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Common health equity issues for Somali populations
Cultural competence is the ability to recognize and understand the role culture plays in health care and to adapt care strategies to meet patient needs.
Get to know patients on an individual level. Each person’s preferences, practices, and health outcomes are shaped by many factors. Generalizations in this material may not apply to your patients.
Minnesota’s largest Somali communities are in Minneapolis, Faribault, Rochester, St. Cloud, and Wilmar.
Somalis in Minnesota
An estimated 74,000 Somali live in Minnesota, according to the U.S. Census Bureau (2017)—37 percent were born in the U.S. Minneapolis is said to have the largest Somali population of any city outside Somalia; its Cedar Riverside neighborhood is referred to as “Little Mogadishu” by many Somalis, because Mogadishu is the capital of Somalia.
Somalia is a country on the most eastern tip of Africa. Large numbers of Somalis began arriving in Minnesota in 1992. Most were refugees or immigrants escaping the Somali civil war. This war displaced at least 1.5 million Somalis worldwide.
About half of the Somali-language speakers in a 2017 U.S. Census Bureau survey indicated they speak English very well. Conflicts between Somali clans can impact Somali patient trust in paid interpreters from opposing clans and can negatively impact perceptions of paid interpreters overall.
Disaggregated data on African populations is often not available. Data on African Americans in general may not apply to Somali Minnesotans. Some health issues could be biologically tied to race; many are tied to social inequities, including poverty. Performance results on Minnesota quality measures in 2016-2017 indicate that:
Social determinant disparities
Social determinants of health are economic and social conditions that influence the health of people and communities. Somali people often experience race or ethnicity discrimination, which may impact housing, employment, legal status, and suffering from violence and bullying. Dealing with discrimination is associated with higher reported stress and poorer reported health.
More data on social determinants for Somalis.
Many aspects of Somali-Minnesotan culture today reflect the culture of the general U.S. population. Generational differences impact social practices.
Family lineage and clan association are important concepts to Somalis. Many Somalis are able recite the names of ancestors going back many centuries. Somalia has five major clans and many minor and sub-clans. In the U.S., the importance of clans has diminished but clans are still vital social structures. Clans meet as groups, provide support to their members, and raise money for various causes. Conflicts exist between some clans, often as a result of current discrimination or past clan-based violence.
In traditional Somali culture, the family is most important institution. The status, reputation and well-being of the family is more important than the well-being or happiness of any individual. Family members are expected to support one another. Traditional Somali culture is patriarchal. Families are large and multi-generational, and children often live at home until they are married.
For some older, traditional Somalis, views of modesty require that direct eye contact be avoided between people of the opposite sex. Close physical proximity may be avoided as well. Standing three or four feet away from a member of the opposite sex is seen as respectful.
Of the Somali population, about 99 percent are Sunni Muslims.
Prayer, food, and gender practices have resulted in students being bullied in school.
Health Issues and Medical Care
As Somalis adopt an American lifestyle, changing activity, and eating habits, they are now at higher risk for heart disease than they were in 2001. Health issues prevalent among Somalis in Minnesota include:
Some Somalis may not want vaccines. People of Muslim faith can be reassured that vaccines which contain porcine gelatin, derived from pork products, have been approved as Halal, allowed according to Islamic teaching.
2017 Minnesota Measles Outbreak Cases
Somalis were at increased risk of contracting measles due to lower vaccination rates. Misinformation about autism resulted in a large decline in the number of Somali children who had received the measles, mumps, and rubella (MMR) vaccine, dropping from 90 percent vaccinated in 2006 to 42 percent in 2016. During the 2017 measles outbreak, health organizations increased outreach efforts to the Somali community. Parental concerns were addressed by building trust with the community and identifying effective, culturally appropriate ways to address questions, concerns, and misinformation about MMR vaccine.
Female genital cutting (FGC) has been a topic of concern among Somali Minnesotans. FGC is illegal in the U.S. and has become rare among Somali women born in the U.S. The practice is still common in Somalia, and many Somali women have undergone it. Clinicians who see Somali women may want to research evidenced-based best practices for care.
Among many traditional Somalis, modesty dictates that, whenever possible, a patient is seen by a clinician of the same sex. If a male clinician is treating a woman, it is desirable to have a woman present in the exam. Clinicians should limit requests to remove clothing and should ask permission of a patient more than may be typical. Some older, traditional women may avoid eye contact out of a sense of modesty, and not because they don’t respect or aren’t listening to the clinician.
Traditional Somali food includes rice, pasta, and meat. A banana is served with most meals. Most Somali Muslims don’t eat pork or drink alcohol. For observant Muslims, all meat must be halal, or slaughtered according to Islamic laws. Most Somalis observe Ramadan (the Muslim holy month) by fasting from sunrise until sunset. For the observant, even a sip of water during daylight would be a break in the fast. Pregnant, breastfeeding, and menstruating women, in addition to children, elderly, and people with illnesses are exempt from fasting during this holy month.
Many acculturated immigrants replace traditional meals with fast food, contributing to an increase in obesity, diabetes, and hypertension.
War and ongoing violence in Somalia, along with experiences in refugee camps, have exposed many Somalis to trauma, including torture, imprisonment, loss of family members to violence, and beyond. As a result, post-traumatic stress disorder (PTSD), depression, and anxiety are common in the Somali refugee population. Many Somalis have a very different concept of mental health than Americans. A report on Somali mental health found evidence of stigma and negative associations with admitting to mental health problems and seeking treatment for mental health problems. Words Somalis associated with the term “mental health” included “crazy” and “unstable.” Older immigrants are less likely to have English skills which may increase the loneliness, isolation, and depression already caused by discrimination, torture, and loss of homeland.
End of life
When discussing end of life issues with any patient, health care providers need to understand preferences based on personal and family views. Islam is clear that suicide or active euthanasia, even to alleviate suffering, is not permitted. Autopsy is not permitted in Somali culture. Palliative care is permitted and encouraged. Life sustaining technology may be withdrawn for brain death and persistent vegetative state. Advanced directives are encouraged, since they can play a valuable role in helping the family of a terminally-ill person make decisions about care.
Many Somalis will prefer a care plan for the terminally ill that allows the patient to remain at home, rather than in a long-term care facility. Somalis tend to place a high value on caring for family members and being able to perform Islamic prayers without difficulty.
* The federal poverty threshold in 2014 for a family with two parents and two children was about $24,000 annually.
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