Alphaeus M. Wise and Dr. Barry L. Johnson, Sociology

Somalis represent a growing group of new immigrants to Minnesota. Because of their recent immigration, there has been very little research done on their perceptions of Western medicine, in particular, preventive measures such as cervical cancer screenings. I became interested in this while working at a community clinic in Minneapolis which saw a large number of Somali patients. The physician I was working with, Dr. Tina Martin, expressed a desire to better understand the Somali patients in order to better serve them. One of the things we had observed was that Somali women showed a reluctance to Pap smears that was somewhat stronger than women of other cultures.

Our goal was to find the reason for this reluctance using the Health Belief Model to measure their perceptions. The Health Belief Model measures the four factors that determine if a person will participate in a health action. The first factor is how susceptible the person feels to the disease. The second factor is how severe the person perceives the disease. If someone feels susceptible to a disease and feels that there would be serious consequences to contracting the disease, then they are more likely to act in prevention. The third factor is perceived benefits of the action. These benefits must then outweigh barriers to the action. If the perceived barriers are greater than perceived benefits, the action will not be taken. Added to these four factors is the idea of a “cue”. In many cases there must be something to trigger the action, such as a physician’s warning or the advice of a friend.

Methods

It was planned that we would use survey methods to gather the information. We developed an instrument by modifying questionnaires used by other studies of breast and cervical cancer screenings. As a way to improve our questionnaire, we had a focus group of Somali women and asked about the issues that were going to be on the questionnaire. The focus group was conducted by Dr. Martin with the assistance of one of the interpreters from the clinic. After the first focus group, it was decided that we would need to conduct more and that this would be essential in developing a good questionnaire. Because of the difficulty of scheduling and having women attend these focus groups, it took six months to have the four focus groups. The data in this report is from these four focus groups. The questions asked were grouped to try and correlate to the Health Belief Model. There were six categories and in each category the women were asked their thoughts on the subject with the moderator asking follow up questions where necessary. The six categories were: cancer, Western medicine, preventive medicine, Pap smears, cultural beliefs, and female circumcision. Our sample consisted of 13 Somali women between the ages of 20 and 67 years old. They were all women who lived in Minneapolis and had been in the US for five years or less. They were all patients at the clinic. Those who participated were given a $10 gift certificate to Target. All of the women had children or were pregnant with their first child. They were all Muslim and wore the traditional dress and head coverings.

Results

Out of the 13, only two had known women with breast cancer, and only one had known someone with uterine cancer. None of the women had known anyone with cervical cancer. Only 54% knew someone with any form of cancer. However, almost all of the women associated cancer with death. It was uniformly agreed among the women that cancer was more of a problem in the US than in Somalia.

There were three concerns that came up in the discussion of Western medicine. One of the women was disappointed with how little physicians prescribe drugs in the US. She said that in Somalia she would not leave the doctor’s office without drugs of some kind. Another woman said that she felt like doctors here would not understand if she left her health in the hands of God. Many of the women complained of seeing male physicians for having babies and gynecological exams, they said they were shy, uncomfortable, and one said it was against her religion.

All of the women had participated in immunizations in Somalia and believed these to be important. They were split on the importance of Pap smears. In Somalia, women only receive Pap tests when sick. 85% of the women had had Pap smears. Only one of the women had had a Pap smear in Somalia. Two of the women knew that Pap smears were to look for precancerous cells. Most of the women thought that they were checking for infection. None of the women knew how often they should have the tests done. Almost all said that they would go in to see the doctor and would participate in screenings if the doctor told them to. Three women said that they would refuse Pap smears from a male physician.

During the discussion, 77% expressed a fatalistic view toward medicine. Several expressed the idea that even after consulting physicians and receiving medication, it was God’s will whether or not that medicine would work.

All of the women that participated in the focus groups had been circumcised in Somalia. All of the women stated that the purpose for it was to control the sexual behavior of girls. There were mixed feelings toward their own circumcisions. One woman was proud of hers. Another woman felt traumatized by the experience at age eight, and ran away from home. Several said that they felt embarrassed being circumcised in front of American providers and that being circumcised affects their participation in gynecological exams. One of the women said that everyone came to watch when she was giving birth. 62% said that they will not have their girls circumcised. However, almost all of the women expressed fear about their girls in the US. They felt that sexual promiscuity was sure to be a problem here, whereas it was not a problem in Somalia where there is female circumcision and a tradition of banishment from the family for sexual promiscuity.

Discussion

We were able to find several factors that affect participation in Pap smears. Somali women do not feel overly susceptible to cancer, especially cancer of the cervix. Cancer is not a major health concern in Somalia, they see it as an American problem. However, cancer is seen as a severe disease. All of the women associated cancer with death and many thought that there are no ways to treat it. This lack of knowledge leads to a low perception of benefits of cancer screenings. We also found several barriers. Female circumcision seems to play a role in making Somali women feel even more uncomfortable than most women about gynecological exams. This goes along with a deep sense of modesty. Many said they feel uncomfortable with male physicians, and some said that they would flatly refuse a Pap smear from a male. One of the largest factors in determining participation seems to be cues from the physician. All of the women said they would have pap smears when asked by a physician.

This information suggests several things that can be done by providers to increase participation in cervical cancer screenings. There needs to be increased education of the treatments of cancer and the purpose of Pap smears, more access to female physicians for Somali patients, increased cultural awareness among physicians about female circumcision, as well as making sure that doctors schedule and follow up on Pap smears.

The information we found in this study was limited by both the number of people we talked to and the means of study. Dr. Martin is finishing the questionnaire and will be administering it at the clinic. The information found from this study will prove very useful in treating Somali patients and in their participation in preventive care in the future.