By: Kortney, Jessica, Lisa, Logan, Shannon, and Tiffany
Somalia is a country on the east coast of Africa, part of what is known as the Horn of Africa. Agriculture is the most important sector of the economy, making up about 40% of the GDP. The Somali culture is one that has, and continues to, endure suffering and hardship. Government and rule are fought over and many Somali people have fled the country in escape from famine, drought, and opposed governmental rule. However, even those who have escaped greatly identify with the culture from which they originated, and maintain an even closer bond with those of their native clans.
85% of those living in Somalia are native Somalis. The last official population noted by the country’s census was over 9.8 million. The average life expectancy for a native Somali is about 50 years, give or take a year depending on gender. Much of the cause to such a short life span can be attributed to the country’s high risk of contracting an infectious disease, many of which are not treated to the extent they would be if accessible to modern Western medicine. Only 37.8% of the overall population is considered literate, which by definition means over the age of 15 and can read and write.
ii. History of the People The Somali are not the only native people to this land. The Somali Bantu share the same country, but have very different origins. Unlike their co-inhabitors, the Somali Bantu came into Somalia as slaves. In the 1800’s, Arab slave traders invaded southeast Africa and forced native Mozambique and native Malawi out of their resepctive regions and into Somalia to work for plantation owners there. Since then, the Somali Bantu have been considered an underclassman compared to the native Somali people and discriminated against. Many are often denied access to education, jobs, and land because of their differing culture and ancestory. Over the course of the last 50 years, much has transpired for both of these groups. In 1960, the country as a whole gained it’s independence from British and Italian control and became known as the modern-day Somalia. In 1969, Muhammad Siad Barre become President of the country and founded Barre’s Supreme Revolutionary Council as the sole political party of the country, and in the process did away with the country’s long standing constitution. Barre’s rule focused primarily of ridding the country of any ethnic segregation and tribalism, and thereby turning the country into a socialist state. In 1991, Barre was overthrown and a power struggle between clan warlords for the position of president broke out, killing thousands of civilians, and starting the country’s biggest Civil War. Thousands of refugees have since fled the country to places such as Kenya and even the United States, especially those targeted most often for attacks, the Somali Bantu.
Listed below are several various and common traditions and customs practiced by the Somali people, varying from diet preferences to greeting’s customs.
-Qat is a traditional stimulant used by Somalian men. It is a leaf that comes from the Catha edulis tree. The men will chew the leaves and it is thought that it will make thoughts sharper. In the U.S. this is a schedule 1 drug because there is a potential for abuse. -The traditional diet in Somalia is rice, bananas, and meat. The meat usually comes from sheep, goats, cattle, and camels. Because parts of Somalia used to be under Italian rule there are a lot of people who still eat a lot of pastas.
-Healing is a very traditional event. Illness is thought to be caused by the “evil eye. This evil eye is misfortune or illness caused by someone else wishing harm on another. A mother’s behavior while she is pregnant or the will of God will affect the health and birth of that baby. Illness is sometimes thought to come from the spirits that reside within an individual. If the spirit becomes upset it can result in a fever, headache, dizziness and weakness. There are rituals for healing. The people who perform these rituals learned them from older family members who once had the role of healing. Some rituals are applying a heated sick from certain tress to the skin, herbs, and different prayers, eating special foods, and burning incense.
-The right hand is considered clean. It is used for eating, writing, and greeting people. The left hand is not correct and it is rude to overuse it. Men and women do not touch members of the opposite gender outside of the family. Handshaking is only done man to man or woman to woman; never will a man shake a woman’s hand. Most of their social norms and etiquette originate from Islam.
-After a baby is born the mother and baby will say inside for 40 days, this is known as afatanbah. Only female relatives and friends visit and they will help take care of the new mother and baby. Special foods and teas will be prepared. During this time, the mother will wear earring made from string placed thought a clove of garlic. They baby will wear a bracelet made from sting and herbs to ward away the evil eye. Incense will be burned twice a day to protect the baby from ordinary smells; smells that would have potential to make them sick. After these 40 days there is a celebration. The baby will then be given a name.
Many Somali people are not overly concerced with the concept of being “on time”, and consider it not to be a sign of disrespect to waiver somewhat on a previously stated time of meeting. Often times, specific appointments including those to see a doctor are not kept as a result of this view, and opportunities are missed to speak with a health care provider. It is important then to reiterate the punctuality in these types of situations so it is understood the consequences of not maintaining pumctuality.
Somali people organize their time and activities according to the different seasons, time of day, and duties of Islam. The Somalis who live in the U.S. will still follow Islam but will adapt to many of the country’s norms.
v. Communication Style/Language
The most common language in Somalia is Somali with some regional variations. Arabic is the second most common langue because it is the language of Islam. Most Somalis are fluent in several languages. Their written language uses the Roman alphabet; however literacy rates are very low because it has only been since 1971 that their language was written. Traditionally, their language has been oral. Story telling is a very honorable and is considered an art. Most traditionally sorties, and political topics and discussions would be created into a poem which would then be delivered and told to numerous communities around the area and country. Singing, folk dancing, and the performance of plays are also traditional ways in which the Somali will communicate. When providing healthcare it is important to familiarize people from Somali with U.S. health care practices because they will not be used to the different procedures and concepts. When starting a health care plan both the mother and the father should be addressed if possible. It would be wise to repeat information during long procedures to help comfort and reassure the patient the new and sometimes frightful setting. When talking and explaining things to a patient, try to avoid figure gestures (such as thumbs up or pointing) because they can be seen as very rude.
vi. Relationships/Social Organization
Somalia’s social structure is founded around the family and clan. The clan a person is a part of depends on their father’s lineage. Families live in muli-generational homes. Men can have up to four wives. However, he has to be able to support all of the women equally. The father in the home traditionally makes the decisions and earns the money. If there is no father in the home, then that responsibility is passed on to an older male relative or to an adult son. Women have a strong influence in their families. Her main roles are to care for the children and cook the food. Large families are very common. Birth control practices are not really used. Traditionally, marriage is arranged. With most arranged marriages, the bride will usually be much younger than the groom. Marriage to a cousin from the mother’s side of the family (of a different lineage) is traditionally favored. This will strengthen family alliance. This practice is not as common as it used to be. Virginity is valued in women prior to marriage. It is becoming more common for people who choose who they want to marry but even these choices are influenced by the partner’s clan.
- 2003, September 25). Somali Culture and Medical Traditions 1. Retrieved March 28, 2010 retrieved from: http://www.mbali.info/doc326.htm
vii. Health Care
a. Is there a perceived discrimination problem?
When Somalian refugees come to America it is very difficult for them to find and be able to pay for health care, and when they do seek care it often isn’t the same experience that the average American born in the U.S. has. Language barriers in a health care setting can become a big issue for Somalians. A lot of clinics and hospitals do not provide translators for them, and often when there is a translator available they are not used. Sometimes a family member or friend will serve as an interpreter. Without a certified translator, the Somalian patients do not get a full understanding of the important information regarding their health care that is being expressed. Many Somalians, especially newer refugees, cannot afford private health insurance or are aided by the government. They are often refused of care because of this and have trouble finding clinics and hospitals that will accept them as a new patient.
In the article “Somali Women’s Birth Experiences in Canada after Female Genital Mutilation” there are interviews taken from Somali women living in Canada who have given birth in the past 5 years. In the interviews some of the questions regard their hospital stay and the treatment they received from doctors and nurses. The answers they give are appalling. When doing the exams the women reported the doctors as not being gentle even though the area was very sore. They reported the doctors as giving “expressions of surprise” both verbal and nonverbal when their perineum area was exposed. Nurses were even worse. They were said to treat the women as if they were lazy and even worse, they acted like they had no idea that postpartum pain would be worse with female circumcision. The doctors and nurses were discriminating the Somali women. They treated them as if they were guilty of being circumcised and did not give them the gentle care that they needed and deserved.
b. What are the biggest differences between the culture you are researching and the US culture?
According to the article “Knowledge and Beliefs About Health Promotion and Prevention About Health Care Among Somali Women in the United States,” several cultural similarities and differences exist between Somalis and Americans. Carroll et. al. interviewed 34 resettled Somali refugee women about their experience with the United States health care system. It was common for the Somali women to compare their health experiences in the United States with those experienced in Somali refugee camps. During the interviews, five themes emerged regarding the Somali beliefs of health care: (1) good sanitation, (2) adequate nutrition and exercise, (3) traditional remedies and rituals, (4) the role of religion, and (5) access to health care and medications.
Of the 34 Somali and Somali Bantu women interviewed, 71% believed that hand washing, home cleanliness, and the importance of washing food before meals were congruent with avoiding infection and staying healthy.
Adequate Nutrition and Exercise
Similar to American beliefs, Somalis believe that behaviors such as regular exercise, a balanced diet, access to health care and avoidance of alcohol and tobacco are congruent with a healthy lifestyle. However, it was noted that while some Somalis recognize the importance of regular exercise, they find it much more difficult to do on a daily basis when compared with life in Somalia. A woman’s life in Somalia is filled with hard, physical labor because the women are expected to manage the household chores and all food preparation. Life in the United States, however, is much more sedentary. An example of how relative lack of exercise can lead to a “new” problem of obesity among Somali women in the United States is highlighted by Participant 030, a 25-year-old English-speaking Somali woman:
“Most of the Somalis [women] don’t do much exercise [be]cause most of them stay home to take care of the kids. [It’s] a problem. It’s better [for doctors] to give them an idea where to go, a prescription to do the exercise. They like [exercise], but they don’t know where to go to do the exercise.”
In addition, 59% of women interviewed talked about the importance of eating a balanced diet including fresh fruits, vegetables, protein and dairy. A typical diet while living in Somalia consisted of three meals of ground corn soor, often topped with vegetables. In the United States, the Somali diet is quickly incorporating more high-sugar, high-carbohydrate options. The women discussed that while it was easier to obtain food while living in the United States than Somalia, there were more high-fat options that are quickly contributing to a new health problem for Somalis: obesity.
Traditional Remedies and Rituals
The Somali culture places high importance on traditional home remedies and healers to promote health and wellness. Healing ceremonies, prayer, herbs, botanicals, and traditional food are often used as preventative measures to ward off illness. According to participants, accessing the U.S. health care system is usually used as a last resort, after exhausting traditional Somali healing methods. A resulting theme among interviewees was that American health care providers should employ both Western medicine as well as traditional Somali healing methods to provide culturally competent care.
The Role of Religion
Health prevention is practiced primarily through prayer and living a life according to Islam. According to the study, 41% of participants modify their health behaviors based on their Islamic beliefs, which includes avoiding the use of tobacco and alcohol products because those behaviors are strictly forbidden in the Koran. Many Somalis believe that an individual cannot prevent illness, as the ultimate decision is in God’s hands. Somalis also often believe that mental illness is caused by spirit possession or as a punishment from God. Traditional spiritual healers use religious rituals for healing.
Access to Health Care and Medications
In comparison with Somali refugee camps, 97% of participants felt that the U.S. health care system was “better” in providing accessible medical care in terms of number of physicians, the plethora of available medications and treatment options, and affordability of health care with insurance. However, many Somali women do not access the U.S. health care system until they are very sick and have exhausted their cultural remedies. This is mainly due to fear of the unknown or lack of knowledge regarding Western medical practices.
“Some [Somali women] are afraid to go [to medical appointments]. They are afraid of what’s going to happen. They don’t know about health. Some of them know; some don’t know. Education is very important for a person to know different things.” (Participant 012, a 34-year-old English-speaking Somali woman).
The study identified a serious lack of knowledge regarding cancer screening and other preventative measures such as PAP testing and mammography. In addition, 74% of women did not understand or recognize the term “cancer” because there is not a synonymous term in the Somali language. However, 100% of participants stated understanding of the importance of immunizations.
Carroll and associates recognized that interventions to provide culturally competent care includes methods such as using female Somali health care workers to teach refugee women about the importance of cancer screenings, targeting Somali women in their homes via community networking groups, or using in-person discussions or media campaigns to reach women who are unable to read or understand English.
c. Identify health risks/high risk behaviors common to this culture.
Major medical conditions in Somalia and among recent immigrants to the US are malnutrition, iron deficiency anemia, Vitamin A deficiency, and scurvy. Common infectious diseases are diarrheal disease, measles, malaria, and acute respiratory illness. At least 47 percent of recent arrivals to the US are affected by intestinal parasites. In 1997, Somalia’s HIV infection rate was 0.25 percent—well below that of other African nations.
Female circumcision is a common practice in Somalia because it is considered a rite of passage and a requirement for marriage. As a health care provider, it is important to be familiar with the procedure and recognize that a female Somali patient will likely have had the procedure done if the patient was not born in the United States (where the procedure is illegal). According to the Culture Care Connection analysis of the large Somali population in Minnesota, studies show that female circumcision can create many health problems for women including chronic pain, urinary tract and chronic kidney infections, menstrual problems, and increased risks for complications during pregnancy. This procedure usually takes place around the age of four years old, although it can take place at birth or right before marriage. The procedure is usually done by an elderly woman in the community, but it is sometimes done by a midwife, nurse, or doctor. The tools used include a razor blade, scalpel, or a piece of glass among other things. After the procedure there is a hole that is supposedly big enough for urine and menstrual flow to pass through, although backup of urine and other bodily fluids occurs and results in the complications mentioned above.
· Use the right hand to give food or medications; the left hand is considered impolite.
· Ask permission before touching a patient to offer comfort.
· Provide a location and opportunities for prayer (at dawn, noon, mid-afternoon, sunset, and evening). Do not interrupt prayer. Somalis believe the divine is present during prayer.
· Consider changing medication schedules during Ramadan, when Somalis may be fasting during the day.
· Do not use finger gestures to get attention. It is viewed as disrespectful.
1. Role of the family: The husband or father is the head of the family. Somalis customarily live in a multi-generational household. The social structure of Somali families is changing as refugees immigrate to the United States because polygamy (a common practice in Somalia of taking more than one wife) is illegal in the United States.
2. Death and Dying: Somalis view dying as salvation and part of the life cycle. When a Somali person is terminally ill, it is considered uncaring for a health care provider to tell the dying person. The family tells the patient. When death is impending, a special portion of the Koran, called yasin, is read at the bedside. After death, a sheik prepares the body.
3. Female circumcision: Female circumcision is a common practice in Somalia because it is considered a rite of passage and a requirement for marriage. Female circumcision is performed before adolescence, and involves several different procedures in which varying amounts of genitalia are removed, after which the area is sewn together. Circumcision creates many health problems for women, including chronic pain, urinary tract infections, menstrual problems, and increased pregnancy risks. Before a child is born, a Somali mother’s circumcision site must be cut open to allow passage of the infant. After delivery, the area is again sewn together. Most Somalis in the US believe the practice to be obsolete, and it is not a requirement of Islam. US law forbids circumcision of a female child.
4. Religious beliefs: The majority of Somalis are Sunni Muslims. For Somalis, Islamic religious teachings provide meaning for living, dying, health, child rearing, and family life. In Islam, prayer is performed five times a day: at dawn, noon, mid-afternoon, sunset, and in the evening. Prayer can take place at home, at school, in the workplace, outdoors, or in a mosque. Hands, face, and feet are washed before prayer. Islam forbids eating pork, drinking alcohol, and touching or being near dogs. Ramadan is observed as the most important Islamic holiday, a month long holiday during which people refrain from taking medications, and eating and drinking during daylight hours, with the exception of pregnant women, the very ill, and young children.
5. Treating refugees: Depression and anxiety are common to Somali refugees, who may have lost family members or were separated from them. An estimated 30 percent of Somali refugees have been victims of torture; they have experienced horrific events and may be suffering posttraumatic stress. There is no word for stress in the Somali language. Due to years of witnessing and experiencing horrendous violence, many Somali Bantu refugees suffer from mental health problems such as depression and Post Traumatic Stress Disorder which can lead to flashbacks, nightmares, angry or irritable behavior, insomnia, etc. Somali Bantu refugees suffer from these mental health problems at a high rate, due to their long history of marginalization and abuse.
- Carroll, J., Epstein, R., Fiscella, K., Volpe, E., Diaz, K., & Omar, S. (2007). Knowledge and beliefs about health promotion and prevention about health care among Somali women in the United States. Health Care for Women International, 28, 360–380.
Adair, R., Nwaneri O., & Barnes, N. Health care access for Somali refugees: views of patients, doctors, nurses. American Journal of Health Behavior, 23(4): 286-92.
Chalmers, B., & Hashi, K. O. (2001, December 24). 432 Somali Women’s Birth Experiences in Canada after Earlier Female Genital Mutilation. Birth, 27(4), 227-234. doi:10.1046/ j.1523-536x.2000.00227.x