Cultural Adaptation of occupational therapy for Somalis in the UK

The presentation

Varsha Chauhan Gawde and Anita Atwal delivered a presentation titled ‘The cultural adaptation of occupational therapy as a complex intervention for Somalis in the United Kingdom’ at a contemporary practice session. Their research, funded by RCOT, represents a collaborative effort between Central North West London NHS Foundation Trust, Safi (a Somali advice and information organisation), and South Bank University. 

The project emerged in response to stark health inequalities highlighted during the COVID-19 pandemic. Brent, described as London's most diverse borough, was severely impacted by COVID-19, with the Church End area (home to a large British Somali population) experiencing mortality rates three times higher than the national average. The researchers were prompted to act after a Somali community member named Rhoda wrote a letter to The Guardian expressing concerns about the social deprivation and high COVID-related death rates affecting her community. 

This situation revealed a significant disparity in healthcare provision, particularly in occupational therapy. The presenters noted an ‘inverse law’ in OT distribution – deprived areas like Brent have fewer occupational therapists compared to more privileged communities like Surrey. This workforce imbalance compounds healthcare inequalities for marginalised communities. 

The research team adopted a decolonial methodological approach called Participatory Action Research. This method was deliberately chosen to understand the Somali community through a ‘Somali lens’ rather than imposing traditional Eurocentric research methods. The researchers acknowledged that the Somali community is collectively oriented, necessitating research methods that reflect this cultural characteristic. They emphasised ‘researching with’ rather than ‘researching on’ the community, challenging traditional research paradigms that often extract information without offering sustainable benefits. 

The team identified several key principles guiding their approach: establishing power-with rather than power-over relationships, transforming the researched into researchers, building trust, demonstrating cultural competence, maintaining continuous engagement, and practising ethical reflexivity. These principles required prolonged engagement and deep understanding, which posed challenges given time constraints and professional pressures. 

Having a Somali research assistant proved valuable, though the presenters observed that being Somali doesn't automatically guarantee acceptance within the community. Trust-building takes time and is influenced by factors such as tribal affiliations and political considerations from the home country. This highlighted the complexity of cultural issues that can affect research and service delivery. 

The research process involved several stages: engagement and capacity building, exploration and visioning, visual and narrative mobilisation, and evaluation. The team conducted ‘World Cafés’ involving London occupational therapists and ‘storytelling cafés’ with the Somali community – the latter approach chosen to align with the community's oral tradition. 

Themes

Through their initial analysis, the researchers identified several key themes. First, ‘fair access to OT’ emerged as a significant concern. The Somali community generally lacks awareness about occupational therapy services, raising questions about accessibility and referral pathways. Currently, access largely depends on referrals from other healthcare professionals who may themselves have limited understanding of occupational therapy. 

The second theme centred on how occupational therapy is ‘shrouded in mystery.’ The term ‘occupational therapy’ doesn't exist in the Somali language, making it challenging to explain the profession. The researchers attempted various approaches, including using plain English descriptions, showing pictures, and providing examples of equipment and interventions, but found translation and communication barriers significant. 

A third theme concerned the relevance of occupational therapy to the Somali community. The researchers found that many Somali families prefer to address health issues ‘in-house’ rather than seeking external help. Trust is paramount, with many preferring to speak with people who understand their cultural needs, share their background, speak the same language, and can relate to their experiences. 

This led to discussions around independence versus interdependence. While Western healthcare often emphasises individual autonomy (independence), the Somali community tends to value collaborative relationships (interdependence). The researchers shared stories illustrating how this cultural difference affects healthcare decisions, including a family who managed serious illnesses without external support because they weren't aware of available services, and a mother who faced community criticism for allowing her son to access mental health counselling. 

Concluding the presentation

The presentation concluded by highlighting numerous barriers the Somali community faces in accessing healthcare services. These included: waiting lists, inconvenient clinic locations, limited appointment options, stigma, discrimination, racism, language barriers, transportation issues, unfamiliar systems, confusing online referrals, and notifications provided only in English. These challenges are further compounded by other stressors such as asylum claims, housing issues, cost-of-living crises, and trauma from war experiences. 

During the brief Q&A session, Dr Anita Atwal emphasised the need for occupational therapists to go out into communities rather than expecting communities to come to them. She suggested that the profession tends to ‘hide’ behind locked buildings and may be ‘frightened of the community,’ partly due to concerns about waiting lists and resource constraints.  

The researchers plan to continue their work with further storytelling workshops and will share their findings with the wider occupational therapy community through a webinar, inviting London-based occupational therapists to participate in the ongoing project.