This study explores the perceptions of Somali women in the Netherlands about the prevention of cervical cancer. Based on the HBM and intersectionality, the girls’ and the mothers’ perceptions have been distinguished in the following themes, in which gender and culture play particular roles: (1) Somali women and preventive healthcare; (2) Knowledge, language, and negotiating decisions; and (3) Sexual standards, culture, and religion.
With regard to the HBM, Somali women perceive many barriers to the use of preventive cervical cancer care, such as a lack of information and knowledge, distrust towards the HPV vaccination and side effects, and distrust towards the ‘government’ and the Dutch healthcare system, as reported earlier [14, 25, 33]. Especially Somali mothers from both migration waves express distrust towards the Dutch health care system, which may be explained by war trauma and FGM experienced in the country of origin (Table 1). Also, given the Somali cultural context, young women consider 12-year old girls as too young to discuss sex. However, they perceive potential benefits from HPV prevention: it protects women from cervical cancer and, just as childhood vaccinations, it is assumed to be mandated and not linked to STIs. Pap smears performed by a male practitioner and FGM have been reported earlier as barriers to participation [13, 16, 34]. Somali mothers are said to be reluctant to visit a Dutch, male practitioner, which seems related to Dutch doctors’ unfamiliarity with aspects of their cultural and religious background, such as FGM, the value of chastity, their mother tongue, and ways of communicating their illnesses , rather than because of their gender .
In the second theme, about how decisions in regards to the HPV vaccination are negotiated between mothers and daughters, we see that Somali mothers’ poor Dutch language skills - particularly from the second migration wave - give their children the role of translating information about HPV vaccination. This, in turn, is perceived as a barrier to participation by Somali girls. Furthermore, these Somali women live by certain traditions of information exchange. The formal leaflet is read with suspicion, or not read at all. In the Somali, female community, cultural peers are a major source of information, and decision-making on the medical prevention of cervical cancer takes places within social relations. Mothers and daughters exchange information on the HPV vaccination with each other, even though the mothers’ opinion often forms a cue to (reject) action. Some mothers perceive a limit of freedom for determining their daughters’ health actions because of the experienced information gap and the ‘dominant’ Dutch culture, in which decision-making is individualized.
The participation of Somali women in measures to prevent cervical cancer is heavily influenced by cultural beliefs and behaviors. An intersectional approach allows us to thoroughly explore how social identities relate to each other and how the intersection of these identities influences the participation of Somali women in measures to prevent cervical cancer. In the third theme, on sexual standards, and in contrast with Dutch mothers and girls, the perceived susceptibility to HPV is lower among Somali women, because they are expected to abide by the religious and cultural norm of virginity before marriage. In addition, in the Somali community, a cultural double sexual standard is present that allows only boys to have premarital sex. Although most girls in the study accept this double sexual standard, some express criticism towards it. Nevertheless, girls who have premarital sex are stigmatized in the Somali community and, thus, mothers often promote chastity among their daughters, as mentioned earlier . Most of the girls have internalized the traditional value of chastity and express the importance of virginity, independent of educational background. From a Western point of view, chastity may have a negative impact on a girl’s self-image in regard to sexuality and limit her ability to discuss sexual matters with her future partner(s) . However, from a religious Islamic and cultural perspective, the value of chastity may enhance a girl’s self-image concerning sexuality in the sense that virginity before marriage is believed to protect the body from sexual hazards such as cervical cancer, STIs, and teenage pregnancy. Chastity can be an expression of self-respect or respect for one’s own body .
The Somali women in the study had not been aware of possible susceptibility to HPV through partners, even though they had been aware of a cultural double sexual standard, as also found in a study among Turkish and Moroccan mothers . Also, cancer is perceived as a sensitive topic by the women . The Somali mothers particularly attribute cervical cancer to metaphysical beliefs such as fate and God’s will . However, the Islamic faith also plays the role of a cue to action: some participants state that their religion supports preventive care and/or medicine to improve health.
Combining an intersectional approach with the Health Belief Model provides contextualized knowledge on how the women’s different positions in aspects such as age, migration status and language skills, religion, or culture are interdependent and influence individual perceptions of preventive measures and health. According to Hankivsky et al. , intersectionality directs attention to health issues that are less well understood for certain groups, in our case, Somali women and the prevention of cervical cancer. Gendered, cultural, and social structures produce and reproduce inequalities that intersect, overlap, and reinforce each other in shaping a person’s health status. To prevent disease, it is important to gain an understanding of how women’s perceptions are contextualized, and we must also target our interventions towards institutions, such as healthcare and health promotion programs, rather than target individuals.
Strengths and limitations to the study
This study has some limitations. First, discussion within natural existing groups may have inhibited truthful disclosure. However, the women in this study generally have felt safe to discuss sensitive topics within their already established group of cultural peers. Besides, according to the organizations who helped recruit interviewees, the women would not have accepted a structured focus group.
Second, in a few cases, a participant’s friend was present during an interview and some interviews were held in public spaces, which may have influenced the responses to some questions. Third, group discussions and interviews with Somali mothers were conducted in Somali. Meanings of some responses by participants may have inadvertently changed during translation, which could affect the validity of this study . Fourth, some mothers have declined audio-recording, and nuances may have been lost because the information gathered from them is based on extended field reports.
Finally, although the level of education of Somali people in the Netherlands is generally low (Table 1), most young Somali women in this study followed higher education. The researcher has had limited access to lower educated young Somali women, which could be attributed to her own educational background and the short time available for the research. It is difficult to say how such selection bias influences the results. In hindsight, the results do not show major differences in perceptions towards prevention of cervical cancer between higher educated and lower educated girls. Most girls in this study have expressed the importance of these traditional values, independent of their educational background. The recruitment of girls with lower education levels could perhaps have led to more diverse results and saturation . More studies including quantitative research could be used to increase the validity of our findings.
This study has several strengths. First, the recruitment methods applied in this study led to low-cost recruitment and the inclusion of a large number of Somali people. JS’s Somali background has created easy access to the community . Second, this also has helped the participants feel more comfortable and disclose information, enhancing the ecological validity of the study. However, having the same background as the participants also could become a barrier: JS has a reputation to maintain within the community. Possibly, this made it difficult for her to pose questions about sensitive issues, which a Dutch researcher would not have experienced.
Third, data triangulation has been reached by collecting data from different sources, including individual interviews and natural group interviews. Fourth, researcher triangulation and a member check have been applied to increase the validity of the study. During the member check, the researcher established credibility by presenting all findings derived from the interviews and group discussions. These findings were recognized, validated, and further clarified by the participants. Finally, some mothers have been recruited from the first, and other mothers were recruited from the second migration wave. Mothers who are only recently in the Netherlands may be less knowledgeable about the Dutch health system and its preventive measures.
We identified several implications of our study. More information that clarifies misperceptions around the prevention of cervical cancer and the Dutch health care system is important. Furthermore, our study shows how a reversal of parent-child roles can take place as a consequence of parents’ difficulties in navigating the new country in which they live. This study also shows that religion is subordinate to culturally defined gender norms that control the behavior of boys and girls by stigmatizing girls having premarital sex. Moreover, this study shows that Somali women in the Netherlands are often not aware of men’s roles in HPV transmission. Despite the finding that men can be infected with HPV and transmit the virus to women, there are no nationally funded HPV vaccination programs or HPV DNA testing programs targeting men in Europe (with the exception of Austria). Thus, in order to protect the sexual health of ethnic minorities in the Netherlands, it is important to not only consider informing ethnic minorities about men’s roles in HPV transmission, but also to implement nationally funded HPV-related preventive care for men.
This study also shows how social factors influence Somali women’s health beliefs, which underlie participation in cervical cancer prevention. One can question whether the current cervical cancer prevention programs, the ways they are promoted, and by whom, fits with Somali culture. The framing of HPV vaccination messages as specifically preventing cervical cancer affecting Somali women in Somalia and in the Netherlands may increase the perceived severity of HPV and thus increase acceptability of vaccination amongst the Dutch-Somali population . Also, the message that male circumcision has a protective effect against cervical cancer must be presented with caution to Somali women.
Oral education in Somali may reach mothers best [14, 41], as Somalia is known for its long tradition of poetry . Hence, culturally sensitive information on cervical cancer prevention and the Dutch healthcare system can be provided through poetry or theater, and developed together with the target group. In addition, group meetings in which mothers can ask questions, reflect on cultural values, and exchange experiences with each other is recommended. Also, the use of cultural brokers in health care settings, who can identify with and have knowledge of a client’s cultural background as well as the Dutch health care system, might increase the demand for preventive health care .
Teachers can provide and discuss culturally appropriate information targeting the double sexual standard in schools. It is also recommended to take the cultural stigma on sexual matters into account and extend the HPV vaccination to an older age, as suggested earlier .
This study has unexpectedly increased Somali women’s awareness of their own cultural values and norms, and has stimulated them to reflect on perceptions different from their own. For some, it has even empowered them to change their attitudes towards the prevention of cervical cancer . Forms of participatory research therefore seem appropriate for studying taboo topics, most likely for other marginalized groups as well.