Case Study: Somali Health in Seattle
In November 2014, the Somali Health Board of Seattle surveyed 141 Somalis in Washington State at a community health fair. The participants’ ages ranged from 18 to 78 and 94% of the respondents were born in Somalia. Since the health fair attracted people interested in preventative screenings and 84% of the survey participants had health insurance, the results of this survey may not accurately reflect the Somali community as a whole.
In regards to health service access, there were no significant differences between the responses of men and women. Overall, 81% of the participants stated they had a doctor that accepted their medical insurance and 79% stated that travel to the doctor’s office was easy. When asked about interpretation services, 83% reported receiving interpretation all or most of the time. The area where there was a distinct difference between men and women was in their diagnoses. A higher number of men reported having high blood pressure than women (20% v.5%) and with high blood pressure (14% v. 9%).
In March 2015, EthnoMed conducted a survey to determine health provider’s perceptions of health and health disparities in the Somali community in Seattle. In total, 21 Seattle-based health providers completed surveys. More than half of the providers who participated in the survey were physicians (56%), the remainder consisted of nurses, interpreters and social workers. These providers expressed concern for Somali health and health disparities within the community.
In regards to Somali health, care providers expressed more concern than the community in the surveys. In the provider surveys, 83% stated that they had concerns about health in the Somali community. In the health fair survey, 68% of Somalis stated that they had concerns about their health and reported a limited number of diagnosed conditions. The top five self-reported diagnoses in the Somali community (in order) were high blood pressure, diabetes, high cholesterol, heartburn and arthritis. The top five diagnoses that doctors reported were diabetes, depression, post-traumatic stress disorder, h. pylori and obesity. The table below demonstrates the difference between patient and provider perceptions. PTSD and h. pylori that providers reported have been left out of this table because these two diagnoses were not reported at all in the Somali community survey.
Approximately 80% of the providers we surveyed stated that their Somali patients had health disparities that concerned them. Since there were no specific questions on health disparities in the Somali community survey, below is a table that compares Seattle health providers’ perceptions of Somali health disparities, compared to disparities found in literature.
Health Disparities
In Somalia
Somalis are at high risk for health problems from infectious diseases and nutritional deficiencies while in Africa and when returning to Africa to visit relatives. The most prevalent infectious diseases in refugees and migrants from East Africa are diarrheal illness/parasitic infections, tuberculosis, cavities, anemia, eosinophilia, malaria and measles.
In the US
Upon arrival in the United States, Somalis are at higher risk for developing non-infectious diseases. The most prevalent of these diseases are diabetes, high blood pressure, high cholesterol and mental health diagnoses.
Diabetes
While there isn’t significant research on the prevalence of diabetes in Somalis after they have resettled in the United States, research on refugees in general has indicated that this group has an increased likelihood of developing diabetes. In a 2014 study, 15.2% of newly arrived Somalis in the U.S. already had diabetes. This already is higher than the U.S. national average, which is 9.3% of the American population. Since there is a strong association between the number of primary care appointments and successful diabetes management, it is critical to ensure that Somali patients with diabetes come in for regular medical appointments. For a more thorough review of Diabetes in Somalis and approaches to support patients, please see EthnoMed’s Diabetes in the Somali Community.
High Cholesterol and High Blood Pressure
In the Somali Health Board survey, 17% of participants reported having high cholesterol and 38% reported having high blood pressure. There is, however, scant peer reviewed literature on these two diseases. Several studies indicate that Somalis walk less and consume more processed and high fat foods after settling in the U.S. A lack of nutritious food and a sedentary lifestyle lead to an increased risk of diabetes, high blood pressure and high cholesterol. See resources for treating Somali patients with high cholesterol and improving nutrition on EthnoMed’s Hyperlipidemia page.
Mental Health Diagnoses
There is a high prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) in the Somali community. Refugees from Somalia have likely experienced traumatic events, such as forced displacement, violence and torture. A further complication is the stigma around mental illness within the Somali community, which may prevent Somalis from seeking treatment. Two community-based participatory research studies conducted in two different areas in the United States determined that it is customary to remain silent about mental illness in the Somali community. Other studies indicate that mental illness may be described with somatic symptoms during appointments with health providers. For more on mental health in the Somali Community, please go to Somali Mental Health.
Relaxation techniques familiar to Somalis such as reading the Qur’an at sunrise and sunset or before bed, deep breathing and massage may be effective complimentary treatments for anxiety and depression. Traditionally, Somali women use massage for relief of physical pain and stress. Daryel is an exercise, massage-therapy and social support group for Somali women in Seattle to help meet this need. Read more about this group in an article published in the Seattle Times.
Other Health Problems in Literature
Obesity
Ethnic minorities and people living on lower incomes in general are at greater risk of becoming obese compared to the general US population. There is little research on this topic in the Somali community, however, it is a concern that both Somalis and providers had in the Seattle-based surveys. For Somalis, meat is a staple in the Somali diet. Somali immigrants prioritize purchasing meat and therefore have less money to purchase other items, for example, cheaper processed pastas and starches may be purchased in place of fruits and vegetables. Diets heavy in meat protein and processed foods with little fruit and vegetables are associated with obesity. In addition, children who are overweight or obese are also at risk for being obese as adults.
Autism Spectrum Disorder (ASD)
There is a small body of research indicating higher rates of Autism Spectrum Disorder in Somalis. Anecdotally, ASD is perceived as being so prevalent that Somali immigrants in the Minneapolis area refer to ASD as the “American Disease.” The same phenomenon appears to be occurring in Sweden. A research study indicated that the prevalence of ASD in Somali children was four to five times higher than children of other ethnicities in Swedish special education classrooms. American physicians diagnose ASD in children who are ethnic minorities much later than white children. Early childhood screenings are critical to ensure appropriate interventions and therapies for Somali children. For more on developmental screenings in the immigrant and refugee population, see Developmental Screening with Recent Immigrant and Refugee Children: A Preliminary Report.
Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV)
HBV and HCV are a growing health concern in the Somali population. The Mayo Clinic reported that 4% of Somalis in a test group had chronic HBV infection, while 33.3% were HBV-exposed, but their body cleared the infection on its own. In this same group, 9% of the participants tested positive for HCV. In another study, 17% of Somalis newly diagnosed with HCV declined treatment. The fear of bad medication side effects and liver biopsy procedures were the two top barriers to Somali patients receiving treatment. For these reasons, researchers recommended exploring interferon-free treatment options and noninvasive methods to determine the health of the liver in Somali patients with HBV or HCV.
Human Immunodeficiency Virus (HIV)
There has been little research to determine HIV prevalence in Somalia or the Somali community in the United States. The most recent prevalence data from 2004 indicates that 1% of the Somali population was infected with HIV. This is relatively low compared to other East African nations. Nevertheless, the incidence is slowly rising in East Africa, especially in refugee camps and urban areas. There is a strong stigma around HIV/AIDS in Somalia and discrimination against people living with HIV/AIDS is common. In addition, discussion of sexual health is taboo and there may be limited knowledge on how infections are spread.
Approaches
Use an Interpreter. There is a strong association between completed preventative services and screenings when health providers used an interpreter, even if the provider believes the patient does not need one.
Identify Bantu patients and provide them with a Bantu interpreter. Due to political history in Somalia this ethnic minority has a lower literacy rate than their Somali counterparts. They also may feel uncomfortable being candid in the presence of a non-Bantu Somali interpreter. For more support, please see our page on Somali Bantus.
Incorporate spirituality into the treatment plan. The Qur’an and prayer are central to healing and recovery from illness in Somalia. Somalis sometimes use Qur’anic readers, who are individuals from the community that read passages of the Qur’an to the sick. In the U.S., a Qur’anic reader would provide support and comfort in conjunction with Western therapies. Incorporating spirituality into a medical treatment plan provides a frame of reference for the patient and increases adherence when the religious community is in support of medical treatment. If at all possible, coordinate with the patient’s Imam or Qur’anic readers from the community. Religion and community are central to Somali life and healing.
Provide community health workers. Counseling, advocacy and continuing education in a refugee’s native language are critical to good health outcomes. Trained health workers from the Somali community could provide clinic orientations, outreach and explanations of concepts in preventative health. In a Minnesota study, Somali women reported that they had a hard time understanding all the steps necessary to complete screenings, manage a chronic illness or prevent an illness. Not only could community health workers help patients navigate these steps, but they can also connect to people in the community who are not seeking help with appropriate resources or providers.
Incorporate mental health screenings into primary care whenever possible. Several studies indicate that post-traumatic stress disorder, anxiety and depression are common within the Somali community due to the extensive history of violence in Somalia. Somali patients may report somatic complaints which indicate an underlying mental illness. Primary care visits for these somatic complaints are a good time to conduct mental illness screening alongside other tests. It is critical to have a culturally appropriate interventions in place to support someone if they are struggling to cope. For more on mental health in the Somali Community, please go to Somali Mental Health.
Place African Americans and African immigrants in separate groups during research. There are commonalities among these two groups, such as challenges in access to affordable health care and racial bias in clinical decision-making. However, Somalis and other African immigrants face the additional challenges of adapting to a new culture, losing social identity, learning an entirely different societal and medical system and adjusting to different definitions of illness.
Conduct more screenings. In a retrospective chart review, the completion of mammographies, colorectal cancer screening and pap smears were significantly lower in Somalis when compared to non-Somali patients. Researchers from another study urged health professionals working with East African clients to provide ongoing testing and treatment for tuberculosis (TB), Hepatitis B, Schistosomiasis and Strongyloides due to the long latency periods in these diseases. Over 50% of tuberculosis infections occur more than two years after a Somali’s immigration. This is especially important since TB control in refugee camps is poor. Please refer to the Somali Tuberculosis Cultural Profile for further information.
Screen Somalis when they return from visits to Somalia. When a refugee or immigrant returns to Somalia to visit, they are at risk of acquiring communicable disease s such as cholera, malaria, dengue fever, TB and Hepatitis B. Health providers should explain the risks and prophylaxis to the patient before they leave when possible. Please refer to the travel-counseling page for more information.
References:
The World Health Organization Donor Information Web site. Somalia page. http://www.who.int/hac/about/donorinfo/somalia.pdf Published 2004. Accessed March 14, 2015.
Barnett ED, Weld LH, McCarthy AE, et al. Spectrum of Illness in International Migrants Seen at GeoSentinel Clinics in 1997–2009, Part 1: US-Bound Migrants Evaluated by Comprehensive Protocol-Based Health Assessment. Clinical Infectious Diseases. 2013; 56(7): 913-924.
Redko C, Rogers N, Bule L, Siad H, Choh A. Development and validation of the Somali WHOQOL-BREF among refugees living in the USA. Quality of Life Research. 2014; 1-11.
Wieland ML, Morrison TB, Cha SS, Rahman AS, Chaudhry R. Diabetes care among Somali immigrants and refugees. Journal of community health. 2012; 37(3): 680-684.
Redko C, Rogers N, Bule L, Siad H, Choh A. Development and validation of the Somali WHOQOL-BREF among refugees living in the USA. Quality of Life Research. 2014; 1-11.
Centers for Disease Control FastStats Homepage. http://www.cdc.gov/nchs/fastats/diabetes.htm. Published January 9, 2014. Accessed February 22, 2015.
Wieland ML, Morrison TB, Cha SS, Rahman AS, Chaudhry R. Diabetes care among Somali immigrants and refugees. Journal of community health. 2012; 37(3): 680-684.
Filippi MK, Faseru B, Baird M, Ndikum-Moffor F, Greiner KA, Daley CM. A pilot study of health priorities of somalis living in kansas city: laying the groundwork for CBPR. J of Imm and Min Health. 2014; 16(2):314-320.
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Hauck F, Corr K, Lewis S, Oliver N. Health and Health care of African Refugees: An Underrecognized Minority. Journal of the National Medical Association. 2012; 104 (1&2):61-71.
Dharod JM, Croom, JE, Sady, CG. Food insecurity: its relationship to dietary intake and body weight among Somali refugee women in the United States. Journal of nutrition education and behavior. 2013; 45(1): 47-53.
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[Giama NH, Shire A, Shaleh HM, Mohamed EA, Roberts LR. Community-wide outreach and screening to reduce hepatitis B and hepatitis C disparities among Somali immigrants in Minnesota. Hepatology 2014; 60; 960A-960A.
Connor E, Ndzengue A, Giama NH, Menk J, Mohamed EA, Elwir, et al. Fear of a liver biopsy is the primary barrier leading to disparities in the treatment and outcomes of hepatitis C in Somali patients in Minnesota. Hepatology 2014; 60: 925A-925A.
UNAIDS. Mogadishu – HIV in a time of unrest. http://www.unaids.org/en/resources/presscentre/featurestories/2012/july/20120726mogadishu Published July 2012. Accessed February 25, 2015.
Schäferhoff M. External Actors and the Provision of Public Health Services in Somalia. Governance. 2014; 27(4): 675-695.
Morrison T, Wieland ML, Cha SS, Rahman AS, Chaudhry R. Disparities in preventive health services among Somali immigrants and refugees. Journal of Immigrant and Minority Health. 2012; 14 (6): 968-974.
Springer PJ, Black M, Martz K, Deckys C, Soelberg T. Somali Bantu refugees in southwest Idaho: assessment using participatory research. Advances in Nursing Science. 2010; 33(2): 170-181.
Pavlish CL, Noor S, Brandt J. Somali immigrant women and the American health care system: Discordant beliefs, divergent expectations, and silent worries. Social Science & Medicine. 2010; 71(2): 353-361.
Filippi MK, Faseru B, Baird M, Ndikum-Moffor F, Greiner KA, Daley CM. A Pilot Study of Health Priorities of Somalis Living in Kansas City: Laying the Groundwork for CBPR. Journal of Immigrant and Minority Health. 2014; 16(2): 314-320.
Wieland ML, Morrison TB, Cha SS, Rahman AS, Chaudhry R. Diabetes care among Somali immigrants and refugees. Journal of community health. 2012; 37(3): 680-684.
Pavlish CL, Noor S, Brandt J. Somali immigrant women and the American health care system: Discordant beliefs, divergent expectations, and silent worries. Social Science & Medicine. 2010; 71(2): 353-361.
Hauck F, Corr K, Lewis S, Oliver N. Health and Health care of African Refugees: An Underrecognized Minority. Journal of the National Medical Association. 2012; 104 (1&2):61-71.
Morrison T, Wieland ML, Cha SS, Rahman AS, Chaudhry R. Disparities in preventive health services among Somali immigrants and refugees. Journal of Immigrant and Minority Health. 2012; 14 (6): 968-974.
Barnett ED, Weld LH, McCarthy AE, et al. Spectrum of Illness in International Migrants Seen at GeoSentinel Clinics in 1997–2009, Part 1: US-Bound Migrants Evaluated by Comprehensive Protocol-Based Health Assessment. Clinical Infectious Diseases. 2013; 56(7): 913-924.
World Health Organization Somalia Situation Report August- October 2013. http://www.emro.who.int/images/stories/somalia/WHO_Somalia_Sit_Rep_Aug-Oct_Soft_Resolution.pdf Updated October 2013. Accessed February 15, 2015.
