SOMALIA

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Country Profile

Somalia has suffered from a long history of colonialism, disputed borders, oppressive governments, civil and external wars, border clashes, massive displacement of populations, economic disaster, inter-clan violence and famine. Rape and torture have been commonplace. Drought, flooding and desertification also cause ongoing difficulties in Somalia and malnutrition is common. Large numbers of ethnic Somalians live as refugees in neighbouring states and in Europe and North America.

Clan affiliation is stronger than national allegiance in Somalia but nationhood is very important and is tied to language use as most Somalians define themselves as such by the use of their common language of Somali. Some Somalians speak Arabic, English or Italian. There are many Kenyans who claim to be ethnic Somalians as they migrated from Somalia in colonial times and were subsequently trapped behind closed borders and denied traditional trading and herding routes. However, their ethnicity is contested by many Somalians on the basis of their inability to speak the Somali language. Clans are strongly patrilineal but families can be relatively egalitarian. Ancestral connections are important in Somalia and ancestors are revered. Somalians are given a first name followed by their fathers and grandfathers names.

There is no fixed government in place in Somalia and its administration is run in some areas by individual clans within their geographical boundaries. This has led to a breakdown in previously well established services such as health care and education. For example, literacy rates have dropped from 83% to 30% and there has been an increasing reliance on traditional healthcare due to the breakdown of the established Western healthcare system.

Many Somalians are nomadic or have come from a nomadic tradition. 75% of Somalians live off the land. Camels remain the backbone of the economic life in Somalia.

Somalians have rich oral and artistic traditions and are especially poetic. They use poetry in everyday life, from politics to ordinary family communication.

99% of Somalians are Muslims - mostly Sunni - and as such they may like to pray five times a day. However, schedules in Ireland do not always permit this. The most important holidays include Ramadan, when Muslims fast from sunrise to sunset (pregnant women, the infirm, and children are typically exempt). Many religious holidays and events are marked by the ritualized sacrifice of a goat or lamb.

Birthdays are not particularly celebrated by Somalians, and it is quite common for people not to know the exact date of their birth. Ages are determined by how many rainy seasons (gu) a person has lived through. At the time of immigration, birthdays are typically rounded off to the nearest year, e.g. 1-1-98, 31-12-62, etc. However, the anniversary of family members' deaths are observed and celebrated.

Somalians in Ireland

Somalians in Ireland often feel that they are victims of racism. The women receive comments because they wear the Hajab and many Somalian women go out in public as little as possible because of this. The men often receive comments referring to them as nigger or black which they find highly insulting as they consider themselves to be Arabic Africans. Somalians will often respond to racial comments and any perceived discrimination with aggression, usually confined to shouting.

Somalian women do not like to talk about sexuality and they find that the openness of conversation in Ireland around sexuality very difficult and shameful.

Somalians do not have a word for `please' in their language and will usually ask for things in Ireland without using the term. This can appear to the Irish as being rude but no rudeness is intended at all. Somalians, on the other hand, are used to helping each other in all aspects of life and they find it strange and difficult that this is often not the case in Ireland. Somalians will turn to other Somalian families for social support and assistance.

All medical services in Somalia are free, including medication. Somalians will go to hospitals to see a health provider as private clinics are rare and are only available in Magadishu. Similarly, in Ireland Somalians will assume to go to a hospital rather than a GP surgery. Also they will prefer to see a specialist rather than a GP. Somalians will expect to be asked for their full medical history so that they can feel that the doctor is making a correct diagnosis. If the appropriate questions are not asked a Somalian patient may doubt the doctor and may seek a more thorough practitioner. Medication is provided both from GPs and pharmacies in Somalia. Treatment and/or medication will always be expected.  Paying for health care in Ireland will be an unfamiliar practice and it may make some people reluctant to seek health care. In fact, even paying utility bills will be unfamiliar for Somalians as this is not the practice in Somalia where services are provided at no cost. This is important for CWOs and Social Workers to understand.

Child Rearing Practices

Somali families are typically large - seven or eight children is considered ideal. Contraception, and similarly, abortion, are anathema to most Somalians, given the strong Muslim belief that pregnancy is a blessing from God and should not be interfered with.

Prenatal care

Somalian women in Ireland will usually access prenatal care but only if they can be assured of having a female examiner. Hospital births are the preferred norm but heavier reliance is usually placed on the midwife rather than a doctor and the doctor should be female.

Some religious Somali women may insist on fasting during their pregnancy throughout Ramadan, a month-long religious holiday of Muslims. However, the Qur'an (Koran), exempts pregnant women, nursing women and the ill from fasting. Some women are unaware of this exemption and some may wish to observe the fast as a further religious sacrifice despite their pregnant state. However, such a strict fast may have detrimental effects on the pregnant woman and her developing foetus. This should be explained to the woman with cultural sensitivity and respect for her ultimate decision. Amendments can always be made to the ideal diet and mealtime in order to accommodate the woman's cultural and religious beliefs. Comfort, knowledge, and acceptance of her cultural values can strengthen the patient-provider relationship, increase the patient's confidence and trust in her health care provider, and thus, improve patient compliance with recommendations made to her.

Birthing

It is normal for a woman to return to her mothers home for a month or two prior to giving birth. Her mother is the most supportive person at this time. This will not be possible for most Somali women in Ireland and they will most likely feel very isolated. Their husbands will also be unfamiliar with this stage of pregnancy and may feel anxious or reluctant to get involved.

Nearly all Somalian mothers in Ireland will have been infibulated (with a severe from of FGC, sometimes called pharoenic circumcision) and this can present problems during labour due to Keloid formation. The vulval tissue can be fibrosed and rigid, not allowing it to expand as needed during childbirth. This can increase the chances of obstetric complications, such as perineal lacerations and severe asphyxia in the baby. Thus, the maternal mortality risk among women who have been circumcised is doubled, and the risk of delivering a stillborn baby is tripled.  The maternal death rate in Somalia is very high (1 in 7 women). Similarly, the infant mortality rate is very high (126 in 1000 births).

Despite these complications most women fear Caesarean section delivery, as it is thought that the surgery may impede subsequent pregnancies and render the postpartum mother infirm. However, many women are also concerned that episiotomies or even natural childbirth could damage their infibulation. Women from Somalia may express a desire to be re-infibulated after giving birth. While infibulation is against the law in Ireland and many other countries around the world, including some parts of Africa, it is acceptable in Ireland to re-infibulate a woman if she was previously infibulated.

Feeding

Breast-feeding is the norm for Somalians, sometimes for two years or longer. However, some women believe erroneously that colostrum is not healthy for the newborn. This can delay breastfeeding for 24-48 hours. Breast fed babies typically receive supplements prior to six months - animal milks are used in Somalia while formula is accepted in Ireland.  This is because breast milk was considered insufficient and/or because the addition of supplements in the diet was thought to result in a healthier baby.

In addition to breast milk, children of urban Somalians are fed soft foods such as bananas and rice at eight months. Children of nomadic Somalians are not fed any solid food until they are one year old. Most Somali children are fed normal solid foods at eighteen months. Normal adult food mainly consists of carbohydrate and meat; such foods are cooked until they are soft enough for the child to chew.

Somali mothers and the newborn typically remain at home indoors for a period of 40 days called afatanbah. During this time, the mother consumes special recuperative foods, including soup and teas. She also wears earrings made of garlic to ward off the "evil eye." In the past, for similar reasons of protection against the evil eye, the newborn infant of some ethnic groups in Somalia wears a bracelet made of an herb called malmal during this 40-day postpartum period. This herb was also traditionally applied to the umbilicus for one week following birth. This herb is not available in Ireland. At the culmination of this postpartum period, a celebration is held with relatives and friends. Infant care includes massages and warm water baths.

Teething

Somalians associate teething with diarrhea, fever, nausea, and vomiting. Children usually begin teething when they are between nine months and one year, although it can occur as early as four months. Those who get their teeth earlier are thought to have more difficulties. Oil is sometimes placed on the gums to calm teething children, but pacifiers are not traditionally used.

Diet

Somalians prefer to eat shared meals with family or friends. Frying is the most common method of cooking. Somalians like to eat with their fingers. Lamb or goat meat is considered the best meat to eat. Tea is the most common drink and is taken with lots of sugar usually 4-6 times a day. Camel milk is a particular favourite of rural Somalians. There is a widespread belief in Somalia that it also prevents cancer. Homemade cakes are often eaten as snacks.

Religion influences Somali dietary practices in a number of ways. As almost all Somalians are Sunni Muslims only "Halal" foods are allowed. Halal foods include all foods of plant origin and some of animal origin but only if they conform to the religious method of slaughtering. "Haram" are forbidden foods or drinks, including pork, blood and animals not slaughtered in the proper way, alcohol and drugs, and any foods containing ingredients obtained from other haram foods. Westernization appears to have already influenced some aspects of the dietary practices of Somalians. A common concern of most Somali parents is that while they like to cook and eat Somali foods, their chidren are moving more towards a diet of fast foods. French fries, fizzy drinks and high-fat snacks are readily becoming popular in Somali homes in the West. Cheese is now being included among foods regularly eaten by Somalians. Excessive fruit juice consumption by children is also an emerging concern. These practices are observed as contributing to feeding disorders in children.

Dental care

Somalians are fastidious about oral hygiene and traditionally have few cavities although that is changing due to the adoption of bad Western dietary habits. They clean their teeth twice a day and scrape their tongues with a cleaning stick. Bad breath is unacceptable.

Children are taught to clean their teeth when they are eighteen months old and are usually expected to clean their teeth on their own by the time they are three years old. Somalians do not traditionally use toothbrushes, they use a stick collected from the branches of a tree called "Roomay" found in Somalia, or a stick called "Muswaki" made from the root of another type of tree. Both types of sticks are available in Ireland.  Ashes and wood charcoal, derived from tree burning, are also rubbed on the teeth to whiten them. Most Somalians do not use dental floss. Toothpicks are used to pick meat out of teeth.

Many Somalian children have overcrowded mouths, but straight teeth are not as desired in Somalia as in other parts of the world. If a child's teeth are not growing in straight, their mother will push the tooth into place every evening.

Circumcision

Male Circumcision - All Somalian boys are circumcised according to Muslim and tribal law. Most ethnic groups will choose to have the circumcision within a few weeks. Others wait until the child is older but all boys will be circumcised by the time they are 7 years of age.

FGC - An estimated 98% of Somalian women, at 8-10 years of age, have undergone FGC (female genital cutting/circumcision), usually Type III (or infibulation), which consists of the removal of the clitoris, the adjacent labia (majora and minora), followed by the pulling of the scraped sides of the vulva across the vagina. The sides are then secured with thorns or sewn with catgut or thread. A small opening to allow passage of urine and menstrual fluid is left. A traditional midwife or grandmother usually performs the procedure in a non-sterile environment and without anesthetic or painkillers. Sometimes scissors or an unsterilized knife or machete is used to make the incisions, and thorns are used as sutures. The girls' legs are usually bound for a few days to a week to enable healing of the scar. An infibulated woman must be cut open to allow for intercourse on her wedding night, and the opening may then be closed again afterwards to secure fidelity to her husband.

Unlike in other African countries there is no celebration around this ritual in Somalia. However, there is evidence that Somalian women from the cities are increasingly rejecting these more severe forms of FGC for their daughters and are opting for the less severe Sunna type or refusing to have their daughters cut at all.

Discipline

Somalians in Ireland often feel uneasy with regard to their children's safety. In Somalia it is common practice to allow children to play outdoors where they are considered to be safe and protected. Somalians in Ireland are afraid for their children - in particular they fear kidnapping and child abuse - and they may be reluctant to allow their children outside to play without constant direct supervision.

Children are expected to behave well and to not be `wild'. It is usual for parents to use corporal punishment in order to maintain this sense of discipline. It is believed that it is better to instil a sense of fear through discipline rather than allow them a false sense of security within the unsafe world in which they live. Somalians believe that Irish children are `spoilt' and they strive to teach different values to their children.

Somalians have a high regard for parents and mothers in particular. Insulting someone's mother is taken very badly. Indeed, insulting anyone, even in jokes, is not allowed for children and is disapproved of in adulthood as it is seen as disrespectful. Children respect their fathers as the person who gives them security in life. To rebel against a father would threaten a child's security so it is not done. In Somalian culture all children stay in the family home until marriage and banishment would be seen as the ultimate punishment and would be particularly shameful.

Traditional Health Seeking Practices and Beliefs

In Somalia there are traditional medical practitioners - herbalists, bone-setters and religious practitioners. Herbal medicines are widely used, especially for chest and abdominal symptoms; haemorrhoids, blood pressure, diabetes, and headaches. The herbal pharmacopeia is vast, and some recipes are closely guarded by practitioners. However, because only fresh herbs are used it is not possible for Somalians to use these herbal remedies in Ireland. Healers also treat psychosomatic disorders, sexually transmitted diseases, respiratory and digestive diseases, and snake and other reptile bites.

Ritualized dancing is used mostly for psychosomatic disorders, as a ritual of exorcism.  Koranic cures are used as well throughout Somalia and will often be used within the hospital setting whereby the Koran will be read to the patient by family members.

An older traditional healing practice is termed "fire-burning," or cauterization where a special stick is burned and then applied to the skin to treat illnesses such as hepatitis and to remove parasites.

In Somali culture, there is a belief in the "evil eye," which can be given to someone by the purposeful or accidental gaze from an envious or admiring eye. As a result, some harm is done to the person who is being praised or admired. A relevant example of this is when a service provider tells an expectant mother that her baby is big and healthy. While Western culture might interpret this statement as a sign of good news and reason for relief and happiness, a Somali mother may fear that as a result of such praise, some harm will come to the baby.

In addition, health professionals working with any immigrant group should not assume that their patients bring a basic knowledge of reproductive health and anatomy. In Somalia, where there is a culture of strict sexual modesty and sexual taboos a woman might be kept uninformed or actively evade these topics because of embarrassment, shyness, or social stigma. This kind of response, perpetuated by society or by the woman herself, can keep these women misinformed or uninformed about their reproductive health. It can also make it difficult for both the Health Service Provider and the immigrant woman to comfortably broach issues on reproductive health and contraception.

Moreover, because female genital cutting (FGC) is prevalent throughout Somalia, this can affect women's reproductive health knowledge and their cultural perceptions toward sex. In addition, women who have undergone FGC often reject interventions that HCPs commonly recommend to them. For example, according to a study by Calder, Brown, & Rae (1993), about 84% of Somali women in the study were more inclined to reduce fluid intake during urinary tract infections instead of increase it. This is because urination is difficult, particularly for infibulated women, and also because the increased fluids are believed to reduce the effectiveness of the circumcision by softening the tissues. The women also did not find it acceptable to sit in warm water to promote urination, or to wear a pad to absorb any leakage of urine.

Somali women often limit their food intake to limit the size of their baby. This is commonly the case among women who have been infibulated because they may be worried about a difficult delivery due to the small vaginal opening that they have after circumcision. Health service providers should be alert to this practice, which may cause poor gestational weight gain or nutritional deficiencies, further endangering the health of the mother and infant.

Some adult Somalians chew a substance known as "chat" or "quat" - a mild stimulant derived from a plant that stains their teeth green or red and may contribute to cavities and oral health problems. It is used primarily by Somali men.

Somalians who cannot afford dental care may seek treatment from community members known as "Mo-Alem" (teacher). The Mo-Alem have no Western training and use crude tools such as pliers to pull teeth. Mo-Alem are usually the only dental care option available to Somalians who live outside the city. Somalians in Ireland may typically go first to a doctor if they have tooth pain and expect their doctor to refer them to a dentist.

In Somalia there is understanding about the communicability of some diseases, such as tuberculosis and leprosy, and isolation is sometimes performed. 

The idea of preventive care is unfamiliar to most Somalians and when Somalians visit a doctor or hospital in Ireland, they typically expect some form of treatment, such as medication. Thus, visits to the doctor are usually for sick care only. As a result, low utilization of prenatal care and delayed diagnosis of complications in pregnancy may arise in this population group.

Elderly are always looked after by the family.

Life expectancy in Somalia is very low (47 years). When death is imminent, a Muslim cleric, a sheik, is summoned to pray for the person's soul and recite special verses from the Koran. After death, the body is ritually cleansed and clad in white clothes for burial.

Gender Issues

There is strict separation of the sexes in Somalia, and women, including sometimes prepubescent girls, are expected to cover their bodies, including hair, when in public. However, women in Somali culture have considerable status, and many resettled refugee women are highly educated and have held professional positions inside Somalia.

Handshakes are appropriate only between people of the same sex and Somalians may not like to shake the hand of a stranger. The right hand is considered clean, and is used for eating, handshaking, etc; children are taught early to use only their left hand for hygiene during toilet training. Muslims prefer to wash with poured water after a bowel movement. Ritual cleaning of the body, especially before prayers, is dictated by Islam.

Men, in accordance with the law of Islam, will sometimes have more than one wife but no more than four. Marriage usually takes place at a young age - nineteen and over for men but only 15 or 16 for women. Once a girl menstruates she is considered to be a `women' and ready for marriage. Women must be virgins when they marry. While sex outside of marriage does sometimes take place it will never be admitted as it is a crime.

Marriages are usually arranged and will often be based on political and economic ties. A bride price is paid to the groom but it is essentially the property of the bride and if she is divorced she can take her wealth with her. Women can be economically independent and own property, goods and land.

The use of modern contraception is extremely low in Somalia (1%). HIV incidence is very low (0.8% reported in 2000) but STDs are relatively common.

Because of the division of the sexes, female Somalians will prefer female interpreters and health service providers.

Another concern is the common practice of corporal punishment of children, and less frequently, wives. Careful counselling in orientation must be provided to explain the legal ramifications and definitions of abuse in this country.

Ethnic Sub Groups

There are four main ethnic groups in Somalia and numerous smaller minority ethnic groups. There are also ethnic divisions within the four main groups. Many group divisions are based on geographical residence so that a Somalian may feel affiliated to two different groups - the one their family comes from and the one where they have settled. The uniting bond between all these groups is the common use of the Somali language. The four groups are:

Hawiye - the largest group. They live in the south.

Darod - the second largest group who also live in the south.

Rahanwayn - the third group who live in the south.

Isaq - this group live in the north.

Other Ethnic Sub Groups

Bantu - This term is used in Somalia as referring to Somali residents from a Kenyan background. They make up less than 15% of the population. They speak Bantu languages but they do claim Somali ethnicity.

Benadirs - Benadirs are another large ethnic group, originally nomadic who come from Somalia. However, the Benadirs consider themselves a different, elite, class from other Somalians. Due to persecution - and frequent incidences of rape perpetrated by other ethnic groups - they form a large population within the refugee community from Somalia. The tensions between Benadirs and other Somalians remain when they resettle abroad. Interpretation services for Benadirs should make provision for this. Benadirs are devout Sunni Moslems, and are well known for their peace-loving, non-violent ways.

SOURCES and FURTHER RESOURCES

Somalia - Ethnomed

This is a very approachable American site (2006) that gives cultural profiles on 12 different ethnic groups in relation to health. It also presents cultural barriers in seeking effective health care. There are also invaluable links from this site that are related to special interest topics such as cultural considerations for those dealing with death and dying. There are also excellent links for those developing cultural competency, and cultural competency training. This is an invaluable resource site for health care providers. ۞ ۞ ۞ ۞ ۞  

Somalia - Cross Cultural Healthcare

This 10 year old American site gives details of Somali culture and the political situation including religion and language. It covers relevant health related issues such as traditional medical, health seeking practices, medical practices, family issues, maternal and child health, birthing, gender issues, and circumcision. The site presents its most relevant material under the headings of Concepts of Health Care and Medicine and Cultural Barriers to Health Care. ۞ ۞ ۞ ۞ ۞  

Somalia - Charles_Kemp & Baylor School of Nursing

This is a very good American site that describes traditional health seeking practices as well as giving useful facts (i.e. outlining prevalent diseases amongst the target community). It specifically looks at refugee populations and includes excellent links to other sections that give more detail on issues such as women and health, refugee experiences and health, infectious diseases etc. Recommended. ۞ ۞ ۞ ۞ ۞  

Somalia - American Public Health Association

This American general health site has well written articles on traditional health beliefs although it covers broad geographical zones so it is rarely culture specific enough. However it has done a specific case study for Somalia which is well worth reading. ۞ ۞  ۞۞

Somalia to Canada

This very readable Canadian site gives a short account of the county's geography, history, sports, arts, work, family and health. It is socially orientated rather than health focussed, as it is designed to initiate communication and integration between habitual Canadian residents and newly arrived immigrants.  It will therefore not explain aspects of culture to a depth that some health care providers would need. However, it does offer avenues and ideas that could be used to open up a productive communication process between health care providers and clients that would lead to relevant information being exchanged.  ۞ ۞  ۞

Somalia - UNICEF

This reliable UNICEF site gives background information and health related statistics that could prove especially useful for health care providers who need to determine the health and social history of their clients. Some cultural information can also be deduced relatively easily from the statistical detail. There is an emphasis on children's and women's health due to UNICEF's focus on children. ۞ ۞

Somalia - Library of Congress 1992

This site from the US Library of Congress presents an extensive volume on the country, but it is no longer up to date especially where statistical data is sought. However, it is easy to find sections on health and social topics which are very comprehensive. It gives the major diseases that affect the people and it outlines the classical medical services that are available. Although the volume is easy to navigate the writing is not very approachable. It is heavy on fact but gives no information on traditional medicine and cultural issues that could affect access to health. Use as a last resort and be aware that major changes will have taken place in the last decade. ۞

Somalia - BBC

This BBC site will give you a brief overview of the current political situation in each country. This may help you to know what political situation your client may have left behind and what their relations are currently living with. It also gives a brief overview of statistics - population, religions, languages, life expectancy and exports. ۞

Somalia - CIA

This site gives you basic facts and a map of each country. It gives basic demographic details that include religion, ethnicities, health risks, mortality rates etc. which may be useful, especially if comparative material is required. A short synopsis of the political situation in the country is included. ۞

References

Lance A. Rasbridge 1998 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

http://www.apha.org/ppp/red/somalia.htm

Arbesman, Kahler, & Buck, 1993; http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge 1998 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge1998 http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge1998 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lewis, Ahmed, & Hussein, 1996 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Massachusetts Department of Public Health, 1999 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Calder, Brown, & Rae, 1993 in http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lewis, Ahmed, & Hussein, 1996 in http://www.baylor.edu/~Charles_Kemp/rsomali_refugees.htm

Lance A. Rasbridge 1998http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge 1998http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge 1998 http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge 1998 http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

Lance A. Rasbridge 1998 http://www.baylor.edu/~Charles_Kemp/somali_refugees.htm

SPIRASI does not necessarily agree with the facts and opinions presented in this guide or any linked websites.