Introduction

The number of Black immigrants in the U.S. has grown rapidly from 800,000 in 1980 to 4.6 million in 2019 and is projected to reach 9.5 million by 2060 [71]. African immigrants have the fastest growth rate among Black immigrants in the U.S., having grown 246% between 2000 and 2019 [71]. Black immigrants are motivated to move to the U.S. for a myriad of reasons, including pre-migration stressors such as political upheaval, war, gender-based violence, and poverty [21]. For Black immigrants who immigrate to the U.S., challenges with adapting to a new country, such as cultural and linguistic barriers, financial stressors, racism, discrimination, and social isolation add another level of stress and vulnerability that exacerbate previous experiences of trauma and abuse. Moreover, these migration-related stressors have negative implications for both physical and mental health and may aggravate existing mental health problems and/or precipitate new conditions [8, 22, 44, 56].

A comprehensive understanding of different health services used by Black immigrant women is essential to guide efforts that support the intricate needs of this growing population. Most public health efforts with Black immigrants have centered around infectious diseases, but as Black immigrants become long-term residents in the U.S., an emphasis on screening, prevention, and treatment of disease is imperative. Health promotion and treatment of disease is especially important due to the “healthy immigrant effect,” or the phenomenon of deterioration in health status among immigrants following extended time in the host country, despite having better health outcomes compared to native populations upon entry [24]. Studies have also shown that immigrants’ risk for negative health outcomes increases overtime as their health profiles shift to align more with that of the American population [73]. Taking this into account, the promotion of essential health screenings and other health services is essential to reduce health inequities that occur in immigrant populations over time.

Unfortunately, little is known about health service utilization (HSU) practices of Black immigrant women. Black populations in the U.S., which also include Black immigrant women, have a history of being amalgamated despite existing differences in culture and health needs and outcomes. The health care needs and experiences of Black immigrant populations in the U.S. cannot be assumed to be identical to those of African Americans. However, it is difficult to extricate differences in HSU among immigrant groups because U.S. immigrant health data are rarely stratified by country or region of origin and are often categorized broadly using designations such as “foreign-born” [6]. Moreover, existing research focuses on individual health services such as mental health [7], emergency department [37], and informal support from friends and religious leaders [25], rather than a wide variety of health services.

Purpose

The goal of this review was to gain a comprehensive understanding of the different health services utilized by Black immigrant women in the U.S. and factors influencing decisions to use health services to guide efforts to support the complex health needs of this growing population.

Methods

Theoretical Framework

This review is guided by Yang and Hwang’s [75] adapted version of Andersen’s Behavior Model of Health Services Use (BMHSU), which seeks to explain health service utilization behavior of immigrants by specifying elements from the original model to fit the immigrant context [75]. Much like Andersen’s original model, Yang and Hwang’s adapted model proposes that health service utilization is determined by four factors: (1) predisposing factors, (2) enabling factors, (3) need for care, and (4) macrostructural/contextual factors (Fig. 1). All factors influence the health outcomes of perceived health and satisfaction with care services received [10, 75].

Fig. 1
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Adapted Behavior Model of Health Service Use [75]

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Predisposing factors include demographic factors such as age and gender, social factors such as education, occupation, and ethnicity, and health beliefs, which include attitudes, values, and knowledge about health and health services that influence perceptions of the need for health services. Immigrant-specific predisposing factors include immigration status (legal status, human rights, psychological status), assimilation (English proficiency, length of host residency, residential integration, participation in community organizations), and immigrant ethnic culture (norms, values, beliefs, traditions, behaviors, and additional cultural patterns brought to the host country from the homeland of the immigrant).

Enabling factors describe three different types of resources: financial resources (income, means to pay for services and transportation to services), social resources (relationships with friends, family, and the community), and access to health care (availability of health services and health professionals to provide needed services).

Need for care encompasses both perceived (individual feelings about personal health, response to symptoms, and magnitude of health problem) and evaluated needs (judgment by medical professional).

Macrostructural/contextual factors are related to government policy, the health system, and the larger social, economic, and political systems that influence the decision-making process for utilizing health services. Immigrant-specific contextual factors include the context of emigration (leaving the home country), experiences of care in the home country prior to moving to the host country, and attitudes of the host society toward new immigrants. This model will be used to guide the data extraction and organization of results for this review.

Search Strategy and Selection Criteria

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for this systematic review of health service utilization of Black immigrants residing in the U.S. An informationist was consulted to complete a detailed literature search and a search strategy (Fig. 2) was developed using keywords, synonyms, and controlled vocabularies (Medical Subject Headings [MeSH], Emtree) related to Black immigrants and health service utilization. Four databases were searched: PubMed, PsychInfo, CINAHL, and Embase. Articles published until October 19, 2022 were eligible for inclusion. Ethical approval was not required for this review.

Fig. 2
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Search Terms

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Study Selection and Eligibility

All articles identified using the search strategy were imported to Covidence, a web-based collaboration software platform that streamlines the production of systematic literature reviews [18]. Title and abstract screenings were conducted by three reviewers (JL, JC, AA) on Covidence. Two reviewers independently reviewed each article to determine eligibility for the review and discrepancies that arose from the title and abstract screening processes were resolved through discussion by all three reviewers. All studies from the initial screening were eligible for full-text screening. For full-text review, two primary reviewers determined eligibility and referred to a third reviewer to resolve cases of discrepancies.

Inclusion and Exclusion Criteria

Full-text articles were included if they were empirical studies, had samples of female immigrants over the age of 18 who identified as Black, African, or of Caribbean-descent, discussed health services delivered by a professional in a health care setting, examined experiences of using health services, were set in the U.S., written in English, and peer-reviewed. Articles were excluded during the full-text screening process if they were gray literature, contained study samples consisting of only men, only discussed opinions of providers and not patient experiences, or only examined patient health beliefs of health services that did not arise from personal experiences. The literature was limited to immigrants living in the U.S. to examine patient experiences within the context of the U.S. health care system, which is distinct from health systems in other countries.

Data Extraction

Following full-text review, data were independently extracted by two reviewers (JL, KA). The data extraction form included information such as first author and publication year, sample size and description, study aim, study design, type of health service used, health professional involved, and factors influencing health service utilization (HSU). The factors influencing HSU were then organized by the categories in the immigrant health service utilization theoretical framework by Yang and Hwang [75]. The first author (JL) cross-checked the extracted data and resolved inconsistencies upon discussion with a second reviewer (KA).

Quality Assessment

Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tools [42]. For quantitative studies, the following domains were assessed: bias due to study population, setting, outcome measurements, identification and assessment of confounding factors, and statistical analysis method. For qualitative studies, philosophical perspective and methodology congruity, research methodology, cultural location of researcher, researcher influence, ethical approval, and establishment of conclusion were domains that were appraised. Each item was rated either yes, no, unclear, or not applicable. The PRISMA checklist guided transparent reporting [52]. For mixed-methods studies, the Mixed Methods Appraisal Tool [31] was used. The tool contains five items that evaluate both qualitative and quantitative study quality components, as well as how both study methods were integrated and interpreted. All articles were appraised for quality and all studies (n = 46) except for one [16] met 60 to 100% of the criteria from the Joanna Briggs Institute Critical Appraisal Tool. All studies were deemed appropriate to include in the review.

Results

A total of 15,245 records were identified from the literature search and 11,468 duplicates were removed (Fig. 3). Title and abstract screening were conducted with the remaining 3777 studies, and 3567 were excluded, leaving 210 studies. During the full-text review, 150 studies were excluded. A more detailed overview of reasons for exclusions is in Fig. 3. After full-text screening, 47 articles were included in the review. Study characteristics and data were summarized in Table 1, and a variety of different health services were accessed by the Black immigrant population (Table 2). These included hepatitis screening (n = 2), reproductive health services (n = 4), cancer screenings (n = 18), substance abuse treatment (n = 1), mental health services (n = 5), HIV services/testing (n = 7), dental services (n = 1), genetic testing (n = 1), and cardiovascular risk testing (n = 1). A few studies (n = 6) discussed more than one type of health services.

Fig. 3
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PRISMA Flow Diagram

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Table 1 Studies Examining Health Service Utilization Among Black Immigrant Women
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Table 2 Types of Health Services Examined by Studies
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Factors Affecting Utilization of Health Services

Factors influencing health service usage spanned across all four components of Yang and Hwang’s [75] adapted version of Andersen’s Behavior Model of Health Services Use and will be discussed in greater detail in the following sections.

Predisposing Factors

Demographic factors, social factors, health beliefs, and health knowledge were predisposing factors that influenced Black immigrants’ health service utilization behavior. For some immigrants, country of origin increased their likelihood of facing challenges with utilizing health services; Somali immigrants were less likely to access health services compared to immigrants from other African countries living in Minnesota [29]. Age was another factor that significantly affected health service usage. In two studies assessing HIV screening reception, immigrants younger than 25 years and older than 44 years of age were less likely to obtain health services [49, 50]. Female sex was a factor that increased likelihood of not acquiring health services [70], and older women were also less likely than younger women to get mammography screenings in an immigrant sample of Somali and Haitian women [74]. Both single [23] and married status also contributed to decreased use of health services [49]. Higher degrees of acculturation as measured by years resided in the U.S.; English proficiency, social preferences, and personal identity were associated with increased use of health services [12]. Immigrants who identified with a blended sense of cultural attitudes and beliefs were also more likely to report utilization of preventative screening services compared to immigrants who resisted acculturation and did not identify with the new culture [3].

Length of stay in the U.S. was another factor that influenced care reception, but findings were mixed. Several studies concluded that immigrants who had recently arrived in the U.S. [16], resided in the U.S. for less than 5 years [29], or lived part-time in the U.S. and their country of origin [74] were less likely to utilize care services than immigrants who had lived in the U.S. for longer than 5 years. However, other studies found that immigrants residing in the U.S. for longer than 5 years used fewer services compared to immigrants who had newly moved in the past year [19, 50, 51]. For cardiac screening, Black immigrants who lived in the U.S. longer were more likely to get screened [47].

Many studies noted that limited health knowledge inhibited Black immigrant women from navigating and accessing health care systems. Lacking knowledge of health conditions and transmission [48], differing understanding of disease cause and progression [11, 74], and decreased availability of reliable health information [30, 74] were all barriers to using health services for the female Black immigrant population [2, 48, 74]. Confusion about the non-curative nature of chronic disease treatment also led to distrust of the U.S. medical system and health providers among Liberian refugee women in Virginia [11].

Challenges navigating the U.S. health care system also stemmed from unfamiliarity with the U.S. health care system [11, 30, 67], lack of awareness of local health facilities [49], and lower levels of health literacy [6, 30]. Immigrant populations that were knowledgeable about available health services were more likely to use health services compared to immigrant populations that were unaware of existing services and how to access them [20, 35, 39, 51]. Low education in consequence of disparities in education also decreased health service utilization [11, 51]. Although higher level of education (college education or higher) was associated with increased use of HIV services [49] and hepatitis B testing [48], college education was negatively associated with seeking treatment for alcohol use disorders for immigrant women compared to immigrant men [70].

Fear related to intrusiveness and discomfort with hospital procedures [2, 29, 40], treatment side effects [5, 30], and confirmed medical diagnoses, particularly for breast and cervical cancer due to the linked fear that diagnoses could lead to death, were additional reasons for Black immigrant women to not seek health services [9, 74]. Fear of public and self-directed stigma towards certain mental health [46] and sexual health diagnoses including HIV/AIDs [51, 58, 67] were additional obstacles to obtaining necessary health care services. Personal inclinations to avoid thinking about certain health conditions such as HIV also diminished attempts to use health care services by immigrants [49, 68]. Some African immigrant women disclosed that they were averse to genetic screening because they anticipated feelings of guilt related to passing down cancer genes to members of their family if they tested positive for breast cancer susceptibility genes [68].

In addition to fears concerning stigma and health implications from diagnoses of negative health conditions, legal factors such as immigrant status and cultural challenges related to language barriers played a large role in influencing Black immigrant women’s decision to use health services. At the legal level, immigrant status [6, 58, 65] and fear of deportation as consequence of lacking documentation [67, 74] were reasons for Black immigrant women to refuse health services. At the cultural level, language barriers restricted Black immigrants from effectively communicating and building trusting relationships with health care providers [66]. Immigrants also disclosed that communication challenges with providers decreased their willingness to use health services [2, 17, 19, 28, 30, 51, 66]. Even with translators present, immigrants expressed that they were concerned that translators would mistranslate their words or the physician’s words [28]. Overestimations of English language proficiency by both providers and the patients also decreased care satisfaction [43]. Black immigrant patients also shared that they experienced discrimination based on English fluency by health care providers and staff assisting with insurance and disability coverage [11].

Distrust of western medicine and health care providers, which often arose from language and communication barriers, further impeded utilization of health services by Black immigrant [66]. Encounters with providers that were perceived as unsympathetic by patients [28], medical violence [30], and challenges with building trusting relationships due to communication barriers caused Black immigrant women to be weary of western providers and medicine, which contributed to decreased levels of health service usage.

In contrast, positive past experiences and relationships with health care providers motivated participants to continue seeking health services [3, 9, 58]. Physician recommendations of certain treatments and tests strongly indicated initiation of health services, although it did not predict treatment maintenance over time [17]. Having access to regular care providers [26, 48] and previous experiences of using health services [26, 43] also made immigrant populations more likely to use health services.

Variations in cultural beliefs and expectations created challenges to accessing health services for Black immigrant women. Discomfort related to having male physicians as care providers was a deterrent to care reception for Somali Bantu women [28, 66] as well as other immigrant women from African countries [29]. Lack of cultural fluency between patients and providers also led to passive acceptance of incorrect care, hesitancy with questioning health visit outcomes, uncertainty about physician understanding of patient concerns, and decreased decision-making in medical settings [28, 40, 67]. A wide range of cultural beliefs created additional barriers to using health services. Fatalism, the belief in a lack of personal power to control destiny or fate, led to an understanding among African immigrants that talking about illness invites illness into people’s lives, which impeded participation and perceptions about need to use health services [40, 51]. Religious beliefs, which served as protective measures for disease decreased immigrant women’s usage of health services [2]. Concerns with privacy and confidentiality, especially concerning sexual and reproductive information, were barriers to care reception [2, 51, 68, 74]. Another barrier to health services related to personal and cultural beliefs was the desire to resolve psychological distress and health-related issues independently without assistance from others [62].

Enabling Factors

According to the adapted Andersen’s Behavior Model of Health Services Use (BMHSU), enabling factors encompass three general types of resources: financial, social, and access to health care [75]. Financial barriers to using health services described in the studies included high cost of care [2, 16, 28, 62], unemployment [11, 29, 32, 61], and low income [32, 51]. As such, financial comfort [1] and steady employment [19, 32] were two main reasons that increased likelihood of Black immigrant populations using health services. Having health insurance also increased the likelihood of using health services among immigrants compared to those without health insurance [1, 6, 20, 26, 29, 32, 35, 43, 48].

For social resources, positive social interactions with people and affectionate support from family and significant others that generated feelings of love, care, and value created conducive environments that encouraged preventative health behaviors and increased likelihood of having Pap screening services for Black immigrant women [1]. In addition to motivating health service utilization, support from family and friends buffered the negative consequences of stigma and uncomfortable exchanges with the U.S. health system [58]. Barriers to accessing health services were many: not having transportation to health services [66, 67, 74], challenges with scheduling and identifying health facilities [51, 66], and decreased availability of health care providers [9, 19, 48,49,50].

Need for Care

Barriers to health care services that fall under the “Need for Care” category in the BMHSU comprise of both perceived needs such as individual feelings about personal health, symptom responses, and magnitude of health issues, as well as evaluated needs ascertained by medical professionals [75]. In this review, the two main reasons that prevented Black immigrant populations from freely accessing health services consisted of ambiguities about the necessity of care and prioritization of other schedules and daily tasks over health needs. Individually perceived sense of good health [16] and lack of physical symptoms [30, 48] were cited as reasons for not seeking care services. Health service acquisition was also seen as inconvenient due to busy work schedules that did not leave room for frequenting health appointments [9, 32]. Life stressors requiring immediate attention, such as feeding young children, finding transportation to work, and challenges acquiring housing also took precedence over HIV health care needs for African immigrants who were inconsistently engaged in HIV medical care [58]. However, perceived need for oral health care services and provider-determined needs such as decayed teeth and bleeding increased the likelihood of Black immigrant women using dental services [19].

Macrostructural/Contextual Factors

Macrostructural and contextual factors that impeded of Black immigrant populations’ access to care services encompassed experiences of structural racism and discrimination. East African immigrants in Virginia specifically described instances of being subjected to unequal treatment in health care settings based on their appearance and need for interpreters [30]. Moreover, Black immigrants experienced discrimination in intersecting forms related to race, gender, and religious identification, which further discouraged them from accessing health services [32, 62].

Health Service Utilization Findings

Findings related to the frequency of health service utilization behavior among Black immigrant populations remain mixed. Studies with Black immigrants reported that a higher percentage of Black immigrants utilized health services than expected [20, 51, 62]. Specifically, 63% of first- and second-generation African immigrants utilized mental health services [62] and Black immigrants were significantly more likely to have received HIV tests compared to Hispanic white immigrants [49]. Studies that compared the behaviors of multiple immigrant groups described that Black immigrants were more likely to use health services compared to other immigrant populations [14, 49]. Black immigrant populations utilized more colorectal cancer screening services compared to U.S.-born Black populations [14] and more than 70% of Black immigrants utilized Papanicolaou testing [20] and had a primary care provider [51].

While some studies found high usage of health services by Black immigrant women, more studies reported low usage of health services. A study with Somali women found that fewer than half of the sample used reproductive health services [33]. In particular, fewer than half of the people who reported sexual dysfunction and only 30% of women with female genital cutting who experienced pain from intercourse reported that they used available health services, although those who used health services stated that their problems were mostly resolved following service reception [33]. Black immigrant women were also less likely to seek gynecologists, well-woman services, family planning services, and contraceptive services compared to African American women [5, 9].

Black immigrant women were also less likely to have had a recent HIV test compared to U.S.-born Black populations [50]. A study with Francophone and Anglophone African immigrants found that Francophone Africans were less likely to utilize HIV health services compared to Anglophone African immigrants [67]. Many immigrants also disclosed overall low utilization of cervical cancer screenings [1, 2]. Compared to U.S.-born Black citizens or other immigrant groups, Black immigrants were less likely to screen for breast cancer [16, 17, 43, 68, 74], cervical cancer [9, 23, 26, 43], colorectal cancer [43], and prostate cancer [16].

Black immigrant populations also noted fewer use of mental health services compared to U.S.-born Black women [12, 34]. Only 40% of Somalians reported use of mental health services despite experiencing feelings of sadness [33] and Black immigrants were more likely to have low rates of hepatitis screenings [48] compared to Asian immigrants [35]. Rates of having a regular health care provider or a usual source of care [6, 16], seeking alcohol disorder treatments [69], and using outpatient care services such as dental care, surgery, and hospital visits were also lower in comparison to U.S.-born Black populations [16, 38]. Dental care was also used less frequently by Black Caribbean immigrants compared to Asian immigrants [19].

While many quantitative studies included in this review discussed frequency or usage patterns of health services, the qualitative studies focused on participant experiences of using health services and factors influencing decisions to engage in health care [2, 11, 19, 28, 30, 32, 45, 57, 58, 60, 65, 66, 74]. There were also conflicting results within the same study or among different studies. Black immigrants were more likely to attend doctor visits and have hospital stays compared to white immigrants, yet attended fewer dental appointments [38].

A study with Francophone African immigrants and Anglophone African immigrants in Philadelphia found that the health needs of most Anglophone African immigrants were met by their primary care physicians while Francophone African immigrants used traditional care and ordered medicines from their country of origin [67]. Furthermore, more Anglophone African immigrants received their first health care at the emergency room compared to Francophone African immigrants. Francophone African immigrants described that they avoided health care centers due to lacking immigration documentation and used the emergency room when in crisis [67].

Discussion

A total of 47 articles were reviewed to understand the patterns of health service utilization among Black immigrant women residing in the U.S. The most common study designs were cross-sectional studies (n = 26), followed by qualitative studies (n = 11), and prevalence studies (n = 6). Due to the heterogenetic nature of the study samples, the findings of this review must be considered with caution when making a general estimation for all immigrant groups in the U.S.

The study samples of the articles were highly variant. Study populations included women from countries in Africa, the Caribbean, and Latin America. The studies also differed in their inclusion of different demographic factors that influenced health service utilization. Many studies measured demographic information such as age, education level, income, employment status, marital status, and length of stay in the U.S. These variables were included in the multivariable models to account for their effect on health service utilization but the influence of these variables across immigrant populations remain indefinite.

A limitation of the studies in the review is that the majority of data on health service utilization were self-reported and are therefore subject to recall and reporting bias. Moreover, variables that may significantly affect health service utilization such as years lived in the U.S., health literacy, existing health conditions necessitating health services, and perceptions of personal health and need for medical care were not always measured. To obtain a comprehensive understanding of factors that influence health service utilization among this population, there is a critical need for studies that explore the association of these variables with health service use among immigrant populations.

We used Yang and Hwang’s adapted version of Andersen’s Behavior Model of Health Services Use (BMHSU) as an organizational framework. In accordance with the theoretical framework, predisposing, enabling, and need factors were commonly associated with HSU. Based on the current review, several factors were identified to increase likelihood of HSU among Black immigrant women. These factors include older age [49, 50, 62], longer length of stay in the U.S. [1, 29, 47], higher levels of acculturation [3, 12, 20], knowledge of health resources and conditions [2, 6, 20, 66, 74], English proficiency [6, 20, 29, 62], previous positive experiences with providers [3, 9, 17, 32, 58], history of health conditions [19, 30, 49, 69], married or cohabiting status [26, 48, 49, 69], having insurance ([1, 6, 20, 26, 29, 32, 35, 43, 48]), and having access to primary care services [20, 35, 39, 51].

The studies included in the review described a plethora of factors that influence health service utilization behaviors of Black immigrant women. While some factors could be clearly categorized as either barriers or motivators, others were less distinct and simultaneously prompted and hindered the utilization of health services. Length of time spent in the U.S. was a particular factor that had contradictory effects on Black immigrant women’s behavior of using health services. A study in the review reported that recent immigrants to the U.S. had a lower odds of having a source of care relative to those who immigrated 10 or more years ago to the U.S. [36]. This phenomenon of increased health service utilization among immigrants who have resided in the U.S. for longer than 10 years could be explained in part by the increased knowledge and familiarity of the U.S. health care system, as well as improved English proficiency that often follow extended time spent in the U.S. [29]. Yet, other studies have shown that extended stay in the U.S. can deter utilization of the health system due to encounters with stigma, mistrust of the American health care system, and extensive hospital bills [59]. Another factor that may impact the relationship between length of time in the U.S. and usage of health services is the motive behind the pursuit of using health services. A study on HIV testing practices among immigrant populations found that more than half of the non-U.S.-born sample had received HIV testing as a requirement of obtaining immigrant status, rather than due to their own perceived risk for infection [50]. Thus, more immigrants who had lived in the U.S. for less than 1 year had undergone HIV testing in the past year compared to those who had resided in the U.S. for longer than 5 years [50]. As such, it is possible that extended length of stay in the U.S. can both prevent and promote health service utilization among immigrant populations.

Age was another factor that significantly affected health service usage among Black immigrant populations. Studies that assessed HIV screening reception reported that immigrants younger than 25 years and older than 35 years of age were less likely to get tested for HIV [49, 50]. Older age also increased the likelihood of using mental health services among first- and second-generation African immigrants [62]. Improved knowledge of available health services over time and increased need for more health services with age due to deterioration in health may explain this association [4]. Further research is needed to delineate how social experiences across the lifespan influence health behavior patterns of seeking necessary health services among immigrant populations [62].

Another factor that caused bilateral effects on health service utilization was education. Low levels of education resulted in decreased use of health services while those with higher education levels used more HIV [49] and hepatitis B testing services [48]. Differences in education level can contribute to inequalities in health. Low education levels are associated with decreased health literacy, which results in sub-optimal health care use [13]. Studies with Black immigrants have found associations between higher education and fewer hospitalizations [11], as well as increased use of recommended screening services such as HIV screening [49] and hepatitis B testing [48] compared to Black immigrants with lower levels of education. As such, it is possible that populations with lower levels of education have decreased health literacy, which could hinder efforts to access health care services.

Language barriers were another deterrent to care that was mentioned by participants in several studies [2, 17, 19, 28, 30, 51, 66]. Even when translation services were available, some language line services did not offer interpretations in the languages spoken by Black immigrant populations [28]. While there are many benefits to working with interpreters, especially for patients who are not fluent in English, there are also many challenges. These include dynamics of trust, control, and power between patients, interpreters, and practitioners, as well as within health care institutions at large. Establishing an alliance of trust regarding information that is shared, controlling the accuracy and validity of dialogues, and maintaining power balances when they are offset by institutional constraints such as time limitations, cost of interpretation services, and continuity of same interpreter services are essential to create an ideal environment for patients, providers, and interpreters [15]. Moreover, it is important to remember that language line interpreters may be unable to act as cultural liaisons because they only serve to translate brief conversations without having the cultural context of the people they were interpreting for [28]. Ad-hoc interpreters, who are untrained in interpretation work, can exercise control by omitting, modifying, or condensing content that is shared during a meeting between a care provider and patient [15].

However, not all transformation by interpreters has negative effects; interpreters may also temper language used by practitioners to make communication less confrontational or abrupt, provide emotional support, and clarify medical jargon [54]. To ensure health care quality, speech transformations must be monitored, transformations must be completed in an overt manner, and trained, professional interpreters must be used as much as possible [54]. The reliability of interpreters and the help they provide in strengthening communication between patients and providers should also be emphasized to patients.

This review corroborates previous studies that have determined that immigrants use fewer health services compared to U.S.-born adults. A previous literature reviews on health service utilization practices of immigrants living in North America found that immigrants were less likely to use health services compared to native populations [22, 64] including mental health services [41, 63].

To improve access to health services for immigrant populations, health care models must prioritize participatory approaches that focus on communication and meaningful dialogue to account for language barriers, marginalization, and unfamiliarity of the U.S. health care system among immigrants. The incorporation of community health workers into health care teams may assist with improving access to using health services among immigrant populations. Community health workers serve as a bridge between communities and the health care system by providing culturally appropriate health education and information to members of underserved communities [27]. In a national study of community health workers, 49% of community health workers responded that they served immigrant populations [72]. Moreover, community health workers are involved in existing programs that serve immigrants and have contributed to increasing access to health care services, improving the frequency of health screenings, expanding adherence to health recommendations, and decreasing the need for emergency and specialty services [72]. As community health workers consist of lay members from the community, those who practice as community health workers also gain entry-level employment experiences by working closely with clinicians, organizations, counselors, and other health professionals. Thus, the broader inclusion of community health workers into health care teams may not only improve access to health services and resources for immigrant members of the community, but also create space for immigrant advocacy and participation within the U.S. health system.

Existing weaknesses in the health system such as high cost of health services and availability of health insurance must also be addressed to decrease the burden of decreased access and availability of health services to this population. It is critical to leverage the health system and state level policy to increase access to health services for Black immigrant women. One of the most frequently mentioned deterrents to using health services were high health care expenses and lack of insurance. Although Medicaid and the Affordable Care Act has improved access to health insurance for many people, disparities remain and must be improved. Currently, foreign-born individuals who do not meet the 5-year residency requirement are ineligible for Medicaid. While they are eligible for health insurance exchange subsidies, exchange plans are not as comprehensive as Medicaid, and unfamiliarity with private health insurance creates challenges to navigating the health care system [53]. Systems-level changes at the policy level that provide financial support to immigrants before they complete their 5-year waiting period is essential. As of September 2023, five states (California, Colorado, Illinois, Oregon, and New York) and Washington DC provide state-funded coverage or subsidies to immigrant adults regardless of immigrant status. However, greater advocacy is critical to increase access to health services for immigrants across all of the states in the U.S.

While insurance coverage by private or public health plans is the first step to increasing access to health care systems, coverage does not automatically translate into using health services. Immigrants must become knowledgeable of the differences in care quality, prices, payment methods, and patient–physician relationship expectations that may be a stark contrast to the health system approach from their home country. Programs that educate immigrants on the overall U.S. health care system structure and how to navigate it are paramount.

This review has some limitations. As the purpose of the literature review was to understand the types of health services utilized by Black immigrant women in the U.S., studies that contained aggregated data on the health practices of immigrant populations without reporting data that was specific to Black immigrants were excluded. Further, studies with only male immigrants or without separate data for female immigrants were excluded. This was done to obtain data specific to Black immigrants and not assume all immigrant groups as homogenous. Articles were also not limited by publication year to include as many articles as possible. This resulted in including an article that was published in 1998, which may be unrepresentative of current African immigrant health behaviors [55]. However, the article was judged as valuable because it included health practices of a lesser known population of Sudanese immigrants residing in Minnesota. The review also expands existing literature on health service use practices of Black immigrant populations. To our knowledge, this is the first systematic review to specifically look at overall health service utilization behavior of Black immigrants in the U.S. The review also undertook a comprehensive search of multiple electronic databases and appraised the quality of each article to ascertain study validity. Moreover, the review found that there was no clear pattern of care utilization among the Black immigrant population. Thus, it highlights the need for patient-centered care that individualizes care plans to meet the needs of each patient. Even among Black immigrations, there was much heterogeneity of care needs and perceptions of health services offered in the U.S.

Conclusion

This systematic review was conducted to understand health service utilization patterns among Black immigrant women residing in the U.S. Several different types of health services spanning from preventative to acute health services were reported to have been used by Black immigrant populations living in the U.S. The most common type of health service utilized in the studies were cancer screenings and HIV tests and treatment. Factors that increased use of health services included possession of health insurance, being knowledgeable about resources and detrimental health conditions, and positive experiences with providers. Barriers to utilizing health services included challenges with navigating the U.S. health care system, language barriers/health literacy, and cultural beliefs against health service utilization. The findings of this review inform future research by identifying factors that motivate and encourage Black immigrants to use health services in the U.S. However, these must be considered with caution, as the health needs of Black immigrants varied greatly on the individual. Many predisposing, enabling, need, and contextual factors could both encourage or deter use of health services depending on the circumstances of each person. It is critical that care providers listen to the health needs and goals of each individual and refrain from assuming that all immigrants have similar health needs. Factors that positively influence health service utilization behavior must be expanded at the institutional, societal, and policy levels to improve access to health services, especially for immigrant populations that face compounded health risks compared to their U.S.-born counterparts.