2. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 2
Somali Perceptions of Mental and Physical Health
For decades, Somalia has experienced civil war and instability. With the political and
economic instabilities in Somalia, many Somali people have immigrated to other countries.
Between 1990 and 2015, “the total number of people born in Somalia but living outside the
country more than doubled, from about 850,000 to 2 million” (Connor & Krogstad, 2016). As a
result of this immigration to the outside of Somalia, there is an increased Somali population in
the United States dating back to the early 1990’s due to the civil unrest.
I became interested in focusing on the Somali population because my parents have
emigrated from Somalia to the US in the early 90’s. In Somali communities in the US, there are
different mental and physical health practices, and there is stigma related to mental health. First,
I would like to explore and discover the perceptions of Somali people about mental and physical
health compared with common perceptions I have observed anecdotally. The question guiding
this research project is: What are the beliefs and perceptions of Somali-Americans in the US
towards mental and physical health?
Literature Review
A review of the literature on Somali beliefs towards mental and physical health showed a
lack of research on this topic. More studies on this subject are needed to expand on the
knowledge about Somali-Americans and their perceptions of mental and physical health. In the
Somali culture, a common theme is the association of spirits and mental health. It is common for
people to disregard mental health issues by not seeking proper mental health services due to
cultural stigma (Bettmann, Penney, Freeman, & Lecy, 2015). This is because mental health
issues are commonly believed to be a result of a spirit possession or an evil eye and this is the
concept of projecting comments or praises upon someone which results in a negative outcome
3. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 3
for the recipient of the evil eye (Scuglik, Alarcon, Lapeyre, Williams, & Logan, 2007). Mental
health is associated with stigma in the Somali communities, and is generally divided into the
categories of sanity or insanity. In addition, “mood disorders are addressed by family support,
religiously based interventions, and indigenous herbal remedies” (Boynton, Bentley, Jackson, &
Gibbs, 2010, p. 267).
Much of the literature on Somali perceptions of mental and physical health were
qualitative studies. In a study by Greeson, Veach & Leroy (2001), female Somali immigrants
were interviewed about their perceptions towards disability. The researchers found that the
participants identified mental and physical disabilities to be actual disabilities with the view that
the mental disability was more severe (Greeson, Veach, & Leroy, 2001). Findings also showed
that Somali families typically cared for their relatives with mental disabilities in the home where
utilization of nonfamilial organizations or agencies were regarded as unacceptable, which are
therefore nonexistent in the Somali culture (Greeson, Veach, & Leroy, 2001).
Another common theme found in the literature was the use of religion as a form of
support and therapy for existing mental illness. The majority of Somali-Americans follow the
religion of Islam and adhere to the teachings of the Quran, the holy book in the Islamic faith. In a
study by Wolf et al. (2016), evidence of religion was seen in Somali perceptions of mental health
and illness where there was a belief that illness is a test from God. Mental health beliefs and
practices that incorporate “jinn possession and Qur’an verse reading as first-line treatment are
indicators of how religion has the most influence on health beliefs, values, and practices in the
Somali community” (Wolf et al., 2016, p.355). Jinn represents an evil spirit that causes suffering
in a person once it possesses the human body (Boynton et al., 2010). Somali-Americans view the
recitation of Quran, the holy book in the Islamic faith, as a non-medical form of treatment for
4. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 4
mental illness. Additionally, study findings show that talk therapy, also known as speaking to a
therapist, is generally not endorsed as a form of treatment while a common treatment for mental
illness consists of home family care.
Other themes found in the literature included stigma surrounding mental and physical
disabilities. Discomfort with mental health issues was frequently reported. Seeking treatment
was found to not be a common practice, demonstrating the disconnect between the Somali
population perceptions and the providers. In a study of Somali mothers of children with mental
illness, mothers indicated that their “expectations for treatment were low because service
providers failed to understand their culture and as a result were unable to communicate with
them” (Miller-Gairy & Mofya, 2015, p. 335). In addition to this perceived outcome, there was
also a belief that Autism Spectrum Disorder was caused by a combination of factors such as
vaccines, processed food, and the evil eye (Miller-Gairy & Mofya, 2015). Additionally, studies
showed that mistreatment of individuals with physical and mental disabilities in Somali
communities often resulted in isolation and unmet social and health care needs (Higginbottom,
Rivers, & Story, 2014).
Additional research is needed to better understand Somali perceptions toward mental and
physical health. While the majority of current literature is scant, further research can help
providers determine appropriate strategies of care for Somali-Americans experiencing mental
and physical health problems. (Bettmann, Penney, Freeman, & Lecy, 2015; Scuglik et al., 2007).
This study seeks to identify the perception of Somali-Americans toward mental and physical
health. It is hypothesized that there will be a negative perception regarding mental health and
physical health.
Methodology
6. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 6
message stating that the participant has selected an option to end the survey and a message
thanking them for participating. Information was included that informed the participants that
they could stop and exit out of the survey at any given moment if they were uncomfortable
answering any of the questions. The purpose of the study was explained, the risk and benefits of
the study, and the participant was informed that the responses would be kept confidential and
that the surveys would be anonymous. The study was approved by the Internal Review Board
(IRB) through the ASU Office of Research Integrity and Assurance.
Recruitment Strategy
The link to the survey was posted initially on Facebook with an announcement describing
the purpose of the survey, criteria to take the survey, and a chance to win a Starbucks gift card.
Also, this post included information asking Facebook friends to share the post since it was made
public. This way, additional potential participants were recruited. The same announcement was
posted on Twitter. The survey was posted on Facebook ten times and on Twitter 8 times between
the period of April 2016 and September 2016. The social media sites Facebook and Twitter were
the only sites used for recruitment in this study.
Participants in this study were given the option to submit an entry for a $15 Starbucks gift
card drawing. On the last page of the online survey, those wanting to enter the drawing clicked
on a link to enter their email addresses. This was an external link that led to the
surveymonkey.com website. This external link was provided to maintain privacy and not
associate the participants’ responses with the gift card drawing.
Data Collection & Instrument
An online survey link created with REDCap was posted on social media (REDCap,
2014). Questions used in the online survey were adapted from a study conducted by Wilder
7. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 7
Research (MartinRogers et al., 2015). The instrument used was created initially by Wilder
Research and the data collection approach was an innovative approach called Respondent Driven
Sampling. As for the validity of the instrument, community members and professionals
collaborated on the development of the instrument which is considered face validity
(MartinRogers et al., 2015). Data used for the survey were also adapted from an instrument used
in a study by the Centers for Disease Control and Prevention (CDC) to track attitudes toward
mental illness. The instrument used was the Behavioral Risk Factor Surveillance System
(BRFSS) which was reliable as it has been used in a previous study with a Cronbach alpha of
0.69 indicating consistency (Kobau, 2009). There were consistent and stable results in the CDC
study. This tool has been previously used in studies to measure what people believe about mental
health (CDC, 2012). Kobau et al. (2009) reported the BRFSS instrument exhibited rigorous
convergent validity.
The instrument used in this study was an online survey that was developed from the
BRFSS tool and the Wilder Research team described above (MartinRogers et al., 2015; CDC,
2012). The survey was developed to measure perceptions Somali-Americans had toward mental
and physical health. The survey included 22 questions consisting of both multiple choice and
short answer questions. Questions about perceptions toward seeking treatment, professional help,
definitions of mental and physical health, and perceptions about how participants feel about what
others thought if they got help were included in the survey.
The first eleven questions that were used to create the survey included demographic
questions that measured gender, age, race, education level, marital status, family size, birthplace
and religious preference. The other questions also asked participants how they found out about
the study, if they identified as Somali, and whether or not they knew anyone with an emotional
8. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 8
or mental impairment. Questions #12 and #13 were adapted from a summary report by the
Wilder Research organization (MartinRogers et al., 2015). Questions #14 and #15 were adapted
from a report by the CDC (CDC, 2012). Also, Questions #16 to #20 were adapted from the
report by Wilder Research mentioned above and Questions #21 and #22 were created by the
research team. The survey questions can be found in Appendix A.
Data Analysis
Data Analysis. Data analysis was conducted using the version 24 of the IBM SPSS
program. Frequencies and the distributions of responses to the survey were conducted.
Descriptive statistics were used to analyze the frequencies and the crosstabs. To analyze the
associations between the different variables, several crosstabs were conducted involving gender,
education, and age. The Chi-Square test was used to identify relationships between the variables.
If there were problems with cells with low counts, Fisher’s Exact test was used. For data
analysis, the responses to the age question were collapsed into the following 3 categories: 18-20,
21-24, 25-40. Similarly, the responses to the education level question were also collapsed to 3
categories: high school graduate, some college or technical school, college graduate or more.
Results
Sample Characteristics
The sample (n = 63) yielded 57 complete responses. The sample consisted of 25% males
and 75% females. Eighty-eight % of the participants reported they heard about the survey
through social media with 12% hearing about it through a friend. There were 82% who reported
they either attended some college or were a college graduate and there were 18% reporting they
were a high school graduate or less. To assess those that were currently in college, 60% said they
were currently in college while the other 40% reported they were not. For marital status, 23%
9. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 9
reported they were married or partnered living together and 77% identified as single or divorced.
When asked about birth in the Unites States, 79% reported they were not born in the United
States while 21% reported they were born in the Unites States. For religious preference, 95%
reported they identify with the religion of Islam with 2% identifying with Christianity and 3%
with other. The typical respondent was a Somali female identifying with the Islamic faith
between the ages of 18-24.
Perceptions Toward Mental Illness
When participants were asked if they knew anyone with an emotional or mental
impairment, 82% of the respondents reported yes and 18% reported no. Also, 63% of the
participants responded they would be very or somewhat embarrassed if friends and relatives
knew they were getting help for an emotional problem. Additionally, 82% of participants said
they would definitely or probably seek professional help if they had a serious mental or
emotional impairment. This finding contradicts what is reported in the literature, that many
Somali-Americans don’t seek professional mental health due to stigma (Bettmann, Penney,
Freeman, & Lecy, 2015). Ninety-five % of the participants also responded with strongly or
slightly agree in regards to the statement that treatment can help people with emotional or mental
impairments lead normal lives. The participants also responded to the statement that people are
generally caring and sympathetic to people with emotional or mental impairments with 47%
agreeing or remaining neutral to the statement. The other 53% slightly or strongly agreed with
the statement. To assess the understanding of emotional or mental impairment, participants were
asked to write their interpretation in a text box. The results from that question are available in
Appendix B in the form of a word cloud. To test whether getting professional help for an
emotional problem would be embarrassing and differed by age, a Chi-Square test was conducted.
10. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 10
The results show that there was a significant difference by age, with younger age groups
indicating that they would be more embarrassed than older age group (χ2
= 4.567, p = 0.012).
(See Appendix B, Graph 1). A Chi-square test was also used to see if one would go for
professional help if they have a serious emotional or mental impairment differed by education.
The results indicate that those with college or some college were more likely to seek professional
help than those with a high school education (χ2
= 8.312, p = 0.044) which can be seen in
Appendix B Graph 2. A crosstab looking at gender and the statement regarding the ability of
treatment to help people with emotional or mental illness lead normal lives showed that females
more strongly thought that treatment can help as compared to males (χ2
= 11.511, p = 0.28)
which can be seen in Appendix B Graph 3.
Perceptions Toward Physical Disabilities
There was an 80% response to knowing someone with a physical disability and mobility
impairment with 20% of participants not knowing anyone with a physical disability and mobility
impairment. For the statement that stated people are generally caring and sympathetic to people
with physical disabilities and mobility impairments, 90% either responded with strongly or
slightly agree or remained neutral on the statement. To evaluate perceptions on treatment, 97%
either slightly or strongly agreed or remained neutral with the statement that treatment can help
people with physical disabilities and mobility impairments lead normal lives. Also, 98% of the
participants responded to the question about seeking help by saying they would definitely or
probably seek professional help if they had a serious physical disability. Eighty-two % of the
participants said they would not feel embarrassed at all or not very embarrassed if their friends
and relatives knew they were getting professional help for a physical disability and mobility
impairment. This finding was not consistent with studies that have shown there is stigma
11. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 11
regarding physical disabilities as evidenced by unmet health care needs in Somali communities
for those with physical and mental disabilities (Higginbottom et al., 2014). There was 18% who
responded with very or somewhat embarrassed in regards to that statement. To assess the
understanding of the participants about the concept of physical disability or mobility impairment,
they were asked to write their interpretation in a text box. The results from that question are
available in Appendix B in the form of a word cloud. There was also a crosstab on gender and
relationship with the question that asked if participants knew anyone with a physical disability or
mobility impairment. The results show that females were much more likely to know someone
with a disability or impairment than males (χ2
= 5.202, p = 0.033); which can be seen in
Appendix B Table 4.
Conclusions
The findings of this study support the negative perception of mental health but also
suggest that this particular sample did not support other cultural behaviors such as seeking
professional help and feeling embarrassed when getting professional help (Bettmann et al., 2015;
Greeson et al., 2001). These inconsistencies may be due to the fact that the sample of Somalis
studied were more acculturated into western health care beliefs and norms. Acculturation was not
included in this study, but should be included in future studies that look at perceptions of mental
and physical health. This study confirms that there is stigma attached to how Somali-Americans
perceive mental and emotional impairments compared to the perception of physical disabilities
and impairments. Also, there were statistical significances showing age, education, and gender
significantly affected the perceptions of mental and physical health. Because many Somali-
Americans have immigrated from Somalia to escape civil war and traumatizing experiences, it is
important that mental or emotional impairments are addressed appropriately on the same level
12. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 12
that physical disabilities are addressed. The findings of this study show that more Somali-
Americans are willing to seek help regarding their mental and physical health which is a positive
step in improving the perceptions of Somali-Americans towards mental or emotional
impairments and physical disabilities. Some possible limitations of this study include the small
sample size and the large portion of the sample identifying as females which is not equally
representative of both genders. Overall, the findings of this study can contribute to the
knowledge that health care professionals (i.e. nurses) can use in caring for patients identifying as
Somali to promote culturally competent care.
13. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 13
References
Bettmann, J. E., Penney, D., Freeman, P. C., & Lecy, N. (2015). Somali Refugees’ Perceptions
of Mental Illness. Social Work in Health Care, 54(8), 738-757. Retrieved from
http://www.tandfonline.com.ezproxy1.lib.asu.edu/doi/full/10.1080/00981389.2015.10465
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Boynton, L., Bentley, J., Jackson, J. C., & Gibbs, T. A. (2010). The Role of Stigma and State in
the Mental Health of Somali-Americans. Journal of Psychiatric Practice, 16(4), 265-268.
Retrieved from
http://ovidsp.ovid.com.ezproxy1.lib.asu.edu/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&P
AGE=fulltext&D=&AN=00131746-201007000-00009&PDF=y
Bhui, K., Warfa, N., Edonya, P., Mckenzie, K., & Bhugra, D. (2007). Cultural competence in
mental health care: A review of model evaluations. BMC Health Services Research, 7(1).
doi:10.1186/1472-6963-7-15
Centers for Disease Control and Prevention (2012). Attitudes towards mental health. Retrieved
from http://www.cdc.gov/hrqol/Mental_Health_Reports/pdf/BRFSS_Full%20Report.pdf
Cherry, K. (2016). Cross-Sectional Research Method: How Does It Work? Retrieved from
https://www.verywell.com/what-is-a-cross-sectional-study-2794978
Connor, P., & Krogstad, J. M. (2016, June). 5 facts about the global Somali diaspora | Pew
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tank/2016/06/01/5-facts-about-the-global-somali-diaspora/
Greeson, C. J., Veach, P. M., & Leroy, B. S. (2001). A Qualitative Investigation of Somali
Immigrant Perceptions of Disability: Implications for Genetic Counseling. Journal of
Genetic Counseling, 10(5), 359-378. doi:10.1023/a:1016625103697
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Kobau, R., Diiorio, C., Chapman, D., & Delvecchio, P. (2009). Attitudes About Mental Illness
and its Treatment: Validation of a Generic Scale for Public Health Surveillance of Mental
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Miller-Gairy, S., & Mofya, S. (2015). Elements of culture and tradition that shape the
perceptions and expectations of Somali refugee mothers about autism. International
Journal of Child & Adolescent Health, 8(4), 335-349. Retrieved from
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shape-perceptions-expectations-somali-refugee-mothers-about-autism-spectrum-disorder
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Wolf, K. M., Zoucha, R., McFarland, M., Salman, K., Dagne, A., & Hashi, N. (2016). Somali
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immigrant perceptions of mental health and illness. Journal of Transcultural Nursing,
27(4), 349-358.
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Appendix A
1. How did you hear about this study?
Fill in the blank______________________
2. Do you identify as Somali? (If the participant does not identify as Somali, the survey will
end).
a. If yes, you may continue.
b. If no, please stop.
3. What is your gender?
a. Male
b. Female
4. How old are you?
Short Answer_________
5. What is your level of education?
a. Some high school or less
b. High school graduate
c. Some college or technical school
d. College graduate or more
6. Are you currently in college?
a. Yes
b. No
7. What is your marital status?
a. Single
b. Married or partnered living together
17. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 17
c. Divorced
d. Widowed
8. How many members are there in your immediate family?
Short Answer________
9. Were you born in the US?
a. Yes
b. No
10. What is your religious preference?
a. Hinduism
b. Islam
c. Christianity
d. Judaism
e. Other
11. Do you know anyone with an emotional or mental impairment?
a. Yes
b. No
12. If your friends and relatives knew you were getting professional help for an emotional
problem, would you be:
a. Very embarrassed
b. Somewhat embarrassed
c. Not very embarrassed
d. Not embarrassed at all
18. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 18
13. People differ a lot in their feelings about professional help for emotional or mental
impairment. If you had a serious emotional or mental impairment, would you:
a. Definitely go for professional help
b. Probably go for professional help
c. Probably not go for professional help
d. Definitely not go for professional help
14. Treatment can help people with emotional or mental impairments lead normal lives
a. Strongly agree
b. Slightly agree
c. Neither agree or disagree
d. Slightly disagree
e. Strongly Disagree
15. People are generally caring and sympathetic to people with emotional or mental
impairments
a. Strongly agree
b. Slightly agree
c. Neither agree or disagree
d. Slightly disagree
e. Strongly Disagree
16. Do you know anyone with a physical disability or mobility impairment?
a. Yes
b. No
19. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 19
17. People are generally caring and sympathetic to people with physical disabilities and
mobility impairments:
a. Strongly agree
b. Slightly agree
c. Neither agree or disagree
d. Slightly disagree
e. Strongly Disagree
18. Treatment can help people with physical disabilities and mobility impairments lead normal
lives:
a. Strongly agree
b. Slightly agree
c. Neither agree or disagree
d. Slightly disagree
e. Strongly Disagree
19. People differ a lot in their feelings about professional help for physical disabilities and
mobility impairments. If you had a serious physical disability, would you:
a. Definitely go for professional help
b. Probably go for professional help
c. Probably not go for professional help
d. Definitely not go for professional help
20. If your friends and relatives knew you were getting professional help for a physical
disability and mobility impairment, would you be…
a. Very embarrassed
20. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 20
b. Somewhat embarrassed
c. Not very embarrassed
d. Not embarrassed at all
21. In your own words, what does an emotional or mental impairment mean to you?
Short Answer________
22. In your own words, what does a physical disability and mobility impairment mean to you?
Short Answer__________
22. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 22
Graph 3
Table 3
Chi-Square Tests (1)
Value df
Asymptotic
Significance
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Point
Probability
Pearson Chi-Square 11.511a
3 .009 .006
Likelihood Ratio 11.359 3 .010 .011
Fisher's Exact Test 9.515 .010
Linear-by-Linear
Association
3.464b
1 .063 .062 .059 .028
N of Valid Cases 57
a. 5 cells (62.5%) have expected count less than 5. The minimum expected count is .25.
b. The standardized statistic is -1.861.
23. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 23
Table 4
Chi-Square Tests (2)
Value df
Asymptotic
Significance
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Point
Probability
Pearson Chi-Square 5.309a
1 .021 .031 .031
Continuity
Correctionb
3.712 1 .054
Likelihood Ratio 4.795 1 .029 .053 .031
Fisher's Exact Test .053 .031
Linear-by-Linear
Association
5.216c
1 .022 .031 .031 .026
N of Valid Cases 57
a. 1 cells (25.0%) have expected count less than 5. The minimum expected count is 2.95.
b. Computed only for a 2x2 table
c. The standardized statistic is 2.284.
Graph 4
24. SOMALI PERCEPTIONS OF MENTAL AND PHYSICAL HEALTH 24
21. What does an emotional or mental impairment mean to you?
22. What does a physical disability or mobility impairment mean to you?
