Clinical and Health Affairs
Use of the Emergency Department by Somali Immigrants and Refugees
By Pamela J. DeShaw, R.N., M.P.H.
Abstract
Staff at a hospital emergency department (ED) located in an urban neighborhood densely populated by Somali immigrants and refugees have observed that a large number of Somali patients use the ED for care that is normally provided in a clinic setting. This article reports on the Somali population’s use of the ED for such care. It also explores Somali traditions and culture in order to shed light on this population’s health care practices and attitudes toward the medical system in this country, and it makes recommendations consistent with those findings for more effectively meeting the health needs of Somalis.
Large numbers of Somali immigrants and refugees began resettling in Minnesota in 1993, two years after the onset of the civil war in their home country.1,2 Today, more Somalis live in Minnesota than anywhere else in the United States. Unofficial estimates of the number of Somalis living in Minnesota range from 10,000 to 70,000.1 In 2000, 11,164 Somalis in Minnesota responded to the 2000 U.S. Census, and of those, 7,316 indicated that they lived in Hennepin County.3,4
Many of the Somalis who have come here were forced to leave their homeland out of fear of persecution and death. They lived in refugee camps in neighboring African countries before being granted refugee status and transferred to a Western country.5 Because of the living conditions in Somalia and the camps, a number of refugees arrived in the United States with medical problems. The Minnesota Department of Health (MDH) has reported that the refugees from Africa have high rates of tuberculosis and intestinal parasitic infections.4 The Africans also have low rates of documented immunizations. Untreated mental health problems, such as depression and post-traumatic stress disorder, also have been common among Somali refugees.6
Although many Somalis have adapted well to certain aspects of life in the United States, they have struggled to understand the health care system. Evidence of this is shown in their use of hospital emergency departments (EDs) for care that is normally provided in a clinic. Although the race and ethnicity of patients have not been documented in hospital records, staff in a Minneapolis hospital have observed that Somali patients often use the ED for routine care rather than exclusively for emergency medical needs.
History of Somalia
Somalis’ use of American health care services today, specifically their frequent use of the ED for routine care, can be better understood in the light of their history and traditional health care practices.
As early as 100 AD, the ancestors of present-day Somalis inhabited what is now Somalia.5 People from Arabia, Persia, India, and Portugal gradually settled along the coast of eastern Africa, while the Somalis lived inland.7 Arabs ruled the southern coast of Somalia from the 9th century until European colonization in the mid 1800s. Colonial rule by the British, French, and Italians divided the country into three respective “Somalilands” until 1960, when the British- and Italian-controlled regions united to form the modern Somali Republic.5,7
The Somali Republic was undermined by internal corruption and clan rivalries despite efforts by President Mohammed Siad Barre to reorder society by declaring Somalia a socialist state in 1969.7 Barre’s government collapsed in 1991 following gradually increasing clan-based conflicts and political disintegration. Civil war ensued, and there has been no effective government in Somalia since 1991. The country’s people, who are Muslim and primarily were rural—often nomadic or semi-nomadic herders, farmers, or fisherman, have since been subjected to infectious diseases, violence, epidemics, and famine.7
Health Care in Somalia
Traditional medicine was common in Somalia, especially in rural areas.8 Traditional healers were usually male elders who learned their skills from older family members. Traditional medicine was used to treat problems such as broken bones, infectious diseases, hunchback, and facial droop. Prayer, herbs, and fire-burning (the process of applying the tip of a heated stick to a part of the body) were frequently used for healing.
Spirits were believed to live within each person.8 Symptoms of illness such as fever, headache, weakness, and dizziness were believed to occur when the spirits become angry. Traditional healers helped to cure illnesses caused by spirits with a healing ceremony that involved reading from the Koran, burning incense, and eating certain foods. Somalis also believed in the “evil eye,” which can be given to a person on purpose or accidentally by praising that person and, thereby, bringing harm to him or her.
Both males and females are circumcised as young children.8 Muslim Somalis view circumcision as a rite of passage and a prerequisite for marriage. Uncircumcised persons are considered unclean. Approximately 98 percent of females born in Somalia have experienced infibulation, the most severe form of circumcision. Infibulation involves the removal (often with a sharp stone) and suturing (usually with thorns) of most of the external genital tissue, including the clitoris, the labia minora, and the labia majora. The procedure leaves a small posterior opening the diameter of a pencil through which urine and menstrual blood can flow.9 Infection, hemorrhage, and other health complications often result from infibulation.
Most Somalis living in or near urban areas before the civil war were treated in free and government-owned clinics located within hospitals.5 Somalis who could afford to pay had the option of receiving care at private clinics.8 Nongovernmental organizations (NGOs) such as the Red Cross and organizations sponsored by the United Nations sometimes ran clinics in rural areas. Fever (usually caused by malaria), vomiting, and diarrhea were the most common complaints that brought Somalis to the hospital. Patients almost always received an antibiotic or other medicine in the form of a pill or an injection from the hospital-based clinics. Medications could also be purchased, with or without a prescription, at the many pharmacies found in cities and towns. The majority of Somalis associate doctors, nurses, and hospitals with sick care. The concept of using the health care system to keep people healthy, such as for well-child care and routine prenatal visits, is unfamiliar to them.10
Much of the health care system in Somalia has been destroyed as a result of the civil war, famine, and drought.7 Few hospitals continue to function. Clinics are privately owned and expensive, or run by NGOs. However, many have been closed as a result of the violence. Tuberculosis, malaria, hepatitis B, parasitic infections, depression, and other diseases are prevalent. People suffer from poor nutrition, the effects of consuming unsafe water, and lack of medical care. Although there is no official tracking system at present, it is estimated that the average life expectancy in Somalia in 2001 was 46.6 years of age, and the estimated infant mortality rate was 123.97 per 1,000 live births.11
Experience with Health Care in the United States
The literature reports that reliance on hospitals as a regular source of care when ill is common among Somali families who live in the United States.12 Studies have shown that these families are more likely to use the ED regularly for care if they live in the inner city, live close to an ED, live in a family headed by a female single parent, live in poverty, live in households headed by less-educated adults, if they do not speak English, and if their primary doctor is not available.12-15 In one study of Ethiopian and Somali families in Minneapolis that was conducted by the Minneapolis Way to Grow organization, more than half of the families who participated consisted of mothers, married and unmarried, raising children alone.16 Their husbands may be living in Somalia or in refugee camps. The families tended to live in neighborhoods south of downtown Minneapolis, with many living in high-rise apartment buildings located near a hospital.
The fact that the ED is always available and that clinics have limited hours and services also increases the potential for using the ED for routine sick care.17 Other factors associated with ED use for routine care are parenting skills, ability to evaluate the severity of an illness or injury, home safety practices, lack of knowledge of the health care system, and the satisfaction of family members with primary care clinics.12,13,18 Other studies have shown that use of the ED is based more on whether people have a primary physician or clinic than if they have insurance or are on Medical Assistance.19
The Study
To better understand the way Somalis view health care and the reasons why they rely on the ED rather than clinics for care, we conducted interviews with 15 men and 15 women who are either Somali, familiar with the Somali culture, and/or familiar with the health care needs of Somalis. Twenty-seven of the participants were Somali community leaders or Somalis employed in health-related professions; three were Caucasian physicians who treat a large number of Somalis in their practices.
According to participants, Somalis expect high-quality medical treatment, the availability of advanced technology, and the best doctors and nurses. They also expect to get medicine when they see a doctor in the United States. Many Somali patients leave the ED or clinic disappointed when they are told to go home, rest, and drink fluids as treatment for viral infections. They expect medicine and a cure. Furthermore, they expect the doctor to know what is wrong with them. Many participants stated that a physician should understand what is causing an illness without asking any questions.
One participant commented, “Their expectation is that with all our money and technology and resources put into health care, ailments … from which they have suffered for a very long time might be able to be cured with all the things we have to offer … there probably is a cure waiting for them; all they have to do is come somewhere and get evaluated.” Another participant noted, “They expect a lot of medicine from the doctor … Just to give them something to make them OK. Here … if the doctor finds out the patient has had a virus or a cold, no infection, no major problems—no medication. He says, ‘Drink a lot of water and rest.’ They get really mad. They say, ‘Are you sure he is a doctor, because I’m supposed to have something. I’m feeling not well. I’m supposed to get some medicine.’ Some doctors also give them Tylenol, and then they still want some medicine … they think, ‘the doctor must confirm that something is wrong with me.’”
Somalis use the ED rather than the clinic for routine care of illnesses for many reasons. One reason noted by study participants was that the ED is like the walk-in hospitals in Somalia and, thus, familiar. On the other hand, primary care clinics are not familiar in concept or practice to many Somalis. One participant said, “When we were in Somalia, there was no identification of the emergency room and the hospital. There was no differentiation. People went to the hospital when they were ill. They went to the hospital and were admitted. There was no ER system in Somalia.” Also, many Somalis wait until they are too sick to go to the clinic, and thus need to go to the ED for treatment.
Other reasons given for overuse of the ED by Somalis were changes in their insurer’s provider network that leave them confused as to where they should go for primary health care, lack of health insurance, and inability to read and understand insurance or clinic information. Lack of interpreters at clinics, lack of transportation, child care needs, and a fear of the American health care system are other reasons why Somalis turn to the ED.
♦ Discussion
One of the reasons why Somalis don’t get preventive health care—and thus end up in the ED for routine illnesses—is that preventing sickness is a foreign concept. Somali refugees do not usually go to the doctor for routine checkups. However, when they understand the reasoning behind preventive measures such as immunizations, health screenings, and prenatal care, they readily adopt them. Somalis are eager to learn how to independently access care.1 The problem is that the majority do not have the knowledge to make effective use of preventive care. Further, their belief that sickness is Allah’s will does not lead them to make an effort toward preventing disease.
Also, lack of trust in the health care system, lack of Somali health care providers, lack of insurance, lack of education, and working night shifts discourage Somalis from going to clinics. In addition, encounters with American health care professionals who don’t understand Somali culture or language, tropical diseases, infibulation, and how to identify and treat depression and post-traumatic stress syndrome in Somali patients—who believe you are either crazy or not crazy—can discourage Somalis from seeking any health care.
As significant a barrier to care as language and the lack of interpreters at clinics is the difference between Somali and American concepts of time. Most Somalis have never owned a clock or kept time in a formal manner. A meeting scheduled for tomorrow afternoon in Somalia meant that any time tomorrow would be an acceptable time to arrive. Somalis are often late for or miss clinic appointments, stating they forget the time. One participant commented, “We did things as they came.” Another participant noted, “The doctor is there anyway. He was not there [just] for me, so why bother calling.”
♦ Recommendations
Although study participants cited many factors that discourage Somalis from seeking preventive care, they suggested that Somalis can and are likely to change with education. Education is highly valued by Somalis and was considered by study participants to be the best way to reduce Somalis’ use of the ED. Almost all of the study participants supported the idea of providing health education in EDs. One suggestion was to open walk-in health resource centers in EDs; another was to hold open meetings and health fairs. Participants also suggested partnering with religious leaders and community leaders to provide health information to the community.
Somalis need to be educated about insurance, preventive care, first aid, CPR, illnesses, nutrition, exercise, and female circumcision and its health consequences. Because the Somali society is an oral one, people receive most of their information regarding where to get health care from family and friends, according to study participants. Ninety percent of participants in the Way to Grow study said they relied on friends for information regarding resources and services in the community.16 One Somali participant in our study stated, “If you have a good message to tell Somalis, tell it to one Somali. In one day, the message will be heard over the whole community.” Another explained it this way: “Many of them [Somalis] are illiterate in their own language. It is a waste of money to translate documents into Somali. No one reads it. But, if it is visual—videos or cassette tapes—they might listen and they can borrow.” Somali community members can be trained to teach other Somalis about health as well as learn how to treat themselves for minor illnesses and injuries.
Conclusion
The study participants offered insight into the best ways to approach Somalis in order to obtain the best outcomes possible from interventions geared toward increasing preventive and primary care as well as discouraging use of the ED for routine care. Somalis want to assimilate into American society in many ways, and community education is a good way to get the message out about the importance of preventive care and where to go for routine medical care. The ED was identified as an ideal location for a health resource center that could provide audio- and videotaped information and classes on topics such as preventing disease, CPR, nutrition, and exercise. For interventions to succeed, it is critical to include members of the Somali community in planning, implementing, and evaluating culturally appropriate health education.
Study participants also indicated that clinics can help Somalis access health care effectively and efficiently and, therefore, reduce their use of the ED for routine medical care. Clinics can provide interpreters with training in health care, call Somali patients to remind them—in Somali—of appointments, involve Somali staff and patients in the development of health education projects, teach providers about the Somali culture, and assist patients as they navigate the health care system. The bottom line is that health education in the Somali community needs to be provided in a manner that is compatible with Somali culture and traditions. In addition, Somalis must be motivated to participate in the design and delivery of health education. MM
Pamela DeShaw is a staff nurse in the emergency department at the University of Minnesota Medical Center, Fairview Riverside campus. She is also the executive director of Family Opportunities for Living Collaboration, a nonprofit organization that connects individuals and organizations that address the needs of residents of the Cedar Riverside and surrounding Minneapolis neighborhoods.
This study was funded in part by the Division of Epidemiology in the School of Public Health, University of Minnesota.
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