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. Author manuscript; available in PMC: 2015 Feb 1.
Published in final edited form as: Arch Psychiatr Nurs. 2013 Oct 10;28(1):17–20. doi: 10.1016/j.apnu.2013.09.006

Recruitment of Older African American Males for Depression Research: Lessons Learned

Keneshia Bryant 1, Mona Newsome Wicks 2, Nathaniel Willis 3
PMCID: PMC4259097  NIHMSID: NIHMS645409  PMID: 24506982

Abstract

Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease in approximately 10 years. Few studies have explored the signs and symptoms of depression experienced by older African American men. Therefore, a pilot study was developed with the goal of addressing this gap in knowledge. Despite a variety of recruitment strategies, the study yielded no participants after nine months of effort. Lessons learned from the recruitment efforts and other researchers’ successful techniques and strategies are discussed.

Keywords: African American, men, depression, research subject recruitment

Introduction

The challenges experienced in recruiting African Americans for research have been extensively discussed in relation to the historical mistreatment of this population and the mistrust it has engendered. However, little research has focused on the participation of African American men in studies of mental health. Although the prevalence of major depressive disorder (MDD) is lower among African American men than in white men, African American men tend to have more severe depressive symptoms and disability (Williams et al., 2007). This finding underscores the greater risk among African American men for MDD to impact their quality of life and daily functioning. It is imperative therefore to explore how African American men recognize and express MDD and acknowledge associated symptoms. Here we report on our unsuccessful efforts to recruit for a pilot study investigating exactly this issue. Our recruitment efforts ceased after 9 months despite diverse strategies and eventual consultation with community liaisons and a local community development group to explore additional recruitment strategies at 6 months into recruitment. This report concludes with proposed solutions for moving forward with studies focused on this important and understudied area.

Background and Significance

Markedly elevated rates of morbidity, disability, and mortality occur among ethnic minority men with MDD compared with their majority counterparts (Rich & Ro, 2002), and these disparities are especially marked for African American men (Williams et al., 2007; Watkins et al., 2007). In addition, the psychosocial stressors and negative life events linked to higher levels of depression may place African American men in particular at a greater risk for depression than exists for the majority population. For older adults, moreover, the risk of depression may be greater because of disability and chronic comorbidities (Love & Love, 2006). Findings from several studies suggest that depressive symptoms are measured and structured differently in older black men (Foley, Reed, Mutran, & Devellis, 2002; Love & Love, 2006), who are more likely to report somatic rather than affective symptoms. There is concern, however, about the limitations of the Diagnostic and Statistical Manual-IV-TR (DSM) (American Psychiatric Association, 2000) list of symptoms because it does not capture the influences of gender, ethnicity, and culture on the symptom presentation of depression (Campinha-Bacote, 1994; Das, et al., 2006). As a result, use of its criteria may have led to the lower frequency of the diagnosis of depression among African American men. Further, with respect to the frequency of the diagnosis of depression, African American men use mental health services at low rates (Ward & Besson, 2012; Neighbors, 2007).

Depression among African American men has been the focus of limited research, although gender, ethnicity, and culture have been shown to affect the expression of depression, self-recognition of symptoms, and treatment effectiveness (Kendrick, Anderson, & Moore, 2007; Watkins et al., 2006; Love & Love, 2006). Depression among older African American men, the focus of our pilot study, is an area of even more limited research (Watkins et al., 2006), and we therefore developed a study to understand how older African American men recognize, express, and describe their depression.

Eligibility Criteria and Recruitment

With Institutional Review Board approval of the study protocol, recruitment began in October 2011, with the goal of recruiting a sample of approximately 20 African American men, ages 60 and older, over a 3- to 4-month period. To be included, a potential participant had to be a self-identified U.S.-born African American man with a self-reported diagnosis of MDD made by a health care provider on the basis of DSM-IV (American Psychiatric Association, 2000) criteria within the past 10 years. A time limit was chosen so that participants would be more likely to accurately recall the details of their depression. We excluded men who self-reported a diagnosis of schizophrenia, anxiety, post-traumatic stress disorder, psychosis, mania, or hypomania to avoid the influence that these co-occurring diagnoses might have on the presentation and interpretation of depressive symptoms. Men who had a severe or life-threatening medical illness, current substance abuse or a history of abuse within the past year, and/or a learning disability were also excluded.

The recruitment plan was based on a previous study that the lead author had conducted in a large metropolitan area in a West coast state (Bryant-Bedell & Waite, 2010). In Arkansas, she had developed relationships with local health care providers and, before initiating the study, had gained some exposure by being interviewed on local cable television on the topic of depression in African American men. However, no “official” pre-recruitment plan was developed in conjunction with the community.

Initial recruiting in the form of flyers developed by the lead author targeted community clinics and physician offices serving older African American men in the Little Rock, Arkansas, metropolitan area. In addition to these sites, flyers were distributed to and posted in community locations, including churches and businesses, such as barbershops, that catered to a predominant African American male clientele, as well as other businesses located in a predominant African American community within the city. The colorful, glossy flyers included pictures of “sad” older African American men and included a description of the depression research study, participant qualifications, and contact information for those who were interested in participating. An advertisement was also planned for the local African American newspaper, but this had to be dropped when the paper ceased publication. Because of limited funds for the study, paid advertisements were not an option. A local radio station that targeted the African American community was contacted with a press release about the study and a request to “appear” on the morning talk show, but the station staff did not respond to our request, perhaps because we did not have any relationships with key individuals at the station. Despite these recruitment strategies, at 6 months into the recruitment phase, no telephone inquiries about the study had been received.

Results of a Consultation

The recruitment process had been expected to take only 3 to 4 months; so in view of the impasse that the study had reached, a member of the research team consulted with university community liaisons and a local community development group to discuss the study and explore additional recruitment strategies. Meeting attendees recognized the importance of the study and ascribed the lack of recruitment success to the likely influence of multiple barriers. Some of the attendees’ comments were related to the stigma associated with depression. Specifically, they noted that older black men (1) believe that they are too strong to be depressed, (2) do not easily trust outsiders, (3) do not experience depression, (4) associate depression with “craziness” and do not think they are crazy, and (5) view the word “depression” as scary.

With regard to the protocol, meeting attendees took issue with the requirement for a formal diagnosis of MDD because they believed that many eligible men would not have been formally diagnosed with depression by a health care provider. They also provided valuable feedback on the recruitment flyer: (1) the older African American men in the photos on the flyer should be happy and smiling rather than looking sad, and (2) the presence of the university’s name and logo on the flyer could cause reluctance because of lack of trust. The attendees recommended word of mouth as the best recruitment approach because of the stigma associated with depression and lack of trust in the university. Unfortunately, due to time constraints and a limited budget, the recruitment recommendations could not be utilized for the study. Therefore, in June 2012, 9 months after the start of recruitment, with only one telephone inquiry by a potential participant, who did not meet the eligibility criteria, it was decided to cease recruitment efforts and to analyze the barriers to moving forward with this type of study.

Analysis and Discussion

While exposing the limitations of our approach, this report also illustrates many of the common barriers to recruiting African Americans, particularly African American men, for research studies. Researchers typically experience challenges in recruiting African Americans who have been diagnosed with depression. Factors contributing to this situation include lack of awareness of the importance of health care research (Paskett et al., 2008) and more specifically mental health research, mistrust of researchers by African Americans (Corbie-Smith, Thomas, & St. George, 2002), and the stigma associated with mental health disorders as a medical diagnosis and research topic (Givens, Katz, Bellamy, & Holmes, 2007). These challenges have led to an overall under-representation of African Americans in mental health research in general in the U.S. (Dennis & Neese, 2000; Reed, Foley, Hatch, & Mutran, 2003; Paskett et al., 2008). The challenges are attributable in part to several well documented instances of historical mistreatment of African Americans in health research, the most notable being the U.S. Public Health Service Tuskegee Syphilis Study. Accounts of opprobrious conduct in health research have created ripple effects of distrust for researchers within African American communities. This distrust is particularly problematic because the willingness of African Americans to participate in research is largely determined by trust (Freimuth et al., 2001; Mason, 2005).

Our failure to recruit participants can be ascribed to a number of missteps: non–culturally relevant recruitment materials, a failure to build trust and engage community coalitions beforehand, the use of ineffective strategies to address the stigma associated with mental illness, and the failure to reach African American men diagnosed with MDD. Greater stigma may be associated with depression among African American men in the southern U.S. than among black men in other regions. Generational differences in beliefs and stigma may also exist among African American men.

Several literature reviews have examined the participation of African American men in depression research (Cooper et al., 2003; Cooper-Patrick et al., 1999), and studies have documented the difficulties that African Americans encounter in seeking mental health services to resolve depression (Das, Olfson, McCurtis, & Weissman, 2006; Miranda & Cooper, 2004). Few studies, however, have focused on the relationship between race and depression among blacks in the U.S. (Williams et al., 2007); most have focused on symptoms and risk factors for the disorder (Gallo, Cooper-Patrick, & Lesikar, 1998; Schulz et al., 2006; Blazer, Landerman, Hays, Simonsick, & Saunders, 1998). Furthermore, studies of depression among African American men have focused not on those who have been diagnosed with depression but rather on perceptions and beliefs about depression among African American men. Depression research in the African American community has also focused on connections with religion or spirituality (Cooper, Brown, Thi Vu, Ford, & Powe, 2001; Musick, Koenig, Hays, & Cohen, 1998; Brown & Gary, 1994). The literature examining depression among African Americans in rural areas is especially limited. Help-seeking often begins in trusted community settings, such as the church; however, too few of these studies include African American men, particularly men living in rural communities.

Conclusion

Application of the lessons we have drawn from this study, as well as the lessons of other, previous studies, should facilitate future recruitment efforts for mental health research involving African American men. In previous mental health research in this group, including both qualitative and quantitative studies, recruitment strategies have varied. A key factor in successful recruitment of African American men for research studies has been the establishment and nurturing of community relationships to build trust and rapport (Ward & Besson, 2012; Kendrick et al., 2007). Partnerships between the researchers and the community are part of a “prerecruitment” effort, which may include a community research advisory board or other community members. Such partnerships help ensure cultural appropriateness of the recruitment strategies, process, and materials (Ward & Besson, 2012). Specific methods include snowball sampling, direct person-to-person contact, posting of flyers in barbershops and other, similar locations serving an African American clientele, referral by community groups, personal and professional contacts of research team members, emails, trained interviewers in clinical settings, and presentations in classrooms, discussion groups, and organizational meetings (Ward & Besson, 2012; Bryant-Bedell & Waite, 2010; Watkins & Neighbors, 2007; Kendrick et al., 2007; Love & Love, 2006; Utsey, 1997; Gary, 1985). In a study by Horowitz, Brenner, Lachapelle, Amara, & Arniella (2009), a community partner-led recruitment approach was the most successful in comparison to other approaches. Though the study participants were minority patients with prediabetes, the principles of a community partnership in developing and managing recruitment efforts is also applicable to mental health research. The churches in African American communities are a common site for study recruitment. In this setting, gaining the support and permission of the pastor is always a priority before seeking to do presentations or other activities in a church (Reed, Foley, Hatch & Mutran, 2003).

The stigma of depression and mental illness in general may be overcome by incorporating these variables into a larger study with a focus on overall health or other specific illnesses. Other studies have used this approach to address the psychological impact of racism, including stress and depression among African American men (Utsey & Payne, 2000; Utsey, 1997). Some researchers have turned to the strategy of extracting mental health–related data specifically pertaining to African American men from large data sets (Mizell,1999; Weaver & Gary, 1993). Lastly, though the stigma of mental illness and the lack of trust among African Americans will remain tough barriers to recruiting for depression research, there are effective strategies (often learned the hard way) for overcome these barriers.

Acknowledgments

This study was funded by the University of Arkansas for Medical Sciences (UAMS) College of Nursing Intramural Pilot Grant. Support was also received from the UAMS Translational Research Institute (UL1RR029884) and the KL2 Scholar Program (KL2RR029883). UAMS Office of Grants and Scientific Publications provided the authors editing services.

Footnotes

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Contributor Information

Keneshia Bryant, Email: kjbryant@uams.edu, Assistant Professor, Translational Research Institute KL2 Scholar, College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot #529, Little Rock, Arkansas 72205, Phone: (501) 296-1759.

Mona Newsome Wicks, Email: mwicks@uthsc.edu, Professor, The University of Tennessee Health Science Center, College of Nursing, 920 Madison Avenue, Suite 939, Room 950, Memphis, Tennessee 38163, Phone: (901) 448-6250.

Nathaniel Willis, Email: nwillisii@uams.edu, Research Assistant, College of Nursing, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot #529, Little Rock, Arkansas 72205, Phone: (501) 686-7996.

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