Identifying Frequently Endorsed Benefits and Barriers to Breast Cancer Screening for African-Born Women in the NYC Metropolitan Area: A Pilot Study

Abstract

Most cancer screening data report on Black participants without distinguishing nativity, limiting our understanding of the needs of distinct groups within the African diaspora. The purpose of this pilot study was to assess demographic characteristics and perceptions of the benefits of and barriers to mammography among African immigrant women in New York City (NYC). Forty-two women who were 40 years or older, born in Africa, and English and/or French speaking were recruited from African immigrant communities in NYC to complete a survey. Eighty percent of our sample aged 50 to 73 was adherent with the 2016 USPSTF mammography screening guideline. The most frequently endorsed benefits were that mammography will help find breast cancer early, could help find a breast lump before it is big enough to feel, and that if found early, breast cancer could be successfully treated. The most endorsed barriers were that having a mammogram is painful and that lack of insurance or being treated rudely at the mammogram center would keep participants from having a mammogram. Chi-square analyses assessed relationships between demographic characteristics and perceptions about mammography and revealed that endorsement of barriers to screening (e.g., health issues, transportation problems, pain and time associated with mammography) varied by educational attainment. Findings suggest that future interventions should be multi-level and: 1) support patients in accessing screening via resource sharing; 2) address other commonly cited barriers such as fear of pain during the procedure; and 3) support anti-racist healthcare environments especially in terms of treatment by providers.

Introduction

Among women living in the United States (U.S.), for whom breast cancer is the second leading cause of cancer death [1], racial health inequities related to breast cancer are pervasive. Black women, for example, experience a death rate 40% higher than white women [2]. Previous research has shown that racial disparities in breast cancer mortality cannot be reduced to “differential biology,” especially since racial groups are a social rather than natural biological construct and contain considerable in-group genetic diversity [3,4]. Disparate breast cancer outcomes must be contextualized within a structural analysis of the health system and other “interconnected macro-level systems, institutions, processes, and social forces [that] produce and reinforce racial disparities in health” [5]. In comparison to white women, multiple studies have found that Black women are: (1) more often screened at facilities that are lower resourced and less likely to be designated Breast Imaging Centers of Excellence by the American College of Radiology [6–8]; (2) less likely to have a prompt diagnostic examination when reporting signs and symptoms of breast cancer or when abnormal results are found through screening mammograms; (3) less likely to have a breast imaging specialist (as compared to a general radiologist) reading their mammograms [8,9]; (4) less likely to have abnormal results appropriately and effectively communicated to them [10]; (6) less likely to start treatment in the first month after being diagnosed [11]; (7) less likely to receive treatment through adjuvant therapy such as hormonal therapy or chemotherapy [12]; and (8) less likely to be engaged in appropriate surveillance as survivors [13].

Most available data report on the healthcare and breast cancer screening experiences of Black communities in the U.S. without further distinguishing nativity [14,15]. Race is a poor proxy for genetics and ancestry [16] as well as lived experience and culture as African Americans, Afro-Caribbean immigrants, African immigrants, and Black immigrants from other regions of the globe have differing experiences of the U.S. and its healthcare system [17]. Aggregating demographic data in a way that presents people simply as Black/African American limits understanding of each group and their needs [15,18,19]. We maintain that policies and programs informed by one-size-fits-all aggregate data do a disservice to patients and likely fall short of the specific healthcare needs of the many communities within the African diaspora. In terms of breast cancer education, women who are minoritized in terms of race, ethnicity, and/or immigration status might benefit from participating in interventions informed by their unique backgrounds and needs [20–22].

Although it is fragmentary, previous research on breast cancer screening engagement suggests that African-born women feel disempowered to or are unable to navigate the healthcare system when they do not have health insurance [23]; are more likely to have completed a mammogram after living in the country for at least 5 years as compared to those who have lived in the country for fewer than 5 years [24]; and have acute awareness of the benefits of early detection of breast cancer, regardless of compliance with screening guidelines [15]. In terms of adherence to screening guidelines, one group of researchers surveying foreign-born New Yorkers (54% of whom were African immigrants) found that 34.9% of the study sample had never completed mammography screening [25]. It is important to note as a baseline that in 2020, 82% of women ages 50-74 across New York City (NYC), where this study took place, were adherent with the U.S. Preventative Services Task Force (USPSTF)¹ [27] mammography screening guideline (i.e., they were screened within the past two years) [28]. Finally, a 2008 special report from the NYC Department of Health and Mental Hygiene indicated that 73% of foreign-born and 80% of Black women over the age of 40 had completed a mammogram in the past two years [29].

This pilot study contributes formative data to the broader literature by presenting the results of a community assessment conducted with African immigrant women living in the metropolitan area of NYC assessing their health beliefs related to screening mammography uptake. We report salient demographic information including mammogram adherence according to the USPSTF guideline, alongside participants’ perceptions of the main benefits of and barriers to obtaining a mammogram. We also discuss relevant relationships between participants’ demographic characteristics and their perceptions of the benefits of and barriers to mammography. This research can inform future interventions that aim to mitigate barriers and increase healthcare engagement among African-born women.

Methods

Participants

Study team members recruited participants from African immigrant communities in NYC between December 2021 and March 2022. Eligibility criteria for this pilot study included being: a woman, age 40 or over, born in Africa, and able to speak English and/or French. Key community leaders introduced the study to community members and assessed interest. Next, members of the research team approached interested women in person or over the phone to conduct the assessment. In total, 46 surveys were completed; four surveys were not included in the analysis due to ineligibility of participants based on established inclusion criteria. Thus, the analytic sample size for this study was 42 women. This pilot study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai as part of a larger mixed methods study.

Data Collection

After obtaining informed consent, members of the research team gave women the choice to complete the survey in English or French: 76.2% (N=32/42) participated in English and 23.8% (N=10/42) participated in French. Participants received a $30 gift card for their time and effort.

Measures

A native and fluent French speaker translated all measures into French. Then, the measures were back-translated to English by another fluent French speaker and reviewed to ensure accuracy of the translation.

Participants completed a sociodemographic survey (see Supplement 1) including questions about age, educational attainment, marital status, health insurance status, location of residence, income, country of birth, time in the U.S., spoken languages, religion, and employment status. The survey also included items regarding health behaviors such as last mammogram completed (to which participants could answer, “Never had a mammogram,” “Within the past year,” “Within the past two years,” “More than 2 years ago,” and “Don’t know/don’t remember”).

Six benefits of and fifteen barriers to mammography were measured through a 5-point Likert-type scale adapted from Champion’s 1999 scale [30]. Responses ranged from one (strongly disagree) to five (strongly agree). One subscale (see Supplement 2) assessed participants’ perceptions of the benefits of mammography, while the other subscale (see Supplement 3) assessed participants’ perceptions of barriers to completing a mammogram. We adapted Champion’s scale to include items regarding benefits (e.g., cancer could be treated successfully if found early) and barriers (e.g., lack of insurance, transportation problems, other health problems, treatment for cancer being worse than the illness itself) of mammography specifically applicable to our study population. We also altered the language of some items to make them more accessible to our population. For these adaptations, we took guidance from Champion et al.’s revised 2008 scale [31].

Analysis

Using SPSS, we conducted univariate analyses in order to report on demographic trends as well as the level of agreement with different benefits and barriers across the sample. We collapsed response categories for some demographic items for simplicity (see Supplement 1 for full demographic survey). Furthermore, we conducted chi-square statistical tests to report on the relationships between selected demographic variables (e.g., employment, education) and participants’ endorsement of benefits of and barriers to mammography. We collapsed agree and strongly agree responses into “agree” and disagree and strongly disagree responses into “disagree” for the purpose of the chi-square analyses. We also assessed via cross-tabulation how many women who answered the survey question about mammography pain had actually previously completed a mammogram in order to understand if endorsement of this barrier was rooted in previous direct experience or not. In order to quantify the compliance of our sample with recommendations for mammography screening, we used the guideline published by the U.S. Preventative Services Task Force (USPSTF) in 2016 [27]. We filtered our data by age (i.e., 50-73 years old) and assessed screening completion within the past two years to understand our sample’s adherence to the USPSTF guideline.

Results

Demographic Characteristics

Table 1 presents the demographic characteristics of the sample. The average age of the participants was 53.2 years (SD=9.4 years), with an age range from 40 to 73 years, excluding one participant whose age was not reported. The mean length of time spent living in the United States was 19.5 years (SD=11.4 years), excluding one participant whose time in the U.S. was not reported. Eighty-five percent (N=35/41) of the sample had lived in the U.S. for more than 5 years. Nearly half of study participants (N=20/42; 47.6%) were born in Ghana. The majority of participants (N=25/42; 59.5%) had obtained a high school (or equivalent) education.

Table 1.

Demographic Characteristics of Study Sample

Demographic Category	N	%
Socioeconomic Status Related Characteristics
Marital Status
Partnered	21	50
Unpartnered	20	47.6
Missing	1	2.4
Location of Residence
Manhattan	9	21.4
Bronx	25	59.5
Queens	1	2.4
Brooklyn	2	4.8
NYC Greater Metropolitan Area (Yonkers, New Jersey, Long Island)	4	9.5
Missing	1	2.4
Total Household Income
Less than $20,000	12	28.6
$20,000 to $49,999	15	35.7
More than $50,000	5	11.9
Prefer not to answer	7	16.7
Missing	3	7.1
Education
Less than high school	17	40.5
High school graduate or equivalent (GED)	10	23.8
Some higher education or professional training	15	35.7
Religion
Muslim	29	69
Christian	13	31
Survey Language
English	32	76.2
French	10	23.8
Currently Employed
No	26	61.9
Yes	16	38.1
Countries of Birth
Burkina Faso	6	14.3
Cote d’ivoir	1	2.4
Gambia	1	2.4
Ghana	20	47.6
Kenya	1	2.4
Mali	4	9.5
Nigeria	4	9.5
Senegal	2	4.8
Sierra Leone	1	2.4
Missing	2	4.8
Health-Related Characteristics
Type of Health Insurance
No Insurance	12	28.6
Public Insurance	16	38.1
Private Insurance	11	26.2
Multiple Insurances	3	7.1
Healthcare Professional Seen Regularly
No	6	14.3
Yes	36	85.7
General Assessment of Health
Excellent	7	16.7
Very good	7	16.7
Good	19	45.2
Fair	9	21.4
Last Mammogram
Never had a mammogram	5	11.9
Within the past year	23	54.8
Within the past 2 years	7	16.7
More than 2 years ago	6	14.3
Missing	1	2.4
USPSTF Mammogram Adherence (considering participants aged 50-73, N=25)
Adherent	20	80
Nonadherent	5	20

Excluding one participant who did not report speaking any African languages, 65.8% (N=27/41) of participants spoke one African language, while the remainder of the sample spoke multiple African languages (N=13/41 spoke 2-4 African languages; N=1/41 spoke seven African languages). The most commonly spoken African language was Hausa (N=18), followed by Twi² (N=10), Ga (N=7), Wolof (N=5), Mooré (N=4), and Igbo and Yoruba, each spoken by three participants. Twelve additional African languages alongside the aforementioned – including Malinké, Bambara, Kotokoli, Fulani, Swahili, among others – were spoken by one or two participants in our sample.

Table 1 shows that 71.4% (N=30/42) of our study cohort had some form of health insurance and 85.7% (N=36/42) had a healthcare provider that they were able to see regularly. Table 1 also indicates the level of mammogram adherence of our population according to 2016 USPSTF recommendations.

Perceptions of Benefits and Barriers

Considering only the items in our subscales adapted from Champion’s 1999 scale [30], which includes 5 benefits and 11 barriers, some with slight wording changes, the mean of our benefits subscale was 20.32 (SD=2.27) and the mean of our barriers subscale was 22.73 (SD=6.32). Figures 1 and 2 demonstrate participants’ level of agreement or disagreement with all measured benefits of and barriers to completing mammography (see Supplements 2 and 3 for full subscales). In terms of benefits of mammography, the most endorsed statement was Benefit 2, “Having a mammogram will help me find breast cancer early,” with which 97.6% (N=40/41) of the sample agreed or strongly agreed. The second most endorsed statement was Benefit 4, “Having a mammogram could help me find a breast lump before it is big enough to feel,” with which 92.7% (N=38/41) of the sample agreed or strongly agreed. Finally, 90.2% (N=37/41) of our study population agreed or strongly agreed with Benefit 3, “If breast cancer was found early, the cancer could be successfully treated.” The lowest level of endorsement (i.e., combined agreement and strong agreement) for any benefit was 74.4% (N=29/39) for Benefit 1, “If I get a mammogram and nothing is found, I do not worry as much about breast cancer.”

Figure 1.

Perceived Benefits of Mammography: Percentage Distribution of Responses

Figure 2.

Perceived Barriers to Mammography: Percentage Distribution of Responses

Concerning barriers to mammography, the highest level of combined agreement and strong agreement was 32.5% (N=13/40) for Barrier 6, “Having a mammogram is painful.” Notably, of the women who had previously completed a mammogram, 32.4% (N=11/34) agreed or strongly agreed with this barrier, while 40.0% (N=2/5) of the women who had never completed a mammogram endorsed that mammogram is painful. Next, thirty percent (N=12/40) of the sample agreed or strongly agreed with Barrier 14, “Lack of insurance would keep me from having a mammogram.” Finally, 28.2% (N=11/39) of participants endorsed Barrier 7, “Being treated rudely at the mammogram center would keep me from having a mammogram.” The lowest level of endorsement for any barrier was 2.4% (N=1/41) for both “Having a mammogram would expose me to unnecessary x-ray radiation” (Barrier 8) and “I am afraid to have a mammogram because I don’t understand what will be done” (Barrier 2).

Furthermore, we conducted chi-square tests assessing the relationships between dichotomized demographic variables and participants’ endorsements of the benefits of and barriers to mammography. Several significant relationships emerged, including between mammogram adherence and the benefit, “Having a mammogram could help me find a breast lump before it is big enough to feel,” X² (2, N=24) = 8.409, p=.015. Furthermore, our analysis demonstrated several significant relationships between demographic variables and barriers to mammography, including: (1) employment status and “I don’t know how to go about getting a mammogram,” X² (2, N=41) = 6.8, p=.03; (2) education and “Having a mammogram takes too much time,” X² (2, N=41) = 10.1, p=.006; (3) education and “Having a mammogram is painful,” X² (2, N=40) = 8.29, p=.016; (4) education and “I have other health problems that would keep me from having a mammogram,” X² (2, N=41) = 6.15, p=.046; (5) education and “Transportation problems would keep me from having a mammogram,” X² (2, N=41) = 9.89, p=.007; (6) time in U.S. and “Having a mammogram would expose me to unnecessary x-ray radiation,” X² (2, N=40) = 7.32, p=.026; and (7) having a regular health care provider and “Having a mammogram would expose me to unnecessary x-ray radiation,” X² (2, N=41) = 7.432, p=.024.

Discussion

The healthcare needs of African immigrant women, including access to mammography screening, are understudied. This pilot study adds to the available literature by presenting data collected from African-born women residing in the New York City area. We describe our sample’s demographic characteristics and perceptions of the benefits of and barriers to mammography, as well as the relationships between these findings. These data can be utilized to support the development and refinement of interventions to promote greater healthcare engagement among African immigrant women.

In general, the perceived benefits of completing a mammogram were highly endorsed and the barriers were endorsed less by our study population. There are limited studies that use Champion’s 1999 scale that we employed [30], especially with a comparative sample of Black or African-born women, to research breast cancer screening. Champion’s 2003 study, however, can serve as a means of comparison for the outcomes of our benefits and barriers survey. The authors sampled from “(1) a large health maintenance organization (HMO) serving a metropolitan area and (2) a university-related general medicine clinic serving primarily low-income African American women,” counting 30% African American participants [33]. The mean of their benefits subscale, 19.88 (SD=3.24), is less than one point lower than the average of our benefits subscale; the mean of their barriers subscale, 22.54 (SD=3.92), almost exactly reflects our average [33]. This suggests that our study population endorsed barriers and benefits in a relatively similar manner to a sample comprised partially of African American women.

New Contributions to the Literature

The most endorsed benefits to mammography reflect that the women in our sample are familiar with the importance of mammography screening. Indeed, most women agreed that a mammogram will help find breast cancer early and could help find a breast lump before it is big enough to feel, and that breast cancer found early could be successfully treated. Furthermore, very few participants agreed that they fear mammography because they do not understand what will be done, indicating a general knowledge of the screening procedure. The benefit endorsed by the lowest percentage of the sample (although still agreed with by a majority of participants), however, was that having a mammogram contributes to decreased worry about breast cancer – demonstrating that some members of this population may continuously fear the illness, regardless of screening completion.

Although most participants indicated understanding the value of mammography, through the most endorsed barriers many members of our study population (of which about a quarter is uninsured) acknowledged the hypothetical impact on mammogram completion of lack of insurance, pain associated with mammography, and being treated rudely within a healthcare setting. This reveals the importance of supporting community members in accessing screening by helping them navigate insurance systems for mammography coverage and/or providing and highlighting free or low-cost options for under or uninsured patients. Furthermore, it is essential to address barriers such as fear of pain in educational interventions, both for patients who have and have not previously completed mammography. Finally, future interventions should link African immigrant women to facilities that perform breast cancer screening in an environment in which healthcare providers are receptive to their concerns (e.g., related to pain or bills) and uphold high standards of care, including in terms of respect and courtesy.

This seems to be aligned with previous work with marginalized communities. In a systematic review by Adunlin and colleagues, not having (or being able to obtain) healthcare coverage from an insurance plan and lacking a stable provider for care ranked first among the endorsed barriers to breast (and cervical) cancer screening among immigrant women [22]. Focusing on racialized groups, Miller and colleagues found that experiencing pain and discomfort during the procedure are predominant concerns for African American/Black women, who also often identified rudeness of the healthcare personnel as a barrier to screening [20]. Furthermore, lack of insurance and previous mammogram pain or discomfort were commonly cited as barriers among a sample of low-income and under or uninsured African American women in Missouri [34]. This points to the importance of holistic and multi-level interventions impacting the recipients and also the providers of healthcare to support the creation of anti-racist healthcare environments [20].

Of note, chi-square statistical tests demonstrated several significant relationships between level of educational attainment and endorsement of barriers to mammography, including health and transportation problems as well as pain and time associated with mammography. Those with lower levels of educational attainment had more variability in their responses to these barriers, while those with higher levels of educational attainment more often disagreed or strongly disagreed with them. Interestingly, one of our findings contrasts with that of a study measuring perceptions of mammography among Asian American women in southeastern Michigan, which found that women with at least a college degree endorsed discomfort as a barrier to mammography at a much higher level than women without a college degree [35]. This demonstrates that there may be differences across groups in terms of linkages between education and perception of the pain or discomfort of mammography. Furthermore, in a study of women across low, middle, and high income levels in the Midwest and North Carolina, participants decreasingly endorsed barriers to mammography as their income levels increased; this result was statistically significant [36]. Specifically, as income level increased, endorsement of difficulty getting transport and of mammogram costing too much statistically significantly decreased, while endorsement for lack of time as a barrier to completing mammography increased [36]. Since there was not enough variation in income level within our sample to conduct similar analyses, the results from this study may help contextualize our findings across socioeconomically disparate groups. Moreover, there was some variability in both groups, but participants who were unemployed in our study more often agreed with the barrier that they did not know how to go about getting a mammogram than those who were employed. Finally, we found a significant relationship between mammogram adherence and endorsement of the benefit that having a mammogram could help find a breast lump before it is big enough to feel. Those who were not adherent with screening guidelines had more variability in their responses, while adherent participants largely agreed or strongly agreed with this benefit. Since our sample size is small, it is difficult to interpret the real-world significance of these findings, but they are important formative data for the development of future research and interventions.

Significantly, our findings indicate that most of our sample had a reliable engagement with the healthcare system, had health insurance, and were adherent with 2016 USPSTF mammography screening recommendations [27]. The results of our survey exceeded our expectations of engagement in screening for African immigrant women in NYC. Only 12.2% (N=5/41) of our study cohort had never completed a mammogram, as compared to aforementioned research [25] with largely African-born immigrant New Yorkers, about 35% of whom had never had a mammogram. Furthermore, the 80% adherence rate to USPSTF mammography screening recommendations among our participants over the age of 50 was comparable to the mammogram adherence rate for all women ages 50-74 across NYC in 2020 [28]. Moreover, our full study cohort’s screening completion rate in the past two years, nearly 75%, is similar to aforementioned 2008 statistics published by the NYC Department of Health and Mental Hygiene describing the percentages of foreign-born women and Black women over 40 who had completed a mammogram in the previous two years [29].

Our study was not powered to run analyses that could demonstrate relationships within our findings to explain the participants’ level of engagement with screening. The following considerations, however, contextualize our outcomes. First, it is important to note that expanded health care access (e.g., insurance, patient navigation) is critical, but is not the only determinant of engagement with screening and may not fully overcome patients’ complex barriers to completing mammography [37]. Significantly, our participants were largely tied into an established network of African-born New Yorkers as the study cohort was recruited from faith-based and community-based organizations through community-wide events and community leader introductions. Being part of a solid network increases the social capital of an individual and likely impacts their knowledge of and access to the U.S. healthcare system [38,39], especially through resource-sharing and community support that facilitates the achievement of screening and other health benchmarks. Second, the African-born women that we were able to reach and involve in the study had been living in the U.S. for an average of 19.5 years. Other studies have asserted that being an established immigrant influences healthcare engagement and mammography uptake [40]. Finally, it is important to note that many of our participants were comfortable with being surveyed in English and/or were born in Ghana, whose national language is English. This may influence our sample’s ability to navigate the healthcare system and general adherence to mammography guidelines. Knowledge, access, and healthcare needs likely vary by community, as the African immigrant population within NYC is not monolithic. This is reflected by the many African languages (e.g., Kru, Ibo, Yoruba, Arabic, Amharic) largely spoken across Brooklyn, Queens, and the Bronx [41]. Future work should investigate the different needs of the many communities who make up the African immigrant population in NYC.

It is essential to comment on the breadth and diversity of languages represented within our study population. In total, participants spoke 19 different African languages; many participants spoke multiple African languages. Many African languages represented within our sample transverse the boundaries of specific countries and coordinate primarily with the spread of groups connected by ethnicity, ancestry, etc.; for example, Hausa, the language spoken by the most participants, is commonly spoken across West and Central Africa [42,43]. This demonstrates the importance for future public health research and practice of conceptualizing African immigrant communities not just through country of origin but also language and ethnic group.

Limitations

This study was not without limitations. First, participants self-reported mammogram completion status; social desirability bias may have affected adherence rates. Furthermore, our sample is small and not representative of all African-born women in NYC, especially since all participants had some English and/or French proficiency. Almost half of our participants were born in Ghana, and all but one participant were from West African countries. Although this may in part reflect the fact that Ghanaians are the most populous group of African-born residents in NYC (over 18%) [44], the oversampling of women from Ghana is largely a manifestation of the snowball effect due to our convenience sampling. Study team members recruited participants in close collaboration with faith-based and community service organizations that serve mostly West African immigrants, which likely limited our understanding of the needs of community members from other parts of the continent or who might lack a connection to the support network that trusted, established institutions are able to provide to their constituencies. While this sample’s general adherence to screening guidelines may be a limitation to the generalizability of the results of the study, we believe it also demonstrates the importance of trusted organizations that link community members to care. Significantly, however, the fact that our participants had high health care access certainly limits the applicability of our findings to populations of African-born women who have less access to care, especially in places outside of New York City. Finally, we acknowledge that the English questionnaire itself was not specifically designed for the performance of a community assessment with African-born immigrants.

Conclusions

We aimed to report participants’ demographic information and perceptions of various benefits of and barriers to mammography, based on quantitative surveys completed by African immigrant women in NYC. As we are aware of the limited capacity of a small quantitative dataset to capture the complexity of the lived experiences of a diverse community, we believe in-depth qualitative research would enhance our findings. Thus, we aim to integrate our preliminary quantitative findings with a future analysis of in-depth semi-structured interviews conducted with a comparable sample. We expect this to provide a richer exploration of this community’s experiences with mammography screening that will allow us to consider how structural elements, systemic policies, and cultural identities intertwine, as scholars have previously done with other populations [45]. Nonetheless, our work contributes to the dearth of literature available about the demographic characteristics and perceptions of mammography of African-born women.

Moving forward, we aim to culturally adapt the Witness Project, an evidenced-based breast cancer education program initially designed for African American women [46-49], based on our results. Our outcomes will be especially important in adapting the educational presentation addressing values, fears, myths, benefits, and barriers related to breast cancer and mammography to reflect participants’ knowledge and deficits. Significantly, we aim to make needs-specific adaptations, especially via resource sharing, an approach also suggested by Miller and others [20,21]. Furthermore, in recognizing the limits of education and in agreement with other scholars [20], we advocate for other pathways towards reducing inequities in breast cancer screening and mortality, specifically through acknowledging and working to mitigate the impact of structural barriers (e.g., insurance access, limited English proficiency, childcare needs, documentation status, transportation access, healthcare costs, etc.) on healthcare engagement.

There is certainly more work to do with less engaged African immigrant women in NYC who may not be as adherent to mammography screening guidelines as the population we were able to recruit. We encourage investment in non-exploitative and mutually beneficial partnerships with community-service organizations to expand outreach in the community, especially among more recent, less connected, and potentially more vulnerable immigrants.

Data Availability:

The datasets generated during and/or analyzed during the current pilot study are not publicly available to protect the privacy of participants but are available from the corresponding author on reasonable request.