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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.

24. 24
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. 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. 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. 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. 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. 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. 30
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