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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 [ 33]. Also, cancer is perceived as a sensitive topic by the women [ 14]. The Somali mothers particularly attribute cervical cancer to metaphysical beliefs such as fate and God’s will [ 37]. 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. ICO Information Centre on HPV and Cancer. Human Papillomavirus and related cancers, fact sheet 2013 [ http://www.hpvcentre.net/statistics/reports/SOM_FS.pdf] Natural groups” refers to groups consisting of people who know each other already from other situations, such as sports teams, work, or women’s support groups. Researching with these groups maximizes the interaction between participants, and between participants and the facilitator. It provides access to a shared group culture [ 14]. In this case, the women gathered regularly to discuss issues that were important to them. With the support of the chair of a Somali women’s organization and a Community Health Service (CHS) educator, natural group discussions were facilitated. Wong LP. HPV information needs, educational messages and channel of delivery preferences: Views from developing country with multiethnic populations. Vaccine. 2009;27(9):1410–5. The government thinks: ‘you [a 13 or 14-year-old] probably had sex’, so you [a 12-year old] must take a heavy test or vaccine. I think that you [the government] encourage it [sex at a young age]. As if it is normal?! [N4 (young Somali woman)]

Raymond NC, Osman W, O'Brien JM, Ali N, Kia F, Mohamed F, et al. Culturally informed views on cancer screening: a qualitative research study of the differences between younger and older Somali immigrant women. BMC Public Health. 2014;14:1188. Van Keulen HM, Otten W, Ruiter RA, Fekkes M, Van Steenbergen J, Dusseldorp E, et al. Determinants of HPV vaccination intentions among Dutch girls and their mothers: a cross-sectional study. BMC Public Health. 2013;13(1):111. World Health Organization (WHO). Noncommunicable Diseases (NCD) Country Profiles - Somalia [ http://www.who.int/nmh/countries/som_en.pdf] You can hardly find Somalian women in bars and cafes if you venture to go to Somalia to find a wife there. This country is not a touristic place and not the best place to go.The worst thing that can happen is that he makes a girl pregnant, which of course is awful, but the boy can walk away. If she is sexually active and gets pregnant, then it is a problem. In Islam, you cannot have an abortion. So you have to take care of the child and you [will] have an eternal shame. Even if she was with a boy who she would marry, everyone would [still] think: ‘She slept with every guy, because she has a child.’ [N 11 (young Somali woman)] Another major barrier is related to language. The Somali mothers from the second migration wave are often not fluent in Dutch, while Somali girls have access to Dutch language and culture through school. Hence, some young Somali women have to translate information about the HPV vaccination to their mothers, which daughters then sometimes perceive as a barrier. As a consequence, they have not always informed their mothers. Although most participants believe they can control the risk of cervical cancer through sexual behavior, the Somali mothers particularly believe that all diseases are determined by God and indicate low self-efficacy. However, there is also individual religious responsibility to improve one’s health and prevent disease. Fatima Siad is a Somali-Ethiopian model. This sexy Somali girl was a participant of the 10th cycle of the show America’s Next Top Model. She was managed to take 3rd place. Nowadays, Fatima is a successful model cooperating with New York Model Management, L.A. Model Management, Ace Models and Ice Models. Iman Mohamed Abdulmajid The interviews and group discussions were carried out by JS between March and June 2013. The interviews with young Somali women were conducted in Dutch, while most of the interviews with the mothers were conducted in Somali. Interviews lasted approximately 30 to 40 min. Interviewees (with the exception of one) preferred to be interviewed at a location other than home. Interviews were held at cafés, libraries, schools, and community centers. Nearly all the individual interviews were recorded and transcribed verbatim. However, five interviews with mothers were not recorded because those mothers were suspicious of recording. Short notes were taken during those interviews and immediately written out afterwards in field reports.

All of the mothers in the study were born in Somalia. Three mothers were part of the first migration wave (after 1990) and three of the second wave (after 2006). Two mothers from the first migration wave obtained education in Somalia and additional education in the Netherlands. Two mothers had received a Pap smear earlier, while three declined the invitation. One mother did not receive an invitation.It becomes apparent in this interview that the girl fears that the HPV vaccination campaign normalizes sex at a young age. This is related to young Somali women’s doubts about the vaccination age. However, while they consider the age of 12 too early for girls to be confronted with sex talk, they also see the potential benefits of being prevented from acquiring HPV. The HPV vaccination is also considered as positive, as it protects women from cervical cancer and is considered as similar to other childhood vaccinations. The HPV vaccination is not seen as a measure to prevent Sexually Transmitted Infections (STIs). Aside from this, the HPV vaccine is often assumed to be mandated. The inclusion criteria has been comprised of being female and of Somali origin, living in the Netherlands, aged between 18 and 65, and having a migration date from the first or second wave of migration (see Table 1). Daughters whose mothers have participated in the study were excluded and vice versa because sexuality issues and health issues are sensitive to discuss in the Somali community, and it would have limited building rapport between the interviewees and the interviewer. Furthermore, convenience sampling has been used at community gatherings of the Somali women.

Olden A. Somali refugees in London: Oral culture in a western information environment. Libri. 1999;49(4):212–24.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.

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