Cultural awareness
Would a patient with a refugee background be treated differently if the doctor had broad knowledge of the culture in the patient's home country? It is unrealistic to expect doctors to have knowledge of all cultures and world views in order to work in a diverse society. However, it is almost certainly the case that refugees would receive better treatment if the doctors felt comfortable with establishing a respectful conversation on the possible impact of fleeing from conflict or persecution and any experiences of trauma before and after migration to Norway. Health personnel can achieve this by increasing their cultural awareness, competence and humility.
A culturally aware, competent and humble approach can support the establishment of a relationship of trust between doctor and patient
Cultural awareness is about insight into how perceptions of reality, including views of normality and deviation, may vary between cultures, and that the therapist's understanding is also culturally situated, and hence not neutral. Cultural competence is the ability to communicate effectively with people from different cultural backgrounds (11). Furthermore, cultural competence includes knowing how to build dialogical bridges to other cultures, willingness to engage with patients from other cultural backgrounds, and ability to draw on experiences from such encounters (11). Such competence can be trained through trial and error, but also through expert guidance.
In addition, another concept has recently attracted increasing attention: cultural humility. Humility in an intercultural context requires openness, self-confidence and self-reflection (12). To achieve this, one needs a critical and conscious view of the values, expectations and mindsets that are embedded in one's own culture (13). Furthermore, cultural humility is associated with acknowledging that health personnel are responsible for minimising the effect of cultural differences and misunderstandings that can lead to suboptimal diagnosis and treatment.
A culturally aware, competent and humble approach can support the establishment of trust between doctor and patient and help create a dynamic whereby the patient becomes more open to sharing their experiences and their own understanding of their problem (9). In turn, this could help the doctor identify the most appropriate treatment (9). In this context, patient-centred communication and adequate use of an interpreter will go a long way. However, other tools are also available. The Cultural Formulation Interview (CFI), developed by the American Psychiatric Association, can help health personnel work in a more culturally competent and humble way (14). The Cultural Formulation Interview includes questions that investigate explanatory models, level of functioning, social network, psychosocial stressors, spirituality, religion and moral traditions, coping and help-seeking, and other relevant factors in the patient. The Cultural Formulation Interview should not be the only information basis for making a diagnosis, but this person-centred approach could be an aid in contextualising mental disorders. Research supports the claim that using the Cultural Formulation Interview can be useful for obtaining important information on the patient's understanding of the problem, for developing and maintaining the therapeutic alliance and communication, and for implementing the treatment plan (15).
Is equality in mental health care, and not least equity of patient outcomes, feasible in a diverse society? It is a challenge when different inhabitants have widely differing starting points and needs. The road ahead must start with removing barriers to accessing medical care for persons with a refugee background. Furthermore, an increased focus on cultural competence and humility in medical education and training and in doctors' surgeries all over the country, for example in the form of more widespread use of the Cultural Formulation Interview or similar, is also crucial. We can all contribute to this, and we should challenge ourselves to reflect on cultural issues, for example what kind of cultures we belong to (medical culture, Norwegian culture etc.), how our education, culture and world view can impact on our understanding of mental health problems, and how our answers may differ from those of persons from another cultural background.