Addressing Cancer Control Needs of African-born Immigrants in the US: A Systematic Literature Review

Full text

Review
Addressing cancer control needs of African-born immigrants in the US: A
systematic literature review
Alejandra Hurtado-de-Mendoza
a,
⁎,MinnaSong
a
,OclaKigen
b
, Yvonne Jennings
a
,
Ify Nwabukwu
c
, Vanessa B. Sheppard
a
a
Breast Cancer Program and Office of MinorityHealth andHealth Disparities,Lombardi Comprehensive Cancer Center, Department of Oncology,GeorgetownUniversityMedical Center, Washington,
DC, USA
b
Cancer Biology, Prevention & Control, University District of Columbia, Lombardi Cancer Center Cancer Prevention Master's Degree Program, Washington, DC, USA
c
African Women's Cancer Awareness Association, Silver Spring, MD, USA
abstractarticle info
Available online 14 July 2014
Keywords:
African immigrants
Cancer
Cancer prevention
Systematic literature review
Compared to non-Hispanic Whites, African immigrants have worse cancer outcomes. However, there is little
research about cancer behaviors and/or interventions in this growing population as they are generally grouped
with populations from America or the Caribbean. This systematic review examines cancer-related studies that
included African-born participants.
We searched PsycINFO, Ovid Medline, Pubmed, CINHAL, and Web of Science for articles focusing on any type of
cancer that included African-bornimmigrant participants. Twenty articles met study inclusion criteria; only two
were interventions. Mostarticles focused on one typeof cancer (n = 11) (e.g.,breast cancer) and were conducted
in disease-free populations (n = 15). Studies included African participants mostly from Nigeria (n = 8) and
Somalia (n = 6). However, many papers (n = 7) did not specify nationality or had small percentages (b5%)
of African immigrants (n = 5). Studies found lower screening rates in African immigrants compared to other
subpopulations (e.g. US-born). Awareness of screening practices was limited. Higher acculturation levels were
associated with higher screening rates. Barriers to screening included access (e.g. insurance), pragmatic
(e.g. transportation), and psychosocial barriers (e.g. shame).
Interventions to improve cancer outcomes in African immigrants are needed. Research that includes larger
samples with diverse African subgroups including cancer survivors is necessary to inform future directions.
© 2014 Elsevier Inc. All rights reserved.
Contents
Introduction................................................................. 90
Methods................................................................... 90
Searchstrategy ............................................................. 90
Identificationofstudies.......................................................... 90
Reviewandabstractionprocess ...................................................... 90
Inclusion/exclusioncriteria ........................................................ 90
Results ................................................................... 90
Breastcancer .............................................................. 91
Cervicalcancer ............................................................. 93
Prostatecancer ............................................................. 93
Uterinecancer.............................................................. 97
Colorectalcancerscreening........................................................ 97
Unspecifiedcancer............................................................ 97
Discussion.................................................................. 97
Conflictofintereststatement ......................................................... 98
Acknowledgments .............................................................. 98
References.................................................................. 99
Preventive Medicine 67 (2014) 89–99
⁎Corresponding author at: 3300 Whitehaven St. NW, Suite 4100, Washington, DC 20007, USA. Fax: +1 202 687 0305.
E-mail address: ahd28@georgetown.edu (A. Hurtado-de-Mendoza).
http://dx.doi.org/10.1016/j.ypmed.2014.07.006
0091-7435/© 2014 Elsevier Inc. All rights reserved.
Contents lists available at ScienceDirect
Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Introduction
African-born immigrants are one of the fastest growing immigrant
groups in the US; increasing from 881,300 in 2000 to 1,606,914 by
2010 (US Census Bureau, 2013). The majority of African immigrants
come from Western (35.71%) and Eastern Africa (29.612%). Specific
top countries of origin include Nigeria (13.65%), Ghana (7.76%),
Ethiopia (10.80%), and Kenya (5.51%) (Immigration Policy Center,
2014). More than half of the African immigrants arrived recently to the
US. Thus, there has been limited research on African immigrant health,
and it has mostly focused on infectious diseases (e.g. tuberculosis,
HIV) while chronic diseases, such as cancer, have been understudied
(Venters and Gany, 2011).
Previous research has shown disparities among US and immigrant
populations in cancer information (Zhao, 2010), screening rates
(Bazargan et al., 2004; Consedine, 2012; Goel et al., 2003; Lofters et al.,
2010; Shih et al., 2008; Swan et al., 2003), early diagnosis (Kouri et al.,
2010), quality of care (Nielsen et al., 2010), receipt of recommended
treatment (Kouri et al., 2010; Nielsen et al., 2010), and survival out-
comes (Creque et al., 2010). Identified barriers to accessing health ser-
vices include access to care factors (e.g. insurance, citizenship status)
(De et al., 2005; Echeverria and Carrasquillo, 2006; Shahidi et al.,
2013), pragmatic factors (e.g. language difficulties) (Shahidi et al.,
2013), and psychosocial factors (e.g. limited knowledge, embarrass-
ment and fear of screening procedures, cultural beliefs) (Consedine,
2012; Consedine et al., 2007, 2011; Johnson et al., 2008). Having a
usual source of care (Jandorf et al., 2010; Shih et al., 2008; Taylor et al.,
2009), provider recommendation (Jandorf et al., 2010; Taylor et al.,
2009), and acculturation (Brown et al., 2006; Jandorf et al., 2010), are
some of the identified protective factors that increase the odds of
screening in this population.
However, African immigrants are underrepresented in this research.
The scarceresearch that includes African immigrants has shown cancer-
related disparities across the cancer control continuum (Creque et al.,
2010; Goel et al., 2003; Morrison et al., 2012; Seeff and McKenna,
2003; Sussner et al., 2009; Tsui et al., 2007; Zhao, 2010). However,
African-born immigrants tend to constitute small percentages of the
samples and/or they tend to be lumped with African Americans or
Caribbean, or categorized as “African”or “Black foreign-born”without
specifying country of origin (Goel et al., 2003; Seeff and McKenna,
2003; Zhao, 2010). The goal of this paper is to offer a systematic litera-
ture review of cancer studies that include African-born populations to
suggest venues for further research and interventions that can be
implemented in the US.
Methods
Search strategy
The research team participated on a literature search course conducted by
a librarian at Georgetown University. The course included strategies for
conducting searches (e.g. selecting, exploding, and combining medical subject
heading terms —MeSH terms) as well as the particularities of different search
engines (e.g. Ovid, CINHAL). The authors followed the guidelines outlined
by the Preferred Reporting Items for Systematic Literature Reviews and Meta-
Analysis (PRISMA) (Liberati et al., 2009; Moher et al., 2009).
Identification of studies
We searchedPsycINFO, Ovid Medline, Pubmed, CINHAL, and Web of Science
for papers on any type of cancer (including disease free) with African-born im-
migrant participants. The search was conducted in May 1, 2013. We used the
following search terms: “cancer”and “African immigrant”to find the appropri-
ate MeSH terms within each search engine. For the cancer keyword we used
neoplasm as a MeSH term in all search engines. However, “African immigrant”
elicited different MeSH terms in the various search engines. We developed spe-
cific search strategies for each search engine to maximize the number of papers
retrieved without losing the population target. For instance, when typing
AfricanImmigrants in PsycINFOwe obtained several MeSHterms including: Im-
migration, Blacks, and African cultural groups. After examining the scope and
the papers retrieved we realized that Black referred to African Americans
whereas African cultural groups referred to the cultural groups from Continen-
tal Africa. Combining “immigrant”and “African cultural groups”and “neo-
plasms”yielded fewer results (n = 5), so we decided to use African cultural
groups in combination with neoplasm (n = 11). We used “African cultural
groups”in PsycINFO, “African continental ancestry group”in combination
with “emigrants and immigrants”in Ovid Medline, “African”in CINHAL,
“African immigrant”in Pubmed, and “African”combined with “immigrant”in
Web of Science. An exemplary search with PsycINFO is provided in Table 1.
We additionally included other papers retrieved from the reference list of the
selected papers and others suggested by scholars. References were imported
to Refworks to delete duplicates.
Review and abstraction process
First, two members of the research team (AH and MS) independently
reviewed all the abstracts and categorized the papers based on whether they
met the inclusion criteria (i.e. Yes, No, and Maybe). In the second round of
review, the two members of the team independently reviewed the full text
articles categorized as “Maybe”to further determine eligibility. Discrepancies
were solved by discussion until consensus was reached (AH, MS) and a third
researcher was consulted (VS) to resolve disagreements. We developed a data
abstraction document to capture the information from the studies that met
the eligibility criteria (e.g. samplecharacteristics, main outcomes, main results).
Two members of the research team conducted the data abstraction (AH, MS).
Inclusion/exclusion criteria
Retrieved papers were eligible if they addressed (1) any type of cancer and
included (2) African-born immigrant populations in the sample. No year,
language, or study location limits were added in the search. We did not set a
threshold for the number or percent of African-born persons in study samples.
Case studies, review papers, and epidemiological studies outside the US were
excluded.
Results
The five search engines yielded a total of 104 records, and 24
additional records were identified through the list of references, scholars,
and study authors. After deleting duplicates, 99 records were screened
for eligibility. A total of 20 papers met inclusion criteria (see Fig. 1 for
additional details). Although English language was not an inclusion
criteria, all the articles that met the eligibility criteria were written in
English.
Most papers focused on a single type of cancer (55%) and breast,
cervical, and prostate were the most common among those studies.
The majority of the studies were conducted with disease free samples
(75%). Half used quantitative methods (50%) and there were only two
intervention studies(Lepore et al., 2012; Piwowarczyk et al., 2013).
Most research focused on women only (60%), and Nigerians (40%) and
Somalis (30%) were the most represented nationalities in the articles.
However, a significant number of studies (35%) did not specify nation-
ality or had African immigrant samples (25%) that were less than 5%
of the total sample, so no specific results about African immigrants
were reported (see Table 2 for summary description). The retrieved
Table 1
PsycINFO search.
Steps search terms number of retrieved papers
1 Exp neoplasms/ 31,295
2 Exp African cultural groups/ 1020
3 Exp immigration/ 12,807
4 (African cultural groups and immigration). 77
5 (Neoplasms and (African cultural groups and immigration)) 5
6 (Neoplasms and African cultural groups). 11
Exp: exploded terms.
Note: Step 6 is presented in bold text to highlight the search we used.
90 A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

main findings from studies are summarized below based on the type of
cancer and in relation to the cancer control continuum (see Table 3 for
paper's description).
Breast cancer
Ten studies, all conducted in the US, examined breast cancer, either
exclusively (Borrell et al., 2006; Sheppard et al., 2010; Sussner et al.,
2009) or along with other types of cancers (Ndukwe et al., 2013;
Piwowarczyk et al., 2013). Six were quantitative (Borrell et al., 2006;
Harcourt et al., 2014; Morrison et al., 2012; Piwowarczyk et al., 2013;
Samuel et al., 2009; Sussner et al., 2009) and four used qualitative
methods (Bache et al., 2012; Carroll et al., 2007; Ndukwe et al., 2013;
Sheppard et al., 2010). Paper foci included breast cancer prevention
(Borrell et al., 2006) and detection, including barriers to genetic testing
(Sussner et al., 2009) and barriers to mammography screening (Carroll
et al., 2007; Harcourt et al., 2014; Morrison et al., 2012; Piwowarczyk
et al., 2013; Sheppard et al., 2010; Ndukwe et al., 2013).
With regard to prevention, Borrell et al. (2006) found that foreign-
born Black women were twice as likely to have breastfed their children
(a protective factor) compared to US-born Blacks. However, only 3% of
the sample was African-born and no specificfindings were reported
for African immigrants. In relation to quantitativestudies focused onde-
tection, Sussner et al. (2009) found that foreign-born women of African
descent anticipated having greater negative emotional reactions to
genetic testing than US-born women from African descent. Neverthe-
less, African immigrant women were underrepresented (89% were
Caribbean), and no specific results for the African-born population
were described. Other studies reported lower mammography screening
rates amongSomali women in the US compared to non-Somali patients
(Morrison et al., 2012) and compared to non-African immigrants from
Vietnam and Cambodia (Samuel et al., 2009). However, in a study com-
paring African immigrants from different nationalities (Harcourt et al.,
2014), Somali women had 5 times higher odds of having received a
mammogram compared to the “other African immigrant groups.”
Factors associated with higher screening rates among Somalis in these
studies included greater interaction with the medical system, use of
trained medical interpreters (Morrison et al., 2012), acculturation, and
socio-demographic factors, such as education and employment status
(Harcourt et al., 2014).
Several qualitative studies explored African immigrant women's
perceptions of breast cancer and barriers and facilitators to breast
cancer screening. Findings from these studies suggest that African
immigrants have limited knowledge about cancer (Carroll et al., 2007),
associate breast cancer with fear and certain death (Sheppard et al.,
2010), and sometimes attribute breast cancer to a punishment from
God, a curse, or a boil (Ndukwe et al., 2013; Sheppard et al., 2010). A
study by Carroll et al. (2007) conducted with Somalis from different
ethnic groups (Bantu and non-Bantu) and different settlement patterns
showed how knowledge and perceptions varied depending on the
specific ethnic group and acculturation. Bantu Somali immigrants who
lived longer in refugee camps and had arrived more recently to the US
lacked terms in their native languages to express cancer and were less
familiar with screening practices and the notion of preventive health
than their non-Bantu Somali counterparts.
Barriers to screening noted in qualitative studies included limited
knowledge and awareness about screening practices (Carroll et al.,
2007; Ndukwe et al., 2013; Piwowarczyk et al., 2013; Sheppard et al.,
2010), emotions (e.g. shame, modesty, fear of screening procedures)
(Carroll et al., 2007; Ndukwe et al., 2013; Sheppard et al., 2010), access
and pragmatic barriers (e.g. lack of insurance, financial barriers, trans-
portation, language difficulties) (Carroll et al., 2007; Ndukwe et al.,
2013; Sheppard et al., 2010), sociodemographic factors (e.g. age,
education) (Ndukwe et al., 2013), and cultural values perceived to be
at odds with medical practices. For instance, breast self-examination
or mammograms challenged Muslim women's notions of modesty
Fig. 1. Articles identified and screened for eligibility.
91A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Table 2
Summary characteristics of cancer-related papers that include African immigrant samples.
Characteristics N = 20 N (%) References
Percentage of AI population
100 9 (45) Abdullahi et al. (2009);Carroll et al. (2007);Ehiwe et al. (2012);Ehiwe et al. (2013);
Harcourt et al. (2014);Morrison et al. (2013);Ndukwe et al. (2013);Sheppard et al.
(2010);Piwowarczyk et al. (2013)
51–99 0 (0) –
26–50 3 (15) Kumar et al. (2009);Odedina et al. (2009);Samuel et al. (2009)
5–25 3 (15) Bache et al (2012);Lepore et al. (2012);Sussner et al. (2009)
Less than 5% 5 (25) Borrell et al. (2006);Creque et al. (2010);Morrison et al. (2012);Tsui et al. (2007);
Perkins et al. (2010)
African countries of origin
Nigeria 8 (40) Bache et al (2012);Ehiwe et al. (2012);Ehiwe et al. (2013);Kumar et al. (2009) ;
Odedina et al. (2009);Ndukwe et al. (2013);Sheppard et al. (2010) ;Perkins et al.
(2010)
Somalia 6 (30) Abdullahi et al. (2009);Carroll et al. (2007);Harcourt et al. (2014);Morrison et al.
(2012);Morrison et al. (2013);Piwowarczyk et al (2013)
Ghana 3 (15) Ehiwe et al. (2012);Ehiwe et al. (2013);Ndukwe et al. (2013)
Other (Cameroon, Zambia, Ivory Coast; Zimbabwe,
Ethiopia, Tanzania, Cape Verde, Congo)
4 (20) Ndukwe et al. (2013);Sheppard et al. (2010);Perkins et al. (2010);Piwowarczyk et al
(2013)
Unspecified 7 (35) Borrell et al. (2006);Creque et al. (2010);Harcourt et al. (2014);Lepore et al. (2012);
Samuel et al. (2009);Sussner et al. (2009);Tsui et al. (2007)
Study location
US 14 (70) Borrell et al. (2006);Carroll et al. (2007);Creque et al. (2010);Harcourt et al. (2014);
Lepore et al. (2012);Morrison et al. (2012);Morrison et al. (2013);Ndukwe et al.
(2013);Perkins et al. (2010);Piwowarczyk et al (2013);Samuel et al. (2009);Sheppard
et al. (2010);Sussner et al. (2009);Tsui et al. (2007)
UK 4 (20) Abdullahi et al. (2009);Bache et al. (2012);Ehiwe et al. (2012);Ehiwe et al. (2013)
US and Nigeria 2 (10) Kumar et al. (2009);Odedina et al. (2009)
Gender
Women only 12 (60) Abdullahi et al. (2009);Borrell et al. (2006);Carroll et al. (2007);Creque et al. (2010);
Harcourt et al. (2014);Morrison et al. (2013);Ndukwe et al. (2013);Samuel et al.
(2009);Sheppard et al. (2010);Sussner et al. (2009);Tsui et al. (2007);Piwowarczyk
et al (2013)
Men only 3 (15) Kumar et al. (2009);Odedina et al. (2009);Lepore et al. (2012)
Women + men 5 (25) Bache et al (2012);Ehiwe et al. (2012);Ehiwe et al. (2013);Morrison et al. (2012);
Perkins et al. (2010)
Type of population
Disease free only 15 (75) Abdullahi et al. (2009);Borrell et al. (2006);Carroll et al. (2007);Ehiwe et al. (2012);
Ehiwe et al. (2013);Harcourt et al. (2014);Kumar et al. (2009);Odedina et al. (2009);
Lepore et al. (2012);Morrison et al. (2012);Morrison et al. (2013);Samuel et al. (2009);
Tsui et al. (2007);Perkins et al. (2010);Piwowarczyk et al. (2013)
Survivors only 2 (10) Bache et al (2012);Creque et al. (2010)
Disease free + survivors 3 (15) Ndukwe et al. (2013);Sheppard et al. (2010);Sussner et al. (2009)
Type of cancer
Breast only 3 (15) Borrell et al. (2006);Sheppard et al. (2010);Sussner et al. (2009)
Cervical only 4 (20) Abdullahi et al. (2009);Morrison et al. (2013);Tsui et al. (2007);Perkins et al. (2010)
Prostate only 3 (15) Kumar et al. (2009);Odedina et al. (2009);Lepore et al. (2012)
Unspecified 2 (10) Ehiwe et al. (2012);Ehiwe et al. (2013)
Uterine only 1 (5) Creque et al. (2010)
Multiple: breast, cervical, colorectal 7 (35) Bache et al (2012);Carroll et al. (2007);Harcourt et al. (2014);Morrison et al. (2012);
Ndukwe et al. (2013);Samuel et al. (2009);Piwowarczyk et al. (2013)
Design
Qualitative 8 (40) Abdullahi et al. (2009);Bache et al (2012);Carroll et al. (2007);Ehiwe et al. (2012);
Ehiwe et al. (2013);Ndukwe et al. (2013);Sheppard et al. (2010);Perkins et al.
(2010)
Quantitative 10 (50) Borrell et al. (2006);Creque et al. (2010);Harcourt et al. (2014);Kumar et al. (2009);
Odedina et al. (2009);Morrison et al. (2012);Morrison et al. (2013);Samuel et al.
(2009);Sussner et al. (2009) ;Tsui et al. (2007)
Intervention 2 (10) Lepore et al. (2012);Piwowarczyk et al. (2013)
Types of outcomes
Screening rates 5 (25) Harcourt et al. (2014);Morrison et al. (2012);Morrison et al. (2013);Samuel et al.
(2009);Tsui et al. (2007)
Survival rates 1 (5) Creque et al. (2010)
Risk factors rates 1 (5) Borrell et al. (2006)
Life-style/cognitive behavioral factors 2 (10) Kumar et al. (2009);Odedina et al. (2009)
Beliefs, experiences 8 (40) Abdullahi et al. (2009);Bache et al (2012);Carroll et al. (2007);Ehiwe et al. (2012);
Ehiwe et al. (2013);Ndukwe et al. (2013);Sheppard et al. (2010);Perkins et al. (2010)
Genetic counseling and testing perceptions 1 (5) Sussner et al. (2009)
Intervention outcomes 2 (10) Lepore et al. (2012); Piwowarczyk et al.(2014)
Cancer continuum main focus
Prevention 3 (15) Borrell et al. (2006);Kumar et al. (2009);Perkins et al. (2010)
92 A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

(Sheppard et al., 2010) and spousal consentfor screening was often nec-
essary (Ndukwe et al., 2013). Motivators for screening included
reminders from primary care providers, death of a family member due
to cancer, and experiencing cancer symptoms such as breast lump
(Ndukwe et al., 2013). Religiosity and spirituality were mentioned as
coping strategies (Carroll et al., 2007; Ndukwe et al., 2013; Sheppard
et al., 2010). Finally, the only intervention study retrieved was a single-
arm intervention consisting of a linguistically and culturally tailored
DVD-centered workshop (n = 120) that showed promise in increasing
awareness and intentions toward mammograms in African immigrants
and refugees from Congo and Somalia (Piwowarczyk et al., 2013).
Cervical cancer
Ten out of 11 identified studies focused on cervical cancer detection
(pap smear screening) and most were quantitative studies based on
cross-sectional surveys or medical record abstractions (Harcourt et al.,
2014; Morrison et al., 2012; Morrison et al., 2013; Piwowarczyk et al.,
2013; Samuel et al., 2009; Tsui et al., 2007) and included other types
of cancer in addition to cervical cancer (Harcourt et al., 2014; Morrison
et al., 2012, 2013; Piwowarczyk et al., 2013; Samuel et al., 2009; Tsui
et al., 2007). There were four qualitative studies (Abdullahi et al.,
2009; Carroll et al., 2007; Ndukwe et al., 2013; Perkins et al., 2010)
and one intervention study (Piwowarczyk et al., 2013). Only one study
was conducted in the UK (Abdullahi et al., 2009).
A US nationally representative sample that includedforeign women
(Tsui et al., 2007), found disparities in pap screening based on place
of birth and length of stay in the US, as a higher percentage of recent
immigrants (19%) had never received a pap smear test compared to
established immigrants (10%) and to US-born women (6%). Because
African immigrants only constituted 2% of the sample, no specificresults
were discussed.
Harcourt et al. (2014) found that only 52% of a sample of African
immigrant women in the US adhered to cervical cancer screening.
Contrary to breast cancer screening, where Somali women were more
likely to get tested, women from Somalia were less likely to get tested
for cervical cancer than their “other African immigrants”counterparts.
Similarly, other studies found that Somali women had lower pap
smear screening rates compared to non-Somali patients (48.79% vs.
69.1%) (Morrison et al., 2012), and to Vietnamese and Cambodian immi-
grants (around 70% vs. slightly over 70%, and slightly over 80% respec-
tively) (Samuel et al., 2009). Factors associated with greater odds of
cervical cancer screening included length of residence in the US
(Harcourt et al., 2014; Tsui et al., 2007), greater interaction with the
health care system, and gender concordance of the visits (Morrison
et al., 2012). The only intervention study, a DVD-based program by
Piwowarczyk et al. (2013) showed increased awareness and intention
toward pap smears in African immigrants.
Qualitative studies shed light upon women's perceptions of pap-
smear tests, important barriers preventing adherence of recommended
guidelines, and attitudes toward the HPV vaccine. Women from Somalia
and other African nationalities reported a limited knowledge and
familiarity with cervical cancer and screening (Abdullahi et al., 2009;
Carroll et al., 2007; Ndukwe et al., 2013), and they commonly attributed
cervical cancer to the will of God or a curse (Abdullahi et al., 2009;
Ndukwe et al., 2013). Somali Bantu women tended to associate pap
smears with detection of infections and routine care for pregnant
women rather than screening for cervical cancer (Carroll et al., 2007;
Ndukwe et al., 2013). Other barriers to screening included language
difficulties, distrust of the interpreters, fear of the test (pain, lack of
trust in sterilization), negative past experiences, and pragmatic (sched-
ule of appointments, childcare) and cultural barriers (Abdullahi et al.,
2009; Ndukwe et al., 2013). For instance, as many women were circum-
cised, they anticipated feeling embarrassed by the possible reaction of
practitioners unfamiliar with that practice. Muslim women were also
wary of having a male doctor perform the test (Abdullahi et al., 2009).
The only study on the HPV vaccine (b5% African immigrants) showed
that minority parents were more supportive of school entry require-
ments than Caucasian parents, citing the importance of protecting
their adolescent daughters as well as other young women (Perkins
et al., 2010).
Prostate cancer
Four papers focused on prostate cancer. Most of them had a cross-
sectional quantitative design and focused only on prostate cancer
(Kumar et al., 2009; Lepore et al., 2012; Odedina et al., 2009). One focused
on prevention (Kumar et al., 2009) and two on detection (screening), in-
cluding a crosssectional survey of cognitive behavioral factors related to
screening (Odedina et al., 2009) and a randomized controlled trial
screening decision-making intervention (Lepore et al., 2012). The only
qualitative study retrieved (Bache et al., 2012) was conducted in the
UK and only had one African immigrant prostate cancer survivor in
the sample, so no specificfindings about African immigrants were
presented.
Odedina et al. (2009) compared cognitive behavioral factors
(e.g. attitudes, behavioral intentions) related to prostate screening in
Nigerian immigrants living in the US with indigenous non-immigrant
Nigerians. Results suggested that Nigerian men who migrated to the
US had significantly higher knowledge, perceived behavioral control,
more positive attitudes,and higher intentionsto get screened compared
to indigenous Nigerian men. CaP screening was low among Nigerian
immigrants (61% overall, 44% within 1 year) but practically non-
existent among the indigenous Nigerian men (7.2% overall, 5.6% within
1 year). Using the same study sample, Kumar et al. (2009) found that
Nigerian immigrants in the US practiced healthier lifestyle choices,
such as significantly higher fruit and whole grain intake, more hours
of purposeful physical activity, and lower tobacco use and intake of
trans fats compared to Nigerians who had not migrated.
Lepore et al. (2012) conducted a randomized controlled trial within
a sample of predominantly immigrant black men (n = 490) (77%
Caribbean) in the US to evaluate the efficacy of a decision support inter-
vention focused on prostate cancer testing. The intervention aimed to
provide information, exercises (e.g., values clarification), and encour-
agement to aid informed testing decisions that were consistent with
the men's own values. The intervention improved prostate cancer test-
ing knowledge, decision conflict, and doctor–patient communication
Table 2 (continued)
Characteristics N = 20 N (%) References
Cancer continuum main focus
Detection 15 (75) Abdullahi et al. (2009); Carroll et al. (2007); Ehiwe et al. (2012);Ehiwe et al. (2013);
Harcourt et al. (2014);Lepore et al. (2012);Morrison et al. (2013);Morrison et al.
(2013);Ndukwe et al. (2013);Odedina et al. (2009);Piwowarczyk et al. (2013);Samuel
et al. (2009);Sheppard et al. (2010);Sussner et al. (2009);Tsui et al. (2007)
Diagnosis 0 (0) –
Treatment 3 (15) Bache et al. (2012); Ehiwe et al. (2012);Ehiwe et al. (2013)
Survivorship 2 (10) Bache et al. (2012); Creque et al. (2010);
Note: AI: African immigrants.
93A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Table 3
Description of cancer-related papers that include African immigrant samples.
Authors/year Setting Sample Study design Type of cancer Type of
population
Types of outcomes Main findings
Abdullahi
et al.
(2009)
UK
Urban
Community outreach
Total N = 50
AI = 50 (100%) (Somalia)
Gender: women
Age: 25–64
Education: not reported
Insurance: not reported
Years in UK: 88% ≥4 years
Qualitative (focus groups/
interviews)
Cervical Disease-free Knowledge and barriers to
screening
Limited knowledge of cancer screening and risk
factors. Barriers to screening included fatalism,
anticipating embarrassment due to female
circumcision, fear of the test, language, and pragmatic
barriers. Need to provide culturally appropriate
education and services.
Bache et al.
(2012)
UK
Urban
Community outreach
Total N = 8
AI = 1 (12.5%) (Nigeria)
Gender: women and men
Age: 35–81
Education: not reported
Insurance: not reported
Years in UK: 87.5% N10
Qualitative (in depth
interviews)
Multiple (prostate
and breast)
Cancer survivors Lay explanations of cancer,
coping styles, and experiences
with health services
Lay explanations of cancer were biomedical and
cultural. Participants were generally satisfied with
their health care. Coping strategies included denial,
gaining knowledge, living each day at a time, religious
coping, and maintaining a positive attitude.
Borrell et al.
(2006)
US
Urban
Community outreach
Total N = 236
AI = 7 (3%)
Gender: women
Age: 42 median (foreign born
only)
Education: 22.4% bHigh
school
Insurance: not reported
Years in US: not reported
Quantitative (cross-
sectional survey)
Breast Disease-free Association
between nativity and breast
cancer risk factors
U.S.-born blacks were more likely to smoke, not
breastfeed, and breastfeed for a shorter duration than
foreign-born Blacks (all p b0.01).
No specificfindings for African immigrants due to
small sample sizes.
Carroll et al.
(2007)
US
Urban
Community outreach
Total N = 34
AI = 34 (100%) Somali (Bantu
and non-Bantu)
Gender: women
Age: 18–53 (Median = 27)
Education: 79% bHigh school
Insurance: not reported
Years in US: 30% N5 years
Qualitative (interviews) Multiple (cervical
and breast)
Disease-free Beliefs and experiences
regarding health promotion
and screening
Participants had limited knowledge about breast and
cervical cancer screening services, especially Bantu
women. Reasons included lack of familiarity with the
health care system, language barriers, fear and stigma.
Creque et al.
(2010)
US
Urban
Cancer registry
Total N = 311
AI = 2 (1%)
Gender: women
Age: 22 ≥71
Education: not reported
Insurance: 7.1% uninsured
Years in US: not reported
Quantitative (cohort
study)
Uterine Cancer survivors Survival rates of black women
with uterine cancer
5-Year survival rate slightly higher for US-born black
women. Age was predictor of death in US-born women
and type of treatment was predictor for foreign-born
women.
No specificfindings for African immigrants due to
small sample sizes.
Ehiwe et al.
(2012)
UK
Urban
Community outreach
Total N = 53
AI = 53 (100%) (Ghana,
Nigeria)
Gender: women and men
Age: 20–55
Education: not reported
Insurance: not reported
Years in UK: 100% 3–5 years
Qualitative (focus group) Unspecified Disease-free Perceptions and knowledge
about cancer
Feelings of fear, apprehension, shame, and secrecy
were mentioned as barriers to cancer screening, health
services seeking, and family communication.
Ehiwe et al.
(2013)
UK
Urban
Community outreach
Total N = 53
AI = 53 (100%) (Ghana,
Nigeria)
Gender: women and men
Age: 20–55
Education: not reported
Insurance: not reported
Years in UK: 100% 3–5 years
Qualitative (focus group) Unspecified Disease-free Perceptions and knowledge
about cancer
Participant's perceptions of cancer were both
biomedical and faith-based. There were diverse opin-
ions in relation to God's role in the cause and cure of
cancer and the effectiveness of African herbal medicine
to treat cancer.
94 A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Table 3 (continued)
Authors/year Setting Sample Study design Type of cancer Type of
population
Types of outcomes Main findings
Harcourt
et al.
(2014)
US
Urban
Community outreach
Total N = 533 (112 breast/421
cervical)
AI = 533 (100%): Somali and
other AI
Gender: women
Age:
M = 52.7, SD = 10.1 (breast)
M = 34.4, SD = 13.2
(cervical)
Education:
76% ≤High school (breast)
55% ≤High school (cervical)
Insurance: not reported
Years in US:
61% N5 years (breast)
70% N5 years (cervical)
Quantitative (cross-
sectional survey)
Multiple (breast
and cervical)
Disease-free Screening rates and factors
associated with screening
Only 61% and 52% had ever been screened for breast
and cervical cancer respectively. Duration of residence
in the US and ethnicity were significantly associated
with non-screening.
Somali immigrants had 5 times greater odds of ever
having a mammogram than other AI. Recent immi-
grants had only 15% and 40% odds of ever having a
mammogram and a pap smear compared to more
established immigrants.
Kumar et al.
(2009)
US and Nigeria
Urban and rural
Community outreach
Total N = 249
AI = 121 (48.6%) (Nigeria)
Gender: men
Age: 35–79
Education:bHigh school
19.5%
Insurance: not reported
Years in US: M = 16.9
SD = 9.19
Quantitative (cross-
sectional survey)
Prostate Disease free Behavioral factors that
contribute to prostate cancer
mortality and morbidity
Compared with Nigerians who did not migrate,
Nigerian migrants had significantly higher fruit and
whole grain intake, higher of purposeful physical ac-
tivity, lower tobacco use and trans fats intake which
may contribute to decreased CaP risk in Nigerian
migrants.
Lepore et al.
(2012)
US
Urban
List of health insurance
beneficiaries
Total N = 490
AI = 22.6%⁎
Gender: men
Age: 45–70
Education: 31.3% bHigh
school
Insurance: not reported
Years in US: not reported
Quantitative (randomized
controlled trial
intervention)
Prostate Disease free Intervention outcomes related
to screening
Compared to the control, the intervention group
reported significantly greater knowledge and
likelihood of discussing screening with their doctors,
and lower decision conflict. No significant differences
were found in testing, congruence between testing
intention and behavior, or anxiety.
Morrison
et al.
(2012)
US Urban
Secondary analysis in a
primary care practice
database
Total N = 91,557
AI = 810 (0.9%) (Somalia)
Gender: women and men
Age: 25–54 (57.8%) (Somali)
Education: not reported
Insurance: not reported
Years in the US: not
reported
Quantitative (medical
records)
Multiple (breast,
cervical, colorectal)
Disease free Factors associated with
preventive services including
cancer screening
Compared to non-Somali patients, Somali patients had
significantly lower completion rates of colorectal can-
cer screening (38.46% vs. 73.35), mammography
(15.38% vs. 48.52%), and pap smears (48.79% vs.
69.1%). Use of medical interpreters and primary care
services were generally associated with higher pre-
ventive services use.
Morrison
et al.
(2013)
US Urban
Secondary analysis in a
primary care practice
database
Total N = 310
AI = 310 (100%) (Somalia)
Gender: women
Age: 18–65
Education: not reported
Insurance: not reported
Years in the US: not reported
Quantitative (medical
records)
Cervical Disease free Screening rates and factors
associated with screening
51% adhered to cervical cancer screening guidelines.
Adherence was associated with greater visits to the
health care system. The majority of patients (65.8%)
saw male providers. However, screening was more
likely to occur during a visit with a female doctor
(6.9%) compared to a male doctor (1.2%).
Ndukwe
et al.
(2013)
US Urban
Community outreach
Total N = 38
AI = 38 (100%) (Ghana,
Nigeria, Cameroon, Zambia,
Ivory Coast)
Gender: women
Age: 20–70
Education: 13.2% ≤High
school
Insurance: 16% uninsured
Years in the US: not
reported
Qualitative (focus groups/
interviews)
Multiple (breast
and cervical)
Disease
free + survivors
Knowledge and awareness of
breast and cervical cancer
screening
Cancer awareness was low, especially cervical cancer.
Barriers to breast and cervical cancer screening
included pragmatic and access barriers as well as
fatalism, stigma, privacy concerns, and fear. Motivators
for screening were reminders from primary care
providers, cancer death in the family, and experiencing
cancer symptoms.
(continued on next page)
95A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Table 3 (continued)
Authors/year Setting Sample Study design Type of cancer Type of
population
Types of outcomes Main findings
Odedina et al
(2009)
US and Nigeria
Urban and rural
Community outreach
Total N = 249
AI = 121 (48.6%) (Nigeria)
Gender: men
Age: 35–79
Education: 19.5% bHigh school
Insurance: not reported
Years in US: M = 16.9
SD = 9.19
Quantitative (cross-
sectional survey)
Prostate Disease free Cognitive-behavioral factors
associated to screening
Immigrant Nigerian men had higher knowledge, more
positive attitudes, and higher screening intentions. The
role of acculturation was highlighted.
Piwowarczyk
et al
(2013)
US
Urban
Community outreach
Total N = 120
AI = 120 (100%) (Congo,
Somalia)
Gender: women
Age: 25–60
Education: 33% bHigh school
Insurance: not reported
Years in US: M = 7.16
SD = 4.12
Quantitative (single arm
intervention)
Multiple (breast
and cervical)
Disease free Intervention outcomes
(knowledge and intentions)
related to screening
The tailored DVD-based intervention increased knowl-
edge of purposes of mammograms, pap smears, and
mental health services, as well as the intent to pursue
them.
Perkins et al.
(2010)
US
Urban
Community outreach
Total N = 73
AI = 3 (4%)
Gender: women and men
Age: 31–60
Education: M = 13 years
Insurance: 5% uninsured
Years in the US: M = 16
range = 4–33
Qualitative (interviews) Cervical Disease free Attitudes toward mandatory
HPV vaccination
Most parents accept HPV vaccination for their daugh-
ters. Caucasian parents mostly opposed school entry
requirements, citing parental autonomy and fears of
promoting promiscuity. Most minority parents would
support the school mandate to protect their own
daughters and other young women.
Samuel et al.
(2009)
US
Urban
Chart review primary
care setting
Total N = 100
AI = 39 (39%)
Gender: women
Age: 50–75 M = 60
Education: not reported
Insurance: not reported
Years in US: M = 5.5 (1–32)
Quantitative (chart
review + survey)
Multiple (breast,
cervical, and
colorectal)
Disease free Screening rates and factors
associated with screening
Somali immigrants had the lowest breast, cervical, and
colorectal cancer screening rates compared to
Cambodian and Vietnamese immigrants. Uptake of co-
lorectal cancer screening was associated with years of
residency in the US. Discomfort with exams conducted
by male physicians was reported as one of the most
salient barriers for screening.
Sheppard
et al.
(2010)
US Urban
Community outreach
Total N = 20
AI = 20 (100%) (West, South,
and East Africa)
Gender: Women
Age: 21–60
Insurance: 25% uninsured
Education: not reported
Years in the US: 3–20 years
Qualitative (focus group) Breast Disease
free + survivors
Knowledge, experiences and
beliefs about breast cancer and
barriers to screening
Breast cancer prevention knowledge and screening
was low. Breast cancer was commonly conceived as a
boil or God's punishment. Barriers to screening
included limited knowledge, lack of insurance, and
stigma and secrecy.
Sussner et al.
(2009)
US
Urban
Retrospective study and
community outreach
Total N = 146
AI = 11 (11%)⁎
Gender: women
Age: M = 45.8, SD = 9.6
Education: not reported
Insurance: not reported
Years in US: M = 0.4, SD = 0.3
(proportion of years lived in US)
Quantitative (cross-
sectional survey)
Breast Disease
free + survivors
Perceived barriers to genetic
testing for breast cancer
Being foreign-born was a significant predictor of antic-
ipated negative emotional reactions to genetic testing.
Breast cancer specific distress, in particular avoidance
symptoms subscale, was positively correlated with
three types of barriers to genetic testing: anticipated
negative emotions, confidentiality concerns, and
family-related guilt.
Tsui et al.
(2007)
US
NHIS sample
Total N = 70,775
AI = 178 (0.3%)
Gender: women
Age: 18–N70
Education: 3% bHigh school
Insurance: 14.9% uninsured
Years in US: 70% ≥25%
proportion of time in the US
Quantitative (cross-
sectional survey)
Cervical Disease free Screening rates and factors
associated with screening
Birthplace and length of residence in the US were sig-
nificant predictors of screening rates. The percentage
for never having a pap smear test was 19% for recent
immigrants compared to 10% among established im-
migrants and 6% among US- born women. Women
from Asia, South East Asia, and India had the highest
percentage of having never been screened.
96 A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

among black men without arousing anxiety or biasing men for or
against testing. However, the intervention had no effect on PSA testing.
Uterine cancer
The only retrieved uterine cancer study (Creque et al., 2010) com-
pared survival rates in a sample of 311 black women from different coun-
tries of origin using cancer registry data in the US. US-born women had a
slightly higher but not significant five-year survival rate compared to
their foreign-born counterparts (56.7% vs. 49.7%). Nevertheless, most
foreign-born women were Caribbean (1% African immigrants), so no
specific information was displayed.
Colorectal cancer screening
Two quantitative studies conducted in the US focused on detection,
as they examined colorectal cancer screening ratesamong Somali immi-
grants. Morrison et al. (2013) found that Somali patients had lower
rates of colorectal cancer screening compared to non-Somali patients
(38.46% vs. 73.35%). Higher screening was correlated with higher use
of primary care services. Comparing screening rates within immigrant
groups, Samuel et al. (2009) found that Somali women had the lowest
colorectal (8%) screening rates. Length of stay in the US was related
with a 39% increase in undergoing a colonoscopy. An additional survey
administered to 15 women (2 Somali women) identified discomfort
with a male provider as one of the main screening barriers.
Unspecified cancer
One qualitative study conducted five focus groups in the UK with
immigrants from Nigeria and Ghana stratified by gender, nationality,
and religion (Christians and Muslims) to examine cancer perceptions
(Ehiwe et al., 2012, 2013). Study results suggested that participants
had limited knowledge about cancer causes and symptoms and some
lacked an equivalent translation in their own languages. Denial, appre-
hension, fear of a cancer diagnosis, shame, and stigma were mentioned
as barriers to seeking medical services and communicating with family
members (Ehiwe et al., 2012, 2013). Change in the environment and
lifestyle in the UK (e.g. nuclear energy, fatty food) were mentioned as
factors that increased their cancer risk. Most participants believed in
both turning to God for healing and seeking healthcare when one had
cancer (Ehiwe et al., 2013) and expressed mixed opinions about the
effectiveness of traditional African herbal medicine to cure cancer.
Discussion
To our knowledge, this is the first systematic review of cancer
controlresearch in this growing subgroup. Findings from this systematic
literature review highlight that (1) African immigrants are underrepre-
sented and/or grouped with other populations, limiting ourunderstand-
ing of how results are most relevant to African immigrants; (2) most
studies focus on the detection phase of the cancer control continuum
(screening) in disease-free populations and suggest suboptimal cancer
screening rates in several subpopulations of African immigrants. Higher
screening appears to be related to health care factors (provider recom-
mendation) and acculturation (e.g. number of years in the US) while
access factors (limited insurance), pragmatic factors (transportation),
and psychosocial factors (limited knowledge, fear, stigma, shame,
cultural values) were perceived as the main barriers; (3) there are
limited cancer related interventions specifically designed for African
immigrants. These findings highlight research gaps and can inform
potential future lines of research and suggesthealth care related recom-
mendations (see Table 4).
There has been a paucity of research with African-born immigrants
as more studies focus on Caribbean populations (Bache et al., 2012;
Borrell et al., 2006; Creque et al., 2010; Lepore et al., 2012; Sussner
et al., 2009). While a few studies were conducted in large samples, im-
migrants constituted less than 5% of the sample (Bache et al., 2012;
Borrell et al., 2006; Creque et al., 2010; Lepore et al., 2012). In addition
to limited representation in studies, some research often failed to
account for the specificities within African-born immigrants and either
lump them with other groups (e.g. Caribbean, Latin American), or
categorize them as “Black,”“other Africans,”or “non-Caribbean”with-
out specifying participants' nationalities (Borrell et al., 2006; Creque
et al., 2010; Lepore et al., 2012; Perkins et al., 2010; Sussner et al.,
2009; Tsui et al., 2007). Carefully, examining differences by subgroups
is important because the studies that differentiate African-born immi-
grants from other subpopulations suggest that there are important
differences in cancer risks, cancer screening, and cancer perceptions
and experiences between African-born immigrants and US-born popu-
lations (Creque et al., 2010; Morrison et al., 2012, 2013; Tsui et al.,
2007), US-born Black (Sussner et al., 2009; Borrell et al., 2006),and
with immigrants from other non-African countries (Samuel et al.,
2009). Moreover, differences were reported between African immi-
grants from different nationalities (Harcourt et al., 2014), between
Africans who migrated and who did not migrate (Kumar et al., 2009;
Odedina et al., 2009), and even between different ethnic groups within
the same African country (Carroll et al., 2007). Thus, these studies point
to the need for more research that examines nuances among specific
subpopulations.
Additionally, there is limited diversity within the African immigrant
samples, as most studies tend to include immigrants who are mostly
from Somalia and Nigeria, mostly insured (Creque et al., 2010;
Notes to Table 3:
Note: AI: African-born immigrants.
⁎Papers that specify the percentage of Caribbean and categorize the rest as non-Caribbean.
Table 4
Research and health care related recommendations.
Research related recommendations
•The capability to analyze data by specific subgroups is needed:
•Include larger samples of African immigrants
•Include diverse African immigrants–nationalities, different levels of
acculturation, non-English speakers, uninsured
•Avoid grouping African immigrants with other subgroups (e.g. Caribbean,
African American)
•Report socio-demographic characteristics and results pertaining to specific
subgroups
•Expand research across different types of cancers and across the cancer control
continuum:
•Understudied types of cancer (e.g. lung, uterine)
•Other phases of the cancer control continuum (e.g. diagnosis, treatment, and
survivorship)
•Develop and test interventions specifically targeted to African immigrants across
the cancer control continuum:
•Engage community based organizations through community based
participatory research
Healthcare related recommendations
•Increase awareness of African immigrant's barriers to cancer related services
•Provide linguistically and culturally sensitive services:
•Trained translators, gender concordance for visits
•Use patient navigators to address access issues (e.g. insurance, transportation,
financial barriers)
•Use community outreach to provide education around cancer and increase
awareness of services
•Engage religious leaders in health outreach efforts
•Educate providers on African immigrant's practices and health services
preferences
97A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Harcourt et al., 2014; Lepore et al., 2012; Morrison et al., 2012; Samuel
et al., 2009; Sheppard et al., 2010; Sussner et al., 2009), living in urban
settings (Borrell et al., 2006; Creque et al., 2010; Harcourt et al., 2014;
Ndukwe et al., 2013; Samuel et al., 2009; Sheppard et al., 2010;
Sussner et al., 2009), English speakers (Ehiwe et al., 2012, 2013;
Ndukwe et al., 2013; Sussner et al., 2009; Tsui et al., 2007), and non-
recently arrived immigrants (Bache et al., 2012; Harcourt et al., 2014;
Kumar et al., 2009; Odedina et al., 2009; Sheppard et al., 2010; Tsui
et al., 2007). Thus, uninsured, recently arrived, non-English speakers
are underrepresented in research, which suggests a challenge in
reaching this population. Conducting community-based participatory
research with community-based organizations like the African
Women's Cancer Awareness Association that serve this type of popula-
tion (e.g. uninsured, non-English speaker, diverse African nationalities)
may be a potential strategy to access this underrepresented group.
Most studies have been conducted in disease free populations
and focused mainly on the cancer detection phase of the cancer con-
trol continuum (cancer screening). Study results suggested that can-
cer screening rates are suboptimal (Harcourt et al., 2014; Morrison
et al., 2012; Morrison et al., 2013; Samuel et al., 2009; Tsui et al.,
2007) and studies that compare African immigrants with other pop-
ulations show screening disparities (Morrison et al., 2012; Samuel
et al., 2009; Tsui et al., 2007). Barriers to cancer screening included
access factors (e.g. health insurance, financial barriers) (Abdullahi
et al., 2009; Harcourt et al., 2014; Ndukwe et al., 2013; Sheppard
et al., 2010; Tsui et al., 2007) and pragmatic constraints (e.g. lan-
guage difficulties, childcare) (Abdullahi et al., 2009; Ndukwe et al.,
2013). Other psychosocial barriers noted were limited knowledge
and awareness, beliefs (e.g. linking cancer with God's punishment
or a death sentence), stigma and secrecy surrounding cancer, and an-
ticipated emotions to the test or diagnosis such as shame, embarrass-
ment,orfear(Abdullahi et al., 2009; Ehiwe et al., 2012, 2013;
Ndukwe et al., 2013; Sussner et al., 2009). Perceiving cultural values
to be at odds with the medical system posed challenges to cancer
screening as well (Abdullahi et al., 2009; Samuel et al., 2009;
Sheppard et al., 2010).
While some access, pragmatic, and psychosocial barriers have been
noted in African Americans and other immigrant populations (De
et al., 2005; Echeverria and Carrasquillo, 2006; Shahidi et al., 2013),
other barriers do not necessarily overlap with the subgroups that
African immigrants tend to be lumped with. For instance, language
difficulties, including the lack of an equivalent translation to cancer
(Sheppard et al., 2010; Ndukwe et al., 2013; Abdullahi et al., 2009)do
not constitute a barrier for African Americans or Caribbean. Medical
mistrust, which has been identified as a barrier for using cancer services
in African Americansand Caribbean (Halbert et al., 2009; Pedersen et al.,
2012; Ng et al., 2013) did not emerge as an obstacle for African immi-
grants. In fact, several studies noted that African immigrants had a
positive perception of health services and providers (Bache et al.,
2012; Carroll et al., 2007; Harcourt et al., 2014). Although screening
fear and embarrassment have been reported in African American and
Caribbean samples (Consedine et al., 2006, 2007), to our knowledge,
embarrassment related to female circumcision (Abdullahi et al., 2009)
has not been reported as a barrier to cervical screening in Caribbean
or African American populations. Shame and secrecy related to a cancer
diagnosis and the attribution of cancer to a curse or God's punishment
was also salient among African immigrants (Ndukwe et al., 2013;
Sheppard et al., 2010). Thus, lumping together African immigrants
with other subpopulations may result in overlooking important differ-
ences that can inform prevention efforts in specific groups. For instance,
it would be important for health care providers working with African
immigrants to be aware of the cultural practices (e.g. female circumci-
sion), preferences (e.g. provider–patient gender concordance), and spe-
cific barriers African immigrants face for cancer screening in order to
provide linguistically and culturally sensitive services. Such services
could include incorporating patient navigators to address access and
pragmatic barriers, providing written and oral information in their na-
tive languages, engaging spiritual leaders as health advocates, and
conducting outreach efforts in community settings to increase cancer
knowledge and services awareness (Sheppard et al., 2010).
In relation to acculturation, some studies support previous findings
with other non-African immigrants (Jandorf et al., 2010) that point to
the role of acculturation in increasing screening rates. In this review,
several factors used as proxies for acculturation such as the length of
stay in the US (Carroll et al., 2007; Harcourt et al., 2014; Samuel et al.,
2009; Tsui et al., 2007), English preference (Carroll et al., 2007), and
higher interaction with the medical system (Morrison et al., 2012)
were related to higher screening rates in African immigrants. Despite
the beneficial impact of acculturation in screening rates, participants
in qualitative studies identified acculturation with environmental and
lifestyle changes such as exposure to nuclear energy, the lack of physical
exercise, and fatty diet, that could increase their cancer risks (Carroll
et al., 2007; Ehiwe et al., 2013). Interestingly, Kumar et al.'s (2009)
study suggested that Nigerians who migrated to the US had a healthier
life style (diet and physical exercise) compared to their Nigerian coun-
terparts who did not migrate to the US. Thus, further research is needed
to elucidate the impact of acculturation in different cancer preventive
behaviors among African immigrants.
Within the 20 articles reviewed, there were only two intervention
studies. One was a RCT but the sample mainly consisted of Caribbean
immigrants (Lepore et al., 2012). The study with the single arm inter-
vention with women from Somalia and Congo showed promising
results of a culturally sensitive DVD workshop around breast and
cervical cancer screening (Piwowarczyk et al., 2013). Thus, developing
and testing other culturally targeted interventions for African immi-
grants across different types ofcancers and across thecancer continuum
are warranted. Potential intervention targets include increasing cancer
knowledge, services awareness, targeting shame and stigma in the
community, screening and treatment decision aids, interventions
designed to improve doctor–patient communication, and survivorship
issues.
The study had certain limitations. Due to publication bias and to the
limitations of using MeSH terms, we cannot guarantee that all studies
using African-born samples were included in this review. MeSH terms
use automatic mapping, which means that search terms may be trans-
lated to the closest MeSH term, which carries the risk of losing accuracy.
However, we used five different search engines and we chose broad
MeSH terms and eligibility criteria to capture as many studies as
possible. We also used the paper's reference lists and other scholars'
suggestions to complement the search. The fact that we did not set a
specific percent of African-born immigrants in the studies' study sam-
ples as eligibility criteria resulted in the retrieval of studies that included
very low percentages of Africanimmigrants. Thus, the study results may
not be representative of the African-born population. Despites these
caveats, this is the first review that addresses cancer related issues in
African immigrant populations. The review suggests the need to
advance the research in this underrepresented population and the
need to avoid lumping African immigrants with other groups or under
broad categories such as “African.”Conducting more studies with immi-
grants from diverse African nationalities, reaching out to the uninsured,
newly arrived, non-English speaking population, and developing and
testing interventions for disease free as well as cancer survivors is
warranted.
Conflict of interest statement
The authors declare that there are no conflicts of interests.
Acknowledgments
This work was funded by a Clinical and Translational Science Award
(Sheppard: PI, Grant Award #: 2012-5) and partly by a Susan G. Komen
Breast Cancer Foundation Baccalaureate Training in Breast Cancer
98 A. Hurtado-de-Mendoza et al. / Preventive Medicine 67 (2014) 89–99

Health Award to Ocla Kigen (PI. Dr. Lucile Adams-Campbell, Award#:
PBTDR12228366).
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