Racially minoritised black women’s experiences of depression and barriers and facilitators to utilising healthcare services in high-income countries: a systematic review and qualitative evidence synthesis co-analysed and co-written with experts by ex

Abstract Background Black women have a high prevalence of depression. However, they are underrepresented in healthcare services, limiting our understanding of their experiences and the barriers and facilitators they face when seeking care. To address these race and gender inequalities, we aimed to conduct a qualitative evidence synthesis and develop an interpretive mechanistic framework examining the structural, social and cultural factors shaping depression and help-seeking among Black women. Experts by experience contributed to the analysis, synthesis and interpretation of findings, recommendations and manuscript writing. Methods We searched seven databases (ASSIA, MEDLINE, APA PsycInfo, Sociological Abstracts, CINAHL, AMED and EMBASE) with English-language restrictions from inception to December 2025. Eligible studies were qualitative or mixed methods studies examining experiences of depression or low mood and related help-seeking behaviours among Black women aged 18 + living in high-income countries where they are considered racially minoritised individuals. Study quality was assessed using the CASP, and confidence in findings was evaluated using the Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual). PROSPERO registration: CRD42022304571. Results The search retrieved 29,056 records, of which 12,148 were duplicates, leaving 16,908 records for screening. Fifty-eight papers published between 1994 and 2025 were included and thematically analysed. Studies were generally well reported, and of the 11 themes developed, 10 were rated as high confidence and 1 as low confidence. Depression was associated with race and gender-related stressors (i.e., racism), social isolation, and loss of faith, with the Strong Black Woman Schema (SBWS) masking symptoms. Barriers to care included mistrust of healthcare providers, stigma, religious coping, and societal pressures. Facilitators included a good rapport between women and their clinicians, faith leader endorsements, and crisis points. Conclusion The SBWS may encourage some Black women to minimise, conceal or interpret distress in ways that delay recognition and help-seeking. By highlighting how these expectations may shape some women’s experiences, we offer clinicians a framework for exploring distress, functioning and help-seeking within the woman’s social and cultural context. Our findings and interpretive mechanistic framework can inform the development and evaluation of culturally adapted interventions and outreach programmes aimed at supporting earlier recognition, engagement and care.