Applying the theoretical domains framework to identify determinants to mental healthcare use among older African Americans with type 2 diabetes: a qualitative study

Objectives: There is a paucity of research focused on enhancing access to mental healthcare for older African Americans with type 2 diabetes (T2D), who may be at risk for or living with comorbid depression. This study aims to identify barriers and facilitators to mental healthcare utilisation among this population, guided by the theoretical domains framework (TDF).

Design: This qualitative study involved 30 interviews with older African American adults diagnosed with T2D. The interview questions were aligned with TDF domains to capture participant perspectives on barriers and facilitators to mental healthcare use.

Setting: Interviews were conducted via telephone by a licensed clinician trained in social work. Each session lasted 60-90 min and was transcribed and analysed.

Participants: The study included 30 African American adults (15 males and 15 females), aged 60 and above, living in an urban area in the Midwest.

Primary and secondary outcomes: The primary outcome was the identification of themes from participant responses, analysed using thematic content techniques and categorised into TDF constructs. Demographic data served as the secondary outcome.

Results: Nine key themes were identified, categorised under major TDF domains and constructs. Significant barriers included (1) systemic racism ('knowledge'), (2) normalisation of depressive symptoms ('beliefs about consequences'), (3) perceived stigma ('beliefs about consequences') and 4) costs of medications and healthcare ('environmental context and resources'). Facilitators to seeking mental healthcare included (1) empowerment ('beliefs about capabilities'), (2) perceived benefits of mental health exams ('beliefs about consequences'), (3) positive provider experiences ('reinforcement'), (4) recognition of depressive symptoms as a motivator ('goals') and (5) support networks ('social influences').

Conclusion and implications: Key findings highlight that fostering positive patient-provider relationships and enhancing self-recognition of depressive symptoms can significantly encourage mental healthcare utilisation among older African Americans with T2D. These findings suggest that future interventions should focus on strengthening these relationships and improving self-awareness to better mental health outcomes.