A Synthesis of the Theory of Silencing the Self and the Social Ecological Model: Understanding Gender,Race,and Depression in African American Women Living with HIV Infection

Abstract

The challenges that face African American women living with HIV are immense. African American women continue to be disproportionately infected and affected by this chronic and life-threatening infection in a complex context of individual experience, interactions with the environment, formal and informal support systems, and cultural belief systems. This article identifies the Theory of Silencing the Self (STS) and a widely known model, the Social Ecological Model (SEM), as a synthesized explanatory framework in helping nurses understand how to address research questions and clinical care that is congruent with the experience of African American women living with HIV infection. In synthesizing the components of these two frameworks, an explanation of the relationship between disempowerment and depression in this population will be uncovered as a key component to making relationships at the individual, family, and community level better. Helping African American women living with HIV infection to explore and address how choosing to be silent across their life systems will advance healthcare adherence as we currently know it to improved self-management of a chronic, gender-specific, culturally-bound experience of depression.

Introduction

Worldwide, the HIV pandemic has proven to be a healthcare challenge from the perspective of testing and treatment, including how to create sustainable positive prevention, prevention after becoming HIV positive, that is culturally relevant and gender sensitive. The utilization of positive prevention as an approach to prevention advocates an increase in the well-being of HIV-positive individuals. Positive prevention promotes HIV prevention through activities such as empowerment, advocacy, and the development of effective strategies that influence HIV prevention among those individuals living with HIV. In the United States alone, more than one million people are infected with HIV and greater than 18,000 deaths occur annually from AIDS.¹ Since the emergence of the global pandemic over a span of three decades, greater than 576,000 people in the United States have succumbed to the disease.¹

African American women are disproportionately affected by the disease, particularly in the southeastern United States, with one in every 30 African American females being diagnosed with HIV, a rate nearly 15 times higher than that of Caucasian women.¹ Economic, relational, and cultural normative influences, including those related to gender role, abuse, and oppression are associated with a higher HIV incidence among this minority group.¹ Even more, African American women have an increased risk that may be related to those obstacles or health disparities they must tackle in their pursuit of healthcare at a preventive level and adherence to treatment after acquiring the virus.¹

African American women at risk and living with HIV often sustain the brunt of racism, gender discrimination, poverty, and intimate partner abuse.^2,3 In fact, many HIV-positive African American women describe histories of child sexual abuse in their past.^4,5 In this context, low self-esteem, perceptions of stigma and actual stigma, and depression rates are reported to be greater among HIV-infected populations and in particular African American women in comparison to the general population.^6
–8 Each of these experiences hold formidable challenges related to follow-up care outreach, self-advocacy, disclosure in sexual relationships, as well as quality of life in general. Whether the effects of racial and gender discrimination influence the trajectory to high risk behaviors leading to acquiring HIV, they are ever present factors for this group of women before and after diagnosis. Low self-esteem, depression, and stigma will and do compromise chronic disease care from the perspective of missed primary care and wellness appointments, medication adherence, and continued risk behaviors.⁹ The question is how do clinicians assist in advancing protective behaviors in African American women living with HIV within a context of gender and race where many formal and informal structures intersect with important aspects of care such as adherence.

The purpose of this article is to discuss how the synthesis of the Theory of Silencing the Self (STS) and Social Ecological Model (SEM) can assist in recognizing the complexities that can be described and tested more readily in HIV prevention and implementation science in African American women living with HIV. Particular emphasis is placed on the integration of individual experiences, environment, support systems, and cultural belief systems as they relate to the gender sensitive and culturally relevant experiences of African American women living with HIV known as silencing the self behaviors.

The Theory of Silencing the Self and HIV-Positive African American Women

DeMarco, a nurse researcher and AIDS care registered nurse in clinical practice, has studied and tested the theory of STS^10
–12 with HIV-positive African American women for a decade.^13

–19 DeMarco and colleagues found that levels of “silencing the self” as a concept measured through outcome measures created by Jack and Dill²⁰ demonstrate high levels of putting others first in their lives, not telling others their true feelings or what they need directly, as well as feeling outwardly compliant to others while feeling angry internally.¹³ DeMarco and colleagues¹⁷ point out that silencing the self in African American women or black women more generally can be an impediment to safe sex negotiation, honest dialogue with healthcare providers, and self-advocacy in the context of health disparities and continued barriers to diagnosis and care after diagnosis.

The STS theory was developed by Jack and confirmed by DeMarco and colleagues to be present in African American women living with HIV/AIDS,¹³ while also demonstrating evidence of depression and negative affectivity. This is congruent with Jack's findings of significant correlations between silencing the self and depression in her original studies.¹⁰ Jack¹⁰ proposed that women silence themselves as a mechanism to secure and maintain relationships, and to maintain adherence to the traditional female role;^10
–12 yet, the outcome may have maladaptive consequences. Jack proposed self-silencing, which is highly related to depression and depressive symptoms involves the concealment of one's true feelings that may be accompanied by anger, rage, frustration, and self-condemnation.^10
–12 This self silencing behavior occurs when women “bite their tongues” due to a loss of self in their relationships (i.e., loss of voice, loss of being who she truly is, and the loss of traditional gender roles) and fears (i.e., fear of annihilation, fear of being authentic self resulting from a history of abuse, and the fear of being wrong and ultimately rejected).^10
–12 The woman utilizing self-silencing holds the belief it is easier to conceal her feelings rather than revealing her authentic self, promoting repression and, at the same time, leading to depression.^10
–12

According to DeMarco and Stokes (2010), the Ecological Model that stems from the original work of Bronfenbrenner^21,22 and with subsequent use in HIV/AIDS research of El-Bassel and colleagues,^23

–28 ideally addresses the complexity influences that are critical in addressing culturally relevant and gender sensitive prevention intervention approaches for African American seropositive women and includes key emphasis on silencing behaviors and their relationship to depression and stigma in particular. The Ecological Model proposes that individuals function within multiple ecologies that influence each other as well as human growth and improvement. This model consists of a layered arrangement of successive underlying levels. In the context of African American seropositive women, these layers represent the various levels of influence in positive prevention and disease management. All the more, the Ecological model demonstrates the interconnectedness of the various influences throughout the life of African American seropositive women. Of more importance, this model emphasizes how stigma, depression, risky sexual behavior, and other influences fit into the larger structure of self-silencing. The Ecological model supports the premise that protective health behaviors of individuals need to be considered in conjunction with their broader social contexts and influences including personal characteristics, interpersonal relationships, physical environment, and culture. Four levels of protective factors and disease management that influence behavior are identified and include four systems: (1) ontogenetic; (2) microsystem; (3) exosystem; and (4) macrocultural (Fig. 1).^20,21

FIG. 1.

Intersection of Silencing the Self and the Social Ecological Model.

Synthesis of Silencing the Self and the Ecological Model

The following identifies seminal and developing research across the Ecological Model Systems to explain the applicability with African American women living with HIV infection and its interconnected relationship to self-silencing as a culturally relevant and gender sensitive concern to health protective behaviors. Overall, individual experiences, environment, support systems, and cultural beliefs are supported predictors of depression, HIV risk, and self-silencing.

Ontogenic influence: Individual experiences

The ontogenic system is the ecology of the individual and represents factors within the individual that influence developmental adaptation. These influences include factors such as race, gender, and education. For example, research has demonstrated race and level of education are predictors of effective HIV prevention strategies.^29
–31 More specifically: (1) black women with lower levels of education are less likely to use HIV prevention measures than other groups surveyed; (2) women of color are less likely to use condoms; and (3) education levels and AIDS related knowledge are highly correlated with high rates of depressive symptoms and major depression diagnoses are common in persons of color receiving HIV care.³² Regardless of gender, race, or ethnicity, traumatic events, mental illness, distrust, and stigma have all been linked to poorer healthcare adherence and HIV risk behavior.³³

Although race and gender indirectly influence African American women through their impact on contexts both proximal and distal to African American women, they also have a direct impact on African American women. The context of these factors is a constraining key barrier in HIV prevention for black women (i.e., the lack of economic opportunity that disempowers and demands focus of immediate survival and restricts choices). Lack of adequate and sustaining income despite the help of public funding and support services is formidable.^4,34

Microsystem influence: Interactions with the environment

Within the microsystem are environments such as home, family, peer groups, and school. The microsystem takes into account the proximal processes that either facilitate or impede treatment.²¹ These influences include factors such as shame and stigma that may be a trickledown product of the environment of African American women. For example, shame and stigma indirectly affects culturally relevant and gender sensitive improved self-management of the culturally-bound experience of depression, which serves as a filter to self-silencing behaviors. In previous research, Jack discussed the concept of silencing in the context of women's experiences with relationships.¹⁰ Jack supports the contention that relationships of women are influenced not only by biological factors but also by psychosocial factors. She asserts “women's orientation to relationships is the central component of female identity and emotional activity”.¹⁰

It is all too clear that shame and stigma creates disruptions in all of the microsystems within which African American women develop. However, research on the microsystems impacted by both shame and stigma has tended to focus on poor self-image, abuse,^{35

–42} and withdrawal.^43,44 For example, trauma such as child sexual abuse (CSA), intimate partner violence, adult sexual abuse (ASA), and victimization from exposure to violent environments contribute to HIV risk behaviors and disease sequelae.^{35

–42}

“Research has shown that histories of physical and sexual trauma can affect the decisions women make with regard to risks for sexually transmitted infections and HIV, including the choice of partners and the ability to use or not use their voice to negotiate the use of barrier methods of protection.”³⁷

Stigma is understood historically as a trait highly correlated with poor self-image and the outcome of possessing that trait.⁴³ Withdrawal from personal interaction as a way to reduce tension is part of stigmatization and, for persons living with HIV and living with AIDS (PLWAs) with strong histories of substance abuse, the temptation to fall out of recovery is profound.⁴⁴ Poor self-image is linked to increased HIV risk behaviors⁴⁴ and decreased disease adjustment, health-promotion, self-advocacy, self-efficacy for negotiating safe sex^{45
46} and safe-sex behaviors.

Stigma is highly correlated with low self-image, depression, lack of support, lack of subjective social integration, and social conflict.⁴⁴ Satisfaction with personal, informational, and emotional support mediates adaptive coping and psychological distress during and after disclosure. Of more importance, there is a relationship between low self-image, negative affectivity (depression), and lack of self-advocacy in sexual relationships in women.¹³ From a treatment perspective, depressive symptoms are underdiagnosed and are associated with lower medication adherence, risky behaviors, substance abuse, and poor health outcomes.^47
–49

Exosystem influence: Role of formal and informal support systems

The exosystem consists of settings or events that influence the socialization of African American women, although in some instances there may not be a direct role in those settings. Typically, the exosystem indirectly influences African American women through a trickledown perspective. Of importance, these influences originate in contexts that do not involve African American women (e.g., racism) and have their effects by creating disruptions in contexts that do involve African American women (e.g., finances and stigma). Events such as financial upheaval and social turmoil are examples of the exosystem in African American seropositive women.

For poor women of color, medication adherence and medical follow-up are often compromised by the following: (1) believing that others in their lives, specifically children and sexual partners, come first; (2) subsisting on low incomes that affects resource allocation; (3) experiencing race discrimination that magnifies stigma as a seropositive individual; and (4) choosing to enter high risk situations to get money (sex) to try to change their circumstances. Despite a variety of strategies to help with medication adherence, such as improving motivation and self-efficacy and incorporating directly observed therapy (DOT), bringing about long-term behavior change remains unknown.^50,51

Research suggests issues such as racism, discrimination, oppression, and finances contribute to the mental health of African Americans;⁵² these are the same issues that research reveals are highly correlated with the Ecological model, self-silencing, and HIV. Even more, financial issues are an identified risk factor for depression and its treatment.⁵² Still, it is essential to explore those effects of depression such as sadness, loss of joy, malaise, loss of motivation, lack of social interaction, difficulty concentrating, synthesizing, memory loss, and disturbances in sleep patterns, eating patterns, and sexual functioning, all of which influence the treatment of depression.⁵³ Moreover, these effects may further promote the misdiagnosis and incidence of depression in African American women; creating further hindrance in her ability to seek treatment.⁵³ Although Jones and Ford⁵³ do not specifically address how such effects hinder treatment, it is reasonable to propose that sadness, malaise, loss of motivation, lack of social interaction, and insufficient finances would have a negative effect on the African American woman's ability to seek treatment for depression and HIV through isolation and decreased energy. It is worthy to mention, women with an established relationship, a relationship that demonstrates trust, with their health care provider are more likely to obtain care for depression.⁵⁴

Macroculture influence: Role of cultural belief systems

Macroculture is characterized as the evolving person's society and subculture with particular reference to their belief systems, lifestyles, and patterns of social exchange.^21,22 Serving as a personal set of values and beliefs that forms within African American women, macroculture is the more distal ecology that serves as a filter through which African American women interpret their future experiences. There are many social and contextual factors that contribute to decreased positive prevention in women such as feeling intense stigma, victimization, substance abuse, mental health problems, and other sexually transmitted diseases (STDs) in the midst of current connections and relationships.⁵⁵

Gender roles of women and, in particular, the need to maintain connections in relationships at the cost of one's own health are key issues for all women living with chronic diseases, especially those who are seropositive.^14,56
–58 Her extensive exploratory and longitudinal studies with diverse groups of women resulted in the development of the concept of “silencing the self” and the Silencing the Self Scale (STSS). Women living with HIV will continue to be sexually active with men. Silencing their voice during times of sexual intimacy in order to maintain connection with their partner, rather than taking care of themselves with direct requests, will not protect them against further strains of HIV and other STDs and they will infect others.^16,46,59

In a sample of 30 African American women, participants described depression as a barrier in maintaining their health and as a hindrance in their ability of seeking healthcare.⁶⁰ Research suggests these barriers are founded on the African American woman's beliefs, traditions, and peers' perceptions concerning depression,⁶¹ a belief system founded on the premise that depressed African American women are experiencing one or more of the following: a weakened mental status, poor health, troubled spirit, self-love deficiency, distrust for health care providers, self-denial, knowledge deficit, depression stigma, gender role responsibilities, and/or insufficient finances.^62,63 All of these factors have been identified as adherence issues in the treatment of depression.^60

–63 More recently, in a sample of 202 women of which 87% were African American women, 138 were HIV positive.⁶⁴ These results demonstrated in both HIV positive and HIV negative women a higher ability to recover corresponded with lower depressive symptoms.⁶⁴

Depression, stigma, and self-silencing in African American women

Jack^10
–12 proposes there is a strong correlation among silencing the self and clinical depression; yet, there is no single paradigm integrating those factors that contribute to the association among self-silencing and depression in African American women. Research has revealed there are numerous factors that are causal in depression in African American women, including personal beliefs, societal issues, and situational factors.^{52,54,65

–68} For some, a number of these factors are the cause of depression, while for others a single factor may be the culprit of the disorder. In the African American populace, societal issues and situational factors such as racism, discrimination, fear of disclosure, perceived stigma, negative self-image, and having a life threatening illness factor into a higher percentage of women experiencing depression.^52,62,69,70

Depression in HIV- infected African American women has been collectively contributed to racism, discrimination, and fear of disclosure.^52,62 Racism is considered a part of African American women's every day survival⁷¹ and has contributed to them being treated discriminatorily, experiencing greater disadvantages, and being placed at the bottom of the racial, gender, and class social orders. In a study of 379 African American women, Settles et al.⁷² proposed the direct and indirect effects of racial identity were associated with depression suggesting African American women experience racial issues that exceed their coping abilities, which may result in an outcome such as depression. Even more, in a qualitative study investigating health beliefs concerning depression in 14 African American women, Waite and Killian⁶² suggested African American women experiences of segregation and fears of being rejected, increased their isolation, and served as barriers in seeking treatment for depression. Additionally, African American women perceived the management of such behaviors as being causal of depression, further promoting misdiagnosis and disproportionate treatment among the group.

Preliminary research, although limited, demonstrates a positive association among HIV-infected African American women, stigma, depression, and risky behavior.^73,74 This association is founded on a similar premise as the Ecological model Exosystem and Microsystem. A negative association has also been demonstrated among HIV stigma, social support, and functional support.⁷⁴ Collectively, these positive and negative associations suggest that HIV-infected African American women experience stigma that is related to an inefficient social support system, risky behavior, negative attitudes, hasty problem solving abilities, and the need for social interaction with others to promote a positive self-image and avoid negative influences.^73,74 Additionally, HIV stigma in African Americans is attributed to poverty and access to healthcare, which are intertwined with a lack of HIV knowledge and rejection in the community.⁷⁵ In contrast, research has revealed social support and HIV disclosure are inversely associated with depressive symptoms in the African American woman with limited resources.⁵⁴ This inconsistency in research further confirms investigative efforts should focus on the perceived stigma, dysfunctional problem solving, and support in African American women.

African Americans, specifically women living with HIV, report more depressive symptoms and risky sexual behavior that have been linked to their perceived stigma of the disease.^73,76 In a sample of 147 women, Clum et al.⁷³ found HIV related stigma can result in an increased negative self-awareness that depletes resources and causes depressive symptoms, demonstrating a relationship between stigma, risky sexual behavior, and depressive symptoms.

Depression is the most common psychiatric disorder associated with HIV diagnosis, affecting HIV-infected individuals who have not disclosed their status or those who are in an advanced stage of the illness with serious health threats,^69,77 premises that are shared with the Exosystem. Today, being diagnosed with HIV/AIDS is perceived on a continuum from a manageable chronic disease associated with psychological stress and fear to a fatal illness,⁵⁴ which is founded on a similar premise as loss of traditional gender role and loss of voice. Consequently, HIV-infected individuals are reluctant in disclosing their HIV status owing to the perceived stigma associated with the disease.⁷⁸

Extensive research investigating the prevention of HIV among African American women has addressed factors associated with their history of trauma.^4,79,80 Consequently, a history of trauma has revealed itself as another factor to be considered in the development of effective HIV treatment and preventive interventions and is at the core of the Ecological model. African Americans have a history of greater than 350 years of physical and sexual trauma.⁷⁹ In a multiethnic sample of 457 African American, European American, and Latina women, Wyatt et al.⁷⁹ investigated whether a history of sexual and physical trauma is associated with HIV risk. Study results suggest seropositive African American women are more likely to have a history of childhood sexual abuse, and HIV seropositive women were more likely to have a history of trauma.⁴ Even more, ethnicity was not an independent predictor of HIV risk when other risk factors (i.e., history of trauma, number of sexual partners, employment status, number of sexually transmitted diseases, and education) were taken into consideration.⁴

Discussion

For years, a clear delineation regarding the basis of increasing HIV infections among African American women has beleaguered researchers attempting to understand the phenomena. Certainly, part of this challenge has been the numerous factors that African American women face in treating and living with the disease. Furthermore, when those challenges are diverse, conventional strategies will need to be expanded to address empirically supported factors of causality taking into consideration the individuality of African American women including their environment, relationships, and cultural beliefs.

Two factors that serve at the core of STS (i.e., loss of self and fear) have been empirically supported as being associated with HIV infections and depression in African American women. The loss of self is linked to factors associated with loss of traditional role and loss of voice and fear is linked to such factors as poverty, history of abuse, and the fear of being wrong with the possibility of rejection. Even more, it is these same factors that are highly correlated with the Ecological model and depression providing further support that there is a strong association among silencing the self and depression as suggested by Jack.^10
–12

Findings from previous HIV preventive research are congruent with the concepts of STS,^10
–12 which suggests loss of self and fears are the core factors influencing the woman's views of living with depression. Research reinforces the notion that African American women who experience a loss of traditional gender role, loss of voice, history of abuse, and the fear of being wrong are at greater risk for HIV and depression. Therefore, understanding the African American woman's ecological status in developing appropriate HIV treatment and prevention strategies is essential. This extraction of knowledge will promote a culturally appropriate and gender specific approach, one that will address those factors specifically aimed at African American women, such as oppression, racism, and discrimination. Such an approach could also promote interventions designed at decreasing those factors that serve as barriers in living with the disease among the minority group.

The effect of depression on health promotion and prevention in health care is a significant issue. Still, only 12% of African American women seek help or treatment for depression.⁷⁰ A variety of explanations have been proposed to rationalize this lack of treatment, including the African American woman's perceived stigma of the disorder and their view of depression as a personal dilemma rather than a health problem.^60,62 Still, previous research presented establishes the importance of examining those factors associated with HIV and depression such as perceived stigma, dysfunctional problem solving, support, life threatening illness, fear of disclosure, and history of trauma. Future research endeavors should incorporate the African American woman's environment, relationships, and cultural beliefs. When holistic, culturally motivated, and gender specific care is the goal, balance amongst African American women, HIV, and depression may be enhanced.

Since the emergence of the global pandemic, HIV has been associated with mental stress⁷⁶ and numerous negative outcomes. Depression, a demonstrated maladaptive outcome of silencing the self, presents an immense challenge in the treatment of HIV in African American women. Depression in African American women has been recognized as a barrier in health maintenance and a hindrance in their ability of seeking healthcare. Silencing the self, the concealment of the African American woman's true feelings, setting aside her needs for others to promote a reduction of conflict in her relationships, is highly related to depression, and may perhaps, play an essential role in the prevention and treatment of the disease. Yet, there is limited research investigating the interrelationships among silencing the self, the Ecological model, depression, HIV, and their link to those negative sequelae such as loss of traditional gender role and loss of voice, stigma, educational attainment, history of abuse, and the fear of being wrong with the possibility of rejection. A greater understanding, specifically the association between self-silencing and the underpinnings of depression, may promote the development of culturally sensitive and gender specific interventions geared at African American women.

There is empirical support that numerous factors (i.e., racism, discrimination, perceived stigma, dysfunctional problem solving, support, diagnosis with a life threatening illness, and trauma) present challenges for African American women and their ability to overpower self-silencing behavior and possibly serve as deterrents in the prevention and treatment of HIV; yet no study has investigated their association collectively. For example, DeMarco et al.¹⁷ point out that silencing the self in African American women can be an impediment to safe sex negotiation, honest dialogue with healthcare providers, and self-advocacy in the context of health disparities and continued barriers to diagnosis and care after diagnosis. Still, regardless of this awareness, African American women continue to be hidden and isolated. By probing deeper into a more holistic view of silencing the self in African American women, this would assist nursing research in advancing culturally sensitive care, decrease the transmission of the HIV, and defeat depression. Furthermore, the ecological model proposes that comparable management occurs at every level from the ontogenic system to macroculture, crossing all phases of disease management and positive prevention.

The value of synthesizing the theoretical influences of the STS theory and SEM is to provide structure for conceptualizing the many influences regarding the adherence to medication, engagement in medical care, and sexual risk behavior of African American seropositive women. Some of those influences have a direct effect on African American women, while other influences have an indirect effect that trickles down through their relationships and immediate environments (i.e., exosystem and macroculture). Thus, it is for these reasons, future research should consider investigating the Ecological model and the dynamics of self-silencing and depression in African American women living with HIV as it may prove beneficial in HIV preventive intervention efforts. By taking into consideration how self-silencing takes many forms (i.e., stigma, depression, and risky sexual behavior), innovative ways to advance effective HIV preventive interventions in African American seropositive women future health promotion and preventive effects may prove more operative.

Footnotes

Author Disclosure Statement

Dr. Latrona Lanier and Dr. Rosanna DeMarco report no financial interests or potential conflict of interests with any entities whose products or services are related to topics in this article that could be interpreted as a conflict of interest.

References

Centers for Disease Control and Prevention. HIV Surveillance Report. Diagnosis of HIV Infection and AIDS in the United States and Dependent Areas, 2008; 20:1–143.

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 2007. Atlanta: U.S. Department of Health and Human Services. 2007; 19:1–63.

Clark

, Mayben

, Hartman

, et al. Conspiracy beliefs about HIV infection are common but not associated with delayed diagnosis or adherence to care. AIDS Patient Care STDs, 2008; 22:753–759.

Wyatt

. Enhancing cultural and contextual intervention strategies to reduce HIV/AIDS among African Americans. Am J Public Health, 2009; 99:1941–1945.

Wyatt

, Axelrod

, Chin

, et al. Examining the patterns of vulnerability to domestic violence among African American women. Violence Against Women, 2000; 6:495–514.

Ciesla

, Roberts

. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry, 2001; 158:725–730.

Miles

, Holditch-Davis

, Pederson

, et al. Emotional distress in African American women with HIV. J Prevent Intervent Commun, 2007; 33:35–50.

Moneyham

, Sowell

, Seals

, Demi

. Depressive symptoms among African American women with HIV disease. Schol Inquir Nursing Practice, 2000; 14:9–39.

Wingood

, Hardin

, DiClemente

, et al. HIV discrimination and the health of women living with HIV. Women Health, 2007; 46:99–112.

10.

Jack

. Silencing the Self: Women and Depression. Harvard University Press: Cambridge, MA, 1991.

11.

Jack

. Behind the Mask: Destruction and Creativity in Women's Aggression. Harvard University Press: Cambridge, MA, 1999.

12.

Jack

, Ali

. Silencing the Self across Cultures: Depression and Gender in the Social World. Oxford University Press: New York, New York, 2010.

13.

DeMarco

, Johnsen

, Fukuda

, Deffenbaugh

. Content validity of a scale to measure silencing and affectivity among women living with HIV/AIDs. J Assoc Nurses AIDS Care, 2001; 12:77–88.

14.

DeMarco

, Johnsen

. Vulnerable Populations: Women Living with HIV/AIDS. In: Mahoney

, Shaw

. (Eds.) HIV/AIDS Nursing Secrets. Philadelphia, PA: Hanely & Belfus, Inc, 2002.

15.

DeMarco

, Lanier

. The Concept of “Silencing the Self” in low income, aging, HIV-infected Black women: A ten-year community-based participatory program of research with results. J Assoc Nurses AIDS Care, 2014; 25:112–122.

16.

DeMarco

, Norris

. Women's Voices Women's Lives: A Web-Based HIV Prevention Film Project. Welie

JVM

, JLee (Eds.). Jesuit health sciences and the promotion of justice: An invitation to a discussion. Milwaukee, WI: Marquette University Press, 2004a.

17.

DeMarco

, Kendricks

, Dolmo

, et al. The effect of prevention messages and self-efficacy skill building with inner city women at risk for HIV infection. J Assoc Nurses AIDS Care, 2009; 20:283–292.

18.

DeMarco

, Stokes

. Midlife Black women living with HIV/AIDS in the United States: A treatment strategy using peer-led, structured writing in a group with global possibilities. Treatment Strategies-AIDS. Available at: http://viewer.zmags.com/publication/d4b7caf8#/d4b7caf8/1 (2010) (Last accessed March 12, 2014 ).

19.

DeMarco

. Supporting voice in women living with HIV/AIDS. In: Jack

, Ali

. (eds.), Cultural Perspectives on Womens' Depression: Self-Silencing, Psychological Distress and Recovery. NY: Oxford University Press, 2010.

20.

Jack

, Dill

. The silencing the self scale: Schemas of intimacy associated with depression in women. Psychol Women Quart, 1992; 16:97–106.

21.

Bronfenbrenner

. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University, 1979.

22.

Bronfenbrenner

. Making Human Beings Human. Bioecological Perspectives on Human Development. Thousand Oaks, CA: Sage Publications, 2004.

23.

El-Bassel

, Witte

, Gilbert

, et al. The efficacy of a relationship-based HIV/STD prevention program for heterosexual couples. Am J Public Health, 2003; 93:963–969.

24.

El-Bassel

, Caldeira

, Ruglass

, Gilbert

. Addressing the unique needs of African American women in HIV prevention. Am J Public Health, 2009; 99:996–1001.

25.

Eddy

, Donahue

, Webster

, Bjournstad

. Application of an ecological perspective in worksite health promotion: A review. Am J Health Studies, 2002; 17:197–202.

26.

Schaalma

, Abraham

, Gillmore

, Kok

. Sex education as health promotion: What does it take?. Arch Sexual Behav, 2004;2003;33:259–269.

27.

Burke

. Intimate partner violence among low income women: Associated individual and contextual risk factors. Violence Against Wom, 2005; 11:1140–1161.

28.

Bhattacharya

. Health care seeking for HIV/AIDS among South Asians in the United States. Health Social Work, 2004; 29:106–116.

29.

Crosby

, Yarber

, Myerson

. Prevention strategies other than male condoms employed by low-income women to prevent HIV infection. Public Health Nursing, 2000; 17:53–60.

30.

Pulerwitz

, Amaro

, DeJong

, et al. Relationship power, condom use and HIV risk among women in the USA. AIDS Care, 2002; 14:789–800.

31.

Yates

, Stellato

, Joannes

, Avis

. The importance of AIDS-related knowledge for mid-life and older women. AIDS Edu Prevent, 1999; 11:224–231.

32.

Berger-Greenstein

, Cuevas

, Brady

, et al. Major depression in patients with HIV/AIDS and substance abuse. AIDS Patient Care STDs, 2007; 21:942–955.

33.

Whetten

, Reif

, Whetten

, Murphy-McMillan

. Trauma, mental health, distrust, and stigma among HIV-positive persons: Implications for effective care. Psychosom Med, 2008; 70:531–538.

34.

Newman

, Williams

, Massaquoi

, et al. HIV prevention for Black women: Structural barriers and opportunities. J Health Care Poor Underserved, 2008; 19:829–844.

35.

Myers

, Sumner

, Ullman

, et al. Trauma and psychosocial predictors of substance abuse in women impacted by HIV/AIDS. J Behav Health Services Res, 2009; 36:233–246.

36.

Myers

, Wyatt

, Loeb

, et al. Severity of child sexual abuse, post- traumatic stress and risky sexual behaviors among HIV-positive women. AIDS Behav, 2006; 10:191–199.

37.

Wyatt

, Carmona

, Loeb

, Williams

. HIV-positive black women with histories of childhood sexual abuse: Patterns of substance use and barriers to health care. J Health Care Poor Underserved, 2005; 16:9–23.

38.

Laughon

, Gielen

, Campbell

, et al. The relationships among sexually transmitted infection, depression, and lifetime violence in a sample of predominantly African American women. Res Nursing Health, 2007; 30:413–428.

39.

Liu

, Longshore

, Williams

, et al. Substance abuse and medication adherence among HIV-positive women with histories of child sexual abuse. AIDS Behav, 2006; 10:279–286.

40.

Warren-Findlow

, Prohaska

. Families, social support, and self-care among older African-American women with chronic illness. Am J Health Promot, 2008; 22:342.

41.

Trzynka

, Erlen

. HIV disease susceptibility in women and the barriers to adherence. Med Surg Nursing, 2004; 13:97–104.

42.

Herek

, Capitanio

, Widaman

. HIV-related stigma and knowledge in the United States: Prevalence, and trends, 1991–1999. Res Pract, 2002; 92:371–377.

43.

Goffman

. Stigma: Notes on the Management of Spoiled Identity. Prentice Hall: Englewood Cliffs, NJ, 1963.

44.

Colbert

, Sereilca

. An examination of the relationships among gender, health status, social support, and HIV-related stigma. J Assoc Nurses AIDS Care, 2010; 21:302–313.

45.

Neely-Smith

, Patsdaughter

. The influence of self-esteem and self-silencing on self-efficacy for negotiating safer sex behaviors in urban Bahamian women. J Multicult Nursing Health, 2004; 10:15–27.

46.

Norris

, DeMarco

. The experience of African American women living with HIV creating a prevention film for teens. J Assoc Nurses AIDS Care, 2005; 16:32–39.

47.

Sanzero

, Corless

, Bunch

, et al. Self-care strategies for depressive symptoms in people with HIV disease. J Adv Nursing, 2005; 51:119–130.

48.

Ironson

, O'Cleirigh

, Fletcher

, et al. Psychosocial factors predict CD4 and viral load change in men and women with human immunodeficiency virus in the era of highly active antiretroviral treatment. Psychosom Med, 2005; 67:1013–1021.

49.

Liebschutz

, Geier

, Horton

, et al. Physical and sexual violence and health care utilization in HIV-infected persons with alcohol problems. AIDS Care, 2005; 17:566–578.

50.

Wolitski

, Janssen

, Onorato

. An overview of prevention with people living with HIV. In: Kalichman

(Ed.). Positive Prevention: Reducing HIV Transmission among People Living with HIV/AIDS. New York: Kluwer, 2005.

51.

Haynes

, Ackloo

, Sahota

, McDonald

, Yao

. Interventions for enhancing medication adherence. [Review] [455 refs][Update of Cochrane Database Syst Rev., 2005; 4:CD000011.

52.

Hunn

, Craig

. Depression, sociocultural factors, and African American women. J Multicult Counsel Devel, 2009; 37:83–93.

53.

Jones

, Ford

. Depression in African American women. J Women Social Work, 2008; 23:134–143.

54.

Vyavaharker

, Moneyham

, Corwin

, et al. HIV-disclosure, social support, and depression among HIV-infected African American women living in the rural southeastern United States. AIDS Edu Prevent, 2011; 23:78–90.

55.

Paranjape

, Bersntein

, St. George

, et al. Effect of relationship factors on safer sex decisions in older inner city women. J Women's Health, 2006; 15:90–97.

56.

DeMarco

, Miller

, Patsdaughter

, et al. From silencing the self to action: Experiences of women living with HIV/AIDS. Women's Health Care Intl, 1998; 19:539–552.

57.

DeMarco

, Johnsen

. Taking action in communities: Women living with HIV lead the way. J Commun Health Nursing, 2003; 20:51–62.

58.

DeMarco

, Lynch

, Board

. Mothers who silence themselves: Clinical implications for women living with HIV/AIDS and their children. J Pediatr Nursing, 2002; 17; 89–95.

59.

DeMarco

, Norris

. Culturally relevant HIV interventions: Transcending ethnicity. J Cult Diversity, 2004b;11:65–68.

60.

Nicolaidis

, Timmons

, Thomas

, et al. “You don't go tell white people nothing”: African American women's perspectives on the influence of violence and race on depression and depression care. Am J Public Health, 2010; 100:1470–1476.

61.

Carrington

. Clinical depression in African American women: Diagnosis, treatment, and research. J Clin Psychol, 2006; 62:779–791.

62.

Waite

, Killiian

. Health beliefs about depression among African American women. Persp Psychiat Care, 2008; 44:185–195.

63.

Waite

. Perceptions of treatment for depression among underserved African American women. J Chi Eta Phi Sorority, 2008; 53:14–19.

64.

Dale

, Cohen

, Cruise

, Brody

. Resilience moderates the association between childhood sexual abuse and depressive symptoms among women with and at-risk for HIV. AIDS Behav 2014.

65.

Abu-Bader

, Crewe

. Predictors of depression among African American women who were former welfare recipients: A path diagram. Best Pract Mental Health, 2006; 2:1–22.

66.

Grote

, Bledsoe

, Wellman

, Brown

. Depression in African American and white women with low incomes: The role of chronic stress. Soc Work Public Health, 2007; 23:59–88.

67.

O'Malley

, Forrest

, Miranda

. Primary care attributes and care for depression among low-income African American women. Am J Public Health, 2003; 93:1328.

68.

Ramos

, Carlson

, McNutt

. Lifetime abuse, mental health, and African American women. J Family Violence, 2004; 19:153–164.

69.

American Psychiatric Association, Office of HIV Psychiatry. HIV mental health treatment issues—HIV and clinical depression. Available at http://www.psych.org (2002) (Last accessed March 23, 2011 ).

70.

National Alliance on Mental Illness. African American women and depression. Available at: http://www.nami.org/Template.cfm?Section=Women_and_Depression&Template=/ContentManagement/ContentDisplay.cfm&ContentID=88884 (2009) (Last accessed August 9, 2013 ).

71.

Brown

, Keith

, Jackson

, Gary

. (Dis) Respected and (dis) Regarded: Experiences of Racism and Psychological Distress. In and Out of our Right Minds: The Mental Health of African American Women. New York: Columbia University Press, 2003.

72.

Settles

, Naverrete

, Pagano

, et al. Racial identity and depression among African American women. Cult Diversity Ethnic Minority Psychol, 2010; 16:248–255.

73.

Clum

, Chung

, Ellen

. Mediators of HIV-related stigma and risk behavior in HIV infected young women. AIDS Care, 2009; 21:1455–1462.

74.

Vyavaharker

, Moneyham

, Corwin

, et al. Relationships between stigma, social support, and depression in HIV-infected African American women living in the rural southeastern United States. J Assoc Nurses AIDS Care, 2010; 21:144–152.

75.

Sengupta

, Strauss

, Miles

, et al. A conceptual model exploring the relationship between HIV stigma and implementing HIV clinical trials in rural communities of North Carolina. N Carolina Med J, 2010; 71:113–122.

76.

Prachakul

, Grant

, Keltner

. Relationships among functional support, HIV-related stigma, social problem solving, and depressive symptoms in people living with HIV: A pilot study. J Assoc Nurses AIDS Care, 2007; 18:67–76.

77.

Sherbourne

, Forge

, Kung

, et al. Personal and psychosocial characteristics associated with psychiatric conditions among women with human immunodeficiency virus. Women's Health Issues, 2003; 13:104–110.

78.

Vance

. The relationship between HIV disclosure and adjustment. Psychol Rep, 2006; 99:659–663.

79.

Wyatt

, Myers

, Williams

, et al. Does a history of trauma contribute to HIV risk for women of color? Implications for prevention and policy. Am J Public Health, 2002; 92:660–665.

80.

Wyatt

, Myers

, Loeb

. Women, trauma, and HIV: An overview. AIDS Behav, 2004; 8:401–403.