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.

COVID-19 Vaccine Acceptability and Adherence to Preventive Measures in Somalia: Results of an Online Survey.

Most countries are currently gravitating towards vaccination as mainstay strategy to quell COVID-19 transmission. Between December 2020 and January 2021, we conducted a follow-up online survey in Somalia to monitor adherence to COVID-19 preventive measures, and COVID-19 vaccine acceptability and reasons for vaccine hesitancy. Adherence was measured via a composite adherence score based on four measures (physical distancing, face mask use, hand hygiene, and mouth covering when coughing/sneezing). We analyzed 4543 responses (mean age: 23.5 ± 6.4 years, 62.4% males). The mean adherence score during this survey was lower than the score during a similar survey in April 2020. A total of 76.8% of respondents were willing to receive the COVID-19 vaccine. Flu-like symptoms were more frequently reported in the current survey compared to previous surveys. Multiple logistic regression showed that participants who experienced flu-like symptoms, those in the healthcare sector, and those with higher adherence scores had higher odds for vaccine acceptability while being a female reduced the willingness to be vaccinated. In conclusion, our data suggest that the decreasing adherence to COVID-19 preventive measures may have caused increased flu-like symptoms over time. COVID-19 vaccine acceptance in Somalia is relatively high but could be improved by addressing factors that contribute to vaccine hesitancy.

COVID-19 in Somalia: Adherence to Preventive Measures and Evolution of the Disease Burden.

Following the COVID-19 outbreak in Somalia, strict preventive measures were implemented by the government. We assessed adherence to the government recommendations via two consecutive online cross-sectional surveys between April and July 2020. A five-point adherence score was constructed based on self-reported observance of five preventive measures (physical distancing, face mask use, hand hygiene, mouth covering when coughing/sneezing, and avoidance of touching the face). 4124 and 4703 responses were analyzed during the first and second survey, respectively. The mean adherence score decreased from 3.54 ± 1.5 in the first survey to 3.40 ± 1.6 during the second survey; p < 0.001. More participants experienced at least one flu-like symptom during the second survey (38.2%) compared to the first (16.2%); however, the proportion of positive COVID-19 tests in the first (26.9%) and second survey (26.5%) was similar. The ordinal logistic regression model identified the following predictors for high adherence scores: female gender (odds ratio (OR) = 1.715 (1.581-1.861), p < 0.001); being a healthcare worker/student (OR = 2.180 (2.000-2.377), p < 0.001); obtaining COVID-19 information from official sources (OR = 1.460 (1.341-1.589), p < 0.001); and having postgraduate education (OR = 1.679 (1.220-2.307), p < 0.001). Conversely, obtaining COVID-19 information from social media and residing in urban settings were associated with lower adherence. Targeted and context-specific adaptations of the COVID-19 response may be required in Somalia.

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.

Barriers to access to the Norwegian healthcare system among sub-Saharan African immigrant women exposed to female genital cutting.

INTRODUCTION: Millions of women and girls have been exposed to female genital cutting (FGC). The practice of FGC extends beyond countries in Africa and Asia in which it is traditionally practiced. Women living with FGC in Norway have been reported to be in need of healthcare, but there is evidence of suboptimal use of healthcare services among this group, and we lack the women's perspective about this problem. This study aims to explore the experiences and perceptions hindering access and use of the Norwegian healthcare system among sub- Saharan African (SSA) immigrant women exposed to FGC. METHOD: This qualitative research was conducted using purposive and snowball sampling to recruit thirteen SSA immigrant women in Norway previously exposed to FGC. Interviews were conducted from October 2017 to July 2018. The Interpretative Phenomenological Analysis method was used. RESULTS: The findings indicate that women experience barriers both in reaching out to the healthcare system and within the healthcare system. Barriers prior to contact with the healthcare system include lack of information, husband and family influence on healthcare, and avoiding disclosing health problems. Barriers within the healthcare system include care providers with insufficient knowledge and poor attitudes of care providers. CONCLUSION: This study reveals multiple barriers to healthcare access that co-exist and overlap. This indicates that SSA immigrant women are 'left behind' in being able to access and use the Norwegian healthcare system. Therefore, appropriate interventions to improve access to healthcare should be considered in order to reach Universal Health Coverage, thus having a positive impact on the health of these women. Equitable healthcare should be reflected in policy and practice.

Barriers and facilitators to contraceptive use among Somali immigrant women in Oslo: A qualitative study.

BACKGROUND: The European Action Plan for Sexual and Reproductive Health emphasizes the importance of improving access to contraceptive services for disadvantaged groups. However, a prior study showed that the prevalence of abortion is two times higher among refugees compared to non-immigrants in Norway. Similarly, a recent study reported that 50% of Somali women in Oslo had unintended childbirth on one occasion or more. These findings are supported by several studies in Europe that showed immigrant and refugee women have higher rates of unintended pregnancy and abortion than Non-immigrant women, and more than half of immigrants, who seek abortion are not using any form of contraception, raising concerns about their access to utilization of modern contraception. However, none of these studies have explored reasons underlying immigrant women's underutilization of modern contraception. The present study aimed to explore the barriers and facilitators to contraceptive usage among Somali immigrant women in Oslo area. METHODS: A qualitative study using unstructured in-depth interviews with twenty one Somali women of reproductive age, >18 years, was conducted in Oslo from May-August 2018. The participants were recruited using purposive sampling method. Interviews began with a general question and were followed with some probing questions, and were continued until data saturation was reached. Data were analyzed using thematic analysis. RESULTS: Although the majority of the participants were educated, aware of the importance of contraceptive methods and interested in child spacing, systemic and socio-cultural barriers were found to be hindering their access to contraception. Several barriers were identified, including: language problems, lack of adequate information, religious beliefs, gender roles and social pressure. CONCLUSION: Eliminating the barriers which prevent women from receiving their desired form of contraception will have important public health implications, including lengthening inter-pregnancy intervals, and fewer unplanned pregnancies and abortions. These findings can support policy makers, civil society organizations and health providers to develop cultural sensitive programmes and educational interventions, which help Somali immigrant women overcome the identified barriers to contraception.

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.

Unmet needs for contraception: A comparative study among Somali immigrant women in Oslo and their original population in Mogadishu, Somalia.

INTRODUCTION: Unmet need for contraception is defined as the proportion of fertile individuals who do not use contraceptives despite wanting to space or limit their childbearing. Studies show that immigrant women in Europe, have higher rates of unintended pregnancies and abortion than native born women. Somali women, have the highest fertility rate in Norway which is much higher than the total fertility rate in Norway (4.0 vs. 1.7). This study investigates the unmet need for contraception among Somali immigrant women in Oslo, Norway, compared to their original population in Mogadishu, Somalia. METHODS: A community based, cross sectional study was carried out among Somali women in Oslo (N = 228) and Mogadishu (N = 229) from May to December 2018. Pre-structured questionnaires were given to women who were recruited through snow-ball sampling. Data was analyzed using SPSS version 25. We performed a chi-square test for the analyses of categorical variables, a t-test for continuous variables and multivariate logistic analysis to determine the association between exposure and outcome variable. RESULTS: The unmet needs for contraception among Somali women in Oslo was 20.2%, which is similar to unmet needs for contraception of women in many sub-Saharan African countries. The unmet needs for Somali immigrant women in Oslo (20.2) is two times lower than that of their original population in Somalia (48.5). The odds of having unmet needs for contraception was nearly, three times higher among Somali women in Mogadishu compared to those in Oslo (OR: 2.6, CI: 2.56-7.68). The mean intended fertility was 4 among the women in Oslo and 10.8 in Mogadishu. About 13.4% of study participants in Oslo and 86.6% of those in Mogadishu consider modern contraception irrelevant for women's health. Nearly 50% of women in both places had unintended childbirth on one or more occasion. CONCLUSION: The study results show the prevalence of unmet needs for contraception among Somali immigrant women Oslo, is 4 fold higher than that of Norway (20.2 vs 5.5). Information Education Communication to both men and women, may reduce the high unmet need for contraception and also improve partner communication on family planning among Somali immigrants in Oslo. Training primary health providers for provision of tailored information about the modern contraception to immigrant women, which includes an individualized counselling may improve partners' knowledge, demand and uptake of modern contraception.

Sick and solo: a qualitative study on the life experiences of people living with HIV in Somalia.

BACKGROUND: HIV stigma and the resultant fear of being identified as HIV-positive can compromise the effectiveness of HIV programs by undermining early diagnosis and antiretroviral treatment initiation and adherence of people living with HIV (PLHIV). In the wake of the longstanding conflict in the country, little is known about the life experiences of PLHIV in Somalia. METHODS: A qualitative study using unstructured interviews was conducted in Somalia from September to December 2017. A convenience sampling approach was used to recruit 13 participants, including 10 persons who live with HIV and three senior officials who work for the HIV program at the Ministry of Health. Data were analyzed using a thematic analysis. RESULTS: Our findings show that PLHIV are alienated and prefer to isolate themselves due to widespread stigma subjected to them by their family members, society, employers, and health providers, which continue to undermine the scale-up of testing and treatment of PLHIV in Somalia. Consequently, they are reluctant to seek voluntary diagnosis and treatment of HIV. They often come to know about their status when their partners are found HIV positive, they are tested for other clinical purposes, or when an individual's health deteriorates, and all other means fail to work in improving his/her situation. The study also pointed out a shortage of facilities that provide HIV diagnosis, counseling and treatment in Somalia. CONCLUSION: Addressing stigma and discrimination subjected to PLHIV are critical to a successful HIV response in Somalia. To successfully address stigma, HIV programs need evidence on effective interventions at individual, community, and societal levels in order to strategically incorporate stigma and discrimination reduction into national HIV programs.

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.

Beneficiaries of conflict: a qualitative study of people's trust in the private health care system in Mogadishu, Somalia.

BACKGROUND: In 2005, the World Health Conference called for all nations to move toward universal health coverage, which is defined as "access to adequate health care for all at an affordable price". Despite this, an estimated 90% of Somalia's largely impoverished population use private health care. Therefore, considering that the private health care system is the dominant health care system in Mogadishu, Somalia, exploring the accessibility to, as well as people's trust in, the private sector is essential to help contribute an equitable and affordable health care system in the country. METHODS: A qualitative study using unstructured interviews was conducted in Mogadishu from August to November of 2016. A purposive sampling approach was used to recruit 23 participants, including seven medical doctors who own private health centers, eight patients, five medical students and three senior officials who work for the Ministry of Health. Data were analyzed using a thematic analysis. RESULTS: Our findings show that the private health care system in Mogadishu is not only unregulated but also expensive, with the cost of health care often unaffordable for the majority of the country's citizens. There is evidence of prescription of inappropriate treatment, tendency to conduct unnecessary laboratory tests, excessive use of higher diagnostic technologies and overcharging - including the widespread practice of further appointments for follow-up - which inflates the costs. The study also found poor patient-provider relationship and widespread distrust of the private health care system. CONCLUSION: The study findings underline the need for the Somali government to develop regulatory mechanisms and guidelines with the potential to guide the private health care sector to provide equitable and affordable health care to people in Mogadishu. The doctor-patient relationship has been - and remains - a keystone of care; thus, there is an urgent need for guidelines for private health care providers to treat their patients with dignity and respect. The education system, particularly the syllabus used by medical faculties, should be reviewed and improved to provide medical students with necessary knowledge, skills and attitudes to maintain patient dignity and rights.

Relying on Visiting Foreign Doctors for Fistula Repair: The Profile of Women Attending Fistula Repair Surgery in Somalia.

Obstetric fistula is treatable by surgery, although access is usually limited, particularly in the context of conflict. This study examines the profile of women attending fistula repair surgery in three hospitals in Somalia. A cross-sectional study was conducted in Somalia from August to September 2016. Structured questionnaires were administered to 81 women who registered for fistula repair surgery in the Garowe, Daynile, and Kismayo General Hospitals in Somalia. Findings revealed that 70.4% of the study participants reported obstetric labor as the cause of their fistula, and 29.6% reported iatrogenic causes. Regarding the waiting time for the repair surgery, 45% waited for the surgery for over one year, while the rest received the surgery within a year. The study suggests that training for fistula surgery has to be provided for healthcare professionals in Somalia, fistula centers should be established, and access to these facilities has to be guaranteed for all patients who need these services.

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.

Barriers and facilitators to cervical cancer screening among Pakistani and Somali immigrant women in Oslo: a qualitative study.

Norway has a low incidence and mortality rate of cervical cancer, which is mainly due to the high participation rate of women in cervical cancer screening. However, the attendance of cervical cancer screening was reported to be low among immigrant women. For this reason, we conducted a qualitative study to obtain better insight into perceived barriers and challenges to cervical cancer screening among Somali and Pakistani women in the Oslo region. A convenient sample of 35 (18 Pakistani, 17 Somali) women were recruited for the study in collaboration with Somali and Pakistani community partners. Focus group discussions were used to explore barriers and facilitators to cervical cancer screening, whereas the Ecological Model was used as the framework for the study. The study found three levels of barriers to cervical cancer screening. The individual level included a lack of understanding of the benefits of the screening. The sociocultural level included the stigma attached to the disease and the belief that women who are unmarried are sexually inactive. The system-related level included a lack of trust toward the health care system. Based on the study results, and using a common denominator approach for the immigrant groups included, the study recommends three communication strategies with the potential to improve women's participation in cervical cancer screening: 1) in-person communication and information material at health centers; 2) verbal communication with women through seminars and workshops to educate them about their risk of cancer and the importance of screening and 3) the initiation of better recall through SMS and letters written in native languages. Finally, an intervention study that compares the aforementioned strategies and proves their effectiveness in increasing immigrant women's participation in cervical cancer screening is recommended.

Attitude towards the Practice of Female Genital Cutting among School Boys and Girls in Somali and Harari Regions, Eastern Ethiopia.

Introduction. Female genital cutting (FGC) is a harmful traditional practice that violates women's rights and threatens their health. Although much work has been done to tackle this practice in Ethiopia, the prevalence remains very high in Somali and Harari regions. This study aims to investigate the attitude towards FGC of young people (boys and girls) in Somali and Harari regions of Eastern Ethiopia. Methods. A cross-sectional quantitative study was carried out in Somali and Harari regions from October to December 2015. Two districts were purposely selected from the two regions, and a stratified random sampling technique was employed to select 480 subjects from the randomly selected schools. Results. Out of 480 questionnaires distributed, 478 (99.6%) respondents filled the questionnaires and returned them. The finding of the study reveals that 86% of study participants condemn the practice of FGC. Almost 59% of male participants from both study areas preferred to marry uncircumcised girls. Being a female and being a Muslim are significantly associated with the support toward the continuation of the FGC (P < 0.05). Conclusion. Although the study demonstrates a positive attitude towards the abandonment of FGC, there is a need to increase the knowledge about the position of Islam in FGC and to educate women about the harmful effect of FGC.

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.

Attitude toward female genital mutilation among Somali and Harari people, Eastern Ethiopia.

BACKGROUND: Female genital mutilation (FGM) is a worldwide problem, and it is practiced by many communities in Africa and Asia as well as immigrants from those areas. This practice results in short- and long-term health consequences on women's health. Like many other developing countries, FGM is widely practiced in Ethiopia, especially among Somali and Harari ethnic groups. Despite intensive campaigns against FGM in Ethiopia, since 2011, it has been practiced in the aforementioned communities. There is no recent information as to whether these campaigns have an impact on the attitude and practice of the community regarding FGM. This qualitative research was aimed at exploring the attitudes of Somali and Harari people between 18 and 65 years toward FGM. METHODS: A purposive sampling technique was used to recruit 64 (32 in each region) participants. Data were collected from October to December 2015 in Somali and Harari Regions. RESULTS: The findings showed that there was a strong support for the continuation of the practice among female discussants in Somali region, whereas male discussants from the same region and the majority of the participants from Harari region had a positive attitude toward the discontinuation of the practice. Marriageability was the major reason for practicing FGM in Somali region, whereas making girls calm, sexually inactive, and faithful for their husbands were mentioned in Harari region. Although young men in both the regions prefer to marry uncircumcised girls, the study showed that there are some differences in the attitude toward the FGM practice between the people in the two regions. CONCLUSION: The findings show that there is an attitudinal difference between the people in the two regions, which calls for behavioral change communication using women-centered approach and culturally appropriate strategies. As young people in both the regions had the intention to marry uncircumcised girls, there has to be a strong advocacy and multisectoral collaboration to stop FGM in both the regions.

Diabetes Risk by Length of Residence among Somali Women in Oslo Area.

Type 2 diabetes represents a major health problem worldwide, with immigrants strongly contributing to the increase in diabetes in many countries. Norway is not immune to the process, and immigrants in the country are experiencing an increase in the prevalence of diabetes after arrival. However, the dynamics of these transitions in relation to the duration of residence in the new environment in Norway are not clearly understood. From this background, a cross-sectional quantitative study using a respondent-driven sampling method was conducted among 302 Somali women living in Oslo area. The results show that 41% of the study participants will be at risk for developing diabetes in the coming 10 years, which coincides with 85% of the study participants being abdominally obese. Significant associations were found between years of stay in Norway and the risk for diabetes with those who lived in Norway >10 years, having twofold higher odds of being at risk for developing diabetes compared to those who lived in Norway ≤5 years (OR: 2.16, CI: 1.08-4.32). Understanding the mechanisms through which exposure to the Norwegian environment leads to higher obesity and diabetes risk may aid in prevention efforts for the rapidly growing African immigrant population.

Is female circumcision evolving or dissolving in Norway? A qualitative study on attitudes toward the practice among young Somalis in the Oslo area.

Female genital mutilation or female circumcision (FC) is increasingly visible on the global health and development agenda - both as a matter of social justice and equality for women and as a research priority. Norway is one of the global nations hosting a large number of immigrants from FC-practicing countries, the majority from Somalia. To help counteract this practice, Norway has adopted a multifaceted policy approach that employs one of the toughest measures against FC in the world. However, little is known about the impact of Norway's approach on the attitudes toward the practice among traditional FC-practicing communities in Norway. Against this background, this qualitative study explores the attitudes toward FC among young Somalis between the ages of 16 to 22 living in the Oslo and Akershus regions of Norway. Findings indicate that young Somalis in the Oslo area have, to a large extent, changed their attitude toward the practice. This was shown by the participants' support and sympathy toward criminalization of FC in Norway, which they believed was an important step toward saving young girls from the harmful consequences of FC. Most of the uncircumcised girls see their uncircumcised status as being normal, whereas they see circumcised girls as survivors of violence and injustice. Moreover, the fact that male participants prefer a marriage to uncircumcised girls is a strong condition for change, since if uncut girls are seen as marriageable then parents are unlikely to want to circumcise them. As newly arrived immigrants continue to have positive attitudes toward the practice, knowledge of FC should be integrated into introduction program classes that immigrants attend shortly after their residence permit is granted. This study adds to the knowledge of the process of the abandonment of FC among immigrants in Western countries.