Transcript Somali-Bantu Refugee Women’s Beliefs About Preventative

Somali-Bantu
Refugee Women’s Beliefs
About Preventative Healthcare and Experiences
in Healthcare Settings in
San Diego:
Implications for Health Care Delivery
Paula Lloyd, RN, MSN, CNS
September 19, 2009
A “grandmother” tells
“grandchildren” the story of their
Somali-Bantu origins….
Where “we” came from
 How “we” came to be in Somalia
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Background
Captivity as slaves in Somalia
since late 18th century
 Somalia colonized by the Italians
 Emancipation in 1930’s
 Somali Bantu subject to attacks
and harsh mistreatment by Italian
colonialists, rogue slave traders,
bandits, government officials,
civilian militia, and local warlords.
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Outbreak of civil war and collapse of the government 1991
Somali people flee the country
Somali-Somali, Somali-Bantu, and other people groups flee to
refugee camps in Kenya (Kakuma, Dadaab, others)
2003, US and
UNHCR agree
to resettle 1215,000 Somali
Bantu Refugees
in US cities
Background
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(continued)
San Diego County Health and Human Services
statistics report 9/17/07 states 1,238 refugees
from Somalia between 2002 and 2006 .(report does
not distinguish between Somali-Somali and Somali-Bantu)
Organization “Somali-Bantu Community of San
Diego” (established 2005) estimates 500 SomaliBantu adults in San Diego October 2007.
 Currently, many Somali-Bantu are leaving San
Diego for other US cities to find jobs and
cheaper housing.
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The Problem is…
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Though the Somali-Bantu share some common problems
with other refugee groups, they have unique history,
beliefs and background that influence their health,
contributing to healthcare disparities.
Communication impedance beyond language alone:
related to divide in basic worldview, health beliefs,
health understanding, and health literacy.
Scant published research literature about the health
beliefs and experience of the Somali-Bantu.
Therefore, research is needed to increase culturally
relevant health communication, increase equity of care,
and improve health care outcomes.
Significance to medicine/nursing

The real challenge of providing safe, ethical, culturally congurent
care to an increasingly diverse patient population; each with their
own criteria of health/illness, when to seek care, and differing
expectations for that care (specifically a significant population of
Somali-Bantu).

Culturally competent care improves communication and increases
patient satisfaction, improves compliance and improves health
outcomes (IOM,2001; George,2002).

Knowledge of patient’s worldview on health, and provision of
culturally relevant care is important for moral/ethical reasons:
autonomy, self determination, informed decision making,
beneficence, nursing code of ethics.
Purpose of the study

Explore the understanding and health
beliefs of the Somali-Bantu refugee
women about preventative healthcare and
their experience in American healthcare
settings to illumine their specific health
beliefs for health care professionals to
improve understanding and healthcare
outcomes.
Methodology
Leininger
 Qualitative
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– Content Analysis
 “fracture” the data, finding relationships, themes,
and reintegrate the themes in relationship,
conveying the results of the findings in such a way
to bring meaning and understanding to the study
phenomenon.
 Rigor: credibility, dependability, confirmability and
transferability. Add to this, meaning in context and
repatternancy
Design Process

Entrée to community
– Role of the elders
– Friendships
Key informants
 Interpreter and translator processes
 Setting and Sample
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Setting and Sample
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Sample inclusion criteria:
– Over 18, born in Somalia and ethnic Bantu,
experience in American healthcare, willing to share
beliefs and experience
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Demographics
– Age range: 21 yrs to 58 yrs.
– Marital status: 1 widow, 2 divorced, 5 married
– Children: all have living children, number range from 1 to 7
kids. Widow had no living children- 5 babies died in infancy
– Years in refugee camp: 7-15 years
– Years in the US: all 5 years or less
A sample of the Semi-structured
Interview Questions
What does good health mean to you?
 How do you stay strong and healthy?
 What causes people to get sick?
 How can American HCP give better care to
their Somali-Bantu patients?
 What do you know about TB, hypertension
and immunizations?
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So, what did the interviews reveal?
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What is good health?
– Absence of sickness or pain
– No cough or sickness, “you feel strong and
happy, not mad, and (health) means you
don’t think a lot also.”
– Go to doctor and you get medicine
– Allah gives health and illness
What causes illness?
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Behavioral Causes:
– I don’t know
– Poor personal hygiene and dirty living environment
(6)
– “Thinking too much” (7)
– Poor handwashing (1)
– Smoking and drinking alcohol (3)
– Having sex with people not your spouse (2)
– “Working too hard” causes TB, hypertension and
other diseases (3-common)
– No food, or dirty food (6)
What causes illness?
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Spiritual Causes
– Allah’s will- “we beg to Allah for health” (4)
– “majini” (3)
– Name to big for child (2-common)
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Environmental Causes
– Public hygiene (2)
– No clean food and water (6)
– Some idea of contagion (4)
– Malaria (1), fever
Beliefs about Preventative
Healthcare
Though the women worried about diseases such as HIV,
STDs, TB, to name a few, they said that they would not
go to the doctor to find out if they had any of these
diseases.
 They would not go to the MD to do a test to find out if
they had a disease, for disease prevention.
 Many women stated that they only go to the doctor
when they or their family is sick.
 Will go for prenatal visits.
 Will take their children for well visits to be sure that they
are growing and developing.
 Heavy reliance on doctor office and school officials to tell
them what to do, when to return, etc.
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Beliefs and Understanding about
Tuberculosis
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Causation:
– Heavy labor
– Some understanding of the element of contagion from coughing
or sharing eating utensils (so noted by 4/8 people)
– Most participants stated they had heard about it, but have not
had it and do not know.
Symptoms:
– Coughing, chest pain, weight loss. One mentioned coughing up
blood.
Treatment:
– In Africa, prior to war, would isolate sick person in the jungle
where they would improve or die. Since war, must live together.
– In America, the women opine, people do not die of TB because
here there is medicine.
– One mentioned that she was asymptomatic with TB and received
6 months of treatment prior to coming to the US.
Beliefs and Understanding about
hypertension
“Most Somali-Bantu don’t know about it” (6)
 Causation:
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– Most stated they had heard about it but do not know
much about it.
– Hypertension comes from working very hard (3), and
thinking too much. (6)
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Symptoms:
– Headache, body feels like its burning, get angry, dizzy
– “Go to the doctor and he can tell you if you have it.”
Beliefs and Understanding about
immunizations
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All had heard of and experienced immunizations
in preparation for trip to USA.
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Only half the interviewed women knew and
verbalized that the purpose of the immunizations
was to protect against disease (“to keep disease from
coming to you”).
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Will take the children for immunizations when
prompted by the care provider
Experience in American healthcare
settings
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Overall, healthcare experience has been positive,
and women satisfied with their care (though there
have been situations producing patient undue anxiety,
and poor health outcomes).
All compare their experience here with total lack
of care in Africa.
 Will go to MD for prenatal care, birth control, or
illness. Rarely for screenings/preventative care.
 Fear of hospitalizations, surgery, C-sections.
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What do American Healthcare providers
(HCP) need to know about their
Somali-Bantu patients?
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General situation:
– Every participant stated that they are distinct from
the Somali-Somali, speaking a different language;
appropriate translator is of prime importance for
understanding.
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Their past influences their present worlview and
adaptation:
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Profound lack of basics for survival
lack of any modernity/technology
Second-class citizens
War-torn country in Africa; adapt to lifeways in America
What do American HCP need to Know about
their Somali-Bantu patients?
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Customs:
– “mitia gosha”: cutting, burning, herbal remedies of
the area
– “ma jini”
– These practices diminishing, but are important
aspects of healing in the past
– Female needs female HCP
– Birth control generally acceptable
– Tradition of female circumcision for reasons of health,
tradition, womanhood
What do American HCP need to Know about
their Somali-Bantu patients?
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Religion:
– Part of the animist beliefs underneath the
overlay of Islam is the spiritual practices of
“ma jini”
– Islam and medical care:
 Ritual month of fasting (Ramadan) impacts normal
schedule of work, family life.
 health of nursing mothers, young or old, people
following medical treatment.
What are the characteristics of a
good/helpful HCP?
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General:
– Want HCP that genuinely listens to them.
– Helpful to have HCP explain and teach.
– Want HCP who is patient and kind.
– 6/8 said waiting too long in the waiting room is
common and discourages future visits (interesting
interpretations of reasons for the wait).
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Specific:
– Need HCP to recognize that they are different.
– The nurse is the most important one in the office.
Implications for Healthcare delivery
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For Nursing/medical Practice:
– Build on the women’s statements of the import of
personal and environmental cleanliness, especially as
it pertains to their medical condition.
– Recommend methods and products for cleaning self
and home.
– When speaking with Somali-Bantu, the HCP cannot
assume the same frame of reference: must start with
the very basics of A&P etc.
– Written instructions are not helpful. For care
instructions and teaching, need creative ways to
prompt memory, eg, use pictures where possible.
Implications for Healthcare delivery
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For nursing/medical practice:
– Besides their own condition, the Somali-Bantu patient needs
instruction about the basics of the healthcare system, OTC
meds, self care and informed consent
– HCP may need to negotiate a treatment plan that fits their
cultural values (eg knee surgery)
Working towards having a method of obtaining
quality interpretation services would vastly improve trust
in relationship and patient care outcomes
Nurses are in an excellent position to give education to
the patients about preventative health care. Making
appointments for such screenings when they come in for
appointments for other reasons.
Implications for healthcare delivery
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Reality of supernatural forces, both positive and
negative, are part of the health/illness worldview
of the Somali-Bantu. This may obfuscate medical
diagnosis and treatment.
Implications for Healthcare delivery
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Nursing/healthcare Administration:
– Provide in-service training on cultural competence for
staff and HCP.
– Develop patient education programs and materials
relevant for, and at an appropriate level for the
Somali-Bantu and other immigrant groups.
– Find funding streams for the development and
retention of appropriate translators who are able to
communicate in Kzigua.
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Rationale for these actions
Implications for Healthcare delivery
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Nursing/medical education:
– Nursing and medical students need, as a part of their
curriculum and coursework, to be educated about
how to become culturally competent.
– Curricula should include skills by which to do a
cultural assessment of a patient, and learning to find
reliable resources to learn more about their specific
area of interest.
– Important at the undergrad and graduate level.
– Research continues to be needed in this area.
Closing Comments
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Small sample size
– Saturation reached in responses to the scope
of study questions
– Results not broadly generalizable
– Some other confirmatory results
Closing comments
(continued)
In the words of one participant,
“I agree.. It is true that it is important to
tell the American doctor and nurse about
all our situation, our culture, everything.
We appreciate that you made it and you
are giving us interview and to learn about
our culture. I appreciate that. It is very
important to us, and Thank you.”

Special Thanks to
Hamadi Mokoma and Isha Mberwa
References
American Nurses Association, ANA Position statements, Ethics and Human Rights
Position Statements: Cultural diversity in nursing practice (1991). Retrieved October
18, 2006. http://www.nursingworld.org/readroom/position/ethics/etcldv.htm
American Nurse’s Association (2005). Silver Spring, MD. ANA’s Health care agenda 2005.
Retrieved December 4, 2007 at
http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/HS/H
ealthcareAgenda.aspx.
Brouwer, K.C., Rodwell, T. (2007) Assessment of community member attitudes towards
health needs of refugees in San Diego. International Health & Cross-Cultural Medical
department at University of California, San Diego, and Count of San Diego Health
and Human Services agency (CSDHHSA). Received November 8, 2007 from
CSDHHSA.
References
(continued)
Carroll, J., Epstein, R., Fiscella, K., Volpe, E., Diaz, K., & Omar, S. (April,2007). Knowledg
and Beliefs about health promotion and preventative health care among Somali
women in the United States. Health Care for Women International, 28, 360-380.
Retrieved November 29, 2007, from MEDLINE database.
de la Cruz, O., Jumale, H., Krause, C., Madisa, H., Pan, A., (2008) Somali-Bantu
Community of San Diego health needs assessment findings. San Diego: SomaliBantu Community of San Diego.
Donnelly, P.L. (2000). Ethics and Cross-Cultural Nursing. Journal of Transcultural
Nursing,11 (2),119-126. Retrieved October 12, 2007 from Sage Publications.
References
(continued)
George, J. (2002). Theory of culture care diversity and universality: Madeline M.
Leininger. In J. George (Ed.), Nursing theories the base for professional nursing
practice (5th Ed). (pp.490-511). Upper Saddle River, New Jersey: Prentice Hall.
Institute of Medicine,(IOM) Committee on Quality Of health Care in America. (2001).
Crossing the quality chasm: A new health system for the twenty-first century.
Washington, D.C. National Academy Press.
Roter,D., & Makoul, G. (2000). Healthy People 2010 Objective 11-6 Healthcare
Providers Communication skills. Retreived October 31, 2007 from
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Roter, D. L., Rudd, R. E., & Comings, J. (1998). Patient Literacy A Barrier to Quality
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2007 from Blackwell-Synergy.
U.S. Department of State. Fact sheet, Bureau of Population, Refugees and Migration.
Washington, D.C. February 5, 2003. Somali-Bantu Refugees. Accessed October 15,
2007. http://www.state.gov/g/prm/rls/fs/2003/17270.htm
U.S. Department of Health and Human Services Offices of Disease Prevention and
Health Promotion (2000). Healthy People 2010.Health Communication, section 11.
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history and culture. Developed under agreement for the US Department of State,
published by the Center for Applied Linguistics.
Appendix: Interview Questions
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What does good health mean to you?
How do you stay strong and healthy?
What causes people to get sick?
What kind of health problems do Somali-Bantu women worry about?
What are the reasons that you go to the doctor?
Tell me about your care by American HCP
How can Am. HCP give better care to their Somali-Bantu patients?
Would you go to the doctor to find out if you had a disease hiding in
your body? “check-up”
Have you heard about TB? Have you heard about shots or
vaccinations, or immunizations? Have you heard about
hypertension?
What do you think Am. HCP need to know to improve
communication and understanding of their Somali-Bantu patients