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Cultural Competency and Family Planning Services for Somali

Immigrants and Refugees

A master’s project report submitted in partial fulfillment of the requirements for the degree of

Master of Public Health

by

Renzo Amaya Torres

May 2008

Project Committee:

Dr. Eileen Harwood

Dr. Deborah Hennrikus

Dr. Cheryl Robertson

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Abstract

The growth of the Somali population in Minnesota coupled with low infant mortality rates and

low rates of contraceptive usage call for culturally appropriate reproductive health information

and services. This paper reports on findings from a qualitative study involving six focus groups

with 28 Somali men and 28 Somali women. Many participants were familiar with the practice of

child spacing, admitted that it is permitted by Islam and recognized multiple benefits. They

agreed that traditionally the number of children is never planned. However, many participants

acknowledged considering limiting the size of their families upon relocation in the U.S. Many

expressed concerns about possible side effects of contraceptive use. The vast majority of

participants regarded television and health professionals as effective and credible sources of

information and preferred to receive health information in Somali. Efforts to educate and care for

the Somali community require increasing cultural competency skills, understanding religious and

traditional beliefs, and addressing concerns related to family planning. Other recommendations

are provided.

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Introduction

Purpose

In Minnesota, low rates of contraceptive usage in the Somali population - just 8% for all

methods and 1% for modern methods (2007 world, 2007), lower infant mortality rates (compared

to rates in Somalia), and small housing units for large immigrant families makes evident the need

for culturally appropriate reproductive health information and services. Culturally appropriate

they must be because the United States continues to become more and more culturally diverse,

posing several challenges to health care providers as research shows that linguistic and cultural

barriers contribute to healthcare disparities (Betancourt, Carrillo & Green, 2002). Analysis of

data collected by Minnesota International Health Volunteers (MIHV) from Somali refugees will

provide important information on community knowledge, beliefs, and normative practices

related to family planning in the Twin Cities Somali population. This information will be useful

to inform health care providers who serve Somalis and to support other initiatives related to

family planning in that immigrant population. This paper reports on findings from that analysis.

To be successful, such endeavors ought to be guided by a framework of cultural competency.

Cultural Competency

The concept of cultural competency is one that has gained a lot of attention over the last

years by policy makers, public health workers, and administrators as a strategy to reduce ethnic

health disparities (Betancourt, 2003). Indeed, the variation in patients’ beliefs, values,

preferences, and behaviors that are influenced by their culture, the lack of preparation on part of

the health care system and lack of expertise on part of providers have been argued to be part of

the cause for such disparities.

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There is not a single definition of cultural competency, but in general, it is described as a

set of knowledge, attitudes, and skills that enhances cross-cultural communication and effective

interaction with others (Callister, 2005). In the healthcare field, specifically, it is characterized by

the ability of systems to tailor delivery of care to meet patients’ social, cultural, and linguistic

needs (Betancourt, Carrillo & Green, 2002). This can be possible with the practice of cultural

awareness on part of health professionals, recognizing the impact that social and cultural factors

have on patients’ beliefs and behaviors, and the use of tools that enable them to deal with those

factors. For instance, there is good evidence that cultural competency trainings and interventions

positively affect providers’ attitudes and skills (Beach, 2005), which calls for adequate research

to be put in their hands in a practical way.

In the pursuit of cultural awareness through the description of norms, values, beliefs, and

customs of a particular culture, there must be care to avoid promoting stereotyping and

generalization, which are exhibited by many providers in their interaction with ethnic minority

patients (Beach et al., 2005). The description of a population’s characteristics such as beliefs and

norms that is product of research should be viewed simply as a tool for identifying common

threads and as a guide for asking questions, always remembering that those generalizations do

not hold true for everyone. For example, 99% of Somalis are Muslim, which means that, at some

point, providers may interact with a Somali who is Christian and for whom principles and beliefs

about reproductive health in Muslim thought are irrelevant. Such scenario reinforces the need to

continue promoting and endorsing efforts to build and maintain a culturally competent health

care workforce.

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Somali Immigrants

Minnesota is home to the largest Somali population in the United States, with estimates

ranging from 25,000 to over 60,000 (Ronningen, 2004). Refugees began arriving in the early

1990s with the onset of the civil war in Somalia in 1991 and they continue to relocate to

Minnesota in increasing numbers. More immigrants arrived in Minnesota in 2005 than in any of

the previous 25 years and Somalis represented 44% of all primary refugee arrivals for that year

(Record, 2006). In addition, 75% of Somali refugees are women and children.

Somalis almost universally can be categorized by their strong adherence to Islam, the

Sunni sect in particular (Somalia, 2008). Consequently, Islam shapes many aspects of Somali

culture. Somali is the common language of Somalia, and since Islam is so widespread, Arabic is

also spoken by many Somalis. Additionally, educated Somalis are frequently conversant in

Italian and English. While Islam and the Somali language unite all of Somalia, the societal

structure is split by membership to patrilineal clans.

The civil war in Somalia pits clan against clan. The trauma that many Somali people

experienced was severe. Many men died and family members were frequently separated.

Refugee camps in Kenya and Ethiopia lacked food, medical care or security (Rasbridge, n. d.).

Many health conditions such as hepatitis B, tuberculosis, cardiovascular disease, HIV/AIDS,

diabetes, breast and cervical cancer, and lack of child immunizations have aggravated the

wellbeing of this population (Keys, 2002). After surviving the horrors of civil war and bad

refugee camp conditions, Somalis face further challenges as they attempt to readjust to their new

lives in the United States. A variety of stress factors they may face include lack of English skills,

limited employment opportunities, need for affordable housing, coping with cultural adjustment,

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overcoming loss and isolation, lack of health care coverage, and discrimination based on race

and/or religion.

Islam and Reproductive Health

Islam is a comprehensive system that regulates the spiritual, as well as civic, aspects of

individual and communal life in accordance with human nature (Hasna, 2003). Religious

authority in Islam is derived primarily from the Koran (“Qur’an”), and other texts that include

the sunnah, a collection of writings by the prophet Muhammad (Boonstra, 2001). Reproduction

is highly valued in Islam; children are a gift of God, “the decoration of life,” according to the

Koran. Some religious leaders (e.g. imams) argue that this principle condemns and forbids

family planning; others contend that the teachings both encourage reproduction and permit

family planning to the extent that the practices do not harm women’s health. Muslim religious

leaders are considered by many arbiters of society’s norms, influential in public life and private

affairs (Hasna, 2003). That is why the beliefs these leaders hold and their teachings have

important repercussions in the attitudes and behaviors of Muslim believers.

Because of the importance of family in Muslim societies, legal scholars from various Islamic

schools have given considerable attention to family planning. Many believe that contraception

helps families achieve tranquility – an important notion in Islam. According to Muslim scholars,

Islamic texts generally do not oppose family planning (Improving, 2004). For example, they

interpret the Koran’s recommendation of two years of breastfeeding and the Prophet’s

recommendation against pregnancy during lactation as an endorsement for child spacing. While

the great majority of theologians believe contraception is sanctioned in Islam, they mostly limit

the practice to temporary methods of family planning. The majority of those who have approved

the use of modern contraceptives have expressed some reservations regarding the permanent

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methods of female and male sterilization (Mohamud, 2006). Appendix A shows a compilation of

some of the arguments for and against family planning in Islamic societies found in the literature.

The Need for Family Planning

The concept of family planning includes two elements: “it is most usually applied to the

circumstance of a couple who wish to limit the number of children they have and/or to control

the timing of pregnancy (also known as spacing children)” (Family, 2008). The need to explore

the concept of family planning in Somali refugees is evident. Somali families are typically large.

Women have seven live births on average (2007 world, 2007). Upon relocation in the U.S.,

many Somali women no longer have access to extended female relatives who used to provide

guidance on issues of sexuality and to help take care of children.

In addition, many Somali refugees feel isolated and lack the necessary navigational skills

to access the care they need. They often have not learned about preventive health care in their

country, do not get proper treatment, and have a different set of beliefs about health care which

may inhibit their ability to properly access health care for themselves and their families (Plaisted,

2002). This is why it is important to survey community knowledge, beliefs, and normative

practices related to family planning in the Somali population in order to increase awareness

among health care providers about such cultural practices and beliefs. This in turn, will hopefully

help build their capacity to provide more culturally sensitive family planning and reproductive

health care to their Somali clients.

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Methods

IRB Approval

The Institutional Review Board of the University of Minnesota approved this project on

April 15, 2008 (see appendix B). The project was filed under category #4 Existing Data; Records

Review; Pathological Specimens and assigned study number 0804E29722.

Sample

The sampling frame for this study included twenty eight Somali women of reproductive

age (for the purposes of this study it was set between the ages of eighteen and forty five) and

twenty eight Somali men eighteen years and older (n=56). Participant selection criteria included

men and women who were married, had children, lived in different locations of the Twin Cities,

and had not participated in previous studies conducted by Minnesota International Health

Volunteers. The last two criteria were intended to create diverse groups.

Procedure

Focus groups were used to collect data. The main reasons for choosing this method

included previous experience conducting focus groups to investigate sensitive health topics, the

oral tradition of the target population, and feasibility. A total of six focus groups were conducted

with an average of nine participants each, which was based on previous experience and

Krueger’s recommendations (2000). Three groups included only women and three groups

included only men. This homogeneity within groups allows participants to interact in ways that

they might not otherwise, potentially maximizing the quality of the outcome of the discussions

(Stewart & Shamdasani, 2007).

Participants were recruited by three community health workers and in partnership with

Confederation of Somali Community in Minnesota, a non-profit organization in Minneapolis.

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Recruitment methods included telephone calls and visits to groceries and apartment buildings. A

$30 cash incentive was offered. After the first contact, participants were reminded of focus

groups a few days before, the day before, and the day of the focus groups. Verbal or written

confirmations and reminders are needed to demonstrate both the importance of both the event

and the participant’s presence. Sessions took place at a Somali mall, community clinic, and

community centers that participants could take the bus to, acting as an incentive of its own. If

focus group sessions are held in familiar and reachable destinations, they become more appealing

(Stewart & Shamdasani, 2007). Informed consents were provided before the beginning of the

sessions allowing time to answer participants’ questions (see appendix C).

Focus group facilitators were Somali and led sessions of their same gender in Somali

language, which is a best strategy for conducting focus groups interviews (Krueger, 2000). The

male facilitator had experience in focus groups interviews while the female facilitator did not,

although she was trained. Experience is critical because how effective the facilitator plays his or

her role may impact the quality of the data. For instance, the facilitator should try to motivate

participants to contribute to the discussion and to help every participant express his or her

opinions, thus keeping a handful of participants from dominating the conversation (Issel, 2004).

Sessions were tape-recorded and field notes (a written record of responses and/or observations)

were taken. In the women’s sessions field notes were only observational. Audio tapes were not

transcribed in Somali, but rather directly translated into English.

Measures

The guide for the focus group interviews contained a total of seventeen questions, which

might have limited the flexibility to pursue other questions as unanticipated topics emerged

(Stewart & Shamdasani, 2007). Questions were related to knowledge and perceptions about

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family planning, family communication, and access to information. Participants were asked

about sources of information if they knew about family planning, perceived advantages and

disadvantages of family planning, and changes in beliefs or behaviors around family planning

before and after migrating to the U.S. Other questions focused on participants’ decision to use a

contraceptive method and their opinions on credible sources of information as well as best ways

to educate the community. Participants received a list of contraceptive methods to identify the

ones they used, if they used any. Appendix D shows these questions included in the facilitator’s

guide.

Data Analysis

Focus group data were scrutinized and categorized within groups and across groups in

order to identify common themes based on frequency, consistency, and intensity of responses.

Analysis of data was based on reading the transcripts directly translated from audio tapes.

Responses from all groups were compiled by using the copy/paste feature of Microsoft Word so

as to conserve the original documents. Responses were kept separate by type of respondent (i.e.

gender) and their order was not altered. In the first round of analysis, a general impression of

responses was recorded by taking concept notes. In the second round, responses were color-

coded based on emerging themes (one color per theme). In subsequent rounds of analysis, some

responses continued to be color coded and themes were adjusted according to the refining of the

conceptual themes. The most representative quotes were attached to the themes they belonged to.

Naming and ordering of themes into categories changed as a result of new insights in the final

rounds of analysis. The analysis of the focus groups was generated independently by the author

of this paper.

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Findings

The focus group interviews provided rich information to learn more about Somalis’

beliefs and behaviors related to family planning and how best to target the Somali population in

regards to that topic. The following data provide a description of the characteristics of the

participants in the study.

Participant Demographics

The mean age of participants was thirty two (women) and forty four (men). The mean age

at which participants married were nineteen (women) and twenty-four (men). The mean number

of children was four (women) and six (men). The mean number of years living in the United

States was six (women) and four (men). Forty six percent of participants were using a method to

space their children (Table I). Most participants preferred to receive information in their native

language (Table II).

Familiarity with the Concept of Family Planning

Many participants were familiar with the concept of family planning, particularly as it

pertains to the practice of child spacing. Their exposure to this concept occurred through

different means. One of the most frequently cited was programming through the Somali Ministry

of Health, which lead a massive campaign since the beginning of the 1980s. Some radio stations

broadcasted programs, some organizations went door to door, and health centers provided

information as well. Other important sources of information were United Nations agencies such

as the United Nations High Commissioner for Refugees (UNHCR). Some participants did not

learn about family planning until they came to the United States.

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Table 1 – Use of contraceptive methods (n=56)

Contraceptive Use Women Men

Currently using a method?

Yes

No

16

12

10

16

Condom 1 7

Birth Control Pills 4 2

Intrauterine Device (IUD) 3 0

Injections 3 0

Breastfeeding 2 1

Withdrawal 2 0

Abstinence 1 0

Barrier Method/Diaphragm 0 1

Other 0 1

Don’t know 0 6

Note: more than one method could be selected

Table 2 - Language preference for talking and reading about health (n=56)

Language Women Men

Talk about health Read about health Talk about health Read about health

Somali 20 18 23 21

Somali/English 4 7 3 4

English 4 2 2 3

No response 0 1 0 0

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Main Themes

Upon analysis of the data, five main themes were identified. First, participants admitted

that child spacing is permitted by Islam as instructed by the Koran through the explicit practice

of breastfeeding. Second, participants believed that there are limits for practicing family planning

as only Allah can determine the number of children a family can have. Third, most Somali

parents indicated that living in a foreign land requires changes in their reproductive behavior.

Fourth, participants expressed concerns about family planning practices, that is, the side effects

of modern contraceptive methods and the possibility of not being able to procreate in the future.

Fifth, the vast majority of participants regarded television and health professionals as effective

and credible sources of information. Next, an expanded explanation of these themes is presented.

Child Spacing Permissibility

Many participants cited their religion as the source of knowledge and consent for

practicing child spacing. Interestingly, the overwhelming majority of individuals in this group

cited the Koran’s instruction to breastfeed children for two years as irrefutable evidence that

Islam not only allows child spacing but even encourages it:

I heard about it from my religion. Our religion tells us that the child has to be breastfeed

for 24 months. This is the method I use, our fathers used, to space children.

Despite this acknowledgement, a couple of male participants added that extending child

spacing beyond two years was not desirable or important. Many Somalis pointed out that the

Koran specifically instructs two years for breastfeeding but they did not make clear whether they

perceived this time to be a minimum or a maximum period for spacing their children. There were

no reactions to the statements made by the male participants and the facilitator did not ask

participants what they thought about what “two years” meant for them.

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Child Spacing Offers Many Benefits

Participants expressed consensus about the perceived benefits of child spacing,

particularly the health advantages it gives to mothers and children. Their basic arguments were

that more time between births gives children more time to breastfeed and that way children can

have an adequate intake of nutrients. More time between births also gives the mother more time

for her body to recover and prepare for the next birth, while at the same time making stronger the

bonds between mother and child.

Families can have children two to three years apart so that the mother can have time to

educate the children and breast feed the children. It’s also about the mother’s health.

In addition to better health, some female participants mentioned time for self and

properly raising their children as added benefits of child spacing (an argument later used by

some participants for family planning in general). When a mother is caring for one child after the

other, she is taking time from her other children and herself in order to care for the newborn.

I have had seven children: one year apart. I couldn’t work; I couldn’t do anything during

this time. I realized I had to stop. This is when I used the IUD device. I started going back

to work, doing my own thing, and being myself.

It is good for me as a mother because I will find time for myself and I will find time to

raise my children.

The perceived benefits of child spacing expanded to other members of the family -

husbands and siblings - and men were as vociferous as women when commenting on this topic.

They agreed that child spacing improves health, financial, and social aspects of the family. For

example, they complained that by having children too frequently, women can “forget” their

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husbands and the communication between them may be negatively affected. But if children are

spaced in a proper way, the parents can find time for each other and for the rest of the children.

Rejecting ‘Planning the Size’

While the majority of participants were quick to point out the religious instruction to

space children, they were also ready to mention another principle from their religious tradition

which challenges the notion of family planning, specifically, the number of children that a

Muslim family can have. This is a delicate aspect of family planning to bring up because of the

Muslim notion that only Allah determines how many children a family has, as confirmed by

participants in the groups. The literature shows that there are Muslims who believe doing

anything to interfere with Allah’s plan is an offense and that large families are desired because

this gives parents status and supports the expansion of Muslims (Mohamud, 2006).

Allah’s Will

The primary argument participants used to explain why they do not traditionally plan the

number of children is illustrated in these statements:

I strongly believe that we should follow our religion which enables us to have unlimited

number of children.

According to our religion, I can have any number of children that Allah has given us. It

is something Allah has promised to take care of.

It is clear that not only do participants believe, like other Muslims, that Allah decides

how big a family will be but also that he will provide what is necessary to maintain that family.

Male participants seemed to be more assertive when commenting on this specific topic. On the

other hand, female participants simply mentioned that Muslim couples do not plan the size of

their families; it is a matter controlled by Allah. The implication of this belief, from the

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perspective of many participants, is that any efforts on their part to control births may prove to be

futile.

Naturally, the family planning campaigns led by governmental or non-governmental

agencies in Somalia since the 1980s faced some opposition. One participant said:

I remember a lot of discussion between the religious groups and the Ministry of Health

As previously mentioned, there is another aspect that is worth noting in Muslim thought,

which is a call for the expansion of the Muslim nation; hence the vital role of reproduction. In

this regard, the literature exposes a rather popular belief in some Muslim societies and that is

family planning is viewed as a deliberate plan by Western societies to significantly reduce other

populations (Improving, 2004). A few participants mentioned it:

The European community encouraged people to have children. In Africa, we were told to

have small family. I thought this was a big conspiracy to limit poor families on this

planet.

I thought it was a method to decrease the number of people on this planet. Its purpose

was based on the fact that the number of people coming into the world and the resources

available is not balanced.

These same participants later acknowledged learning about the benefits of family

planning, but only as it pertains to child spacing. The revelation of these previously held beliefs

showed once again that participants tended to perceive different things when they heard the

terms child spacing and family planning.

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Not All Believers Are Homogeneous

Despite the strong belief that family size is a plan that should be left to Allah and that the

expansion of Muslims is a religious duty, there were participants whose values seemed to

contrast with such beliefs.

Two children that are will raised, well mannered, well educated, are better than ten

children. Therefore, we should think about the quality and not the quantity. We should

not make ourselves so tired all the time. What I mean by quality is to have time to follow

their education, go to their school, assist them with homework, and their physical

activities.

Children need education, financial support, and health care in order to grow and be

productive later in life. I think family planning is the way to avoid raising children that

lack these things.

I recall some neighbors in Somalia… they had eighteen children… the whole family was

disorganized, children were kind of lost, and the parents never had time to spend with

their children.

In contrast to the literature, the last statement reflects the importance that Islam places on

the notion of tranquility. Different verses in the Koran suggest that tranquility is an important

purpose of family life which is achieved through marriage. From the same Islamic point of view,

when procreation takes place, it should support and endorse tranquility rather than disrupt it

(Mohamud, 2006). Thus, when participants refer to better communication, proper raising

(including education), financial benefits, and ‘relief’ of taking care of fewer children, they may

be considering this notion of tranquility, making things easier for the family. This concept of

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tranquility seems to become more important upon relocation in another country, as

acknowledged by participants.

Change in Reproductive Behavior

Resettlement in a different country has had effects on Somalis attitudes towards

reproduction. According to the latest statistics released by the Population Reference Bureau,

families in Somalia experience an infant mortality rate of 117 per 1,000 live births. In

comparison, families in the United States experience an infant mortality rate of 6.5 per 1,000 live

births (World, 2007). Despite the disadvantages that Somali refugees (like other refugees) face

upon arriving to the U.S., they are experiencing lower infant mortality. Participants admitted that

economic hardship for providing for large families and changes in their social support networks

upon relocating in the U.S. are changing their attitudes towards family planning in general, that

is, both the number and timing of pregnancies.

In the United States, it is very hard to have too many children because there’s no help

from relatives. There are no jobs. Not enough money.

The only reason I cannot have too many children in this country is economic. Every child

needs education, healthcare, food, daycare, and clothing. It is more expensive here than

in Africa.

The previous statement is a perfect example of how participants overwhelmingly

identified two main reasons why it is difficult to have large families in Minnesota. First, raising

children in the U.S. costs a lot of money and they recognize that they are struggling

economically and educationally. “Hardship” is a word they frequently used as they perceived

that almost everything was more difficult in their new home. Second, participants noted that

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families in Somalia are used to relying on relatives and neighbors to help take care of the kids

and that support system is weaker in the U.S. among Somali refugees.

It is very obvious that raising a large family in this country is far harder than in Africa.

Therefore, I believe that individuals change their ideas about family size after arriving in

this country.

The number of children in the family should not exceed three. I have talked to some of my

friends who have been in this country longer than me and the only concern they have is to

have smaller families.

Communication and Decision-Making

If Somali refugees are changing their attitudes and perceptions towards family planning,

communication and decision making in regards to contraception are bound to be critical elements

in changing reproductive behavior. Two thirds of participants who commented on whether they

were comfortable talking about family planning at home revealed that there was mutual dialogue

between husband and wife. Several women thought that their husbands were open to discuss this

subject and understood the importance of a mutual agreement on the use of contraception.

However, a few men thought the decision to use contraception should be their wife’s. Some of

the participants already used to talk about the topic in Somalia and some began to approach it

after arriving in the U.S. The reasons some of them cited for the lack of communication on the

topic in Somalia were that either those couples did not see the need for family planning before

coming to the U.S. and/or they found the topic too sensitive to talk about back in Somalia.

When you are alone you make your own decisions. When you have a wife the decision

has to be bilateral.

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Both parents should decide this issue since it is not any different than other issues that

come up in a marriage.

There was one particular argument that a few participants brought up to state their

position on who makes the decision regarding contraceptive use: “[the woman] is going to carry

the child for nine months.” One female participant used this argument to express her opinion

that, in light of this fact, men should understand that women want to be part of the decision-

making process. Another female participant used the same argument to explain why women

should not have to consult with their husbands about it. Yet another female participant explained

that women should have the last say if there is disagreement after they consult with their

husbands. Finally, one male participant shared the belief that women should decide regardless of

whether her husband agreed with her. The view of this participant contrasted with that of a few

men who perceived their decision to be the one that mattered:

...according to our culture the man is the king of the house. The only time that a woman

should take part in the decision making regarding this subject would be when there is a

serious health concern.

I give my wife an order to breast feed the new born. When it’s time to conceive, I tell her

to stop breastfeeding.

A couple of female participants admitted not to consult this topic with their husbands and

to keep their contraceptive use a secret. Whether this is a result of the attitude of some Somali

men as depicted in the previous quotes is not really clear. About one third of all participants who

commented on the topic of communication said that they did not talk about family planning and

birth control methods. One participant said: “It is culturally forbidden to have an open discussion

about this subject.”

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Concerns About Contraceptive Use

It is evident that for many participants, making the decision to practice family planning

gives rise to some questions and fears. There are two main fears that participants identified: the

risk of infertility and the overall health effects that the use of contraceptive methods can have on

women. As already mentioned, giving birth within Muslim tradition is an event that gives parents

status and perpetuates the Muslim nation. Both men and women in the groups cited the inability

to produce children as their primary concern when considering the use of contraception

medication and treatments.

After using birth control methods, some women run into medical problems that might

cause them not to have children.

If I use family planning or child spacing methods to finish university or college

education, I could end up not having children for the rest of my life.

One female participant related that in Somalia, if the family has two or three children

people would think that they do not have enough children and there would be gossip that the man

should marry another woman to have more children. This statement did not provoke any

particular reactions among participants and a plausible explanation is the fact they know well:

these refugees are not in Somalia anymore; they are living in a place where religious and cultural

tradition is being challenged by new economic and social realities.

Some participants expressed another type of fear, a belief in the negative side effects of

contraception use resulting in health problems for the mother and/or the child:

Birth control medications might cause birth defects. This could be a physical handicap, a

mental handicap, or low intelligence. I have seen a lot of Somali families in Minnesota.

The reason their children are handicapped is because they used birth control.

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When women mentioned a specific type of contraceptive method that could lead to such

problems, they were more likely to mention injections. In general, participants’ concerns for the

reproductive and health problems that contraception may cause were largely constrained to

modern birth control methods.

Preference for Natural Contraceptive Methods

The overall comments of participants regarding contraceptive methods suggest that

modern methods are not a common practice among many Somalis. Some participants responded

as a group that they never used birth control methods and many confirmed that they prefer

natural birth control methods such as breast feeding, abstinence, or withdrawal.

I use one of the methods… the method was that I was avoiding seeing my wife 16 days

after she had her period.

I have been taught by nature.

Outreach and Education

A few questions in the focus groups aimed to assess the sources of information that

participants have used or would like to use, and consider to be credible. Participants

overwhelmingly regarded television and doctors among the most effective sources of

information. They also thought that there is a need to continue educating the Somali population.

Most of them thought that men and women should be educated about family planning, but there

were variations in regards to how much education they thought each gender should receive. Male

participants tended to say that both men and women should be educated equally although a

couple of them highlighted that they should be educated separately. Women were divided on

their opinion of who needs more education.

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Both men and women should be educated about this subject but women should get more

education. This reason is because the woman uses the methods and needs to know more

about this.

To avoid disagreement between husband and wife the man should be notified and given

enough information so he can understand the position of the women.

It’s easier to educate women about this subject than men. I believe Somali men need

more time and education about this subject.

Ultimately, participants agreed that there should be continued efforts to educate both men

and women. To this end, they identified sources of information deemed to be the best means.

Television and Health Professionals are Preferred Sources of Information

Participants expressed their desire to access information on family planning through

different means, but both television and doctors/health centers were the top choices to get

information from.

I take advice from my doctor and anybody that has health related training.

When asked where they went to get information on family planning, a note in the

transcript records read: “All other interviewees agreed they receive information from the

doctors.” Sometimes, participants referred to clinics or health centers, but the vast majority

explicitly mentioned doctors. Somali television tied for first place because of the advantages it

offers:

I think, since Somali’s are visual and word-of-mouth people, the TV would be the most

important way to teach information about this subject.

Since I am new to this county, I think the only way to educate about this subject is Somali

TV. This is where I listen and get information about health and other subjects.

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A few participants acknowledged that many Somalis do not know how to read or write.

Evidence demonstrates that health professionals are frequently faced with such reality, which

becomes a challenge for public health efforts. Television is a means to compensate for this. In

addition, television can address other barriers including physicians’ poor communication skills

and time constraints to educate patients as well as inconsistency of recommendations (Powe,

2004).

According to Noar, the literature has begun to show evidence that “targeted, well-

executed health mass media campaigns can have small-to-moderate effects not only on health

knowledge, beliefs, and attitudes, but on behaviors as well” (2006). This can result in a great

impact on public health when those effects are multiplied by the number of individuals who are

reached by mass media.

Next to doctors and television, there was a pretty equal distribution in the number of

responses that participants gave to other mediums of information. These were community

centers, radio, written information (translated into Somali), and elders. Male participants were

more likely to cite elders as a credible source.

Discussion

In an effort to educate health care providers and inform future projects led by Minnesota

International Health Volunteers, a study consisting of six focus groups with fifty six Somali men

and women was conducted. The objectives of the study were to gather information on

community knowledge, beliefs, and normative practices related to family planning in that

population. Focus groups were used partly because of past successful experience conducting

focus groups in the Somali population. Investigators have confirmed that Somali culture is

fundamentally an oral society, which partly supports the use of focus groups as a research

25

method (Olden, 1999). The use of individuals who reflect the gender and ethnic background of

the participants and the use of their native language may have proved effective in building

rapport with the participants and thus gain rich information. The number of participants in each

group (mean=9) seemed appropriate to allow each participant to share his or her thoughts and the

number of focus groups was adequate to reach saturation. This is the point at which repetition of

ideas occurs and patterns become evident, which usually happens after three or four groups by

type of participant – in this case women and men (Krueger, 2000).

It is surprising that participants already had some knowledge about family planning due

to educational initiatives in Somalia and through health and community centers in the U.S. It is

unclear whether this played any role in the participants accepting to take part of the focus groups

(besides the $30 incentive). A few participants acknowledged learning about family planning as

a conspiracy theory. International organizations such as Pathfinder International have found

while working around family planning in Muslim countries that many Muslims believe that

family planning is “foreign” and driven to reduce the Muslim population and their power

(Improving, 2004). The difference in the participants’ statements is that the perceived target

population was poor people as opposed to only Muslims. The few comments on this specific

topic do not tell us much about whether many Somalis have believed or still believe in that

conspiracy theory, but the fact that this was brought up warns us about the delicate nature of the

concept of family planning for some Somalis, according to the study, and for many Muslims

around the world, according to the literature.

The literature overwhelmingly indicates that religion plays a crucial role in Muslims’

perceptions about family planning and participants corroborated this reality by quickly

referencing religious texts, mainly the Koran, to offer arguments in favor or against family

26

planning. On one hand, there was a general favorable view that breastfeeding serves to practice

child spacing. On the other hand, the idea of planning the size of the family was traditionally

rejected by using the argument that the number of children a family has is in the hands of Allah.

Because the purpose of family planning is two-folded, that is timing and number of pregnancies,

attention must be given to how this topic is presented to Somali men and women as the findings

seemed to suggest.

It is evident that religious and cultural beliefs around family planning are abundant.

Although those beliefs can dictate the attitudes and behaviors of the individuals holding them,

there are other aspects that reveal a dilemma the Somali population in Minnesota is facing: the

contradiction between traditional beliefs and practices and the reality of life in a different

society. Although not stated by participants, local research suggests that changing demographic

trends upon relocation to the U.S. due to lower infant mortality makes family planning an

important health issue (Ronningen, 2004). Participants did acknowledge that economic

difficulties for providing for large families in the U.S. and social changes they experience as a

refugee population are compelling them to change their reproductive behavior.

The reality of these changes and the fact that participants identified them provide an

opportunity to approach Somalis to talk about family planning, provided that such efforts are

accompanied by proper acknowledgement and respect for religious and traditional beliefs. While

doing this, educators and providers should address the popular beliefs that modern contraceptives

can cause infertility and/or illnesses. Focus group findings suggest that these beliefs resulted in

many participants choosing natural methods for contraceptive practice (i.e. breastfeeding and

withdrawal). This reveals a need to focus education on the effectiveness, safety, and other

benefits of different birth control methods. In line with the oral tradition of Somali culture, the

27

findings highlight the need to use media, in particular television, to reach a broad audience of

Somalis and doctors who are perceived to be credible sources of information for sensitive health

topics. Elders were also identified as key sources of information. Previous research confirms that

elders are traditionally considered important figures in Somali communities and that their input

is crucial to the acceptability of educational programs in that population (DuBois, 2004).

The importance of family and reproduction in Muslim tradition can certainly be a

challenge for promoting family planning. A conversation with Somali patients about family

planning is bound to include a discussion about Muslim teachings and traditions with references

to the Koran and other texts. This reinforces the argument that health educators and providers

will find gaining some knowledge on Muslim views of family planning and building intercultural

skills an asset, or better yet, necessary. The findings and forthcoming recommendations provided

in this paper may be a starting point to help support those efforts. Others documents such as the

Mogadishu Declaration may be worth examining. This declaration was product of the National

Conference on Islam and Child Spacing in Mogadishu, capital of Somalia, in 1990 (National,

1990). The work of international agencies such as Pathfinder and the United Nations Population

Fund in collaboration with governments in Muslim countries are largely responsible for the

success in the implementation of local family planning programs (Summary, 2008). While

keeping in mind that efforts should be adapted based on the unique characteristics of the target

population, examining those initiatives can provide some useful insights for local

implementation.

Study Limitations

There are multiple limitations in this study. First, there was an inconsistency in the level

of experience of the focus group facilitators (male facilitator was experienced while female

28

facilitator was not), which poses threats to the validity of the outcomes. For instance, it was

evident in the transcripts that the female facilitator made comments and introduced personal

stories which could have introduced bias by influencing participants’ responses. Furthermore,

there is the possibility of groupthink taking place (respondents can feel peer pressure to give

similar answers), especially with a moderator who was not very experienced. In addition, the

applicability or transferability of the findings of this study to other settings has not been tested

(these terms are equivalent to generalizability in quantitative studies) (Issel, 2004). Finally, the

data analysis was not conducted in collaboration with other individuals who could have helped to

confirm the validity of the findings. However, regular consultation with the project advisor on

analysis and the inclusion of words used by study participants help to show confirmability (also

referred to as objectivity). In addition, the potential sharing of this information among members

of the target population may help demonstrate dependability of the analysis (equivalent to

reliability in quantitative studies).

Conclusion and Recommendations

Religion and culture play a powerful role in individuals’ thinking patterns and behaviors.

This paper showed how these elements are pivotal in shaping Somalis’ views and decisions

about family planning, making clear the large implications for health educators and professionals

who are facing the changing demographic profile of the United States. Additionally, it suggests

that becoming cultural competent is critical for acceptance and success of health initiatives such

as family planning programs. Taking into account that idea, the following recommendations are

aimed to help make the endeavors of health professionals more successful.

29

Recommendations for Increasing Cultural Competency for Staff

Incorporate cultural competency education in the training of current and future health

professionals

Learn about Islam and religious interpretations about issues related to reproductive

health, family planning, and child bearing

Ensure that interpreters and bilingual staff are available

Ensure that health education materials are available in Somali language

Develop rapport by seeking to understand the patient’s point of view - avoid assumptions

- and maintain an open, sensitive approach to patients’ health beliefs

Seek to gain patient’ trust by showing empathy and demonstrating patience

Recommendations for Educating the Somali Community

Stress the benefits of child spacing for mother, father, and children

Start family planning discussion with breastfeeding – the most acceptable method. Then

present other natural methods and move on to modern methods

Lists effectiveness, safety, and benefits of contraceptive methods

• Demonstrate how different methods work

• Show all the options

Encourage male participation in decision-making as appropriate

30

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