Research That Matters (January 17 - 20, 2008)

Purpose: The co-occurrence of depression and diabetes disproportionately impacts low-income Latinos served in primary care. Compared to non-Latino Whites, Latinos are at higher risk of developing diabetes-related complications (e.g., heart disease, visual impairment, kidney disease), are less likely to seek care for these conditions, and when they do receive care it tends to be of poor quality. Studying the help-seeking behaviors of Latinos with diabetes and depression can inform the development of culturally appropriate interventions aimed at increasing service use, adherence to treatments, and treatment effectiveness. This qualitative study examined factors that impact the help-seeking pathways of low-income Latinos with these co-morbid conditions. Structural, personal, and cultural factors influencing recognition of need for care, treatment initiation, and adherence to treatments were identified. Management of barriers to care throughout the help-seeking pathway was explored.

Method: A purposive sample (N = 19) of Spanish-speaking, low-income Latinos was selected from a NIMH funded randomized clinical trial targeting Latinos with diabetes and depression. Four focus groups followed by 10 in-depth qualitative interviews were conducted. Help-seeking narratives were analyzed using the constant comparative method informed by grounded theory.

Findings: The somatization of depression and severe physical symptoms that impaired functioning were key factors in the recognition of need for care and treatment initiation. A common barrier in the recognition of need for care included misattributing depressive symptoms to complications from diabetes or other health conditions. Treatment initiation was also discussed in conjunction with informal and formal gatekeepers, such as healthcare providers and family members, who encouraged or inhibited help-seeking. Treatment initiation was characterized by significant barriers including, lack of knowledge about depression and its treatments, language barriers, previous negative experiences with health and mental health services, competing health demands, and systemic barriers such as difficulties obtaining medical appointments and limited access to trained providers. Factors that positively impacted adherence to antidepressant medications and counseling were patients attributing alleviation of acute physical symptoms to their depression treatment, receiving services from providers perceived as warm, non-judgmental and supportive, and receiving instrumental and emotional support from family members and providers in managing their illnesses and treatments. Denial of depression, self-reliant attitudes, stigma, fears of the harmful and addictive properties of antidepressants, and worries about taking too many pills negatively influenced adherence. Adherence was further hampered by fragmented treatment experiences due to communication difficulties between patients and providers leading to misunderstanding of expressed symptomatology.

Implications: Studying the structural, cultural and personal factors that influence help-seeking pathways can help target interventions to improve recognition, initiation, and adherence to care among low-income Latinos with diabetes and depression. Results from this study suggest that public health campaigns and community outreach activities are needed to activate support networks, raise awareness of depression and its treatments, and reduce stigma among this population. Increased screening for depression in primary care clinics and providing culturally-appropriate patient-centered care will enhance the congruency between patient expectations and treatment goals to improve rates of service use, quality of care, and treatment outcomes for this underserved population.