Breast Cancer Screening among African Immigrants in the United States: An Integrative Review of Barriers, Facilitators, and Interventions

Abstract

The purpose of this review was to synthesize the available literature on breast cancer-screening barriers, facilitators, and interventions among U.S. African immigrants. Following the integrative review framework and PRISMA guidelines for reporting systemic reviews, five electronic databases were searched: PubMed, CINAHL, PsycINFO, Medline, and Google Scholar. Studies were included if they were published in English language journals after 1 January 2000 and reported data on breast cancer-screening barriers, facilitators, or interventions among U.S. African immigrants. Barriers and facilitators reported by studies were descriptively examined and synthesized by two authors and classified as aligning with one of the three levels of influences based on the social–ecological model (intrapersonal, interpersonal, and community). Interventions promoting breast cancer screening were narratively summarized. Search procedures retrieved 1011 articles, with 12 meeting the criteria for inclusion in the review (6 qualitative and 6 quantitative). Intrapersonal barriers included limited awareness, fear of pain, language barriers, health concerns, transportation issues, costs, and negative past experiences. Interpersonal barriers involved modesty, spiritual beliefs, and lack of support, while community-level barriers included provider and healthcare-system challenges. Regarding facilitators, past screening experiences and health insurance were the most commonly reported intrapersonal facilitators. The only interpersonal facilitator identified was observing other women experience a breast cancer diagnosis and undergo treatment. Community-level facilitators included appointment reminders, scheduling assistance, culturally congruent interpreters, transportation to screening facilities, and patient navigators. Three articles reported outcomes of breast cancer-screening interventions. All three were pilot studies and reported increased knowledge and attitudes regarding breast cancer screening following the respective interventions. One study examined the uptake of breast cancer screening following the intervention, with results indicating an increase in screening. Findings provide a comprehensive synthesis of factors influencing breast cancer screening among African immigrants and highlight the need for future research on the topic. This review was registered with Prospero (CRD42024502826) before the initiation of search procedures.

Full text

Citation: Rauch, J.I.; Daniels, J.;
Robillard, A.; Joseph, R.P. Breast
Cancer Screening among African
Immigrants in the United States: An
Integrative Review of Barriers,
Facilitators, and Interventions. Int. J.
Environ. Res. Public Health 2024,21,
1004. https://doi.org/10.3390/
ijerph21081004
Academic Editor: Paul B. Tchounwou
Received: 1 June 2024
Revised: 24 July 2024
Accepted: 26 July 2024
Published: 30 July 2024
Copyright: © 2024 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
International Journal of
Environmental Research
and Public Health
Review
Breast Cancer Screening among African Immigrants in the
United States: An Integrative Review of Barriers, Facilitators,
and Interventions
Julian I. Rauch *, Joseph Daniels, Alyssa Robillard and Rodney P. Joseph
Center for Health Promotion and Disease Prevention, Edson College of Nursing and Health Innovation,
Arizona State University, 500 N 3rd St., Phoenix, AZ 85004, USA; rodney.joseph@asu.edu (R.P.J.)
*Correspondence: julian.rauch@asu.edu; Tel.: +1-832-840-5060
Abstract: The purpose of this review was to synthesize the available literature on breast cancer-
screening barriers, facilitators, and interventions among U.S. African immigrants. Following the
integrative review framework and PRISMA guidelines for reporting systemic reviews, five electronic
databases were searched: PubMed, CINAHL, PsycINFO, Medline, and Google Scholar. Studies were
included if they were published in English language journals after 1 January 2000 and reported data on
breast cancer-screening barriers, facilitators, or interventions among U.S. African immigrants. Barriers
and facilitators reported by studies were descriptively examined and synthesized by two authors and
classified as aligning with one of the three levels of influences based on the social–ecological model
(intrapersonal, interpersonal, and community). Interventions promoting breast cancer screening were
narratively summarized. Search procedures retrieved 1011 articles, with 12 meeting the criteria for
inclusion in the review (6 qualitative and 6 quantitative). Intrapersonal barriers included limited
awareness, fear of pain, language barriers, health concerns, transportation issues, costs, and negative
past experiences. Interpersonal barriers involved modesty, spiritual beliefs, and lack of support,
while community-level barriers included provider and healthcare-system challenges. Regarding
facilitators, past screening experiences and health insurance were the most commonly reported
intrapersonal facilitators. The only interpersonal facilitator identified was observing other women
experience a breast cancer diagnosis and undergo treatment. Community-level facilitators included
appointment reminders, scheduling assistance, culturally congruent interpreters, transportation
to screening facilities, and patient navigators. Three articles reported outcomes of breast cancer-
screening interventions. All three were pilot studies and reported increased knowledge and attitudes
regarding breast cancer screening following the respective interventions. One study examined the
uptake of breast cancer screening following the intervention, with results indicating an increase in
screening. Findings provide a comprehensive synthesis of factors influencing breast cancer screening
among African immigrants and highlight the need for future research on the topic. This review was
registered with Prospero (CRD42024502826) before the initiation of search procedures.
Keywords: breast cancer; screening; African immigrants; United States
1. Introduction
Breast cancer is a major public health concern. Globally, it accounts for approximately
12% of all cancer diagnoses, with over 2.3 million new cases in 2020 [
1
]. Breast cancer is
the most common type of cancer among women and is a leading cause of cancer mortality,
contributing to over 685,000 global deaths in 2020 [
1
,
2
]. In the United States (U.S.), breast
cancer is the second leading cause of cancer-related death among women (behind lung and
bronchus cancer), with over 310,000 new cases diagnosed annually [
3
]. Estimates further
indicate that breast cancer will contribute to over 42,000 U.S. deaths by the end of 2024 [
3
].
Black women in the U.S. face significantly worse cancer-related health compared to
women of other ethnic backgrounds [
4
]. For example, despite Black women having a lower
Int. J. Environ. Res. Public Health 2024,21, 1004. https://doi.org/10.3390/ijerph21081004 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2024,21, 1004 2 of 24
incidence rate of breast cancer than White women (126.7 vs. 134.9 per 100,000 women), they
have a 41% higher mortality rate [
4
]. Reasons for the high mortality rate are attributed to
socioeconomic status (SES), later-stage diagnosis, and limited access to care [
4
–
6
]. Previous
research examining breast cancer screenings among Black women in the U.S. has included
limited acknowledgment of the heterogeneity that exists, including whether women were
born in the US or are immigrants.
African-born immigrants differ significantly from Black/African Americans and the
average U.S. population as a whole. For instance, despite having higher education and
household income levels [
7
], African-born immigrants are more likely to experience poor
physical, psychological, and social health [
8
,
9
], less likely to have a regular health care
provider, and to experience a higher rate of being uninsured [
10
]. They also have different
chronic-disease risk profiles [
11
] and tend to be a slightly older population [
7
]. In addition,
African immigrants face unique barriers to healthcare that are not always universally
experienced by Black Americans, including lack of English language proficiency [
12
],
limited knowledge and mistrust of the U.S. health system [
13
], lack of a culturally and
linguistically competent provider [
14
], and implicit bias among care providers regarding
a patient’s immigrant status, which results in lower-quality care [
15
]. In addition to
these barriers, emerging evidence suggests that women from certain regions of Africa
(e.g., Nigeria) are at greater risk for breast cancer morbidity and mortality due to inherited
genetic mutations of BRCA1 and BRCA2 genes that elevate breast cancer risk [
16
], including
risk for triple-negative breast cancer, a highly aggressive form of cancer that rapidly spreads
and has limited effective treatment options [
17
–
19
]. Given the estimated 2 million African
immigrants in the U.S. [
20
,
21
], there is a pressing need to customize breast cancer-screening
interventions and public health campaigns to align with their unique sociocultural norms,
behaviors, and language preferences.
The purpose of this integrative review was to synthesize the available literature on
the barriers and facilitators with regard to breast cancer screening among US African im-
migrants, as well as to review previous interventions designed to promote breast cancer
screening in this population. To our knowledge, this is the first review examining these
topics exclusively among African immigrants. Results provide a comprehensive synthesis
of the determinants of breast cancer screening among African immigrants and describe ex-
isting evidence on strategies and interventions designed to promote breast cancer screening
among African immigrants.
2. Methods
This integrative review followed the methodological framework proposed by Whitte-
more and Knafl [
22
]. Preferred Reporting Items for Systematic Reviews and Meta-Analysis
(PRISMA) guidelines were used to report the methods and results (see Figure 1) and
the review was registered in Prospero (CRD42024502826) prior to the initiation of search
procedures.

Int. J. Environ. Res. Public Health 2024,21, 1004 3 of 24
Int. J. Environ. Res. Public Health 2024, 21, 1004 3 of 31
Figure 1. PRISMA diagram illustrating the study selection process.
2.1. Search Strategy
The Boolean search strategy was used to retrieve relevant articles from five electronic
databases: PubMed, CINAHL, PsycINFO, Medline, and Google Scholar. Database
searches included various combinations and connections of terms for two broad topical
areas: study population (i.e., African immigrants) and behavior/phenomenon of interest
(i.e., breast cancer screening). Search terms used for each of these topical areas are pre-
sented in Appendix A. An example of a search strategy included “breast cancer AND
screening AND African immigrants AND United States OR U.S.”. Search procedures were
conducted between 1 January 2000 and 31 December 2022.
2.2. Article Inclusion Criteria
All study designs were eligible for inclusion (i.e., quantitative, qualitative, and mixed
methods), as long they met the following inclusion criteria: (1) reported data on breast
cancer-screening barriers, facilitators, or interventions among African immigrants resid-
ing in the U.S., including refugees (i.e., women born in Africa that currently reside in the
U.S.); (2) published between 1 January 2000 and 31 December 2022, in English language
peer-reviewed journals; and (3) focused on women aged ≥18 years old. Journals that in-
cluded other cancer screenings or women’s health promotion were also included in the
search, as long as they reported data on breast cancer screening.
2.3. Study Selection Process
Figure 1 shows the article retrieval and selection process. Search procedures retrieved
1011 articles that were exported to Covidence screening and data extraction software
(Cochrane Collaboration, London, UK). After the removal of duplicates (n = 241), the titles
and abstracts of the remaining 770 articles were reviewed by the first author (JR) for
Figure 1. PRISMA diagram illustrating the study selection process.
2.1. Search Strategy
The Boolean search strategy was used to retrieve relevant articles from five electronic
databases: PubMed, CINAHL, PsycINFO, Medline, and Google Scholar. Database searches
included various combinations and connections of terms for two broad topical areas: study
population (i.e., African immigrants) and behavior/phenomenon of interest (i.e., breast
cancer screening). Search terms used for each of these topical areas are presented in
Appendix A. An example of a search strategy included “breast cancer AND screening
AND African immigrants AND United States OR U.S.”. Search procedures were conducted
between 1 January 2000 and 31 December 2022.
2.2. Article Inclusion Criteria
All study designs were eligible for inclusion (i.e., quantitative, qualitative, and mixed
methods), as long they met the following inclusion criteria: (1) reported data on breast
cancer-screening barriers, facilitators, or interventions among African immigrants residing
in the U.S., including refugees (i.e., women born in Africa that currently reside in the
U.S.); (2) published between 1 January 2000 and 31 December 2022, in English language
peer-reviewed journals; and (3) focused on women aged
≥
18 years old. Journals that
included other cancer screenings or women’s health promotion were also included in the
search, as long as they reported data on breast cancer screening.
2.3. Study Selection Process
Figure 1shows the article retrieval and selection process. Search procedures retrieved
1011 articles that were exported to Covidence screening and data extraction software
(Cochrane Collaboration, London, UK). After the removal of duplicates (n = 241), the
titles and abstracts of the remaining 770 articles were reviewed by the first author (JR) for

Int. J. Environ. Res. Public Health 2024,21, 1004 4 of 24
potential relevance for inclusion in the review, resulting in 104 articles being classified
as potentially eligible. Next, a full-text review of these 104 articles was independently
conducted by JR and a second reviewer (RPJ) to determine article eligibility, with any
discrepancies between the two reviewers being resolved by consensus. This resulted in
12 articles being identified as meeting the criteria to be included in the review.
2.4. Data Extraction
The following data, when applicable, were extracted from studies included in the
review: (a) authors and year of publication, (b) study design, (c) sample characteristics
(i.e., sample size, age of participants, race/ethnicity), (d) data collection method, (e) study
purpose, (f) barriers to breast cancer screening, (g) facilitators of breast cancer screening,
(h) intervention outcomes, and (i) study author reported strengths, limitations, and rec-
ommendations for future research and practice. Initial data extraction was conducted by
1 member of the research team (JR). After the initial extraction of all study data, a second
member of the research team (RPJ) verified that the data extracted were accurate by com-
paring the data tables to the data published in each article. If there were any disagreements
between these, the two reviewers reached agreement by consensus.
2.5. Data Synthesis
Barriers to and facilitators of breast cancer screening were descriptively examined
and synthesized by the authors (JR and RPJ) using an iterative process described by
Whittemore and Knafl [
22
]. In the first level of analysis, data extracted for studies were
classified into two categories: barriers to breast cancer screening and facilitators of breast
cancer screening. Next, using a constant comparison approach, the authors independently
and collaboratively reviewed data extracted from studies to identify overarching themes
and patterns. The themes and patterns emerging from this analysis of barriers and facilita-
tors with respect to breast cancer screening were categorized as aligning with one of three
levels of influence based on the social–ecological model: intrapersonal, interpersonal, or
community [
23
,
24
]. This process of analysis occurred over a series of months and included
numerous meetings between the two authors (JR and RPJ), with final decisions regarding
the classification of barriers and facilitators based on the level of influences achieved by
author consensus.
A narrative review approach was used to summarize each intervention included
in the review. Topics included in this description included the name of the program,
sample population, intervention design aim, and study outcomes. During the final phase
of analysis, all authors (JR, RPJ, AR and JD) collaborated on reviewing and synthesizing
the paper, ensuring that each author’s perspective was considered. Any disagreements
were resolved through consensus among the authors.
3. Results
3.1. Overview of Studies
Among the 12 studies included in the review, half reported data from qualitative
study designs (Table 1) and the other half from quantitative designs (Table 2). The year of
article publication ranged from 2010 to 2022, with 2015 being the modal year of publication.
The majority of qualitative studies employed focus group methodology [
14
,
25
–
27
], one
study used one-on-one interviews [
28
], and one study included both interviews and focus
groups [
29
]. Among the six quantitative studies, three reported data from cross-sectional
surveys [
30
–
32
], one study reported cancer screening uptake following a cancer screening
intervention [
33
], and two studies reported the feasibility and psychosocial outcomes
(i.e., attitudes and knowledge) of brief, one-time education interventions designed to
promote cancer screenings [34,35].

Int. J. Environ. Res. Public Health 2024,21, 1004 5 of 24
Table 1. Overview of qualitative studies included in the review (n = 6).
Author and Year Sample Characteristics Study Design Study Purpose Results Strengths, Limitations, and
Recommendations (Reported by the Authors of the Individual Studies)
Sheppard et al. (2010) [14]
N: 20 women
Age: 21–60 years
Setting: Washington, DC.
Population:
Western Africa (Nigeria and Ivory Coast)
Eastern Africa (Ethiopia)
Southern Africa (Zimbabwe)
Number of years in the U.S.:
3–20 years
Languages:
English
Methodology:
Descriptive
Method:
Focus group sessions
Data Analysis:
Thematic and content analysis
Theoretical model: not stated
To exploreAfrican women’s knowledge
and attitudes towards breast cancer
practices and to identify potential
intervention targets
Barriers:
•Limited knowledge of breast cancer screening
•Lack of insurance
•Cultural/spiritual beliefs
•Shame and stigma
•Privacy and trust
•Challenging access to the U.S. healthcare system
Facilitators:
•Not stated
Strength:
•
Use of storytelling by several women to illustrate their points through brief parables
Limitations:
•Small sample size
•Exclusion of non-English-speaking African immigrant women
•Non-representation of other various subgroups
•Findings do not include the barriers faced by African women who do belong to
the organizations
Recommendations:
•To develop culturally tailoredbreast cancer interventions, additional research will
be useful
•Educating men with assisting with early detection
Al-Amoudi et al. (2015) [25]
N: 14
Age: 30–69 years old
Setting: Seattle, Washington
Population: Muslim Somali women
Number of years in the U.S.: Recent immigrants
(number not stated)
Languages:
English
Methodology:
Qualitative
Method:
Focus groups (90 min)
Data Analysis:
Thematic and content analysis
Theoretical model: not stated
To provideadditional insight into the
knowledge and beliefs about breast cancer
and breast cancer screening among recent
Somali immigrant women
Barriers:
•Language
•Fear of pain
•Transportation problem
•Lack of knowledge of breast cancer and breast
cancer screening
•Lack of female or Muslim doctors
Facilitators:
•Not stated
Strength:
•All recent Somali immigrants were included in the study
Limitations:
•Small study size
•Limited data collected (demographic not collected)
Recommendations:
•Provide breast cancer educational programs to immigrant women to prevent
late-stage disease because of lack of screening
•Ensure female and/or Muslim doctors are available
Saadi et al. (2015) [28]
N: 17
Age: 27–58 years
Setting: Chelsea, Massachusetts
Population:
Somali, Bosnian, and Iraqi refugee women
(convenience and snowballing sampling)
Number of years in the U.S.:
2 to 16 years
Languages:
English
Methodology:
Descriptive
Method:
Semi-structured interview (20–45 min)
Data Analysis:
Thematic and content analysis
Theoretical model:
grounded theory
To exploreBosnian, Iraqi, and Somali
women refugees’ beliefs about preventive
care and breast cancer screening to inform
future community interventions and
best practices
Barriers:
•Fear of pain and diagnosis
•Modesty
•Fatalism
•Inattentiveness to personal health
•Work and childcarecommitments
•Steep learning curve about navigating and
understanding the appointment system
Facilitators:
•Access to state insurance coverage
•Outreach education efforts
•Women who spoke the same language
as participants
•Shuttles and taxi vouchers
•Ready access to public transportation
•Appointment reminders
•Personal contact with health providers
•Perceptions of how the American medical
infrastructure compared with inadequacies in their
home countries
•Positive attitude toward U.S. health professionals
Strength:
•Easy access to conduct local assessments due to low financial outlay
•Use of interview
Limitations:
•The use of a one-way translation method for the interview questions
•Lack of an external review of translations and transcriptions that would have
strengthened study rigor
•Interviewers’ type, level, and depth of prior training and experience affected the
quantity and depth of data related to interviewing
•Possible bias was introduced into transcripts by utilizing health center staff to carry
out the interviewing, transcription, and translation
•
Possibility that participants may have been influenced by the interviewer’s affiliation
with the health center when discussing their perspectives about healthcare providers
•Use of snowballing and convenience sampling rather than random sampling also
reduces the generalizability of the data
Recommendations:
•Healthcare equity can be strengthened by ensuring that programs exist that assist
refugee women in navigating a complicated and new healthcare system
•Implementing programs that optimize patient–physician interactions in
refugee communities
•Designing and implementing a message of a health campaign that focuses on the
unique needs and experiences of different groups
•Understanding religious diversity and that it is not universal or monolithic

Int. J. Environ. Res. Public Health 2024,21, 1004 6 of 24
Table 1. Cont.
Author and Year Sample Characteristics Study Design Study Purpose Results Strengths, Limitations, and
Recommendations (Reported by the Authors of the Individual Studies)
Pratt et al. (2017) [26]
N: 34
Age: 18 and over
Setting:
Urban mosque in Minneapolis, Minnesota
Population:
Somalians
Number of years in the U.S.:
<5 years—N = 4
6–10 years—N= 13
>10 years—N =15
Not answered—N = 3
Languages:
English
Methodology:
Qualitative
Method:
Focus group (two hours)
Data Analysis:
Thematic
Theoretical
model:
Social constructivist version of
grounded theory
To test the acceptability of faith-based
messages aimed at ameliorating concerns
among Somali women and men that cancer
screening conflicts with the religious value
of maintaining modesty and the concept of
predestination, as well as promoting
screening and treatment for cancer
Barriers:
•Fear of the mammography machine
•Negative experiences with testing in the past
•Experiences of pain in undergoing screening
•Faith
•Modesty
•Lack of symptoms
Facilitators:
•Not stated
Strength:
•Novel, as participants were very engaged even though they were in separate rooms
Limitations:
•The impact of actual screening behavior was not tested
•Samples were self-selected, thus the potential for bias
•Age or level of religiosity was not explored
•Small sample size
Recommendations:
•To add faith-based messaging to other interventions that focus on improving
screening uptake as it could help address health disparity among Somali women
•
Future work should engage families and individuals in conversations about cancer in
the Somali immigrant community
•Incidence of screening should be collected in future works
Ndukwe et al. (2013) [29]
N: 38
Age: 20–70 years
Setting:
Washington D.C. metropolitanarea
Population:
Ghana, Cameroon, Nigeria, Zambia, and
Ivory Coast
Number of years in the U.S.:
Not reported
Languages:
English
Methodology:
Qualitative
Method:
Key informant interviews (45–60 min)
and
focus group sessions (45–60 min)
Sociodemographic questionnaire (over a
3-month study period)
Data Analysis:
Thematic analysis
Theoretical model:
not stated
To investigate the knowledge, perceived
barriers, and frequency of breast and
cervical cancer screening among African
immigrant women residing within the
Washington D.C. metropolitanarea
To determine the effectsof cultural factors,
spiritual beliefs, and familyr influences on
breast and cervical cancer screening and to
assess whether these beliefs vary with age
Supplement the minimal available
information regarding the breast- and
cervical-cancer outcomes of African-born
immigrants to the U.S.
Barriers:
•Lack of awareness
•Fatalism
•Stigma/shame
•Privacy
•Fear
•Religious and cultural factors
•Transportation
•Cost of insurance
•Spousal consent/approval
Facilitators:
•Reminders from primary-care physicians
•Cancer-related deaths in the community
Strength:
•Shed light on the cancer outcomes specifically of female African immigrants to
the U.S.
•
Collaborating qualitative methods with community organizations to improve health
outcomes within this population
•The findings are critical for researchers, physicians, and public health educators
aiming to design culturally appropriate interventions to effectively reduce the
prevalence of breast and cervical cancer among female African immigrants living in
the U.S.
Limitations:
•Small sample size and a limited number of participants’ countries of origin—thus
regional-specific in findings
•Lack of generalization due to only English-speaking participants
Recommendations:
•To develop successful outreachto provide more cancer screening among this group
to increase early detection and treatment
•Refrain from categorizing African-born immigrants with AA due to differences in
beliefs and practices
•Utilizing cancer survivors (of similar ethnic descent) in outreach efforts to address
the barrier of fatalism
•Future research should utilize patient navigators to assist women who were
diagnosed with breast cancer in adhering to the prescribed treatment plan
•Utilizing researchers knowledgeable in Biblical scripture to help answer questions
cited by participants referencing the Bible
•Ensure that programs involve churches and religious leaders within the community
to become advocates of cancer screening and treatment

Int. J. Environ. Res. Public Health 2024,21, 1004 7 of 24
Table 1. Cont.
Author and Year Sample Characteristics Study Design Study Purpose Results Strengths, Limitations, and
Recommendations (Reported by the Authors of the Individual Studies)
Raymond et al. (2014) [27]
N: 29
Age: 20–65 years
Setting: Minnesota
Population: Somali immigrant women
Number of years in the U.S.: Not stated
Languages: English
Methodology:
Qualitative
Method:
Focus group
Data Analysis:
Immersion crystallization
Theoretical model: not stated
To gather knowledge to better understand
what Somali immigrant women know
about cancer, the acceptability of
mammograms and pap smears as screening
modalities, and any age-based differences
in attitudes toward screening, to create a
culturally relevant intervention for Somali
women living in Minnesota
Barriers:
•Concerns about radiation
•Modesty and shyness
•Stigma
•Pain and embarrassment
•Lack of accurate knowledge about breast cancer
•Mistrust of the healthcare system
•Language barriers
•Lack of providers from the same
religious background
Facilitators:
•Increasing the role of women in the community
•Staying healthy to fulfill the role of childbearing
•Using religion to encourage health
•Openness to regular checkups and early
identification of health problems
Strength:
•Not stated
Limitations:
•Small sample size
•Findings not generalizable
Recommendations:
•
Cultural misperceptions and attitudes need to be addressed in developing culturally
appropriate interventions to improve screening uptake for Somali women
•The need to integrate culturally informed beliefs into intervention development,
preventive care, and screening promotion
Table 2. Overview of quantitative studies included in the review (n = 6).
Author and Year Sample Characteristics Study Design Study Purpose Study Outcomes Strengths, Limitations, and Recommendations (Reported by the Authors of the
Individual Studies)
Sheppard
et al. (2015) [32]
N: 200 women
Age: 20–60 years
Setting: Washington, DC metro areas
Population:
West, East, Central Africa, and others
Number of years in the U.S.:
<10 years—N =75
>10 years—N = 112
Missing—N = 13
Languages:
English
Methodology:
Cross-sectional
Method:
Self-administered questionnaire (20 min)
Intervention components
N/A
Theoretical model: not stated
To examine factors that areassociated with
higher endorsement of screening
To identify areasfor more in-depth study
Barriers:
•Lack of insurance
•Language
•Marital status
Facilitators:
•Not stated
Other findings:
•Breast cancer-screening endorsement was higher
(81%) among English-speaking women over 40
years, married, insured, living in the U.S. for over
10 years, and having breast cancer knowledge
•Breast cancer screening rate (88%) was higher in
this cohort than other studies (15–61%)
Strength:
•Use of a community-based survey designed and delivered in partnership with a
community-based organization
•
Survey that was informed by previous focus groups with African immigrant women
•Recruitment of an under-represented sample of African women from
diverse nationalities
•The inclusion of items from validated studies
•The assessment of psychosocial factors (breast cancer knowledge and screening
attitudes) that were not previously described in this population
•The study expands current knowledge about psychosocial factors (not captured in
prior studies)
Limitations:
•Non-stratification due to small sample size
•Use of highly insured convenience sample with a high percentage of
established immigrants
•The result cannot be generalized (non-insured or new immigrants)
•Over-reporting due to self-reported measures
•The use of single-item outcomes hindered the possibility of assessing
internal consistency
Recommendations:
•Future studies should consider nuances among diverse women of African origin
•The need to develop interventions to improve doctor–patient communication via
bilingual navigators
•Development of information materials in different African languages

Int. J. Environ. Res. Public Health 2024,21, 1004 8 of 24
Table 2. Cont.
Author and Year Sample Characteristics Study Design Study Purpose Study Outcomes Strengths, Limitations, and Recommendations (Reported by the Authors of the
Individual Studies)
Raines Milenkov et al. (2020) [33]
N: Not stated
Age: 40 and older
Setting:
Fort Worth, Texas
Population:
Central African Region (Democratic Republic of
Congo, Rwanda, Burundi, Tanzania, and Uganda)
Somalia/Kenya
Arabic (Sudan, Iraq, Syria, Egypt, Jordan) Other
(Afghanistan, Angola, Chad, Eritrea, Ethiopia,
Liberia, and Senegal)
Number of years in the U.S.: Not stated
Languages:
English
Methodology:
Cross-sectional
Method:
Education program (video, presentation,
and anatomic model)
Theoretical model:
not stated
To assess differencesin uptake of cervical,
breast, liver, and colorectalscreens across
six cultural groups
Barriers:
•Lack of transportation
•Trauma
•Health literacy
•Education levels
•Lack of culturally congruent providers
•Complex nature of the U.S. healthcare system
•Interpretation
•Scheduling and lack of appointment reminders
Facilitators:
•Not stated
Other findings:
•The uptake for breast cancer screening was 50% or
more in all cultural groups except one, the Central
African region (35%)
•Mammograms were the most accepted cancer
screen among most refugees (54%), except the
Central African group (35%)
•The odds of participants from the Central African
region group accepting a mammogram were 63%
lower than the odds of a mammogram being
accepted by members of the Myanmar group (POR
= 0.37, 95% CI = 0.18–0.73, p-value = 0.01). More
women received a mammogram (54%)
•There is evidence that uptake in screenings varies
among ethnic groups, even with a culturally and
linguistically appropriate outreach and
education strategy
Strength:
•Focused on never-screened and not up-to-date participants
Limitations:
•Lack of generalizability of study findings due to the Texas healthcareenvironment
•Self-reporting of baseline assessment data
•The possible effect of the community health workers’ characteristics could have
prevented members from willingly enrolling in breast cancer screening
•A smaller sample size in the Arabic-speaking group reflects delayed outreach into
this population
Recommendations:
•To meet national goals, detect cancer early, and save lives, there needs to be a
culturally and linguistically appropriate outreach and education to diverse
immigrant groups
•Focus on alternate education delivery methods, such as online or video-based
•Future studies should consider different study settings such as clinics and
community locations
•Understanding diversity within refugee communities and adapting to their specific
cultural and linguistic needs with information, education, and outreach will help
reduce the inequality gap
Pratt et al., (2020) [35]
N: 30
Age:
30–70 years old
Setting: Local Mosque-Minneapolis, Minnesota
Population:
Somali Muslim Women
Number of years in the U.S.:
1–23 years
Languages:
English
Methodology:
Cross-sectional
Method:
Religiously tailored workshops (I week)
Theoretical model:
Social–ecological approaches
To test the feasibility and impact of
religiously tailored workshops in helping to
promote breast and cervical cancer
screening within the Somali
Muslim community
Barriers:
•Modesty
•Faith
•Pre-destination
•Access to preventive health care
Facilitators:
•Not stated
Other findings:
•All women reported that the workshop provided
beneficial information
•That they are more likely to receive breast
cancer screening
•Positive baseline result
•Fewer women believed that screening may cause
harm in post-workshop surveys than in
pre-workshop surveys
Strength:
•The use of an Imam to clarify Islamic understandings of relevant issues had the
potential to utter religiously attributed beliefs that were acting as a barrier to breast
cancer screening
Limitations:
•Bias, as sampled women were currently in breast cancer screening and thus were
more open to screening
•No verification of screening due to self-reporting
•Potential desirability bias, since the workshop was facilitated by a religious leader
•Small size sample
Recommendations:
•To test the message on Somali women who arenot up-to-date with screening
•To test the intervention on a broaderrange of religiously attributed barrier beliefs to
assess the extent of participant religiosity and the role of both self- and
collective-efficacy on screening behavior

Int. J. Environ. Res. Public Health 2024,21, 1004 9 of 24
Table 2. Cont.
Author and Year Sample Characteristics Study Design Study Purpose Study Outcomes Strengths, Limitations, and Recommendations (Reported by the Authors of the
Individual Studies)
Piwowarczyk et al. (2012) [34]
N: 120
Age: 25–64 years
Setting:
Community sites- Greater Boston and New
Hampshire
Population:
Somali and Congolese women
Number of years in the U.S.:
0–19 years
Languages:
English
Methodology:
Cross-sectional
Method:
Pretest survey (30 min)
One session group workshop–DVD (2 h)
Post-test survey
Theoretical model:
not stated
To evaluate the UJAMBO program
addressing the impact on participants’
knowledge of health services and their
intentions to use these services
Barriers:
•Lack of knowledge of mammography
Facilitators:
•Not stated
Other Findings:
•Significant increase in knowledge as to the
purposes of these services
•An increase in the intent to pursue the services
•Significant improvement in knowledge of
mammograms at post-test
•Significant improvement in intentions to
receive mammograms
Strength:
•Not stated
Limitations:
•Possibility of social desirability as a reason for changes in reported intentionality
•Findings were limited to pre-post analyses subject to testing effects
•Lack of behavioral outcome data and other threats to validity
•Pre- and post-tests were administered too close together
•Outcome data were solely based on self-report, subject to social desirability biases
•
Lack of generalizability,as the sample had women from only two African immigrant
countries with women linked to the CBOs serving those communities
Recommendation:
•Conduct larger-scale research with more rigorousevaluation methods
Harcourt
et al. (2013) [31]
N: 112
Age:
40 years and above
Setting:
Minneapolis and St. Paul (participants’ home)
Population:
Somali
Other African women
Number of years in the U.S.:
<5 years—N = 44
>5 years—N = 68
Languages: English
Methodology:
Cross-sectional (secondary data)
Method: Survey
Theoretical model:
Healthcare access and utilization
Behavioral model for
vulnerable populations
To determine the rates of participation in
breast- and cervical-cancer screening
among age-eligible female African
immigrants and to examine barriers
associated with these cancer
screening procedures
Barriers:
•Difficulty with healthcare access
Facilitators:
•Not stated
Other findings:
•African immigrant women in Minneapolis and St.
Paul have low breast- and cervical-cancer
screening rates
•Ethnicity (Somali vs. other African immigrant
groups) and duration of residence in the U.S.
(
≤
5 years vs. >5 years) were significantly related to
ever having had a mammogram
•Somali women were 5 times more likely than other
African women to ever having had a mammogram
(odds ratio = 5.02, 95% CI = 1.72–14.68, p= 0.003)
Strength:
•Use of a conceptual model framework to explore factors impacting breast
cancer-screening behavior among African immigrant women
Limitations:
•Limited sample size
•Restriction of the data to urban areas in Minneapolis and St. Paul with the largest
concentration of African immigrant families
•Secondary data analysis
•Self-reported breast cancer screening
Recommendations:
•
Community-based educational interventions should focus on the need for screening
among all immigrant women in a culturally sensitive manner
•Future research should explore the impact of acculturation on cancer screening
among recent immigrant women
Adegboyega
et al. (2022) [30]
N: 59
Age: 40 years and over
Setting:
Lexington and surrounding cities in Kentucky
Population:
Sub-Saharan women (Nigeria, Cameroon, and
Congo)
Number of years in the U.S.: Not stated
Languages:
English
Methodology:
Cross-sectional
Method:
Survey (20 min)
Theoretical model:
Social cognitive theory (SCT)
To evaluate the relationshipsbetween
beliefs (religiosity,fatalism, temporal
orientation, and acculturation) and
cervical-, breast-, and colorectal-cancer
screening behaviors among African
Americans and Sub-Saharan
African immigrants
Barriers:
•Fatalism, religiosity,belief
Facilitators:
•Not stated
Other Findings:
•Religiosity,cancer fatalism, future orientation, and
acculturation, were not associated with
mammography screening
•Mammogram uptake increased with age
Strength: Not stated
Limitations:
•The study design was a cross-sectional research design, which does not
reflect causation
•Use of convenience and non-probability samples
•
Modest sample size, which was further restricted for each model based on those who
were appropriate for the screening modality
•
Self-reported before completion of screening, which may be subject to recall or social
desirability bias
Recommendations:
•
To promotepreventive screening, health researchers should consider health temporal
orientation and other beliefs in the design of interventions for Black populations
•
Increase breast cancer prevention and awareness efforts among younger individuals
•Larger-scale, powered studies with increased inclusion of participants and
robust sampling

Int. J. Environ. Res. Public Health 2024,21, 1004 10 of 24
Sample sizes ranged from 14 to 38 for qualitative studies and 20 to 200 for quan-
titative studies. Most studies (n = nine studies) were comprised exclusively of African
women [
14
,
25
–
27
,
29
–
31
,
34
,
35
]. Two studies also included immigrant women from non-
African regions (i.e., Europe and Asia) [
28
,
33
], and one study included African Amer-
ican women [
30
]. Studies predominately included women from the African country of
Somalia [
25
–
28
,
31
,
33
–
35
]. Seventy-five percent of the studies (n = 9) were conducted among
women residing on the East Coast. Four were conducted in Minnesota [
26
,
27
,
31
,
35
], three in
Washington D.C [
14
,
29
,
32
], one in Massachusetts [
28
], and one in New
Hampshire [
34
]. The remaining three studies were conducted in Texas, Washington, and
Kentucky [
25
,
30
,
33
]. Among the five studies that provided sufficient data for the calcula-
tion of the mean age of study participants [
28
,
30
,
31
,
34
,
35
], the mean age was 45.4 years
(n = 338 participants). Only two studies reported the income levels of study participants.
One of these studies was primarily comprised of women (i.e., 92%) with household in-
comes of less than USD 35,000/year [
34
]; the second study included women with mostly
middle-to-upper-class incomes (i.e., 40% had income levels of USD 40,000-USD 74,999,
26% had incomes of USD 75,000–USD 119,000, and 17% had incomes
≥
USD 120,000) [
29
].
Eight studies (66.6%) reported information on the education levels of participants. Among
these, five studies predominantly included women with a high school-education level or
lower [
26
,
28
,
31
,
34
,
35
]. Two studies reported that the majority of participants held a college
or graduate degree [29,30].
3.2. Barriers to Breast Cancer Screening
Table 3provides an overview of breast cancer-screening barriers reported by studies
according to the level of influence based on the social–ecological model.
Table 3. Barriers to breast cancer screening according to level of influence based on the Social
Ecological Model [23,24].
Level of Influence Barriers Total N Articles Citing this Barrier
Intrapersonal: Individual characteristics
that influence breast cancer screening,
including attitudes, beliefs, knowledge,
and personality traits
Lack of awareness/limited knowledge about
breast cancer screening. 7 [14,25,26,28,29,32,34]
Fear of pain during breast cancer screening
procedures and/or the disease following
breast cancer diagnosis.
4 [25,27–29]
Inability to speak the English language. 4 [14,25,27,32]
Limited transportation to breast
cancer-screening facilities. 3 [25,29,33]
Competing priorities (i.e., work and
childcare commitments). 2 [28,29]
Health concerns related to mammography. 2 [26,27]
Costs associated with breast
cancer screenings. 1 [29]
Past negative experience with breast
cancer screening. 1 [26]
Interpersonal: Primary social groups
and cultural influences on breast cancer
screening; includes family, friends,
peers, and cultural norms
Sociocultural norms related to modesty
and privacy. 7 [14,25–29,35]
Spiritual beliefs and religious practices (faith
and fatalism). 6 [14,26,28–30,35]
Lack of social support. 1 [32]
Community:
Social structures and policies that
influence breast cancer screening
Lack of culturally congruent providers. 3 [14,25,27]
The complex nature of the U.S.
healthcare system. 2 [14,28]
Lack of access to breast
cancer-screening providers. 2 [31,32]

Int. J. Environ. Res. Public Health 2024,21, 1004 11 of 24
3.2.1. Intrapersonal Barriers
Lack of Awareness/Limited Knowledge about Breast Cancer Screening. Lack of
awareness and/or limited knowledge of breast cancer screening was one of the most
frequently cited intrapersonal barriers (n = seven studies). Qualitative studies reported
that participants had limited or no knowledge or exposure to breast cancer screenings
before moving to the U.S. [
14
,
25
,
26
,
28
,
29
]. This barrier was even reported among women
indicating that they regularly saw a healthcare provider in their home country [
25
]. As a
result, the concept of engaging in breast cancer screening was relatively new, and a topic
many women had only become familiar with since immigrating to the U.S. One study
further reported that because of this lack of knowledge, participants were uncomfortable
with receiving a breast cancer screening [26].
Among the two quantitative studies exploring this barrier, one cross-sectionally ex-
amined the relationship between breast cancer-screening knowledge and endorsement
of receiving a screening [
32
]. Results showed that women with greater levels of breast
cancer-screening knowledge were more likely to endorse receiving a mammography than
women with lower knowledge about breast cancer screening. The second study exam-
ined knowledge of mammography delivering a breast cancer-screening intervention [
34
].
Findings indicated that 33% of participants lacked knowledge of a mammography before
receiving the intervention; however, the specific types of knowledge assessed by the study
were not reported by the authors.
Fear. Fear of experiencing pain during breast cancer-screening procedures and/or
following breast cancer diagnosis was another common theme across qualitative studies.
Four qualitative studies reported fear of experiencing pain during breast cancer-screening
procedures as a barrier to screening (i.e., pressure during mammography was a barrier
in seeking screening) [
25
,
27
–
29
]. Additionally, two qualitative studies also reported that
fear of being diagnosed with breast cancer was a limiting factor for undergoing screening
procedures [28,29]. No quantitative studies reported examining this barrier.
Language. The inability to speak the English language was a barrier cited by three
qualitative studies [
14
,
25
,
27
] and one quantitative study [
32
]. Two qualitative studies
indicated that participants’ inability or limited ability to speak English was a barrier to
breast cancer screening, due to information materials only being available in English, as
opposed to their native language [
14
,
25
]. Participants in the other study further elaborated
on this topic by stating that communication with their healthcare provider relied on the
use of translators, which women perceived as leading to misunderstandings between
themselves and their provider [
27
], thus limiting their motivation to seek breast cancer
screening. The only quantitative study exploring this barrier cross-sectionally examined
associations between English-language proficiency and endorsement of engaging in breast
cancer screening [
32
]. Results showed that women who reported speaking English as a
primary language were more likely to report (p= 0.003) endorsement of engaging in a
breast cancer screening than women with limited English proficiency.
Lack of Transportation. Lack of transportation to a screening facility was a barrier
reported in two qualitative studies [
25
,
29
]. The results of these studies indicated that partic-
ipants were interested in participating in breast cancer screening but lacked transportation
to the screening site. Lack of transportation was also explored as a potential barrier in
one quantitative study [
33
]. Results showed that although participants reported lack of
transportation as a barrier to breast cancer screening, it was not significantly associated
(p> 0.05) with breast cancer-screening engagement.
Competing Priorities. Two qualitative studies reported the prioritization of work
commitments over breast cancer screening as being a barrier [
28
,
29
]. One study further
reported that participants would engage in breast cancer screening if they had a more
flexible work schedule and/or if they had assistance with caring for their children [28].
Health Concerns Related to Mammography. Two studies reported health con-
cerns associated with undergoing mammography procedures as a barrier to breast cancer
screening [
26
,
27
]. Participants in one study expressed the belief that the mammography

Int. J. Environ. Res. Public Health 2024,21, 1004 12 of 24
machine would cause damage to the breast, although the specific type of damage to their
breasts was not reported [
26
]. The second study reported that some women were concerned
that radiation exposure during screening procedures would cause cancer [27].
Costs Associated with Breast Cancer Screenings. One study reported the cost associ-
ated with breast cancer screenings as a barrier to engaging in screening [
29
]. Participants
stated that the cost of breast cancer screening prevented them from engaging in the proce-
dure as they did not have health insurance.
Past Negative Experience with Testing. One qualitative study reported prior negative
experiences with breast cancer screening as a barrier to future screenings [
26
]. However,
the context related to these negative experiences was not elaborated on by the authors of
this study.
3.2.2. Interpersonal Barriers
Sociocultural Norms Related to Modesty and Privacy. Beliefs surrounding the
concepts of modesty and privacy were explored as a barrier to breast cancer screening
by six qualitative studies [
14
,
25
–
29
] and one quantitative study [
30
]. Qualitative studies
reported that participants were uncomfortable with showing their breasts and viewed it
as inappropriate to have someone other than their husband touch their breasts, including
healthcare providers [
26
,
28
,
29
]. One study further reported that some participants indicated
that they would need to receive spousal approval prior to engaging in breast cancer
screening [
29
]. Two studies also reported that participants felt uncomfortable touching their
breasts when conducting a self-breast examination [
14
,
29
]. Results of the one quantitative
study [
35
] examining the influence of modesty/privacy on breast cancer screening did not
confirm these qualitative study findings, as 83% of participants enrolled in this study did
not view modesty as a barrier to breast cancer screening before receiving a brief breast
cancer-screening intervention. Following intervention delivery, the percentage increased
to 90%.
Norms associated with not discussing health issues with others, including preventive
behaviors like breast cancer screening, were reported as a barrier to breast cancer screening
in two studies [
14
,
25
]. One study reported that the women did not discuss breast cancer
screening in their home country, a practice that continued even after immigrating to the
US [
25
]. The second study reported the belief that women are expected to keep personal
details related to their health, such as breast cancer status, private [14].
Spiritual Beliefs and Religious Practices. Spiritual beliefs and religious practices
were reported as impediments to breast cancer screening in multiple qualitative and
quantitative studies [
14
,
26
–
28
,
30
,
35
]. In three qualitative studies, participants expressed
the fact that breast cancer screening conflicted with their religious beliefs [
14
,
26
,
29
]. For
instance, participants believed that entrusting their lives to God would shield them from
breast cancer, leading to a reluctance to undergo screening [
29
]. Additionally, two studies
revealed conflicts between breast cancer screenings and the Muslim faith [
14
,
26
]. Results
of one of these studies showed that participants perceived breast cancer screenings as
an attempt to predict the will of Allah [
26
]. The other study reported that the act of
self-examination during breast cancer screenings contradicted religious beliefs among
participants [
14
]. Interestingly, results from the two quantitative studies examining religious
or spiritual beliefs as barriers to breast cancer screening contradicted the majority of
qualitative study findings. In one study, 90% of participants reported that engaging in
breast cancer screenings was not perceived as conflicting with their religious beliefs [
35
].
The second study cross-sectionally examined the association between beliefs and breast
cancer screenings, with results showing a non-significant association between religiosity
and mammography intake [30].
Fatalism also emerged as a deterrent to breast cancer screening in qualitative stud-
ies [
28
–
30
]. Participants in one study expressed the belief that death was inevitable follow-
ing a breast cancer diagnosis, undermining the effectiveness of screening [
29
]. Similarly,
participants in another study relinquished the status of their health to God, indicating a

Int. J. Environ. Res. Public Health 2024,21, 1004 13 of 24
fatalistic perspective [
28
]. However, findings from the one quantitative study examining
fatalism as a barrier reported that 85% of women who underwent breast cancer screening
disagreed with the notion that little could be done to reduce the risk of breast cancer.
Lack of Social Support. One cross-sectional study reported a lack of social support as
a barrier to not engaging in breast cancer screening [
32
]. In this study, researchers stated
that married women or women who live with a life partner (a proxy of social support) were
more likely to endorse breast cancer screening.
3.2.3. Community-Level Barriers
Lack of Culturally Congruent Providers. Three qualitative studies reported a lack
of culturally congruent providers as a barrier to breast cancer screening. Two of these
studies reported a lack of healthcare providers sharing their religion as a barrier to breast
cancer screening [
25
,
27
]. The other study reported that women did not engage in breast
cancer screening because their providers were not familiar with their cultural beliefs [
14
].
However, the authors did not describe the type of familiarity needed for women to feel
comfortable with seeking breast cancer screenings from a provider.
Complex Nature of the U.S. Healthcare System. Two qualitative studies reported that
the complex process of scheduling and attending appointments with healthcare providers is
a barrier to breast cancer screening [
14
,
28
]. One study reported that making an appointment
to see a doctor was a strange concept for many women, as they did not need to schedule
an appointment in advance to see a healthcare provider in their home country. Instead,
they could go to a hospital or healthcare clinic and receive immediate care for a health
concern [
28
]. Similarly, the findings of the other study indicated that navigating US
healthcare was an unfamiliar and difficult process [14].
Lack of Access to Breast Cancer-Screening Providers. The lack of access to a health-
care professional or facility to engage in breast cancer screening was examined by two
quantitative studies [
31
,
32
]. One study cross-sectionally examined factors associated with
endorsement of breast cancer screening. Results showed that women without health insur-
ance were 18% less likely to endorse engaging in breast cancer screening than women with
insurance [
32
]. The second study examining this barrier reported that the majority (77%) of
the participants enrolled in their study did not view lack of access as a barrier to engaging
in breast cancer screening [31].
3.3. Facilitators of Breast Cancer Screening
Table 4provides an overview of facilitators for breast cancer screening classified
according to the level of influence based on the social–ecological model.
Table 4. Facilitators of breast cancer screening according to level of influence based on the Social
Ecological Model [23,24].
Level of Influence Facilitators Total N Articles Citing this Barrier
Intrapersonal: Individual characteristics
that influence breast cancer screening
Previous breast
cancer-screening experience 1 [29]
Health insurance 1 [28]
Interpersonal: Primary social groups and
cultural influences on breast cancer
screening; includes family, friends, peers,
and cultural norms
Observing other community members’
experiences with breast cancer 1 [29]
Community:
Social structures and policies that influence
breast cancer screening
Appointment reminders and
scheduling assistance 2 [28,29]
Interpreters with the same culture 1 [28]
Transportation to breast
cancer screenings 1 [28]
Patient navigators 1 [28]

Int. J. Environ. Res. Public Health 2024,21, 1004 14 of 24
3.3.1. Intrapersonal Facilitators
Previous Breast Cancer-Screening Experience. One study reported previous breast
cancer-screening engagement as a facilitator for seeking additional breast cancer
screenings [
29
]. Participants in this qualitative study indicated that previously under-
going a breast cancer screening had a positive impact on their willingness to engage in
future screenings.
Health Insurance. One qualitative study reported that having health insurance served
as a facilitator for breast cancer screening [
28
]. Findings suggested that participants with
health insurance coverage in this study were more likely to engage in breast cancer screen-
ings than those without insurance. No other studies included in the review reported on the
influence of health insurance coverage on breast cancer-screening behaviors.
3.3.2. Interpersonal Facilitators
Observing Others’ Experience of Breast Cancer. One study reported that observing
community members receive a breast cancer diagnosis is a motivating factor for individuals
to engage in breast cancer screening [
29
]. Participants in this qualitative study articulated
that the occurrence of one or multiple cancer deaths within the community heightened
their awareness and served as motivation to undergo screening.
3.3.3. Community-Level Facilitators
Appointment Reminders and Scheduling Assistance. Appointment reminders pro-
vided by physicians and/or healthcare providers were reported as facilitators for breast
cancer-screening engagement among participants enrolled in two qualitative studies [
28
,
29
].
In addition to providing appointment reminders, one study reported that provider-based
assistance with scheduling breast cancer-screening appointments further facilitated breast
cancer-screening engagement [28].
Interpreters with the Same Culture during Healthcare Visits. One qualitative study
reported that the utilization of interpreters during healthcare visits played a crucial role
in facilitating access to preventive health screenings, specifically mentioning breast cancer
screenings [
28
]. No other studies examined this potential facilitator of breast cancer screening.
Transportation to Breast Cancer Screenings. Offering taxi vouchers and providing
free transportation were recognized as facilitators of breast cancer screening in one qualita-
tive study [
28
]. In the study, women were offered free transportation and taxi vouchers,
addressing the transportation barrier, and promoting access to screening centers. This
stands in contrast to findings from other studies where the lack of transportation was
identified as a deterrent to engaging in breast cancer screening [25,29,31].
Patient Navigators. In a qualitative study by Saadi et al. [
28
], the utilization of patient
navigators emerged as a significant facilitator for engaging in breast cancer screening. The
study emphasized the crucial role played by patient navigators in facilitating access to
preventive care services, particularly breast cancer screening. A participant in the study
highlighted the indispensable support provided by patient navigators, underscoring their
pivotal role in assisting individuals through the process of accessing and participating in
breast cancer-screening services.
3.4. Review of Breast Cancer-Screening Interventions (n = 3)
Building Better Bridges Program. The Building Bridges program, adapted from the
National Cancer Institute’s Research-Tested Intervention Programs (RTIPs), was a program
that used a community health worker model to provide culturally and linguistically appro-
priate cancer prevention education to U.S. refugees from six cultural groups (i.e., Myanmar,
the Central African Region, Bhutan, Somalia, and Arabic Speaking Countries) [
33
]. Specific
cancers included in the program included breast, cervical, liver, and colorectal. Cultural
and linguistic adaptations of the program were performed collaboratively with community
health workers and community leaders. The intervention was designed to address the lan-
guage preferences, culture, learning styles, and literacy levels of participants. Educational

Int. J. Environ. Res. Public Health 2024,21, 1004 15 of 24
tools used to deliver the program included videos, presentations, and anatomic models.
Following the delivery of the program from 2014 to 2018, screening completion data were
abstracted from an appointment tracking form maintained by community health workers.
Results showed breast cancer screening increased by 50% or more among most cultural
groups, including Somali women. Women from Central Africa were the only participants
not to reach this 50% threshold, with a breast cancer-screening rate of 35%.
Religiously Tailored Workshops to Increase Cancer Screening. Pratt et al. [
35
] ex-
amined the feasibility of religiously tailored workshops designed to promote breast- and
cervical-cancer screenings among Somali American Muslim (n = 30) women. The interven-
tion included a single in-person workshop held at a local mosque, lasting approximately
3 h. The intervention was delivered through the use of three short videos (5–7 min in length)
and facilitated discussions. The development of the intervention followed a community-
engaged process, involving collaboration between community partners (including an Iman
and members of a local mosque) and the research team. Workshops included time for food,
tea, and prayer, and focused on leveraging Islamic values related to promoting balance
among the mind, body, and spirit. Specific barriers addressed by intervention included
faith practice, modesty, predestination, and preventive health care. Results showed that
97% (29/30) of participants reported that the workshop was enjoyable and 100% indicated
that they would recommend the workshop to others. Additionally, the number of women
reporting intent to engage in mammogram or pap smear screening within the next year in-
creased from 80% to 93% following the intervention (p= 0.13). However, actual engagement
in breast cancer screening was not evaluated.
UJAMBO program. Piwowarczyk et al. [
34
] conducted a pilot evaluation of the
UJAMBO program (UJAMBO is a Swahili term for greetings, good state of health, improve-
ments, and well-being), which aimed to encourage the utilization of preventive health
screenings, including mammography, pap smears, and mental health services, among
African immigrant women. Twenty-one workshops were organized by community-based
organizations (CBOs) in the Somali and Congolese communities at community sites. The
intervention comprised a series of group workshops lasting approximately 2 h, accom-
modating 4–12 participants. These single-session group workshops revolved around a
DVD that provided basic information about health services such as mammography and
normative change by sharing stories of African immigrant women’s experiences with these
services. CBO staff received training to implement the workshop using the UJAMBO DVD
and guidebook developed collaboratively by the academic/community team, based on
formative research in these same communities. Following the intervention, participants
reported significant improvements in breast cancer-screening knowledge (p<.001) and
intention to undergo mammography screening in the next 3 months (p< 0.001). Breast
cancer screening following the intervention was not evaluated.
4. Discussion
This review provides a detailed overview of existing evidence regarding social and
contextual factors influencing breast cancer-screening engagement among African immi-
grants, as well as interventions designed to promote breast cancer screening among this
population. Findings highlight key aspects for researchers to consider when promoting
breast cancer screening among U.S. African immigrants.
4.1. Barriers to Breast Cancer Screening
Intrapersonal barriers to breast cancer screening were diverse, with lack of awareness
and/or limited knowledge about breast cancer screenings being the most frequently cited
barrier across studies, followed by fear associated with pain of screening or breast cancer
diagnosis, and lack of English language proficiency. Lack of awareness and/or limited
knowledge of breast cancer screening and fear are commonly reported barriers to breast
cancer screening among women, regardless of race/ethnicity or immigrant status [
36
–
38
].
Accordingly, such concerns appear to be universally shared among immigrant women,

Int. J. Environ. Res. Public Health 2024,21, 1004 16 of 24
rather than specific barriers experienced by African immigrants. Similarly, several studies
investigating breast cancer screening among US immigrants from Latin countries where
English is not their primary language, have also consistently reported limited English
proficiency as a barrier [
12
,
39
]. This finding underscores the importance of language
accessibility in healthcare settings to promote equitable access to health screenings and
treatment. Barriers of limited transportation, health concerns, financial costs, and negative
past experiences are also not unique to African immigrants, as these barriers have been
reported extensively in the breast cancer-screening literature, regardless of race/ethnicity
or immigrant status of study populations [40,41].
At the interpersonal level, modesty and privacy concerns were identified as screening
barriers among qualitative studies (n = 6). Participants expressed discomfort with the
physical aspects of screenings, perceiving the process as immodest or conflicting with their
religious practices [
14
,
25
–
29
]. Similar findings have been observed among other ethnic
groups, including Asians and Koreans [
42
–
46
]. An interesting finding of this review was
that the sole quantitative study [
35
] examining modesty as a barrier to screening failed to
confirm qualitative study findings, as 90% of participants in this study did not consider
modesty as a barrier to breast cancer screening. The limited quantitative research on
this topic highlights the need for additional larger-scale quantitative studies to examine
this barrier, to expand upon previous qualitative findings. Nonetheless, tailoring breast
cancer-screening interventions to address modesty concerns may represent a promising
intervention design strategy to promote breast cancer screening among African immigrants.
Conflicts stemming from religious or spiritual beliefs were reported across qualitative
studies. Several studies reported that participants viewed breast cancer screening as
unnecessary, believing that divine intervention protected them from breast cancer [
14
,
26
,
29
].
In addition, two studies highlighted conflicts between breast cancer screenings and the
Muslim faith [
14
,
26
], with participants perceiving screening as an attempt to predict Allah’s
will [
26
]. Self-breast examination was also considered inconsistent with religious beliefs [
14
].
Two quantitative studies, however, did not entirely endorse the notion that religion posed
a barrier. For example, in one study, 90% of participants did not perceive religious beliefs
as impeding breast cancer screening before the intervention [
35
]. Similarly, in the second
study, there was no notable association found between religion and mammography [30].
Fatalistic views were also prevalent among participants in several qualitative studies,
owing to the belief that Allah predetermined their breast cancer fate, potentially compli-
cating screening decisions [
27
,
28
]. Interestingly, quantitative findings contradicted these
beliefs, with the majority perceiving fatalism as unrelated to screening [
30
]. Despite discrep-
ancies, addressing fatalism in breast cancer interventions for African immigrants represents
a critical opportunity for culturally tailoring breast cancer-screening interventions, as
leveraging religious beliefs to promote behavior change has a longstanding history for
improving health outcomes [47].
Norms associated with not discussing health issues with others, including preventive
behaviors like breast cancer screening, were reported as a barrier in two studies [
14
,
25
].
One study emphasized that women refrained from discussing breast cancer screening in
their home country because cultural norms forbid women from speaking negatively about
their bodies [
25
]. This silence resonated with the findings of another study [
14
], where
women avoided discussing breast cancer screening due to it being perceived as taboo.
The latter study also reported the belief that women are expected to keep details related
to their health, such as breast cancer status, private [
14
]. Understanding and addressing
these privacy concerns are crucial for designing culturally sensitive interventions that can
effectively raise awareness, bridge language gaps, alleviate fears, and address logistical
and financial barriers within this demographic.
In contrast to the numerous individual and interpersonal barriers identified in our
review, only a limited number of studies (n = three) explored community-level barriers to
breast cancer screening. The most frequently cited barriers included the lack of culturally
aligned providers [
14
,
25
,
27
] and the complexity of the U.S. healthcare system [
14
,
28
]. Quali-

Int. J. Environ. Res. Public Health 2024,21, 1004 17 of 24
tative studies reported that women felt disconnected from healthcare providers who did not
share or understand their religious beliefs, contributing to a sense of alienation. Participants
in several studies also expressed challenges in scheduling healthcare appointments, which
contrasts with the walk-in basis of healthcare services in their home countries [
14
,
28
]. These
collective findings underscore the ongoing need for cultural humility and competency train-
ing for healthcare providers. Such training has the potential to assist healthcare providers
in bridging cultural gaps, fostering a more inclusive and understanding healthcare envi-
ronment, and alleviating the fears and concerns that ethnic women may experience during
screening interactions. Similarly, understanding the cultural and social differences in the
health care systems among African countries and designing culturally tailored programs
to address these issues represents another leveraging point for culturally tailored breast
cancer-screening interventions.
Studies examining the role of health insurance on breast cancer-screening behaviors
reported somewhat inconsistent results. Among the two quantitative studies exploring this
barrier, one reported that uninsured women were 18% less likely to engage in breast cancer
screening [
32
]. The second study reported that 77% of participants did not perceive lack of
access as a hindrance [
31
]; however, we hypothesize this outcome may have been related
to the high percentage of participants who reported having insurance coverage. Regardless
of the limited research on this topic among African immigrant women, findings from the
broader literature underscore insurance’s pivotal role in healthcare utilization, including
promoting breast cancer-screening engagement [48–50].
4.2. Facilitators of Breast Cancer Screening
A notable finding of this review was the limited number of studies including a focus
on facilitators of breast cancer screening (compared to the number of studies examining
barriers to screening). At the intrapersonal level, only two facilitators were identified
across studies: previous positive experiences with undergoing a breast cancer-screening
intervention and having health insurance coverage. Ndukwe et al. [
29
] reported that women
with prior screening experience were more inclined to participate in future screenings.
Participants of this study were women who initially avoided screening due to negative
perceptions of breast cancer screening, which were a result of the influence of normative
referents within their community (i.e., family members and friends, suggesting a belief
that breast cancer screening was a painful process). The findings of this study also found
that previously experiencing a breast cancer screening served as a motivational factor
to actively engage in future breast cancer screenings [
29
]. This finding aligns with the
theoretical construct of mastery experiences for the enhancement of self-efficacy [
51
], which
is also an evidence-based behavior-change technique for promoting health screenings [
52
],
underscoring the importance of positive first-hand experiences with breast cancer screening.
Although also explored as a barrier in several studies, health insurance coverage was
identified as a facilitator in one study [
31
]. Findings of this study showed that participants
reported that women with health insurance were more likely to undergo breast cancer
screenings, although it is important to note that almost all participants in this study had
insurance coverage. Regardless of whether health insurance is conceptualized as a barrier
to or facilitator for breast cancer screening, the extant literature supports the notion that
insurance coverage is positively related to both screening behaviors and health outcomes [
53
,
54
].
Ensuring accessible free or affordable health insurance is crucial, especially for low-income
or underserved populations like immigrants, not only for heightened access to preventive
services like breast cancer screening but also for overall disease management and potentially
improved health outcomes in these communities.
At the interpersonal level, the only facilitator for breast cancer screening identified
across studies was observing other community members experience breast cancer [
29
].
This finding is consistent with the concept of observational or social learning, a seminal
phenomenon in Bandura’s Social Cognitive Theory, (SCT), which posits that learning
occurs through social observation and subsequent imitation of modeled behavior [
55
].

Int. J. Environ. Res. Public Health 2024,21, 1004 18 of 24
This approach has been identified as an evidence-based strategy for promoting healthcare
screenings across the study population [
56
–
58
]. As such, investigators developing future
breast cancer-screening interventions for African immigrants should identify effective
design strategies to leverage this concept when promoting breast cancer screening among
African immigrants (e.g., incorporating testimonials from breast cancer survivors describing
their diagnosis/treatment experience and encouraging breast cancer screening).
Facilitators for breast cancer screening identified at the community level encompassed
various strategies to encourage screening, including appointment reminders and cultural
support during healthcare visits [
28
,
29
]. These findings are consistent with other reviews
indicating that client reminders effectively facilitate breast cancer, cervical, and colorec-
tal screenings [
59
,
60
]. Similarly, employing interpreters from the same culture during
healthcare visits, utilizing patient navigators, and providing transportation to breast cancer
screenings are also established practices for improving healthcare delivery and outcomes
among immigrant and other underserved populations [
28
,
38
,
61
–
64
]. Patient navigation
programs, in particular, have an established effectiveness for increasing breast cancer
screenings in various cancer screenings, including breast cancer [
62
,
64
], as does providing
free transportation to screening facilities [38].
4.3. Breast Cancer-Screening Interventions
The results of this review also highlight the limited number of culturally tailored breast
cancer-screening interventions for African immigrants. Among the three identified studies,
two were pilot studies evaluating the preliminary effects of brief, one-time interventions on
breast cancer-screening knowledge or intention [
34
,
35
]. The results of these studies showed
enhanced knowledge and intention to engage in breast cancer screening. Only one study
examined the actual uptake of breast cancer screening following an intervention [
33
], and
reported a marked increase in breast cancer screening following the delivery of the interven-
tion. Despite the limited number of intervention studies promoting breast cancer screening,
several common themes across the three intervention studies reviewed were observed.
All interventions included some type of tailoring designed to address the cultural and
linguistic needs of the African immigrant communities they targeted. Strategies reported
included engaging community health workers (CHWs), collaborating with community
leaders, and adapting education tools to address language preferences, cultural norms,
religious beliefs, and literacy levels of the participants. Numerous studies have indicated
favorable outcomes through the implementation of culturally tailored interventions. For
instance, a narrative review conducted by Racine and Andsoy [
63
] demonstrated improved
mammography rates among Muslim refugees through the delivery of culturally tailored
interventions. Similarly, Allen and Bazargan-Hejazi [
65
] evaluated the effectiveness of
a culturally and ethnically tailored telephone interventions to enhance mammography
screening among women, and reported that the intervention resulted in an 8% increase in
mammography rates. Collaboration between community-based organizations (CBOs) and
local community members played a vital role in shaping the intervention content, ensuring
it resonated with the needs and preferences of the specific population being targeted.
The use of diverse educational tools to convey health information was also a theme ob-
served across all three interventions. These tools included videos, presentations, anatomic
models, and a DVD, and aimed to enhance understanding and engagement among par-
ticipants. Given the findings of all three of these interventions demonstrated positive
outcomes regarding acceptability and feasibility, researchers should consider incorporating
and building upon such methods of intervention delivery in future breast cancer-screening
interventions for African immigrants.
An interesting finding of our review was that only one of the interventions reviewed
appeared to be based on established theories or models of behavior change. This study,
conducted by Pratt et al. [
35
], leveraged both the social–ecological model and the behavior-
change strategies of Social Cognitive Theory by incorporating behavior, cognition, and
environment to influence health behaviors or outcomes. Given the evidence supporting the

Int. J. Environ. Res. Public Health 2024,21, 1004 19 of 24
notion that theoretically based behavior-change interventions for breast cancer screening are
more effective than those that are atheoretical [
66
,
67
], future researchers are encouraged to
leverage existing evidence-based behavior-change strategies and theories when designing
breast cancer-screening interventions for African immigrants.
We were also surprised to find that the interventions reviewed did not appear to
address many of the screening barriers identified in our review. Although a few of the
barriers identified were addressed (i.e., modesty and faith [
35
] and knowledge [
34
]), many
were not (i.e., transportation to screening facilities, appointment reminders, and scheduling).
This lack of direct attention to identified barriers suggests potential areas for enhancement
in future breast cancer-screening interventions.
4.4. Strengths and Limitations
The current review offers several strengths. First, to our knowledge, it is the first
review to comprehensively examine barriers, facilitators, and interventions with respect to
breast cancer screening among African immigrants in the U.S. This unique focus contributes
to a comprehensive understanding of the breast cancer-screening landscape within this
demographic. Second, the integrative methodology employed enables the incorporation
of diverse study types, ensuring a thorough examination of the literature. The systematic
cross-case data analysis employed facilitates the identification of overarching themes,
providing nuanced insights into factors influencing breast cancer screening [
22
]. Adherence
to PRISMA guidelines also enhances the transparency and credibility of the findings
reported. Lastly, the application of the social–ecological model enriches understanding by
elucidating the multifaceted influences shaping breast cancer-screening behavior among
African immigrants [23,24].
Several limitations of our review should also be noted. The over-representation of
Somali immigrants from the East Coast in the included studies may limit generalizability
to other African immigrant groups and regions. Additionally, incomplete reporting of
participant sociodemographic characteristics hampers the ability to draw broad conclu-
sions. Categorizing barriers and facilitators within a single level of influence under the
social–ecological model, while strengthening the providing of a holistic framework, may
oversimplify nuanced influences reported in the literature. Furthermore, potential publi-
cation bias and the exclusion of non-English studies may have restricted the breadth of
evidence considered. These limitations underscore the need for future research to address
these gaps and provide a more nuanced understanding of breast cancer-screening dynamics
among African immigrant communities.
5. Recommendations for Future Research
Based on the findings of this review, we propose several recommendations for re-
searchers to consider when designing culturally tailored breast cancer-screening interven-
tions for African immigrants. As illustrated in Table 5, addressing these recommendations
provides the opportunity to further develop and enhance the rigor of studies promoting
breast cancer screening among African immigrants.
Table 5. Recommendation for future research.
Recommendation Description
1. Recognize that African immigrants are not monolithic and
have different healthcare experiences and delivery
preferences based on their country of origin and prevalent
sociocultural norms
•Researchers should acknowledge the heterogeneity that exists among
African countries and the diverse healthcare experiences among
women from these countries
•Researchers should understand the varied experiences and barriers
related to breast cancer among distinct African immigrant groups

Int. J. Environ. Res. Public Health 2024,21, 1004 20 of 24
Table 5. Cont.
Recommendation Description
2. Conduct additional research examining facilitators and/or
motivators for engaging in breast cancer screening
•Limited research has examined facilitators or motivators of breast
cancer screening among African immigrants. Such factors represent
key leverage points for researchers to include in the design of
culturally tailored breast cancer-screening interventions
•Authors conducting future studies are encouraged to explicitly
examine facilitators identified in our review to further elucidate the
role of these facilitators in promoting breast cancer screenings, while
also exploring other potential facilitators not previously reported
3.
Conduct additional quantitative studies examining barriers to
and facilitators for breast cancer screening
•
The majority of research examining barriers to and facilitators of breast
cancer screening among African immigrant women has been
qualitative. It is vital for further research to confirm and build upon
qualitative insights, crucial for tailoring effective interventions in
breast cancer screening
4. Conduct additional, rigorously designed, theory-driven
intervention studies promoting breast cancer screening
among African immigrants
•We advocate for more extensive exploration and testing of culturally
sensitive breast cancer-screening interventions in larger-scale and
more rigorous trials
•Trials should not only assess psychosocial constructs targeted by the
intervention, but also include the evaluation of the actual prevalence
of breast cancer-screening engagement following the intervention
•
We also recommend that interventions draw upon established theories
and models such as health-behavior theories (e.g., the Health Belief
Model and Theory of Planned Behavior) when designing breast
cancer interventions
5. Ensure collaboration between researchers and
health agencies.
•Future research should include collaborations between researchers
and public health agencies to design and implement culturally tailored
breast cancer-screening interventions that could serve as a significant
platform for increasing BC-screening uptake within this demographic
•For example, ref. [33] collaborated with community health workers
and leaders to deliver culturally and linguistically suitable
cancer-prevention education to refugees from six cultural
backgrounds in the U.S. The findings indicated a significant increase
in breast cancer-screening rates, with most cultural groups
experiencing a rise of 50% or more, including Somali women
6. Conclusions
Limited research has examined barriers, facilitators, and interventions with respect to
breast cancer screening among African immigrant women. Successful promotion of breast
cancer screening in this population will require a comprehensive understanding of not only
barriers, but also facilitators, which can be leveraged to promote breast cancer-screening
engagement. Addressing these factors across all levels of influence according to the social–
ecological model in the context of the design of culturally tailored intervention has the
potential to maximize the public health impact of breast cancer-screening interventions for
African immigrants. Such future work will be imperative for promoting early detection
and timely treatment of breast cancer among U.S. African immigrants, as well as reducing
breast cancer mortality.
Author Contributions: Conceptualization: J.I.R.; literature review: J.I.R. and R.P.J.; initial data
analysis/synthesis: J.I.R. and R.P.J.; final analysis: J.I.R., R.P.J., J.D. and A.R. All authors have read
and agreed to the published version of the manuscript.
Funding: The authors declare that no grants, funds, or other support were received during the
preparation of this manuscript.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.

Int. J. Environ. Res. Public Health 2024,21, 1004 21 of 24
Data Availability Statement: No new data were created or analyzed in this study. Data sharing is
not applicable to this article.
Conflicts of Interest: There are no financial or non-financial interests to be disclosed by the authors.
Appendix A. Search and Combinations
PubMed
(((breast cancer) AND screening) AND African immigrants) AND (United States OR U.S.)
(((breast tumor) AND (screening)) AND (African Immigrants)) AND (United States)
((breast cancer) AND (screening)) AND (African immigrants)
CINAHL
(breast cancer or breast neoplasm or breast carcinoma or breast tumor) AND (screening or assessment or test or diagnosis)
AND (United States or America or USA or U.S or United States of America) AND African AND (immigrants or immigration
or immigrant)
(breast cancer AND screening AND African immigrants AND United States)
(breast tumor AND screening AND African immigrants AND United States)
Medline
(breast cancer) AND (screening OR mammography) AND (Africa OR Nigerian OR Somalian OR Congolese OR Kenyan)
AND (United States OR U.S. OR US)
(breast cancer) AND screening AND (Africa* immigrants) AND (United States)
(breast cancer) AND screening AND (African immigrants)
Google Scholar
“breast cancer screening” among African immigrants in the US
breast cancer African immigrants screening OR or OR self OR examination OR or OR mammography OR and OR united OR
states "United States or US"
breast cancer African immigrants screening "United States or US"
breast cancer mammography among African immigrants in the U.S.
breast cancer screening among African immigrants
PsycINFO
(breast cancer) AND screening AND African AND immigrants AND (United States)
(breast cancer) AND (screening OR mammogram) AND (African immigrants) AND (United States)
(breast neoplasm) AND screening OR mammography AND (African immigrants) AND (United States)
(breast cancer) AND screening AND (African immigrants)
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