Introduction
For many Somali seniors living in King County, Washington, daily life is sedentary and isolated. In 2021 Somali Health Board workers designed and implemented a culturally congruent health education and activity intervention aiming to improve the health of Somali seniors.
Between June 2021 and December 2022, we completed three cohorts of 20 participants each. Participants ranged in age from 51 to 91. Only four of the sixty participants were males. All were born in Somalia and spoke Somali as their primary language.
Each program consisted of 17 weeks of health education workshops, six support group meetings, a weekly exercise class, and a monthly home visit. All activities were conducted in Somali, without interpreters.
The launch of the program coincided with the onset of the Covid-19 pandemic. This necessitated adapting the program so that it could be delivered in-home. We distributed tablets, and home visitors trained participants to use them. Classes, support groups, and exercise sessions were conducted on Zoom.
FINDINGS: Pre/post knowledge surveys showed that participants reported increased knowledge in curriculum topic areas, more social connections, and increased physical activity. Overall, 32% reported improved confidence in their ability to manage their prescription medications. While the transition to virtual program delivery was a challenge, it also contributed to program successes, eliminating the difficulty of procuring transportation for these seniors. Additional work is needed to better recruit and retain male Somali seniors.
Abstract
For many Somali immigrant seniors living in King County, Washington, daily life is sedentary and isolated. In 2021 the Somali Health Board implemented a health education and activity intervention to improve seniors’ health. Somali American healthcare workers developed the Somali Senior Health Promotion program — a 23-week culturally congruent program. Due to the Covid-19 pandemic, we created a virtual classroom on Zoom, distributed tablets and trained the participants to use them. The program included 17 weeks of health education workshops, six support group meetings, a weekly exercise class, and a monthly home visit. We administered pre/post knowledge and activity surveys. Between June 2021 and December 2022, we completed three cohorts of 20 participants each. Participants ranged in age from 51 to 91; four of the sixty participants were males. All were born in Somalia and spoke Somali as their primary language. The pre/post knowledge surveys showed that participants reported increased knowledge in curriculum topic areas, social connections, and physical activity. Overall, 32% reported improved confidence in their ability to manage their prescription medications. A program of culturally congruent health information presented in Somali, combined with exercise sessions and home visits, resulted in positive behavior changes as reported by participating Somali elders. While the transition to virtual program delivery was a challenge, it also contributed to program successes. Additional work is needed to better recruit and retain male Somali seniors. Our program may serve as an example of how to design health promotion programming tailored to community and culture.
Background
In Somalia, before the civil war disrupted normal life, daily exercise, fresh food, and a robust social life supported healthy aging. Most Somali seniors haven’t been able to replicate those patterns in the decades since they began migrating to and settling in King County, Washington. In contrast, life in Seattle for many Somali seniors is isolated and sedentary. Familiar foods are hard to find, while less healthy, processed food is readily available. Many seniors do not feel safe walking outside or using public transportation. The experiences of war and separation have caused emotional wounds, and culturally congruent opportunities for healing those wounds are limited. There is misinformation and stigma concerning mental illness and bias against acknowledgement and treatment [1]. Paradoxically, chronic illnesses that may have shortened life spans in Somalia are now often long-term and poorly managed.
King County has been the site of extensive secondary migration for Somali refugees since they began coming to the U.S. after the outbreak of civil war in 1991. The US Census 2022 ACS 5-Year Survey (Table B04006) counted 14,997 Somali people in Washington state [2]. Even without precise local data, it was obvious to health care providers in the region that a large group of Somali migrants had acute and chronic medical issues without the language or cultural context to engage with existing health programs that were delivered in English. The Somali Health Board (SHB) was founded in 2012 to reduce health disparities that exist in King County’s Somali community. SHB has developed partnerships with key stakeholders in the community to advocate for pertinent research, systems and policy improvements, patient advocacy, and implementation of programs addressing mental health, motherhood, autism, and youth and community empowerment. However SHB recognized that significant needs of Somali seniors were not being met.
Conceptual Approach
In 2019 the SHB with support of a grant from King County Veterans, Seniors, and Human Services Levy [3] developed the Somali Senior Health Promotion Program (SSHPP) as an educational and experiential intervention for Somalis 55 years and older to address sedentary, isolated lifestyles and improve health. The aims of the program were to reduce social isolation, increase exercise, improve nutrition, improve chronic disease management including medication literacy, prevent falls, and reduce the stigma surrounding mental illness. The goal was to implement a culturally and linguistically congruent curriculum which maintained the cultural, religious, and social norms of the Somali senior community.
Methods
Program Development and Delivery
The SSHPP team consisted of nurses, a nurse practitioner, a public health worker, and caseworkers/cultural mediators. All were immigrants or children or grandchildren of immigrants and were fluent in English and Somali. They used feedback received from previous community engagements, and their experience working with the King County Somali community in clinical and professional settings, to develop this 23-week program delivered in Somali, by Somali health professionals.
Home visitors had public health degrees and experience working with seniors as Certified Nursing Assistants (CNAs). They spoke Somali and understood the traditions and culture of the seniors. They used a checklist to assess the health of the seniors and facilitated obtaining medical appointments. They also provided referral resources for assistance with food, utility, rent, and transportation.
The initial plan had been to recruit a cohort of 40 seniors and meet in a community center weekly. Once the Covid-19 pandemic interrupted normal community gatherings, the decision was made to transition to an online program. Cohort size was reduced to 20 individuals to allow for more intensive technical support. The program purchased each participant a tablet that worked with a cellular network, so that internet connectivity was not required. The team worked with participants both during individual home visits (following infection control standards of testing and masking) and via mobile phone until they were proficient in their tablet use.
Some participants requested a second exercise session during the week which was added. In addition, monthly home visits were conducted virtually or in person. Home visitors provided help with the use of technology in addition to implementing the health assessment checklist and offering resource support.
Recruitment
The initial recruitment process included posting flyers at Somali stores and mosques and on social media platforms. The requirements to participate were to be at least 55 years of age, willing to learn to use tablet technology, and willing to participate in once weekly sessions over 23 weeks.
Evaluation
For each cohort, the team administered pre/post knowledge surveys that were specific to the health education workshop topics, the support groups, and the exercise programs. None of the program participants were fluent in English and only a few of the participants could read Somali. Thus, the pre- and post-surveys were completed through interviews during home visits or over the phone.
Exemption from human subject research 45CFR46.106 (2)(i)
This program was not developed or delivered for research purposes, and program participants were not participating in research. Information generated by the program and included here was part of routine program administration and data collection. Assessment of this administrative data meets the exemption for program evaluation. This project included only interactions involving survey and interview procedures, and the information obtained was recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained, directly or through identifiers linked to the subjects.
Results
From June 2021 to December 2022, three SSHP cohorts completed the program. As noted, before the program could be implemented the Covid-19 Pandemic began, and we had to revise the implementation methods in order to address community infection control standards. SSHP’s first cohort was launched in June 2021 with 20 Somali seniors, four males and 16 females. The second and third cohorts each had 20 female participants. The majority of participants in the first cohort learned about the program by word of mouth, from friends and family members, and after the first cohort, from previous participants. Participant ages ranged from 51 to 91 years. All the seniors participating in the program were born in Somalia and spoke Somali as their primary language. The table summarizes participant demographic characteristics.
Discussion
The health and social needs of senior immigrants in the U.S. are well known [4,5,6]. To our knowledge this is the first documentation of using personal technology along with established principles of addressing low English proficiency and low health literacy with this population to decrease social isolation and improve health behaviors. This intervention occurred during a pandemic that had the opposite impact on most seniors in the U.S., immigrant or native born, who experienced increased social isolation, decreased physical activity, and diminished healthy behaviors. Program cohorts retained more than 75% of their enrollees. The program became widely known in the Somali community, and currently SHB is working with the seventh cohort. We learned after pandemic restrictions were lifted that the participants did not want to start meeting in community centers as had been originally planned. Thus, the implementation continues with tablets, Zoom©, and home visits.
One limitation of the program was the small engagement of Somali senior men. Older females out-number older men in health promotion programs and this is true regardless of older men’s culture or beliefs [7]. Future work needs to assess the different needs of males in this community. This might mean having older Somali men being part of the program planning, meeting them where they are at mosques and tea shops, and/or the program being implemented by men. Another limitation was that, although the intervention contained a module on mental health issues, no pre-post questions were included to evaluate changes in attitude or use of services. Finally, the outcomes were primarily participant self-report; this limitation was addressed in part by utilizing validated measures in the pre/post surveys. Future evaluations could include objective measures and staff observations on multiple aspects of the program.
Conclusion
Somali seniors struggle to maintain active, healthy and social lifestyles after emigrating to the United States. Developing a culturally congruent health promotion program delivered in Somali by Somali health care providers resulted in positive impacts on participant-reported health behaviors including social engagement and physical activity. This is particularly striking because this program began while COVID-19 pandemic precautions were still in place and many older adults in the United States were experiencing increased social isolation and sedentary time. This approach may provide a model for developing health promotion programming for other immigrant communities.
Across the three cohorts, 32% reported improved confidence and ability to manage prescription medications. Regarding fall prevention, 75% of participants reported improved confidence in five fall-related domains: I know how [1] to get up if I fall; [2] to reduce falls; [3] to protect myself if I fall; [4] to increase my physical strength; and [5] to be steady on my feet. Finally, each of the three cohorts had more than 80% of participants attending at least 75% of the sessions.
In the pre/post knowledge surveys participants reported increased knowledge and/or experience in all six aims, including reduced social isolation, increased exercise, improved nutrition, improved chronic disease management including medication literacy, knowledge about preventing falls, and reduced stigma surrounding mental illness.
Across the three cohorts 80% of participants reported increased weekly social interactions. Regarding exercise sessions, 42% of participants reported this program was the first exercise class they had ever taken. Seventy-five percent (75%) of participants increased the number of times they walk per week, with an average increase of 1.4 times, and 85% of participants reported increasing their overall weekly physical activity from baseline to follow-up (Figure). Ninety-three percent (93%) reported eating fruits and vegetables daily; for 43% of participants, this was an improvement from the start of the program.
References
1. Mölsä, M., Punamäki, R. L., Saarni, S. I., Tiilikainen, M., Kuittinen, S., & Honkasalo, M. L. Mental and somatic health and pre-and post-migration factors among older Somali refugees in Finland. Transcultural psychiatry. 2014;1363461514526630.
2. https://worldpopulationreview.com/state-rankings/somali-population-by-state, last referenced 2.25.2024.
3. https://kingcounty.gov/en/legacy/depts/community-human-services/initiatives/levy, last referenced 4.28.2024.
4. Venters, H., Gany, F. African Immigrant Health. J Immigrant Minority Health. 2011;13,333–344. https://doi.org/10.1007/s10903-009-9243-x.
5. Pavlish, C. Noor, S, Brandt, J. Somali immigrant women and the American health care system: Discordant beliefs, divergent expectations, and silent worries. 2010. Soc Sci Med. 2010;71(2): 353–361. doi:10.1016/j.socscimed.2010.04.010.
6. Mohamed, A.A., Shah, V., Njeru, J.W. et al. Interventions to increase cancer screening adherence among Somali immigrants in the US and Europe: A systematic review. J Immigrant Minority Health. 2024; 26, 385–394. https://doi.org/10.1007/s10903-023-01532-y.
7. Howell BM, Peterson JR, Corbett S. Where Are All the Men? A Qualitative Review of the Barriers, Facilitators, and Recommendations to Older Male Participation in Health Promotion Interventions. American Journal of Health Promotion. 2023;37(3):386-400. doi:10.1177/08901171221123053.