Table 2. Indirect quotes from key informant interviews describing barriers to accessing preventive health care, as well as the ways to help overcome them, among African immigrant communities in King County, WA (organized according to the domains in the socio-ecological model [37]).

Domain	Barriers to Accessing Preventive Health Care	Ways to Overcome Barriers
Individual	• Lack of individual awareness/knowledge of illnesses or available services 1. And education, talking with them, kind of like in school, we need to know when to do what. And most important, why? Why do we need to do mammography, this colon thing? 56-year-old female, Mexican, site manager 2. More should be done on health education and access to information as many don’t even know what their rights and benefits are. 58-year-old male, Eritrean, medical professional	• Health education 1. Educating the community and giving practical examples on how preventive medicine helps. Getting them involved in volunteering experiences and doing the basics so that way they feel they are making a difference and through that they feel compelled to use the preventive medicine. 24 years-old female, Kenyan, student 2. Having more community-based health caregivers, involving culturally competent professionals to give us education about preventive health care. 54-year-old male, Ethiopian, taxi driver
Interpersonal	• Differing language and cultural practices 1. The culture and language difference always make the care more difficult and the experience less enjoyable but it’s not because the care providers are bad. 32-year-old female, Somali, community organizer • Suboptimal relationships between patients and providers 1. Not trusting the health care system; In hospitals and clinics my community’s ideas and opinions are not validated and this makes them less trusting of the health care system. 24-years-old female, Kenyan, student • Discrimination based on various identities 1. I have heard and faced negative discriminatory treatment which I will say was based on where we are from, our competency, language barrier and race. 39-year-old female, Ethiopian, medical professional	• More community-led and -centered health outreach 1. Involve community members, train people from the community who can give back. 58-year-old male, Eritrean, medical professional • Cultural humility/competency trainings for providers 1. Health care providers should receive adequate training on the cultural and social value of the community it serves. 43-year-old female, Ethiopian, educator • Greater availability of interpreters that speak native languages 1. Language barrier is a big problem- need to have more interpreters, providers who speak different languages. 49-year-old male, U.S.-born, youth educator
Organizational	• Logistical and resource contraints to accessing care: Cost 1. The insurance system should be changed to make it more accessible and suitable for low income makers and immigrants. 41-year-old male, Ethiopian, airport attendant Transportation 1. Accessible transportation, as far as many people do not know the city well. 37-year-old male, Ethiopian, medical professional Time 1. Having services during the weekend helps because many people work during the week or normal clinic hours. 18-year-old female, Ethiopian, student Lost wages due to time taken off from work 1. Our background makes us to give priority to work. 39-year-old female, Ethiopian, medical professional • Lack of culturally-sensitive services or community-based/informed outreach efforts 1. [different] cultural and religious beliefs create miscommunication with care providers which finally may end up in lack of trust. 43-year-old female, Ethiopian, educator • Mistrust of Western health systems and practices 1. Not trusting the health care system. Trusting herbal and traditional medicine more than standard health practices. 24-year-old female, Somali, student	• Community-based and -led care 1. Churches and community centers would be the best places, but it takes a lot of time to get community leaders involved. 38-year-old female, Ethiopian, community health worker 2. I don’t think there are any alternative health care providers. There are many non-practicing health care providers [in our communities] but they are not many practicing ones as the system tries to marginalize and reject them. Actually, that is one of the main problems and I believe has to be improved as it will increase trust [between community members and providers]. 58-year-old male, Eritrean, medical professional 3. Many use the free clinic close to the apartment complex, which works well, because everyone from the community goes there, have built rapport and trust with the community. 18-year-old female, Ethiopian, student • Cultural humility and culturally-competent care 1. It [health care system] should be more transparent and emphasis has to be given to culturally-competent care. 32-year-old female, Somali, medical professional • Health services offered at or near where people live 1. I think people will tend to use it more because it avoids the transportation expenses and time obstacle. 24-year-old female, Somali, student 2. People are much more likely to use services near their apartment. 33-year-old female, Ethiopian, homemaker 3. If offered in the apartment building, makes people in the community feel like there people who care about them. 18-year-old female, Ethiopian, student
Societal/Cultural Norms	• Lack of cultural emphasis on preventive health care 1. We come from a culture where we are more reactionary to health issues than proactive. Female, West African, business owner	• Challenge social/cultural norms in appropriate ways 1. Workshops on health insurance. Raise awareness on preventive health care benefits. Female, West African, business owner • Increase community involvement 1. First of all, acknowledge problem exists; do detailed research about it; involve community members, train people from the community who can give back, involve culturally competent professionals and of course involving donors for budgets is a problem. 58-year-old male, Eritrean, medical professional
Policy/structural	• Difficulty obtaining insurance 1. Insurance, no knowledge on how to navigate the insurance system, the payment is unclear. Health care in the United States is often unaffordable and places a large financial burden on families. 26-year-old female Ethiopian, student 2. The insurance system is not friendly to undocumented immigrants so that has to be changed. 43-year-old female, Ethiopian, educator	• Expand insurance access 1. The insurance system is one of the things that can be changed but I think it is a large scale problem. 26-year-old female, Ethiopian, student 2. I also believe there should be universal health care for everyone. 37-year old female, Ethiopian, medical professional