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Objectives: To evaluate the effectiveness of a culturally tailored parenting support programme on Somali-born parents' mental health and sense of competence in parenting., Design: Randomised controlled trial., Setting: A city in the middle of Sweden., Participants: Somali-born parents (n=120) with children aged 11-16 years and self-perceived stress in their parenting were randomised to an intervention group (n=60) or a waiting-list control group (n=60)., Intervention: Parents in the intervention group received culturally tailored societal information combined with the Connect parenting programme during 12 weeks for 1-2 hours per week. The intervention consisted of a standardised training programme delivered by nine group leaders of Somali background., Outcome: The General Health Questionnaire 12 was used to measure parents' mental health and the Parenting Sense of Competence scale to measure parent satisfaction and efficacy in the parent role. Analysis was conducted using intention-to-treat principles., Results: The results indicated that parents in the intervention group showed significant improvement in mental health compared with the parents in the control group at a 2-month follow-up: B=3.62, 95% CI 2.01 to 5.18, p<0.001. Further, significant improvement was found for efficacy (B=-6.72, 95% CI -8.15 to -5.28, p<0.001) and satisfaction (B=-4.48, 95% CI -6.27 to -2.69, p<0.001) for parents in the intervention group. Parents' satisfaction mediated the intervention effect on parental mental health (β=-0.88, 95% CI -1.84 to -0.16, p=0.047)., Conclusion: The culturally tailored parenting support programme led to improved mental health of Somali-born parents and their sense of competence in parenting 2 months after the intervention. The study underlines the importance of acknowledging immigrant parents' need for societal information in parent support programmes and the importance of delivering these programmes in a culturally sensitive manner., Clinical Trial Registration: NCT02114593., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: There is a gap in understanding of refugee mental health risks unique to urban areas of low-income countries., Material: A qualitative rapid appraisal using focus group interviews with community stakeholders explored main stressors pervasive by Somali refugees in Nairobi, Kenya., Discussion: This study identified the intersection of war trauma and daily stressors that affect both functional and structural challenges and risk of mental health issues among Somali urban refugees., Conclusion: Findings underscore the importance of understanding mental health in the broader context of community adversities, suggesting development of contextually informed interventions responsive to complex needs of urban refugees.

Background and Aims: Migration and khat use were found to correlate with high rates of psychopathology. In this paper we aimed for assessing baseline multimorbidity and its interactions with a Brief Intervention., Methods: In the RCT, 330 male Somali khat users were assigned to treatment conditions (khat use is a predominantly male habit). The ASSIST-linked BI for khat users was administered. Using the TLFB Calendar, the PHQ-9, a Somali short version of the PDS and parts from the CIDI, khat use and comorbidity was assessed. With a regression analysis we tested for the influence of comorbidity and with mixed effect models group differences over time in sleep duration, khat use-time and everyday functioning., Results: We found high rates of baseline multimorbidity: 51% (N = 168) for depression, 22% (N = 74) for PTSD and 23% (N = 73) for khat-psychotic symptoms. Depression and khat-psychotic symptoms, but not PTSD symptoms decreased without group differences. Khat use-time decreased and functional time increased with significant time × group interactions (p ≤ 0.046). Depression and PTSD did not influence therapy success but in participants without comorbid psychopathology, more khat use reduction after the intervention was found (p = 0.024)., Conclusion: Somali khat users in Kenya are highly burdened by multimorbidity of depression, PTSD and khat-psychotic symptoms. The main effects for time and differences in healthy vs. mentally ill khat users indicate potential of unspecific support and the specific need for mental health care in combination with substance abuse treatment. The increase of everyday functioning promises more options for alternative activities, preventing excessive use and addiction.

Westernized approaches to mental health care often place limited emphasis on refugees' own experiences and cultural explanations of symptoms and distress. In order to effectively assess community mental health needs and develop interventions grounded in local needs, mental health programs need to be informed by an understanding of cultural features of mental health, including cultural idioms of distress (CIDs). The current study aims to explore CIDs among Somali refugees displaced in Kenya to understand mental health needs in cultural context and serve the community in a culturally responsive and sensitive manner. This research was conducted as a two-phase qualitative study. First, key informant interviews with Somali mental health stakeholders generated a list of 7 common Somali CIDs: buufis, buqsanaan, welwel, murug, qaracan, jinn, and waali. Typologies of each CID were further explored through four focus group interviews with Somali community members. The findings from a template analysis revealed Somali lay beliefs on how trauma and daily stressors are experienced and discussed in the form of CIDs and how each term is utilized and understood in attributing symptoms to associated causes. This study highlights the need to incorporate colloquial terms in mental health assessment and to adopt a culturally relevant framework to encourage wider utilization of services and religious/spiritual support systems.

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.

The current study uses a multiple goal theoretical perspective to explore how Somali immigrant families living in Ohio, USA, make decisions regarding whether to vaccinate their children against human papillomavirus (HPV)-a leading cause of cervical cancer. A focus was placed on the communication goals of parents in HPV vaccine discussions with their child and health care provider. Semi-structured interviews were audiotaped, transcribed, and analyzed using a grounded theory approach. Key themes are the implications of the vaccine for early sexual activity, confusion between HPV and HIV (human immunodeficiency virus), the perception that the HPV vaccine is unnecessary, uncertainty about the vaccine's efficacy and side effects, avoidance of parent-child communication about the vaccine, and a preference for framing the vaccine as a health promotion behavior. Framing the threat of HPV in the context of initiation of sexual activity, uncertainty regarding vaccine efficacy, and anticipated regret account for the inconsistency in HPV vaccine uptake among Somali parents. Clinicians should consider talking about HPV as a distal versus an immediate threat and HPV vaccine uptake as a health-promotion behavior rather than a sexually transmitted infection prevention behavior.

Objective Ethiopia is home to an increasingly large refugee population. Reproductive health care is a critical issue for these groups because refugee women are at high risk for unmet family planning needs. Efforts to expand contraceptive use, particularly long acting reversible contraceptive (LARC) methods are currently underway in several Ethiopian refugee camps. Despite availability of LARC methods, few refugee women opt to use them. The purpose of this study was to explore how culture influences contraceptive attitudes and behaviors, particularly towards LARC methods, among Ethiopia's refugee populations. Methods Focus group discussions and individual interviews were conducted with Eritrean and Somali refugees living in Ethiopia. The qualitative data was analyzed to identify important themes highlighting the relationship between cultural values and contraceptive attitudes and behaviors. Results Childbearing was highly valued among participants in both study groups. Eritreans reported desire to limit family size and attributed this to constraints related to refugee status. Somalis used cultural and religious faith to deal with economic scarcity and were less likely to feel the need to adapt contraceptive behaviors to reduce family size. Participants held overall positive views of the contraceptive implant. Attitudes toward the intrauterine device (IUD) were overwhelmingly negative due to its long-acting nature. Conclusions Culture, religion and refugee status form a complex interplay with family planning attitudes and behaviors among Eritrean and Somali refugees. For these populations, the three-year implant appears to be a more acceptable contraceptive method than the longer-acting IUD because it is in line with their reproductive plans.

Background: There is evidence that key health behaviours of people who migrate deteriorate over time, which has a consequent impact upon the health of dependent children. As health in the early years sets the course for lifelong health, it is important to explore parents' views on maintaining children's health following migration., Methods: Five focus groups were held with parents of preschool children who had migrated to the UK within the last 10 years (n = 28). Parents originated from Romania, Poland, Somalia and Pakistan, with one group of Roma Gypsy parents. Data collection took place in January to March 2015., Results: All groups, apart from the Roma, perceived barriers to maintaining optimal health and well-being for their preschool children following migration to the UK. Eastern European parents experienced difficulties in ensuring family financial security, while parents from more established communities focused on barriers to children's exercise, play and nutrition., Conclusions: This study highlights aspects of public health where migrants and their children can experience adverse effects in the UK. These findings have implications for policymakers, commissioners and providers of health services who aim to promote good health among preschool children., (© The Author 2016. Published by Oxford University Press on behalf of Faculty of Public Health.)

Objectives: To present the primary outcomes from a baseline study on attitudes towards female genital cutting (FGC) after migration., Design: Baseline data from a planned cluster randomised, controlled trial. Face-to-face interviews were used to collect questionnaire data in 2015. Based on our hypothesis that established Somalis could be used as facilitators of change among those newly arrived, data were stratified into years of residency in Sweden., Setting: Sweden., Participants: 372 Somali men and women, 206 newly arrived (0-4 years), 166 established (>4 years)., Primary Outcome Measures: Whether FGC is acceptable, preferred for daughter and should continue, specified on anatomical extent., Results: The support for anatomical change of girls and women's genitals ranged from 0% to 2% among established and from 4% to 8% among newly arrived. Among those supporting no anatomical change, 75%-83% among established and 53%-67% among newly arrived opposed all forms of FGC, with the remaining supporting pricking of the skin with no removal of tissue. Among newly arrived, 37% stated that pricking was acceptable, 39% said they wanted their daughter to be pricked and 26% reported they wanted pricking to continue being practised. Those who had lived in Sweden ≤ 2 years had highest odds of supporting FGC; thereafter, the opposition towards FGC increased over time after migration., Conclusion: A majority of Somali immigrants, including those newly arrived, opposed all forms of FGC with increased opposition over time after migration. The majority of proponents of FGC supported pricking. We argue that it would have been unethical to proceed with the intervention as it, with this baseline, would have been difficult to detect a change in attitudes given that a majority opposed all forms of FGC together with the evidence that a strong attitude change is already happening. Therefore, we decided not to implement the planned intervention., Trial Registration Number: Trial registration number NCT02335697;Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Psychological distress and lack of family support may explain the mental health problems that are consistently found in young unaccompanied refugees in Western countries. Given the strong relationship between poor mental health and alcohol misuse, this study investigated hospital admissions due to alcohol related disorders among accompanied and unaccompanied young refugees who settled in Sweden as teenagers., Methods: The dataset used in this study was derived from a combination of different registers. Cox regression models were used to estimate the risks of hospital care due to alcohol related disorders in 15,834 accompanied and 4376 unaccompanied young refugees (2005-2012), aged 13 to 19 years old when settling in Sweden and 19 to 32 years old in December 2004. These young refugees were divided into regions with largely similar attitudes toward alcohol: the former Yugoslavian republics, Somalia, and the Middle East. The findings were compared with one million peers in the native Swedish population., Results: Compared to native Swedes, hospital admissions due to alcohol related disorders were less common in young refugees, with a hazard ratio (HR) of 0.65 and 95% confidence interval (CI) between 0.56 and 0.77. These risks were particularly lower among young female refugees. However, there were some differences across the refugee population. For example, the risks were higher in unaccompanied (male) refugees than accompanied ones (HR = 1.49, 95% CI = 1.00-2.19), also when adjusted for age, domicile and income. While the risks were lower in young refugees from Former Yugoslavia and the Middle East relative to native Swedes, independent of their length of residence in Sweden, refugees from Somalia who had lived in Sweden for more than ten years showed increased risks (HR = 2.54, 95% CI = 1.71-3.76), after adjustments of age and domicile. These risks decreased considerably when income was adjusted for., Conclusion: Young refugees have lower risks of alcohol disorders compared with native Swedes. The risks were higher in unaccompanied young (male) refugees compared to the accompanied ones. Moreover, Somalian refugees who had lived in Sweden for more than ten years seems to be particularly vulnerable to alcohol related disorders.

Background: Pricking, classified as female genital cutting (FGC) type IV by the World Health Organization, is an under-researched area gaining momentum among diaspora communities. Our aim was to explore factors associated with being supportive of pricking among Somalis in Sweden., Methods: In a cross-sectional design, attitudes and knowledge regarding FGC, and measures of socioeconomic status, acculturation, and social capital, were assessed by a 49-item questionnaire in four municipalities in Sweden. Data were collected in 2015 from 648 Somali men and women, ≥ 18 years old, of which 113 supported the continuation of pricking. Logistic regression was used for the analysis., Results: Those more likely to support the continuation of pricking were older, originally from rural areas, and newly arrived in Sweden. Further, those who reported that they thought pricking was: acceptable, according to their religion (aOR: 10.59, 95% CI: 5.44-20.62); not a violation of children's rights (aOR: 2.86, 95% CI: 1.46-5.61); and did not cause long-term health complications (aOR: 5.52, 95% CI: 2.25-13.52) had higher odds of supporting pricking. Religion was strongly associated with the support of pricking among both genders. However, for men, children's rights and the definition of pricking as FGC or not were important aspects in how they viewed pricking, while, for women, health complications and respectability were important., Conclusions: Values known to be associated with FGC in general are also related to pricking. Hence, there seems to be a change in what types of FGC are supported rather than in their perceived values.

Objectives: The aim of this study was to examine, first, how past traumatic stress and present acculturation indices, and discrimination are associated with mental health; and, second, whether religiousness can buffer the mental health from negative impacts of war trauma., Method: Participants were 128 older (50-80 years) Somali refugees living in Finland. They reported experiences of war trauma and childhood adversities, and filled-in questionnaires of perceived ethnic discrimination, religiousness (beliefs, attendance, and observance of Islamic faith), and symptoms of posttraumatic stress disorder (PTSD), depressive (BDI-21), psychological distress (GHQ-12), and somatization (SCL-90)., Results: Symptom-specific regression models showed that newly arrived refugees with non-permanent legal status and severe exposures to war trauma, childhood adversity, and discrimination endorsed greater PTSD symptoms, while only war trauma and discrimination were associated with depressive symptoms. Results confirmed that high religiousness could play a buffering role among older Somalis, as exposure to severe war trauma was not associated with high levels of PTSD or somatization symptoms among highly religious refugees., Conclusion: Health care should consider both unique past and present vulnerabilities and resources when treating refugees, and everyday discrimination and racism should be regarded as health risks.

Purpose The purpose of this pilot feasibility project was to examine the potential effectiveness of a digital storytelling intervention designed through a community-based participatory research (CBPR) approach for immigrants and refugees with type 2 diabetes mellitus (T2DM). Methods The intervention was a 12-minute culturally and linguistically tailored video consisting of an introduction, 4 stories, and a concluding educational message. A structured interview was used to assess the intervention for acceptability, interest level, and usefulness among 25 participants with T2DM (15 Latino, 10 Somali) across 5 primary care clinical sites. After watching the video, participants rated their confidence and motivation about managing T2DM as a result of the intervention. Baseline A1C and follow-up values (up to 6 months) were abstracted from medical records. Results All participants reported that the intervention got their attention, was interesting, and was useful; 96% reported that they were more confident about managing their T2DM than before they watched the video, and 92% reported that the video motivated them to change a specific behavior related to T2DM self-management. The mean baseline A1C level for the intervention participants was 9.3% (78 mmol/mol). The change from baseline to first follow-up A1C level was -0.8% (-10 mmol/mol) ( P < .05). Conclusions Implementation of a digital storytelling intervention for T2DM among immigrant populations in primary care settings is feasible and resulted in self-rated improvement in psychosocial constructs that are associated with healthy T2DM self-management behaviors, and there was some evidence of improvement in glycemic control. A large-scale efficacy trial of the intervention is warranted.

Background: Elective abortions show a secular decline in high income countries. That general pattern, however, may mask meaningful differences-and a potentially rising trend-among age, income, and other racial/ethnic groups. We explore these differences in Denmark, a high-income, low-fertility country with excellent data on terminations and births., Methods: We examined monthly elective abortions (n = 225,287) from 1995 to 2009, by maternal age, parity, income level and mother's country of origin. We applied time-series methods to live births as well as spontaneous and elective abortions to approximate the denominator of pregnancies at risk of elective abortion. We used linear regression methods to identify trend and seasonal patterns., Results: Despite an overall declining trend, teenage women show a rising proportion of pregnancies that end in an elective termination (56% to 67%, 1995 to 2009). Non-Western immigrant women also show a slight increase in incidence. Heightened economic disadvantage among non-Western immigrant women does not account for this rise. Elective abortions also show a sustained "summer peak" in June, July and August. Low-income women show the most pronounced summer peak., Conclusions: Identification of the causes of the increase over time in elective abortion among young women, and separately among non-Western immigrant women, represents key areas of further inquiry. The unexpected increase over time in elective abortions among teens and non-Western immigrants in Denmark may signal important social and cultural impediments to contraception. The summer peak in abortions among low-income women, moreover, conflicts with the conventional assumption that the social and demographic composition of mothers who electively end their pregnancy remains stable within a calendar year.

Objectives: To examine the mental health of unaccompanied refugee minors prospectively during the asylum-seeking process, with a focus on specific stages in the asylum process, such as age assessment, placement in a supportive or non-supportive facility and final decision on the asylum applications., Design: This was a2½ year follow-up study of unaccompanied minors (UM) seeking asylum in Norway. Data were collected within three weeks (n=138) and at 4 months (n=101), 15 months (n=84) and 26 months (n=69) after arrival., Setting: Initially in an observation and orientation centre for unaccompanied asylum-seeking adolescents, and subsequently wherever the UM were located in other refugee facilities in Norway., Participants: Male UM from Afghanistan, Somalia, Algeria and Iran., Main Outcome Measures: Mental health symptoms assessed by Hopkins Symptom Checklist-25 and Harvard Trauma Questionnaire., Results: At the group level, the young asylum seekers reported high levels of psychological distress on arrival and symptom levels that stayed relatively unchanged over time. According to age-assessment procedures, 56% of the population were not recognised as minors. Subsequent placement in a low-support facility was associated with higher levels of psychological distress in the follow-up period. Those who were placed in a reception centre for adults had higher levels of psychological distress symptoms both after 15 months and 26 months compared with the remaining participants who were placed in reception centres for youth. Refusal of asylum was highly associated with higher levels of psychological distress., Conclusion: Mental health trajectory of young asylum seekers appears to be negatively affected by low support and refusal of asylum., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Caesarean section (CS) rates are known to vary by country, migration status and social group. However, little population-based, confounder adjusted evidence exists on caesarean rate for African immigrants in Australia., Aim: To investigate disparities in first-time caesarean, mainly unplanned caesarean in labour for women born in Eritrea, Ethiopia, Somalia and Sudan relative to Australian-born women in public care., Methods: A population-based study of 237 943 Australian and 4057 Eastern African singleton births between 1999 and 2007, was conducted using Victorian Perinatal Data Collection. Descriptive and multivariable logistic regression analysis by parity, adjusting for confounders selected a priori, was performed for first-time unplanned caesarean in labour and overall caesarean., Results: Primiparae born in each of the Eastern African countries had elevated odds of unplanned caesarean in labour: Eritrea adjusted odds ratio (OR adj ) 2.04 95% CI (1.41, 2.97), Ethiopia OR adj 2.08 95% CI (1.62, 2.68), Somalia OR adj 1.62 95% CI (1.25, 2.10) and Sudan OR adj 1.39 95% CI (1.03, 1.87). Similarly, multiparae from Eastern African countries had elevated odds of unplanned caesarean in labour: Eritrea OR adj 2.13 95%CI(1.15, 3.97), Ethiopia OR adj 2.05 95% CI (1.38, 3.03), Somalia OR adj 2.16 95% CI (1.69, 2.77) and Sudan OR adj 1.81 95% CI (1.32, 2.49). The odds of any first-time caesarean (planned or unplanned) were elevated for primiparae born in all countries except Sudan and for multiparae born in Ethiopia and Somalia., Conclusions: We observed substantial variations in a first-time CS between Eastern African and Australian-born women in Victoria, Australia. However, these disparities were unexplained by socio-demographic and clinical risks, suggesting the potential importance of other factors such as communication difficulties, support systems for immigrant pregnant women and possible differences in care., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Postpartum depression (PPD) has been described as the most common complication experienced postpartum, affecting about 10-15 % of all new mothers. Factors like a history of mental illness, and experienced recent adverse life events has been associated with an increased risk for developing PPD. Immigrant women in Western countries have been found to have a marked higher prevalence of PPD compared to the general population. In Norway the prevalence of PPD in the general population has been found to be around 8-10 %, and among Pakistani immigrants a rate of 7.6 % was found. Somali people in Norway are the second largest immigrant group in Norway with a non-Western background. No study on PPD and associated factors among Somali women has been found in the literature. The aim of the study was to assess PPD and associated factors among Somali women in greater Oslo region, Norway. A cross-sectional survey was conducted; recruiting new mothers through all maternity wards in the Oslo region. Data was collected with interview-administrated questionnaires. PPD was assessed using Edinburgh Postnatal Depression Scale (EPDS), defining those scoring ≥10 to have a possible PPD. Of the 80 eligible women identified, 39 (49 %) consented to participate, and completed the study. Of the 39 respondents 3 (7.7 %) were assessed to have a possible PPD. Most important associated factors found were history of mental illness, having experienced technical assistance during delivery, self-rated health and experienced economical problems last 12 months. A low prevalence of PPD was found, and both the prevalence and its associated factors should be interpreted with caution. The associated factors do not have enough power to give any strength to the associations. However, some of the results can be used in develop new hypotheses with regard to PPD among Somali women as immigrants in a Western society.

Purpose: As the immigrant population rises in Norway, it becomes ever more important to consider the responsiveness of health services to the specific needs of these immigrants. It has been questioned whether access to mental healthcare is adequate among all groups of immigrants. This study aims to examine the use of specialist mental healthcare services among ethnic Norwegians and specific immigrants groups., Methods: Register data were used from the Norwegian Patient Registry and Statistics Norway. The sample (age 0-59) consisted of 3.3 million ethnic Norwegians and 200,000 immigrants from 11 countries. Poisson regression models were applied to examine variations in the use of specialist mental healthcare during 2008-2011 according to country of origin, age group, reason for immigration, and length of stay., Results: Immigrant children and adolescents had overall significantly lower use of specialist mental healthcare than ethnic Norwegians of the same age. A distinct exception was the high utilization rate among children and youth from Iran. Among adult immigrants, utilization rates were generally lower than among ethnic Norwegians, particularly those from Poland, Somalia, Sri Lanka, and Vietnam. Adult immigrants from Iraq and Iran, however, had high utilization rates. Refugees had high utilization rates of specialist mental healthcare, while labour immigrants had low use., Conclusion: Utilization rates of specialist mental healthcare are lower among immigrants than Norwegians. Immigrants from Poland, Somalia, Sri Lanka, and Vietnam, had generally quite low rates, while immigrants from Iran had high utilization rates. The findings suggest that specialist mental healthcare in Norway is underutilized among considerable parts of the immigrant population.

The study examined potential psychosocial determinants of male condom use in steady heterosexual relationships among Somali and Ethiopian immigrants in Minnesota in two sequential phases: the elicitation (Phase I) and cross-sectional quantitative studies (Phase II). Information from Phase I was used to develop the instrument for Phase II. Study participants who self-identified as Somali and Ethiopian immigrants (n = 205) responded to questions on demographic characteristics, attitudes (affective and instrumental), norms (subject and descriptive), perceived behavioral control, self-efficacy, and intention to use male condoms. Hierarchical regression models were used to assess the relationship between the main independent variables (attitude norms, perceived behavioral control, and self-efficacy, and the dependent variable, the intention to use male condoms. Overall, participants showed low intention and slightly favorable (affective and instrumental) attitudes toward condom use; had experienced weak, but positive social influence as measured by injunctive and descriptive norms. Moreover, study participants had shown slight perceived behavioral control, but had fairly moderate positive self-efficacy. The Theory of Planned Behavior was moderately effective in predicting condom use; however, the Integrated Behavioral Model, explained nearly 40% of the variations in the intention to use male condoms. Among men, self-efficacy had the strongest influence (β = .44, p < .001) on behavioral intention. Among women, descriptive norms (β = .22, p < .05) exerted the strongest effect (model 3). Improving self-efficacy, specifically, among older men, and fostering desirable normative influence among women, are suggested as main components of public health interventions to promote condom use among Somali and Ethiopian immigrants.

Setting and Objective: In low-incidence countries, most tuberculosis (TB) cases are foreign-born. We explored the temporal relationship between immigration and TB in first-generation immigrants between 1995 and 2012 to assess whether immigration can be a predictor for TB in immigrants from high-incidence countries., Design: We obtained monthly data on immigrant TB cases and immigration for the three countries of origin most frequently represented among TB cases in the Netherlands: Morocco, Somalia and Turkey. The best-fit seasonal autoregressive integrated moving average (SARIMA) model to the immigration time-series was used to prewhiten the TB time series. The cross-correlation function (CCF) was then computed on the residual time series to detect time lags between immigration and TB rates., Results: We identified a 17-month lag between Somali immigration and Somali immigrant TB cases, but no time lag for immigrants from Morocco and Turkey., Conclusion: The absence of a lag in the Moroccan and Turkish population may be attributed to the relatively low TB prevalence in the countries of origin and an increased likelihood of reactivation TB in an ageing immigrant population. Understanding the time lag between Somali immigration and TB disease would benefit from a closer epidemiological analysis of cohorts of Somali cases diagnosed within the first years after entry.

Aims: We evaluated the consumption of healthy foods among Russian, Somali and Kurdish immigrants in Finland, and examined the relationship between socio-demographic factors and food consumption., Methods: We used data from the Migrant Health and Wellbeing Study (Maamu), a population-based health interview and examination survey in six different municipalities in Finland between 2010 and 2012. Altogether, 635 men and 737 women, aged 18-64 years, of Russian ( n = 527), Somali ( n = 337) and Kurdish ( n = 508) origin were included. The important socio-demographic determinants of healthy food consumption - sex, age, education, place of residence and household size - were assessed by logistic regression., Results: Based on the consumption frequencies of recommended healthy foods - fruits, berries, vegetables, fish and rye bread - immigrants of Russian origin had higher consumption of healthy foods than their peers of Kurdish and Somali origin. Low consumption of fresh vegetables, fruits and berries was found among Somali immigrants. Sex and age were the most important determinants of healthy food consumption, as women and older age groups had diets closer to the national nutrition recommendations. High educational level was also positively associated with healthy food consumption., Conclusions: We found ethnic differences in the consumption of healthy foods among the immigrant groups of Russian, Somali and Kurdish origin in Finland. Socio-demographic factors, especially age, sex and education, seem to also play an important role in immigrants' food consumption. Further studies examining the consumption of fruits, berries and fresh vegetables among Somali immigrants in Finland are needed.

Objectives: We studied the differences in the mean pre-pregnancy body mass index (BMI) and mean inter-pregnancy weight change in women of Russian, Somali and Kurdish origin and women in the general Finnish population., Methods: The population-based samples were from the Migrant Health and Wellbeing Study and the Health 2011 Survey conducted in six cities in Finland in 2010-2012. This study included women with at least one birth in Finland. Data on their previous pregnancies in Finland were obtained from the National Medical Birth Register for 318 Russian, 584 Somali and 373 Kurdish origin women and for 243 women in the general Finnish population (reference group). Data on pre-pregnancy weight and height were self-reported in early pregnancy. Linear logistic regression was the main method of analysis., Results: The unadjusted mean pre-pregnancy BMI was higher in Somali (27.0 kg/m 2 , p<0.001) and Kurdish (25.8 kg/m 2 , p<0.001) women, but lower in Russian (22.2 kg/m 2 , p<0.001) women than in the reference group (24.1 kg/m 2 ). The adjusted coefficients for the difference in the mean pre-pregnancy BMI were -1.93 (95% CI -2.77 to -1.09) for Russian, 1.82 (95% CI 0.89-2.75) for Somali and 1.30 (95% CI 0.43-2.17) for Kurdish women compared with the reference group. Among women with at least two births, no statistically significant difference was observed in the mean inter-pregnancy weight change between the migrant groups and the reference group., Conclusions: Somali and Kurdish women had higher mean pre-pregnancy BMIs than women in the general Finnish population and may need special support and health promotion strategies for weight management.

This paper explores the dynamics of change in meaning-making about female genital cutting among migrants from Somalia and Sudan residing in Norway. In both countries, female genital cutting is almost universal, and most women are subjected to the most extensive form - infibulation - which entails the physical closure of the vulva. This closure must later be re-opened, or defibulated, to enable sexual intercourse and childbirth. Defibulation can also ease other negative health consequences of the practice. In Norway, surgical defibulation is provided on demand by the public health services, also beyond the traditional contexts of marriage and childbirth. This study explores experiences and perceptions of premarital defibulation. It explores whether Somali and Sudanese men and women understand defibulation as a purely medical issue or whether their use of the services is also affected by the cultural meaning of infibulation. This study analyses data from in-depth interviews with 36 women and men of Somali and Sudanese origin as well as participant observation conducted in various settings during 2014-2015. It reports that although all of the informants displayed negative attitudes towards infibulation, cultural meanings associated with virginity and virtue constitute a significant barrier to the uptake of premarital defibulation.

Causal attributions of mental health problems play a crucial role in shaping and differentiating illness experience in different sociocultural and ethnic groups. The aims of this study were (a) to analyze older Somali refugees' causal attributions of mental health problems; (b) to examine the associations between demographic and diagnostic characteristics, proxy indicators of acculturation, and causal attributions; and (c) to analyze the connections between causal attributions and the manifestation of somatic-affective and cognitive depressive symptoms. A sample of 128 Somali refugees aged 50-80 years living in Finland were asked to list the top three causes of mental health problems. Depressive symptoms were analyzed using the Beck Depression Inventory (BDI). The results showed that the most commonly endorsed causal attributions of mental health problems were jinn, jealousy related to polygamous relationships, and various life problems. We identified five attribution categories: (a) somatic, (b) interpersonal, (c) psychological, (d) life experiences, and (e) religious causes. The most common causal attribution categories were life experiences and interpersonal causes of mental health problems. Men tended to attribute mental health problems to somatic and psychological causes, and women to interpersonal and religious causes. Age and proxy indicators of acculturation were not associated with causal attributions. Participants with a psychiatric diagnosis and/or treatment history reported more somatic and psychological attributions than other participants. Finally, those who attributed mental health problems to life experiences (e.g., war) reported marginally fewer cognitive depressive symptoms (e.g., guilt) than those who did not. The results are discussed in relation to biomedical models of mental health, service use, immigration experiences, and culturally relevant patterns of symptom manifestation.

Background: Metabolic syndrome (MetS) is associated with a substantially increased risk for cardiovascular disease and diabetes. We examined the contribution of length of residence, socioeconomic position and lifestyle-related factors to the differences in the prevalence of MetS among migrants compared with Finns., Methods: Cross-sectional data from randomly sampled 30-64year-old health examination participants (318 Russian, 212 Somali, and 321 Kurdish origin migrants) of the Migrant Health and Wellbeing Survey (2010-2012) were used. Health 2011 Survey participants (n=786) were the reference group., Results: Compared with Finns, prevalence of MetS was significantly higher among all migrants except for Somali men. Among men, age-adjusted prevalence ratio (PR) of MetS compared with Finns was 1.71, 95% confidence interval (CI) 1.19-2.46 for Russians, PR 0.95 (95% CI 0.54-1.67) for Somali, and PR 2.10 (95% CI 1.51-2.93) for Kurds. Among women, respective PRs were 1.45 (95% CI 1.08-1.97) for Russians, PR 2.34 (95% CI 1.75-3.14) for Somali and PR 2.22 (95% CI 1.67-2.97) for Kurds. Adjustment for sociodemographic and lifestyle-related factors attenuated the differences in MetS among women but not men., Conclusions: Further studies should aim at identifying factors related to elevated risk for MetS among Russian and Kurdish men. Interventions aiming at improving lifestyle-related factors are needed for reducing inequalities in the prevalence of MetS among migrant women. Effectiveness of interventions focusing on reducing overweight and obesity among Somali and Kurdish women should be evaluated., (Copyright © 2017. Published by Elsevier B.V.)

Children (particularly low-income minorities and refugees) are at high risk for serious injury or death from motor vehicle crashes. Interpreter-assisted data collection included key informant interviews, focus groups and face-to-face surveys with the Somali community of Columbus, Ohio about child passenger safety. Measurements included prevalence of child safety seats use, awareness and knowledge of and barriers to proper use in order to inform development, implementation, and initial evaluation of a culturally-appropriate intervention for Somali families. Somali parents regarded child passenger safety as an important topic, but many reported improper restraint behaviors of one or more children and/or did not have an adequate number of child safety seats. Few parents reported having child safety seats installed by a professional technician. Child passenger safety practices in the Somali communities of Columbus are a public health concern that should be addressed with culturally-appropriate interventions.

Background: Previous studies revealed low participation in cervical cancer screening among immigrants compared with non-immigrants. Only a few studies about factors associated with immigrants' lower participation rates have been conducted in European countries that have universal access for all eligible women. Our study aimed to explore factors associated with cervical screening participation among women of Russian, Somali, and Kurdish origin in Finland., Methods: We used data from the Migrant Health and Well-being Survey, 2010-2012. Structured face-to-face interviews of groups of immigrants aged 25-60 yielded 620 responses concerning screening participation in the previous five years. Statistical analysis employed logistic regression., Results: The age-adjusted participation rates were as follows: among women of Russian origin 73.9% (95% CI 68.1-79.7), for Somalis 34.7% (95% CI 26.4-43.0), and for Kurds 61.3% (95% CI 55.0-67.7). Multiple logistic regressions showed that the most significant factor increasing the likelihood of screening participation among all groups was having had at least one gynecological check-up in the previous five years (Odds ratio [OR] = 6.54-26.2; p < 0.001). Other factors were higher education (OR = 2.63; p = 0.014), being employed (OR = 4.31; p = 0.007), and having given birth (OR = 9.34; p = 0.014), among Kurds; and literacy in Finnish/Swedish (OR = 3.63; p = 0.003) among Russians., Conclusions: Our results demonstrate that women who refrain from using reproductive health services, those who are unemployed and less educated, as well as those with poor language proficiency, might need more information on the importance of screening participation. Primary and occupational healthcare services may have a significant role in informing immigrant women about this importance.

Background: Minnesota is home to the largest Somali population in USA, and pediatric diabetes teams are seeing increasing numbers of Somali children with diabetes., Objective: To assess the immune basis of diabetes in Somali children in the Twin Cities, Minnesota., Methods: A total of 31 Somali children ≤19 yr were treated for type 1 diabetes (T1D) at the University of Minnesota Masonic Children's Hospital and Children's Hospitals and Clinics of Minnesota underwent analysis of human leukocyte antigen (HLA) alleles (n = 30) and diabetes autoantibodies [glutamic acid decarboxylase (GAD65), islet antigen 2 (IA-2), zinc transporter 8 (ZnT8); n = 31]. HLA alleles were analyzed in 49 Somalis without diabetes (controls). Anti-transglutaminase autoantibodies (TGA) for celiac disease were also measured., Results: In Somali children with T1D aged 13.5 ± 5 yr (35% female, disease duration 6.5 ± 3.6 yr), the most common HLA allele was DRB1*03:01 (93%, compared with 45% of Somali controls), followed by DRB1*13:02 (27%). There was a relatively low frequency of DR4 (13%). Controls showed a similar pattern. All 31 participants were positive for at least one diabetes autoantibody. Insulin antibodies were positive in 84% (all were on insulin). Excluding insulin antibodies, 23 (74%) subjects tested positive for at least one other diabetes autoantibody; 32% had 1 autoantibody, 32% had 2 autoantibodies, and 10% had 3 autoantibodies. GAD65 autoantibodies were found in 56% of subjects, IA-2 in 29%, and ZnT8 in 26%. Four (13%) were TGA positive., Conclusion: The autoantibody and HLA profiles of Somali children with diabetes are consistent with autoimmune diabetes. Their HLA profile is unique with an exceptionally high prevalence of DRB1*03:01 allele and relative paucity of DR4 alleles compared with African Americans with T1D., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

There is some statistical evidence indicating that Somali refugees and immigrants have high rates of autism spectrum disorder (ASD). Somalis in North America call autism the "Western disease" because there is no word for autism in the Somali language and because many believe it does not exist in Somalia. In Toronto, Somali parents have forged an "epistemic community," united around a coherent theory of the development of autism, its defining features, and most successful therapies. They work together with researchers to support the theory that gut bacteria is a causal factor for the development of autism. They argue that it is the diet and medical environment in North America (including the use of preservatives, genetically-modified processing, and antibiotics in both health care and food production) that explains the high rates of autism within the Somali diaspora. The paper argues that race and nationality have been underexplored in theories of embodied health movements. I argue that Somali parents' organizing pushes theories of health social movements in new directions, by suggesting that experiences of forced migration and racial exclusion, as well as non-Western cultural ontologies of health, are important for understanding embodied experiences of illness and the forging of "politicized collective illness identities" that challenge mainstream scientific understandings of autism. As such, Somalis' race and nationality play key roles in their pathways to group construction, in their embodied experiences of illness, and in their resources for mobilization., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: Variations in caesarean section (CS) between some immigrant groups and receiving country populations have been widely reported. Often, African immigrant women are at higher risk of CS than the receiving population in developed countries. However, evidence about subsequent mode of birth following CS for African women post-migration is lacking. The objective of this study was to examine differences in attempted and successful vaginal birth after previous caesarean (VBAC) for Eastern African immigrants (Eritrea, Ethiopia, Somalia and Sudan) compared with Australian-born women., Design: A population-based observational study was conducted using the Victorian Perinatal Data Collection. Pearson's chi-square test and logistic regression analysis were performed to generate adjusted odds ratios for attempted and successful VBAC., Setting: Victoria, Australia., Participants: 554 Eastern African immigrants and 24,587 Australian-born eligible women with previous CS having singleton births in public care., Findings: 41.5% of Eastern African immigrant women and 26.1% Australian-born women attempted a VBAC with 50.9% of Eastern African immigrants and 60.5% of Australian-born women being successful. After adjusting for maternal demographic characteristics and available clinical confounding factors, Eastern African immigrants were more likely to attempt (OR adj 1.94, 95% CI 1.57-2.47) but less likely to succeed (OR adj 0.54 95% CI 0.41-0.71) in having a VBAC., Conclusion/implications for Practice: There are disparities in attempted and successful VBAC between Eastern African origin and Australian-born women. Unsuccessful VBAC attempt is more common among Eastern African immigrants, suggesting the need for improved strategies to select and support potential candidates for vaginal birth among these immigrants to enhance success and reduce potential complications associated with failed VBAC attempt., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Unskilled traditional healers are widely blamed for complications to male circumcision performed in low- and middle-income settings. However, attributions of culpability are mostly anecdotal. We identify self-circumcision in adults that was performed during adolescence, hereby termed retrospective self-circumcision, and unexpectedly discovered during interviews with Somali men in Sweden in 2010. This study explores the phenomenon with the aim to increase our understanding about the health needs of this group. Two focus group discussions (six and seven participants), one informal discussion with three participants, and 27 individual interviews were conducted in 2010 and 2011 with Somali-Swedish fathers, guided by a hermeneutic, comparative natural inquiry method. Eight participants had performed retrospective self-circumcision while living in rural Somalia. Actions were justified according to strong faith in Islam. Genital physiology was described as adequate for producing children, but physical sensation or characteristics were implied as less than optimal. Few had heard about penile reconstruction. There was hesitation to openly discuss concerns, but men nevertheless encouraged each other to seek care options. Presently no medical platform is available for retrospective self-circumcision. Further systematic exploration is recommended in sexual, reproductive and urological health to increase interest in this phenomenon. Our findings suggest approachability if health communication is enabled within an Islamic context., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Objectives: The objectives of this study were to evaluate a culturally tailored parenting support program (Ladnaan) for Somali-born parents and to determine its effectiveness on children's emotional and behavioral problems., Methods: This randomized controlled trial included 120 Somali-born parents with children aged 11 to 16 years. The parents reported self-perceived stress in relation to parenting practices. The intervention consisted of culturally tailored societal information combined with the parenting program Connect. Parents received 12 weeks of intervention, 1 to 2 hours each week, in groups of 12 to 17 parents. Nine group leaders with a Somali background who received a standardized training program delivered the intervention. The primary outcome was a decrease in emotional and behavioral problems based on a Child Behavior Checklist. Parents were randomly allocated either to an intervention group or a wait-list control group. Covariance analyses were conducted according to intention-to-treat principles., Results: The results showed significant improvement in the children in the intervention group for behavioral problems after a 2-month follow-up. The largest effect sizes according to Cohen's d were in aggressive behavior (95% confidence interval [CI], 1.06 to 3.07), social problems (95% CI, 0.64 to 1.70), and externalizing problems (95% CI, 0.96 to 3.53)., Conclusions: The large effect sizes in this study show that this 12-week culturally tailored parenting support program was associated with short-term improvements in children's behavior. The study adds to the field of parenting interventions by demonstrating how to culturally tailor, engage, and retain parenting programs for immigrant parents., (Copyright © 2017 by the American Academy of Pediatrics.)

Increasing recognition of autism in Somali migrant communities means that appropriate support services are needed. Attitudes to autism and barriers related to help-seeking in these communities are poorly understood. We aimed to assess what families affected by autism need, and how health, education and social care services can support them. In partnership with the local Somali community the research team conducted 15 in-depth interviews with parents affected by autism. Two themes are reported; 'Perceptions of Autism' and 'Navigating the System'. Our research shows the importance of understanding cultural views of autism and the need to raise awareness, reduce stigma and provide support to encourage families not to delay seeking help for their children., Competing Interests: Fiona Fox declares that she has no conflict of interest. Nura Aabe declares that she has no conflict of interest. Katrina Turner declares that she has no conflict of interest. Sabi Redwood declares that she has no conflict of interest. Dheeraj Rai declares that he has no conflict of interest. Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical permission for this study was obtained from the Faculty of Medicine and Dentistry Research Ethics Committee, University of Bristol. Informed Consent Informed consent was obtained from all individual participants included in the study.

To test the feasibility and acceptability of implementing an evidence-based, peer-delivered mental health intervention for Somali women in Minnesota, and to assess the impact of the intervention on the mental health of those who received the training. In a feasibility study, 11 Somali female community health workers were trained to deliver an 8-session cognitive behavioral therapy intervention. Each of the trainers recruited 5 participants through community outreach, resulting in 55 participants in the intervention. Self-assessed measures of mood were collected from study participants throughout the intervention, and focus groups were conducted. The 55 Somali women who participated recorded significant improvements in mood, with self-reported decreases in anxiety and increases in happiness. Focus group data showed the intervention was well received, particularly because it was delivered by a fellow community member. Participants reported gaining skills in problem solving, stress reduction, and anger management. Participants also felt that the intervention helped to address some of the stigma around mental health in their community. Delivery of cognitive behavioral therapy by a community health workers offered an acceptable way to build positive mental health in the Somali community.

Background: Approximately 18% of Somali youth in Minnesota intend to use tobacco in the next year and youth perceive that 64% of their peers smoke. High perceived prevalence increases tobacco use intentions and initiation, indicating that Somali youth-targeted tobacco prevention efforts are needed., Objectives: To develop a Somali youth-targeted tobacco prevention intervention using a community-based participatory research (CBPR) approach., Methods: Three focus groups were conducted to inform the development of a tobacco prevention intervention. Three tobacco prevention videos were developed. Twenty interviews were conducted to evaluate the videos., Lessons Learned: It was essential to partner with Somali youth to develop the videos. Recruitment and development of the videos were facilitated through collaborating with trusted, existing community programs., Conclusions: A CBPR approach can be used to develop a culturally tailored intervention. It was important to involve academic and community partners in all stages of the research project.

Background: Community-engaged research partnerships build the capacity of community and educational organizations to work together toward addressing important health issues and disparities for vulnerable populations, such as refugees or immigrants. A critical step for building a community-engaged research partnership is the Thrst contact or entrée into the community., Purpose: The purpose of this paper is to describe how a successful home health community-engaged partnership became the entrée and foundation for a community-engaged research partnership to explore the home health needs of Somali older adults and their families., Methods: A number of strategies were used to engage the Somali community, initially in a clinical home health project and subsequently in an academic research study., Lessons Learned: Valuable lessons were learned on delivering home health care (HHC) services to Somali older adults and their families as well as conducting research with this population. The most important lesson was that none of the work could be done without the involvement of the Somali community. The partnership described is one of the Thrst to address the home health needs and experiences of Somali older adults and their families. The project illustrates a mutually beneThcial relationship that can occur when a community-engaged clinical project expanded to address an issue of importance to the community through research., Conclusions: This foundation served to create an opportunity for more comprehensive community-academic partnerships with the potential to improve the delivery of HHC to Somali older adults, as well as open avenues for research in other areas that are relevant to the Somali, medical, and academic communities.

We examined the prevalence of cardiovascular risk factors among Somali refugees at a midwestern hospital in the U.S. This was a retrospective cohort study of 1007 adult Somali patients and an age and frequency-matched cohort of non-Somali patients actively empanelled to a large, academic primary care practice network in the Midwest United States between January 1, 2011 and December 31, 2012. Cardiovascular risk factors were obtained by chart review and compared between the two cohorts using a Chi squared test. Median age was 35 years (Q1, Q3; 27, 50). The prevalence of diabetes was significantly higher among Somali versus non-Somali patients (12.1 vs 5.3 %; p = 0.0001), as was prediabetes (21.3 vs 17.2 %; p < 0.02) and obesity (34.6 vs 32.1 %; p = 0.047). After adjusting for age, sex, body mass index, education and employment, among the Somali patients, the odds ratio (95 % confidence interval) for diabetes was 2.78 (1.76-4.40) and 1.57 (1.16-2.13) for pre-diabetes. There was a significantly higher prevalence of diabetes, pre-diabetes and obesity among Somali patients compared with non-Somali patients. Further research into the specific causes of these disparities and development of targeted effective and sustainable interventions to address them is needed.

Background: Data from previous studies indicate a short duration of breastfeeding, especially exclusive breastfeeding, among infants of immigrant mothers living in Norway and other Western countries. Norway has a long tradition of supporting breastfeeding., Aim: To explore infant feeding practices among Somali-born mothers in Norway, and the ways in which they navigate among different information sources., Methods: Qualitative in-depth interviews and focus groups were carried out with mothers of children 6, 12 and 24 months of age. Women were recruited by a multi-recruitment strategy. Twenty-one mothers participated in interviews and twenty-two in five focus groups. The analysis was guided by Grounded Theory., Findings: The mothers had positive attitudes to breastfeeding, but were unfamiliar with the concept of exclusive breastfeeding. Early introduction of water and infant formula was a common practice that interfered with exclusive breastfeeding. The mothers experienced challenges of dealing with conflicting recommendations and expectations regarding infant feeding. They navigated among different sources of information, taking into consideration traditional values, experiences and habits from living in Norway, and research-based knowledge. Their prioritization of the different information sources varied with different life situations, children's age, and the extent to which the mothers trusted the information sources., Discussion and Conclusions: Despite the strong focus on breastfeeding in Norway, Somali-born mothers encounter obstacles in their breastfeeding practices. These may be due to lack of information about exclusive breastfeeding and to the conflicting information they received. Breastfeeding practices may be enhanced by promoting culturally sensitive communication, and relations of trust at health-care centers., (Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives To determine use of recommended maternal healthcare services among refugee and immigrant women in a setting of near-universal insurance coverage. Methods Refugee women age ≥18 years, who arrived in the US from 2001 to 2013 and received care at the same Massachusetts community health center, were matched by age, gender, and date of care initiation to Spanish-speaking immigrants and US-born controls. The primary outcome was initiation of obstetrical care within the first trimester (12 weeks gestation). Secondary outcomes were number of obstetrical visits and attending a postpartum visit. Results We included 375 women with 763 pregnancies (women/pregnancies: 53/116 refugee, 186/368 immigrant, 136/279 control). More refugees (20.6 %) and immigrants (15.0 %) had their first obstetric visit after 12 weeks gestation than controls (6.0 %, p < 0.001). In logistic regression models adjusted for age, education, insurance, BMI, and median census tract household income, both refugee (odds ratio [OR] 4.58, 95 % confidence interval [CI] 1.73-12.13) and immigrant (OR 2.21, 95 % CI 1.00-4.84) women had delayed prenatal care initiation. Refugees had fewer prenatal visits than controls (median 12 vs. 14, p < 0.001). Refugees (73.3 %) and immigrant (78.3 %) women were more likely to have postpartum care (controls 54.8 %, p < 0.001) with differences persisting after adjustment (refugee [OR 2.00, 95 % CI 1.04-3.83] and immigrant [OR 2.79, 95 % CI 1.72-4.53]). Conclusions for Practice Refugee and immigrant women had increased risk for delayed initiation of prenatal care, but greater use of postpartum visits. Targeted outreach may be needed to improve use of beneficial care.

Persons from Somalia constitute the largest group of immigrants and refugees from Africa among whom diabetes-related health disparities are well documented. As one of the first steps toward developing a behavioral intervention to address diabetes among Somali immigrants and refugees, we administered a face to face interview-based survey to Somali and Latino adults with diabetes in a single community to assess diabetes knowledge, attitudes and behaviors. Respondents (N = 78) reported several barriers to optimal diabetes management for physical activity and glucose self-monitoring, as well as a high burden of disease and negative perceptions of diabetes. High participant engagement in disease management, self-efficacy, and social support were important assets. Similarities suggest that the shared experiences of immigration and related systemic socioeconomic and linguistic factors play a significant role in the understanding and self-management of diabetes in these populations. Together with previously collected qualitative work, the survey findings will inform development of a behavioral intervention to improve outcomes and reduce diabetes-related health disparities among immigrant and refugee groups to the U.S.

Background: Muscular weakness and severe vitamin D deficiency is prevalent in Somali (veiled) pregnant women, Sweden. The study aims here were to explore adherence to prescribed supplemental vitamin D in new mothers with vitamin D deficiency and its effects on grip strength and upper leg performance in Somali (target group TG) and Swedish women (reference group RG) from spring through winter., Methods: A before- and after study was designed. A cross-sectional sample of women in antenatal care with serum 25-OHD ≤50 nmol/L were prescribed one or two tablets daily (800 or 1600 IU vitamin D3 with calcium) for 10 months. Reminders were made by Somali nurses (TG) or Swedish doctors (RG). Baseline and 10 month measurements of plasma nmol/L 25-OHD, maximal grip strength held for 10 s (Newton, N) and ability to squat (yes;no) were done. Total tablet intake (n) was calculated. Outcome variables were changes from baseline in grip strength and ability to squat. Predicting variables for change in grip strength and ability to squat were calculated using linear and binary regression in final models. Undetectable 25-OHD values (<10 nmol/L) were replaced with '9' in statistic calculations., Results: Seventy-one women (46 TG, 1/3 with undetectable baseline 25-OHD; 25 RG) participated. At the 10-month follow up, 17% TG and 8% RG women reported having refrained from supplement. Mean 25-OHD increased 16 to 49 nmol/L (TG) and 39 nmol/L to 67 nmol/L (RG), (both p < 0.001). Grip strength had improved from 153 to 188 N (TG) (p < 0.001) and from 257 to 297 N (RG) (p = 0.003) and inability to squat had decreased in TG (35 to 9, p < 0.001). Intake of number of tablets predicted increased grip strength (B 0.067, 95%CI 0.008-0.127, p = 0.027). One tablet daily (>300 in total) predicted improved ability to squat (OR 16; 95% CI 1.8-144.6)., Conclusions: Adherence to supplemental vitamin D and calcium should be encouraged as an even moderate intake was associated to improved grip strength and upper leg performance, which was particularly useful for the women with severe 25-OHD deficiency and poor physical performance at baseline., Trial Registration: ClinicalTrials.gov Identifier: NCT02922803 . Date of registration: September 28, 2016.

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.

Objective: Immigrants, specifically African-born black persons, are affected by the HIV epidemic in the U.S. The low level of condom use among immigrants is a risk factor for contracting HIV and STIs. Immigrants go through acculturation process in their new adopted countries-a process reported to influence many health risks and protective factors; however, the mechanism through which acculturation influences health behaviors is not well understood. Thus, study examined the mediating role of attitude in the relationship between acculturation and the intention to use male condoms in steady heterosexual relationships among Somali and Ethiopian immigrants in Minnesota., Design and Sample: The study was a regression analysis and the method of data collection cross-sectional. Participants were (n = 205) Somali and Ethiopian immigrants in Minnesota who volunteered for the study., Measures: Study participants responded to questions on attitudes, behavioral intention, and acculturation levels., Results: The indirect effect of acculturation through the mediator, attitude, was not significant, product coefficient (a × b) = 0.04, 95% CI: [0.00, 0.11]; hence attitude did not mediate the relationship between acculturation and the intention to use condoms in the study population. However, there were significant direct and total effects of acculturation (c' = .27, p < .05; c = .31, p < .05), respectively, on intention to use condoms., Conclusion: Results of the study may suggest that public health intervention strategies targeting condom use among immigrants should incorporate programs that improve English language training tailored to the cultural practices and values of the immigrants, and consider the effect of acculturation on condom use., (© 2016 Wiley Periodicals, Inc.)

Ethnic minorities remain underrepresented in clinical trials despite efforts to increase their enrollment. Although community-based participatory research (CBPR) approaches have been effective for conducting research studies in minority and socially disadvantaged populations, protocols for CBPR recruitment design and implementation among immigrants and refugees have not been well described. We used a community-led and community-implemented CBPR strategy for recruiting 45 Hispanic, Somali, and Sudanese families (160 individuals) to participate in a large, randomized, community-based trial aimed at evaluating a physical activity and nutrition intervention. We achieved 97.7 % of our recruitment goal for families and 94.4 % for individuals. Use of a CBPR approach is an effective strategy for recruiting immigrant and refugee participants for clinical trials. We believe the lessons we learned during the process of participatory recruitment design and implementation will be helpful for others working with these populations.

Objective: To evaluate the percentage of women with female genital mutilation/cutting who request postpartum reinfibulation, and to assess outcomes after specific care and counseling., Methods: A retrospective review was undertaken of consecutive medical files of immigrant women with FGM/C who attended a center in Geneva, Switzerland, between April 1, 2010, and January 8, 2014. The number of postpartum reinfibulation requests and outcomes were assessed. If a patient requests postpartum reinfibulation despite receiving detailed information and counseling, a longer follow-up is arranged for further counseling., Results: Among 196 women with FGM/C, 8 (4.1%) requested postpartum reinfibulation. All eight were of East African origin, had FGM/C type III, and received a longer and more targeted follow-up than did those who did not request reinfibulation. After at least 1year of follow-up, none of the eight was willing to undergo reinfibulation. One woman who attended the clinic only once during her first pregnancy consulted the emergency ward of the study center 3years later because of postcoital bleeding following infibulation performed in her home country a few months after her second delivery in Switzerland., Conclusion: Specific care and counseling for women with FGM/C type III can improve the acceptability of defibulation without reinfibulation., (Copyright © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

African-born immigrants and refugees have HIV infection rates six times higher than any other minority groups in the United States. Despite the increase in the population size and diversity of Somali immigrants and refugees in the United States, Somalis are one of the medically underserved population subgroups in this region. The lack of aggregate HIV infection rates among African-born immigrants, for example, Somali refugees, is a cause for alarm and calls for more research to be conducted in this subgroup. The purpose of this article was to examine contextually relevant HIV prevention strategies that will enhance HIV prevention among Somali immigrant/refugee young adults in the United States. Using the grounded theory approach, a convenience sample of 27 immigrant/refugee young adults was recruited in central Ohio. Recommendations for potential HIV prevention strategies emerged under two main categories: (1) internal community resources and (2) external platforms. Study findings support a collaborative approach involving community leaders (parents, elders, religious leaders) and educational (schools), media, and healthcare settings to tailor HIV prevention strategies that meet the needs of the priority group.

Objectives: Currently louse-borne relapsing fever (LBRF) is primarily found in limited endemic foci in Ethiopia, Somalia and Sudan; no case of imported LBRF has been reported in Europe in the 9 years prior to 2015. The aim of our paper is to describe a new case of imported LBRF detected in Sicily, Italy, and to review all cases reported in migrants arrived in Europe in the last 10 years., Study Design: Mini review of all published cases of louse-borne relapsing fever in Europe in the last 10 years., Methods: A computerized search without language restriction was conducted using PubMed combining the terms '(louse-borne relapsing fever or LBRF or recurrentis) and (refugee or Europe or migrant)' without limits. Furthermore, the 'Ahead-of-Print Articles' of the top 10 journals (ranked by Impact factor - Web of Science) of Infectious diseases and of Epidemiology were checked., Results: Our search identified 26 cases of LBRF between July and October 2015 in migrants recently arrived in Europe: 8 had been described in Italy; 1 in Switzerland; 2 in the Netherlands; 15 in Germany. We describe data regarding the clinical characteristics, diagnostic methods, therapy and outcome of these patients and of the new case., Conclusions: LBRF by Borrelia recurrentis should be considered among the clinical hypotheses in migrants presenting with fever, headache, chills, sweating, arthralgia, myalgia, dizziness, nausea and vomiting., (Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)