RunningHead:STORIESOFTHESOMALIBANTU

Stories of the Somali Bantu Erin M. Thorpe University of Virginia School of Nursing

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Abstract

Objectives: The purpose of this descriptive qualitative study was to explore the narrative histories of Somali Bantu refugees living in Charlottesville, Virginia in order to identify common themes with implications for healthcare providers working with this population. Methods: This IRB approved study utilized informal group and individual interviews in which study participants (n=8) were provided with the opportunity to share personal narratives about their past lives living in Somalia and Kenya, as well as experiences in the United States. Interviews were audio recorded and each participant received a copy of his or her interview, which can be passed down to future generations if desired. Interviews were transcribed and analyzed to identify nine common themes, which were then assessed for healthcare implications. Results: Data analysis resulted in nine common themes: war and trauma, safety, ethnic distinctions, education, vocation, nutrition, health, traditional practices, and view of the United States, all of which impact their utilization of the American healthcare system. Conclusions: This studys findings suggest a need for further research into the health needs of the Somali Bantu refugee population through continued investigation of each of the identified themes.

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Stories of the Somali Bantu Introduction Background According to the United States Bureau of Population, Refugees, and Migration (2011), a refugee is defined as a person who has been forced to leave his or her home for fear of persecution and has crossed an international border in order to find safety. Since 1950, nearly 3 million refugees have come to the United States, fleeing persecution in their home nation and resettling in cities and towns across America (Bureau of Population, Refugees, and Migration, 2011). One of the many populations that has made its way to the United States is the Somali Bantu, who have arrived by way of Kenyan refugee camps from their homeland in Somalia, an Eastern African nation about the size of Texas that borders Djibouti, Ethiopia, and Kenya (Van Lehman & Eno, 2002). This Somali Bantu population, a minority group, makes up an estimated 600,000 of the 7.5 million people living in Somalia today (Van Lehman & Eno, 2002). Barriers These Somali Bantu refugees bring with them a unique set of customs, practices, and beliefs that must be addressed by their new communities in the United States. Healthcare providers are often faced with complex situations related to language and cultural differences when caring for this population, resulting in obstacles to achieving culturally competent care. In light of these differences, a small number of research studies have been conducted in order to identify health related barriers that are faced by this unique population.

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As refugees living in the United States, the Somali Bantu are often confused for their Somali Somali counterparts. Because healthcare providers are typically unaware of this distinction, they often fail to provide translation services in the Bantu native tongue of Af Maay (Maay Maay), but instead in the Somali Somali language of Af Maxaa (Gurnah et al., 2011). Illiteracy is also a major barrier faced by this population. Due to their exclusion from formal education in Somalia, only 5% of Bantu refugees have had any formal education and most are illiterate (Parve &Kaul, 2011). Culturally, the majority of Somali Bantu refugees are Muslim, though many continue to endorse animist and magical beliefs (Van Lehman & Eno, 2002). While many continue to practice traditional medicine, they no longer perform practices such a female circumcision or burning in the United States (Springer et al., 2010; Parve & Kaul, 2011; Upvall et al., 2008). With regards to reproductive health, current research is conflicted with regards to the use and support of family planning techniques and the use of birth control by Somali Bantu refugees(de la Cruz et al., 2008; Gurnah et al., 2011). However, the use of male practitioners for reproductive exams and fears related to American birthing practices and the prevalence of cesarean sections have been identified as barriers by female Somali Bantu (Brown et al., 2010; Gurnah et al., 2011; Springer et al., 2010). Other identified barriers include lack of health knowledge (de la Cruz et al., 2008) and insufficient insurance coverage (de la Cruz et al., 2008; Gurnah et al., 2011; Springer et al., 2010). In order to best serve the needs of Somali Bantu refugees, these identified barriers must be addressed and continued research must be conducted into the health needs of this population.

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There is a need for further research focused on the needs of the Somali Bantu refugee population. Despite that fact that there has been much research devoted to the Somali Somali refugee population, during a thorough review of multiple databases only five research studies were identified that included Somali Bantu subjects and a focus on healthcare. Additionally, the majority of these studies solely included women of childbearing age, with very few including male, elderly, or teenage participants. These studies, though qualitative, tended to be narrowly focused with rigid designs that failed to acknowledge a holistic view of health that appreciates ever facet of day-to-day life. This study was designed to address this need, with a stated purpose of exploring the lived experiences of Somali Bantu refugees living in Charlottesville Virginia in order to perform an analysis of common themes and identify healthcare related implications. Methods Design This Institutional Review Board (IRB) approved study was a descriptive qualitative investigation into the narrative histories of Somali Bantu refugees living in Charlottesville, Virginia. Through the use of open-ended interview questions, the study allowed refugees the unique opportunity to share their stories in their own words and record these narratives for future generations. These interviews were designed to allow participants the opportunity to recount stories and experiences that shaped them, as well as share examples of their day-to-day lives in the settings of Somalia, Kenya, and the United States. Through this qualitative design, researchers were able to analyze common experiences and ultimately identify health related themes that can be utilized to improve care for this distinctive population.

STORIESOFTHESOMALIBANTU Setting

The setting of this study was primarily Charlottesville, Virginia, with one interview conducted in Roanoke, Virginia with a couple that had recently moved from Charlottesville. Interviews were conducted in the participants homes, in a location of their choice, with the amount of privacy left to their discretion. Sample This study only included refugees of Somali Bantu ethnicity who had been a resident of Charlottesville, Virginia within the last five years. There were a total of eight participants, which included six women ranging from 16 years to approximately 55 years in age, with a median age of approximately 30, and two men ages 27 and 43. All of the participants had moved to the United States from Kenya between the years 2003-2005. While all of the participants spoke Maay Maay as their primary language, all but three were able to conduct the interview in English without the aid of a translator. Procedure Recruitment Due to the fact that the studys primary researcher was well invested in the Charlottesville Somali Bantu community prior to study implementation, recruitment was conducted through convenience sampling. The study investigator approached each potential participant in person, in their homes, explained the research goals and process, and asked if he or she would like to participate. A total of 15 Somali Bantu refugees were approached, with a total of 13 agreeing to participation. Ultimately, due to conflicts of timing, 8 were included in the study. An IRB approved oral consent protocol was utilized prior to initiation of each interview. The researcher verbally explained the research goals

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and interview process, explaining that the participants could end the interview at any time without penalty, that they would receive no compensation for participation, and that they would be provided with a copy of their interview following study completion. This explanation was translated into Maay Maay for those with limited English capabilities. Parental consent was obtained for participants under the age of 18. Interview Protocol Interviews were conducted in participants homes, either privately or in a group setting as determined by the participants, for a total of four interviews: two group and two individual. Each session was audio recorded using a digital recorder and lasted between fifteen minutes to one hour, with a median length of thirty-five minutes. Interviews were conducted by a researcher who was well known in the community, utilizing open-ended questions aimed at identifying daily life experiences, access to food, water, and healthcare, traditional beliefs and practices, and differences between life in Somalia, Kenya, and the United States. Data Analysis Interviews were transcribed prior to analysis of content. Data was classified into thematic categories and organized to allow for comparison between individual participant responses. Inferences were made regarding the impact of these findings on Somali Bantu use of the American healthcare system and implications for nursing practice. Findings As participants shared their stories with researchers during the interview process, nine major themes emerged: war and trauma, safety, ethnic distinctions, education, vocation, nutrition, health, traditional practices, and view of the United States. These

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experiences have shaped each of these participants lives and must be recognized by healthcare providers in order to best serve their health related needs. War and Trauma Seven of the participants were born in Somalia, where they lived in small villages and worked as farmers sharecropping for wealthy Somali Somali landowners. When the Somali Civil War broke out in 1991 Somali Somali tribes began vying for power and control over the governmental system. This violence was soon turned upon the Somali Bantu peoples who, as a disenfranchised ethnic minority, faced violent raids for food and money as members of their families and villages were raped, injured, and killed. One forty-three year old male participant described this time explaining, The Somali Somali guns: Give me money, give me clothes, give me food. Pow Pow. Finish everybody: children, wife, everybody. Participants reported fleeing their homes on foot, everybody for themselves, without sufficient food, medicine, or water, on a week long, one hundred mile journey to Kenya. One man, who was five years old when his family made the journey out of Somalia, explained that Whenever someone dies they just leave them somewhere and they walk becauseyou put your family first, six, seven, ten kidsThey sit in one spot to get rest, some of them they cannot walk again. These experiences, incredibly traumatic in nature, have played an integral role in each of the participants lives. However, study participants, especially females, tended to describe their reasons for leaving Somalia in vague terms such as bad people, war, and trouble, clearly avoiding going into detail about the suffering that they experienced. Safety

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Common to each of the interviews was the theme of safety, with an emphasis on the powerful nature of firearms. One man explained that those who owned guns held the power in society and were able to utilize this power to steal unarmed familys vehicles during the flee from Somalia to Kenya. If you have car if you dont have no guns, they gonna rob you and take your car, and hes gonna put his family and he go and you and your family you gonna walk, if you stay they gonna kill you. Guns were also viewed as a source of power in the Kenyan refugee camps. Although one female participant denied any safety concerns living in the camp, others explained that safety was a relative term and that robbery and murder was a regular occurrence, They have guns and they say Bring me your food, I need your food. And you say No, they kill you. This was especially true for women gathering firewood outside of the camp, as one woman reported, They kill sometimes, the people. Its not really safe but you have to get it. If you dont get it you dont eat food. Police were seen as fairly useless in these situations, as they only arrived after the fact and were unwilling to confront armed criminals. When discussing safety in the United States, respondents had mixed responses. One teenage female participant remarked that she had less freedom in the United States and explained that, here, Youre scared that someones gonna have a gun and just shoot you or assault you. While these risks existed in Kenya as well, in Africawe was all close to each other and we was like family. However, she noted that in the United States the police were easily contacted using 911, suggesting that her family trusted the local law enforcement despite their experiences in the refugee camps. Ethnic Distinctions

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When sharing their stories, the Somali Bantu participants were very deliberate in differentiating themselves from the Somali Somali, the Somalian ethnic majority group. According to participants, the Somali Somali held the power in the Somalian society, controlling the government, education, and healthcare systems, and denying access to these to the Somali Bantu minority group. While the Somali Somali were typically able to speak in English, held powerful, high paying jobs, and were protected through tribal systems, the Somali Bantu were typically uneducated and forced to work as sharecroppers for Somali Somali landowners. In their narratives, participants typically described the Somali Somali as bad, and described their lives in Somalia as slavery. Education Education was a common topic of discussion. As previously explained, school was not an option for the Somali Bantu in Somalia. This changed upon their arrival in the Kenyan refugee camps, where children were able to attend school and learn English. While classes were open to both genders, participants shared that girls were often required to forgo school in order to help their families by caring for children, doing household chores, or bringing in a small income through outside employment. Living in the United States, participants placed significant value on the importance of education. When one female participant arrived in the US at the age of eighteen, she didnt know anything Englishdidnt even know how to write [her] name. She admitted to lying about her age in order to attend two years of high school where she was able to learn basic English. Many of the adult participants also reported attending English classes through their employers or local adult learning centers.

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Higher education was widely viewed as essential to success in the United States. Parents consistently reported that they wanted their children, both male and female, to graduate from high school, attend college, and make something of themselves. However, one woman with young children admitted that she didnt always know how to help her children with schoolwork, as she had limited literacy abilities. This emphasis and value on education is a major strength for this population, one which should be recognized and utilized by healthcare providers. Vocation Vocation was another common topic of discussion. According to one male participant, he worked six full days per week as a farmer in Somalia, walking upwards of 20 miles to and from the fields, working in temperatures above one hundred degrees Fahrenheit, and lacking any modern farming equipment. He reported that women would typically work for the wealthy Somali Somali as cooks and housekeepers, where they would make about seven dollars a day. Work was scarce in Kenya. According to one male participant, We was eleven kids nobody working, my mom not working, we dont have enough food, my daddy not working and the lifes not easy. One participant shared stories of selling sambusa, a traditional dish, with her mother to make enough money to purchase milk for her siblings. Another woman reported that, while in Somalia a woman might earn sixty dollars in a month, in Kenya she would be happy to make five to ten dollars in that time. Children, especially girls, were expected to work to support their families, often through childcare. One participant reported that her mother supported her decision to wait to get married because she was needed to help care for her many children. Another

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female participant reported that she is still expected to babysit on a daily basis, reporting Im looking after kids. I have to cook, I have to clean, and right now Im sixteen years old. She explained that these responsibilities began at the age of twelve, that she often felt taken advantage of by relatives who leave their children with her regularly, and that she had noticed a negative impact on her school performance. The ability to consistently find employment in the United States was highly valued. As one man put it, Here its five days working, two days sleeping, very nice, make money. Somalia: work big, money not. America: work small, money big. Nutrition Nutrition and access to sufficient food was a major stressor for participants. While living in Somalia, despite the fact that the Bantu made their living through farming, they received very little produce to feed their families. One participant recalled growing up in Somalia and watching her parents sacrifice for their children, stating If something leftover and is small and not enough for all kids and mom and dad so mom and dad used to sleep so the kids can eat. Food continued to be scarce during the journey to Kenya, where participants recalled having to protect the little food that they had for their families, watching others die of starvation on the side of the road. Upon their arrival in the camps, they didnt have to go and look or food and hunt for food because the IOM was giving them food, like corn and stuff. Participants reported receiving food aid in form of oil, beans, flour, salt, and corn from the International Organization for Migration (IOM) every fifteen days. However, these rations were often insufficient for their large families and lacked essentials such as milk and meat, forcing parents and older siblings to search for

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employment, spending their meager wages on feeding their children. Participants reported ready access to clean water in the form of communal taps, a change from life in Somalia where their only source of water was a nearby river. Easy access to sufficient food supplies was widely regarded as a benefit to living in the United States. As one participant put it, Go America we was happy because we dont have enough money or enough food to eat every day. Thats why we go. The majority of the participants reported receiving governmental assistance through food stamps, WIC for their young children, and participated in the free lunch program at the local public schools. As Muslims, all abstained from pork in their diet. Health Interestingly, none of the participants spoke directly about health or healthcare until prompted by researchers. Even when prompted, most were unable to differentiate between healthcare in Somalia and Kenya, and in the United States. As one woman put it, They was like mostly the same, like they have a bigger hospitals here, back home the hospitals were little. Those are the differences. However, when asked specific questions regarding treatment for illness and the availability of medications, a few of the participants did share some major differences of which American healthcare providers should be made aware. According to one participant, the Somali Bantu did not have access to healthcare facilities while living in Somalia, but instead relied on the use of traditional medicine, for example ingesting mashes made from plant material, such as trees, with curative properties. While living in Kenya, the Somali Bantu had access to small clinics with limited dispensaries and abilities to perform diagnostic tests. One participant reported that

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these were often a waste of time, as one would spend the entire day at one of the two clinics only to receive the same pill, regardless of symptoms. Participants reported that illness was common in the camps, with one man sharing that two of his children had died from diarrhea and vomiting at a young age. Diarrhea was attributed to the refugees changing diets and limited food supplies, as people often consumed food that was spoiled or improperly cooked. Malaria, as well as snake and scorpion bites, were common. Participants reported that birth typically occurred in the home, with babies being seen at the hospital for vaccinations following delivery. One woman reported that having a cesarean section was seen as a death sentence, and that doctors often didnt even bother suturing women up after the procedure, as they rarely survived. When asked about the use of traditional medicine, the majority of participants denied use on their part, but admitted utilization of these practices by others. However, participants openly endorsed past use of common treatment practices such as burning, for the treatment of broken bones, big heads, voodoo, and illness. Other reported traditional treatments included removing childrens teeth to prevent vomiting, shaving their hair or cutting their stomachs with a razor blade to treat illness, and cut inside the neck for children with persistent coughs. In these situations, even in the case of broken bones, only traditional treatments were utilized and the sick or injured were not seen by a provider. Every participant maintained the fact that these traditional practices are not continued in the United States for fear of legal repercussions. Theres a lot of things they have to do in Africa but here they cant do you have to go and get the doctor if the child is sick. Instead, participants reported using the health systems family medicine clinic

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and emergency department as needed, and were satisfied with their care. Most participants were on Medicaid or received insurance through their employers. Traditional Practices When speaking about life in Somalia and Kenya, participants spoke of many traditional and cultural practices. Polygamy was common and marriage often occurred at age fifteen or younger. While one of the participants had four wives while living in Kenya, he reported that he had divorced three of them when moving to the United States. Interestingly, one participant shared that men sometimes continue to practice polygamy while living in the United States, but refer to their wives as girlfriends. Female circumcision was generally performed on young girls between the ages of three and ten years old. All but one of the participating women had been circumcised, but all maintained that this practice is not performed in the United States. View of the United States Consistent in each interview was an incredibly positive and grateful perspective of the United States. Participants viewed America as a place where they could work to support their family, receive an education, and hope in the futures of their children. One of the male participants had passed his citizenship test and stressed the importance of voting in the upcoming election, while another was actively taking classes at the time of the interview. Participants embraced the American view of equality, but identified some difficulty practicing their Muslim religion in a predominantly Christian society. While some of the participants did report receiving some stereotypical comments for their background, manner of dress and accents, one participant explained that he saw these as opportunities for him to teach Americans about his home country and heritage.

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Discussion

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During the interview and analysis processes, nine major themes were identified. Although some differences in responses were evident, especially between male and females, these were typically limited to the fact that female participants were more likely to downplay their negative experiences, while men were more open to acknowledging difficulties such as lack of sufficient food, safety concerns, and presence of death and disease. Further research may be required to investigate this difference, as the female hesitation to complain or share negative experiences may impact the ability of healthcare providers to obtain accurate health histories. Unexpectedly, while all of the participants avoided associating themselves with the use of traditional medicine, they freely admitted to the use of practices such as burning, cutting, and tooth extraction as methods for healing a wide range of ailments. Additionally, despite the fact that all participants viewed these traditional practices as effective methods of treatment, they reported contentment with the American healthcare system and use of Western medicine and denied continued use of customary practices. Despite experiencing war, fear, hunger, and loss, none of the participants dwelled on their pasts, but instead tended to focus on their appreciation for their lives in the United States and the opportunities afforded to them and their children. Their incredible resiliency and continued positivity is inspiring and should be viewed as a strength by providers. Implications for Nursing Practice The nursing profession is one of holistic care encompassing not only physical wellness, but also a persons emotional, social, spiritual, and relational states.

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Accordingly, cultural competency is essential to appropriate nursing care. When working with members of the Somali Bantu refugee community, nurses and other healthcare practitioners should be aware of the fact that most adults will have limited English and literacy skills due to the fact that education was not widely available in their past. When utilizing translators, providers should ensure that the Somali Bantu language of Maay Maay is used, not Af Maxaa which is spoken by the Somali Somali. Providers should not be surprised to find burn marks and scars on their patients skins and should expect their female adult clients to be circumcised. When working with pregnant women, providers should be prepared to educate their patients about cesarean sections and stress the safety and positive outcomes of this procedure when utilized appropriately. When working with children, providers should be aware of past experiences of poor nutrition and traumatic occurrences, which may impact their health and development. Recommendations for Future Research Through its qualitative design and subjective nature, researchers were able to identify nine broad themes that can be utilized by healthcare providers working with the Somali Bantu population in the United States. By identifying these themes, researchers have paved the way for future focused studies exploring in depth what this study has only touched upon. Future researchers should continue to study the Somali Bantu as a separate population from the Somali Somali, and compare the subpopulations of men, teenagers, and the elderly. Research should also be conducted into the specific ways that Somali Bantu refugees utilize the American healthcare system and should explore the perspectives of healthcare providers working with this population.

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This study was limited by a small sample size of only eight participants, with an insufficient sample size to allow accurate comparison of results based on age or gender. Though the participant-driven and open-ended nature of the study allowed for a broad range of responses that may not have otherwise arisen through a more rigid form of data collection, the wide range of participant responses also limited comparison of findings. Funding for the distribution of copies of each interview to study participants was provided by The Rodriguez Nursing Student Research and Leadership Fund. Conclusion The provision of culturally competent care for the Somali Bantu refugee population is essential to ensuring proper health maintenance for this community. While past research has been conducted focusing on the Somali Bantu refugee population, none of these studies have approached this research from the broad perspective of a narrative based interview. This research study was implemented to fill this gap with the ultimate purpose of identifying the shared experiences of Somali Bantu refugees living in Charlottesville, Virginia. Study findings expand upon conclusions of earlier research studies and provide a framework for future studies aimed at exploring Somali Bantu health and use of the American healthcare system. By providing each participant with a copy of his or her interview, this study also allows for the preservation of the unique experiences of the refugees, stories that will be valued by future generations. Nurses must educate themselves about the culture, beliefs, pasts, and practices of the Somali Bantu and must open themselves up to the narrative histories of each of clients. Every person has a story, one that has shaped them, continues to have an impact on their health and wellness, and must be understood to ensure proper provision of healthcare.

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References

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Brown, E., Carroll, J., Fogarty, C., Holt, C. (2010). They get a c-sectionthey gonna die: Somali womens fears of obstetrical interventions in the United States. Journal of Transcultural Nursing, 21(3), 220-226. Bureau of Population, Refugees, and Migration (May 6, 2011). Refugee Admissions Program for Africa. Retrieved from http://www.state.gov/r/pa/ei/bgn/2863.htm. De la Cruz & Associates. (2008). Somali Bantu community of San Diego. Health needs assessment findings. San Diego, CA: de la Cruz, O., Jumale, H., Krause, C., Madisa, H., Pan, A. Gurnah, K., Khoshnood, K., Bradley, E., Yuan, C. (2011). Lost in translation: reproductive health care experiences of Somali Bantu women in Hartford, Connecticut. Journal of Midwifery and Womens Health, 56 (4), 340-345. Parve, J., Kaul, T. (2011). Clinical issues in refugee healthcare: the Somali Bantu population. The Nurse Practitioner, 36 (7), 48-53. Springer, P.J., Black, M., Martz, K., Deckys, C., Soelberg, T. (2010). Somali Bantu refugees in southwest Idaho: assessment using participatory research. Advances in Nursing Science, 33(2), 170-181. Upvall, M.J., Mohammed, K., Dodge, P.D. (2008). Perspectives of Somali Bantu refuge women living with circumcision in the United States: a focus group approach. International Journal of Nursing Studies, 46, 360-368. Van Lehman D, Eno O. (2002) The Somali Bantu: Their history and culture. Retrieved from http://www.cal.org/co/bantu/.