Personal Networks and Cervical Cancer Screening among Black Immigrant Women

Abstract

Background
Prior research has linked personal network characteristics with cancer screening uptake including Papanicolaou (Pap) screening, but less is known about the experiences of Black immigrant women (BIW) in the USA. We examined the relationship between network characteristics and Pap screening among BIW and explored how their network members influence their cancer related knowledge and prevention behaviors.

Methods
A mixed methods study of BIW, aged 21–65 years, in southeastern US included a cross-sectional survey ( N = 204) and in-depth individual interviews ( N = 13). We examined whether high-social connectedness, contact frequency, and social support were associated with Pap screening, using multivariable logistic regression models. Thematic analysis further assessed the roles of personal network factors on BIW’s cancer preventive behaviors.

Results
Pap screening was more likely among BIW with high- versus low-social connectedness (OR: 2.68, CI: 1.12, 6.46). However, the impact of high-social connectedness was attenuated, after adjusting for demographic factors and health insurance. Our qualitative findings revealed that both BIW and their personal networks had limited knowledge on cancer and related prevention measures. Close network members, particularly mother-figures, provided support for BIW’s care seeking efforts, including cancer screening, although some participants mentioned a lack of screening support.

Conclusion
These findings suggest that Black immigrant communities may benefit from tailored cancer prevention interventions among close network members, to improve knowledge and support for cancer control behaviors.

Full text

Vol.:(0123456789)
Journal of Racial and Ethnic Health Disparities
https://doi.org/10.1007/s40615-024-02231-6
Personal Networks andCervical Cancer Screening amongBlack
Immigrant Women
LeslieE.Coe1 · OliviaWhitt1· NikhilBhagat2
Received: 14 February 2024 / Revised: 24 October 2024 / Accepted: 31 October 2024
© The Author(s) 2024
Abstract
Background Prior research has linked personal network characteristics with cancer screening uptake including Papanicolaou
(Pap) screening, but less is known about the experiences of Black immigrant women (BIW) in the USA. We examined the
relationship between network characteristics and Pap screening among BIW and explored how their network members
influence their cancer related knowledge and prevention behaviors.
Methods A mixed methods study of BIW, aged 21–65years, in southeastern US included a cross-sectional survey (N = 204)
and in-depth individual interviews (N = 13). We examined whether high-social connectedness, contact frequency, and social
support were associated with Pap screening, using multivariable logistic regression models. Thematic analysis further
assessed the roles of personal network factors on BIW’s cancer preventive behaviors.
Results Pap screening was more likely among BIW with high- versus low-social connectedness (OR: 2.68, CI: 1.12, 6.46).
However, the impact of high-social connectedness was attenuated, after adjusting for demographic factors and health
insurance. Our qualitative findings revealed that both BIW and their personal networks had limited knowledge on cancer
and related prevention measures. Close network members, particularly mother-figures, provided support for BIW’s care
seeking efforts, including cancer screening, although some participants mentioned a lack of screening support.
Conclusion These findings suggest that Black immigrant communities may benefit from tailored cancer prevention interventions
among close network members, to improve knowledge and support for cancer control behaviors.
Keywords Black immigrants· Social networks· Papanicolaou screening· Cancer prevention
Introduction
The US foreign-born population was approximately
45.3 million in 2021, over a fourfold increase since 1970
[1]. Many foreign-born individuals in the USA are from
various world regions, particularly low- and middle-income
countries (LMICs). For example, in 2020, foreign-born
individuals in the USA included those from Africa (6%),
Asia (35%), and the Americas (52%) [2]. These LMIC
regions are known to have elevated cancer risks and sub-
Saharan Africa in particular has the highest cervical cancer
incidence and mortality[3, 4]. Black immigrants are one of
the fastest growing foreign-born populations in the USA; they
presently makeup nearly 10% of the USA. Black population
and are projected to reach 17% by 2060 [5]. National cancer
surveillance programs and prior research have portrayed US
Blacks as homogeneous, thus overlooking differences in
the cancer related experiences of various Black subgroups.
Recent works have, however, provided evidence of
heterogeneity in cancer incidence, survival, and risk factors
among different subpopulations of Blacks in the USA [6–8].
Cancer remains the second leading cause of death glob-
ally, and a major cause of morbidity across LMIC regions.
This is in-part due to rapid globalization in LMICs, which
has contributed to spread of cancer risk factors such as envi-
ronmental and occupational pollutants, tobacco use, non-
communicable diseases (e.g., diabetes and obesity), physical
inactivity, and unhealthy diets [9–11]. Before migrating to
the USA, foreign-born individuals are susceptible to certain
infection-related cancers, e.g., liver, stomach, and cervical
* Leslie E. Cofie
cofiel18@ecu.edu
1 Department ofHealth Education andPromotion, East
Carolina University, 3016 Belk Building, Mailstop 529,
Greenville, NC27858, USA
2 School ofPublic Health andTropical Medicine, Tulane
University, NewOrleans, LA, USA

Journal of Racial and Ethnic Health Disparities
cancers [7, 12]. Despite these risk exposures, immigrants
from LMIC regions likely have limited cancer knowledge
and access to prevention, early detection, and treatment ser-
vices in their home countries [13]. Upon migrating to the
USA, they further experience challenges navigating the US
healthcare system including accessing cancer prevention and
early detection services [14]. The challenges experienced by
immigrants, especially those from LMIC, may be attributed
to factors including low English proficiency, limited knowl-
edge of the US healthcare system, lack of health insurance,
uncertainty about immigration status, and state and federal
policies related to healthcare access for immigrants [15, 16].
Secondary cancer prevention including early screen-
ings—e.g., for Papanicolaou (Pap) test and mammogram—
are recommended as effective clinical preventive measures
for reducing disease incidence and mortality [17, 18]. Yet,
screening uptake among foreign-born individuals is lower
than those born in the USA [19–22]. Previous research sug-
gests that foreign-born women from various world regions
(e.g., South America, Caribbean, Southeast Asia Central
Asia (20.4%), Middle East, and Africa) were significantly
less likely to report cervical cancer screening uptake than
US-born women [23–25]. Among US immigrants of Afri-
can descent, cervical cancer screening rates were markedly
low, and significantly lower than the screening rates of US
born women [23, 26, 27]. Specifically, low rates of cervical
cancer screening have been observed among Caribbean- and
African-born Black women [26, 28]. Also, recent evidence
suggests that Black immigrant women (BIW) were seven
times less likely to report up-to-date cervical cancer screen-
ing than African American women in the USA [27].
Prior research on factors associated with cancer screen-
ing among immigrants can be understood within the con-
text of the socioecological framework [28–30]. For instance,
individual determinants of screening include cancer-related
knowledge and personal attitudes or beliefs about screening
(e.g., fear, embarrassment or modesty when seeking screen-
ing) [31, 32]. Interpersonal level factors associated with
screening include cultural and fatalistic beliefs about cancer
risks, and spousal consent for screening [33]. Organizational
and community determinants of screening may include phy-
sician recommendation to get screened, availability of cul-
turally competent care such language interpretation services,
and broader structural racism within the healthcare sector
[34, 35]. Additionally, practical challenges to receipt of
screening may include finding childcare, scheduling appoint-
ments, and working long hours [32, 34]. The sociocultural
context of immigrants in terms of their social relationships is
an interpersonal level determinant that has been less exam-
ined, despite being crucial to comprehending how screening
behaviors may be improved among this group.
The present study focuses on Black immigrant women’s
social relationships, which is an interpersonal level factor
within the socioecological framework. The social relation-
ships of immigrants make up their social networks. Social
networks is described as one’s relationship with network
members (e.g., relatives, friends, neighbors, co-workers) and
this relationship is considered as having both a structure and
serving various functions [36]. One’s social network struc-
ture may be composed of different types of network mem-
bers with whom one has varying levels of interactions. The
network members may function in terms of influencing one’s
behaviors and providing various types of social support [36].
Social support is defined as the extent to which individuals
receive aid (e.g., material resources, advice, and emotional
support) from network members when they need it [37].
Prior work has linked network characteristics with health
behaviors including cancer screenings like Pap tests [38–41].
Lager social networks and higher social integration or con-
nectedness (based on the index of network size, frequency
of contact with network members and church membership)
have been positively associated with screenings for breast
cancer [42, 43], colorectal cancer [44], and cervical cancer
[38, 45], among US adults. Research also suggests that hav-
ing social support from close network members is associ-
ated with cancer preventive behaviors including mammog-
raphy and breast and colorectal screening adherence [46,
47]. There is evidence of this relationship among various
race/ethnic minority groups including African Americans,
Hispanics [38, 48], and Asians [49]. Conversely, examina-
tion of the relationship between network characteristics and
social support with cancer screening among foreign-born
individuals is sparce, especially among Black immigrants.
To date, Adegboyega found that positive social interactions
and affectionate support was associated with Pap testing
among sub-Saharan African immigrant women.
Foreign-born groups have unique personal networks and
often emigrate because of social and family ties in their host
country [50]. Like all foreign-born groups, the characteris-
tics and roles of Black immigrant women’s personal net-
works can change over time. Thus, it is critical to understand
how women’s personal networks influence cancer preven-
tive behaviors, as well as ways they may be leveraged to
increase cervical cancer screening adherence. We focus on
Black immigrant women because they have distinct cultural
backgrounds and experiences from their US-born counter-
parts, which impact their cervical cancer risks. For example,
due to high rates of cervical cancer incidence and mortality
in sub-Saharan Africa, immigrant women from the continent
have an increased risk of the disease [3]. Unlike the USA,
cervical cancer screening access and use is limited and not
common practice in regions like Africa [51–53]. Disaggre-
gating Black immigrants from the larger US Black popula-
tion is crucial for gaining a nuanced understanding how an
interpersonal level factor like personal networks influences
their cervical cancer screening uptake upon migrating the

Journal of Racial and Ethnic Health Disparities
USA. It also adds to the limited discourse on cancer health
disparities experienced by various ethnic Blacks in the USA.
To that end, we examined the association between social
network characteristics and Pap test uptake among Black
immigrant women using both quantitative and qualitative
methods. Specifically, we aimed to quantitively assess
whether having a strong social connection with their social
(i.e., personal) networks and receiving social support from
them was related to an increased uptake in cervical cancer
screening (Pap test). We also qualitatively explored how the
personal networks of the women influenced their health deci-
sions and behaviors including their cancer related knowledge
and prevention behaviors. The qualitative examination of the
women’s experiences was intended to provide an in-depth
understanding of how network members contribute to the
Black immigrant women’s cancer screening behaviors.
Methods
Study Design
A Black Immigrant Women Study was conducted between
2020 and 2021 using a mixed methods approach. The study’s
objective was to examine the role of personal network fac-
tors on cancer screening behaviors of Black immigrant
women in southeastern United States. Quantitative and
qualitative data were separately collected and analyzed to
enable qualitative interpretation of the statistical findings
[54]. The quantitative data were derived from a cross-
sectional survey administered to a convenience sample of
women. The qualitative data was from in-depth individual
interviews with a sub-sample of those women. By examining
personal network characteristics and Pap test uptake through
both quantitative surveys and qualitative in-depth interviews,
we enhance the credibility of our findings through meth-
odological triangulation. We integrated the findings from
both approaches to gain a comprehensive understanding
of how Black immigrant women’s interactions with their
personal network relate to their Pap test uptake. This study
was exempt from ethics review by East Carolina University
(UMCIRB 19–000571).
Participant Recruitment andSample
Quantitative Sample
We initially planned to recruit women in North Carolina
(NC) cities with sizeable foreign-born populations including
Black immigrants. The COVID-19 pandemic caused
recruitment challenges, so we pivoted to working with
the company Qualtrics to help recruit study participants.
Qualtrics used various national panel sources to recruit
individuals that fit the inclusion criteria of a study [55].
Women in NC were originally targeted, but due to the
limited number of responses (~ 30 women), we expanded
our recruitment to women in South Carolina, Georgia,
Alabama, Virginia, and Maryland. We developed an online-
based survey, which Qualtrics administered to its participant
pool, that met our inclusion criteria. The inclusion criteria
were (1) Black women born outside of the USA; (2) have
lived in the country for at least a year to ensure that they
have established residency; and (3) were between the ages
of 21–65years, which is the recommended age range for
Papanicolaou (Pap) testing among women in the USA
[17]. Data quality check in Qualtrics included checking for
responses to specific questions to ensure accuracy, checking
for duration of time spent on the survey compared with the
median [55]. The administered survey yielded 213 online
survey responses.
Later, as the pandemic restrictions were eased, we
collaborated with a community leader in the Black
immigrant community in NC, who leveraged her networks
to help recruit 90 additional women who took the survey.
Through word of mouth, she recruited women from her
local network of Black immigrant-focused civil societies
and community-based organizations. Interested study
participants were connected with the data collector who in
turn provided them with more information about the study.
Women who met the inclusion criteria were provided access
to the survey. The survey response data from this community
was combined with the survey data from the Qualtrics panel.
The analytic sample for this study was 204 after excluding
women with missing information on all key variables of
interest.
Qualitative Sample
Additionally, the community leader helped recruit a subsam-
ple (n = 13) of the 90 women surveyed in NC to participate
in individual interviews. Utilizing community members as
recruiters is a recommended strategy to find hard-to-reach
or minority communities and to build trust and increase
inclusion in clinical and public health research [56, 57]. The
community leader facilitated access to women in the com-
munity and connected the first author and data collector with
Black immigrant community organizations. Thus, creating
opportunities for us to establish rapport with women in the
community.
Data Collection
Quantitative Measures
A health survey instrument developed and administered
to the women included questions on social network

Journal of Racial and Ethnic Health Disparities
characteristics, cancer screening behaviors, health access
factors, and demographic questions. The outcome measure,
cervical cancer screening, was based on up-to date screen-
ing as defined by the US Preventive Services Task Force
(USPSTF); i.e., a recommendation for women ages 21 − 65
of average risk to get a Pap test every three years [17]. The
survey question was derived from the was National Health
Interview Survey [58]. Women were asked how long it
has been since their last Pap test. The response categories
“a year ago or less,” “more than 1year but not more than
2years,” or “more than 2years but not more than 3years,”
were coded as “yes”; the rest were coded as “no.”
Key independent measures were derived from the
Berkman-Syme Social Network Index [59, 60], a widely
adopted valid and reliable quantitative measure of social
relationships [61]. This index includes four types of
social connections: marital/partnership status (married/
with partner vs. not), sociability (which examines number
and frequency of contact with close relatives, and close
friends), church group membership (yes vs. no), and mem-
bership in community organizations (yes vs. no). Details
on the network index are described elsewhere [59, 62, 63].
Social connectedness was measured as a composite score
of the four types of connections and categorized into low,
medium, and high levels. Sociability was also categorized
into 3 levels based on number and frequency of intimate
contact (low, medium, and high).
Social support was assessed using a composite score
of five items from the social network index related to the
availability of someone to give advice show love and affec-
tion, provide emotional support, and trust and confide in.
The response options (none, 1 or 2, 3 to 5, 6 to 9, 10 or
more) were categorized into high, medium, and low. We
developed an additional personal network-related question
to assess screening support, “If you need to get cancer
screening (e.g., cervical and breast cancer screening), do
you feel that you have some relatives and close friends that
you can rely on to help get you there or tell you where to
go?” We coded the response categories “definitely have”
as high, “probable have” and “might have” as medium, and
“probably don’t have” as low screening support.
Control measures were adopted from the National
Health Interview Survey comprised of health access,
length of US residency, and demographic factors [58].
Health access factors included having insurance (yes vs.
no) and perceived health status (categorized as excellent/
very good, good, or fair/poor). Length of US residence
was a measure of how many years the women have lived
in the USA; their responses were grouped into < 5, 6–15,
and > 15years). Demographic measures were age, marital
status, education, and household income. These measures
are important factors that have previously been associated
with cervical cancer screening [64].
Qualitative Assessment
An interview guide was developed for the individual inter-
views The questions included (1) what are women’s percep-
tions about cancer control and prevention, (2) what were
their previous experiences with cancer control in their home
country, (3) who are members of their social networks and
what is their level of interactions with them, and (4) what
are the roles of the network members in promoting health
related knowledge, access, and support for preventive behav-
iors including cancer screening? This guide was developed
with input from the research team and the extant literature on
the experience immigrant women’s social network experi-
ences. A trained female data collector conducted and audio-
recorded phone interviews with the women via WhatsApp.
The data collector was trained in qualitative research meth-
odology, ethical considerations for working with vulnerable
populations, and skills for establishing rapport with minor-
ity immigrants. The sample size was adequate to reach data
saturation (n = 13) [65]. Participants’ ages ranged from 33
to 65years old. They emigrated from Africa as adults, and
their length of US residency ranged from 1 to 21years. Each
woman interviewed was verbally consented before partici-
pating in the study and received a $20 gift card after com-
pleting the interview.
Data Analysis
Quantitative analyses were conducted in SAS version
9.34 (SAS Institute, Cary NC). Using chi-square test and
t-test, we examined whether social connectedness, contact
frequency, social support and screening help and advice
support were associated with up-to-date pap screening.
Unadjusted logistic regression models were used to test the
association between the personal network measures and pap
screening. Prior literature has indicated that insurance sta-
tus is significantly associated with Pap test uptake among
women including Black immigrants [34, 66]. We assessed
the interaction between the network factors and insurance,
but the effects were insignificant. Subsequently, an adjusted
multivariable regression model was ran using stepwise
regression with forward selection. The control measures for
the final regression model included insurance, health sta-
tus, age, marital status, and income. The regression analyses
were two-tailed (p < 0.05) with a 95% confidence interval.
Qualitative analysis was conducted using the ATLAS.ti
software (versionver7.0, Scientific Software Development
GmbH, Eden Prairie, MN). First, NB developed narrative
summaries of women’s experiences with the personal net-
works in their health seeking behaviors. We (LC, NB, and
OW) then begun initial close readings of the interview tran-
scripts. A preliminary codebook was developed based on
deductive codes from the interview guides and inductive

Journal of Racial and Ethnic Health Disparities
codes from the transcripts. Specifically, we met to discuss
emerging ideas from the transcripts, narrative summaries
and interview memos to generate the inductive codes;
deductive codes were derived from the interview guide ques-
tions. NB and OW independently applied the codes to the
transcripts and suggested new codes as new ideas emerged
during analysis. NB and OW met regularly with LC for cod-
ing quality checks and to ensure coding reliability. Any dif-
ferences in coding and code creation were discussed until a
consensus was reached. If a new inductive code was added
to the codebook, NB and OW re-reviewed all interviews to
fully capture the phenomena. This process of consensus and
multiple passes allowed for investigator triangulation and
reducing the impact of individual biases. The two coders
later developed code output summaries of parent nodes and
included representative quotes. They then worked with LC
to analyze the output and narrative summaries by creating
analytic matrices [67, 68], which identified salient themes
related to women’s perspectives of how their personal net-
works influence their health decisions and experiences, par-
ticularly related to cancer prevention.
Investigator Reflexivity
The research team reflected racial and ethnic diversity
(Black, white, and Indian) and gender diversity (female and
male). The team also has differing experiences with immi-
gration. The first author is an African-born immigrant, the
second author does not identify as an immigrant, and the
third author is a first-generation immigrant whose parents
are from India. All authors have unique interest in studying
and addressing the health inequities experiences affecting
vulnerable population, particularly immigrants living in the
USA. They consider themselves advocates for racial and
ethnic data disaggregation and immigrant inclusion within
public health research.
Results
Quantitative Findings
As shown in Table1, 62% of all women reported current
cervical cancer screening. The average age of all women
was 37 (SD, 12.1) years. There was a significant age differ-
ence between women that reported current cervical cancer
screening than those not current (39, SD 11.6 vs. 34, SD
12.5). Most women were unmarried (54%), had at least a
high school education (81%) and less than $50,00 annual
income (59%). Only 13% of all women did not have health
insurance. The proportion of uninsured women that reported
current cervical cancer screening was significantly different
from those not current (9% vs. 19, p < 0.01). In terms of
personal network characteristics, 23% of women reported
high-social connectedness, 14% reported high-social sup-
port, 86% reported having health advice support, and 44%
reported having high cancer screening support when needed.
A greater proportion of women that reported current cervi-
cal cancer screening than those no current had high-social
support (18% vs. 8%, p < 0.05).
Table2 presents regression models of the relationship
between network characteristics and cervical cancer screen-
ing. For the unadjusted regression models, women with
high-social connectedness were more likely to report current
cervical cancer screening than those with low-social con-
nectedness (OR: 2.68, CI: 1.12, 6.46). Additionally, women
with private insurance were more likely to report screening
than those without insurance (OR: 4.46, CI: 1.77, 11.26).
The relationship between network characteristics and cervi-
cal cancer screening was further examined after controlling
for insurance, health status, age, marital status, and income,
whereas these relationships were completely mitigated, hav-
ing private insurance compared with none was associated
with screening (aOR: 3.06, CI: 1.04, 9.02).
Qualitative Findings
We identified four distinct themes connecting Black immi-
grant women’s personal networks with cancer related knowl-
edge and capacity to access cancer screening services. The
first and second themes respectively described how women
and their personal networks had limited knowledge of cancer
and related preventive measures. Theme three highlighted
the vital roles of women’s social connections to their care
seeking efforts. The fourth theme revealed that the influence
of women’s personal networks on their cancer preventive
behaviors were mixed. These themes provide contextual
insights on the extent to which women’s personal networks
facilitated screening behaviors like Pap test uptake.
Women Had Limited Cancer Knowledge andRelated
Prevention
Most women had little to no knowledge about differ-
ent types of cancer and could not explain how cancer
is caused, diagnosed, or prevented. Participants who
had some knowledge about cancer identified the types
that affects women. They mostly referenced cancers that
directly impacted someone they knew. One woman men-
tioned, “Uhm I heard about the ovarian and yeah another
one I also experienced was my stepmom…You see she
passed away in 2016 and I uhm already forgot to even
mention that she passed away with cancer…” (Participant
05, age 34). Another woman said, “Yes, there is uhm the
breast cancer, the lungs one, the uterus one and then I,
I know someone who had … what’s the name … oh my

Journal of Racial and Ethnic Health Disparities
Table 1 Descriptive and
personal network characteristics
of Black immigrant women
Personal characteristics Total sample
(N = 204)
n (%)
Pap-test current
(n = 127) n (%)
Pap-test not current
(n = 77) n (%)
p-value
Cervical cancer screening
 Yes 127 (62.2)
 No 77 (37.8)
Age (SD) 37 (12.1) 39 (11.6) 34 (12.5) < 0.01
Married 0.077
 Yes 93 (45.6) 64 (50.4) 48 (62.3)
 No 111(54.4) 63 (49.6) 29 (37.7)
Education 0.126
 No HS 25 (12.3) 16 (12.6) 9 (11.7)
 HS/some college 60 (23.4) 31 (24.4) 29 (37.7)
 College + 119 (58.3) 80 (63.0) 39 (50.6)
Income 0.053
 < 25k 54 (26.5) 26 (20.5) 28 (36.4)
 25– < 49.999K 67 (32.8) 45 (34.4) 22 (28.6)
 50–74.999K 41 (20.1) 25 (19.7) 16 (20.8)
 75k + 42 (20.6) 31 (24.4) 11 (14.3)
Insured
 Private 94 (46.1) 72 (56.7) 22 (28.6) 0.003
 Public/private and public 84 (41.2) 44 (34.6) 40 (51.9)
 No 26 (12.7) 11 (8.7) 15 (19.5)
Health status 0.635
 Excellent/very good 75 (37.5) 44 (35.2) 31 (41.3)
 Good 74 (37) 49 (39.2) 25 (33.3)
 Fair/poor 51 (25.5) 32 (25.6) 19 (25.3)
Length of US residence 0.027
 < = 5 31 (15.2) 13 (10.2) 18 (23.4)
 6–15 54 (26.5) 54 (26.0) 21 (27.3)
 16 + 119 (58.3) 119 (63.8) 38 (49.3)
Social connectedness 0.077
 High 47 (23.0) 35 (27.5) 12 (29.9)
 Medium 109 (53.4) 67 (52.8) 42 (54.5)
 Low 48 (23.5) 25 (19.7) 23 (15.6)
Sociability score 0.831
 High 11 (5.4) 6 (4.7) 5 (6.5)
 Medium 123 (60.3) 78 (61.4) 45 (58.4)
 Low 70 (34.3) 43 (33.9) 27 (35.1)
Social support 0.038
 High 29 (14.2) 23 (18.1) 6 (7.8)
 Medium 84 (41.2) 45 (35.4) 39 (50.6)
 Low 91 (44.6) 59 (46.5) 32 (41.6)
Health advice support 0.764
 Yes 168 (85.7) 103 (85.1) 65 (86.7)
 No 28 (14.3) 18 (14.9) 10 (13.3)
Screening support 0.753
 High 90 (44.1) 58 (45.7) 32 (41.5)
 Medium 69 (33.8) 43 (33.8) 26 (33.8)
 Low 45 (22.1) 26 (20.5) 19 (24.7)

Journal of Racial and Ethnic Health Disparities
god, I forget the name.” (Participant 08, age 28). Besides
mentioning the cancer types, the participants were unable
to provide additional details about the cancer etiology.
Other study participants mentioned their lack of knowl-
edge about cancer causes and prevention. One woman
explained, “I don’t know exactly what causes the cancer, I
don’t know if it’s in the blood or the vein or I don’t know,
that’s what I don’t know how to say to prevent, to prevent
the cancer” (Participant 09, age 63). Even women that
mentioned that they had regular health checkups includ-
ing cancer screening were unable to provide any informa-
tion about cancer risks and prevention. One participant
emphasized this point: “No, I don’t know anything about
cancer, but I go for my own checkup every year” (Partici-
pant 06, age 56). Overall, when asked about cancer pre-
vention most participants simply stated that they “don’t
know.” The few women who described cancer prevention
methods offered inaccurate information related to their
folk remedies. Their responses included “drinking lemon
water”, “avoid eating canned food”, and avoid using “soap
or cream to get the light skin” to prevent cancer.
Personal Networks Had Limited Cancer Knowledge
Participants indicated that their close network members and
members of their communities also generally had limited
knowledge about cancer and related prevention. One noted
that cancer prevention was not important to her friends in
the USA and abroad, due to “lack of knowledge, lack of
resources, lack of…ignorance is bliss, basically” (Participant
10, age 44). Another woman further described the extent of
misinformation is often exchanged through her network and
community members:
“Uhm, well I really don’t know much like I say some-
times I’m actually in some kind of [WhatsApp?]
groups where we share information that would help
us you know in our community and stuff like that so in
this group people come, people post all kind of things
about cancer and the things that you can do to prevent
it like some herbal stuff, some natural stuff you know
that are helpful… Like little things that you can do and
use to prevent it” (Participant 05, age 34).
Table 2 Association between
personal network characteristics
with cervical cancer screening
Adjusted model controlled for age, married, education, income, health status
Cervical cancer screening OR (95% CI)
Unadjusted models p-value Adjusted model p-value
Social connectedness
 High 2.68 (1.12, 6.46) 0.04 1.86 (0.51, 6.79) 0.40
 Medium 1.47 (0.73, 2.94) 0.71 1.33 (0.57, 3.13) 0.95
 Low Ref
Sociability score
 High 0.75 (0.21, 2.76) .61 –
 Medium 1.09 (0.59, 2.01) .55 –
 Low Ref
Social support
 High 2.08 (0.76,5.71) 0.01 2.19 (0.54,8.88) 0.11
 Medium 0.63 (0.34, 1.16) 0.70 0.53 (0.26, 1.08) 0.02
 Low Ref Ref
Health advice support
 Yes 0.88 (0.38, 2.04) 0.76 –
 No Ref
Screening support
 High 1.32 (0.63, 2.78) 0.53 –
 Medium 1.21 (0.56, 2.63) 0.88 –
 Low Ref
Insured
 Private 4.46 (1.77, 11.26) 0.0002 3.06 (1.04, 9.02) 0.01
 Public/private and public 1.50 (0.61, 3.69) 0.29 1.19 (0.42, 3.33) 0.31
 No Ref Ref

Journal of Racial and Ethnic Health Disparities
The woman’s comments further suggest that community
members relied more on folk remedies and generational
knowledge to fill the gaps of their limited cancer understand-
ing. This colloquial information was more readily shared
instead of medically validated information regarding cancer
prevention like Pap tests.
One participant elaborated, “nobody talks about [cancer
prevention and treatment]… they don’t like to, especially
uhm the older, the generation before use they were very
uhm, hm like a little skeptical about you know seeking medi-
cal help because they used to have a lot of herbal remedies”
(Participant 10, age 44). Her statement echoes that sentiment
of most participants who also perceived that their personal
networks did not only have inadequate information about
cancer but were not intentional about seeking accurate infor-
mation about cancer control.
Social Connections andHealth Seeking Behavior—General
Network Role
Most participants identified 2–3 network members that pro-
vided support with health information and decision making.
Co-workers, friends, and immediate family were all refer-
enced as providing support for health-seeking behaviors, but
mother figures were identified as the most common social
tie resource. The influences of these network ties varied
from casual check-ins to active participation in the woman’s
health decisions. Notably, some participants believed their
mom, stepmom, or mother-in-law played a more active role
in their health decisions, and many felt more comfortable
discussing their health decisions with these mother figures.
On women commented, “[My mom is] the only one I have
so, believe me every time she’s ready to you know be with
me, anytime I go to the doctor I am with my mom, so I can
tell you she’s uhm my everything, she’s the only one who
give me uh advice if I don’t want to do something she’s
the only one who tell me to do.” (Participant 06, age 56).
Another participant explained how her mother encouraged
preventative health behaviors. In this participant’s view her
mother “heard about the cancer, the breast cancer, so she felt
concerned, and she was just like she’s going to check all her
kids to see if uhm is nothing wrong with them, yeah” (Par-
ticipant 08, age 28). Other women described similar levels
of concern expressed by their personal networks in ensuring
that they access and received care for their general health
related needs.
Close personal networks that provided support for wom-
en’s health-seeking behavior other than the participants’
mothers, usually had a more utilitarian role such as transla-
tion assistance or connecting them to a medical provider. For
example, when asked about who they ask for medical help or
advice, one woman (Participant 09, age 63) stated that her
close friend, “…help[s] me because uh my English no good.
She call, when I call [my co-worker] helping me to talk to
the doctor or something like that, she’s uh help me, yeah.”
Other women indicated that when they first migrate to the
USA, they depended on their networks to help them navigate
the healthcare system. One woman further explained, “Well,
you know when you first come you don’t know anyone …
you have to talk to friend’s which clinic do I go … so, I
know I did that because I’m here 20years…” (Participant
02). While this support was useful for the women, a few
indicated that they tended to utilize their social networks
less for health-seeking once they found medical providers
or developed English-speaking fluency.
Cancer Specific Network Role
While most women identified network members that sup-
ported their general health-seeking behaviors, the mem-
bers’ influence on their cancer-prevention behaviors varied
greatly. About half of participants identified a network mem-
ber that provided knowledge, advice, and tangible support
which influenced cancer-specific screening, while the other
half was emphatic about the absence of support from their
personal networks in that regard.
Support received from women’s network members
included encouragement to get cancer screening, transpor-
tation or assistance to get to a health facility for screening,
and in some cases language translators during the physi-
cian–patient visits. For instance, one participant (Partici-
pant 06, age 56) said her mother, “knows the importance of
having the [mammogram] exams… [and] asked me every
time what’s the date you go for your mammogram stuff
like that, yeah,” which motivated her to stay current on her
breast cancer screening. Among participants who received
cancer-specific health advice, their description of their inter-
action with their personal networks suggest that some of
the network members had limited cancer knowledge. One
participant (Participant 02) received the following cancer-
prevention recommendation from a friend: “…don’t do too
much sugar … they say that yeah, the cancer likes sugar too
much so if you avoid the sugar it’s good, yeah because they
say that.” Similarly, another participant (Participant 03, age
45) indicated she was told “that uh people shouldn’t drink
too much [inaudible] or something like that. They say it’s to
prevent cancer.” These women perceived a strong network
support for cancer preventive behaviors, although they did
not offer illustrious details of cancer prevention recommen-
dations from their network member.
Other women did not receive cancer-specific advice or
knowledge from their personal networks at all, and as one
participant (Participant 09, age 63) explained, “I don’t have
this chance [to talk about cancer prevention] uh nobody told
me about this, I don’t have this chance, I don’t, nobody told
me.” Because network members often had a gap in their

Journal of Racial and Ethnic Health Disparities
cancer-specific health knowledge, about half of all partici-
pants stated that they relied on information shared from their
medical providers to inform cancer-specific prevention and
care. One participant (Participant 02) recalled, “ok my pri-
mary care doctor and gynecologists they always encourage
women to do your mammogram anybody who turn 40 is
supposed to do a mammogram every year and also every
woman supposed to do pap smear every 2–3years.”
Integration ofQuantitative andQualitative Findings
The above themes offer a nuanced understanding of how
social connectedness and social support may be related
to cervical cancer screening uptake among the BIW. We
observed a significant difference in the bivariable associate
between social support and cervical cancer screening. Also,
high-social connectedness increased the odds of cervical
cancer screening in the unadjusted model. Exploration of
BIW’s experiences with their social networks further sug-
gests that these findings may be due to the various roles their
network members played in their health-seeking behaviors
including the promotion of cancer preventive behaviors.
Comparing the quantitative and qualitative findings allowed
us to observe the degree to which being connected to various
members of their network is essential to the types of cancer
prevention support that may be available to the women [54].
Discussion
In this study, we found that women’s personal networks
played a role in their uptake of cervical cancer screening.
Women who reported high-social connectedness had higher
odds of cervical cancer screening compared to those with
low-social connectedness. After adjusting for demographic
variables and health insurance, this association was attenu-
ated. The qualitative findings provide additional insights
into how the women’s network members support, encourage,
and motivate them to engage in cancer screening behaviors
including cervical cancer screening. Despite having limited
knowledge about cancer preventive measures some women
indicated that their close personal networks motivated them
to seek cancer screening, helped them find a local clinic,
and/or served as a translator within the medical setting.
Our study findings are similar to previous research that
suggest that one’s network members can be influential in
supporting cancer screening uptake including utilization of
Pap screenings [38, 41, 69, 70]. It contributes to the limited
quantitative research on the relationship between personal
networks and cervical cancer screening. Earlier studies con-
ducted by Suarez and colleagues indicated that high-social
connectedness was associated with Pap screening among
older Mexican–American women [71], and of four US
Hispanic groups examined (Mexica, Cuban, Central, and
Puerto Rican) the association was significant among Mexi-
can–American women [38]. The relationship between social
connectedness and cervical cancer screening may in part be
explained by the supportive role of network members. In
our study, we found a significant difference in the associa-
tion between social support and screening, although, this
relationship was mitigated after adjusting for other factors.
To date, one other study found an independent association
between social support, in the form of positive social inter-
actions and greater affectionate support from social ties, and
Pap screening among African immigrant women [69]. In
addition to social support, other factors likely explain our
finding of an attenuated relationship between social con-
nectedness and cervical cancer screening after adjusting for
our control variables.
For example, health insurance is an important predic-
tor of cervical cancer screening. Adunlin and colleagues’
recent systematic review of personal and system level factors
associated with breast and cervical cancer screening among
immigrant women revealed that insurance coverage was an
important predictor of cervical cancer screening [34]. The
majority of the women in our study indicated that they had
health insurance, which may explain the limited impact of
social connectedness and support on cervical cancer screen-
ing uptake in our quantitative findings. Yet, it is worth noting
that previous research suggests that immigrants from LMIC
regions are more likely to be undocumented or have jobs that
do not offer health benefits [72]. Also, as suggested in our
qualitative findings the personal networks of Black immi-
grant women can be leveraged to facilitate support for cervi-
cal cancer screening. Therefore, it is important to consider
ways to address access barriers to screening—e.g., afford-
able insurance coverage and free screening services—while
developing program interventions to enhance the role of
women’s personal networks to promote screening adherence.
Similar to participants in our study, immigrants from
LMICs generally lean on their personal networks to help
navigate the US health care system for both treatment and
preventive services [34]. In the case of Black immigrants,
they often contend with barriers including affordabil-
ity, language, and cultural or religious differences [70].
Our qualitative findings suggest that despite having a
small number of close network members, women’s net-
work members contributed to addressing these barriers
by connecting them to low-cost and/or culturally compe-
tent providers and serving as translators during health-
care visits when translation services were unavailable.
We also found that many of these network members had
inadequate knowledge about cancer and related preventive
measures. Hence, additional research is needed to further
understand the cancer education needs network members,
as well as intervention strategies that will enable them

Journal of Racial and Ethnic Health Disparities
to support Black immigrant women’s uptake of cervical
cancer screening. This endeavor will address the call for
cancer screening programs that leverage the social support
networks of immigrants from LMIC regions [69, 73].
Future research should examine the role of close fam-
ily network members, as evidence suggests that they are
critical in informing health related decisions and providing
support for health care access and use among immigrants
[74]. For immigrant women, these family ties can provide
different types of support for cancer screenings including
pap testing [75]. Our study highlighted women’s percep-
tion of their mother-figures (e.g., mothers, mothers-in-law,
and stepmom) as being essential to their cancer prevention
behaviors because of the different types of support they
provided. Thus, these network members should be mean-
ingfully engaged in research to develop and disseminate
culturally appropriate cancer screening interventions to
reduce the risk of cancers among vulnerable populations
like Black immigrant women. Interventions focusing on
mother-daughter relationships specifically could be espe-
cially beneficial, since women felt more comfortable dis-
cussing health concerns with their mother figure. Prior
work has shown evidence of the feasibility of using this
dyad to promote cervical cancer prevention [76].
Study Implications
Findings from the present study suggest numerous impli-
cations for improving access to cervical cancer screen-
ing uptake among Black immigrant women. First, pro-
moting cervical cancer awareness and prevention among
Black immigrant women should particularly focus on the
women’s personal networks. These efforts should prior-
itize understanding the unique needs of women in terms
of how they navigate the US healthcare system and uti-
lize social networks to improve their access and use of
preventative care. Second, longitudinal studies on Black
immigrant women’s knowledge and awareness of cancer
prevention and trends in their cancer preventive behaviors
should be conducted. Such work can inform the imple-
mentation of tailored public health interventions among a
Black subpopulation population with low cervical cancer
screening rates. Third, policymakers should insider adopt-
ing new policies that promote culturally competent cancer
prevention care, as these efforts would not only benefit
the Black immigrant community, but other populations
experiencing health disparities. Finally, additional health
policies should engage key network members in develop-
ing and implementing community-based interventions to
facilitate Black immigrant women’s adherence to screen-
ing behaviors.
Limitations
The strength of this study is the use of a mixed-methods
approach to examine the role of social connectedness in cancer
screening among Black immigrant women. However, a few
limitations of the study are worth noting. Egocentric network
data is very useful in understanding interactions among network
members but precludes the viewpoints of women’s network
members. The quantitative data was not representative of
Black immigrant women in the USA, as it was from a cross-
sectional survey of a convenience sample of women. Though
this approach allowed us to easily collect information from a
hard to reach and unrepresented population, it can potentially
introduce selection bias. Also, study participants may be limited
in terms of having diverse backgrounds and perspectives on
the research topic. The qualitative interviews were conducted
by a white woman who was not part of the Black immigrant
community. This may have resulted in response bias due to
challenges in establishing rapport with various Black immigrant
women. We worked closely with a key community leader from
the community in recruiting and interacting with women, in
attempt to address this concern.
Conclusion
Network characteristics including social connectedness and social
support are critical interpersonal level factors that promote cancer
preventive behaviors. Despite low cervical cancer screening rates
among Black immigrant women, there is growing evidence
that leveraging social support can improve screening uptake.
Our findings suggest that due to the supportive roles network
members may provide women, it is necessary to explore the
unique network dynamics of women. This approach may offer
insights into how the role of different network members could
evolve and potentially be enhanced to create opportunities for
women’s involvement in health promoting behaviors such as
early cancer detection, prevention, and treatment. Future research
should investigate this relationship further to inform culturally
competent public health interventions and clinical care that
leverage the critical role of personal networks.
Acknowledgements We would like to thank the community leader,
Amina Tahirou, for her support and efforts in facilitating data collec-
tion among our Black immigrant women. The writing of this manu-
script was made possible through support for protected time by the
National Institutes of Health Loan Repayment Program.
Author Contribution All authors contributed to the study conception
and design. Material preparation, data collection, and analysis were
performed by Leslie Cofie, Olivia Whitt, and Nikhil Bhagat. The first
draft of the manuscript was written by Leslie Cofie and Olivia Whitt,
and all authors commented on previous versions of the manuscript. All
authors read and approved the final manuscript.

Journal of Racial and Ethnic Health Disparities
Funding Open access funding provided by the Carolinas Consortium.
This study was supported in part by internal funding from East Carolina
University.
Declarations
Ethics Approval This study was exempted from ethics review by East
Carolina University (UMCIRB 19–000571).
Consent to Participate Informed consent was obtained from all individual
participants included in the study.
Competing Interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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