Somali asylum seekers’ perceptions of privacy in healthcare

Abstract

Background:

Privacy has been recognized as a basic human right and a part of quality of care. However, little is known about the privacy of Somali asylum seekers in healthcare, even though they are one of the largest asylum seeker groups in the world.

Objectives:

The aim of the study was to describe the content and importance of privacy and its importance in healthcare from the perspective of Somali asylum seekers.

Research design:

The data of this explorative qualitative study were collected by four focus group interviews with 18 Somali asylum seekers with the help of an interpreter. The data were analysed by inductive content analysis.

Ethical considerations:

Research permissions were obtained from the director of the reception centre and from the Department of Social Services. Ethical approval was obtained from the Ethics Committee of Turku University.

Findings:

The content of privacy includes visual privacy, physical privacy and informational privacy. All contents can be shared with healthcare professionals. The importance of privacy includes respect, dignity and freedom.

Discussion:

Privacy is strongly connected to the collectivism of Somali culture and religion. Unlike the Western cultures, privacy is not important only for the individual; most of all, it is seen to support collectivism.

Conclusion:

Even though all contents of privacy can be shared with healthcare professionals, it is important to recognize the cultural aspect of privacy especially when using interpreters with Somali background.

Keywords

Interpreter privacy Somali asylum seekers

Background

Privacy as a cultural concept

Privacy is a culturally defined concept influenced by cultural values or beliefs.^1,2 The challenge in healthcare is to determine what the members of a particular culture consider as private.³

In Western cultures, privacy is often seen as a fundamental principle concentrating on an individual. It is seen as an individual’s freedom, personal identity, having private space, having opportunity to control interaction with other persons or sharing information.^4
–6 It is related to respect for persons and is recognized as part of good care.^7,8 It is usually divided into four categories: physical, psychological, social and informational privacy.⁹ Privacy is a complex phenomenon and is related to many concepts, such as intimacy, confidentiality, seclusion and secrecy. These concepts can be seen to be part of privacy, included in one of the four categories.^5,9

Studies conducted in non-Western cultures show differences in values and perceptions of privacy. In Chinese culture, older people in residential care homes gave similar interpretations of privacy as in Western cultures (e.g. keeping secrets, having personal space, being able to keep personal possessions, not being interfered with and not bothering others). They did, however, give privacy less significance than in Western cultures. Their perceptions of privacy were guided by the values of maintaining balance and harmony.¹ In Sri Lanka, privacy is perceived as openhearted, without visible boundaries and privacy for the individual, emphasizing the importance of family. The Western view of protecting privacy can even cause discomfort in non-Western cultures.² Although the importance of recognizing privacy in healthcare in different cultures is addressed,¹⁰ there is a lack of studies defining privacy in healthcare in different cultures. In this study, we are interested in the perceptions of Somali asylum seekers.

An asylum seeker is a person who needs international protection, but whose claim has not yet been definitively evaluated.¹¹ According to the convention and protocol relating to the status of refugees (1951), a refugee is someone who

owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality, and is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country.¹¹

Somalia and Somali asylum seekers

Somalia is a lineage-based society, where members of society are members of a patrimonial clan-family, which is divided into clans, sub-clans and sub-sub-clans, resulting in extended families. The membership of clan-families and clans has an influence on everyday life, safety, politics, economics and social welfare.¹² Combined with Islam, the lineage identity forms a strong collective culture, where culture and religion define the beliefs and values of the individual person.^13,14

Somalia has been without a functioning government since 1991, with fighting between Somali warlords, government forces and various alliances of Islamist insurgents. The fighting has resulted in casualties among combatants and civilians and has caused large population displacements both within Somalia and outside its borders.¹⁵ More than 42,000 Somalis sought asylum in 2013.¹⁶ In Finland, Somalis are the third largest group of asylum seekers, with 217 applications in 2013.¹⁷

In Finland, asylum seekers are accommodated in reception centres, where they get social and healthcare services, financial support, legal and interpreter services and opportunity to work and study. These services are available during the whole asylum seeking process (average 190 days). The number of active reception centres depends on the number of asylum seekers, being 22 at the moment of research data collection. In reception centres, asylum seekers are accommodated in rooms of 1–10 people by gender or family membership. Toilets, bathrooms and kitchens are shared between several rooms.¹⁸

Nearly all asylum seekers, including Somalis, are suffering from losses, and many of them have suffered from traumatic experiences such as rape, torture or other kinds of violence. Furthermore, the long asylum seeking process itself has a negative impact on asylum seekers’ health.¹⁹ Somali refugees are reported to suffer from physical, social and psychological problems related to war traumas and violence.²⁰ Attention has also been paid to cultural issues in the mental healthcare of Somali refugees^21,22 and the challenges in discussing feelings related to traumas because of the shame related to them.^23,24

Working with asylum seekers in healthcare requires diverse knowledge, including knowledge about the country of origin, about the effect of refugeehood on health and awareness of how culture shapes one’s thinking.²⁵ However, there are only few studies focusing on the privacy of Somali immigrants, and studies focusing on the privacy of Somali asylum seekers are lacking. For Somali refugee women, respect for privacy is a key element to a positive healthcare experience;²⁶ however, they are concerned about their privacy when using an interpreter.^23,24,26 Nurses are concerned about the patients’ privacy when using interpreters,²⁷ and concern about the confidentiality of the interpreter, which creates fear of loss of privacy, is reported to be one of the greatest obstacles for the use of interpreters.²⁸

Objectives

The objective of this study is to describe the concept of privacy in healthcare in the Somali culture among Somali asylum seekers, since Somalis are one of the largest asylum seeker groups globally. We aim to answer the following research tasks: (a) What is the content of privacy? (b) What is the importance of privacy?

Ethical considerations and participant selection

The data were collected in four different reception centres in Southern Finland, chosen based on the highest number of Somali asylum seekers. There were a total of 28 Somali asylum seekers in four centres.

Due to the differences in administration of the reception centres, research permissions were obtained from the director of the reception centre and from the Department of Social Services. Ethical approval was obtained from the ethics committee of Turku University.

Prior to the data collection and focus group interviews, oral and written information about the study was given to all 28 adult Somali asylum seekers at the four reception centres 1 week before the interviews with the help of a reception centre worker with Somali background. The information emphasized the aim of the study, the voluntary nature of participation, participants’ anonymity and confidentiality, including the fact that the study does not have any connection with the asylum seeking procedure and the information given is used only for the study. A total of 18 Somali asylum seekers reported their willingness to participate. At the beginning of each interview, the same information was given in writing and orally, with the help of an interpreter, and all participants signed a written informed consent.

Research design

Data collection

The data of this explorative qualitative study were collected by four focus group interviews in December 2011 and January 2012 at each reception centre. This method gives an opportunity to derive a collective perspective, allows synthesis and validation of ideas and concepts in the group and allows access to culturally and linguistically diverse groups through interpreters.²⁹ The strong narrative background in Somali culture supported the use of focus group interviews.¹³ There are, however, some issues to consider in using the focus group method with culturally and linguistically diverse groups. First, careful planning and organization was done prior to the focus group interviews in order to have a private and acceptable environment for the participants, with the help of the interpreter and reception centre workers. Second, the participants’ awareness of the purpose of the focus group, including confidentiality, was ensured before the interviews. Third, time for debriefing after the group interview was allocated for the participants and the interpreter. One focus group interview was done as a pilot in order to check the conduct, timing and the questions; no changes were made, and it was included in the data.²⁹

Participants’ gender, average length of stay in Finland and the size of the group as well as the length of the interview varied in every group (Table 1). The groups were divided by gender; however, in one group, male and female participants wanted to participate in the same group. At three centres, only men or women wanted to participate.

Table 1.

Focus groups.

Group	Number and gender	Age (years)	Length of stay in Finland		Length of interview
Group	Number and gender	Age (years)	Range (months)	Mean (months)	Length of interview
1	3 females, 4 males	18–42	11–24	17	2 h 23 min
2	6 females	19–36	2–19	12	1 h 56 min
3	2 males	23–68	6–7	6.5	1 h 24 min
4	3 males	22–34	1–23	8.3	1 h 22 min

The interviews were conducted in Finnish and interpreted into Somali by a female interpreter and were audiotaped and transcribed in Finnish. Using a male interpreter was considered for the male groups, but the use of the same interpreter in all of the interviews increases the trustworthiness of the data.³⁰ All participants were informed about the gender of the interpreter, and no one considered it to be a problem for participating in the interviews.

There is a disadvantage in using an interpreter in interviews, because the interpreter might summarize or modify the responses.^30,31 In order to minimize these problems, the interpreter was chosen based on her high-level language and cultural knowledge of Somali and Finnish, her nursing education and working experience in both nursing and interpreting. The role of the interpreter was discussed with the interpreter before the interviews. The interpreter was not only interpreting the language but also the cultural differences.

At the beginning of the interviews, the interpreter and the participants discussed the correct Somali term for privacy, since it can vary in different dialects of the Somali language. During the interviews, either the Somali term ‘xad’ (limit) or the English term privacy was used. The interviews started by asking general questions about the content and importance of privacy, such as follows: What is privacy? Why is it important for you? Then the questions focused more on the healthcare, such as follows: What is privacy in healthcare? Are there issues that can not be shared with healthcare professionals? What would disrespect your privacy? During the interviews, discussion was lively, and everyone had a chance to speak. However, there were a few situations which interrupted the interview or caused challenges for the interpretation. In one interview, the participants started to argue about cultural norms. The interpreter could not translate all the spoken messages as the conversation was too rapid. She explained that if she were to interrupt the argument, the cultural aspect of the discussion would be missed. Later, she explained what happened during the argument and how the participants found a consensus on the issue. The translation was checked afterwards from the audiotapes. In two groups, the interview was interrupted by the praying hour, but continued after the praying.

Data analysis

The data were analysed by inductive content analysis.³² Both research tasks were analysed separately, since some of the meaning units included elements for both research tasks. For both tasks, significant statements were identified and condensed twice: first, in order to form a description close to the text, and second, to form an interpretation of the underlying meaning. In order to form sub-themes, the condensed meaning units were combined according to whom the content (e.g. sexuality, naked body) was shared with in research task 1, and according to content similarities (e.g. respect) in research task 2. Sub-themes were further combined into themes according to the similarities (Table 2).

Table 2.

An example of the analysis (research task 2).

Meaning unit	Condensed meaning unit – description close to the original text	Condensed meaning unit – interpretation of the underlying meaning	Sub-theme	Theme
If someone doesn’t use the veil, it is her choice, I use it, because I’m a good Muslim. (Female, group 1)	The use of the veil is an individual choice; it is used to be a good Muslim.	Using the veil to respect the religion	Respect of religion	Respect
In my clan the rules are different than in another clan. If I am among my clan members, I have to obey the rules of my clan. (Male, group 4)	Rules are different in different clans. Rules are obeyed according to the present clan.	Rules are obeyed to respect the clan.	Respect of culture and community
If others find out my secrets, they will put me aside. They won’t respect me anymore. (Male, group 3)	If the secret is revealed, the respect of the community will be lost.	Secrets are kept in order to be respected in the community.	Respect of the community towards its members

Findings

Content of privacy

The content of privacy was divided into three themes: visual privacy, physical privacy and informational privacy (Figure 1). Furthermore, these themes were divided into three or four sub-themes, depending on whom the content of privacy was shared with: (a) no one, (b) family members, (c) representative of the same gender and (d) healthcare professionals and interpreters used in healthcare.

Figure 1.

Privacy of Somali asylum seekers.

Visual privacy

Visual privacy referred to who can see someone’s body, and to whom one’s body could be revealed. It was shared with family members, representatives of the same gender and healthcare professionals and interpreters. The human body was considered to be related to sexuality, and sexuality was strictly limited to between spouses. If the body needed to be revealed, it could be done in the presence of the same gender:

Of course women can see other women and men can see men, but if a man sees a woman, who is not his wife, without clothes, it is bad for the woman. (Male, group 4)

Clothing, including the veil, was seen as a way of protecting one’s visual privacy from other people, especially from the other gender. It was also seen as being respectful of other people’s privacy, as they did not have to see something that would violate their own privacy.

Revealing one’s body for healthcare professionals was considered acceptable when justified. If the justification was unclear, the request of revealing one’s body was considered a violation of privacy:

If I have a spot/pimple on my head, of course I remove my veil, but if my problem is somewhere else, I don’t see why I should take it off. (Female, group 1)

When revealing one’s body was justified in healthcare, the gender of the healthcare worker was not an issue. However, the participants were very strict about the gender when it came to the interpreter and visual privacy. If the interpreter was of the opposite sex, he or she should not see the revealed body of the patient, because the interpreter was not considered to be a healthcare professional:

The worst thing that could happen is if the nurse asked me to take off my clothes and the interpreter was a male. (Female, group 1)

Same thing for me, if the interpreter is a female. (Male, group 1)

Some of the participants were even stricter and did not want the interpreter to see them naked, whatever the interpreter’s gender. The cultural background of the interpreter was also considered important, and revealing one’s body was easier in the presence of a Finnish interpreter than with interpreters from the Somali culture. The participants wanted the interpreter to get out of the room, or at least go behind a curtain when they had to reveal their body.

Physical privacy

Physical privacy referred to physical contact, that is, who could touch someone. Physical privacy was shared with family members, representatives of the same gender and with healthcare professionals.

Within the family, physical contact was appropriate with certain restrictions related to age (e.g. children). When talking about adult members of the family, gender was considered more important than family relations, and physical contact was restricted to between husband and wife. Physical contact between opposite genders was seen as always being associated with some kind of sexuality, so it was not allowed.

Gender was also considered important when it came to healthcare professionals. All of the participants had experiences of physical contact in healthcare and found it confusing or embarrassing, especially when the healthcare professional was of the opposite gender:

It is something we are not used to. If a woman touches me, I might have some feelings … I mean sexual-related feelings and it affects my body … it is very embarrassing. (Male, group 4)

Genital-related health issues were the most private issues of all. Even between persons of the same gender, physical contact in healthcare was considered offensive if it was not clearly explained:

I had a pain in my stomach and I went to see the doctor. He asked me to take off my pants and examined my anus and penis. I don’t understand why he did it, it was my stomach that was hurting! It violated my privacy. (Male, group 1)

All participants emphasized the importance of the gender of nurses when it comes to gynaecological health issues. There was no way that any of the participants would have accepted a male gynaecologist for themselves or their wives. The only possible exception could be during childbirth:

If there absolutely weren’t any other doctor than a male and the baby was coming, I would accept a male doctor (for my wife) … However, it would be horrible! (Male, group 3)

Some participants did not regard the gender of the healthcare professional to be an issue. They were considered to be professionals and ‘doing their job’, so there was nothing sexual involved.

Informational privacy

Informational privacy referred to information that the participants did not want to share with others. Informational privacy was shared with no one, family members, representatives of the same gender or with healthcare professionals and interpreters.

Some issues were considered so private they could not be discussed with anyone. These issues (e.g. pregnancy, rape, sexual relationship outside marriage) seemed to entail serious disrespect of cultural or religious rules. Not sharing such information was justified in order to protect the respect and dignity of the family or clan:

If he tells someone, anyone at all, he and his family, perhaps even his clan would not have dignity anymore. (Male, group 3)

Family-centred issues were information related to sexuality and to mental health problems. Sexuality was explained to include all information related to the ‘covered part of the human body’ and related to love, attraction, dating and so on. Mental health problems included depression, insanity and hysteria. According to the participants, these issues were private between husband and wife, or mother or father, or within gender, if needed. There was a strong consensus in the groups that these topics had to be shared as little as possible. These topics could only be shared in the case of a problem, but in a controlled manner, and as little as possible.

Some issues were considered private within gender because of the mutual understanding within the gender:

Only a man can understand men’s problem, and a woman can understand women’s problems, the genders are different. (Male, group 4)

However, there were also opposite opinions:

I prefer talking to women, they are more understanding, have more empathy and more compassion than men. There is no norm that forbids me to do so if I want. (Male, group 4)

Sharing information with healthcare professionals was not considered a problem. The participants emphasized the justification of culture, religion and society to share health-related information with healthcare professionals. The confidence towards healthcare was strong. However, sometimes trust was seen to be compulsory in order to get treatment. Legislation on patients’ rights was discussed in all of the focus groups, and the participants were aware of the Finnish legislation, which was one of the reasons for trusting healthcare professionals. However, the interpreter was seen to be an outsider, not a member of the healthcare team, and their interpretation or confidentiality was questioned, especially if the interpreter came from the same culture:

I trust nurses and doctors, I know they are professionals. But there is a third person there, the interpreter, I don’t trust him/her. We all use the same interpreters, how can I be sure that he/she doesn’t tell my matters to others? (Female, group 1)

The importance of privacy

The importance of privacy referred to the reasons why privacy is maintained and to the choices a person makes regarding his or her privacy. It was divided into three themes: respect, dignity and freedom (Figure 1).

Respect

Maintaining one’s privacy was seen to be a way of showing respect for religion, culture and community, and it was also a way of being respected by the community.

Respect for religion referred to Islam and its rules on what should be kept private. Privacy was guided by religion, and privacy was respected in order to be a good Muslim. For example, the use of the veil was not only seen as something that gives visual privacy but also as a mark of respect to Islam:

I use it (the veil), because I am a good Muslim. (Female, group 1)

Respect for culture and community referred to Somali culture, and to the culture inside the different clans. The participants emphasized that different clans have different sub-cultures, and what is private within one clan might not be private within another.

Being respected by the community was seen to be one of the main issues in privacy. It referred to ‘keeping one’s face’ in the community. The emphasis was on the respect coming from outside the individual:

Some people are respected in the community, but in secret, they do bad things. If these were revealed, they wouldn’t be respected anymore. (Male group 4)

Dignity

Privacy was seen to be a way of protecting dignity. Dignity referred to the dignity of an individual and to the dignity of the community. While being respected by the community referred to something that came from the community to the individual, dignity was described as being something coming from the individual to the community. Someone could lose the respect of the community without losing his or her dignity. Dignity was mentioned in the groups by telling stories about someone who had lost his or her dignity and that of the community. It was usually related to a feeling of shame, individually and inside the family, or even inside the community:

A girl got pregnant outside marriage, which meant she had revealed her body to someone. She was ashamed, and was almost rejected from the community. The only solution was for the boy to marry the girl, or all of her family would have been ashamed, not only the girl! The boy married her, and she and her family didn’t have to be ashamed anymore. (Male, group 1)

Dignity seemed to play a big role when talking about privacy in healthcare, and it was usually explained by the feeling of shame:

… but when there is an interpreter, I can’t tell everything, I can’t show myself. He/she knows everybody and when I see him/her later at the reception centre, I’m ashamed of what I have told or shown. (Male, group 4)

The use of interpreters from other cultures, for example, Finland, or telephone interpreters was seen to enable culturally forbidden discussions without the element of shame.

Freedom

Freedom for privacy was seen to be important because of the asylum seekers’ special life situation.

Freedom referred to individuals’ choice to show, talk or share personal things with others. Even if it was seen to be individuals’ freedom, it was guided by religion and culture. However, the level of freedom was seen to be strongly related to the society they found themselves in. The participants mentioned that the change from Somali society to Finnish society increased individuals’ choice for privacy. Thanks to the cultural differences, cultural taboos and forbidden subjects could be discussed in another culture:

Here (in Finland) I can talk about things I could never talk about in Somalia. It is because our culture forbids talking about these things, but yours doesn’t, so I don’t feel ashamed so easily and your society doesn’t judge me. (Female, group 2)

However, the change of culture also decreased the freedom, especially in healthcare. Participants felt they did not have freedom to protect their privacy, since the new culture understood privacy in a different way from them. Even though the change of society enabled the participants to speak more freely, it also forced them to do things they did not want to do. The participants felt they were forced to share private information about traumatic events in order to have arguments for the asylum application and to let healthcare professionals of the opposite gender touch them in order to get treatment:

What can I do if I want to be treated by a doctor and he is a male doctor, I am forced to let him touch me. Otherwise I don’t get any treatment. (Female, group 1)

All groups mentioned childbirth as an example. In Somalia, it was traditionally taken care of by women, and men were left outside. In Finland, Somali men could attend childbirth. Some of the participants felt they were forced to act against their own values; however, some of them felt it to be a relief and considered it a freedom.

Discussion

There is a lack of studies focusing on the privacy of Somali asylum seekers. Our aim was to describe the content and importance of privacy in healthcare in the Somali culture by Somali asylum seekers. Somalis are one of the largest asylum seeker groups in the world, and in need of healthcare for their traumatic pre-immigration events and because of the asylum seeking process, which often requires healthcare documents. Content emphasized privacy to be something one can share with someone, while importance explained deeper cultural and religious values and norms behind the content of privacy. They explain why certain things are private in the context of Somali culture and Islam.

The similarities with earlier studies focus on the content of privacy. Privacy can be divided into four categories – physical privacy, psychological privacy, social privacy and informational privacy⁹ – and these categories are used also in studies outside Western cultures.¹⁰ In this study, physical privacy was referred on the visual and physical privacy.

Privacy is influenced by cultural values and beliefs.¹ This study revealed the values related to privacy in Somali culture, which have been difficult to pinpoint in earlier studies. The themes of respect and dignity emphasized religion (Islam), culture and community, and privacy was not seen to be only for the individual; most of all, it was seen to support collectivism. This is probably the biggest difference compared to Western cultures, where privacy is primarily seen as focusing on individuals.⁴

In nursing, especially in Western cultures, these results can be used to understand the cultural and collective aspects of privacy. Since healthcare professionals working with asylum seekers are usually from different culture, it gives Somali asylum seekers a great opportunity to share their privacy and to discuss difficult issues, such as feelings related to traumas or violence, which have been reported to be challenging to discuss.^23,24 However, attention has to be paid to the presence of interpreter, since the interpreter is not considered to be part of healthcare team, and often is from Somali culture. The cultural related issues like respect and dignity have to be acknowledged in order to prevent the person from losing his or her face in the community. In nursing education, the results can be used both in ethics education and multicultural education.

Further research is needed to expand the understanding of the concept and realization of privacy. This study focused on Somali asylum seekers, and further research is needed also to determine the relations of different immigration status on the perception of privacy. The realization of Somalis’ privacy in healthcare should be studied in order to understand the effect of the interpreter in level of privacy.

Trustworthiness of the study

The trustworthiness of a cross-language descriptive study can be evaluated by four criteria: conceptual equivalence, interpreter’s credentials, interpreter’s role and methods.³¹

In this study, conceptual equivalence was challenging since the concept of privacy varies in the Somali language. Prior to the interviews, the interpreter and the participants discussed the phenomenon of privacy in order to reach a common understanding of it; however, there is always a risk of misinterpretations when using an interpreter.³¹ In order to decrease the risk of misinterpretation, the interpreter was chosen based on her wide competence. The interpreter’s role was discussed with the interpreter and all the participants before the interviews. The interpreter didn’t interpret word to word, which can summarize or modify the participants’ responses. Even though all the interviews were audiotaped in order to check the interpretation when needed, the use of interpreter may have an effect on the results.³¹ The disadvantage of using a female interpreter with male participants was recognized; however, none of the participants, male or female, had problems with the interpreter’s gender when it was discussed before the interviews.

There are some challenges in focus group interviews with culturally and linguistically diverse groups.²⁹ However, the strong narrative background of the Somali culture supports the use of focus groups, and the interviews were preceded by careful planning and a pilot interview. Despite the careful planning and the discussions about confidentiality issues with the participants, the level of disclosure can be questioned, especially when using an intepreter.²⁹ In order to get a high level of disclosure, an open dialogue was maintained with the participants.

The trustworthiness of the analysis was achieved by a systematic content analysis.³² The quotations used in this article aim to clarify the steps of the analysis and the trustworthiness of the themes. Since the analysis of the data was done in Finnish, the analysis and the results were discussed with a representative of Somali culture in order to minimize cultural and linguistic misinterpretations.

Conclusion

This study shows that Somali asylum seekers’ perception of privacy is influenced by the collectiveness of Somali culture and Islam. All health-related issues can be shared with healthcare professionals, whereas interpreters are not considered to be part of the healthcare team, and sharing private issues with the interpreter might be perceived as challenging. Privacy is protected in order to show respect for culture and religion, to be respected by the community and to protect the dignity of individuals and family or community.

In healthcare, it is important to recognize the cultural aspect of the content and importance of privacy. Especially, when using interpreters with Somali background, the elements of community and culture are strongly present. The change of country gives Somali asylum seekers freedom to share private issues more freely; however, it may also force them to do so. The special life situation of Somali asylum seekers has to be acknowledged.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This study was supported by the Finnish Cultural Foundation.

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