Bridging the data gap: Partnering with Somali refugees to implement a community-based health survey in Minnesota

1. Bridging the data gap: Partnering with Somali refugees to implement a community-based health survey in Minnesota Nathaly Herrel, MSc Program Associate Minnesota International Health Volunteers nherrel@mihv.org 301-530-5908 November 9th, 2004 American Public Health Association meeting

2. 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

3. Somali Health Care Initiative • 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

4. 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

5. 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

6. Methods: Community mobilization • Flyers (malls, shops, mosques, etc.) • Articles in local Somali newspapers • Radio announcements • Somali cable TV program • Somali “Talking Yellow Pages”

7. 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

8. 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

9. 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

10. 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

11. Results: Demographics

12. Results: Language preferences • Q: In what language do you most prefer to: • talk about your health? 88% of men 92% of women prefer Somali • read about your health? • 86% of men • 86% of women • prefer Somali

13. Results: General health Q: In general, would you say your health is: N= 190 Female, N=106 Male

14. 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)

15. Results: CVD and diabetes • Self-reported prevalence of: • 36% of women & 35% of men have had their cholesterol checked at least once in their life N= 190 Female, N=106 Male

16. Results: Smoking Q: Do you currently smoke cigarettes? • 45% of the men who smoke reported they smoke at least ½ a pack a day

17. 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

18. Results: Dietary habits • Self-reported daily consumption of:

19. Results: Immunizations Q: Are your children up to date on their immunizations ? Q: Do your children have immunization records? • 54% of women and 42% of men reported having an immunization record (for themselves)

20. 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

21. 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%)

22. Results: Breastfeeding practices Q: For how long did you breastfeed? • 94% reported they breastfed/are breastfeeding their child • 40% reported supplemental feeding after delivery (e.g. plain water, infant formula, and other milk)

23. 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

24. 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

25. Survey Limitations • Lack of accurate census data make sample sizeestimationdifficult and random sampling not possible • Difficulttotrack/evaluatethesnowball 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?

26. 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

27. Project Team Data analyzed by Andrea Leinberger, Program Coordinator, MIHV Reviewed by Diana DuBois, Executive Director, MIHV Qamar Ibrahim, Executive Director, LEAD Saeed Fahia, Executive Director, CSCM Sirad Abdirahman, Public Health Advisor, MIHV Nathaly Herrel, Program Associate, MIHV Maryan Del, CHW, CSCM Khadija Sheikh, CHW, MIHV Faduma Abdi, CHW, CSCM