Original Research
Perceived reproductive health needs among Muslim women in the southern US

Sondous Eksheir¹, Jessamyn Bowling¹
Published online: 21 November 2020

¹University of North Carolina at Charlotte, Charlotte, NC, USA
Corresponding Author: Jessamyn Bowling, email jbowlin9@uncc.edu

Background

In spite of growing rates of Muslim women in the United States (US) (1), their health remains under-researched; this is partly due to a lack of inclusion of religious affiliation in research (2-4). Although Muslims in the US have similar rates of education as the general population, they are more likely to report lower household annual incomes (1). Pew Research Center estimates that the number of Muslims living in the US grew from 2.75 million in 2011 to 3.45 million in 2017, with a predicted growth to 8.1 million in 2040 (5). With this growing Muslim population that may be uninsured, there is an increased need for addressing religious-based discrimination, especially in health care settings.

While the Muslim American population is racially and ethnically diverse, it is still a minority group that is bound by a set of practices that influence their behaviors and experiences (2). Factors affecting potential barriers to health care access include gender preference of provider, family involvement in care, fatalism and predestination, maintaining religious practices during illness, low health literacy and language proficiency, preference for traditional remedies, fear of stereotype and discrimination, and limited health care access (6). Budhwani et al. (4) acknowledge the intersectional aspects of identities among Muslim women in the US, including religion, ethnicity, race, and potentially immigrant status, that influence their health and may be different from other women. Clinical practices in the West are often individual-centered, while Muslim societies tend to be collectivistic and value extended family (3).

Patients’ culture influences health care access as well. Health care visits, notably preventive care (e.g. breast cancer screening or cervical cancer screening), are infrequent among immigrant Muslim women (7). American Muslims have lower rates of mammography utilization, likely due to religious engagement (e.g. reading Quran to deal with life stressors instead of seeking professional treatment) and perceived discrimination in health care (8). Additionally, some providers might be reticent about sharing information or asking questions to their Muslim women patients because of the lack of knowledge about their cultural and religious values (9).

Stigma and discrimination against Muslim individuals in the US may result in negative health outcomes through several social-ecological levels: individual (stress reactivity and stereotype threat), interpersonal (social relationships and socialization processes), and structural (institutional policies, media coverage, general islamophobia) (10, 11). Reporting of hate crimes vary widely by state and therefore data by region is unavailable (12). However, 40% of American anti-Muslim organizations are based in the southern region of the US (13). Based on this, there may be different levels of stigma and discrimination in the south compared to elsewhere in the US.

Given the lack of targeted interventions or initiatives to understand Muslim women’s gynecological experiences in the urban South, this study aims to examine variables that promote or impede access to reproductive health care for Muslim women in Charlotte, NC. An examination of Muslim women’s reproductive health experiences may inform trainings for providers, educational programs for Muslim individuals, and identify gaps in access to services.

Theoretical Framework

This study draws upon Aday and Anderson’s (14) framework for health care access (as described by 15). This framework includes the following domains: (1) health policy, (2) characteristics of the health delivery system, (3) characteristics of populations at risk, (4) utilization of health services, and (5) consumer satisfaction. We focus specifically on characteristics of populations at risk (perceived needs), utilization of health services, and consumer satisfaction.

Methods

This study used multiple methods, with an online survey and in-person interview conducted simultaneously. Semi-structured interviews were used to explore the sensitive and personal experiences of Muslim women in reproductive health care. The interviewer was a hijab-wearing person who spoke Arabic and English fluently, in order to increase the comfort of participants. Surveys provided larger context and commonalities across a larger number of participants. The study was approved by University of North Carolina at Charlotte’s Institutional Review Board.

Participants

Survey eligibility criteria included: participants between the ages of 18 and 55 years, who identified as Muslim (either religious or ethnic¹ identity), and who were assigned as female at birth. Interview eligibility was the same with the added criteria of living in Charlotte (and/or surrounding areas) for a least one year, and fluency in English. Participants were recruited from a local free health clinic focused on Muslim populations, local Muslim groups, as well as word of mouth. Recruitment for the survey and the interview were done simultaneously.

Data Collection

In-person semi-structured interviews (n=15) were conducted by a trained Muslim woman in English. Informed consent was obtained from all participants. Participants did not receive compensation. Interview participants selected pseudonyms that were used in this paper. Interviews were audio-recorded, then transcribed for data analysis. An anonymous open- and closed-ended online survey (n=76) was conducted using Qualtrics.

Measures

Interviews asked about experiences accessing maternal and reproductive health care services and provider preferences (see Appendix A for questions). Interviews lasted approximately 45-60 minutes. Survey questions focused on different reproductive care screenings, symptoms of reproductive health issues, and level of comfort with provider (see Appendix B).

Analysis

Dedoose software (16) was used for thematic “theory-enabled” analyses (17, 18). A codebook was created based on the interview guide using components of Aday and Anderson’s framework (14), then refined during initial coding of two interviews. Each interview was coded twice by two coders trained in qualitative coding (JB, SE). We sought to identify subcomponents of the framework and also generate and compare emerging health components (18). Reliability was confirmed using Dedoose’s test function, with any codes of a kappa less than 0.80 discussed and edited until consensus was reached. Survey results were analyzed using descriptive statistics on SPSS and the open-ended response item was thematically analyzed using inductive methods.

¹One can identity as Muslim because it is your religion, or because it was passed down through family but may not necessarily be practicing

Results

The age of survey respondents ranged from 18 to 54 years, with most participants (n=58, 82.86%)² having health insurance. Interview participant ages ranged from 18 to 55 years (see Table 1 for demographic information). We identified three main themes in the interviews: screening, provider, and education (see Table 2 for quotations).

In terms of gynecological care, participants reported limited access. Many survey respondents (39.13%, n=27) had never been to a gynecologist, and 14.49% (n=10) of all survey respondents had been diagnosed with a reproductive health issue in the past. Only 31.88% visit a gynecologist once a year (n=22), and 8.7% (n=6) visit every six months or more often. Jessica, an interview participant, described the lack of service utilization not as an issue of access but of norms (Table 2, 2a). Katie relates this norm to larger cultural community policing and gossip (Table 2, 1b). In this example, Katie advocates for resisting this policing by “having a backbone” and putting the onus on families in raising their children. Similarly, Sarah felt the silence around Muslim womens’ sexuality was dangerous and pushed Muslim women to advocate for themselves (Table 2, 2e).

Among survey respondents, the most common reason for gynecological visits were for pregnancy (38.46%, n=20/52), birth control (21.15%, n=11/52), pelvic exam (11.54%, n=6/52), irregular menstruation (9.62%, n=5/52), and breast exam (5.77%, n=3/52). Interview participants described accessing gynecological care for major concerns or recommendations from doctors or family members. It is worth noting that many interview participants’ family doctors were Muslim (Table 2, 2j).

In terms of gynecological care, participants reported limited access. Many survey respondents (39.13%, n=27) had never been to a gynecologist, and 14.49% (n=10) of all survey respondents had been diagnosed with a reproductive health issue in the past. Only 31.88% visit a gynecologist once a year (n=22), and 8.7% (n=6) visit every six months or more often. Jessica, an interview participant, described the lack of service utilization not as an issue of access but of norms (Table 2, 2a). Katie relates this norm to larger cultural community policing and gossip (Table 2, 1b). In this example, Katie advocates for resisting this policing by “having a backbone” and putting the onus on families in raising their children. Similarly, Sarah felt the silence around Muslim womens’ sexuality was dangerous and pushed Muslim women to advocate for themselves (Table 2, 2e).

Among survey respondents, the most common reason for gynecological visits were for pregnancy (38.46%, n=20/52), birth control (21.15%, n=11/52), pelvic exam (11.54%, n=6/52), irregular menstruation (9.62%, n=5/52), and breast exam (5.77%, n=3/52). Interview participants described accessing gynecological care for major concerns or recommendations from doctors or family members. It is worth noting that many interview participants’ family doctors were Muslim (Table 2, 2j).

Screening

Most survey participants (73.42%, n=58) were screened for breast cancer. Of all participants, 31.65% (n=25) were examined by a doctor, 26.58% (n=21) had a mammogram or an MRI, and 15.19% (n=12) conducted a self-examination. Participants generally were aware of testing recommendations. Factors that contributed positively to breast cancer screening included knowing someone with breast cancer. For example, Fatima waitedfor her provider’s recommendation to do a breast cancer screening, as she believed that she might be diagnosed with it due to her family’s history. Nearly half (47.83%, n=33) of survey participants had never been screened for cervical cancer. Twenty-nine percent (n=20) percent of participants have one every 2-3 years, and 17.39% (n=12) have one every once a year or more often. Jessica describes the reason that the screening rates are low as a lack of perceived risk. (Table 2, 2b) Roughly half (51.72%, n=35) of survey participants had never had a pelvic exam, with 33.33% (n=23) of all participants getting a pelvic exam every 1-2 years, and 5.8% (n=4) every 5 years or less. Participants connected low rates of pelvic screenings to the cultural expectation of Muslim women not being sexually active before marriage, and therefore only starting gynecological visits after marriage (Table 2, 2c, 2d). Family pressure and lack of education may be potential barriers to young Muslim women accessing sexual health services (Table 2, 2e, 2h). Fatima described both the lack of information given to patients about cervical cancer exams and how her family has encouraged self-exams to gain more control over the process (Table 2, 2i).

Almost half (46.38%, n=32) of survey participants had been tested for sexually transmitted diseases (STDs). Given the aforementioned cultural norm of Muslim women’s lack of sexual activity before marriage, Selena’s experience of buying condoms and asking to be tested may be perceived as difficult to do for some (Table 2, 2k). The majority of participants who were sexually active had used contraception at some point (n=25, 64.10%), with 28.21% (n=11) using condoms, 15.38% (n=6) using intrauterine devices (IUDs), and 15% (n=6) using pull out/withdrawal method as the most common methods. Survey respondents reported low uptake of hormonal methods (8%, n=3). In contraception, some participants who were married prioritized their partner’s opinions. Some participants did not want hormonal contraceptives due to perceived side effects (Table 2, 3l).

Provider

Providers’ expertise was generally trusted (Table 2, 3a). Health care providers play a crucial role in the level of comfort Muslim women experience in their office. Generally, the gender of the provider was prioritized over their religion (Table 2, 3c, 3d). Though most participants reported increased comfort with a female provider, some interview participants reported the provider’s gender did not impact their care, unless it was an invasive procedure (Table 2, 3e). Adding to that, some participants expressed concern about the way women’s pain can be perceived by male physicians (Table 2, 3f). Muslim providers increased comfort of provider for Rachel and Cassandra (Table 2, 3g, 3h). Ralph insinuated that if one’s only options were a male Muslim provider or a female Muslim woman without training or expertise, she would be more comfortable talking to the male Muslim provider, due to training and expertise (Table 2, 3i). Then, when asked about the religious or ethnic background of a provider, Ralph acknowledged the possibility of stigma or ignorance from non-Muslim providers (Table 2, 3k). Beyond gender discrimination, participants agreed that religious/ethnic discrimination makes them less likely to seek care (Table 2, 3n).

The close-knit and relatively small Muslim community influenced some participants’ care. Two interview participants reported they did not have “proper” physical exams because their doctor was Muslim and a family acquaintance and hence they would receive less thorough exams. One survey participant describes purposefully avoiding Muslim providers for their sexual health needs (Table 2, 3j). Another strategy in the face of judgment was to ask for provider recommendations from trusted individuals (Table 2, 3b). The Charlotte community was also perceived as supportive of refugees and immigrants (Table 2, 1a).

When asked about access, almost all participants acknowledged cost as a barrier and said transportation was not (Table 2, 1d, 1e, 1f). It was agreed also that language can act as an impediment, especially when discussing a health problem of a sensitive nature. Patients may already feel uncomfortable talking about their reproductive health concerns in addition to not having words in another language to describe these concerns (Table 2, 3o).

Information Seeking

Interview participants emphasized the need for better education-both in terms of religion and reproduction (Table 2, 2g). Participants reported an unmet need for awareness within the community, highlighting the role of parents and community leaders to open this conversation (Table 2, 2h). Participants reported that sexual health knowledge received from secondary school was insufficient, and that their sources of information were directly from family members, their college education, online resources, and providers (Table 2, 4a). Participants described tiered strategies in identifying informational support in reproductive health concerns. Cassandra describes prioritizing seeking support from first her mother, then her doctor (Table 2, 4b). Selena included religious texts as part of her sources of support (Table 2, 4c). Fatima discusses the legacies of health information being transmitted within families between women (Table 2, 4d).

On the other hand, some interviewees did not open up to their parents about their sexual health concerns (Table 2, 2f, 4e). Jennifer felt more aware of sexual health issues than her mother, through learning about it on the internet or from biology-major friends in college, yet she deferred to her mother in birth control decision-making (Table 2, 3m). Multiple interview participants mentioned their desire to go on birth control pills to treat period cramps, but not being able to because of a mother’s disapproval and their lack of knowledge about side effects. Religious education was described as significant, as it allows women to distinguish between religious guidelines and cultural traditions that may act as obstacles in care. Maria advocated for the masjid (Islamic centers) and sheikhs (religious leaders) to provide classes with health professionals. Katie agreed to this statement as well (Table 2, 4f). Conversely, Mona felt that health care professionals must be more aware of Muslim-specific concerns that their patients might face (Table 2, 4g). This was not a common opinion among our interviewees. Another issue raised is that religious leaders (Imams), especially men, are in no place to educate Muslim women about reproductive health (Table 2, 4h). When asked about effective solutions, almost all participants (60%, n=9) pointed towards health education, but Fatima also questioned the efficacy of outreach (Table 2, 1c). Cassandra added that masjids are often not confidential spaces and people’s trust can be compromised. Another way to build trust among participants is a tailored approach for a specific population, such as the youth in the community (Table 2, 4i). It is important to note that ‘community’ is tantamount to the mosque. Therefore, it is important to consider the health impact of participants’ perception of reproductive health being too taboo to be talked about at the masjid. As suggested by some interview participants, an online teaching module would be effective because it ensures people’s confidentiality when seeking information.

² Due to variances in participation by question, we report the percentages based on the total number of responses per question

Discussion

This study identified widespread challenges for accessing reproductive health care among Muslim women in the south. Matin and Lebaron (7) point out that Muslim women may have reservations about clinical exams involving their genitals, regardless of marital status. This study reported supporting evidence with lower uptake of cervical cancer screening. Participants in this study had lower rates of 47.83% (n=33) for cervical cancer screening in contrast to the 84% national average (3). As compared to the 67% of the general U.S. population (8), participants had high screening rates (73.42%, n=58) for breast cancer. Further interview results demonstrate agreement with previous research findings, that knowing someone with breast cancer increases screening (8). Participants also learn about screening from family norms. Many families taught breast cancer self-check and passed down the tradition from mother to daughter.

Participants in our study generally had low rates of contraceptive use, with only 64% of sexually active participants ever using it. According to a 2012 research study (19), 62% of American women in the reproductive age regularly use contraceptives. Of women using a contraceptive method, the most common were the pill (28%) and female sterilization (27%). This may be an opportunity for tailored approaches with the Muslim community. These include acknowledging shared decision-making between spouses and acknowledging the low contraception awareness in this community. In a previous ethnographic research study in India and Bangladesh, minority Muslim countries, participants used prescribed family planning methods, such as sterilization, without the knowledge of their significant others, which could lead to “unfavorable circumstances” if their significant other found out (20). As Muslim individuals in the US are in a minority context, we might expect Muslim women to navigate systems and relationships somewhat similarly as this example, in which Muslim women are learning to navigate decisions and family expectations related to their reproductive health. Fatima describes a provider discounting her menstrual pain and eventually being diagnosed with dysmenorrhea. Though there are cultural differences in conceptualizations of pain among Muslims (21), the experiences of Muslim women’s pain not being recognized by providers connects to larger patterns in the US, since women often experience dismissal of pain from providers (22). Furthermore, race and ethnicity have been linked to differences in pain treatment by providers (23, 24). These issues may be compounded by language barriers, as previously discussed in literature regarding Hispanic patients (23).

Strengths & Limitations

One strength of this study is that the interviewer was an Arabic and English-speaking Muslim woman, which may have increased participants’ comfort. Recruitment was done through existing networks and word of mouth, which may exclude individuals who are less tied to communities (e.g. recent immigrants). Our sample was predominantly younger, in part due to our connections with existing groups. Given generational differences and how life course changes affect health behaviors, this may reduce the generalizability of our findings. The lack of incentive may have deterred potential participants, attempts were made to make the interview as accessible for them as possible (including offering multiple locations). Another limitation was the use of online surveys only, and the small sample size (n=72) in the survey. Additionally, the use of a mixed-method approach was a strength of this study. We did not ask about the amount of time participants had spent in the US, but longer amounts of time in the US for Muslim women reduce delays in seeking care (25). We also did not ask about income of participants, and though none of the participants mentioned cost as a barrier, they did acknowledge it as a potential issue for others.

New Contributions

Given that participants placed trust and respect in providers, there may be important opportunities to train providers in culturally-sensitive care. We report numerous misconceptions from patients regarding reproductive health and screenings, such as self-exams for cervical cancer. This issue, and the low rates for screenings, call for awareness to the community through educational programs. Access must be increased to both physical resources (community-focused lecture series or confidential peer programs) and online resources (training modules, private portal, question submission portal). Education for providers on Muslim women’s reproductive health needs, such as privacy during pelvic exams and basic knowledge of Islamic values (i.e. fasting during Ramadan), is also needed. As not all Muslim women may be visually discernible from others, providers may need to ask questions to determine patients’ religious and cultural identity. In one study, Muslim women in the US delayed seeking health care due to a perceived lack of female physicians (25). This may point to a need to not only promote service awareness, but also provider availability. Overall, education and promotion messaging must be tailored to Muslim communities to maximize efficacy (7). Muslim women’s needs are not wholly different from non-Muslim women (7), but comfort and privacy with a provider is important. For younger individuals whose families are less supportive of reproductive health care, providing resources outside of the family environment may be especially impactful.

References

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Appendix A: Interview Guide

1. Have you heard about breast cancer screening? Have you ever been screened? [If not] What do you think it would take for you to be screened?
   • Do you believe breast cancer screening is necessary? Why or why not?
2. Have you heard about cervical cancer screening? Have you ever been screened? [If not] What do you think it would take for you to be screened?
3. What do you normally do if you have any sexual health concerns?
4. Are there places in Charlotte that you feel more comfortable going for sexual health concerns? What about less comfortable?
5. Are there places in Charlotte where you’ve gone for sexual health services?
• Have you ever or would you ever use contraception? If you needed to get contraception like birth control pills or an IUD, what would be your concerns in getting those?
i. Prompts: Asking a doctor, going to the pharmacy, paying for them or using insurance, understanding how to use them, etc
• Do you think Muslim women (especially the youth) would have a difficult time accessing sexual health services as opposed to people with perhaps another background?
6. How often do you see a gynecologist?
• If you do not see a gynecologist, then why?
• What was the reason why you visited a gynecologist for the first time?
• Do you know of any other sexual health providers other than your general doctor?
7. How does it feel to talk about reproductive health with healthcare providers?
• If your provider is a woman, how does that change the experience for you?
• If your provider is Muslim or from a similar cultural background, but maybe not a woman, how does that change the experience in discussing sexual health concerns?
8. Have you, or someone you know, ever experienced discrimination in a healthcare setting?
9. What have you learned about sexually transmitted diseases? Tell me what you know about them?
10. Where have you gained most of your sexual health knowledge?
• Have you learned or heard about menopause? Where from?
• What have you learned or heard about sexually transmitted infections such as chlamydia, gonorrhea, syphilis, or HIV? Where from?
11. Can you tell me a time when you talked to others about women’s health? That might relate to pregnancy, menstruation or periods, menopause, women’s bodies, etc.
• Growing up, how did you discuss your menstrual cycle with your parents or family members?
• Thinking about intercourse in the context of marriage, do you think that Muslim women view sex as a form of pleasure or for the purpose of reproduction?
• [If they have a partner] Do you ever have conversations about reproductive health with your husband/partner?
12. In thinking about other Muslim women that you know, how do you think their religion or culture influences their sexuality?
13. What, would you say, is a source of support for you when it comes to your sexual health?
14. How do you think we can reach this audience of Muslim women living in Charlotte?
• What programs do you think would be effective in promoting women’s sexual health?
• Thinking of this issue on a populational scale, how do you think we can empower Muslim women to learn about their reproductive health?

Appendix B: Survey Questions

1. How old are you? ___
2. For how long have you been living in the Charlotte area? ___
3. Do you identify yourself as Muslim? Yes · No · Don’t know
4. What is your country of birth? ___
5. What is your relationship status?
   • Single
   • In a Relationship
   • Engaged
   • Married
6. What is your sexual identity?
   • Heterosexual
   • Lesbian/gay
   • bisexual/bi-curious
   • unlabeled/prefer not to be labeled
   • Other
   • Prefer not to answer
7. What is the highest level of education you’ve completed?
   • Didn’t complete high school, GED, or equivalent
   • High school diploma/GED or equivalent
   • Some college (no degree)
   • Associates degree or equivalent
   • Bachelor's degree or equivalent
   • Some graduate (no degree)
   • Masters/ Graduate Certificate
   • Doctorate (or equivalent)
8. What is your living accommodation?
   • Living with parents
   • Living with partner
   • Living with roommates/shared house
   • Living alone
9. Do you have health insurance? Yes No
10. Do you smoke cigarettes? Yes No
11. Are you sexually active? Yes No
12. How many children do you have (including deceased and stillbirths, if any)?___
13. Have you ever had a UTI (Urinary Tract Infection)?
    • Yes, about once a year or more often
    • Yes, sometimes (I’ve had it one or more times)
    • No, I’ve never had it
    • I don’t know
    • Prefer not to answer
14. Have you been diagnosed with any reproductive health issues such as endometriosis, polycystic ovarian syndrome, gynecologic cancer, uterine fibroids, or others?
    • Yes
    • No
    • I don’t know
    • Prefer not to answer
15. Have you ever been checked for breast cancer?
    • Yes, I’ve had a Mammogram
    • Yes, I’ve had an MRI (Breast Magnetic Resonance Imaging)
    • Yes, I’ve checked myself
    • Yes, I’ve been checked by my doctor
    • No, because I don’t know about it/how to
    • No, because I can’t afford it
    • No, because I don’t need it/want it
    • No, but I would like to
    • Prefer not to answer
16. Have you ever been checked for cervical cancer (Pap smear test)?
    • Yes, I have one once a year or more
    • Yes, I have one every 2-3 years
    • Yes, I have one every 4 years or less
    • No, because I didn’t know about it
    • No, because I can’t afford it
    • No, because I don’t need it/want it
    • No, but I would like to
    • Prefer not to answer
17. Have you ever been screened for sexually transmitted infections (such as chlamydia, gonorrhea, syphilis, HIV)?
    • No, I’ve never been tested
    • Yes, but I never tested positive
    • Yes, and I did test positive
    • Yes, and I don’t know the results
    • Prefer not to answer
18. In the past 30 days, have you experienced any breast pain, breast or nipple swelling?
    • Yes
    • No
    • Prefer not to answer
19. In the past 30 days, have you experienced any of these symptoms?
    • Frequent genital itching
    • Unusual vaginal discharge
    • Bad odor from the vagina
    • Rash around the vaginal area
    • Vaginal blisters or sores
    • None of the above
    • Prefer not to answer
20. [If sexually active] Do you experience any pain during intercourse?
    • Yes, and I’ve consulted my doctor about it
    • Yes, but I haven’t consulted my doctor about it
    • Sometimes
    • No
    • I’m not sexually active
    • Prefer not to answer
21. [If sexually active] Which birth control method do you use?
    • I don’t use birth control
    • Hormonal contraceptives (pills, patches, injections, etc.)
    • Condoms
    • Intrauterine device (IUD)
    • Pull-out/withdrawal method
    • Other (sterilization, gel, diaphragm, ring, sponge, etc.)
    • Prefer not to answer
22. Is your menstrual cycle regular?
    • Yes
    • No
    • Sometimes
    • Don’t know
23. How would you rate your knowledge on menopause?
    • I know a lot
    • I know some
    • I know nothing
24. How often do you see a gynecologist?
    • Once every 6 months or more often
    • Once a year
    • Once every 2-3 years or less often
    • Never
25. How comfortable are you discussing reproductive health with healthcare providers?
    • Very comfortable
    • Comfortable
    • Somewhat comfortable
    • Somewhat uncomfortable
    • Uncomfortable
    • Very uncomfortable
26. [If not single] How comfortable are you discussing your reproductive health with your spouse/partner?
    • Very comfortable
    • Comfortable
    • Somewhat comfortable
    • Somewhat uncomfortable
    • Uncomfortable
    • Very uncomfortable
27. What do you normally do if you have any sexual health concerns? (Select all that apply)
    • Schedule an appointment with my gynecologist
    • Schedule an appointment with my General Doctor
    • Tell a parent or a family member
    • Tell my partner/spouse
    • Tell a friend
    • Try to find information online
    • Other ________________
28. Have you visited Shifa Free Health Clinic? If yes, how satisfied were you with the service?
    • I have never been to the clinic
    • Yes, I’ve been to the clinic and I’m satisfied
    • Yes, I’ve been to the clinic and I’m not satisfied
    • Comments _______________

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