Somali Health Care Initiative Bridging the data gap: Partnering with Somali refugees to implement a...

Somali Health Care Initiative

Bridging the data gap: Partnering with Somali

refugees to implement a community-based health

survey in Minnesota

Nathaly Herrel, MScProgram Associate

Minnesota International Health [email protected]

301-530-5908

November 9th, 2004American Public Health Association meeting

mailto:[email protected]


Somali diaspora in MN

• 1991: collapse of Somali government and civil war• Population movements to Kenyan refugee camps• 1993: arrival of first Somali refugees in MN• Population estimates: 20,000 – 60,000• Minneapolis/St. Paul: “Somali capital of the US”• Numerous barriers to health care including: - Linguistic issues - Cultural background - Economic constraints - Expectations and beliefs


• Project launched in 2002 end 2005• Funding: MN DOH & BCBS Foundation of MN• Collaborative partnership: - MN International Health Volunteers (MIHV) - Confederation of Somali Community in MN (CSCM) - Leadership, Empowerment, & Development (LEAD)


• Targeted health disparity areas: - Breast and cervical cancer - Immunizations - Diabetes and CVD - HIV/AIDS - Infant mortality


Key activities

• Annual cultural competence conferences for providers

• Health education forums in the Somali community

• Outreach via Somali Community Health Workers

• Community-based research: Somali Health Survey


Somali Health Survey

• Rationale: Lack of reliable health data about this subpopulation but growing evidence for health disparities

• Goal: To better understand the health assets and needs that exist within MN’s Somali community

• Purpose: Survey data will be used to set priorities for further research and inform SHCI project activities


Methods: Community mobilization

• Flyers (malls, shops, mosques, etc.)

• Articles in local Somali newspapers

• Radio announcements• Somali cable TV

program• Somali “Talking Yellow

Pages”


Methods: Interviewer selection• 65 applicants 17 hired

(11 women and 6 men)• Recruitment process

included whole project team

• Highly qualified Somali health professionals are an underutilized resource

• Interviewers needed to be representative of subgroups

• 2-day training on interview techniques


Methods: Respondent selection

Selection criteria:• Somali community member• Same gender as interviewer • Over 18 years of age• One adult per household• Different socioeconomic and education levels• Diversity of Somali clans• Not a relative or friend of interviewer

Respondent Incentives:• Benefit for the community• $30 cash stipend • Health resource bag with videos + brochures• Copy of survey results upon request


Methods: Questionnaire

• Tool created by staff in all 3 partner agencies• Questionnaire translated English Somali• Pretested in the Somali community• Edited by interviewer team during two-day training• 87 knowledge/behavior questions on:

– Demographic information / health insurance – Health seeking behavior– Cardiovascular health and diabetes– Adult and childhood immunizations– Breast and cervical cancer– Infant health and nutrition


Methods: Sampling

• No sampling frame for this population• Snowball Sampling: Identifying participants suitable for

research and then asking those initial participants to refer the researcher to additional participants

• Most respondents from Twin Cities but also rural MN• Implementation phase: August – October 2003 • Total of 296 interviews: 190 women + 106 men • 50% of the women had children under 5 years• 30% of the women were 40 years or older• Data quality: - supervision of interviewers - detailed review of questionnaires - data checks in the database - interviewer debriefing


Results: Demographics

Characteristics Women (N=190) Men (N=106)

Mean age (range) 38.8 (19 - 75) 39.1 (18 - 79)

Mean years lived in MN (range) 3.9 (0.5 - 10) 3.9 (0.5 - 10)

% Married 55 60.3

Education level:% Never attended school% Attended Elementary school% High school graduate% Have College degree

22 43314

19243422

Occupation: % Homemaker % Student% Retired/disabled % Working at least one job

4616524

3132240

% Have health insurance 94 64

% Have primary physician 76 52


Results: Language preferences

• talk about your health?

88% of men

92% of women

prefer Somali

• read about your health?

86% of men

86% of women

prefer Somali

•Q: In what language do you most prefer to:


Results: General health

Q: In general, would you say your health is:

N= 190 Female, N=106 Male

05

101520253035

Women Men

Per

cen

tag

e

Excellent Very Good Good Fair Poor


Results: Health care seeking

• Over 90% cited ‘doctors’ as one of their sources of general health information and advice (27% TV, 17% nurses, 17% midwives)

• 62% seek care from a doctor first when they are sick (24% OPD, 9% ER)

• 58% indicated that they use a combination of western medicine, herbs, and religious healing when they are sick

• Most common reason for delaying health care is lack of insurance (N=13)


Results: CVD and diabetes

• 36% of women & 35% of men have had their cholesterol checked at least once in their life

N= 190 Female, N=106 Male

Diabetes 10% (n=31)

Heart Disease 8% (n=24)

Stroke 1% (n=3)

High cholesterol 12.5% (n=37)

High BP 16.5% (n=49)

• Self-reported prevalence of:


Results: Smoking

Female Male Total

Yes 4 (2%) 22 (21%) 26 (9%)

No 186 84 270

Total 190 106 296

• 45% of the men who smoke reported they smoke at least ½ a pack a day

Q: Do you currently smoke cigarettes?


Results: Physical activity

In an average week: •No moderate exercise: 17% of women, 22% of men•No vigorous exercise: 10% of women, 20% of men•Some exercise on 2 days: 15-30% of women, 20% of men•Daily exercise: < 10% of men and women

Barriers to exercise: •lack of time & money•not comfortable exercising with opposite gender•no-one to exercise with


Results: Dietary habits

• Self-reported daily consumption of:

Once a day Twice a day

Vegetables 50 % 35 %

Fruits 60 % 25 %

Fried foods 50 % 27 %


Results: Immunizations

Q: Do your children have immunization records?

Yes, all have cardsYes, some have cardsNo, none have cardsDK

Yes, all are up to dateYes, some are up to dateNo, none are up to dateDK

Q: Are your children up to date on their immunizations ?

• 54% of women and 42% of men reported having an immunization record (for themselves)


Results: Breast/cervical cancer

• 93% of women had heard of breast cancer

• 66% of women had heard of cervical cancer

• Most women had heard about these cancers through doctors, TV, friends

• 68% of women aged 40+ had had at least one mammogram

• 55% of all women had had at least one pap smear• 39% of all women conduct ‘regular’ self breast exams


Results: Prenatal care

104 women had children < five years

• 92% of children < 5 were born in the US

• Most women are/were enrolled in WIC (88%)

• 97% of women reported never smoking during pregnancy

• Majority had had at least five prenatal visits (72%)

• Majority had initiated prenatal care in 1st trimester (82%)


Results: Breastfeeding practices

• 94% reported they breastfed/are breastfeeding their child

• 40% reported supplemental feeding after delivery

(e.g. plain water, infant formula, and other milk)

0

5

10

15

20

25

30

35

0 - 3mos 4 - 6mos 7 - 9mos 10 -12mos

> one year

Co

un

t

Q: For how long did you breastfeed?


Results: Infant sleep positions

• Most children slept in their own cribs/beds (94%)

• 43% of infants placed on back to sleep

• 49% of infants placed on side to sleep


Discussion: Assets and needs

• High % of insurance coverage• High % primary provider coverage• Very low % smoke during pregnancy• Early initiation of prenatal care seeking• High % of mothers breastfeed (but not exclusively)• Consumption of fruits/vegetables < USDA recommendation• Frequent consumption of fried food • Frequency of physical activity < CDC recommendation• Cultural media: source of health information

Develop recommendations


Survey Limitations

• Lack of accurate census data make sample size estimation difficult and random sampling not possible

• Difficult to track/evaluate the snowball sampling process

• Biases related to in-person interviews

• In-person interviews very time consuming (3-4 hrs each)

• Issues with translation/interpretation of medical terms

• Some concepts difficult to communicate (e.g. serving size)

• Some questions not culturally appropriate/relevant for ex: Did you consume alcohol during your pregnancy?


Lessons learned and next steps

• SHS is a sound approach to gather quantitative health information about the Somali community

• Partnership of the three agencies was essential to lend credibility to the project in the community

• Disaggregating health data specific to the Somali community provides insight for community members, health providers serving the community, and other service organizations

• Possibility for replication in other settings/communities• Further analysis will include comparisons with

state/ national data for other populations• Critical to document and disseminate


Data analyzed byAndrea Leinberger, Program Coordinator, MIHV

Reviewed byDiana DuBois, Executive Director, MIHV

Qamar Ibrahim, Executive Director, LEADSaeed Fahia, Executive Director, CSCM

Sirad Abdirahman, Public Health Advisor, MIHVNathaly Herrel, Program Associate, MIHV

Maryan Del, CHW, CSCMKhadija Sheikh, CHW, MIHVFaduma Abdi, CHW, CSCM

Project Team

Somali Health Care Initiative Bridging the data gap: Partnering with Somali refugees to implement a...

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