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Background: Differences in the MS course between White and Black populations is well accepted. The existence of a large Somali immigrant population in Minnesota facilitates a study of MS characteristics in this immigrant native African population. The objective of this study was to compare Somali American (SA), African American (AA), and White American (WA) persons with MS (pwMS) regarding clinical features and disease modifying therapy (DMT) use., Methods: This single center (Mayo Clinic) geographically-restricted retrospective cohort study (residing within 250 miles of Rochester, MN, USA) included participants seen before May 2023. Age at immigration to the USA; age at MS onset; DMT use/type; MS phase/phenotype; age at progressive MS (PMS) onset; and proportion with severe MS (expanded disability status scale-EDSS ≥6) were examined., Results: 18 SApwMS, 92 AApwMS, and 94 WApwMS were included. Of the 15 SApwMS not born in USA, 3/15 immigrated pre-puberty, 3/15 peri‑puberty, 8/15 post-puberty, and 1/15 at an unknown date. SApwMS were younger at MS onset (median years, interquartile range (IQR)=25, 22-33 vs. AApwMS: 31, 25-38; p = 0.049 vs. WApwMS: 35, 27-41; p = 0.022). DMT use frequencies were 13/19 SApwMS, 69/92 AApwMS, 80/94 WApwMS (p > 0.05). SApwMS were treated with DMT earlier than AApwMS (HR 2.16, p = 0.012) and WApwMS (HR 1.86, p = 0.041). SApwMS were less commonly treated with natalizumab (SApwMS 0 %, AApwMS 13 %, WApwMS 25 %; p = 0.035) and anti-CD20 therapies (SApwMS 23 %, AApwMS 23 %, WApwMS 48 %; p = 0.005). PMS occurred in 3/19 SApwMS, 28/92 AApwMS and 29/94 WApwMS (p > 0.05). Age of PMS onset in SApwMS (47 years, 34-57) was similar to WApwMS (47 years, 31-71; p > 0.05) but older than AApwMS (41 years, 18-7; p = 0.008)., Conclusions: SApwMS that recently immigrated to the USA have similar disease course to WApwMS, and better than AApwMS from the same geographical region., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier B.V.)

Background: After settling in the United States (US), immigrants often accumulate obesity and cardiovascular risk factors. As mood is often associated with health behaviors in the US population, mood may be an important mediating factor in immigrant populations., Methods: The Healthy Immigrant Community (HIC) study, set in southeast Minnesota, enrolled 475 adult participants in a weight loss intervention designed to reduce cardiovascular risk. Baseline questionnaires assessed mood, nutrition, physical activity, self-efficacy for healthy eating and physical activity, social support, and cohesion. A single-item mood rating of poor or fair was considered "negative", while ratings of good, very good, or excellent were considered "positive"., Results: Hispanic/Latino (n = 268) and Somali (n = 181) adults enrolled in HIC completed baseline measures and were included in this analysis. Participants endorsing negative mood compared to positive mood had lower healthy eating scores (p = 0.02), lower physical activity levels (p = 0.03), lower confidence in eating a healthy diet (p = 0.001), and felt less of a sense of belonging to their community (p = 0.01). Those endorsing negative mood reported receiving less social support to eat healthy (p =  < 0.001) and be physically active (p = 0.01). They also accessed community resources for healthy eating (p = 0.001) and physical activity (p =  < 0.01) less frequently than participants endorsing positive mood., Conclusions: On self-report, negative mood was associated with less healthy nutrition, lower confidence in eating healthy, sedentary lifestyle, and perceived lack of belonging to the community. Integrating mood management and self-efficacy strategies may enhance the effectiveness of lifestyle interventions to reduce obesity and cardiovascular risk among immigrants who report negative mood., Trial Registration: ClinicalTrials.gov registration: NCT05136339; April 23, 2022., (© 2024. The Author(s).)

Purpose: The experience of ethnically diverse parents of children with serious illness in the US health care system has not been well studied. Listening to families from these communities about their experiences could identify modifiable barriers to quality pediatric serious illness care and facilitate the development of potential improvements. Our aim was to explore parents' perspectives of their children's health care for serious illness from Somali, Hmong, and Latin-American communities in Minnesota., Methods: We conducted a qualitative study with focus groups and individual interviews using immersion-crystallization data analysis with a community-based participatory research approach., Results: Twenty-six parents of children with serious illness participated (8 Somali, 10 Hmong, and 8 Latin-American). Parents desired 2-way trusting and respectful relationships with medical staff. Three themes supported this trust, based on parents' experiences with challenging and supportive health care: (1) Informed understanding allows parents to understand and be prepared for their child's medical care; (2) Compassionate interactions with staff allow parents to feel their children are cared for; (3) Respected parental advocacy allows parents to feel their wisdom is heard. Effective communication is 1 key to improving understanding, expressing compassion, and partnering with parents, including quality medical interpretation for low-English proficient parents., Conclusions: Parents of children with serious illness from Somali, Hmong, and Latin-American communities shared a desire for improved relationships with staff and improved health care processes. Processes that enhance communication, support, and connection, including individual and system-level interventions driven by community voices, hold the potential for reducing health disparities in pediatric serious illness., (© 2024 Annals of Family Medicine, Inc.)

Background: Somali women deliver at greater gestational age with limited information on the associated perinatal mortality. Our objective is to compare perinatal mortality among Somali women with the population rates., Methods: This is a retrospective cohort study from all births that occurred in Minnesota between 2011 and 2017. Information was obtained from certificates of birth, and neonatal and fetal death. Data was abstracted from 470,550 non-anomalous births ≥37 and ≤ 42 weeks of gestation. The study population included U.S. born White, U.S. born Black, women born in Somalia or self-identified as Somali, and women who identified as Hispanic regardless of place of birth (377,426). We excluded births < 37 weeks and > 42 weeks, > 1 fetus, age < 18 or > 45 years, or women of other ethnicities. The exposure was documented ethnicity or place of birth, and the outcomes were live birth, fetal death, neonatal death prior to 28 days, and perinatal mortality rates. These were calculated using binomial proportions with 95% confidence intervals and compared using odds ratios adjusted (aOR) for diabetes, hypertension and maternal body mass index., Results: The aOR [95%CI] for stillbirth rate in the Somali cohort was greater than for U.S. born White (2.05 [1.49-2.83]) and Hispanic women (1.90 [1.30-2.79]), but similar to U.S. born Black women (0.88 [0.57-1.34]). Neonatal death rates were greater than for U.S. born White (1.84 [1.36-2.48], U.S. born Black women (1.47 [1.04-2.06]) and Hispanic women (1.47 [1.05-2.06]). This did not change after analysis was restricted to those with spontaneous onset of labor. When analyzed by week, at 42 weeks Somali aOR for neonatal death was the same as for U.S. born White women, but compared against U.S. born Black and Hispanic women, was significantly lower., Conclusions: The later mean gestational age at delivery among women of Somali ethnicity is associated with greater overall risk for stillbirth and neonatal death rates at term, except compared against U.S. born Black women with whom stillbirth rates were not different. At 42 weeks, Somali neonatal mortality decreased and was comparable to that of the U.S. born White population and was lower than that of the other minorities., (© 2021. The Author(s).)

This paper examines age of autism spectrum disorder (ASD) identification and related factors in a diverse urban sample, focusing on ASD identification in the East African Somali community. The overall average age of initial ASD identification was 4.8 years. Somali children received an initial clinical diagnosis of Autistic Disorder later than White children, and Somali children diagnosed with ASD born outside of Minnesota (MN) received their first comprehensive evaluation later than Somali children diagnosed with ASD born in MN. Most children had noted developmental concerns before age 3, with no significant racial or ethnic differences in those concerns. The current study contributes to a limited number of studies on early ASD identification in culturally and linguistically diverse populations.

Background: Somali immigrants and refugees to the United States are at high risk for obesity and related cardiovascular risk. Social network factors influence health behaviors and are important contributors to the obesity epidemic. The objective of this study was to describe social networks and obesity-related characteristics among adult Somali immigrants in a Minnesota city in order to inform a community-based, participatory, research-derived, social network intervention to decrease obesity rates., Methods: Survey data (demographics, general health measures, and sociobehavioral and network measures) and height and weight measures (for calculating body mass index) were collected from adult Somali immigrants by bilingual study team members at community locations. Descriptive statistics were used to report the survey and biometric data. Logistic regression models were used to describe the basic associations of participants and network factors. Network data were analyzed to identify nodes and ties, to visualize the network, and to identify potential interventionists for a future social network intervention., Results: Of the 646 participants, 50% were overweight or affected by obesity. The network had 1703 nodes with 3583 ties between nodes, and modularity was high (0.75). Compared with respondents of normal weight, participants who were overweight or affected by obesity had more network members who were also overweight or obese (odds ratio [OR], 2.90; 95% CI, 1.11-7.56; P = .03); this was most notable for men (OR, 4.58; 95% CI, 1.22-17.22; P = .02) and suggestive for those 50 years or older (OR, 24.23; 95% CI, 1.55-377.83; P = .03). Weight loss intention among participants who were overweight or affected by obesity was associated with number of family members and friends trying to lose weight, enabling functional network factors (social norms for weight loss, social support for healthy eating, and social cohesion), and less favorable obesogenic social norms., Conclusions: In this community sample of Somali immigrants, distinct social networks are clustered by weight status, and social contacts and functional network characteristics are related to individuals' weight loss intentions. These factors should be considered in weight loss interventions and programs. A social network intervention targeting weight loss, within a community-based participatory research framework, is feasible in this vulnerable population.

Children consume nearly one-third of their daily energy intake as snacks (i.e., eating occasions that occur between meals); thus there is a growing interest in understanding what snacking occasions look like in the homes of young children. This study makes use of ecological momentary assessment (EMA) to 1) examine differences in the contextual factors, including location, food preparation style, people present, presence of media devices, and overall atmosphere, between meal and snack occasions; and 2) explore differences in the context of snacking occasions across children's gender and weight status. Data for the current study came from the Family Matters Study, which included 150 families with children aged 5-7 years old (n = 25 from each of the following groups: Black/African American, Hispanic, Hmong, Native American, Somali, White). Parents completed an 8-day EMA observation period, during which they were surveyed after each eating occasion with the study child; questions explored contextual factors including location, food preparation style, people present, presence of media devices, and the overall atmosphere of each eating occasion. Differences between meals and snacks were observed; a smaller percentage of snacks (compared to meals) were prepared by the parent, consisted of only homemade food, and were planned ahead of time, as opposed to being served in response to a child's request. Snacks were more likely than other meals to be eaten on the couch and in the presence of a screen. Furthermore, important differences in snacking context were observed by child gender and weight status. Findings illuminate opportunities to improve children's overall dietary intake via interventions focused on improving the quality of foods served during snacks, as well as the contextual environment in which snacks are eaten., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Interpreters improve the care of patients with limited English proficiency. They can potentially act as unofficial health educators to help dispel misunderstandings about medical risks in a culturally appropriate manner. Somali parents in Minnesota are less likely to immunize their children for MMR than other parents because they believe the MMR vaccine causes autism. The low MMR vaccination rate contributed to measles outbreaks in the state in 2011 and 2017., Objective: To investigate the effects of an educational session on interpreter beliefs and knowledge about childhood vaccines., Methods: A large interpreter service in Minneapolis holds quarterly educational sessions for their interpreters. The investigators presented a one-hour interactive session on childhood vaccinations at one of the meetings. The interpreters were surveyed pre- and post-training to assess their (1) beliefs regarding childhood vaccines, (2) knowledge of childhood vaccination indications and safety, and surveyed pre-training about their perceived impact on patient decision-making., Results: Fifty-five of the 78 interpreters attending the training session completed both the pre- and post-training surveys. Participants made significant improvements in their knowledge of vaccines after the training. Interpreters were less likely to believe that vaccines causes autism after the presentation (p = 0.02), and were more likely to indicate that the current evidence does not support a vaccine - autism connection (p < 0.001). Nineteen percent of the interpreters were from Somalia. Somali interpreters were significantly more likely to expand on what is said by the physician than their non-Somali colleagues (OR = 16.2, 95% CI = 2.8-92.9). They were also significantly more likely to encounter parental worry over vaccine safety (OR = 16.2, 95% CI = 1.9-140.5), and to believe that children get too many vaccines (OR = 30.1, 95% CI = 3.4-271.5)., Conclusions: The training was an effective method to improve interpreters' knowledge and perceptions of vaccine safety. By training Somali interpreters, they can become a part of a team working toward better MMR vaccination rates., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Misinformation and distrust often prevent individuals from minority communities to seek adequate healthcare, including genetic services. Immigrants appear to be further burdened by factors that negatively impact their health outcomes and little is known about their experience with genetic services. We sought to identify attitudes and perception of genetic services in one immigrant group, the Somali community of Minnesota and to establish a culturally informed framework for caring for members. A qualitative study comprised of 11 semi-structured key informant interviews was conducted and analyzed using a thematic approach. Main themes emerged from the analysis fell within one of four major topics: (a) Somali views and perspective on genetics and healthcare, (b) barriers to uptake of genetic services, (c) facilitators to uptake of genetic services, and (d) perspective on genetic service delivery subtypes. Somali views and perspective on genetics are often framed by religious and cultural values. These values, at times, conflicted with those common in the American healthcare system. Supports for different genetic service delivery subtypes also varied, ranging from little to no support in prenatal screening to generally positive support for pharmacogenetic testing. Future studies should prioritize topics with support and ways to better provide genetic counseling services within the Somali community., (© 2019 National Society of Genetic Counselors.)

Context: Since civil unrest broke out in Somalia in the 1990s, large numbers of Somalis have immigrated to Western countries, including the United States. It is unknown whether these immigrants maintain their cultural norms of low contraceptive use and high fertility when they live in settings with different norms., Methods: In 2016, interviews were conducted in Minnesota with Somali immigrants and refugees to explore couple communication and decision making regarding child spacing. Nineteen married men and women aged 25-51 were interviewed. After a coding scheme was developed, key themes were identified and examined by participants' sex, number of children and age of arrival in the United States., Results: Most participants discussed child spacing with their spouse and had positive or neutral experiences. Some participants, especially those with multiple children, stated that living in their new country had influenced their fertility desires. Only those who had arrived after the age of 20 mentioned that experiencing closely spaced births had motivated them to discuss child spacing. Participants emphasized the importance of information sharing, compromise and joint decision making with their spouse. Priority for child-spacing decision making was granted to women, largely because of their primary role in childbirth. Men who had arrived in the United States before turning 20 were more definitive about giving women decision-making priority., Conclusions: These findings provide insight into how Somali immigrant and refugee couples communicate and make decisions about child spacing, and may be helpful in informing the development of culturally specific reproductive health programs., (Copyright © 2019 by the Guttmacher Institute.)

Objective: To compare postpartum contraception use between Somali and non-Somali women., Methods: A retrospective cohort study was performed using the Rochester Epidemiology Project. All Somali women aged 18 and older with live singleton births in Olmsted County, Minnesota, in 2009-2015 (n=317) were included, and a group of age-matched non-Somali women (n=317) were identified. Postpartum contraception was defined as the use of any method within 12 months after the first delivery within the study period. Rates of contraception use and types of contraception used were compared between groups using χ analysis. Among Somali women, an a priori list of factors was evaluated for associations with postpartum contraception use by including these factors in a multivariable logistic regression model., Results: After the index birth, 33 Somali women did not present for follow-up, compared with 12 non-Somali women (10.4% vs 3.8%, difference 6.6%, 95% CI 2.3-10.9%). Somali women were less likely to use postpartum contraception than non-Somali women (69.4% vs 92.8%, odds ratio [OR] 0.18, 95% CI 0.11-0.29). Among those using postpartum contraception, both groups had comparable use of long-acting reversible contraception (LARC) (19.9% vs 23.7%, difference -3.8%, 95% CI -11.8% to 4.0%) and non-LARC hormonal contraception (39.3% vs 42.4%, difference -3.1%, 95% CI -12.7% to 6.0%). However, Somali women were more likely to use less reliable methods (40.3% vs 20.8%, difference 19.5%, 95% CI 11.0-28.5%). Among Somali women, contraception use was less likely with older maternal age (OR 0.12 for oldest vs youngest quartile, 95% CI 0.04-0.37) and more likely with prepregnancy contraception use (OR 15.46, 95% CI 5.18-46.18)., Conclusion: Somali women were less likely to use postpartum contraception. Similar practices and beliefs may also be present in other immigrant populations. Recognition of sociocultural differences in immigrant populations and potential health care provider biases may improve patient-provider relationships and counseling practices.

Introduction: Eastern Africa has the highest rates of cervical cancer incidence (42.7 per 100,000) and mortality (27.6 per 100,000), substantially higher than worldwide incidence (14.0 per 100,000) and mortality (6.8 per 100,000). The purpose of this study was to explore facilitators and barriers to cervical cancer screening and human papilloma virus (HPV) vaccination among Somali refugee women and their children., Method: Focus group discussions were conducted in August of 2016. Investigators performed systematic, comparative, and thematic data analyses., Results: The 31 Somali refugee participants ranged from 23 to 64 years old. Four major themes emerged: (1) knowledge, (2) facilitators, (3) decision making, and (4) views on intervention strategies. Doctor recommendation and family support were important facilitators. Community education was the most popular strategy in promoting screening and vaccine uptake., Discussion: Multilevel targeted interventions should increase knowledge and include family members to increase cervical cancer screening and HPV vaccination uptake in the Somali community.

Background and Aims: Hepatitis C virus (HCV) treatment has changed dramatically in the last few years. Our observations suggest that a minority of HCV infected Somalis are treated. In this study, we aimed to evaluate for treatment and health outcome disparities between Somali and non-Somali patients during the direct acting antiviral (DAA) era., Methods: Patients with HCV seen in the gastroenterology clinic in 2015 were included in the study. Patients were identified using ICD9 and 10 codes. Electronic medical records were analyzed to evaluate for treatment candidacy, acceptance and reasons for refusal of treatment., Results: Genotype 4 followed by 3 were the most common genotypes in the Somalis while genotype 1 was the most common in the non-Somalis. Majority of patients were offered treatment, active alcohol and substance abuse was a common reason for not offering treatment in non-Somalis while the presence of hepatocellular carcinoma was the most common reason in Somalis. Somalis had higher rates of declining treatment given the asymptomatic nature of their disease and the feeling that treatment is not needed. Sustained virologic response rates were comparable in both groups., Conclusions: Disparities in acceptance of HCV treatment persist in the DAA era. The asymptomatic nature of the infection and potential cultural mistrust makes patients hesitant to undergo treatment. Healthcare providers must find interventions aimed at reducing barriers to treatment and increasing acceptance of HCV treatment., (Copyright © 2018 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Minnesota is home to the largest population of Somalis in the USA - most arriving as refugees from the civil war in Somalia. As Somali Americans adjust to life in the USA, they are likely to undergo shifts in their belief systems - including changes in their attitudes toward gays and lesbians. We examined the attitudes of 29 Somali American women in the Minneapolis-St. Paul metropolitan area toward homosexuality via face-to-face, semi-structured interviews. Transcripts were translated, transcribed and analysed using an approach informed by grounded theory. Three major themes were identified: (1) Islamic prohibitions against homosexuality; (2) homosexuals exiled to a hidden community; and (3) community members exploring tolerance. Participants' attitudes toward homosexuality were heavily influenced by religious doctrines and cultural contexts. This is the first known study in the USA of Somali American attitudes toward gays and lesbians. As people mass migrate from nations with negative attitudes toward homosexuality to countries with more progressive attitudes toward varied sexual orientations, refugee attitudes about homosexuality will undergo change. Through research and education, we can better understand how to increase tolerance toward and opportunities for visibility among gay and lesbian refugees throughout the diaspora.

This study examined the associations between positive and negative religious coping, symptoms of depression and anxiety, physical and emotional well-being among Somali college students in Minnesota. In this online cross-sectional survey study, 156 participants (ages 18-21, M = 21, SD = 2.3) were recruited. Participants reported using more positive religious coping methods. Negative religious coping was associated with an increase in symptoms of both depression (b = .06, p = .003) and anxiety (b = .04, p = .05), and positive religious coping was associated with a decrease in symptoms of depression (b = -.04, p = .05).

The potential for culture to impact diagnosis of autism spectrum disorder (ASD) is high, yet remains largely unstudied. This study examined differences across racial/ethnic groups in ASD symptoms, cognitive and adaptive skills, and related behaviors in children with ASD that included a unique subgroup, children from the Somali diaspora. Somali children were more likely to have ASD with intellectual disability than children from all other racial/ethnic groups. Few differences were found in the presence of specific symptoms and behaviors across groups once IQ was controlled. Results lend support to previous studies that found higher rates of ASD intellectual disability in children of immigrants from low human resource index countries compared to other groups. Implications for future research are discussed.

Background: US immigrants often have escalating cardiovascular risk. Barriers to optimal physical activity and diet have a significant role in this risk accumulation., Methods: We developed a physical activity and nutrition intervention with immigrant and refugee families through a community-based participatory research approach. Work groups of community members and health scientists developed an intervention manual with 12 content modules that were based on social-learning theory. Family health promoters from the participating communities (Hispanic, Somali, Sudanese) were trained to deliver the intervention through 12 home visits during the first 6 months and up to 12 phone calls during the second 6 months. The intervention was tested through a randomized community-based trial with a delayed-intervention control group, with measurements at baseline, 6, 12, and 24 months. Primary measurements included accelerometer-based assessment of physical activity and 24-hour dietary recall. Secondary measures included biometrics and theory-based instruments., Results: One hundred fifty-one individuals (81 adolescents, 70 adults; 44 families) were randomized. At baseline, mean (SD) time spent in moderate-to-vigorous physical activity was 64.7 (30.2) minutes/day for adolescents and 43.1 (35.4) minutes/day for adults. Moderate dietary quality was observed in both age groups. Biometric measures showed that 45.7% of adolescents and 80.0% of adults were overweight or obese. Moderate levels of self-efficacy and social support were reported for physical activity and nutrition., Discussion: Processes and products from this program are relevant to other communities aiming to reduce cardiovascular risk and negative health behaviors among immigrants and refugees., Trial Registration: This trial was registered at Clinicaltrials.gov (NCT01952808)., (Copyright © 2015 Elsevier Inc. All rights reserved.)

We investigated the sexual values, attitudes, and behaviors of 30 Somali female refugees living in a large metropolitan area of Minnesota by collecting exploratory sexual health information based on the components of the sexual health model-components posited to be essential aspects of healthy human sexuality. A Somali-born bilingual interviewer conducted the semistructured interviews in English or Somali; 22 participants chose to be interviewed in Somali. Interviews were translated, transcribed, and analyzed using descriptive statistics and thematic analyses. Our study findings highlighted a sexually conservative culture that values sexual intimacy, female and male sexual pleasure, and privacy in marriage; vaginal sexual intercourse as the only sanctioned sexual behavior; and the importance of Islamic religion in guiding sexual practices. Findings related to human immunodeficiency virus (HIV) revealed HIV testing at immigration, mixed attitudes toward condom use, and moderate knowledge about HIV transmission modes. Female genital cutting (FGC) was a pervasive factor affecting sexual functioning in Somali women, with attitudes about the controversial practice in transition. We recommend that health professionals take the initiative to discuss sexual health care and safer sex, sexual behaviors/functioning, and likely challenges to sexual health with Somali women--as they may be unlikely to broach these subjects without permission and considerable encouragement.

Over the past 10 years, Minnesota clinicians have noticed increased resistance to MMR vaccination among Somali Minnesotans. Misinformation about a discredited study asserting a link between the MMR vaccine and autism has permeated this community as parents have increasingly become concerned about the prevalence of autism spectrum disorder among their children. As a result, MMR vaccination rates among U.S.-born children of Somali descent are declining. This article reports findings from an investigation by the Minnesota Department of Health, which was undertaken to better understand vaccine hesitancy among Somali Minnesotans. Based on these and other findings, we propose a multi-pronged approach for increasing vaccination rates in this population.

Unlabelled: Cervical cancer is more common in the Somali immigrant population than the general population in the United States (US). There are low rates of cervical cancer screening among Somali women. This study compares cervical cancer screening test completion rates for a home human papilloma virus (HPV) test and standard clinic Pap test. Sixty-three Somali immigrant women aged 30-70 years who had not undergone cervical cancer screening within the past 3 years were randomly assigned to a home HPV test group (intervention) or a clinic Pap test group (control). Test completion rates were measured at 3 months. Univariate and multivariate logistic regression models were used to explore factors associated with test completion (intention-to-treat analysis). Participants in the HPV test group were 14 times more likely to complete the test compared to those in the Pap test group (P = 0.0002). Women who reported having friends/family members to talk about cancer screening were approximately three times more likely to complete any screening test than those who did not (P = 0.127) and participants who reported residing in the US longer were more likely to complete a screening test (P = 0.011). Future research should explore the potential of using the home-based HPV test kits as an initial approach to cervical cancer screening., Impact: The use of a self-sampling HPV kit has the potential to increase cervical cancer screening in under-served communities in the US., (© 2015 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Background: Somali women are infrequently screened for breast or cervical cancer, and there is a paucity of evidence-based interventions to increase cancer screening in this community. In order to create a culturally relevant intervention for Somali women living in Minnesota, we sought to understand what Somali immigrant women know about breast and cervical cancer, what are the attitudes toward screening and what cultural barriers are there to screen as well as cultural factors that would facilitate screening., Methods: In partnership with a community-based organization, New American Community Services (NACS), focus groups were conducted to explore the issues described above. Two focus groups were held with younger women age 20 to 35 and two were held with women age 36 to 65., Results: Twenty-nine women participated in the four focus groups. The women identified 1) differences in health care seeking behavior in Somalia verses the United States; 2) cultural understanding of cancer and disease; 3) barriers to mammogram or Pap screening; 4) facilitators to seeking preventive cancer screening; and 5) risk factors for developing cancer., Conclusions: Cultural misperceptions and attitudes need to be addressed in developing culturally-appropriate interventions to improve screening uptake for Somali women. A nuanced response is required to address barriers specific to younger and older groups. Culturally informed beliefs can be integrated into intervention development, preventive care and screening promotion.

Ramadan is a month-long period of heightened self-reflection about one's religion and one's relationships with others. During Ramadan, fasting during daylight hours is required. The fast is typically followed by a feast after dark. Although Muslims with certain medical conditions are allowed by Islamic law to abstain from fasting, many choose to fast during Ramadan for personal reasons. Diabetes is one of the most challenging conditions to manage during this time, and physicians and clinics with Muslim patients who have diabetes will need to be prepared if they are to support their patients who desire to fast. This article provides a general overview of Ramadan and offers practical guidance for managing adults and children with diabetes who are fasting during this important time in the Muslim calendar.

Background: The population of the United States is becoming increasingly ethnically and racially diverse, much of it due to immigration patterns. However, little is known about dietary intake and weight-related concerns and behaviors of youth from some ethnic-minority groups, especially Hispanic, Hmong, and Somali adolescents., Objective: Our aim was to describe dietary intake and weight-related concerns and behaviors among Hispanic, Hmong, and Somali adolescents and compare them with white adolescents., Design: We performed a cross-sectional analysis of data from Eating and Activity in Teens 2010, a population-based study in the Minneapolis/St Paul metropolitan area., Participants/setting: Current analysis includes 1,672 adolescents (Hispanic: n=562 [33.6%]; Hmong: n=477 [28.5%]; Somali: n=113 [6.8%]; white: n=520 [31.1%]; mean age=15.0 years). Adolescents completed classroom surveys and had their height/weight measured during the 2009-2010 academic year., Statistical Analysis: Multivariable regression models, adjusted for socioeconomic status, age, and school as a random effect were used to examine racial/ethnic differences for each outcome variable for boys and girls., Results: There were numerous differences in the behaviors of Hispanic, Hmong, and Somali adolescents as compared with whites. Hispanic and Somali youth consumed fruit and fast food more frequently. Hmong adolescents consumed sugar-sweetened beverages less frequently, and Somali boys consumed energy and sport drinks more frequently than whites. Compared with white boys, overweight/obesity was higher among Hispanic and Hmong. A higher percentage of Hmong and Somali adolescents engaged in unhealthy weight control behaviors. Body satisfaction was lower for all Hmong adolescents compared with whites., Conclusions: There were varying areas of concern in dietary intake, weight, and weight-related concerns and behaviors among adolescents in all ethnic groups. Future nutrition and physical activity interventions that include adolescents from these ethnic and cultural groups can benefit from, for example, modifying intervention strategies to the specific priority behaviors within the target population., (Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Immigrants and refugees arrive to the United States healthier than the general population, but this advantage declines with increasing duration of residence. One factor contributing to this decline is suboptimal physical activity, but reasons for this are poorly understood. Persons from Somalia represent the largest African refugee population to the United States, yet little is known about perceptions of physical activity among Somali men. Somali members of a community-based participatory research partnership implemented three age-stratified focus groups and three semistructured interviews among 20 Somali men in Rochester, Minnesota. Team-based inductive analysis generated themes for barriers and facilitators to physical activity. Barriers to physical activity included less walking opportunities in the United States, embarrassment about exercise clothing and lack of familiarity with exercise equipment/modalities, fear of harassment, competing priorities, facility costs, transportation, and winter weather. Facilitators to physical activity included high knowledge about how to be active, success stories from others in their community as inspiration, and community cohesion. Findings may be used to derive interventions aimed to promote physical activity among Somali men in the United States.

Background: According to the 'hygiene hypothesis', an increase in microbial exposure in childhood leads to a T-helper cell 1 (Th1) predominant immune response and protection against asthma and atopic conditions., Aims: To assess the prevalence of asthma and other atopic conditions in Somali immigrants and to determine the humoral immune response to the measles, mumps, and rubella (MMR) vaccine viruses in Somali immigrants with asthma., Methods: A retrospective cohort study was conducted in Olmsted County, Minnesota. Study subjects were Somali immigrants who were born and lived in Africa during childhood and immigrated to the USA. The subjects had participated in a previous MMR vaccine study. Asthma was ascertained using predetermined asthma criteria after a thorough medical record review. An atopic condition was determined from physician-diagnosed ICD codes. Virus-specific IgG levels in response to the MMR vaccine viruses were determined using an enzyme immunoassay., Results: Of the 62 eligible subjects, 33 (53%) were female and 29 (47%) were male; 10 (16%) had asthma and 22 (35%) had other atopic conditions. There was no difference in the rubella (p=0.150) and measles (p=0.715) virus-specific IgG levels between the subjects with and without asthma. Mumps virus-specific IgG antibody levels were lower in those with asthma than in those without asthma (mean±SE 2.08±0.28 vs. 3.06±0.14, p=0.005)., Conclusions: Our study results may not support the hygiene hypothesis. In addition, the previously reported abnormal T-cell development in Caucasian children with atopy can be considered even in Somali immigrants.

Somali women often use creams and soaps to lighten skin tone, fade freckles or get rid of age spots. Use of these products raises a health concern, as some have been found to contain mercury. This article describes an investigation that involved interviewing Somali women about skin-lightening practices and the products they use and then testing those products for mercury. Twenty-seven samples of products purchased at markets in Minneapolis and St. Paul were analyzed bythe Minnesota Department of Health for specific mercury levels. Eleven of the 27 (47%) were found to contain mercury. Some exceeded the current FDA threshold of 1 part per million. This has prompted both state and federal health officials to issue warnings about the use of these products.

Objective: To refine and validate an existing home food inventory (HFI) for low-income Somali- and Spanish-speaking families., Design: Formative assessment was conducted using two focus groups, followed by revisions of the HFI, translation of written materials and instrument validation in participants’ homes., Setting: Twin Cities Metropolitan Area, Minnesota, USA., Subjects: Thirty low-income families with children of pre-school age (fifteen Spanish-speaking; fifteen Somali-speaking) completed the HFI simultaneously with, but independently of, a trained staff member. Analysis consisted of calculation of both item-specific and average food group kappa coefficients, specificity, sensitivity and Spearman’s correlation between participants’ and staff scores as a means of assessing criterion validity of individual items, food categories and the obesogenic score., Results: The formative assessment revealed the need for few changes/additions for food items typically found in Spanish-speaking households. Somali-speaking participants requested few additions, but many deletions, including frozen processed food items, non-perishable produce and many sweets as they were not typical food items kept in the home. Generally, all validity indices were within an acceptable range, with the exception of values associated with items such as ‘whole wheat bread’ (k = 0.16). The obesogenic score (presence of high-fat, high-energy foods) had high criterion validity with k = 0.57, sensitivity = 91.8%, specificity = 70.6% and Spearman correlation = 0.78., Conclusions: The revised HFI is a valid assessment tool for use among Spanish and Somali households. This instrument refinement and validation process can be replicated with other population groups.

Objectives: We examined differences in self-reported mental health (SRMH) between US-born and Somalia-born Black Americans compared with White Americans. We tested how SRMH was affected by stigma toward seeing a mental health provider, discrimination in the health care setting, or symptoms of depression., Methods: Data were from a 2008 survey of adults in Minnesota and were limited to US-born and Somalia-born Black and White Americans (n = 938)., Results: Somalia-born adults were more likely to report better SRMH than either US-born Black or White Americans. They also reported lower levels of discrimination (18.6%) than US-born Black Americans (33.4%), higher levels of stigma (23.6% vs 4.7%), and lower levels of depressive symptoms (9.1% vs 31.6%). Controlling for stigma, discrimination, and symptomatology, Somalia-born Black Americans reported better SRMH than White and Black Americans (odds ratio = 4.76)., Conclusions: Mental health programming and health care providers who focus on Black Americans' mental health might be missing important sources of heterogeneity. It is essential to consider the role of race and ethnicity, but also of nativity, in mental health policy and programming.

Health disparities and solutions are heterogeneous within and among racial and ethnic groups, yet existing administrative databases lack the granularity to reflect important sociocultural distinctions. We measured the efficacy of a natural-language-processing algorithm to identify a specific immigrant group. The algorithm demonstrated accuracy and precision in identifying Somali patients from the electronic medical records at a single institution. This technology holds promise to identify and track immigrants and refugees in the United States in local health care settings.

Background: Since the onset of the Somali civil war in 1991, more than 1 million Somalis have been displaced from Somalia. Minnesota has the largest Somali population in the U.S. Informal tobacco prevalence estimates among Somali populations in the U.S. and the United Kingdom range from 13% to 37%, respectively. Little research has been conducted to determine the extent of Somali tobacco use., Purpose: This paper reports the results from a knowledge, attitudes, and practices (KAP) survey conducted and analyzed in 2009 that explores tobacco use and estimates prevalence among Somali adults aged ≥ 18 years in Minnesota., Methods: Modeled after validated state and national tobacco use surveys, the survey was adapted for Somalis and administered to ethnically Somali adults (N=392) from 25 neighborhood clusters in Minnesota. Participants were chosen through probability proportional to size and multistage random sampling methods., Results: Estimated prevalence for cigarette use among Somalis was 24% (44% among men, 4% among women). Ever users were significantly more likely to be men, have attended college, and have friends who used cigarettes (p<0.0001). Belief in Islamic prohibition of tobacco was protective and affected current use and future intention to use tobacco (p<0.0001). The majority of Somali smokers were unwilling to use current cessation programs., Conclusions: Estimated cigarette use prevalence was lower than perceived prevalence (37%). Contrary to typical results, greater smoking prevalence was found among Somalis with higher education levels. Positive peer pressure and religion are protective factors from tobacco use and should be integrated into prevention and cessation programs., (Copyright © 2012 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The discourse about mental health problems among migrants and refugees tends to focus on adverse pre-migration experiences; there is less investigation of the environmental conditions in which refugee migrants live, and the contrasts between these situations in different countries. This cross-national study of two samples of Somali refugees living in London (UK) and Minneapolis, Minnesota, (USA) helps to fill a gap in the literature, and is unusual in being able to compare information collected in the same way in two cities in different countries., Methods: There were two parts to the study, focus groups to gather in-depth qualitative data and a survey of health status and quantifiable demographic and material factors. Three of the focus groups involved nineteen Somali professionals and five groups included twenty-eight lay Somalis who were living in London and Minneapolis. The quantitative survey was done with 189 Somali respondents, also living in London and Minneapolis. We used the MINI International Neuropsychiatric Interview (MINI) to assess ICD-10 and DSM-IV mental disorders., Results: The overall qualitative and quantitative results suggested that challenges to masculinity, thwarted aspirations, devalued refugee identity, unemployment, legal uncertainties and longer duration of stay in the host country account for poor psychological well-being and psychiatric disorders among this group., Conclusion: The use of a mixed-methods approach in this international study was essential since the quantitative and qualitative data provide different layers and depth of meaning and complement each other to provide a fuller picture of complex and multi-faceted life situations of refugees and asylum seekers. The comparison between the UK and US suggests that greater flexibility of access to labour markets for this refugee group might help to promote opportunities for better integration and mental well-being.

Purpose: To explore the dietary factors that contribute to bone health among first generation Somali girls and to determine the social and cultural contexts that shape these health behaviors., Design and Methods: Findings presented are from a larger, descriptive qualitative study that used a series of focus groups with four cohorts of 11- to 14-year-old Somali girls (n= 39) living in two Minnesota communities., Results: Cultural tradition, developmental stage, acculturation, and environment were major factors contributing to the intake of calcium and vitamin D-rich foods., Practice Implications: Findings provide the foundation for the development of culturally relevant promotion of foods rich in calcium and vitamin D., (© 2012, Wiley Periodicals, Inc.)

Objective: To study the frequencies of chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, and their associations with hepatocellular carcinoma (HCC) in immigrant Somalis seen at Mayo Clinic in Rochester, Minnesota., Patients and Methods: We determined the frequencies of HBV and HCV infection and HCC in immigrant Somalis seen at Mayo Clinic from July 1, 1996, through October 31, 2009. Non-Somali Olmsted County residents served as controls., Results: For Somali males and females, age-adjusted proportions (per 1000 population) were 209 and 123 for hepatitis B surface antigen (HBsAg), 644 and 541 for hepatitis B core antibody (HBcAb), and 99 and 66 for anti-HCV. The comparative proportions in non-Somalis were 20 and 9 for HBsAg, 126 and 97 for HBcAb, and 32 and 17 for anti-HCV. Hepatitis C virus RNA confirmed that 68 of 73 Somalis (93.2%) and 261 of 282 non-Somalis (92.6%) with positive anti-HCV test results had active HCV infection. Of 30 Somali patients with HCC, 22 (73.3%) tested anti-HCV positive (odds ratio [OR], 31.3; 95% confidence interval [CI], 13.0-75.5; P<.001; compared with anti-HCV-negative Somalis), 5 (16.7%) were HBsAg positive (OR, 1.4; 95% CI, 0.5-3.7; P=.53), and 18 (60.0%) were HBcAb positive (OR, 1.8; 95% CI, 0.8-4.2; P=.16). Viral hepatitis was diagnosed coincident with HCC in 9 of 20 patients (45.0%) with HCV-associated HCCs. Only 4 of 24 cases of HCC (16.7%) were detected during surveillance., Conclusion: Both HBV and HCV occurred frequently in this sample of Somali immigrants. However, HCV was the major risk factor for HCC. Screening Somali immigrants for HCV infection may enhance the prevention, early detection, and optimal treatment of HCC., (Copyright © 2012 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Given the large number of Somali refugees living in Minnesota, it is likely that Minnesota physicians will encounter Somali patients, some of whom will have serious illnesses. Although our knowledge of Somali expectations about health care is growing, little has been written about the Somali people's views of treatment for life-threatening illnesses or their ideas about end-of-life care. After encountering a Somali man with advanced cancer in our practice, we attempted to learn about the Somali view of death and dying and the kind of treatment Somali patients might want during their final days. We share what we learned so that others might provide more culturally competent end-of-life care for Somali patients in the future.

Introduction: Initial clinical observation of Somali patients seen at a busy inner-city community clinic (CUHCC) suggested that, in addition to the expected pictures of Posttraumatic Stress Disorder (PTSD) and depression previously seen in the clinic's Southeast Asian refugee population from 1980 to 2000, there was an unusually high number of young Somali men presenting with acute psychotic disturbances., Objectives: The aim of this study of health care utilization of Somali refugees (N = 600) seen in the mental health unit of the clinic from 2001 to 2009 was to investigate the major patterns of psychiatric disorders in this outpatient population and compare these findings with a cohort of non-Somali patients (N = 3,009) seen at the same outpatient clinic during the years 2007-2009. If the results supported the initial clinical observations that the rate of psychoses was higher among young Somali men than non-Somali men attending CUHCC clinic, then several areas of further research would recommend itself. First, since this study was not a study of prevalence of mental illness in the Somali community, the next step would be to undertake a study of community prevalence of mental illness among different age and gender cohorts. Second, further research should look into likely causative and contributory risk factors to explain the development of psychoses among Somali young men., Methods: Somali and non-Somali patients were diagnosed according to DSM-IV-R criteria. Main outcome measures (diagnoses, age cohort, sex) were analyzed by Chi-square tests. Patterns of illness and adjustment varied significantly by age and gender cohorts, reflecting the relevance of age and gender at time of trauma on different trauma and loss experiences and cultural and religious shaping of subsequent adjustment and symptoms., Results: The study confirmed that almost half of the Somali male patients are under age 30, 80% of whom presented with psychoses, compared with the rate of psychosis (13.7%) in the non-Somali control group of same-aged males at the clinic. The older male, and the majority of Somali female patients, show predominantly depressive and PTSD symptomatology., Conclusions: War trauma experienced in childhood, early malnutrition from famines, head trauma, and excess Khat use in male adolescents provide partial explanations for the large number of young psychotic Somali men seen in the clinic from 2001 to 2009.

We evaluated the reproductive impact of cesarean versus vaginal delivery in Somali immigrants. Data were extracted for 106 Somali women delivering vaginally (64%) or by cesarean section (36%) between 1994 and 2006. Index delivery (vaginal versus cesarean) was compared to the cumulative incidence rate of subsequent deliveries. The incidence rate of a delivery after a vaginal delivery was 3.3% (CI:0-7.8%), 55.4% (CI:40.1-66.8%) and 74.4% (CI:59.0-84.0%) at 1, 2 and 3 years. Cesarean delivery lead to a second delivery incidence rate of 2.9%(95%CI:0-8.2%), 25.9%(95%CI:9.8-39.2%) and 58.1% (95%CI:27.0-72.2%) at 1, 2 and 3 years. Somali women delivering vaginally were 1.56 times (95% CI:0.94-2.57; P = 0.084) more likely to have a subsequent delivery. The likelihood of Somali women having a second child after cesarean section is lower at 2 and 3 year follow-up.

On March 2, 2011, the Minnesota Department of Health (MDH) confirmed measles in a Hennepin County resident aged 9 months. As of April 1, investigation of contacts and heightened surveillance had revealed a total of 13 epidemiologically linked cases in Hennepin County residents. Of those cases, 11 were laboratory confirmed, and two were in household contacts of confirmed cases and met the clinical case definition for measles.

We investigated the effect of indicators of acculturation among Somali refugee women's birth outcomes. Data were extracted from medical records of 584 Somali women delivering infants at a Midwestern hospital between 1993 and 2006. Bivariate analyses measured relationships between independent factors and the dependent variables of gestational age and birthweight. Structural equation modeling (SEM) determined the fit between factors hypothesized to reflect acculturation and the data. Significant increases noted over time were substance use/exposure, interpreter use, body mass index, hemoglobin levels, gestational diabetes and preterm birth. Bivariate analyses showed significance between prenatal care utilization and both preterm birth and gestational age. SEM results indicated a moderate to good fit between the hypothesized model and available data. Factors hypothesized to reflect acculturation and effect birth outcomes among Somali women are increasing but did not account for increased preterm birth. Further investigation is warranted to identify and truncate further disparate birth outcomes.

Increasing globalization calls for undergraduate nursing programs to develop opportunities for students to participate in study-abroad activities. For some students, the cost of such activities can prohibit participation. The influx of refugees to the United States provides an alternative opportunity for students to think and act globally without the cost of travel.This article discusses how a community health assessment, completed through a partnership with a public health department, addressed barriers to emergency preparedness for Somali refugees. Students collected data using a focus group of 10 female Somali refugees. The focus group participants had limited understanding of English and fewer than half could read written Somali. Students gained insight into the language barriers among the refugees and the need for cultural sensitivity. They provided outreach, met Somali community leaders, and started the process of communication on emergency preparedness.

Background: Somalis compose the largest African refugee group in the U.S., with more than 55,000 primary arrivals since 2000. Minnesota has the largest Somali population in the U.S. Despite its size, little research has been conducted to determine the extent of tobacco use among Somali youth., Purpose: This paper reports the results from a knowledge, attitudes, and practices (KAP) survey designed to explore factors related to tobacco-use prevention, initiation, and cessation, and to reliably estimate tobacco-use prevalence among Somali youth in grades 9 through 12 in Minnesota., Methods: A KAP survey, modeled after validated state and national youth tobacco-use surveys, was adapted for Somali youth and administered to ethnically Somali youth (N = 302) from seven high schools in Minnesota in 2008. Participants were chosen through probability-proportional-to-size and multi-stage random sampling methods, and the results were analyzed in 2009., Results: Somali high school students' estimated prevalence for "ever-users" of cigarettes was 12.8%, and current use was 4.7%. This is one quarter of the reported statewide smoking prevalence for Minnesota high school students (19.1%) and half of the nationwide prevalence for blacks/African Americans (11.6%). Ever-users were more likely to have close friends or live with someone who smoked cigarettes (p < 0.01). Belief in the Islamic prohibition of tobacco affected future intention to use tobacco (p < 0.01), as did the belief that using hookah/sheisha is less risky than smoking cigarettes (p < 0.01)., Conclusions: Estimated cigarette use prevalence (4.7%) for Somali youth was substantially lower than among Minnesota high school students and also lower than perceived prevalence among Somalis. Positive peer pressure and religion appear to be protective factors in tobacco use and should be integrated into future Somali tobacco prevention and cessation programs, along with education on the risks of hookah/sheisha use., (Copyright © 2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: This study assessed whether a simple, readily implemented four-symptom somatic screen would be able to effectively identify current posttraumatic stress symptoms in victimized populations., Methods: The sample consisted of 622 Somali community-dwelling refugees who fled widespread violence and trauma occurring in East Africa during 1990-1992. Data were collected during 2000-2003 and included demographic characteristics, number of types of torture and nontorture trauma experienced earlier in Africa, and current self-rated posttraumatic stress symptoms, as measured by the Posttraumatic Stress Disorder Checklist (PCL). The sample was also assessed with the HADStress screen, which was developed for this study, to determine whether the screen was effective in detecting current posttraumatic stress symptoms. The HADStress screen assessed for the presence of four somatic symptoms: Headaches, Appetite change, Dizziness, and Sleep problems. All items were given equal weight. Possible scores on the screen range from 0 to 4, with higher scores indicating more somatic symptoms., Results: Univariate analysis showed that persons who experienced more types of trauma (both torture and nontorture trauma) and persons who had higher PCL scores (indicating more current posttraumatic stress symptoms) had significantly higher HADStress scores. Negative binomial regression analysis showed that PCL scores were the most effective variable in predicting HADStress scores. On the Tukey-B post hoc analysis, a HADStress score of 0 or 1 was associated with a mean PCL score of less than 30, a score of 2 was associated with a mean PCL score of 40.28, and a score of 4 was associated with a mean PCL score of 51.07 (suggesting that over 50% of this group would have active posttraumatic stress disorder)., Conclusions: A score of 2 or higher on the HADStress scale among refugees warrants additional evaluation for posttraumatic stress symptoms in clinical settings. For communitywide efforts at early recognition and treatment, a cutoff score of 4 may be more practical and cost-effective.

In recent years, the number of Somali persons treated in the U.S. has increased significantly. Understanding the concepts of pain and pain expression is an important aspect of nursing care. However, pain expression within this specific cultural group has not been extensively studied. This study, guided by core concepts from Margaret Newman's theory of Health as Expanding Consciousness used a focus group design to evaluate the concepts of pain expression within this population. The results of this study provide insight into how Somali women express pain, using verbal and nonverbal communication, and reveal other dynamics that are interconnected with the pain experience. The results show that pain expression for Somali women include verbal expressions that may be unique to the Somali culture. The results are helpful in developing a tool that can be used by others working with Somali women who are experiencing pain. Implications for improving transcultural nursing care, including pain assessment, management, and patient education are summarized.

Background: Somalis compose the largest African refugee group living in the U.S., with more than 10,330 primary arrivals in fiscal year 2006 alone. Half of all Somalis in the U.S. live in Minnesota. Although tobacco use is a considerable problem among Somalis, especially among men, little research has examined factors affecting tobacco use and cessation., Methods: A sequential exploratory design informed the overall study methodology. Key informant interviews (n=20) and focus group discussions (13 groups; n=91) were conducted with Somali adults and youth in the fall of 2006 and the summer of 2007, respectively. Participants were asked about tobacco-use prevalence, prevention, and cessation, and the marketing of tobacco., Results: Perceived prevalence of tobacco use by Somalis is high at 50%. The main reason for initiating tobacco use was the influence of friends or peer pressure and included other social factors. Prevention and cessation messages suggested by participants include medical advice, education on the negative health effects of tobacco use, religion, and the support of family and friends. Barriers to cessation include lack of insurance coverage, lack of knowledge on where to find assistance, and lack of cessation support groups. Severe social stigma for Somali female smokers poses specific challenges to prevention and intervention efforts. Water-pipe smoking is perceived to be prevalent, particularly among female youth., Conclusions: Somalis view tobacco use as an important issue in their community. Religious and social support and demographically targeted approaches should be key factors in creating effective prevention and cessation programs and must address water-pipe smoking.

To characterize seasonal variation of three allergens (dust mite, cat, and cockroach) and total culturable fungi and to explore whether residential characteristics were associated with the concentrations of these agents, floor dust was collected from 47 inner-city homes in Minneapolis, Minnesota, over a 1-year period. A longitudinal analysis of allergen and fungal concentrations was carried out using mixed-effect models. Overall, relative humidity was a better predictor of allergen concentrations over time than indoor temperature. Seasonal variation of cat and cockroach allergens was negligible compared with the variability associated with residential characteristics such as race/ethnicity, family income, and the presence of cats. Fungal concentrations showed significant seasonal variation that outweighed the variability associated with residential characteristics. Less than 30% of the dust mite allergen and cockroach allergens concentrations were above limits of detection. Observed cockroach allergen concentrations were higher in Spanish- and Somali-speaking households than in English-speaking households, while English-speaking households had significantly higher cat allergen concentrations compared with the other language groups. The ratios of within-home to between-home variance for total culturable fungi, dust mite, cockroach, and cat allergen concentrations were 2.54, 1.91, 0.55, and 0.24, respectively. This ratio is used to predict the number of repeated measurements of each allergen required to robustly estimate long-term exposure estimates such that exposure misclassification bias is kept within acceptable limits. It is not clear whether repeated measurements of dust mite and cockroach allergens are required for long-term average exposure because of the large fraction of nondetects. It is concluded that a single measurement of cat allergen is a reasonable surrogate for long-term average exposure, since repeated measurements over time were highly correlated. Total culturable fungi will require greater than nine repeated measurements for robust assessment of long-term exposures because of low correlations in fungal measures over time.