African Migrant Health in the United States

48 Sub-Saharan countries, 2,000 languages, hundreds of ethnic groups, and a multitude of reasons for leaving home. How can the diversity of a continent be categorized into one catch-all category: Black or African American? How can we understand differing needs?

Despite being a rapidly growing group within the total migrant population of the United States(1), the health outcomes and needs of Sub-Saharan African (SSA) migrants are relatively understudied. This is due in part to data on SSA migrants being included within statistics about native-born Black Americans. By combining these data under one demographic category, “Black or African American,”(2) statistics fail to capture the overall diversity of Black people in the United States, obscuring how migrants' health needs may differ from that of native-born citizens based on factors such as legal status, traditional beliefs, and language.

This project applies open-source research, interviews with Federally Qualified Health Centers (FQHCs), and mapping technology to explore how Direct Relief can support health centers in reaching SSA immigrants and refugees through culturally sensitive community-building initiatives.

African immigrants utilize the services where they feel most comfortable." -- Norman Mitchell, CEO of Bee Busy Wellness Center

Federally Qualified Health Centers are community-based health providers that serve underserved populations, such as migrants, unhoused people, and those living in public housing(3). By virtue of their community-based focus, FQHCs are in an extraordinary position to prioritize the needs of African migrants in their area. By incorporating culturally-sensitive practices such as targeted workshops and outreach campaigns, they can connect with African patients based on their ethnic backgrounds and migratory histories.

Additionally, given the socio-economic demographic of patients who seek FQHCs' comprehensive primary care services, these health centers would also be able to note how status and class inform the health experiences of their African patients. Leveraging these features would allow FQHCs to stand out from other healthcare providers and make them desirable places for vulnerable, low-income African patients.

Direct Relief partners with over 830 FQHC sites across the United States, supporting mobile health units that provide life-saving medical services directly to communities, providing medications and cash grants, and assisting in hiring culturally competent staff. Four Direct Relief partners that serve large numbers of African migrants are profiled: AccessHealth, Bee Busy Wellness Center, CCI Health and Wellness Services (CCI), and Union Community Health Center (UCHC).

According to the Migration Policy Institute (MPI), the top countries of origin for Sub-Saharan African migrants in the United States in 2018 were Nigeria, Ethiopia, Ghana, Kenya, Somalia, and South Africa(4). Similar to migrants of various backgrounds, SSA migrants to the United States leave their home country voluntarily or involuntarily and settle in areas where they have familial ties and economic opportunities. Among the top six sending countries, Texas, New York, Maryland, and California have the highest proportion of SSA migrants in the United States, boasting 11.9%, 8.4 %, 8.2 %, and 7.4%, respectively. 

Whether they choose to leave their homes or are forced to do so has an impact on African migrant health outcomes once in the United States. Refugees, or migrants who are forced to flee due to war, violence, or persecution and who are unable to return home until conditions there improve(5), experience traumas such as torture, genocide, and sexual violence that affect their overall physical, mental and emotional health. For example, refugees may experience higher depression and post-traumatic stress disorder levels than their immigrant counterparts due to their identity as refugees(6). While immigrants and migrants who settle in a foreign country but could return to their native country(7) can also experience trauma, their health outcomes in the United States may not be directly related to why they left their home countries. Although there may be some overlap in their health outcomes, African immigrants' and refugees' health needs are correlated with previous experiences that informed their reasons to migrate to the United States.

Health outcomes within this community are also affected by factors that act as barriers to seeking and receiving healthcare in the United States. Examples include a distrust of western medicine rooted in histories of medical experimentation in their home countries, the complexity of navigating the US healthcare system, and public policies that discourage seeking public assistance.

Health centers could build trust among African patients, ease their transition to healthcare in the United States, and improve health outcomes by acknowledging their histories, understanding any hesitancy to western medical treatment, and addressing barriers in culturally appropriate ways.

Diabetes and hypertension are two chronic diseases prominent within the SSA migrant community. Strengthening community initiatives that support this demographic in managing diet and stress could help alleviate the prevalence of these illnesses.

Among the African migrant patients at Bee Busy Wellness Center, 44% suffer from diabetes and 68% from hypertension – rates influenced by the ability to purchase foods from their native homelands, low health literacy rates, and stress-related to migratory experiences and public policies such as the  expansion of the “public charge” rule  during the Trump Administration (N. Mitchell, personal communication, July 23, 2021). An effective way to manage these illnesses is to incorporate healthier foods into diets, such as fruits and vegetables, and cut out processed snacks high in fat and cholesterol. Union Community Health Center recognized the difficult their patients faced in creating a balanced diet. In response, the center implemented healthy food initiatives, distributing food boxes and taking patients to local markets to teach them how to shop healthily (D. York, personal communication, July 16, 2021). 

If you want to be able to impact health outcomes, you have to first be able to connect with the culture, understand the various cultures, and then design your delivery systems around those cultures. Otherwise you will not be successful at all." -- Dr. Douglas York, CEO of UCHC

Despite health literacy programs and direct-action initiatives, a primary barrier to low-income patients incorporating a nutrient-rich diet in their lives is the prevalence and availability of low-cost, processed foods in their communities. For patients focused on survival issues such as housing, employment, and childcare, it is easier and faster to feed their families by purchasing the largest and cheapest items that will feed their families than to plan healthier meals (P. Jalan, personal communication, July 19, 2021). 

One potential approach to alleviate the time-consuming nature of healthy eating for health centers' African patients is installing community fridges and pantries in vulnerable communities.

Refuge Coffee, a coffee shop staffed entirely by immigrants and refugees in Clarkston, GA, installed a community fridge and pantry along-side its building. It allows the community to pick up fresh and non-perishable goods for free. Fruits, vegetables, and nutritious staples such as dry beans and brown rice are readily available for people in need. Not only does this initiative remove the barrier of accessing food, but it also provides people with healthy options. Witnessing individuals pick up apples and lettuce from the fridge while others contributed pasta and peanut butter to the pantry revealed a community's role in welcoming and taking care of all its members. Installing community fridges in low-income communities could ease the burden African migrants may face in accessing healthy and affordable foods.

Additionally, partnering with African community associations to host workshops on cooking traditional foods in healthier ways could improve African patients' overall diet and lower the rate of diabetes and hypertension in these communities. Workshops could include sessions on where to access ingredients from their homelands, how to access these markets using public transportation, and how to substitute certain ingredients for healthier ones without compromising a dish's gastronomic integrity. Health centers could positively affect diet changes by utilizing the influence culturally-specific organizations have on various African communities.

The following map illustrates how far African patients in Houston and the Bronx would need to walk, take public transportation, or drive to access African food stores. Since the relationship among these factors in Montgomery and Prince George's Counties are similar to that in Houston, juxtaposing the geographic landscape of the latter with the Bronx gives a broader picture of how these elements interact.

Given the proximity of multiple African food stores within a 15-minute walk from public transportation or a 15-minute drive from one another, recommending patients continue cooking traditional meals but with healthier ingredients is not only a creative option, but also a feasible one.

Anxiety and depression are prevalent issues within SSA migrant communities. Still, African patients generally seek mental health-related medical care less frequently due to the stigma associated with mental health care and traditional beliefs about these illnesses. However, there is a growing acceptance of these issues among second- and later-generation migrants, the descendants of those who first arrived in the United States (P. Jalan, July 19, 2021). Pre-migration and post-migration risk factors contribute to why African migrants suffer from these ailments (8), and health centers, like CCI Health and Wellness Services, make sure to focus on the needs of refugees, a high-risk, sub-population of this community. Recognizing the traumatic experiences their Cameroonian and Ethiopian refugees have endured, CCI prioritizes screening refugees for mental health conditions during their first Refugee Health Assessment intake appointment (M. Murphy-Ballantyne, personal communication, July 21, 2021). 

Similarly, Bee Busy Wellness Center noted high rates of suicide among its Eritrean refugee population and prioritized connecting with this community through targeted outreach services destigmatizing the need to seek mental health services. After communicating with a patient attempting to take his own life, doctors realized his reasons for doing so stemmed from not having access to specific resources and feeling that society overlooked his community (N. Mitchell, July 13, 2021). African migrants feeling ignored and isolated and trying to assimilate to their new country correlates with high rates of mental health conditions among this population.

Feeling comfortable seeking mental health services is a crucial first step for African migrants accessing behavioral health-related care. Health centers recognize this as a reason there was an uptick in the utilization of behavioral services via telehealth methods during the Covid-19 pandemic – people could take an appointment over the phone or via video chat from the privacy of their own homes or personal spaces (D. York, July 16, 2021; P. Jalan, July 19, 2021; M. Murphy-Ballantyne, July 21, 2021). Utilizing telephonic (audio only) or telemedicine (audiovisual) services requires access to a phone or broadband service. Since some patients did not have access to the latter, health centers utilized both methods or never closed their doors during the pandemic to reach patients in the best ways for their lifestyles. The destigmatizing effect telehealth methods had on patients seeking mental health services illustrates the importance of normalizing mental health care within African migrant communities and prioritizing policies that support broadband equity across the nation.

The following maps show the American Community Survey's (ACS)  2021 Median Household Income  and  2020 Internet Access by Income  data at the census tract level. By sliding the center arrows horizontally, you will be able to compare the median income levels of all people with the percentage of households without internet access in the geographic areas serviced by the four health centers. Overall, areas with low income levels correlate with high rates of households without internet access. This indicates a potential gap in the ability of African patients to pay for broadband service that would allow them to use telemedicine for mental health appointments.

Click the legend button in the bottom left-hand corner of the map to see what each symbol represents.

In Southwest Houston, where Bee Busy Wellness Center and AccessHealth sites are located, the median household income among the general population ranges from $38,862 near Bee Busy's Sharpstown Clinic to $109,741 near AccessHealth's East Fort Bend Center. Comparing these areas with internet access data reveals a negative relationship between the two – the higher the median household income in an area, the less likely that area will have households without an internet subscription. 28.9% of households in the Sharpstown Clinic census tract are without an internet subscription, while only 5.1% of households in the East Fort Bend Center census tract do not have one. Even in areas with overall high median household incomes, health centers would need to consider how the financial demographics among their African patients would impact patients' ability to access the internet required for telemedicine services.

In Montgomery and Prince George's Counties, CCI Health and Wellness Services, the median household income among the general population ranges from $66,724 near the Greenbelt clinic to $103,516 near the Takoma Park clinic. The corresponding rates of households without an internet subscription are 15.5% and 5.3%, respectively.

Lastly, in the Bronx, New York, where UCHC is located, the median household income among the general population ranges from $20,644 near Center #5 to $58,431 near Center #6. The corresponding rates of households without an internet subscription are 32.7% and 19%, respectively.

Internet access is a primary barrier for African patients seeking mental health services via telemedicine. Health Centers could assist patients in applying for the  Emergency Broadband Benefit  through the Federal Communications Commission, and encourage them to sign up for longer-term, low-income internet plans through various internet providers. While incorporating these initiatives, continuing to implement culturally-sensitive, mental-health outreach campaigns in African communities is a necessary first step towards destigmatizing this form of care and making patients comfortable seeking it in the first place. All these efforts would contribute to lowering rates of anxiety and depression within this population.

Stay-at-home orders and organizational closures exacerbated medical access and health issues among African patients. Not being able to see their doctors in person to monitor illnesses such as diabetes, hypertension, stress, and depression made it more difficult for African patients to manage these issues independently. To mitigate the compounding effects of the pandemic, meet patients' needs, and minimize interrupted care, health centers expanded their use of their mobile health units and ramped up telehealth services.

UCHC partnered with the NYC Housing Authority, community boards, and veterans organizations to reach various communities with their mobile health units in the Bronx. Its primary unit was stationed in front of the E. 188th Street facility and served as a screening unit that separated Covid patients from those not experiencing Covid symptoms (E. Pring, personal communication, July 29, 2021). The mobile units supplemented UCHC's previous access- related initiative of providing patients with pre-filled metro cards, and they helped reach a population-dense city during a difficult period.

In Southwest Houston, AccessHealth and Bee Busy Wellness Center deployed their mobile delivery units throughout the region with the latter covering a range of 100 miles beyond its front doors (N. Mitchell, July 23, 2021). Stationed at community centers and churches made it possible for these health centers to continue providing routine care to their patients despite social distancing and stay-at-home orders. Further, Bee Busy Wellness Center made home visits to patients for whom this method was most effective, and distributed blood pressure monitors so patients could monitor their conditions from home while providing the center with important data (N. Mitchell, July 13, 2021). Mobile health units became invaluable assets during the pandemic as health centers could use them as Covid testing and vaccination sites. AccessHealth administered more than 100,000 vaccines in Waller and Fort Bend Counties and extend its reach in rural communities (P. Jalan, July 19, 2021).

With the introduction of Covid-19 vaccines, hesitancy among African patients became apparent. Distrust of western medicine, vaccine-related disinformation, and low overall health literacy have caused low vaccination rates across all four health centers' African patients. For example, vaccination rates within this population vary between 20-35% at Bee Busy Wellness Center (N. Mitchell, July 23, 2021). Health centers are tackling this issue by educating their patients on the safety and efficacy of the vaccine while acknowledging their understandable apprehension.

AccessHealth has given presentations at town halls and has leveraged the power of African patients' community leaders, such as pastors, to disseminate accurate vaccine information. CCI is collaborating with local organizations to host community events to tackle vaccine hesitancy among their patients. It has already partnered with the City of Takoma, Uber, and Lyft to host Covid vaccination clinics and provide travel vouchers to people in need. The events have reached up to 10,000 people at the time of this publication. Direct Relief has also partnered with ride-share companies to remove transportation barriers that low-income patients across the country may face in receiving a vaccine. UCHC and Bee Busy Wellness Center have incorporated outreach through community leaders, testimonials from Covid-19 survivors, and encouraging their providers to connect with African patients with whom they share the same cultural background. 

We're tackling misinformation by leveraging the power of the peer"-- Palak Jalan, Chief Population Health Officer, AccessHealth

Overall, the community-centered approaches health centers have taken to continue providing care during the pandemic and address vaccine hesitancy within African communities have reduced barriers to services and information, and have promoted trust between them and their African patients. To keep patients utilizing services that will help keep them safe during the pandemic, maintaining these bonds through consistent outreach and check-ins is of the utmost importance.

To effectively meet the health needs of Sub-Saharan African migrants in the United States, it is imperative that they feel comfortable seeking out care. Health centers that tailor their services to the specific needs of this population will be the most successful in connecting with and improving the well-being of their African patients. Centers must continue to consider this population's clinical needs and the socioeconomic factors that influence their health outcomes. For example, health centers, recognizing that not all of their African patients can access cultural food stores consistently due to unreliable and unaffordable public transportation, could provide van shuttles or subsidize transit fares. Lastly, by understanding how the needs of Sub-Saharan African migrants differ from those of native-born Black Americans, health centers could approach the specific health needs of African patients more directly – ultimately improving this population's overall health outcomes.

Health centers should employ community-centered best practices to improve the overall well-being of their African patients. For example, health centers could encourage their African patients to build ties to the larger community to feel less isolated from the broader society. One way to do this is for patients to attend and participate in multicultural events in their areas. Health centers could also take part in these local events to connect with African migrants directly and to share how their health services would benefit their families.

Additional community-centered best practices include:

• Conducting a study on the benefits of collecting health outcomes data based on country of origin to address specific needs
• Installing free community fridges in low-income neighborhoods
• Continuing to hire providers that match the cultural and linguistic background of patients
• Nurturing relationships with culturally-specific organizations and faith leaders to connect with diverse African communities
• Utilizing telehealth services and employing mobile health units in targeted neighborhoods