Samis in the city. A qualitative study of mental health and well-being among Samis in Stockholm

ABSTRACT

Indigenous people globally suffer from poorer health than majority populations. For the Sami, the indigenous people living in the north of Norway, Sweden, Finland and Russia, physical health conditions seem to be comparable to the population in general, but there are concerns about mental health. Studies have shown a higher risk of suicide, especially for young men active in traditional reindeer herding in the north. There is less knowledge about the mental health of Samis that have migrated to the cities. In this study, we interviewed 25 Samis, recruited through convenience sampling in the Stockholm area, about their perceptions of health and well-being, the importance of the Sami background and culture, their views of mental health services and the need of adapting them to Sami needs. Throughout the process, the researchers collaborated closely with the Stockholm Sami Association, in an approach of participatory research. The interviews were analysed with thematic analysis. For the participants, a secure Sami identity and being treated with respect for their identity was seen as essential for mental health and well-being. Informants’ emphasis on respect for their Sami identity and belonging can be seen as a call for restoration of basic human rights. Historical experiences, current harassments and political decisions affected their health. The informants wished caregivers to increase their knowledge of Sami history and traditions.

KEYWORDS:

• Indigenous people
• Sami
• mental health
• culture
• identity
• participatory research

“What does it do to a person and his or her mental health, to deny who you are…?”

Introduction

The Sami are the Indigenous people traditionally living in northern Norway, Sweden, Finland and north-western Russia, an area referred to as Sápmi. They were recognised as an Indigenous people by the Swedish parliament in 1977 [1]. Sweden is also a signatory of the United Nations Declaration on the Rights of Indigenous Peoples [2], a declaration that stresses the right of self-determination, development, protection, as well as physical and mental health. Further, Sweden has adhered to the European convention on protection of national minorities, and, in 2009, a law on national minorities and minority languages was adopted [3].

As the Sami are one of five acknowledged national minorities, this means that the Sami language should be protected and promoted. Furthermore, it means that the Sami have the right of keeping and developing their culture, and that authorities have the duty of informing them of their rights and to give them influence in questions of concern to Samis. Also, in 2011, the Instrument of Government, one of Sweden’s four constitutional documents [4], included the right of the Sami people as an Indigenous people to keep and develop their own cultural and societal life.

Since 2019, Region Stockholm (the regional authority with responsibility for healthcare) is part of the administrative area for Sami in Sweden according to the law on national minorities. This gives the region obligations concerning language rights and promotion of the Sami language beyond the general responsibilities of all municipalities and regions mentioned above.

History of Samis in Sweden

Samis have lived in Sápmi for several thousand years, living from reindeer herding, fishing, hunting, and small-scale farming. Colonisation by the state started in the 16^th century in the Swedish part of Sápmi, initially based on taxation, and missionary work by the protestant Church of Sweden. In later periods, small-holding farmers were moved in as settlers. After the breakthrough of industrialism in the 19^th century, interest in exploiting the natural resources (minerals, waterpower, wood) and colonisation in this area increased. As a result, the traditional rights of the Sami people were restricted and, at the same time, authorities adopted a more negative view of Samis as “strangers” in Sweden [5]. During the past century, there have been repeated conflicts between Sami land rights and industrial, extractivist projects, and conflicts regarding fishing and hunting rights. In the early 20^th century, reindeer herding communities were forcefully displaced by the state from northern Sweden further south, where other Sami communities had to leave reindeer herding to become small-holding farmers or move to other parts of Sweden.

The nomadic school reform, from 1913 to 1916, established that the children of reindeer herders should be taught in separate boarding schools where they were neither taught, nor even allowed to speak, their own language [6]. The schools were administered by the Church of Sweden (a state church until the year 2000) clergy and were closed in 1962. Recently, the church apologised to the Sami people for the abuses at the nomadic schools and for helping racial biologists to access Sami children in the schools [7]. Researchers from the State Institute for Racial Biology, who were strongly influenced by racial theories about the Sami as an inferior people, studied many Samis with the purpose of characterising them racially, for example, with the method of so-called skull measurements [6,8].

The state made a distinction between nomadic reindeer herding Sami and other Sami in successive legislation on reindeer grazing, reinforced by the nomadic school reform and institutionalised in the 1928 Reindeer Grazing Act, on the right to reindeer herding and other Sami rights [9]. The law covered only “authentic” Sami, with Sami lineage, engaged in reindeer herding and owning reindeer identification marks. Analysing official policies, Lantto [9] claimed that there existed a dual approach of, on the one hand, restricting the number of reindeer herders and isolating them from surrounding society, and on the other, assimilating the forest Sami as quickly as possible. Consequently, the legislation contributed to creating a split between the two different Sami groups. This policy has also contributed to less than ten percent of the Sami population today earning their living from reindeer herding, whereas the majority have other occupations, and many have moved to cities in the south of the country.

The United Nations Special Rapporteur on the rights of Indigenous peoples, Victoria Tauli Corpuz, examined the human rights situation of the Sami people in Finland, Norway and Sweden in 2015. In her report she noted that the Sami rights over their lands and resources were essential for the long-term well-being and continued existence of the Sami people. However, those rights were not sufficiently established, implemented, or judicially protected in the three countries, leading to “perpetual insecurity and instability of the Sami people” [10]p.359). She noted especially that Sami rights were not considered in the legislation that regulated natural resource extraction, such as mining activities [10].

In an interview published on the webpage of the Sami parliament of Sweden, Tauli Corpuz presented the United Nations Declaration on the Rights of Indigenous Peoples as directly related to, and an interpretation of, United Nations’ Universal Declaration of Human Rights (1945). She especially stressed the importance of the right of self-determination being violated since the colonial era, the right of ownership and control of land, territories and natural resources, and protection of Indigenous peoples’ culture [11].

In Sweden, a Truth Commission for the Sami People has been appointed by the government. The commission will survey and examine the policies pursued towards the Sami from a historical perspective, including their consequences today for the living conditions of the Sami people. The commission shall also suggest measures to contribute to rectification, reconciliation, and a sustainable Sami society [12].

Research on Samis and health

Studies in many countries have shown that Indigenous people suffer from poorer socioeconomic conditions and poorer health than majority populations [13]. Sami, however, have physical health conditions comparable to majority populations [14]. Differences in living conditions and access to health make comparisons between different parts of Sápmi difficult. However, some studies in both Norway and Sweden have shown increased levels of mental ill-health compared to majority populations [15–17]. In studies from historical registers, Sami men in Norway, Sweden and Finland were shown to have higher suicide rates than men in the majority population in the same geographical areas [18]. In the reindeer herding population, younger men more often committed suicide [19].

Globally, the number of Indigenous people living in cities has increased drastically in recent decades. Some studies indicate that socioeconomic conditions, loss of traditional lifestyles and cultural belonging, and discrimination affect their health [20,21]. Little is known about Samis living in cities and their living conditions and health. In Sweden no such studies have been made. Norwegian researchers have studied the conditions of urban Samis, although not with a particular focus on health. Dankertsen and Åhrén [22] found that young Norwegian Samis living in the cities perceived the existence of colonial structures on the microlevel in the urban surrounding reducing their possibilities of expressing their culture and using their language. Berg-Nordlie [23] studied how local governance of urban indigenous social spaces affect local indigenous self-government. He found that a major challenge was the absence of unifying organisations representing local Sami populations.

In studies of Indigenous peoples and ethnic minorities, the importance of involving and allowing real influence of the studied group is stressed [24]. Challenges noted in the study of Indigenous peoples are differences in the perception of how knowledge is created; research being too focused on individuals and not on community perspectives; research focusing more on weaknesses than resilience and strength; research using a top-down approach satisfying the needs of funders and the scientific society more than local and contextual knowledge. Wexler et al. [24], recommended an approach of participatory research to meet those challenges, an approach that is supported by guidelines and position papers from the Swedish Sami Association and the Sami Parliament in Sweden [25,26].

The aim of this study was to increase knowledge on how Samis in the Stockholm area perceive their own needs regarding welfare and health, with a special focus on psychological well-being and mental health.

Material and methods

Process

The Transcultural Centre, Region Stockholm, collaborated with the Stockholm Sami Association in this study, through the participation of a reference group from the association in all stages of the study, the inclusion of a member of the reference group (EE) as a research assistant and co-author of the study, and the dissemination of information about the study through the publications and other channels of the Association.

Subjects

Twenty-five Samis living in the Stockholm area were recruited with purposeful sampling, striving for a variation in gender, age, and experiences [27]. The informants were self-identified as Samis. We disseminated information about the project through a project leaflet, articles in papers and on websites, contacts with national media covering Sami issues, Facebook groups, and above all through personal contacts made by the research assistant (EE). To recruit younger informants, the research assistant approached the Sami youth organisation, Sámi Nuorra. The risk of the informant and the Sami researcher knowing each other was avoided by not including acquaintances.

Material

We formulated an interview guide with some sociodemographic questions and open questions covering perception of health; identity/background; life situation and welfare needs; needs in relation to health and experiences of help seeking; and perceptions of mental health. (See Appendix for the full text of the interview guide.) The reference group participated in the formulation of the guide, suggesting, among other things, items related to historical conditions and discrimination. Following the advice of the reference group, we assessed that it was not necessary to translate the guide into Sami languages.

Procedure and data analysis

Because of the restrictions due to the COVID-19 pandemic, we performed most of the interviews on the telephone or via digital interviews. All interviews were conducted in Swedish. The interviews were taped and transcribed by a medical secretary. The transcriptions were compared with the taped interviews, and they were anonymised, omitting, or changing details that might allow identification of the informant.

The interviews were analysed with thematic analysis [28,29], with the support of QSR N’Vivo 12 [30], a software programme for qualitative text analysis. There were several steps in the analysis:

• all authors familiarising themselves with the interviews.

• one author (MS) coding each text line by line identifying important meaning units.

• the other two authors reading the codings and adding or commenting on codes.

• writing informal memos reflecting noteworthy observations in the material.

• discussing the coding and understanding of the material and recording the discussions.

• gathering codes in categories and identifying sub-themes and overarching themes from those categories.

• using the software programme to raise queries about the material.

• discussing the final themes and sub-themes until consensus was reached.

An important aspect of our participatory approach [31], and a way to validate the themes, was to give the informants access to the preliminary results and encourage their comments, so-called member check. The reference group also read and discussed the preliminary results with us.

Ethical approval was given by the Ethics Review Authority (number 2020–01549).

Results

Description of the informants

We interviewed 25 informants, 17 women and 8 men. The median age was 44 years (range 18–76). Eight were born in Stockholm County, but some of them had moved from the area and returned. The other seventeen had lived in Stockholm between 10 and 50 years. Seventeen informants had post-secondary education and the other eight had completed or were still attending secondary school. Sixteen were occupied in full-time work or education, only one was on sick leave and the rest were retired.

Thematic analysis

In the thematic analysis of the interviews, we identified four main themes: To have or to reconquer one’s identity; Visibility and invisibility in the city; Bringing your culture and history to the care encounter; and Healthcare adapted to the needs of the Sami (See Figure 1.)

Figure 1. Themes, sub-themes, and examples of meaning units in thematic analysis.

Figure 1. (Continued).

To have or to reconquer one’s identity

This overarching theme refers to most of the informants describing the Sami identity as important and a source of security. The Sami language, Sami culture and access to nature were highlighted as important parts of identity. The informants’ description of their Sami identity varied from a life-long stable sense of identity, to an in-betweenness without a clear belonging, to an active and sometimes stressful process of reconquering Sami identity in adult life.

Strong family ties and awareness of historical injustices suffered by relatives were described as a fundamental part of identity. The informants described their identity as linked to the geographical areas where the family lived and sometimes still lives, and to nature.

”I feel that as human beings we are part of nature. Or we are nature, too. And that is something I have learned … from the Sami [culture], that you must protect and take care of nature, because … then you take care of yourself”. (Middle-aged man)

The informants said that the language oppression the parent generation had been subjected to, for example, through not being allowed to speak Sami (or Meänkieli, a language related to Finnish spoken in parts of northern Sweden) at school, led to parents opting out of the Sami language on behalf of their children. Even today, the shortcomings in Sami teaching at school were seen as a serious problem.

Culture had different meanings for different informants. Some emphasised an existential, sometimes spiritual, dimension. To others, culture meant language, Sami handicraft (especially clothing), Sami art including the traditional music, the joik, but also participating in Sami activities. The gakti (traditional Sami clothing, “kolt” in Swedish) emerged as an important culture bearer that gives a rich story about the wearer’s geographical and family origin. However, the gakti may also become the subject of conflicts within the Sami group about what is the “correct” tradition. Further, as a cultural expression, the gakti also makes its wearer visible and more exposed as Sami. Several informants described cultural norms of socialising and relationships different to a Swedish culture.

“You have something extra. You have the Swedish culture but then you also have the Sami culture” (Middle-aged woman).

The term “in-betweenness” was used by several persons. “To be aware of not being part of a majority… Always being different … Never being the person on whom normality or neutrality is based” (Young woman). An older informant described a similar feeling without using the phrase in-betweenness. “It is very difficult to be Sami in Swedish society”, she said, giving the example of constantly having to know both cultures.

Informants described how their identity had been questioned by people within the Sami group as well as by people in the surrounding society. Conflicts within the Sami group were also described by several informants.

“There are Sami who still today deny their Sami heritage… What does it do to a person and his or her mental health, to deny who you are … ?” (Middle-aged woman).

Some informants described the struggle as part of identity: To be Sami is to fight for one’s rights against the Swedish state, sometimes as part of an international Indigenous struggle.

”To me, it is almost like Sami [culture] means family relations and relations in Sami society, where networks combine with politics … To me, there is a need of resistance woven into identity. Both the fact that it is a minority identity and an identity coloured by colonial history. And colonial present, if you ask me” (Young woman).

Several of the informants described how, in adulthood, they decided to regain their Sami identity, a process described as arduous. Informants thought that conditions for Samis had improved: more Sami people assert their identity and become prominent in different areas; the younger ones are more visible. Those who were on the “journey” of reconquering, described it as strengthening identity and family networks, giving increased pride and self-esteem, and strengthening mental health.

Several informants spoke of how the culture of silence of earlier generations affects the descendants. Not even having been told about one’s Sami identity aroused sadness and anger.

Visibility and invisibility in the city

This theme refers to the informants’ description of living in the Stockholm area. They had moved to the big city for good reasons (work, studies, and relationships) and generally had a good life. The city provided advantages in terms of increased protection but also disadvantages in the form of reduced access to the Sami community. The theme includes the description of being visible or invisible in Stockholm.

Most informants expressed that they had a good life in Stockholm, particularly assessing increased job opportunities, easier access to specialist medical care and more diverse cultural activities as beneficial. Disadvantages associated with urban life were the poorer environment, noise, stress, and that it is more difficult to lead a life close to nature. The anonymity of the city could pose both a risk of loneliness and reduce vulnerability to harassment.

“Living in Stockholm means that your relatives are far away. And it makes you feel lonelier” (Middle-aged woman).

Informants had become both more and less visible as Sami in Stockholm compared to northern Sweden, depending on whether they had chosen to talk about their origins or dress in Sami clothes. An informant described that an increased anti-immigrant attitude had also been turned against the Sami and that the Sami and their rights as an Indigenous people were increasingly questioned. On the other hand, other informants reported that it could be positive and “contact-making” to be Sami in Stockholm.

“Many of us avoid doing things that identify us as Sami … In that situation you become very aware of this being the first time they meet someone they know is Sami … But then you [think] ‘OK, now I am the first impression of the Sami people for this person’”. (Young woman)

Bringing your culture and history to the healthcare encounter

This theme refers to the informants bringing their Sami culture, belonging and their family’s historical experiences into healthcare encounters, often without the background being acknowledged. Further, the theme explores the informants’ perceptions of health and illness and their experiences of clinicians’ lack of knowledge of Sami issues. The informants described themselves as part of a dense web of ongoing and past family relationships and events. Most informants described strong family bonds as part of Sami culture. Family ties existed even at long geographical distances. The informants also described how family stories of harsh living conditions, injustices, forced displacement, language loss, forced assimilation and discrimination, both past and ongoing, affected them. They also argued that such conditions often strengthened family ties, but also might lead to severed bonds. Several informants mentioned how previous generations had been subjected to medical abuse.

”I think that … many older people who have been exposed to racist attacks and … who haven’t been allowed to speak Sami, they lose trust in many people … They almost seem… bitter and suspicious, like they don’t really trust authorities to be there for them” (Middle-aged woman).

However, the informants did not indicate that this history affected them when they sought care. When asked where to seek help in case of mental health problems, most said that they would seek established healthcare. The informants did not feel that they had been directly personally discriminated against in the healthcare system in Stockholm but described other experiences from northern Sweden.

The informants described how their cultural background and history usually remained invisible in the care encounter. Their fluent Swedish made them invisible as Samis in the eyes of clinicians, who did not understand that they might have other experiences and needs. An older woman thought that her lack of nuances in the use of Swedish even led to clinicians misunderstanding her physical state. One question on which the informants expressed different, conflicting, and ambivalent opinions was whether it was important to talk about their Sami descent in the care meeting. Many informants believed that it could be important, but others were unsure what role it could play. One informant said that the question of provenance would not be important at all in healthcare, “because they see me as any other human being”. Others stressed the importance of background for all people. It would be particularly important to pay attention to the problem of loneliness, especially for older Sami and for persons seeking help for psychological problems.

Informants pointed out that healthcare professionals might help a Sami person understand how the experiences of previous generations, that had disappeared from consciousness due to the culture of silence, affected him or her. One informant said there is a connection between “how you have treated a people and how the people feel”.

The reason given by the informants for their hesitancy to talk about their Sami background was above all the fear of facing prejudice. The informants experienced an almost non-existent knowledge of Sami people in Swedish society, including in healthcare, and this ignorance affected them. The ignorance aroused strong feelings among the informants.

“Sometimes if you are going to explain … about your mental, either health or way of thinking, you must also explain Sami culture at the same time, because I do not know of any psychologists in Sweden who have Sami competence. You would have to go to Norway where they have it” (Young woman).

The consequence for the informants when they sought care – and if it “emerged” that they were Sami – was that they had to “teach” the caregiver, thereby removing focus and time from their care needs. A couple of informants also mentioned that psychiatric clinicians seemed ignorant of the research on mental illness in Sami people and did not show interest in exploring it.

Informants saw historical injustices, including the shame experienced as victims, as well as being an outsider in society today as affecting mental health. Older informants who had personal experiences of nomadic school or being deprived of their maternal language expressed the relation with their current well-being clearly.

“(N)omadic school time affects all the way into old age. Lack of security and of adults to confide in leave you with great wounds. You left home at the age of seven ˗ everything was new, language, food, customs, you should become a real Swede. It’s hard that it is not recognised that we were second-class citizens. A burden to carry” (Old woman).

The informants described cultural factors affecting the perception of illness and help-seeking behaviour, as well as the management of stressful situations. For example, they described how a historically and culturally characterised ideal of strength affected the perception of illness. At least in previous generations, illness was seen as weakness, or perhaps punishment, and was therefore kept secret. Nature and the ability to move freely in the forest and land were described by the informants as one of the most important sources of health and well-being.

Healthcare adapted to the needs of the Sami

This theme refers to the informants’ reflections on how they want care to be developed to meet their rights and needs as Indigenous people and Sami. It includes the informants’ reflections on the necessary competence of care staff as well as their reflections on necessary changes in society at large. The informants expressed that the most important thing in healthcare was to be met with respect and responsiveness by knowledgeable staff with professional medical expertise. Yet, informants also stressed the importance of healthcare professionals having knowledge of the Sami and their conditions and being able to understand the importance of the background.

“I don’t know if … [caregivers having] a Sami background would help more than having healthcare professionals who can meet people where they are, believe in them and make them feel confident” (Middle-aged woman).

Informants also stressed the need of training for healthcare professionals on issues like minority stress as well as the importance of cultural aspects and identity. Informants raised the importance of considering the needs and status of the Sami as Indigenous peoples. Several informants wished access to care in the Sami language in healthcare for those who need it and to increase the visibility of the Sami in society. Even those who speak Swedish fluently but have Sami as their mother tongue might need care in the Sami language, for instance in psychological crises. Elderly people, especially with memory disorders, were another group with special needs to speak Sami.

“(At) all levels, both the one that meets the patient or the Sami… and higher up with research and decision-making, that is, all the way up, this … needs to permeate the organisation … ” (Young man).

In general, the informants neither sought Sami traditional healing nor did they expect specialised Sami care units in Stockholm mental healthcare. Some suggested networks being built to refer patients to online culturally-adapted Sami care. For many informants, the connection between historical abuse and ongoing deficiencies in society’s treatment of Sami people on the one hand, and mental health and well-being on the other, was clear. Among factors considered to affect mental health, historical experiences were prominent, and many emphasised that they still experience abuse today.

However, informants above all highlighted concrete shortcomings on the part of the authorities and how they, directly or in the long term, affected health and well-being. Just as informants had a very negative view of the nomadic schools and how previous generations of Sami were denied their language in school, those who were parents saw shortcomings in today’s schools specifically regarding language teaching. Informants said that society should support Sami people in giving them visibility, access to the language and gathering places where Sami can meet.

“As a group in the Stockholm area, we might get better health if we had some … natural meeting place, actually both physical and mental health … If you can share and strengthen each other and if you can feel, that whether we are in the mountains or in the city, we are there for each other” (Young woman).

Discussion

The overarching aim of this study was to increase knowledge about how Samis in the Stockholm area perceive their own needs regarding welfare and health, with a special focus on psychological well-being and mental health. The data, consisting of interviews with twenty-five Samis living in the Stockholm area, were analysed with thematic analysis. Four major themes were identified: To have or to reconquer one’s identity; Visibility and invisibility in the city; Bringing your culture and history to the care encounter; and Healthcare adapted to the needs of the Sami.

To have or to reconquer one’s identity was the most prominent theme given major attention. Sami identity was seen primarily as a resource for confidence and well-being. The informants varied in how confident they were in their belonging to a Sami identity. For some, the identity was self-evident since childhood; for others, it was rediscovered in adult life. This process was often difficult, implying re-evaluations of contacts with family and relatives. Informants sometimes addressed their conditions as Sami as abuses of human rights, describing how they had been seen as second-class citizens. For them, the consequences of the colonisation of their land by the Swedish state were evident [32] and among the abuses they mentioned, historical injustices, not having been corrected or apologised for, had a prominent place and a continued effect on their well-being. Informants gave a wealth of information about personal experiences and family histories of perceived discrimination and injustice, like forced displacements, boarding schools, forced assimilation, loss of Sami language, and devaluation of Sami identity. Other examples of abuses of human rights were their reports of current discrimination and racist attacks in the traditional Sami areas of northern Sweden. In the Stockholm area, some informants had experienced direct physical attacks and harassments. However, in Stockholm, informants were primarily and deeply affected by the surrounding community’s lack of knowledge of, and interest in, Sami people. Several informants used the concept of in-betweenness for their vulnerable position of belonging to a minority group.

Different configurations of the self

The informants related their Sami identity to the family, the relatives, family history, nature, and geographical places. Kirmayer [33] discussed the formation of self and the concept of the person, and outlined variations in the form of personhood and how they may influence effective treatment interventions. He suggested four major cultural configurations of the self: the egocentric self, defined by personal history and accomplishment; the sociocentric self, defined by family, clan, lineage, and community; the ecocentric self, defined by environment and ecology, and the cosmocentric self, including the ancestors. Kirmayer noted that among Indigenous peoples, the ecocentric self relates the individual to the environment. The theoretical descriptions of sociocentric and ecocentric self correspond to the way the informants in this study talked about themselves, even in the context of living in Stockholm. They repeatedly described family cohesion and socialisation as well as the closeness to nature, including the access to the traditional locations where their family had lived as essential to their identity. The variation in cultural configurations of the self may be unfamiliar to clinicians and require adaptation of psychological treatment approaches.

Some informants reported painful experiences of having their Sami identity questioned, either by persons in the Sami community or in mainstream society. The reasons for being questioned internally were said to be not living in the north, coming from families that had not been reindeer herders for generations but small landholders, or not knowing the language. Some of them drew the same conclusions as researchers who have stressed the strong role of the state intervening in the definitions of Saminess as a source of internal conflicts [34,35]. The most important way of claiming or reclaiming their Sami identity was without any doubt the wish and efforts to learn the Sami language – an effort that could be seen as strengthening the sociocentric self.

Identity and mental health

In our study, informants stressed the experience of identity as a source of confidence and well-being. Being questioned in your identity, repressing it yourself, or being in an in-between position were described as reasons for mental ill-health. Similarly, other studies on Sami mental health find an association with identity issues. In his thesis, Stoor [36] explored how suicide is understood among Sami in Nordic parts of Sápmi. He found that the cultural meaning of suicide among Samis may be understood to be linked to the threat of losing Sami identities, seen as central to meaning in life. Thus, he suggested that the loss of Sami identity might increase the risk of suicide. A survey of mental health in the Sami community in Sweden showed the importance of a confident Sami identity for mental health and well-being. Sami-speaking persons in the Sami community were found to have better mental health and well-being than non-Sami speaking persons [37]. Native language proficiency was seen as a marker for strong Sami belonging and a link to cultural continuity. In Canada, many Indigenous communities have a high prevalence of mental health problems that has been understood to be related to the effects of rapid cultural change, cultural oppression, and marginalisation, whereas other communities have done well despite similar challenges [38]. Local control of community institutions and cultural continuity have been suggested to contribute to better mental health [38].

The role of historical trauma

The informants in this study experienced their present mental health and well-being to be affected by previous family experiences of injustice. Exposure to severe psychological trauma is a strong risk factor for several debilitating disorders, post-traumatic stress disorder (PTSD) and depression [39]. There is evidence that an enduring possible consequence of trauma exposure is that it can be passed on to offspring transgenerationally [40]. Reviewing the history of research on intergenerational transmission of trauma, Lehrner and Yehuda [41] considered this to be shaped by psychodynamic processes, vicarious trauma, learning and modelling, parenting and family environment, and biological influences. They pointed to the importance of community processes for healing.

The concept of historical trauma has been used to describe the impact of colonisation, cultural suppression, and historical oppression of Indigenous peoples in North America and to capture both historical oppression and psychological trauma [42]. The historian Lennart Lundmark [32] suggests that in Sweden, Sami land and culture have not been colonised through armed repression but through different administrative regulations by the Swedish state and that the result concerning land resembles other colonialised contexts, like North America.

Another important theme was Visibility and invisibility in the city. For informants, the urban surroundings included advantages concerning education, work and increased protection against harassment and discrimination. However, the disadvantages of the city included decreased contact with the Sami community and with nature. Unlike findings from other studies about Indigenous people moving to the urban areas [20], the informants in this study were not socially or economically disadvantaged.

Need of person-centred care

Concerning healthcare, the two themes Bringing your culture and history to the care encounter and Healthcare adapted to the needs of the Sami were identified. Even though informants brought their background as invisible shadows into healthcare contacts, the ambivalence of several informants regarding divulging information about their background in care encounters was noteworthy. This ambivalence was expressed even though they considered clinicians’ knowledge on such issues as valuable and saw their Sami background with family histories of injustice as impacting their current mental health. Our findings indicate that exploring background and identity would be facilitated by a truly person-centred orientation, with clinicians having enough background knowledge to be sensitive to the range of possible experiences and taking a genuine interest in the subjective world of the patient.

In person-centred care, clinicians are recommended to base the clinical encounter and treatment planning on the patient’s narrative [43]. One way of eliciting a narrative could be the Cultural Formulation Interview (CFI), included in the diagnostical manual DSM-5 as a tool supporting the clinician in the joint exploration with the patient of his or her culture and background [44]. The CFI can increase understanding of how patients’ cultural backgrounds may affect their current problems and help seeking. The CFI has been adapted to the Sami context and translated into the North and South Sami languages, Norwegian and English [45].

Kirmayer and Jarvis [46] stressed the importance of services, systems and interventions being culturally responsive to the needs of patients. This will mean different adaptations in different contexts, including the use of language interpreters or cultural brokers, addressing discrimination, and increasing the diversity of the workforce. In our study, all informants stressed the importance of being treated with respect for their Sami identity and of clinicians being sensitive to their patients’ background. To enable this, informants emphasised that clinicians need some basic knowledge about Sami history and community, and about “minority stress”, that is stress due to belonging to a minority group. They also stressed the importance of access to care in the Sami language in Stockholm, particularly for the elderly.

Even though many informants knew about, and approved of, the culturally adapted Sami mental health services in northern Norway, they did not express a demand for similar services in the Stockholm area, or for traditional Sami care. This dual attitude may be seen as a “realist” stance, knowing the small size of the Sami population in Stockholm. It might also be seen as a sign of informants’ general trust of healthcare services in Stockholm.

Trustworthiness and rigour

The variety of informants regarding age, sex, and occupation, the collaboration between the Stockholm Sami Association and two researchers, and the rigorous analysis process including member checks with informants contribute to the credibility of this study. A problem performing the study is the small Sami population in the Stockholm area, involving a risk of the informant and the Sami researcher knowing each other. Another problem might be that we mainly managed to recruit through the channels of the Stockholm Sami Association, possibly reducing the variation in the perception of the informants on issues like identity and Saminess. Some informants assessed their Swedish language mastery in general as lacking in nuances, which might constitute a problem in the interview situation.

Conclusion and clinical implications

For informants in this study, a secure Sami identity and being treated with respect for their identity were experienced as essential to mental health and well-being. Informants’ emphasis on respect for their Sami identity and belonging can be seen as a call for restoration of basic human rights. For physical and mental healthcare in the Stockholm area, this means that clinicians need to have knowledge of the statutory rights of the Sami as Indigenous people in Sweden and of Region Stockholm as an administrative Sami management area, as well as some basic knowledge of Sami history, culture, and community. Further, results of this study emphasise the importance of implementation of clinical methods approaching minority identity and minority status with sensitivity and respect.

Acknowledgments

We thank all the informants who have contributed with their time and commitment, the Stockholm Sami Association and especially Peter Rodhe and Mariana Wiik from the Sami reference group for fruitful collaboration, as well as Anna Jernberg Sørensen, Therese Lindman and Mehrnaz Aram representing the Health and Medical Care Administration in the steering group. We also thank the Health and Medical Care Administration for the funding of the interview study. Furthermore, we thank Stephen Wicks for linguistic advice.

Disclosure statement

No possible conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the Health and Medical Care Administration, Region Stockholm, Sweden [HNSV 19882 HSN 2019-2129].

Appendix

1. Health and Identity/Background

How do you perceive your health today?

Concerning your health, what aspects of your background/identity do you consider most important?

What does your Sami background mean to you?

What does living in Stockholm as a Sami mean to you? Do you think that it affects your health?

If the informant has moved: What did moving to Stockholm mean to you as a Sami? Do you think that it has affected your health?

What does Sami culture mean to you?

2. Situation in Life and Welfare Needs

Do you think that your situation in life in any way affects your health?

What factors support you in having a good situation in life?

What do you do to obtain calm and security when you are worried or troubled?

In what ways can authorities support you and your family to attain a good situation in life? If necessary, give examples: childcare, school, elderly care, social assistance, unemployment assistance.

If you or your family would seek such help in a difficult situation in life, what would you like the support to be like? Do you think that your Sami background would affect the support? How would you wish your Sami background to be taken account of?

Have you ever been badly treated because of your Sami background? If yes, was it on any occasion an authority representative who treated you badly? How does that affect you?

Have your family and relatives been badly treated in the past because of their Sami identity in a way that affects you today?

How do you experience the attitudes of the surrounding society to you as a Sami and how does that affect you? Give examples: media, social media, but also the local community.

3. Needs Related to Health and Experience of Help Seeking

What do you think is most important to maintain good health, both physically and mentally?

In a situation when a person has health issues, what do you think he or she could do to cope with them? Do you have any example you want to tell me about? Do you have any example concerning mental health issues?

Help seeking outside the established care system is common, for example, help seeking from alternative or folk medicine. Do you have examples of help seeking you want to tell me about? Do you have examples regarding help seeking for mental health issues? You could give examples from your own or some other person’s experiences.

In a situation when you or someone in your family has mental ill-health, what kind of help would you wish to get? Is there anything that would make it more difficult for you or your family to get the help you need? Do you think that your Sami background would affect the access to help in any way?

Sometimes, healthcare staff and patients misunderstand each other because they have different backgrounds or different expectations. Do you have any examples of such misunderstandings that you want to tell me about? Was it in any way related to your or other persons’ Sami background? How do you assess the knowledge of healthcare staff of Samis and their health? Feel free to give examples. Have you ever felt badly treated in healthcare because of your Sami background?

How do you think encounters with healthcare could improve? How do you wish healthcare, especially for mental ill-health, to develop? If the clinician knew about your Sami background, what implications would that have?

4. Perceptions of Mental Health

With whom would you like to talk first if you had mental health problems? Would you describe your problems in any other way to healthcare staff than you would to your family, your friends, or others in your community?

We know that people develop mental ill-health for many reasons. In your experience, is there some factor related to living as a Sami in the city that affects mental health?

How would you recommend someone you knew to seek help in Stockholm for mental health problems? Would it matter if the person had a Sami background or not? Does language matter? Are there any particular aspects, in your view, that healthcare staff should consider in the encounter with a Sami patient?

Is there something else you would like to highlight?