Participation in Human Papillomavirus (HPV) vaccination and Papanicolaou Screening (Pap smears) is low among ethnic minorities in the Netherlands and hardly any information is available about the cervical cancer prevention methods of Somali women living in the diaspora. This qualitative study, based on the Health Belief Model (HBM) and an intersectionality-based framework, explores the perceptions of Somali women living in the Netherlands regarding measures to prevent cervical cancer. Methods

Every mother tells a lie to herself [and thinks]: ‘My daughter is great.’ While the daughter was just two months old when she arrived in the Netherlands, she is now 22 or 24 years old. What is the outcome? The child takes over the [Dutch] culture. Your child will not take over your [Somali] culture. Who is stronger than you? The people your child associates with. These people give her freedom. So we are obligated to vaccinate or examine her. [A mother in group discussion] Van Nes F, Abma T, Jonsson H, Deeg D. Language differences in qualitative research: Is meaning lost in translation? Eur J Ageing. 2010;7(4):313–6. 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 [ 38]. 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.If parents choose between educating their daughters and helping with the household chores, parents will choose the latter. There is an acute problem in Somalia that soon girls will stop visiting schools at all.

Morrison B, Flynn P, Weaver A, Wieland M. Cervical cancer screening adherence among Somali immigrants and refugees to the United States. Health Care Women Int. 2013;34(11):980–8. Remschmidt C, Fesenfeld M, Kaufmann A, Deleré Y. Sexual behavior and factors associated with young age at first intercourse and HPV vaccine uptake among young women in Germany: implications for HPV vaccination policies. BMC Public Health. 2014;14:1248. Somalian femmes can appreciate life. These women are forced to suffer from early childhood, and their death means nothing in their country. Despite this, Somalian women are very beautiful and nice. Somalia Girls are Beautiful, Shy, and Religious Drain P, Halperin D, Hughes J, Klausner J, Bailey R. Male circumcision, religion, and infectious diseases: An ecologic analysis of 118 developing countries. BMC Infectious Diseases. 2006;6(1):172.

SITE SEARCH

I think it is scary, because what if [you get HPV]? I find it strange: why do not they [the government] have vaccines for boys? Or is that not possible? [N 14 (young Somali woman)] 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. 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 [ 40]. Also, the message that male circumcision has a protective effect against cervical cancer must be presented with caution to Somali women. Naish J, Brown J, Denton B. Intercultural consultations: investigation of factors that deter non-English speaking women from attending their general practitioners for cervical screening. Brit Med J. 1994;309(6962):1126–8. 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)]

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.However, some participants anticipate difficulties with testing and vaccinating Somali men for HPV. Participants have mentioned that Somali men may assume that their partners do not trust them and feel offended. 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.