Barriers to accessing preventive health care among African-born individuals in King County, Washington: A qualitative study involving key informants

Adherence and Correlates of Cervical Cancer Screening Among East African Immigrant Women in Washington State

INTRODUCTION

Cervical cancer screening (CCS) among East African immigrants (EAI) in the USA is under explored. This study aimed to investigate adherence to CCS and its correlates among EAI.

METHODS

We identified 1664 EAI women (25-65 years) with ≥ 1 primary care clinic visit(s) between 2017 and 2018, using University of Washington (UW) Medicine electronic health record data. CCS adherence was defined as Pap testing within 3 years or human papillomavirus/Pap co-testing within 5 years. We used Poisson regression with robust standard errors to cross-sectionally estimate associations with correlates of adherence. Twelve-month screening uptake was also evaluated among overdue women.

RESULTS

CCS adherence was 63%. Factors associated with higher adherence included older age (adjusted prevalence ratios [APRs]:1.47:95%CI:1.14-1.90, 1.38:95%CI:1.05-1.80, respectively, for ages 30-39 and 40-49 vs 25-29 years), longer duration of care at UW Medicine (APR:1.22:95%CI:1.03-1.45, comparing > 10 vs < 5 years), higher visit frequency (APR:1.23:95%CI:1.04-1.44, 1.46:95%CI:1.24-1.72, respectively, for 3-5 and ≥ 6 vs 1-2 visits), index visit in an obstetrics-gynecology clinic (APR:1.26:95%CI:1.03-1.55, vs family practice), having an assigned primary care provider (APR:1.35: 95%CI:1.02-1.79), breast cancer screening adherence (APR:1.66: 95%CI:1.27-2.17), and colorectal cancer screening adherence (APR:1.59:95%CI:1.24-2.03). Low BMI was associated with lower adherence (APR:0.50:95%CI:0.26-0.96, comparing < 18.5 kg/m2 vs 18.5-24.9 kg/m2). Among 608 (37%) overdue women, 9% were screened in the subsequent 12 months. Having commercial health insurance vs Medicare/Medicaid was associated with higher uptake (adjusted risk ratio:2.44:95%CI:1.15-5.18).

CONCLUSION

CCS adherence among EAI was lower than the national average of 80%. Interventions focused on increasing healthcare access/utilization or leveraging healthcare encounters to address barriers could increase CCS in EAIs.

Addressing COVID-19 Vaccine Hesitancy and Uptake Among African Immigrants: Lessons from a Community-Based Outreach Program

In 2021, the African Cultural Alliance of North America (ACANA) implemented a community-based vaccine education and outreach program to decrease hesitancy and increase COVID-19 vaccine uptake among African immigrants in Philadelphia. The program had three components: (1) tailored messaging on the benefits of vaccines by trusted community health navigators in familiar languages/dialects, (2) use of educational/tabling events, and (3) establishment of a vaccine clinic in community settings. Using secondary data analysis, in-depth interviews, focus group discussions and a self-administered survey, we explored (i) the impact and effectiveness of the outreach program and extent of vaccine uptake, (ii) African immigrants' beliefs about the COVID-19 pandemic and the vaccine, and (iii) barriers and facilitators of vaccine knowledge, uptake, and hesitancy. Our analysis showed that ACANA's outreach program was effective in addressing several cultural, logistic, and systematic barriers to vaccine uptake. The program distributed 2000 educational/informational flyers, reached 3000 community members via social media campaigns, and an additional 2320 through other person-to-person outreach events. The program was effective and resulted in the vaccination of 1265 community members over the course of the outreach. The impact of this outreach underscores the critical role of community-based organizations in addressing COVID-19 vaccine hesitancy and increasing vaccine uptake in underserved and minority communities. The paper concludes with suggestions and recommendations for using community-based outreach programs to increase COVID-19 vaccine uptake and decrease hesitancy.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Early Pandemic Access to COVID-19 Testing in the Somali Community in King County, Washington, USA: a Mixed-Methods Evaluation

BACKGROUND

Racial and ethnic disparities in COVID-19 infection and outcomes have been documented, but few studies have examined disparities in access to testing.

METHODS

We conducted a mixed methods study of access to COVID-19 testing in the Somali immigrant community in King County, Washington, USA, early during the COVID-19 pandemic. In September 2020-February 2021, we conducted quantitative surveys in a convenience sample (n = 528) of individuals who had accessed PCR testing, recruited at King County testing sites near Somali population centers and through social media outreach in the Somali community. We compared self-identified Somali and non-Somali responses using Chi-square and Wilcoxon rank sum tests. We also conducted three Somali-language focus groups (n = 26) by video conference to explore Somali experiences with COVID-19 testing, and in-depth interviews with King County-based policymakers and healthcare workers (n = 13) recruited through the research team's professional network to represent key demographics and roles. Data were analyzed using qualitative rapid analysis to explore the county's COVID-19 testing landscape.

RESULTS

Among 420 survey respondents who had received COVID-19 testing in the prior 90 days, 29% of 140 Somali vs. 11% of 280 non-Somali respondents tested because of symptoms (p = 0.001), with a trend for longer time from symptom onset to testing (a measure of testing access) among Somali respondents (median 3.0 vs. 2.0 days, p = 0.06). Focus groups revealed barriers to testing, including distrust, misinformation, stigma, language, lack of awareness, and transportation. Stakeholders responding from all sectors highlighted the importance of community partnership to improve access.

CONCLUSION

Somali communities experience barriers to COVID-19 testing, as evidenced by the longer time from symptom onset to testing and corroborated by our qualitative findings. These barriers, both structural and community-derived, may be overcome through partnerships between government and community to support community-led, multilingual service delivery and racial representation among medical staff.

Impact of HIV/AIDS on African-born Women Living in the United States: a Systematic Review

BACKGROUND

There is paucity of surveillance data about African-born women (ABW) living with HIV/AIDS in the USA. Out of the 50 US states, only Washington state and Minnesota report HIV surveillance data about African-born people, and Minnesota is the only state that reports data about ABW, specifically. In Minnesota, ABW have the largest prevalence rate of HIV/AIDS among all women. In Washington state, foreign-born Black people have the highest incidence of HIV behind white people and foreign-born Hispanic people. This study aims to better understand the impact HIV/AIDS on ABW.

METHODS

This systematic review is based on articles available on three databases (PubMed, Embase, and Cochrane Library). Databases were searched for articles that included quantitative and/or qualitative findings about the impact of HIV/AIDS on ABW in the USA.

RESULTS

Several themes were identified including disproportionate impact of HIV/AIDS on ABW, barriers to care, low sexual health knowledge, HIV-related stigma, and limited HIV testing. Based on 2013 data, the incidence of HIV among ABW was 12 times higher than the incidence among women in the general US population. In 2008-2014, ABW had the smallest decline in HIV diagnosis rate when compared to US-born men and women, African-born men, and Caribbean-born men and women. Barriers that ABW face when trying to access care include, language barriers, fear of deportation and difficulty navigating the US healthcare system.

CONCLUSION

ABW living in the USA are uniquely impacted by HIV/AIDS. Lasting negative health consequences can be mitigated by improving HIV surveillance and investing in further studies about this population.

Social support and cervical cancer screening among sub-Saharan African immigrant (SAI) women

BACKGROUND

Low rates of Papanicolaou (Pap) screening among sub-Saharan African immigrant (SAI) women in the US contribute to cancer diagnoses at late stages and high mortality rates. This study was conducted to examine if social support, positively associated with preventive health practices, was predictive of Pap screening in a sample of SAI women.

METHODS

We conducted a cross-sectional study with SAI women who recently immigrated to the US. Participants completed a survey to assess ever having had Pap screening and social support using the Medical Outcomes Study Social Support Survey.

RESULTS

Among the 108 SAI women in our study, Pap screening uptake was 65.7%. Affectionate and positive social support were each associated with Pap screening [adjusted odds ratio (AOR) = 1.73 (1.05, 2.87) and 1.68 (1.01, 2.78), respectively].

DISCUSSION

These findings suggest that consideration should be given to strengthening certain aspects of social support to increase uptake of Pap screening among SAI women.

Acculturation and Cardiovascular Risk Screening among African Immigrants: The African Immigrant Health Study

Acculturation and immigration-related factors may impact preventive, routine cardiovascular risk (CV) screening among African immigrants. We examined the associations between length of stay, percent of life spent in the U.S. (proxy for acculturation), and CV screening. Outcomes were recent screening for hypertension, diabetes, and dyslipidemia. Multivariable logistic regression analyses were used to examine these relationships. Among 437 African immigrants, 60% were males, mean age was 47 years, 61% had lived in the U.S. for ≥10 years, mean length of stay was 15 years, and 81% were employed. Only 67% were insured. In the 12 months prior, 85% had screened for hypertension, 45% for diabetes, and 63% for dyslipidemia. African immigrants with a ≥10-year length of U.S. stay had 2.20 (95%Confidence Intervals: 1.31−3.67), and those with >25% years of life spent in the U.S. had 3.62 (95%CI: 1.96−6.68) higher odds of dyslipidemia screening compared to those with a <10-year length of stay and ≤25% years of life spent in the U.S., respectively. Overall, screening for CV risk higher in African immigrants who have lived longer (≥10 years) in the U.S. Recent African immigrants may experience challenges in accessing healthcare. Health policies targeting recent and uninsured African immigrants may improve access to CV screening services.

"They Wait until the Disease Has Taking over You and the Doctors Cannot Do Anything about It": Qualitative Insights from Harambee! 2.0

African immigrants make up a large subgroup of Black/African-Americans in the US. However, because African immigrant groups are typically categorized as "Black," little is known about their preventative healthcare needs. Differences in culture, life and healthcare experiences between African immigrant populations and US-born people may influence preventive health care uptake. Thus, policymakers and healthcare providers lack information needed to make informed decisions around preventive care for African immigrants. This formative study was conducted among the largest East African immigrant communities in King County, WA. We recruited religious leaders, community leaders, health professionals, and lay community members to participate in thirty key informant interviews and five focus group discussions (n = 72 total), to better understand preventative healthcare attitudes in these communities. Through inductive coding and thematic analysis, we identified factors that impact preventative healthcare attitudes of the Somali, Ethiopian and Eritrean immigrant communities and deter them from accessing and utilizing healthcare. Cultural beliefs and attitudes around preventative healthcare, mistrust of westernized healthcare, religious beliefs/views, intersecting identities and shared immigrant experiences all influence how participants view preventative healthcare. Our results suggest that interventions that address these factors are needed to most effectively increase uptake of preventative healthcare in African immigrant communities.