Somali-Bantu Somali-Bantu Refugee Women’s Refugee Women’s Beliefs About Preventative Healthcare and Beliefs About Preventative Healthcare and

Experiences in Healthcare Settings in Experiences in Healthcare Settings in San Diego: San Diego:

Implications for Health Care DeliveryImplications for Health Care Delivery

Paula Lloyd, RN, MSN, CNSPaula Lloyd, RN, MSN, CNS

September 19, 2009September 19, 2009

A “grandmother” tells A “grandmother” tells “grandchildren” the story of “grandchildren” the story of

theirtheirSomali-Bantu origins….Somali-Bantu origins….

Where “we” came fromWhere “we” came from How “we” came to be in SomaliaHow “we” came to be in Somalia

BackgroundBackground

Captivity as slaves in Somalia Captivity as slaves in Somalia since late 18since late 18thth century century

Somalia colonized by the ItaliansSomalia colonized by the Italians Emancipation in 1930’sEmancipation in 1930’s Somali Bantu subject to attacks Somali Bantu subject to attacks

and harsh mistreatment by and harsh mistreatment by Italian colonialists, rogue slave Italian colonialists, rogue slave traders, bandits, government traders, bandits, government officials, civilian militia, and officials, civilian militia, and local warlords.local warlords.

Outbreak of civil war and collapse of the government 1991Outbreak of civil war and collapse of the government 1991 Somali people flee the countrySomali people flee the country Somali-Somali, Somali-Bantu, and other people groups flee Somali-Somali, Somali-Bantu, and other people groups flee

to refugee camps in Kenya (Kakuma, Dadaab, others)to refugee camps in Kenya (Kakuma, Dadaab, others)

2003, US and 2003, US and UNHCR agree UNHCR agree to resettle 12-to resettle 12-15,000 15,000 Somali Bantu Somali Bantu Refugees in Refugees in US citiesUS cities

Background Background (continued)(continued)

San Diego County Health and Human Services San Diego County Health and Human Services statistics report 9/17/07 states 1,238 refugees statistics report 9/17/07 states 1,238 refugees from Somalia between 2002 and 2006 .from Somalia between 2002 and 2006 .(report (report does not distinguish between Somali-Somali and Somali-Bantu)does not distinguish between Somali-Somali and Somali-Bantu)

Organization “Somali-Bantu Community of Organization “Somali-Bantu Community of San Diego” (established 2005) estimates 500 San Diego” (established 2005) estimates 500 Somali-Bantu adults in San Diego October Somali-Bantu adults in San Diego October 2007.2007.

Currently, many Somali-Bantu are leaving San Currently, many Somali-Bantu are leaving San Diego for other US cities to find jobs and Diego for other US cities to find jobs and cheaper housing.cheaper housing.

The Problem is…The Problem is… Though the Somali-Bantu share some common Though the Somali-Bantu share some common

problems with other refugee groups, they have problems with other refugee groups, they have unique history, beliefs and background that unique history, beliefs and background that influence their health, contributing to healthcare influence their health, contributing to healthcare disparities.disparities.

Communication impedance beyond language Communication impedance beyond language alone: related to divide in basic worldview, health alone: related to divide in basic worldview, health beliefs, health understanding, and health literacy.beliefs, health understanding, and health literacy.

Scant published research literature about the Scant published research literature about the health beliefs and experience of the Somali-Bantu.health beliefs and experience of the Somali-Bantu.

Therefore, research is needed to increase Therefore, research is needed to increase culturally relevant health communication, increase culturally relevant health communication, increase equity of care, and improve health care outcomes.equity of care, and improve health care outcomes.

Significance to medicine/nursingSignificance to medicine/nursing

The real challenge of providing safe, ethical, culturally The real challenge of providing safe, ethical, culturally congurent care to an increasingly diverse patient congurent care to an increasingly diverse patient population; each with their own criteria of health/illness, population; each with their own criteria of health/illness, when to seek care, and differing expectations for that care when to seek care, and differing expectations for that care (specifically a significant population of Somali-Bantu).(specifically a significant population of Somali-Bantu).

Culturally competent care improves communication and Culturally competent care improves communication and increases patient satisfaction, improves compliance and increases patient satisfaction, improves compliance and improves health outcomes improves health outcomes (IOM,2001; George,2002).(IOM,2001; George,2002).

Knowledge of patient’s worldview on health, and provision Knowledge of patient’s worldview on health, and provision of culturally relevant care is important for moral/ethical of culturally relevant care is important for moral/ethical reasons: autonomy, self determination, informed decision reasons: autonomy, self determination, informed decision making, beneficence, nursing code of ethics.making, beneficence, nursing code of ethics.

Purpose of the studyPurpose of the study

Explore the understanding and Explore the understanding and health beliefs of the Somali-Bantu health beliefs of the Somali-Bantu refugee women about preventative refugee women about preventative healthcare and their experience in healthcare and their experience in American healthcare settings to American healthcare settings to illumine their specific health beliefs illumine their specific health beliefs for health care professionals to for health care professionals to improve understanding and improve understanding and healthcare outcomes. healthcare outcomes.

MethodologyMethodology

LeiningerLeininger QualitativeQualitative

– Content AnalysisContent Analysis ““fracture” the data, finding relationships, fracture” the data, finding relationships,

themes, and reintegrate the themes in themes, and reintegrate the themes in relationship, conveying the results of the relationship, conveying the results of the findings in such a way to bring meaning and findings in such a way to bring meaning and understanding to the study phenomenon.understanding to the study phenomenon.

Rigor: credibility, dependability, Rigor: credibility, dependability, confirmability and transferability. Add to confirmability and transferability. Add to this, meaning in context and repatternancythis, meaning in context and repatternancy

Design ProcessDesign Process

Entrée to communityEntrée to community– Role of the eldersRole of the elders– FriendshipsFriendships

Key informantsKey informants Interpreter and translator processesInterpreter and translator processes Setting and SampleSetting and Sample

Setting and SampleSetting and Sample

Sample inclusion criteria:Sample inclusion criteria:– Over 18, born in Somalia and ethnic Bantu, Over 18, born in Somalia and ethnic Bantu,

experience in American healthcare, willing to experience in American healthcare, willing to share beliefs and experienceshare beliefs and experience

DemographicsDemographics– Age rangeAge range: : 21 yrs to 58 yrs.21 yrs to 58 yrs.

– Marital statusMarital status: : 1 widow, 2 divorced, 5 married1 widow, 2 divorced, 5 married

– ChildrenChildren: : all have living children, number range from 1 all have living children, number range from 1 to 7 kids. Widow had no living children- 5 babies died in to 7 kids. Widow had no living children- 5 babies died in infancyinfancy

– Years in refugee campYears in refugee camp: 7-15 years: 7-15 years

– Years in the US: Years in the US: all 5 years or lessall 5 years or less

A sample of the Semi-A sample of the Semi-structured Interview Questionsstructured Interview Questions

What does good health mean to you?What does good health mean to you? How do you stay strong and healthy?How do you stay strong and healthy? What causes people to get sick?What causes people to get sick? How can American HCP give better How can American HCP give better

care to their Somali-Bantu patients?care to their Somali-Bantu patients? What do you know about TB, What do you know about TB,

hypertension and immunizations?hypertension and immunizations?

So, what did the interviews So, what did the interviews reveal?reveal?

What is good health?What is good health?– Absence of sickness or painAbsence of sickness or pain– No cough or sickness, “you feel strong No cough or sickness, “you feel strong

and happy, not mad, and (health) and happy, not mad, and (health) means you don’t think a lot also.”means you don’t think a lot also.”

– Go to doctor and you get medicineGo to doctor and you get medicine– Allah gives health and illnessAllah gives health and illness

What causes illness?What causes illness?

Behavioral Causes:Behavioral Causes:– I don’t knowI don’t know– Poor personal hygiene and dirty living Poor personal hygiene and dirty living

environment (6)environment (6)– ““Thinking too much” (7)Thinking too much” (7)– Poor handwashing (1)Poor handwashing (1)– Smoking and drinking alcohol (3)Smoking and drinking alcohol (3)– Having sex with people not your spouse (2)Having sex with people not your spouse (2)– ““Working too hard” causes TB, hypertension Working too hard” causes TB, hypertension

and other diseases (3-common)and other diseases (3-common)– No food, or dirty food (6)No food, or dirty food (6)

What causes illness?What causes illness?

Spiritual CausesSpiritual Causes– Allah’s will- “we beg to Allah for health” Allah’s will- “we beg to Allah for health”

(4)(4)– ““majini” (3)majini” (3)– Name to big for child (2-common)Name to big for child (2-common)

Environmental CausesEnvironmental Causes– Public hygiene (2)Public hygiene (2)– No clean food and water (6)No clean food and water (6)– Some idea of contagion (4)Some idea of contagion (4)– Malaria (1), feverMalaria (1), fever

Beliefs about Preventative Beliefs about Preventative HealthcareHealthcare

Though the women worried about diseases such Though the women worried about diseases such as HIV, STDs, TB, to name a few, they said that as HIV, STDs, TB, to name a few, they said that they would not go to the doctor to find out if they they would not go to the doctor to find out if they had any of these diseases. had any of these diseases.

They would not go to the MD to do a test to find They would not go to the MD to do a test to find out if they had a disease, for disease prevention.out if they had a disease, for disease prevention.

Many women stated that they only go to the Many women stated that they only go to the doctor when they or their family is sick.doctor when they or their family is sick.

Will go for prenatal visits.Will go for prenatal visits. Will take their children for well visits to be sure Will take their children for well visits to be sure

that they are growing and developing.that they are growing and developing. Heavy reliance on doctor office and school Heavy reliance on doctor office and school

officials to tell them what to do, when to return, officials to tell them what to do, when to return, etc.etc.

Beliefs and Understanding Beliefs and Understanding about Tuberculosisabout Tuberculosis

Causation:Causation: – Heavy laborHeavy labor– Some understanding of the element of contagion from Some understanding of the element of contagion from

coughing or sharing eating utensils (so noted by 4/8 people)coughing or sharing eating utensils (so noted by 4/8 people)– Most participants stated they had heard about it, but have Most participants stated they had heard about it, but have

not had it and do not know.not had it and do not know. Symptoms:Symptoms:

– Coughing, chest pain, weight loss. One mentioned coughing Coughing, chest pain, weight loss. One mentioned coughing up blood.up blood.

Treatment:Treatment:– In Africa, prior to war, would isolate sick person in the jungle In Africa, prior to war, would isolate sick person in the jungle

where they would improve or die. Since war, must live where they would improve or die. Since war, must live together.together.

– In America, the women opine, people do not die of TB In America, the women opine, people do not die of TB because here there is medicine.because here there is medicine.

– One mentioned that she was asymptomatic with TB and One mentioned that she was asymptomatic with TB and received 6 months of treatment prior to coming to the US.received 6 months of treatment prior to coming to the US.

Beliefs and Understanding Beliefs and Understanding about hypertensionabout hypertension

““Most Somali-Bantu don’t know about it” (6)Most Somali-Bantu don’t know about it” (6) Causation:Causation:

– Most stated they had heard about it but do not Most stated they had heard about it but do not know much about it. know much about it.

– Hypertension comes from working very hard (3), Hypertension comes from working very hard (3), and thinking too much. (6)and thinking too much. (6)

Symptoms:Symptoms:– Headache, body feels like its burning, get angry, Headache, body feels like its burning, get angry,

dizzydizzy– ““Go to the doctor and he can tell you if you have Go to the doctor and he can tell you if you have

it.”it.”

Beliefs and Understanding Beliefs and Understanding about immunizationsabout immunizations

All had heard of and experienced All had heard of and experienced immunizations in preparation for trip to USA.immunizations in preparation for trip to USA.

Only half the interviewed women knew and Only half the interviewed women knew and verbalized that the purpose of the verbalized that the purpose of the immunizations was to protect against immunizations was to protect against disease disease (“to keep disease from coming to you”).(“to keep disease from coming to you”).

Will take the children for immunizations Will take the children for immunizations when prompted by the care providerwhen prompted by the care provider

Experience in American Experience in American healthcare settingshealthcare settings

Overall, healthcare experience has been Overall, healthcare experience has been positive, and women satisfied with their carepositive, and women satisfied with their care (though there have been situations producing patient (though there have been situations producing patient undue anxiety, and poor health outcomes).undue anxiety, and poor health outcomes).

All compare their experience here with total All compare their experience here with total lack of care in Africa.lack of care in Africa.

Will go to MD for prenatal care, birth control, or Will go to MD for prenatal care, birth control, or illness. Rarely for screenings/preventative care.illness. Rarely for screenings/preventative care.

Fear of hospitalizations, surgery, C-sections.Fear of hospitalizations, surgery, C-sections.

What do American Healthcare What do American Healthcare providers (HCP) need to know providers (HCP) need to know

about their Somali-Bantu patients?about their Somali-Bantu patients? General situation:General situation:

– Every participant stated that they are distinct Every participant stated that they are distinct from the Somali-Somali, speaking a different from the Somali-Somali, speaking a different language; appropriate translator is of prime language; appropriate translator is of prime importance for understanding.importance for understanding.

Their past influences their present worlview Their past influences their present worlview and adaptation: and adaptation:

Profound lack of basics for survivalProfound lack of basics for survival lack of any modernity/technologylack of any modernity/technology Second-class citizensSecond-class citizens War-torn country in Africa; adapt to lifeways in AmericaWar-torn country in Africa; adapt to lifeways in America

What do American HCP need to Know What do American HCP need to Know about their Somali-Bantu patients?about their Somali-Bantu patients?

Customs:Customs:– ““mitia gosha”: cutting, burning, herbal mitia gosha”: cutting, burning, herbal

remedies of the arearemedies of the area– ““ma jini”ma jini”– These practices diminishing, but are important These practices diminishing, but are important

aspects of healing in the pastaspects of healing in the past– Female needs female HCPFemale needs female HCP– Birth control generally acceptableBirth control generally acceptable– Tradition of female circumcision for reasons of Tradition of female circumcision for reasons of

health, tradition, womanhoodhealth, tradition, womanhood

What do American HCP need to Know What do American HCP need to Know about their Somali-Bantu patients?about their Somali-Bantu patients?

Religion:Religion:– Part of the animist beliefs underneath Part of the animist beliefs underneath

the overlay of Islam is the spiritual the overlay of Islam is the spiritual practices of “ma jini”practices of “ma jini”

– Islam and medical care:Islam and medical care: Ritual month of fasting (Ramadan) impacts Ritual month of fasting (Ramadan) impacts

normal schedule of work, family life.normal schedule of work, family life. health of nursing mothers, young or old, health of nursing mothers, young or old,

people following medical treatment.people following medical treatment.

What are the characteristics of What are the characteristics of a good/helpful HCP?a good/helpful HCP?

General:General:– Want HCP that genuinely listens to them.Want HCP that genuinely listens to them.– Helpful to have HCP explain and teach.Helpful to have HCP explain and teach.– Want HCP who is patient and kind.Want HCP who is patient and kind.– 6/8 said waiting too long in the waiting room is 6/8 said waiting too long in the waiting room is

common and discourages future visitscommon and discourages future visits (interesting interpretations of reasons for the wait).(interesting interpretations of reasons for the wait).

Specific:Specific:– Need HCP to recognize that they are different.Need HCP to recognize that they are different.– The nurse is the most important one in the The nurse is the most important one in the

office.office.

Implications for Healthcare Implications for Healthcare deliverydelivery

For Nursing/medical Practice:For Nursing/medical Practice:– Build on the women’s statements of the import of Build on the women’s statements of the import of

personal and environmental cleanliness, personal and environmental cleanliness, especially as it pertains to their medical condition.especially as it pertains to their medical condition.

– Recommend methods and products for cleaning Recommend methods and products for cleaning self and home.self and home.

– When speaking with Somali-Bantu, the HCP When speaking with Somali-Bantu, the HCP cannot assume the same frame of reference: must cannot assume the same frame of reference: must start with the very basics of A&P etc.start with the very basics of A&P etc.

– Written instructions are not helpful. For care Written instructions are not helpful. For care instructions and teaching, need creative ways to instructions and teaching, need creative ways to prompt memory, eg, use pictures where possible. prompt memory, eg, use pictures where possible.

Implications for Healthcare Implications for Healthcare deliverydelivery

For nursing/medical practice:For nursing/medical practice:– Besides their own condition, the Somali-Bantu patient Besides their own condition, the Somali-Bantu patient

needs instruction about the basics of the healthcare needs instruction about the basics of the healthcare system, OTC meds, self care and informed consentsystem, OTC meds, self care and informed consent

– HCP may need to negotiate a treatment plan that fits their HCP may need to negotiate a treatment plan that fits their cultural values (eg knee surgery)cultural values (eg knee surgery)

Working towards having a method of Working towards having a method of obtaining quality interpretation services would obtaining quality interpretation services would vastly improve trust in relationship and patient care vastly improve trust in relationship and patient care outcomesoutcomesNurses are in an excellent position to give education Nurses are in an excellent position to give education to the patients about preventative health care. to the patients about preventative health care. Making appointments for such screenings when Making appointments for such screenings when they come in for appointments for other reasons.they come in for appointments for other reasons.

Implications for healthcare Implications for healthcare deliverydelivery

Reality of supernatural forces, both Reality of supernatural forces, both positive and negative, are part of the positive and negative, are part of the health/illness worldview of the Somali-health/illness worldview of the Somali-Bantu. This may obfuscate medical Bantu. This may obfuscate medical diagnosis and treatment.diagnosis and treatment.

Implications for Healthcare Implications for Healthcare deliverydelivery

Nursing/healthcare Administration:Nursing/healthcare Administration:– Provide in-service training on cultural Provide in-service training on cultural

competence for staff and HCP.competence for staff and HCP.– Develop patient education programs and Develop patient education programs and

materials relevant for, and at an appropriate materials relevant for, and at an appropriate level for the Somali-Bantu and other immigrant level for the Somali-Bantu and other immigrant groups.groups.

– Find funding streams for the development and Find funding streams for the development and retention of appropriate translators who are retention of appropriate translators who are able to communicate in Kzigua.able to communicate in Kzigua.

Rationale for these actionsRationale for these actions

Implications for Healthcare Implications for Healthcare deliverydelivery

Nursing/medical education:Nursing/medical education:– Nursing and medical students need, as a part Nursing and medical students need, as a part

of their curriculum and coursework, to be of their curriculum and coursework, to be educated about how to become culturally educated about how to become culturally competent. competent.

– Curricula should include skills by which to do a Curricula should include skills by which to do a cultural assessment of a patient, and learning cultural assessment of a patient, and learning to find reliable resources to learn more about to find reliable resources to learn more about their specific area of interest.their specific area of interest.

– Important at the undergrad and graduate level.Important at the undergrad and graduate level.– Research continues to be needed in this area.Research continues to be needed in this area.

Closing CommentsClosing Comments

Small sample sizeSmall sample size– Saturation reached in responses to the Saturation reached in responses to the

scope of study questionsscope of study questions– Results not broadly generalizableResults not broadly generalizable– Some other confirmatory resultsSome other confirmatory results

Closing comments Closing comments (continued)(continued)

In the words of one participant, In the words of one participant,

“ “I agree.. It is true that it is important I agree.. It is true that it is important to tell the American doctor and nurse to tell the American doctor and nurse about all our situation, our culture, about all our situation, our culture, everything. We appreciate that you everything. We appreciate that you made it and you are giving us made it and you are giving us interview and to learn about our interview and to learn about our culture. I appreciate that. It is very culture. I appreciate that. It is very important to us, and Thank you.”important to us, and Thank you.”

Special Thanks to Special Thanks to Hamadi Mokoma and Isha Hamadi Mokoma and Isha

MberwaMberwa

ReferencesReferences

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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 References (continued)(continued)

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References References (continued)(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.

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Van Lehman, D., & Eno,O. (2003). Cultural Profile No. 16. The Somali-Bantu: Their history and culture. Developed under agreement for the US Department of State, published by the Center for Applied Linguistics.

Appendix: Interview Appendix: Interview QuestionsQuestions

What does good health mean to you?What does good health mean to you? How do you stay strong and healthy?How do you stay strong and healthy? What causes people to get sick?What causes people to get sick? What kind of health problems do Somali-Bantu women worry What kind of health problems do Somali-Bantu women worry

about?about? What are the reasons that you go to the doctor?What are the reasons that you go to the doctor? Tell me about your care by American HCPTell me about your care by American HCP How can Am. HCP give better care to their Somali-Bantu How can Am. HCP give better care to their Somali-Bantu

patients?patients? Would you go to the doctor to find out if you had a disease Would you go to the doctor to find out if you had a disease

hiding in your body? “check-up”hiding in your body? “check-up” Have you heard about TB? Have you heard about shots or Have you heard about TB? Have you heard about shots or

vaccinations, or immunizations? Have you heard about vaccinations, or immunizations? Have you heard about hypertension?hypertension?

What do you think Am. HCP need to know to improve What do you think Am. HCP need to know to improve communication and understanding of their Somali-Bantu communication and understanding of their Somali-Bantu patientspatients