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When pain speaks different languages

Helping non-Nordic patients suffering with pain in a multicultural care setting.

A guide to culture, communication and understanding.

Tel +46 (0)8 50580500 www.reumatikerforbundet.org • info@reumatikerforbundet.org

When pain speaks different languages

Contents

What is the purpose of this document? 6

Background, project description and data collection.

Multicultural healthcare 9

Differences in illnesses, pains and sickness roles 10

Patient and care provider perceptions of the significance of the illness and sickness role in relation to interpreting symptoms. Examples of illness explanations.

Sickness roles in different cultures 11

Case studies of Fatima and Tomasz: the role of the family in relation to the sickness role.

Communication and interaction in the medical consultation 16

Being taken seriously. Communication patterns. Language confusion – a healthcare barrier. How social, cultural, financial and educational factors determine whether the content of the information is relevant.

Using an interpreter 19There is more to interpreting than just translating words.The advantages of working with professional interpreters.

Pain expression and pain behaviour in different cultures 21

Misunderstandings in discussions about pain. What do different cultures regard as an accepted pain threshold? Differences in the way pain is expressed: restrained and forceful expressions.

Strategies for handling a patient in pain 23

Six-point healthcare strategy for handling a patient who has pain.

Proposals for models to test in the medical consultation 25

Models with six stages/meetings: meeting with doctor, meeting with nurse, and group meetings.

Health questionnaire – EQ5D 28

Patient form to use in discussions about the patient’s health.

References and suggestions for further reading 30

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What is the purpose of this document?

Reumatikerförbundet’s project entitled “Hälsa Välkommen” started in 2010 in partnership with Svensk Reumatologisk Förening (the Swedish Society for Rheumatology) and Vårdförbundet (the Swedish Association of Health Professionals) and is funded by Arvsfonden (Swedish Inheritance Fund Commission). The purpose of the project is to develop and test tools and methods that facilitate the medical consultation between the care provider and patients born outside Scandinavia with long-term generalised pain or other rheumatic diseases. This document, together with supervisor materials, is one such tool. Our hope is that it will encourage new approaches and discussions at the care providers’ place of work.

Language and resource barriersAt the beginning of the project, 10 focus group discussions and nine in-depth interviews were conducted with patients and care providers at three health-care units. The quotes in this document are taken from these discussions and interviews. The results identified several factors that facilitate or impede the medical consultation. The amount of time allocated for the consultation was a significant factor in ensuring that the consultation was satisfactory, as was the care provider’s knowledge of and access to supervision for handling this patient group.

Patients’ language skills, their expectations in relation to Swedish healthcare, and perceptions of symptoms and treatment that may differ from the care provider’s perceptions were factors that could generate feelings of powerless-ness and frustration. These were feelings that both parties took with them into the medical consultation and had a negative impact.

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“Having some time to listen to patients; that’s the most important thing, because while they’re listening it might help them understand one another better.” [Woman from Iran suffering from Sjögren’s syndrome, fibromyalgia and osteoarthritis.]

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Multicultural healthcare

Sweden has become an increasingly multicultural society over the past 20 years, with an estimated 20 percent of the population either being born outside Sweden or having two parents born in a country other than Sweden.1 Care providers see patients from all over the world on a daily basis and despite the fact that both parties do their best to get their message across in the medical consultation, misunderstandings and confusion can still occur.

This may be because of differences in non-verbal and verbal communica-tion, but also due to a lack of shared notions about illnesses and the various treatment options. People appropriate their cultural identity through exchange and dialogue with those around them, and it is formed and reshaped in their interaction with others.2

Common features despite major differencesPeople born outside Sweden are not a homogenous group; there are major differences when it comes to linguistic, religious, cultural and socioeconomic background. However, the generalised knowledge contained in this docu-ment may indicate certain common features in a culture and encourage awareness of the fact that there is more than one way of communicating and interacting. This awareness can make us more open to the fact that another person’s perception of a situation may differ from our own.2

“A transcultural perspective in healthcare means, as a care provider, being able to reflect on the significance of your own background and that of other people, cultural and otherwise, and current living conditions in a power perspective, and how this relates to work with patients and relatives, or with healthcare colleagues.”3

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Differences in illnesses, pains and sickness roles

The Swedish word “sjukdom” covers many different aspects, which is why the literature often uses the English words disease, illness and sickness.

Disease is a condition for which medical science has a diagnosis; that is, diagnosed ill-health.

Illness is the collection of symptoms experienced by the patient and the significance the patient attaches to their condition; that is, self-reported ill-health.

Sickness is the social role (that is, the sickness role) that the patient is assigned or takes on in a particular society. The factors that warrant a sickness role change over time and vary between different cultures. Disease and illness are both physical concepts, while sickness is a prenegotiated social position that indicates some aspect of the relationship between the individual and his or her environment.4

Culture clashes in illness explanationsEvery culture has explanations of why an individual falls ill; in Western biomedicine, we look for an underlying cause of an illness that can be measured and observed objectively. In other societies, the illness experience may be just as important and the patient may expect a care provider to devote plenty of time to the consultation and to listening to the patient. Therefore, coming into contact with a care provider who gets straight to the point and is short on time can be discouraging.2

Culture affects sickness behaviour The way a person has learned to relate to illness is significant for how that person perceives their symptoms, evaluates the illness and handles it; that is,

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their sickness behaviour.4,5 Both the care provider and the patient regard their culture’s illness explanations and treatment practices as the natural way of doing things, but when meeting individuals who have perceptions and expectations that differ from your own it can cause feelings of uncertainty in both parties.2

Sickness roles in different cultures

Swedish care providers learn to see the patient as a strong individual and the strategy for handling illnesses focuses on self-help, self-care, independence and promoting the patient’s own needs – proactive behaviour. We do not expect individuals who are used to coping with their condition to complain of pain and discomfort “unnecessarily”, and we expect patients to express themselves clearly when there is a “genuine” need for help.

A person who is raised in this spirit, both in the role of care provider and patient, may find it different to work with patients who have been socialised in a behaviour that is characterised by interdependence and accountability.

Examples of illness explanations:

• The patient’s living conditions and lifestyle• Imbalance between yin and yang or with nature• Disease as a punishment• The evil eye, or a curse• Obsession with the devil or evil spirits, magic

and the spirits of dead ancestors

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The patient and the sickness role – case study Fatima

Fatima is 59 years old and was born in Turkey. For most of the 23 years that she has lived in Sweden she has been employed (she is cur-rently working in a school kitchen). She has a good level of spoken Swedish. Fatima is overweight and has recently been diagnosed with osteoarthritis and diabetes by the GP at her local health centre. Fatima has been given

advice by her district nurse regarding self-care, including dietary and exercise advice, as well as leaflets about osteoarthritis and diabetes in Swedish and Turkish.

At her second follow-up appointment with the district nurse three months after Fatima was diagnosed, she did not appear to have changed her behaviour in relation to diet and exercise. Fatima had not lost weight, was not doing any exercise, experienced joint pain, primarily in her knees, and had high glucose levels. The district nurse talked to her again about the importance of changing her behaviour, but got the feeling that Fatima was not taking in what she is saying, even though she was nodding.

Discuss – what can be done to help Fatima?

Food and social functionFatima’s family needs to be involved in her care and in helping her to change her behaviour. Fatima is responsible for all the cooking in the

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family and this function is a huge part of her identity. This can make it difficult for her to change her own dietary behaviour without it affecting her role in the family. She probably puts the needs of her family before her own needs. As long as she is feeling reasonably well and is capable of taking care of her family, she feels no need to make any changes. In addition to having a discussion with Fatima together with her family, it could also be good to set up a group of women with similar ages and backgrounds to Fatima, in which discussions can focus on diet and exercise. Body imageFatima probably does not regard herself as being overweight. She thinks she looks like women of her age are expected to look if they are to be valued and respected. ExerciseFatima probably associates doing exercise with manual labour. Not having to do much physical work is a sign of status and well-being. It can be difficult to change her way of thinking and see exercise and physical work as a prerequisite for well-being.

Follow-up question – case study FatimaFatima calls a few days after her most recent appointment and says that she is finding it hard to cope with her job in the school kitchens, where she has to stand, do a lot of walking and lift heavy items. She wonders if the doctor can sign her off on sick leave. Discuss how you would handle this.

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The patient and the sickness role – case study Tomasz

Tomasz, a Polish man aged 65, has recently been discharged from hospital following a knee operation due to osteoarthritis. Tomasz’s wife has been in contact with the physiothera-pist at their local health centre and their home has been equipped with various aids in preparation for his return home.

At the hospital, Tomasz met a physiotherapist and learned and worked through a home exercise programme without any major difficulties. One week after the operation, Tomasz and his wife met the local physiotherapist to check the level of mobility in Tomasz’s knee. Tomasz admitted that he has stopped exercising completely since coming home. The physiotherapist emphasises the importance of exercise to regain as much mobility as possible and to reduce the pain. When Tomasz has an appointment with the district nurse to remove his stitches, his wife says that Tomasz just remains seated, moves as little as possible and needs his wife to help him with pretty much everything.

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Discuss – what can be done to help Tomasz?Osteoarthritis and rehabilitation following an operationFirstly, the care provider must understand that patients and their families do not necessarily share the same goals as the care provider. At the hospital, you can allow the family to watch while Tomasz goes through his physiotherapy exercises. The physiotherapist at the local health centre can do the same thing and not focus primarily on the importance of continuing the exercises at home. In many cultures, the interdependency between family members is valued above self-care.

Respect Tomasz’s role in the familyAnother significant factor is the difference between egalitarian and hierarchical cultures. In egalitarian cultures like our own, all roles are theoretically valued equally; no-one in the family is regarded as being subordinate to anyone else. In hierarchical cultures, certain family members (men and older people) clearly dominate, while others (women and children) have a definite subordinate role; it is their duty to obey and look after the dominant family members – their husbands and fathers.

Accept the need for controlControl may also be a factor in the failure of the patient to look after himself. Tomasz comes from a culture that clearly acknowledged his power and authority. His health has reduced him to a condition of physical weakness. Demanding that his family tend to his needs is a way of continuing to display dominance. It may be disguised as helplessness, but it is a way of maintaining control.

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Communication and interaction in the medical consultation

For a patient who does not have command of the language or any knowledge of how the healthcare system functions, a medical consultation can be confusing and therefore cause anxiety. Communication problems restrict the patient’s opportunities to convey his or her thoughts and feelings to the care provider and can even isolate the patient.

What are the main shortcomings?GP and researcher Kristian Svenberg summarises the main shortcomings of transcultural medical consultations identified in both international and Swedish research.6 Patients from minority groups, particularly those who do not speak the predominant language fluently, participate less in medical care and are frequently given inadequate information. They are often not taken seriously and feel that the care provider is not listening to them, which can lead to misunderstandings and an ineffective consultation. Healthcare professionals describe a sense of frustration and feeling of powerlessness caused by difficulties in reaching an understanding.

Emphasising the cultural differences instead of just being open to them can mean that social and financial factors are underestimated as possible causes of poor health. As a patient, experiencing discrimination on the grounds of cultural differences is described as a key factor in relation to poor mental and physical health and may lead to a reluctance to seek medical help.6

Natural as opposed to professional careNursing theorist Madeleine Leininger explains that culture has long been a significant factor in nursing care.7 She talks about two different forms of nursing care, which are based on different kinds of knowledge. The first is

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natural nursing, which is based on familiar and traditional skills within a culture, such as treating osteoarthritis with food items like meat, fish, carrots, nuts, raisins, honey, tea and coffee, and wrapping oneself up in several layers of clothing and blankets.

The second kind of knowledge is professional nursing, which is the profes-sional sphere of a nurse. When the gulf between these two forms of nursing becomes too wide, a cultural conflict arises in healthcare, which causes stress for the patient and can lead to an inability to follow instructions. For example, studies have shown that patients had a lower pain tolerance when the

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healthcare staff had a cultural background different to that of the patient.8 To build trust in the medical consultation and to ensure that the information is meaningful, the care provider must have an understanding of cultural differences, but also of the fact that social factors and the patient’s level of education are significant.

When it comes to the content of the information, it is the patient’s general state of health, view of their illness, its causes and treatment expectations that will determine whether the information given by the care provider is meaningful. The way in which a person views information and “truth”, as well as the situations in which one provides information openly – and the situations in which one does not – have both a cultural and personal basis.

“I remember a consultation at the clinic involving an inter-preter, when I was sitting with a female interpreter and an Arabic man. When we were talking about a difficult issue […] he started to cry. And then the interpreter immediately turned and sat facing the wall […] For me, the obvious thing to do was to lean towards this man and treat him with compassion, but I understood that this was completely the wrong thing to do because she turned away. Afterwards she explained that when a man from this particular culture cries, a woman should not watch. It was very difficult, and it’s just ignorance not knowing how to handle it, because it goes completely against one’s instincts to turn away from someone who is unhappy.” [Doctor, rheumatology clinic]

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Using an interpreter

Interpreting is not just about transferring a set of words from one language into another. It is just as much about interpreting a message in a given context and transferring that message into another language in a way that gives it the same meaning for the recipient as for the speaker.2

Main reasons for communication problemsThere are usually three main reasons behind communication problems between care providers and patients and relatives from different cultures:1. The parties speak the same language but do not use the same symbols.

The word “yes” has a different symbolic meaning in many parts of the Middle East, for example, which can give rise to a lot of misunderstan-dings. For example, a “yes” can mean “Yes, I hear and understand what you’re saying, but I don’t agree with you”, or “Yes, I hear what you’re saying but I don’t want to trouble you by saying that I don’t understand you”.

2. The patient/relatives have basic Swedish but do not fully understand the subtleties of the language.

3. The parties have no common language.

Authorised interpretersHealthcare professionals should use authorised interpreters and, if possible, authorised medical interpreters.9 In Sweden, there are currently about 130 authorised medical interpreters who work with 36 different languages. The official agency in Sweden that is responsible for authorising interpreters and overseeing their activities is called Kammarkollegiet. Kammarkollegiet’s oversight of authorised interpreters is the only monitoring of interpreting activities that takes place in Sweden.

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Good Interpreting PracticeAn authorised interpreter observes what is known as “good interpreting practice”, which is a set of regulations ensuring that:• Theinterpreterhasadutyofconfidentiality,isimpartialandrenderswhat

has been said in the first person and informs both the care provider and the patient of this at the start of the discussion.

• Theinterpreterrelaysalltheinformationaspreciselyaspossible,whichmeans not “withholding, adding or amending”. Strong language, expres-sions of emotion or body language are not toned down. If the interpreter is unable to translate a term, he/she should ask the speaker to paraphrase.

• Theinterpretershouldnotexpresshis/herownopinionsandvalues,orinany other way allow them to influence the interpretation.

• Theinterpretershouldrejectanassignmentifthereisanychancethatitcould affect confidence in his or her impartiality or independence.

• Theinterpretermustconsiderhis/herabilitytocarryouttheinterpretingassignment in a satisfactory manner.

New types of supportIn addition to the linguistic support provided by an interpreter, new forms of support for intercultural communication are beginning to emerge. One such resource is health communicators, with expertise in health matters and cultural aspects. They are tasked with informing and guiding foreign-born patients about “pathways in healthcare”, migration and health, and are available in the counties of Skåne, Östergötland and Stockholm.

In Stockholm, health communicators are employed by Stockholm County Council at Transkulturellt Centrum. For further information and contact, go to www.slso.sll.se/hk.

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Expressions of pain and pain behaviour in different cultures

How we express pain is a key component of the sickness behaviour and communication pattern. A great deal of research has been conducted into the link between ethnic origin and pain tolerance, but answers suggest that what differs is probably the expectations about when and how pain is to be expressed. Pain behaviour is learned by imitating the behaviour of those around us and rewarding certain kinds of behaviour.2, 4, 5

What is accepted pain behaviour?There is a tendency for care providers and patients to misunderstand one another in pain-related situations, which may be due to language confusion but also because we have different ideas about what constitutes accepted pain behaviour.10 The Scandinavian culture, together with several West African and some East African cultures, is characterised by the ideal of expressing pain in a restrained way.2

With a “voluntary” interpreter (a child, relative or friend of the patient), the care provider knows nothing of the person’s language qualifications or understanding of Western approaches to medical care. A voluntary interpreter is not neutral or impartial; there is a conflict of interest. By using voluntary interpreters, the users of the interpreter undermine their own responsibility and expose the patient to the risk of being incorrectly treated.

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In other cultures, such as in the Middle East and some Asian countries, it is more acceptable to express pain in a forceful way, both verbally and physically, which can be harder for Swedish care providers to relate to.2, 5

A forceful expression of pain can also be a way of communicating anxiety when language is limited.11

Somali women’s perception of pain has been described from Finland. The way they respond to pain has been related to Islam, which views suffering as a test or as a punishment for sins. Therefore, Somali women living in exile are encouraged to display acceptance, forbearance and endurance as a way of coping with suffering, and to try to reduce it through good deeds. A Swedish study has described a stoical view of pain, where crying and complaining are signs of weakness.12 The examples above show that as a care provider, encoun-tering and understanding the pain behaviour of different people is not entirely without its problems.

“That’s the important thing, that they get some kind of acknowledgement that this kind of pain exists, that it’s possible to explain the cause of this pain, why they in particular have this pain and how to treat it. Is it curable or incurable? Do I just have to live with it?” [Doctor, health centre]

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Strategies for handling a patient in pain

Andrews and Boyle describe the six following strategies that can help the care provider when handling patients in pain.13 The transcultural aspects are integrated into these strategies.

1. Identifying your own personal attitudes. Care providers need to understand their own values and ideas about pain. They should thoroughly examine their attitudes and identify any prejudices they have about the way they expect patients to express pain.

2. Creating a good and effective relationship with your patients. Pain is a subjective experience, which means it can be difficult to acknowl-edge. Patients in pain rely on the care provider to understand the way they express their pain. This is why it is important to adopt a supportive and understanding attitude towards the patient to achieve the best result from, for example, pain relief and the use of tools for pain assessment.

3. Respecting patients as individuals. Care providers need to respect patients as unique individuals, while at the same time understanding that culture forms an important basis for their individuality. Care providers must be aware that there are many different ideas and values about pain, and that it is the patient’s own way of viewing pain that the patient regards as being the most correct.

4. Respecting the patient’s response to pain. Patients should never have to feel guilty about the way they express their pain. There are many different ways of expressing pain, and care providers who are aware of these differences will not be surprised or distracted by highly emotional forms of expression, in the same way as they will not overlook calm and controlled ways of displaying pain.

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“… what I sometimes encounter is that these patients feel angry because they have been treated in a way that is insulting. Sometimes I see patients who have many emotions that I need to deal with first before we get to the real problem.” [Physiotherapist, pain clinic]

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5. Never adopting a stereotypical approach to a patient based on his culture. There are always differences, even within a culture. Care providers must also consider other aspects that affect a patient in pain. These may be personal experiences and psychological aspects to the situation.

6. Base the care on your skills as a care provider. Care providers have a duty to apply the best current research results of the care they are providing. Patients must always feel confident about the medical and human knowledge of the care provider.

Proposals for models to test in the medical consultation

This model has been developed by Hälsa Välkommen in partnership with healthcare services, and comprises:• Anindividualdoctor’sappointment• Anindividualdistrictnurse/nurseappointment• Threetofourgroupmeetingswithadoctor,physiotherapist,occupational

therapist, welfare officer, district nurse/nurse and representative from the local rheumatology association.

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There should be no more than one week between the first and second meetings in order for the information and discussion to remain relevant. There should be no more than four weeks between meetings 2 and 3, and no more than two weeks between group meetings 3–6.

Meeting 1: Consultation with doctorThe doctor uses the following three questions during the consultation:• Howhaveyourproblems/painsbeenoverthepastfewweeks?• Whatisyourworkandfamilysituationlikeatthemoment?• Whatdoyouhopetoachievefromthismeetingwithmetoday?

Meeting 2: Consultation with district nurse (dns) or nurse (ns)• Thepatienthasaprivateconsultationwiththedns/ns,whoistrainedin

motivational interviewing techniques. The dns/ns uses the Menu/Agenda tool and/or the EQ5D patient questionnaire (new, easy-to-read version available on next page) in the first exploratory discussion with the patient.

• Thedoctor’snotesarecheckedagainstthepatient’sexperienceoftheappointment and the patient is given the opportunity to discuss and ask questions about the doctor’s appointment.

• Duringtheconsultation,thepatientanddns/nsdecidejointlywhetherthe patient will continue on to the subsequent group meetings at the health centre.

The dns/ns gives the doctor who will be involved in the discussion in meeting 3 information about the patients’ symptoms, to gain an adequate focus for the discussion.

Preparations ahead of group meeting 3One week before meeting 3, the dns/ns calls the patient at home to invite him/her to attend the group meeting, and asks the patient to think about any questions they want to bring up at the meeting.

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Group meetings 3 and 4• Thedns/nswelcomeseveryoneandinformsthemofthepurpose,length

(90 minutes, depending on the number of participants) and arrangement of the meeting.

• Allpatientsintroducethemselvesbystatingtheirnamesandcountryofbirth.• Thirty-minutediscussionwithdoctoraboutsymptoms,illnessandtreatment.• Thirty-minutediscussionaboutquestionsthatpatientshaveprepared

beforehand.• Thepatientsareaskedtopreparequestionsandtopicsfordiscussionat

the next meeting.• Discusspatients’ownphysicaloutdoororindooractivitiesandgive

examples of exercises from Reumatikerförbundet’s exercise blog (www.reumatikerforbundetstraningsblogg.blogspot.com).

Group meetings 5 and 6• Thedns/nswelcomeseveryoneandinformsthemofthepurpose,length

(90 minutes, depending on the number of participants) and arrangement of the meeting.

• Thirty-minutediscussionaboutsymptoms,illnessandtreatmentwithphysiotherapist, welfare officer or occupational therapist, depending on which meeting it is.

• Thirty-minutediscussionaboutquestionsthatpatientshavepreparedsince the previous meeting.

• InformationaboutReumatikerföreningenintheareabyarepresentativefrom the local association.

• Physicaloutdoororindooractivitytoconcludethemeeting.

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Health questionnaire – EQ5D

Questions about how you are feelingIf we are to offer you the best care, it is important that we know how you are feeling today. That is why we would like you to answer a few questions. When you answer the questions, please put a cross by the statement that best describes how you are feeling today.

How much can you move? I can walk without difficulty. I can walk, but it’s difficult. I can’t walk. I spend most of my time in bed.

How are you coping with looking after yourself? I can cope with getting dressed, eating and washing. I’m finding it hard to get dressed, eat and wash. I need help with getting dressed, eating and washing.

How are you coping with normal daily activities?By activities, we mean being at work, at school, leisure activities or doing the housework.

I can cope with most of these activities. I’m finding it hard to cope with most of these activities. I’m not coping with most of these activities.

Are you in pain? I don’t have any pain in my body. I have a little pain in my body. I have a lot of pain in my body.

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How is your mood? I’m feeling happy and in a good mood. I’m feeling a bit worried or down. I’m feeling bad. I’m feeling really worried or depressed.

How do you feel?We would like you to tell us how good or bad you are feeling using the image on the right, which looks like a thermometer with the figures 0 to 100.

The figure 0, right at the bottom of the thermometer, means that you are feeling really bad.

The figure 100, right at the top of the thermometer, means that you are feeling really good.

We would like you to put a ring round the figure on the thermometer that best describes how you are feeling today.

Thank you for answering these questions and helping to improve healthcare!

Revised “easy-to-read” Swedish version 2011 after © Euro Qol Group 1990

I feel really good

I feel really bad

100

9 0

8 0

7 0

6 0

5 0

4 0

3 0

2 0

1 0

0

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References and suggestions for further reading

References1. Statistiska Centralbyrån, SCB (2010).2. Hanssen, I. (2009). Omvårdnad i ett mångkulturellt samhälle. 3:e upplagan, Studentlitteratur AB, Stockholm.3. Ekblad, S., Lindencrona, L. Inventering av ett transkulturellt perspektiv på utbildning. Rapport. Karolinska Institutet, 2005-07-15.4. Helman, C. (2007). Culture, health and illness. 5th edition. Butterworth-Heinemann, Oxford.5. Hattar, H. (2010). Kulturella aspekter på smärta. Smärtbiblioteket, Mundipharma AB, Mölndal.6. Svenberg, K. (2011). Mötet mellan patienten och läkaren – erfarenheter hos somaliska flyktingar och läkare under utbildning. Doktorsavhandling, 111216. Sahlgrenska Akademin vid Göteborgs Universitet.7. Leininger, M.M. (2001). Culture Care Diversity and Universality: a theory of nursing. Boston: Jones and Bartlett.8. Stier J. (2004). Kulturmöten: en introduktion till interkulturella studier. Lund: Studentlitteratur.9. Kammarkollegiet (2010). God tolksed. Vägledning för auktoriserade tolkar. Stockholm.10. Ernst, G. et al. (2000). The myth of the “Mediterranean syndrome”: do immigrants feel different pain? Etnicity & Health, 5(2), 121–126.11. Löfvander, M., Engström, A. (2007). Immigrant patients having widespread pain. Clinical findings by physicians in Swedish primary care. Dis & Rehabilitation, 29, 381–388.

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12. Svenberg, K., Mattsson, B., & Skott, C. (2009). ”A person of two countries”. Life and health in exile: Somali refugees in Sweden. Anthropology & Medicine, 16(3), 279–291.13. Andrews, M. M. & Boyle, J. S. (2003). Transcultural Concepts in Nursing Care (4th Edition). Philadelphia: Lippincott William & Wilkins.

For further reading:Läkemedelsboken’s chapter on transcultural medicine http://www.lakeme-delsverket.se/upload/om-lakemedelsverket/publika-tioner/lakemedelsbo-ken/LB-2011-2012/Transkulturell%20medicin.pdf

Berlin, A. (2010). Watchfully checking rapport with the Primary Child Health Care nurses – a theoretical model from the perspective of parents of foreign origin, BMC Nurs 7(20), 9–14.

Can, M. (2007). Tätt intill dagarna. Månpocket.

Fadiman, A. (1997). The Spirit Catches You and then You Fall Down. Farrar, Straus, Giroux.

Ruby, T.F. (2006). Listening to the voices of hijab. Women’s Studies International Forum, 29, 54–56.

Sjögren, A. (1993). Här går gränsen: Om integritet och kulturella mönster i Sverige och medelhavsområdet. Botkyrka: Arena.http://culturedmed.binghamton.edu

Hälsa Välkommen, a project managed by Reumatikerförbundet, financed by Arvsfonden, with Svensk Reumatologisk Förening, Vårdförbundet, CeFAM at Stockholm County Council and Kompetenscentrum för patient- och närstående-utbildning in Västra Götaland, and the local health centre in Bredäng, the Rheumatology Clinic at Karolinska University Hospital and Smärtcentrum at Angered local hospital as project or reference partners.

Reumatikerförbundet Tel +46 (0)8 50580500 www.reumatikerforbundet.org • info@reumatikerforbundet.org

© Copyright Reumatikerförbundet 2012

heart.se 1211 Foto: Magnus Fröderberg