Nurses, community providers and moms teaching us about a system approach to increase low income women's access to depression treatment

There is a large and growing literature on barriers for vulnerable populations' access to depression treatment. Through focus groups with women and semi-structured interviews with community providers and home visitation nurses who serve low income mothers, we developed a model that takes a systemic approach to treatment barriers faced by depressed low income mothers. Our model incorporates women's internalized barriers to treatment such as the “myth of the strong woman”, external barriers such as transportation and insurance, and competing life demands that low income women face in their day to day existence. We found that these barriers have more to do with social class than with race.

The model presents the service system and organizational modifications needed to address treatment barriers. These modifications include psychoeducation for depressed mothers, their families, and the community; treatment co-location in community settings; cultural adaptation of the treatment; and training of providers. Interventions must address the hierarchy of barriers in order to be effective. In focus groups women mentioned more internal barriers to reaching for help such as stigma, trust, and the “myth of the strong women.” On the other hand, although nurses and community providers identified internal barriers, they focused more on the external barriers and competing demands. Without understanding these barriers, and how they relate to each other, providers may interpret “no shows” as solely treatment resistance. In reality, women may be struggling with internal, external and competing demands barriers that impact their recruitment, retention and success in depression treatments.