014;46(4):226–35.

77. Renzaho AMN. Fat, rich and beautiful: changing socio-cultural paradigms
associated with obesity risk, nutritional status and refugee children from
sub-Saharan Africa. Health Place. 2004;10(1):105.

Omenka et al. BMC Public Health (2020) 20:27 Page 12 of 13

78. Agyemang C, Owusu-Dabo E, de Jonge A, Martins D, Ogedegbe G, Stronks
K. Overweight and obesity among Ghanaian residents in the Netherlands:
how do they weigh against their urban and rural counterparts in Ghana?
Public Health Nutr. 2009;12(7):909–16.

79. O’Keefe SJD, Li JV, Lahti L, Ou J, Carbonero F, Mohammed K, et al. Fat, fibre
and cancer risk in African Americans and rural Africans. Nat Commun. 2015;
6:6342.

80. Witcomb GL, Jon ARCELUSJ, Chen J. Can cognitive dissonance methods
developed in the west for combatting the “thin ideal” help slow the rapidly
increasing prevalence of eating disorders in non-Western cultures?
Shanghai Arch Psychiatry. 2013;25(6):332–41.

81. Tangwa GB. How not to compare Western scientific medicine with African
traditional medicine. Dev World Bioeth. 2007;7(1):41–4.

82. Rivers PA, Patino FG. Barriers to health care access for Latino immigrants in
the USA. Int J Soc Econ. 2006;33(3):207–20.

83. Okie S. Immigrants and health care — at the intersection of two broken
systems. N Engl J Med. 2007;357(6):525–9 5p.

84. Saasa SK. Discrimination, coping, and social exclusion among African
immigrants in the United States: A moderation analysis. Soc Work. 2019;
64(3):198–206.

85. Showers F. Being black, foreign and woman: African immigrant identities in
the United States. Ethn Racial Stud. 2015;38(10):1815–30.

86. Cudjoe J, Turkson-Ocran R-A, Ezeigwe AK, Commodore-Mensah Y,
Nkimbeng M, Han H-R. Recruiting African immigrant women for
community-based Cancer prevention studies: lessons learned from the
AfroPap study. J Community Health. 2019;44(5):1019–26.

87. Kennedy BR, Mathis CC, Woods AK. African Americans and their distrust of
the health care system: healthcare for diverse populations. J Cult Divers.
2007;14(2):56–60 Summer.

88. Okafor MC, Carter-pokras OD, Picot SJ, Zhan M. The relationship of language
acculturation (English proficiency) to current self-rated health among
African immigrant adults. J Immigr Minor Health. 2013;15(3):499–509.

89. Ugwu NU, de Kok B. Socio-cultural factors, gender roles and religious
ideologies contributing to caesarian-section refusal in Nigeria. Reprod
Health. 2015;12(1):1–13.

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Omenka et al. BMC Public Health (2020) 20:27 Page 13 of 13