Tuberculosis in a weak health system, conflict and fragile zone: The monetary value of human lives lost associated with deaths of persons older than 14 years in Somalia.

BACKGROUND: Low tuberculosis (TB) detection and conflict and fragility have overburdened Somalia. This study estimated economic loss associated with TB deaths among persons aged >14 years. METHOD: Using epidemiologic and economic data, we calculated the cost based on the framework of the World Health Organization guide of identifying the economic consequences of disease and injury. Baseline loss is the product of years of life lost, non-health expenditure, and number of deaths. Adjusting for conflict and fragility conditions and growth of non-health expenditure, we discounted the loss at 3% rate. We conducted a sensitivity analysis of epidemiologic and economic factors. RESULTS: In 2017 values, the 9180 reported deaths result in a loss of US$ 44.77 million, a US$ 4877 per death over the discounted years. Conflict conditions would increase the loss by 5.3%, while simultaneous adjustment for conflict and attunement to growth of non-health expenditure would increase the burden by 54% to US$ 67.28 million. Male fatalities account for 59% of the burden. The baseline result is robust to input variations, although sensitivity analysis suggests conflict and fragility conditions account for greater uncertainty of the loss. CONCLUSION: Stakeholders in the healthcare system should minimise the sizeable economic loss by taking measures to enhance surveillance of TB and security.

[Vaccine hesitancy among immigrants during the COVID-19 pandemic ­ a qualitative study]. / Vaksineusikkerhet blant innvandrere under covid-19-pandemien ­ en kvalitativ studie.

BACKGROUND: Vaccination against SARS-CoV-2 has been an important measure in dealing with the pandemic. In Norway, vaccination coverage has been lower in several immigrant groups than in the general population. The aim of this study was to investigate which factors may have played a role in the low uptake rate among immigrants. MATERIAL AND METHOD: Eighty-eight semi-structured, qualitative interviews were conducted remotely in the period March to June 2021. The interviewees consisted of 49 women and 39 men aged 19-78, from ten different countries. In a thematic analysis (NVivo-12), four main categories relating to vaccine hesitancy emerged: system-based factors, factors linked to personal conviction, factors linked to fear and factors linked to trust. RESULTS: Although many of the informants were willing to take the vaccine, several expressed vaccine hesitancy. Lack of evidence-based information and fear of adverse effects were cited as reasons. Vaccine hesitancy was also linked to misinformation and conspiracy theories. Some had no confidence in the vaccination programme or the efficacy of the vaccine. INTERPRETATION: The study revealed that vaccine hesitancy among immigrants was due to a range of factors. The main reasons included lack of information, low health literacy, insufficient knowledge of how the vaccine works, and little trust in the authorities.

The correlation between socioeconomic factors and COVID-19 among immigrants in Norway: a register-based study.

AIM: Immigrants in Norway have higher COVID-19 notification and hospitalisation rates than Norwegian-born individuals. The knowledge about the role of socioeconomic factors to explain these differences is limited. We investigate the relationship between socioeconomic indicators at group level and epidemiological data for all notified cases of COVID-19 and related hospitalisations among the 23 largest immigrant groups in Norway. METHODS: We used data on all notified COVID-19 cases in Norway up to 15 November 2020, and associated hospitalisations, from the Norwegian Surveillance System for Communicable Diseases and the emergency preparedness register at the Norwegian Institute of Public Health. We report notified COVID-19 cases and associated hospitalisation rates per 100,000 and their correlation to income, education, unemployment, crowded housing and years of residency at the group level. RESULTS: Crowded housing and low income at a group level were correlated with rates of both notified cases of COVID-19 (Pearson`s correlation coefficient 0.77 and 0.52) and related hospitalisations (0.72, 0.50). In addition, low educational level and unemployment were correlated with a high number of notified cases. CONCLUSIONS: Immigrant groups living in disadvantaged socioeconomic positions are important to target with preventive measures for COVID-19. This must include targeted interventions for low-income families living in overcrowded households.

Effect of a community-based intervention to increase participation in cervical cancer screening among Pakistani and Somali women in Norway.

BACKGROUND: Norway implemented a regular cervical cancer screening program based on triennial screening in 1995, recommending participation of all women between 25 and 69 years of age. Somali and Pakistani women have the lowest participation in cervical cancer screening in Norway. This study evaluates the effect of a community-based intervention aimed at increasing participation in the screening program among women from these two groups. METHODS: The intervention consisted of an oral 20-25 min presentation in Urdu and Somali on cervical cancer and screening and practical information on how to make an appointment and payment for the test. The participants were invited to pose questions related to the topic after the presentation. This study was carried out in four geographical areas surrounding the capital Oslo between February and October 2017, among women aged 25-69 years from Pakistan and Somalia. We recruited women in the intervention group directly from different community institutions, households, and religious sites. Women from Pakistan and Somalia residing in Oslo were the controls. The absolute intervention effect was measured as difference in absolute proportion of women screened and estimated as the interaction between time and group allocation in a generalized estimation equation model with binomial distribution and identity link function. RESULTS: The percentage of women screened in the intervention group increased, from 46 to 51%. The corresponding increase in proportion in the control group was from 44 to 45.5%. After adjustment for potential confounders the intervention group showed a significant larger increase in participation in the screening program as compared to the control group with an absolute difference in change in proportion screened of 0.03 (95% CI; 0.02- 0.06). CONCLUSIONS: Our findings suggest that theory-based, culturally and linguistically sensitive educational interventions can raise awareness and motivate immigrant women to participate in cervical cancer screening program. In addition, approaching health professionals as well as immigrant women, might improve participation even more. TRIAL REGISTRATION: NCT03155581 . Retrospectively registered, on 16 May 2017.

Culture clash of female Somali adolescents and sexual and reproductive health services in Oslo, Norway.

OBJECTIVE: Culture influences an individual's perception of health needs. The influence of culture also applies to Somali individuals' perception of their sexual and reproductive health (SRH) and uptake of related services. An understanding of female Somali adolescents' SRH needs is vital to achieve inclusive health coverage. No research has, however, been conducted to explore the SRH needs of this population group in Oslo; hence, the aim of this qualitative study was to minimise the knowledge gap. METHODS: Fourteen young women aged 16-20 years were recruited using the snowball technique with purposive sampling. In-depth interviews using a semi-structured interview guide were used to collect data, and thematic analysis was applied. RESULTS: Participants perceived SRH as a very private matter and open discussion of SRH was extremely limited owing to certain Somali cultural beliefs and values. As the participants intend to practise chastity before marriage, they believed that existing SRH services were largely irrelevant and inappropriate. Where they felt the need to access SRH services, participants wished to do so in a way they considered culturally appropriate. CONCLUSION: Somali culture markedly influences individuals' perceptions of SRH services. It is recommended to modify existing SRH services by increasing confidentiality and anonymity in order to take into account the cultural requirements of female Somali adolescents.

Associations of socio-demographic factors with adiposity among immigrants in Norway: a secondary data analysis.

BACKGROUND: Obesity is becoming an important public health challenge, especially among immigrants coming from low and middle income to high-income countries. In this study we examined the relationship between overweight/obesity and various socio-demographic indicators among different immigrant groups in Norway. METHODS: We used data from the Living Conditions Survey among Immigrants 2016, conducted by Statistics Norway. Our study sample included 4194 immigrants from 12 different countries. Participants were asked about a number of topics including health, weight, height, demographic factors, length of residence and employment. We ran logistic regression analysis to determine the odds ratio (OR) of the associations between socio-demographic factors with adiposity among immigrants. RESULTS: Approximately 53% of the sample was overweight/obese. There was a significant difference in overweight/obesity by gender, age, country of origin and marital status. Overall immigrant men were almost 52% more likely to be overweight/obese than women. Women from Somalia had the highest odds (13.1; CI: 7.4-23.1) of being overweight/obese, followed by Iraq (8.6; CI: 4.9-14.9), Pakistan (7.5; CI: 4.2-13.4), Kosovo (7.0; CI: 4.1-12.1), and Turkey (6.8; CI: 4.0-11.6) as compared to the women from Vietnam (reference). Whereas men from Turkey had the highest odds (5.2; CI: (3.2-8.3)) of being overweight/obese, followed by Poland (4.2; CI: 2.7-6.1), Bosnia (4.1; CI: (2.6-6.5) and Kosovo (3.9; CI: 2.5-6.1). The odds for obesity increased with age and odds were highest in the eldest group 45-66 years (4.3; CI: 3.2-5.8) as compared to reference group16-24 years. The odds of being overweight/obese was higher among married (1.6; CI: 1.3-1.9) and divorced/separated/widowed (1.5; CI: 1.1-2.0) as compared to singles. Education, employment status, physical activity and length of residence were not associated with the odds of being overweight/obese. CONCLUSION: The findings of this study call attention to the importance of a greater understanding of the processes leading to obesity among certain immigrant groups in Norway. Moreover, there is a need for culturally adapted prevention strategies targeting immigrant men and women with high rates of overweight/obesity.

A community-based intervention to increase participation in cervical cancer screening among immigrants in Norway.

BACKGROUND: The attendance to cervical cancer screening is low among immigrants in many high-income countries. Although several interventions have been experimentally tested,implementation remains a challenge. Several factors are an impediment, including the lack of methodological descriptions of the development and implementation of such interventions. In this paper,we present in detail the development, methodological challenges and practical implementation of a community based intervention aimed to increase the participation of immigrant women in cervical cancer screening in Norway. METHODS: This study was initially designed as a cluster randomized trial to be carried out in four geographical areas near Oslo between Feb-October 2017. Participants were immigrant women aged 25-69 years from Pakistan and Somalia. This paper describes the theoretical background for the development of the intervention,followed by challenges,the changes in the original design and solutions adopted related to the study design,recruitment and implementation of the intervention. The intervention was developed based on two theoretical frameworks, the Ecological and the Heron's six categories intervention framework. An oral 20-25 min presentation in the language of participants encompassing topics of cervical cancer and screening was given according to the needs detected in focus groups conducted at the beginning of the study,followed by an opportunity to raise questions and answering a short questionnaire. RESULTS: Contrary to the initial study design, this had to be converted into a non-randomised trial due to the difficulties associated with randomization of immigrant families who are finely scattered in heavily populated towns and a high risk of contamination. We therefore adopted a pragmatic approach and recruited women in the intervention areas through a variety of channels and institutions. Neighboring areas were considered to be non-randomised controls. Female researchers with Pakistani and Somali background invited as many women as possible in the intervention areas. Among the women who were invited to participate,42% of the Pakistani and 78% of Somali attended the meetings. CONCLUSION: Despite the careful development of a culturally adapted health intervention in collaboration with the community; randomization and recruitment of immigrants for community trials remains challenging. Nevertheless, sharing strategies to overcome specific challenges related to promoting health interventions for immigrants, can be of potential help to scale-up interventions and for building new research projects. TRIAL REGISTRATION: NCT03155581 . Retrospectively registered, on 16 May 2017.

Access to Norwegian healthcare system - challenges for sub-Saharan African immigrants.

BACKGROUND: Immigrants face barriers in accessing healthcare services in high-income countries. Inequalities in health and access to healthcare services among immigrants have been previously investigated. However, little is known on the sub-Saharan African immigrants' (SSA) access to the Norwegian healthcare system. METHODS: The study had a qualitative research design. We used the snowball technique to recruit participants from networks including faith-based organizations and cultural groups. Forty-seven qualitative in-depth interview and two focus group discussions with immigrants from sub-Saharan African were conducted from October 2017 to July 2018 in Oslo and its environs. Interviews were conducted in Norwegian, English or French, audio-recorded and transcribed verbatim into English. The analysis was based on a thematic approach, using NVivo software. Interview data were analyzed searching for themes and sub-themes that emerged inductively from the interviews. RESULTS: Our findings reveal barriers in two main categories when accessing the Norwegian healthcare services. The first category includes difficulties before accessing the healthcare system (information access, preference for doctors with an immigrant background, financial barriers, long waiting time and family and job responsibility). The second category includes difficulties experienced within the system (comprehension/expression and language, the black elephant in the room and dissatisfaction with healthcare providers). CONCLUSION: Healthcare is not equally accessible to all Norwegian residents. This ultimately leads to avoidance of the healthcare system by those most in need. Lack of seeking healthcare services by immigrants from Sub Saharan Africa may have significant implications for the long-term health of this group of immigrants. Therefore measures to address the issues raised should be prioritized and further examined.

Pupil's perspectives on female genital cutting abandonment in Harari and Somali regions of Ethiopia.

BACKGROUND: Female Genital Cutting (FGC) is a harmful traditional practice that affects the physical and mental health of girls and women in many ways. In Ethiopia, although both governmental institutions and None-Governmental- Institutions (NGOs) launched different campaigns against FGC, their effects on the peoples' attitudes towards the practice have not been deeply investigated yet. Hence, this study particularly aimed to investigate the pupils' perspectives on FGC abandonment in the Harari and the Somali Regional States of Ethiopia where the prevalence of the practice was thought to be high. METHODS: A school-based cross-sectional study was conducted in the Somali and the Harari Regional States of eastern Ethiopia from October to December 2015. While purposive sampling was implemented to select the study areas from the two Regional States, stratified random sampling method was used to select 480 study subjects from those areas. RESULTS: The findings showed that the participants who received information through multiple information channels were more likely to support the abandonment of FGC than those who received information from a single source (p < 0.05). Similarly, the findings indicated that school-based awareness campaigns and TV-based media communications were the main sources of information that influenced a high proportion of young people to support the abandonment of the practice. The findings revealed that the majority of the participants strongly supported the abandonment of FGC. CONCLUSIONS: Multiple information channels that include school-based awareness campaigns were found to be the best way to support the abandonment of FGC. Although the study shows an impressive improvement among the school girls and boys in recognizing the harmful effects FGC, complete abandonment of the practice might not be easily achieved due to its deep-rooted nature. Thus, to quicken the perpetuation of FGC in the stated Regional States, awareness creating campaigns that change the attitudes of youths towards the practice should be delivered through various sources. In this regard, school-based education, school mini-media, social media, and using the co-curricular activities to uncover the danger of this harmful practice could play significant roles in changing the pupils' attitudes towards the practice.

Health care-seeking patterns for female genital mutilation/cutting among young Somalis in Norway.

BACKGROUND: Female genital mutilation/cutting (FGM/C) is a great concern, considering all the potential health implications. Use of health care services related to FGM/C by women who have been subjected to FGM/C in Norway remains to be understood. This study aims to explore the health care-seeking patterns for FGM/C-related health care problems, among young Somalis in Norway. METHODS: A cross-sectional study involving 325 young Somalis in Oslo was conducted in 2014 using respondent-driven sampling (RDS) technique. The RDS was initiated by a small number of recruited seeds, who were given coded coupons to recruit their peers to participate in the study. Eligible recruiters who participated in the study and redeemed their coupons created the first wave of respondents. The first wave further recruited their peers, the second wave. The cycle continued to attain the needed samples. Using interviews and structured questionnaires, data on socio-demographic, FGM/C status and FGM/C-related use of health care were obtained. Logistic regressions were used to compute the odds ratio (OR) and the confidence interval (CI) for the associations between demographic variables, to circumcision status and health care-seeking for FGM/C. This study will focus on the 159 female participants of the total 325. RESULTS: While 51.6% of the 159 women were subjected to FGM/C, only 20.3% of them used health care services for FGM/C-related problems. Women's FGM/C status was associated with age ≥ 12 years at migration, experience of stigma regarding FGM/C practice (p <  0.05), support of FGM/C practice, and place of birth of women (p <  0.05). CONCLUSION: Only one-fifth of the women with FGM/C sought care for FGM/C-related health problems. Our study does not provide the answers to why only a few of them sought care for FGM/C. However, as a large proportion of women did not seek care, it is important to investigate the reasons for this. For, we propose to conduct further research targeting girls and women who have undergone FGM/C to assess challenges in accessing health care services for proper intervention.

Differences in primary health care use among sub-Saharan African immigrants in Norway: a register-based study.

BACKGROUND: Immigrants' utilization of primary health care (PHC) services differs from that of the host populations. However, immigrants are often classified in broad groups by continent of origin, and the heterogeneity within the same continent may hide variation in use among immigrant groups at a national level. Differences in utilization of PHC between sub-Saharan African immigrants have not received much attention. METHODS: Registry-based study using merged data from the National Population Register and the Norwegian Health Economics Administration. African immigrants and their descendants registered in Norway in 2008 (36,366 persons) where included in this study. Using χ2 test and logistic regression models, we assessed the differences in the use of PHC, including general practitioner (GP) and emergency room (ER) services, and the distribution of morbidity burden for immigrants from Somalia, Ethiopia, Eritrea, and Gambia. For the analyses, we used the number of visits and medical diagnoses from each consultation registered by the physician. RESULT: Among the total studied population, 66.1% visited PHC within 1 year. The diagnoses registered were similar for all four immigrants groups, regardless of country of origin. Compared to immigrants from Somalia, the age and sex adjusted odds ratios (OR) for use of GP were significantly lower for Ethiopians (OR 0.91; 0.86-0.97), Eritreans (OR 0.85; 0.79-0.91), and Gambians (OR 0.88; 0.80-0.97). Similarly, we also observed lower use of ER among Ethiopians (OR 0.88; 0.81-0.95), Eritreans (OR 0.56; 0.51-0.62) and Gambians (OR 0.81; 0.71-0.92). However, immigrants from Somalia reduced their use of PHC with longer duration of stay in Norway. Differences between groups persisted after further adjustment for employment status. CONCLUSION: Despite the similarities in diagnoses among the sub-Saharan African immigrant groups in Norway, their use of PHC services differs by country of origin and length of stay. It is important to assess the reasons for the differences in these groups to identify barriers and facilitators to access to healthcare for future interventions.

Health literacy: the missing link in improving the health of Somali immigrant women in Oslo.

BACKGROUND: Existing studies report a positive association between inadequate health literacy and immigrant's adverse health outcomes. Despite substantial research on this topic among immigrants, little is known about the level of health literacy among Somali women in Europe, and particularly in Norway. METHODS: A cross sectional study using respondent driven sampling was conducted in Oslo, Norway. A sample of 302 Somali women, 25 years and older, was interviewed using the short version of the European Health Literacy Questionnaire. Data was analysed using logistic regression. RESULTS: Findings revealed that 71 % of Somali women in Oslo lack the ability to obtain, understand and act upon health information and services, and to make appropriate health decisions. Being unemployed (OR 3.66, CI 1.08-12.3) and socially less integrated (OR 8.17, CI 1.21-54.8) were independent predictors of an inadequate health literacy among Somali women. CONCLUSIONS: Enhanced health literacy will most likely increase the chance to better health outcomes for immigrants, thereby moving towards health equity in the Norwegian society. Therefore, policies and programs are required to focus and improve health literacy of immigrant communities.

Exploring knowledge of autism, its causes and treatment among immigrant and nonimmigrant parents in Somalia\Somaliland.

BACKGROUND: The prevalence of autism spectrum disorders (ASDs) has increased over the recent years; however, little is known about the experience of parents of children with autism in Africa such as Somalia. The aim of this study is to understand the knowledge on autism of Somali parents of children with autism and their perceptions of causes and treatment of ASD. METHODS: We conducted a qualitative study involving 22 parents of children with autism who lived in Mogadishu and Hargeisa; the two largest cities in Somalia. In-depth interviews were used to collect the data. Of the 22 participants, 9 were returned immigrants and 13 were local people (non-immigrants). Data were analysed using thematic analysis. RESULTS: The data revealed that most of the parents hold the belief that their children's autism were caused by the measles vaccine. The findings demonstrated that parents sought diagnosis and treatment care from outside Somalia due to the lack of experience of health providers in the diagnosis and treatment of autism. The data also revealed a lack of knowledge about autism among the public with resultant stigma and discrimination against children with autism and their families. CONCLUSIONS: Efforts to increase public knowledge on autism, its causes and treatments are of paramount importance, while a public health campaign designed to eliminate the stigma subjected to children with autism is necessary to improve the quality of life of children with autism and their caregivers. Finally, to counteract vaccine hesitancy, particularly in response to the measles vaccine, health policy makers should take steps to separate the cooccurrence of the onset of autism symptoms and the provision of the measles vaccine.

Does living in major towns favor institutional delivery in Somalia?

Background: In developing countries, institutional delivery is a key proven intervention that reduces maternal mortality and can reduce maternal deaths by approximately 16%-33%. In Somalia, only 32% of births are delivered in a health facility with the assistance of a skilled healthcare provider. We aimed to investigate the factors hindering women from giving birth at healthcare facilities in major towns in Somalia, where most of the health facilities in the country are concentrated. Methods: A community-based health survey was carried out in 11 major towns in Somalia between October and December 2021. A structured and pretested questionnaire was used to collect data from 430 women who gave birth in the last five years. Women were recruited through convenient sampling. Descriptive statistics were used to summarize the data, and binary and multivariable logistic regression analysis was performed. Adjusted odds ratios (AOR) with 95% CI were estimated to assess the associations. Results: The overall prevalence of institutional delivery was 57%. Approximately 38% of women living in Mogadishu and 53% living in another ten towns give birth at home. Women who had poor knowledge of the importance of health facility delivery had nearly four times higher odds of delivering at home (AOR 3.64 CI: 1.49-8.93). Similarly, those who did not receive antenatal care (AOR 2.5, CI: 1.02-6.39) and those who did not receive a consultation on the place of delivery (AOR 2.15, CI: 1.17-3.94) were more likely to give birth at home. The reasons for home delivery included financial reasons, the long distance to the health facility, and the fact that it was easier to give birth at home. Conclusion: The study found that home delivery is high in major towns in Somalia and is associated with a lack of understanding of the importance of health facility delivery, not using ANC, and not receiving consultancy about where to give birth. Primary health care should strengthen information, education, and communication activities. Since the health care system in Somalia is overwhelmingly private, the government may consider access to free and within-reach ANC and health facility delivery for women and girls from families who cannot pay the ANC and childbirth delivery cost.

Factors influencing the motivation of maternal health workers in conflict setting of Mogadishu, Somalia.

Motivated health workers play an important role in delivering high-quality maternal health services, especially in low-income countries where maternal mortality rates are high, and shortages of human resource for health is prevalent. The aim of this study is to investigate maternal health workers' motivation in three tertiary hospitals in Mogadishu Somalia. We used a semi-structured questionnaire that was validated and widely used in Sub-Saharan Africa to collect data from 220 health workers across three tertiary hospitals in Mogadishu between February and April 2020. Health worker motivation was measured using seven constructs: general motivation, burnout, job satisfaction, intrinsic job satisfaction, organizational commitment, conscientiousness, timeliness and attendance. A multiple linear regression analysis was performed to determine the predictors of health worker motivation. The results show that male health workers have a higher work motivation, with a mean score of 92.75 (SD 21.31) versus 90.43 (SD 21.61) in women. As regards to profession, significant correlation was found between health workers' motivation and being an assistant (coeff, 6.873, p = 0.001), nurse (coeff, 5.111, p = 0.000), physicians (coeff, 2.898 p = 0.042), pediatric assistants (coeff, 2.878, p = 0.048), midwife (coeff, 3.822, P = 0.01), and others (supervisor and pharmacist) (coeff, 5.623, P = 0.001). Unexpectedly, the gynecologists and midwives were the least motivated groups among the different professions, with mean scores of 83.63, (SD: 27.41) and 86.95 (SD: 21.08), respectively. Of the aforementioned seven motivation constructs, the highest mean motivation scores (from 1-5) were observed in conscientiousness and intrinsic job satisfaction. These results highlight the importance of targeted interventions that increase female health workers' motivation, particularly gynecologists and midwives. This can be done by providing non-financial incentives, in addition to encouraging their participation in the decision-making process. Further research is needed to investigate the effect of a lack of motivation among gynecologists and midwives on maternal health in Somalia.

Constraints to maternal healthcare access among pastoral communities in the Darussalam area of Mudug region, Somalia "a qualitative study".

Background: While countries embrace efforts to achieve Sustainable Development Goals (SDG) goal 3.1 (to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 and end preventable deaths of new-borns and children), an estimated 2.5 million pastoralists in Somalia are struggling to access maternal and child healthcare services. Institutional delivery and access to antenatal care remained to be a challenge in Somalia, where pastoralism is a common means of livelihood. The aim of this study is to explore the maternal health services available for settled pastoralists (transhumant) and their families who still practice nomadic pastoralism in the Mudug region of Somalia. Methods: A qualitative study, including 14 interviews and one FGD, was conducted in Darussalam village (a transhumant village along the border between Somalia and Ethiopia), Puntland State, from December 2022 to January 2023. The study participants were community members who support the maternal and child health clinic (MCH), village administration, and health providers. Results: We found that the efficiency of the health facilities that serve for pastoralist women and children are hampered by staff-related, supply-related, patients-related and referral-related constraints. This study highlights that the absence of essential supplies, the unmet need for training among the staff as well as the absence of important facilities in the MCH such as ambulance and blood bags. Conclusion: Numerous strides could be made in the provision of affordable maternal healthcare to pastoralist communities in Darussalam areas of the Mudug region when organizations that support health care in Somalia and the Ministry of Health include pastoralists' healthcare in their priorities.

Prevalence of diabetes foot ulcers and associated factors among adult diabetic patients in three referral hospitals in Mogadishu, Somalia.

Background: Diabetes mellitus (DM) causes significant morbidity and mortality in sub-Saharan Africa (SSA), including Somalia. Among diabetic patients, diabetic foot ulcers (DFUs) constitute the largest proportion of admissions, amputations, and mortality. The aim of this study is to assess the prevalence of diabetic foot ulcers and subsequently determine factors associated with it among diabetic patients at three major hospitals in Somalia. Methods: An institutional-based cross-sectional study was conducted among 193 diabetic patients between August and November 2022. All eligible diabetes patients who were attending De Martini Hospital, Madina General Hospital, and Deynile General Hospital during the study period were included in the study. Patients were interviewed using a structured questionnaire. We collected demographic, clinical, and behavioral variables from all participants. A bivariate and multivariable logistic regression model was fitted to identify factors associated with diabetic foot ulcer. An odds ratio with a 95% confidence interval was computed to determine the level of significance. Result: The mean age of the study's participants was 50.9 ± 13.6 years. The prevalence of diabetic foot ulcer was 15%. Patients who were either overweight or obese (OR 4.63, CI: 2.08-10.30), had a lack of family support in managing diabetes (OR 3.33, CI: 1.74-6.36), and did not check their feet regularly were more likely to develop DFU (OR 1.99, CI:1.08-3.66). Conclusion: Increased body mass index, lack of family support, and not checking feet regularly were associated with DFUs. The high prevalence of DFUs and the plethora of needs of people with DFUs pose challenges for health care. A coordinated health care system is necessary to meet the needs of diabetic patients and prevent DFUs.

When female circumcision comes to the West: attitudes toward the practice among Somali Immigrants in Oslo.

BACKGROUND: Female circumcision (FC) has lifelong adverse social and health consequences for women, and its abolition will not only enhance the health of children and women, but also promote gender equality. Like many other Western countries, Norway hosts a large proportion of immigrants from FC-practicing countries, though primarily from Somalia, which is the country with the highest prevalence of FC in the world. A behavioral change by the practicing communities has the best chance to successfully and sustainably eliminate this practice. However, FC prevention programs require a behavioral surveillance that monitors the process of change, with this being the first quantitative study since the major migration of the Somali community to Norway began in 1991 to investigate whether or not Somali immigrants' attitudes toward the practice has improved in favor of its abandonment. METHODS: A cross-sectional study using a respondent-driven sampling (RDS) was conducted in Oslo from April to June of 2011. A sample of 214 persons was interviewed, using structured questionnaires. RESULTS: The results show that 70% of Somalis in Oslo support the discontinuation of all forms of FC compared to 30% who support its continuation, with the latter group more likely to be people who lived in Norway ≤ 4 years. Of the 10 girls who came to Norway at the age of ≤ 7 years, only one was circumcised, though whether the circumcision occurred before or after the girl's arrival in Norway remains unclear. The perception that FC is required by religion was the sole factor to be significantly associated with an ongoing support of FC. CONCLUSION: The study reveals that Somalis in Oslo demonstrate a trend to abandon this practice over time. Nevertheless, the 30% of the people who still support its continuation, and who are primarily newly arrived immigrants, require a targeted intervention that is implemented in the early phase of the immigrants' arrival.

Health disparities, and health behaviours of older immigrants & native population in Norway.

We aimed to investigate and compare activities of daily living (ADL), instrumental ADL (IADL), poor self-rated health and the health behaviours among immigrants and the native population in Norway. We present results from analysis of two Norwegian surveys, (Living Conditions Survey on Health from 2015, Living Conditions Survey among Immigrants 2016). Using logistic regression models, odds ratios were estimated for functional ability, self-reported health, and health behavior among immigrants, with Norwegian born being the reference category. The first model was controlled for age and gender and the second model was additionally adjusted for educational level. Our analysis included 5343 participants, 2853 men (913 immigrants), and 2481 women (603 immigrants), aged 45-79 years. The age-group 45-66 years includes n = 4187 (immigrants n = 1431, men n = 856; women n = 575) and 67-79 years n = 1147 (immigrants n = 85, men n = 57; women n = 28). The percentage of Norwegians having ≥ 14 years of education was 86%, as compared to 56% among immigrants. The percentage of immigrants with no education at all was 11%. The employment rate among the Norwegian eldest age group was nearly double (14%) as compared to the immigrant group. Adjusted for age, gender and education, immigrants had higher odds than Norwegian of ADL and IADL, chronic diseases and overweight. There were no differences between immigrants and Norwegians in prevalence of poor self-reported health and smoking. Overall elderly immigrants are worse-off than Norwegians in parameters of health and functioning. Knowledge about health and functioning of elderly immigrants can provide a basis for evidence-based policies and interventions to ensure the best possible health for a growing number of elderly immigrants. Furthermore, for a better surveillance, planning of programs, making policies, decisions and improved assessment and implementation, ADL and IADLs limitations should be included as a variable in public health studies.

Uptake of Covid-19 Preventive Measures Among 10 Immigrant Ethnic Groups in Norway.

Background: A pessimistic view of the impact of Covid-19 on immigrants has generated an interest in exploring the role of socio-economic and cultural factors on excess infection, hospitalization and death among immigrants. Nowhere in the world is such interest more palpable than in Western countries, including Norway. An expanding amount of literature has demonstrated that preexisting socio-economic inequalities have affected Covid-19 control programs through a disruption of immigrants' uptake to preventive measures. Nonetheless, until very recently, no qualitative research has been conducted to address the impact of socio-economic and socio-cultural factors on immigrants' uptake on preventive measures of Covid-19 in Norway. Methods: An interview-based qualitative study consisting of 88 participants (49 women and 39 men) from 10 immigrant ethnic groups were carried out. Participants were recruited through purposive sampling and snowballing. In-depth interviews were held through telephone or online for those who have experience in the use of zoom or teams. Data were analyzed using thematic analysis. Results: We found that participants' attitudes toward the pandemic in general, and more specifically their adherence to preventive measures, have increased over time. However, the number of barriers that hinder immigrants from adhering to preventive measures were identified and classified more broadly into three main subthemes: (1) socio-economic barriers; (2) socio-cultural barriers, and (3) other barriers. Socio-economic barriers include overcrowded households, working in first-line jobs, education and language. Socio-cultural barriers include collectivist culture, religious fatalism and risk perception toward the pandemic. Conclusion: To reduce the health inequality that arises from overcrowded housing, there is a need for a long-term strategy to help improve the housing situation of low-income immigrant families that live in overcrowded households. In addition, increasing health literacy and more generally, the integration of immigrants, may also reduce the effect of socio-cultural factors on an immigrant's uptake of preventive measures.