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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. The information in the natural group discussions was collected only after JS was introduced by the moderators and she had become acquainted with the mothers who participated in the weekly group gatherings. Information on (the prevention of) HPV and cervical cancer was presented by JS to the participants at different moments. Facilitating a discussion with mothers who only recently moved to the Netherlands would have been difficult without the provision of any information on HPV and cervical cancer.

The executing researcher (JS), who is a young female of Somali origin and studied Health Sciences in Amsterdam, approached Somali organizations and Community Health Services (CHSs) through gatekeepers who had access to the Somali community. Participants were recruited from a wide range of settings, including community gatherings, CHSs, the university, and Facebook. The recruitment was mostly done by JS and via members of the Somali organizations and CHS professionals. 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. Central Committee on Research Involving Human Subjects: Behavioural research and the WMO. [ http://www.ccmo.nl/attachments/files/ccmo-notitie-gedragswetensch-onderzoek-eng.pdf]CharmDate– a safe dating web resource that provides with video and live chat options and helps find hot Russian women, and not only. The young Somali women, between 18 and 21 years old, were recruited because they have been a part of the target group for the first (catch-up) HPV vaccination program, and they will be invited for Pap smears when they turn 30. The mothers who were over the age of 30 were recruited in this study because they had either been invited to receive Pap smears or because they had to decide whether their 12 year old daughters would receive the HPV vaccination. Teachers can provide and discuss culturally appropriate information targeting the double sexual standard in schools. It is also recommended to take the cultural stigma on sexual matters into account and extend the HPV vaccination to an older age, as suggested earlier [ 33]. Some studies suggest this low risk may be due to having circumcised partners [ 7], among other reasons, male circumcision being a common practice in Islamic communities [ 8].

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. 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. 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)]

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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. Madriz E. Focus groups in feminist research. In: Denzin NK, Lincoln YS, Madriz E, editors. Handbook of Qualitative Research. 2nd ed. Thousand Oaks: Sage; 2000. p. 835–50. Gele A, Kumar B, Hjelde K, Sundby J. Attitudes toward female circumcision among Somali immigrants in Oslo: A qualitative study. Int J Womens Health. 2012;4:7–17.

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)] In the United Kingdom, embarrassment due to Female Genital Mutilation (FGM) is a barrier for getting Pap smears among Somali women [ 13]. In the United States (US), FGM is associated with a concern that Pap smears would increase pain among Somali girls and women [ 14]. Another study in the US has found that Somali girls accept HPV vaccination, but are less likely to complete the HPV vaccination series in comparison with white non-Hispanic girls [ 15]. Moreover, Somali women in the US are less likely to adhere to cervical cancer screening procedures than non-Somali women in the US [ 16]. Hence, there is a need to deepen our understanding of the perceptions of Somali women in the diaspora regarding the prevention of cervical cancer.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. 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. Athar S. Sex education for Muslim youth and their parents. Indianapolis: Indiana University School of Medicine; 1999.

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.As it was already mentioned, a woman in Somalia has no rights. Parents may sell their daughter to bandits or marry her off in exchange for water or food, so the number of unions increases dramatically during a drought. Almost half of Somali women married before the age of 18.