Mental health is influenced by social and structural factors. According to the CDC, social determinants that increase the likelihood of poor mental health include experiencing interpersonal and institutional discrimination, and lack of access to education, housing, healthcare, employment, and economic opportunities (12). Other risk factors include adverse childhood experiences and other types of interpersonal violence and social isolation (12). Despite experiencing multiple risk factors and being overburdened with social inequities, mental health often goes under-reported in Black Americans (13, 14). A review of the literature revealed that underdiagnosis in Black women impacts prevalence rates (8, 14).

The mental health of Black women is also complicated by structural determinants of health, such as gendered racism (2). Gendered racism is defined as the complex oppression experienced by women of color based on the simultaneity of racism and sexism (15). Gendered racism often manifests as microaggressions. Gendered racial microaggressions (GRM) are subtle and daily verbal, behavioral, and environmental expressions of oppression based on the intersection of one’s race and gender (16). GRM has been related to a myriad of adverse mental health outcomes, including psychological distress and depression (16–21).

Though the mental health impact of experiencing GRM is clear, much of the extant literature is based on college samples and those with higher incomes (16–20). There is a dearth of literature on the relationship between GRM and the mental health of rural Black women in the Southeastern U.S. The purpose of this study is to explore the relationships between gendered racial microaggressions (GRM) and mental health within a rural community sample of Black women.

To understand GRM, we draw from two theoretical frameworks, intersectionality and racial microaggressions. Intersectionality theory (22, 23) has been applied to public health equity research (24, 25). Intersectionality posits that women of color experience multiple, inseparable identities based on race and gender/sex that are tied to multiple marginalizations, such as racism and sexism. An intersectional approach uncovers the health outcomes of women of color made invisible by single-lens metrics that focus on race or gender. Rather, an intersectional lens to health understands that race and gender are inseparable, socially constructed through norms and policies, and vary based on other social identities (e.g., social class, ability, age, immigration history) (25). Thus, gendered racism provides a more complete view of Black women’s experiences of discrimination as it accounts for their gender and race, Gendered racism may be experienced as microaggressions (16). Racial microaggressions theory (26) suggests that subtle forms of oppression are normalized and stem from the idea that racism is normalized, woven into the fabric of American society, and may appear ordinary (15). Identity-based microaggressions include intentional and unintentional insults, putdowns, invalidations, slights, and offensive behaviors as well as through environmental policies and ideologies that cumulatively harm mental health (25).

Depression is severe yet underdiagnosed in Black women. Depressive symptoms often manifest differently in this population due to the influence of social and structural determinants of mental health (33). Absent research that specifically focuses on rural Black women and risk factors such as GRM, prevalence rates will remain unknown. This study aims to determine the prevalence of depression and psychological distress among Black women in rural Alabama and explore the relationship between depression and GRM while controlling for sociodemographic characteristics among Black women in rural Alabama. We also sought to explore the relationship between psychological distress and GRM while controlling for sociodemographic characteristics among Black women in rural Alabama.

As part of a parent community-based participatory research (CBPR) study (11), community health surveys were administered in five rural Alabama communities. The purpose of the CBPR study was to assess health concerns among residents. The study was implemented in partnership with the Alabama Conference of Black Mayors. Community member representatives, selected by their respective mayors because of their knowledge and engagement in their communities, facilitated the data collection process. Convenience sampling was used to recruit participants through a variety of community events. Paper and pencil surveys were distributed at community events organized by the mayors of each community. The events included health fairs, vaccine clinics, and community education meetings. Surveys were also administered via canvassing the community to obtain a representative sample. Each representative completed an orientation process consisting of human subjects research training. Results of the parent study suggested a high prevalence of mental health concerns among residents. In consequence, an additional data-collection phase was added to further identify the mental health concerns of Black women. The University of Alabama’s institutional review board approved this study, protocol #21-03-4465.

Enrolled participants (n = 206) were self-identified Black women living in rural Alabama communities, aged 18 and older. Verbal consent was obtained from all participants before the study commencement.

Inclusion criteria involved self-identification of Black race, female gender, residence in a rural Alabama community among adults over the age of 18. Participants with completed surveys containing non-missing values for depression and psychological distress were eligible for study inclusion. Surveys with missing depression and psychological distress (n = 6) scores were excluded from the analyses. The final analytic sample included 200 participants.

The Gendered Racial Microaggressions Scale (GRMS) is a 26-item multidimensional validated scale that assesses the lifetime frequency and stress appraisal of gendered racial microaggressions (16). A sample item includes: “Someone accused me of being angry when I was speaking in a calm manner.” The GRMS frequency composite is scored using a 6-level response scale, ranging from 0 to 5 where 0 = “never,” 1 = “less than once a year,” 2 = “a few times a year,” 3 = “about once a month,” 4 = “a few times a month,” and 5 = “once a week or more.” The GRMS stress appraisal composite is scored using a 6-level response scale, ranging from 0 to 5 where 0 = “this has never happened to me,” 1 = “not at all stressful,” 2 = “slightly stressful,” 3 = “moderately stressful,” 4 = “very stressful,” and 5 = “extremely stressful.” For each composite, total scores are found by averaging the 26 items; this generates a scoring scale with a range of 0 to 5. GRMS consists of four subscales specific to Black women: beauty assumptions and sexual objectification, silenced and marginalized, Strong Black Woman, and Angry Black Woman. The GRMS frequency (α = 0.95) and stress appraisal (α = 0.97) composites had good internal consistency for this sample (16).

The Patient Health Questionnaire (PHQ-9) assesses the severity of self-reported depressive symptoms over the past two weeks (27). We used eight of the nine questions, known as PHQ-8. The ninth item was deleted as it asks about suicidal attempts and ideation. Although DSM-IV criteria assess suicidal ideation, this item was deemed inappropriate for nonclinical research that lacks the ability to conduct an appropriate intervention (28). A sample item reads, “Over the past two weeks, how often have you been bothered by the following problems? Little interest or pleasure in doing things.” Response categories for each item are based on a 4-point Likert scale where 0 = “not at all,” 1 = “several days,” 2 = “more than half the days,” and 3 = “nearly every day.” Total scores are found by summing the eight items. For scores ≥10, the PHQ-8 has high sensitivity and specificity for depression (27). In this study, scores ≥10 indicate current depression. The PHQ-8 had good internal consistency for this sample (α = 0.91). Higher scores indicate increased depression severity.

The Kessler 6 (K6) is a six-item validated scale that measures non-specific psychological distress (PD) during the past 30 days (29). A sample survey question is, “During the past 30 days, about how often did you feel nervous?” Item responses are based on a 5-point Likert scale from 0 to 4 where 0 = “none of the time” and 5 = “all of the time” (21). Total scores are found by summing the scores from all six questions. Psychological distress scores range from 0 to 24 with scores from 0 to 4 classified as none or low mental distress, scores from 5 to 12 indicating moderate mental distress, and scores ≥13 indicating serious mental distress, possibly warranting further assessment (30). The K6 had good internal consistency for this sample (α = 0.86).

The following sociodemographic characteristics were considered as independent variables in this study: age, education, income, and relationship status. For analysis purposes, we operationalized these variables as follows: age (continuous), education (some high school (reference); high school diploma or GED; some college or college degree), income [≤ $2,999 (reference); $25,000 to $49,999; ≥ $50,000], relationship status [married; not married (reference)]. GRMS frequency and stress appraisal composite scores were also included as covariates.

Descriptive statistics were used to summarize characteristics of the cohort using means and standard deviations for continuous variables and frequencies and percentages for categorical characteristics. We used linear regression to independently examine the association between depression and psychological distress outcomes, GRMS frequency, and stress appraisal composite scores while controlling for age, education, income, and relationship status. We did not impute missing data. Participants missing values for outcome measures were excluded from the analyses. The significance level for comparisons was set at p ≤ 0.05. JMP Pro 18 was used for all analyses.

Participants (N = 200) were Black females and were, on average, 56.6 years (SD = 16.1). The majority (26.3%, n = 45) had completed high school, 21% reported earning a college degree, and 96.7% identified as non-Hispanic. Over half of the sample (51.2%) earned an income of less than $24,999. The relationship status reported by most participants (31.5%) was married; see Table 1.

In this sample, the mean depression score was 6.0 (SD = 6.3, Range: 0–24) with 43 (21.5%) reporting depression (PHQ-8 ≥ 10). For psychological distress, 13 (6.5%) reported serious (K6 ≥ 13), 62 (31%) reported moderate (K6: 5–12), and 125 (62.5%) reported none to low mental distress, with a mean of 4.5 (SD = 4.7, Range: 0–24), Table 1. The GRMS composite subscale of stress appraisal was positively correlated with depression, r (127) = 0.27, p = 0.002, but not with frequency (p = 0.237). As stress appraisal increases, depression increases. Neither GRMS frequency nor stress appraisal was significantly correlated with PD, all p > 0.05; see Table 2.

GRMS frequency and stress appraisal were assessed in different models per outcome as they were highly correlated. Due to multicollinearity, income was not included in the regression models. The final regression models best explain the variation in depression, psychological distress, GRM, and demographic characteristics. Missingness among GRMS frequency and stress appraisal composite scores was evaluated in this sample. Neither were associated with model covariates nor outcomes, all p ≥ 0.05.

Depression was significantly associated with GRMS stress appraisal, [F (1, 125) = 10.1, R² = 0.074, p = 0.002]. For every unit increase in stress appraisal, depression scores increased by 1.2 units; see Table 3. Models containing GRMS frequency and other covariates were not statistically significant, p > 0.05.

Psychological distress was significantly associated with education, but not with GRMS stress appraisal (p = 0.9212), [F (3, 104) = 2.7, R² = 0.072, p = 0.0483]. Compared to those who completed some high school, participants with some college or a college degree saw a decrease of 3.5 units in psychological distress scores, and participants with a high school diploma or GED saw a decrease of 1.5 units; see Table 4. In a separate model, psychological distress was significantly associated with education, but not with GRMS frequency, age (p = 0.0779), or relationship status (p = 0.4055), [F (5, 136) = 2.5, R² = 0.084, p = 0.0331]. Compared to those who completed some high school, participants with some college or a college degree saw a decrease of 3 units in psychological distress scores, and participants with a high school diploma or GED saw a decrease of 1.1 units; see Table 5.