Sexual and Reproductive Health and Rights for Young Migrants in Sweden: An Ideal-Type Analysis Exploring Regional Variations of Accessible Documents.

Objectives: This study aims to map sexual and reproductive health and rights (SRHR) policies, strategies, and interventions targeting young migrants and describe the patterns of organisation, resources, and services across Sweden's 21 regions. Methods: We conducted a document analysis of accessible online documents on SRHR policies, strategies, and interventions targeting young migrants in Sweden's 21 regions. We used ideal-type analysis of the documents to create a typology, which formed the basis of a ratings system illustrating variations in organisation, resources, and services across regions. Results: Findings suggest that efforts aimed at addressing young migrants' SRHR are fragmented and unequal across regions. While SRHR policies and strategies are commonplace, they routinely lack specificity. Available resources vary depending on region and resource type. Additionally, information and interventions, although common, do not consistently meet the specific needs of migrant youths. Conclusion: This study suggests that fragmented efforts are fuelling geographic inequalities in fulfilling SRHR among young migrants. There is an urgent need to improve national coordination and collaboration between national and local actors in SRHR efforts targeting young migrants to ensure equity.

Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents' sexual and reproductive health needs in rural Zambia.

INTRODUCTION: Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents. METHODS: Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis. RESULTS: We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges. CONCLUSION: Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

Prevalence of perceived discrimination, determinants and associations with self-rated general and sexual health, healthcare utilization and self-perceived integration: a cross-sectional survey of migrants in Sweden.

BACKGROUND: Sweden has welcomed migrants, but attitudes have shifted, becoming hostile due to populism and the growing number of migrants. This has left migrants feeling unwelcome and marginalized. Few studies have examined the extent to which migrants perceive discrimination, who, why, where and its relationships with different outcomes. This study has two aims: to assess the prevalence, reasons, and determinants of perceived discrimination among migrants (1) and its associations with self-rated health, sexual health, healthcare use, and integration (2). METHODS: We analysed data from a 2018 survey on migrants' sexual and reproductive health and rights. The survey included 1740 migrants aged 16 or older. We used descriptive and log-binomial regression analyses to estimate prevalence, crude and adjusted prevalence ratios (APR) with 95% confidence interval (CI). RESULTS: About 36% of participants perceived discrimination in Sweden, with ethnic origin (62%) and religion (35%) as main reasons. Perceived discrimination occurred in public spaces (47%), schools (33%), internet (20%), work (19%), public services (18%), residential areas (16%), and healthcare settings (10%). Migrant men (APR: 1.26, CI:1.07-1.49), born in Middle East and North Africa (APR: 1.57, CI:1.26-1.95) and South Asia (APR: 1.61, CI:1.27-2.04) regions, with more than 12 years of education (APR: 1.33, CI:1.10-1.60), a non-heterosexual orientation (APR: 1.21, CI: 1.02-1.43), a non-Christian religion (APR: 1.41, CI: 1.10-1.80), economic stress (APR:1.67, CI: 1.44-1.93) or Swedish language skills (APR: 1.24, CI:1.07-1.43) perceived discrimination more than their counterparts. In contrast, the oldest participants (46 years or more) perceived less discrimination (APR:0.55, CI: 0.37-0.80) than the youngest ones (16-25 years). Moreover, perceived discrimination was associated with poor self-rated general (APR:1.72, CI: 1.45-2.04) and sexual health (APR:1.40, CI:1.2-1.64), integration (APR:1.25, CI:1.14-1.37), and healthcare access (APR: 1.48, 1.16-1.89). CONCLUSIONS: This study shows that migrants in Sweden face widespread perceived discrimination based on ethnicity and religion. This can affect their health, healthcare use, and social integration. The study calls for policies and interventions that tackle systemic perceived discrimination, foster inclusion, and guarantee equal opportunities in accessing healthcare and resources for migrants. It also urges support for vulnerable groups who perceive more discrimination, such as migrants from certain regions or under economic stress.

Exploring cross-boundary collaboration for youth mental health in Sweden - a qualitative study using the integrative framework for collaborative governance.

BACKGROUND: Youth mental health is a major health concern in almost every country. Mental health accounts for about 13% of the global burden of disease in the 10-to-19-year age group. Still there are significant gaps between the mental health needs of young people and the quality and accessibility of available services. Collaboration between health and social service actors is a recognized way of reducing gaps in quality and access. Yet there is little scientific evidence on how these collaborations are applied, or on the challenges of cross-boundary collaboration in the youth mental health space. This study aims to explore how collaboration is understood and practiced by professionals working in the Swedish youth mental health system. METHODS: We conducted 42 interviews (November 2020 to March 2022) with health and social care professionals and managers in the youth mental health system in Sweden. Interviews explored participants' experience and understanding of the purpose, realization, and challenges of collaboration. Data were analysed under an emergent study design using reflexive thematic analysis. RESULTS: The analysis produced three themes. The first shows that collaboration is considered as essential and important, and that it serves diverse purposes and holds multiple meanings in relation to professionals' roles and responsibilities. The second addresses the different layers of collaboration, in relation to activities, relationships, and target levels, and the third captures the challenges and criticisms in collaborating across the youth mental health landscape, but also in growing possibilities for future development. CONCLUSION: We conclude that collaboration serves multiple purposes and takes many shapes in the Swedish youth mental health system. Despite the many challenges, participants saw potential in further building collaboration. Interestingly our participants also raised concerns about too much collaboration. There was scepticism about collaboration directing attention away from young people to the professionals, thereby risking the trust and confidentiality of their young clients. Collaboration is not a panacea and will not compensate for an under-resourced youth mental health system.

Addressing the workforce crisis in (rural) social care: A scoping review.

BACKGROUND: This scoping review identifies strategies potentially addressing the 'workforce crisis' in rural social care. The increasing global demand for social care has been coupled with widely recognised challenges in recruiting and retaining sufficient staff to provide this care. While the social care workforce crisis is a global phenomenon, it is particularly acute in rural areas. METHODS: The review identified 75 papers which (i) had been published since 2017, (ii) were peer reviewed, (iii) concerned social care, (iv) were relevant to rural settings, (v) referenced workforce shortages, and (vi) made recommendations for ways to address those shortages. Thematic synthesis was used to derive three analytical themes with a combined 17 sub-themes applying to recommended strategies and evidence supporting those strategies. RESULTS: The most common strategies for addressing social care workforce shortages were to improve recruitment and retention ('recruit and retain') processes without materially changing the workforce composition or service models. Further strategies involved 'revitalising' the social care workforce through redeploying existing staff or identifying new sources of labour. A small number of strategies involved 're-thinking' social care service models more fundamentally. Very few papers specifically considered how these strategies might apply to rural contexts, and evidence for the effectiveness of strategies was sparse. CONCLUSION: The review identifies a significant gap in the literature in relation to workforce innovation and placed-based studies in rural social care systems. It is unlikely that the social care workforce crisis can be addressed through continuing attempts to recruit and retain workers within existing service models.

More than meets the eye: a critical discourse analysis of a Swedish health system reform.

BACKGROUND: In line with international trends acknowledging the importance of Primary Health Care (PHC) for improving population health and reducing health inequalities, the Swedish health system is undergoing a restructuring towards the coordinated development of a modern, equitable, accessible, and effective system, with PHC principles and functions at its core. Since discursive analyses of documents underpinning PHC reforms are scarce in Sweden and beyond, the aim of this study was to explore how the reorientation towards good quality and local health care has been represented in official government reports. METHODS: Based on a policy-as-discourse analysis, four Swedish Government Official Reports underpinning the good quality and local health care reform were interrogated following four questions of Bacchi's "What's the Problem Represented to be?" (WPR) approach. By applying the first WPR question, concrete proposals guiding the reorientation were identified, analyzed and thematized into candidate problem representations. These problem representations were then analyzed in relation to previous empirical and conceptual research considering WPR questions two and three, which resulted in the development of three problem representations. Potential silences that the problem representations might produce were then identified by applying WPR question four. RESULTS: The three problem representations connected the Swedish health system "problem" to a narrow mission, a siloed structure, and a front-line service disconnected, especially from the needs and preferences of individual patients. By representing the problem along these lines, the analysis also illustrated how the policy reorientation towards good quality and local health care risk silencing important PHC aspects such as health promotion, equitable access, and human resources. CONCLUSION: The results from this study indicate that as discursively framed within concrete proposals, government official reports in Sweden represent the health system problem in particular ways and with these problem representations overlooking several aspects that are central to a health system characterized by PHC principles and functions. In the continued reorientation towards good quality and local health care, these silences might need to be acknowledged.

Unlocking policy synergies, challenges and contradictions influencing implementation of the Comprehensive Sexuality Education Framework in Zambia: a policy analysis.

BACKGROUND: Comprehensive sexuality education (CSE) has recently become salient, but adolescent sexual reproductive health and rights (ASRHR) challenges are still a global health problem. Studying policies which have implications for CSE implementation is a crucial but neglected issue, especially in low and middle-income countries (LMICs) like Zambia. We analyzed policy synergies, challenges and contradictions influencing implementation of CSE framework in Zambia. METHODS: We conducted a document review and qualitative interviews with key stakeholders from Non-Governmental Organizations, as well as health and education ministries at the National and all (10) provincial headquarters. Our methods allowed us to capture valuable insights into the synergies, challenges and contradictions that exist in promoting CSE framework in Zambia. RESULTS: The study highlighted the synergies between policies that create opportunities for implementation of CSE through the policy window for adoption of sexual reproductive health and rights (SRHR) that opened around the 1990s in Zambia, promotion of inclusive development via education, adoption of an integrated approach in dealing with SRHR problems, and criminalization of gender-based violence (GBV). This analysis also identified the policy challenges and contradictions including restricted delivery of education on contraception in schools; defining childhood: dual legal controversies and implications for children, grey zones on the minimum age to access SRHR services; inadequate disability inclusiveness in SRHR legal frameworks; policy silences/contentious topics: LGBTQI + rights, abortion, and grey zones on the minimum age to access SRHR services. CONCLUSION: While many policies support the implementation of CSE in schools, the existence of policy silences and challenges are among the barriers affecting CSE implementation. Thus, policy reformulation is required to address policy silences and challenges to enhance effective promotion and integration of the CSE framework.

"Discrimination is harder to live with than the disease": an interview study of the perceptions and experiences of sexual and reproductive health and rights among women living with HIV in Sweden.

Around 40% of people living with human immunodeficiency virus (HIV) in Sweden are women. However, little is known about their experiences, particularly those related to sexual and reproductive health and rights (SRHR). This study aims to explore perceptions and experiences of SRHR among women living with HIV (LWH). Twelve interviews were conducted with women LWH from September to October 2019 and analysed using thematic analysis. The central theme describing participants' experiences of social relationships, intimate encounters and reproductive life, "Discrimination is harder to live with than the disease itself", is based on three themes that contain subthemes. Theme 1 describes how participants reconsider and reorient their sexual and reproductive life after diagnosis. Theme 2 highlights how (mis)perceptions of HIV affect sexual and reproductive life and lead to abusive treatment and internalisation. Theme 3 describes a paradoxical shift of responsibilities where participants experience being compelled to take greater responsibility in some situations and stripped of the right to decide in others. This study suggests that despite notable progress in HIV treatment, stigma and discrimination stemming from outdated beliefs and (mis)conceptions, ambiguous policies and guidelines, and unequal access to information affect SRHR experiences of women LWH more than the virus itself. The results emphasise the need to: update knowledge within healthcare settings and among the public; clarify ambiguous legislations and guidelines; ensure equal access to information to enable all women LWH to take informed decisions, make fully informed choices and realise their SRHR; and consider the diversity of women LWH and enable shared decision-making.

Role of health facility governing committees in strengthening social accountability to improve the health system in Tanzania: protocol for a participatory action research study.

INTRODUCTION: Social accountability is important for improving the delivery of health services and empowering citizens. The government of Tanzania has transferred authority to plan, budget and manage financial resources to the lower health facilities since 2017. Health facility governing committees (HFGCs) therefore play a pivotal role in ensuring social accountability. While HFGCs serve as bridges between health facilities and their communities, efforts need to be made to reinforce their capacity. This project therefore aims to understand whether, how and under what conditions informed and competent HFGCs improve social accountability. METHODS AND ANALYSIS: This study adopts a participatory approach to realist evaluation, engaging members of the HFGCs, health managers and providers and community leaders to: (1) map the challenges and opportunities of the current reform, (2) develop an initial programme theory that proposes a plan to strengthen the role of the HFGCs, (3) test the programme theory by developing a plan of action, (4) refine the programme theory through multiple cycles of participatory learning and (5) propose a set of recommendations to guide processes to strengthen social accountability in the Tanzanian health system. This project is part of an ongoing strong collaboration between the University of Dar es Saalam (Tanzania), and Umeå University (Sweden), providing opportunities for action learning and close interactions between researchers, decision-makers and practitioners. ETHICS AND DISSEMINATION: Ethical approval to conduct the study was obtained from the National Ethical Review Committee in Tanzania- National Institute for Medical Research (NIMR/HQ/R.8a/Vol.IX/3928). Permissions to conduct the study in the health facilities were given by the President's Office Regional Administration and Local Government and relevant regional and district authorities. The results will be published in open-access, peer-reviewed journals and presented at scientific conferences.

Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study.

BACKGROUND: Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania. METHODS: An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data. RESULTS: Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement. CONCLUSION: While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.

The good, the bad, and the why: How do Arabic-speaking migrant men perceive and experience information and services related to sexual and reproductive health in Sweden?

Although migrant men constitute a large and growing proportion of men in Sweden, literature exploring migrant men's experiences in sexual and reproductive health (SRH) services is scarce. We aimed to explore how Arabic-speaking migrant men perceive and experience information and services related to SRH in Sweden. We conducted 13 semi-structured interviews with Arabic-speaking migrant men and analysed the data using reflexive thematic analysis. We developed four themes: 1) SRH is 'something essential in life'; 2) the good: a transition to a 'new open society'; 3) the bad: barriers to sexual education and health services; and 4) the why: blaming oneself or the system. SRH services and sexual education/information were perceived as needs and rights, and the participants were content with the new possibilities and the 'new open society'. However, sexual education was not provided to most migrants, and SRH services provided to men had shortcomings that deprived some migrant men from fulfilling their needs. Moreover, internalised and cultural racism created a challenge to receive adequate/acceptable SRH services. There is a need to provide comprehensive sexual education for all, strengthen SRH services provided to men, and develop an action plan to reinforce the anti-discrimination/racism policies in healthcare and society.

'HIV ended up in second place' - prioritizing social integration in the shadow of social exclusion: an interview study with migrants living with HIV in Sweden.

BACKGROUND: Migrants are overrepresented among people living with HIV in Sweden as they often face conditions that increased their risk and vulnerability for HIV/STI infections prior, during or after migration. Yet, there is limited research on their experiences and perceptions of living with HIV in the Swedish context. This study aims to explore migrants' experiences of living with HIV in Sweden. METHODS: This is a qualitative study based on in-depth interviews with 13 migrants from 11 countries living with HIV in Sweden. Interviews were analysed with thematic analysis using an intersectional perspective to explore the interactions of multiple social identities such as ethnicity, socio-economic status, gender, age, and sexual orientation that shape an individual's or group's experiences. RESULTS: The analysis resulted in a main theme: 'Prioritizing social integration-HIV ends up in second place', which is based on four subthemes: 'Better opportunities in the new country than what the home country could offer', 'Better conditions for LGBTQI people than in the home country', 'Navigating a new system: linguistic and bureaucratic challenges' and 'Feeling like a second-class resident: racism, xenophobia and multiple discrimination'. The results suggest that migrants living with HIV in Sweden experience social integration as a greater challenge than HIV infection. Although the new country offers opportunities for better living conditions, many participants described being challenged in their daily life by linguistic and structural barriers in their encounters with public services. They are facing multiple discrimination simultaneously as migrants due to their multiple and intersecting identities (e.g. being non-white, foreigners/foreign-born and non-Swedish speakers), which is compounded by HIV status and thus limit their opportunities in the new country and too often result in an existence of exclusion. CONCLUSION: The study shows that most of the challenges that migrants living with HIV face are related to their status as migrants rather than HIV status, which is often not known by the public or authorities. These challenges are similar, but still differ depending on social position, previous experiences, time since arrival and since diagnosis. This emphasizes the importance of both intersectional, intersectoral and multisectoral approaches to address reported issues.

Innovation in Rural Health Services Requires Local Actors and Local Action.

Objectives: We examine the role of "local actors" and "local action" (LALA) in health service innovation in high-resource small rural settings and aim to inform debates about the extent to which communities can be empowered to drive change in service design and delivery. Methods: Using an adapted roles and activities framework we analyzed 32 studies of innovation projects in public health, clinical interventions, and service models. Results: Rural communities can investigate, lead, own and sustain innovation projects. However, there is a paucity of research reflecting limited reporting capacity and/or understanding of LALA. Highlighting this lack of evidence strengthens the need for study designs that enable an analysis of LALA. Conclusion: Innovation and community participation in health services are pressing issues in small rural settings where population size and distance from health infrastructure make service delivery challenging. Current reviews of community participation in rural health give little insight into the process of innovation nor understanding of how local actors produce improvements in innovation. This review outlines how communities and institutions can harness the essential role of LALA in supporting health innovations.

Factors influencing the integration of comprehensive sexuality education into educational systems in low- and middle-income countries: a systematic review.

BACKGROUND: Comprehensive sexuality education (CSE) plays a critical role in promoting youth and adolescent's sexual and reproductive health and wellbeing. However, little is known about the enablers and barriers affecting the integration of CSE into educational programmes. The aim of this review is to explore positive and negative factors influencing the integration of CSE into national curricula and educational systems in low- and middle-income countries. METHODS: We conducted a systematic literature review (January 2010 to August 2022). The results accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards for systematic reviews. Data were retrieved from the PubMed, Cochrane, Google Scholar, and Web of Hinari databases. The search yielded 442 publications, of which 34 met the inclusion criteria for full-text screening. The review is guided by an established conceptual framework that incorporates the integration of health innovations into health systems. Data were analysed using a thematic synthesis approach. RESULTS: The magnitude of the problem is evidenced by sexual and reproductive health challenges such as high teenage pregnancies, early marriages, and sexually transmitted infections. Awareness of these challenges can facilitate the development of interventions and the implementation and integration of CSE. Reported aspects of the interventions include core CSE content, delivery methods, training materials and resources, and various teacher-training factors. Reasons for adoption include perceived benefits of CSE, experiences and characteristics of both teachers and learners, and religious, social and cultural factors. Broad system characteristics include strengthening links between schools and health facilities, school and community-based collaboration, coordination of CSE implementation, and the monitoring and evaluation of CSE. Ultimately, the availability of resources, national policies and laws, international agendas, and political commitment will impact upon the extent and level of integration. CONCLUSION: Social, economic, cultural, political, legal, and financial contextual factors influence the implementation and integration of CSE into national curricula and educational systems. Stakeholder collaboration and involvement in the design and appropriateness of interventions is critical.

Adolescents and young people, especially those from low and middle-income countries (LMICs) face sexual and reproductive health (SRH) challenges. This review identifies factors that impact upon the integration of comprehensive sexuality education (CSE) into national curricula and educational systems in LMICs. A total of 442 original articles, published between 2010 and August 2022, were sourced from various databases. Thirty-four articles met the inclusion criteria. Social, economic, cultural, political, legal and financial factors are major enablers and barriers affecting the integration of CSE into educational systems in LMICs. Authorities in many countries are motivated to develop CSE interventions to help reduce SRH issues such as teenage pregnancies, early marriages, HIV/AIDS, and sexually transmitted infections (Yakubu and Salisu in Reprod Health 15:15, 2018;Herat in Reprod Health 15:1­4, 2018;). The rollout of CSE interventions is highly dependent on the availability of training resources, manuals, skilled teachers, and financing. In addition, the perception of teachers, students, politicians, and the community, influences the integration of interventions. This review shows that the involvement of key players in teaching is vital for successful implementation, as is building working relationships between teachers and community actors. Such collaborations enable the integrated delivery of SRH services. Insufficient monitoring and evaluation systems affects the quality of the implementation and therefore the success of CSE. We believe that community involvement in the development, implementation, monitoring, and evaluation of CSE is a major enabler for successful implementation and integration. Recognising and acknowledging the importance of political, social, legal and financial factors is critical for sustainable CSE integration.

Reducing or reproducing inequalities in health? An intersectional policy analysis of how health inequalities are represented in a Swedish bill on alcohol, drugs, tobacco and gambling.

BACKGROUND: According to post-structural policy analyses, policies and interventions aiming at reducing social inequalities have been found to be part in producing and reifying such inequalities themselves. Given the central role of health inequalities on the public health policy agenda globally it seems important to examine the way policy on health inequalities may potentially counteract the goal of health equity. The aim of this intersectional policy analysis, was to critically analyze the representation of health inequalities in a government bill proposing a national strategy on alcohol, drugs, tobacco and gambling, to examine its performative power, and to outline alternative representations. METHOD: A post-structural approach to policy analysis was combined with an intersectional framework. The material was analyzed through an interrogating process guided by the six questions of the "What's the problem represented to be?" (WPR) approach. Thus, the underlying assumptions of the problem representation, its potential implications and historical background were explored. In a final step of the analysis we examined our own problem representations. RESULTS: The recommendations found in the gender and equity perspective of the bill represented the problem of health inequalities as a lack of knowledge, with an emphasis on quantitative knowledge about differences in health between population groups. Three underlying assumptions supporting this representation were found: quantification and objectivity, inequalities as unidimensional, and categorization and labelling. The analysis showed how the bill, by opting into these partly overlapping assumptions, is part of enacting a discourse on health inequalities that directs attention to specific subjects (e.g., vulnerable) with special needs (e.g., health care), in certain places (e.g., disadvantaged neighborhoods). It also showed how underlying processes of marginalization are largely neglected in the bill due to its focus on describing differences rather than solutions. Finally, we showed how different intersectional approaches could be used to complement and challenge this, potentially counteractive, problem representation. CONCLUSIONS: The problem representation of health inequalities and its underlying assumptions may have counteractive effects on health equity, and even though some of its strengths are raised, it seems to be profoundly entangled with a system resisting the kind of change that the bill itself advocates for. If carefully used, intersectionality has the potential to support a more comprehensive and inclusive equality-promoting public health policy and practice.

'History obligates us to do it': political capabilities of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala.

Growing interest in how marginalised citizens can leverage countervailing power to make health systems more inclusive and equitable points to the need for politicised frameworks for examining bottom-up accountability initiatives. This study explores how political capabilities are manifested in the actions and strategies of Indigenous grassroots leaders of health accountability initiatives in rural Guatemala. Qualitative data were gathered through group discussions and interviews with initiative leaders (called defenders of the right to health) and initiative collaborators in three municipalities. Analysis was oriented by three dimensions of political capabilities proposed for evaluating the longer-term value of participatory development initiatives: political learning, reshaping networks and patterns of representation. Our findings indicated that the defenders' political learning began with actionable knowledge about defending the right to health and citizen participation. The defenders used their understanding of local norms to build trust with remote Indigenous communities and influence them to participate in monitoring to attempt to hold the state accountable for the discriminatory and deficient healthcare they received. Network reshaping was focused on broadening their base of support. Their leadership strategies enabled them to work with other grassroots leaders and access resources that would expand their reach in collective action and lend them more influence representing their problems beyond the local level. Patterns of representing their interests with a range of local and regional authorities indicated they had gained confidence and credibility through their evolving capability to navigate the political landscape and seek the right authority based on the situation. Our results affirm the critical importance of sustained, long-term processes of engagement with marginalised communities and representatives of the state to enable grassroots leaders of accountability initiatives to develop the capabilities needed to mobilise collective action, shift the terms of interaction with the state and build more equitable health systems.

Social factors associated with trust in the health system in northern Sweden: a cross-sectional study.

BACKGROUND: Despite the importance of having trust in the health system, there is a paucity of research in this field in Sweden. The aim of this study was to estimate the level of trust in the health system and to assess the factors associated with it in northern Sweden. METHODS: A cross-sectional survey was conducted in 2014 in the four northern regions of Sweden. A total of 24 795 participants (48% response rate) aged 18 to 84 years were involved in the study. A log-binomial regression was used to measure the association between sociodemographic factors and trust in the health system. RESULTS: Two thirds of the participants (68.5%) reported high trust in the health system i.e. had very much or quite a lot confidence in the health system. Women had lower prevalence of trust compared to men (PR = 0.96; 95% CI = 0.94-0.98) while older participants had a higher trust compared to youth (PR = 1.11; 95% CI = 1.06-1.16). Participants with lower level of education, those who experienced economic stress, those who were born outside Sweden and those living in small municipalities also had lower prevalence of trust in the health system. Conversely, lower income was associated with higher trust (PR = 1.08; 95% CI = 1.04-1.12). Finally, a strong relationship between higher social capital (having emotional and instrumental support, horizontal trust, and higher social participation) and trust in the health system was also found. CONCLUSIONS: Trust in the health system was moderately high in northern Sweden and strongly associated with sociodemographic and social capital factors. Trust is a complex phenomenon and a deeper exploration of the relation between trust in the health system and sociodemographic factors is needed.

Combining photo-elicitation and discourse analysis to examine adolescents' sexuality in rural Zambia.

INTRODUCTION: This article aimed to analyse constructions of adolescents' sexualities and sexual health and the consequences of these discourses for adolescents' exercise of their sexual reproductive health and rights (SRHR) in rural Zambia. METHODS: Interpretative repertoires, which is rooted in discursive psychology was used to analyse data from photo-elicitations interviews and focus group discussions. Our participants included 25 adolescents who participated in a SRHR intervention that aimed to reduce adolescents' pregnancies and early marriages. RESULTS: We identified three interpretative repertories: 1) sex is for mature people in which adolescents positioned themselves as 'immature, and young to engage in sex; 2) gendered respectful behaviours in which what was considered disrespectful (and respectful) behaviour in relation to sexuality were strongly influenced by gender, and more clearly defined for girls than it was for boys. Sexuality was not only about individual choices but about being respectful to parents; and 3) acquiring and using knowledge about sexuality in which adolescents conflicted between having and applying SRHR knowledge. CONCLUSION: These repertories offer an important context that shape how adolescents negotiate, adopt and resist SRHR interventions. Future interventions that target adolescents' SRHR must aim to address the sexual scripts that serve to erect barriers against positive sexual behaviours, including access to SRHR services that promote safer sex.

"One-time interventions, it doesn't lead to much" - healthcare provider views to improving sexual and reproductive health services for young migrants in Sweden.

BACKGROUND: Sexual and reproductive health and rights (SRHR) is an important aspect for young people. In Sweden, young migrants often encounter barriers to accessing and using sexual and reproductive health (SRH) services, despite that these services are free of charge for young people (ages 15-25). Healthcare providers' views and best practices are of great importance for improving the utilisation of existing SRH services, particularly for young people. This study aims to understand healthcare providers' experiences and perspectives on barriers to SRHR among young migrants and their suggestions for strategies to improve the provision of SRH services to this group. METHODS: Midwives, counsellors and nurses with at least five years of professional experience within SRHR were reached through a purposeful sample at primary care clinics, specialised clinics and youth-friendly clinics, which provide SRH services to migrant youths in Stockholm. Twelve interviews were conducted from May 2018 to February 2020. Qualitative content analysis was performed. RESULTS: The analysis identified one theme: Improving the fragmentation in the SRH services, and four sub-themes: 1. Being unaware of SRHR; 2. Creating trust and responsive interactions; 3. Communicating in the same language; and 4. Collaborating to build bridges. The barriers included distrust in the healthcare system, socio-cultural norms surrounding SRHR, incomplete translations, and a need for long-lasting collaboration with SRH services and other range of services for migrants. The strategies for improvement as suggested by participants included involving existing cultural groups and organisations to enable trust, consistent and dependable interpreters, a streamline of SRH services with other healthcare staff and health facilities, and collaborations with homes designated for young migrants and language schools for a direct linkage to service providers. CONCLUSIONS: Findings indicate that there are fragmentations in SRH services, and these include lack of knowledge about SRHR among migrant youth, language and communication barriers, and a lack of structure needed to build dependable services that go beyond one-time interventions. While initiatives and strategies from healthcare providers for improvement of SRH services exist, the implementation of some strategies may also require involving the regional and national decision-makers and multi-stakeholders like communities, civil society and young migrants themselves.

Recurrent pain in school-aged children: a longitudinal study focusing on the relation to academic achievement.

ABSTRACT: Recurrent pain is an increasing public health problem among school-aged children, with potential negative impact on children's daily lives, such as schoolwork. The overall aim of this study was to investigate whether recurrent pain in school year 6 was associated with poorer academic achievement at the end of elementary school in school year 9. The study was a follow-up study based on data from " The Study of Health in School-Aged Children from Umeå". Participants were 1567 children aged 12 to 13 years who attended school year 6. A follow-up was performed in school year 9, when the children were 16 years old. The children answered a questionnaire about recurrent pain (headache, stomachache, and backache). Information about academic achievement was collected from school registers. The results showed that having weekly recurrent pain in school year 6 predicted lower final overall grade points in school year 9 than in children with no recurrent pain. This applied for recurrent headache, stomachache, backache, and multiple pains and for both girls and boys. Recurrent pain did not predict secondary school eligibility, however. Perceived problems with academic achievement and problems with concentration partly mediated the association between recurrent pain and lower final overall grade points. Sleep problems were not associated with academic achievement and were therefore not a mediator. Thus, the results suggest that recurrent pain may predict later impairment of academic achievement and that problems with concentration and children's perceived achievement in school, but not sleep problems, may partly explain this relationship.