Understanding the healthcare experiences and needs of African immigrants in the United States: a scoping review

The health of African immigrants in the United States (U.S.) is a vastly under-studied topic, despite the rapidly increasing size of the population and its uniqueness. African immigrants make up about 5% of the U.S. population, which represents a 41% increase from the year 2000 [1]. More than 36% of them arrive from West Africa, followed by 29 and 17% from Eastern and Northern Africa, respectively. Over 14% of African immigrants in the U.S. come from Nigeria, followed by 10% from Ethiopia [2]. Factors contributing to the migration of Africans to the U.S. include family reunification, political disturbances in their country of origin, and education. Other reasons include the diversity lottery program, and brain drain [3, 4]. For instance, many African physicians and nurses migrate to the U.S. for higher-paying opportunities, leaving behind dilapidated health systems in their home countries [5, 6]. The healthcare experiences and needs of African immigrants are not universal, and research has shown there is considerable variation in healthcare experiences across populations [7, 8]. Prior to their arrival in the U.S., many African immigrants face severe health threats such as war, extreme poverty and mental health challenges, in their countries of origin [9]. Consequently, many African immigrants already carry significant health vulnerabilities upon arrival in the U.S., which can only worsen without proper healthcare access [10].

The paucity of knowledge regarding the healthcare experiences and needs of African immigrants in the U.S. due to two main factors: the absence of research or funding on immigrant health focused on this population [11], and the view that all black populations in the U.S. are the same [12]. The majority of research on immigrant healthcare in the U.S. has concentrated on populations from Latin and some Asian countries. However, the healthcare needs and experiences of other immigrant populations cannot be assumed to be identical to those of African immigrants. Also, African immigrants, which primarily comprises African Americans and Caribbean immigrants are often included in the “black” category [13‐17]. This monolithic view of the black population in the U.S. bears serious health and healthcare implications for African immigrants, because while an Africa-born black immigrant and a U.S.-born black citizen may be phenotypically similar, their health beliefs and health outcomes may differ [18, 19]. For instance, babies born to Africa-born black mothers were found to have higher birth weights than those born to U.S.-born black mothers [20]. Also, African immigrants have shown lower prevalence of cardiovascular risk factors, including hypertension and diabetes, than African Americans [17]. Merging these groups obscures the distinctions that may exist within them, including the unique cultural backgrounds and healthcare experiences of African immigrant community [15‐17, 21, 22].

Previously published studies have sought to gain insight into African immigrant health in the U.S., with focus ranging from barriers to healthcare—including cancer and HIV screenings [9, 10, 13, 23‐25]—to dietary health and health status [11, 26‐30]. However, the study results did not provide insight into the underpinnings of the healthcare experiences of African immigrants in the U.S. In addition, there have been a few projects aimed at understanding African immigrant health in other countries. Those studies revealed a number of barriers to African immigrants’ healthcare access that were similar to U.S. studies [31‐33]. For instance, African immigrants in other countries, like in the U.S., were found to be often viewed as a part of a larger homogeneous population [34‐36]. However, unlike in the U.S., in some other countries, African immigrants are grouped together in the same immigrant population with Asian and Latin Americans [37, 38]. While these studies have contributed to the African immigrant health knowledge-base, healthcare experiences and needs of Africans in other countries or continents cannot be assumed to match with those of U.S. African immigrants. For instance, the ways health insurances are operated in other countries may not be obtainable in the U.S. [39, 40]. In addition, policies that may affect health and healthcare access vary across countries [41, 42]. The current scoping review assesses existing data on the healthcare experiences and access barriers specifically of African immigrants in the U.S., with the aim of understanding the both impact of those experiences, and the putative underlying causes.

A Scoping Review is ideal for the initial step in understanding African immigrant health due to its usefulness for exploring an issue that has not been well studied [43, 44]. Following Arksey and O’Malley’s Scoping Review framework, the review was carried out in five stages: (a) research question identification, (b) identification of relevant studies, (c) screening of studies, (d) data extraction and synthesis, and (e) presentation of results [43]. This study was approved by the Indiana University Institutional Review Board (IRB) as a part of an overarching study that examined the healthcare experiences of African immigrants.

A PRISMA flowchart delineating the article screening process is represented in Fig. 1. The entire screening process yielded a total of 1446 articles, of which 206 were duplicates. Additional 644 were rejected for not meeting the inclusion criteria, including those in different languages from English, and studies not conducted in the U.S.. Of the remaining articles 596 articles, 240 were excluded for not meeting additional criteria for inclusion, including articles based on secondary data. Articles derived from secondary databases were excluded because those data were not primarily collected to examine African immigrant healthcare experiences. As such, they lacked the necessary indicators for understanding the problem. Also, studies deemed insufficiently empirical, including those conducted with surveys, but lacking qualitative data analyses, were excluded. Of the 356 remaining articles, 342 were rejected for ineligibility for inclusion, including those that had refugees as participants, studies not focused on the healthcare experiences or behavior of African immigrants, and articles we could not access.

This study’s findings have highlighted two themes that underline some of the healthcare experiences of African immigrants in the U.S.. Culture and spirituality inform the ways African immigrants perceive their health and healthcare experiences, as shown by both the explicit and nuanced roles of traditional beliefs, stigma within the community, and language variance. The importance that African immigrants place on their culture with regard to health, seem supported by evidence of its health benefits. Studies of African immigrants in both the U.S. and Australia found a link between African-style diets and lower health risks, including obesity [76, 77]. Agyemang et al., found that well acculturated Ghanaian immigrants in the Netherlands had higher levels of cardiovascular risks [78], while another study showed higher colon cancer risk among African Americans in the U.S. than Africans in their home countries [79]. Understanding African immigrants’ health beliefs is critical due to potential discordance with U.S. providers’ views. For instance, a common African health perception equates higher weight with better nourishment, and lower weight with malnourishment or illness, a notion that is opposed to the predominant cultural view in the U.S. [77, 80]. Also, the perception of diseases among African immigrants has been found to emanate largely from pre-migration notion of diseases which associates most of them with spiritual origins, including cancer [73, 81]. In addition, the U.S. healthcare system presents some challenges to African immigrants, including the lack of culturally sensitive care, cost of care, complexity, and hostile provider attitudes that reinforce the lack of trust in the system. While the complexity and high costs associated with the U.S. healthcare system may not be unique to African immigrants [82, 83], their poor treatment by the U.S. medical institution is idiosyncratic [73, 84, 85]. This contributes to the pre-existing distrust of the U.S. healthcare system, which makes it difficult to engage them in intervention programs and research [86]. Contrary to the well-documented mistreatment of African Americans by the U.S. health system, including the Tuskegee Syphilis experiment [87], the underpinnings of the cynicism among African immigrants towards the U.S. healthcare system, have not yet been well identified [75].

Despite the insight provided by this study and other research examining the healthcare experiences of African immigrants, some knowledge-gaps still need to be addressed. We still need to understand the root-causes of the identified barriers. The healthcare impact of the consequences of the “black” grouping needs to be studied although it appears that being identified either as African immigrants or African Americans attracts distinct barriers, including provider biases and discrimination [61]. However, some participants in the selected studies were discouraged by the negative attitudes and biases from both white and black providers. The interpretation of barriers to African immigrants’ healthcare access in the U.S. has been oversimplified, with language often being identified [25, 88]. However, language barrier should not only include deficiency in English language proficiency as witnessed by the fact that the availability of translators for African immigrants does not guarantee the absence of communication barriers in their healthcare experiences [25]. Accents, the complex U.S. healthcare system, and culture-derived healthcare expectations, can still constitute barriers to African immigrants [18]. Even when providers communicated accurately the required dietary changes, the participants were at a loss regarding their implementation, because they were not provided any guidelines. Not only did those health goals go unmet, the opportunities for some critical patient education were lost [11, 70]. African immigrants encounter barriers to good nutrition in the U.S. as regards availability, affordability, and accessibility [61], so provider-recommended nutrition changes are insufficient.

Religion and culture also affect gender roles in African immigrant communities, which then can influence their healthcare experiences [89]. In order to meet this population’s healthcare needs, it would be necessary to examine how gender roles affect both their perception of healthcare, and the accurate understanding of provider recommendations or treatments in their communities. The antagonism between African immigrants and U.S. providers cannot be addressed without the examination of the views and attitudes of U.S. providers on African immigrant health experiences and needs. This study’s results indicated many African immigrants felt U.S. providers were not adequately equipped to address their health concerns. Finding the roots of this deep-lying distrust with input from U.S. providers, would be fundamental in improving the African immigrant healthcare experience.

Very little is known about African immigrant health in the U.S.. Even as the number of African immigrants in the U.S. continues to climb exponentially, healthcare providers and policymakers have little information to guide their decision-making concerning this population. As far as we know, this is the first review of the healthcare experiences of African immigrants, which includes the overall assessment of their barriers to care or specific healthcare interventions. The findings from this review clarify some critical issues with African immigrants’ healthcare in the U.S. In addition to the identified gaps, they have also provided important cues for subsequent lines of inquiries necessary for building an understanding of the unique healthcare needs of African immigrants. However, the study still has some limitations. The language of the selected articles was limited to English. Articles published in other languages may have yielded additional findings. Also, the selected studies were limited to peer-reviewed journal articles, which excluded potential findings in grey literature, and other documents. Another limitation is the exclusion of broader studies that may report on the experiences of African immigrants within the context of other U.S. immigrants’ experiences. In addition, studies focused on refugees were not included in this study, and the participants of the selected studies were mostly from Sub-Saharan Africa. Therefore, the generalizability of the findings is limited.