Refugee populations in Norway: health beliefs and behaviours

Keeping in mind the limitations of equating nationality with culture, previous literature suggests that there are patterns within groups of people from similar backgrounds with regards to explanatory models of mental illness, as well as preferred coping and help-seeking behaviours. These may have implications for the inter-cultural clinical encounter.

Somalis in Norway

There are currently more than 27,000³ Somali refugees in Norway (Statistics Norway, personal communication, October 1, 2021). Refugee groups, in general, have reported poorer mental health (Ben Farhat et al., 2018; de Jong et al., 2003; Fazel et al., 2005;

Harris et al., 2019; Hassan et al., 2016; Poole et al., 2018; Steel et al., 2009), and lower use of health services than the majority population (Fuhr et al., 2020; Satinsky et al., 2019). However, this pattern may not apply to Somali refugees, who have self-reported good physical and mental health (Madar et al., 2020; Rask et al., 2016), are more likely to make use of GP services than other sub-Saharan non-refugee migrants in Norway for somatic complaints (Diaz et al., 2017), and have higher contact rates to emergency services than the majority population (Sandvik et al., 2012). Despite a higher use of services for physical health complaints, Somalis in Finland have been found to have low use of mental health services (Molsa et al., 2019) even though it has been suggested that they reported similar rates of depressive and anxiety symptoms as the majority population in Finland when assessed using the Hopkins Symptom Checklist-25 (Rask et al., 2016). Underuse of mental health services has also been observed among Somali women with a refugee background in Norway

3 Number retrieved by internal employee at Statistics Norway from Table "08144: Personer med flyktningbakgrunn, etter statistikkvariabel, flyktningstatus, år, region og landbakgrunn".

(Elstad et al., 2015), and it has been suggested that this underuse does not necessarily mean that Somali women do not experience psychological distress, but rather that they feel they must conceal their distress (Naess, 2019). Somalis have previously reported hesitation regarding seeking mental health help due to the stigma associated with mental health problems (Cavallera et al., 2016; Piwowarczyk et al., 2014), or the belief that mental disorders ought to be treated through spiritual approaches

(Markova & Sandal, 2016). This suggests that while Somalis have self-reported good mental health, the issue may be more complex.

In Norway, and most other European countries, conditions such as depression and anxiety are largely accepted and considered to be real disorders. Among people from Somalia, however, the conditions called depression and anxiety in the DSM-5 and ICD-10 may be seen as normal reactions to stressful life events, as opposed to disorders that require treatment (Cavallera et al., 2016). Among Somali refugees, mental illness has previously been attributed to shock and devastation of war, dead, missing, or separated family members, and spirit possession or a curse (Carroll, 2004). Explanatory models and coping strategies of Somali refugees in Norway have been previously described through focus group interviews (Markova & Sandal, 2016). In Markova and Sandal’s study, for example, participants were asked to read a vignette about a character with symptoms of depression, in line with ICD-10 and DSM-5 criteria (American Psychiatric Association, 2013; World Health

Organization, 1993) and to discuss what they felt caused the character’s problem, as well as how best to cope with it. Participants described the condition presented in the vignette as an ‘illness of thought’ or something spiritual inside the person that needed to be taken out. Stress and biological causes, such as drug use, were also mentioned, but were not the focus of the discussion. Many participants attributed the vignette characters’ condition to their family situation, i.e., being unmarried and living alone.

Participants explained that the family’s views played a large role in an individual’s likelihood to seek mental health support. While the choice of coping or help-seeking strategies depended on the believed cause of the problem, participants preferred

coping with the condition described in the vignette by religious practices and reliance on family, rather than seeking professional treatment. Similar findings have

previously been found among refugees from Somalia in New York (Carroll, 2004).

These findings are furthermore in line with a UNHCR report on culture, context, and mental health of Somali refugees, which suggests that discussing mental health in purely psychological terms may seem unhelpful to individuals from Somalia, where health is more often seen holistically and intertwined with spiritual forces (Cavallera et al., 2016).

Syrians in Norway

While Somalis consistently constitute one of the largest refugee and non-refugee migrant groups in Norway over the last decades, one of the largest recently arrived groups of refugees to Norway originated from Syria. A recent cross-sectional study found that 33% of Syrian refugees in Norway reported symptoms indicative of anxiety or depression, and 7% reported symptoms of post-traumatic stress disorder (PTSD) (Strømme et al., 2020). These rates are substantially higher than the 12-month prevalence of 10-15% for anxiety or depression (Norwegian Institute of Public Health, 2016), and 1-1.7% for PTSD (for men and women respectively) among the Norwegian majority population (Lassemo et al., 2017).

Explanatory models and coping strategies among Syrian refugees in Norway have been examined through focus group interviews (Aarethun et al., 2021). Participants were presented either with a vignette character showing symptoms of depression or PTSD, in line with ICD-10 and DSM-5 criteria (American Psychiatric Association, 2013; World Health Organization, 1993). In the case of the PTSD vignette, the participants explained that the vignette character’s experiences were likely to be the result of difficult experiences they had had in Syria. Participants stated that the problems experienced by the vignette character were not purely psychological and should not be labelled as such. This is in line with a report suggesting that labelling emotional reactions to difficult experiences as disorders can be seen as shameful in

Syrian culture (Hassan et al., 2016). Similarly, participants focused on external factors that were influencing the vignette character’s problems, including being unmarried and living alone (Aarethun et al., 2021).

The different role of the GP in Syria and Norway was also highlighted among Syrian participants (Aarethun et al., 2021). They explained that in Syria, one could go directly to a specialist for support. In Norway, on the other hand, individuals are required to initially contact their GP, wait for an appointment, and then receive a referral, often resulting in further waiting times.

The explanatory models and coping mechanisms of Somali and Syrians in Norway have implications for clinical consultations. For example, the spiritual explanation of mental illness among Somali populations may not align with the perspectives of GPs in Norway, who rarely focus on religious or spiritual explanations or treatments for mental illness. Similarly, the differing role of the GP in Syria vs. Norway may lead to patients having different expectations of GPs in Norway, which may lead to

dissatisfaction if GPs do not live up to these expectations. Some of these issues are taken up in Rothlind’s (2018) ‘circling the undefined’ model (Figure 2). Their model, which is the result of a qualitative study examining physician-patient communication in primary care consultations, addresses the perceived complexities of inter-cultural consultations. It presents the concept of ‘circling the undefined’, referring to the presumed agreement between patient and practitioner regarding format and content of the consultation as well as their fundamental views on what constitutes health and illness. It describes how both practitioner and patient hold certain assumptions and expectations about one another and the consultations that may remain unspoken and lead to misunderstandings and dissatisfaction (Rothlind et al., 2018). They present themes that impact communication such as ‘fragmentizing the story’ i.e., only fragments of a patient’s history being available to the clinician due to time constraints and communication problems, ‘culture blaming and explaining’, i.e., using culture as an explanation of differences and challenges perceived in consultations, and ‘fitting

the box’, i.e., patients are made to fit diagnostic categories. They also present themes that make the framework of the consultation unclear, such as ‘expanding one’s role’, i.e., the clinician being expected to take on roles beyond their job, and ‘shuffling responsibilities’, i.e., the behaviour associated with being unclear about which responsibilities the patient and the clinician have in the consultation. The model is based on a modest sample size of 15 clinicians and 30 patients with a migrant background, but it highlights the importance of considering culture, different explanatory models, and coping strategies, as well as taken for granted assumptions about health and healthcare in the inter-cultural clinical encounter.

Figure 2. Rothlind and colleagues’ (2018) conceptual model describing how clinicians and patients continue to ‘circle the undefined’ through their behaviours in intercultural consultations. Reprinted under PLOS open access license.