Figure 2—Included Articles by Year (1980—2016)
Table 2 – Characteristics of Included Articles
Author(s)
|
Year
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Location
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Study Design
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Study Purpose
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Participants
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Adekeye et al. (58)
|
2014
|
Greensboro, NC
|
Qualitative; Photovoice; Community-based participatory research (CBPR)
|
Comprehend African immigrants’ views on their health and well-being, as well as barriers to their healthcare access.
|
Youth: 5 females and 5 males; Elderly: 1 woman and 4 men; Average age: N/A; Countries: N/A (West, North, East, South Africa)
|
Asare & Sharma (59)
|
2012
|
Cincinnati, OH
|
Quantitative; Cross-sectional
|
Understanding sexual communication behaviors among African immigrants, using health belief model (HBM) and acculturation.
|
Males: 249; Females: 163; Average age: 36.9; Countries: Ghana, Nigeria, Senegal, Cameroon, Kenya, Other
|
Blanas et al. (60)
|
2015
|
New York, NY
|
Qualitative; Focus Groups
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Assess factors that affect the access to medical care of African immigrants from French-speaking countries.
|
Females: 12; Males: 27; Average age: 39; Countries: Burkina Faso, Guinea, Mali, Senegal
|
Chu & Akinsulure-Smith (61)
|
2016
|
New York, NY
|
Qualitative; Focus Groups & Questionnaires
|
Examine the health beliefs of African immigrants regarding female genital cutting (FGC), across different demographics.
|
Females; Average age: 35.2; Countries: Sierra Leone, Guinea, Mali, Gambia
|
Daramola & Scisney-Matlock (62)
|
2014
|
Detroit, MI
|
Quantitative; Cross-sectional (Correlational Surveys)
|
Examine the interaction between migration and health behaviors of African immigrant women.
|
Females; Average age: 56.5; Countries: Nigeria
|
De Jesus et al. (63)
|
2015
|
Washington, DC
|
Qualitative; Semi-structured Questionnaire
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Explore health behaviors of East African immigrant women regarding HIV testing services.
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Females; Average age: 31; Countries: Ethiopia, Eritrea, Kenya, Tanzania, Uganda
|
Foley (64)
|
2005
|
Philadelphia, PA
|
Qualitative; Focus Groups
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Understand the cultural and structural barriers that affect African immigrant women’s access to HIV services.
|
Females; Average age: 32; Countries: Liberia, Sierra Leone, Mali, Senegal, Guinea, Ivory Coast, and Burkina Faso
|
Kaplan, Ahmed, & Musah (65)
|
2015
|
Kaplan, Ahmed, & Musah
|
Qualitative; Focus Groups
|
Comprehend how Ghanaian immigrants perceive their health experiences.
|
Females: 16; Males: 37; Average age: 45; Countries: Ghana, Gambia, Nigeria, Cameroon
|
Ndukwe, Williams, & Sheppard (66)
|
2013
|
Washington, DC
|
Qualitative; Focus Groups & Questionnaires
|
Assess the health behavior of African immigrants regarding breast and cervical cancer prevention services.
|
Females; Average age: 46; Countries: Ghana, Nigeria, Cameroon, Zambia, Ivory Coast
|
Raymond et al. (67)
|
2014
|
Minneapolis, MN
|
Qualitative; Focus Groups
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Assess the health behavior and attitudes of Somali immigrant women regarding cancer prevention services.
|
Females; Average age: ~40+; Countries: Somalia
|
Sellers, Ward, & Pate (68)
|
2006
|
Madison, WI
|
Qualitative; Focus Groups
|
Understand the health and well-being of black African immigrant women.
|
Females; Average age: 44; Countries: Ghana, Cameroon, Nigeria
|
Turk, Fapohunda, & Zucha (11)
|
2015
|
Western Pennsylvania, PA
|
Qualitative; Photovoice
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Assess the influence of cultural beliefs of Nigerian immigrants on healthy eating and physical activity
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Females; Average age: 34; Countries: Nigeria
|
Vaughn & Holloway (69)
|
2010
|
Cincinnati, OH
|
Qualitative; Narrative Interviews
|
Learn from West African immigrant families in Cincinnati about their perceptions, barriers
|
Females: 5; Males: 5; Average Age: N/A; Countries: Mauritania, Senegal
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Table 3 – Themes and subthemes generated from the analysis of included studies
Themes
|
Sub-themes
|
Examples
|
|
- Religiosity and Spirituality
· Complex U.S. healthcare system
· Cost of healthcare
· Biased/hostile provider attitudes
· Lack of trust of the U.S. health system
|
· ‘‘Why pay to find out that nothing is wrong? And why pay to find out that I have a costly problem that I can’t feel, like diabetes and high blood pressure?’’
· ‘‘God makes people differently and God creates people with imperfections. If you go to the doctor, God gives the doctor power to help.’’
· “In the eyes of a family with a person with hepatitis B, hepatitis B equals AIDS. If a family member is sick, the family no longer has the same image in the community.”
· ‘If you don’t speak English, they just ignore you, or you can’t even understand your name when they call it.”
· “If I’m seeing a doctor here, the doctor doesn’t understand what I’m eating in terms of the African dishes…”
· “Whenever I have a hospital visit coming up, I always pray and fast for days to ensure it goes well.”
· “Hospital visits are expensive; unfortunately, there are very few ethno-medical centers. In America, I don’t have access to local herbs...local herbs work!”
· “If you go to a hospital and you are wearing African clothing, they don’t even want to touch you. They think we bring diseases from Africa.”
· “Cancer will kill you anyway…it is a cover-up meant to use African immigrants as guinea pigs.”
|
Identified themes
The two over-arching themes derived from the data analysis were the influence of culture on the provision of health care and negative experiences of the African immigrants with the U.S. healthcare system. Each one, along with the sub-themes, is discussed below.
Cultural Influence
Traditional Beliefs
Cultural perspectives of diseases and illness determine healthcare behaviors, which in turn shape healthcare experiences. Eight articles discussed the impact of culture on the healthcare experiences of African immigrants in the U.S.. (11,58,65,66,68–71). In African immigrant communities, for example, diseases such as HIV and cancer are viewed as the result of spiritual issues? Therefore, it is not uncommon for many African immigrants to consult oracles and traditional healers in their home countries, regarding those types of health problems (69,70). The study by Kaplan et al., showed it was common for participants to delay office visits until the diseases or illnesses were certifiably irreversible or severe enough to halt daily activities (65). Results from another study showed HIV-positive African immigrant women sought treatment when the condition was already in its late stage (71). In one study, participants believed that unnecessary physician contact would lead to unwanted diagnoses. In which case an unwarranted exam would be tantamount to tempting fate. Thus, seeing a doctor was reserved for cases requiring immediate medical treatment. (66). Prior to their migration to the U.S., many African immigrants utilized herbal remedies for different health problems. In the U.S., the fear that such options may not be explored by healthcare providers, resulted in office visits and routine checks being viewed by some participants as waste of time and resources, especially given the high cost of healthcare (68). Participants’ deference to their culture also had dietary implications. Turk and co. (2015) discovered some participants had problems with their providers’ dietary recommendations. These participants found it difficult to replace their long-held cultural perspectives regarding food and health due their contrasting outlook on body size. Whereas a big body size was considered unhealthy in the U.S., it was regarded as a sign of healthy eating in their cultures (11). In addition, they described the fast-food culture in the U.S. not only as inescapable but problematic, due to its incongruence with their own cultural views of food preparation and consumption (58,65).
Religiosity and Spirituality
The influence of African immigrants’ religious and spiritual outlooks on health and well-being was presented in eight articles (58,62,63,66,67,69,70,72). In Vaughn and Holloway’s study, both the Muslim and Christian participants ascribed health status and outcomes primarily to God. They believed in spite of their efforts, their ultimate health outcomes were beyond their, or anyone’s control. Therefore, even if physicians were able to treat them successfully, that could only happen through divine assistance. Participants explained health imperfections such as illnesses and diseases as the consequences of human inadequacies, from which no one was exempt (69). One study found that Muslim participants believed death by disease was a result of the expiration of a person’s time on earth. According to the participants, if it was God’s will that one would die from cancer for example, then there was nothing anyone could do about it. Conversely, if it was not destined for one to die yet, then despite such a disease, one would still live (63,67,70). Findings from a study of key-informant focus groups indicated the African immigrant women participants were reluctant to go for cancer screening, due to their belief that their health was determined by God, who would shield them from diseases not meant for them (66). Other participants felt Western medical care was mainly dependent on human abilities to rectify health problems, and almost negligent of the roles of spirituality and God in shaping human health (72).
This connection between spirituality and health also influenced how the participants viewed preventive healthcare. Some participants refused to answer hypothetical questions about what they would do, were they to be diagnosed with diseases such as cancer. Their rationale was that words and thoughts could affect one’s life outcomes, such as health experiences. Therefore, speaking about adverse events hypothetically was equivalent to invoking them into one’s life (62). The Christian participants in the study expressly rejected the question, stating that it was not their lot to suffer from such diseases (66). In addition, Adekeye et al., found a connection between African immigrants’ religiosity and dealing with mental health. Both the Christian and Muslim participants described their church and mosque attendance respectively, as necessary for coping with life’s challenges. In their views, religiosity was instrumental in shaping healthy spiritual lives, which was crucial for overall health and well-being (58).
Stigma in the African community
The significance of culturally-situated stigma in the healthcare experiences of African immigrants in the U.S., was identified in eight studies (59,60,63–68). Blanas et al., found that one of the reasons why the African immigrant participants in their study did not make use of certain healthcare services in the U.S., was the resultant negative reactions individuals within their communities. They explained that even when the services were preventive and did not involve subjects commonly regarded as taboo, such as sexual health, they still attracted stigma from their communities (60). This experience was applicable to participants in another study which focused on utilization of human immunodeficiency virus (HIV) prevention services. The participants emphatically preferred not knowing their status to the potential stigma and social consequences from utilizing such services, especially with HIV-positive results. According to these participants, merely going to get tested was sufficient to elicit stigma in their communities; many would deem that a positive confirmation (63). Healthcare-related stigma within African immigrant communities is not restricted to sexually transmitted diseases or infections. Participants in the study by Ndukwe et al., explained that cancer was perceived as a curse in their communities. Consequently, the notion that the person with a cancer diagnosis has been cursed spiritually, translated to avoidance of, or cautious interaction with, the affected person (66). Another group of participants interviewed by Raymond et al., equated cancer with HIV, in terms of perception. According to them, because both diseases were viewed by community members as death sentences and shameful, family and friends tended to be distant from the sufferer (67).
Although not linked with death as are HIV and cancer, depression is also stigmatized within African immigrant communities. Results from Sellers et al., revealed that even when participants were aware of depression, the fear of the stigma attached to being identified as depressed within their community often overrode the desire to seek treatment. According to the participants, depression was viewed as a conception and condition of white people in their communities (68). Also, because depression was not a recognized mental health condition in many African cultures, some participants could not differentiate between health issues referred to in the U.S. as mental health problems, such as bipolar disorder, from those commonly known as “madness” in their home countries, which described mentally ill individuals roaming the streets (68). Furthermore, the impact of health-related culturally-situated stigma within African immigrant communities, also extended beyond the affected individuals. With a cultural emphasis on a good reputation, many participants expressed fear of what would happen to their families’ standings, were it to be known that they suffered from dreaded health problems, such as cancer and mental illness. Thus, they would rather not find out their health status (63). Even when they decided to utilize healthcare services, participants’ perceptions of privacy were an obstacle. For instance, results from Foley’s study indicated participants saw confidentiality, as managed by U.S. providers as inadequate, due to concerns about insufficient anonymity (64). In addition, some participants suspected certain healthcare facilities were more interested in testing them unnecessarily during office visits. They feared it was only a matter of time before their private data were compromised and their livelihoods jeopardized, especially in cases of positive results for stigmatized diseases (65).
Linguistic Discordance
Three studies discussed how the impact of language on the healthcare experiences of African immigrants in the U.S.. (64,65,67). Some participants experienced difficulties with translating their health needs to terms and concepts understood by U.S. providers, especially in dire circumstances. Other participants believed the language barriers they encountered were exacerbated by negative provider attitudes towards them (64). This challenge was also pointed out by participants in the study by Kaplan et al., who felt their communication with U.S. providers would be greatly improved if the providers were more patience and less dismissive. To the participants, the poor attitudes resulted from those providers’ prejudiced expectations of language barriers from their interactions with their African immigrant patients (65).
According to some participants, productive interactions with U.S. providers entailed more than linguistic competency or availability of translators. Cultural know-how, in their views, was an inseparable aspect of effective healthcare communication. These participants’ interactions with providers were compounded by different cultural names and descriptions which were difficult to fully translate into the English language (67). This was true even for Somali immigrants, who, despite having the highest number of translators in the public service sphere, continue to find their interactions with U.S. challenging., Participants regarded this wearisome communication with providers as a deterrent to their healthcare access, due to their fears their health needs would be unmet, or they would receive wrong treatments (67).
Adverse experiences with the U.S. healthcare system
Lack of culturally-competent providers
The absence of healthcare sensitive to the backgrounds of African immigrant patients, was a pervasive theme in six articles (11,58,65,67–69). Participants in one study were disinclined towards office visits, because they feared they would result in complications, due to providers’ lack of understanding of their health needs. Not only did the participants regard those unproductive office visits as a waste of scarce resources, they considered them justifications of their lack of trust in the health system (58). Also, participants explained that their unique cultural and healthcare backgrounds received little to no attention from the providers. In their views, those encounters constituted missed opportunities for the providers to gain broader, deeper understanding of their patients, which would have resulted in more informed interactions, and effective treatment decisions. According to the participants, even when they initiated efforts to bridge the providers’ knowledge-gap, the outcomes were still the same, due to the providers’ unaccommodating outlooks (58).
In another study, participants expressed their dissatisfaction about not being asked about their cultural or religious beliefs, which could interfere with their care. They described those omitted questions as crucial, with the power to improve effectiveness of care, though they might have seemed trivial to the providers (65). According to other participants, the Christian or Muslim faith came with certain considerations in healthcare, including gender-roles in patient-provider interactions, and treatment options, none of which was addressed in their interactions with providers (67). Some participants described this experience as a double-edged barrier, because their backgrounds and preferences were often excluded from their healthcare, leaving them only with the providers’ approaches, to which they had difficulties comprehending and adhering (69). For example, some participants described how providers would often recommend difficult modifications to their diets, such as substituting one of their culturally staple foods, but without any guidance to help them achieve those goals (11). Results from the study by Sellers et al., showed participants preferred physicians from comparable ethnicities, or, with whom they could relate. They described interactions with these types of providers as more emotionally soothing, effective, and less resource-consuming, due to quicker resolution of their health challenges (68).
Complex U.S. healthcare system
Difficulty navigating the U.S. healthcare system was discussed by four studies (58,64,68,69). However, this barrier did not present itself similarly in every setting. Results from the study by Adekeye et al., indicated participants ascribed their challenges with navigating the complicated U.S. healthcare system, mainly to linguistic discordance. To them, this barrier was not only in reference to low English language proficiency, but also lack of understanding of the culturally divergent aspects of the U.S. healthcare system, including terms and policies. Some participants highlighted inundation with excessive information and paperwork, with little or no guidance towards grasping their import, as a key challenge (58). Other participants, although they had health insurance coverage, described as difficult, utilizing healthcare services, due to the challenges with deciphering which services they were eligible for and which providers were suitable (64). Results from the study by Sellers et al showed participants viewed the U.S. healthcare system as the most challenging aspect of their immigrant experiences. They described their healthcare experiences as replete with emotional and mental anguish, emanating from caring for the sick individual while navigating the myriad barriers to care, and knowing that the problems might not be adequately addressed (68).
Cost of healthcare
Five articles described the relationship between the cost of healthcare in the U.S. and the healthcare experiences of African immigrants (58,60,64–66). In the study by Adekeye et al., participants identified high cost of care and the lack of western treatment alternatives, as the key barrier to their access to healthcare. Also in their views, the western assessment of African treatments as quack, inadvertently contributed to high cost of care, since it left them without cheaper alternatives (58). Due to the exorbitant healthcare costs, some participants regarded preventive care or cases not perceptibly serious, as resource-wasting. Their rationale was that spending a lot of time and money to determine the presence of a health problem would be fiscally irresponsible, if it turned out nothing was wrong (65).
According to findings by Foley, when participants did go to the doctor, they felt it difficult to find out that the services they received were not well-covered by their health insurance. This did not only disincline the participants towards subsequent visits, it also further reduced their already distrustful views of providers, who they felt were not looking out for them as patients (64). The problem of high healthcare cost was compounded for participants without health insurance. They could not afford the payments because they held jobs that neither provided health insurance nor paid high enough salary to allow the participants to afford healthcare services (60). Also, participants cited the lack of transportation as one of the contributors to the high cost of care. Due to family members and friends always working, and unfamiliarity with, or absence of an easily accessible transit system, often the participants could not take advantage of some healthcare services, even including free screenings (66).
Biased/hostile provider attitudes
Five articles discussed the negative? role of discrimination in the healthcare experiences of African immigrants in the U.S.. (58,64,65,69,70). In one study, the participants believed that their accents or dressing styles often triggered unfavorable provider attitudes. They described their poor experiences including hostile, condescending staff approach, and provider dismissiveness and reliance on African cultural stereotypes (58). In another study, participants described the perfunctory manners providers interacted with them, both in-person and on the telephone. The participants described that they and their health needs, being considered as undesirable encumbrances by providers, made then feel disrespects and humiliated, rendering the prospect of interacting with providers, difficult? (69).
Additionally, adverse provider behaviors towards African immigrants were not restricted to one race or ethnicity. According to Foley’s study results, participants’ accents, looks, names, amongst other background information, elicited some type of hostile attitudes from both white and black providers (64). Other participants described their experiences with providers whose approaches were mainly derived from uninformed or stereotypical information about African immigrants, which were manifested in the providers’ questions or comments about their health issues. Still, other participants felt they were unreasonably subjected to certain tests as a result of the providers’ suspicions, founded on related stereotypes. For this reason, the participants felt targeted and avoided those locations as well as growing more distrustful of other providers (65). Findings from Opoku-Dapaah’s study revealed a similar pattern. Participants avoided certain healthcare services, including cancer screenings, due to their suspicions that the services provided to African immigrants were more harmful than those received by their White counterparts (70).
Lack of trust of the U.S. health system
Three articles discussed African immigrants’ distrust of the U.S. health system and its healthcare implications (67,68,70). According to the study by Sellers et al., participants’ lack of trust in the U.S. healthcare system, was inspired by the unwelcome ways they felt African immigrants and blacks in general were targeted in their personal and public domains (68). Other participants did not believe U.S. providers had the best interests of African patients at heart, and even if they did, they felt those providers were equipped with adequate information or tactics. Also, some of the participants were convinced the health of some of their community members deteriorated after receiving western medical treatment. They expressed their unwillingness to fully acquiesce to the views of US providers, because they may not be aware of, or care about, the adverse effects of western medical approaches on African immigrants (68). In addition, some participants’ distrust of the U.S. health system emanated from their negative views of the possible role of the pharmaceutical industry. They believed that the operational philosophy of the pharmaceutical industry primarily targeted the general public’s susceptibilities. For instance, it was their views that the expensive medical interventions were inventions of the pharmaceutical industry, primarily aimed at profiteering, while cancer screenings were smokescreens used to identify unwitting Africans as possible participants in pernicious Western health research (70). Some participants in a study by Sellers et al believed certain medications would result in previously absent health complications, or the exacerbation of existing ones. They were convinced they would be left to bear the brunt of the cost should that happen, while the drug manufacturers’ agenda of profiting from people’s health challenges would remain uninterrupted (68).