Running Head: WELL CHILD CARE FOR A REFUGEE SOMALI BANTU FAMILY Well Child Care for a Somali Bantu Family Community This project consisted of the Somali Bantu refugees living in the Tennessee Village Community in Nashville, TN. Within this population set, the subset includes families with children aged 12 months and younger. It is estimated that 8-12, 000 Somali Bantu will to arrive in the US in the 2003-2004 year (USES: IIP, 2003). Of this 8-12, 000 refugees, the students of Belmont University were able to interact with approximately 200 of them. Of these 200, about 1/2 have children under the age of 12 months. This is consistent with the findings of the International Organization for Migration, (IOM) which reports that there is a high birth rate experienced by the Bantu culture, with most married women either lactating or pregnant and that there is little concept of family planning (2003).

Although members of the Somali Bantu culture come to America dealing with health problems like Tuberculosis, infection related to genital mutilation, HIV and syphilis; well baby care presents challenges for this culture as well. In fact, (50%) of newly arrived Somali Bantu children experience preventable injuries related to immunizations, safety, and hygiene which are effected by their cultural practices (Eno et al. , 2002). These are issues that need to be addressed in order to provide advancement in the quality of well baby care; care that is provided to the child who is without illness in order to prevent illness or maintain health.

Within this first group of problems are those that related to increased risk for communicable diseases: o Lack of immunizations and knowledge deficit of the need for immunizations, o close living spaces, o lack of access to medical care, o a high incidence of Low Birth Weight infants, o poor nutritional status related to maternal nutritional status, o High Crude Birth Rates creating oversized families, and Poor infant feeding practices. While these problems seem easily preventable within the framework of American society and values, many times, these are not available in Kakuma or other Somali Bantu camps. In addition, Americans have a more proactive approach in utilizing the above measure, while the Somali Bantu take a more reactive approach to health care (U of W, 2003). Immunizations that are available in the particular camp in Kenya mentioned in this article are OP, oral polio vaccine and the MMR, measles, mumps and rubella. While all the vaccines that are required in the unites states would be necessary and are high on the list of what would be necessary in the camps in Kakuma, additionally the Hepatitis B vaccine would be a valuable asset to those living in close spaces (IRC, 2004).

The second item in this group is close living spaces. In both the refugee camps and in America, the large families are placed in small spaces and apartments. Close living spaces are a risk factor for both communicable and non-communicable diseases (AGHA, 2004). In America, these small apartments provide more affordable housing which allows a refugee resettlement agency like Catholic Charities, to provide more help for more families and allows the refugee family a better chance to become self-sufficient.

In the camps, there is limited access to medical care (IRC, 2004). This affects the health of the children who immigrate to America and creates a need for health assessments once the infants become American citizens. The infants born in America are affected differently by the limited access to medical care because of the public health facilities available in each county. Facilities like the Lentz Public Health Center Provide free access to basic well child check-ups and immunizations.

The fourth item of this group is the high incidence of Low Birth Weight (LBW) babies, which refers to the incidence of the birth of infants born less than 2. 5 kilograms. In fact, (19%) of infants born since July of 2002 have been categorized as Low Birth Weight (U of W, 2003). Many of these babies have a poor chance for survival past infancy. The babies that do survive are almost always stunted for life and may experience complications from other congenital problems that are associated with children who are born with Low Birth Weights and malnourishment (U of W, 2003).

In a class at Belmont University's School of Nursing, it was required that pairs of students each assess a Somali Bantu family for health and wellness. One of the findings from this class was that 100% of Somali Bantu children fell below the 3 rd percentile on the Center for Disease Control's "Length-for-age and Weight-for-Age" chart, for infants up to 36 months old, and the "Stature-for-Age and Weight-for-Length" chart, for children between the ages of 2 - 20 years. Women with poor nutritional status, who are admitted to the Supplementary Feeding Program; a program in the refugee camp in Kakuma which admits those underweight or severely malnourished, (62%) of the total admissions are those of pregnant or lactating mothers (1). There is a distinct connection between the LBW infants who survive and mature into stunted adolescent women, and the malnourished women who are giving birth to LBW babies. This cycle perpetuates itself and should be broken when these families relocate to America.

There is also a High Crude Birth Rate that has been assessed at the camp in Kakuma. The numbers indicate that, between January and March of 2003, there were 368 babies born. There are approximately 3, 000 women of child bearing age in this community and assuming that the rate of the first quarter had continued, it would have yielded a child born to almost half of the women who were of child bearing age (U of W, 2003). Poor infant feeding practices occur because of the multiple and frequent pregnancies of the Somali Bantu women. Many times the infant, who may be malnourished from in-uteri, is weaned early, at 6 months, from the breast because of another pregnancy.

This practice puts the child at risk for infection, malnutrition and dehydration. The most common causes of death in children below five years old are pneumonia (41%), malaria (24. 5%), and watery diarrhea (16. 9%) (U of W, 2003). Well child care can provide close monitoring of the child's growth patterns and rates and advice or counseling is available at pediatric offices.

Because well baby care focuses primarily on the first year of life, it is important to note that supplementation of foods other than breast milk and cereal is unlikely in this cultural group. The second set of problems deals with safety in the home and in the community. Some problems that pertain to safety creating a Risk for Injury are: o Unfamiliar environment, o the lack of previous access to technological advances (Electricity, automobiles, modern appliances, etc. ) and the cultural outlook on childcare and oversized families creating a lack of supervision.

The following is a statement taken from a Belmont University nursing student. The excerpt describes some things that were assessed in the kitchen of a Somali Bantu apartment: "We were teaching her to cook in the oven because, up until we opened the door, she wasn't aware that the oven was anything more than the four burners. It was then that I observed the large, circular burn on the floor. When I pointed to the burn and looked at her, she smiled and said "too hot" and pointed at her pot with which she was currently cooking. This could have started a fire. I also noticed a can of bug spray on the floor right next to some food that had been opened-noodles and flour, some bananas - those types of things, It looked like she had just openly sprayed it on the floor next to the food - especially around the food.

I wanted to tell her that it was not safe to have the bug spray on the floor nor was it safe to spray it near her food, but I didn't know how. I just took the can, held my stomach and made a sick face and pointed to the scull and crossbones on the back of the can. I gave it to her and she immediately put it on top of her refrigerator. It was my evaluation that she got the point." Most Somali Bantu people have neither lived with electricity nor have they been exposed to other parts of western culture (Burgess, 2004). This means that there is no knowledge of how to use a light switch, a stove, a telephone or an electrical outlet.

Furthermore, depending on the ages of the children in the household, someone may fall in a dark room, experience injury from a burn on the stove or a fire started by a misplaced hot cooking pot, choke on a telephone cord while curiously playing with it, or suffer electrocution from an electrical outlet while inserting a foreign object into it. Although most of them do not own cars, most of them of their children will either be in one or own one at some point. In Tennessee Village, where there were at least 10 Somali Bantu families, consisting of an average of 6 members, it was assessed that (90%) of them had used the bus. The last set of problems deals with hygiene which presents a Risk for Impaired Skin Integrity and Risk for Infection.

Contributing factors to this are: o Lack of previous access to hygiene and skin care products, o poor hygiene practices like the use of pit latrines and communal bathing, o lack of diaper and skin care knowledge and practices, o cultural practices like therapeutic burning creating a break in skin integrity, and limited access to medical care. In the refugee camps, there is no access to Western methods of hygiene or skin care products. Communal bathing is an example of the type of hygiene control that is practiced in the camps. Many Somali Bantu have never seen a shower or a bathtub and have little concept of a faucet. Long lines for water and bathing, cholera warnings, and sharing water with cattle are common conditions at certain camps in Sudan (Oxfam, 2004).

The Bantu use pit latrines for bowel and urinary needs. They are unfamiliar with typical American bathroom facilities and common sanitation items such as diapers and feminine care products (Burgess, 2004). In the camps, diapers are not used and therefore diaper rash is not an issue of concern however, once the refugees are placed in America, they are provided with diapers and have little knowledge about their use and associated problems such as diaper rash and. Therapeutic burning is a practice that is done among the Somali Bantu people. It is the process of burning the area that is afflicted, such as the chest area if there is a cough present, and burning the evil spirits out. These burns create a break in the first line of defense for the body; the skin; and provide an opportunity for infection to occur.

Cupping and coining are also seen in the clinical setting and are considered culturally acceptable methods or the treatment of an illness for those within the culture (Ball & Bindler, 2003). Interventions The following is a summary of the problems identified in this document and the interventions recommended in the "Well Baby Care Manual": Problem Intervention Risk for communicable diseases related to: o Lack of immunizations, o close living spaces, o lack of access to medical care, o a high incidence of Low Birth Weight infants, o poor nutritional status related to maternal nutritional status, o High Crude Birth Rates creating oversized families, and Poor infant feeding practices. o Recommended Schedule in English and Somali-Bantu, o Teaching tool depicting importance and benefit of inoculation, o Basic visual demonstration of immunizations preventing communicable disease so Community resources such as locations of public health facilities. Risk for injury related to: o Unfamiliar environment, o the lack of previous access to technological advances (Electricity, automobiles, modern appliances, etc. ) and the cultural outlook on childcare and oversized families creating a lack of supervision. o Home safety - locations in the house where injuries can occur - kitchen cabinets, stairs, windows and blinds, bath tubs, eat.

o Fire Safety - exiting the building and the importance of having a smoke detector. o Electricity safety - the use of outlet covers and proper placement. o Automobile safety - care seat safety, specific weights for specific models, and proper placemen to Community resources - where they can purchase needed items. Risk for Impaired Skin Integrity related to: o Poor diaper care o Diaper care - Pictorial demonstration and list of needed item so Community Resources - places to go to purchase such items Risk for Infection related to o Poor hygiene o Bath supplies - Pictorial listing of useful items like soap, lotion, water, water thermometer, and towel.

Importance of maintaining infant body temperature. o Diaper care - Pictorial demonstration and list of needed item so Community Resources - places to go to purchase such items Goals Short-term goals: o Use the teaching tool titled "Well Baby Care Manual" for an educational sessions; o To have families express the importance of the concepts contained within the tool, o To increase Somali Bantu child vaccinations, o For case managers to note positive changes in safety practices, and For case managers to note positive changes in hygiene practices. Long-term goals are: o To decrease the incidence of communicable diseases in Somali Bantu infants and children, o Somali Bantu children will decrease the amount of visits to the emergency room due to safety related injuries and skin infection, and Somali Bantu children born in the United States will be free from immunization-preventable diseases. Plan of Action Community Health groups were formed according to the issues that needed to be covered. Issues were chosen based on an open forum discussion by the students who had worked with the Somali Bantu families. It was decided that the issue of Well Baby Care would be of importance to this community, among other topics such as Nutrition, Sick Baby care, and Women's Health Issues.

Amy and I were the first ones to sign up for the Well Baby Care intervention group. Next Lauren, Marti and Betty were recruited to the group. We met each week for four weeks, on Wednesdays, until the week of November 16 th, when we met for an additional day, the Monday before the Symposium to put the poster together. We met with Dr. Dunlap during the first meeting, which helped us get on the right track. During the remainder of the meeting, we discussed the elements of the project that would be needed and what types of things we wanted to cover within our topic.

The second meeting, after we had done some research, we fine tuned the topics that we wanted to cover and distributed the "$100. 00" between members. We decided to cover immunizations, safety, and hygiene / skin care. We took some time to look at strengths and weaknesses of each group member, and after some discussion, came to decisions about how the work would be distributed. We concluded our meeting after we set goals for the following week.

On the Third week, we brought some of our resources, photos, and the paper for everyone to see. We each shared resources and went over citations. We decided to alter the presentation of the immunization photos so that they would convey the message of what immunizations DO and what they PREVENT. This was done per the recommendations of Dr. Dunlap. We reevaluated whether our topics still flowed, once in a paper format, and adjourned.

The last week, we met to put the binders together, print out the PowerPoint slides, preview the paper, and discuss plans to assemble the poster. Two members went on site at Tennessee Village, and met a local translator who had been informally designated as the translator for the Tennessee Village apartments. He, and two other members our group met with a Somali Bantu family and used the binder to do actual teaching. After the session, group members evaluated what worked and what was confusing. Luckily, everything but one or two pages worked. We decided that the picture of the places where the skin care and baby safety supplies could be bought should only depict a logo of the store and not a photograph of the store.

This was done because of the confusion during the teaching session about where a specific Kroger was located. It had to be explained that, although that was a picture of a specific Kroger, they could find these items at any Kroger. We felt that applying this change to the picture of the Wal-Mart was appropriate too. The end result was a page that showed the LOGOS for Kroger and Wal-Mart instead of actual locations. We decided that Monday night before the presentation would be a good time to do get together and assemble the poster.

The night that the poster was assembled, we got together and had a great time! We looked it over to make sure it had the title, members of the group, short-term and long-term goals, a description of the population, interventions, and risks; all clearly stated. We also decided to add additional pictures in frames and to place them in front of the poster to draw people to our booth. This brings us to the night of the senior symposium but does not cover the plan to continue the use of these interventions and books. What is our plan to perpetuate the usage of these materials? Because Case Managers at Catholic Charities and World Relief have unlimited access to the records for these families, the manuals can be used and distributed by them as they see fit. In order to involve the population that is affected; the Somali Bantu families in the Tennessee Village community; Case Managers and future community health Belmont University Nursing students can provide the continued use of the pictorial manuals in the teaching intervention process.

Resources needed would include, but not be limited to transportation for those who are doing the teaching, bus schedules for Somali Bantu refugees, "Well Baby Care Manual", and supplies to demonstrate procedures like diapers, bath supplies and outlet plugs. There would be little or no financial obligation on the part of the teacher but would be some on the part of the family as they realize that these things are needed in their lives and are worked into their budget. The "Well Baby Care Manual" provides a list of places where needed items may be bought and pictures of actual items used in the care. This plan of action was evaluated by a pilot teaching session using the initial layout of the manual. During the teaching session it was assessed that the family was receptive to looking at the manual and that the photographs helped. There was a translator available during the demonstration and, through him, the family was able to verbalize an understanding of all of the concepts contained in the manual.

During the portion of the session that dealt with car seat safety, the family asked about the car seat. There was some confusion about the carrier being suitable as a car seat as well as the other model; that does not double as a car seat; being suitable as well. It was assessed that it would clear up any confusion if the pictures were changed to depict a child inside both models. This would provide an understanding of how the child is properly restrained by both. Our group felt that this projects was realistic in it's goals and that truly effective interventions were made. We also felt that our group helped to lay the framework for other students to use as an example of teaching families about immunizations, safety, and hygiene / skin care as they apply to Somali Bantu families in the Tennessee Village community.

Community Health nursing has its challenges and it was a fun experience to be able to rise up and meet them! References Anonymous (Personal Communication, November 2, 2004) Australian Government: Department of Health and Aging. (2004). Communicable diseases intelligence publications: Risk factors. Retrieved on November 22, 2004 from web Ball, J.

W. & Bindler, R. C. (2003). Pediatric nursing: Caring for children. New Jersey: Upper Saddle River Burgess, A.

(2004). Health challenges for refugees and immigrants. Refugee Reports: A News Service of Immigration and Refugee Services of America, 25 (2), 14-16. Catholic Charities of Tennessee.

(2004). Refugee and immigration services. Retrieved on November 10, 2004 from web web bantu. html (1) Eno, O.

& Van Lehman, D. (2002). Culture profile. In The somali bantu: Their history and culture. (pp. 000-000).

New York: Center for Applied Linguistics. (2) International Refugee Committee. (2004). IRC health programs in Kenya. Retrieved on November 22, 2004 from web New Zealand. (2004).

Media brief on Oxfam Humanitarian Relief at Sudanese refugee camps in Chad. Retrieved on November 22, 2004 from web of Washington: Harborview Medical Center. (2004). Somali bantu refugees.

Retrieved on October 29, 2004 from United States Department of State: International Information Programs. (2003). Fact sheet: February 7, 2003. Retrieved on October 29, 2004 from web.