Toward a Structural Approach: Exploring Barriers of Access to Primary Healthcare Services Among African Immigrant Women

Background and purpose: Immigrants are disproportionately affected by low rates of health insurance coverage and poor access to healthcare services. It was reported that 23% of lawfully present immigrants and 45% of undocumented immigrants are uninsured as compared to the 8% of uninsured citizens. Accordingly, immigrant women experience multiple barriers in accessing healthcare services and are at higher risk of health problems. Within the immigrant women population, African immigrant women are most vulnerable because of the lowest access and utilization of healthcare, a high rate of HIV and STDs, a high rate of employment in unskilled labor. Still, African immigrant women remained understudied and underrepresented in the immigrant health literature. This study explored the barriers experienced by African immigrant women in accessing primary healthcare (PHC) with a particular focus on Ethiopian immigrant women (EIW).

Methods: A qualitative design with a phenomenological approach was conducted to investigate what barriers were experienced by EIW. Data were collected using in-depth interviews with EIW (N=21) aged 18 and older (M=36.6) through both in-person and virtually via phone and Zoom. Participants were included if they were: 1) identified as an Ethiopian immigrant; 2) identified as a female; 3) 18 years old and older; 4) arrived in the U.S. within the last five years; and 5) spoke Amharic or English. Interviews were audio-recorded and transcribed verbatim. Data were analyzed thematically using Nvivo12 software.

Results: Thematic analysis revealed that the barriers experienced by EIW were predominantly structural in nature. The primary barrier was immigration status which limited EIW’s ability for employment-based insurance, and eligibility for PHC which led to precarious work conditions and fear of losing legal status. Secondary barriers included that participants experienced discrimination in the PHC system fueled by racial stereotypes, cultural insensitivity, and being a Black immigrant woman increasing their vulnerability. The complexity of the PHC system and lack of adequate, understandable, and customized health information affected EIW’s ability to navigate and access services. The findings also showed that PHC was unaffordable due to the highly expensive insurance, costly multiple tests, and limited financial capacity of EIW.

Conclusion and implications: This study is among the first studies exploring barriers to access to PHC experienced by Ethiopian immigrant women in the U.S. The study demonstrated that EIW’s PHC experience was shaped and constrained by intersecting structural forces including immigration, unaffordability, complexity, and discrimination. The findings implied that there is a strong need to move toward a structural approach in both policy and research efforts. Immigration and labor policy reforms are needed to facilitate employment authorization, lift restrictive rules, and diversify the healthcare workforce. Further research is needed to examine the impacts of specific immigration categories (e.g., asylum seekers, refugees, and twilights, etc.) and the double layers of discrimination as Blacks and immigrants on African immigrant women’s ability to access and utilize PHC services in the U.S.